Blue Rx Completesm Formulary

BLUE RX COMPLETESM 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 Formulary Tier 4 Complete Plan 4 Tier Tier 1 Tier 2 Tier 3 Tier 4 Complete Plan 3 Tier Tier 1 Tier 2 Tier 3 and Tier 4 combined Complete Plan 2 Tier Tier 1 Tier 2, Tier 3 and Tier 4 combined Complete Plan 1 Tier Tier 1, Tier 2, Tier 3 and Tier 4 combined

Pharmacy Durable Medical Equipment (RxDME): Devices available on this tier include select durable medical equipment (DME) that are used in conjunction with a drug and may be obtained from a pharmacy.

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 Complete 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.

©2021 Wellmark, Inc. 1 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 care professional through an exception request for a non-formulary prescription drug (outlined below). Generally, one of the following guidelines must be documented 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 Complete 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 Complete formulary, other quick reference guides are available at Wellmark.com.

1 TIER 1 2 TIER 2 3 TIER 3 4 TIER 4 5 SP-P 6 SP-NP 7 RX-DME 8 P&T 9 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 preferred biosimilar or generic specialty drug. Please Specialty Biosimilars and SBG read your enrollment information to see how specialty biosimilars and Specialty Generics specialty generics are covered specific to your plan. 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.

©2021 Wellmark, Inc. 3 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 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

ANAPROX DS 550 MG ANAPROX DS TAB TIER 4 GA naproxen sodium ARTHROTEC (50-0.2 MG TAB DR, 75-0.2 MG TAB ARTHROTEC TIER 4 GA DR) diclofenac w/ misoprostol butalbital-aspirin- butalbital-aspirin-caffeine TIER 1 caffeine 50-325-40 mg cap cataflam cataflam 50 mg tab TIER 1 CELEBREX (50 MG CAP, 100 MG CAP, 200 MG CELEBREX TIER 4 QL (60 PER 30 DAYS), GA CAP) celecoxib celecoxib (50 mg cap, 100 celecoxib TIER 1 QL (60 PER 30 DAYS) mg cap, 200 mg cap) choline-mag choline-mag trisalicylate TIER 1 trisalicylate 500 mg/5ml liquid DAYPRO 600 MG TAB DAYPRO TIER 4 GA oxaprozin 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-NAPROSYN (375 MG EC-NAPROSYN TAB DR, 500 MG TAB DR) TIER 4 GA naproxen ec-naproxen (375 mg tab ec-naproxen TIER 1 dr, 500 mg tab dr)

©2021 Wellmark, Inc. 5 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) FELDENE (10 MG CAP, 20 FELDENE MG CAP) TIER 4 GA piroxicam fenoprofen calcium (400 mg fenoprofen calcium TIER 1 cap, 600 mg tab) FIORINAL 50-325-40 MG FIORINAL CAP TIER 4 GA butalbital-aspirin-caffeine FLECTOR 1.3 % PATCH PA, QL (60 PER 30 DAY(S)), FLECTOR TIER 4 diclofenac epolamine GA 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) INDOCIN 25 MG/5ML PA, QL (1200 PER 30 INDOCIN SUSPENSION TIER 2 DAY(S)) 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)) LODINE 400 MG TAB LODINE TIER 4 GA etodolac MECLOFENAMATE MECLOFENAMATE SODIUM (50 MG CAP, 100 TIER 1 SODIUM MG CAP) meclofenamate sodium

©2021 Wellmark, Inc. 6 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS mefenamic acid 250 mg mefenamic acid TIER 1 cap meloxicam (7.5 mg tab, 15 meloxicam TIER 1 mg tab) MOBIC (7.5 MG TAB, 15 MOBIC MG TAB) TIER 4 GA meloxicam nabumetone (500 mg tab, nabumetone TIER 1 750 mg tab) NALFON (400 MG CAP, NALFON 600 MG TAB) TIER 4 GA fenoprofen calcium NAPROSYN 500 MG TAB NAPROSYN TIER 4 GA naproxen naproxen (250 mg tab, 375 naproxen mg tab, 375 mg tab dr, 500 TIER 1 mg tab, 500 mg tab dr) naproxen sodium (275 mg naproxen sodium TIER 1 tab, 550 mg tab) oxaprozin oxaprozin 600 mg tab TIER 1 PENNSAID 2 % PENNSAID SOLUTION TIER 4 PA, QL (2 PER 30 DAY(S)) diclofenac sodium (topical) piroxicam (10 mg cap, 20 piroxicam TIER 1 mg cap) PONSTEL 250 MG CAP PONSTEL TIER 4 GA mefenamic acid 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) TOLMETIN SODIUM (200 MG TAB, 400 MG CAP, TOLMETIN SODIUM TIER 1 600 MG TAB) tolmetin sodium

OPIOID ANALGESICS, LONG-ACTING

ARYMO ER (ER 15 MG TBER DETER, ER 30 MG ARYMO ER TIER 4 PA, QL (90 PER 25) TBER DETER) morphine sulfate

©2021 Wellmark, Inc. 7 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ARYMO ER 60 MG TBER ARYMO ER DETER TIER 4 morphine sulfate 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) BUTRANS (5 PATCH WK, 7.5 PATCH WK, 10 PATCH BUTRANS WK, 15 PATCH WK, 20 TIER 4 PA, QL (4 PER 25), GA PATCH WK) buprenorphine CONZIP (100 MG CAP ER 24H, 200 MG CAP ER 24H, CONZIP TIER 4 PA, QL (30 PER 25) 300 MG CAP ER 24H) tramadol hcl DOLOPHINE 10 MG TAB DOLOPHINE TIER 4 PA, QL (60 PER 25), GA methadone hcl DOLOPHINE 5 MG TAB DOLOPHINE TIER 4 PA, QL (90 PER 25), GA methadone hcl DURAGESIC-100 100 DURAGESIC-100 MCG/HR PATCH 72HR TIER 4 PA, QL (10 PER 25), GA fentanyl DURAGESIC-12 12 DURAGESIC-12 MCG/HR PATCH 72HR TIER 4 PA, QL (10 PER 25), GA fentanyl DURAGESIC-25 25 DURAGESIC-25 MCG/HR PATCH 72HR TIER 4 PA, QL (10 PER 25), GA fentanyl DURAGESIC-50 50 DURAGESIC-50 MCG/HR PATCH 72HR TIER 4 PA, QL (10 PER 25), GA fentanyl DURAGESIC-75 75 DURAGESIC-75 MCG/HR PATCH 72HR TIER 4 PA, QL (10 PER 25), GA fentanyl EMBEDA (20-0.8 MG CAP ER, 30-1.2 MG CAP ER, EMBEDA TIER 4 PA, QL (60 PER 25) 100-4 MG CAP ER) morphine-naltrexone EMBEDA (50-2 MG CAP ER, 60-2.4 MG CAP ER, EMBEDA TIER 4 PA, QL (30 PER 25) 80-3.2 MG CAP ER) morphine-naltrexone

©2021 Wellmark, Inc. 8 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EXALGO (8 MG TAB ER 24H, 12 MG TAB ER 24H, PA, QL (30 PER 25 DAY(S)), EXALGO 16 MG TAB ER 24H, 32 TIER 4 GA MG TAB ER 24H) hydromorphone hcl 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 mg cap er 12h, er 20 mg hydrocodone cap er 12h, er 30 mg cap er TIER 1 PA, QL (60 PER 25) bitartrate er 12h, er 40 mg cap er 12h, er 50 mg cap er 12h, er 100 mg tb24 deter) hydrocodone bitartrate er (er 20 mg tb24 deter, er 30 hydrocodone mg tb24 deter, er 40 mg TIER 1 PA, QL (30 PER 25) bitartrate er tb24 deter, er 60 mg tb24 deter, er 80 mg tb24 deter, er 120 mg tb24 deter) hydromorphone hcl er (er 8 mg tab er 24h, er 12 mg tab hydromorphone hcl er TIER 1 PA, QL (30 PER 25 DAY(S)) er 24h, er 16 mg tab er 24h, er 32 mg tab er 24h) HYSINGLA ER (ER 20 MG TB24 DETER, ER 30 MG TB24 DETER, ER 40 MG TB24 DETER, ER 60 MG HYSINGLA ER TIER 4 PA, QL (30 PER 25), GA TB24 DETER, ER 80 MG TB24 DETER, ER 120 MG TB24 DETER) hydrocodone bitartrate HYSINGLA ER 100 MG HYSINGLA ER TB24 DETER TIER 4 PA, QL (60 PER 25), GA hydrocodone bitartrate KADIAN (10 MG CAP ER 24H, 20 MG CAP ER 24H, 30 MG CAP ER 24H, 40 KADIAN MG CAP ER 24H, 100 MG TIER 4 PA, QL (60 PER 25) CAP ER 24H, 200 MG CAP ER 24H) morphine sulfate

©2021 Wellmark, Inc. 9 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KADIAN (50 MG CAP ER 24H, 60 MG CAP ER 24H, KADIAN TIER 4 PA, QL (30 PER 25), GA 80 MG CAP ER 24H) morphine sulfate 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 10 MG/ML METHADOSE CONC TIER 4 PA, QL (60 PER 25), GA methadone hcl methadose methadose 40 mg tab sol TIER 1 METHADOSE SUGAR- METHADOSE FREE 10 MG/ML CONC TIER 4 PA, QL (60 PER 25), GA SUGAR-FREE methadone hcl MORPHINE SULFATE ER (ER 10 MG CAP ER 24H, ER 20 MG CAP ER 24H, ER 30 MG CAP ER 24H, MORPHINE ER 40 MG CAP ER 24H, TIER 1 PA, QL (60 PER 25) SULFATE ER ER 100 MG CAP ER 24H, ER 100 MG TAB ER, ER 200 MG TAB ER) morphine sulfate 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)

©2021 Wellmark, Inc. 10 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MORPHINE SULFATE ER BEADS (ER BEADS 30 MG CAP ER 24H, ER BEADS 45 MG CAP ER 24H, ER BEADS 60 MG CAP ER MORPHINE 24H, ER BEADS 75 MG TIER 4 PA, QL (30 PER 25) SULFATE ER BEADS CAP ER 24H, ER BEADS 90 MG CAP ER 24H, ER BEADS 120 MG CAP ER 24H) morphine sulfate beads MS CONTIN (100 MG TAB MS CONTIN ER, 200 MG TAB ER) TIER 4 PA, QL (60 PER 25), GA morphine sulfate MS CONTIN (15 MG TAB ER, 30 MG TAB ER, 60 MG MS CONTIN TIER 4 PA, QL (90 PER 25), GA TAB ER) morphine sulfate NUCYNTA ER (ER 50 MG TAB ER 12H, ER 100 MG TAB ER 12H, ER 200 MG NUCYNTA ER TIER 4 PA, QL (60 PER 25) TAB ER 12H, ER 250 MG TAB ER 12H) tapentadol hcl NUCYNTA ER 150 MG NUCYNTA ER TAB ER 12H TIER 4 PA, QL (90 PER 25) tapentadol hcl OPANA ER (ER 5 MG TB12 DETER, ER 7.5 MG TB12 DETER, ER 10 MG TB12 DETER, ER 15 MG OPANA ER TIER 4 PA, QL (60 PER 25) TB12 DETER, ER 30 MG TB12 DETER, ER 40 MG TB12 DETER) oxymorphone hcl OPANA ER 20 MG TB12 OPANA ER DETER TIER 4 PA, QL (90 PER 25) oxymorphone hcl 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

©2021 Wellmark, Inc. 11 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 OXYMORPHONE 10 MG TAB ER 12H, ER 15 TIER 1 PA, QL (60 PER 25) HCL ER MG TAB ER 12H, ER 30 MG TAB ER 12H, ER 40 MG TAB ER 12H) oxymorphone hcl OXYMORPHONE HCL ER OXYMORPHONE 20 MG TAB ER 12H TIER 1 PA, QL (90 PER 25) HCL ER oxymorphone hcl 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) TRAMADOL HCL ER (ER 100 MG CAP ER 24H, ER 150 MG CAP ER 24H, ER TRAMADOL HCL ER TIER 4 PA, QL (30 PER 25) 200 MG CAP ER 24H, ER 300 MG CAP ER 24H) tramadol hcl 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) ZOHYDRO ER (ER 10 MG CAP ER 12H, ER 15 MG CAP ER 12H, ER 20 MG CAP ER 12H, ER 30 MG ZOHYDRO ER TIER 4 PA, QL (60 PER 25), GA CAP ER 12H, ER 40 MG CAP ER 12H, ER 50 MG CAP ER 12H) hydrocodone bitartrate

OPIOID ANALGESICS, SHORT-ACTING

ABSTRAL (100 MCG SL TAB, 200 MCG SL TAB, 300 MCG SL TAB, 400 ABSTRAL TIER 4 PA MCG SL TAB, 600 MCG SL TAB, 800 MCG SL TAB) fentanyl citrate 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 ACTIQ (200 MCG LOZ HANDLE, 400 MCG LOZ HANDLE, 600 MCG LOZ HANDLE, 800 MCG LOZ ACTIQ TIER 4 PA, GA HANDLE, 1200 MCG LOZ HANDLE, 1600 MCG LOZ HANDLE) fentanyl citrate 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- (50-300-40-30 mg cap, 50- TIER 1 cod 325-40-30 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 carisoprodol-aspirin- carisoprodol-aspirin- TIER 1 codeine codeine 200-325-16 mg tab

©2021 Wellmark, Inc. 13 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS codeine sulfate (15 mg tab, codeine sulfate TIER 1 PA, QL (42 PER 25) 30 mg tab, 60 mg tab) DEMEROL 100 MG TAB DEMEROL TIER 4 PA, QL (18 PER 25), GA meperidine hcl DILAUDID 1 MG/ML DILAUDID LIQUID TIER 4 PA, QL (600 PER 25), GA hydromorphone hcl DILAUDID 2 MG TAB DILAUDID TIER 4 PA, QL (180 PER 25), GA hydromorphone hcl DILAUDID 4 MG TAB DILAUDID TIER 4 PA, QL (150 PER 25), GA hydromorphone hcl DILAUDID 8 MG TAB DILAUDID TIER 4 PA, QL (60 PER 25), GA hydromorphone hcl 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) 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) FENTORA (100 MCG TAB, 200 MCG TAB, 400 MCG FENTORA TAB, 600 MCG TAB, 800 TIER 4 PA, GA MCG TAB) fentanyl citrate FIORICET/CODEINE 50- 300-40-30 MG CAP FIORICET/CODEINE TIER 4 GA butalbital-acetaminophen- caffeine w/ codeine FIORINAL/CODEINE #3 FIORINAL/CODEINE 50-325-40-30 MG CAP TIER 4 GA #3 butalbital-aspirin-caffeine w/cod hydrocodone- hydrocodone- acetaminophen (10-300 mg TIER 1 QL (180 PER 25 DAY(S)) acetaminophen tab, 10-325 mg tab)

©2021 Wellmark, Inc. 14 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 (5-300 mg TIER 1 QL (240 PER 25) acetaminophen tab, 5-325 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 ibudone (5-200 mg tab, 10- ibudone TIER 1 QL (50 PER 25) 200 mg tab) LAZANDA (100 SOLUTION, 300 LAZANDA SOLUTION, 400 TIER 4 PA SOLUTION) fentanyl citrate 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 10-300 MG/15ML ELIXIR LORTAB TIER 4 QL (2025 PER 25) hydrocodone- acetaminophen

©2021 Wellmark, Inc. 15 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) suppos, 30 mg tab) 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 NORCO 10-325 MG TAB QL (180 PER 25 DAY(S)), NORCO hydrocodone- TIER 4 GA acetaminophen NORCO 5-325 MG TAB NORCO hydrocodone- TIER 4 QL (240 PER 25), GA acetaminophen NORCO 7.5-325 MG TAB NORCO hydrocodone- TIER 4 QL (180 PER 25), GA acetaminophen NUCYNTA 100 MG TAB NUCYNTA TIER 4 PA, QL (60 PER 25) tapentadol hcl NUCYNTA 50 MG TAB NUCYNTA TIER 4 PA, QL (120 PER 25) tapentadol hcl NUCYNTA 75 MG TAB NUCYNTA TIER 4 PA, QL (90 PER 25) tapentadol hcl OPANA 10 MG TAB OPANA TIER 4 PA, QL (90 PER 25), GA oxymorphone hcl OPANA 5 MG TAB OPANA TIER 4 PA, QL (180 PER 25), GA oxymorphone hcl 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)

©2021 Wellmark, Inc. 16 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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- 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 PERCOCET (2.5-325 MG TAB, 5-325 MG TAB) PERCOCET TIER 4 QL (360 PER 25), GA oxycodone w/ acetaminophen PERCOCET 10-325 MG TAB PERCOCET TIER 4 QL (180 PER 25), GA oxycodone w/ acetaminophen PERCOCET 7.5-325 MG TAB PERCOCET TIER 4 QL (240 PER 25), GA oxycodone w/ acetaminophen ROXICODONE 15 MG TAB ROXICODONE TIER 4 PA, QL (120 PER 25), GA oxycodone hcl ROXICODONE 30 MG TAB ROXICODONE TIER 4 PA, QL (60 PER 25), GA oxycodone hcl ROXICODONE 5 MG TAB ROXICODONE TIER 4 PA, QL (180 PER 25), GA oxycodone hcl

©2021 Wellmark, Inc. 17 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SUBSYS (100 MCG LIQUID, 200 MCG LIQUID, 400 MCG LIQUID, 600 MCG LIQUID, 800 MCG SUBSYS TIER 4 PA LIQUID, 1200 (600 X 2) MCG LIQUID, 1600 (800 X 2) MCG LIQUID) fentanyl SYNALGOS-DC 356.4-30- 16 MG CAP SYNALGOS-DC TIER 4 GA aspirin-caffeine- dihydrocodeine bitartrate 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) TYLENOL WITH CODEINE TYLENOL WITH #3 300-30 MG TAB TIER 4 QL (360 PER 25), GA CODEINE #3 acetaminophen w/ codeine TYLENOL WITH CODEINE TYLENOL WITH #4 300-60 MG TAB TIER 4 QL (180 PER 25), GA CODEINE #4 acetaminophen w/ codeine ULTRACET 37.5-325 MG ULTRACET TAB TIER 4 QL (40 PER 25), GA tramadol-acetaminophen ULTRAM 50 MG TAB ULTRAM TIER 4 PA, QL (180 PER 25), GA tramadol hcl 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)) XODOL 10-300 MG TAB QL (180 PER 25 DAY(S)), XODOL hydrocodone- TIER 4 GA acetaminophen XODOL 5-300 MG TAB XODOL hydrocodone- TIER 4 QL (240 PER 25), GA acetaminophen XODOL 7.5-300 MG TAB XODOL hydrocodone- TIER 4 QL (180 PER 25), GA acetaminophen xylon xylon 10-200 mg tab TIER 1 QL (50 PER 25)

ANESTHETICS

LOCAL ANESTHETICS

7t lido 7t lido 2 % gel TIER 1 glydo glydo 2 % prsyr TIER 1 lidocaine lidocaine 5 % ointment TIER 1 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 LIDODERM 5 % PATCH LIDODERM TIER 4 QL (3 PER DAY), GA lidocaine 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 ANTABUSE (250 MG TAB, ANTABUSE 500 MG TAB) TIER 4 GA disulfiram disulfiram (250 mg tab, 500 disulfiram TIER 1 PV mg tab) naltrexone hcl naltrexone hcl 50 mg tab TIER 1 PV REVIA 50 MG TAB REVIA TIER 4 GA naltrexone hcl

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 film, - naloxone 8-2 mg sl tab, - naloxone 12-3 mg film) SUBOXONE (2-0.5 MG FILM, 4-1 MG FILM, 8-2 SUBOXONE MG FILM, 12-3 MG FILM) TIER 4 GA buprenorphine hcl-naloxone hcl dihydrate ZUBSOLV (0.7-0.18 MG SL TAB, 1.4-0.36 MG SL TAB, 2.9-0.71 MG SL TAB, 5.7- 1.4 MG SL TAB, 8.6-2.1 ZUBSOLV TIER 4 MG SL TAB, 11.4-2.9 MG SL TAB) buprenorphine hcl-naloxone hcl dihydrate

OPIOID REVERSAL AGENTS

KLOXXADO 8 MG/0.1ML KLOXXADO LIQUID TIER 2 naloxone hcl 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 0.3 % OINTMENT GENTAK TIER 1 GA gentamicin sulfate (ophth)

©2021 Wellmark, Inc. 20 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS gentamicin sulfate (0.1 % cream, 0.1 % ointment, 0.3 gentamicin sulfate TIER 1 % ointment, 0.3 % solution, 10 mg/ml solution) HUMATIN 250 MG CAP HUMATIN TIER 4 GA paromomycin sulfate 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 recon soln, 1.2 gm/30ml tobramycin sulfate solution, 2 gm/50ml TIER 1 solution, 10 mg/ml solution, 80 mg/2ml solution) TOBREX 0.3 % OINTMENT TOBREX TIER 3 tobramycin (ophth) TOBREX 0.3 % SOLUTION TOBREX TIER 4 GA tobramycin (ophth)

ANTIBACTERIALS, OTHER

AEMCOLO 194 MG TAB AEMCOLO DR TIER 4 QL (6 PER 3 DAY(S)) rifamycin sodium ALTABAX 1 % OINTMENT ALTABAX TIER 4 retapamulin azuphen mb azuphen mb 120 mg cap TIER 1 BACITRACIN 500 BACITRACIN UNIT/GM OINTMENT TIER 1 bacitracin (ophthalmic) BACTROBAN 2 % CREAM BACTROBAN TIER 4 QL (60 PER 30 DAY(S)), GA mupirocin calcium (topical) BACTROBAN NASAL 2 % BACTROBAN NASAL OINTMENT TIER 4 mupirocin calcium BENZAMYCIN 5-3 % GEL BENZAMYCIN benzoyl peroxide- TIER 4 GA erythromycin benzoyl peroxide- benzoyl peroxide- TIER 1 erythromycin erythromycin 5-3 % gel CENTANY 2 % OINTMENT CENTANY TIER 4 GA mupirocin

©2021 Wellmark, Inc. 21 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CLEOCIN (2 % CREAM, 75 MG CAP, 75 MG/5ML RECON SOLN, 150 MG CLEOCIN TIER 4 GA CAP, 300 MG CAP) clindamycin palmitate hydrochloride 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 CLEOCIN-T (1 % GEL, 1 % LOTION, 1 % SWAB) CLEOCIN-T TIER 4 GA clindamycin phosphate (topical) CLEOCIN-T 1 % SOLUTION QL (180 PER 30 DAY(S)), CLEOCIN-T TIER 4 clindamycin phosphate GA (topical) 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) clindamycin palmitate clindamycin palmitate hcl TIER 1 hcl 75 mg/5ml recon soln clindamycin phosphate (1 % gel, 1 % lotion, 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 CLINDESSE 2 % CREAM CLINDESSE clindamycin phosphate TIER 4 (one dose) 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

©2021 Wellmark, Inc. 22 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EVOCLIN 1 % FOAM EVOCLIN clindamycin phosphate TIER 4 PA, GA (topical) FIRVANQ (25 MG/ML RECON SOLN, 50 MG/ML FIRVANQ TIER 2 QL (450 PER 23 DAY(S)) RECON SOLN) vancomycin hcl FLAGYL (250 MG TAB, 375 MG CAP, 500 MG FLAGYL TIER 4 GA TAB) metronidazole fosfomycin fosfomycin tromethamine 3 TIER 1 tromethamine gm packet FURADANTIN 25 MG/5ML FURADANTIN SUSPENSION TIER 4 GA nitrofurantoin HIPREX 1 GM TAB HIPREX TIER 4 GA methenamine hippurate 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 KIMYRSA 1200 MG KIMYRSA RECON SOLN SP-M oritavancin diphosphate linezolid (100 mg/5ml recon linezolid TIER 1 susp, 600 mg tab) MACROBID 100 MG CAP MACROBID nitrofurantoin monohyd TIER 4 GA macro MACRODANTIN (25 MG CAP, 50 MG CAP, 100 MG MACRODANTIN TIER 4 GA CAP) nitrofurantoin macrocrystal 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) METROGEL-VAGINAL METROGEL- 0.75 % GEL TIER 4 GA VAGINAL metronidazole vaginal

©2021 Wellmark, Inc. 23 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS metronidazole (0.75 % gel, metronidazole 250 mg tab, 375 mg cap, TIER 1 500 mg tab) MONUROL 3 GM PACKET MONUROL TIER 4 GA 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 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 NUVESSA 1.3 % GEL NUVESSA TIER 4 metronidazole vaginal 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 SOLOSEC 2 GM PACKET SOLOSEC TIER 4 secnidazole SULFAMYLON 5 % SULFAMYLON PACKET TIER 4 GA mafenide acetate SULFAMYLON 85 MG/GM SULFAMYLON CREAM TIER 3 mafenide acetate TINDAMAX 500 MG TAB TINDAMAX TIER 4 GA tinidazole 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

©2021 Wellmark, Inc. 24 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS UREX 1 GM TAB UREX TIER 4 methenamine hippurate uribel uribel 118 mg cap TIER 1 URIMAR-T 120 MG TAB methenamine-hyosc- URIMAR-T TIER 4 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 UROGESIC-BLUE 81.6 MG TAB UROGESIC-BLUE methenamine-hyoscamine- TIER 4 GA methylene blue-sodium phosphate 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 VANCOCIN 250 MG CAP VANCOCIN TIER 4 QL (80 PER 23 DAY(S)), GA vancomycin hcl VANCOCIN HCL 125 MG VANCOCIN HCL CAP TIER 4 QL (80 PER 23 DAY(S)), GA vancomycin hcl vancomycin hcl (125 mg vancomycin hcl TIER 4 QL (80 PER 23 DAY(S)) cap, 250 mg cap) vancomycin hcl (5 gm vancomycin hcl recon soln, 750 mg recon TIER 1 soln) VANCOMYCIN HCL 250 VANCOMYCIN HCL MG RECON SOLN TIER 4 vancomycin hcl 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 ZYVOX (100 MG/5ML RECON SUSP, 600 MG ZYVOX TIER 4 GA TAB) linezolid

BETA-LACTAM, CEPHALOSPORINS

CEDAX (180 MG/5ML RECON SUSP, 400 MG CEDAX TIER 4 GA CAP) ceftibuten 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 mg cefadroxil TIER 1 cap, 500 mg/5ml recon susp) 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 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 mg cefpodoxime proxetil TIER 1 tab, 100 mg/5ml recon susp, 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) CEFTIN (125 RECON CEFTIN SUSP, 250 RECON SUSP) TIER 4 cefuroxime axetil

©2021 Wellmark, Inc. 26 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 cap, 500 mg tab, 750 mg cap) KEFLEX (250 MG CAP, 500 MG CAP, 750 MG KEFLEX TIER 4 GA CAP) cephalexin MAXIPIME 1 GM RECON MAXIPIME SOLN TIER 2 GA cefepime hcl SPECTRACEF 400 MG SPECTRACEF TAB TIER 4 GA cefditoren pivoxil SUPRAX (100 MG CHEW TAB, 200 MG CHEW TAB, SUPRAX 500 MG/5ML RECON TIER 3 SUSP) cefixime SUPRAX (100 MG/5ML RECON SUSP, 200 SUPRAX MG/5ML RECON SUSP, TIER 4 GA 400 MG CAP) 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 cap, 250 mg amoxicillin TIER 1 chew tab, 250 mg/5ml recon susp, 400 mg/5ml recon susp, 500 mg cap, 500 mg tab, 875 mg tab) amoxicillin-pot clavulanate (200-28.5 mg chew tab, 200-28.5 mg/5ml recon susp, 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 AMPICILLIN 500 MG CAP AMPICILLIN TIER 1 ampicillin AUGMENTIN (125-31.25 MG/5ML RECON SUSP, 250-62.5 MG/5ML RECON AUGMENTIN SUSP, 500-125 MG TAB, TIER 4 GA 875-125 MG TAB) amoxicillin & pot clavulanate AUGMENTIN ES-600 600- 42.9 MG/5ML RECON AUGMENTIN ES-600 SUSP TIER 4 GA amoxicillin & pot clavulanate AUGMENTIN XR 1000- 62.5 MG TAB ER 12H AUGMENTIN XR TIER 4 GA amoxicillin & pot clavulanate 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)

©2021 Wellmark, Inc. 28 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS penicillin v potassium (125 mg/5ml recon soln, 250 mg penicillin v potassium TIER 1 tab, 250 mg/5ml recon soln, 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 tab, clarithromycin TIER 1 250 mg/5ml recon susp, 500 mg tab) clarithromycin er 500 mg clarithromycin er TIER 1 tab er 24h DIFICID 200 MG TAB DIFICID TIER 4 fidaxomicin DIFICID 40 MG/ML RECON PA, QL (300 PER 30 DIFICID SUSP TIER 4 DAY(S)) fidaxomicin e.e.s. 400 e.e.s. 400 400 mg tab TIER 1 E.E.S. 400 400 MG TAB E.E.S. 400 TIER 4 GA erythromycin ethylsuccinate E.E.S. GRANULES 200 E.E.S. GRANULES MG/5ML RECON SUSP TIER 4 GA erythromycin ethylsuccinate 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) ERYGEL 2 % GEL ERYGEL TIER 4 GA erythromycin (acne aid) ERYPED 200 200 MG/5ML ERYPED 200 RECON SUSP TIER 4 GA erythromycin ethylsuccinate ERYPED 400 400 MG/5ML ERYPED 400 RECON SUSP TIER 4 GA erythromycin ethylsuccinate ERYTHROCIN STEARATE ERYTHROCIN 250 MG TAB TIER 1 STEARATE erythromycin stearate

©2021 Wellmark, Inc. 29 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS erythromycin (2 % gel, 2 % pad, 2 % solution, 5 mg/gm erythromycin ointment, 250 mg tab dr, TIER 1 333 mg tab dr, 500 mg tab dr) erythromycin base (250 mg cp dr part, 250 mg tab, 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 ZITHROMAX (100 MG/5ML RECON SUSP, 200 MG/5ML RECON SUSP, ZITHROMAX TIER 4 GA 250 MG TAB, 500 MG TAB, 600 MG TAB) azithromycin ZITHROMAX TRI-PAK 500 ZITHROMAX TRI- MG TAB TIER 4 GA PAK azithromycin ZITHROMAX Z-PAK 250 ZITHROMAX Z-PAK MG TAB TIER 4 GA azithromycin ZMAX 2 GM RECON SUSP ZMAX TIER 4 azithromycin

QUINOLONES

AVELOX 400 MG TAB AVELOX TIER 4 GA moxifloxacin hcl BAXDELA 450 MG TAB BAXDELA TIER 4 delafloxacin meglumine BESIVANCE 0.6 % BESIVANCE SUSPENSION TIER 3 besifloxacin hcl CETRAXAL 0.2 % CETRAXAL SOLUTION TIER 4 ciprofloxacin hcl (otic) CILOXAN 0.3 % CILOXAN OINTMENT TIER 3 ciprofloxacin hcl (ophth)

©2021 Wellmark, Inc. 30 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CILOXAN 0.3 % CILOXAN SOLUTION TIER 4 GA ciprofloxacin hcl (ophth) CIPRO (250 MG TAB, 250 MG/5ML (5%) RECON SUSP, 500 MG TAB, 500 CIPRO TIER 4 GA MG/5ML (10%) RECON SUSP) ciprofloxacin 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 FACTIVE 320 MG TAB FACTIVE TIER 4 gemifloxacin mesylate FLOXIN OTIC 0.3 % FLOXIN OTIC SOLUTION TIER 4 GA ofloxacin (otic) gatifloxacin gatifloxacin 0.5 % solution TIER 1 LEVAQUIN (250 MG TAB, 500 MG TAB, 750 MG LEVAQUIN TIER 4 GA TAB) levofloxacin levofloxacin (0.5 % solution, 25 mg/ml solution, 250 mg levofloxacin TIER 1 tab, 500 mg tab, 750 mg tab) MOXEZA 0.5 % MOXEZA SOLUTION TIER 4 GA moxifloxacin hcl (ophth) 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 OCUFLOX 0.3 % OCUFLOX SOLUTION TIER 4 GA ofloxacin (ophth)

©2021 Wellmark, Inc. 31 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ofloxacin (0.3 % solution, ofloxacin TIER 1 300 mg tab, 400 mg tab) VIGAMOX 0.5 % VIGAMOX SOLUTION TIER 4 GA moxifloxacin hcl (ophth) ZYMAXID 0.5 % ZYMAXID SOLUTION TIER 4 GA gatifloxacin (ophth)

SULFONAMIDES

AVC VAGINAL 15 % AVC VAGINAL CREAM TIER 4 sulfanilamide vaginal BACTRIM 400-80 MG TAB BACTRIM sulfamethoxazole- TIER 4 GA trimethoprim BACTRIM DS 800-160 MG TAB BACTRIM DS TIER 4 GA sulfamethoxazole- trimethoprim BLEPH-10 10 % SOLUTION BLEPH-10 TIER 4 GA sulfacetamide sodium (ophth) KLARON 10 % LOTION KLARON sulfacetamide sodium TIER 4 GA (acne) SILVADENE 1 % CREAM SILVADENE TIER 4 GA silver sulfadiazine 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 coremino (45 mg tab er coremino 24h, 90 mg tab er 24h, 135 TIER 1 PA mg tab er 24h) demeclocycline hcl (150 mg demeclocycline hcl TIER 1 tab, 300 mg tab) DORYX 50 MG TAB DR DORYX TIER 4 PA, GA doxycycline hyclate DOXYCYCLINE 40 MG DOXYCYCLINE CAP DR TIER 4 PA doxycycline (rosacea) doxycycline hyclate (20 mg doxycycline hyclate tab, 50 mg cap, 100 mg TIER 1 cap, 100 mg tab) 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 cap, 50 mg tab, 75 mg TIER 1 monohydrate tab, 100 mg cap, 100 mg tab) MINOCIN (50 MG CAP, 75 MINOCIN MG CAP, 100 MG CAP) TIER 4 GA minocycline hcl minocycline hcl (50 mg cap, 50 mg tab, 75 mg cap, 75 minocycline hcl TIER 1 mg tab, 100 mg cap, 100 mg tab) minocycline hcl er (er 45 mg tab er 24h, er 90 mg tab minocycline hcl er TIER 1 PA er 24h, er 135 mg tab er 24h) mondoxyne nl (50 mg cap, mondoxyne nl TIER 1 100 mg cap) MONODOX (75 MG CAP, MONODOX 100 MG CAP) TIER 4 GA doxycycline (monohydrate) morgidox (50 mg cap, 100 morgidox TIER 1 mg cap) okebo okebo 100 mg cap TIER 1 ORACEA 40 MG CAP DR ORACEA TIER 4 PA doxycycline (rosacea)

©2021 Wellmark, Inc. 33 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 (25 MG/5ML RECON SUSP, 100 MG VIBRAMYCIN TIER 4 GA CAP) doxycycline (monohydrate) VIBRAMYCIN 50 MG/5ML VIBRAMYCIN SYRUP TIER 3 doxycycline calcium

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

BRIVIACT (10 MG TAB, 10 MG/ML SOLUTION, 25 MG BRIVIACT TAB, 50 MG TAB, 75 MG TIER 4 TAB, 100 MG TAB) brivaracetam DIACOMIT (250 MG CAP, PA, QL (360 PER 30 DIACOMIT 250 MG PACKET) SP-P DAY(S)) stiripentol DIACOMIT (500 MG CAP, PA, QL (180 PER 30 DIACOMIT 500 MG PACKET) SP-P DAY(S)) stiripentol EPIDIOLEX 100 MG/ML PA, QL (600 PER 30 EPIDIOLEX SOLUTION SP-P DAY(S)) cannabidiol FINTEPLA 2.2 MG/ML SOLUTION PA, QL (360 PER 30 FINTEPLA SP-NP fenfluramine hcl DAY(S)) (anticonvulsant) KEPPRA (100 MG/ML SOLUTION, 250 MG TAB, KEPPRA 500 MG TAB, 750 MG TAB, TIER 4 GA 1000 MG TAB) levetiracetam KEPPRA XR (500 MG TAB ER 24H, 750 MG TAB ER KEPPRA XR TIER 4 GA 24H) levetiracetam

©2021 Wellmark, Inc. 34 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 cap, ethosuximide TIER 1 PV 250 mg/5ml solution) ZARONTIN (250 MG CAP, ZARONTIN 250 MG/5ML SOLUTION) TIER 4 GA ethosuximide ZONEGRAN (25 MG CAP, ZONEGRAN 100 MG CAP) TIER 4 GA zonisamide zonisamide (25 mg cap, 50 zonisamide TIER 1 PV mg cap, 100 mg cap)

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

PA, QL (120 PER 30 DAYS), clobazam clobazam 10 mg tab TIER 1 PV 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 DEPAKENE (250 MG CAP, DEPAKENE 250 MG/5ML SOLUTION) TIER 4 GA valproate sodium DEPAKOTE (125 MG TAB DR, 250 MG TAB DR, 500 DEPAKOTE TIER 4 GA MG TAB DR) divalproex sodium DEPAKOTE ER (ER 250 MG TAB ER 24H, ER 500 DEPAKOTE ER TIER 4 GA MG TAB ER 24H) divalproex sodium

©2021 Wellmark, Inc. 35 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DEPAKOTE SPRINKLES DEPAKOTE 125 MG CAP DR TIER 4 GA SPRINKLES divalproex sodium DIASTAT ACUDIAL (10 MG DIASTAT ACUDIAL GEL, 20 MG GEL) TIER 4 GA diazepam (anticonvulsant) DIASTAT PEDIATRIC 2.5 DIASTAT PEDIATRIC MG GEL TIER 4 GA diazepam (anticonvulsant) diazepam (2.5 mg gel, 10 diazepam TIER 1 mg gel, 20 mg gel) divalproex sodium (125 mg divalproex sodium cap dr, 125 mg tab 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) GABITRIL (2 MG TAB, 4 MG TAB, 12 MG TAB, 16 GABITRIL TIER 4 GA MG TAB) tiagabine hcl LYRICA CR (82.5 MG TAB ER 24H, 165 MG TAB ER LYRICA CR TIER 4 GA 24H, 330 MG TAB ER 24H) pregabalin (once-daily) MYSOLINE (50 MG TAB, MYSOLINE 250 MG TAB) TIER 4 GA primidone NEURONTIN (100 MG CAP, 250 MG/5ML SOLUTION, 300 MG CAP, NEURONTIN TIER 4 GA 400 MG CAP, 600 MG TAB, 800 MG TAB) gabapentin ONFI 10 MG TAB PA, QL (120 PER 30 DAYS), ONFI TIER 4 clobazam GA ONFI 2.5 MG/ML PA, QL (480 PER 30 DAYS), ONFI SUSPENSION TIER 4 GA clobazam ONFI 20 MG TAB PA, QL (60 PER 30 DAYS), ONFI TIER 4 clobazam GA

©2021 Wellmark, Inc. 36 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) pregabalin er (er 82.5 mg pregabalin er tab er 24h, er 165 mg tab er TIER 1 24h, er 330 mg tab er 24h) primidone (50 mg tab, 250 primidone TIER 1 PV mg tab) SABRIL (500 MG PACKET, SABRIL 500 MG TAB) 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) 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) QL (180 PER 30 DAYS), vigabatrin (500 mg packet, vigabatrin SP-P SBG (Specialty Biosimilars 500 mg tab) and Specialty generics) QL (180 PER 30 DAYS), vigadrone vigadrone 500 mg packet SP-P SBG (Specialty Biosimilars and Specialty generics)

GLUTAMATE REDUCING AGENTS

felbamate (400 mg tab, 600 felbamate mg tab, 600 mg/5ml TIER 1 PV suspension)

©2021 Wellmark, Inc. 37 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FELBATOL (400 MG TAB, 600 MG TAB, 600 MG/5ML FELBATOL TIER 4 GA SUSPENSION) felbamate FYCOMPA (0.5 MG/ML SUSPENSION, 2 MG TAB, 4 MG TAB, 6 MG TAB, 8 FYCOMPA TIER 4 MG TAB, 10 MG TAB, 12 MG TAB) perampanel LAMICTAL (5 MG CHEW TAB, 25 MG CHEW TAB, 25 MG TAB, 100 MG TAB, LAMICTAL TIER 4 GA 150 MG TAB, 200 MG TAB) lamotrigine LAMICTAL ODT (ODT 25 MG TAB DISP, ODT 50 MG TAB DISP, ODT 100 MG LAMICTAL ODT TIER 4 GA TAB DISP, ODT 200 MG TAB DISP) lamotrigine LAMICTAL XR (25 MG TAB ER 24H, 50 MG TAB ER 24H, 100 MG TAB ER 24H, LAMICTAL XR 200 MG TAB ER 24H, 250 TIER 4 GA MG TAB ER 24H, 300 MG TAB ER 24H) lamotrigine lamotrigine (5 mg chew tab, 25 mg chew tab, 25 mg tab, 25 mg tab disp, 50 mg tab lamotrigine TIER 1 PV disp, 100 mg tab, 100 mg tab disp, 150 mg tab, 200 mg tab, 200 mg tab disp) 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) QUDEXY XR (25 MG CP24 SPRNK, 50 MG CP24 SPRNK, 100 MG CP24 QUDEXY XR SPRNK, 150 MG CP24 TIER 4 GA SPRNK, 200 MG CP24 SPRNK) topiramate

©2021 Wellmark, Inc. 38 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS subvenite (25 mg tab, 100 subvenite mg tab, 150 mg tab, 200 TIER 1 PV mg tab) TOPAMAX (25 MG TAB, 50 MG TAB, 100 MG TAB, 200 TOPAMAX TIER 4 GA MG TAB) topiramate TOPAMAX SPRINKLE (15 TOPAMAX MG CAP SPRINK, 25 MG TIER 4 GA SPRINKLE CAP SPRINK) topiramate 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) TROKENDI XR (25 MG CAP ER 24H, 50 MG CAP TROKENDI XR ER 24H, 100 MG CAP ER TIER 4 24H, 200 MG CAP ER 24H) topiramate XCOPRI (150 MG TAB, XCOPRI 200 MG TAB) TIER 4 PA, QL (60 PER 30 DAY(S)) cenobamate XCOPRI (250 MG DAILY XCOPRI (250 MG DOSE) 100 & 150 MG TAB TIER 4 PA, QL (2 PER 1 DAY(S)) DAILY DOSE) THPK cenobamate XCOPRI (250 MG DAILY XCOPRI (250 MG DOSE) 50 & 200 MG TAB TIER 4 PA, QL (1 PER 28 DAY(S)) DAILY DOSE) THPK cenobamate XCOPRI (350 MG DAILY XCOPRI (350 MG DOSE) 150 & 200 MG TAB TIER 4 PA, QL (1 PER 28 DAY(S)) DAILY DOSE) THPK cenobamate XCOPRI (50 MG TAB, 100 XCOPRI MG TAB) TIER 4 PA, QL (30 PER 30 DAY(S)) cenobamate

©2021 Wellmark, Inc. 39 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XCOPRI (COPRI 14 12.5 MG 14 25 MG TAB THPK, COPRI 14 150 MG 14 200 XCOPRI MG TAB THPK, COPRI 14 TIER 4 PA, QL (1 PER 28 DAY(S)) 50 MG 14 100 MG TAB THPK) cenobamate

SODIUM CHANNEL AGENTS

APTIOM (200 MG TAB, 400 MG TAB, 600 MG TAB, APTIOM TIER 4 800 MG TAB) eslicarbazepine acetate BANZEL (200 MG TAB, PA, QL (240 PER 30 DAYS), BANZEL 400 MG TAB) TIER 4 GA rufinamide BANZEL 40 MG/ML PA, QL (2400 PER 30 BANZEL SUSPENSION TIER 4 DAYS), GA rufinamide carbamazepine (100 mg carbamazepine chew tab, 100 mg/5ml TIER 1 PV suspension, 200 mg tab) carbamazepine er (er 100 mg cap er 12h, er 100 mg tab er 12h, er 200 mg cap carbamazepine er TIER 1 PV er 12h, er 200 mg tab er 12h, er 300 mg cap er 12h, er 400 mg tab er 12h) CARBATROL (100 MG CAP ER 12H, 200 MG CAP CARBATROL ER 12H, 300 MG CAP ER TIER 4 GA 12H) carbamazepine DILANTIN (30 MG CAP, 100 MG CAP, 125 MG/5ML DILANTIN TIER 4 SUSPENSION) phenytoin sodium extended DILANTIN INFATABS 50 DILANTIN INFATABS MG CHEW TAB TIER 4 GA phenytoin epitol epitol 200 mg tab TIER 1 PV oxcarbazepine (150 mg tab, oxcarbazepine 300 mg tab, 300 mg/5ml TIER 1 PV suspension, 600 mg tab)

©2021 Wellmark, Inc. 40 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OXTELLAR XR (150 MG TAB ER 24H, 300 MG TAB OXTELLAR XR ER 24H, 600 MG TAB ER TIER 4 24H) oxcarbazepine PEGANONE 250 MG TAB PEGANONE TIER 2 PV ethotoin PHENYTEK (200 MG CAP, PHENYTEK 300 MG CAP) TIER 4 GA phenytoin sodium extended 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) rufinamide (200 mg tab, PA, QL (240 PER 30 DAYS), rufinamide TIER 1 400 mg tab) PV rufinamide 40 mg/ml PA, QL (2400 PER 30 rufinamide TIER 1 suspension DAYS), PV TEGRETOL (100 MG/5ML SUSPENSION, 200 MG TEGRETOL TIER 4 GA TAB) carbamazepine TEGRETOL-XR (100 MG TAB ER 12H, 200 MG TAB TEGRETOL-XR ER 12H, 400 MG TAB ER TIER 4 GA 12H) carbamazepine TRILEPTAL (150 MG TAB, 300 MG TAB, 300 MG/5ML TRILEPTAL SUSPENSION, 600 MG TIER 4 GA TAB) oxcarbazepine 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

ARICEPT (5 MG TAB, 10 ARICEPT MG TAB, 23 MG TAB) TIER 4 GA donepezil hydrochloride donepezil hcl (5 mg tab, 5 donepezil hcl mg tab disp, 10 mg tab, 10 TIER 1 mg tab disp, 23 mg tab) EXELON (4.6 MG/24HR PATCH 24HR, 9.5 MG/24HR PATCH 24HR, EXELON TIER 4 GA 13.3 MG/24HR PATCH 24HR) rivastigmine 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) RAZADYNE (4 MG TAB, 8 RAZADYNE MG TAB, 12 MG TAB) TIER 4 GA galantamine hydrobromide RAZADYNE ER (ER 8 MG CAP ER 24H, ER 16 MG RAZADYNE ER CAP ER 24H, ER 24 MG TIER 4 GA CAP ER 24H) galantamine hydrobromide 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 PA, QL (300 PER 30 memantine hcl solution, 10 mg/5ml TIER 1 DAY(S)) solution) memantine hcl (5 mg tab, memantine hcl TIER 1 10 mg tab) 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) NAMENDA (5 MG TAB, 10 NAMENDA MG TAB) TIER 4 GA memantine hcl NAMENDA 10 MG/5ML PA, QL (300 PER 30 NAMENDA SOLUTION TIER 4 DAY(S)), GA memantine hcl NAMENDA XR (7 MG CAP ER 24H, 14 MG CAP ER NAMENDA XR 24H, 21 MG CAP ER 24H, TIER 4 GA 28 MG CAP ER 24H) memantine hcl

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, 15 mg tab disp, 30 mirtazapine TIER 1 PV mg tab, 30 mg tab disp, 45 mg tab, 45 mg tab disp)

©2021 Wellmark, Inc. 43 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, 4-10 TIER 1 AMITRIPTYLINE MG TAB, 4-25 MG TAB, 4- 50 MG TAB) perphenazine-amitriptyline REMERON (15 MG TAB, REMERON 30 MG TAB, 45 MG TAB) TIER 4 GA mirtazapine REMERON SOLTAB (15 MG TAB DISP, 30 MG TAB REMERON SOLTAB TIER 4 GA DISP, 45 MG TAB DISP) mirtazapine SYMBYAX (3-25 MG CAP, 6-25 MG CAP, 6-50 MG SYMBYAX CAP, 12-25 MG CAP, 12- TIER 4 GA 50 MG CAP) olanzapine-fluoxetine hcl WELLBUTRIN SR (100 MG TAB ER 12H, 150 MG TAB WELLBUTRIN SR ER 12H, 200 MG TAB ER TIER 4 GA 12H) bupropion hcl WELLBUTRIN XL (150 MG TAB ER 24H, 300 MG TAB WELLBUTRIN XL TIER 4 GA ER 24H) bupropion hcl

MONOAMINE OXIDASE INHIBITORS

EMSAM (6 MG/24HR PATCH 24HR, 9 MG/24HR EMSAM PATCH 24HR, 12 TIER 4 MG/24HR PATCH 24HR) selegiline MARPLAN 10 MG TAB MARPLAN TIER 2 PV isocarboxazid NARDIL 15 MG TAB NARDIL TIER 4 GA phenelzine sulfate PARNATE 10 MG TAB PARNATE TIER 4 GA tranylcypromine sulfate 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)

BRISDELLE 7.5 MG CAP BRISDELLE paroxetine mesylate TIER 4 QL (30 PER 30 DAYS), GA (vasomotor) CELEXA (10 MG TAB, 20 CELEXA MG TAB, 40 MG TAB) TIER 4 GA citalopram hydrobromide citalopram hydrobromide citalopram (10 mg tab, 20 mg tab, 40 TIER 1 PV hydrobromide mg tab) citalopram citalopram hydrobromide 10 PA, QL (600 PER 30 TIER 1 hydrobromide mg/5ml solution DAY(S)), PV desvenlafaxine er (er 50 mg PA, QL (30 PER 30 DAYS), desvenlafaxine er tab er 24h, er 100 mg tab er TIER 1 PV 24h) DESVENLAFAXINE ER DESVENLAFAXINE (ER 50 MG TAB ER 24H, PA, QL (30 PER 30 DAYS), TIER 4 ER ER 100 MG TAB ER 24H) PV, GA desvenlafaxine 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) EFFEXOR XR (37.5 MG CAP ER 24H, 75 MG CAP EFFEXOR XR ER 24H, 150 MG CAP ER TIER 4 GA 24H) venlafaxine hcl escitalopram oxalate (5 mg escitalopram oxalate tab, 5 mg/5ml solution, 10 TIER 1 PV mg tab, 20 mg tab) FETZIMA (20 MG CAP ER 24H, 40 MG CAP ER 24H, FETZIMA 80 MG CAP ER 24H, 120 TIER 4 PA, QL (30 PER 30 DAYS) MG CAP ER 24H) levomilnacipran hcl FLUOXETINE HCL (10 MG CAP, 20 MG CAP, 20 FLUOXETINE HCL MG/5ML SOLUTION, 40 TIER 1 PV 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)

©2021 Wellmark, Inc. 45 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) KHEDEZLA (50 MG TAB ER 24H, 100 MG TAB ER PA, QL (30 PER 30 DAYS), KHEDEZLA TIER 4 24H) GA desvenlafaxine LEXAPRO (5 MG TAB, 10 LEXAPRO MG TAB, 20 MG TAB) TIER 4 GA escitalopram oxalate 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 PAXIL (10 MG TAB, 10 MG/5ML SUSPENSION, 20 PAXIL MG TAB, 30 MG TAB, 40 TIER 4 GA MG TAB) paroxetine hcl PAXIL CR (12.5 MG TAB ER 24H, 25 MG TAB ER PAXIL CR 24H, 37.5 MG TAB ER TIER 4 GA 24H) paroxetine hcl PEXEVA (10 MG TAB, 20 MG TAB, 30 MG TAB, 40 PEXEVA TIER 4 PA MG TAB) paroxetine mesylate PRISTIQ (25 MG TAB ER 24H, 50 MG TAB ER 24H, PRISTIQ TIER 4 QL (30 PER 30 DAYS), GA 100 MG TAB ER 24H) desvenlafaxine succinate PROZAC (10 MG CAP, 20 PROZAC MG CAP, 40 MG CAP) TIER 4 GA fluoxetine hcl

©2021 Wellmark, Inc. 46 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) TRINTELLIX (5 MG TAB, TRINTELLIX 10 MG TAB, 20 MG TAB) TIER 4 PA vortioxetine hbr 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) VIIBRYD (10 MG TAB, 20 VIIBRYD MG TAB, 40 MG TAB) TIER 4 PA vilazodone hcl ZOLOFT (20 MG/ML CONC, 25 MG TAB, 50 MG ZOLOFT TIER 4 GA TAB, 100 MG TAB) sertraline hcl

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 ANAFRANIL (25 MG CAP, ANAFRANIL 50 MG CAP, 75 MG CAP) TIER 4 GA clomipramine hcl clomipramine hcl (25 mg clomipramine hcl TIER 1 PV cap, 50 mg cap, 75 mg cap) 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)

©2021 Wellmark, Inc. 47 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ELAVIL 25 MG TAB ELAVIL TIER 4 GA amitriptyline hcl imipramine hcl (10 mg tab, imipramine hcl TIER 1 PV 25 mg tab, 50 mg tab) NORPRAMIN (10 MG TAB, NORPRAMIN 25 MG TAB) TIER 4 GA desipramine hcl nortriptyline hcl (10 mg cap, nortriptyline hcl 25 mg cap, 50 mg cap, 75 TIER 1 PV mg cap) nortriptyline hcl 10 mg/5ml PA, QL (2400 PER 30 nortriptyline hcl TIER 1 solution DAY(S)) PAMELOR (10 MG CAP, 25 MG CAP, 50 MG CAP, PAMELOR TIER 4 GA 75 MG CAP) nortriptyline hcl protriptyline hcl (5 mg tab, protriptyline hcl TIER 1 PV 10 mg tab) SURMONTIL (25 MG CAP, SURMONTIL 50 MG CAP, 100 MG CAP) TIER 4 GA trimipramine maleate TOFRANIL (10 MG TAB, TOFRANIL 25 MG TAB, 50 MG TAB) TIER 4 GA imipramine hcl 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 tab, 5 mg/5ml solution, 10 metoclopramide hcl TIER 1 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

©2021 Wellmark, Inc. 48 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS prochlorperazine prochlorperazine maleate TIER 1 maleate (5 mg tab, 10 mg tab) promethazine hcl (12.5 mg suppos, 12.5 mg tab, 25 mg promethazine hcl TIER 1 suppos, 25 mg tab, 50 mg suppos, 50 mg tab) PROMETHEGAN (12.5 MG SUPPOS, 25 MG PROMETHEGAN SUPPOS, 50 MG TIER 1 GA SUPPOS) promethazine hcl REGLAN (5 MG TAB, 10 REGLAN MG TAB) TIER 4 GA metoclopramide hcl scopolamine 1 mg/3days scopolamine TIER 1 patch 72hr TIGAN 300 MG CAP TIGAN TIER 4 GA trimethobenzamide hcl TRANSDERM SCOP (1.5 TRANSDERM SCOP MG) 1 MG/3DAYS PATCH TIER 4 GA (1.5 MG) 72HR scopolamine TRANSDERM-SCOP (1.5 TRANSDERM-SCOP MG) 1 MG/3DAYS PATCH TIER 4 GA (1.5 MG) 72HR scopolamine trimethobenzamide trimethobenzamide hcl 300 TIER 1 hcl mg cap

EMETOGENIC THERAPY ADJUNCTS

AKYNZEO 300-0.5 MG AKYNZEO CAP TIER 4 netupitant-palonosetron ANZEMET (50 MG TAB, ANZEMET 100 MG TAB) TIER 2 dolasetron mesylate aprepitant (40 mg cap, 80 & 125 mg cap, 80 & 125 mg aprepitant TIER 1 misc, 80 mg cap, 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 (40 MG CAP, 80 EMEND MG CAP, 125 MG CAP) TIER 4 GA aprepitant

©2021 Wellmark, Inc. 49 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EMEND 125 MG/5ML EMEND RECON SUSP TIER 2 aprepitant EMEND TRI-PACK 80 & EMEND TRI-PACK 125 MG CAP TIER 4 GA aprepitant granisetron hcl granisetron hcl 1 mg tab TIER 1 MARINOL (2.5 MG CAP, 5 MARINOL MG CAP, 10 MG CAP) TIER 4 GA dronabinol 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 SANCUSO 3.1 MG/24HR SANCUSO PATCH TIER 4 QL (4 PER 28 DAYS) granisetron VARUBI (180 MG DOSE) 2 VARUBI (180 MG X 90 MG TAB THPK TIER 4 QL (4 PER 28 DAYS) DOSE) rolapitant hcl ZOFRAN (4 MG TAB, 8 MG ZOFRAN TAB) TIER 4 GA ondansetron hcl ZOFRAN 4 MG/5ML ZOFRAN SOLUTION TIER 4 QL (300 PER 30 DAYS), GA ondansetron hcl ZOFRAN ODT (ODT 4 MG TAB DISP, ODT 8 MG TAB ZOFRAN ODT TIER 4 GA DISP) ondansetron ZUPLENZ (4 MG FILM, 8 ZUPLENZ MG FILM) TIER 4 ondansetron

ANTIFUNGALS

ANCOBON (250 MG CAP, ANCOBON 500 MG CAP) TIER 4 GA flucytosine 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)

©2021 Wellmark, Inc. 50 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ciclopirox olamine (0.77 % ciclopirox olamine TIER 1 cream, 0.77 % suspension) clotrimazole clotrimazole 10 mg troche TIER 1 CRESEMBA 186 MG CAP CRESEMBA TIER 4 isavuconazonium sulfate DIFLUCAN (10 MG/ML RECON SUSP, 40 MG/ML RECON SUSP, 50 MG DIFLUCAN TIER 4 GA TAB, 100 MG TAB, 150 MG TAB, 200 MG TAB) fluconazole econazole nitrate 1 % econazole nitrate TIER 1 QL (170 PER 30 DAY(S)) cream ECOZA 1 % FOAM ECOZA TIER 4 econazole nitrate ERTACZO 2 % CREAM ERTACZO TIER 4 sertaconazole nitrate EXELDERM (1 % CREAM, EXELDERM 1 % SOLUTION) TIER 4 GA sulconazole nitrate EXTINA 2 % FOAM QL (200 PER 30 DAY(S)), EXTINA TIER 4 ketoconazole (topical) GA 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) GRIS-PEG (125 MG TAB, GRIS-PEG 250 MG TAB) TIER 4 GA griseofulvin ultramicrosize 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) GYNAZOLE-1 2 % CREAM GYNAZOLE-1 butoconazole nitrate (one TIER 4 dose) 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))

©2021 Wellmark, Inc. 51 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ketoconazole ketoconazole 2 % foam TIER 1 QL (200 PER 30 DAY(S)) ketodan ketodan 2 % foam TIER 1 QL (200 PER 30 DAY(S)) LAMISIL 250 MG TAB LAMISIL TIER 4 GA terbinafine hcl LOPROX (0.77 % CREAM, 0.77 % SUSPENSION, 1 % LOPROX TIER 4 GA SHAMPOO) ciclopirox luliconazole luliconazole 1 % cream TIER 1 LUZU 1 % CREAM LUZU TIER 4 GA luliconazole 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) NAFTIN (1 % GEL, 2 % NAFTIN CREAM, 2 % GEL) TIER 4 naftifine hcl NATACYN 5 % NATACYN SUSPENSION TIER 3 natamycin NIZORAL 2 % SHAMPOO NIZORAL TIER 4 GA ketoconazole (topical) NOXAFIL (40 MG/ML SUSPENSION, 100 MG NOXAFIL TIER 4 TAB DR) posaconazole nyamyc 100000 unit/gm nyamyc TIER 1 powder nyata 100000 unit/gm nyata TIER 1 powder nystatin (100000 unit/gm cream, 100000 unit/gm ointment, 100000 unit/gm nystatin TIER 1 powder, 100000 unit/ml suspension, 500000 unit tab) nystatin-triamcinolone nystatin-triamcinolone TIER 1 (cream, ointment) nystop 100000 unit/gm nystop TIER 1 powder ONMEL 200 MG TAB ONMEL TIER 4 PA itraconazole

©2021 Wellmark, Inc. 52 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ORAVIG 50 MG TAB ORAVIG TIER 4 miconazole (mouth-throat) PENLAC 8 % SOLUTION PENLAC TIER 4 GA ciclopirox posaconazole 100 mg tab posaconazole TIER 1 dr SPORANOX (10 MG/ML SPORANOX SOLUTION, 100 MG CAP) TIER 4 PA, GA itraconazole SPORANOX PULSEPAK SPORANOX 100 MG CAP TIER 4 PA, GA PULSEPAK itraconazole sulconazole nitrate (1 % sulconazole nitrate TIER 1 cream, 1 % solution) TERAZOL 7 0.4 % CREAM TERAZOL 7 TIER 4 GA terconazole vaginal terbinafine hcl terbinafine hcl 250 mg tab TIER 1 terconazole (0.4 % cream, terconazole 0.8 % cream, 80 mg TIER 1 suppos) VFEND (40 MG/ML RECON SUSP, 50 MG VFEND TIER 4 GA TAB, 200 MG TAB) voriconazole 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 VUSION 0.25-15-81.35 % OINTMENT VUSION TIER 4 GA miconazole-zinc oxide- white petrolatum

ANTIGOUT AGENTS

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

©2021 Wellmark, Inc. 53 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS COLCRYS 0.6 MG TAB COLCRYS TIER 4 GA colchicine febuxostat (40 mg tab, 80 febuxostat TIER 1 mg tab) MITIGARE 0.6 MG CAP MITIGARE TIER 4 GA colchicine probenecid probenecid 500 mg tab TIER 1 ULORIC (40 MG TAB, 80 ULORIC MG TAB) TIER 4 GA febuxostat ZURAMPIC 200 MG TAB ZURAMPIC TIER 4 lesinurad ZYLOPRIM (100 MG TAB, ZYLOPRIM 300 MG TAB) TIER 4 GA allopurinol

ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS

CAFERGOT 1-100 MG CAFERGOT TAB TIER 4 GA ergotamine w/ caffeine D.H.E. 45 1 MG/ML SOLUTION D.H.E. 45 TIER 4 GA dihydroergotamine mesylate dihydroergotamine dihydroergotamine TIER 1 mesylate mesylate 1 mg/ml solution ERGOMAR 2 MG SL TAB ERGOMAR TIER 4 ergotamine tartrate 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) ALSUMA 6 MG/0.5ML PA, QL (12 PER 30 DAYS), ALSUMA SOLN A-INJ TIER 4 GA sumatriptan succinate AMERGE (1 MG TAB, 2.5 AMERGE MG TAB) TIER 4 QL (12 PER 30 DAYS), GA naratriptan hcl

©2021 Wellmark, Inc. 54 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS AXERT (6.25 MG TAB, AXERT 12.5 MG TAB) TIER 4 QL (12 PER 30 DAYS), GA almotriptan malate eletriptan eletriptan hydrobromide (20 TIER 1 PA, QL (12 PER 30 DAYS) hydrobromide mg tab, 40 mg tab) FROVA 2.5 MG TAB PA, QL (18 PER 30 DAYS), FROVA TIER 4 frovatriptan succinate GA frovatriptan succinate 2.5 frovatriptan succinate TIER 1 PA, QL (18 PER 30 DAYS) mg tab IMITREX (20 MG/ACT SOLUTION, 25 MG TAB, IMITREX TIER 4 QL (12 PER 30 DAYS), GA 50 MG TAB, 100 MG TAB) sumatriptan succinate IMITREX 5 MG/ACT IMITREX SOLUTION TIER 4 QL (24 PER 30 DAYS), GA sumatriptan IMITREX 6 MG/0.5ML PA, QL (12 PER 30 DAYS), IMITREX SOLUTION TIER 4 GA sumatriptan succinate IMITREX STATDOSE IMITREX STATDOSE REFILL 4 MG/0.5ML SOLN PA, QL (18 PER 30 DAYS), TIER 4 REFILL CART GA sumatriptan succinate IMITREX STATDOSE IMITREX STATDOSE REFILL 6 MG/0.5ML SOLN PA, QL (12 PER 30 DAYS), TIER 4 REFILL CART GA sumatriptan succinate IMITREX STATDOSE IMITREX STATDOSE SYSTEM 4 MG/0.5ML PA, QL (18 PER 30 DAYS), TIER 4 SYSTEM SOLN A-INJ GA sumatriptan succinate IMITREX STATDOSE IMITREX STATDOSE SYSTEM 6 MG/0.5ML PA, QL (12 PER 30 DAYS), TIER 4 SYSTEM SOLN A-INJ GA sumatriptan succinate MAXALT (5 MG TAB, 10 MAXALT MG TAB) TIER 4 QL (18 PER 30 DAYS), GA rizatriptan benzoate MAXALT-MLT (5 MG TAB MAXALT-MLT DISP, 10 MG TAB DISP) TIER 4 QL (18 PER 30 DAYS), GA rizatriptan benzoate naratriptan hcl (1 mg tab, naratriptan hcl TIER 1 QL (12 PER 30 DAYS) 2.5 mg tab) RELPAX (20 MG TAB, 40 PA, QL (12 PER 30 DAYS), RELPAX MG TAB) TIER 4 GA eletriptan hydrobromide

©2021 Wellmark, Inc. 55 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS REYVOW 100 MG TAB PA, QL (4 PER 30 DAY(S)), REYVOW TIER 3 lasmiditan succinate PA-QL (8/30 days) REYVOW 50 MG TAB REYVOW TIER 3 PA, QL (4 PER 30 DAY(S)) lasmiditan succinate rizatriptan benzoate (5 mg rizatriptan benzoate tab, 5 mg tab disp, 10 mg TIER 1 QL (18 PER 30 DAYS) tab, 10 mg tab disp) 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 (25 sumatriptan succinate mg tab, 50 mg tab, 100 mg TIER 1 QL (12 PER 30 DAYS) tab) sumatriptan succinate (6 sumatriptan succinate soln a-inj, 6 soln prsyr, 6 TIER 1 PA, QL (12 PER 30 DAYS) 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 SUMAVEL DOSEPRO 4 SUMAVEL MG/0.5ML SOLN J-INJ TIER 4 PA, QL (18 PER 30 DAYS) DOSEPRO sumatriptan succinate SUMAVEL DOSEPRO 6 SUMAVEL MG/0.5ML SOLN J-INJ TIER 4 PA, QL (12 PER 30 DAYS) DOSEPRO sumatriptan succinate TREXIMET (10-60 MG TAB, 85-500 MG TAB) PA, QL (9 PER 30 DAYS), TREXIMET TIER 4 sumatriptan-naproxen GA sodium zolmitriptan (2.5 mg zolmitriptan TIER 1 PA, QL (12 PER 30 DAYS) solution, 5 mg solution) zolmitriptan (2.5 mg tab, 2.5 zolmitriptan mg tab disp, 5 mg tab, 5 mg TIER 1 QL (12 PER 30 DAYS) tab disp) ZOMIG (2.5 MG SOLUTION, 5 MG PA, QL (12 PER 30 DAYS), ZOMIG TIER 4 SOLUTION) GA zolmitriptan

©2021 Wellmark, Inc. 56 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZOMIG (2.5 MG TAB, 5 MG ZOMIG TAB) TIER 4 QL (12 PER 30 DAYS), GA zolmitriptan ZOMIG ZMT (2.5 MG TAB ZOMIG ZMT DISP, 5 MG TAB DISP) TIER 4 QL (12 PER 30 DAYS), GA zolmitriptan

ANTIMIGRAINE AGENTS, OTHER

AIMOVIG (140 MG DOSE) AIMOVIG (140 MG 70 MG/ML SOLN A-INJ SP-P PA, QL (1 PER 30 DAY(S)) DOSE) erenumab-aooe AIMOVIG (70 MG/ML SOLN A-INJ, 140 MG/ML AIMOVIG SP-P PA, QL (1 PER 30 DAY(S)) SOLN A-INJ) erenumab-aooe AJOVY 225 MG/1.5ML AJOVY SOLN PRSYR SP-P PA, QL (3 PER 90 DAY(S)) fremanezumab-vfrm EMGALITY (120 MG/ML SOLN A-INJ, 120 MG/ML EMGALITY SP-P PA, QL (1 PER 28 DAY(S)) SOLN PRSYR) galcanezumab-gnlm EMGALITY (300 MG EMGALITY (300 MG DOSE) 100 MG/ML SOLN SP-P PA, QL (1 PER 28 DAY(S)) DOSE) PRSYR galcanezumab-gnlm NURTEC 75 MG TAB DISP PA, QL (8 PER 30 DAY(S)), NURTEC TIER 3 rimegepant sulfate PA-QL (15/30 days) QL (8 PER 30 DAY(S)), MN- UBRELVY (50 MG TAB, PA (Medically Necessary UBRELVY 100 MG TAB) TIER 4 Prior Authorization), PA-QL ubrogepant (16/30 days)

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

©2021 Wellmark, Inc. 57 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MESTINON (60 MG TAB, 60 MG/5ML SOLUTION, MESTINON TIER 4 GA 180 MG TAB ER) pyridostigmine bromide 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) MYCOBUTIN 150 MG CAP MYCOBUTIN TIER 4 GA rifabutin 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 MYAMBUTOL (100 MG MYAMBUTOL TAB, 400 MG TAB) TIER 4 GA ethambutol hcl PASER 4 GM PACKET PASER TIER 1 aminosalicylic acid PRETOMANID 200 MG PRETOMANID TAB TIER 4 QL (30 PER 30 DAY(S)) pretomanid PRIFTIN 150 MG TAB PRIFTIN TIER 3 rifapentine pyrazinamide pyrazinamide 500 mg tab TIER 1 RIFADIN (150 MG CAP, RIFADIN 300 MG CAP) TIER 4 GA rifampin rifampin (150 mg cap, 300 rifampin TIER 1 mg cap)

©2021 Wellmark, Inc. 58 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RIFATER 50-120-300 MG TAB RIFATER TIER 4 isoniazid-rifampin w/ pyrazinamide SIRTURO 100 MG TAB SIRTURO TIER 4 bedaquiline fumarate TRECATOR 250 MG TAB TRECATOR TIER 3 ethionamide

ANTINEOPLASTICS

ALKYLATING AGENTS

ALKERAN 2 MG TAB ALKERAN TIER 4 GA melphalan 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, SBG (Specialty Biosimilars temozolomide SP-P 140 mg cap, 180 mg cap, and Specialty generics) 250 mg cap) VALCHLOR 0.016 % GEL VALCHLOR mechlorethamine hcl SP-P (topical)

ANTIANDROGENS

abiraterone acetate (250 SBG (Specialty Biosimilars abiraterone acetate SP-P mg tab, 500 mg tab) and Specialty generics) bicalutamide bicalutamide 50 mg tab TIER 1 CASODEX 50 MG TAB CASODEX TIER 4 GA bicalutamide ERLEADA 60 MG TAB ERLEADA SP-P apalutamide flutamide flutamide 125 mg cap TIER 1 NILANDRON 150 MG TAB NILANDRON TIER 4 GA nilutamide nilutamide nilutamide 150 mg tab TIER 1 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-NP GA 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 FARESTON 60 MG TAB FARESTON TIER 4 GA toremifene citrate

©2021 Wellmark, Inc. 60 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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, SBG (Specialty Biosimilars capecitabine SP-P 500 mg tab) and Specialty generics) DROXIA (200 MG CAP, 300 MG CAP, 400 MG DROXIA CAP) TIER 3 hydroxyurea (sickle cell anemia) EFUDEX 5 % CREAM EFUDEX TIER 4 GA fluorouracil (topical) FLUOROURACIL (2 % SOLUTION, 5 % CREAM, 5 FLUOROURACIL TIER 1 % SOLUTION) fluorouracil (topical) HYDREA 500 MG CAP HYDREA TIER 4 GA hydroxyurea hydroxyurea hydroxyurea 500 mg cap TIER 1 mercaptopurine mercaptopurine 50 mg tab TIER 1 PURIXAN 2000 MG/100ML PURIXAN SUSPENSION TIER 4 PA mercaptopurine 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 (25 MG TAB, 50 MG TAB, 100 MG TAB, 200 AYVAKIT SP-P MG TAB, 300 MG TAB) avapritinib

©2021 Wellmark, Inc. 61 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BALVERSA (3 MG TAB, 4 BALVERSA MG TAB, 5 MG TAB) SP-P erdafitinib BRUKINSA 80 MG CAP BRUKINSA SP-P zanubrutinib HEMANGEOL 4.28 MG/ML HEMANGEOL SOLUTION TIER 4 propranolol hcl IDHIFA (50 MG TAB, 100 IDHIFA MG TAB) SP-P enasidenib mesylate INQOVI 35-100 MG TAB INQOVI SP-NP QL (5 PER 28 DAY(S)) decitabine-cedazuridine 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 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

©2021 Wellmark, Inc. 62 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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)) 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 WEEKLY) (MG 20 MG TAB XPOVIO (100 MG THPK, MG 50 MG TAB SP-P ONCE WEEKLY) THPK) selinexor XPOVIO (40 MG ONCE WEEKLY) (MG 20 MG TAB XPOVIO (40 MG THPK, MG 40 MG TAB SP-P ONCE WEEKLY) THPK) selinexor

©2021 Wellmark, Inc. 63 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XPOVIO (40 MG TWICE WEEKLY) (MG 20 MG TAB XPOVIO (40 MG THPK, MG 40 MG TAB SP-P TWICE WEEKLY) THPK) selinexor XPOVIO (60 MG ONCE WEEKLY) (MG 20 MG TAB XPOVIO (60 MG THPK, MG 60 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 WEEKLY) (MG 20 MG TAB XPOVIO (80 MG THPK, MG 40 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 ARIMIDEX 1 MG TAB ARIMIDEX TIER 4 PA, GA anastrozole AROMASIN 25 MG TAB AROMASIN TIER 4 PA, GA exemestane exemestane exemestane 25 mg tab TIER 1 PA, PV FEMARA 2.5 MG TAB FEMARA TIER 4 GA letrozole letrozole letrozole 2.5 mg tab TIER 1 PV

ENZYME INHIBITORS

SBG (Specialty Biosimilars etoposide etoposide 50 mg cap SP-P and Specialty generics) GAVRETO 100 MG CAP GAVRETO SP-P pralsetinib

©2021 Wellmark, Inc. 64 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 (200 MG DAILY PIQRAY (200 MG DOSE) 200 MG TAB THPK SP-P DAILY DOSE) alpelisib PIQRAY (250 MG DAILY PIQRAY (250 MG DOSE) 200 & 50 MG TAB SP-P DAILY DOSE) THPK alpelisib PIQRAY (300 MG DAILY PIQRAY (300 MG DOSE) 2 X 150 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 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

©2021 Wellmark, Inc. 65 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 SBG (Specialty Biosimilars erlotinib hcl SP-P mg tab, 150 mg tab) and Specialty generics) QL (60 PER 30 DAYS), SBG everolimus (2.5 mg tab, 7.5 everolimus SP-P (Specialty Biosimilars and mg tab) Specialty generics) QL (120 PER 30 DAYS), everolimus everolimus 5 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) 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 IBRANCE (75 MG CAP, 75 MG TAB, 100 MG CAP, IBRANCE 100 MG TAB, 125 MG SP-P CAP, 125 MG TAB) palbociclib

©2021 Wellmark, Inc. 66 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ICLUSIG (10 MG TAB, 15 MG TAB, 30 MG TAB, 45 ICLUSIG SP-P MG TAB) ponatinib hcl imatinib mesylate (100 mg SBG (Specialty Biosimilars imatinib mesylate SP-P tab, 400 mg tab) and Specialty generics) 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 KANJINTI (150 MG RECON SOLN, 420 MG KANJINTI SP-M RECON SOLN) trastuzumab-anns KISQALI (200 MG DOSE) KISQALI (200 MG 200 MG TAB THPK SP-P DOSE) ribociclib succinate KISQALI (400 MG DOSE) KISQALI (400 MG 200 MG TAB THPK SP-P DOSE) ribociclib succinate KISQALI (600 MG DOSE) KISQALI (600 MG 200 MG TAB THPK SP-P DOSE) ribociclib succinate KISQALI FEMARA (400 MG DOSE) 200 & 2.5 MG KISQALI FEMARA TAB THPK SP-P (400 MG DOSE) ribociclib succinate- letrozole KISQALI FEMARA (600 MG DOSE) 200 & 2.5 MG KISQALI FEMARA TAB THPK SP-P (600 MG DOSE) ribociclib succinate- letrozole

©2021 Wellmark, Inc. 67 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KISQALI FEMARA(200 MG KISQALI DOSE) 200 & 2.5 MG TAB FEMARA(200 MG THPK SP-P DOSE) ribociclib succinate- letrozole KOSELUGO (10 MG CAP, KOSELUGO 25 MG CAP) SP-P PA, QL (4 PER DAY(S)) selumetinib sulfate QL (180 PER 30 DAYS), lapatinib ditosylate 250 mg lapatinib ditosylate SP-P SBG (Specialty Biosimilars tab and Specialty generics) 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) 3 X 4 MG CAP SP-P DAILY DOSE) THPK 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 MG & 2 X 4 MG SP-P DAILY DOSE) CAP THPK lenvatinib mesylate LENVIMA (20 MG DAILY LENVIMA (20 MG DOSE) 2 X 10 MG CAP SP-P DAILY DOSE) THPK lenvatinib mesylate LENVIMA (24 MG DAILY LENVIMA (24 MG DOSE) 2 X 10 MG & 4 MG SP-P DAILY DOSE) CAP 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) 2 X 4 MG CAP SP-P DAILY DOSE) THPK lenvatinib mesylate LYNPARZA (50 MG CAP, 100 MG TAB, 150 MG LYNPARZA SP-P TAB) olaparib

©2021 Wellmark, Inc. 68 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MEKINIST (0.5 MG TAB, 2 MG TAB) MEKINIST SP-P trametinib dimethyl sulfoxide 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 OGIVRI (150 MG RECON SOLN, 420 MG RECON OGIVRI SP-M SOLN) trastuzumab-dkst 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 sunitinib malate (12.5 mg SBG (Specialty Biosimilars sunitinib malate cap, 25 mg cap, 37.5 mg SP-P and Specialty generics) cap, 50 mg cap) SUTENT (25 MG CAP, SUTENT 37.5 MG CAP, 50 MG CAP) SP-NP GA sunitinib malate SUTENT 12.5 MG CAP SBG (Specialty Biosimilars SUTENT SP-NP sunitinib malate and Specialty generics), GA 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

©2021 Wellmark, Inc. 69 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TRAZIMERA (150 MG RECON SOLN, 420 MG TRAZIMERA SP-M RECON SOLN) trastuzumab-qyyp 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 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

AVASTIN (100 MG/4ML SOLUTION, 400 MG/16ML MN-PA (Medically Necessary AVASTIN SP-M SOLUTION) Prior Authorization) bevacizumab 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

©2021 Wellmark, Inc. 70 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HERCEPTIN (150 MG RECON SOLN, 440 MG MN-PA (Medically Necessary HERCEPTIN SP-M RECON SOLN) Prior Authorization) trastuzumab HERZUMA (150 MG RECON SOLN, 420 MG HERZUMA SP-M RECON SOLN) trastuzumab-pkrb 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 RIABNI (100 MG/10ML SOLUTION, 500 MG/50ML RIABNI SP-M PA SOLUTION) rituximab-arrx

RETINOIDS

SBG (Specialty Biosimilars bexarotene bexarotene 75 mg cap SP-P and Specialty generics) 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 ALBENZA 200 MG TAB ALBENZA TIER 4 GA albendazole BILTRICIDE 600 MG TAB BILTRICIDE TIER 4 GA praziquantel ivermectin (0.5 % lotion, 3 ivermectin TIER 1 mg tab)

©2021 Wellmark, Inc. 71 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS praziquantel praziquantel 600 mg tab TIER 1 SKLICE 0.5 % LOTION SKLICE TIER 4 ivermectin (pediculicide) STROMECTOL 3 MG TAB STROMECTOL TIER 4 GA ivermectin

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 4 nitazoxanide QL (QL varies), GA 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) COARTEM 20-120 MG COARTEM TAB TIER 4 artemether-lumefantrine 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 MALARONE (62.5-25 MG MALARONE TAB, 250-100 MG TAB) TIER 4 GA atovaquone-proguanil hcl mefloquine hcl mefloquine hcl 250 mg tab TIER 1 PV MEPRON 750 MG/5ML MEPRON SUSPENSION TIER 4 GA atovaquone NEBUPENT 300 MG NEBUPENT RECON SOLN TIER 4 GA pentamidine isethionate QL (20 PER 10 DAY(S)), PA- nitazoxanide nitazoxanide 500 mg tab TIER 1 QL (QL varies) pentamidine pentamidine isethionate TIER 1 isethionate 300 mg recon soln PLAQUENIL 200 MG TAB PLAQUENIL TIER 4 GA hydroxychloroquine sulfate

©2021 Wellmark, Inc. 72 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS primaquine primaquine phosphate 26.3 TIER 1 PV phosphate (15 base) mg tab pyrimethamine pyrimethamine 25 mg tab TIER 1 QUALAQUIN 324 MG CAP QUALAQUIN TIER 4 GA quinine sulfate quinine sulfate quinine sulfate 324 mg cap TIER 1

PEDICULICIDES/SCABICIDES

acticin acticin 5 % cream TIER 1 CROTAN 10 % LOTION CROTAN TIER 1 crotamiton ELIMITE 5 % CREAM ELIMITE TIER 4 GA permethrin EURAX 10 % CREAM EURAX TIER 3 crotamiton EURAX 10 % LOTION EURAX TIER 4 crotamiton LINDANE 1 % SHAMPOO LINDANE TIER 1 lindane malathion malathion 0.5 % lotion TIER 1 NATROBA 0.9 % NATROBA SUSPENSION TIER 4 spinosad OVIDE 0.5 % LOTION OVIDE TIER 4 GA malathion permethrin permethrin 5 % cream TIER 1 SPINOSAD 0.9 % SPINOSAD SUSPENSION TIER 4 spinosad 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)

©2021 Wellmark, Inc. 73 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) COMTAN 200 MG TAB COMTAN TIER 4 GA entacapone 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 25 MG CAP ONGENTYS TIER 3 PA, QL (1 PER 1 DAY(S)) opicapone ONGENTYS 50 MG CAP ONGENTYS TIER 3 PA, QL (30 PER 30 DAY(S)) opicapone STALEVO 100 25-100-200 MG TAB STALEVO 100 TIER 4 GA carbidopa-levodopa- entacapone STALEVO 125 31.25-125- 200 MG TAB STALEVO 125 TIER 4 GA carbidopa-levodopa- entacapone STALEVO 150 37.5-150- 200 MG TAB STALEVO 150 TIER 4 GA carbidopa-levodopa- entacapone STALEVO 200 50-200-200 MG TAB STALEVO 200 TIER 4 GA carbidopa-levodopa- entacapone STALEVO 50 12.5-50-200 MG TAB STALEVO 50 TIER 4 GA carbidopa-levodopa- entacapone STALEVO 75 18.75-75-200 MG TAB STALEVO 75 TIER 4 GA carbidopa-levodopa- entacapone TASMAR 100 MG TAB TASMAR TIER 4 PA, GA tolcapone 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) KYNMOBI (10 MG FILM, 15 MG FILM, 20 MG FILM, KYNMOBI SP-NP PA, QL (5 PER DAY(S)) 25 MG FILM, 30 MG FILM) apomorphine hydrochloride KYNMOBI TITRATION KIT KYNMOBI 10/15/20/25/30 MG KIT SP-NP PA, QL (1 PER RX) TITRATION KIT apomorphine hydrochloride MIRAPEX (0.125 MG TAB, 0.25 MG TAB, 0.5 MG TAB, 0.75 MG TAB, 1 MG TAB, MIRAPEX TIER 4 GA 1.5 MG TAB) pramipexole dihydrochloride MIRAPEX ER (ER 0.375 MG TAB ER 24H, ER 0.75 MG TAB ER 24H, ER 1.5 MG TAB ER 24H, ER 2.25 MG TAB ER 24H, ER 3 MG MIRAPEX ER TIER 4 PA, GA TAB ER 24H, ER 3.75 MG TAB ER 24H, ER 4.5 MG TAB ER 24H) pramipexole dihydrochloride NEUPRO (1 MG/24HR PATCH 24HR, 2 MG/24HR PATCH 24HR, 3 MG/24HR PATCH 24HR, 4 MG/24HR NEUPRO TIER 4 PA PATCH 24HR, 6 MG/24HR PATCH 24HR, 8 MG/24HR PATCH 24HR) rotigotine PARLODEL (2.5 MG TAB, PARLODEL 5 MG CAP) TIER 4 GA bromocriptine mesylate 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)

©2021 Wellmark, Inc. 75 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) REQUIP (0.25 MG TAB, 0.5 MG TAB, 1 MG TAB, 2 REQUIP MG TAB, 3 MG TAB, 4 MG TIER 4 GA TAB, 5 MG TAB) ropinirole hydrochloride REQUIP XL (2 MG TAB ER 24H, 4 MG TAB ER 24H, 6 MG TAB ER 24H, 8 MG REQUIP XL TIER 4 PA, GA TAB ER 24H, 12 MG TAB ER 24H) ropinirole hydrochloride 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, 25-100 carbidopa-levodopa TIER 2 mg tab disp, 25-250 mg tab disp) carbidopa-levodopa (10- carbidopa-levodopa 100 mg tab, 25-100 mg tab, TIER 1 25-250 mg tab) carbidopa-levodopa er (er carbidopa-levodopa 25-100 mg tab er, er 50- TIER 1 er 200 mg tab er) LODOSYN 25 MG TAB LODOSYN TIER 4 GA carbidopa SINEMET (10-100 MG TAB, 25-100 MG TAB, 25- SINEMET TIER 4 GA 250 MG TAB) carbidopa-levodopa

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

AZILECT (0.5 MG TAB, 1 AZILECT MG TAB) TIER 4 GA rasagiline mesylate ELDEPRYL 5 MG CAP ELDEPRYL TIER 4 GA selegiline hcl rasagiline mesylate (0.5 mg rasagiline mesylate TIER 1 tab, 1 mg tab) selegiline hcl (5 mg cap, 5 selegiline hcl TIER 1 mg tab) XADAGO (50 MG TAB, 100 XADAGO MG TAB) TIER 4 PA safinamide mesylate ZELAPAR 1.25 MG TAB ZELAPAR DISP TIER 4 PA selegiline hcl

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) FLUPHENAZINE HCL (1 MG TAB, 2.5 MG TAB, 2.5 FLUPHENAZINE MG/5ML ELIXIR, 5 MG TIER 1 PV HCL TAB, 5 MG/ML CONC, 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) ORAP (1 MG TAB, 2 MG ORAP TAB) TIER 4 pimozide

©2021 Wellmark, Inc. 77 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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

ABILIFY (2 MG TAB, 5 MG TAB, 10 MG TAB, 15 MG ABILIFY TAB, 20 MG TAB, 30 MG TIER 4 GA TAB) aripiprazole aripiprazole (2 mg tab, 5 mg tab, 10 mg tab, 10 mg aripiprazole tab disp, 15 mg tab, 15 mg TIER 1 PV tab disp, 20 mg tab, 30 mg tab) aripiprazole 1 mg/ml PA, QL (900 PER 30 aripiprazole TIER 1 solution DAY(S)), PV asenapine maleate (2.5 mg asenapine maleate sl tab, 5 mg sl tab, 10 mg sl TIER 1 tab) CAPLYTA 42 MG CAP CAPLYTA TIER 4 PA, QL (30 PER 30 DAY(S)) lumateperone tosylate FANAPT (1 MG TAB, 2 MG TAB, 4 MG TAB, 6 MG FANAPT TAB, 8 MG TAB, 10 MG TIER 4 QL (60 PER 30 DAYS) TAB, 12 MG TAB) iloperidone GEODON (20 MG CAP, 40 MG CAP, 60 MG CAP, 80 GEODON TIER 4 GA MG CAP) ziprasidone hcl INVEGA (1.5 MG TAB ER 24H, 3 MG TAB ER 24H, 6 INVEGA MG TAB ER 24H, 9 MG TIER 4 GA TAB ER 24H) paliperidone

©2021 Wellmark, Inc. 78 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LATUDA (20 MG TAB, 40 MG TAB, 60 MG TAB, 80 LATUDA TIER 3 MG TAB, 120 MG TAB) lurasidone hcl NUPLAZID (10 MG TAB, NUPLAZID 17 MG TAB, 34 MG CAP) TIER 4 pimavanserin tartrate 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, 15 mg tab disp, 20 mg tab, 20 mg tab disp) 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) 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) REXULTI (0.25 MG TAB, 0.5 MG TAB, 1 MG TAB, 2 REXULTI MG TAB, 3 MG TAB, 4 MG TIER 4 PA, QL (30 PER 30 DAYS) TAB) brexpiprazole RISPERDAL (0.25 MG TAB, 0.5 MG TAB, 1 MG RISPERDAL TAB, 2 MG TAB, 3 MG TIER 4 GA TAB, 4 MG TAB) risperidone RISPERDAL 1 MG/ML PA, QL (480 PER 30 RISPERDAL SOLUTION TIER 4 DAY(S)), GA risperidone RISPERDAL M-TAB (0.5 MG TAB DISP, 1 MG TAB DISP, 2 MG TAB DISP, 3 RISPERDAL M-TAB TIER 4 PA, GA MG TAB DISP, 4 MG TAB DISP) risperidone

©2021 Wellmark, Inc. 79 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS risperidone (0.25 mg tab disp, 0.5 mg tab disp, 1 mg risperidone TIER 1 PA, PV tab disp, 2 mg tab disp, 3 mg tab disp, 4 mg tab disp) risperidone (0.25 mg tab, risperidone 0.5 mg tab, 1 mg tab, 2 mg TIER 1 PV tab, 3 mg tab, 4 mg tab) risperidone 1 mg/ml PA, QL (480 PER 30 risperidone TIER 1 solution DAY(S)), PV risperidone m-tab (0.5 mg tab disp, 1 mg tab disp, 2 risperidone m-tab TIER 1 PA, PV mg tab disp, 3 mg tab disp, 4 mg tab disp) SAPHRIS (2.5 MG SL TAB, 5 MG SL TAB, 10 MG SL SAPHRIS TIER 4 GA TAB) asenapine maleate SEROQUEL (25 MG TAB, 50 MG TAB, 100 MG TAB, SEROQUEL 200 MG TAB, 300 MG TAB, TIER 4 GA 400 MG TAB) quetiapine fumarate SEROQUEL XR (50 MG TAB ER 24H, 150 MG TAB ER 24H, 200 MG TAB ER SEROQUEL XR TIER 4 PV, GA 24H, 300 MG TAB ER 24H, 400 MG TAB ER 24H) quetiapine fumarate VRAYLAR (1.5 & 3 MG CAP THPK, 1.5 MG CAP, 3 VRAYLAR MG CAP, 4.5 MG CAP, 6 TIER 4 PA, QL (30 PER 30 DAYS) MG CAP) cariprazine hcl ziprasidone hcl (20 mg cap, ziprasidone hcl 40 mg cap, 60 mg cap, 80 TIER 1 PV mg cap) ZYPREXA (2.5 MG TAB, 5 MG TAB, 7.5 MG TAB, 10 ZYPREXA MG TAB, 15 MG TAB, 20 TIER 4 GA MG TAB) olanzapine ZYPREXA ZYDIS (5 MG TAB DISP, 10 MG TAB ZYPREXA ZYDIS DISP, 15 MG TAB DISP, 20 TIER 4 GA MG TAB DISP) olanzapine

TREATMENT-RESISTANT

clozapine (12.5 mg tab disp, 25 mg tab, 25 mg tab clozapine disp, 50 mg tab, 100 mg TIER 1 PV tab, 100 mg tab disp, 200 mg tab, 200 mg tab disp) CLOZAPINE 200 MG TAB CLOZAPINE DISP TIER 1 PV, GA clozapine CLOZARIL (25 MG TAB, 50 MG TAB, 100 MG TAB, 200 CLOZARIL TIER 4 GA MG TAB) clozapine FAZACLO (12.5 MG TAB DISP, 25 MG TAB DISP, FAZACLO 100 MG TAB DISP, 200 TIER 4 GA MG TAB DISP) clozapine VERSACLOZ 50 MG/ML VERSACLOZ SUSPENSION TIER 4 clozapine

ANTISPASTICITY AGENTS

baclofen (10 mg tab, 20 mg baclofen TIER 1 tab) BOTOX (100 RECON BOTOX SOLN, 200 RECON SOLN) SP-M PA, QL (400 PER DAY(S)) onabotulinumtoxina DANTRIUM (25 MG CAP, DANTRIUM 50 MG CAP) TIER 4 GA dantrolene sodium 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) ZANAFLEX 4 MG TAB ZANAFLEX TIER 4 GA tizanidine hcl

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

JULUCA 50-25 MG TAB JULUCA dolutegravir sodium- TIER 2 rilpivirine hcl

©2021 Wellmark, Inc. 81 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PREVYMIS (240 MG TAB, PREVYMIS 480 MG TAB) TIER 4 letermovir VALCYTE (50 MG/ML RECON SOLN, 450 MG VALCYTE TIER 4 GA TAB) valganciclovir hcl valganciclovir hcl (50 mg/ml valganciclovir hcl TIER 1 recon soln, 450 mg tab) ZIRGAN 0.15 % GEL ZIRGAN TIER 4 ganciclovir ophthalmic

ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil adefovir dipivoxil 10 mg tab TIER 1 BARACLUDE (0.5 MG BARACLUDE TAB, 1 MG TAB) TIER 4 GA entecavir BARACLUDE 0.05 MG/ML PA, QL (630 PER 30 BARACLUDE SOLUTION TIER 4 DAY(S)) entecavir entecavir (0.5 mg tab, 1 mg entecavir TIER 1 tab) EPIVIR HBV 100 MG TAB EPIVIR HBV TIER 4 GA lamivudine (hbv) EPIVIR HBV 5 MG/ML EPIVIR HBV SOLUTION TIER 3 lamivudine (hbv) HEPSERA 10 MG TAB HEPSERA TIER 4 GA adefovir dipivoxil lamivudine lamivudine 100 mg tab TIER 1 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 200-50 MG TAB EPCLUSA SP-P PA, QL (28 PER 28 DAY(S)) sofosbuvir-velpatasvir EPCLUSA 400-100 MG EPCLUSA TAB SP-P PA, QL (28 PER 28 DAYS) sofosbuvir-velpatasvir

©2021 Wellmark, Inc. 82 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HARVONI (33.75-150 MG PACKET, 45-200 MG HARVONI SP-P PA, QL (28 PER 28 DAY(S)) PACKET, 45-200 MG TAB) 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) 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

COPEGUS 200 MG TAB COPEGUS TIER 4 GA ribavirin (hepatitis c) moderiba moderiba 200 mg tab TIER 1 PEG-INTRON REDIPEN PEG-INTRON 120 MCG/0.5ML KIT SP-P REDIPEN 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 PEGINTRON 50 PEGINTRON MCG/0.5ML KIT SP-P peginterferon alfa-2b REBETOL (40 MG/ML REBETOL SOLUTION, 200 MG CAP) TIER 4 ribavirin (hepatitis c) ribasphere (200 mg cap, ribasphere TIER 1 200 mg tab) 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

©2021 Wellmark, Inc. 84 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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

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

ATRIPLA 600-200-300 MG TAB ATRIPLA efavirenz-emtricitabine- TIER 4 GA tenofovir disoproxil fumarate 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 etravirine (100 mg tab, 200 etravirine TIER 1 mg tab) INTELENCE (100 MG TAB, INTELENCE 200 MG TAB) TIER 4 GA etravirine INTELENCE 25 MG TAB INTELENCE TIER 2 etravirine

©2021 Wellmark, Inc. 85 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 SUSTIVA (50 MG CAP, 200 MG CAP, 600 MG SUSTIVA TIER 4 GA TAB) efavirenz VIRAMUNE (50 MG/5ML SUSPENSION, 200 MG VIRAMUNE TIER 4 GA TAB) nevirapine VIRAMUNE XR (100 MG TAB ER 24H, 400 MG TAB VIRAMUNE XR TIER 4 GA ER 24H) nevirapine

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 CIMDUO 300-300 MG TAB CIMDUO lamivudine-tenofovir TIER 2 disoproxil fumarate COMBIVIR 150-300 MG COMBIVIR TAB TIER 4 GA lamivudine-zidovudine didanosine (200 mg cap dr, didanosine 250 mg cap dr, 400 mg cap TIER 1 dr) emtricitabine emtricitabine 200 mg cap TIER 1

©2021 Wellmark, Inc. 86 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS emtricitabine-tenofovir df emtricitabine-tenofovir (100-150 mg tab, 133-200 TIER 1 PV df mg tab, 167-250 mg tab, 200-300 mg tab) EMTRIVA 10 MG/ML EMTRIVA SOLUTION TIER 2 emtricitabine EMTRIVA 200 MG CAP EMTRIVA TIER 4 GA emtricitabine EPIVIR (10 MG/ML SOLUTION, 150 MG TAB, EPIVIR TIER 4 GA 300 MG TAB) lamivudine EPZICOM 600-300 MG EPZICOM TAB TIER 4 GA abacavir sulfate-lamivudine lamivudine (10 mg/ml lamivudine solution, 150 mg tab, 300 TIER 1 mg tab) lamivudine- lamivudine-zidovudine 150- TIER 1 zidovudine 300 mg tab RETROVIR (50 MG/5ML RETROVIR SYRUP, 100 MG CAP) TIER 4 GA zidovudine 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 TRIZIVIR 300-150-300 MG TAB TRIZIVIR TIER 4 GA abacavir sulfate- lamivudine-zidovudine TRUVADA (100-150 MG TAB, 133-200 MG TAB, 167-250 MG TAB, 200-300 TRUVADA TIER 4 GA MG TAB) emtricitabine-tenofovir disoproxil fumarate VIDEX (2 GM RECON SOLN, 4 GM RECON VIDEX TIER 3 SOLN) didanosine

©2021 Wellmark, Inc. 87 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VIDEX EC (EC 125 MG CAP DR, EC 200 MG CAP VIDEX EC DR, EC 250 MG CAP DR, TIER 4 GA EC 400 MG CAP DR) didanosine VIREAD (150 MG TAB, 200 MG TAB, 250 MG TAB) VIREAD TIER 2 tenofovir disoproxil fumarate VIREAD 300 MG TAB VIREAD tenofovir disoproxil TIER 4 GA fumarate VIREAD 40 MG/GM POWDER VIREAD TIER 3 tenofovir disoproxil fumarate ZERIT (1 MG/ML RECON SOLN, 15 MG CAP, 20 MG ZERIT CAP, 30 MG CAP, 40 MG TIER 4 GA CAP) stavudine ZIAGEN (20 MG/ML ZIAGEN SOLUTION, 300 MG TAB) TIER 4 GA abacavir sulfate 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 CABENUVA (400 600 MG/2ML SUSP, 600 900 CABENUVA SP-M MG/3ML SUSP) cabotegravir & rilpivirine 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)

©2021 Wellmark, Inc. 88 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 SYMFI 600-300-300 MG TAB SYMFI efavirenz-lamivudine- TIER 4 GA tenofovir disoproxil fumarate SYMFI LO 400-300-300 MG TAB SYMFI LO efavirenz-lamivudine- TIER 4 GA tenofovir disoproxil fumarate 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) 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

©2021 Wellmark, Inc. 89 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS INVIRASE (200 MG CAP, INVIRASE 500 MG TAB) TIER 2 saquinavir mesylate KALETRA (100-25 MG TAB, 200-50 MG TAB, 400- KALETRA TIER 4 GA 100 MG/5ML SOLUTION) lopinavir-ritonavir LEXIVA 50 MG/ML LEXIVA SUSPENSION TIER 3 fosamprenavir calcium LEXIVA 700 MG TAB LEXIVA TIER 4 GA fosamprenavir calcium lopinavir-ritonavir (100-25 lopinavir-ritonavir mg tab, 200-50 mg tab, TIER 1 400-100 mg/5ml solution) NORVIR (80 MG/ML SOLUTION, 100 MG NORVIR TIER 3 PACKET) ritonavir NORVIR 100 MG CAP NORVIR TIER 2 ritonavir NORVIR 100 MG TAB NORVIR TIER 4 GA 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 (150 MG CAP, 200 MG CAP, 300 MG REYATAZ TIER 4 GA CAP) atazanavir sulfate 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

FLUMADINE 100 MG TAB FLUMADINE TIER 4 rimantadine hydrochloride oseltamivir phosphate (6 oseltamivir phosphate mg/ml recon susp, 30 mg TIER 1 cap, 45 mg cap, 75 mg cap) RELENZA DISKHALER 5 RELENZA MG/BLISTER AER POW TIER 2 DISKHALER BA zanamivir RIMANTADINE HCL 100 RIMANTADINE HCL MG TAB TIER 1 rimantadine hydrochloride TAMIFLU (6 MG/ML RECON SUSP, 30 MG TAMIFLU CAP, 45 MG CAP, 75 MG TIER 4 GA CAP) oseltamivir phosphate

ANTIHERPETIC AGENTS

acyclovir (5 % cream, 5 % ointment, 200 mg cap, 200 acyclovir TIER 1 mg/5ml suspension, 400 mg tab, 800 mg tab) DENAVIR 1 % CREAM DENAVIR TIER 4 penciclovir famciclovir (125 mg tab, famciclovir TIER 1 250 mg tab, 500 mg tab) SITAVIG 50 MG TAB SITAVIG TIER 4 acyclovir trifluridine trifluridine 1 % solution TIER 1 valacyclovir hcl (1 gm tab, valacyclovir hcl TIER 1 500 mg tab) VALTREX (1 GM TAB, 500 VALTREX MG TAB) TIER 4 GA valacyclovir hcl VIROPTIC 1 % SOLUTION VIROPTIC TIER 4 GA trifluridine XERESE 5-1 % CREAM XERESE TIER 4 acyclovir-hydrocortisone

©2021 Wellmark, Inc. 91 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZOVIRAX (5 % CREAM, 5 % OINTMENT, 200 MG CAP, 200 MG/5ML ZOVIRAX TIER 4 GA SUSPENSION, 400 MG TAB, 800 MG TAB) acyclovir

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, 1 mg tab disp, 2 mg tab, 2 mg tab disp) 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) ATIVAN (0.5 MG TAB, 1 ATIVAN MG TAB, 2 MG TAB) TIER 4 GA lorazepam chlordiazepoxide hcl (5 mg chlordiazepoxide hcl TIER 1 cap, 10 mg cap, 25 mg cap) 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)

©2021 Wellmark, Inc. 92 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS diazepam (2 mg tab, 5 mg diazepam tab, 5 mg/5ml solution, 5 TIER 1 mg/ml conc, 10 mg tab) diazepam intensol 5 mg/ml diazepam intensol TIER 1 conc KLONOPIN (0.5 MG TAB, 1 KLONOPIN MG TAB, 2 MG TAB) TIER 4 GA clonazepam 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) TRANXENE-T 7.5 MG TAB TRANXENE-T TIER 4 GA clorazepate dipotassium VALIUM (2 MG TAB, 5 MG VALIUM TAB, 10 MG TAB) TIER 4 GA diazepam XANAX (0.25 MG TAB, 0.5 MG TAB, 1 MG TAB, 2 MG XANAX TIER 4 GA TAB) alprazolam XANAX XR (0.5 MG TAB ER 24H, 1 MG TAB ER XANAX XR 24H, 2 MG TAB ER 24H, 3 TIER 4 GA MG TAB ER 24H) alprazolam

BIPOLAR AGENTS

MOOD STABILIZERS

EQUETRO (100 MG CAP ER 12H, 200 MG CAP ER EQUETRO 12H, 300 MG CAP ER 12H) TIER 4 carbamazepine (antipsychotic) 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) ACTOPLUS MET (15-500 MG TAB, 15-850 MG TAB) ACTOPLUS MET TIER 4 GA pioglitazone hcl-metformin hcl ACTOPLUS MET XR (15- 1000 MG TAB ER 24H, 30- ACTOPLUS MET XR 1000 MG TAB ER 24H) TIER 4 pioglitazone hcl-metformin hcl ACTOS (15 MG TAB, 30 ACTOS MG TAB, 45 MG TAB) TIER 4 GA pioglitazone hcl ADLYXIN 20 MCG/0.2ML MN-PA (Medically Necessary ADLYXIN SOLN PEN TIER 4 Prior Authorization) lixisenatide ADLYXIN STARTER PACK ADLYXIN STARTER 10 & 20 MCG/0.2ML PEN MN-PA (Medically Necessary TIER 4 PACK KIT Prior Authorization) lixisenatide alogliptin benzoate (6.25 alogliptin benzoate mg tab, 12.5 mg tab, 25 mg TIER 1 PV tab) alogliptin-metformin hcl alogliptin-metformin (12.5-1000 mg tab, 12.5- TIER 1 PV hcl 500 mg tab) alogliptin-pioglitazone (12.5-15 mg tab, 12.5-30 alogliptin-pioglitazone mg tab, 12.5-45 mg tab, 25- TIER 1 PV 15 mg tab, 25-30 mg tab, 25-45 mg tab) AMARYL (1 MG TAB, 2 MG AMARYL TAB, 4 MG TAB) TIER 4 GA glimepiride AVANDAMET 2-1000 MG TAB AVANDAMET TIER 2 rosiglitazone maleate- metformin hcl

©2021 Wellmark, Inc. 94 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS AVANDIA (2 MG TAB, 4 AVANDIA MG TAB) TIER 4 rosiglitazone maleate BYDUREON (2 MG PEN, 2 BYDUREON MG SRER) 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 CYCLOSET 0.8 MG TAB CYCLOSET bromocriptine mesylate TIER 4 (diabetes) DUETACT (30-2 MG TAB, DUETACT 30-4 MG TAB) TIER 4 GA pioglitazone hcl-glimepiride FARXIGA (5 MG TAB, 10 FARXIGA MG TAB) TIER 2 PV dapagliflozin propanediol 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) GLUCOPHAGE (500 MG TAB, 850 MG TAB, 1000 GLUCOPHAGE TIER 4 GA MG TAB) metformin hcl

©2021 Wellmark, Inc. 95 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GLUCOPHAGE XR (500 MG TAB ER 24H, 750 MG GLUCOPHAGE XR TIER 4 GA TAB ER 24H) metformin hcl GLUCOTROL (5 MG TAB, GLUCOTROL 10 MG TAB) TIER 4 GA glipizide GLUCOTROL XL (2.5 MG TAB ER 24H, 5 MG TAB GLUCOTROL XL ER 24H, 10 MG TAB ER TIER 4 GA 24H) glipizide GLUCOVANCE (2.5-500 GLUCOVANCE MG TAB, 5-500 MG TAB) TIER 4 GA glyburide-metformin 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) GLYNASE (1.5 MG TAB, 3 GLYNASE MG TAB, 6 MG TAB) TIER 4 GA glyburide micronized GLYSET (25 MG TAB, 50 GLYSET MG TAB, 100 MG TAB) TIER 4 GA miglitol GLYXAMBI (10-5 MG TAB, GLYXAMBI 25-5 MG TAB) TIER 2 PV empagliflozin-linagliptin INVOKAMET (50-1000 MG TAB, 50-500 MG TAB, 150- MN-PA (Medically Necessary INVOKAMET 1000 MG TAB, 150-500 TIER 4 Prior Authorization) MG TAB) canagliflozin-metformin hcl INVOKAMET XR (50-1000 MG TAB ER 24H, 50-500 MG TAB ER 24H, 150-1000 MN-PA (Medically Necessary INVOKAMET XR TIER 4 MG TAB ER 24H, 150-500 Prior Authorization) MG TAB ER 24H) canagliflozin-metformin hcl INVOKANA (100 MG TAB, MN-PA (Medically Necessary INVOKANA 300 MG TAB) TIER 4 Prior Authorization) canagliflozin

©2021 Wellmark, Inc. 96 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS JANUMET (50-1000 MG JANUMET TAB, 50-500 MG TAB) TIER 2 PV sitagliptin-metformin hcl JANUMET XR (50-1000 MG TAB ER 24H, 50-500 JANUMET XR MG TAB ER 24H, 100-1000 TIER 2 PV MG 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 JENTADUETO (2.5-1000 MG TAB, 2.5-500 MG TAB, MN-PA (Medically Necessary JENTADUETO TIER 4 2.5-850 MG TAB) Prior Authorization) linagliptin-metformin hcl JENTADUETO XR (2.5- 1000 MG TAB ER 24H, 5- MN-PA (Medically Necessary JENTADUETO XR TIER 4 1000 MG TAB ER 24H) Prior Authorization) linagliptin-metformin hcl KAZANO (12.5-1000 MG MN-PA (Medically Necessary KAZANO TAB, 12.5-500 MG TAB) TIER 4 Prior Authorization), GA alogliptin-metformin hcl KOMBIGLYZE XR (2.5- 1000 MG TAB ER 24H, 5- MN-PA (Medically Necessary KOMBIGLYZE XR 1000 MG TAB ER 24H, 5- TIER 4 Prior Authorization) 500 MG TAB ER 24H) saxagliptin-metformin hcl 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) NESINA (6.25 MG TAB, MN-PA (Medically Necessary NESINA 12.5 MG TAB, 25 MG TAB) TIER 4 Prior Authorization), GA alogliptin benzoate ONGLYZA (2.5 MG TAB, 5 MN-PA (Medically Necessary ONGLYZA MG TAB) TIER 4 Prior Authorization) saxagliptin hcl

©2021 Wellmark, Inc. 97 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OSENI (12.5-15 MG TAB, 12.5-30 MG TAB, 12.5-45 MG TAB, 25-15 MG TAB, MN-PA (Medically Necessary OSENI TIER 4 25-30 MG TAB, 25-45 MG Prior Authorization), GA TAB) alogliptin-pioglitazone 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, 4 TIER 2 QL (2 PER 28 DAY(S)) MG/DOSE) MG/3ML SOLN PEN) semaglutide 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 15-500 mg TIER 1 PV metformin hcl tab, -metformin 15-850 mg tab) PRANDIN (1 MG TAB, 2 PRANDIN MG TAB) TIER 4 GA repaglinide PRECOSE (25 MG TAB, 50 PRECOSE MG TAB, 100 MG TAB) TIER 4 GA acarbose 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 500 MG/5ML PA, QL (765 PER 30 RIOMET SOLUTION TIER 4 DAY(S)), GA metformin hcl RIOMET ER 500 MG/5ML PA, QL (765 PER 30 RIOMET ER SRER TIER 2 DAY(S)), PV metformin hcl RYBELSUS (3 MG TAB, 7 RYBELSUS MG TAB, 14 MG TAB) TIER 2 PV semaglutide

©2021 Wellmark, Inc. 98 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SEGLUROMET (2.5-1000 MG TAB, 2.5-500 MG TAB, MN-PA (Medically Necessary SEGLUROMET 7.5-1000 MG TAB, 7.5-500 TIER 4 Prior Authorization) MG TAB) ertugliflozin-metformin hcl STARLIX (60 MG TAB, 120 STARLIX MG TAB) TIER 4 GA nateglinide STEGLATRO (5 MG TAB, 15 MG TAB) MN-PA (Medically Necessary STEGLATRO TIER 4 ertugliflozin l-pyroglutamic Prior Authorization) acid 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 TANZEUM (30 MG PEN, 50 QL (4 PER 28 DAYS), MN- TANZEUM MG PEN) TIER 4 PA (Medically Necessary albiglutide Prior Authorization) TOLAZAMIDE (250 MG TOLAZAMIDE TAB, 500 MG TAB) TIER 1 PV tolazamide TOLBUTAMIDE 500 MG TOLBUTAMIDE TAB TIER 1 PV tolbutamide TRADJENTA 5 MG TAB MN-PA (Medically Necessary TRADJENTA TIER 4 linagliptin Prior Authorization)

©2021 Wellmark, Inc. 99 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TRIJARDY XR (5-2.5-1000 MG TAB ER 24H, 10-5- 1000 MG TAB ER 24H, 12.5-2.5-1000 MG TAB ER TRIJARDY XR TIER 2 PV 24H, 25-5-1000 MG TAB ER 24H) empagliflozin-linagliptin- metformin TRULICITY (0.75 SOLN QL (4 PER 28 DAYS), MN- TRULICITY PEN, 1.5 SOLN PEN) TIER 4 PA (Medically Necessary dulaglutide Prior Authorization) TRULICITY (3 SOLN PEN, QL (4 PER 28 DAY(S)), MN- TRULICITY 4.5 SOLN PEN) TIER 4 PA (Medically Necessary dulaglutide Prior Authorization) VICTOZA 18 MG/3ML VICTOZA SOLN PEN TIER 2 QL (3 PER 30 DAYS), PV liraglutide XIGDUO XR (2.5-1000 MG TAB ER 24H, 5-1000 MG TAB ER 24H, 5-500 MG XIGDUO XR TAB ER 24H, 10-1000 MG TIER 2 PV TAB ER 24H, 10-500 MG TAB ER 24H) dapagliflozin-metformin hcl

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 1 mg glucagon emergency TIER 1 kit GLUCAGON EMERGENCY GLUCAGON 1 MG KIT TIER 4 GA EMERGENCY glucagon (rdna) GLUCAGON EMERGENCY GLUCAGON 1 MG/ML RECON SOLN TIER 2 QL (2 PER RX) EMERGENCY glucagon hcl

©2021 Wellmark, Inc. 100 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 PROGLYCEM 50 MG/ML PROGLYCEM SUSPENSION TIER 4 GA diazoxide

INSULINS

ADMELOG 100 UNIT/ML MN-PA (Medically Necessary ADMELOG SOLUTION TIER 4 Prior Authorization) insulin lispro ADMELOG SOLOSTAR ADMELOG MN-PA (Medically Necessary 100 UNIT/ML SOLN PEN TIER 4 SOLOSTAR Prior Authorization) insulin lispro AFREZZA (12 POWDER, AFREZZA 90 X 4 & 90X8 POWDER) TIER 4 PA, QL (108 PER 1 DAY(S)) insulin regular (human) AFREZZA (4 (30) & 8 (60) POWDER, 8 POWDER, 30 AFREZZA X 4 & 60X8 POWDER, 90 TIER 4 PA, QL (120 PER 1 DAY(S)) X 8 & 90X12 POWDER) insulin regular (human) AFREZZA (4 (60) 8 (30) POWDER, 60 X 4 30X8 AFREZZA TIER 4 PA, QL (80 PER 1 DAY(S)) POWDER) insulin regular (human) AFREZZA (8 (60)& 12 (30) POWDER, 60 X 8 & 30X12 AFREZZA TIER 4 PA, QL (112 PER 1 DAY(S)) POWDER) insulin regular (human) AFREZZA 4 & 8 & 12 UNIT AFREZZA POWDER TIER 4 PA, QL (96 PER 1 DAY(S)) insulin regular (human) AFREZZA 4 UNIT AFREZZA POWDER TIER 4 PA, QL (74 PER 1 DAY(S)) insulin regular (human)

©2021 Wellmark, Inc. 101 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS APIDRA 100 UNIT/ML MN-PA (Medically Necessary APIDRA SOLUTION TIER 4 Prior Authorization) insulin glulisine APIDRA SOLOSTAR 100 MN-PA (Medically Necessary APIDRA SOLOSTAR UNIT/ML SOLN PEN TIER 4 Prior Authorization) insulin glulisine 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) FIASP PENFILL 100 UNIT/ML SOLN CART FIASP PENFILL TIER 2 PV insulin aspart (with niacinamide) HUMALOG (100 SOLN MN-PA (Medically Necessary HUMALOG CART, 100 SOLUTION) TIER 4 Prior Authorization) insulin lispro HUMALOG JUNIOR HUMALOG JUNIOR KWIKPEN 100 UNIT/ML MN-PA (Medically Necessary TIER 4 KWIKPEN SOLN PEN Prior Authorization) insulin lispro HUMALOG KWIKPEN (100 HUMALOG SOLN PEN, 200 SOLN MN-PA (Medically Necessary TIER 4 KWIKPEN PEN) Prior Authorization) insulin lispro HUMALOG MIX 50/50 (50- 50) 100 UNIT/ML HUMALOG MIX MN-PA (Medically Necessary SUSPENSION TIER 4 50/50 Prior Authorization) insulin lispro protamine & lispro HUMALOG MIX 50/50 KWIKPEN (50-50) 100 HUMALOG MIX MN-PA (Medically Necessary UNIT/ML SUSP PEN TIER 4 50/50 KWIKPEN Prior Authorization) insulin lispro protamine & lispro HUMALOG MIX 75/25 (75- 25) 100 UNIT/ML HUMALOG MIX MN-PA (Medically Necessary SUSPENSION TIER 4 75/25 Prior Authorization) insulin lispro protamine & lispro

©2021 Wellmark, Inc. 102 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HUMALOG MIX 75/25 KWIKPEN (75-25) 100 HUMALOG MIX MN-PA (Medically Necessary UNIT/ML SUSP PEN TIER 4 75/25 KWIKPEN Prior Authorization) insulin lispro protamine & lispro HUMULIN 70/30 (70-30) 100 UNIT/ML MN-PA (Medically Necessary HUMULIN 70/30 SUSPENSION TIER 4 Prior Authorization) insulin nph isophane & reg (human) HUMULIN 70/30 KWIKPEN (70-30) 100 UNIT/ML HUMULIN 70/30 MN-PA (Medically Necessary SUSP PEN TIER 4 KWIKPEN Prior Authorization) insulin nph isophane & reg (human) HUMULIN N 100 UNIT/ML SUSPENSION MN-PA (Medically Necessary HUMULIN N TIER 4 insulin nph (human) Prior Authorization) (isophane) HUMULIN N KWIKPEN 100 HUMULIN N UNIT/ML SUSP PEN MN-PA (Medically Necessary TIER 4 KWIKPEN insulin nph (human) Prior Authorization) (isophane) HUMULIN R 100 UNIT/ML MN-PA (Medically Necessary HUMULIN R SOLUTION TIER 4 Prior Authorization) insulin regular (human) 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

©2021 Wellmark, Inc. 103 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) INSULIN LISPRO (1 UNIT INSULIN LISPRO (1 DIAL) 100 UNIT/ML SOLN MN-PA (Medically Necessary TIER 4 UNIT DIAL) PEN Prior Authorization) insulin lispro INSULIN LISPRO 100 MN-PA (Medically Necessary INSULIN LISPRO UNIT/ML SOLUTION TIER 4 Prior Authorization) insulin lispro INSULIN LISPRO JUNIOR INSULIN LISPRO KWIKPEN 100 UNIT/ML MN-PA (Medically Necessary TIER 4 JUNIOR KWIKPEN SOLN PEN Prior Authorization) insulin lispro INSULIN LISPRO PROT & LISPRO (75-25) 100 INSULIN LISPRO MN-PA (Medically Necessary UNIT/ML SUSP PEN TIER 4 PROT & LISPRO Prior Authorization) insulin lispro protamine & lispro LANTUS 100 UNIT/ML MN-PA (Medically Necessary LANTUS SOLUTION TIER 4 Prior Authorization) insulin glargine LANTUS SOLOSTAR 100 MN-PA (Medically Necessary LANTUS SOLOSTAR UNIT/ML SOLN PEN TIER 4 Prior Authorization) insulin glargine 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 LYUMJEV 100 UNIT/ML MN-PA (Medically Necessary LYUMJEV SOLUTION TIER 4 Prior Authorization) insulin lispro-aabc LYUMJEV KWIKPEN (100 SOLN PEN, 200 SOLN MN-PA (Medically Necessary LYUMJEV KWIKPEN TIER 4 PEN) Prior Authorization) insulin lispro-aabc

©2021 Wellmark, Inc. 104 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NOVOLIN 70/30 (70-30) 100 UNIT/ML NOVOLIN 70/30 SUSPENSION TIER 2 PV insulin nph isophane & reg (human) 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)

©2021 Wellmark, Inc. 105 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 NOVOLOG 70/30 FLEXPEN RELION (70-30) NOVOLOG 70/30 100 UNIT/ML SUSP PEN TIER 2 PV FLEXPEN RELION insulin aspart protamine & aspart (human) NOVOLOG FLEXPEN 100 NOVOLOG UNIT/ML SOLN PEN TIER 2 PV FLEXPEN insulin aspart NOVOLOG FLEXPEN NOVOLOG RELION 100 UNIT/ML TIER 2 PV FLEXPEN RELION SOLN PEN 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 MIX 70/30 RELION (70-30) 100 NOVOLOG MIX UNIT/ML SUSPENSION TIER 2 PV 70/30 RELION insulin aspart protamine & aspart (human) NOVOLOG PENFILL 100 NOVOLOG PENFILL UNIT/ML SOLN CART TIER 2 PV insulin aspart NOVOLOG RELION 100 NOVOLOG RELION UNIT/ML SOLUTION TIER 2 PV insulin aspart SEMGLEE (100 SOLN MN-PA (Medically Necessary SEMGLEE PEN, 100 SOLUTION) TIER 4 Prior Authorization) insulin glargine TOUJEO MAX SOLOSTAR TOUJEO MAX MN-PA (Medically Necessary 300 UNIT/ML SOLN PEN TIER 4 SOLOSTAR Prior Authorization) insulin glargine TOUJEO SOLOSTAR 300 MN-PA (Medically Necessary TOUJEO SOLOSTAR UNIT/ML SOLN PEN TIER 4 Prior Authorization) insulin glargine

©2021 Wellmark, Inc. 106 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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

ARIXTRA (2.5 MG/0.5ML SOLUTION, 5 MG/0.4ML SOLUTION, 7.5 MG/0.6ML ARIXTRA TIER 4 GA SOLUTION, 10 MG/0.8ML SOLUTION) fondaparinux sodium 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 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)

©2021 Wellmark, Inc. 107 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 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) LOVENOX (30 MG/0.3ML SOLUTION, 40 MG/0.4ML SOLUTION, 60 MG/0.6ML SOLUTION, 80 MG/0.8ML SOLUTION, 100 MG/ML LOVENOX TIER 4 GA SOLUTION, 120 MG/0.8ML SOLUTION, 150 MG/ML SOLUTION, 300 MG/3ML SOLUTION) enoxaparin sodium PRADAXA (75 MG CAP, 110 MG CAP, 150 MG MN-PA (Medically Necessary PRADAXA CAP) TIER 4 Prior Authorization) dabigatran etexilate mesylate

©2021 Wellmark, Inc. 108 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SAVAYSA (15 MG TAB, 30 MN-PA (Medically Necessary SAVAYSA MG TAB, 60 MG TAB) TIER 4 Prior Authorization) edoxaban tosylate 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 XARELTO STARTER XARELTO STARTER PACK 15 & 20 MG TAB TIER 2 PV PACK THPK rivaroxaban

BLOOD FORMATION MODIFIERS

AGRYLIN 0.5 MG CAP AGRYLIN TIER 4 GA anagrelide hcl 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/0.4ML SOLN PRSYR, 40 MCG/ML SOLUTION, 60 MCG/0.3ML SOLN PRSYR, 60 MCG/ML ARANESP (ALBUMIN SOLUTION, 100 SP-P FREE) MCG/0.5ML SOLN PRSYR, 100 MCG/ML SOLUTION, 150 MCG/0.3ML SOLN PRSYR, 200 MCG/0.4ML SOLN PRSYR, 200 MCG/ML SOLUTION, 300 MCG/0.6ML SOLN PRSYR, 300 MCG/ML SOLUTION, 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

©2021 Wellmark, Inc. 109 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EPOGEN (2000 SOLUTION, 3000 SOLUTION, 4000 MN-PA (Medically Necessary EPOGEN SOLUTION, 10000 SP-P Prior Authorization) SOLUTION, 20000 SOLUTION) epoetin alfa FULPHILA 6 MG/0.6ML SBG (Specialty Biosimilars FULPHILA SOLN PRSYR SP-P and Specialty generics) 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, 50 SOLN PRSYR, 75 SOLN PRSYR, 100 SOLN PRSYR, 150 SOLN MN-PA (Medically Necessary MIRCERA SP-P PRSYR, 200 SOLN Prior Authorization) PRSYR) 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 MN-PA (Medically Necessary NEULASTA SOLN PRSYR SP-P Prior Authorization) pegfilgrastim NEULASTA ONPRO 6 NEULASTA ONPRO MG/0.6ML PREF SY KT SP-P PA pegfilgrastim NEUPOGEN (300 MCG/0.5ML SOLN PRSYR, 300 MCG/ML SOLUTION, MN-PA (Medically Necessary NEUPOGEN 480 MCG/0.8ML SOLN SP-NP Prior Authorization) PRSYR, 480 MCG/1.6ML SOLUTION) filgrastim

©2021 Wellmark, Inc. 110 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NIVESTYM (300 MCG/0.5ML SOLN PRSYR, 300 MCG/ML SOLUTION, SBG (Specialty Biosimilars NIVESTYM 480 MCG/0.8ML SOLN SP-P and Specialty generics) 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 NYVEPRIA 6 MG/0.6ML SBG (Specialty Biosimilars NYVEPRIA SOLN PRSYR SP-P and Specialty generics) pegfilgrastim-apgf PROCRIT (2000 SOLUTION, 3000 SOLUTION, 4000 SOLUTION, 10000 MN-PA (Medically Necessary PROCRIT SP-P SOLUTION, 20000 Prior Authorization) 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 SOLN, 75 MG REBLOZYL SP-M PA RECON SOLN) luspatercept-aamt RETACRIT (2000 SOLUTION, 3000 SOLUTION, 4000 SOLUTION, 10000 SBG (Specialty Biosimilars RETACRIT SP-P SOLUTION, 20000 and Specialty generics) SOLUTION, 40000 SOLUTION) epoetin alfa-epbx TAVALISSE (100 MG TAB, TAVALISSE 150 MG TAB) SP-P PA fostamatinib disodium

©2021 Wellmark, Inc. 111 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS UDENYCA 6 MG/0.6ML SBG (Specialty Biosimilars UDENYCA SOLN PRSYR SP-P and Specialty generics) pegfilgrastim-cbqv ZARXIO (300 MCG/0.5ML SOLN PRSYR, 480 SBG (Specialty Biosimilars ZARXIO SP-P MCG/0.8ML SOLN PRSYR) and Specialty generics) filgrastim-sndz ZIEXTENZO 6 MG/0.6ML SBG (Specialty Biosimilars ZIEXTENZO SOLN PRSYR SP-P and Specialty generics) pegfilgrastim-bmez

HEMOSTASIS AGENTS

ADVATE (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 RECON SOLN, 3000 ADVATE SP-M RECON SOLN, 4000 RECON SOLN) antihemophilic factor (rcmb) plasma/albumin free (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 (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 ALPHANATE SP-M RECON SOLN) antihemophilic factor/von willebrand factor complex (human)

©2021 Wellmark, Inc. 112 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) 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) AMICAR (0.25 GM/ML SOLUTION, 500 MG TAB, AMICAR TIER 4 GA 1000 MG TAB) aminocaproic acid 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)

©2021 Wellmark, Inc. 113 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ELOCTATE (250 RECON SOLN, 500 RECON SOLN, 750 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 RECON SOLN, 3000 ELOCTATE SP-M RECON SOLN, 4000 RECON SOLN, 5000 RECON SOLN, 6000 RECON SOLN) antihemophilic factor (rcmb) fc fusion protein(bdd-rfviiifc) FEIBA (500 RECON SOLN, 1000 RECON SOLN, 2500 FEIBA RECON SOLN) SP-M antiinhibitor coagulant complex 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)

©2021 Wellmark, Inc. 114 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) JIVI (500 RECON SOLN, 1000 RECON SOLN, 2000 RECON SOLN, 3000 JIVI RECON SOLN) SP-M antihemophil fact(rcmb) pegylated-aucl (bdd-rfviii peg-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)

©2021 Wellmark, Inc. 115 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KOVALTRY (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 2000 RECON SOLN, 3000 KOVALTRY SP-M RECON SOLN) antihemophilic factor (rcmb) plasma/albumin free (rahf- pfm) LYSTEDA 650 MG TAB LYSTEDA TIER 4 GA tranexamic acid MONOCLATE-P (1000 KIT, 1500 KIT) MONOCLATE-P SP-M antihemophilic factor (human) MONONINE 1000 UNIT MONONINE RECON SOLN SP-M coagulation factor ix 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 KIT, 500 RECON SOLN, 1000 KIT, 1000 RECON SOLN, 2000 KIT, 2000 RECON SOLN, 2500 KIT, 2500 NUWIQ SP-M RECON SOLN, 3000 KIT, 3000 RECON SOLN, 4000 KIT, 4000 RECON SOLN) antihemophilic factor (rcmb) simoctocog alfa(bdd- rfviii,sim) OBIZUR 500 UNIT RECON SOLN OBIZUR antihemophilic factor SP-M (recombinant porcine) (rpfviii)

©2021 Wellmark, Inc. 116 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 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)

©2021 Wellmark, Inc. 117 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XYNTHA (250 KIT, 500 KIT, 1000 KIT, 2000 KIT) XYNTHA antihemophilic factor (rcmb) SP-M moroctocog alfa(bdd- rfviii,mor) XYNTHA SOLOFUSE (250 KIT, 500 KIT, 1000 KIT, 2000 KIT, 3000 KIT) XYNTHA SOLOFUSE SP-M antihemophilic factor (rcmb) moroctocog alfa(bdd- rfviii,mor)

PLATELET MODIFYING AGENTS

ADAKVEO 100 MG/10ML ADAKVEO SOLUTION SP-M PA crizanlizumab-tmca AGGRENOX 25-200 MG AGGRENOX CAP ER 12H TIER 4 GA aspirin-dipyridamole aspirin-dipyridamole aspirin-dipyridamole er 25- TIER 1 PV er 200 mg cap er 12h 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) EFFIENT (5 MG TAB, 10 EFFIENT MG TAB) TIER 4 GA prasugrel hcl OXBRYTA 500 MG TAB PA, QL (84 PER 28 DAY(S)), OXBRYTA SP-NP voxelotor PA-QL (140/28 days) PLAVIX (75 MG TAB, 300 PLAVIX MG TAB) TIER 4 GA clopidogrel bisulfate prasugrel hcl (5 mg tab, 10 prasugrel hcl TIER 1 PV mg tab)

COAGULANTS

MEPHYTON 5 MG TAB MEPHYTON TIER 4 GA phytonadione phytonadione phytonadione 5 mg tab TIER 1

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

CATAPRES (0.1 MG TAB, CATAPRES 0.2 MG TAB, 0.3 MG TAB) TIER 4 GA clonidine hcl CATAPRES-TTS-1 0.1 CATAPRES-TTS-1 MG/24HR PATCH WK TIER 4 GA clonidine CATAPRES-TTS-2 0.2 CATAPRES-TTS-2 MG/24HR PATCH WK TIER 4 GA clonidine CATAPRES-TTS-3 0.3 CATAPRES-TTS-3 MG/24HR PATCH WK TIER 4 GA clonidine 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

CARDURA (1 MG TAB, 2 MG TAB, 4 MG TAB, 8 MG CARDURA TIER 4 GA TAB) doxazosin mesylate DIBENZYLINE 10 MG CAP DIBENZYLINE TIER 4 GA phenoxybenzamine hcl doxazosin mesylate (1 mg doxazosin mesylate tab, 2 mg tab, 4 mg tab, 8 TIER 1 mg tab) MINIPRESS (1 MG CAP, 2 MINIPRESS MG CAP, 5 MG CAP) TIER 4 GA prazosin hcl phenoxybenzamine phenoxybenzamine hcl 10 TIER 1 hcl mg cap prazosin hcl (1 mg cap, 2 prazosin hcl TIER 1 mg cap, 5 mg cap)

ANGIOTENSIN II RECEPTOR ANTAGONISTS

ATACAND (4 MG TAB, 8 MG TAB, 16 MG TAB, 32 ATACAND TIER 4 GA MG TAB) candesartan cilexetil AVAPRO (75 MG TAB, 150 AVAPRO MG TAB, 300 MG TAB) TIER 4 GA irbesartan BENICAR (5 MG TAB, 20 BENICAR MG TAB, 40 MG TAB) TIER 4 GA olmesartan medoxomil candesartan cilexetil (4 mg candesartan cilexetil tab, 8 mg tab, 16 mg tab, TIER 1 PV 32 mg tab) COZAAR (25 MG TAB, 50 COZAAR MG TAB, 100 MG TAB) TIER 4 GA losartan potassium DIOVAN (40 MG TAB, 80 MG TAB, 160 MG TAB, 320 DIOVAN TIER 4 GA MG TAB) valsartan EDARBI (40 MG TAB, 80 EDARBI MG TAB) TIER 4 azilsartan medoxomil 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) MICARDIS (20 MG TAB, 40 MICARDIS MG TAB, 80 MG TAB) TIER 4 GA telmisartan 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

ACCUPRIL (5 MG TAB, 10 MG TAB, 20 MG TAB, 40 ACCUPRIL TIER 4 GA MG TAB) quinapril hcl ACEON (4 MG TAB, 8 MG ACEON TAB) TIER 4 GA perindopril erbumine ALTACE (1.25 MG CAP, 2.5 MG CAP, 5 MG CAP, ALTACE TIER 4 GA 10 MG CAP) ramipril 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) enalapril maleate 1 mg/ml PA, QL (1200 PER 30 enalapril maleate TIER 1 solution DAY(S)) EPANED 1 MG/ML PA, QL (1200 PER 30 EPANED SOLUTION TIER 4 DAY(S)), GA enalapril maleate 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) LOTENSIN (10 MG TAB, LOTENSIN 20 MG TAB, 40 MG TAB) TIER 4 GA benazepril hcl 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) PRINIVIL (5 MG TAB, 10 PRINIVIL MG TAB, 20 MG TAB) TIER 4 GA lisinopril QBRELIS 1 MG/ML PA, QL (1200 PER 30 QBRELIS SOLUTION TIER 4 DAY(S)) lisinopril quinapril hcl (5 mg tab, 10 quinapril hcl mg tab, 20 mg tab, 40 mg TIER 1 PV tab)

©2021 Wellmark, Inc. 121 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ramipril (1.25 mg cap, 2.5 ramipril mg cap, 5 mg cap, 10 mg TIER 1 PV cap) trandolapril (1 mg tab, 2 mg trandolapril TIER 1 PV tab, 4 mg tab) VASOTEC (2.5 MG TAB, 5 MG TAB, 10 MG TAB, 20 VASOTEC TIER 4 GA MG TAB) enalapril maleate ZESTRIL (2.5 MG TAB, 5 MG TAB, 10 MG TAB, 20 ZESTRIL MG TAB, 30 MG TAB, 40 TIER 4 GA MG TAB) lisinopril

ANTIARRHYTHMICS

amiodarone hcl (100 mg amiodarone hcl tab, 200 mg tab, 400 mg TIER 1 PV tab) BETAPACE (80 MG TAB, 120 MG TAB, 160 MG BETAPACE TIER 4 GA TAB) sotalol hcl BETAPACE AF (80 MG TAB, 120 MG TAB, 160 MG BETAPACE AF TIER 4 GA TAB) sotalol hcl (afib/afl) 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 (100 MG CAP, NORPACE 150 MG CAP) TIER 4 GA disopyramide phosphate 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)

©2021 Wellmark, Inc. 122 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 RYTHMOL SR (225 MG CAP ER 12H, 325 MG CAP RYTHMOL SR ER 12H, 425 MG CAP ER TIER 4 GA 12H) propafenone hcl 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) SOTYLIZE 5 MG/ML PA, QL (1920 PER 30 SOTYLIZE SOLUTION TIER 4 DAY(S)) sotalol hcl TIKOSYN (125 MCG CAP, 250 MCG CAP, 500 MCG TIKOSYN TIER 4 GA CAP) dofetilide

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) BYSTOLIC (2.5 MG TAB, 5 MG TAB, 10 MG TAB, 20 BYSTOLIC TIER 4 MG TAB) nebivolol hcl

©2021 Wellmark, Inc. 123 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) COREG (3.125 MG TAB, 6.25 MG TAB, 12.5 MG COREG TIER 4 GA TAB, 25 MG TAB) carvedilol COREG CR (10 MG CAP ER 24H, 20 MG CAP ER COREG CR 24H, 40 MG CAP ER 24H, TIER 4 GA 80 MG CAP ER 24H) carvedilol phosphate CORGARD (20 MG TAB, CORGARD 40 MG TAB, 80 MG TAB) TIER 4 GA nadolol INDERAL LA (60 MG CAP ER 24H, 80 MG CAP ER INDERAL LA 24H, 120 MG CAP ER 24H, TIER 4 GA 160 MG CAP ER 24H) propranolol hcl labetalol hcl (100 mg tab, labetalol hcl TIER 1 PV 200 mg tab, 300 mg tab) LOPRESSOR (50 MG TAB, LOPRESSOR 100 MG TAB) TIER 4 GA metoprolol tartrate 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) metoprolol tartrate (37.5 mg metoprolol tartrate TIER 4 tab, 75 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 tab, 40 TIER 1 PV mg/5ml solution, 60 mg tab, 80 mg tab)

©2021 Wellmark, Inc. 124 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) TENORMIN (25 MG TAB, TENORMIN 50 MG TAB, 100 MG TAB) TIER 4 GA atenolol timolol maleate (5 mg tab, timolol maleate TIER 1 PV 10 mg tab, 20 mg tab) TOPROL XL (25 MG TAB ER 24H, 50 MG TAB ER TOPROL XL 24H, 100 MG TAB ER 24H, TIER 4 GA 200 MG TAB ER 24H) metoprolol succinate ZEBETA 10 MG TAB ZEBETA TIER 4 GA bisoprolol fumarate

CALCIUM CHANNEL BLOCKING AGENTS

ADALAT CC (30 MG TAB ER 24H, 60 MG TAB ER ADALAT CC TIER 4 GA 24H, 90 MG TAB ER 24H) nifedipine 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) CALAN (80 MG TAB, 120 CALAN MG TAB) TIER 4 GA verapamil hcl CALAN SR (120 MG TAB ER, 180 MG TAB ER, 240 CALAN SR TIER 4 GA MG TAB ER) verapamil hcl CARDIZEM (30 MG TAB, CARDIZEM 60 MG TAB, 120 MG TAB) TIER 4 GA diltiazem hcl CARDIZEM CD (120 MG CAP ER 24H, 180 MG CAP ER 24H, 240 MG CAP ER CARDIZEM CD TIER 4 GA 24H, 300 MG CAP ER 24H, 360 MG CAP ER 24H) diltiazem hcl coated beads

©2021 Wellmark, Inc. 125 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CARDIZEM LA (120 MG TAB ER 24H, 180 MG TAB ER 24H, 240 MG TAB ER CARDIZEM LA 24H, 300 MG TAB ER 24H, TIER 4 GA 360 MG TAB ER 24H, 420 MG TAB ER 24H) diltiazem hcl coated beads 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 100 MG DILTIAZEM HCL RECON SOLN TIER 4 diltiazem hcl 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)

©2021 Wellmark, Inc. 126 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS diltiazem hcl er coated beads (er beads 120 mg cap er 24h, er beads 180 mg cap er 24h, er beads 180 mg tab 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) ISOPTIN SR (120 MG TAB ISOPTIN SR ER, 240 MG TAB ER) TIER 4 GA verapamil hcl isradipine (2.5 mg cap, 5 isradipine TIER 1 PV mg cap) KATERZIA 1 MG/ML PA, QL (300 PER 30 KATERZIA SUSPENSION TIER 4 DAY(S)) amlodipine benzoate 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) 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

©2021 Wellmark, Inc. 127 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) NORVASC (2.5 MG TAB, 5 NORVASC MG TAB, 10 MG TAB) TIER 4 GA amlodipine besylate NYMALIZE (30 MG/10ML SOLUTION, 60 MG/20ML NYMALIZE TIER 4 SOLUTION) nimodipine PROCARDIA 10 MG CAP PROCARDIA TIER 4 GA nifedipine PROCARDIA XL (30 MG TAB ER 24H, 60 MG TAB PROCARDIA XL ER 24H, 90 MG TAB ER TIER 4 GA 24H) nifedipine SULAR (8.5 MG TAB ER 24H, 17 MG TAB ER 24H, SULAR TIER 4 GA 34 MG TAB ER 24H) nisoldipine 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) TIAZAC (120 MG CAP ER 24H, 180 MG CAP ER 24H, 240 MG CAP ER 24H, 300 MG CAP ER 24H, 360 MG TIAZAC TIER 4 GA CAP ER 24H, 420 MG CAP ER 24H) diltiazem hcl extended release beads verapamil hcl (40 mg tab, verapamil hcl TIER 1 PV 80 mg tab, 120 mg tab)

©2021 Wellmark, Inc. 128 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VERAPAMIL HCL ER (ER 100 MG CAP ER 24H, ER 120 MG CAP ER 24H, ER 120 MG TAB ER, ER 180 MG CAP ER 24H, ER 180 MG TAB ER, 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 VERELAN (120 MG CAP ER 24H, 180 MG CAP ER VERELAN 24H, 240 MG CAP ER 24H, TIER 4 360 MG CAP ER 24H) verapamil hcl VERELAN PM (100 MG CAP ER 24H, 200 MG CAP VERELAN PM ER 24H, 300 MG CAP ER TIER 4 GA 24H) verapamil hcl

CARDIOVASCULAR AGENTS, OTHER

ACCURETIC (10-12.5 MG TAB, 20-12.5 MG TAB, 20- ACCURETIC 25 MG TAB) TIER 4 GA quinapril- hydrochlorothiazide ALDACTAZIDE (25-25 MG TAB, 50-50 MG TAB) ALDACTAZIDE TIER 4 spironolactone & hydrochlorothiazide 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, 5-10 amlodipine besy- mg cap, 5-20 mg cap, 5-40 TIER 1 PV benazepril hcl mg cap, 10-20 mg cap, 10- 40 mg cap) amlodipine besylate- amlodipine besylate- valsartan (5-160 mg tab, 5- TIER 1 PV valsartan 320 mg tab, 10-160 mg tab, 10-320 mg tab)

©2021 Wellmark, Inc. 129 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS amlodipine-atorvastatin (2.5-10 mg tab, 2.5-20 mg tab, 2.5-40 mg tab, 5-10 mg amlodipine- tab, 5-20 mg tab, 5-40 mg TIER 1 PV atorvastatin tab, 5-80 mg tab, 10-10 mg tab, 10-20 mg tab, 10-40 mg tab, 10-80 mg tab) amlodipine-olmesartan (5- amlodipine- 20 mg tab, 5-40 mg tab, 10- TIER 1 PV olmesartan 20 mg tab, 10-40 mg tab) amlodipine-valsartan-hctz (5-160-12.5 mg tab, 5-160- amlodipine-valsartan- 25 mg tab, 10-160-12.5 mg TIER 1 PV hctz tab, 10-160-25 mg tab, 10- 320-25 mg tab) ATACAND HCT (16-12.5 MG TAB, 32-12.5 MG TAB, ATACAND HCT 32-25 MG TAB) TIER 4 GA candesartan cilexetil- hydrochlorothiazide atenolol- atenolol-chlorthalidone (50- TIER 1 PV chlorthalidone 25 mg tab, 100-25 mg tab) AVALIDE (150-12.5 MG TAB, 300-12.5 MG TAB) AVALIDE TIER 4 GA irbesartan- hydrochlorothiazide AZOR (5-20 MG TAB, 5-40 MG TAB, 10-20 MG TAB, AZOR 10-40 MG TAB) TIER 4 GA amlodipine besylate- olmesartan medoxomil 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) BENICAR HCT (20-12.5 MG TAB, 40-12.5 MG TAB, BENICAR HCT 40-25 MG TAB) TIER 4 GA olmesartan medoxomil- hydrochlorothiazide BIDIL 20-37.5 MG TAB BIDIL isosorbide dinitrate- TIER 4 hydralazine hcl bisoprolol- bisoprolol- hydrochlorothiazide (2.5- TIER 1 PV hydrochlorothiazide 6.25 mg tab, 5-6.25 mg tab, 10-6.25 mg tab)

©2021 Wellmark, Inc. 130 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CADUET (5-10 MG TAB, 5- 20 MG TAB, 5-40 MG TAB, 5-80 MG TAB, 10-10 MG CADUET TAB, 10-20 MG TAB, 10-40 TIER 4 GA MG TAB, 10-80 MG TAB) amlodipine besylate- atorvastatin calcium candesartan cilexetil-hctz candesartan cilexetil- (16-12.5 mg tab, 32-12.5 TIER 1 PV hctz mg tab, 32-25 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 CLORPRES (0.1-15 MG TAB, 0.2-15 MG TAB, 0.3- CLORPRES TIER 4 15 MG TAB) clonidine & chlorthalidone CORLANOR (5 MG TAB, CORLANOR 7.5 MG TAB) TIER 4 PA, QL (60 PER 30 DAY(S)) ivabradine hcl CORLANOR 5 MG/5ML PA, QL (450 PER 30 CORLANOR SOLUTION TIER 4 DAY(S)) ivabradine hcl CORZIDE (40-5 MG TAB, 80-5 MG TAB) CORZIDE TIER 4 GA nadolol & bendroflumethiazide DEMSER 250 MG CAP DEMSER TIER 4 GA metyrosine 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) DIOVAN HCT (80-12.5 MG TAB, 160-12.5 MG TAB, 160-25 MG TAB, 320-12.5 DIOVAN HCT TIER 4 GA MG TAB, 320-25 MG TAB) valsartan- hydrochlorothiazide

©2021 Wellmark, Inc. 131 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DYAZIDE 37.5-25 MG CAP DYAZIDE triamterene & TIER 4 GA hydrochlorothiazide EDARBYCLOR (40-12.5 MG TAB, 40-25 MG TAB) EDARBYCLOR TIER 4 azilsartan medoxomil- chlorthalidone 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 2 PA, QL (60 PER 30 DAYS) 103 MG TAB) sacubitril-valsartan EXFORGE (5-160 MG TAB, 5-320 MG TAB, 10- 160 MG TAB, 10-320 MG EXFORGE TIER 4 GA TAB) amlodipine besylate- valsartan EXFORGE HCT (5-160- 12.5 MG TAB, 5-160-25 MG TAB, 10-160-12.5 MG EXFORGE HCT TAB, 10-160-25 MG TAB, TIER 4 GA 10-320-25 MG TAB) amlodipine-valsartan- hydrochlorothiazide fosinopril sodium-hctz (10- fosinopril sodium-hctz 12.5 mg tab, 20-12.5 mg TIER 1 PV tab) HYZAAR (50-12.5 MG TAB, 100-12.5 MG TAB, HYZAAR 100-25 MG TAB) TIER 4 GA losartan potassium & hydrochlorothiazide 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) LANOXIN (62.5 MCG TAB, 125 MCG TAB, 187.5 MCG LANOXIN TIER 4 TAB, 250 MCG TAB) digoxin lisinopril- lisinopril- hydrochlorothiazide (10- TIER 1 PV hydrochlorothiazide 12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab)

©2021 Wellmark, Inc. 132 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LOPRESSOR HCT (50-25 MG TAB, 100-25 MG TAB) LOPRESSOR HCT TIER 4 GA metoprolol & hydrochlorothiazide losartan potassium-hctz losartan potassium- (50-12.5 mg tab, 100-12.5 TIER 1 PV hctz mg tab, 100-25 mg tab) LOTENSIN HCT (10-12.5 MG TAB, 20-12.5 MG TAB, LOTENSIN HCT 20-25 MG TAB) TIER 4 GA benazepril & hydrochlorothiazide LOTREL (5-10 MG CAP, 5- 20 MG CAP, 10-20 MG LOTREL CAP, 10-40 MG CAP) TIER 4 GA amlodipine besylate- benazepril hcl MAXZIDE 75-50 MG TAB MAXZIDE triamterene & TIER 4 GA hydrochlorothiazide MAXZIDE-25 37.5-25 MG TAB MAXZIDE-25 TIER 4 GA triamterene & hydrochlorothiazide 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 MICARDIS HCT (40-12.5 MG TAB, 80-12.5 MG TAB, MICARDIS HCT 80-25 MG TAB) TIER 4 GA telmisartan- hydrochlorothiazide moexipril- moexipril- hydrochlorothiazide (7.5- TIER 1 PV hydrochlorothiazide 12.5 mg tab, 15-12.5 mg tab, 15-25 mg tab) nadolol- nadolol- bendroflumethiazide (40-5 TIER 1 PV bendroflumethiazide mg tab, 80-5 mg tab)

©2021 Wellmark, Inc. 133 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NEXLETOL 180 MG TAB NEXLETOL TIER 4 PA, QL (30 PER 30 DAY(S)) bempedoic acid 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- 12.5 mg tab, 40-10-25 mg TIER 1 PV amlodipine-hctz tab, 40-5-12.5 mg tab, 40- 5-25 mg tab) pentoxifylline er 400 mg tab pentoxifylline er TIER 1 er PRESTALIA (3.5-2.5 MG TAB, 7-5 MG TAB, 14-10 PRESTALIA MG TAB) TIER 4 perindopril arginine- amlodipine besylate 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, 20-12.5 mg tab, 20-25 mg tab) RANEXA (500 MG TAB ER 12H, 1000 MG TAB ER RANEXA TIER 4 GA 12H) ranolazine 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 TARKA (2-180 MG TAB ER, 2-240 MG TAB ER, 4- TARKA TIER 4 GA 240 MG TAB ER) trandolapril-verapamil hcl TEKTURNA (150 MG TAB, TEKTURNA 300 MG TAB) TIER 4 GA aliskiren fumarate

©2021 Wellmark, Inc. 134 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TEKTURNA HCT (150-12.5 MG TAB, 150-25 MG TAB, 300-12.5 MG TAB, 300-25 TEKTURNA HCT TIER 4 MG TAB) aliskiren- hydrochlorothiazide telmisartan-amlodipine (40- telmisartan- 10 mg tab, 40-5 mg tab, 80- TIER 1 PV amlodipine 10 mg tab, 80-5 mg tab) telmisartan-hctz (40-12.5 telmisartan-hctz mg tab, 80-12.5 mg tab, 80- TIER 1 PV 25 mg tab) TENORETIC 100 100-25 TENORETIC 100 MG TAB TIER 4 GA atenolol & chlorthalidone TENORETIC 50 50-25 MG TENORETIC 50 TAB TIER 4 GA atenolol & chlorthalidone 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 triamterene-hctz mg cap, 37.5-25 mg tab, TIER 1 PV 75-50 mg tab) TRIBENZOR (20-5-12.5 MG TAB, 40-10-12.5 MG TAB, 40-10-25 MG TAB, 40-5-12.5 MG TAB, 40-5-25 TRIBENZOR TIER 4 GA MG TAB) olmesartan medoxomil- amlodipine- hydrochlorothiazide TWYNSTA (40-10 MG TAB, 40-5 MG TAB, 80-10 MG TWYNSTA TIER 4 GA TAB, 80-5 MG TAB) telmisartan-amlodipine valsartan- hydrochlorothiazide (80- valsartan- 12.5 mg tab, 160-12.5 mg TIER 1 PV hydrochlorothiazide tab, 160-25 mg tab, 320- 12.5 mg tab, 320-25 mg tab) VASERETIC 10-25 MG TAB VASERETIC TIER 4 GA enalapril maleate & hydrochlorothiazide

©2021 Wellmark, Inc. 135 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VERQUVO (2.5 MG TAB, 5 VERQUVO MG TAB, 10 MG TAB) TIER 3 PA, QL (30 PER 30 DAY(S)) vericiguat 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) ZESTORETIC (10-12.5 MG TAB, 20-12.5 MG TAB, 20- ZESTORETIC 25 MG TAB) TIER 4 GA lisinopril & hydrochlorothiazide ZIAC (2.5-6.25 MG TAB, 5- 6.25 MG TAB, 10-6.25 MG ZIAC TAB) TIER 4 GA bisoprolol & hydrochlorothiazide

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 DIAMOX SEQUELS 500 DIAMOX SEQUELS MG CAP ER 12H TIER 4 GA acetazolamide KEVEYIS 50 MG TAB KEVEYIS SP-P dichlorphenamide

DIURETICS, LOOP

bumetanide (0.5 mg tab, 1 bumetanide TIER 1 mg tab, 2 mg tab) BUMEX (0.5 MG TAB, 1 BUMEX MG TAB, 2 MG TAB) TIER 4 GA bumetanide DEMADEX (10 MG TAB, DEMADEX 20 MG TAB) TIER 4 GA torsemide EDECRIN 25 MG TAB EDECRIN TIER 4 GA ethacrynic acid 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)

©2021 Wellmark, Inc. 136 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LASIX (20 MG TAB, 40 MG LASIX TAB, 80 MG TAB) TIER 4 GA furosemide torsemide (5 mg tab, 10 mg torsemide TIER 1 tab, 20 mg tab, 100 mg tab)

DIURETICS, POTASSIUM-SPARING

ALDACTONE (25 MG TAB, ALDACTONE 50 MG TAB, 100 MG TAB) TIER 4 GA spironolactone amiloride hcl amiloride hcl 5 mg tab TIER 1 CAROSPIR 25 MG/5ML PA, QL (600 PER 30 CAROSPIR SUSPENSION TIER 4 DAY(S)) spironolactone DYRENIUM (50 MG CAP, DYRENIUM 100 MG CAP) TIER 4 GA triamterene eplerenone (25 mg tab, 50 eplerenone TIER 1 mg tab) INSPRA (25 MG TAB, 50 INSPRA MG TAB) TIER 4 GA eplerenone 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 cap, 12.5 mg tab, 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 (45 mg cap fenofibric acid TIER 1 PV dr, 135 mg cap dr) gemfibrozil gemfibrozil 600 mg tab TIER 1 PV LIPOFEN (50 MG CAP, LIPOFEN 150 MG CAP) TIER 4 PV, GA fenofibrate LOFIBRA 200 MG CAP LOFIBRA TIER 4 GA fenofibrate micronized LOPID 600 MG TAB LOPID TIER 4 GA gemfibrozil TRICOR (48 MG TAB, 145 TRICOR MG TAB) TIER 4 GA fenofibrate TRILIPIX (45 MG CAP DR, TRILIPIX 135 MG CAP DR) TIER 4 GA choline fenofibrate

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

ALTOPREV (20 MG TAB ER 24H, 40 MG TAB ER ALTOPREV TIER 4 24H, 60 MG TAB ER 24H) lovastatin atorvastatin calcium (10 mg atorvastatin calcium tab, 20 mg tab, 40 mg tab, TIER 1 PV 80 mg tab) CRESTOR (5 MG TAB, 10 MG TAB, 20 MG TAB, 40 CRESTOR TIER 4 GA MG TAB) rosuvastatin calcium 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

©2021 Wellmark, Inc. 138 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LESCOL XL 80 MG TAB LESCOL XL ER 24H TIER 4 GA fluvastatin sodium LIPITOR (10 MG TAB, 20 MG TAB, 40 MG TAB, 80 LIPITOR TIER 4 GA MG TAB) atorvastatin calcium 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) PRAVACHOL (20 MG TAB, PRAVACHOL 40 MG TAB, 80 MG TAB) TIER 4 GA pravastatin sodium 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) ZOCOR (5 MG TAB, 10 MG TAB, 20 MG TAB, 40 MG ZOCOR TIER 4 GA TAB, 80 MG TAB) simvastatin ZYPITAMAG (1 MG TAB, 2 ZYPITAMAG MG TAB, 4 MG TAB) TIER 2 PV pitavastatin magnesium

DYSLIPIDEMICS, OTHER

cholestyramine (4 gm cholestyramine TIER 1 PV packet, 4 gm/dose powder) cholestyramine light (4 gm cholestyramine light TIER 1 PV packet, 4 gm/dose powder) colesevelam hcl (3.75 gm colesevelam hcl TIER 1 PV packet, 625 mg tab) COLESTID (1 GM TAB, 5 GM GRANULES, 5 GM COLESTID TIER 4 GA PACKET) colestipol hcl

©2021 Wellmark, Inc. 139 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS COLESTID FLAVORED (5 COLESTID GM GRANULES, 5 GM TIER 4 GA FLAVORED PACKET) colestipol hcl colestipol hcl (1 gm tab, 5 colestipol hcl TIER 1 PV gm granules, 5 gm packet) ezetimibe ezetimibe 10 mg tab TIER 1 PV ezetimibe-simvastatin (10- 10 mg tab, 10-20 mg tab, ezetimibe-simvastatin TIER 1 10-40 mg tab, 10-80 mg tab) icosapent ethyl icosapent ethyl 1 gm cap TIER 4 PA, QL (4 PER DAY(S)) 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 NEXLIZET 180-10 MG TAB NEXLIZET TIER 4 PA, QL (30 PER 30 DAY(S)) bempedoic acid-ezetimibe NIACIN NIACIN (ANTIHYPERLIPIDEMIC) (ANTIHYPERLIPIDE TIER 4 500 MG TAB MIC) niacin (antihyperlipidemic) niacin er niacin er (antihyperlipidemic) (er 500 TIER 1 PV (antihyperlipidemic) mg tab er, er 750 mg tab er, er 1000 mg tab er) NIACOR 500 MG TAB NIACOR TIER 4 niacin (antihyperlipidemic) NIASPAN (500 MG TAB ER, 750 MG TAB ER, 1000 NIASPAN TIER 4 GA MG TAB ER) niacin (antihyperlipidemic) PRALUENT (75 MG/ML PA, QL (2 PER 28 DAY(S)), SOLN A-INJ, 150 MG/ML PRALUENT TIER 3 MN-PA (Medically Necessary SOLN A-INJ) Prior Authorization) alirocumab prevalite (4 gm packet, 4 prevalite TIER 1 PV gm/dose powder) QUESTRAN (4 GM PACKET, 4 GM/DOSE QUESTRAN TIER 4 GA POWDER) cholestyramine

©2021 Wellmark, Inc. 140 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QUESTRAN LIGHT 4 QUESTRAN LIGHT GM/DOSE POWDER TIER 4 GA cholestyramine light 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 VASCEPA 0.5 GM CAP VASCEPA TIER 4 PA, QLV (QL varies) icosapent ethyl VASCEPA 1 GM CAP VASCEPA TIER 4 PA, QL (4 PER DAY(S)), GA icosapent ethyl VYTORIN (10-10 MG TAB, 10-20 MG TAB, 10-40 MG VYTORIN TIER 4 GA TAB, 10-80 MG TAB) ezetimibe-simvastatin WELCHOL (3.75 GM WELCHOL PACKET, 625 MG TAB) TIER 4 GA colesevelam hcl ZETIA 10 MG TAB ZETIA TIER 4 GA ezetimibe

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

DILATRATE-SR 40 MG DILATRATE-SR CAP ER TIER 4 isosorbide dinitrate isoditrate er isoditrate er 40 mg tab er TIER 1 ISORDIL TITRADOSE 5 ISORDIL MG TAB TIER 4 GA TITRADOSE isosorbide dinitrate isosorbide dinitrate (5 mg isosorbide dinitrate tab, 10 mg tab, 20 mg tab, TIER 1 PV 30 mg tab)

©2021 Wellmark, Inc. 141 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) 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-DUR (0.1 PATCH 24HR, 0.2 PATCH 24HR, 0.3 PATCH 24HR, 0.4 NITRO-DUR TIER 4 PATCH 24HR, 0.6 PATCH 24HR, 0.8 PATCH 24HR) 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 sl tab, 0.4 mg/hr patch nitroglycerin TIER 1 PV 24hr, 0.4 mg/spray solution, 0.6 mg sl tab, 0.6 mg/hr patch 24hr, 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) NITROLINGUAL 0.4 NITROLINGUAL MG/SPRAY SOLUTION TIER 4 GA nitroglycerin NITROMIST 400 NITROMIST MCG/SPRAY AERO SOLN TIER 4 PV, GA nitroglycerin NITROSTAT (0.3 MG SL TAB, 0.4 MG SL TAB, 0.6 NITROSTAT TIER 4 GA MG SL TAB) nitroglycerin

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

ADDERALL (5 MG TAB, 7.5 MG TAB, 10 MG TAB, 12.5 MG TAB, 15 MG TAB, ADDERALL TIER 4 GA 20 MG TAB, 30 MG TAB) amphetamine- dextroamphetamine ADDERALL XR (5 MG CAP ER 24H, 10 MG CAP ER 24H, 15 MG CAP ER 24H, 20 MG CAP ER 24H, 25 ADDERALL XR TIER 4 PA, GA MG CAP ER 24H, 30 MG CAP ER 24H) amphetamine- dextroamphetamine 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) DESOXYN 5 MG TAB DESOXYN TIER 4 GA methamphetamine hcl DEXEDRINE (5 MG CAP ER 24H, 10 MG CAP ER DEXEDRINE TIER 4 PA, GA 24H, 15 MG CAP ER 24H) dextroamphetamine sulfate dexedrine dexedrine 10 mg tab TIER 1 dextroamphetamine sulfate dextroamphetamine (15 mg tab, 20 mg tab, 30 TIER 4 sulfate mg tab) dextroamphetamine sulfate dextroamphetamine (5 mg tab, 5 mg/5ml TIER 1 sulfate solution, 10 mg tab) 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)

©2021 Wellmark, Inc. 143 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 CAP, 20 MG CHEW TAB, 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 (2.5 MG TAB, 7.5 MG TAB, 15 MG TAB, 20 ZENZEDI TIER 4 MG TAB, 30 MG TAB) dextroamphetamine sulfate zenzedi (5 mg tab, 10 mg zenzedi TIER 1 tab)

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

APTENSIO XR (10 MG CAP ER 24H, 15 MG CAP ER 24H, 20 MG CAP ER 24H, 30 MG CAP ER 24H, APTENSIO XR TIER 4 PA, GA 40 MG CAP ER 24H, 50 MG CAP ER 24H, 60 MG CAP ER 24H) methylphenidate hcl 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 CONCERTA (18 MG TAB ER, 27 MG TAB ER, 36 MG CONCERTA TIER 4 PA, GA TAB ER, 54 MG TAB ER) methylphenidate hcl DAYTRANA (10 PATCH, 15 PATCH, 20 PATCH, 30 DAYTRANA TIER 4 PA PATCH) methylphenidate dexmethylphenidate hcl dexmethylphenidate (2.5 mg tab, 5 mg tab, 10 TIER 1 hcl mg tab)

©2021 Wellmark, Inc. 144 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) FOCALIN (2.5 MG TAB, 5 FOCALIN MG TAB, 10 MG TAB) TIER 4 GA dexmethylphenidate hcl FOCALIN XR (5 MG CAP ER 24H, 10 MG CAP ER 24H, 15 MG CAP ER 24H, 20 MG CAP ER 24H, 25 FOCALIN XR MG CAP ER 24H, 30 MG TIER 4 PA, GA CAP ER 24H, 35 MG CAP ER 24H, 40 MG CAP ER 24H) dexmethylphenidate hcl 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) INTUNIV (1 MG TAB ER 24H, 2 MG TAB ER 24H, 3 INTUNIV MG TAB ER 24H, 4 MG TIER 4 GA TAB ER 24H) guanfacine hcl (adhd) KAPVAY 0.1 MG TAB ER KAPVAY 12H TIER 4 GA clonidine hcl (adhd) metadate er metadate er 20 mg tab er TIER 1 PA METHYLIN (5 SOLUTION, METHYLIN 10 SOLUTION) TIER 4 GA methylphenidate hcl methylphenidate hcl (2.5 mg chew tab, 5 mg chew tab, 5 mg tab, 5 mg/5ml methylphenidate hcl TIER 1 solution, 10 mg chew tab, 10 mg tab, 10 mg/5ml solution, 20 mg tab)

©2021 Wellmark, Inc. 145 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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, er 54 mg tab er 24h, 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) methylphenidate hcl er (xr) (er 10 mg cap er 24h, er 15 mg cap er 24h, er 20 mg methylphenidate hcl cap er 24h, er 30 mg cap er TIER 4 PA er (xr) 24h, er 40 mg cap er 24h, er 50 mg cap er 24h, er 60 mg cap er 24h) QUILLICHEW ER (ER 20 QUILLICHEW ER MG, ER 30 MG, ER 40 MG) TIER 4 PA methylphenidate hcl QUILLIVANT XR 25 QUILLIVANT XR MG/5ML SRER TIER 4 PA methylphenidate hcl RELEXXII 72 MG TAB ER RELEXXII TIER 4 PA, GA methylphenidate hcl RITALIN (5 MG TAB, 10 RITALIN MG TAB, 20 MG TAB) TIER 4 GA methylphenidate hcl RITALIN LA (10 MG CAP ER 24H, 20 MG CAP ER RITALIN LA 24H, 30 MG CAP ER 24H, TIER 4 PA, GA 40 MG CAP ER 24H) methylphenidate hcl STRATTERA (10 MG CAP, 18 MG CAP, 25 MG CAP, STRATTERA TIER 4 QL (60 PER 30 DAYS), GA 40 MG CAP, 60 MG CAP) atomoxetine hcl

CENTRAL NERVOUS SYSTEM, OTHER

AUSTEDO (6 MG TAB, 9 AUSTEDO MG TAB, 12 MG TAB) SP-P deutetrabenazine bac bac 50-325-40 mg tab TIER 1 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 ESGIC 50-325-40 MG TAB ESGIC butalbital-acetaminophen- TIER 4 GA caffeine EVRYSDI 0.75 MG/ML PA, QL (120 PER 24 EVRYSDI RECON SOLN SP-P DAY(S)) risdiplam FIORICET 50-300-40 MG CAP FIORICET TIER 4 GA butalbital-acetaminophen- caffeine INGREZZA (40 MG CAP, INGREZZA 80 MG CAP) SP-P PA valbenazine tosylate INGREZZA 60 MG CAP INGREZZA SP-P PA, QL (1 PER 1 DAY(S)) valbenazine tosylate marten-tab marten-tab 50-325 mg tab TIER 1 NUEDEXTA 20-10 MG CAP NUEDEXTA TIER 4 QL (60 PER 30 DAY(S)) dextromethorphan hbr- quinidine sulfate phrenilin forte 50-300-40 phrenilin forte TIER 1 mg cap RADICAVA 30 MG/100ML RADICAVA SOLUTION SP-M PA edaravone

©2021 Wellmark, Inc. 147 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RILUTEK 50 MG TAB RILUTEK TIER 4 GA riluzole 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 QL (240 PER 30 DAYS), tetrabenazine tetrabenazine 12.5 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) QL (120 PER 30 DAYS), tetrabenazine tetrabenazine 25 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) 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

CYMBALTA (20 MG CP DR PART, 30 MG CP DR CYMBALTA PART, 60 MG CP DR TIER 4 GA PART) duloxetine hcl 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) LYRICA (25 MG CAP, 50 MG CAP, 75 MG CAP, 100 MG CAP, 150 MG CAP, LYRICA TIER 4 GA 200 MG CAP, 225 MG CAP, 300 MG CAP) pregabalin LYRICA 20 MG/ML PA, QL (900 PER 30 LYRICA SOLUTION TIER 4 DAY(S)), GA pregabalin 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))

©2021 Wellmark, Inc. 148 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SAVELLA (12.5 MG TAB, 25 MG TAB, 50 MG TAB, SAVELLA TIER 4 QL (60 PER 30 DAY(S)) 100 MG TAB) milnacipran hcl SAVELLA TITRATION SAVELLA PACK 12.5 & 25 & 50 MG TIER 4 QL (1 PER LIFETIME) TITRATION PACK MISC milnacipran hcl

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 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 BAFIERTAM DR SP-P PA, QL (4 PER DAY(S)) monomethyl fumarate 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 QL (60 PER 30 DAYS), SBG dalfampridine er 10 mg tab dalfampridine er SP-P (Specialty Biosimilars and er 12h Specialty generics) PA, QL (60 PER 30 DAYS), dimethyl fumarate (120 mg dimethyl fumarate SP-P SBG (Specialty Biosimilars cap dr, 240 mg cap dr) and Specialty generics) PA, QL (1 PER FILL), SBG dimethyl fumarate dimethyl fumarate starter SP-P (Specialty Biosimilars and starter pack pack 120 & 240 mg misc Specialty generics) 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

©2021 Wellmark, Inc. 149 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GILENYA 0.5 MG CAP GILENYA SP-P PA, QL (30 PER 30 DAYS) fingolimod hcl PA, QL (12 PER 28 DAYS), glatiramer acetate 40 mg/ml glatiramer acetate SP-P SBG (Specialty Biosimilars soln prsyr and Specialty generics) PA, QL (12 PER 28 DAYS), glatopa glatopa 40 mg/ml soln prsyr SP-P SBG (Specialty Biosimilars and Specialty generics) KESIMPTA 20 MG/0.4ML KESIMPTA SOLN A-INJ SP-NP PA, QL (1 PER 28 DAY(S)) ofatumumab (ms) 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) 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

©2021 Wellmark, Inc. 150 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MAYZENT STARTER MAYZENT STARTER PACK 12 X 0.25 MG TAB SP-P PA, QL (12 PER 5 DAY(S)) PACK THPK siponimod fumarate OCREVUS 300 MG/10ML MN-PA (Medically Necessary OCREVUS SOLUTION SP-M Prior Authorization) ocrelizumab PLEGRIDY (125 SOLN PLEGRIDY PEN, 125 SOLN PRSYR) SP-NP PA, QL (2 PER 28 DAYS) peginterferon beta-1a PLEGRIDY 125 PLEGRIDY MCG/0.5ML SOLN PRSYR SP-NP PA, QL (2 PER 28 DAY(S)) peginterferon beta-1a PLEGRIDY STARTER PACK (PACK 63 94 SOLN PLEGRIDY PEN, PACK 63 94 SOLN SP-NP PA, QL (1 PER 28 DAYS) STARTER PACK PRSYR) 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 TECFIDERA 120 & 240 MG QL (1 PER FILL), MN-PA TECFIDERA MISC SP-NP (Medically Necessary Prior dimethyl fumarate Authorization), GA TECFIDERA 120 MG CAP PA, QL (60 PER 30 DAYS), TECFIDERA DR SP-NP MN-PA (Medically Necessary dimethyl fumarate Prior Authorization), GA TECFIDERA 240 MG CAP QL (60 PER 30 DAYS), MN- TECFIDERA DR SP-NP PA (Medically Necessary dimethyl fumarate Prior Authorization), GA TYSABRI 300 MG/15ML TYSABRI CONC SP-M PA, QL (1 PER 28 DAYS) natalizumab

©2021 Wellmark, Inc. 151 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 EVOXAC 30 MG CAP EVOXAC TIER 4 GA cevimeline hcl oralone oralone 0.1 % paste TIER 1 paroex paroex 0.12 % solution TIER 1 PERIDEX 0.12 % SOLUTION PERIDEX TIER 4 GA chlorhexidine gluconate (mouth-throat) periogard periogard 0.12 % solution TIER 1 pilocarpine hcl (5 mg tab, pilocarpine hcl TIER 1 7.5 mg tab) SALAGEN (5 MG TAB, 7.5 SALAGEN MG TAB) TIER 4 GA pilocarpine hcl (oral) triamcinolone triamcinolone acetonide TIER 1 acetonide (0.1 % cream, 0.1 % paste)

DERMATOLOGICAL AGENTS

ACANYA 1.2-2.5 % GEL ACANYA clindamycin phosphate- TIER 4 PA, GA benzoyl peroxide accutane (10 mg cap, 20 accutane mg cap, 30 mg cap, 40 mg TIER 1 cap) acitretin (10 mg cap, 17.5 acitretin TIER 1 mg cap, 25 mg cap) ACZONE (5 % GEL, 7.5 % ACZONE GEL) TIER 4 PA, GA dapsone (topical) adapalene adapalene 0.3 % gel TIER 1 PA ALDARA 5 % CREAM ALDARA TIER 4 GA imiquimod amnesteem (10 mg cap, 20 amnesteem TIER 1 mg cap, 40 mg cap) ANALPRAM HC 2.5-1 % CREAM ANALPRAM HC TIER 4 GA hydrocortisone acetate w/ pramoxine ANALPRAM HC SINGLES ANALPRAM HC 2.5-1 % CREAM TIER 4 GA SINGLES hydrocortisone acetate w/ pramoxine ANALPRAM-HC (1-1 % CREAM, 2.5-1 % LOTION) ANALPRAM-HC TIER 4 hydrocortisone acetate w/ pramoxine ATRALIN 0.05 % GEL ATRALIN TIER 4 PA, GA tretinoin avita (0.025 % cream, avita TIER 1 PA 0.025 % gel) azelaic acid azelaic acid 15 % gel TIER 1 AZELEX 20 % CREAM AZELEX TIER 4 PA azelaic acid (acne) BENZACLIN 1-5 % GEL BENZACLIN clindamycin phosphate- TIER 4 PA, GA benzoyl peroxide BENZACLIN WITH PUMP BENZACLIN WITH 1-5 % GEL TIER 4 PA, GA PUMP clindamycin phosphate- benzoyl peroxide

©2021 Wellmark, Inc. 153 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS calcipotriene (0.005 % calcipotriene foam, 0.005 % ointment, TIER 1 0.005 % solution) calcipotriene 0.005 % calcipotriene TIER 1 QL (120 PER 30 DAY(S)) cream CALCIPOTRIENE 0.005 % CALCIPOTRIENE FOAM TIER 4 GA calcipotriene 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 CARAC 0.5 % CREAM CARAC TIER 4 PA, GA fluorouracil (topical) 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) CONDYLOX 0.5 % GEL CONDYLOX TIER 4 PA podofilox CORTISPORIN (1 % OINTMENT, 3.5-10000-0.5 CORTISPORIN TIER 4 CREAM) neomycin-polymyxin-hc COSENTYX (300 MG COSENTYX (300 MG DOSE) 150 MG/ML SOLN SP-P PA, QL (2 PER 28 DAYS) DOSE) PRSYR secukinumab COSENTYX 75 MG/0.5ML COSENTYX SOLN PRSYR SP-P PA, QL (1 PER 28 DAY(S)) secukinumab COSENTYX COSENTYX SENSOREADY (300 MG) SENSOREADY (300 SP-P PA, QL (2 PER 28 DAYS) 150 MG/ML SOLN A-INJ MG) secukinumab

©2021 Wellmark, Inc. 154 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS dapsone (5 % gel, 7.5 % dapsone TIER 1 PA gel) DIFFERIN 0.3 % GEL DIFFERIN TIER 4 PA, GA adapalene DOVONEX 0.005 % QL (120 PER 30 DAY(S)), DOVONEX CREAM TIER 4 GA calcipotriene DUAC 1.2-5 % GEL clindamycin phosphate- DUAC TIER 4 PA, GA benzoyl peroxide (refrigerate) DUPIXENT (200 MG/1.14ML SOLN PEN, 200 MG/1.14ML SOLN DUPIXENT PRSYR, 300 MG/2ML SP-P PA, QL (2 PER 28 DAY(S)) SOLN PEN, 300 MG/2ML SOLN PRSYR) dupilumab DUROLANE 60 MG/3ML PRSYR MN-PA (Medically Necessary DUROLANE SP-M sodium hyaluronate Prior Authorization) (viscosupplement) ELIDEL 1 % CREAM QL (100 PER 30 DAY(S)), ELIDEL TIER 4 pimecrolimus GA EUCRISA 2 % OINTMENT EUCRISA TIER 4 PA crisaborole FINACEA 15 % FOAM FINACEA TIER 4 PA azelaic acid FINACEA 15 % GEL FINACEA TIER 4 GA azelaic acid 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-M PA (Medically Necessary tildrakizumab-asmn Prior Authorization) imiquimod imiquimod 3.75 % cream TIER 1 PA imiquimod imiquimod 5 % cream TIER 1 imiquimod pump 3.75 % imiquimod pump TIER 1 PA cream

©2021 Wellmark, Inc. 155 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS isotretinoin (10 mg cap, 20 isotretinoin mg cap, 30 mg cap, 40 mg TIER 1 cap) IVERMECTIN 1 % CREAM IVERMECTIN TIER 4 PA, GA ivermectin (rosacea) 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, 3-0.5 TIER 1 hydrocortisone ace % kit, 3-1 % kit, 3-2.5 % kit) lidocort lidocort 3-0.5 % cream TIER 1 LOTRISONE 1-0.05 % CREAM LOTRISONE TIER 4 GA clotrimazole w/ betamethasone methoxsalen rapid 10 mg methoxsalen rapid TIER 1 cap METROCREAM 0.75 % METROCREAM CREAM TIER 4 GA metronidazole (topical) METROGEL 1 % GEL METROGEL TIER 4 GA metronidazole (topical) METROLOTION 0.75 % METROLOTION LOTION TIER 4 GA metronidazole (topical) metronidazole (0.75 % metronidazole cream, 0.75 % gel, 0.75 % TIER 1 lotion, 1 % gel) MIRVASO 0.33 % GEL MIRVASO brimonidine tartrate TIER 4 PA, QL (30 PER 30 DAY(S)) (topical) myorisan (10 mg cap, 20 myorisan mg cap, 30 mg cap, 40 mg TIER 1 cap) NEO-SYNALAR 0.5-0.025 % CREAM NEO-SYNALAR TIER 4 neomycin sulfate- fluocinolone acetonide neuac neuac 1.2-5 % gel TIER 1 PA OXSORALEN ULTRA 10 OXSORALEN ULTRA MG CAP TIER 4 GA methoxsalen rapid PICATO (0.015 % GEL, PICATO 0.05 % GEL) TIER 4 PA ingenol mebutate

©2021 Wellmark, Inc. 156 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS pimecrolimus pimecrolimus 1 % cream TIER 1 QL (100 PER 30 DAY(S)) PODOCON 25 % PODOCON SOLUTION TIER 1 podophyllum resin podofilox podofilox 0.5 % solution 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 PROTOPIC (0.03 % OINTMENT, 0.1 % PROTOPIC TIER 4 GA OINTMENT) tacrolimus (topical) RECTIV 0.4 % OINTMENT RECTIV TIER 4 nitroglycerin (intra-anal) REGRANEX 0.01 % GEL REGRANEX TIER 3 becaplermin RETIN-A (0.01 % GEL, 0.025 % CREAM, 0.025 % RETIN-A GEL, 0.05 % CREAM, 0.1 TIER 4 PA, GA % CREAM) tretinoin RETIN-A MICRO (0.04 % RETIN-A MICRO GEL, 0.1 % GEL) TIER 4 PA, GA tretinoin microsphere RETIN-A MICRO PUMP RETIN-A MICRO (PUMP 0.04 % GEL, PUMP TIER 4 PA, GA PUMP 0.1 % GEL) tretinoin microsphere rosadan (0.75 % cream, rosadan TIER 1 0.75 % gel) 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)

©2021 Wellmark, Inc. 157 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SKYRIZI (150 MG DOSE) SKYRIZI (150 MG 75 MG/0.83ML PREF SY SP-P PA, QL (2 PER 84 DAY(S)) DOSE) KT risankizumab-rzaa SOOLANTRA 1 % CREAM SOOLANTRA TIER 4 PA, GA ivermectin (rosacea) SORIATANE (10 MG CAP, SORIATANE 17.5 MG CAP, 25 MG CAP) TIER 4 GA acitretin SORILUX 0.005 % FOAM SORILUX TIER 4 GA calcipotriene STELARA (45 MG/0.5ML SOLN PRSYR, 45 PA, QLV (Quantity Limit STELARA MG/0.5ML SOLUTION, 90 SP-P Varies), PA-QL (for Crohn's MG/ML SOLN PRSYR) Disease) 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 TACLONEX 0.005-0.064 % OINTMENT QL (120 PER 30 DAY(S)), TACLONEX calcipotriene- TIER 4 GA betamethasone dipropionate TACLONEX 0.005-0.064 % SUSPENSION TACLONEX calcipotriene- TIER 4 GA betamethasone dipropionate tacrolimus (0.03 % tacrolimus TIER 1 ointment, 0.1 % ointment) 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 TAZORAC (0.05 % CREAM, 0.05 % GEL, 0.1 TAZORAC TIER 4 % CREAM, 0.1 % GEL) tazarotene

©2021 Wellmark, Inc. 158 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TREMFYA (100 MG/ML QL (1 PER 56 DAY(S)), MN- SOLN PEN, 100 MG/ML TREMFYA SP-NP PA (Medically Necessary SOLN PRSYR) Prior Authorization) guselkumab TRETIN-X 0.075 % CREAM TRETIN-X TIER 4 PA tretinoin tretinoin (0.01 % gel, 0.025 % cream, 0.025 % gel, 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) URAMAXIN 45 % CREAM URAMAXIN TIER 4 urea VECTICAL 3 MCG/GM VECTICAL OINTMENT TIER 4 GA calcitriol (topical) VELTIN 1.2-0.025 % GEL VELTIN clindamycin phosphate- TIER 4 PA, GA tretinoin VEREGEN 15 % VEREGEN OINTMENT TIER 3 PA sinecatechins zenatane (10 mg cap, 20 zenatane mg cap, 30 mg cap, 40 mg TIER 1 cap) ZIANA 1.2-0.025 % GEL ZIANA clindamycin phosphate- TIER 4 PA, GA tretinoin ZYCLARA 3.75 % CREAM ZYCLARA TIER 4 PA, GA imiquimod ZYCLARA PUMP (PUMP 2.5 % CREAM, PUMP 3.75 ZYCLARA PUMP TIER 4 PA, GA % CREAM) imiquimod

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

©2021 Wellmark, Inc. 159 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CARNITOR (1 GM/10ML SOLUTION, 330 MG TAB) CARNITOR TIER 4 GA levocarnitine (metabolic modifiers) CARNITOR SF 1 GM/10ML SOLUTION CARNITOR SF TIER 4 GA levocarnitine (metabolic modifiers) CRYSVITA (10 MG/ML SOLUTION, 20 MG/ML CRYSVITA SOLUTION, 30 MG/ML SP-M PA SOLUTION) burosumab-twza DOJOLVI 100 % LIQUID DOJOLVI SP-P PA triheptanoin EFFER-K (10 EFFER TAB, 20 EFFER TAB) EFFER-K TIER 4 potassium bicarbonate- citric acid effervescent pot effervescent pot chloride 25 TIER 1 chloride meq effer tab K-PHOS 500 MG TAB K-PHOS potassium phosphate TIER 3 monobasic K-TAB (8 TAB ER, 10 TAB K-TAB ER, 20 TAB ER) TIER 4 GA potassium chloride 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 klor-con m15 klor-con m15 15 meq tab er TIER 1 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

©2021 Wellmark, Inc. 160 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 MEQ TIER 1 GA CHLORIDE EFFER TAB potassium bicarb & chloride potassium chloride (10 % solution, 20 meq packet, 20 potassium chloride meq/15ml (10%) solution, TIER 1 40 meq/15ml (20%) solution) potassium chloride crys er potassium chloride (crys er 10 tab er, crys er TIER 1 crys er 15 tab er, 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) saline flush saline flush 0.9 % solution TIER 1 saline flush zr 0.9 % saline flush zr TIER 1 solution 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 SBG (Specialty Biosimilars clovique clovique 250 mg cap SP-P and Specialty generics)

©2021 Wellmark, Inc. 161 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS deferasirox (90 mg packet, 90 mg tab, 125 mg tab sol, 180 mg packet, 180 mg tab, SBG (Specialty Biosimilars deferasirox SP-P 250 mg tab sol, 360 mg and Specialty generics) packet, 360 mg tab, 500 mg tab sol) deferasirox granules (granules 90 mg packet, SBG (Specialty Biosimilars deferasirox granules SP-P granules 180 mg packet, and Specialty generics) granules 360 mg packet) SBG (Specialty Biosimilars deferiprone deferiprone 500 mg tab SP-P and Specialty generics) 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 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 PA, QL (60 PER 30 DAYS), SAMSCA SP-P tolvaptan GA

©2021 Wellmark, Inc. 162 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 15 GM/60ML SUSPENSION SPS TIER 1 GA sodium polystyrene sulfonate SYPRINE 250 MG CAP SYPRINE SP-NP GA trientine hcl PA, QL (60 PER 30 DAYS), tolvaptan (15 mg tab, 30 tolvaptan SP-P SBG (Specialty Biosimilars mg tab) and Specialty generics) SBG (Specialty Biosimilars trientine hcl trientine hcl 250 mg cap SP-P and Specialty generics)

PHOSPHATE BINDERS

calcium acetate (phos calcium acetate (phos binder) (667 mg cap, 667 TIER 1 binder) mg tab) ELIPHOS 667 MG TAB ELIPHOS calcium acetate (phosphate TIER 4 GA binder) FOSRENOL (500 MG CHEW TAB, 750 MG FOSRENOL CHEW TAB, 1000 MG TIER 4 GA CHEW TAB) lanthanum carbonate K-PHOS-NEUTRAL 155- 852-130 MG TAB K-PHOS-NEUTRAL pot phosphate monobasic TIER 4 GA w/ sod phosphate dibasic & monobasic lanthanum carbonate (500 lanthanum carbonate mg chew tab, 750 mg chew TIER 1 tab, 1000 mg chew tab) PHOSLYRA 667 MG/5ML SOLUTION PHOSLYRA TIER 4 calcium acetate (phosphate binder) 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

©2021 Wellmark, Inc. 163 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS phosphorous 155-852-130 phosphorous TIER 1 mg tab RENAGEL (400 MG TAB, RENAGEL 800 MG TAB) TIER 4 GA sevelamer hcl RENVELA (0.8 GM PACKET, 2.4 GM PACKET, RENVELA TIER 4 GA 800 MG TAB) sevelamer carbonate 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) VELPHORO 500 MG VELPHORO CHEW TAB TIER 4 sucroferric oxyhydroxide 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

©2021 Wellmark, Inc. 164 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 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

©2021 Wellmark, Inc. 165 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 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

©2021 Wellmark, Inc. 166 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 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 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

©2021 Wellmark, Inc. 167 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SE-NATAL 19 (19 MG CHEW TAB, 19 MG TAB) SE-NATAL 19 TIER 2 PV prenatal vit w/ docusate-fe fumarate-folic acid 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

©2021 Wellmark, Inc. 168 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VINATE C 30-1 MG TAB VINATE C prenatal without a vit w/ fe TIER 2 fumarate-folic acid 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 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 VP-GGR-B6 PRENATAL VP-GGR-B6 1.2 MG TAB TIER 2 PV PRENATAL prenatal w/ calcium-vit b6- folic acid-ginger

©2021 Wellmark, Inc. 169 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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

ANASPAZ 0.125 MG TAB ANASPAZ DISP TIER 4 GA hyoscyamine sulfate BENTYL 10 MG CAP BENTYL TIER 4 GA dicyclomine hcl 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 cap, dicyclomine hcl 10 mg/5ml solution, 20 mg TIER 1 tab) DONNATAL EXTENTABS TAB ER DONNATAL phenobarbital- TIER 4 EXTENTABS hyoscyamine-atropine- scopolamine ed-spaz ed-spaz 0.125 mg tab disp TIER 1 GLYCATE 1.5 MG TAB GLYCATE TIER 4 glycopyrrolate glycopyrrolate (1 mg tab, 2 glycopyrrolate TIER 1 mg tab) GLYCOPYRROLATE 1.5 GLYCOPYRROLATE MG TAB TIER 4 glycopyrrolate hyoscyamine sulfate (0.125 mg sl tab, 0.125 mg tab, hyoscyamine sulfate 0.125 mg tab disp, 0.125 TIER 1 mg/5ml elixir, 0.125 mg/ml solution) 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/5ml hyosyne TIER 1 elixir, 0.125 mg/ml solution)

©2021 Wellmark, Inc. 170 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LEVBID 0.375 MG TAB ER LEVBID 12H TIER 4 GA hyoscyamine sulfate LEVSIN 0.125 MG TAB LEVSIN TIER 4 GA hyoscyamine sulfate LEVSIN/SL 0.125 MG SL LEVSIN/SL TAB TIER 4 GA hyoscyamine sulfate LIBRAX 5-2.5 MG CAP LIBRAX chlordiazepoxide hcl- TIER 4 GA clidinium bromide 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 sl tab, oscimin 0.125 mg tab, 0.125 mg tab TIER 1 disp) oscimin sr 0.375 mg tab er oscimin sr TIER 1 12h PAMINE FORTE 5 MG TAB PAMINE FORTE TIER 4 GA methscopolamine bromide PROPANTHELINE PROPANTHELINE BROMIDE 15 MG TAB TIER 1 BROMIDE propantheline bromide ROBINUL 1 MG TAB ROBINUL TIER 4 GA glycopyrrolate ROBINUL-FORTE 2 MG ROBINUL-FORTE TAB TIER 4 GA glycopyrrolate SYMAX DUOTAB 0.375 SYMAX DUOTAB MG TAB ER TIER 4 hyoscyamine sulfate 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

ACTIGALL 300 MG CAP ACTIGALL TIER 4 GA ursodiol alvimopan alvimopan 12 mg cap TIER 1 amoxicill-clarithro- amoxicill-clarithro-lansopraz TIER 1 lansopraz misc CHENODAL 250 MG TAB CHENODAL TIER 2 chenodiol

©2021 Wellmark, Inc. 171 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 4 GA alvimopan GASTROCROM 100 MG/5ML CONC GASTROCROM TIER 4 GA cromolyn sodium (mastocytosis) GATTEX 5 MG KIT GATTEX SP-M teduglutide (rdna) IMCIVREE 10 MG/ML IMCIVREE SOLUTION SP-NP PA, QL (9 PER 30 DAY(S)) setmelanotide acetate LOMOTIL 2.5-0.025 MG LOMOTIL TAB TIER 4 GA diphenoxylate w/ atropine MOTEGRITY (1 MG TAB, 2 MN-PA (Medically Necessary MOTEGRITY MG TAB) TIER 4 Prior Authorization) prucalopride succinate MOTOFEN 1-0.025 MG MOTOFEN TAB TIER 4 difenoxin w/ atropine MOVANTIK (12.5 MG TAB, MOVANTIK 25 MG TAB) TIER 2 PA naloxegol oxalate OMECLAMOX-PAK 500- 500-20 MG MISC OMECLAMOX-PAK TIER 4 amoxicillin-clarithromycin w/ omeprazole opium 10 mg/ml (1%) opium TIER 1 tincture PAREGORIC 2 MG/5ML PAREGORIC TINCTURE TIER 1 paregoric PREVPAC MISC PREVPAC amoxicillin-clarithromycin w/ TIER 4 GA lansoprazole RELISTOR (8 MG/0.4ML QL (30 PER 30 DAYS), MN- SOLUTION, 12 MG/0.6ML RELISTOR TIER 4 PA (Medically Necessary SOLUTION) Prior Authorization) methylnaltrexone bromide

©2021 Wellmark, Inc. 172 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RELISTOR 150 MG TAB MN-PA (Medically Necessary RELISTOR TIER 4 methylnaltrexone bromide Prior Authorization) URSO 250 250 MG TAB URSO 250 TIER 4 GA ursodiol URSO FORTE 500 MG URSO FORTE TAB TIER 4 GA ursodiol 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 mg/5ml cimetidine hcl solution, 400 mg/6.67ml TIER 1 solution) famotidine (40 mg tab, 40 famotidine TIER 1 mg/5ml recon susp) nizatidine (15 mg/ml nizatidine solution, 150 mg cap, 300 TIER 1 mg cap) PEPCID (40 MG TAB, 40 PEPCID MG/5ML RECON SUSP) TIER 4 GA famotidine ranitidine hcl (15 mg/ml syrup, 75 mg/5ml syrup, ranitidine hcl 150 mg cap, 150 mg/10ml TIER 1 syrup, 300 mg cap, 300 mg tab) ZANTAC 300 MG TAB ZANTAC TIER 4 GA ranitidine hcl

IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl (0.5 mg tab, 1 alosetron hcl TIER 1 mg tab) AMITIZA (8 MCG CAP, 24 MN-PA (Medically Necessary AMITIZA MCG CAP) TIER 4 Prior Authorization), GA lubiprostone LINZESS (72 MCG CAP, 145 MCG CAP, 290 MCG LINZESS TIER 2 CAP) linaclotide LOTRONEX (0.5 MG TAB, LOTRONEX 1 MG TAB) TIER 4 GA alosetron hcl lubiprostone (8 mcg cap, 24 lubiprostone TIER 1 mcg cap)

LAXATIVES

CASCARA SAGRADA 1 CASCARA GM/ML FL EXTRACT TIER 2 SAGRADA cascara sagrada CLENPIQ 10-3.5-12 MG- GM -GM/160ML SOLUTION CLENPIQ TIER 4 sodium picosulfate- magnesium oxide- anhydrous citric acid COLYTE WITH FLAVOR PACKS 240 GM RECON COLYTE WITH SOLN TIER 4 GA FLAVOR PACKS peg 3350-kcl-sod bicarb- sod chloride-sod sulfate 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 GOLYTELY (227.1 GM RECON SOLN, 236 GM GOLYTELY RECON SOLN) TIER 4 GA peg 3350-kcl-sod bicarb- sod chloride-sod sulfate lactulose (10 gm/15ml lactulose solution, 20 gm/30ml TIER 1 solution) lactulose lactulose encephalopathy TIER 1 encephalopathy 10 gm/15ml solution

©2021 Wellmark, Inc. 174 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MOVIPREP 100 GM RECON SOLN MOVIPREP peg 3350-kcl-nacl-na TIER 4 GA sulfate-na ascorbate- ascorbic acid NULYTELY LEMON-LIME 420 GM RECON SOLN NULYTELY LEMON- peg 3350-potassium TIER 4 GA LIME chloride-sod bicarbonate- sod chloride NULYTELY WITH FLAVOR PACKS 420 GM RECON NULYTELY WITH SOLN TIER 4 GA FLAVOR PACKS peg 3350-potassium chloride-sod bicarbonate- sod chloride OSMOPREP 1.102-0.398 GM TAB OSMOPREP sodium phosphate TIER 2 PV monobasic-sodium phosphate dibasic 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 PLENVU 140 GM RECON SOLN PLENVU peg 3350-kcl-nacl-na TIER 4 sulfate-na ascorbate- ascorbic acid PREPOPIK 10-3.5-12 MG- GM-GM PACKET PREPOPIK sodium picosulfate- TIER 4 magnesium oxide- anhydrous citric acid

©2021 Wellmark, Inc. 175 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 SUTAB 1479-225-188 MG TAB SUTAB TIER 4 sodium sulfate-magnesium sulfate-potassium chloride trilyte trilyte 420 gm recon soln TIER 1 PV

PROTECTANTS

CARAFATE (1 GM TAB, 1 CARAFATE GM/10ML SUSPENSION) TIER 4 GA sucralfate CYTOTEC (100 MCG TAB, CYTOTEC 200 MCG TAB) TIER 4 GA misoprostol misoprostol (100 mcg tab, misoprostol TIER 1 200 mcg tab) sucralfate (1 gm tab, 1 sucralfate TIER 1 gm/10ml suspension)

PROTON PUMP INHIBITORS

ACIPHEX 20 MG TAB DR PA, QL (60 PER 30 DAYS), ACIPHEX TIER 4 rabeprazole sodium PA-QL (90 / 30 days), GA ACIPHEX SPRINKLE (5 MG CAP SPRINK, 10 MG PA, QL (30 PER 30 DAYS), ACIPHEX SPRINKLE TIER 4 CAP SPRINK) PA-QL (60 / 30 days) rabeprazole sodium cvs lansoprazole 15 mg tab cvs lansoprazole TIER 1 PA-QL (90 / 30 days) dr disp DEXILANT (30 MG CAP PA, QL (30 PER 30 DAYS), DEXILANT DR, 60 MG CAP DR) TIER 4 PA-QL (60 / 30 days) dexlansoprazole esomeprazole magnesium esomeprazole (10 mg packet, 20 mg PA, QL (60 PER 30 DAYS), TIER 1 magnesium packet, 40 mg cap dr, 40 PA-QL (90 / 30 days) mg packet) ESOMEPRAZOLE ESOMEPRAZOLE STRONTIUM 24.65 MG TIER 4 PA, QL (60 PER 30 DAYS) STRONTIUM CAP DR esomeprazole strontium ESOMEPRAZOLE ESOMEPRAZOLE STRONTIUM 49.3 MG CAP PA, QL (60 PER 30 DAYS), TIER 4 STRONTIUM DR PA-QL (90 / 30 days) esomeprazole strontium

©2021 Wellmark, Inc. 176 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) NEXIUM (2.5 MG PACKET, 5 MG PACKET, 10 MG PACKET, 20 MG PACKET, PA, QL (60 PER 30 DAYS), NEXIUM TIER 4 40 MG CAP DR, 40 MG PA-QL (90 / 30 days) PACKET) esomeprazole magnesium 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) PREVACID 30 MG CAP DR QL (60 PER 30 DAYS), PA- PREVACID TIER 4 lansoprazole QL (90 / 30 days), GA PREVACID SOLUTAB (15 PREVACID MG TAB DR DISP, 30 MG PA, QL (60 PER 30 DAYS), TIER 4 SOLUTAB TAB DR DISP) PA-QL (90 / 30 days), GA lansoprazole PRILOSEC (2.5 MG PA, QL (60 PER 30 DAYS), PRILOSEC PACKET, 10 MG PACKET) TIER 4 PA-QL (90 / 30 days) omeprazole magnesium PROTONIX (20 MG TAB QL (60 PER 30 DAYS), PA- PROTONIX DR, 40 MG TAB DR) TIER 4 QL (90 / 30 days), GA pantoprazole sodium PROTONIX 40 MG PA, QL (60 PER 30 DAYS), PROTONIX PACKET TIER 4 PA-QL (90 / 30 days), GA pantoprazole sodium RABEPRAZOLE SODIUM RABEPRAZOLE PA, QL (30 PER 30 DAYS), 10 MG CAP SPRINK TIER 4 SODIUM PA-QL (60 / 30 days) rabeprazole sodium 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

©2021 Wellmark, Inc. 177 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CARBAGLU 200 MG TAB CARBAGLU SP-P carglumic acid CERDELGA 84 MG CAP CERDELGA SP-P PA eliglustat tartrate CEREZYME 400 UNIT MN-PA (Medically Necessary CEREZYME RECON SOLN SP-M Prior Authorization) 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 ELELYSO RECON SOLN SP-M PA 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 sodium KUVAN (100 MG PACKET, 100 MG TAB, 500 MG KUVAN SP-NP GA PACKET) sapropterin dihydrochloride LUMIZYME 50 MG RECON LUMIZYME SOLN SP-M alglucosidase alfa PA, SBG (Specialty miglustat miglustat 100 mg cap SP-P Biosimilars and Specialty generics)

©2021 Wellmark, Inc. 178 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NAGLAZYME 1 MG/ML NAGLAZYME SOLUTION SP-M galsulfase nitisinone (2 mg cap, 5 mg SBG (Specialty Biosimilars nitisinone SP-P cap, 10 mg cap) and Specialty generics) 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 OXLUMO 94.5 MG/0.5ML OXLUMO SOLUTION SP-M PA lumasiran sodium 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, 2600-8800 CP DR PART, 4200 CP DR PART, 10500 CP DR PART, 16800 CP DR PART, PANCREAZE TIER 2 21000 CP DR PART, 37000-97300 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) PROCYSBI (25 MG CAP DR, 75 MG CAP DR, 75 PROCYSBI MG PACKET, 300 MG SP-P PACKET) cysteamine bitartrate

©2021 Wellmark, Inc. 179 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RAVICTI 1.1 GM/ML RAVICTI LIQUID SP-P PA, QL (525 PER 30 DAYS) glycerol phenylbutyrate sapropterin dihydrochloride sapropterin SBG (Specialty Biosimilars (100 mg packet, 100 mg SP-P dihydrochloride and Specialty generics) tab, 500 mg packet) sodium phenylbutyrate (3 sodium SBG (Specialty Biosimilars gm/tsp powder, 500 mg SP-P phenylbutyrate and Specialty generics) 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 (10440-39150 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) ZOKINVY (50 MG CAP, 75 ZOKINVY MG CAP) SP-P QLV (Quantity Limit Varies) lonafarnib

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) DETROL (1 MG TAB, 2 MG DETROL TAB) TIER 4 GA tolterodine tartrate DETROL LA (2 MG CAP ER 24H, 4 MG CAP ER DETROL LA TIER 4 GA 24H) tolterodine tartrate DITROPAN XL (5 MG TAB ER 24H, 10 MG TAB ER DITROPAN XL TIER 4 GA 24H, 15 MG TAB ER 24H) oxybutynin chloride ENABLEX (7.5 MG TAB ER ENABLEX 24H, 15 MG TAB ER 24H) TIER 4 GA darifenacin hydrobromide flavoxate hcl flavoxate hcl 100 mg tab TIER 1 GELNIQUE 10 % GEL GELNIQUE TIER 4 oxybutynin chloride GELNIQUE PUMP 10 % GELNIQUE PUMP GEL TIER 4 oxybutynin chloride MYRBETRIQ (25 MG TAB ER 24H, 50 MG TAB ER MYRBETRIQ TIER 4 24H) mirabegron 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)

©2021 Wellmark, Inc. 181 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TOVIAZ (4 MG TAB ER TOVIAZ 24H, 8 MG TAB ER 24H) TIER 4 QL (30 PER 30 DAYS) fesoterodine fumarate trospium chloride trospium chloride 20 mg tab TIER 1 trospium chloride er 60 mg trospium chloride er TIER 1 cap er 24h VESICARE (5 MG TAB, 10 VESICARE MG TAB) TIER 4 GA solifenacin succinate VESICARE LS 5 MG/5ML PA, QL (300 PER 30 VESICARE LS SUSPENSION TIER 4 DAY(S)) solifenacin succinate

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl er 10 mg tab alfuzosin hcl er TIER 1 er 24h AVODART 0.5 MG CAP AVODART TIER 4 GA dutasteride CARDURA XL (4 MG TAB ER 24H, 8 MG TAB ER CARDURA XL TIER 4 24H) doxazosin mesylate (bph) CIALIS (2.5 MG TAB, 5 MG CIALIS TAB) TIER 4 QL (30 PER 30 DAYS), GA tadalafil 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 FLOMAX 0.4 MG CAP FLOMAX TIER 4 GA tamsulosin hcl JALYN 0.5-0.4 MG CAP JALYN TIER 4 GA dutasteride-tamsulosin hcl PROSCAR 5 MG TAB PROSCAR TIER 4 GA finasteride RAPAFLO (4 MG CAP, 8 RAPAFLO MG CAP) TIER 4 QL (30 PER 30 DAYS), GA silodosin 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)

GENITOURINARY AGENTS, OTHER

bethanechol chloride (5 mg bethanechol chloride tab, 10 mg tab, 25 mg tab, TIER 1 50 mg tab) CAVERJECT (20 MCG RECON SOLN, 40 MCG CAVERJECT TIER 4 QL (6 PER 30 DAYS) RECON SOLN) alprostadil (vasodilator) CAVERJECT IMPULSE (10 CAVERJECT MCG KIT, 20 MCG KIT) TIER 4 QL (6 PER 30 DAYS) IMPULSE alprostadil (vasodilator) CIALIS (10 MG TAB, 20 CIALIS MG TAB) TIER 4 QL (6 PER 30 DAYS), GA tadalafil CYTRA K CRYSTALS CYTRA K 3300-1002 MG PACKET TIER 1 GA CRYSTALS potassium citrate-citric acid D-PENAMINE 125 MG TAB D-PENAMINE TIER 2 penicillamine DEPEN TITRATABS 250 DEPEN TITRATABS MG TAB SP-NP GA penicillamine EDEX (10 MCG KIT, 20 EDEX MCG KIT, 40 MCG KIT) TIER 4 QL (6 PER 30 DAYS) alprostadil (vasodilator) ELMIRON 100 MG CAP ELMIRON pentosan polysulfate TIER 3 sodium K-PHOS NO 2 305-700 MG TAB K-PHOS NO 2 TIER 4 potassium & sodium acid phosphates LEVITRA (2.5 MG TAB, 5 MG TAB, 10 MG TAB, 20 LEVITRA TIER 4 QL (6 PER 30 DAYS), GA MG TAB) vardenafil hcl LITHOSTAT 250 MG TAB LITHOSTAT TIER 3 acetohydroxamic acid

©2021 Wellmark, Inc. 183 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MUSE (125 MCG PELLET, 250 MCG PELLET, 500 MUSE MCG PELLET, 1000 MCG TIER 4 QL (6 PER 30 DAYS) PELLET) alprostadil (vasodilator) ORACIT 490-640 MG/5ML ORACIT SOLUTION TIER 4 sodium citrate & citric acid penicillamine penicillamine 250 mg tab SP-P 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) PYRIDIUM 200 MG TAB PYRIDIUM TIER 4 GA phenazopyridine hcl 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 STAXYN 10 MG TAB DISP STAXYN TIER 4 QL (6 PER 30 DAYS), GA vardenafil hcl STENDRA (50 MG TAB, 100 MG TAB, 200 MG STENDRA TIER 4 QL (6 PER 30 DAYS) TAB) avanafil taron-crystals 3300-1002 taron-crystals TIER 1 mg packet THIOLA 100 MG TAB THIOLA SP-NP GA tiopronin THIOLA EC (EC 100 MG TAB DR, EC 300 MG TAB THIOLA EC SP-P DR) tiopronin tiopronin tiopronin 100 mg tab SP-P tricitrates 550-500-334 tricitrates TIER 1 mg/5ml solution

©2021 Wellmark, Inc. 184 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS URECHOLINE (5 MG TAB, 10 MG TAB, 25 MG TAB, URECHOLINE TIER 4 GA 50 MG TAB) bethanechol chloride UROCIT-K 10 10 MEQ (1080 MG) TAB ER UROCIT-K 10 TIER 4 GA potassium citrate (alkalinizer) UROCIT-K 15 15 MEQ (1620 MG) TAB ER UROCIT-K 15 TIER 4 GA potassium citrate (alkalinizer) UROCIT-K 5 5 MEQ (540 MG) TAB ER UROCIT-K 5 TIER 4 GA potassium citrate (alkalinizer) vardenafil hcl (2.5 mg tab, 5 vardenafil hcl mg tab, 10 mg tab, 10 mg TIER 1 QL (6 PER 30 DAYS) tab disp, 20 mg tab) VIAGRA (25 MG TAB, 50 VIAGRA MG TAB, 100 MG TAB) TIER 4 QL (6 PER 30 DAYS), GA sildenafil citrate 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)

ACLOVATE 0.05 % ACLOVATE CREAM TIER 4 GA alclometasone dipropionate ACTHAR 80 UNIT/ML GEL ACTHAR SP-M PA corticotropin 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 % LOTION, AMCINONIDE TIER 1 0.1 % OINTMENT) amcinonide APEXICON E 0.05 % CREAM APEXICON E TIER 4 diflorasone diacetate emollient base

©2021 Wellmark, Inc. 185 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS baycadron baycadron 0.5 mg/5ml elixir TIER 1 beser beser 0.05 % lotion TIER 1 betamethasone betamethasone dipropionate (0.05 % TIER 1 dipropionate cream, 0.05 % lotion, 0.05 % ointment) betamethasone betamethasone dipropionate aug (0.05 % TIER 1 dipropionate aug cream, 0.05 % gel, 0.05 % lotion, 0.05 % ointment) betamethasone valerate betamethasone (0.1 % cream, 0.1 % lotion, TIER 1 valerate 0.1 % ointment, 0.12 % foam) BRYHALI 0.01 % LOTION BRYHALI TIER 4 QL (200 PER 30 DAY(S)) halobetasol propionate CAPEX 0.01 % SHAMPOO CAPEX TIER 4 fluocinolone acetonide clobetasol prop clobetasol prop emollient TIER 1 emollient base base 0.05 % cream clobetasol propionate (0.05 % cream, 0.05 % foam, 0.05 % gel, 0.05 % liquid, clobetasol propionate TIER 1 0.05 % lotion, 0.05 % ointment, 0.05 % shampoo, 0.05 % solution) clobetasol propionate clobetasol propionate e TIER 1 e 0.05 % cream clobetasol propionate clobetasol propionate TIER 1 emulsion emulsion 0.05 % foam CLOBEX (0.05 % LOTION, CLOBEX 0.05 % SHAMPOO) TIER 4 GA clobetasol propionate CLOBEX SPRAY 0.05 % CLOBEX SPRAY LIQUID TIER 4 GA clobetasol propionate 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 CLODERM 0.1 % CREAM CLODERM TIER 4 QL (90 PER 30 DAY(S)), GA clocortolone pivalate CLODERM PUMP 0.1 % CLODERM PUMP CREAM TIER 4 QL (90 PER 30 DAY(S)), GA clocortolone pivalate

©2021 Wellmark, Inc. 186 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CORDRAN (0.05 % CREAM, 0.05 % CORDRAN TIER 4 GA OINTMENT) flurandrenolide CORDRAN 0.05 % LOTION QL (120 PER 30 DAY(S)), CORDRAN TIER 4 flurandrenolide GA cormax scalp cormax scalp application TIER 1 application 0.05 % solution CORTEF (5 MG TAB, 10 CORTEF MG TAB, 20 MG TAB) TIER 4 GA hydrocortisone CORTISONE ACETATE 25 CORTISONE MG TAB TIER 4 ACETATE cortisone acetate CUTIVATE 0.05 % LOTION CUTIVATE TIER 4 GA fluticasone propionate 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 DERMA-SMOOTHE/FS DERMA- BODY 0.01 % OIL TIER 4 GA SMOOTHE/FS BODY fluocinolone acetonide DERMA- DERMA-SMOOTHE/FS SMOOTHE/FS SCALP 0.01 % OIL TIER 4 GA SCALP fluocinolone acetonide DERMATOP 0.1 % DERMATOP OINTMENT TIER 4 prednicarbate DESONATE 0.05 % GEL DESONATE TIER 4 GA desonide desonide (0.05 % cream, desonide 0.05 % gel, 0.05 % lotion, TIER 1 0.05 % ointment) DESOWEN (0.05 % CREAM, 0.05 % LOTION, DESOWEN TIER 4 GA 0.05 % OINTMENT) desonide desoximetasone (0.05 % cream, 0.05 % gel, 0.05 % desoximetasone ointment, 0.25 % cream, TIER 1 0.25 % liquid, 0.25 % ointment)

©2021 Wellmark, Inc. 187 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS desrx desrx 0.05 % gel TIER 1 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 DIPROLENE 0.05 % OINTMENT DIPROLENE TIER 4 GA betamethasone dipropionate augmented DIPROLENE AF 0.05 % CREAM DIPROLENE AF TIER 4 GA betamethasone dipropionate augmented ELOCON (0.1 % CREAM, ELOCON 0.1 % OINTMENT) TIER 4 GA mometasone furoate 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 % cream, 0.01 % TIER 1 acetonide solution, 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 fluocinonide (0.05 % cream, fluocinonide 0.05 % gel, 0.05 % TIER 1 ointment, 0.05 % solution)

©2021 Wellmark, Inc. 188 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 cream, 0.05 % ointment) flurandrenolide 0.05 % flurandrenolide TIER 1 QL (120 PER 30 DAY(S)) lotion fluticasone propionate fluticasone propionate (0.005 % ointment, 0.05 % TIER 1 cream, 0.05 % lotion) halobetasol propionate halobetasol (0.05 % cream, 0.05 % TIER 1 propionate ointment) 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 % cream, 0.1 % lotion, TIER 1 butyrate 0.1 % ointment, 0.1 % solution) hydrocortisone hydrocortisone valerate (0.2 TIER 1 valerate % cream, 0.2 % ointment) IMPOYZ 0.025 % CREAM IMPOYZ TIER 4 clobetasol propionate 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)) KENALOG (10 MG/ML SUSPENSION, 40 MG/ML KENALOG TIER 4 GA SUSPENSION) triamcinolone acetonide KENALOG 0.147 MG/GM AERO SOLN KENALOG TIER 4 QL (4.5 PER 1 DAY(S)), GA triamcinolone acetonide (topical)

©2021 Wellmark, Inc. 189 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KORLYM 300 MG TAB PA, QL (120 PER 30 KORLYM mifepristone SP-P DAY(S)) (hyperglycemia) LOCOID (0.1 % CREAM, 0.1 % LOTION, 0.1 % LOCOID OINTMENT, 0.1 % TIER 4 GA SOLUTION) hydrocortisone butyrate LOCOID LIPOCREAM 0.1 LOCOID % CREAM TIER 4 QL (60 PER 30 DAY(S)), GA LIPOCREAM hydrocortisone butyrate hydrophilic lipo base lokara lokara 0.05 % lotion TIER 1 LUXIQ 0.12 % FOAM LUXIQ TIER 4 GA betamethasone valerate MEDROL (2 MG TAB, 4 MG TAB, 4 MG TAB THPK, MEDROL 8 MG TAB, 16 MG TAB, 32 TIER 4 GA MG TAB) methylprednisolone methylprednisolone (4 mg methylprednisolone tab, 4 mg tab thpk, 8 mg TIER 1 tab, 16 mg tab, 32 mg tab) methylprednisolone methylprednisolone sodium TIER 1 sodium succ succ 500 mg recon soln MICORT-HC 2.5 % CREAM MICORT-HC hydrocortisone acetate TIER 4 (topical) MILLIPRED (5 MG TAB, 10 MILLIPRED MG/5ML SOLUTION) TIER 4 prednisolone MILLIPRED DP (5 MG (21) TAB THPK, 5 MG (48) TAB MILLIPRED DP TIER 4 THPK) prednisolone MILLIPRED DP 12-DAY 5 MILLIPRED DP 12- MG (48) TAB THPK TIER 4 DAY prednisolone mometasone furoate (0.1 % mometasone furoate cream, 0.1 % ointment, 0.1 TIER 1 % solution) nolix nolix 0.05 % cream TIER 1 nolix nolix 0.05 % lotion TIER 1 QL (120 PER 30 DAY(S)) NOVACORT 1-2 % GEL NOVACORT TIER 4 pramoxine-hc

©2021 Wellmark, Inc. 190 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NUCORT 2 % LOTION NUCORT hydrocortisone acetate TIER 3 (topical) OLUX 0.05 % FOAM OLUX TIER 4 GA clobetasol propionate OLUX-E 0.05 % FOAM OLUX-E clobetasol propionate TIER 4 GA emulsion ORAPRED ODT (ODT 10 MG TAB DISP, ODT 15 MG TAB DISP, ODT 30 MG ORAPRED ODT TIER 4 GA TAB DISP) prednisolone sodium phosphate PEDIAPRED 6.7 (5 BASE) MG/5ML SOLUTION PEDIAPRED TIER 4 GA prednisolone sodium phosphate PRAMOSONE (1-1 % CREAM, 1-1 % LOTION, 1- PRAMOSONE TIER 1 2.5 % LOTION) pramoxine-hc PRAMOSONE (1-1 % OINTMENT, 1-2.5 % PRAMOSONE CREAM, 1-2.5 % TIER 4 OINTMENT) pramoxine-hc PRAMOSONE E 1-2.5 % CREAM PRAMOSONE E TIER 4 pramoxine-hc emollient base PREDNICARBATE (0.1 % CREAM, 0.1 % PREDNICARBATE TIER 1 OINTMENT) prednicarbate prednisolone (15 solution, prednisolone TIER 1 15 syrup)

©2021 Wellmark, Inc. 191 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS prednisolone sodium phosphate (6.7 (5 base) mg/5ml solution, 10 mg tab prednisolone sodium disp, 10 mg/5ml solution, TIER 1 phosphate 15 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 mg prednisone tab, 5 mg/5ml solution, 10 TIER 1 mg (21) tab thpk, 10 mg (48) tab thpk, 10 mg tab, 20 mg tab, 50 mg tab) PREDNISONE INTENSOL PREDNISONE 5 MG/ML CONC TIER 1 INTENSOL prednisone 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 SYNALAR (0.01 % SOLUTION, 0.025 % SYNALAR CREAM, 0.025 % TIER 4 GA OINTMENT) fluocinolone acetonide TEMOVATE (0.05 % CREAM, 0.05 % GEL, 0.05 TEMOVATE % OINTMENT, 0.05 % TIER 4 GA SOLUTION) clobetasol propionate TEMOVATE E 0.05 % CREAM TEMOVATE E TIER 4 GA clobetasol propionate emollient base TEXACORT 2.5 % TEXACORT SOLUTION TIER 4 hydrocortisone (topical)

©2021 Wellmark, Inc. 192 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TOPICORT (0.05 % CREAM, 0.05 % GEL, 0.05 % OINTMENT, 0.25 % TOPICORT TIER 4 GA CREAM, 0.25 % OINTMENT) desoximetasone TOPICORT SPRAY 0.25 % TOPICORT SPRAY LIQUID TIER 4 GA desoximetasone tovet tovet 0.05 % foam TIER 1 triamcinolone acetonide (0.025 % cream, 0.025 % lotion, 0.025 % ointment, triamcinolone 0.1 % cream, 0.1 % lotion, TIER 1 acetonide 0.1 % ointment, 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) TRIDESILON 0.05 % TRIDESILON CREAM TIER 4 GA desonide ULTRAVATE (0.05 % CREAM, 0.05 % LOTION, ULTRAVATE TIER 4 GA 0.05 % OINTMENT) halobetasol propionate VANOS 0.1 % CREAM QL (120 PER 30 DAY(S)), VANOS TIER 4 fluocinonide GA VERDESO 0.05 % FOAM VERDESO TIER 4 desonide VERIPRED 20 20 MG/5ML SOLUTION VERIPRED 20 TIER 4 GA prednisolone sodium phosphate WESTCORT 0.2 % WESTCORT OINTMENT TIER 4 GA hydrocortisone valerate

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

DDAVP (0.01 % SOLUTION, 0.1 MG TAB, DDAVP TIER 4 GA 0.2 MG TAB) desmopressin acetate

©2021 Wellmark, Inc. 193 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DDAVP RHINAL TUBE DDAVP RHINAL 0.01 % SOLUTION TIER 4 TUBE desmopressin acetate refrigerated 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 DESMOPRESSIN ACETATE 1.5 MG/ML TIER 4 ACETATE SOLUTION desmopressin acetate 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 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 MYFEMBREE 40-1-0.5 MG TAB MYFEMBREE TIER 4 PA, QL (1 PER 1 DAY(S)) relugolix-estradiol- norethindrone acetate

©2021 Wellmark, Inc. 194 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 OMNITROPE (5 MG/1.5ML SOLN CART, 5.8 MG MN-PA (Medically Necessary OMNITROPE RECON SOLN, 10 SP-NP Prior Authorization) MG/1.5ML SOLN CART) somatropin ORIAHNN 300-1-0.5 & 300 MG CAP THPK ORIAHNN TIER 4 PA, QL (56 PER 28 DAY(S)) elagolix sodium-estradiol- norethindrone acetate SAIZEN (5 MG RECON SOLN, 8.8 MG RECON MN-PA (Medically Necessary SAIZEN SOLN) SP-NP Prior Authorization) somatropin (non- refrigerated) 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) STIMATE 1.5 MG/ML STIMATE SOLUTION TIER 4 desmopressin acetate

©2021 Wellmark, Inc. 195 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 OXANDRIN (2.5 MG TAB, OXANDRIN 10 MG TAB) TIER 4 GA oxandrolone oxandrolone (2.5 mg tab, oxandrolone TIER 1 10 mg tab)

ANDROGENS

ANDRODERM (2 MG/24HR PATCH 24HR, 4 MG/24HR ANDRODERM TIER 4 PA PATCH 24HR) testosterone ANDROGEL (20.25 MG/1.25GM (1.62%) GEL, 25 MG/2.5GM (1%) GEL, ANDROGEL 40.5 MG/2.5GM (1.62%) TIER 4 PA, GA GEL, 50 MG/5GM (1%) GEL) testosterone ANDROGEL PUMP 20.25 ANDROGEL PUMP MG/ACT (1.62%) GEL TIER 4 PA, GA testosterone ANDROID 10 MG CAP ANDROID TIER 4 PA, GA methyltestosterone ANDROXY 10 MG TAB ANDROXY TIER 3 fluoxymesterone AXIRON 30 MG/ACT AXIRON SOLUTION TIER 4 PA, GA testosterone

©2021 Wellmark, Inc. 196 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS danazol (50 mg cap, 100 danazol TIER 1 mg cap, 200 mg cap) DEPO-TESTOSTERONE DEPO- (100 MG/ML SOLUTION, TIER 4 GA TESTOSTERONE 200 MG/ML SOLUTION) testosterone cypionate FORTESTA 10 MG/ACT FORTESTA (2%) GEL TIER 4 PA, GA testosterone methyltestosterone 10 mg methyltestosterone TIER 1 PA cap STRIANT 30 MG MISC STRIANT TIER 4 PA testosterone TESTIM 50 MG/5GM (1%) TESTIM GEL TIER 4 PA, GA testosterone testosterone (1.62 % gel, 12.5 mg/act (1%) gel, 20.25 mg/1.25gm (1.62%) gel, 20.25 mg/act (1.62%) gel, testosterone TIER 2 PA 25 mg/2.5gm (1%) gel, 30 mg/act solution, 40.5 mg/2.5gm (1.62%) gel, 50 mg/5gm (1%) gel) testosterone 10 mg/act testosterone TIER 4 PA (2%) 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 TESTRED 10 MG CAP TESTRED TIER 4 PA, GA methyltestosterone VOGELXO 50 MG/5GM VOGELXO (1%) GEL TIER 4 PA, GA testosterone VOGELXO PUMP 12.5 VOGELXO PUMP MG/ACT (1%) GEL TIER 4 PA, GA testosterone

ESTROGENS

ACTIVELLA (0.5-0.1 MG TAB, 1-0.5 MG TAB) ACTIVELLA TIER 4 GA estradiol & norethindrone acetate afirmelle 0.1-20 mg-mcg afirmelle TIER 1 PV tab

©2021 Wellmark, Inc. 197 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 ANGELIQ (0.25-0.5 MG ANGELIQ TAB, 0.5-1 MG TAB) TIER 4 drospirenone-estradiol ANNOVERA 0.013-0.15 MG/24HR RING ANNOVERA TIER 4 segesterone acetate-ethinyl estradiol 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 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

©2021 Wellmark, Inc. 198 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BALCOLTRA 0.1-20 MG- MCG(21) TAB BALCOLTRA levonorgestrel-ethinyl TIER 4 estradiol-ferrous bisglycinate 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 BEYAZ 3-0.02-0.451 MG TAB BEYAZ drospirenone-ethinyl TIER 4 GA estradiol-levomefolate calcium 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 BREVICON (28) 0.5-35 MG-MCG TAB BREVICON (28) TIER 4 GA norethindrone & eth estradiol 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 (0.025 MG/24HR PATCH WK, 0.0375 MG/24HR PATCH WK, 0.05 MG/24HR PATCH CLIMARA WK, 0.06 MG/24HR TIER 4 GA PATCH WK, 0.075 MG/24HR PATCH WK, 0.1 MG/24HR PATCH WK) estradiol

©2021 Wellmark, Inc. 199 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 cyclafem 7/7/7 0.5/0.75/1- cyclafem 7/7/7 TIER 1 PV 35 mg-mcg tab CYCLESSA 0.1/0.125/0.15 -0.025 MG TAB CYCLESSA TIER 4 GA desogestrel-ethinyl estradiol (triphasic) 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 DESOGEN 0.15-30 MG- MCG TAB DESOGEN TIER 4 GA desogestrel & ethinyl estradiol 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)

©2021 Wellmark, Inc. 200 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DIVIGEL (0.25 MG/0.25GM GEL, 0.5 MG/0.5GM GEL, 0.75 MG/0.75GM GEL, 1 DIVIGEL TIER 4 MG/GM GEL, 1.25 MG/1.25GM GEL) estradiol dolishale dolishale 90-20 mcg tab TIER 1 PV 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 (3-0.02 mg tab, 3- TIER 1 PV estradiol 0.03 mg tab) eemt eemt 1.25-2.5 mg tab TIER 1 eemt hs eemt hs 0.625-1.25 mg tab TIER 1 ELESTRIN 0.52 MG/0.87 ELESTRIN GM (0.06%) GEL TIER 4 estradiol 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 50-30/75-40/ enpresse-28 TIER 1 PV 125-30 mcg tab enskyce 0.15-30 mg-mcg enskyce TIER 1 PV tab est estrogens-methyltest est estrogens- (rogens-methylt0.625-1.25 TIER 1 methyltest mg tab, rogens- methylt1.25-2.5 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

©2021 Wellmark, Inc. 201 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ESTRACE (0.1 MG/GM CREAM, 0.5 MG TAB, 1 ESTRACE TIER 4 GA MG TAB, 2 MG TAB) estradiol 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 ESTROGEL 0.75 MG/1.25 ESTROGEL GM (0.06%) GEL TIER 4 estradiol ESTROPIPATE (0.75 MG TAB, 1.5 MG TAB, 3 MG ESTROPIPATE TIER 1 TAB) estropipate ESTROSTEP FE 1-20/1- 30/1-35 MG-MCG TAB ESTROSTEP FE TIER 4 GA norethindrone acetate- ethinyl estradiol-fe ethynodiol diac-eth ethynodiol diac-eth estradiol (1-35 tab, 1-50 TIER 1 PV estradiol tab) etonogestrel-ethinyl etonogestrel-ethinyl estradiol 0.12-0.015 TIER 1 PV estradiol mg/24hr ring EVAMIST 1.53 MG/SPRAY EVAMIST SOLUTION TIER 4 estradiol

©2021 Wellmark, Inc. 202 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FALESSA 20-1-0.1 MCG- MG KIT FALESSA TIER 4 levonorgestrel-ethinyl estradiol & folic acid falmina falmina 0.1-20 mg-mcg tab TIER 1 PV fayosim 42-21-21-7 days fayosim TIER 1 PV tab FEMHRT 0.5-2.5 MG-MCG TAB FEMHRT TIER 4 GA norethindrone acetate- ethinyl estradiol FEMRING (0.05 MG/24HR FEMRING RING, 0.1 MG/24HR RING) TIER 4 estradiol acetate vaginal femynor 0.25-35 mg-mcg femynor TIER 1 PV tab fyavolv (0.5-2.5 tab, 1-5 fyavolv TIER 1 tab) gemmily 1-20 mg-mcg(24) gemmily TIER 1 cap GENERESS FE 0.8-25 MG-MCG CHEW TAB GENERESS FE TIER 4 GA norethindrone & ethinyl estradiol-fe 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 iclevia iclevia 0.15-0.03 mg tab TIER 1 PV 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

©2021 Wellmark, Inc. 203 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 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 50-30/75-40/ 125- levonest TIER 1 PV 30 mcg tab levonorg-eth estrad levonorg-eth estrad triphasic 50-30/75-40/ 125- TIER 1 PV triphasic 30 mcg tab

©2021 Wellmark, Inc. 204 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 LOESTRIN FE 1 MG-10 MCG / 10 MCG TAB LO LOESTRIN FE norethindrone acetate- TIER 4 ethinyl estradiol-fe fum (biphasic) lo-zumandimine 3-0.02 mg lo-zumandimine TIER 1 PV tab loestrin 1.5/30 (21) 1.5-30 loestrin 1.5/30 (21) TIER 1 PV mg-mcg tab loestrin 1/20 (21) 1-20 mg- loestrin 1/20 (21) TIER 1 PV mcg tab loestrin fe 1.5/30 1.5-30 loestrin fe 1.5/30 TIER 1 PV mg-mcg tab loestrin fe 1/20 1-20 mg- loestrin fe 1/20 TIER 1 PV mcg 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 LOSEASONIQUE 0.1-0.02 & 0.01 MG TAB LOSEASONIQUE TIER 4 GA levonorgestrel-ethinyl estradiol (91-day) low-ogestrel 0.3-30 mg-mcg low-ogestrel TIER 1 PV tab lutera lutera 0.1-20 mg-mcg tab TIER 1 PV

©2021 Wellmark, Inc. 205 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lyllana (0.025 mg/24hr patch tw, 0.0375 mg/24hr patch tw, 0.05 mg/24hr lyllana TIER 1 QL (8 PER 28 DAYS) patch tw, 0.075 mg/24hr patch tw, 0.1 mg/24hr patch tw) 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 MENEST (0.3 MG TAB, 0.625 MG TAB, 1.25 MG MENEST TIER 4 TAB, 2.5 MG TAB) esterified estrogens MENOSTAR 14 MENOSTAR MCG/24HR PATCH WK TIER 4 estradiol merzee 1-20 mg-mcg(24) merzee TIER 1 cap 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 MINASTRIN 24 FE 1-20 MINASTRIN 24 FE MG-MCG(24) CHEW TAB TIER 4 GA norethin acet & estrad-fe MINIVELLE (0.025 MG/24HR PATCH TW, 0.0375 MG/24HR PATCH TW, 0.05 MG/24HR PATCH MINIVELLE TIER 4 QL (8 PER 28 DAYS), GA TW, 0.075 MG/24HR PATCH TW, 0.1 MG/24HR PATCH TW) estradiol

©2021 Wellmark, Inc. 206 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MIRCETTE 0.15-0.02/0.01 MG (21/5) TAB MIRCETTE TIER 4 GA desogestrel-ethinyl estradiol (biphasic) 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 50-30/75-40/ 125- myzilra TIER 1 PV 30 mcg tab NATAZIA 3/2-2/2-3/1 MG NATAZIA TAB TIER 4 estradiol valerate-dienogest necon 0.5/35 (28) 0.5-35 necon 0.5/35 (28) TIER 1 PV mg-mcg tab NECON 1/50 (28) 1-50 MG- NECON 1/50 (28) MCG TAB TIER 4 norethindrone & mestranol 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 tab, 1-20 norethin ace-eth mg-mcg(24) cap, 1-20 mg- TIER 1 PV estrad-fe mcg(24) chew tab, 1-20 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) 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

©2021 Wellmark, Inc. 207 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 NUVARING 0.12-0.015 MG/24HR RING NUVARING TIER 4 GA etonogestrel-ethinyl estradiol nylia 7/7/7 0.5/0.75/1-35 nylia 7/7/7 TIER 1 PV mg-mcg tab nymyo nymyo 0.25-35 mg-mcg tab TIER 1 PV 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 ORTHO TRI-CYCLEN (28) 0.18/0.215/0.25 MG-35 ORTHO TRI- MCG TAB TIER 4 GA CYCLEN (28) norgestimate-ethinyl estradiol (triphasic) ORTHO TRI-CYCLEN LO 0.18/0.215/0.25 MG-25 ORTHO TRI- MCG TAB TIER 4 GA CYCLEN LO norgestimate-ethinyl estradiol (triphasic) ORTHO-CYCLEN (28) ORTHO-CYCLEN 0.25-35 MG-MCG TAB TIER 4 GA (28) norgestimate-ethinyl estradiol ORTHO-NOVUM 1/35 (28) ORTHO-NOVUM 1-35 MG-MCG TAB TIER 4 GA 1/35 (28) norethindrone & eth estradiol ORTHO-NOVUM 7/7/7 (28) 0.5/0.75/1-35 MG-MCG ORTHO-NOVUM TAB TIER 4 GA 7/7/7 (28) norethindrone-eth estradiol (triphasic) 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

©2021 Wellmark, Inc. 208 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS portia-28 0.15-30 mg-mcg portia-28 TIER 1 PV tab PREFEST 1/1-0.09 MG PREFEST (15/15) TAB TIER 4 estradiol-norgestimate 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 PREMPRO (0.3-1.5 MG TAB, 0.45-1.5 MG TAB, 0.625-2.5 MG TAB, 0.625-5 PREMPRO MG TAB) TIER 2 conjugated estrogens- medroxyprogesterone acetate previfem 0.25-35 mg-mcg previfem TIER 1 PV tab QUARTETTE 42-21-21-7 DAYS TAB QUARTETTE TIER 4 GA levonorgestrel-ethinyl estradiol (91-day) 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 SAFYRAL 3-0.03-0.451 MG TAB SAFYRAL drospirenone-ethinyl TIER 4 GA estradiol-levomefolate calcium SEASONIQUE 0.15-0.03 &0.01 MG TAB SEASONIQUE TIER 4 GA levonorgestrel-ethinyl estradiol (91-day) 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

©2021 Wellmark, Inc. 209 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 taysofy 1-20 mg-mcg(24) taysofy TIER 1 cap TAYTULLA 1-20 MG- TAYTULLA MCG(24) CAP TIER 4 GA norethin acet & estrad-fe 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 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-NORINYL (28) 0.5/1/0.5-35 MG-MCG TAB TRI-NORINYL (28) TIER 4 GA norethindrone-eth estradiol (triphasic)

©2021 Wellmark, Inc. 210 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS tri-nymyo 0.18/0.215/0.25 tri-nymyo TIER 1 PV mg-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) 50-30/75-40/ trivora (28) TIER 1 PV 125-30 mcg tab TWIRLA 120-30 MCG/24HR PATCH WK TWIRLA TIER 4 levonorgestrel-ethinyl estradiol TYBLUME 0.1-20 MG-MCG CHEW TAB TYBLUME TIER 4 PV levonorgestrel & eth estradiol tydemy 3-0.03-0.451 mg tydemy TIER 1 PV tab VAGIFEM 10 MCG TAB VAGIFEM TIER 4 GA estradiol vaginal 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 VIVELLE-DOT (0.025 MG/24HR PATCH TW, 0.0375 MG/24HR PATCH TW, 0.05 MG/24HR PATCH VIVELLE-DOT TIER 4 QL (8 PER 28 DAYS), GA TW, 0.075 MG/24HR PATCH TW, 0.1 MG/24HR PATCH TW) estradiol volnea 0.15-0.02/0.01 mg volnea TIER 1 PV (21/5) tab

©2021 Wellmark, Inc. 211 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 xulane TIER 1 PV patch wk YASMIN 28 3-0.03 MG TAB YASMIN 28 TIER 4 GA drospirenone-ethinyl estradiol YAZ 3-0.02 MG TAB YAZ drospirenone-ethinyl TIER 4 GA estradiol yuvafem yuvafem 10 mcg tab TIER 1 zafemy 150-35 mcg/24hr zafemy TIER 1 patch wk zarah zarah 3-0.03 mg tab TIER 1 PV zenchent 0.4-35 mg-mcg zenchent TIER 1 PV tab zenchent fe 0.4-35 mg-mcg zenchent fe TIER 1 PV chew tab zovia 1/35 (28) 1-35 mg- zovia 1/35 (28) TIER 1 PV mcg 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

PROGESTERONE AGONISTS/ANTAGONISTS

ELLA 30 MG TAB ELLA TIER 4 ulipristal acetate

PROGESTINS

AYGESTIN 5 MG TAB AYGESTIN TIER 4 GA norethindrone acetate 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

©2021 Wellmark, Inc. 212 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DEPO-PROVERA (150 MG/ML SUSP PRSYR, 150 DEPO-PROVERA MG/ML SUSPENSION) TIER 4 GA medroxyprogesterone acetate (contraceptive) DEPO-SUBQ PROVERA 104 104 MG/0.65ML SUSP DEPO-SUBQ PRSYR TIER 4 PROVERA 104 medroxyprogesterone acetate (contraceptive) 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) lyleq lyleq 0.35 mg tab TIER 1 PV 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 susp prsyr, 150 mg/ml suspension) MEGACE ES 625 MG/5ML SUSPENSION MEGACE ES TIER 4 GA megestrol acetate (appetite)

©2021 Wellmark, Inc. 213 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS megestrol acetate (20 mg tab, 40 mg tab, 40 mg/ml megestrol acetate suspension, 400 mg/10ml TIER 1 suspension, 625 mg/5ml suspension) MIRENA (52 MG) 20 MIRENA (52 MG) MCG/24HR IUD SP-M levonorgestrel (iud) 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 ORTHO MICRONOR 0.35 MG TAB ORTHO MICRONOR TIER 4 GA norethindrone (contraceptive) progesterone (50 mg/ml oil, progesterone TIER 1 100 mg cap, 200 mg cap) PROMETRIUM (100 MG PROMETRIUM CAP, 200 MG CAP) TIER 4 GA progesterone PROVERA (2.5 MG TAB, 5 MG TAB, 10 MG TAB) PROVERA TIER 4 GA medroxyprogesterone acetate sharobel sharobel 0.35 mg tab TIER 1 PV SKYLA 13.5 MG IUD SKYLA SP-M levonorgestrel (iud) SLYND 4 MG TAB SLYND TIER 4 drospirenone tulana tulana 0.35 mg tab TIER 1 PV

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

DUAVEE 0.45-20 MG TAB DUAVEE conjugated estrogens- TIER 4 bazedoxifene EVISTA 60 MG TAB EVISTA TIER 4 PA, GA raloxifene hcl OSPHENA 60 MG TAB OSPHENA TIER 4 ospemifene raloxifene hcl raloxifene hcl 60 mg tab TIER 1 PA, PV

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

ARMOUR THYROID (15 MG TAB, 30 MG TAB, 60 MG TAB, 90 MG TAB, 120 ARMOUR THYROID TIER 4 GA MG TAB, 180 MG TAB, 240 MG TAB, 300 MG TAB) thyroid CYTOMEL (5 MCG TAB, 25 MCG TAB, 50 MCG CYTOMEL TIER 4 GA TAB) liothyronine sodium 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) LEVOTHYROXINE SODIUM (13 MCG CAP, 25 MCG CAP, 50 MCG CAP, 75 MCG CAP, 88 MCG LEVOTHYROXINE CAP, 100 MCG CAP, 112 TIER 4 SODIUM MCG CAP, 125 MCG CAP, 137 MCG CAP, 150 MCG CAP, 175 MCG CAP, 200 MCG CAP) levothyroxine sodium 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)

©2021 Wellmark, Inc. 215 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) NATURE-THROID (16.25 MG TAB, 32.5 MG TAB, 48.75 MG TAB, 65 MG TAB, 81.25 MG TAB, 97.5 MG TAB, 113.75 MG TAB, NATURE-THROID TIER 4 130 MG TAB, 146.25 MG TAB, 162.5 MG TAB, 195 MG TAB, 260 MG TAB, 325 MG TAB) thyroid 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 THYQUIDITY 100 THYQUIDITY MCG/5ML SOLUTION TIER 4 levothyroxine sodium thyroid (15 mg tab, 30 mg thyroid tab, 60 mg tab, 90 mg tab, TIER 1 120 mg tab) THYROLAR-1 60 (12.5-50) THYROLAR-1 MG (MCG) TAB TIER 4 liotrix (t3-t4) THYROLAR-1/2 30 (6.25- THYROLAR-1/2 25) MG (MCG) TAB TIER 4 liotrix (t3-t4) THYROLAR-1/4 15 (3.1- THYROLAR-1/4 12.5) MG (MCG) TAB TIER 4 liotrix (t3-t4)

©2021 Wellmark, Inc. 216 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS THYROLAR-2 120 (25-100) THYROLAR-2 MG (MCG) TAB TIER 4 liotrix (t3-t4) THYROLAR-3 180 (37.5- THYROLAR-3 150) MG (MCG) TAB TIER 4 liotrix (t3-t4) TIROSINT (13 MCG CAP, 25 MCG CAP, 50 MCG CAP, 75 MCG CAP, 88 MCG CAP, 100 MCG CAP, TIROSINT 112 MCG CAP, 125 MCG TIER 4 CAP, 137 MCG CAP, 150 MCG CAP, 175 MCG CAP, 200 MCG CAP) levothyroxine sodium TIROSINT-SOL (13 MCG/ML SOLUTION, 25 MCG/ML SOLUTION, 37.5 MCG/ML SOLUTION, 44 MCG/ML SOLUTION, 50 MCG/ML SOLUTION, 62.5 MCG/ML SOLUTION, 75 MCG/ML SOLUTION, 88 TIROSINT-SOL MCG/ML SOLUTION, 100 TIER 4 MCG/ML SOLUTION, 112 MCG/ML SOLUTION, 125 MCG/ML SOLUTION, 137 MCG/ML SOLUTION, 150 MCG/ML SOLUTION, 175 MCG/ML SOLUTION, 200 MCG/ML SOLUTION) levothyroxine sodium 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) WESTHROID (32.5 MG TAB, 65 MG TAB, 97.5 MG WESTHROID TAB, 130 MG TAB, 195 MG TIER 4 TAB) thyroid

©2021 Wellmark, Inc. 217 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS WP THYROID (16.25 MG TAB, 32.5 MG TAB, 48.75 MG TAB, 65 MG TAB, WP THYROID 81.25 MG TAB, 97.5 MG TIER 4 TAB, 113.75 MG TAB, 130 MG TAB) thyroid

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)

©2021 Wellmark, Inc. 218 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LUPRON DEPOT (6- LUPRON DEPOT (6- MONTH) 45 MG KIT SP-M MONTH) leuprolide acetate (6 month) 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) MYCAPSSA 20 MG CAP MYCAPSSA DR SP-NP PA, QL (4 PER DAY(S)) octreotide acetate octreotide acetate (50 mcg/ml solution, 100 mcg/ml solution, 200 SBG (Specialty Biosimilars octreotide acetate mcg/ml solution, 500 SP-P and Specialty generics) mcg/ml solution, 1000 mcg/5ml solution, 1000 mcg/ml solution) ORGOVYX 120 MG TAB ORGOVYX SP-P relugolix ORILISSA 150 MG TAB ORILISSA TIER 4 PA, QL (28 PER 28 DAY(S)) elagolix sodium ORILISSA 200 MG TAB ORILISSA TIER 4 PA, QL (56 PER 28 DAY(S)) elagolix sodium 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 SP-M DEPOT MG KIT, 30 MG KIT) octreotide acetate SIGNIFOR (0.3 MG/ML SOLUTION, 0.6 MG/ML SIGNIFOR SOLUTION, 0.9 MG/ML SP-P SOLUTION) pasireotide diaspartate

©2021 Wellmark, Inc. 219 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 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 SSKI 1 GM/ML SOLUTION SSKI potassium iodide TIER 4 (expectorant) TAPAZOLE (5 MG TAB, 10 TAPAZOLE MG TAB) TIER 4 GA methimazole

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

©2021 Wellmark, Inc. 220 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HAEGARDA (2000 RECON SOLN, 3000 RECON HAEGARDA SOLN) SP-P PA c1 esterase inhibitor (human) PA, SBG (Specialty icatibant acetate 30 mg/3ml icatibant acetate SP-P Biosimilars and Specialty solution generics) KALBITOR 10 MG/ML KALBITOR SOLUTION SP-M PA ecallantide ORLADEYO (110 MG CAP, ORLADEYO 150 MG CAP) SP-P PA, QL (30 PER 30 DAY(S)) berotralstat hcl RUCONEST 2100 UNIT RECON SOLN RUCONEST SP-M PA c1 esterase inhibitor (recombinant) PA, SBG (Specialty sajazir sajazir 30 mg/3ml solution SP-P Biosimilars and Specialty generics) 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)

©2021 Wellmark, Inc. 221 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 cyclosporine modified mg cap, 50 mg cap, 100 mg TIER 1 PV cap, 100 mg/ml solution) 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 ENSPRYNG 120 MG/ML ENSPRYNG SOLN PRSYR SP-P PA satralizumab-mwge ENTYVIO 300 MG RECON ENTYVIO SOLN SP-M PA vedolizumab 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, SBG (Specialty Biosimilars everolimus SP-P 0.5 mg tab, 0.75 mg tab) and Specialty generics) GAMIFANT (10 MG/2ML SOLUTION, 50 MG/10ML GAMIFANT SOLUTION, 100 MG/20ML SP-M SOLUTION) emapalumab-lzsg gengraf (25 mg cap, 50 mg gengraf cap, 100 mg cap, 100 TIER 1 PV mg/ml solution)

©2021 Wellmark, Inc. 222 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 80 MG/0.8ML HUMIRA PEN KIT SP-P PA, QL (1 PER LIFETIME) 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-PEDIATRIC HUMIRA PEN- UC START 80 MG/0.8ML PEDIATRIC UC SP-P PA, QL (1 PER LIFETIME) PEN KIT START 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

©2021 Wellmark, Inc. 223 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HUMIRA PEN- HUMIRA PEN- PSOR/UVEIT STARTER 80 PSOR/UVEIT MG/0.8ML & 40MG/0.4ML SP-P PA, QL (1 PER LIFETIME) STARTER PEN KIT adalimumab IMURAN 50 MG TAB IMURAN TIER 4 GA azathioprine 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) LUPKYNIS 7.9 MG CAP LUPKYNIS SP-NP PA, QL (6 PER DAY(S)) voclosporin 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 methotrexate sodium gm/40ml solution, 50 TIER 1 (pf) mg/2ml 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) MYFORTIC (180 MG TAB MYFORTIC DR, 360 MG TAB DR) TIER 4 GA mycophenolate sodium NEORAL (25 MG CAP, 100 MG CAP, 100 MG/ML NEORAL SOLUTION) 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

©2021 Wellmark, Inc. 224 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ORENCIA 250 MG RECON ORENCIA SOLN SP-M PA, QL (4 PER 28 DAY(S)) abatacept 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 (10 SOLN A- INJ, 12.5 SOLN A-INJ, 15 SOLN A-INJ, 17.5 SOLN A- INJ, 20 SOLN A-INJ, 22.5 OTREXUP SP-M 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 RAPAMUNE (0.5 MG TAB, RAPAMUNE 1 MG TAB, 2 MG TAB) TIER 4 GA sirolimus RAPAMUNE 1 MG/ML PA, QL (1200 PER 30 RAPAMUNE SOLUTION TIER 4 DAY(S)), GA sirolimus 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- RASUVO INJ, 20 MG/0.4ML SOLN A- SP-M INJ, 22.5 MG/0.45ML SOLN A-INJ, 25 MG/0.5ML SOLN A-INJ, 30 MG/0.6ML SOLN A-INJ) methotrexate (antirheumatic)

©2021 Wellmark, Inc. 225 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS REDITREX (7.5 MG/0.3ML SOLN PRSYR, 10 MG/0.4ML SOLN PRSYR, 12.5 MG/0.05ML SOLN PRSYR, 15 MG/0.6ML SOLN PRSYR, 17.5 REDITREX MG/0.7ML SOLN PRSYR, SP-M 20 MG/0.8ML SOLN PRSYR, 22.5 MG/0.9ML SOLN PRSYR, 25 MG/ML SOLN PRSYR) methotrexate (antirheumatic) REMICADE 100 MG REMICADE RECON SOLN SP-M PA infliximab RENFLEXIS 100 MG RENFLEXIS RECON SOLN SP-M PA infliximab-abda 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 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 mg sirolimus TIER 1 PV tab, 2 mg tab) PA, QL (1200 PER 30 sirolimus sirolimus 1 mg/ml solution TIER 1 DAY(S)), PV tacrolimus (0.5 mg cap, 1 tacrolimus TIER 1 PV mg cap, 5 mg cap) TREXALL (5 MG TAB, 7.5 MG TAB, 10 MG TAB, 15 TREXALL TIER 4 MG TAB) methotrexate sodium UPLIZNA 100 MG/10ML UPLIZNA SOLUTION SP-M PA inebilizumab-cdon

©2021 Wellmark, Inc. 226 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XATMEP 2.5 MG/ML XATMEP SOLUTION TIER 4 PA methotrexate 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 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

©2021 Wellmark, Inc. 227 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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/200ML SOLUTION, 20 GM/400ML 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 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

©2021 Wellmark, Inc. 228 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GAMMAPLEX (5 GM/100ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML SOLUTION, 10 GAMMAPLEX SP-M PA GM/200ML 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 SOLN PRSYR, 1 GM/5ML SOLUTION, 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) 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)

©2021 Wellmark, Inc. 229 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) VARIZIG 125 UNIT/1.2ML SOLUTION VARIZIG SP-M varicella-zoster immune globulin (human) XEMBIFY (1 GM/5ML SOLUTION, 2 GM/10ML SOLUTION, 4 GM/20ML XEMBIFY SOLUTION, 10 GM/50ML SP-M PA SOLUTION) 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 ARAVA (10 MG TAB, 20 ARAVA MG TAB) TIER 4 GA leflunomide 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 GRASTEK 2800 BAU SL TAB GRASTEK TIER 4 PA, QL (30 PER 30 DAYS) timothy grass pollen allergen extract ILARIS (150 MG RECON SOLN, 150 MG/ML ILARIS SP-M SOLUTION) canakinumab KEVZARA (150 SOLN A- INJ, 150 SOLN PRSYR, QL (2 PER 28 DAY(S)), MN- KEVZARA 200 SOLN A-INJ, 200 SP-NP PA (Medically Necessary SOLN PRSYR) Prior Authorization) sarilumab leflunomide (10 mg tab, 20 leflunomide TIER 1 mg tab) ORALAIR 300 IR SL TAB ORALAIR grass mixed pollens TIER 4 PA, QL (30 PER 30 DAYS) allergen extract

©2021 Wellmark, Inc. 231 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ORALAIR ADULT SAMPLE ORALAIR ADULT KIT 300 IR SL TAB TIER 4 PA, QL (30 PER 30 DAYS) SAMPLE KIT grass mixed pollens allergen extract ORALAIR ADULT STARTER PACK 300 IR SL ORALAIR ADULT TAB TIER 4 PA, QL (30 PER 30 DAYS) STARTER PACK grass mixed pollens allergen extract OTEZLA 10 & 20 & 30 MG OTEZLA TAB THPK SP-P PA, QL (2 PER LIFETIME) apremilast 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

©2021 Wellmark, Inc. 232 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 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 RAGWITEK 12 AMB A 1-U SL TAB RAGWITEK TIER 4 PA, QL (30 PER 30 DAYS) short ragweed pollen allergen extract RIDAURA 3 MG CAP RIDAURA TIER 2 auranofin SYNAGIS (50 MG/0.5ML SOLUTION, 100 MG/ML SYNAGIS SP-M PA, QL (5 PER 6 MONTH(S)) SOLUTION) palivizumab

VACCINES

ACTHIB RECON SOLN ACTHIB haemophilus b polysac conj TIER 2 PV vac

©2021 Wellmark, Inc. 233 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 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) 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

©2021 Wellmark, Inc. 234 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) FLUBLOK QUADRIVALENT 0.5 ML FLUBLOK SOLN PRSYR TIER 2 PV QUADRIVALENT influenza virus vac recomb hemagglutinin (ha) quadrivalent 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

©2021 Wellmark, Inc. 235 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 FLUZONE QUADRIVALENT (0.25 ML SUSP PRSYR, 0.5 ML SUSP PRSYR, 0.5 ML FLUZONE SUSPENSION, 9 TIER 2 PV QUADRIVALENT MCG/STRAIN SUSP PEN, SUSPENSION) influenza virus vaccine split quadrivalent GARDASIL 9 (9SUSPENSION, 9SUSPPRSYR) 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 SOLN PRSYR, 20 SOLUTION) HEPLISAV-B 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 JANSSEN COVID-19 VACCINE 0.5 ML JANSSEN COVID-19 SUSPENSION TIER 2 PV VACCINE covid-19 (sars-cov-2) adenovirus vaccine

©2021 Wellmark, Inc. 236 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 MENACTRA (4MCG/0.5MLINJECTABLE , INJECTABLE) MENACTRA TIER 2 PV meningococcal (a,c,y&w- 135) polysaccharide conjugate 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 MODERNA COVID-19 VACCINE 100 MCG/0.5ML MODERNA COVID- SUSPENSION TIER 2 PV 19 VACCINE covid-19 (sars-cov-2) mrna virus vaccine 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 PFIZER-BIONTECH COVID-19 VACC 30 PFIZER-BIONTECH MCG/0.3ML SUSPENSION TIER 2 PV COVID-19 VACC covid-19 (sars-cov-2) mrna virus vaccine PNEUMOVAX 23 25 MCG/0.5ML INJECTABLE PNEUMOVAX 23 TIER 2 PV pneumococcal vac polyvalent

©2021 Wellmark, Inc. 237 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PREVNAR 13 SUSPENSION PREVNAR 13 TIER 2 PV pneumococcal 13-valent conjugate vaccine 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)

©2021 Wellmark, Inc. 238 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TWINRIX 720-20 ELU- MCG/ML SUSP PRSYR 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 VAXELIS (SUSPENSION, SUSPPRSYR) VAXELIS diph-tet tox-acell pert ad- TIER 2 PV polio ipv-hib-hepatitis b recomb XOFLUZA (40 MG DOSE) (OFLUZA MG 1 40 MG XOFLUZA (40 MG TAB THPK, OFLUZA MG 2 TIER 3 DOSE) 20 MG TAB THPK) baloxavir marboxil XOFLUZA (80 MG DOSE) (OFLUZA MG 1 80 MG XOFLUZA (80 MG TAB THPK, OFLUZA MG 2 TIER 3 DOSE) 40 MG TAB THPK) baloxavir marboxil

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

APRISO 0.375 GM CAP APRISO ER 24H TIER 4 GA mesalamine ASACOL HD 800 MG TAB ASACOL HD DR TIER 4 GA mesalamine balsalazide disodium 750 balsalazide disodium TIER 1 mg cap CANASA 1000 MG CANASA SUPPOS TIER 4 GA mesalamine COLAZAL 750 MG CAP COLAZAL TIER 4 GA balsalazide disodium DELZICOL 400 MG CAP DELZICOL DR TIER 4 GA mesalamine

©2021 Wellmark, Inc. 239 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DIPENTUM 250 MG CAP DIPENTUM TIER 2 olsalazine sodium GIAZO 1.1 GM TAB GIAZO TIER 4 balsalazide disodium LIALDA 1.2 GM TAB DR LIALDA TIER 4 GA mesalamine 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 SFROWASA 4 GM/60ML SFROWASA ENEMA TIER 4 mesalamine

GLUCOCORTICOIDS

anucort-hc anucort-hc 25 mg suppos TIER 1 ANUSOL-HC 2.5 % ANUSOL-HC CREAM TIER 4 GA hydrocortisone (rectal) 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 CORTENEMA 100 CORTENEMA MG/60ML ENEMA TIER 4 GA hydrocortisone (intrarectal) CORTIFOAM 10 % FOAM CORTIFOAM hydrocortisone acetate TIER 4 (intrarectal) ENTOCORT EC 3 MG CP ENTOCORT EC DR PART TIER 4 GA budesonide hemmorex-hc (25 mg hemmorex-hc TIER 1 suppos, 30 mg suppos) 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)

©2021 Wellmark, Inc. 240 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS procto-med hc procto-med hc 2.5 % cream TIER 1 procto-pak procto-pak 1 % cream TIER 1 PROCTOCORT (1 % CREAM, 30 MG SUPPOS) PROCTOCORT TIER 4 GA hydrocortisone acetate (rectal) proctosol hc proctosol hc 2.5 % cream TIER 1 proctozone-hc proctozone-hc 2.5 % cream TIER 1 UCERIS (2 MG/ACT UCERIS FOAM, 9 MG TAB ER 24H) TIER 4 GA budesonide

SULFONAMIDES

AZULFIDINE 500 MG TAB AZULFIDINE TIER 4 GA sulfasalazine AZULFIDINE EN-TABS 500 AZULFIDINE EN- MG TAB DR TIER 4 GA TABS sulfasalazine sulfasalazine (500 mg tab, sulfasalazine TIER 1 500 mg tab dr)

METABOLIC BONE DISEASE AGENTS

ACTONEL (5 MG TAB, 30 MG TAB, 35 MG TAB, 150 ACTONEL TIER 4 GA MG TAB) risedronate sodium alendronate sodium (5 mg alendronate sodium tab, 10 mg tab, 35 mg tab, TIER 1 PV 40 mg tab, 70 mg tab) alendronate sodium 70 alendronate sodium TIER 4 mg/75ml solution ATELVIA 35 MG TAB DR ATELVIA TIER 4 GA risedronate sodium BONIVA 150 MG TAB BONIVA TIER 4 GA ibandronate sodium calcitonin (salmon) 200 calcitonin (salmon) TIER 1 PV unit/act solution calcitriol (0.25 mcg cap, 0.5 calcitriol TIER 1 mcg cap) calcitriol calcitriol 1 mcg/ml solution TIER 4 cinacalcet hcl (30 mg tab, SBG (Specialty Biosimilars cinacalcet hcl SP-P 60 mg tab, 90 mg tab) and Specialty generics) doxercalciferol (0.5 mcg doxercalciferol cap, 1 mcg cap, 2.5 mcg TIER 1 cap)

©2021 Wellmark, Inc. 241 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DRISDOL 1.25 MG (50000 DRISDOL UT) CAP TIER 4 GA ergocalciferol ergocalciferol (1.25 mg ergocalciferol (50000 ut) cap, 50000 unit 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 620 MCG/2.48ML PA, QL (24 PER MONTH(S)), FORTEO SOLN PEN SP-NP MN-PA (Medically Necessary teriparatide (recombinant) Prior Authorization) FOSAMAX 70 MG TAB FOSAMAX TIER 4 GA alendronate sodium FOSAMAX PLUS D (70- 2800 TAB, 70-5600 TAB) FOSAMAX PLUS D TIER 4 alendronate sodium- cholecalciferol HECTOROL (0.5 MCG CAP, 1 MCG CAP, 2.5 HECTOROL TIER 4 GA MCG CAP) doxercalciferol ibandronate sodium 150 mg ibandronate sodium TIER 1 PV tab MIACALCIN 200 UNIT/ACT MIACALCIN SOLUTION TIER 4 GA calcitonin (salmon) 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 RAYALDEE 30 MCG CAP RAYALDEE ER TIER 4 calcifediol

©2021 Wellmark, Inc. 242 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 35 mg tab dr, 150 mg tab) ROCALTROL (0.25 MCG CAP, 0.5 MCG CAP, 1 ROCALTROL TIER 4 GA MCG/ML SOLUTION) calcitriol 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-NP MN-PA (Medically Necessary abaloparatide Prior Authorization) vitamin d vitamin d (ergocalciferol) TIER 1 (ergocalciferol) 1.25 mg (50000 ut) cap XGEVA 120 MG/1.7ML XGEVA SOLUTION SP-M denosumab ZEMPLAR (1 MCG CAP, 2 ZEMPLAR MCG CAP) TIER 4 GA paricalcitol 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/100ML SOLUTION, 4 MG/5ML ZOMETA SP-M GA CONC) 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) 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)

©2021 Wellmark, Inc. 243 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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- 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) AEROCHAMBER MINI AEROCHAMBER CHAMBER DEVICE RX-DME MINI CHAMBER spacer/aerosol-holding chambers AEROCHAMBER MV MISC AEROCHAMBER MV RX-DME spacer/aerosol-holding chambers AEROCHAMBER PLUS AEROCHAMBER FLO-VU MISC RX-DME PLUS FLO-VU spacer/aerosol-holding chambers AEROCHAMBER PLUS AEROCHAMBER FLO-VU LARGE MISC PLUS FLO-VU RX-DME spacer/aerosol-holding LARGE chambers

©2021 Wellmark, Inc. 244 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS AEROCHAMBER PLUS AEROCHAMBER FLO-VU MEDIUM MISC PLUS FLO-VU RX-DME spacer/aerosol-holding MEDIUM chambers AEROCHAMBER PLUS AEROCHAMBER FLO-VU SMALL MISC PLUS FLO-VU RX-DME spacer/aerosol-holding SMALL chambers AEROCHAMBER PLUS AEROCHAMBER FLO-VU W/MASK MISC PLUS FLO-VU RX-DME spacer/aerosol-holding W/MASK chambers AEROCHAMBER PLUS AEROCHAMBER FLOW VU MISC RX-DME PLUS FLOW VU spacer/aerosol-holding chambers AEROCHAMBER AEROCHAMBER W/FLOWSIGNAL MISC RX-DME W/FLOWSIGNAL spacer/aerosol-holding chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS MISC RX-DME STAT PLUS spacer/aerosol-holding chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS CHAMBR MISC STAT PLUS RX-DME spacer/aerosol-holding CHAMBR chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS/LARGE MISC RX-DME STAT PLUS/LARGE spacer/aerosol-holding chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS/MEDIUM MISC RX-DME STAT PLUS/MEDIUM spacer/aerosol-holding chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS/SMALL MISC RX-DME STAT PLUS/SMALL spacer/aerosol-holding chambers AEROVENT PLUS DEVICE AEROVENT PLUS RX-DME spacer/aerosol-holding chambers 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)

©2021 Wellmark, Inc. 245 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) 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) ARIAL CHAMBER DEVICE ARIAL CHAMBER RX-DME spacer/aerosol-holding chambers 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) 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)

©2021 Wellmark, Inc. 246 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- BLULINK GLUCOSE TEST BLULINK GLUCOSE PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) BREATHE EASE LARGE BREATHE EASE DEVICE RX-DME LARGE spacer/aerosol-holding chambers BREATHE EASE MEDIUM BREATHE EASE DEVICE RX-DME MEDIUM spacer/aerosol-holding chambers BREATHE EASE SMALL BREATHE EASE DEVICE RX-DME SMALL spacer/aerosol-holding chambers BREATHERITE MISC BREATHERITE spacer/aerosol-holding RX-DME chambers BREATHERITE COLL BREATHERITE SPACER ADULT MISC COLL SPACER RX-DME spacer/aerosol-holding ADULT chambers BREATHERITE COLL BREATHERITE SPACER CHILD MISC COLL SPACER RX-DME spacer/aerosol-holding CHILD chambers BREATHERITE COLL BREATHERITE SPACER INFANT MISC COLL SPACER RX-DME spacer/aerosol-holding INFANT chambers BREATHERITE RIGID BREATHERITE SPACER/MASK MISC RIGID RX-DME spacer/aerosol-holding SPACER/MASK chambers BREATHERITE SPACER BREATHERITE NEONATE MISC RX-DME SPACER NEONATE spacer/aerosol-holding chambers BREATHERITE SPACER BREATHERITE SMALL CHILD MISC SPACER SMALL RX-DME spacer/aerosol-holding CHILD chambers BREATHERITE/LARGE BREATHERITE/LAR MASK MISC RX-DME GE MASK spacer/aerosol-holding chambers

©2021 Wellmark, Inc. 247 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BREATHERITE/MEDIUM BREATHERITE/MEDI MASK MISC RX-DME UM MASK spacer/aerosol-holding chambers BREATHERITE/SMALL BREATHERITE/SMA MASK MISC RX-DME LL MASK spacer/aerosol-holding chambers BREEZE 2 TEST DISK BREEZE 2 TEST TIER 3 glucose blood BRONCHITOL BRONCHITOL TOLERANCE TEST 40 MG SP-NP PA, QL (10 PER DAY(S)) TOLERANCE TEST CAP mannitol (cystic fibrosis) 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) 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 PV CONTROL acetone (urine) test CHEMSTRIP 10 MD CHEMSTRIP 10 MD STRIP TIER 2 PV multiple urine tests CHEMSTRIP 10/SG CHEMSTRIP 10/SG STRIP TIER 2 PV multiple urine tests CHEMSTRIP 2 GP STRIP CHEMSTRIP 2 GP TIER 2 PV multiple urine tests CHEMSTRIP 5 OB STRIP CHEMSTRIP 5 OB TIER 2 PV multiple urine tests CHEMSTRIP 7 STRIP CHEMSTRIP 7 TIER 2 PV multiple urine tests CHEMSTRIP 9 STRIP CHEMSTRIP 9 TIER 2 PV multiple urine tests CHEMSTRIP K STRIP CHEMSTRIP K TIER 2 PV acetone (urine) test

©2021 Wellmark, Inc. 248 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CHEMSTRIP UGK STRIP CHEMSTRIP UGK TIER 2 PV 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) CLEVER CHOICE HOLDING CHAMBER CLEVER CHOICE DEVICE RX-DME HOLDING CHAMBER spacer/aerosol-holding chambers 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) 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 PV multiple urine tests COMPACT SPACE COMPACT SPACE CHAMBER DEVICE RX-DME CHAMBER spacer/aerosol-holding chambers

©2021 Wellmark, Inc. 249 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS COMPACT SPACE CHAMBER/LG MASK COMPACT SPACE DEVICE RX-DME CHAMBER/LG MASK spacer/aerosol-holding chambers COMPACT SPACE COMPACT SPACE CHAMBER/MED MASK CHAMBER/MED DEVICE RX-DME MASK spacer/aerosol-holding chambers COMPACT SPACE COMPACT SPACE CHAMBER/SM MASK CHAMBER/SM DEVICE RX-DME MASK spacer/aerosol-holding chambers CONTOUR NEXT TEST CONTOUR NEXT QL (150 PER 30 DAYS), PA- STRIP TIER 2 TEST QL (300 / 30 days), PV glucose blood CONTOUR TEST STRIP QL (150 PER 30 DAYS), PA- CONTOUR TEST TIER 2 glucose blood QL (300 / 30 days), PV 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 PV 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) 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)

©2021 Wellmark, Inc. 250 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 EASIVENT MISC EASIVENT spacer/aerosol-holding RX-DME chambers EASIVENT MASK LARGE EASIVENT MASK MISC RX-DME LARGE spacer/aerosol-holding chambers EASIVENT MASK MEDIUM EASIVENT MASK MISC RX-DME MEDIUM spacer/aerosol-holding chambers EASIVENT MASK SMALL EASIVENT MASK MISC RX-DME SMALL spacer/aerosol-holding chambers 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)

©2021 Wellmark, Inc. 251 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EASY TOUCH QL (150 PER 30 DAYS), MN- EASY TOUCH HEALTHPRO GLUCOSE PA (Medically Necessary HEALTHPRO TIER 3 STRIP Prior Authorization), PA-QL GLUCOSE 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) 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)

©2021 Wellmark, Inc. 252 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) 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) EQ SPACE CHAMBER EQ SPACE ANTI-STATIC DEVICE CHAMBER ANTI- RX-DME spacer/aerosol-holding STATIC chambers EQ SPACE CHAMBER EQ SPACE ANTI-STATIC L DEVICE CHAMBER ANTI- RX-DME spacer/aerosol-holding STATIC L chambers EQ SPACE CHAMBER EQ SPACE ANTI-STATIC M DEVICE CHAMBER ANTI- RX-DME spacer/aerosol-holding STATIC M chambers EQ SPACE CHAMBER EQ SPACE ANTI-STATIC S DEVICE CHAMBER ANTI- RX-DME spacer/aerosol-holding STATIC S chambers 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)

©2021 Wellmark, Inc. 253 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) 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) FLEXICHAMBER DEVICE FLEXICHAMBER spacer/aerosol-holding RX-DME chambers FLEXICHAMBER ADULT FLEXICHAMBER MASK/SMALL MISC ADULT RX-DME spacer/aerosol-holding MASK/SMALL chamber supplies - masks

©2021 Wellmark, Inc. 254 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FLEXICHAMBER CHILD FLEXICHAMBER MASK/LARGE MISC RX-DME CHILD MASK/LARGE spacer/aerosol-holding chamber supplies - masks FLEXICHAMBER CHILD FLEXICHAMBER MASK/SMALL MISC RX-DME CHILD MASK/SMALL spacer/aerosol-holding chamber supplies - masks QL (150 PER 30 DAYS), MN- FORA 6 CONNECT PA (Medically Necessary FORA 6 CONNECT STRIP TIER 3 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)

©2021 Wellmark, Inc. 255 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FORA GTEL BLOOD FORA GTEL BLOOD KETONE TEST STRIP TIER 2 PV KETONE TEST ketone blood test QL (150 PER 30 DAYS), MN- FORA TN'G ADVANCE FORA TN'G PA (Medically Necessary PRO STRIP TIER 3 ADVANCE PRO Prior Authorization), PA-QL glucose blood (300 / 30 days) 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 G1 TEST FORTISCARE G1 PA (Medically Necessary STRIP STRIP TIER 3 TEST STRIP 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)

©2021 Wellmark, Inc. 256 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) 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)

©2021 Wellmark, Inc. 257 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) 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) GNP TRUE METRIX QL (150 PER 30 DAYS), MN- GNP TRUE METRIX GLUCOSE STRIPS PA (Medically Necessary TIER 3 GLUCOSE STRIPS STRIP 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 PV KETONE TEST ketone blood test

©2021 Wellmark, Inc. 258 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 PV multiple urine tests 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)

©2021 Wellmark, Inc. 259 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS INSPIRACHAMBER/LARG INSPIRACHAMBER/L E DEVICE RX-DME ARGE spacer/aerosol-holding chambers INSPIRACHAMBER/MEDI INSPIRACHAMBER/ UM DEVICE RX-DME MEDIUM spacer/aerosol-holding chambers INSPIRACHAMBER/MOUT INSPIRACHAMBER/ HPIECE DEVICE RX-DME MOUTHPIECE spacer/aerosol-holding chambers INSPIRACHAMBER/SMAL INSPIRACHAMBER/ L DEVICE RX-DME SMALL spacer/aerosol-holding chambers INSPIREASE MISC INSPIREASE spacer/aerosol-holding RX-DME chambers INSULIN PEN INSULIN PEN NEEDLE TIER 2 PV NEEDLE insulin pen needle INSULIN SYRINGE INSULIN SYRINGE TIER 2 PV insulin syringe INSULIN SYRINGE INSULIN SYRINGE NEEDLE TIER 2 PV NEEDLE insulin syringe needle IODINE STRONG 5 % IODINE STRONG SOLUTION TIER 4 iodine strong (lugol's) ISOMETHEPTENE- CAFFEINE-APAP 65-20- ISOMETHEPTENE- 325 MG TAB TIER 1 CAFFEINE-APAP isometheptene-caffeine- acetaminophen KETO-DIASTIX STRIP KETO-DIASTIX TIER 2 PV urine glucose-ketones test KETONE TEST STRIP KETONE TEST TIER 2 PV acetone (urine) test KETOSTIX STRIP KETOSTIX TIER 2 PV acetone (urine) test 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)

©2021 Wellmark, Inc. 260 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 PV 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) LITEAIRE DEVICE LITEAIRE spacer/aerosol-holding RX-DME chambers MASK VORTEX MISC MASK VORTEX spacer/aerosol-holding RX-DME chamber supplies - masks MASK MASK VORTEX/CHILD/FROG VORTEX/CHILD/FRO MISC RX-DME G spacer/aerosol-holding chamber supplies - masks MASK MASK VORTEX/TODDLER/LADY VORTEX/TODDLER/ BUG MISC RX-DME LADYBUG spacer/aerosol-holding chamber supplies - masks 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)

©2021 Wellmark, Inc. 261 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 MICROCHAMBER (DEVICE, MISC) MICROCHAMBER RX-DME spacer/aerosol-holding chambers 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) MICROSPACER MISC MICROSPACER spacer/aerosol-holding RX-DME chambers 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 MORPHABOND ER (ER 15 MG TB12 DETER, ER 30 MG TB12 DETER, ER 60 MORPHABOND ER TIER 4 PA, QL (60 PER 25) MG TB12 DETER, ER 100 MG TB12 DETER) morphine sulfate MULTISTIX STRIP MULTISTIX TIER 2 PV multiple urine tests MULTISTIX 10 SG STRIP MULTISTIX 10 SG TIER 2 PV multiple urine tests MULTISTIX 5 STRIP MULTISTIX 5 TIER 2 PV multiple urine tests MULTISTIX 7 STRIP MULTISTIX 7 TIER 2 PV multiple urine tests MULTISTIX 8 STRIP MULTISTIX 8 TIER 2 PV multiple urine tests

©2021 Wellmark, Inc. 262 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MULTISTIX 9 STRIP MULTISTIX 9 TIER 2 PV multiple urine tests MULTISTIX 9 SG STRIP MULTISTIX 9 SG TIER 2 PV 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) 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 PV KETONE TEST ketone blood test ODACTRA 12 SQ-HDM SL TAB ODACTRA TIER 4 PA dust mite mixed allergen extract OMNIPOD DASH 5 PACK OMNIPOD DASH 5 PODS MISC RX-DME QL (30 PER 30 DAY(S)) PACK PODS insulin infusion disposable pump 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), PV

©2021 Wellmark, Inc. 263 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 OPTICHAMBER OPTICHAMBER ADVANTAGE MISC RX-DME ADVANTAGE spacer/aerosol-holding chambers OPTICHAMBER OPTICHAMBER ADVANTAGE-LG MASK ADVANTAGE-LG MISC RX-DME MASK spacer/aerosol-holding chambers OPTICHAMBER OPTICHAMBER ADVANTAGE-MED MASK ADVANTAGE-MED MISC RX-DME MASK spacer/aerosol-holding chambers OPTICHAMBER OPTICHAMBER ADVANTAGE-SM MASK ADVANTAGE-SM MISC RX-DME MASK spacer/aerosol-holding chambers OPTICHAMBER DIAMOND OPTICHAMBER (DEVICE, MISC) RX-DME DIAMOND spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-LG MASK OPTICHAMBER DEVICE RX-DME DIAMOND-LG MASK spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-MD MASK OPTICHAMBER MISC RX-DME DIAMOND-MD MASK spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-SM MASK OPTICHAMBER MISC RX-DME DIAMOND-SM MASK spacer/aerosol-holding chambers OPTICHAMBER FACE OPTICHAMBER MASK-LARGE MISC RX-DME FACE MASK-LARGE spacer/aerosol-holding chambers

©2021 Wellmark, Inc. 264 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OPTICHAMBER FACE OPTICHAMBER MASK-MEDIUM MISC FACE MASK- RX-DME spacer/aerosol-holding MEDIUM chambers OPTICHAMBER FACE OPTICHAMBER MASK-SMALL MISC RX-DME FACE MASK-SMALL spacer/aerosol-holding chambers OPTIHALER (DEVICE, MISC) OPTIHALER RX-DME spacer/aerosol-holding chambers 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 PANDA MASK LARGE PANDA MASK MISC RX-DME LARGE spacer/aerosol-holding chamber supplies - masks PANDA MASK MEDIUM PANDA MASK MISC RX-DME MEDIUM spacer/aerosol-holding chamber supplies - masks PANDA MASK SMALL PANDA MASK MISC RX-DME SMALL spacer/aerosol-holding chamber supplies - masks PARAGARD PARAGARD INTRAUTERINE COPPER INTRAUTERINE SP-M IUD COPPER copper (iud) PEDIATRIC PANDA MASK PEDIATRIC PANDA MISC RX-DME MASK spacer/aerosol-holding chamber supplies - masks

©2021 Wellmark, Inc. 265 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) POCKET CHAMBER DEVICE POCKET CHAMBER RX-DME spacer/aerosol-holding chambers 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 PV 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) PRO COMFORT SPACER PRO COMFORT ADULT MISC RX-DME SPACER ADULT spacer/aerosol-holding chambers

©2021 Wellmark, Inc. 266 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PRO COMFORT SPACER PRO COMFORT CHILD MISC RX-DME SPACER CHILD spacer/aerosol-holding chambers PRO COMFORT SPACER PRO COMFORT INFANT DEVICE RX-DME SPACER INFANT spacer/aerosol-holding chambers 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) PROCARE PROCARE SPACER/ADULT MASK SPACER/ADULT DEVICE RX-DME MASK spacer/aerosol-holding chambers PROCARE PROCARE SPACER/CHILD MASK SPACER/CHILD DEVICE RX-DME MASK spacer/aerosol-holding chambers 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) PRODRIN 65-20-325 MG TAB PRODRIN TIER 4 isometheptene-caffeine- acetaminophen PTS PANELS KETONE PTS PANELS TEST STRIP TIER 2 PV 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 STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 267 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 PV acetone (urine) test RELION KETONE TEST RELION KETONE STRIP TIER 2 PV 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) QL (150 PER 30 DAYS), MN- RELION TRUE RELION TRUE METRIX PA (Medically Necessary METRIX TEST TEST STRIPS STRIP TIER 3 Prior Authorization), PA-QL STRIPS glucose blood (300 / 30 days) 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)

©2021 Wellmark, Inc. 268 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) QL (150 PER 30 DAYS), MN- RIGHTEST GT333 BLOOD RIGHTEST GT333 PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) RITEFLO DEVICE RITEFLO spacer/aerosol-holding RX-DME chambers 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 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 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)

©2021 Wellmark, Inc. 269 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 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)

©2021 Wellmark, Inc. 270 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 SOLUTION, 300 MG/3ML ULTOMIRIS SOLUTION, 1100 SP-M PA MG/11ML SOLUTION) 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) URISTIX STRIP URISTIX TIER 2 PV multiple urine tests URISTIX 4 STRIP URISTIX 4 TIER 2 PV multiple urine tests VALVED HOLDING VALVED HOLDING CHAMBER DEVICE RX-DME CHAMBER spacer/aerosol-holding chambers 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)

©2021 Wellmark, Inc. 271 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) VORTEX VALVED HOLDING CHAMBER VORTEX VALVED DEVICE RX-DME HOLDING CHAMBER spacer/aerosol-holding chambers WATCHHALER DEVICE WATCHHALER spacer/aerosol-holding RX-DME chambers 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) ALCAINE 0.5 % ALCAINE SOLUTION TIER 4 GA proparacaine hcl altacaine altacaine 0.5 % solution TIER 1 altafrin (2.5 % solution, 10 altafrin TIER 1 % solution) atropine sulfate 1 % atropine sulfate TIER 1 solution bacitra-neomycin- bacitra-neomycin- TIER 1 polymyxin-hc polymyxin-hc 1 % ointment

©2021 Wellmark, Inc. 272 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 CYCLOGYL (0.5 % SOLUTION, 1 % CYCLOGYL SOLUTION, 2 % TIER 4 GA SOLUTION) cyclopentolate hcl CYCLOMYDRIL 0.2-1 % SOLUTION CYCLOMYDRIL TIER 4 cyclopentolate w/ phenylephrine cyclopentolate hcl (0.5 % cyclopentolate hcl solution, 1 % solution, 2 % TIER 1 solution) CYSTADROPS 0.37 % CYSTADROPS SOLUTION SP-P QL (4 PER 28 DAY(S)) cysteamine hcl 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 MAXITROL (OINTMENT, SUSPENSION) MAXITROL TIER 4 GA neomycin-polymy- dexameth

©2021 Wellmark, Inc. 273 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS mydral (0.5 % solution, 1 % mydral TIER 1 solution) MYDRIACYL 1 % MYDRIACYL SOLUTION TIER 4 GA tropicamide 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) 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) NEOSPORIN 1.75-10000- .025 SOLUTION NEOSPORIN TIER 4 neomycin-polymyxin- gramicidin 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 POLYTRIM 10000-0.1 POLYTRIM UNIT/ML-% SOLUTION TIER 4 GA polymyxin b-trimethoprim

©2021 Wellmark, Inc. 274 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 PREDNISOLON- PREDNISOLON- MOXIFLOX-BROMFENAC MOXIFLOX- 1-0.5-0.09 % SOLUTION TIER 4 BROMFENAC prednisolone-moxifloxacin- bromfenac PREDNISOLON- PREDNISOLON- MOXIFLOX-KETOROLAC MOXIFLOX- 1-0.5-0.5 % SOLUTION TIER 4 KETOROLAC prednisolone-moxifloxacin- ketorolac 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 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 TOBRADEX 0.3-0.1 % TOBRADEX SUSPENSION TIER 4 GA tobramycin-dexamethasone TOBRADEX ST 0.3-0.05 % TOBRADEX ST SUSPENSION TIER 4 tobramycin-dexamethasone

©2021 Wellmark, Inc. 275 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 bepotastine besilate 1.5 % bepotastine besilate TIER 1 solution BEPREVE 1.5 % BEPREVE SOLUTION TIER 4 GA bepotastine besilate cromolyn sodium 4 % cromolyn sodium TIER 1 solution ELESTAT 0.05 % ELESTAT SOLUTION TIER 4 GA epinastine hcl (ophth) EMADINE 0.05 % EMADINE SOLUTION TIER 3 emedastine difumarate epinastine hcl 0.05 % epinastine hcl TIER 1 solution LASTACAFT 0.25 % LASTACAFT SOLUTION TIER 4 alcaftadine

OPHTHALMIC ANTI-INFLAMMATORIES

ACULAR 0.5 % SOLUTION ACULAR ketorolac tromethamine TIER 4 GA (ophth)

©2021 Wellmark, Inc. 276 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ACULAR LS 0.4 % SOLUTION ACULAR LS TIER 4 GA ketorolac tromethamine (ophth) ACUVAIL 0.45 % SOLUTION ACUVAIL TIER 3 ketorolac tromethamine (ophth) 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) FML FORTE 0.25 % FML FORTE SUSPENSION TIER 4 fluorometholone (ophth) FML LIQUIFILM 0.1 % FML LIQUIFILM SUSPENSION TIER 4 GA fluorometholone (ophth) ILEVRO 0.3 % ILEVRO SUSPENSION TIER 4 nepafenac ketorolac tromethamine ketorolac (0.4 % solution, 0.5 % TIER 1 tromethamine solution)

©2021 Wellmark, Inc. 277 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LOTEMAX (0.5 % GEL, 0.5 LOTEMAX % SUSPENSION) TIER 4 GA loteprednol etabonate LOTEMAX 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 % gel, 0.5 % suspension) MAXIDEX 0.1 % MAXIDEX SUSPENSION TIER 3 dexamethasone (ophth) NEVANAC 0.1 % NEVANAC SUSPENSION TIER 4 nepafenac OMNIPRED 1 % SUSPENSION OMNIPRED TIER 4 GA prednisolone acetate (ophth) PRED FORTE 1 % SUSPENSION PRED FORTE TIER 4 GA prednisolone acetate (ophth) PRED MILD 0.12 % SUSPENSION PRED MILD TIER 3 prednisolone acetate (ophth) prednisolone acetate 1 % prednisolone acetate TIER 1 suspension PREDNISOLONE SODIUM PREDNISOLONE PHOSPHATE 1 % SODIUM SOLUTION TIER 1 PHOSPHATE prednisolone sodium phosphate (ophth) PROLENSA 0.07 % PROLENSA SOLUTION TIER 4 bromfenac sodium (ophth)

OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P (ALHAGAN 0.1 % SOLUTION, ALPHAGAN P ALHAGAN 0.15 % TIER 4 GA SOLUTION) brimonidine tartrate apraclonidine hcl 0.5 % apraclonidine hcl TIER 1 solution

©2021 Wellmark, Inc. 278 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS AZOPT 1 % SUSPENSION AZOPT TIER 4 GA brinzolamide BETAGAN 0.5 % BETAGAN SOLUTION TIER 4 GA levobunolol hcl 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) brinzolamide 1 % brinzolamide TIER 1 suspension carteolol hcl carteolol hcl 1 % solution TIER 1 COMBIGAN 0.2-0.5 % SOLUTION COMBIGAN TIER 4 brimonidine tartrate-timolol maleate COSOPT 22.3-6.8 MG/ML SOLUTION COSOPT TIER 4 GA dorzolamide hcl-timolol maleate COSOPT PF 2-0.5 % SOLUTION COSOPT PF TIER 4 GA dorzolamide hcl-timolol maleate 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 0.5 % IOPIDINE SOLUTION TIER 4 GA apraclonidine hcl IOPIDINE 1 % SOLUTION IOPIDINE TIER 3 apraclonidine hcl ISOPTO CARPINE (1 % SOLUTION, 2 % ISOPTO CARPINE SOLUTION, 4 % TIER 4 GA SOLUTION) pilocarpine hcl

©2021 Wellmark, Inc. 279 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ISTALOL 0.5 % SOLUTION ISTALOL TIER 4 GA timolol maleate (ophth) 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 NEPTAZANE (25 MG TAB, NEPTAZANE 50 MG TAB) TIER 4 GA methazolamide PHOSPHOLINE IODIDE PHOSPHOLINE 0.125 % RECON SOLN TIER 3 IODIDE echothiophate iodide pilocarpine hcl (1 % pilocarpine hcl solution, 2 % solution, 4 % TIER 1 solution) SIMBRINZA 1-0.2 % SUSPENSION SIMBRINZA TIER 4 brinzolamide-brimonidine tartrate timolol maleate (0.25 % gel f soln, 0.25 % solution, 0.5 timolol maleate TIER 1 % (daily) solution, 0.5 % gel f soln, 0.5 % solution) timolol maleate timolol maleate ocudose TIER 1 ocudose 0.5 % solution timolol maleate pf 0.5 % timolol maleate pf TIER 1 solution TIMOPTIC (0.25 % SOLUTION, 0.5 % TIMOPTIC TIER 4 GA SOLUTION) timolol maleate (ophth) TIMOPTIC OCUDOSE TIMOPTIC (0.25 % SOLUTION, 0.5 % TIER 4 GA OCUDOSE SOLUTION) timolol maleate (ophth) TIMOPTIC-XE (0.25 % GEL F SOLN, 0.5 % GEL F TIMOPTIC-XE TIER 4 GA SOLN) timolol maleate (ophth) TRUSOPT 2 % SOLUTION TRUSOPT TIER 4 GA dorzolamide hcl

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 TRAVATAN Z 0.004 % TRAVATAN Z SOLUTION TIER 4 GA travoprost travoprost (bak free) 0.004 travoprost (bak free) TIER 1 % solution XALATAN 0.005 % XALATAN SOLUTION TIER 4 GA latanoprost ZIOPTAN 0.0015 % ZIOPTAN SOLUTION TIER 4 tafluprost

OTIC AGENTS

acetasol hc acetasol hc 2-1 % solution TIER 1 acetic acid acetic acid 2 % solution TIER 1 CIPRO HC 0.2-1 % SUSPENSION CIPRO HC TIER 3 ciprofloxacin- hydrocortisone CIPRODEX 0.3-0.1 % SUSPENSION CIPRODEX TIER 4 GA ciprofloxacin- dexamethasone 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

©2021 Wellmark, Inc. 281 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DERMOTIC 0.01 % OIL DERMOTIC fluocinolone acetonide TIER 4 GA (otic) flac flac 0.01 % oil TIER 1 fluocinolone fluocinolone acetonide 0.01 TIER 1 acetonide % oil 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)

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

AEROSPAN 80 MCG/ACT MN-PA (Medically Necessary AEROSPAN AERO SOLN TIER 4 Prior Authorization) flunisolide hfa ALVESCO (80 AERO MN-PA (Medically Necessary ALVESCO SOLN, 160 AERO SOLN) TIER 4 Prior Authorization) ciclesonide 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) (110 AER POW ASMANEX (30 BA, 220 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 (7 METERED DOSES) 110 MCG/INH ASMANEX (7 AER POW BA TIER 1 PV METERED DOSES) mometasone furoate (inhalation)

©2021 Wellmark, Inc. 282 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ASMANEX HFA (50 AEROSOL, 100 AEROSOL, 200 ASMANEX HFA TIER 1 PV AEROSOL) mometasone furoate (inhalation) BECONASE AQ 42 MCG/SPRAY BECONASE AQ SUSPENSION TIER 4 PA beclomethasone diprop monohyd budesonide (0.25 budesonide suspension, 0.5 TIER 1 PV suspension, 1 suspension) FLOVENT DISKUS (50 AER POW BA, 100 AER POW BA, 250 AER POW MN-PA (Medically Necessary FLOVENT DISKUS TIER 4 BA) Prior Authorization) fluticasone propionate (inhalation) FLOVENT HFA (44 AEROSOL, 110 MN-PA (Medically Necessary FLOVENT HFA AEROSOL, 220 TIER 4 Prior Authorization) AEROSOL) fluticasone propionate hfa FLUNISOLIDE 25 MCG/ACT (0.025%) FLUNISOLIDE TIER 1 SOLUTION flunisolide (nasal) mometasone furoate 50 mometasone furoate TIER 1 PA mcg/act suspension NASONEX 50 MCG/ACT SUSPENSION NASONEX TIER 4 PA, GA mometasone furoate (nasal) OMNARIS 50 MCG/ACT OMNARIS SUSPENSION TIER 4 PA ciclesonide (nasal) PULMICORT (0.25 SUSPENSION, 0.5 PULMICORT SUSPENSION, 1 TIER 4 GA SUSPENSION) budesonide (inhalation) PULMICORT FLEXHALER PULMICORT (90 AER POW BA, 180 MN-PA (Medically Necessary TIER 4 FLEXHALER AER POW BA) Prior Authorization) budesonide (inhalation)

©2021 Wellmark, Inc. 283 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QNASL 80 MCG/ACT AERO SOLN QNASL TIER 4 PA beclomethasone dipropionate (nasal) QNASL CHILDRENS 40 MCG/ACT AERO SOLN QNASL CHILDRENS TIER 4 PA beclomethasone dipropionate (nasal) 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 AER POW BA, TRELEGY ELLIPTA 200-62.5-25 AER POW BA) TIER 2 PV fluticasone-umeclidinium- vilanterol ZETONNA 37 MCG/ACT ZETONNA AERO SOLN TIER 4 PA ciclesonide (nasal)

ANTIHISTAMINES

ASTEPRO 0.15 % ASTEPRO SOLUTION TIER 4 GA azelastine hcl azelastine hcl (0.1 % azelastine hcl solution, 0.15 % solution, TIER 1 137 mcg/spray solution) BROMPHENIRAMINE BROMPHENIRAMIN TANNATE 12 MG CHEW TIER 1 E TANNATE TAB brompheniramine tannate carbinoxamine carbinoxamine maleate (4 TIER 1 maleate mg tab, 4 mg/5ml solution) CLARINEX (0.5 MG/ML CLARINEX SYRUP, 5 MG TAB) TIER 4 GA desloratadine CLEMASTINE FUMARATE CLEMASTINE 2.68 MG TAB TIER 1 FUMARATE clemastine fumarate cyproheptadine hcl (2 cyproheptadine hcl TIER 1 mg/5ml syrup, 4 mg tab)

©2021 Wellmark, Inc. 284 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DESLORATADINE (2.5 MG TAB DISP, 5 MG TAB, 5 DESLORATADINE TIER 1 MG TAB DISP) desloratadine diphenhydramine hcl 50 diphenhydramine hcl TIER 1 mg/ml solution hydroxyzine hcl (10 mg tab, hydroxyzine hcl 10 mg/5ml syrup, 25 mg TIER 1 tab, 50 mg tab) hydroxyzine pamoate (25 hydroxyzine pamoate mg cap, 50 mg cap, 100 mg TIER 1 cap) KARBINAL ER 4 MG/5ML KARBINAL ER SUSP TIER 4 carbinoxamine maleate olopatadine hcl 0.6 % olopatadine hcl TIER 1 solution PATANASE 0.6 % PATANASE SOLUTION TIER 4 GA olopatadine hcl (nasal) promethazine hcl (6.25 promethazine hcl TIER 1 solution, 6.25 syrup) VISTARIL (25 MG CAP, 50 VISTARIL MG CAP) TIER 4 GA hydroxyzine pamoate

ANTILEUKOTRIENES

ACCOLATE (10 MG TAB, ACCOLATE 20 MG TAB) TIER 4 GA zafirlukast montelukast sodium (4 mg montelukast sodium chew tab, 4 mg packet, 5 TIER 1 PV mg chew tab, 10 mg tab) SINGULAIR (4 MG CHEW TAB, 4 MG PACKET, 5 MG SINGULAIR TIER 4 GA CHEW TAB, 10 MG TAB) montelukast sodium zafirlukast (10 mg tab, 20 zafirlukast TIER 1 PV mg tab) zileuton er 600 mg tab er zileuton er TIER 1 PV 12h ZYFLO 600 MG TAB ZYFLO TIER 4 zileuton ZYFLO CR 600 MG TAB ZYFLO CR ER 12H TIER 4 GA zileuton

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 TUDORZA PRESSAIR 400 TUDORZA MCG/ACT AER POW BA TIER 4 PRESSAIR aclidinium bromide YUPELRI 175 MCG/3ML YUPELRI SOLUTION TIER 4 revefenacin

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 0.1 % ADRENALIN SOLUTION TIER 4 GA epinephrine hcl (nasal) 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)

©2021 Wellmark, Inc. 286 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS albuterol sulfate hfa 108 (90 albuterol sulfate hfa TIER 1 base) mcg/act aero soln ARCAPTA NEOHALER 75 ARCAPTA MCG CAP TIER 4 NEOHALER indacaterol maleate arformoterol tartrate 15 arformoterol tartrate TIER 1 PV mcg/2ml nebu soln BROVANA 15 MCG/2ML BROVANA NEBU SOLN TIER 4 GA arformoterol tartrate epinephrine (0.15 mg/0.15ml soln a-inj, 0.15 epinephrine TIER 3 QL (2 PER RX) mg/0.3ml 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) formoterol fumarate 20 formoterol fumarate TIER 1 PV mcg/2ml nebu soln levalbuterol hcl (0.31 mg/3ml nebu soln, 0.63 levalbuterol hcl mg/3ml nebu soln, 1.25 TIER 1 mg/0.5ml nebu soln, 1.25 mg/3ml nebu soln) levalbuterol tartrate 45 levalbuterol tartrate TIER 2 mcg/act aerosol METAPROTERENOL SULFATE (10 MG TAB, 10 METAPROTERENOL MG/5ML SYRUP, 20 MG TIER 1 SULFATE TAB) metaproterenol sulfate PERFOROMIST 20 PERFOROMIST MCG/2ML NEBU SOLN TIER 4 GA formoterol fumarate PROAIR HFA 108 (90 BASE) MCG/ACT AERO PROAIR HFA TIER 4 GA SOLN albuterol sulfate

©2021 Wellmark, Inc. 287 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROAIR RESPICLICK 108 PROAIR (90 BASE) MCG/ACT AER TIER 4 RESPICLICK POW BA albuterol sulfate PROVENTIL HFA 108 (90 BASE) MCG/ACT AERO PROVENTIL HFA TIER 4 GA SOLN 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 VENTOLIN HFA TIER 4 GA SOLN albuterol sulfate VOSPIRE ER (ER 4 MG TAB ER 12H, ER 8 MG VOSPIRE ER TIER 4 GA TAB ER 12H) albuterol sulfate XOPENEX (0.31 NEBU SOLN, 0.63 NEBU SOLN, XOPENEX TIER 4 GA 1.25 NEBU SOLN) levalbuterol hcl XOPENEX XOPENEX CONCENTRATE 1.25 TIER 4 GA CONCENTRATE MG/0.5ML NEBU SOLN levalbuterol hcl XOPENEX HFA 45 XOPENEX HFA MCG/ACT AEROSOL TIER 4 GA levalbuterol tartrate

CYSTIC FIBROSIS AGENTS

BETHKIS 300 MG/4ML BETHKIS NEBU SOLN SP-NP GA tobramycin BRONCHITOL 40 MG CAP BRONCHITOL SP-NP PA, QL (20 PER 1 DAY(S)) mannitol (cystic fibrosis)

©2021 Wellmark, Inc. 288 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 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 SBG (Specialty Biosimilars tobramycin nebu soln, 300 mg/5ml SP-P and Specialty generics) nebu soln) TRIKAFTA 100-50-75 & 150 MG TAB THPK TRIKAFTA SP-P PA, QL (84 PER 28 DAY(S)) elexacaftor-tezacaftor- ivacaftor TRIKAFTA 50-25-37.5 & 75 MG TAB THPK TRIKAFTA SP-P PA, QL (3 PER 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) DALIRESP (250 MCG TAB, DALIRESP 500 MCG TAB) TIER 4 roflumilast ELIXOPHYLLIN 80 ELIXOPHYLLIN MG/15ML ELIXIR TIER 4 theophylline 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 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 PA, QL (60 PER 30 DAYS), alyq alyq 20 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) PA, QL (30 PER 30 DAYS), ambrisentan (5 mg tab, 10 ambrisentan SP-P SBG (Specialty Biosimilars mg tab) and Specialty generics) PA, QL (60 PER 30 DAY(S)), bosentan (62.5 mg tab, 125 bosentan SP-P SBG (Specialty Biosimilars mg tab) and Specialty generics) epoprostenol sodium (0.5 epoprostenol sodium mg recon soln, 1.5 mg SP-M PA recon soln)

©2021 Wellmark, Inc. 290 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) 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 PA, QL (720 PER 30 DAYS), sildenafil citrate 10 mg/ml sildenafil citrate SP-P SBG (Specialty Biosimilars recon susp and Specialty generics) PA, QL (360 PER 30 DAYS), sildenafil citrate sildenafil citrate 20 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) PA, QL (60 PER 30 DAYS), tadalafil (pah) tadalafil (pah) 20 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) TRACLEER (62.5 MG TAB, PA, QL (60 PER 30 DAY(S)), TRACLEER 125 MG TAB) SP-NP GA bosentan

©2021 Wellmark, Inc. 291 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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 VENTAVIS (10 MCG/ML SOLUTION, 20 MCG/ML VENTAVIS SP-P PA, QL (9 PER DAY) SOLUTION) iloprost

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)

©2021 Wellmark, Inc. 292 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS 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) CARBAPHEN 12 10-4-27.5 MG/5ML LIQUID CARBAPHEN 12 phenylephrine- TIER 4 chlorpheniramine- carbetapentane CARBAPHEN 12 PED 2.5- 1.25-7.5 MG/ML CARBAPHEN 12 SUSPENSION TIER 4 PED phenylephrine- chlorpheniramine- carbetapentane CINQAIR 100 MG/10ML CINQAIR SOLUTION SP-M PA reslizumab CLARINEX-D 12 HOUR CLARINEX-D 12 2.5-120 MG TAB ER 12H TIER 4 HOUR desloratadine- pseudoephedrine

©2021 Wellmark, Inc. 293 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS COMBIVENT RESPIMAT COMBIVENT 20-100 MCG/ACT AERO TIER 2 RESPIMAT SOLN ipratropium-albuterol difil-g forte 100-100 mg/5ml difil-g forte TIER 1 liquid DULERA (50-5 AEROSOL, 100-5 AEROSOL, 200-5 AEROSOL) MN-PA (Medically Necessary DULERA TIER 4 mometasone furoate- Prior Authorization) formoterol fumarate dihydrate DYMISTA 137-50 MCG/ACT SUSPENSION DYMISTA TIER 4 PA, GA azelastine hcl-fluticasone propionate EXACTUSS 10-28-388 EXACTUSS MG/5ML LIQUID TIER 4 GA phenylephrine w/ dm-gg FASENRA 30 MG/ML FASENRA SOLN PRSYR SP-M PA benralizumab FASENRA PEN 30 MG/ML FASENRA PEN SOLN A-INJ SP-M PA benralizumab FLOWTUSS 2.5-200 FLOWTUSS MG/5ML SOLUTION TIER 4 hydrocodone-guaifenesin fluticasone-salmeterol (55- 14 aer pow ba, 113-14 aer fluticasone-salmeterol TIER 1 PV pow ba, 232-14 aer pow ba) GILTUSS 10-28-388 GILTUSS MG/5ML LIQUID TIER 4 GA phenylephrine w/ dm-gg giltuss pediatric 2.5-7.5-88 giltuss pediatric TIER 1 mg/ml liquid HYCODAN 5-1.5 MG/5ML SYRUP HYCODAN TIER 4 GA hydrocodone w/ homatropine HYCOFENIX 30-2.5-200 MG/5ML SOLUTION HYCOFENIX TIER 4 pseudoeph w/hydrocodone- gg hydrocod polst-cpm hydrocod polst-cpm polst er TIER 1 polst er 10-8 mg/5ml susp

©2021 Wellmark, Inc. 294 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HYDROCODONE- HYDROCODONE- GUAIFENESIN 2.5-200 TIER 4 GUAIFENESIN MG/5ML SOLUTION hydrocodone-guaifenesin hydrocodone- hydrocodone-homatropine TIER 1 homatropine (mg tab, mg/5ml syrup) hydromet 5-1.5 mg/5ml hydromet TIER 1 syrup HYPERSAL (3.5 % NEBU HYPERSAL SOLN, 7 % NEBU SOLN) TIER 4 GA sodium chloride (inhalant) ipratropium-albuterol 0.5- ipratropium-albuterol TIER 1 2.5 (3) mg/3ml solution nebusal nebusal 3 % nebu soln TIER 1 NEBUSAL 6 % NEBU NEBUSAL SOLN TIER 4 sodium chloride (inhalant) NEOTUSS PLUS 7.5-4-30 MG/5ML LIQUID NEOTUSS PLUS TIER 4 phenylephrine-chlorphen- dm NUCALA (100 MG/ML SOLN A-INJ, 100 MG/ML NUCALA SP-M PA, QL (1 PER 28 DAY(S)) SOLN PRSYR) mepolizumab NUCALA 100 MG RECON NUCALA SOLN SP-M PA, QL (1 PER 28 DAYS) mepolizumab OBREDON 2.5-200 OBREDON MG/5ML SOLUTION TIER 4 hydrocodone-guaifenesin phenylephrine- phenylephrine-guaifenesin TIER 1 guaifenesin 1.5-20 mg/ml liquid promethazine vc 6.25-5 promethazine vc TIER 1 mg/5ml syrup 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 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

©2021 Wellmark, Inc. 295 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS promethazine- promethazine- phenylephrine 6.25-5 TIER 1 phenylephrine mg/5ml syrup 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 RESCON-JR 3-20 MG TAB ER 12H RESCON-JR TIER 4 dexchlorpheniramine- phenylephrine REZIRA 60-5 MG/5ML SOLUTION REZIRA TIER 4 pseudoephedrine w/ hydrocodone SEMPREX-D 8-60 MG CAP SEMPREX-D acrivastine & TIER 4 pseudoephedrine 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 SYMBICORT (80-4.5 AEROSOL, 160-4.5 SYMBICORT AEROSOL) TIER 2 PV, GA budesonide-formoterol fumarate dihydrate TESSALON PERLES 100 TESSALON PERLES MG CAP TIER 4 GA benzonatate TUSNEL 60-30-400 MG TUSNEL TAB TIER 4 pseudoephedrine w/ dm-gg TUSSICAPS (5-4 MG CAP ER 12H, 10-8 MG CAP ER TUSSICAPS 12H) TIER 4 hydrocodone polistirex- chlorpheniramine polistirex tussigon tussigon 5-1.5 mg tab TIER 1

©2021 Wellmark, Inc. 296 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TUSSIONEX PENNKINETIC ER 10-8 TUSSIONEX MG/5ML SUSP TIER 4 GA PENNKINETIC ER hydrocodone polistirex- chlorpheniramine polistirex TUZISTRA XR 14.7-2.8 MG/5ML SUSP TUZISTRA XR TIER 4 codeine polistirex- chlorpheniramine polistirex VITUZ 5-4 MG/5ML SOLUTION VITUZ TIER 4 hydrocodone- chlorpheniramine XOLAIR (150 MG RECON SOLN, 150 MG/ML SOLN XOLAIR SP-M PA, QL (8 PER 28 DAY(S)) PRSYR) omalizumab XOLAIR 75 MG/0.5ML XOLAIR SOLN PRSYR SP-M PA, QL (2 PER 28 DAY(S)) omalizumab ZUTRIPRO 60-4-5 MG/5ML SOLUTION ZUTRIPRO TIER 4 GA pseudoephed-cpm w/ hydrocod

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) DYSPORT (300 RECON DYSPORT SOLN, 500 RECON SOLN) SP-M PA, QL (1500 PER DAY(S)) 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)

©2021 Wellmark, Inc. 297 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MYOBLOC (2500 UNIT/0.5ML SOLUTION, QL (10000 PER DAY(S)), 5000 UNIT/ML SOLUTION, MYOBLOC SP-M MN-PA (Medically Necessary 10000 UNIT/2ML Prior Authorization) SOLUTION) rimabotulinumtoxinb orphenadrine citrate orphenadrine citrate er 100 TIER 1 er mg tab er 12h PARAFON FORTE DSC PARAFON FORTE 500 MG TAB TIER 4 GA DSC chlorzoxazone ROBAXIN 500 MG TAB ROBAXIN TIER 4 GA methocarbamol ROBAXIN-750 750 MG ROBAXIN-750 TAB TIER 4 GA methocarbamol SKELAXIN 800 MG TAB SKELAXIN TIER 4 GA metaxalone SOMA (250 MG TAB, 350 SOMA MG TAB) TIER 4 GA carisoprodol vanadom vanadom 350 mg tab TIER 1 XEOMIN (50 RECON SOLN, 100 RECON SOLN, XEOMIN SP-M PA, QL (400 PER DAY(S)) 200 RECON SOLN) incobotulinumtoxina

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

AMBIEN (5 MG TAB, 10 AMBIEN MG TAB) TIER 4 GA zolpidem tartrate AMBIEN CR (6.25 MG TAB AMBIEN CR ER, 12.5 MG TAB ER) TIER 4 PA, GA zolpidem tartrate EDLUAR (5 MG SL TAB, EDLUAR 10 MG SL TAB) TIER 4 PA zolpidem tartrate 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

©2021 Wellmark, Inc. 298 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HALCION 0.25 MG TAB HALCION TIER 4 GA triazolam INTERMEZZO (1.75 MG SL INTERMEZZO TAB, 3.5 MG SL TAB) TIER 4 PA, GA zolpidem tartrate LUNESTA (1 MG TAB, 2 LUNESTA MG TAB, 3 MG TAB) TIER 4 PA, GA eszopiclone RESTORIL (7.5 MG CAP, 15 MG CAP, 22.5 MG CAP, RESTORIL TIER 4 GA 30 MG CAP) temazepam SONATA (5 MG CAP, 10 SONATA MG CAP) TIER 4 GA zaleplon 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) XYWAV 500 MG/ML SOLUTION PA, QL (540 PER 30 XYWAV calcium, magnesium, SP-NP DAY(S)) potassium, & sodium oxybates 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) zolpidem tartrate er (er 6.25 zolpidem tartrate er mg tab er, er 12.5 mg tab TIER 1 PA er) ZOLPIMIST 5 MG/ACT ZOLPIMIST SOLUTION TIER 4 PA zolpidem tartrate

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) BELSOMRA (5 MG TAB, 10 MG TAB, 15 MG TAB, BELSOMRA TIER 4 PA, QL (30 PER 30 DAYS) 20 MG TAB) suvorexant

©2021 Wellmark, Inc. 299 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BUTISOL SODIUM 30 MG BUTISOL SODIUM TAB TIER 3 butabarbital sodium DAYVIGO (5 MG TAB, 10 DAYVIGO MG TAB) TIER 4 PA, QL (30 PER 30 DAY(S)) lemborexant 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) NUVIGIL (50 MG TAB, 150 MG TAB, 200 MG TAB, 250 PA, QL (30 PER 30 DAYS), NUVIGIL TIER 4 MG TAB) GA armodafinil PROVIGIL (100 MG TAB, PA, QL (60 PER 30 DAYS), PROVIGIL 200 MG TAB) TIER 4 GA modafinil ramelteon ramelteon 8 mg tab TIER 1 PA ROZEREM 8 MG TAB ROZEREM TIER 4 PA, GA ramelteon SECONAL 100 MG CAP SECONAL TIER 3 secobarbital sodium SILENOR (3 MG TAB, 6 SILENOR MG TAB) TIER 4 PA, GA doxepin hcl (sleep) 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

Uncategorized

Unclassified

ABECMA SUSPENSION ABECMA SP-M idecabtagene vicleucel ADUHELM (170 MG/1.7ML SOLUTION, 300 MG/3ML ADUHELM P&T SOLUTION) aducanumab-avwa

©2021 Wellmark, Inc. 300 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS AZSTARYS (26.1-5.2 MG CAP, 39.2-7.8 MG CAP, 52.3-10.4 MG CAP) AZSTARYS P&T PA, QL (1 PER DAY(S)) serdexmethylphenidate chloride- dexmethylphenidate hcl BIO-STATIN (500000 CAP, BIO-STATIN 1000000 CAP) TIER 4 nystatin BYLVAY (400 MCG CAP, BYLVAY 1200 MCG CAP) P&T odevixibat BYLVAY (PELLETS) (200 MCG CAP SPRINK, 600 BYLVAY (PELLETS) P&T MCG CAP SPRINK) odevixibat COSELA 300 MG RECON COSELA SOLN SP-M trilaciclib dihydrochloride CYCLOPHOSPHAMIDE CYCLOPHOSPHAMI (25 MG TAB, 50 MG TAB) TIER 1 DE cyclophosphamide EMPAVELI 1080 MG/20ML EMPAVELI SOLUTION P&T pegcetacoplan ENGERIX-B (10 MCG/0.5ML INJECTABLE, ENGERIX-B 20 MCG/ML INJECTABLE) TIER 2 PV hepatitis b vaccine (recomb) EVKEEZA (345 MG/2.3ML SOLUTION, 1200 MG/8ML EVKEEZA SP-M PA SOLUTION) evinacumab-dgnb FOTIVDA (0.89 MG CAP, FOTIVDA 1.34 MG CAP) SP-P QL (21 PER 28 DAY(S)) tivozanib hcl HETLIOZ LQ 4 MG/ML HETLIOZ LQ SUSPENSION SP-P PA, QL (5 PER 1 DAY(S)) tasimelteon JEMPERLI 500 MG/10ML JEMPERLI SOLUTION SP-M dostarlimab-gxly KERENDIA (10 MG TAB, KERENDIA 20 MG TAB) P&T finerenone

©2021 Wellmark, Inc. 301 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LUMAKRAS 120 MG TAB LUMAKRAS SP-P sotorasib MARGENZA 250 MG/10ML MARGENZA SOLUTION SP-M margetuximab-cmkb NEXTSTELLIS 3-14.2 MG NEXTSTELLIS TAB TIER 4 drospirenone-estetrol NEXVIAZYME 100 MG NEXVIAZYME RECON SOLN P&T avalglucosidase alfa-ngpt NULIBRY 9.5 MG RECON SOLN NULIBRY SP-M fosdenopterin hydrobromide PEPAXTO 20 MG RECON PEPAXTO SOLN SP-M melphalan flufenamide hcl QL (1 PER 1 DAY(S)), MN- PONVORY 20 MG TAB PONVORY SP-NP PA (Medically Necessary ponesimod Prior Authorization) PONVORY STARTER QL (1 PER 14 DAY(S)), MN- PONVORY PACK 2,3,4,5,6,7,8,9 & 10 SP-NP PA (Medically Necessary STARTER PACK MG TAB THPK Prior Authorization) ponesimod PREVNAR 20 0.5 ML SUSP PRSYR PREVNAR 20 TIER 2 PV pneumococcal 20-valent conjugate vaccine REZUROCK 200 MG TAB REZUROCK P&T belumosudil mesylate RYBREVANT 350 MG/7ML RYBREVANT SOLUTION SP-M amivantamab-vmjw RYLAZE 10 MG/0.5ML SOLUTION RYLAZE asparaginase erwinia SP-M chrysanthemi (recombinant)-rywn SAPHNELO 300 MG/2ML SAPHNELO SOLUTION P&T anifrolumab-fnia SKYRIZI (150 MG/ML SOLN A-INJ, 150 MG/ML SKYRIZI SP-P PA, QL (1 PER 84 DAY(S)) SOLN PRSYR) risankizumab-rzaa

©2021 Wellmark, Inc. 302 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TEPMETKO 225 MG TAB TEPMETKO SP-P tepotinib hcl TRUSELTIQ (100MG TRUSELTIQ (100MG DAILY DOSE) 100 MG SP-P DAILY DOSE) CAP THPK infigratinib phosphate TRUSELTIQ (125MG TRUSELTIQ (125MG DAILY DOSE) 100 & 25 SP-P DAILY DOSE) MG CAP THPK infigratinib phosphate TRUSELTIQ (50MG DAILY TRUSELTIQ (50MG DOSE) 25 MG CAP THPK SP-P DAILY DOSE) infigratinib phosphate TRUSELTIQ (75MG DAILY TRUSELTIQ (75MG DOSE) 25 MG CAP THPK SP-P DAILY DOSE) infigratinib phosphate UKONIQ 200 MG TAB UKONIQ SP-P umbralisib tosylate UPTRAVI 1800 MCG UPTRAVI RECON SOLN SP-M selexipag WELIREG 40 MG TAB WELIREG P&T belzutifan XELJANZ 1 MG/ML XELJANZ SOLUTION SP-P PA, QL (10 PER 1 DAY(S)) tofacitinib citrate XTANDI (40 MG TAB, 80 XTANDI MG TAB) SP-P enzalutamide ZEGALOGUE (0.6 SOLN ZEGALOGUE A-INJ, 0.6 SOLN PRSYR) TIER 3 dasiglucagon hcl ZYNLONTA 10 MG ZYNLONTA RECON SOLN SP-M loncastuximab tesirine-lpyl

©2021 Wellmark, Inc. 303 Index of covered drugs AcipHex Sprinkle 176 A ACITRETIN 153,158 ABACAVIR SULFATE 86,88 ACLIDINIUM BROMIDE 286 ABACAVIR SULFATE-LAMIVUDINE 86,87 Aclovate 185 ABACAVIR SULFATE-LAMIVUDINE- ACRIVASTINE & PSEUDOEPHEDRINE 296 ZIDOVUDINE 86,87 Actemra 231 ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE 89 Actemra ACTPen 231 ABALOPARATIDE 243 Acthar 185 ABATACEPT 224,225 ActHIB 233 Abecma 300 Actigall 171 ABEMACICLIB 70 Actimmune 231 Abilify 78 Actiq 13 ABIRATERONE ACETATE 60 Activella 197 ABOBOTULINUMTOXINA 297 Actonel 241 Abstral 13 Actoplus Met 94 ACALABRUTINIB 65 Actoplus met XR 94 ACAMPROSATE CALCIUM 19 Actos 94 Acanya 153 Acular 276 ACARBOSE 94,98 Acular LS 277 Accolate 285 Acuvail 277 Accu-Chek Aviva Plus 243 ACYCLOVIR 91,92 Accu-Chek Compact Plus 243 ACYCLOVIR-HYDROCORTISONE 91 Accu-Chek Guide 244 Aczone 153 Accu-Chek SmartView 244 Adacel 234 Accupril 121 Adakveo 118 Accuretic 129 Adalat CC 125 Accutrend Glucose 244 ADALIMUMAB 223,224 ACEBUTOLOL HCL 123 ADAPALENE 153,155 Aceon 121 Adcirca 290 ACETAMINOPHEN W/ CODEINE 13,18 Adderall 143 ACETAMINOPHEN-CAFF-DIHYDROCOD 13,14,17,18 Adderall XR 143 ACETAMINOPHEN-SALICYLAMIDE- ADEFOVIR DIPIVOXIL 82 PHENYLTOLOXAMINE 251 Adempas 290 Acetaminophen-Salicylamide-Phenyltoloxamine 252 Adlyxin 94 ACETAZOLAMIDE 136 Adlyxin Starter Pack 94 ACETIC ACID (OTIC) 281 Admelog 101 ACETOHYDROXAMIC ACID 183 Admelog SoloStar 101 ACETONE (URINE) TEST 248,260,268 Adrenaclick 286 Acetone (Urine) Test 260 Adrenalin 286 ACETYLCYSTEINE 292 ADUCANUMAB-AVWA 300 Aciphex 176 Aduhelm 300

©2021 Wellmark, Inc. 304 Advair Diskus 293 Aimovig 57 Advair HFA 293 Aimovig (140 MG Dose) 57 Advance Intuition Test 244 Ajovy 42,57 Advate 112 Akten 272 Advocate Redi-Code 244 Akynzeo 49 Advocate Redi-Code+ Test 244 ALBENDAZOLE 71 Advocate Test 244 Albenza 71 Adynovate 112 ALBIGLUTIDE 99 Aemcolo 21 ALBUTEROL SULFATE 286,287,288 AeroChamber Mini Chamber 244 ALCAFTADINE 276 AeroChamber MV 244 Alcaine 272 AeroChamber Plus Flo-Vu 244 ALCLOMETASONE DIPROPIONATE 185 AeroChamber Plus Flo-Vu Large 244 ALCOHOL SWABS 246,267,269 AeroChamber Plus Flo-Vu Medium 245 Aldactazide 129 AeroChamber Plus Flo-Vu Small 245 Aldactone 137 AeroChamber Plus Flo-Vu w/Mask 245 Aldara 153 AeroChamber Plus Flow VU 245 Aldurazyme 177 AeroChamber w/FLOWSIGnal 245 Alecensa 65 AeroChamber Z-Stat Plus 245 ALECTINIB HCL 65 AeroChamber Z-Stat Plus Chambr 245 ALEMTUZUMAB (MS) 150 AeroChamber Z-Stat Plus/Large 245 ALENDRONATE SODIUM 241,242 AeroChamber Z-Stat Plus/Medium 245 ALENDRONATE SODIUM-CHOLECALCIFEROL 242 AeroChamber Z-Stat Plus/Small 245 ALFUZOSIN HCL 182,183 Aerospan 282 ALGLUCOSIDASE ALFA 178 AeroVent Plus 245 Alinia 72 AFAMELANOTIDE ACETATE 157 ALIROCUMAB 140 AFATINIB DIMALEATE 66 ALISKIREN FUMARATE 129,134 Afinitor 65 ALISKIREN-HYDROCHLOROTHIAZIDE 135 Afinitor Disperz 65 ALITRETINOIN 71 Afluria 234 Alkeran 59 Afluria Preservative Free 234 ALLOPURINOL 53,54 Afluria Quadrivalent 234 ALMOTRIPTAN MALATE 54,55 Afrezza 101 Alocril 276 Afstyla 112 ALOGLIPTIN BENZOATE 94,97 AGALSIDASE BETA 178 ALOGLIPTIN-METFORMIN HCL 94,97 AgaMatrix AMP Test 245 ALOGLIPTIN-PIOGLITAZONE 94,98 AgaMatrix Jazz Test 246 Alomide 276 AgaMatrix KeyNote Test 246 ALOSETRON HCL 173 AgaMatrix Presto Test 246 ALPELISIB 65 Aggrenox 118 Alphagan P 278 Agrylin 109 Alphanate 112

©2021 Wellmark, Inc. 305 Alphanate/VWF Complex/Human 113 AMLODIPINE BESYLATE-OLMESARTAN AlphaNine SD 113 MEDOXOMIL 130 ALPRAZOLAM 92,93 AMLODIPINE BESYLATE-VALSARTAN 129,132 ALPRAZolam Intensol 92 AMLODIPINE-VALSARTAN- Alprolix 113 HYDROCHLOROTHIAZIDE 130,132 ALPROSTADIL (VASODILATOR) 183,184 AMOXAPINE 47 Alrex 277 Amoxapine 47 Alsuma 54 AMOXICILLIN 28 Altabax 21 AMOXICILLIN & POT CLAVULANATE 28 Altace 121 AMOXICILLIN-CLARITHROMYCIN W/ Altoprev 138 LANSOPRAZOLE 171,172 ALTRETAMINE 59 AMOXICILLIN-CLARITHROMYCIN W/ Alunbrig 61 OMEPRAZOLE 172 Alvesco 282 AMPHETAMINE-DEXTROAMPHETAMINE 143 ALVIMOPAN 171,172 AMPICILLIN 28 AMANTADINE HCL 73 Ampicillin 28 Amaryl 94 Ampyra 149 Ambien 298 Anadrol-50 196 Ambien CR 298 Anafranil 47 AMBRISENTAN 290,291 ANAGRELIDE HCL 109 AMCINONIDE 185 ANAKINRA 224 Amcinonide 185 Analpram HC 153 Amerge 54 Analpram HC Singles 153 Amicar 113 Analpram-HC 153 AMIFAMPRIDINE 58 Anaprox DS 5 AMIKACIN SULFATE LIPOSOME 20 Anaspaz 170 AMILORIDE & HYDROCHLOROTHIAZIDE 129 ANASTROZOLE 64 AMILORIDE HCL 137 Ancobon 50 Aminocaproic Acid 113 Androderm 196 AMINOCAPROIC ACID 113 AndroGel 196 AMINOSALICYLIC ACID 58 AndroGel Pump 196 AMIODARONE HCL 122 Android 196 Amitiza 173 Androxy 196 AMITRIPTYLINE HCL 47 Angeliq 198 Amitriptyline HCl 48 ANIFROLUMAB-FNIA 302 AMIVANTAMAB-VMJW 302 Annovera 198 AMLODIPINE BENZOATE 127 Anoro Ellipta 293 AMLODIPINE BESYLATE 125,128 Antabuse 19 AMLODIPINE BESYLATE-ATORVASTATIN ANTIHEMOPHIL FACT(RCMB) PEGYLATED-AUCL CALCIUM 130,131 (BDD-RFVIII PEG-AUCL) 115 AMLODIPINE BESYLATE-BENAZEPRIL HCL 129,133 ANTIHEMOPHILIC FACTOR (HUMAN) 114,115,116

©2021 Wellmark, Inc. 306 ANTIHEMOPHILIC FACTOR (RCMB) BD Arcapta Neohaler 287 TRUNCATED (BD TRUNC-RFVIII) 116 ARFORMOTEROL TARTRATE 287 ANTIHEMOPHILIC FACTOR (RCMB) FC FUSION Arial Chamber 246 PROTEIN(BDD-RFVIIIFC) 114 Aricept 42 ANTIHEMOPHILIC FACTOR (RCMB) Arikayce 20 MOROCTOCOG ALFA(BDD-RFVIII,MOR) 118 Arimidex 64 ANTIHEMOPHILIC FACTOR (RCMB) ARIPIPRAZOLE 78 PLASMA/ALBUMIN FREE (RAHF-PFM) 112,116 Arixtra 107 ANTIHEMOPHILIC FACTOR (RCMB) SIMOCTOCOG ARMODAFINIL 299,300 ALFA(BDD-RFVIII,SIM) 116 Armour Thyroid 215 ANTIHEMOPHILIC FACTOR (RECOMBINANT Aromasin 64 PORCINE) (RPFVIII) 116 ARTEMETHER-LUMEFANTRINE 72 ANTIHEMOPHILIC FACTOR Arthrotec 5 (RECOMBINANT) 114,115,117 ARTIFICIAL TEAR INSERT 273 ANTIHEMOPHILIC FACTOR (RECOMBINANT) Arymo ER 7,8 PEGYLATED 112 Asacol HD 239 ANTIHEMOPHILIC FACTOR (RECOMBINANT) Asceniv 227 SINGLE CHAIN 112 Ascensia Autodisc Test 246 ANTIHEMOPHILIC FACTOR/VON WILLEBRAND ASENAPINE MALEATE 78,80 FACTOR COMPLEX (HUMAN) 112,113,114,117 ASFOTASE ALFA 180 ANTIINHIBITOR COAGULANT COMPLEX 114 Asmanex (120 Metered Doses) 282 Antiinhibitor Coagulant Complex 114 Asmanex (14 Metered Doses) 282 Anusol-HC 240 Asmanex (30 Metered Doses) 282 Anzemet 49 Asmanex (60 Metered Doses) 282 APALUTAMIDE 60 Asmanex (7 Metered Doses) 282 ApexiCon E 185 Asmanex HFA 283 Apidra 102 ASPARAGINASE ERWINIA CHRYSANTHEMI Apidra SoloStar 102 (RECOMBINANT)-RYWN 302 APIXABAN 107 ASPIRIN-CAFFEINE-DIHYDROCODEINE Apokyn 75 BITARTRATE 13,18 APOMORPHINE HYDROCHLORIDE 75 ASPIRIN-DIPYRIDAMOLE 118 APRACLONIDINE HCL 278,279 Assure 4 Test 246 APREMILAST 232 Assure II Check 246 APREPITANT 49,50 Assure Platinum 246 Apriso 239 Assure Prism multi Test 246 Aptensio XR 144 Assure Pro Test 246 Aptiom 40 Astagraf XL 221 Aptivus 89 Astepro 284 Aranesp (Albumin Free) 109 Atabex EC 164 Arava 231 Atabex OB 164 Arcalyst 231 Atacand 120

©2021 Wellmark, Inc. 307 Atacand HCT 130 Aygestin 212 ATAZANAVIR SULFATE 89,90 Ayvakit 61 ATAZANAVIR SULFATE-COBICISTAT 89 AZACITIDINE 62 Atelvia 241 Azactam 27 ATENOLOL 123,125 AzaSite 29 ATENOLOL & CHLORTHALIDONE 130,135 AZATHIOPRINE 221,224 Ativan 92 AZELAIC ACID 153,155 ATOMOXETINE HCL 144,146,147 AZELAIC ACID (ACNE) 153 ATORVASTATIN CALCIUM 138,139 AZELASTINE HCL 284 ATOVAQUONE 72 AZELASTINE HCL (OPHTH) 276 ATOVAQUONE-PROGUANIL HCL 72 AZELASTINE HCL-FLUTICASONE Atralin 153 PROPIONATE 293,294 Atripla 85 Azelex 153 Atropine Sulfate (Ophthalmic) 272 Azilect 77 ATROPINE SULFATE (OPHTHALMIC) 273 AZILSARTAN MEDOXOMIL 120 Atrovent HFA 286 AZILSARTAN MEDOXOMIL-CHLORTHALIDONE 132 Aubagio 149 AZITHROMYCIN 29,30 Augmentin 28 AZITHROMYCIN (OPHTH) 29,30 Augmentin ES-600 28 Azopt 279 Augmentin XR 28 Azor 130 AURANOFIN 233 Azstarys 301 Austedo 147 AZTREONAM 27 AVALGLUCOSIDASE ALFA-NGPT 302 AZTREONAM LYSINE 289 Avalide 130 Azulfidine 241 AVANAFIL 184 Azulfidine EN-tabs 241 Avandamet 94 Avandia 95 B AVAPRITINIB 61 Bacitracin 21 Avapro 120 BACITRACIN (OPHTHALMIC) 21 Avastin 70 BACITRACIN-POLY-NEOMYCIN-HC 272,274 AVATROMBOPAG MALEATE 109 BACITRACIN-POLYMYXIN B (OPHTH) 272,273,274 AVC Vaginal 32 BACLOFEN 81 Avelox 30 Bactrim 32 Avodart 182 Bactrim DS 32 Avonex 149 Bactroban 21 Avonex Pen 149 Bactroban Nasal 21 Avonex Prefilled 149 Bafiertam 149 Avsola 221 Balcoltra 199 Axert 55 BALOXAVIR MARBOXIL 239 Axiron 196 BALSALAZIDE DISODIUM 239,240 AXITINIB 67 Balversa 62

©2021 Wellmark, Inc. 308 Banzel 40 BEROTRALSTAT HCL 221 Baqsimi One Pack 100 BESIFLOXACIN HCL 30 Baqsimi Two Pack 100 Besivance 30 Baraclude 82 Betadine Ophthalmic Prep 273 BARICITINIB 224 Betagan 279 Basaglar KwikPen 102 BETAINE 178 Baxdela 30 BETAMETHASONE DIPROPIONATE (TOPICAL) 186 BD Swab Single Use Regular 246 BETAMETHASONE DIPROPIONATE Bebulin 113 AUGMENTED 186,188 BECAPLERMIN 157 BETAMETHASONE VALERATE 186,190 BECLOMETHASONE DIPROP MONOHYD 283 Betapace 122 BECLOMETHASONE DIPROPIONATE 284 Betapace AF 122 BECLOMETHASONE DIPROPIONATE (NASAL) 284 Betaseron 149 BECLOMETHASONE DIPROPIONATE HFA 284 BETAXOLOL HCL 123 Beconase AQ 283 BETAXOLOL HCL (OPHTH) 279 BEDAQUILINE FUMARATE 59 BETHANECHOL CHLORIDE 183,185 BELANTAMAB MAFODOTIN-BLMF 70 Bethkis 288 BELIMUMAB 231 Betimol 279 Belsomra 299 Betoptic-S 279 BELUMOSUDIL MESYLATE 302 BEVACIZUMAB 70 BELZUTIFAN 303 BEXAROTENE 71 BEMPEDOIC ACID 134 BEXAROTENE (TOPICAL) 71 BEMPEDOIC ACID-EZETIMIBE 140 Bexsero 234 BENAZEPRIL & HYDROCHLOROTHIAZIDE 130,133 Beyaz 199 BENAZEPRIL HCL 121 BICALUTAMIDE 60 BeneFIX 113 Bicillin L-A 28 Benicar 120 BICTEGRAVIR-EMTRICITABINE-TENOFOVIR Benicar HCT 130 ALAFENAMIDE FUMARATE 88 Benlysta 231 BiDil 130 BENRALIZUMAB 294 Biktarvy 88 Bentyl 170 Biltricide 71 BenzaClin 153 BIMATOPROST 281 BenzaClin with Pump 153 BINIMETINIB 69 Benzamycin 21 Bio-Statin 301 BENZONATATE 293,296 BISOPROLOL & HYDROCHLOROTHIAZIDE 130,136 BENZOYL PEROXIDE-ERYTHROMYCIN 21 BISOPROLOL FUMARATE 123,125 BENZTROPINE MESYLATE 73 Bivigam 227 BENZYL ALCOHOL (PEDICULICIDE) 73 Blenrep 70 BEPOTASTINE BESILATE 276 Bleph-10 32 Bepreve 276 Blephamide 273 Berinert 220 Blephamide S.O.P. 273

©2021 Wellmark, Inc. 309 Blood Glucose Test 246 BROMFENAC SODIUM (OPHTH) 277,278 BluLink Glucose Test 247 BROMOCRIPTINE MESYLATE 75 Boniva 241 BROMOCRIPTINE MESYLATE (DIABETES) 95 Boostrix 234 BROMPHENIRAMINE TANNATE 284 BOSENTAN 290,291,292 Brompheniramine Tannate 284 Bosulif 65 Bronchitol 288 BOSUTINIB 65 Bronchitol Tolerance Test 248 Botox 81 Brovana 287 BP FoliNatal Plus B 164 Brukinsa 62 BP MultiNatal Plus 164 Bryhali 186 Braftovi 65 BUDESONIDE 240,241 Breathe Ease Large 247 BUDESONIDE (INHALATION) 283 Breathe Ease Medium 247 BUDESONIDE-FORMOTEROL FUMARATE Breathe Ease Small 247 DIHYDRATE 293,296 BreatheRite 247 BUMETANIDE 136 BreatheRite Coll Spacer Adult 247 Bumex 136 BreatheRite Coll Spacer Child 247 Buphenyl 177 BreatheRite Coll Spacer Infant 247 BUPRENORPHINE 8 BreatheRite Rigid Spacer/Mask 247 BUPRENORPHINE HCL 20 BreatheRite Spacer Neonate 247 BUPRENORPHINE HCL-NALOXONE HCL BreatheRite Spacer Small Child 247 DIHYDRATE 20 BreatheRite/Large Mask 247 BUPROPION HCL 43,44 BreatheRite/Medium Mask 248 BUROSUMAB-TWZA 160 BreatheRite/Small Mask 248 BUSPIRONE HCL 92 Breeze 2 Test 248 BUSULFAN 59 Breo Ellipta 293 BUTABARBITAL SODIUM 300 Brevicon (28) 199 BUTALBITAL-ACETAMINOPHEN 147,148 BREXPIPRAZOLE 79 BUTALBITAL-ACETAMINOPHEN-CAFFEINE 147,148 BREXUCABTAGENE AUTOLEUCEL 63 BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ BRIGATINIB 61 CODEINE 13,14 Brilinta 118 BUTALBITAL-ASPIRIN-CAFFEINE 5,6 BRIMONIDINE TARTRATE 278,279 BUTALBITAL-ASPIRIN-CAFFEINE W/COD 13,14 BRIMONIDINE TARTRATE (TOPICAL) 156 Butisol Sodium 300 BRIMONIDINE TARTRATE-TIMOLOL MALEATE 279 BUTOCONAZOLE NITRATE (ONE DOSE) 51 BRINZOLAMIDE 279 BUTORPHANOL TARTRATE 13 BRINZOLAMIDE-BRIMONIDINE TARTRATE 280 Butrans 8 Brisdelle 45 Bydureon 95 BRIVARACETAM 34 Bydureon BCise 95 Briviact 34 Byetta 10 MCG Pen 95 BRODALUMAB 157 Byetta 5 MCG Pen 95 Bromfenac Sodium 277 Bylvay 301

©2021 Wellmark, Inc. 310 Bylvay (Pellets) 301 Caplyta 78 Bynfezia Pen 218 CAPMATINIB HCL 63 Bystolic 123 Caprelsa 65 CAPTOPRIL 121 C CAPTOPRIL & HYDROCHLOROTHIAZIDE 131 C1 ESTERASE INHIBITOR (HUMAN) 220,221 Captopril-Hydrochlorothiazide 131 C1 ESTERASE INHIBITOR (RECOMBINANT) 221 Carac 154 Cabenuva 88 Carafate 176 CABERGOLINE 218 Carbaglu 178 Cablivi 109 CARBAMAZEPINE 40,41 Cabometyx 65 Carbamazepine 40 CABOTEGRAVIR & RILPIVIRINE 88 CARBAMAZEPINE (ANTIPSYCHOTIC) 93 CABOZANTINIB S-MALATE 65,66 Carbaphen 12 293 Caduet 131 Carbaphen 12 Ped 293 Cafergot 54 Carbatrol 40 CAFFEINE CITRATE 290 CARBIDOPA 76 Calan 125 CARBIDOPA-LEVODOPA 76,77 Calan SR 125 CARBIDOPA-LEVODOPA-ENTACAPONE 74 CALCIFEDIOL 242 CARBINOXAMINE MALEATE 284,285 CALCIPOTRIENE 154,155,158 Cardizem 125 Calcipotriene 154 Cardizem CD 125 CALCIPOTRIENE-BETAMETHASONE Cardizem LA 126 DIPROPIONATE 154,158 Cardura 119 CALCITONIN (SALMON) 241,242 Cardura XL 182 CALCITRIOL 241,243 CareOne Blood Glucose Test 248 CALCITRIOL (TOPICAL) 154,159 CareSens N Glucose Test 248 CALCIUM ACETATE (PHOSPHATE BINDER) 159,163 CareTouch Test 248 CALCIUM, MAGNESIUM, POTASSIUM, & SODIUM CARGLUMIC ACID 178 OXYBATES 299 Carimune NF 227 Calquence 65 CARIPRAZINE HCL 80 CANAGLIFLOZIN 96 CARISOPRODOL 297,298 CANAGLIFLOZIN-METFORMIN HCL 96 CARISOPRODOL W/ ASPIRIN 297 CANAKINUMAB 231 CARISOPRODOL W/ ASPIRIN & CODEINE 13 Canasa 239 Carnitor 160 CANDESARTAN CILEXETIL 120 Carnitor SF 160 CANDESARTAN CILEXETIL- CaroSpir 137 HYDROCHLOROTHIAZIDE 130,131 CARTEOLOL HCL (OPHTH) 279 CANNABIDIOL 34 CARVEDILOL 124 CAPECITABINE 61 CARVEDILOL PHOSPHATE 124 Capex 186 CASCARA SAGRADA 174 CAPLACIZUMAB-YHDP 109 Cascara Sagrada 174

©2021 Wellmark, Inc. 311 Casodex 60 Chek-Stix Control 248 Catapres 119 Chemet 161 Catapres-TTS-1 119 Chemstrip 10 MD 248 Catapres-TTS-2 119 Chemstrip 10/SG 248 Catapres-TTS-3 119 Chemstrip 2 GP 248 Caverject 183 Chemstrip 5 OB 248 Caverject Impulse 183 Chemstrip 7 248 Cayston 289 Chemstrip 9 248 Cedax 26 Chemstrip K 248 CEFACLOR 26 Chemstrip uGK 249 Cefaclor ER 26 Chenodal 171 CEFACLOR MONOHYDRATE 26 CHENODIOL 171 CEFADROXIL 26 CHLORAMBUCIL 59 CEFDINIR 26 CHLORDIAZEPOXIDE HCL 92 CEFDITOREN PIVOXIL 26,27 Chlordiazepoxide HCl-Clidinium Bromide 170 CEFEPIME HCL 26,27 CHLORDIAZEPOXIDE HCL-CLIDINIUM CEFEPIME HCL-DEXTROSE 26 BROMIDE 171 Cefepime-Dextrose 26 CHLORDIAZEPOXIDE-AMITRIPTYLINE 43 CEFIXIME 26,27 Chlordiazepoxide-Amitriptyline 43 CEFPODOXIME PROXETIL 26 CHLORHEXIDINE GLUCONATE (MOUTH- CEFPROZIL 26 THROAT) 152 CEFTIBUTEN 26 CHLOROQUINE PHOSPHATE 72 Ceftin 26 CHLOROTHIAZIDE 137 CEFTRIAXONE SODIUM 27 CHLORPROMAZINE HCL 77 CEFUROXIME AXETIL 26,27 CHLORPROPAMIDE 95 CeleBREX 5 ChlorproPAMIDE 95 CELECOXIB 5 CHLORTHALIDONE 137 CeleXA 45 CHLORZOXAZONE 297,298 CellCept 221 CHOLESTYRAMINE 139,140 Celontin 35 CHOLESTYRAMINE LIGHT 139,140,141 CENEGERMIN-BKBJ 274 CHOLINE & MAG SALICYLATE 5 CENOBAMATE 39,40 CHOLINE FENOFIBRATE 138 Centany 21 Cialis 182,183 CEPHALEXIN 27 CICLESONIDE 282 Cerdelga 178 CICLESONIDE (NASAL) 283,284 Cerezyme 178 CICLOPIROX 50,52,53 CERITINIB 70 CICLOPIROX OLAMINE 51 CERTOLIZUMAB PEGOL 221,222 CILOSTAZOL 118 Cesamet 49 Ciloxan 30,31 Cetraxal 30 Cimduo 86 CEVIMELINE HCL 152 CIMETIDINE 173

©2021 Wellmark, Inc. 312 CIMETIDINE HCL 173 CLINDAMYCIN PHOSPHATE 22 Cimzia 221 CLINDAMYCIN PHOSPHATE (ONE DOSE) 22 Cimzia Prefilled 221 CLINDAMYCIN PHOSPHATE (TOPICAL) 22,23 Cimzia Starter Kit 222 CLINDAMYCIN PHOSPHATE VAGINAL 22 CINACALCET HCL 241,243 CLINDAMYCIN PHOSPHATE-BENZOYL Cinqair 293 PEROXIDE 153 Cinryze 220 CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE Cipro 31 (REFRIGERATE) 154,155,156 Cipro HC 281 CLINDAMYCIN PHOSPHATE-TRETINOIN 154,159 Ciprodex 281 Clindesse 22 CIPROFLOXACIN 31 Clinistix 249 CIPROFLOXACIN HCL 31 CLOBAZAM 35,36 CIPROFLOXACIN HCL (OPHTH) 30,31 CLOBETASOL PROPIONATE 186,187,189,191 CIPROFLOXACIN HCL (OTIC) 30 Clobetasol Propionate 192 Ciprofloxacin-Ciproflox HCl ER 31 CLOBETASOL PROPIONATE EMOLLIENT CIPROFLOXACIN-CIPROFLOXACIN HCL 31 BASE 186,192 CIPROFLOXACIN-DEXAMETHASONE 281 CLOBETASOL PROPIONATE CIPROFLOXACIN-HYDROCORTISONE 281 EMULSION 186,191,193 CITALOPRAM HYDROBROMIDE 45 Clobex 186 CLADRIBINE (MULTIPLE SCLEROSIS) 150 Clobex Spray 186 Clarinex 284 CLOCORTOLONE PIVALATE 186 Clarinex-D 12 Hour 293 Cloderm 186 CLARITHROMYCIN 29 Cloderm Pump 186 CLEMASTINE FUMARATE 284 CLOMIPRAMINE HCL 47 Clemastine Fumarate 284 CLONAZEPAM 92,93 Clenpiq 174 CLONIDINE 119 Cleocin 22 CLONIDINE & CHLORTHALIDONE 131 Cleocin Phosphate 22 CLONIDINE HCL 119 Cleocin-T 22 CLONIDINE HCL (ADHD) 144,145 Clever Chek Auto-Code Test 249 CLOPIDOGREL BISULFATE 118 Clever Chek Auto-Code Voice 249 CLORAZEPATE DIPOTASSIUM 92,93 Clever Chek Test 249 Clorpres 131 Clever Choice Auto-Code Test 249 CLOTRIMAZOLE 51 Clever Choice Holding Chamber 249 CLOTRIMAZOLE W/ BETAMETHASONE 154,156 Clever Choice Micro Test 249 CLOZAPINE 81 Clever Choice No Coding 249 cloZAPine 81 Clever Choice Talk System 249 Clozaril 81 Climara 199 Coagadex 113 Climara Pro 200 COAGULATION FACTOR IX 113,116 CLINDAMYCIN HCL 22 COAGULATION FACTOR IX (RECOMB) FC FUSION CLINDAMYCIN PALMITATE HYDROCHLORIDE 22 PROTEIN (RFIXFC) 113

©2021 Wellmark, Inc. 313 COAGULATION FACTOR IX Complera 85 (RECOMBINANT) 113,115,117 Complete Natal DHA 165 COAGULATION FACTOR IX (RECOMBINANT) CompleteNate 165 GLYCOPEGYLATED 117 Comtan 74 COAGULATION FACTOR IX RECOMB ALBUMIN Concept OB 165 FUSION PROTEIN (RIX-FP) 115 Concerta 144 COAGULATION FACTOR VIIA (RECOMBINANT) 116 Condylox 154 COAGULATION FACTOR VIIA (RECOMBINANT)- CONJUGATED ESTROGENS-BAZEDOXIFENE 214 JNCW 117 CONJUGATED ESTROGENS- COAGULATION FACTOR X (HUMAN) 113 MEDROXYPROGESTERONE ACETATE 209 Coartem 72 Contour Next Test 250 COBICISTAT 89 Contour Test 250 COBIMETINIB FUMARATE 66 ConZip 8 CODEINE POLISTIREX-CHLORPHENIRAMINE Cool Blood Glucose Test Strips 250 POLISTIREX 297 Copaxone 149 CODEINE SULFATE 14 Copegus 84 Colazal 239 Copiktra 66 COLCHICINE 53,54 COPPER (IUD) 265 COLCHICINE W/ PROBENECID 53 Cordran 187 Colcrys 54 Coreg 124 COLESEVELAM HCL 139,141 Coreg CR 124 Colestid 139 Corgard 124 Colestid Flavored 140 Corlanor 131 COLESTIPOL HCL 139,140 Cortef 187 COLISTIMETHATE SODIUM 22 Cortenema 240 COLLAGENASE 157 CORTICOTROPIN 185 Coly-Mycin M 22 Cortifoam 240 Coly-Mycin S 281 CORTISONE ACETATE 187 Colyte with Flavor Packs 174 Cortisone Acetate 187 Combigan 279 Cortisporin 154 CombiPatch 200 Cortisporin-TC 281 Combistix 249 Corzide 131 Combivent Respimat 294 Cosela 301 Combivir 86 Cosentyx 154 Cometriq (100 mg Daily Dose) 66 Cosentyx (300 MG Dose) 154 Cometriq (140 mg Daily Dose) 66 Cosentyx Sensoready (300 MG) 154 Cometriq (60 mg Daily Dose) 66 Cosopt 279 Compact Space Chamber 249 Cosopt PF 279 Compact Space Chamber/Lg Mask 250 Cotellic 66 Compact Space Chamber/Med Mask 250 Coumadin 107 Compact Space Chamber/Sm Mask 250

©2021 Wellmark, Inc. 314 COVID-19 (SARS-COV-2) ADENOVIRUS CYCLOSPORINE MODIFIED (FOR VACCINE 236 MICROEMULSION) 222,224 COVID-19 (SARS-COV-2) MRNA VIRUS Cymbalta 148 VACCINE 237 CYPROHEPTADINE HCL 284 Cozaar 120 Cystadane 178 Creon 178 Cystadrops 273 Cresemba 51 Cystagon 178 Crestor 138 Cystaran 273 Crinone 212 CYSTEAMINE BITARTRATE 178,179 CRISABOROLE 155 CYSTEAMINE HCL 273 Crixivan 89 Cytogam 228 CRIZANLIZUMAB-TMCA 118 CYTOMEGALOVIRUS IMMUNE GLOBULIN CRIZOTINIB 70 (HUMAN) 228 CROMOLYN SODIUM 290 Cytomel 215 CROMOLYN SODIUM (MASTOCYTOSIS) 172 Cytotec 176 CROMOLYN SODIUM (OPHTH) 276 Cytra K Crystals 183 CROSS-LINKED HYALURONATE 257 CROTAMITON 73 D Crotan 73 D-Care Blood Glucose 250 Crysvita 160 D-Penamine 183 Cutaquig 227 D.H.E. 45 54 Cutivate 187 DABIGATRAN ETEXILATE MESYLATE 108 Cuvitru 228 DABRAFENIB MESYLATE 69 Cuvposa 170 DACLATASVIR DIHYDROCHLORIDE 82 CVS Advanced Glucose Test 250 DACOMITINIB 63 CVS Glucose Meter Test Strips 250 Daklinza 82 CVS Ketone Care 250 DALFAMPRIDINE 149 CYANOCOBALAMIN 165 Daliresp 290 Cyclessa 200 DALTEPARIN SODIUM 108 CYCLOBENZAPRINE HCL 297 DANAZOL 197 Cyclogyl 273 Dantrium 81 Cyclomydril 273 DANTROLENE SODIUM 81 CYCLOPENTOLATE HCL 273 DAPAGLIFLOZIN PROPANEDIOL 95 CYCLOPENTOLATE W/ PHENYLEPHRINE 273 DAPAGLIFLOZIN-METFORMIN HCL 100 CYCLOPHOSPHAMIDE 59,301 DAPSONE 58 Cyclophosphamide 59,301 DAPSONE (TOPICAL) 153,155 CYCLOSERINE 58 Daptacel 234 Cycloset 95 Daraprim 72 CYCLOSPORINE 222,226 DARATUMUMAB-HYALURONIDASE-FIHJ 70 CYCLOSPORINE (OPHTH) 275 DARBEPOETIN ALFA 109 DARIFENACIN HYDROBROMIDE 181

©2021 Wellmark, Inc. 315 DAROLUTAMIDE 60 Derma-Smoothe/FS Body 187 DARUNAVIR ETHANOLATE 90 Derma-Smoothe/FS Scalp 187 DARUNAVIR-COBICISTAT 90 Dermatop 187 DARUNAVIR-COBICISTAT-EMTRICITABINE- DermOtic 282 TENOFOVIR ALAFENAMIDE 85 Descovy 88 Darzalex Faspro 70 DESIPRAMINE HCL 47,48 DASATINIB 69 DESIRUDIN 108 DASIGLUCAGON HCL 303 DESLORATADINE 284,285 Daurismo 66 Desloratadine 285 Daypro 5 DESLORATADINE-PSEUDOEPHEDRINE 293 Daytrana 144 DESMOPRESSIN ACETATE 193,194,195 DayVigo 300 Desmopressin Acetate 194 DDAVP 193 DESMOPRESSIN ACETATE REFRIGERATED 194 DDAVP Rhinal Tube 194 DESMOPRESSIN ACETATE SPRAY 194 Debacterol 152 DESMOPRESSIN ACETATE SPRAY DECITABINE-CEDAZURIDINE 62 REFRIGERATED 194 DEFERASIROX 162 Desogen 200 DEFERIPRONE 162 DESOGESTREL & ETHINYL DEFLAZACORT 188 ESTRADIOL 198,200,201,203,204,209 DEGARELIX ACETATE 218 DESOGESTREL-ETHINYL ESTRADIOL DELAFLOXACIN MEGLUMINE 30 (BIPHASIC) 198,199,204,207,208,209,211 DELAVIRDINE MESYLATE 86 DESOGESTREL-ETHINYL ESTRADIOL Delestrogen 200 (TRIPHASIC) 199,200,211 Delstrigo 85 Desonate 187 Delzicol 239 DESONIDE 187,188,190,193 Demadex 136 Desonide 187 DEMECLOCYCLINE HCL 33 DesOwen 187 Demerol 14 DESOXIMETASONE 187,193 Demser 131 Desoxyn 143 Denavir 91 DESVENLAFAXINE 45,46 DENOSUMAB 242,243 Desvenlafaxine ER 45 Depakene 35 DESVENLAFAXINE SUCCINATE 45,46 Depakote 35 Detrol 181 Depakote ER 35 Detrol LA 181 Depakote Sprinkles 36 DEUTETRABENAZINE 147 Depen Titratabs 183 Dexamethasone 186 Depo-Estradiol 200 DEXAMETHASONE 187,188 DEPO-Medrol 187 DEXAMETHASONE (OPHTH) 278 Depo-Provera 213 Dexamethasone Intensol 188 Depo-SubQ Provera 104 213 DEXAMETHASONE SODIUM PHOSPHATE 188 Depo-Testosterone 197 Dexamethasone Sodium Phosphate 277

©2021 Wellmark, Inc. 316 DEXAMETHASONE SODIUM PHOSPHATE DIGOXIN 131,132 (OPHTH) 277 DIHYDROERGOTAMINE MESYLATE 54 Dexchlorpheniramine-Phenylephrine 296 Dilantin 40 Dexedrine 143 Dilantin Infatabs 40 Dexilant 176 Dilatrate-SR 141 DEXLANSOPRAZOLE 176 Dilaudid 14 DEXMETHYLPHENIDATE HCL 144,145 DILTIAZEM HCL 125,126 DEXTRANOMER-SODIUM HYALURONATE 269 DilTIAZem HCl 126 DEXTROAMPHETAMINE SULFATE 143,144 DILTIAZEM HCL COATED BEADS 125,126,127 DEXTROMETHORPHAN HBR-QUINIDINE DILTIAZEM HCL EXTENDED RELEASE SULFATE 147 BEADS 126,128 Diacomit 34 DIMETHYL FUMARATE 149,151 Diamox Sequels 136 Diovan 120 Diastat AcuDial 36 Diovan HCT 131 Diastat Pediatric 36 Dipentum 240 Diastix 250 DIPH-AC PERT-TET TOX AD-POLIO IPV- Diathrive Blood Glucose Test 250 HAEMOPHIL B POLY VAC 237 Diathrive Glucose Test 251 DIPH-TET TOX-ACELL PERT AD-POLIO IPV-HIB- Diathrive+ Glucose Test 251 HEPATITIS B RECOMB 239 DiaTrue Plus Test 251 DIPH-TETANUS TOX AD-ACELL PERTUSSIS & DIAZEPAM 93 POLIO VIRUS, IPV VAC 237,238 DIAZEPAM (ANTICONVULSANT) 36,37 DIPH-TETANUS TOX-ACELL PERT-HEPATITIS B DIAZOXIDE 100,101 RECOMB-POLIO IPV VAC 237 Dibenzyline 119 DIPHENHYDRAMINE HCL 285 DICHLORPHENAMIDE 136 DIPHENOXYLATE W/ ATROPINE 172 DICLOFENAC EPOLAMINE 5,6 Diphenoxylate-Atropine 172 DICLOFENAC POTASSIUM 5 DIPHTHERIA, ACELLULAR PERTUSSIS & TETANUS DICLOFENAC SODIUM 5 TOXOIDS 234,236 DICLOFENAC SODIUM (OPHTH) 277 DIPHTHERIA-TETANUS TOXOIDS (DT) 234 DICLOFENAC SODIUM (TOPICAL) 5,6,7 Diphtheria-Tetanus Toxoids DT 234 DICLOFENAC W/ MISOPROSTOL 5 Diprolene 188 DICLOXACILLIN SODIUM 28 Diprolene AF 188 DICYCLOMINE HCL 170 DIPYRIDAMOLE 118 DIDANOSINE 86,87,88 DIROXIMEL FUMARATE 152 DIFENOXIN W/ ATROPINE 172 DISOPYRAMIDE PHOSPHATE 122 Differin 155 DISULFIRAM 19 Dificid 29 Ditropan XL 181 DIFLORASONE DIACETATE EMOLLIENT BASE 185 Diuril 137 Diflucan 51 DIVALPROEX SODIUM 35,36 DIFLUNISAL 5 Divigel 201 DIFLUPREDNATE 277 DOFETILIDE 122,123

©2021 Wellmark, Inc. 317 Dojolvi 160 Duavee 214 DOLASETRON MESYLATE 49 Duetact 95 Dolophine 8 DULAGLUTIDE 100 DOLUTEGRAVIR SODIUM 85 Dulera 294 DOLUTEGRAVIR SODIUM-LAMIVUDINE 88 DULOXETINE HCL 148 DOLUTEGRAVIR SODIUM-RILPIVIRINE HCL 81 DUPILUMAB 155 DONEPEZIL HYDROCHLORIDE 42 Dupixent 155 Donnatal Extentabs 170 Duragesic-100 8 Doptelet 109 Duragesic-12 8 DORAVIRINE 86 Duragesic-25 8 DORAVIRINE-LAMIVUDINE-TENOFOVIR Duragesic-50 8 DISOPROXIL FUMARATE 85 Duragesic-75 8 DORNASE ALFA 289 Duraxin 251 Doryx 33 Durezol 277 DORZOLAMIDE HCL 279,280 Durolane 155 DORZOLAMIDE HCL-TIMOLOL MALEATE 279 Durysta 281 DOSTARLIMAB-GXLY 301 DUST MITE MIXED ALLERGEN EXTRACT 263 Dovato 88 DUTASTERIDE 182 Dovonex 155 DUTASTERIDE-TAMSULOSIN HCL 182 DOXAZOSIN MESYLATE 119 DUVELISIB 66 DOXAZOSIN MESYLATE (BPH) 182 Dyazide 132 DOXEPIN HCL 47 Dymista 294 DOXEPIN HCL (SLEEP) 300 DYPHYLLINE-GUAIFENESIN 294 DOXERCALCIFEROL 241,242 Dyrenium 137 Doxycycline 33 Dysport 297 DOXYCYCLINE (MONOHYDRATE) 33,34 DOXYCYCLINE (ROSACEA) 33 E DOXYCYCLINE CALCIUM 34 E.E.S. 400 29 DOXYCYCLINE HYCLATE 33,34 E.E.S. Granules 29 Drisdol 242 EasiVent 251 DRONABINOL 49,50 EasiVent Mask Large 251 DRONEDARONE HCL 122 EasiVent Mask Medium 251 DROSPIRENONE 214 EasiVent Mask Small 251 DROSPIRENONE-ESTETROL 302 Easy Plus Blood Glucose Test 251 DROSPIRENONE-ESTRADIOL 198 Easy Plus II Glucose Test 251 DROSPIRENONE-ETHINYL Easy Step Test 251 ESTRADIOL 201,203,205,207,208,210,211,212 Easy Talk Blood Glucose Test 251 DROSPIRENONE-ETHINYL ESTRADIOL- Easy Touch HealthPro Glucose 252 LEVOMEFOLATE CALCIUM 199,201,209,211 Easy Touch Test 252 Droxia 61 Easy Trak Blood Glucose Test 252 Duac 155 Easy Trak II Glucose Test 252

©2021 Wellmark, Inc. 318 EasyGluco 252 ELETRIPTAN HYDROBROMIDE 55 EasyGluco Plus 252 ELEXACAFTOR-TEZACAFTOR-IVACAFTOR 289 EasyMax 15 Test 252 Elidel 155 EasyMax Test 252 Eligard 218 EasyPlus Blood Glucose Test 252 ELIGLUSTAT TARTRATE 178 EasyPRO Plus 252 Elimite 73 EC-Naprosyn 5 Eliphos 163 ECALLANTIDE 221 Eliquis 107 ECHOTHIOPHATE IODIDE 280 Eliquis DVT/PE Starter Pack 107 ECONAZOLE NITRATE 51 Elixophyllin 290 Ecoza 51 Ella 212 ECULIZUMAB 269 Elmiron 183 EDARAVONE 147 Elocon 188 Edarbi 120 Eloctate 114 Edarbyclor 132 ELTROMBOPAG OLAMINE 111 Edecrin 136 ELUXADOLINE 174 Edex 183 ELVITEGRAVIR-COBICISTAT-EMTRICITABINE- Edluar 298 TENOFOVIR ALAFENAMIDE 84 EDOXABAN TOSYLATE 109 ELVITEGRAVIR-COBICISTAT-EMTRICITABINE- Edurant 85 TENOFOVIR DF 85 EFAVIRENZ 85,86 Emadine 276 EFAVIRENZ-EMTRICITABINE-TENOFOVIR EMAPALUMAB-LZSG 222 DISOPROXIL FUMARATE 85 Embeda 8 EFAVIRENZ-LAMIVUDINE-TENOFOVIR Embrace Blood Glucose Test 253 DISOPROXIL FUMARATE 88,89 Embrace Evo Blood Glucose Test 253 Effer-K 160 Embrace Pro Glucose Test 253 Effexor XR 45 Embrace Talk Glucose Test 253 Effient 118 Emcyt 60 Efudex 61 EMEDASTINE DIFUMARATE 276 ELAGOLIX SODIUM 219 Emend 49,50 ELAGOLIX SODIUM-ESTRADIOL-NORETHINDRONE Emend Tri-Pack 50 ACETATE 195 Emflaza 188 Elaprase 178 Emgality 57 Elavil 48 Emgality (300 MG Dose) 57 ELBASVIR-GRAZOPREVIR 83 EMICIZUMAB-KXWH 114 Eldepryl 77 EMPAGLIFLOZIN 97 Elelyso 178 EMPAGLIFLOZIN-LINAGLIPTIN 96 Element Compact Test 252 EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN 100 Element Test 252 EMPAGLIFLOZIN-METFORMIN HCL 99 Elestat 276 Empaveli 301 Elestrin 201 Emsam 44

©2021 Wellmark, Inc. 319 EMTRICITABINE 86,87 EpiPen 2-Pak 287 EMTRICITABINE-RILPIVIRINE-TENOFOVIR EpiPen Jr 2-Pak 287 ALAFENAMIDE FUMARATE 86 Epivir 87 EMTRICITABINE-RILPIVIRINE-TENOFOVIR Epivir HBV 82 DISOPROXIL FUMARATE 85 EPLERENONE 137 EMTRICITABINE-TENOFOVIR ALAFENAMIDE EPOETIN ALFA 110,111 FUMARATE 88 EPOETIN ALFA-EPBX 111 EMTRICITABINE-TENOFOVIR DISOPROXIL Epogen 110 FUMARATE 87 EPOPROSTENOL SODIUM 290,291,292 Emtriva 87 EPROSARTAN MESYLATE 120 Enablex 181 Eprosartan Mesylate 120 ENALAPRIL MALEATE 121,122 EPTINEZUMAB-JJMR 57 ENALAPRIL MALEATE & Epzicom 87 HYDROCHLOROTHIAZIDE 132,135 EQ Blood Glucose Test 253 ENASIDENIB MESYLATE 62 EQ Space Chamber Anti-Static 253 Enbrel 222 EQ Space Chamber Anti-Static L 253 Enbrel Mini 222 EQ Space Chamber Anti-Static M 253 Enbrel SureClick 222 EQ Space Chamber Anti-Static S 253 ENCORAFENIB 65 Equetro 93 ENFUVIRTIDE 89 ERDAFITINIB 62 Engerix-B 234,301 ERENUMAB-AOOE 57 ENOXAPARIN SODIUM 107,108 ERGOCALCIFEROL 242,243 Enspryng 222 Ergocalciferol 242 ENTACAPONE 74 ERGOLOID MESYLATES 42 ENTECAVIR 82 Ergoloid Mesylates 42 Entereg 172 Ergomar 54 Entocort EC 240 ERGOTAMINE TARTRATE 54 ENTRECTINIB 62 ERGOTAMINE W/ CAFFEINE 54 Entresto 132 Erivedge 66 Entyvio 222 Erleada 60 Envarsus XR 222 ERLOTINIB HCL 66,69 ENZALUTAMIDE 60,303 Ertaczo 51 Epaned 121 ERTUGLIFLOZIN L-PYROGLUTAMIC ACID 99 Epclusa 82 ERTUGLIFLOZIN-METFORMIN HCL 99 Epidiolex 34 Ery 29 Epifoam 188 Erygel 29 EPINASTINE HCL (OPHTH) 276 EryPed 200 29 Epinastine HCl (Ophth) 276 EryPed 400 29 EPINEPHRINE (ANAPHYLAXIS) 286,287,288 Erythrocin Stearate 29 Epinephrine HCl 287 ERYTHROMYCIN (ACNE AID) 29 EPINEPHRINE HCL (NASAL) 286,287 Erythromycin (Ophth) 30

©2021 Wellmark, Inc. 320 ERYTHROMYCIN BASE 29,30 Etidronate Disodium 242 ERYTHROMYCIN ETHYLSUCCINATE 29,30 ETODOLAC 6 ERYTHROMYCIN STEARATE 29 ETONOGESTREL-ETHINYL ESTRADIOL 201,202,208 Esbriet 292 ETOPOSIDE 64 ESCITALOPRAM OXALATE 45,46 ETRAVIRINE 85 Esgic 147 Eucrisa 155 ESLICARBAZEPINE ACETATE 40 Euflexxa 253 ESOMEPRAZOLE MAGNESIUM 176,177 Eurax 73 ESOMEPRAZOLE STRONTIUM 176 Evamist 202 Esomeprazole Strontium 176 EvenCare + Blood Glucose Test 253 ESTAZOLAM 298 EvenCare Blood Glucose Test 253 ESTERIFIED ESTROGENS 206 EvenCare G2 Test 254 ESTERIFIED ESTROGENS & EvenCare G3 Test 254 METHYLTESTOSTERONE 200,201 EvenCare Mini Glucose Test 254 Estrace 202 EvenCare ProView Glucose Test 254 ESTRADIOL 199,201,202,206,211 Evenity 242 ESTRADIOL & NORETHINDRONE EVEROLIMUS 65,66 ACETATE 197,198,200,202,205,206 EVEROLIMUS (IMMUNOSUPPRESSANT) 222,227 ESTRADIOL ACETATE VAGINAL 203 EVINACUMAB-DGNB 301 ESTRADIOL CYPIONATE 200 Evista 214 ESTRADIOL VAGINAL 202,211,212 Evkeeza 301 ESTRADIOL VALERATE 200,202 Evoclin 23 ESTRADIOL VALERATE-DIENOGEST 207 EVOLOCUMAB 141 ESTRADIOL-LEVONORGESTREL 200 Evolution Autocode 254 ESTRADIOL-NORGESTIMATE 209 Evotaz 89 ESTRAMUSTINE PHOSPHATE SODIUM 60 Evoxac 152 Estring 202 Evrysdi 147 Estrogel 202 Exactuss 294 ESTROGENS, CONJUGATED 209 Exalgo 9 ESTROPIPATE 202 Exelderm 51 Estropipate 202 Exelon 42 Estrostep Fe 202 EXEMESTANE 64 ESZOPICLONE 298,299 EXENATIDE 95 ETANERCEPT 222 Exforge 132 ETHACRYNIC ACID 136 Exforge HCT 132 ETHAMBUTOL HCL 58 Exjade 162 ETHIONAMIDE 59 Extavia 149 ETHOSUXIMIDE 35 Extina 51 ETHOTOIN 41 Ez Smart Blood Glucose Test 254 ETHYNODIOL DIACET & ETH ESTRAD 202,204,212 Ez Smart Plus Glucose Test 254 ETIDRONATE DISODIUM 242 EZETIMIBE 140,141

©2021 Wellmark, Inc. 321 EZETIMIBE-SIMVASTATIN 140,141 Fiasp 102 Fiasp FlexTouch 102 F Fiasp PenFill 102 Fabrazyme 178 FIDAXOMICIN 29 Factive 31 Fifty50 Glucose Test 2.0 254 FACTOR IX COMPLEX 113,117 FILGRASTIM 110 FaLessa 203 FILGRASTIM-AAFI 111 FAMCICLOVIR 91 FILGRASTIM-SNDZ 112 FAMOTIDINE 173 Finacea 155 Fanapt 78 FINASTERIDE 182 Fareston 60 FINERENONE 301 Farxiga 95 FINGOLIMOD HCL 149,150 Farydak 66 Fintepla 34 Fasenra 294 Fioricet 147 Fasenra Pen 294 Fioricet/Codeine 14 FastTake Test 254 Fiorinal 6 FazaClo 81 Fiorinal/Codeine #3 14 FEBUXOSTAT 54 Firazyr 220 FEDRATINIB HCL 67 Firmagon 218 Feiba 114 Firmagon (240 MG Dose) 218 Feiba NF 114 Firvanq 23 FELBAMATE 37,38 Flagyl 23 Felbatol 38 Flarex 277 Feldene 6 FLAVOXATE HCL 181 FELODIPINE 127 Flebogamma DIF 228 Femara 64 FLECAINIDE ACETATE 122 Femhrt 203 Flector 6 Femring 203 Flexichamber 254 FENFLURAMINE HCL (ANTICONVULSANT) 34 Flexichamber Adult Mask/Small 254 FENOFIBRATE 138 Flexichamber Child Mask/Large 255 FENOFIBRATE MICRONIZED 138 Flexichamber Child Mask/Small 255 FENOPROFEN CALCIUM 6,7 Flolan 291 Fensolvi (6 Month) 218 Flomax 182 FENTANYL 8,9,18 Flovent Diskus 283 FENTANYL CITRATE 13,14,15 Flovent HFA 283 Fentora 14 Flowtuss 294 FERRIC DERISOMALTOSE 160 Floxin Otic 31 Ferriprox 162 Fluad 234 Ferriprox Twice-A-Day 162 Fluad Quadrivalent 235 FESOTERODINE FUMARATE 182 Fluarix Quadrivalent 235 Fetzima 45 Flublok 235

©2021 Wellmark, Inc. 322 Flublok Quadrivalent 235 FLUVOXAMINE MALEATE 45,46 Flucelvax Quadrivalent 235 Fluzone High-Dose 236 FLUCONAZOLE 51 Fluzone High-Dose Quadrivalent 236 FLUCYTOSINE 50,51 Fluzone Quadrivalent 236 FLUDROCORTISONE ACETATE 188 FML 277 Flulaval Quadrivalent 235 FML Forte 277 Flumadine 91 FML Liquifilm 277 FluMist 235 Focalin 145 FluMist Quadrivalent 235 Focalin XR 145 Flunisolide 283 Folivane-OB 165 FLUNISOLIDE (NASAL) 283 Fondaparinux Sodium 107 FLUNISOLIDE HFA 282 FONDAPARINUX SODIUM 107 FLUOCINOLONE ACETONIDE 186,187,188,192 Fora 6 Connect 255 FLUOCINOLONE ACETONIDE (OTIC) 282 FORA Blood Glucose Test 255 FLUOCINONIDE 188,189,193 FORA D15g Blood Glucose Test 255 FLUOCINONIDE EMULSIFIED BASE 189 FORA D20 Blood Glucose Test 255 FLUOROMETHOLONE (OPHTH) 277 Fora D40/G31 Blood Glucose 255 FLUOROMETHOLONE ACETATE 277 FORA G20 Blood Glucose Test 255 Fluoroplex 155 FORA G30/Prem V10 Glucose Test 255 Fluorouracil 61 Fora GD20 Test 255 FLUOROURACIL (TOPICAL) 61,154,155 FORA GD50 Blood Glucose Test 255 FLUOXETINE HCL 45,46 FORA GTel Blood Glucose Test 255 FLUoxetine HCl 45 FORA GTel Blood Ketone Test 256 Fluoxetine HCl (PMDD) 45 FORA TN'G Advance Pro 256 FLUOXYMESTERONE 196 Fora TN'G/TN'G Voice 256 FLUPHENAZINE HCL 77 FORA V10 Blood Glucose Test 256 FluPHENAZine HCl 77 FORA V12 Blood Glucose Test 256 FLURANDRENOLIDE 187,189,190 FORA V20 Blood Glucose Test 256 FLURAZEPAM HCL 298 FORA V30a Blood Glucose Test 256 Flurazepam HCl 298 ForaCare GD40 Test 256 FLURBIPROFEN 6 ForaCare premium V10 Test 256 FLURBIPROFEN SODIUM 277 ForaCare Test N Go Test 256 FLUTAMIDE 60 FORMOTEROL FUMARATE 287 FLUTICASONE FUROATE-VILANTEROL 293 Forteo 242 FLUTICASONE PROPIONATE 186,187,189 Fortesta 197 FLUTICASONE PROPIONATE (INHALATION) 283 FortisCare G1 Test Strip 256 FLUTICASONE PROPIONATE HFA 283 FortisCare Test 256 FLUTICASONE-SALMETEROL 293,294 Fosamax 242 FLUTICASONE-UMECLIDINIUM-VILANTEROL 284 Fosamax Plus D 242 FLUVASTATIN SODIUM 138,139 FOSAMPRENAVIR CALCIUM 89,90 Fluvirin 235 FOSDENOPTERIN HYDROBROMIDE 302

©2021 Wellmark, Inc. 323 FOSFOMYCIN TROMETHAMINE 23,24 GaviLyte-C 174 FOSINOPRIL SODIUM 121 Gavreto 64 FOSINOPRIL SODIUM & GE100 Blood Glucose Test 257 HYDROCHLOROTHIAZIDE 132 GEFITINIB 67 Fosrenol 163 Gel-One 257 FOSTAMATINIB DISODIUM 111 Gelnique 181 FOSTEMSAVIR TROMETHAMINE 89 Gelnique Pump 181 Fotivda 301 Gelsyn-3 257 Fragmin 108 GEMFIBROZIL 138 FreeStyle InsuLinx Test 257 GEMIFLOXACIN MESYLATE 31 FreeStyle Lite Test 257 Generess FE 203 FreeStyle Precision Neo Test 257 Genotropin 194 FreeStyle Test 257 Genotropin MiniQuick 194 FREMANEZUMAB-VFRM 42,57 GenStrip 50 257 Frova 55 Gentak 20 FROVATRIPTAN SUCCINATE 55 Gentamicin Sulfate 21 Fulphila 110 GENTAMICIN SULFATE (OPHTH) 20 Furadantin 23 GENTAMICIN-PREDNISOLONE ACETATE 275 FUROSEMIDE 136,137 GenUltimate Test 257 Fuzeon 89 GenVisc 850 257 Fycompa 38 Genvoya 84 Geodon 78 G GHT Test 257 GABAPENTIN 36 Giazo 240 Gabitril 36 Gilenya 149,150 Galafold 178 Gilotrif 66 GALANTAMINE HYDROBROMIDE 42 GILTERITINIB FUMARATE 63 GALCANEZUMAB-GNLM 57 Giltuss 294 GALSULFASE 179 Givlaari 178 GamaSTAN 228 GIVOSIRAN SODIUM 178 Gamifant 222 GLASDEGIB MALEATE 66 Gammagard 228 GLATIRAMER ACETATE 149,150 Gammagard S/D Less IgA 228 GLECAPREVIR-PIBRENTASVIR 83 Gammaked 228 Gleevec 66 Gammaplex 229 Gleostine 59 Gamunex-C 229 GLIMEPIRIDE 94,95 GANCICLOVIR OPHTHALMIC 82 GLIPIZIDE 95,96 Gardasil 9 236 GLIPIZIDE-METFORMIN HCL 95 Gastrocrom 172 GlucaGen HypoKit 100 GATIFLOXACIN (OPHTH) 31,32 GLUCAGON 100,101 Gattex 172 GLUCAGON (RDNA) 100

©2021 Wellmark, Inc. 324 Glucagon Emergency 100 GoodSense Blood Glucose 259 GLUCAGON HCL 100 GRANISETRON 50 GLUCAGON HCL (RDNA) 100 GRANISETRON HCL 50 Gluco Perfect 3 Test 257 Granix 110 Glucocard 01 Sensor Plus 258 GRASS MIXED POLLENS ALLERGEN Glucocard Expression Test 258 EXTRACT 231,232 Glucocard Shine Test 258 Grastek 231 Glucocard Vital Test 258 Gris-PEG 51 Glucocard X-Sensor 258 GRISEOFULVIN MICROSIZE 51 GlucoCom Test 258 GRISEOFULVIN ULTRAMICROSIZE 51 GlucoNavii Blood Glucose Test 258 GUANFACINE HCL 119 Glucophage 95 GUANFACINE HCL (ADHD) 145 Glucophage XR 96 GUANIDINE HCL 57 GLUCOSE Guanidine HCl 57 BLOOD 243,244,245,246,247,248,249,250,251,252,25 GUSELKUMAB 159 3,254,255,256,257,258,259,260,261,262,263,264,265, Gvoke HypoPen 1-Pack 101 266,267,268,269,270,271,272 Gvoke HypoPen 2-Pack 101 Glucose Blood 244,246,252,254,258,261,263,266,270 Gvoke PFS 101 Glucose Meter Test 258 Gynazole-1 51 Glucose Urine Test-(Glucose Oxidase) 249 GLUCOSE URINE TEST-(GLUCOSE OXIDASE) 250 H Glucotrol 96 Haegarda 221 Glucotrol XL 96 HAEMOPHILUS B POLYSAC CONJ VAC 233,236,237 Glucovance 96 Halcion 299 GLYBURIDE 96 HALOBETASOL PROPIONATE 186,189,193 GLYBURIDE MICRONIZED 96 HALOPERIDOL 77 GLYBURIDE-METFORMIN 96 HALOPERIDOL LACTATE 77 Glycate 170 Harmony Blood Glucose Test 259 GLYCEROL PHENYLBUTYRATE 180 Harvoni 83 GLYCOPYRROLATE 170,171 Havrix 236 Glycopyrrolate 170 Hectorol 242 Glynase 96 Helixate FS 114 Glyset 96 Hema-Combistix 259 Glyxambi 96 Hemangeol 62 GNP Easy Touch Glucose Test 258 HemeNatal OB + DHA 165 GNP True Metrix Glucose Strips 258 Hemlibra 114 Gojji Blood Glucose Test 258 Hemofil M 114 Gojji Blood Ketone Test 258 Heparin Lock Flush 108 Gojji Blood Test Strip/Lancets 259 HEPARIN SODIUM (PORCINE) 108 GOLIMUMAB 226 Heparin Sodium (Porcine) 108 Golytely 174 Heparin Sodium (Porcine) Lock Flush 108

©2021 Wellmark, Inc. 325 HEPARIN SODIUM (PORCINE) LOCK FLUSH 108 HumuLIN N KwikPen 103 HEPATITIS A (INACTIVATED)-HEPATITIS B HumuLIN R 103 (RECOMBINANT) VACCINES 239 HumuLIN R U-500 (CONCENTRATED) 103 HEPATITIS A VACCINE 236,239 HumuLIN R U-500 KwikPen 103 HEPATITIS B VACCINE (RECOMB) 234,238,301 HW Embrace Pro Glucose Test 259 HEPATITIS B VACCINE RECOMBINANT HW Embrace Talk Glucose Test 259 ADJUVANTED 236 Hyalgan 259 Heplisav-B 236 HYALURONAN 259,262,265 Hepsera 82 Hycamtin 65 Herceptin 71 Hycodan 294 Herzuma 71 Hycofenix 294 Hetlioz 300 HYDRALAZINE HCL 141 Hetlioz LQ 301 Hydrea 61 Hexalen 59 HYDROCHLOROTHIAZIDE 137,138 Hiberix 236 HYDROCODONE BITARTRATE 9,12 Hiprex 23 HYDROCODONE POLISTIREX- Hizentra 229 CHLORPHENIRAMINE POLISTIREX 294,296,297 Homatropaire 273 HYDROCODONE W/ HOMATROPINE 294,295,296 HOMATROPINE HBR 273 HYDROCODONE-ACETAMINOPHEN 14,15,16,18,19 HumaLOG 102 Hydrocodone-Acetaminophen 15 HumaLOG Junior KwikPen 102 HYDROCODONE-CHLORPHENIRAMINE 297 HumaLOG KwikPen 102 HYDROCODONE-GUAIFENESIN 294,295 HumaLOG Mix 50/50 102 HYDROcodone-GuaiFENesin 295 HumaLOG Mix 50/50 KwikPen 102 HYDROCODONE-IBUPROFEN 15,18 HumaLOG Mix 75/25 102 HYDROCORTISONE 187,189 HumaLOG Mix 75/25 KwikPen 103 HYDROCORTISONE (INTRARECTAL) 240 HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT HYDROCORTISONE (RECTAL) 240,241 RECOMBINANT VACCINE 236 HYDROCORTISONE (TOPICAL) 185,192 Humate-P 114 HYDROCORTISONE ACETATE (INTRARECTAL) 240 Humatin 21 HYDROCORTISONE ACETATE (RECTAL) 240,241 Humatrope 194 HYDROCORTISONE ACETATE (TOPICAL) 190,191 Humira 223 HYDROCORTISONE ACETATE W/ Humira Pediatric Crohns Start 223 PRAMOXINE 153,155,157,189 Humira Pen 223 HYDROCORTISONE BUTYRATE 189,190 Humira Pen-CD/UC/HS Starter 223 HYDROCORTISONE BUTYRATE HYDROPHILIC Humira Pen-Pediatric UC Start 223 LIPO BASE 189,190 Humira Pen-Ps/UV/Adol HS Start 223 HYDROCORTISONE SOD SUCCINATE 192 Humira Pen-Psor/Uveit Starter 224 HYDROCORTISONE VALERATE 189,193 HumuLIN 70/30 103 HYDROCORTISONE W/ACETIC ACID 281,282 HumuLIN 70/30 KwikPen 103 HYDROMORPHONE HCL 9,14,15 HumuLIN N 103 HYDROmorphone HCl 15

©2021 Wellmark, Inc. 326 HYDROXYCHLOROQUINE SULFATE 72 IMIGLUCERASE 178 HYDROXYprogesterone Caproate 213 IMIPRAMINE HCL 48 HYDROXYPROGESTERONE CAPROATE 213 IMIQUIMOD 153,155,159 HYDROXYPROGESTERONE CAPROATE Imitrex 55 (ANTINEOPLASTIC) 213 Imitrex STATdose Refill 55 HYDROXYUREA 61 Imitrex STATdose System 55 HYDROXYUREA (SICKLE CELL ANEMIA) 61 IMMUNE GLOBULIN (HUMAN) IM 228 HYDROXYZINE HCL 285 IMMUNE GLOBULIN (HUMAN) IV 227,228,229,230 HYDROXYZINE PAMOATE 285 IMMUNE GLOBULIN (HUMAN) IV OR HYLAN 270 SUBCUTANEOUS 228,229 Hymovis 259 IMMUNE GLOBULIN (HUMAN) Hyophen 23 SUBCUTANEOUS 228,229 HYOSCYAMINE SULFATE 170,171 IMMUNE GLOBULIN (HUMAN)-HIPP 227 HyperRHO S/D 229 IMMUNE GLOBULIN (HUMAN)-HYALURONIDASE HyperSal 295 (HUMAN RECOMBINANT) 229 Hyqvia 229 IMMUNE GLOBULIN (HUMAN)-IFAS 230 Hysingla ER 9 IMMUNE GLOBULIN (HUMAN)-KLHW 230 Hyzaar 132 IMMUNE GLOBULIN (HUMAN)-SLRA 227 Impavido 72 I Impoyz 189 IBANDRONATE SODIUM 241,242 Imuran 224 Ibrance 66 In Touch Blood Glucose Test 259 IBRUTINIB 67 Inatal GT 165 IBUPROFEN 6 INCOBOTULINUMTOXINA 298 ICATIBANT ACETATE 220,221 Increlex 194 Iclusig 67 INDACATEROL MALEATE 287 ICOSAPENT ETHYL 140,141 INDAPAMIDE 137 IDECABTAGENE VICLEUCEL 300 Inderal LA 124 IDELALISIB 70 INDINAVIR SULFATE 89 Idelvion 115 Indocin 6 IDHIFA 62 INDOMETHACIN 6 IDURSULFASE 178 INEBILIZUMAB-CDON 226 iGlucose Test Strips 259 Infanrix 236 Ilaris 231 INFIGRATINIB PHOSPHATE 303 Ilevro 277 Infinity Blood Glucose Test 259 ILOPERIDONE 78 Infinity Voice 259 ILOPROST 292 Inflectra 224 Ilumya 155 INFLIXIMAB 226 IMATINIB MESYLATE 66,67 INFLIXIMAB-ABDA 226 Imbruvica 67 INFLIXIMAB-AXXQ 221 Imcivree 172 INFLIXIMAB-DYYB 224

©2021 Wellmark, Inc. 327 INFLUENZA VIRUS VAC RECOMB Insulin Aspart PenFill 104 HEMAGGLUTININ (HA) QUADRIVALENT 235 Insulin Aspart Prot & Aspart 104 INFLUENZA VIRUS VAC SPLIT HIGH-DOSE QUAD INSULIN ASPART PROTAMINE & ASPART PRESERVATIVE FREE 236 (HUMAN) 103,104,106 INFLUENZA VIRUS VACC TYPES A & B SURF INSULIN DEGLUDEC 107 ANTIGEN ADJUVANT QUAD 235 INSULIN DETEMIR 104 Influenza Virus Vaccine Live 235 INSULIN GLARGINE 102,104,106 INFLUENZA VIRUS VACCINE LIVE INSULIN GLULISINE 102 QUADRIVALENT 235 INSULIN INFUSION DISPOSABLE PUMP 263 INFLUENZA VIRUS VACCINE RECOMBINANT INSULIN LISPRO 101,102,104 HEMAGGLUTININ (HA) 235 Insulin Lispro 104 Influenza Virus Vaccine Split 234 Insulin Lispro (1 Unit Dial) 104 INFLUENZA VIRUS VACCINE SPLIT HIGH-DOSE Insulin Lispro Junior KwikPen 104 PRESERVATIVE FREE 236 Insulin Lispro Prot & Lispro 104 INFLUENZA VIRUS VACCINE SPLIT INSULIN LISPRO PROTAMINE & PRESERVATIVE FREE 234 LISPRO 102,103,104 INFLUENZA VIRUS VACCINE SPLIT INSULIN LISPRO-AABC 104 QUADRIVALENT 234,235,236 INSULIN NPH (HUMAN) (ISOPHANE) 103,105 INFLUENZA VIRUS VACCINE TISSUE-CULTURED INSULIN NPH ISOPHANE & REG (HUMAN) 103,105 SUBUNIT QUADRIVALENT 235 INSULIN PEN NEEDLE 260 INFLUENZA VIRUS VACCINE TYPES A & B INSULIN REGULAR (HUMAN) 101,103,105,106 SURFACE ANTIGEN 235 INSULIN SYRINGE 260 INFLUENZA VIRUS VACCINE TYPES A & B INSULIN SYRINGE NEEDLE 260 SURFACE ANTIGEN ADJUVANT 234 Intelence 85 INGENOL MEBUTATE 156 INTERFERON BETA-1A 149,151 Ingrezza 147 INTERFERON BETA-1B 149 Inlyta 67 INTERFERON GAMMA-1B 231 INOTERSEN SODIUM 148 Intermezzo 299 Inqovi 62 Intuniv 145 Inrebic 67 Invega 78 InspiraChamber/Large 260 Invirase 90 InspiraChamber/Medium 260 Invokamet 96 InspiraChamber/Mouthpiece 260 Invokamet XR 96 InspiraChamber/Small 260 Invokana 96 Inspirease 260 Iodine Strong 260 Inspra 137 IODINE STRONG (LUGOL'S) 260 Insulin Asp Prot & Asp FlexPen 103 Iopidine 279 INSULIN ASPART 103,104,106 Ipol 236 Insulin Aspart 103 IPRATROPIUM BROMIDE (NASAL) 286 INSULIN ASPART (WITH NIACINAMIDE) 102 IPRATROPIUM BROMIDE HFA 286 Insulin Aspart FlexPen 103 IPRATROPIUM-ALBUTEROL 294,295

©2021 Wellmark, Inc. 328 Iprivask 108 IRBESARTAN 120 J IRBESARTAN-HYDROCHLOROTHIAZIDE 130,132 Jadenu 162 Iressa 67 Jadenu Sprinkle 162 ISAVUCONAZONIUM SULFATE 51 Jakafi 67 Isentress 84 Jalyn 182 Isentress HD 84 Janssen COVID-19 Vaccine 236 ISOCARBOXAZID 44 Janumet 97 ISOMETHEPTENE-CAFFEINE- Janumet XR 97 ACETAMINOPHEN 260,267 Januvia 97 Isometheptene-Caffeine-APAP 260 Jardiance 97 ISONIAZID 58 Jemperli 301 Isoniazid 58 Jentadueto 97 ISONIAZID-RIFAMPIN W/ PYRAZINAMIDE 59 Jentadueto XR 97 Isoptin SR 127 Jivi 115 Isopto Atropine 273 Juluca 81 Isopto Carpine 279 Juxtapid 140 Isordil Titradose 141 Jynarque 162 ISOSORBIDE DINITRATE 141,142 Isosorbide Dinitrate 141 K Isosorbide Dinitrate ER 142 K-Phos 160 ISOSORBIDE DINITRATE-HYDRALAZINE HCL 130 K-Phos No 2 183 ISOSORBIDE MONONITRATE 142 K-Phos-Neutral 163 ISOTRETINOIN 153,154,156,159 K-Tab 160 ISOXSUPRINE HCL 132 Kadian 9,10 ISRADIPINE 127 Kalbitor 221 Istalol 280 Kaletra 90 ISTRADEFYLLINE 74 Kalydeco 289 Isturisa 189 Kanjinti 67 ITRACONAZOLE 51,52,53 Kapvay 145 IVABRADINE HCL 131 Karbinal ER 285 IVACAFTOR 289 Katerzia 127 IVERMECTIN 71,72 Kazano 97 Ivermectin 156 Keflex 27 IVERMECTIN (PEDICULICIDE) 72 Kenalog 189 IVERMECTIN (ROSACEA) 156,158 Keppra 34 IVOSIDENIB 63 Keppra XR 34 IXAZOMIB CITRATE 62 Kerendia 301 IXEKIZUMAB 158 Kesimpta 150 Ixinity 115 Keto-Diastix 260 KETOCONAZOLE 51

©2021 Wellmark, Inc. 329 KETOCONAZOLE (TOPICAL) 51,52 Kynmobi Titration Kit 75 KETONE BLOOD TEST 256,258,263,266,267 Ketone Test 260 L KETOPROFEN 6 LABETALOL HCL 124 Ketoprofen ER 6 Labstix 261 KETOROLAC TROMETHAMINE 6 LACOSAMIDE 41 KETOROLAC TROMETHAMINE (OPHTH) 276,277 Lacrisert 273 Ketostix 260 LACTULOSE 174 Keveyis 136 LACTULOSE (ENCEPHALOPATHY) 174 Kevzara 231 LaMICtal 38 Khedezla 46 LaMICtal ODT 38 Kimyrsa 23 LaMICtal XR 38 Kineret 224 LamISIL 52 Kinrix 237 LAMIVUDINE 87 Kisqali (200 MG Dose) 67 LAMIVUDINE (HBV) 82 Kisqali (400 MG Dose) 67 LAMIVUDINE-TENOFOVIR DISOPROXIL Kisqali (600 MG Dose) 67 FUMARATE 86,87 Kisqali Femara (400 MG Dose) 67 LAMIVUDINE-ZIDOVUDINE 86,87 Kisqali Femara (600 MG Dose) 67 LAMOTRIGINE 38,39 Kisqali Femara(200 MG Dose) 68 LANADELUMAB-FLYO 221 Kitabis Pak 289 LANCETS 261 Klarity-A 30 Lanoxin 132 Klaron 32 LANREOTIDE ACETATE 220 KlonoPIN 93 LANSOPRAZOLE 176,177 Kloxxado 20 LANTHANUM CARBONATE 163 Koate 115 Lantus 104 Koate-DVI 115 Lantus SoloStar 104 Kogenate FS 115 LAPATINIB DITOSYLATE 68,70 Kogenate FS Bio-Set 115 LARONIDASE 177 Kombiglyze XR 97 LAROTRECTINIB SULFATE 63 Korlym 190 Lasix 137 Koselugo 68 LASMIDITAN SUCCINATE 56 Kovaltry 116 Lastacaft 276 Kroger Blood Glucose Test 260 LATANOPROST 281 Kroger HealthPro Glucose Test 260 Latuda 79 Kroger Premium Glucose Test 261 Lazanda 15 Kroger Test 261 LEDIPASVIR-SOFOSBUVIR 83 Kuvan 178 Ledipasvir-Sofosbuvir 83 Kyleena 213 LEFLUNOMIDE 231 Kynamro 140 LEMBOREXANT 300 Kynmobi 75 Lemtrada 150

©2021 Wellmark, Inc. 330 LENALIDOMIDE 60 LEVONORGESTREL & ETH LENVATINIB MESYLATE 68 ESTRADIOL 197,198,199,200,203,204,205,206,208,20 Lenvima (10 MG Daily Dose) 68 9,210,211 Lenvima (12 MG Daily Dose) 68 LEVONORGESTREL (IUD) 213,214 Lenvima (14 MG Daily Dose) 68 LEVONORGESTREL-ETH ESTRADIOL Lenvima (18 MG Daily Dose) 68 (TRIPHASIC) 201,204,207,211 Lenvima (20 MG Daily Dose) 68 LEVONORGESTREL-ETHINYL ESTRADIOL 211 Lenvima (24 MG Daily Dose) 68 LEVONORGESTREL-ETHINYL ESTRADIOL & FOLIC Lenvima (4 MG Daily Dose) 68 ACID 203 Lenvima (8 MG Daily Dose) 68 LEVONORGESTREL-ETHINYL ESTRADIOL (91- Lescol XL 139 DAY) 198,199,200,203,204,205,209,210 LESINURAD 54 LEVONORGESTREL-ETHINYL ESTRADIOL Letairis 291 (CONTINUOUS) 198,201,205 LETERMOVIR 82 LEVONORGESTREL-ETHINYL ESTRADIOL- LETROZOLE 64 FERROUS BISGLYCINATE 199 LEUCOVORIN CALCIUM 62 LEVORPHANOL TARTRATE 10 Leukeran 59 LEVOTHYROXINE SODIUM 215,216,217 Leukine 110 Levothyroxine Sodium 215 LEUPROLIDE ACETATE 218 Levsin 171 LEUPROLIDE ACETATE & NORETHINDRONE Levsin/SL 171 ACETATE 218 Lexapro 46 LEUPROLIDE ACETATE (3 MONTH) 218 Lexiva 90 LEUPROLIDE ACETATE (4 MONTH) 218 Lialda 240 LEUPROLIDE ACETATE (6 MONTH) 219 Liberty Next Generation Test 261 LEUPROLIDE ACETATE (CPP) 219 Librax 171 LEUPROLIDE ACETATE (CPP) (3 MONTH) 219 LIDOCAINE 19 LEUPROLIDE ACETATE (CPP) (6 MONTH) 218 LIDOCAINE HCL 19 LEVALBUTEROL HCL 287,288 Lidocaine HCl 19 LEVALBUTEROL TARTRATE 287,288 LIDOCAINE HCL (MOUTH-THROAT) 19 Levaquin 31 LIDOCAINE HCL (OPHTH) 272 Levbid 171 LIDOCAINE-HYDROCORTISONE ACETATE Levemir 104 (RECTAL) 156 Levemir FlexTouch 104 LIDOCAINE-PRILOCAINE 19 LEVETIRACETAM 34,35 Lidoderm 19 Levetiracetam 35 LIFITEGRAST 276 Levitra 183 Liletta (52 MG) 213 LEVOBUNOLOL HCL 279,280 LINACLOTIDE 173 LEVOCARNITINE (METABOLIC MODIFIERS) 160 LINAGLIPTIN 99 LEVOFLOXACIN 31 LINAGLIPTIN-METFORMIN HCL 97 LEVOMILNACIPRAN HCL 45 LINDANE 73 Lindane 73

©2021 Wellmark, Inc. 331 LINEZOLID 23,25 LOSARTAN POTASSIUM 120 Linzess 173 LOSARTAN POTASSIUM & LIOTHYRONINE SODIUM 215,216 HYDROCHLOROTHIAZIDE 132,133 LIOTRIX (T3-T4) 216,217 LoSeasonique 205 Lipitor 139 Lotemax 278 Lipofen 138 Lotemax SM 278 LIRAGLUTIDE 100 Lotensin 121 LISDEXAMFETAMINE DIMESYLATE 144 Lotensin HCT 133 LISINOPRIL 121,122 LOTEPREDNOL ETABONATE 277,278 LISINOPRIL & HYDROCHLOROTHIAZIDE 132,136 LOTEPREDNOL ETABONATE-TOBRAMYCIN 276 LiteAire 261 Lotrel 133 LITHIUM 93 Lotrisone 156 Lithium 93 Lotronex 173 LITHIUM CARBONATE 93,94 LOVASTATIN 138,139 Lithobid 94 Lovenox 108 Lithostat 183 LOXAPINE SUCCINATE 77 Livalo 139 LUBIPROSTONE 173 LIXISENATIDE 94 LULICONAZOLE 52 Lo Loestrin Fe 205 LUMACAFTOR-IVACAFTOR 289 Locoid 190 Lumakras 302 Locoid Lipocream 190 LUMASIRAN SODIUM 179 Lodine 6 LUMATEPERONE TOSYLATE 78 Lodosyn 76 Lumigan 281 LODOXAMIDE TROMETHAMINE 276 Lumizyme 178 Lofibra 138 Lunesta 299 Lokelma 160 Lupaneta Pack 218 LOMITAPIDE MESYLATE 140 Lupkynis 224 Lomotil 172 Lupron Depot (1-Month) 218 LOMUSTINE 59 Lupron Depot (3-Month) 218 LONAFARNIB 180 Lupron Depot (4-Month) 218 LONCASTUXIMAB TESIRINE-LPYL 303 Lupron Depot (6-Month) 219 Lonsurf 62 Lupron Depot-Ped (1-Month) 219 Lopid 138 Lupron Depot-Ped (3-Month) 219 LOPINAVIR-RITONAVIR 90 LURASIDONE HCL 79 Lopressor 124 LUSPATERCEPT-AAMT 111 Lopressor HCT 133 LUSUTROMBOPAG 110 Loprox 52 Luxiq 190 LORAZEPAM 92,93 Luzu 52 Lorbrena 65 Lynparza 68 LORLATINIB 65 Lyrica 148 Lortab 15 Lyrica CR 36

©2021 Wellmark, Inc. 332 Lysodren 62 Mayzent 150 Lysteda 116 Mayzent Starter Pack 151 Lyumjev 104 MEASLES, MUMPS & RUBELLA VIRUS Lyumjev KwikPen 104 VACCINES 237 MEASLES-MUMPS-RUBELLA-VARICELLA VIRUS M VACCINES 238 M-M-R II 237 MECASERMIN 194 MACITENTAN 291 MECHLORETHAMINE HCL (TOPICAL) 59 Macrobid 23 MECLOFENAMATE SODIUM 6 Macrodantin 23 Meclofenamate Sodium 6 MAFENIDE ACETATE 23,24 Medrol 190 Makena 213 MEDROXYPROGESTERONE ACETATE 213,214 Malarone 72 MEDROXYPROGESTERONE ACETATE MALATHION 73 (CONTRACEPTIVE) 213 MANNITOL (CYSTIC FIBROSIS) 248,288 MEFENAMIC ACID 7 MAPROTILINE HCL 46 MEFLOQUINE HCL 72 Maprotiline HCl 46 Megace ES 213 MARAVIROC 89 MEGESTROL ACETATE (APPETITE) 213,214 Margenza 302 Meijer Blood Glucose Test 261 MARGETUXIMAB-CMKB 302 Meijer Essential Glucose Test 261 Marinol 50 Meijer Premium Glucose Test 261 Marplan 44 Meijer TRUEtest Test 262 Mask Vortex 261 Meijer TRUEtrack Test 262 Mask Vortex/Child/Frog 261 Mekinist 69 Mask Vortex/Toddler/Ladybug 261 Mektovi 69 Matulane 59 MELOXICAM 7 Mavenclad (10 Tabs) 150 MELPHALAN 59 Mavenclad (4 Tabs) 150 MELPHALAN FLUFENAMIDE HCL 302 Mavenclad (5 Tabs) 150 MEMANTINE HCL 43 Mavenclad (6 Tabs) 150 Menactra 237 Mavenclad (7 Tabs) 150 Menest 206 Mavenclad (8 Tabs) 150 MENINGOCOCCAL (A,C,Y&W-135) Mavenclad (9 Tabs) 150 OLIGOSACCHARIDE CONJUGATE VAC 237 Mavyret 83 Meningococcal (A,C,Y&W-135) Polysaccharide Maxalt 55 Conjugate Vaccine 237 Maxalt-MLT 55 MENINGOCOCCAL (A,C,Y&W-135) Maxidex 278 POLYSACCHARIDE CONJUGATE VACCINE 237 Maxipime 27 MENINGOCOCCAL GROUP B VACCINE Maxitrol 273 (RECOMBINANT) 238 Maxzide 133 MENINGOCOCCAL VAC GROUP B (RECOMBANT Maxzide-25 133 OMV ADJUVANTED) 234

©2021 Wellmark, Inc. 333 Menostar 206 METHOXY POLYETHYLENE GLYCOL-EPOETIN MenQuadfi 237 BETA 110 Menveo 237 METHSCOPOLAMINE BROMIDE 171 MEPERIDINE HCL 14,16 METHSUXIMIDE 35 Meperidine HCl 16 METHYCLOTHIAZIDE 137 Mephyton 118 Methyclothiazide 137 MEPOLIZUMAB 295 METHYLDOPA 119 MEPROBAMATE 92 METHYLDOPA & HYDROCHLOROTHIAZIDE 133 Mepron 72 Methyldopa-Hydrochlorothiazide 133 MERCAPTOPURINE 61 METHYLERGONOVINE MALEATE 262 MESALAMINE 239,240 Methylin 145 MESNA 71 METHYLNALTREXONE BROMIDE 172,173 Mesnex 71 METHYLPHENIDATE 144 Mestinon 58 METHYLPHENIDATE HCL 144,145,146 METAPROTERENOL SULFATE 287 METHYLPREDNISOLONE 190 Metaproterenol Sulfate 287 METHYLPREDNISOLONE ACETATE 187 METAXALONE 297,298 METHYLPREDNISOLONE SOD SUCC 190,192 METFORMIN HCL 95,96,97,98 METHYLTESTOSTERONE 196,197 Metformin HCl 97 METIPRANOLOL 280 METHADONE HCL 8,10 Metipranolol 280 Methadone HCl 10 METOCLOPRAMIDE HCL 48,49 Methadose 10 METOLAZONE 137 Methadose Sugar-Free 10 METOPROLOL & HYDROCHLOROTHIAZIDE 133 METHAMPHETAMINE HCL 143,144 METOPROLOL SUCCINATE 124,125 METHAZOLAMIDE 280 METOPROLOL TARTRATE 124 METHENAMINE HIPPURATE 23 MetroCream 156 Methenamine Hippurate 25 Metrogel 156 METHENAMINE MANDELATE 23 MetroGel-Vaginal 23 METHENAMINE-HYOSC-METHYLENE BLUE- MetroLotion 156 BENZOIC ACID-PHENYL SAL 23,25 METRONIDAZOLE 23,24 METHENAMINE-HYOSC-METHYLENE BLUE-SOD METRONIDAZOLE (TOPICAL) 156,157 PHOS-PHENYL SAL 21,23,24,25 METRONIDAZOLE VAGINAL 23,24,25 METHENAMINE-HYOSCAMINE-METHYLENE BLUE- METYROSINE 131,133 SODIUM PHOSPHATE 23,25 MEXILETINE HCL 122 METHIMAZOLE 220 Miacalcin 242 METHOCARBAMOL 297,298 Micardis 120 METHOTREXATE 227 Micardis HCT 133 METHOTREXATE (ANTIRHEUMATIC) 225,226 MICONAZOLE (MOUTH-THROAT) 53 METHOTREXATE SODIUM 224,226 MICONAZOLE-ZINC OXIDE-WHITE METHOXSALEN RAPID 156 PETROLATUM 52,53 MiCort-HC 190

©2021 Wellmark, Inc. 334 MICRhoGAM Ultra-Filtered Plus 229 MOMETASONE FUROATE 188,190 Microchamber 262 MOMETASONE FUROATE (INHALATION) 282,283 Microdot Test 262 MOMETASONE FUROATE (NASAL) 283 Microspacer 262 MOMETASONE FUROATE-FORMOTEROL Microzide 138 FUMARATE DIHYDRATE 294 MIDAZOLAM (ANTICONVULSANT) 19 Monjuvi 71 MIDODRINE HCL 119 Monoclate-P 116 MIDOSTAURIN 63 Monodox 33 MIFEPRISTONE (HYPERGLYCEMIA) 190 Monoferric 160 MIGALASTAT HCL 178 MONOMETHYL FUMARATE 149 MIGLITOL 96,97 Mononine 116 MIGLUSTAT 178,180 Monovisc 262 Millipred 190 MONTELUKAST SODIUM 285 Millipred DP 190 Monurol 24 Millipred DP 12-Day 190 MorphaBond ER 262 MILNACIPRAN HCL 149 MORPHINE SULFATE 7,8,9,10,11,16,262 MILTEFOSINE 72 Morphine Sulfate 16 Minastrin 24 Fe 206 MORPHINE SULFATE BEADS 11 Minipress 119 Morphine Sulfate ER 10 Minivelle 206 Morphine Sulfate ER Beads 11 Minocin 33 MORPHINE-NALTREXONE 8 MINOCYCLINE HCL 33,34 Motegrity 172 MINOXIDIL 141 Motofen 172 MIPOMERSEN SODIUM 140 Movantik 172 MIRABEGRON 181 MoviPrep 175 Mirapex 75 Moxeza 31 Mirapex ER 75 MOXIFLOXACIN HCL 30,31 Mircera 110 MOXIFLOXACIN HCL (OPHTH) 31,32 Mircette 207 Mozobil 110 Mirena (52 MG) 214 MS Contin 11 MIRTAZAPINE 43,44 Mulpleta 110 Mirvaso 156 Multaq 122 MISOPROSTOL 176 MULTIPLE URINE Mitigare 54 TESTS 248,249,259,261,262,263,271 MITOTANE 62 Multistix 262 MM Easy Touch Glucose 262 Multistix 10 SG 262 Mobic 7 Multistix 5 262 MODAFINIL 300 Multistix 7 262 Moderna COVID-19 Vaccine 237 Multistix 8 262 MOEXIPRIL HCL 121 Multistix 9 263 MOEXIPRIL-HYDROCHLOROTHIAZIDE 133 Multistix 9 SG 263

©2021 Wellmark, Inc. 335 MUPIROCIN 21,24 Nasonex 283 MUPIROCIN CALCIUM 21 Natacyn 52 MUPIROCIN CALCIUM (TOPICAL) 21,24 NATALIZUMAB 151 Muse 184 Natalvit 165 Myambutol 58 NATAMYCIN 52 Mycapssa 219 Natazia 207 Mycobutin 58 NATEGLINIDE 97,99 MYCOPHENOLATE MOFETIL 221,224 Natpara 242 MYCOPHENOLATE SODIUM 224 Natroba 73 Mydriacyl 274 Nature-Throid 216 Myfembree 194 Nayzilam 19 Myfortic 224 NEBIVOLOL HCL 123 MyGlucoHealth Test 263 Nebupent 72 Myleran 59 Nebusal 295 Mynatal 165 Necon 1/50 (28) 207 Mynatal Advance 165 NEDOCROMIL SODIUM (OPHTH) 276 Mynate 90 Plus 165 NEFAZODONE HCL 46 Myobloc 298 NELFINAVIR MESYLATE 90 Myrbetriq 181 Neo-Synalar 156 Mysoline 36 NEOMYCIN SULFATE 21 NEOMYCIN SULFATE-FLUOCINOLONE N ACETONIDE 156 NABILONE 49 NEOMYCIN-BACITRACIN ZN-POLYMYXIN 274 NABUMETONE 7 NEOMYCIN-COLISTIN-HC-THONZONIUM 281 NADOLOL 124 NEOMYCIN-POLYMY-DEXAMETH 273,274 NADOLOL & BENDROFLUMETHIAZIDE 131,133 Neomycin-Polymy-Dexameth 274 NAFTIFINE HCL 52 NEOMYCIN-POLYMYXIN-GRAMICIDIN 274 Naftin 52 Neomycin-Polymyxin-Gramicidin 274 Naglazyme 179 NEOMYCIN-POLYMYXIN-HC 154 Nalfon 7 Neomycin-Polymyxin-HC 274 NALOXEGOL OXALATE 172 NEOMYCIN-POLYMYXIN-HC (OPHTH) 274 NALOXONE HCL 20 Neomycin-Polymyxin-HC (Otic) 282 NALTREXONE HCL 19 Neoral 224 Namenda 43 Neosporin 274 Namenda XR 43 NeoTuss Plus 295 Naprosyn 7 NEPAFENAC 277,278 NAPROXEN 5,7 Neptazane 280 NAPROXEN SODIUM 5,7 NERATINIB MALEATE 69 NARATRIPTAN HCL 54,55 Nerlynx 69 Narcan 20 Nesina 97 Nardil 44 NETUPITANT-PALONOSETRON 49

©2021 Wellmark, Inc. 336 Neulasta 110 Nitrostat 142 Neulasta Onpro 110 Nivestym 111 Neupogen 110 NIZATIDINE 173 Neupro 75 Nizoral 52 Neurontin 36 Norco 16 Neutek 2Tek Test 263 Norditropin FlexPro 195 Nevanac 278 NORELGESTROMIN-ETHINYL ESTRADIOL 212 NEVIRAPINE 86 NORETHIN ACET & ESTRAD- NexAVAR 69 FE 198,199,203,204,205,206,207,210 NexIUM 177 NORETHINDRONE & ETH Nexletol 134 ESTRADIOL 198,199,200,203,207,208,212 Nexlizet 140 NORETHINDRONE & ETHINYL ESTRADIOL- Nextstellis 302 FE 203,204,207,212 Nexviazyme 302 NORETHINDRONE & MESTRANOL 207 NIACIN (ANTIHYPERLIPIDEMIC) 140 NORETHINDRONE (CONTRACEPTIVE) 212,213,214 Niacin (Antihyperlipidemic) 140 NORETHINDRONE ACET & ETH Niacor 140 ESTRA 198,203,204,205,206,207 Niaspan 140 NORETHINDRONE ACETATE 212,214 NICARDIPINE HCL 127 NORETHINDRONE ACETATE-ETHINYL NIFEDIPINE 125,127,128 ESTRADIOL 203,207 Nifedipine 127 NORETHINDRONE ACETATE-ETHINYL Nilandron 60 ESTRADIOL-FE 202,210 NILOTINIB HCL 69 NORETHINDRONE ACETATE-ETHINYL NILUTAMIDE 60 ESTRADIOL-FE FUM (BIPHASIC) 205 NIMODIPINE 127,128 NORETHINDRONE-ETH ESTRADIOL Ninlaro 62 (TRIPHASIC) 198,200,204,207,208,210 NINTEDANIB ESYLATE 292 NORGESTIMATE-ETHINYL NIRAPARIB TOSYLATE 64 ESTRADIOL 201,203,206,207,208,209,210,212 NISOLDIPINE 128 NORGESTIMATE-ETHINYL ESTRADIOL NITAZOXANIDE 72 (TRIPHASIC) 207,208,210,211 NITISINONE 179 NORGESTREL & ETHINYL Nitro-Bid 142 ESTRADIOL 200,201,205,208 Nitro-Dur 142 Norpace 122 Nitro-Time 142 Norpace CR 122 NITROFURANTOIN 23,24 Norpramin 48 NITROFURANTOIN MACROCRYSTAL 23,24 NORTRIPTYLINE HCL 48 NITROFURANTOIN MONOHYD MACRO 23,24 Norvasc 128 NITROGLYCERIN 142 Norvir 90 NITROGLYCERIN (INTRA-ANAL) 157 Nourianz 74 Nitrolingual 142 Nova Max Glucose Test 263 NitroMist 142 Nova Max Plus Ketone Test 263

©2021 Wellmark, Inc. 337 Novacort 190 Nuvessa 24 Novoeight 116 Nuvigil 300 NovoLIN 70/30 105 Nuwiq 116 NovoLIN 70/30 FlexPen 105 Nymalize 128 NovoLIN 70/30 FlexPen Relion 105 NYSTATIN 50,52,301 NovoLIN 70/30 ReliOn 105 NYSTATIN (TOPICAL) 52 NovoLIN N 105 NYSTATIN-TRIAMCINOLONE 52 NovoLIN N FlexPen 105 Nyvepria 111 NovoLIN N FlexPen ReliOn 105 NovoLIN N ReliOn 105 O NovoLIN R 105 O-Cal Prenatal 166 NovoLIN R FlexPen 105 OBETICHOLIC ACID 179 NovoLIN R FlexPen ReliOn 105 Obizur 116 NovoLIN R ReliOn 106 Obredon 295 NovoLOG 106 Obstetrix DHA 166 NovoLOG 70/30 FlexPen ReliOn 106 Obstetrix EC 166 NovoLOG FlexPen 106 Ocaliva 179 NovoLOG FlexPen ReliOn 106 OCRELIZUMAB 151 NovoLOG Mix 70/30 106 Ocrevus 151 NovoLOG Mix 70/30 FlexPen 106 Octagam 230 NovoLOG Mix 70/30 ReliOn 106 OCTREOTIDE ACETATE 218,219 NovoLOG PenFill 106 Ocuflox 31 NovoLOG ReliOn 106 Odactra 263 NovoSeven RT 116 Odefsey 86 Noxafil 52 ODEVIXIBAT 301 Nplate 111 Odomzo 69 Nubeqa 60 OFATUMUMAB (MS) 150 Nucala 295 Ofev 292 NuCort 191 OFLOXACIN 32 Nucynta 16 OFLOXACIN (OPHTH) 31 Nucynta ER 11 OFLOXACIN (OTIC) 31 Nuedexta 147 Ogestrel 208 Nulibry 302 Ogivri 69 Nulytely Lemon-Lime 175 OLANZAPINE 79,80 Nulytely with Flavor Packs 175 OLANZAPINE-FLUOXETINE HCL 44 Nuplazid 79 OLAPARIB 68 Nurtec 57 OLMESARTAN MEDOXOMIL 120 Nutropin AQ NuSpin 10 195 OLMESARTAN MEDOXOMIL-AMLODIPINE- Nutropin AQ NuSpin 20 195 HYDROCHLOROTHIAZIDE 134,135 Nutropin AQ NuSpin 5 195 OLMESARTAN MEDOXOMIL- NuvaRing 208 HYDROCHLOROTHIAZIDE 130,134

©2021 Wellmark, Inc. 338 OLODATEROL HCL 288 OptiChamber Advantage-Lg Mask 264 OLOPATADINE HCL (NASAL) 285 OptiChamber Advantage-Med Mask 264 OLSALAZINE SODIUM 240 OptiChamber Advantage-Sm Mask 264 Olumiant 224 OptiChamber Diamond 264 Olux 191 OptiChamber Diamond-Lg Mask 264 Olux-E 191 OptiChamber Diamond-Md Mask 264 Olysio 83 OptiChamber Diamond-Sm Mask 264 OMACETAXINE MEPESUCCINATE 63 OptiChamber Face Mask-Large 264 OMALIZUMAB 297 OptiChamber Face Mask-Medium 265 OMBITASVIR-PARITAPREVIR-RITONAVIR 83 OptiChamber Face Mask-Small 265 OMBITASVIR-PARITAPREVIR-RITONAVIR- OptiHaler 265 DASABUVIR 83 Optium Test 265 Omeclamox-Pak 172 OptiumEZ Test 265 OMEPRAZOLE 177 OptumRx Blood Glucose Test 265 OMEPRAZOLE MAGNESIUM 177 Oracea 33 Omnaris 283 Oracit 184 OmniPod Dash 5 Pack Pods 263 Oralair 231 Omnipred 278 Oralair Adult Sample Kit 232 Omnitrope 195 Oralair Adult Starter Pack 232 On Call Express Blood Glucose 263 Orap 77 On Call Plus Blood Glucose 263 Orapred ODT 191 On Call Vivid Blood Glucose 263 Oravig 53 ONABOTULINUMTOXINA 81 Orencia 224,225 Ondansetron 50 Orencia ClickJect 225 ONDANSETRON 50 Orenitram 291 ONDANSETRON HCL 50 Orfadin 179 One Drop Test 263 Orgovyx 219 OneTouch Test 263 Oriahnn 195 OneTouch Ultra 264 Orilissa 219 OneTouch Verio 264 ORITAVANCIN DIPHOSPHATE 23 Onfi 36 Orkambi 289 Ongentys 74 Orladeyo 221 Onglyza 97 ORPHENADRINE CITRATE 298 Onmel 52 Ortho Micronor 214 Onureg 62 Ortho Tri-Cyclen (28) 208 Opana 16 Ortho Tri-Cyclen Lo 208 Opana ER 11 Ortho-Cyclen (28) 208 OPICAPONE 74 Ortho-Novum 1/35 (28) 208 OPIUM TINCTURE 172 Ortho-Novum 7/7/7 (28) 208 Opsumit 291 OrthoVisc 265 OptiChamber Advantage 264 OSELTAMIVIR PHOSPHATE 91

©2021 Wellmark, Inc. 339 Oseni 98 Palforzia (200 MG Daily Dose) 232 OSILODROSTAT PHOSPHATE 189 Palforzia (240 MG Daily Dose) 232 OSIMERTINIB MESYLATE 69 Palforzia (3 MG Daily Dose) 233 OsmoPrep 175 Palforzia (300 MG Maintenance) 233 OSPEMIFENE 214 Palforzia (300 MG Titration) 233 Osphena 214 Palforzia (40 MG Daily Dose) 233 Otezla 232 Palforzia (6 MG Daily Dose) 233 Otrexup 225 Palforzia (80 MG Daily Dose) 233 Ovide 73 Palforzia Initial Escalation 233 Oxandrin 196 PALIPERIDONE 78,79 OXANDROLONE 196 PALIVIZUMAB 233 OXAPROZIN 5,7 Palynziq 179 OXAZEPAM 93 Pamelor 48 Oxbryta 118 Pamine Forte 171 OXCARBAZEPINE 40,41 Pancreaze 179 Oxervate 274 PANCRELIPASE (LIPASE-PROTEASE- Oxlumo 179 AMYLASE) 178,179,180 Oxsoralen Ultra 156 Panda Mask Large 265 Oxtellar XR 41 Panda Mask Medium 265 OXYBUTYNIN CHLORIDE 181 Panda Mask Small 265 OXYCODONE HCL 11,12,16,17 PANOBINOSTAT LACTATE 66 OxyCODONE HCl ER 11 Panretin 71 OXYCODONE W/ ACETAMINOPHEN 14,17 PANTOPRAZOLE SODIUM 177 Oxycodone-Acetaminophen 17 Panzyga 230 OXYCODONE-ASPIRIN 17 Parafon Forte DSC 298 OXYCODONE-IBUPROFEN 17 Paragard Intrauterine Copper 265 Oxycodone-Ibuprofen 17 PARATHYROID HORMONE (RECOMBINANT) 242 OxyCONTIN 12 PAREGORIC 172 OXYMETHOLONE 196 Paregoric 172 OXYMORPHONE HCL 11,12,16,17 PARICALCITOL 242,243 OxyMORphone HCl ER 12 Parlodel 75 OZANIMOD HCL 152 Parnate 44 Ozempic (0.25 or 0.5 MG/DOSE) 98 PAROMOMYCIN SULFATE 21 Ozempic (1 MG/DOSE) 98 PAROXETINE HCL 46 Paroxetine HCl 46 P PAROXETINE MESYLATE 46 PALBOCICLIB 66 PAROXETINE MESYLATE (VASOMOTOR) 45,46 Palforzia (12 MG Daily Dose) 232 Paser 58 Palforzia (120 MG Daily Dose) 232 PASIREOTIDE DIASPARTATE 219 Palforzia (160 MG Daily Dose) 232 Patanase 285 Palforzia (20 MG Daily Dose) 232 PATIROMER SORBITEX CALCIUM 164

©2021 Wellmark, Inc. 340 Paxil 46 Pennsaid 7 Paxil CR 46 Pentacel 237 PAZOPANIB HCL 70 PENTAMIDINE ISETHIONATE 72 PEANUT (ARACHIS HYPOGAEA) ALLERGEN Pentasa 240 POWDER-DNFP 232,233 PENTAZOCINE W/ NALOXONE 17 Pediapred 191 PENTOSAN POLYSULFATE SODIUM 183 Pediarix 237 PENTOXIFYLLINE 134 Pediatric Panda Mask 265 Pepaxto 302 Pedvax HIB 237 Pepcid 173 PEG 3350-KCL-NACL-NA SULFATE-NA PERAMPANEL 38 ASCORBATE-ASCORBIC ACID 175 Percocet 17 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD Perforomist 287 SULFATE 174,175 Peridex 152 PEG 3350-POTASSIUM CHLORIDE-SOD PERINDOPRIL ARGININE-AMLODIPINE BICARBONATE-SOD CHLORIDE 174,175,176 BESYLATE 134 PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod PERINDOPRIL ERBUMINE 121 Chloride 175 Permethrin 73 Peg-Intron Redipen 84 PERMETHRIN 73 Peganone 41 PERPHENAZINE 48 Pegasys 84 PERPHENAZINE-AMITRIPTYLINE 44 Pegasys ProClick 84 Perphenazine-Amitriptyline 44 PEGCETACOPLAN 301 PERTUZUMAB-TRASTUZUMAB-HYALURONIDASE- PEGFILGRASTIM 110 ZZXF 62 PEGFILGRASTIM-APGF 111 Pertzye 179 PEGFILGRASTIM-BMEZ 112 Pexeva 46 PEGFILGRASTIM-CBQV 112 PEXIDARTINIB HCL 63 PEGFILGRASTIM-JMDB 110 Pfizer-BioNTech COVID-19 Vacc 237 PEGINTERFERON ALFA-2A 84 Pharmacist Choice Autocode 266 PEGINTERFERON ALFA-2B 84 Pharmacist Choice No Coding 266 PEGINTERFERON ALFA-2B (ANTINEOPLASTIC) 63 PHENAZOPYRIDINE HCL 184 PEGINTERFERON BETA-1A 151 Phenazopyridine HCl 184 PegIntron 84 PHENELZINE SULFATE 44 PEGVALIASE-PQPZ 179 PHENOBARBITAL 37 PEGVISOMANT 220 PHENOBARBITAL-HYOSCYAMINE-ATROPINE- Pemazyre 62 SCOPOLAMINE 170 PEMIGATINIB 62 PHENOXYBENZAMINE HCL 119 PENCICLOVIR 91 PHENYLEPHRINE HCL (MYDRIATIC) 274 PENICILLAMINE 183,184 PHENYLEPHRINE HCL (OPHTH) 272 PENICILLIN G BENZATHINE 28 PHENYLEPHRINE W/ DM-GG 294 PENICILLIN V POTASSIUM 29 PHENYLEPHRINE-CHLORPHEN-DM 295 Penlac 53 Phenylephrine-Chlorpheniramine-Carbetapentane 293

©2021 Wellmark, Inc. 341 Phenylephrine-Guaifenesin 295 PNV Prenatal Plus Multivit+DHA 166 Phenytek 41 PNV Tabs 29-1 166 PHENYTOIN 40,41 PNV-VP-U 166 PHENYTOIN SODIUM EXTENDED 40,41 Pocket Chamber 266 Phesgo 62 PocketChem EZ Test 266 Phoslyra 163 Podocon 157 Phospholine Iodide 280 PODOFILOX 154,157 PHYTONADIONE 118 PODOPHYLLUM RESIN 157 Picato 156 POLATUZUMAB VEDOTIN-PIIQ 71 Pifeltro 86 POLIOVIRUS VACCINE, IPV 236 PILOCARPINE HCL 279,280 Polivy 71 PILOCARPINE HCL (ORAL) 152 POLYMYXIN B-TRIMETHOPRIM 274 PIMAVANSERIN TARTRATE 79 Polytrim 274 PIMECROLIMUS 155,157 POMALIDOMIDE 60 PIMOZIDE 77,78 Pomalyst 60 Pimozide 78 PONATINIB HCL 67 PINDOLOL 124 PONESIMOD 302 PIOGLITAZONE HCL 94,98 Ponstel 7 PIOGLITAZONE HCL-GLIMEPIRIDE 95,98 Ponvory 302 PIOGLITAZONE HCL-METFORMIN HCL 94,98 Ponvory Starter Pack 302 Piqray (200 MG Daily Dose) 65 POSACONAZOLE 52,53 Piqray (250 MG Daily Dose) 65 POT & SOD CITRATES W/CITRIC AC 184,185 Piqray (300 MG Daily Dose) 65 Pot Bicarb-Pot Chloride 161 PIRFENIDONE 292 POT PHOSPHATE MONOBASIC W/ SOD PIROXICAM 6,7 PHOSPHATE DIBASIC & MONOBASIC 163,164 PITAVASTATIN CALCIUM 139 POTASSIUM & SODIUM ACID PHOSPHATES 183 PITAVASTATIN MAGNESIUM 139 POTASSIUM BICARB & CHLORIDE 160,161 PITOLISANT HCL 300 POTASSIUM BICARBONATE-CITRIC ACID 160 Plaquenil 72 POTASSIUM CHLORIDE 160,161 Plavix 118 POTASSIUM CHLORIDE MICROENCAPSULATED PLECANATIDE 174 CRYSTALS ER 160,161 Plegridy 151 POTASSIUM CITRATE (ALKALINIZER) 184,185 Plegridy Starter Pack 151 POTASSIUM CITRATE-CITRIC ACID 183,184,185 Plenvu 175 POTASSIUM IODIDE (EXPECTORANT) 220 PLERIXAFOR 110 POTASSIUM PHOSPHATE MONOBASIC 160 PNEUMOCOCCAL 13-VALENT CONJUGATE POVIDONE-IODINE (OPHTH) 273 VACCINE 238 PR Natal 400 166 PNEUMOCOCCAL 20-VALENT CONJUGATE PR Natal 400 ec 166 VACCINE 302 PR Natal 430 166 PNEUMOCOCCAL VAC POLYVALENT 237 PR Natal 430 ec 166 Pneumovax 23 237 Pradaxa 108

©2021 Wellmark, Inc. 342 PRALSETINIB 64 PREGABALIN (ONCE-DAILY) 36,37 Praluent 140 Premarin 209 PRAMIPEXOLE DIHYDROCHLORIDE 75,76 Premium Blood Glucose Test 266 PRAMLINTIDE ACETATE 99 Premphase 209 Pramosone 191 Prempro 209 Pramosone E 191 Prenaissance Next 167 PRAMOXINE-HC 188,189,190,191 PreNata 167 PRAMOXINE-HC EMOLLIENT BASE 191 Prenatabs FA 167 Prandin 98 Prenatabs Rx 167 PRASUGREL HCL 118 Prenatal 19 167 Pravachol 139 PRENATAL MV & MIN W/FE BISGLYC-FE PROT PRAVASTATIN SODIUM 139 SUCC-FA-CA-OMEGA 3 165,166,168 PRAZIQUANTEL 71,72 Prenatal Plus Iron 167 PRAZOSIN HCL 119 PRENATAL VIT W/ DOCUSATE-FE FUMARATE- Precision PCx 266 FOLIC ACID 165,167,168 Precision PCX Plus Test 266 PRENATAL VIT W/ DOCUSATE-IRON CARBONYL- Precision Point of Care Test 266 FOLIC ACID 164,165,166,168,169 Precision QID Test 266 Prenatal Vit w/ Docusate-Iron Carbonyl-Folic Acid 165 Precision Xtra Blood Glucose 266 PRENATAL VIT W/ FE BISGLYCINATE CHELATE- Precision Xtra Ketone 266 FOLIC ACID 164 Precose 98 Prenatal Vit w/ Fe Bisglycinate Chelate-Folic Pred Forte 278 Acid 168,169 Pred Mild 278 PRENATAL VIT W/ FE POLY CMPLX-FE HEME Pred-G 275 POLYPEPT-FA & OMEGA 3 165,170 Pred-G S.O.P. 275 PRENATAL VIT W/ FERROUS FUMARATE-FA- PREDNICARBATE 187,191 OMEGA 3 FATTY ACIDS 166 Prednicarbate 191 PRENATAL VIT W/ FERROUS FUMARATE-FOLIC Prednisolon-Moxiflox-Bromfenac 275 ACID 165,166,167,168,169 Prednisolon-Moxiflox-Ketorolac 275 PRENATAL VIT W/ FERROUS FUMARATE-L PREDNISOLONE 190,191 METHYLFOLATE-FOLIC ACID 168 PREDNISOLONE ACETATE (OPHTH) 278 PRENATAL VIT W/ IRON CARBONYL-FE PREDNISOLONE SODIUM PHOSPHATE 191,192,193 GLUCONATE-FOLIC ACID 169 PrednisoLONE Sodium Phosphate 278 PRENATAL VIT W/ IRON CARBONYL-FOLIC PREDNISOLONE SODIUM PHOSPHATE ACID 166,167,168,169 (OPHTH) 278 PRENATAL VIT W/ SELENIUM-FE FUMARATE- PREDNISOLONE-MOXIFLOXACIN-BROMFENAC 275 FOLIC ACID 169 PREDNISOLONE-MOXIFLOXACIN-KETOROLAC 275 PRENATAL W/ CALCIUM CARBONATE-VIT B6-VIT PREDNISONE 187,192 B12-FOLIC ACID 164 PredniSONE Intensol 192 PRENATAL W/ CALCIUM-VIT B6-FOLIC ACID- Prefest 209 GINGER 167,169 PREGABALIN 148

©2021 Wellmark, Inc. 343 PRENATAL W/FE CARBONYL-FA-DSS-OMEGA 3 Procardia XL 128 FATTY ACIDS 166 Procare Spacer/Adult Mask 267 PRENATAL WITHOUT A VIT W/ FE FUM-IRON Procare Spacer/Child Mask 267 POLYSACCH COMPLEX -FA 165,167,169 PROCHLORPERAZINE 48 Prenatal without A Vit w/ Fe Fumarate-Folic PROCHLORPERAZINE MALEATE 49 Acid 164,169 ProCort 157 PRENATAL WITHOUT A VIT W/ FE FUMARATE- Procrit 111 FOLIC ACID 166,167 Proctocort 241 PRENATAL WITHOUT VIT A W/ IRON CARBONYL- Proctofoam HC 157 FOLIC ACID & VIT B6 168 Procysbi 179 Prenatal-U 167 Prodigy No Coding Blood Gluc 267 Prepopik 175 Prodrin 267 Prestalia 134 Profilnine 117 PreTAB 167 Profilnine SD 117 PRETOMANID 58 PROGESTERONE 214 Pretomanid 58 PROGESTERONE (VAGINAL) 212 Prevacid 177 Proglycem 101 Prevacid SoluTab 177 Prograf 225 Prevnar 13 238 Prolensa 278 Prevnar 20 302 Prolia 242 Prevpac 172 Promacta 111 Prevymis 82 PROMETHAZINE & PHENYLEPHRINE 295,296 Prezcobix 90 PROMETHAZINE HCL 48,49,285 Prezista 90 PROMETHAZINE W/CODEINE 295 Priftin 58 PROMETHAZINE-DM 295 PriLOSEC 177 PROMETHAZINE-PHENYLEPHRINE-CODEINE 295 PRIMAQUINE PHOSPHATE 73 Promethegan 49 PRIMIDONE 36,37 Prometrium 214 Primsol 24 PROPAFENONE HCL 123 Prinivil 121 PROPANTHELINE BROMIDE 171 Pristiq 46 Propantheline Bromide 171 Privigen 230 PROPARACAINE HCL 272,275 Pro Comfort Spacer Adult 266 PROPRANOLOL & HYDROCHLOROTHIAZIDE 134 Pro Comfort Spacer Child 267 PROPRANOLOL HCL 62,124,125 Pro Comfort Spacer Infant 267 Propranolol-HCTZ 134 Pro Voice V8/V9 Glucose 267 PROPYLTHIOURACIL 220 ProAir HFA 287 ProQuad 238 ProAir RespiClick 288 Proscar 182 PROBENECID 54 Protonix 177 PROCARBAZINE HCL 59 Protopic 157 Procardia 128 PROTRIPTYLINE HCL 48

©2021 Wellmark, Inc. 344 Proventil HFA 288 QuiNIDine Sulfate 123 Provera 214 QUININE SULFATE 73 Provida OB 167 Quintet AC Blood Glucose Test 267 Provigil 300 Quintet Blood Glucose Test 267 PROzac 46 Qvar 284 PRUCALOPRIDE SUCCINATE 172 Qvar RediHaler 284 PSEUDOEPH W/HYDROCODONE-GG 294 PSEUDOEPHED-BROMPHEN-DM 293,296 R PSEUDOEPHED-CPM W/ HYDROCOD 296,297 RA Alcohol Swabs 267 PSEUDOEPHEDRINE W/ DM-GG 296 RA TRUEtest Test 267 PSEUDOEPHEDRINE W/ HYDROCODONE 296 RABEPRAZOLE SODIUM 176,177 PTS Panels Ketone Test 267 RABEprazole Sodium 177 Pulmicort 283 Radicava 147 Pulmicort Flexhaler 283 Ragwitek 233 Pulmozyme 289 RALOXIFENE HCL 214 PureFe OB Plus 167 RALTEGRAVIR POTASSIUM 84 Purixan 61 RAMELTEON 300 PYRAZINAMIDE 58 RAMIPRIL 121,122 Pyridium 184 Ranexa 134 PYRIDOSTIGMINE BROMIDE 58 RANITIDINE HCL 173 PYRIMETHAMINE 72,73 RANOLAZINE 134 Rapaflo 182 Q Rapamune 225 Qbrelis 121 RASAGILINE MESYLATE 77 Qinlock 62 Rasuvo 225 Qnasl 284 Ravicti 180 Qnasl Childrens 284 RAVULIZUMAB-CWVZ 271 Quadracel 238 Rayaldee 242 Qualaquin 73 Razadyne 42 Quartette 209 Razadyne ER 42 Qudexy XR 38 Rebetol 84 Questran 140 Rebif 151 Questran Light 141 Rebif Rebidose 151 QUETIAPINE FUMARATE 79,80 Rebif Rebidose Titration Pack 151 QuilliChew ER 146 Rebif Titration Pack 151 Quillivant XR 146 Rebinyn 117 QUINAPRIL HCL 121 Reblozyl 111 Quinapril HCl 121 Reclast 243 QUINAPRIL-HYDROCHLOROTHIAZIDE 129,134 Recombinate 117 QUINIDINE GLUCONATE 123 Recombivax HB 238 QUINIDINE SULFATE 123 Rectiv 157

©2021 Wellmark, Inc. 345 RediTrex 226 Retacrit 111 RefuAH Plus Blood Glucose Test 268 RETAPAMULIN 21 Reglan 49 Retevmo 62 REGORAFENIB 69 Retin-A 157 Regranex 157 Retin-A Micro 157 Relenza Diskhaler 91 Retin-A Micro Pump 157 Relexxii 146 Retrovir 87 ReliOn Blood Glucose Test 268 Revatio 291 ReliOn Confirm/micro Test 268 Reveal Blood Glucose Test 268 ReliOn Ketone 268 REVEFENACIN 286 ReliOn Ketone Test 268 ReVia 19 ReliOn Premier Test 268 Revlimid 60 ReliOn Prime Test 268 Rexall Blood Glucose Test 268 ReliOn True Metrix Test Strips 268 Rexulti 79 ReliOn Ultima Test 268 Reyataz 90 Relistor 172,173 Reyvow 56 Relpax 55 Rezira 296 RELUGOLIX 219 Rezurock 302 RELUGOLIX-ESTRADIOL-NORETHINDRONE RHO D IMMUNE GLOBULIN (HUMAN) 229,230 ACETATE 194 RhoGAM Ultra-Filtered Plus 230 Remeron 44 Rhophylac 230 Remeron SolTab 44 Riabni 71 Remicade 226 RIBAVIRIN (HEPATITIS C) 84 Remodulin 291 RIBOCICLIB SUCCINATE 67 Renagel 164 RIBOCICLIB SUCCINATE-LETROZOLE 67,68 Renflexis 226 Ridaura 233 Renvela 164 RIFABUTIN 58 REPAGLINIDE 98 Rifadin 58 REPAGLINIDE-METFORMIN HCL 98 RIFAMPIN 58 Repaglinide-Metformin HCl 98 RIFAMYCIN SODIUM 21 Repatha 141 RIFAPENTINE 58 Repatha Pushtronex System 141 Rifater 59 Repatha SureClick 141 RIFAXIMIN 25 Requip 76 Rightest GS100 Blood Glucose 268 Requip XL 76 Rightest GS300 Blood Glucose 268 Rescon-Jr 296 Rightest GS550 Blood Glucose 269 Rescriptor 86 Rightest GT333 Blood Glucose 269 RESLIZUMAB 293 RILONACEPT 231 Restasis 275 RILPIVIRINE HCL 85 Restasis Multidose 275 Rilutek 148 Restoril 299 RILUZOLE 148

©2021 Wellmark, Inc. 346 RIMABOTULINUMTOXINB 298 ROTAVIRUS VACCINE, LIVE ORAL RiMANTAdine HCl 91 PENTAVALENT 238 RIMANTADINE HYDROCHLORIDE 91 ROTIGOTINE 75 RIMEGEPANT SULFATE 57 Roxicodone 17 Rinvoq 226 Rozerem 300 RIOCIGUAT 290 Rozlytrek 62 Riomet 98 Rubraca 63 Riomet ER 98 RUCAPARIB CAMSYLATE 63 RIPRETINIB 62 Ruconest 221 RISANKIZUMAB-RZAA 158,302 RUFINAMIDE 40,41 RISDIPLAM 147 Rukobia 89 RISEDRONATE SODIUM 241,243 RUXOLITINIB PHOSPHATE 67 RisperDAL 79 Ruzurgi 58 RisperDAL M-TAB 79 Rybelsus 98 RISPERIDONE 79,80 Rybrevant 302 Ritalin 146 Rydapt 63 Ritalin LA 146 Rylaze 302 RiteFlo 269 Rythmol SR 123 RITONAVIR 90 RITUXIMAB-ARRX 71 S RIVAROXABAN 109 Sabril 37 RIVASTIGMINE 42 SACROSIDASE 180 RIVASTIGMINE TARTRATE 42 SACUBITRIL-VALSARTAN 132 Rixubis 117 SAFINAMIDE MESYLATE 77 RIZATRIPTAN BENZOATE 55,56 Safyral 209 Robaxin 298 Saizen 195 Robaxin-750 298 Saizen Click.Easy 195 Robinul 171 Saizenprep 195 Robinul-Forte 171 Salagen 152 Rocaltrol 243 SALMETEROL XINAFOATE 288 ROFLUMILAST 290 SALSALATE 7 ROLAPITANT HCL 50 Samsca 162,163 ROMIPLOSTIM 111 Sancuso 50 ROMOSOZUMAB-AQQG 242 SandIMMUNE 226 ROPINIROLE HYDROCHLORIDE 76 SandoSTATIN 219 ROSIGLITAZONE MALEATE 95 SandoSTATIN LAR Depot 219 ROSIGLITAZONE MALEATE-METFORMIN HCL 94 Santyl 157 ROSUVASTATIN CALCIUM 138,139 Saphnelo 302 Rotarix 238 Saphris 80 RotaTeq 238 SAPROPTERIN DIHYDROCHLORIDE 178,180 ROTAVIRUS VACCINE, LIVE ORAL 238 SAQUINAVIR MESYLATE 90

©2021 Wellmark, Inc. 347 SARGRAMOSTIM 110 SEVELAMER HCL 164 SARILUMAB 231 Sevenfact 117 SATRALIZUMAB-MWGE 222 SfRowasa 240 Savaysa 109 Shingrix 238 Savella 149 SHORT RAGWEED POLLEN ALLERGEN Savella Titration Pack 149 EXTRACT 233 SAXAGLIPTIN HCL 97 Signifor 219 SAXAGLIPTIN-METFORMIN HCL 97 SILDENAFIL CITRATE 184,185 Scenesse 157 SILDENAFIL CITRATE (PULMONARY SCOPOLAMINE 49 HYPERTENSION) 291 Se-Natal 19 168 Silenor 300 Seasonique 209 Siliq 157 SECNIDAZOLE 24 SILODOSIN 182 SECOBARBITAL SODIUM 300 Silvadene 32 Seconal 300 SILVER SULFADIAZINE 32 SECUKINUMAB 154 Simbrinza 280 SEGESTERONE ACETATE-ETHINYL SIMEPREVIR SODIUM 83 ESTRADIOL 198 Simponi 226 Segluromet 99 Simponi Aria 226 SELEGILINE 44 SIMVASTATIN 139 SELEGILINE HCL 77 SINECATECHINS 159 SELENIUM SULFIDE 157 Sinemet 76 SELEXIPAG 292,303 Sinemet CR 77 SELINEXOR 63,64 Singulair 285 SELPERCATINIB 62 SIPONIMOD FUMARATE 150,151 SELUMETINIB SULFATE 68 SIROLIMUS 225,226 Selzentry 89 Sirturo 59 SEMAGLUTIDE 98 SITAGLIPTIN PHOSPHATE 97 Semglee 106 SITAGLIPTIN-METFORMIN HCL 97 Semprex-D 296 Sitavig 91 Sensipar 243 Sivextro 24 SERDEXMETHYLPHENIDATE CHLORIDE- Skelaxin 298 DEXMETHYLPHENIDATE HCL 301 Sklice 72 Serevent Diskus 288 Skyla 214 SEROquel 80 Skyrizi 302 SEROquel XR 80 Skyrizi (150 MG Dose) 158 Serostim 195 Slynd 214 SERTACONAZOLE NITRATE 51 SM Alcohol Prep 269 SERTRALINE HCL 47 Smart Sense Premium Test 269 SETMELANOTIDE ACETATE 172 Smart Sense Value Test 269 SEVELAMER CARBONATE 164 Smartest Blood Glucose Test 269

©2021 Wellmark, Inc. 348 Sodium Bicarbonate 161 SORAFENIB TOSYLATE 69 SODIUM CHLORIDE 161 Soriatane 158 SODIUM CHLORIDE (INHALANT) 295,296 Sorilux 158 SODIUM CHLORIDE FLUSH 159,161 SOTALOL HCL 122,123 SODIUM CITRATE & CITRIC ACID 184,185 SOTALOL HCL (AFIB/AFL) 122,123 Sodium Hyaluronate 269 SOTORASIB 302 SODIUM HYALURONATE Sotylize 123 (VISCOSUPPLEMENT) 155,253,257,259,269,270,272 Sovaldi 83 SODIUM OXYBATE 300 SPACER/AEROSOL-HOLDING CHAMBER SODIUM PHENYLBUTYRATE 177,180 SUPPLIES - MASKS 254,255,261,265 SODIUM PHOSPHATE MONOBASIC-SODIUM SPACER/AEROSOL-HOLDING PHOSPHATE DIBASIC 175 CHAMBERS 244,245,246,247,248,249,250,251,253,25 SODIUM PICOSULFATE-MAGNESIUM OXIDE- 4,260,261,262,264,265,266,267,269,271,272 ANHYDROUS CITRIC ACID 174,175 Spacer/Aerosol-Holding Chambers 260,264 SODIUM POLYSTYRENE SULFONATE 162,163 Spectracef 27 SODIUM SULFATE-MAGNESIUM SULFATE- SPINOSAD 73 POTASSIUM CHLORIDE 176 Spinosad 73 SODIUM SULFATE-POTASSIUM SULFATE- Spiriva HandiHaler 286 MAGNESIUM SULFATE 176 Spiriva Respimat 286 SODIUM ZIRCONIUM CYCLOSILICATE 160 SPIRONOLACTONE 137 SOFOSBUVIR 83 SPIRONOLACTONE & SOFOSBUVIR-VELPATASVIR 82,83 HYDROCHLOROTHIAZIDE 129,134 Sofosbuvir-Velpatasvir 83 Sporanox 53 SOFOSBUVIR-VELPATASVIR-VOXILAPREVIR 83 Sporanox Pulsepak 53 Solesta 269 Sprycel 69 SOLIFENACIN SUCCINATE 181,182 SPS 163 Soliris 269 SSKI 220 Solodyn 34 Stalevo 100 74 Solosec 24 Stalevo 125 74 Soltamox 61 Stalevo 150 74 Solu-CORTEF 192 Stalevo 200 74 SOLU-medrol 192 Stalevo 50 74 Solus V2 Test 269 Stalevo 75 74 Soma 298 Starlix 99 SOMATROPIN 194,195,196 STAVUDINE 87,88 SOMATROPIN (NON-REFRIGERATED) 195,196 Staxyn 184 Somatuline Depot 220 Steglatro 99 Somavert 220 Stelara 158 Sonata 299 Stendra 184 SONIDEGIB PHOSPHATE 69 Stimate 195 Soolantra 158 Stiolto Respimat 296

©2021 Wellmark, Inc. 349 STIRIPENTOL 34 SureChek Blood Glucose Test 270 Stivarga 69 SureStep Test 270 Strattera 146,147 Surmontil 48 Strensiq 180 Sustiva 86 Striant 197 Sutab 176 Stribild 85 Sutent 69 Striverdi Respimat 288 SUVOREXANT 299 Stromectol 72 Sylatron 63 Suboxone 20 Symax Duotab 171 Subsys 18 Symbicort 296 SUCCIMER 161 Symbyax 44 Sucraid 180 Symdeko 289 SUCRALFATE 176 Symfi 89 SUCROFERRIC OXYHYDROXIDE 164 Symfi Lo 89 Sular 128 Symjepi 288 SULCONAZOLE NITRATE 51,53 SymlinPen 120 99 SULFACETAMIDE SOD-PREDNISOLONE 273,275 SymlinPen 60 99 SULFACETAMIDE SODIUM (ACNE) 32 Symtuza 85 SULFACETAMIDE SODIUM (OPHTH) 32 Synagis 233 SULFACETAMIDE SODIUM-SULFUR IN UREA Synalar 192 VEHICLE 158 Synalgos-DC 18 Sulfacetamide-Sulfur in Urea 158 Synjardy 99 SULFADIAZINE 32 Synjardy XR 99 SulfADIAZINE 32 Synribo 63 SULFAMETHOXAZOLE-TRIMETHOPRIM 32 Synthroid 216 Sulfamylon 24 Synvisc 270 SULFANILAMIDE VAGINAL 32 Synvisc One 270 SULFASALAZINE 241 Syprine 163 SULFURIC ACID-SULFONATED PHENOLICS 152 SULINDAC 7 T SUMATRIPTAN 55,56 Tabloid 61 Sumatriptan Succinate 54 Tabrecta 63 SUMATRIPTAN SUCCINATE 55,56 Taclonex 158 SUMATRIPTAN-NAPROXEN SODIUM 56 TACROLIMUS 221,222,225,226 Sumavel DosePro 56 TACROLIMUS (TOPICAL) 157,158 SUNITINIB MALATE 69 TADALAFIL 182,183 Supartz FX 269 TADALAFIL (PULMONARY HYPERTENSION)290,291 Suprax 27 TAFAMIDIS 136 Suprep Bowel Prep Kit 176 TAFAMIDIS MEGLUMINE (CARDIAC) 136 Sure Edge Test 269 TAFASITAMAB-CXIX 71 Sure-Test EasyPlus Mini Test 270 Tafinlar 69

©2021 Wellmark, Inc. 350 TAFLUPROST 281 TELMISARTAN-HYDROCHLOROTHIAZIDE 133,135 Tagrisso 69 TEMAZEPAM 299 Takhzyro 221 Temixys 87 TALAZOPARIB TOSYLATE 69 Temodar 59 TALIGLUCERASE ALFA 178 Temovate 192 Taltz 158 Temovate E 192 Talzenna 69 TEMOZOLOMIDE 59 Tamiflu 91 Tencon 148 TAMOXIFEN CITRATE 61 Tenivac 238 TAMSULOSIN HCL 182,183 TENOFOVIR ALAFENAMIDE FUMARATE 82 Tanzeum 99 TENOFOVIR DISOPROXIL FUMARATE 87,88 Tapazole 220 Tenoretic 100 135 TAPENTADOL HCL 11,16 Tenoretic 50 135 Tarceva 69 Tenormin 125 Targretin 71 Tepezza 275 Tarka 134 Tepmetko 303 Taron-Bc 168 TEPOTINIB HCL 303 Tasigna 69 TEPROTUMUMAB-TRBW 275 TASIMELTEON 300,301 Terazol 7 53 Tasmar 74 TERAZOSIN HCL 120 Tavalisse 111 TERBINAFINE HCL 52,53 Taytulla 210 TERBUTALINE SULFATE 288 TAZAROTENE 158 TERCONAZOLE VAGINAL 53 TAZEMETOSTAT HBR 63 TERIFLUNOMIDE 149 Tazorac 158 TERIPARATIDE (RECOMBINANT) 242,243 Tazverik 63 Teriparatide (Recombinant) 243 TBO-FILGRASTIM 110 Tessalon Perles 296 TDVAX 238 Testim 197 Tecartus 63 TESTOSTERONE 196,197 Tecfidera 151 TESTOSTERONE CYPIONATE 197 Technivie 83 TESTOSTERONE ENANTHATE 197 TEDIZOLID PHOSPHATE 24 Testred 197 TEDUGLUTIDE (RDNA) 172 TETANUS TOXOID-DIPHTHERIA-ACELLULAR TEGretol 41 PERTUSSIS ADSORB (TDAP) 234 TEGretol-XR 41 TETANUS-DIPHTHERIA TOXOIDS (TD) 238 Tegsedi 148 Tetanus-Diphtheria Toxoids Td 238 Tekturna 134 TETRABENAZINE 148 Tekturna HCT 135 TETRACAINE HCL (OPHTH) 272,275 Telcare Blood Glucose Test 270 TETRACYCLINE HCL 34 TELMISARTAN 120 Texacort 192 TELMISARTAN-AMLODIPINE 135 TEZACAFTOR-IVACAFTOR 289

©2021 Wellmark, Inc. 351 TGT Blood Glucose Test 270 Tirosint-SOL 217 THALIDOMIDE 60 Tivicay 85 Thalomid 60 Tivicay PD 85 THEOPHYLLINE 290 TIVOZANIB HCL 301 THIOGUANINE 61 TIZANIDINE HCL 81 Thiola 184 TL Folate 168 Thiola EC 184 Tobi 289 THIORIDAZINE HCL 78 Tobi Podhaler 289 THIOTHIXENE 78 TobraDex 275 Thrivite Rx 168 TobraDex ST 275 Thyquidity 216 TOBRAMYCIN 288,289 Thyrogen 270 TOBRAMYCIN (OPHTH) 21 THYROID 215,216,217,218 TOBRAMYCIN SULFATE 21 Thyrolar-1 216 TOBRAMYCIN-DEXAMETHASONE 275,276 Thyrolar-1/2 216 Tobrex 21 Thyrolar-1/4 216 TOCILIZUMAB 231 Thyrolar-2 217 TOFACITINIB CITRATE 227,303 Thyrolar-3 217 Tofranil 48 THYROTROPIN ALFA 270 TOLAZAMIDE 99 TIAGABINE HCL 36,37 TOLAZamide 99 Tiazac 128 TOLBUTAMIDE 99 Tibsovo 63 TOLBUTamide 99 TICAGRELOR 118 TOLCAPONE 74 Tigan 49 TOLMETIN SODIUM 7 Tikosyn 123 Tolmetin Sodium 7 TILDRAKIZUMAB-ASMN 155 TOLTERODINE TARTRATE 181 TIMOLOL 279 TOLVAPTAN 162,163 TIMOLOL MALEATE 125 Topamax 39 TIMOLOL MALEATE (OPHTH) 280 Topamax Sprinkle 39 Timoptic 280 Topicort 193 Timoptic Ocudose 280 Topicort Spray 193 Timoptic-XE 280 TOPIRAMATE 38,39 TIMOTHY GRASS POLLEN ALLERGEN TOPOTECAN HCL 65 EXTRACT 231 Toprol XL 125 Tindamax 24 TOREMIFENE CITRATE 60,61 TINIDAZOLE 24 TORSEMIDE 136,137 TIOPRONIN 184 Toujeo Max SoloStar 106 TIOTROPIUM BROMIDE MONOHYDRATE 286 Toujeo SoloStar 106 TIOTROPIUM BROMIDE-OLODATEROL HCL 296 Toviaz 182 TIPRANAVIR 89 Tracleer 291,292 Tirosint 217 Tradjenta 99

©2021 Wellmark, Inc. 352 TRAMADOL HCL 8,12,18 TRIAMTERENE & TraMADol HCl ER 12 HYDROCHLOROTHIAZIDE 132,133,135 TRAMADOL-ACETAMINOPHEN 18 TRIAZOLAM 299 TRAMETINIB DIMETHYL SULFOXIDE 69 Tribenzor 135 Trandolapril 122 Tricor 138 TRANDOLAPRIL-VERAPAMIL HCL 134,135 Tridesilon 193 TRANEXAMIC ACID 116,117 TRIENTINE HCL 161,163 Transderm Scop (1.5 MG) 49 TRIFLUOPERAZINE HCL 78 Transderm-Scop (1.5 MG) 49 TRIFLURIDINE 91 Tranxene-T 93 TRIFLURIDINE-TIPIRACIL 62 TRANYLCYPROMINE SULFATE 44 TRIHEPTANOIN 160 TRASTUZUMAB 71 TRIHEXYPHENIDYL HCL 73 TRASTUZUMAB-ANNS 67 Trijardy XR 100 TRASTUZUMAB-DKST 69 Trikafta 289 TRASTUZUMAB-PKRB 71 TRILACICLIB DIHYDROCHLORIDE 301 TRASTUZUMAB-QYYP 70 Trileptal 41 Travatan Z 281 Trilipix 138 TRAVOPROST 281 Triluron 270 Trazimera 70 TRIMETHOBENZAMIDE HCL 49 Trazodone HCl 47 TRIMETHOPRIM 24 Trecator 59 TRIMETHOPRIM HCL 24 Trelegy Ellipta 284 TRIMIPRAMINE MALEATE 48 Trelstar Mixject 220 Trimpex 24 Tremfya 159 Trinatal GT 168 TREPROSTINIL 291,292 Trinatal Rx 1 168 TREPROSTINIL DIOLAMINE 291 Trinate 168 Tresiba 107 Trintellix 47 Tresiba FlexTouch 107 TRIPTORELIN PAMOATE 220 Tretin-X 159 Triumeq 89 TRETINOIN 153,157,159 Triveen-Duo DHA 168 TRETINOIN (CHEMOTHERAPY) 71 TriVisc 270 TRETINOIN MICROSPHERE 157,159 Trizivir 87 Trexall 226 Trokendi XR 39 Treximet 56 Tropicamide 274 Tri-Norinyl (28) 210 TROPICAMIDE 274,276 TriAdvance 168 TROSPIUM CHLORIDE 182 TRIAMCINOLONE ACETONIDE 189,193 True Focus Blood Glucose Strip 270 TRIAMCINOLONE ACETONIDE (MOUTH) 152 True Metrix Blood Glucose Test 270 TRIAMCINOLONE ACETONIDE (TOPICAL) 189,193 True Metrix Pro Blood Glucose 270 TRIAMTERENE 137 TRUEtest Test 271 TrueTrack Test 271

©2021 Wellmark, Inc. 353 Trulance 174 Ultomiris 271 Trulicity 100 Ultracet 18 Trumenba 238 Ultram 18 Truseltiq (100MG Daily Dose) 303 UltraTRAK PRO Test 271 Truseltiq (125MG Daily Dose) 303 UltraTRAK Ultimate Test 271 Truseltiq (50MG Daily Dose) 303 Ultravate 193 Truseltiq (75MG Daily Dose) 303 UMBRALISIB TOSYLATE 303 Trusopt 280 UMECLIDINIUM-VILANTEROL 293 Truvada 87 Unistrip1 Generic 271 TUCATINIB 70 UPADACITINIB 226 Tudorza Pressair 286 Uplizna 226 Tukysa 70 Uptravi 292,303 Turalio 63 Uramaxin 159 Tusnel 296 UREA 159 TussiCaps 296 Urecholine 185 Tussionex Pennkinetic ER 297 Urex 25 Tuzistra XR 297 URIDINE TRIACETATE (EMERGENCY Twinrix 239 TREATMENT) 272 Twirla 211 Urimar-T 25 Twynsta 135 URINE GLUCOSE-KETONES TEST 249,250,260 Tyblume 211 Uristix 271 Tybost 89 Uristix 4 271 Tykerb 70 Urocit-K 10 185 Tylenol with Codeine #3 18 Urocit-K 15 185 Tylenol with Codeine #4 18 Urocit-K 5 185 Tymlos 243 Urogesic-Blue 25 Tysabri 151 Uroxatral 183 Tyvaso 292 Urso 250 173 Tyvaso Refill 292 Urso Forte 173 Tyvaso Starter 292 URSODIOL 171,173 USTEKINUMAB 158 U USTEKINUMAB (IV) 158 Ubrelvy 57 UBROGEPANT 57 V Uceris 241 Vagifem 211 Udenyca 112 VALACYCLOVIR HCL 91 Ukoniq 303 VALBENAZINE TOSYLATE 147 Ulesfia 73 Valchlor 59 ULIPRISTAL ACETATE 212 Valcyte 82 Uloric 54 VALGANCICLOVIR HCL 82 Ultima Test 271 Valium 93

©2021 Wellmark, Inc. 354 VALPROATE SODIUM 35,37 Ventavis 292 VALSARTAN 120 Ventolin HFA 288 VALSARTAN-HYDROCHLOROTHIAZIDE 131,135 VERAPAMIL HCL 125,128,129 Valtoco 10 MG Dose 37 Verapamil HCl 127 Valtoco 15 MG Dose 37 Verapamil HCl ER 129 Valtoco 20 MG Dose 37 Verasens Blood Glucose Test 271 Valtoco 5 MG Dose 37 Verdeso 193 Valtrex 91 Verdrocet 18 Valved Holding Chamber 271 Veregen 159 Vancocin 25 Verelan 129 Vancocin HCl 25 Verelan PM 129 VANCOMYCIN HCL 23,25 VERICIGUAT 136 Vancomycin HCl 25 Veripred 20 193 VANDETANIB 65 Verquvo 136 Vanos 193 Versacloz 81 Vaqta 239 VERTEPORFIN 276 VARDENAFIL HCL 183,184,185 Verzenio 70 VARICELLA VIRUS VACCINE LIVE 239 VESIcare 182 VARICELLA-ZOSTER IMMUNE GLOBULIN VESIcare LS 182 (HUMAN) 230 Vfend 53 Varivax 239 Vfend IV 53 VariZIG 230 Viagra 185 Varubi (180 MG Dose) 50 Viberzi 174 Vascepa 141 Vibramycin 34 Vaseretic 135 Victory AGM-4000 Test 271 Vasotec 122 Victoza 100 Vaxelis 239 Videx 87 Vectical 159 Videx EC 88 VEDOLIZUMAB 222 Viekira Pak 83 VELAGLUCERASE ALFA 180 Viekira XR 83 Veletri 292 VIGABATRIN 37 Velphoro 164 Vigamox 32 Veltassa 164 Viibryd 47 Veltin 159 Vil-Rx 168 Vemlidy 82 VILAZODONE HCL 47 VEMURAFENIB 70 Vimpat 41 Venclexta 70 Vinate AZ Extra 168 Venclexta Starting Pack 70 Vinate C 169 VENETOCLAX 70 Vinate Calcium 169 VENLAFAXINE HCL 45,47 Vinate IC 169 Venlafaxine HCl 47 Vinate II 169

©2021 Wellmark, Inc. 355 Vinate M 169 Vumerity 152 Vinate One 169 Vumerity (Starter) 152 Viokace 180 Vusion 53 Viracept 90 Vyepti 57 Viramune 86 Vyndamax 136 Viramune XR 86 Vyndaqel 136 Viread 88 Vytorin 141 Viroptic 91 Vyvanse 144 Virt Nate 169 Virt-Advance 169 W Virt-Vite GT 169 Wakix 300 Visco-3 272 WARFARIN SODIUM 107,108 VISMODEGIB 66 Warfarin Sodium 109 Vistaril 285 Watchhaler 272 Vistogard 272 WaveSense Presto 272 Visudyne 276 Welchol 141 Vitrakvi 63 Welireg 303 Vituz 297 Wellbutrin SR 44 VivaGuard Ino Test Strips 272 Wellbutrin XL 44 Vivelle-Dot 211 Westcort 193 Vizimpro 63 Westhroid 217 Vocal Point Blood Glucose Test 272 Wilate 117 VOCLOSPORIN 224 WP Thyroid 218 Vogelxo 197 Vogelxo Pump 197 X Vol-Nate 169 Xadago 77 Vol-Tab Rx 169 Xalatan 281 VON WILLEBRAND FACTOR (RECOMBINANT) 117 Xalkori 70 Vonvendi 117 Xanax 93 VORICONAZOLE 53 Xanax XR 93 VORINOSTAT 64 Xarelto 109 Vortex Valved Holding Chamber 272 Xarelto Starter Pack 109 VORTIOXETINE HBR 47 Xatmep 227 Vosevi 83 Xcopri 39,40 VoSpire ER 288 Xcopri (250 MG Daily Dose) 39 Votrient 70 Xcopri (350 MG Daily Dose) 39 VOXELOTOR 118 Xeljanz 227,303 VP-GGR-B6 Prenatal 169 Xeljanz XR 227 VP-Heme OB + DHA 170 Xeloda 61 Vpriv 180 Xembify 230 Vraylar 80 Xenazine 148

©2021 Wellmark, Inc. 356 Xeomin 298 Zarontin 35 Xerese 91 Zarxio 112 Xgeva 243 Zavesca 180 Xifaxan 25 Zebeta 125 Xigduo XR 100 Zegalogue 303 Xiidra 276 Zejula 64 Xodol 18 Zelapar 77 Xofluza (40 MG Dose) 239 Zelboraf 70 Xofluza (80 MG Dose) 239 Zemplar 243 Xolair 297 Zenpep 180 Xopenex 288 Zenzedi 144 Xopenex Concentrate 288 Zepatier 83 Xopenex HFA 288 Zeposia 152 Xospata 63 Zeposia 7-Day Starter Pack 152 Xpovio (100 MG Once Weekly) 63 Zeposia Starter Kit 152 Xpovio (40 MG Once Weekly) 63 Zerit 88 Xpovio (40 MG Twice Weekly) 64 Zestoretic 136 Xpovio (60 MG Once Weekly) 64 Zestril 122 Xpovio (60 MG Twice Weekly) 64 Zetia 141 Xpovio (80 MG Once Weekly) 64 Zetonna 284 Xpovio (80 MG Twice Weekly) 64 Ziac 136 Xtandi 60,303 Ziagen 88 Xyntha 118 Ziana 159 Xyntha Solofuse 118 ZIDOVUDINE 87,88 Xyrem 300 Ziextenzo 112 Xywav 299 ZILEUTON 285 Zioptan 281 Y ZIPRASIDONE HCL 78,80 Yasmin 28 212 Zirgan 82 YAZ 212 Zithromax 30 Yonsa 60 Zithromax Tri-Pak 30 Yupelri 286 Zithromax Z-Pak 30 Zmax 30 Z Zocor 139 ZAFIRLUKAST 285 Zofran 50 ZALEPLON 299 Zofran ODT 50 Zamicet 19 Zohydro ER 12 Zanaflex 81 Zokinvy 180 ZANAMIVIR 91 ZOLEDRONIC ACID 243 Zantac 173 Zolinza 64 ZANUBRUTINIB 62 ZOLMITRIPTAN 56,57

©2021 Wellmark, Inc. 357 Zoloft 47 ZOLPIDEM TARTRATE 298,299 Zolpidem Tartrate 299 Zolpimist 299 Zomacton 196 Zomacton (for Zoma-Jet 10) 196 Zometa 243 Zomig 56,57 Zomig ZMT 57 Zonegran 35 ZONISAMIDE 35 Zorbtive 196 Zortress 227 ZOSTER VACCINE RECOMBINANT ADJUVANTED 238 Zovirax 92 Zubsolv 20 Zuplenz 50 Zurampic 54 Zutripro 297 Zyclara 159 Zyclara Pump 159 Zydelig 70 Zyflo 285 Zyflo CR 285 Zykadia 70 Zylet 276 Zyloprim 54 Zymaxid 32 Zynlonta 303 Zypitamag 139 ZyPREXA 80 ZyPREXA Zydis 80 Zytiga 60 Zyvox 25

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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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