National Direct Drug List

Drug list — Four Tier Drug Plan

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

If you are a current Anthem member with questions about your pharmacy benefits, we're here to help. Just call us at the Pharmacy Member Services number on your ID card.

Here are a few things to remember:

o You can view and search our current drug lists when you visit anthem.com/ca and choose Prescription Benefits. Please note: The formulary is subject to change and all previous versions of the formulary are no longer in effect.

o Additional tools and resources are available for current Anthem members to view the most up-to-date list of drugs for your plan - including drugs that have been added, generic drugs and more – by logging in at anthem.com/ca.

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

o You and your doctor can use this list as a guide to choose drugs that are best for you. Drugs that aren’t on this list may not be covered by your plan and may cost you more out of pocket. To help you see how the drug list works with your drug benefit, we've included some frequently asked questions (FAQ) in this document about how the list is set up and what to do if a drug you take isn't on it.

Last Updated: September 1, 2021 LG National Direct Drug List Four Tier

Table of Contents

INFORMATIONAL SECTION...... 4 *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 11 *ALLERGENIC EXTRACTS/BIOLOGICALS MISC* - BIOLOGICAL AGENTS...... 15 *AMEBICIDES* - DRUGS FOR INFECTIONS...... 19 *AMINOGLYCOSIDES* - DRUGS FOR INFECTIONS...... 19 *ANALGESICS - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER...... 19 *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER...... 22 *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER...... 25 *ANDROGENS-ANABOLIC* - HORMONES...... 29 *ANORECTAL AND RELATED PRODUCTS* - RECTAL PREPARATIONS...... 30 *ANTACIDS* - DRUGS FOR THE STOMACH...... 30 *ANTHELMINTICS* - DRUGS FOR INFECTIONS...... 30 *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART...... 31 *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 31 *ANTIARRHYTHMICS* - DRUGS FOR THE HEART...... 32 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS...... 33 *ANTICOAGULANTS* - DRUGS FOR THE BLOOD...... 36 *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 38 *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 41 *ANTIDIABETICS* - HORMONES...... 44 *ANTIDIARRHEAL/PROBIOTIC AGENTS* - DRUGS FOR THE STOMACH...... 48 *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING...... 48 *ANTIEMETICS* - DRUGS FOR THE STOMACH...... 50 *ANTIFUNGALS* - DRUGS FOR INFECTIONS...... 51 *ANTIHISTAMINES* - DRUGS FOR THE LUNGS...... 52 *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART...... 53 *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART...... 55 *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS...... 59 *ANTIMALARIALS* - DRUGS FOR INFECTIONS...... 63 *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 63 *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS...... 63 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR CANCER...... 64 *ANTIPARKINSON AND RELATED THERAPY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 80 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 82 *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS...... 85 *ANTIVIRALS* - DRUGS FOR INFECTIONS...... 85 *BETA BLOCKERS* - DRUGS FOR THE HEART...... 91 *CALCIUM CHANNEL BLOCKERS* - DRUGS FOR THE HEART...... 92 *CARDIOTONICS* - DRUGS FOR THE HEART...... 94 *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART...... 95 *CEPHALOSPORINS* - DRUGS FOR INFECTIONS...... 97 *CONTRACEPTIVES* - DRUGS FOR WOMEN...... 99 *CORTICOSTEROIDS* - HORMONES...... 105 *COUGH/COLD/ALLERGY* - DRUGS FOR THE LUNGS...... 107 *DERMATOLOGICALS* - DRUGS FOR THE SKIN...... 109 *DIAGNOSTIC PRODUCTS*...... 120 *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH...... 120 *DIURETICS* - DRUGS FOR THE HEART...... 120 *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES...... 122 *ESTROGENS* - HORMONES...... 128 *FLUOROQUINOLONES* - DRUGS FOR INFECTIONS...... 129 *GASTROINTESTINAL AGENTS - MISC.* - DRUGS FOR THE STOMACH...... 130 *GENERAL ANESTHETICS* - DRUGS FOR PAIN AND FEVER...... 133 *GENITOURINARY AGENTS - MISCELLANEOUS* - DRUGS FOR THE URINARY SYSTEM...... 133 *GOUT AGENTS* - DRUGS FOR PAIN AND FEVER...... 135 *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD...... 135 *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION...... 140 *HEMOSTATICS* - DRUGS FOR THE BLOOD...... 143 TOC-2 *HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 144 *LAXATIVES* - DRUGS FOR THE STOMACH...... 146 *LOCAL ANESTHETICS-PARENTERAL* - DRUGS FOR PAIN AND FEVER...... 149 *MACROLIDES* - DRUGS FOR INFECTIONS...... 150 *MEDICAL DEVICES AND SUPPLIES* - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT...... 151 *MIGRAINE PRODUCTS* - DRUGS FOR THE NERVOUS SYSTEM...... 168 *MINERALS & ELECTROLYTES* - DRUGS FOR NUTRITION...... 169 *MISCELLANEOUS THERAPEUTIC CLASSES* - VITAMINS AND MINERALS...... 172 *MOUTH/THROAT/DENTAL AGENTS* - DRUGS FOR THE MOUTH AND THROAT...... 176 *MULTIVITAMINS* - DRUGS FOR NUTRITION...... 178 *MUSCULOSKELETAL THERAPY AGENTS* - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES...... 188 *NASAL AGENTS - SYSTEMIC AND TOPICAL* - DRUGS FOR THE NOSE...... 190 *NEUROMUSCULAR AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 191 *NUTRIENTS* - DRUGS FOR NUTRITION...... 192 *OPHTHALMIC AGENTS* - DRUGS FOR THE EYE...... 193 *OTIC AGENTS* - DRUGS FOR THE EAR...... 200 *OXYTOCICS* - HORMONES...... 201 *PASSIVE IMMUNIZING AND TREATMENT AGENTS* - BIOLOGICAL AGENTS...... 201 *PENICILLINS* - DRUGS FOR INFECTIONS...... 203 *PROGESTINS* - HORMONES...... 204 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* - DRUGS FOR THE NERVOUS SYSTEM...... 204 *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS...... 210 *SULFONAMIDES* - DRUGS FOR INFECTIONS...... 211 *TETRACYCLINES* - DRUGS FOR INFECTIONS...... 211 *THYROID AGENTS* - HORMONES...... 212 *TOXOIDS* - BIOLOGICAL AGENTS...... 213 *ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS* - DRUGS FOR THE STOMACH...... 214 *URINARY ANTISPASMODICS* - DRUGS FOR THE URINARY SYSTEM...... 216 *VACCINES* - BIOLOGICAL AGENTS...... 216 *VAGINAL AND RELATED PRODUCTS* - DRUGS FOR WOMEN...... 218 *VASOPRESSORS* - DRUGS FOR THE HEART...... 219 *VITAMINS* - DRUGS FOR NUTRITION...... 220

TOC-3 National Direct Drug List – Informational Section

Definitions

“$0” next to a drug means this is a preventive drug. For some members, this product may be covered at 100% with $0 cost share with a prescription from your provider if specified criteria are met.

“BRAND name drug” means a drug that is marketed under a proprietary, trademark-protected name. A BRAND name drug is listed in this formulary in all CAPITAL letters.

“Coinsurance” means a percentage of the cost of a covered health care benefit that you pay after you have paid the deductible, if a deductible applies to the health care benefit.

“Copayment” means a fixed dollar amount that you pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the health care benefit.

“Deductible” means the amount you pay for covered health care benefits that are subject to the deductible before your health insurer begins to pay. If your health insurance policy has a deductible, it may have either one deductible or separate deductibles for medical benefits and prescription drug benefits. After you pay your deductible, you usually pay only a copayment or coinsurance for covered health care benefits. Your insurance company pays the rest.

“Dose Optimization (DO)” means dose optimization. Usually, this means you may have to switch from taking a drug twice a day to taking it once a day at a higher strength.

“Drug Tier” means a group of prescription drugs that correspond to a specified cost sharing tier in your health insurance policy. The drug tier in which a prescription drug is placed determines your portion of the cost for the drug.

“Exigent circumstances” means when you are suffering from a medical condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug.

“Formulary” or “prescription drug list” means the list of drugs that is covered by your health insurance policy under the prescription drug benefit of the policy.

“Generic drug” means a drug that is the same as its BRAND name drug equivalent in dosage, strength, effect, how it is taken, quality, safety, and intended use. A generic drug is listed in this formulary in italicized lowercase letters.

“Limited Distribution (LD)” means limited distribution. These drugs are available only through certain pharmacies or wholesalers, depending on what the manufacturer decides.

“Medically Necessary” means health care benefits needed to diagnose, treat, or prevent a medical condition or its symptoms and that meet accepted standards of medicine. Health insurance usually does not cover health care benefits that are not medically necessary.

“Non-formulary drug” means a prescription drug that is not listed on this formulary.

“Oral Chemotherapy (OC)” Notwithstanding any deductible, the total amount of copayments and coinsurance an insured is required to pay shall not exceed two hundred dollars ($200) for an individual prescription of up to a 30-day supply of a prescribed orally administered anticancer medication covered by the policy.

“Out-of-pocket costs” means your expenses for health care benefits that aren't reimbursed by your health insurance. Out-of- pocket costs include deductibles, copayments, and coinsurance for covered health care benefits, plus all costs for health care benefits that are not covered.

“Prescribing provider” means a health care provider who can write a prescription for a drug to diagnose, treat, or prevent a medical condition.

“Prescription” means an oral, written, or electronic order from a prescribing provider authorizing a prescription drug to be provided to a specific individual.

“Prescription drug” means a drug that by law requires a prescription.

“Prior Authorization (PA)” means a decision by your health insurer that a health care benefit is medically necessary for you. If a prescription drug is subject to prior authorization in this formulary, your prescribing provider must request approval from your health insurer to cover the drug before you fill your prescription. Your health insurer must grant a prior authorization request when it is medically necessary for you to take the drug.

“Quantity limit (QL)” means a restriction on the number of doses of a prescription drug covered by a health insurance product during a specific time period, or any other limitation on the quantity of a drug that is covered.

“Specialty Drugs (SP)” means specialty drugs. Specialty drugs are used to treat difficult, long-term conditions. You may need to get this drug through a specialty pharmacy.

“Step therapy (ST)” means a specific sequence in which prescription drugs for a particular medical condition must be tried. If a drug is subject to step therapy in this formulary, you may have to try one or more other drugs before your health insurance policy will cover that drug for your medical condition.

Frequently Asked Questions

How do I know what drugs are covered under my benefits? This is a complete listing of all the drugs on the drug list. But, it’s possible a drug(s) on this list may not be covered, depending on your plan’s design.

Your pharmacy benefit covers prescription drugs, including Specialty Drugs, that may be administered to you as part of a doctor’s visit, home care visit, or at an outpatient Facility when they are Covered Services. Benefits that are administered to you in your provider’s office are typically covered under your medical benefit. This may include Drugs for infusion therapy, chemotherapy, blood products, certain injectables and any drug that must be administered by a Provider.

How can I find a drug on the list? (A) A prescription drug may be located by looking up the therapeutic category and class to which the drug belongs or the BRAND name or generic name of the drug in the alphabetical index; and (B) If a generic equivalent for a BRAND name drug is not available on the market or is not covered, the drug will not be separately listed by its generic name.

You can search the PDF drug list by:

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

How are drugs shown on the list? o A drug is listed alphabetically by its BRAND name and generic names in the therapeutic category and class to which it belongs; o The generic name for a BRAND name drug is included after the BRAND name in parentheses and all lowercase italicized letters;

o If a generic equivalent for a BRAND name drug is both available and covered, the generic drug will be listed separately from the BRAND name drug in all lowercase italicized letters; and

o If a generic drug is marketed under a proprietary, trademark-protected BRAND name, the BRAND name will be listed after the generic name in parentheses and regular typeface with the first letter of each word capitalized.

The “Under Coverage Requirements and Limits” section will indicate if you need preapproval before you can take the drug (called prior authorization or PA), or if you need to try other drugs first for your treatment (called step therapy or ST).

Note: The presence of a prescription drug on the formulary does not guarantee that your doctor will prescribe that prescription drug for a particular medical condition.

What are my options for getting my prescriptions? You have plenty of choices about how and where to get your prescription medicines, including local pharmacies in your plan, convenient home delivery or specialty pharmacies. Most plans include our home delivery program at no extra cost to you.

Current Anthem members can find out more by logging in at anthem.com/ca and choose Prescription Benefits or call 833-236-6196. For more details about your coverage, you can call the phone number on your member ID card. What if my drug isn’t on the list? We understand that only you and your doctor know what is best for you. If you want to take a drug that’s not on the drug list, you may have to pay the full cost for it. You can also talk to your doctor or pharmacist to see if there’s another drug covered by your plan that will work just as well, or if generic or OTC drugs are an option. Only you and your doctor can decide what drugs are right for you.

If a drug you’re taking isn’t covered, your doctor can ask us to review the coverage. This process is called preapproval or prior authorization.

Your doctor can get the process started by completing an electronic Prior Authorization, calling the Pharmacy Member Services number on the back of your member ID card or by downloading a prior authorization form from our website and submitting it. If your request is approved, the amount you pay for the drug will depend on your plan’s benefit.

There are a few options for your doctor to start the Prior Authorization (PA) process: 1. Submit an electronic PA request by going to https://www.covermymeds.com/main/partners/anthem. 2. Log in at anthem.com/ca and choose Pharmacy. o Go to Pharmacy Resources and Search Your Drug List for your medication. o Choose the correct medication strength and form. o Scroll down to Definition of Restrictions and locate the applicable Fax Form in the table. o Your doctor completes and faxes the form to us at 844-474-3347. 3. Calling Pharmacy Member Services number on the back of your member ID card.

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

What is a specialty drug and how do I get them? If you’re taking a medicine that is considered a specialty drug, you may need to use a specialty pharmacy in order for your drug to be covered. Specialty drugs come in many forms like pills, liquids, injections (shots), infusions or inhalers and may need special storage and handling. Typically benefits for specialty drugs that are self-administered will be covered under the pharmacy benefit. Benefits for specialty drugs that are administered to you in your provider’s office are typically covered under your medical benefit. If you use pharmacies that are not in the network, your medicine may not be covered and you may have to pay the full cost. For more details about your coverage, you can call the phone number on your member ID card.

Does the drug list change, and how will I know if it does? Drugs on our list are reviewed and updated on a monthly basis. Sometimes, drugs are added, removed, change tiers or have updated requirements. The changes will usually go into effect the first day of the month. But don’t worry, we’ll let you know if a drug you take is taken off the list and, in some cases, if a drug you take is moved to a higher tier.

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

What kind of drugs can I find on the formulary? We cover FDA-approved preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA) and California state regulations. Your doctor may need to write a prescription for these preventive services to be covered by your plan, even if they are listed as over-the-counter. The availability or coverage of these medications without cost-sharing may be subject to criteria established by the health plan.

We cover FDA-approved equipment and supplies for the management and treatment of insulin-using diabetes, non-insulin-using diabetes and gestational diabetes as medically necessary. Medication encompasses insulin, insulin pumps, and oral hypoglycemic agents. Covered supplies and equipment are limited to glucose monitors, test strips, syringes and lancets. Covered benefits also include outpatient self-management and educational services used to treat diabetes if services are provided through a program authorized by the State's Diabetes Control Project within the Bureau of Health.

What drugs can I find in each tier? We place drugs on different tiers based on how well they work to improve health, whether there are over-the-counter (OTC) options and their costs compared to other drugs used for the same type of treatment. The lower the tier, the lower your share of the cost. Here’s a breakdown of the tiers in your plan:

o Tier 1 drugs have the lowest cost share for you. These are usually generic drugs that offer the best value compared to other drugs that treat the same conditions. Some plans split Tier 1 into Tier 1a and Tier 1b:

- Tier 1a drugs have the lowest cost share. These are often generic drugs that offer the greatest value compared to others that treat the same conditions. - Tier 1b drugs have a low cost share. These are typically generic drugs that offer the greatest value compared to others that treat the same conditions.

o Tier 2 drugs have a higher cost share than Tier 1. They may be preferred brand drugs, based on how well they work and their cost compared to other drugs used for the same type of treatment. Some are generic drugs that may cost more because they're newer to the market.

o Tier 3 drugs have a higher cost share. They often include brand and generic drugs that may cost more than drugs on lower tiers that are used to treat the same condition. Tier 3 may also include drugs recently approved by the FDA.

o Tier 4 drugs have the highest cost share and usually include specialty brand and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 4 may also include drugs recently approved by the FDA or specialty drugs used to treat serious, long-term health conditions and that may need special handling.

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

Note: For oral chemotherapy drugs - Notwithstanding any deductible, the total amount of copayments and coinsurance an insured is required to pay shall not exceed two hundred dollars ($200) for an individual prescription of up to a 30- day supply of a prescribed orally administered anticancer medication covered by the policy.

How does Anthem promote safety? When you go to a pharmacy, the pharmacist will get an electronic message from Anthem if a drug needs prior authorization, requires step therapy or has a limit on the amount that can be given. Here’s a closer look at all of the programs we’ve put into place to help make sure you get the care you need, while helping to keep you safe.1

Our clinical edit programs are:  Prior authorization, which requires you to get approval before taking a medicine. This helps make sure a drug is used properly and focuses on drugs that may have: — Risk of side effects. — Risk of harmful effects when taken with other drugs. — Potential for incorrect use or abuse. — Rules for use with certain conditions.  Step therapy, which requires that other drugs be tried first. It focuses on whether a drug is right for your condition.  Dose optimization, which involves changing from taking a dose twice a day to once a day, when medically appropriate. Taking fewer doses may lower your costs; a single higher dose of a drug taken once a day may cost less than a lower dose taken twice a day.  Quantity Limits impose a limit on the amount in a prescription and how often it can be refilled. — If a refill request is submitted too soon or the doctor prescribes an amount that's higher than what is allowed, the drug won't be covered at that time. — If there are medical reasons to prescribe the drug as originally dosed, the doctor can ask for review by our Prior Authorization Center.

Also, If you’re taking a medicine that is considered a specialty drug, you may need to use a specialty pharmacy in order for your drug to be covered. How does my doctor start the Prior Authorization process? If your drug is on our formulary but requires a PA or Step Therapy, there are a few options for your doctor to start the Prior Authorization (PA) process: 1. Submit an electronic PA request by going to https://www.covermymeds.com/main/partners/anthem. 2. Log in at anthem.com/ca and choose Pharmacy. o Go to Pharmacy Resources and Search Your Drug List for your medication. o Choose the correct medication strength and form. o Scroll down to Definition of Restrictions and locate the applicable Fax Form in the table. o Your doctor completes the form and faxes it to Anthem at 844-474-3347. 3. Calling Pharmacy Member Services number on the back of your member ID card.

What is Step Therapy? How does it work? Step therapy requires trying other drugs before certain medications may be covered. The pharmacy will let you know if step therapy is required and you must first try the drug or treatment included in the program. If the drug or treatment does not treat the condition well, the doctor can contact our Prior Authorization Center to ask that we approve the original drug.1

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

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

1 If the Prior Authorization Center concludes the prescription claim should be denied, members and their doctors will get letters that explain the appeals and/or grievance process.

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

Brand name drugs are in UPPER CASE, bold type.

Generic drugs are in lower case, plain type. $0 = preventive drugs. For some members, this Tier 1 = drugs have the lowest cost share for you. product may be covered at 100% with $0 cost share These are usually generic drugs that offer the best with a prescription from your provider if specified value compared to other drugs that treat the same criteria are met. conditions.

DO = dose optimization. Usually, this means you may Tier 1a = drugs have the lowest cost share. These are have to switch from taking a drug twice a day to taking often generic drugs that offer the greatest value it once a day at a higher strength. compared to others that treat the same conditions.

LD = limited distribution. These drugs are available Tier 1b = drugs have a low cost share. These are only through certain pharmacies or wholesalers, typically generic drugs that offer the greatest value depending on what the manufacturer decides. compared to others that treat the same conditions.

OC = oral chemotherapy. These drugs after deductible Tier 2 = drugs have a higher cost share than Tier 1. shall not exceed $200 per an individual prescription for They may be preferred brand drugs, based on how well up to a 30 day supply. they work and their cost compared to other drugs used for the same type of treatment. Some are generic PA = prior authorization. You may need to get benefits drugs that may cost more because they’re newer to the approved before certain prescriptions can be filled. market.

QL = quantity limits. There are limits on the amount of Tier 3 = drugs have a higher cost share. They often medicine covered within a certain amount of time. include brand and generic drugs that may cost more than drugs on lower tiers that are used to treat the SP = specialty drugs. Specialty drugs are used to treat same condition. difficult, long-term conditions. You may need to get this drug through a specialty pharmacy. Tier 4 = drugs have the highest cost share and usually include specialty brand and generic drugs. ST = step therapy. You may need to use another They may cost more than drugs on lower tiers that recommended drug first before a prescribed drug is are used to treat the same condition. covered.

Four Tier

CURRENT AS OF 9/1/2021

Coverage Requirements and Prescription Drug Name Drug Tier Limits *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* - DRUGS FOR THE NERVOUS SYSTEM *ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS*** - DRUGS FOR ATTENTION DEFICIT DISORDER clonidine hcl er oral tablet extended release 12 hour 1 or 1b* PA; QL (4 tablets per 1 day) guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg 1 or 1b* PA guanfacine hcl er oral tablet extended release 24 hour 3 mg, 4 mg 1 or 1b* PA; QL (1 tablet per 1 day) KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR (clonidine 3 PA; QL (4 tablets per 1 day) hcl) *ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR*** - DRUGS FOR ATTENTION DEFICIT DISORDER atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg 1 or 1b* PA atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg 1 or 1b* PA; QL (1 capsule per 1 day) *AMPHETAMINE MIXTURES*** - DRUGS FOR ATTENTION DEFICIT DISORDER amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 1 or 1b* PA 15 mg, 5 mg amphetamine-dextroamphet er oral capsule extended release 24 hour 20 mg, 1 or 1b* PA; QL (1 capsule per 1 day) 25 mg, 30 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 5 mg, 7.5 1 or 1b* PA mg amphetamine-dextroamphetamine oral tablet 20 mg 1 or 1b* PA; QL (3 tablets per 1 day) amphetamine-dextroamphetamine oral tablet 30 mg 1 or 1b* PA; QL (2 tablets per 1 day) MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 ST; QL (1 capsule per 1 day) (amphetamine-dextroamphetamine) *AMPHETAMINES*** - DRUGS FOR ATTENTION DEFICIT DISORDER ADZENYS ER ORAL SUSPENSION EXTENDED RELEASE 3 PA; QL (15 mL per 1 day) (amphetamine) ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE 3 ST; QL (1 tablet per 1 day) DISPERSIBLE (amphetamine) amphetamine er oral suspension extended release 1 or 1b* QL (15 mL per 1 day) amphetamine sulfate oral tablet 10 mg 1 or 1b* QL (6 tablets per 1 day) amphetamine sulfate oral tablet 5 mg 1 or 1b* dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 1 or 1b* PA; QL (4 capsules per 1 day) mg dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg 1 or 1b* PA dextroamphetamine sulfate oral solution 1 or 1b* PA; QL (60 mL per 1 day) dextroamphetamine sulfate oral tablet 10 mg 1 or 1b* PA; QL (6 tablets per 1 day) dextroamphetamine sulfate oral tablet 5 mg 1 or 1b* PA DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE 3 ST; QL (8 mL per 1 day) (amphetamine) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 11 Coverage Requirements and Prescription Drug Name Drug Tier Limits EVEKEO ODT ORAL TABLET DISPERSIBLE (amphetamine sulfate) 3 ST; QL (2 tablets per 1 day) procentra oral solution 1 or 1b* PA; QL (60 mL per 1 day) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG (lisdexamfetamine 2 PA dimesylate) VYVANSE ORAL CAPSULE 40 MG, 50 MG, 60 MG, 70 MG 2 PA; QL (1 capsule per 1 day) (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG 2 PA (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 40 MG, 50 MG, 60 MG 2 PA; QL (1 tablet per 1 day) (lisdexamfetamine dimesylate) zenzedi oral tablet 10 mg, 7.5 mg 1 or 1b* PA; QL (6 tablets per 1 day) zenzedi oral tablet 15 mg 1 or 1b* PA; QL (3 tablets per 1 day) zenzedi oral tablet 2.5 mg, 5 mg 1 or 1b* PA zenzedi oral tablet 20 mg, 30 mg 1 or 1b* PA; QL (2 tablets per 1 day) *ANALEPTICS*** - DRUGS FOR THE NERVOUS SYSTEM CAFCIT INTRAVENOUS SOLUTION (caffeine citrate) 3 caffeine citrate intravenous solution 1 or 1b* caffeine citrate oral solution 1 or 1b* DOPRAM INTRAVENOUS SOLUTION (doxapram hcl) 3 *ANOREXIANT COMBINATIONS*** - DRUGS FOR THE NERVOUS SYSTEM PLENITY ORAL CAPSULE (carboxymeth-cellulose-citricac) 3 PLENITY WELCOME KIT ORAL CAPSULE (carboxymeth-cellulose- 3 citricac) QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 PA (phentermine-topiramate) *ANOREXIANTS NON-AMPHETAMINE*** - DRUGS FOR THE NERVOUS SYSTEM ADIPEX-P ORAL CAPSULE (phentermine hcl) 3 PA ADIPEX-P ORAL TABLET (phentermine hcl) 3 PA benzphetamine hcl oral tablet 25 mg 1 or 1b* benzphetamine hcl oral tablet 50 mg 1 or 1b* PA diethylpropion hcl er oral tablet extended release 24 hour 1 or 1b* PA diethylpropion hcl oral tablet 1 or 1b* PA LOMAIRA ORAL TABLET (phentermine hcl) 3 PA phendimetrazine tartrate er oral capsule extended release 24 hour 1 or 1b* PA phendimetrazine tartrate oral tablet 1 or 1b* PA phentermine hcl oral capsule 1 or 1b* PA phentermine hcl oral tablet 1 or 1b* PA *ANTI-OBESITY - GLP-1 RECEPTOR AGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM SAXENDA SUBCUTANEOUS SOLUTION PEN-INJECTOR (liraglutide - 3 PA weight management)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 12 Coverage Requirements and Prescription Drug Name Drug Tier Limits WEGOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 PA (semaglutide-weight management) *ANTI-OBESITY AGENT COMBINATIONS** - DRUGS FOR THE NERVOUS SYSTEM CONTRAVE ORAL TABLET EXTENDED RELEASE 12 HOUR 3 PA (naltrexone-bupropion hcl) *DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)*** - DRUGS FOR SLEEP DISORDER SUNOSI ORAL TABLET 150 MG (solriamfetol hcl) 3 PA; QL (1 tablet per 1 day) SUNOSI ORAL TABLET 75 MG (solriamfetol hcl) 3 PA *HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS*** - DRUGS FOR SLEEP DISORDER PA; LD; SP; QL (2 tablets per 1 WAKIX ORAL TABLET 17.8 MG (pitolisant hcl) 4 day) WAKIX ORAL TABLET 4.45 MG (pitolisant hcl) 4 PA; LD; SP *LIPASE INHIBITORS*** - DRUGS FOR THE NERVOUS SYSTEM XENICAL ORAL CAPSULE (orlistat) 3 PA *MELANOCORTIN 4 (MC4) RECEPTOR AGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM IMCIVREE SUBCUTANEOUS SOLUTION (setmelanotide acetate) 4 PA; LD; QL (9 vials per 30 days) *STIMULANTS - MISC.*** - DRUGS FOR ATTENTION DEFICIT DISORDER ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 ST; QL (1 capsule per 1 day) (methylphenidate hcl) APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 3 ST MG, 15 MG, 20 MG, 30 MG (methylphenidate hcl) APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 3 ST; QL (1 capsule per 1 day) MG, 50 MG, 60 MG (methylphenidate hcl) armodafinil oral tablet 150 mg, 200 mg, 250 mg 1 or 1b* PA; QL (1 tablet per 1 day) armodafinil oral tablet 50 mg 1 or 1b* PA; QL (2 tablets per 1 day) COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE 3 ST; QL (2 tablets per 1 day) DISPERSIBLE (methylphenidate) DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR 3 ST (methylphenidate) DAYTRANA TRANSDERMAL PATCH 20 MG/9HR, 30 MG/9HR 3 ST; QL (1 patch per 1 day) (methylphenidate) dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 1 or 1b* PA mg, 20 mg, 5 mg dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 30 1 or 1b* PA; QL (1 capsule per 1 day) mg, 35 mg, 40 mg dexmethylphenidate hcl oral tablet 10 mg 1 or 1b* PA; QL (2 tablets per 1 day) dexmethylphenidate hcl oral tablet 2.5 mg, 5 mg 1 or 1b* PA FOCALIN ORAL TABLET 10 MG (dexmethylphenidate hcl) 3 PA; QL (2 tablets per 1 day) FOCALIN ORAL TABLET 2.5 MG, 5 MG (dexmethylphenidate hcl) 3 PA JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 3 ST; QL (1 capsule per 1 day) MG, 60 MG, 80 MG (methylphenidate hcl)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 13 Coverage Requirements and Prescription Drug Name Drug Tier Limits JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 3 ST MG, 40 MG (methylphenidate hcl) METHYLIN ORAL SOLUTION 10 MG/5ML (methylphenidate hcl) 3 ST; QL (30 mL per 1 day) METHYLIN ORAL SOLUTION 5 MG/5ML (methylphenidate hcl) 3 ST; QL (60 mL per 1 day) methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg 1 or 1b* PA methylphenidate hcl er (cd) oral capsule extended release 40 mg, 50 mg, 60 mg 1 or 1b* PA; QL (1 capsule per 1 day) methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 1 or 1b* PA mg methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg 1 or 1b* PA; QL (2 capsules per 1 day) methylphenidate hcl er (la) oral capsule extended release 24 hour 40 mg, 60 1 or 1b* PA; QL (1 capsule per 1 day) mg methylphenidate hcl er (xr) oral capsule extended release 24 hour 10 mg, 15 1 or 1b* PA mg, 20 mg, 30 mg methylphenidate hcl er (xr) oral capsule extended release 24 hour 40 mg, 50 1 or 1b* PA; QL (1 capsule per 1 day) mg, 60 mg methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 27 mg 1 or 1b* PA methylphenidate hcl er oral tablet extended release 20 mg 1 or 1b* PA; QL (3 tablets per 1 day) methylphenidate hcl er oral tablet extended release 24 hour 1 or 1b* PA methylphenidate hcl er oral tablet extended release 36 mg 1 or 1b* PA; QL (2 tablets per 1 day) methylphenidate hcl er oral tablet extended release 54 mg 1 or 1b* PA; QL (1 tablet per 1 day) METHYLPHENIDATE HCL ER ORAL TABLET EXTENDED 3 ST; QL (1 tablet per 1 day) RELEASE 72 MG methylphenidate hcl oral solution 10 mg/5ml 1 or 1b* PA; QL (30 mL per 1 day) methylphenidate hcl oral solution 5 mg/5ml 1 or 1b* PA; QL (60 mL per 1 day) methylphenidate hcl oral tablet 10 mg, 5 mg 1 or 1b* PA methylphenidate hcl oral tablet 20 mg 1 or 1b* PA; QL (3 tablets per 1 day) methylphenidate hcl oral tablet chewable 10 mg 1 or 1b* PA; QL (3 tablets per 1 day) methylphenidate hcl oral tablet chewable 2.5 mg 1 or 1b* ST methylphenidate hcl oral tablet chewable 5 mg 1 or 1b* PA modafinil oral tablet 100 mg 1 or 1b* PA modafinil oral tablet 200 mg 1 or 1b* PA; QL (1 tablet per 1 day) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED 3 ST RELEASE 20 MG (methylphenidate hcl) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED 3 ST; QL (2 tablets per 1 day) RELEASE 30 MG (methylphenidate hcl) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED 3 ST; QL (1 tablet per 1 day) RELEASE 40 MG (methylphenidate hcl) QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER 3 QL (12 mL per 1 day) (methylphenidate hcl) RELEXXII ORAL TABLET EXTENDED RELEASE (methylphenidate 3 ST; QL (1 tablet per 1 day) hcl) RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 3 PA MG, 20 MG (methylphenidate hcl) RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 30 3 PA; QL (2 capsules per 1 day) MG (methylphenidate hcl)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 14 Coverage Requirements and Prescription Drug Name Drug Tier Limits RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 3 PA; QL (1 capsule per 1 day) MG (methylphenidate hcl) RITALIN ORAL TABLET 10 MG, 5 MG (methylphenidate hcl) 3 PA RITALIN ORAL TABLET 20 MG (methylphenidate hcl) 3 PA; QL (3 tablets per 1 day) *ALLERGENIC EXTRACTS/BIOLOGICALS MISC* - BIOLOGICAL AGENTS *ALLERGENIC EXTRACTS*** - BIOLOGICAL AGENTS ACACIA SUBCUTANEOUS SOLUTION 3 ACREMONIUM SUBCUTANEOUS SOLUTION 3 ALDER SUBCUTANEOUS SOLUTION 3 ALTERNARIA SUBCUTANEOUS SOLUTION 3 AMERICAN BEECH SUBCUTANEOUS SOLUTION 3 AMERICAN COCKROACH SUBCUTANEOUS SOLUTION 3 AMERICAN ELM SUBCUTANEOUS SOLUTION 3 ARIZONA CYPRESS SUBCUTANEOUS SOLUTION 3 ASPERGILLUS FUMIGATUS INJECTION SOLUTION 3 AUREOBASIDIUM PULLULANS INJECTION SOLUTION 3 AUREOBASIDIUM SUBCUTANEOUS SOLUTION 3 AUSTRALIAN PINE SUBCUTANEOUS SOLUTION 3 BAHIA SUBCUTANEOUS SOLUTION 3 BALD CYPRESS SUBCUTANEOUS SOLUTION 3 BAYBERRY (WAX MYRTLE) SUBCUTANEOUS SOLUTION 3 BERMUDA GRASS INJECTION SOLUTION 3 BERMUDA GRASS SUBCUTANEOUS SOLUTION 3 BLACK WILLOW SUBCUTANEOUS SOLUTION 3 BOTRYTIS INJECTION SOLUTION 3 BOTRYTIS SUBCUTANEOUS SOLUTION 3 BROME SUBCUTANEOUS SOLUTION 3 CALIFORNIA PEPPER TREE SUBCUTANEOUS SOLUTION 3 CANDIDA ALBICANS EXTRACT INJECTION SOLUTION 3 CANDIDA ALBICANS EXTRACT SUBCUTANEOUS SOLUTION 3 CAT HAIR EXTRACT INJECTION SOLUTION 3 CAT HAIR EXTRACT SUBCUTANEOUS SOLUTION 3 CATTLE EPITHELIUM SUBCUTANEOUS SOLUTION 3 CEDAR ELM SUBCUTANEOUS SOLUTION 3 CLADOSPORIUM CLADOSPORIOIDES INJECTION SOLUTION 3 CLADOSPORIUM CLADOSPORIOIDES INTRADERMAL SOLUTION 3 CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS 3 SOLUTION CLADOSPORIUM SPHAEROSPERMUM SUBCUTANEOUS 3 SOLUTION COCKLEBUR SUBCUTANEOUS SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 15 Coverage Requirements and Prescription Drug Name Drug Tier Limits CORN POLLEN SUBCUTANEOUS SOLUTION 3 CURVULARIA SUBCUTANEOUS SOLUTION 3 DANDELION SUBCUTANEOUS SOLUTION 3 DOG EPITHELIUM SUBCUTANEOUS SOLUTION 3 DOG FENNEL SUBCUTANEOUS SOLUTION 3 DRECHSLERA SUBCUTANEOUS SOLUTION 3 EASTERN COTTONWOOD SUBCUTANEOUS SOLUTION 3 EPICOCCUM NIGRUM INJECTION SOLUTION 3 EPICOCCUM SUBCUTANEOUS SOLUTION 3 FIRE ANT SUBCUTANEOUS SOLUTION 3 FUSARIUM SUBCUTANEOUS SOLUTION 3 GERMAN COCKROACH SUBCUTANEOUS SOLUTION 3 GOLDENROD SUBCUTANEOUS SOLUTION 3 GRASS POLLEN(K-O-R-T-SWT VERN) INJECTION SOLUTION 3 GRASTEK SUBLINGUAL TABLET SUBLINGUAL (timothy grass pollen 3 PA; QL (1 tablet per 1 day) allergen) HACKBERRY SUBCUTANEOUS SOLUTION 3 HONEY BEE VENOM PROTEIN INJECTION SOLUTION 3 RECONSTITUTED (honey bee venom) HONEY BEE VENOM SUBCUTANEOUS SOLUTION 3 RECONSTITUTED HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 3 JOHNSON GRASS SUBCUTANEOUS SOLUTION 3 JUNE GRASS POLLEN STANDARDIZED SUBCUTANEOUS 3 SOLUTION KAPOK SUBCUTANEOUS SOLUTION 3 KOCHIA SUBCUTANEOUS SOLUTION 3 LENSCALE SUBCUTANEOUS SOLUTION 3 MEADOW FESCUE GRASS POLLEN SUBCUTANEOUS SOLUTION 3 MELALEUCA SUBCUTANEOUS SOLUTION 3 MESQUITE SUBCUTANEOUS SOLUTION 3 MITE (D. FARINAE) INJECTION SOLUTION 3 MITE (D. FARINAE) SUBCUTANEOUS SOLUTION 3 MITE (D. PTERONYSSINUS) INJECTION SOLUTION 3 MITE (D. PTERONYSSINUS) SUBCUTANEOUS SOLUTION 3 MIXED RAGWEED SUBCUTANEOUS SOLUTION 3 MIXED VESPID VENOM PROTEIN INJECTION SOLUTION 3 RECONSTITUTED MIXED VESPID VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED MOUNTAIN CEDAR SUBCUTANEOUS SOLUTION 3 MOUSE EPITHELIUM SUBCUTANEOUS SOLUTION 3 MUCOR INJECTION SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 16 Coverage Requirements and Prescription Drug Name Drug Tier Limits MUCOR INTRADERMAL SOLUTION 3 MUCOR SUBCUTANEOUS SOLUTION 3 MUGWORT SUBCUTANEOUS SOLUTION 3 OLIVE TREE SUBCUTANEOUS SOLUTION 3 ORCHARD GRASS POLLEN SUBCUTANEOUS SOLUTION 3 PALFORZIA (12 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (120 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (160 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (20 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (200 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (240 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (3 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (300 MG MAINTENANCE) ORAL PACKET (peanut PA; LD; SP; QL (1 packet per 1 4 powder-dnfp) day) PALFORZIA (300 MG TITRATION) ORAL PACKET (peanut powder- 4 PA; LD; SP; QL (1 kit per 1 fill) dnfp) PALFORZIA (40 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (6 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (80 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA INITIAL ESCALATION ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PENICILLIUM NOTATUM INJECTION SOLUTION 3 PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION 3 PERENNIAL RYE GRASS POLLEN INJECTION SOLUTION 3 PHOMA EXIGUA SUBCUTANEOUS SOLUTION 3 PRIVET SUBCUTANEOUS SOLUTION 3 QUEEN PALM SUBCUTANEOUS SOLUTION 3 RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 3 RAGWITEK SUBLINGUAL TABLET SUBLINGUAL (short ragweed 3 PA; QL (1 tablet per 1 day) pollen ext) RED MAPLE SUBCUTANEOUS SOLUTION 3 RED MULBERRY SUBCUTANEOUS SOLUTION 3 RED TOP GRASS POLLEN SUBCUTANEOUS SOLUTION 3 RHIZOPUS SUBCUTANEOUS SOLUTION 3 ROUGH MARSH ELDER SUBCUTANEOUS SOLUTION 3 RUSSIAN THISTLE SUBCUTANEOUS SOLUTION 3 SACCHAROMYCES CEREVISIAE INJECTION SOLUTION 3 SACCHAROMYCES CEREVISIAE SUBCUTANEOUS SOLUTION 3 SHAGBARK HICKORY SUBCUTANEOUS SOLUTION 3 SHEEP SORREL SUBCUTANEOUS SOLUTION 3 SHORT RAGWEED POLLEN EXT SUBCUTANEOUS SOLUTION 3 SPINY PIGWEED SUBCUTANEOUS SOLUTION 3 STEMPHYLIUM SUBCUTANEOUS SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 17 Coverage Requirements and Prescription Drug Name Drug Tier Limits SWEET GUM SUBCUTANEOUS SOLUTION 3 SWEET VERNAL GRASS POLLEN SUBCUTANEOUS SOLUTION 3 TALL RAGWEED SUBCUTANEOUS SOLUTION 3 TIMOTHY GRASS POLLEN ALLERGEN INJECTION SOLUTION 3 TIMOTHY GRASS POLLEN ALLERGEN SUBCUTANEOUS 3 SOLUTION TRICHOPHYTON MENTAGROPHYTES SUBCUTANEOUS 3 SOLUTION TRICHOPHYTON SUBCUTANEOUS SOLUTION 3 VENOMIL HONEY BEE VENOM INJECTION KIT (honey bee venom) 3 VENOMIL MIXED VESPID VENOM INJECTION SOLUTION 3 RECONSTITUTED (mixed vespid venom) VENOMIL WASP VENOM INJECTION KIT (wasp venom) 3 VENOMIL WHITE FACED HORNET INJECTION KIT (white faced 3 hornet venom) VENOMIL YELLOW HORNET VENOM INJECTION KIT (yellow 3 hornet venom) VENOMIL YELLOW JACKET VENOM INJECTION KIT (yellow jacket 3 venom) WASP VENOM PROTEIN INJECTION SOLUTION 3 RECONSTITUTED WASP VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED WESTERN JUNIPER SUBCUTANEOUS SOLUTION 3 WHITE BIRCH SUBCUTANEOUS SOLUTION 3 WHITE FACED HORNET VENOM SUBCUTANEOUS SOLUTION 3 RECONSTITUTED WHITE MULBERRY SUBCUTANEOUS SOLUTION 3 WHITE OAK SUBCUTANEOUS SOLUTION 3 WHITE PINE SUBCUTANEOUS SOLUTION 3 WHITE-FACED HORNET VENOM INJECTION SOLUTION 3 RECONSTITUTED (white faced hornet venom) YELLOW DOCK SUBCUTANEOUS SOLUTION 3 YELLOW HORNET VENOM PROTEIN INJECTION SOLUTION 3 RECONSTITUTED YELLOW HORNET VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED YELLOW JACKET VENOM PROTEIN INJECTION SOLUTION 3 RECONSTITUTED YELLOW JACKET VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED *MIXED ALLERGENIC EXTRACTS*** - BIOLOGICAL AGENTS DUST MITE MIXED ALLERGEN EXT INJECTION SOLUTION 3 DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS SOLUTION 3 MIXED ASPERGILLUS SUBCUTANEOUS SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 18 Coverage Requirements and Prescription Drug Name Drug Tier Limits MIXED FEATHERS SUBCUTANEOUS SOLUTION 3 ODACTRA SUBLINGUAL TABLET SUBLINGUAL (dust mite mixed 3 PA; QL (1 tablet per 1 day) allergen ext) ORALAIR SUBLINGUAL TABLET SUBLINGUAL (grass mix pollens 3 PA; LD; QL (1 tablet per 1 day) allergen ext) SORREL/DOCK MIX SUBCUTANEOUS SOLUTION 3 *AMEBICIDES* - DRUGS FOR INFECTIONS *AMEBICIDES*** - DRUGS FOR PARASITES SOLOSEC ORAL PACKET (secnidazole) 3 ST; QL (2 grams per 1 fill) *AMINOGLYCOSIDES* - DRUGS FOR INFECTIONS *AMINOGLYCOSIDES*** - ANTIBIOTICS amikacin sulfate injection solution 1 or 1b* ARIKAYCE INHALATION SUSPENSION (amikacin sulfate liposome) 4 PA; LD; QL (1 kit per 28 days) BETHKIS INHALATION NEBULIZATION SOLUTION (tobramycin) 4 LD; SP; QL (224 mL per 28 days) gentamicin in saline intravenous solution 1 or 1b* gentamicin sulfate injection solution 1 or 1b* HUMATIN ORAL CAPSULE (paromomycin sulfate) 3 neomycin sulfate oral tablet 1 or 1a* paromomycin sulfate oral capsule 1 or 1b* streptomycin sulfate intramuscular solution reconstituted 1 or 1b* LD; SP; QL (224 capsules per 28 TOBI PODHALER INHALATION CAPSULE (tobramycin) 4 days) tobramycin inhalation nebulization solution 300 mg/4ml 4 SP; QL (224 mL per 28 days) tobramycin inhalation nebulization solution 300 mg/5ml 4 SP; QL (9.4 mL per 1 day) tobramycin sulfate injection solution 1 or 1b* tobramycin sulfate injection solution reconstituted 1 or 1b* QL (30 vials per 30 days) ZEMDRI INTRAVENOUS SOLUTION (plazomicin sulfate) 3 *ANALGESICS - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER *ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS*** - ARTHRITIS AND PAIN DRUGS RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 PA; SP; QL (1 tablet per 1 day) (upadacitinib) XELJANZ ORAL SOLUTION (tofacitinib citrate) 4 PA; SP; QL (10 ML per 1 day) XELJANZ ORAL TABLET (tofacitinib citrate) 4 PA; SP; QL (2 tablets per 1 day) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 4 PA; SP; QL (1 tablet per 1 day) MG (tofacitinib citrate) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 22 4 PA; QL (1 tablet per 1 day) MG (tofacitinib citrate) *ANTIRHEUMATIC ANTIMETABOLITES*** - ARTHRITIS AND PAIN DRUGS OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QL (4 auto-injector per 28 4 (methotrexate (anti-rheumatic)) days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 19 Coverage Requirements and Prescription Drug Name Drug Tier Limits RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QL (4 auto-injector per 28 4 (methotrexate (anti-rheumatic)) days) REDITREX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; QL (4 auto-injector per 28 4 (methotrexate (anti-rheumatic)) days) *ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES*** - ARTHRITIS AND PAIN DRUGS HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS 4 PA; SP; QL (1 kit per 365 days) PREFILLED SYRINGE KIT (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML 4 PA; SP; QL (2 EA per 28 days) (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML 4 PA; SP; QL (2 pens per 28 days) (adalimumab) PA; SP; QL (2 kits per 28 days (QL HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML 4 exception needed for maintenance (adalimumab) therapys) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- 4 PA; SP; QL (1 kit per 365 days) INJECTOR KIT (adalimumab) HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PEN- 4 PA; SP; QL (1 kit per 365 days) INJECTOR KIT (adalimumab) HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN- 4 PA; SP; QL (1 kit per 365 days) INJECTOR KIT (adalimumab) HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PEN- 4 PA; SP; QL (1 kit per 365 days) INJECTOR KIT (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 4 PA; SP; QL (2 EA per 28 days) MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML 4 PA; SP; QL (2 syringes per 28 days) (adalimumab) SIMPONI ARIA INTRAVENOUS SOLUTION (golimumab) 4 PA; SP *CYCLOOXYGENASE 2 (COX-2) INHIBITORS*** - ARTHRITIS AND PAIN DRUGS celecoxib oral capsule 100 mg, 200 mg, 50 mg 1 or 1b* ST; QL (2 capsules per 1 day) celecoxib oral capsule 400 mg 1 or 1b* ST; QL (1 capsule per 1 day) *GOLD COMPOUNDS*** - ARTHRITIS AND PAIN DRUGS RIDAURA ORAL CAPSULE (auranofin) 2 *INTERLEUKIN-1 BLOCKERS*** - ARTHRITIS AND PAIN DRUGS ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED PA; LD; SP; QL (4 vials per 28 4 (rilonacept) days) *INTERLEUKIN-1BETA BLOCKERS*** - ARTHRITIS AND PAIN DRUGS PA; LD; SP; QL (2 vials per 28 ILARIS SUBCUTANEOUS SOLUTION (canakinumab) 4 days) *NONSTEROIDAL ANTI-INFLAMMATORY AGENT COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS diclofenac-misoprostol oral tablet delayed release 50-0.2 mg 1 or 1b* ST; QL (4 tablets per 1 day) diclofenac-misoprostol oral tablet delayed release 75-0.2 mg 1 or 1b* ST; QL (2 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 20 Coverage Requirements and Prescription Drug Name Drug Tier Limits *NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)*** - ARTHRITIS AND PAIN DRUGS ANJESO INTRAVENOUS INJECTABLE (meloxicam) 3 CALDOLOR INTRAVENOUS SOLUTION (ibuprofen) 3 cataflam oral tablet 1 or 1b* DAYPRO ORAL TABLET (oxaprozin) 3 QL (2 tablets per 1 day) diclofenac potassium oral tablet 1 or 1b* diclofenac sodium er oral tablet extended release 24 hour 1 or 1b* QL (2 tablets per 1 day) diclofenac sodium oral tablet delayed release 25 mg 1 or 1b* QL (5 tablets per 1 day) diclofenac sodium oral tablet delayed release 50 mg 1 or 1b* QL (4 tablets per 1 day) diclofenac sodium oral tablet delayed release 75 mg 1 or 1b* QL (2 tablets per 1 day) ec-naproxen oral tablet delayed release 1 or 1b* etodolac er oral tablet extended release 24 hour 400 mg, 500 mg 1 or 1b* QL (2 tablets per 1 day) etodolac er oral tablet extended release 24 hour 600 mg 1 or 1b* QL (1 tablet per 1 day) etodolac oral capsule 200 mg 1 or 1b* QL (4 capsules per 1 day) etodolac oral capsule 300 mg 1 or 1b* QL (3 capsules per 1 day) etodolac oral tablet 1 or 1b* QL (2 tablets per 1 day) FELDENE ORAL CAPSULE (piroxicam) 3 QL (1 capsule per 1 day) fenoprofen calcium oral tablet 1 or 1b* QL (4 tablets per 1 day) flurbiprofen oral tablet 100 mg 1 or 1b* QL (3 tablets per 1 day) flurbiprofen oral tablet 50 mg 1 or 1b* QL (4 tablets per 1 day) ibu oral tablet 1 or 1a* QL (4 tablets per 1 day) ibuprofen lysine intravenous solution 1 or 1b* ibuprofen oral suspension 1 or 1a* QL (4 mL per 1 day) ibuprofen oral tablet 1 or 1a* QL (4 tablets per 1 day) indomethacin er oral capsule extended release 1 or 1b* QL (2 capsules per 1 day) indomethacin oral capsule 25 mg 1 or 1b* QL (3 capsule per 1 day) indomethacin oral capsule 50 mg 1 or 1b* QL (4 capsule per 1 day) indomethacin sodium intravenous solution reconstituted 1 or 1b* ketoprofen er oral capsule extended release 24 hour 1 or 1b* QL (1 capsule per 1 day) ketoprofen oral capsule 50 mg 1 or 1b* ketoprofen oral capsule 75 mg 1 or 1b* QL (4 capsules per 1 day) ketorolac tromethamine injection solution 15 mg/ml 1 or 1b* QL (4 mL per 30 days) ketorolac tromethamine injection solution 30 mg/ml 1 or 1b* QL (2 mL per 30 days) ketorolac tromethamine intramuscular solution 1 or 1b* QL (2 mL per 30 days) ketorolac tromethamine oral tablet 1 or 1a* QL (20 tablets per 30 days) LODINE ORAL TABLET (etodolac) 3 QL (2 tablets per 1 day) meclofenamate sodium oral capsule 1 or 1b* QL (4 capsules per 1 day) mefenamic acid oral capsule 1 or 1b* QL (29 capsule per 1 fill) meloxicam oral tablet 1 or 1b* QL (1 tablet per 1 day) nabumetone oral tablet 500 mg 1 or 1b* QL (4 tablets per 1 day) nabumetone oral tablet 750 mg 1 or 1b* QL (2 tablets per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 21 Coverage Requirements and Prescription Drug Name Drug Tier Limits naproxen oral suspension 1 or 1b* naproxen oral tablet 1 or 1b* naproxen oral tablet delayed release 1 or 1b* naproxen sodium oral tablet 275 mg 1 or 1b* QL (4 tablets per 1 day) naproxen sodium oral tablet 550 mg 1 or 1b* QL (2 tablets per 1 day) NEOPROFEN INTRAVENOUS SOLUTION (ibuprofen lysine) 3 oxaprozin oral tablet 1 or 1b* QL (2 tablets per 1 day) piroxicam oral capsule 1 or 1b* QL (1 capsule per 1 day) relafen oral tablet 500 mg 1 or 1b* QL (4 tablets per 1 day) relafen oral tablet 750 mg 1 or 1b* QL (2 tablets per 1 day) sulindac oral tablet 1 or 1b* QL (2 tablets per 1 day) *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** - ARTHRITIS AND PAIN DRUGS OTEZLA ORAL TABLET (apremilast) 4 PA; SP; QL (2 tablets per 1 day) OTEZLA ORAL TABLET THERAPY PACK (apremilast) 4 PA; SP; QL (1 pack per 365 days) *PYRIMIDINE SYNTHESIS INHIBITORS*** - ARTHRITIS AND PAIN DRUGS ARAVA ORAL TABLET (leflunomide) 3 leflunomide oral tablet 1 or 1b* *SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS*** - ARTHRITIS AND PAIN DRUGS ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE PA; SP; QL (4 cartridge per 28 4 (etanercept) days) PA; SP; QL (8 injections per 28 ENBREL SUBCUTANEOUS SOLUTION (etanercept) 4 days) ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 4 PA; SP; QL (8 syringes per 28 days) MG/0.5ML (etanercept) ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 4 PA; SP; QL (4 syringes per 28 days) MG/ML (etanercept) ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; SP; QL (8 vials per 28 days) (etanercept) ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- 4 PA; SP; QL (4 pens per 28 days) INJECTOR (etanercept) *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER *ANALGESICS OTHER*** - ARTHRITIS AND PAIN DRUGS acetaminophen intravenous solution 1 or 1b* clonidine hcl (analgesia) epidural solution 1 or 1b* DURACLON EPIDURAL SOLUTION (clonidine hcl (analgesia)) 3 OFIRMEV INTRAVENOUS SOLUTION (acetaminophen) 3 *ANALGESICS-SEDATIVES*** - ARTHRITIS AND PAIN DRUGS bac oral tablet 1 or 1b* QL (6 tablets per 1 day) bupap oral tablet 1 or 1b* QL (6 tablets per 1 day) butalbital-acetaminophen oral capsule 1 or 1b* QL (6 capsules per 1 day) butalbital-acetaminophen oral tablet 25-325 mg 1 or 1b* QL (12 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 22 Coverage Requirements and Prescription Drug Name Drug Tier Limits butalbital-acetaminophen oral tablet 50-300 mg, 50-325 mg 1 or 1b* QL (6 tablets per 1 day) butalbital-apap-caffeine oral capsule 1 or 1b* QL (6 capsules per 1 day) butalbital-apap-caffeine oral tablet 1 or 1b* QL (6 tablets per 1 day) butalbital-aspirin-caffeine oral capsule 1 or 1b* QL (6 capsules per 1 day) esgic oral capsule 1 or 1b* QL (6 capsules per 1 day) tencon oral tablet 1 or 1b* QL (6 tablets per 1 day) zebutal oral capsule 1 or 1b* QL (6 capsules per 1 day) *SALICYLATE COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS sm aspirin tri-buffered oral tablet 1 or 1b*; $0 tri-buffered aspirin oral tablet 1 or 1b*; $0 *SALICYLATES*** - ARTHRITIS AND PAIN DRUGS adult aspirin regimen oral tablet delayed release 1 or 1a*; $0 aspirin 81 oral tablet chewable 1 or 1a*; $0 aspirin adult low dose oral tablet delayed release 1 or 1a*; $0 aspirin adult low strength oral tablet delayed release 1 or 1a*; $0 aspirin childrens oral tablet chewable 1 or 1a*; $0 aspirin ec adult low strength oral tablet delayed release 1 or 1a*; $0 aspirin ec low dose oral tablet delayed release 1 or 1a*; $0 aspirin ec low strength oral tablet delayed release 1 or 1a*; $0 aspirin ec oral tablet delayed release 1 or 1a*; $0 aspirin low dose oral tablet chewable 1 or 1a*; $0 aspirin low dose oral tablet delayed release 1 or 1a*; $0 aspirin low strength oral tablet chewable 1 or 1a*; $0 aspirin oral tablet 1 or 1a*; $0 aspirin oral tablet chewable 1 or 1a*; $0 aspirin oral tablet delayed release 1 or 1a*; $0 bayer advanced aspirin reg st oral tablet 1 or 1a*; $0 bayer aspirin ec low dose oral tablet delayed release 1 or 1a*; $0 bayer aspirin oral tablet 1 or 1a*; $0 bayer aspirin oral tablet delayed release 1 or 1a*; $0 bayer low dose oral tablet chewable 1 or 1a*; $0 bayer low dose oral tablet delayed release 1 or 1a*; $0 childrens aspirin oral tablet chewable 1 or 1a*; $0 cvs aspirin adult low dose oral tablet chewable 1 or 1a*; $0 cvs aspirin adult low strength oral tablet delayed release 1 or 1a*; $0 cvs aspirin ec oral tablet delayed release 1 or 1a*; $0 cvs aspirin low dose oral tablet delayed release 1 or 1a*; $0 cvs aspirin low strength oral tablet delayed release 1 or 1a*; $0 cvs aspirin oral tablet 1 or 1a*; $0 diflunisal oral tablet 1 or 1b* ecotrin low strength oral tablet delayed release 1 or 1a*; $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 23 Coverage Requirements and Prescription Drug Name Drug Tier Limits eq aspirin adult low dose oral tablet delayed release 1 or 1a*; $0 eq aspirin low dose oral tablet chewable 1 or 1a*; $0 eq aspirin oral tablet 1 or 1a*; $0 eql aspirin ec oral tablet delayed release 1 or 1a*; $0 eql aspirin low dose oral tablet chewable 1 or 1a*; $0 eql aspirin low dose oral tablet delayed release 1 or 1a*; $0 gnp adult aspirin low strength oral tablet chewable 1 or 1a*; $0 gnp aspirin low dose oral tablet delayed release 1 or 1a*; $0 gnp aspirin oral tablet 1 or 1a*; $0 gnp aspirin oral tablet delayed release 1 or 1a*; $0 goodsense aspirin adult low st oral tablet chewable 1 or 1a*; $0 goodsense aspirin adults oral tablet 1 or 1a*; $0 goodsense aspirin low dose oral tablet delayed release 1 or 1a*; $0 goodsense aspirin oral tablet 1 or 1a*; $0 goodsense aspirin oral tablet chewable 1 or 1a*; $0 goodsense aspirin oral tablet delayed release 1 or 1a*; $0 h-e-b aspirin oral tablet delayed release 1 or 1a*; $0 hm adult aspirin oral tablet 1 or 1a*; $0 hm aspirin ec low dose oral tablet delayed release 1 or 1a*; $0 hm aspirin ec oral tablet delayed release 1 or 1a*; $0 hm aspirin oral tablet 1 or 1a*; $0 hm aspirin oral tablet chewable 1 or 1a*; $0 hm aspirin oral tablet delayed release 1 or 1a*; $0 kls aspirin low dose oral tablet delayed release 1 or 1a*; $0 kp aspirin oral tablet delayed release 1 or 1a*; $0 meijer aspirin ec oral tablet delayed release 1 or 1a*; $0 px aspirin oral tablet 1 or 1a*; $0 px aspirin oral tablet chewable 1 or 1a*; $0 px enteric aspirin oral tablet delayed release 1 or 1a*; $0 qc aspirin low dose oral tablet chewable 1 or 1a*; $0 qc aspirin low dose oral tablet delayed release 1 or 1a*; $0 qc aspirin oral tablet 1 or 1a*; $0 qc aspirin oral tablet delayed release 1 or 1a*; $0 qc childrens aspirin oral tablet chewable 1 or 1a*; $0 qc enteric aspirin oral tablet delayed release 1 or 1a*; $0 ra aspirin adult low dose oral tablet chewable 1 or 1a*; $0 ra aspirin adult low strength oral tablet chewable 1 or 1a*; $0 ra aspirin childrens oral tablet chewable 1 or 1a*; $0 ra aspirin ec adult low st oral tablet delayed release 1 or 1a*; $0 ra aspirin ec oral tablet delayed release 1 or 1a*; $0 ra aspirin oral tablet 1 or 1a*; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 24 Coverage Requirements and Prescription Drug Name Drug Tier Limits ra pain relief aspirin oral tablet 1 or 1a*; $0 sb aspirin adult low strength oral tablet delayed release 1 or 1a*; $0 sb aspirin ec oral tablet delayed release 1 or 1a*; $0 sb aspirin oral tablet 1 or 1a*; $0 sb aspirin oral tablet delayed release 1 or 1a*; $0 sb childrens aspirin oral tablet chewable 1 or 1a*; $0 sb low dose asa ec oral tablet delayed release 1 or 1a*; $0 sm aspirin adult low strength oral tablet chewable 1 or 1a*; $0 sm aspirin adult low strength oral tablet delayed release 1 or 1a*; $0 sm aspirin ec low strength oral tablet delayed release 1 or 1a*; $0 sm aspirin ec oral tablet delayed release 1 or 1a*; $0 sm aspirin low dose oral tablet chewable 1 or 1a*; $0 sm aspirin oral tablet 1 or 1a*; $0 sm childrens aspirin oral tablet chewable 1 or 1a*; $0 st joseph aspirin oral tablet delayed release 1 or 1a*; $0 st joseph low dose oral tablet chewable 1 or 1a*; $0 st joseph low dose oral tablet delayed release 1 or 1a*; $0 *SELECTIVE N-TYPE NEURONAL CALCIUM CHANNEL BLOCKERS*** - ARTHRITIS AND PAIN DRUGS PRIALT INTRATHECAL SOLUTION (ziconotide acetate) 4 PA; LD *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER *CODEINE COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS acetaminophen-codeine #2 oral tablet 1 or 1a* QL (6 tablets per 1 day) acetaminophen-codeine #3 oral tablet 1 or 1a* QL (6 tablet per 1 day) acetaminophen-codeine #4 oral tablet 1 or 1a* QL (6 tablet per 1 day) acetaminophen-codeine oral solution 1 or 1a* QL (30 mL per 1 day) acetaminophen-codeine oral tablet 300-15 mg 1 or 1a* QL (6 tablets per 1 day) acetaminophen-codeine oral tablet 300-30 mg, 300-60 mg 1 or 1a* QL (6 tablet per 1 day) ascomp-codeine oral capsule 1 or 1b* QL (6 capsule per 1 day) butalbital-apap-caff-cod oral capsule 50-300-40-30 mg 1 or 1b* QL (6 capsules per 1 day) butalbital-apap-caff-cod oral capsule 50-325-40-30 mg 1 or 1b* QL (6 capsule per 1 day) butalbital-asa-caff-codeine oral capsule 1 or 1b* QL (6 capsule per 1 day) *DIHYDROCODEINE COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS apap-caff-dihydrocodeine oral capsule 1 or 1b* QL (6 capsules per 1 day) apap-caff-dihydrocodeine oral tablet 1 or 1b* QL (6 tablets per 1 day) trezix oral capsule 1 or 1b* QL (6 capsules per 1 day) *FENTANYL COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS FENTANYL CIT-ROPIVACAINE-NACL EPIDURAL SOLUTION 3 FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 25 Coverage Requirements and Prescription Drug Name Drug Tier Limits *HYDROCODONE COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS hydrocodone-acetaminophen oral solution 1 or 1b* QL (90 mL per 1 day) hydrocodone-acetaminophen oral tablet 1 or 1b* QL (6 tablets per 1 day) hydrocodone-ibuprofen oral tablet 1 or 1b* QL (5 tablets per 1 day) *OPIOID AGONISTS*** - ARTHRITIS AND PAIN DRUGS ALFENTANIL HCL INTRAVENOUS SOLUTION 3 CODEINE SULFATE ORAL TABLET 15 MG, 60 MG 3 QL (6 tablets per 1 day) codeine sulfate oral tablet 30 mg 1 or 1b* QL (6 tablets per 1 day) CONZIP ORAL CAPSULE EXTENDED RELEASE 24 HOUR (tramadol 3 PA; QL (1 capsule per 1 day) hcl) DEMEROL INJECTION SOLUTION (meperidine hcl) 3 QL (4 mL per 1 day) DILAUDID INJECTION SOLUTION (hydromorphone hcl) 3 QL (6 mL per 1 day) DILAUDID ORAL LIQUID (hydromorphone hcl) 3 QL (24 mL per 1 day) DILAUDID ORAL TABLET (hydromorphone hcl) 3 QL (6 tablets per 1 day) DSUVIA SUBLINGUAL TABLET SUBLINGUAL (sufentanil citrate) 3 DURAGESIC-100 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) DURAGESIC-12 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) DURAGESIC-25 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) DURAGESIC-50 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) DURAGESIC-75 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) duramorph injection solution 1 or 1b* QL (6 mL per 1 day) FENTANYL CITRATE (PF) INJECTION SOLUTION 100 MCG/2ML, 3 250 MCG/5ML, 50 MCG/ML fentanyl citrate (pf) injection solution 1000 mcg/20ml, 2500 mcg/50ml, 500 1 or 1b* mcg/10ml fentanyl citrate (pf) injection solution cartridge 1 or 1b* fentanyl citrate buccal lozenge on a handle 1 or 1b* PA; QL (4 lozenge per 1 day) fentanyl citrate buccal tablet 1 or 1b* PA; QL (4 tablet per 1 day) FENTANYL CITRATE INTRAVENOUS SOLUTION 3 FENTANYL CITRATE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE FENTANYL CITRATE PF INJECTION SOLUTION PREFILLED 3 SYRINGE FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE fentanyl transdermal patch 72 hour 1 or 1b* PA; QL (15 patches per 30 days) FENTORA BUCCAL TABLET (fentanyl citrate) 3 PA; QL (4 tablet per 1 day) hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent 1 or 1b* PA; QL (1 tablet per 1 day) hydromorphone hcl er oral tablet extended release 24 hour 1 or 1b* PA; QL (1 tablet per 1 day) hydromorphone hcl injection solution 1 or 1b* QL (2 mL per 1 day) hydromorphone hcl oral liquid 1 or 1b* QL (24 mL per 1 day) hydromorphone hcl oral tablet 1 or 1b* QL (6 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 26 Coverage Requirements and Prescription Drug Name Drug Tier Limits HYDROMORPHONE HCL PF INJECTION SOLUTION 1 MG/ML, 2 3 QL (6 mL per 1 day) MG/ML HYDROMORPHONE HCL PF INJECTION SOLUTION 10 MG/ML 3 QL (1 injection per 30 days) HYDROMORPHONE HCL PF INJECTION SOLUTION 4 MG/ML 3 QL (2 mL per 1 day) hydromorphone hcl pf injection solution 50 mg/5ml, 500 mg/50ml 1 or 1b* QL (1 injection per 30 days) HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE INFUMORPH 200 INJECTION SOLUTION (morphine sulfate 3 QL (2 vials per 30 days) microinfusion) INFUMORPH 500 INJECTION SOLUTION (morphine sulfate 3 QL (2 vials per 30 days) microinfusion) levorphanol tartrate oral tablet 1 or 1b* PA; QL (6 tablets per 1 day) meperidine hcl injection solution 1 or 1b* QL (4 mL per 1 day) meperidine hcl oral solution 1 or 1b* QL (7 days per 1 fill) meperidine hcl oral tablet 1 or 1b* QL (6 tablets per 1 day) METHADONE HCL INJECTION SOLUTION 3 PA; QL (1 mL per 1 day) methadone hcl intensol oral concentrate 1 or 1b* PA; QL (6 mL per 1 day) methadone hcl oral concentrate 1 or 1b* PA; QL (6 mL per 1 day) methadone hcl oral solution 10 mg/5ml 1 or 1b* PA; QL (30 mL per 1 day) methadone hcl oral solution 5 mg/5ml 1 or 1b* PA; QL (60 mL per 1 day) methadone hcl oral tablet 10 mg 1 or 1b* PA; QL (6 tablet per 1 day) methadone hcl oral tablet 5 mg 1 or 1b* PA; QL (6 tablets per 1 day) methadone hcl oral tablet soluble 1 or 1b* PA; QL (1 tablet per 1 day) METHADOSE ORAL CONCENTRATE (methadone hcl) 3 PA; QL (6 mL per 1 day) methadose oral tablet soluble 1 or 1b* PA; QL (1 tablet per 1 day) METHADOSE SUGAR-FREE ORAL CONCENTRATE (methadone hcl) 3 PA; QL (6 mL per 1 day) mitigo injection solution 1 or 1b* QL (2 vials per 30 days) morphine sulfate (concentrate) oral solution 1 or 1b* QL (6 mL per 1 day) morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml 1 or 1b* QL (6 mL per 1 day) MORPHINE SULFATE (PF) INJECTION SOLUTION 10 MG/ML, 2 3 QL (6 mL per 1 day) MG/ML, 4 MG/ML, 5 MG/ML, 8 MG/ML MORPHINE SULFATE (PF) INTRAVENOUS SOLUTION 3 QL (6 mL per 1 day) morphine sulfate er beads oral capsule extended release 24 hour 1 or 1b* PA; QL (1 capsule per 1 day) morphine sulfate er oral capsule extended release 24 hour 1 or 1b* PA; QL (2 capsules per 1 day) morphine sulfate er oral tablet extended release 100 mg, 200 mg 1 or 1b* PA; QL (2 tablets per 1 day) morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg 1 or 1b* PA; QL (3 tablet per 1 day) MORPHINE SULFATE INJECTION SOLUTION 3 QL (6 mL per 1 day) morphine sulfate oral solution 1 or 1b* QL (30 mL per 1 day) morphine sulfate oral tablet 1 or 1b* QL (6 tablets per 1 day) MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE NUCYNTA ORAL TABLET 100 MG (tapentadol hcl) 3 QL (181 tablets per 30 days) NUCYNTA ORAL TABLET 50 MG (tapentadol hcl) 3 QL (6 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 27 Coverage Requirements and Prescription Drug Name Drug Tier Limits NUCYNTA ORAL TABLET 75 MG (tapentadol hcl) 3 QL (8 tablet per 1 day) OLINVYK INTRAVENOUS SOLUTION (oliceridine fumarate) 3 OXAYDO ORAL TABLET (oxycodone hcl) 3 QL (6 tablets per 1 day) oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 15 mg, 20 mg, 3 PA; QL (2 tablets per 1 day) 30 mg, 40 mg, 60 mg oxycodone hcl er oral tablet er 12 hour abuse-deterrent 80 mg 3 PA; QL (2 tablet per 1 day) oxycodone hcl oral capsule 1 or 1b* QL (7 days per 1 fill) oxycodone hcl oral concentrate 1 or 1b* QL (6 mL per 1 day) oxycodone hcl oral solution 1 or 1b* QL (30 mL per 1 day) oxycodone hcl oral tablet 1 or 1b* QL (6 tablets per 1 day) OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 3 PA; QL (2 tablets per 1 day) MG, 15 MG, 20 MG, 30 MG, 40 MG (oxycodone hcl) OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 60 3 PA; QL (2 tablet per 1 day) MG, 80 MG (oxycodone hcl) oxymorphone hcl er oral tablet extended release 12 hour 1 or 1b* PA; QL (2 tablets per 1 day) oxymorphone hcl oral tablet 10 mg 1 or 1b* QL (6 tablet per 1 day) oxymorphone hcl oral tablet 5 mg 1 or 1b* QL (6 tablets per 1 day) QDOLO ORAL SOLUTION (tramadol hcl) 3 QL (80 mL per 1 day) remifentanil hcl intravenous solution reconstituted 1 or 1b* ROXICODONE ORAL TABLET (oxycodone hcl) 3 QL (6 tablets per 1 day) SUFENTANIL CITRATE INTRAVENOUS SOLUTION 3 tramadol hcl er (biphasic) oral tablet extended release 24 hour 1 or 1b* PA; QL (1 tablet per 1 day) tramadol hcl er oral capsule extended release 24 hour 1 or 1b* PA; QL (1 capsule per 1 day) tramadol hcl er oral tablet extended release 24 hour 1 or 1b* PA; QL (1 tablet per 1 day) tramadol hcl oral tablet 100 mg 1 or 1b* QL (4 tablets per 1 day) tramadol hcl oral tablet 50 mg 1 or 1b* QL (8 tablet per 1 day) ULTIVA INTRAVENOUS SOLUTION RECONSTITUTED (remifentanil 3 hcl) *OPIOID COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS APADAZ ORAL TABLET (benzhydrocodone-acetaminophen) 3 QL (6 tablets per 1 day) BENZHYDROCODONE-ACETAMINOPHEN ORAL TABLET 3 QL (6 tablets per 1 day) endocet oral tablet 10-325 mg, 2.5-325 mg, 7.5-325 mg 1 or 1b* QL (6 tablets per 1 day) endocet oral tablet 5-325 mg 1 or 1b* QL (6 tablet per 1 day) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 7.5-325 mg 1 or 1b* QL (6 tablets per 1 day) oxycodone-acetaminophen oral tablet 5-325 mg 1 or 1b* QL (6 tablet per 1 day) *OPIOID PARTIAL AGONISTS*** - ARTHRITIS AND PAIN DRUGS BELBUCA BUCCAL FILM (buprenorphine hcl) 3 PA; QL (2 film per 1 day) BUNAVAIL BUCCAL FILM 4.2-0.7 MG (buprenorphine hcl-naloxone hcl) 3 QL (3 films per 1 day) BUNAVAIL BUCCAL FILM 6.3-1 MG (buprenorphine hcl-naloxone hcl) 3 QL (2 films per 1 day) BUPRENEX INJECTION SOLUTION (buprenorphine hcl) 3 QL (3 mL per 1 day) buprenorphine hcl injection solution 1 or 1b* QL (3 mL per 1 day) buprenorphine hcl sublingual tablet sublingual 2 mg 1 or 1b* QL (12 tablets per 90 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 28 Coverage Requirements and Prescription Drug Name Drug Tier Limits buprenorphine hcl sublingual tablet sublingual 8 mg 1 or 1b* QL (3 tablets per 90 days) buprenorphine hcl-naloxone hcl sublingual film 12-3 mg 1 or 1b* QL (2 films per 1 day) buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg 1 or 1b* QL (12 films per 1 day) buprenorphine hcl-naloxone hcl sublingual film 4-1 mg 1 or 1b* QL (6 films per 1 day) buprenorphine hcl-naloxone hcl sublingual film 8-2 mg 1 or 1b* QL (3 films per 1 day) buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg 1 or 1b* QL (12 tablets per 1 day) buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg 1 or 1b* QL (3 tablets per 1 day) buprenorphine transdermal patch weekly 1 or 1b* PA; QL (1 package per 28 days) butorphanol tartrate injection solution 1 mg/ml 1 or 1b* QL (8 mL per 1 day) butorphanol tartrate injection solution 2 mg/ml 1 or 1b* QL (4 mL per 1 day) butorphanol tartrate nasal solution 1 or 1b* QL (2 bottles per 30 days) BUTRANS TRANSDERMAL PATCH WEEKLY (buprenorphine) 3 PA; QL (1 package per 28 days) nalbuphine hcl injection solution 1 or 1b* QL (2 mL per 1 day) pentazocine-naloxone hcl oral tablet 1 or 1b* QL (6 tablets per 1 day) PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT 3 PA; LD (buprenorphine hcl) SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 LD; QL (1 syringe per 28 days) (buprenorphine) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG 2 QL (23 tablets per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG 2 QL (12 tablets per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG 2 QL (1 tablet per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 2.9-0.71 MG 2 QL (5 tablets per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 5.7-1.4 MG 2 QL (3 tablets per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 8.6-2.1 MG 2 QL (2 tablets per 1 day) (buprenorphine hcl-naloxone hcl) *TRAMADOL COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS tramadol-acetaminophen oral tablet 1 or 1b* QL (8 tablet per 1 day) *ANDROGENS-ANABOLIC* - HORMONES *ANABOLIC STEROIDS*** - DRUGS FOR MEN oxandrolone oral tablet 1 or 1b* PA *ANDROGENS*** - DRUGS FOR MEN ANDRODERM TRANSDERMAL PATCH 24 HOUR (testosterone) 3 PA; QL (1 patch per 1 day) danazol oral capsule 1 or 1b* DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION (testosterone 3 PA cypionate) JATENZO ORAL CAPSULE 158 MG, 198 MG (testosterone undecanoate) 3 PA; QL (4 capsules per 1 day) JATENZO ORAL CAPSULE 237 MG (testosterone undecanoate) 3 PA; QL (2 capsules per 1 day) TESTOPEL IMPLANT PELLET (testosterone) 3 PA; LD testosterone cypionate intramuscular solution 1 or 1b* PA

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 29 Coverage Requirements and Prescription Drug Name Drug Tier Limits testosterone enanthate intramuscular solution 1 or 1b* PA testosterone transdermal gel 1.62 %, 12.5 mg/act (1%), 20.25 mg/act (1.62%) 1 or 1b* PA; QL (1 bottle per 30 days) testosterone transdermal gel 10 mg/act (2%) 1 or 1b* PA; QL (1 pump per 30 days) testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 40.5 mg/2.5gm 1 or 1b* PA; QL (1 packet per 1 day) (1.62%), 50 mg/5gm (1%) testosterone transdermal gel 25 mg/2.5gm (1%) 1 or 1b* PA; QL (2 packet per 1 day) testosterone transdermal solution 1 or 1b* PA; QL (1 pump bottle per 30 days) *ANORECTAL AND RELATED PRODUCTS* - RECTAL PREPARATIONS *INTRARECTAL STEROIDS*** - RECTAL PREPARATIONS CORTENEMA RECTAL ENEMA (hydrocortisone) 3 CORTIFOAM EXTERNAL FOAM (hydrocortisone acetate) 3 QL (2.15 gram per 1 day) hydrocortisone rectal enema 1 or 1b* UCERIS RECTAL FOAM (budesonide) 2 QL (4.78 gm per 1 day) *NITRATE VASODILATING AGENTS*** - RECTAL PREPARATIONS RECTIV RECTAL OINTMENT (nitroglycerin) 3 QL (1 unit per 1 day) *RECTAL ANESTHETIC/STEROIDS*** - RECTAL PREPARATIONS ANALPRAM-HC EXTERNAL CREAM (hydrocortisone ace-pramoxine) 3 ANALPRAM-HC EXTERNAL LOTION (hydrocortisone ace-pramoxine) 3 hydrocortisone ace-pramoxine external cream 1 or 1b* PROCTOFOAM HC EXTERNAL FOAM (hydrocortisone ace-pramoxine) 3 *RECTAL LOCAL ANESTHETICS*** - RECTAL PREPARATIONS LIDOCAINE (ANORECTAL) RECTAL SUPPOSITORY 3 *RECTAL STEROIDS*** - RECTAL PREPARATIONS ANUSOL-HC EXTERNAL CREAM (hydrocortisone) 3 hydrocortisone (perianal) external cream 1 or 1b* PROCTOCORT EXTERNAL CREAM (hydrocortisone) 3 procto-med hc external cream 1 or 1b* procto-pak external cream 1 or 1b* proctozone-hc external cream 1 or 1b* *ANTACIDS* - DRUGS FOR THE STOMACH *ANTACIDS - BICARBONATE*** - DRUGS FOR ULCERS AND STOMACH ACID SODIUM BICARBONATE ORAL POWDER 3 *ANTHELMINTICS* - DRUGS FOR INFECTIONS *ANTHELMINTICS*** - DRUGS FOR PARASITES albendazole oral tablet 1 or 1b* PA; QL (4 tablets per 1 day) ALBENZA ORAL TABLET (albendazole) 3 PA; QL (4 tablets per 1 day) BENZNIDAZOLE ORAL TABLET 3 BILTRICIDE ORAL TABLET (praziquantel) 3 EMVERM ORAL TABLET CHEWABLE (mebendazole) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 30 Coverage Requirements and Prescription Drug Name Drug Tier Limits ivermectin oral tablet 1 or 1b* praziquantel oral tablet 1 or 1b* STROMECTOL ORAL TABLET (ivermectin) 3 *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART *ANTIANGINALS-OTHER*** - DRUGS FOR ANGINA RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 3 (ranolazine) ranolazine er oral tablet extended release 12 hour 1 or 1b* *NITRATES*** - DRUGS FOR ANGINA DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE (isosorbide 2 dinitrate) GONITRO SUBLINGUAL PACKET (nitroglycerin) 3 ISORDIL TITRADOSE ORAL TABLET (isosorbide dinitrate) 3 isosorbide dinitrate oral tablet 1 or 1b* isosorbide mononitrate er oral tablet extended release 24 hour 1 or 1b* isosorbide mononitrate oral tablet 1 or 1b* minitran transdermal patch 24 hour 1 or 1b* NITRO-BID TRANSDERMAL OINTMENT (nitroglycerin) 3 NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 3 MG/HR, 0.4 MG/HR, 0.6 MG/HR (nitroglycerin) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 2 MG/HR (nitroglycerin) nitroglycerin in d5w intravenous solution 1 or 1b* NITROGLYCERIN INTRAVENOUS SOLUTION 3 nitroglycerin sublingual tablet sublingual 1 or 1b* nitroglycerin transdermal patch 24 hour 1 or 1b* nitroglycerin translingual solution 1 or 1b* NITROLINGUAL TRANSLINGUAL SOLUTION (nitroglycerin) 3 NITROMIST TRANSLINGUAL AEROSOL SOLUTION (nitroglycerin) 3 NITROSTAT SUBLINGUAL TABLET SUBLINGUAL (nitroglycerin) 3 *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM *ANTIANXIETY AGENTS - MISC.*** - DRUGS FOR ANXIETY buspirone hcl oral tablet 1 or 1b* droperidol injection solution 1 or 1b* hydroxyzine hcl intramuscular solution 1 or 1b* hydroxyzine hcl oral syrup 1 or 1b* hydroxyzine hcl oral tablet 1 or 1b* hydroxyzine pamoate oral capsule 1 or 1a* meprobamate oral tablet 1 or 1b* VISTARIL ORAL CAPSULE (hydroxyzine pamoate) 3 *BENZODIAZEPINES*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN alprazolam er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 31 Coverage Requirements and Prescription Drug Name Drug Tier Limits ALPRAZOLAM INTENSOL ORAL CONCENTRATE (alprazolam) 3 QL (4 mL per 1 day) alprazolam oral tablet 1 or 1b* QL (3 tablets per 1 day) alprazolam oral tablet dispersible 1 or 1b* QL (3 tablets per 1 day) alprazolam xr oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) chlordiazepoxide hcl oral capsule 1 or 1b* QL (4 capsules per 1 day) clorazepate dipotassium oral tablet 1 or 1b* QL (4 tablets per 1 day) diazepam injection solution 1 or 1a* diazepam intensol oral concentrate 1 or 1a* QL (8 mL per 1 day) DIAZEPAM INTRAMUSCULAR SOLUTION AUTO-INJECTOR 3 diazepam oral concentrate 1 or 1a* QL (8 mL per 1 day) diazepam oral solution 1 or 1a* diazepam oral tablet 1 or 1a* QL (4 tablets per 1 day) lorazepam injection solution 1 or 1b* lorazepam intensol oral concentrate 1 or 1b* QL (3 mL per 1 day) lorazepam oral concentrate 1 or 1b* QL (3 mL per 1 day) lorazepam oral tablet 1 or 1b* QL (3 tablets per 1 day) oxazepam oral capsule 1 or 1b* QL (4 capsules per 1 day) *ANTIARRHYTHMICS* - DRUGS FOR THE HEART *ANTIARRHYTHMICS - MISC.*** - DRUGS FOR ABNORMAL HEART RHYTHMS adenosine intravenous solution 1 or 1b* *ANTIARRHYTHMICS TYPE I-A*** - DRUGS FOR ABNORMAL HEART RHYTHMS disopyramide phosphate oral capsule 1 or 1b* NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 2 (disopyramide phosphate) NORPACE ORAL CAPSULE (disopyramide phosphate) 3 procainamide hcl injection solution 1 or 1b* quinidine gluconate er oral tablet extended release 1 or 1b* quinidine sulfate oral tablet 1 or 1a* *ANTIARRHYTHMICS TYPE I-B*** - DRUGS FOR ABNORMAL HEART RHYTHMS LIDOCAINE HCL (CARDIAC) INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 100 MG/10ML LIDOCAINE HCL (CARDIAC) INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 100 MG/5ML lidocaine hcl (cardiac) intravenous solution prefilled syringe 50 mg/5ml 1 or 1b* LIDOCAINE HCL (CARDIAC) PF INTRAVENOUS SOLUTION 3 lidocaine hcl (cardiac) pf intravenous solution prefilled syringe 1 or 1b* lidocaine in d5w intravenous solution 1 or 1b* mexiletine hcl oral capsule 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 32 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIARRHYTHMICS TYPE I-C*** - DRUGS FOR ABNORMAL HEART RHYTHMS flecainide acetate oral tablet 100 mg 1 or 1b* QL (4 tablets per 1 day) flecainide acetate oral tablet 150 mg 1 or 1b* QL (2 tablets per 1 day) flecainide acetate oral tablet 50 mg 1 or 1b* QL (3 tablets per 1 day) propafenone hcl er oral capsule extended release 12 hour 1 or 1b* propafenone hcl oral tablet 1 or 1b* RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 3 (propafenone hcl) *ANTIARRHYTHMICS TYPE III*** - DRUGS FOR ABNORMAL HEART RHYTHMS AMIODARONE HCL IN DEXTROSE INTRAVENOUS SOLUTION 3 amiodarone hcl intravenous solution 1 or 1b* amiodarone hcl oral tablet 100 mg, 400 mg 1 or 1b* amiodarone hcl oral tablet 200 mg 1 or 1b* QL (3 tablets per 1 day) BRETYLIUM TOSYLATE INJECTION SOLUTION 3 CORVERT INTRAVENOUS SOLUTION (ibutilide fumarate) 3 dofetilide oral capsule 1 or 1b* ibutilide fumarate intravenous solution 1 or 1b* MULTAQ ORAL TABLET (dronedarone hcl) 3 QL (2 tablets per 1 day) NEXTERONE INTRAVENOUS SOLUTION (amiodarone hcl in dextrose) 3 pacerone oral tablet 100 mg, 400 mg 1 or 1b* pacerone oral tablet 200 mg 1 or 1b* QL (3 tablets per 1 day) *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS *ADRENERGIC COMBINATIONS*** - DRUGS FOR ASTHMA/COPD ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH 1 or 1b* QL (1 package per 30 days) ACTIVATED (fluticasone-salmeterol) ADVAIR HFA INHALATION AEROSOL (fluticasone-salmeterol) 2 QL (1 inhaler per 30 days) ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (umeclidinium-vilanterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (fluticasone furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL (budeson- 3 QL (1 inhaler per 30 days) glycopyrrol-formoterol) budesonide-formoterol fumarate inhalation aerosol 1 or 1b* QL (3 inhalers per 30 days) COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 2 QL (2 inhalers per 30 days) (ipratropium-albuterol) fluticasone-salmeterol inhalation aerosol powder breath activated 1 or 1b* QL (1 inhaler per 30 days) ipratropium-albuterol inhalation solution 1 or 1b* STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2 QL (1 inhaler per 30 days) (tiotropium bromide-olodaterol) SYMBICORT INHALATION AEROSOL (budesonide-formoterol 2 QL (3 inhalers per 30 days) fumarate)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 33 Coverage Requirements and Prescription Drug Name Drug Tier Limits TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (fluticasone-umeclidin-vilant) *ANTI-IGE MONOCLONAL ANTIBODIES*** - DRUGS FOR ASTHMA/COPD XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; SP (omalizumab) XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (omalizumab) *ANTI-INFLAMMATORY AGENTS*** - DRUGS FOR ASTHMA/COPD cromolyn sodium inhalation nebulization solution 1 or 1b* *BETA ADRENERGICS*** - DRUGS FOR ASTHMA/COPD albuterol sulfate hfa inhalation aerosol solution 1 or 1b* QL (2 inhalers per 30 days) albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 1 or 1b* QL (360 mL per 30 days) mg/3ml, 1.25 mg/3ml albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%, 2.5 mg/0.5ml 1 or 1b* QL (60 mL per 30 days) albuterol sulfate oral syrup 1 or 1b* albuterol sulfate oral tablet 1 or 1b* arformoterol tartrate inhalation nebulization solution 1 or 1b* QL (60 vial per 30 days) BROVANA INHALATION NEBULIZATION SOLUTION (arformoterol 3 QL (60 vial per 30 days) tartrate) formoterol fumarate inhalation nebulization solution 1 or 1b* QL (120 ML per 30 days) isoproterenol hcl injection solution 1 or 1b* ISOPROTERENOL-SODIUM CHLORIDE INTRAVENOUS 3 SOLUTION ISUPREL INJECTION SOLUTION (isoproterenol hcl) 3 levalbuterol hcl inhalation nebulization solution 1 or 1b* QL (90 mL per 30 days) levalbuterol tartrate inhalation aerosol 1 or 1b* QL (2 inhalers per 30 days) PERFOROMIST INHALATION NEBULIZATION SOLUTION 3 QL (120 ML per 30 days) (formoterol fumarate) PROAIR DIGIHALER INHALATION AEROSOL POWDER BREATH 3 ST; QL (2 inhalers per 30 days) ACTIVATED (albuterol sulfate) PROAIR HFA INHALATION AEROSOL SOLUTION (albuterol sulfate) 2 ST; QL (2 inhalers per 30 days) PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH 2 QL (2 inhalers per 30 days) ACTIVATED (albuterol sulfate) PROVENTIL HFA INHALATION AEROSOL SOLUTION (albuterol 3 ST; QL (2 inhalers per 30 days) sulfate) SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (salmeterol xinafoate) STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 3 QL (1 inhaler per 30 days) (olodaterol hcl) terbutaline sulfate injection solution 1 or 1b* terbutaline sulfate oral tablet 1 or 1b* VENTOLIN HFA INHALATION AEROSOL SOLUTION (albuterol 2 ST; QL (2 inhalers per 30 days) sulfate) XOPENEX HFA INHALATION AEROSOL (levalbuterol tartrate) 3 QL (2 inhalers per 30 days) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 34 Coverage Requirements and Prescription Drug Name Drug Tier Limits *BRONCHODILATORS - ANTICHOLINERGICS*** - DRUGS FOR ASTHMA/COPD ATROVENT HFA INHALATION AEROSOL SOLUTION (ipratropium 2 QL (2 inhalers per 30 days) bromide hfa) ipratropium bromide inhalation solution 1 or 1b* QL (378 ML per 30 days) LONHALA MAGNAIR REFILL KIT INHALATION SOLUTION 3 ST; QL (2 vials per 1 day) (glycopyrrolate) LONHALA MAGNAIR STARTER KIT INHALATION SOLUTION 3 ST; QL (1 kit per 365 days) (glycopyrrolate) SPIRIVA HANDIHALER INHALATION CAPSULE (tiotropium bromide 2 QL (30 capsules per 30 days) monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION (tiotropium 2 QL (1 inhaler per 30 days) bromide monohydrate) YUPELRI INHALATION SOLUTION (revefenacin) 3 ST; QL (1 vial per 1 day) *INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)*** - DRUGS FOR ASTHMA/COPD FASENRA PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; QL (1 autoinjector per 8 4 (benralizumab) weekss) FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (1 syringes per 8 4 (benralizumab) weekss) NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; SP; QL (1 autoinjector per 4 (mepolizumab) 4 weekss) NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (1 syringe per 4 4 (mepolizumab) weekss) NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED PA; LD; SP; QL (1 injections per 28 4 (mepolizumab) days) *INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)*** - DRUGS FOR ASTHMA/COPD CINQAIR INTRAVENOUS SOLUTION (reslizumab) 4 PA; LD; SP *LEUKOTRIENE RECEPTOR ANTAGONISTS*** - DRUGS FOR ASTHMA/COPD ACCOLATE ORAL TABLET (zafirlukast) 3 QL (2 tablets per 1 day) montelukast sodium oral packet 1 or 1b* QL (1 packet per 1 day) montelukast sodium oral tablet 1 or 1b* QL (1 tablet per 1 day) montelukast sodium oral tablet chewable 1 or 1b* QL (1 tablet per 1 day) zafirlukast oral tablet 1 or 1b* QL (2 tablets per 1 day) *SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** - DRUGS FOR ASTHMA/COPD DALIRESP ORAL TABLET (roflumilast) 3 PA; QL (1 tablet per 1 day) *STEROID INHALANTS*** - DRUGS FOR ASTHMA/COPD ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (fluticasone furoate) budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml 1 or 1b* QL (120 ML per 30 days) budesonide inhalation suspension 1 mg/2ml 1 or 1b* QL (60 ML per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 35 Coverage Requirements and Prescription Drug Name Drug Tier Limits FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST (fluticasone propionate 2 QL (1 inhaler per 30 days) (inhal)) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH 2 QL (4 inhalers per 30 days) ACTIVATED 250 MCG/BLIST (fluticasone propionate (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 44 2 QL (1 inhaler per 30 days) MCG/ACT (fluticasone propionate hfa) FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT (fluticasone 2 QL (2 inhalers per 30 days) propionate hfa) PULMICORT FLEXHALER INHALATION AEROSOL POWDER 2 QL (2 inhalers per 30 days) BREATH ACTIVATED (budesonide) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 2 QL (1 inhaler per 30 days) 40 MCG/ACT (beclomethasone diprop hfa) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 2 QL (2 inhalers per 30 days) 80 MCG/ACT (beclomethasone diprop hfa) *XANTHINES*** - DRUGS FOR ASTHMA/COPD aminophylline intravenous solution 1 or 1b* ELIXOPHYLLIN ORAL ELIXIR (theophylline) 2 QL (112.5 mL per 1 day) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG 2 QL (4 tablets per 1 day) (theophylline) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG 2 QL (3 capsules per 1 day) (theophylline) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG, 2 QL (2 capsules per 1 day) 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg 1 or 1b* QL (2 tablets per 1 day) theophylline er oral tablet extended release 12 hour 450 mg 1 or 1b* QL (1 tablet per 1 day) theophylline er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) THEOPHYLLINE IN D5W INTRAVENOUS SOLUTION 3 theophylline oral solution 1 or 1b* QL (112.5 mL per 1 day) *ANTICOAGULANTS* - DRUGS FOR THE BLOOD *ANTICOAGULANTS - MISC.*** - DRUGS TO PREVENT BLOOD CLOTS SODIUM CITRATE LOCK FLUSH INTRAVENOUS SOLUTION 3 SODIUM CITRATE LOCK FLUSH INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE *COUMARIN ANTICOAGULANTS*** - DRUGS TO PREVENT BLOOD CLOTS jantoven oral tablet 1 or 1a* warfarin sodium oral tablet 1 or 1a* *DIRECT FACTOR XA INHIBITORS*** - DRUGS TO PREVENT BLOOD CLOTS ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY PACK 2 QL (74 tablets per 30 days) (apixaban) ELIQUIS ORAL TABLET 2.5 MG (apixaban) 2 QL (2 tablets per 1 day) ELIQUIS ORAL TABLET 5 MG (apixaban) 2 QL (74 tablets per 30 days) XARELTO ORAL TABLET 10 MG, 20 MG (rivaroxaban) 2 QL (1 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 36 Coverage Requirements and Prescription Drug Name Drug Tier Limits XARELTO ORAL TABLET 15 MG (rivaroxaban) 2 QL (42 tablet per 1 fill) XARELTO ORAL TABLET 2.5 MG (rivaroxaban) 2 QL (2 tablets per 1 day) XARELTO STARTER PACK ORAL TABLET THERAPY PACK 2 QL (1 pack per 365 days) (rivaroxaban) *HEPARINS AND HEPARINOID-LIKE AGENTS*** - DRUGS TO PREVENT BLOOD CLOTS heparin (porcine) in nacl intravenous solution 1000-0.9 ut/500ml-%, 2000-0.9 1 or 1b* unit/l-% HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 12500- 3 0.45 UT/250ML-%, 25000-0.45 UT/250ML-%, 25000-0.45 UT/500ML-% HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 2500-0.9 UT/500ML-%, 30000-0.9 UNIT/L-%, 500-0.9 UT/500ML-%, 5000-0.9 3 UNIT/L-%, 5000-0.9 UT/500ML-% heparin lock flush intravenous solution 1 or 1b* HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS SOLUTION 100 3 UNIT/ML, 25000-5 UT/500ML-% heparin sod (porcine) in d5w intravenous solution 40-5 unit/ml-% 1 or 1b* heparin sodium (porcine) injection solution 1 or 1b* HEPARIN SODIUM (PORCINE) INJECTION SOLUTION PREFILLED 3 SYRINGE heparin sodium (porcine) pf injection solution 5000 unit/0.5ml 1 or 1b* HEPARIN SODIUM (PORCINE) PF INJECTION SOLUTION 5000 3 UNIT/ML heparin sodium lock flush intravenous solution 1 or 1b* *LOW MOLECULAR WEIGHT HEPARINS*** - DRUGS TO PREVENT BLOOD CLOTS enoxaparin sodium injection solution 4 QL (30 syringes per 30 days) enoxaparin sodium subcutaneous solution 4 QL (30 syringes per 30 days) FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 4 QL (30 syringes per 30 days) UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML (dalteparin sodium) FRAGMIN SUBCUTANEOUS SOLUTION 95000 UNIT/3.8ML 4 QL (6 vials per 30 days) (dalteparin sodium) *SYNTHETIC HEPARINOID-LIKE AGENTS*** - DRUGS TO PREVENT BLOOD CLOTS ARIXTRA SUBCUTANEOUS SOLUTION (fondaparinux sodium) 4 QL (30 syringes per 30 days) fondaparinux sodium subcutaneous solution 4 QL (30 syringes per 30 days) *THROMBIN INHIBITORS - HIRUDIN TYPE*** - DRUGS TO PREVENT BLOOD CLOTS ANGIOMAX INTRAVENOUS SOLUTION RECONSTITUTED 3 (bivalirudin trifluoroacetate) BIVALIRUDIN RTU INTRAVENOUS SOLUTION 3 BIVALIRUDIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 *THROMBIN INHIBITORS - SELECTIVE DIRECT & REVERSIBLE*** - DRUGS TO PREVENT BLOOD CLOTS ARGATROBAN IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 37 Coverage Requirements and Prescription Drug Name Drug Tier Limits ARGATROBAN INTRAVENOUS SOLUTION 3 *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM *AMPA GLUTAMATE RECEPTOR ANTAGONISTS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN FYCOMPA ORAL SUSPENSION (perampanel) 3 QL (24 mL per 1 day) FYCOMPA ORAL TABLET (perampanel) 3 QL (1 tablet per 1 day) *ANTICONVULSANTS - BENZODIAZEPINES*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN clobazam oral suspension 1 or 1b* QL (16 mL per 1 day) clobazam oral tablet 1 or 1b* QL (2 tablets per 1 day) clonazepam oral tablet 1 or 1b* QL (3 tablets per 1 day) clonazepam oral tablet dispersible 1 or 1b* QL (3 tablets per 1 day) DIASTAT ACUDIAL RECTAL GEL (diazepam) 3 QL (2 syringes per 1 fill) DIASTAT PEDIATRIC RECTAL GEL (diazepam) 3 QL (2 syringes per 1 fill) diazepam rectal gel 1 or 1b* QL (2 syringes per 1 fill) NAYZILAM NASAL SOLUTION (midazolam (anticonvulsant)) 3 PA; QL (50 mg per 30 days) SYMPAZAN ORAL FILM 10 MG, 20 MG (clobazam) 3 QL (2 film strips per 1 day) SYMPAZAN ORAL FILM 5 MG (clobazam) 3 QL (1 film strip per 1 day) PA; QL (10 blister packs per 30 VALTOCO 10 MG DOSE NASAL LIQUID (diazepam) 3 days) PA; QL (10 blister packs per 30 VALTOCO 15 MG DOSE NASAL LIQUID THERAPY PACK (diazepam) 3 days) PA; QL (10 blister packs per 30 VALTOCO 20 MG DOSE NASAL LIQUID THERAPY PACK (diazepam) 3 days) PA; QL (10 blister packs per 30 VALTOCO 5 MG DOSE NASAL LIQUID (diazepam) 3 days) *ANTICONVULSANTS - MISC.*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN APTIOM ORAL TABLET 200 MG, 400 MG (eslicarbazepine acetate) 3 APTIOM ORAL TABLET 600 MG, 800 MG (eslicarbazepine acetate) 3 QL (2 tablets per 1 day) BANZEL ORAL SUSPENSION (rufinamide) 3 QL (80 mL per 1 day) BANZEL ORAL TABLET 200 MG (rufinamide) 3 QL (6 tablets per 1 day) BANZEL ORAL TABLET 400 MG (rufinamide) 3 QL (8 tablets per 1 day) BRIVIACT INTRAVENOUS SOLUTION (brivaracetam) 3 BRIVIACT ORAL SOLUTION (brivaracetam) 3 QL (20 mg per 1 day) BRIVIACT ORAL TABLET 10 MG (brivaracetam) 3 BRIVIACT ORAL TABLET 100 MG, 25 MG, 50 MG, 75 MG 3 QL (2 tablets per 1 day) (brivaracetam) carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg 1 or 1b* QL (2 capsules per 1 day) carbamazepine er oral capsule extended release 12 hour 300 mg 1 or 1b* QL (5 capsules per 1 day) carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg 1 or 1b* QL (2 tablets per 1 day) carbamazepine er oral tablet extended release 12 hour 400 mg 1 or 1b* QL (4 tablets per 1 day) carbamazepine oral suspension 1 or 1b* QL (50 mL per 1 day) carbamazepine oral tablet 1 or 1b* QL (8 tablets per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 38 Coverage Requirements and Prescription Drug Name Drug Tier Limits carbamazepine oral tablet chewable 1 or 1b* QL (10 tablets per 1 day) DIACOMIT ORAL CAPSULE 250 MG (stiripentol) 4 PA; LD; QL (12 capsules per 1 day) DIACOMIT ORAL CAPSULE 500 MG (stiripentol) 4 PA; LD; QL (6 capsules per 1 day) DIACOMIT ORAL PACKET 250 MG (stiripentol) 4 PA; LD; QL (8 packets per 1 day) DIACOMIT ORAL PACKET 500 MG (stiripentol) 4 PA; LD; QL (6 packets per 1 day) ELEPSIA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (2 tablets per 1 day) (levetiracetam) EPIDIOLEX ORAL SOLUTION (cannabidiol) 4 PA; LD; SP epitol oral tablet 1 or 1b* QL (8 tablets per 1 day) FINTEPLA ORAL SOLUTION (fenfluramine hcl) 4 PA; LD; QL (26 mg per 1 day) gabapentin oral capsule 100 mg, 400 mg 1 or 1b* QL (6 capsules per 1 day) gabapentin oral capsule 300 mg 1 or 1b* QL (9 capsules per 1 day) gabapentin oral solution 1 or 1b* QL (72 mL per 1 day) gabapentin oral tablet 600 mg 1 or 1b* QL (6 tablets per 1 day) gabapentin oral tablet 800 mg 1 or 1b* QL (4 tablets per 1 day) lamotrigine er oral tablet extended release 24 hour 100 mg 1 or 1b* QL (4 tablets per 1 day) lamotrigine er oral tablet extended release 24 hour 200 mg, 250 mg, 300 mg 1 or 1b* QL (2 tablets per 1 day) lamotrigine er oral tablet extended release 24 hour 25 mg, 50 mg 1 or 1b* QL (3 tablets per 1 day) lamotrigine oral kit 1 or 1b* QL (1 kit per 35 days) lamotrigine oral tablet 1 or 1b* QL (2 tablets per 1 day) lamotrigine oral tablet chewable 25 mg 1 or 1b* QL (2 tablets per 1 day) lamotrigine oral tablet chewable 5 mg 1 or 1b* QL (4 tablets per 1 day) lamotrigine oral tablet dispersible 100 mg, 200 mg 1 or 1b* QL (2 tablets per 1 day) lamotrigine oral tablet dispersible 25 mg 1 or 1b* QL (3 tablets per 1 day) lamotrigine oral tablet dispersible 50 mg 1 or 1b* QL (4 tablets per 1 day) lamotrigine starter kit-blue oral kit 1 or 1b* QL (1 kit per 28 days) lamotrigine starter kit-green oral kit 1 or 1b* QL (1 kit per 35 days) lamotrigine starter kit-orange oral kit 1 or 1b* QL (1 kit per 35 days) levetiracetam er oral tablet extended release 24 hour 500 mg 1 or 1b* QL (6 tablets per 1 day) levetiracetam er oral tablet extended release 24 hour 750 mg 1 or 1b* QL (4 tablets per 1 day) LEVETIRACETAM IN NACL INTRAVENOUS SOLUTION 3 levetiracetam intravenous solution 1 or 1b* levetiracetam oral solution 1 or 1b* levetiracetam oral tablet 1000 mg 1 or 1b* QL (3 tablets per 1 day) levetiracetam oral tablet 250 mg 1 or 1b* QL (2 tablets per 1 day) levetiracetam oral tablet 500 mg 1 or 1b* QL (6 tablets per 1 day) levetiracetam oral tablet 750 mg 1 or 1b* QL (4 tablets per 1 day) oxcarbazepine oral suspension 1 or 1b* QL (40 mL per 1 day) oxcarbazepine oral tablet 150 mg, 300 mg 1 or 1b* QL (2 tablets per 1 day) oxcarbazepine oral tablet 600 mg 1 or 1b* QL (4 tablets per 1 day) OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 3 QL (3 tablets per 1 day) MG, 300 MG (oxcarbazepine)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 39 Coverage Requirements and Prescription Drug Name Drug Tier Limits OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 600 3 QL (4 tablets per 1 day) MG (oxcarbazepine) pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg 1 or 1b* QL (3 capsule per 1 day) pregabalin oral capsule 225 mg, 300 mg, 75 mg 1 or 1b* QL (2 capsules per 1 day) pregabalin oral solution 1 or 1b* QL (30 mL per 1 day) primidone oral tablet 1 or 1b* QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 25 3 QL (1 capsule per 1 day) MG, 50 MG (topiramate) QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 150 MG, 200 3 QL (2 capsules per 1 day) MG (topiramate) roweepra oral tablet 1 or 1b* QL (6 tablets per 1 day) rufinamide oral suspension 1 or 1b* QL (80 mL per 1 day) rufinamide oral tablet 200 mg 1 or 1b* QL (6 tablets per 1 day) rufinamide oral tablet 400 mg 1 or 1b* QL (8 tablets per 1 day) SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 3 QL (2 tablets per 1 day) 250 MG, 500 MG (levetiracetam) SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 750 MG 3 QL (4 tablets per 1 day) (levetiracetam) subvenite oral tablet 1 or 1b* QL (2 tablets per 1 day) subvenite starter kit-blue oral kit 1 or 1b* QL (1 kit per 28 days) subvenite starter kit-green oral kit 1 or 1b* QL (1 kit per 35 days) subvenite starter kit-orange oral kit 1 or 1b* QL (1 kit per 35 days) topiramate er oral capsule er 24 hour sprinkle 100 mg, 25 mg, 50 mg 1 or 1b* QL (1 capsule per 1 day) topiramate er oral capsule er 24 hour sprinkle 150 mg, 200 mg 1 or 1b* QL (2 capsules per 1 day) topiramate oral capsule sprinkle 1 or 1b* QL (2 capsules per 1 day) topiramate oral tablet 1 or 1b* QL (2 tablets per 1 day) TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 QL (1 capsule per 1 day) 100 MG, 25 MG, 50 MG (topiramate) TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 QL (2 capsules per 1 day) 200 MG (topiramate) VIMPAT INTRAVENOUS SOLUTION (lacosamide) 3 VIMPAT ORAL SOLUTION (lacosamide) 3 QL (40 mL per 1 day) VIMPAT ORAL TABLET (lacosamide) 3 QL (2 tablets per 1 day) zonisamide oral capsule 1 or 1b* QL (6 capsule per 1 day) *CARBAMATES*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN felbamate oral suspension 1 or 1b* felbamate oral tablet 1 or 1b* XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 3 QL (1 blister pack per 28 days) 100 & 150 MG (cenobamate) XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 50 3 QL (1 pack per 28 days) & 200 MG (cenobamate) XCOPRI (350 MG DAILY DOSE) ORAL TABLET THERAPY PACK 3 QL (1 pack per 28 days) (cenobamate)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 40 Coverage Requirements and Prescription Drug Name Drug Tier Limits XCOPRI ORAL TABLET 100 MG, 150 MG, 50 MG (cenobamate) 3 QL (1 tablet per 1 day) XCOPRI ORAL TABLET 200 MG (cenobamate) 3 QL (2 tablets per 1 day) XCOPRI ORAL TABLET THERAPY PACK (cenobamate) 3 QL (1 pack per 28 days) *GABA MODULATORS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN tiagabine hcl oral tablet 1 or 1b* vigabatrin oral packet 1 or 1b* LD; SP; QL (6 packets per 1 day) vigabatrin oral tablet 1 or 1b* LD; SP; QL (6 tablets per 1 day) vigadrone oral packet 1 or 1b* LD; QL (6 packets per 1 day) *HYDANTOINS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN CEREBYX INJECTION SOLUTION (fosphenytoin sodium) 3 DILANTIN INFATABS ORAL TABLET CHEWABLE (phenytoin) 3 DILANTIN ORAL CAPSULE 100 MG (phenytoin sodium extended) 3 DILANTIN ORAL CAPSULE 30 MG (phenytoin sodium extended) 2 DILANTIN ORAL SUSPENSION (phenytoin) 3 fosphenytoin sodium injection solution 1 or 1b* PHENYTEK ORAL CAPSULE (phenytoin sodium extended) 3 phenytoin infatabs oral tablet chewable 1 or 1b* phenytoin oral suspension 1 or 1b* phenytoin oral tablet chewable 1 or 1b* phenytoin sodium extended oral capsule 1 or 1b* phenytoin sodium injection solution 1 or 1b* *SUCCINIMIDES*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN CELONTIN ORAL CAPSULE (methsuximide) 3 ethosuximide oral capsule 1 or 1b* ethosuximide oral solution 1 or 1b* *VALPROIC ACID*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN divalproex sodium er oral tablet extended release 24 hour 250 mg 1 or 1b* QL (2 tablets per 1 day) divalproex sodium er oral tablet extended release 24 hour 500 mg 1 or 1b* QL (7 tablets per 1 day) divalproex sodium oral capsule delayed release sprinkle 1 or 1b* QL (8 capsules per 1 day) divalproex sodium oral tablet delayed release 125 mg, 250 mg 1 or 1b* QL (2 tablets per 1 day) divalproex sodium oral tablet delayed release 500 mg 1 or 1b* QL (7 tablets per 1 day) valproate sodium intravenous solution 1 or 1b* valproic acid oral capsule 1 or 1b* QL (4 capsules per 1 day) valproic acid oral solution 1 or 1b* *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM *ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)*** - DRUGS FOR DEPRESSION mirtazapine oral tablet 1 or 1b* mirtazapine oral tablet dispersible 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 41 Coverage Requirements and Prescription Drug Name Drug Tier Limits REMERON ORAL TABLET (mirtazapine) 3 REMERON SOLTAB ORAL TABLET DISPERSIBLE (mirtazapine) 3 *ANTIDEPRESSANTS - MISC.*** - DRUGS FOR DEPRESSION APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 174 MG 3 ST (bupropion hbr) APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 348 MG, 3 ST; QL (1 tablet per 1 day) 522 MG (bupropion hbr) bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg 1 or 1b* bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg 1 or 1b* QL (2 tablets per 1 day) bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg 1 or 1b* bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg, 450 mg 1 or 1b* QL (1 tablet per 1 day) bupropion hcl oral tablet 100 mg 1 or 1b* QL (4.5 tablet per 1 day) bupropion hcl oral tablet 75 mg 1 or 1b* *GABA RECEPTOR MODULATOR - NEUROACTIVE STEROID*** - DRUGS FOR DEPRESSION ZULRESSO INTRAVENOUS SOLUTION (brexanolone) 4 PA; LD; SP *MONOAMINE OXIDASE INHIBITORS (MAOIS)*** - DRUGS FOR DEPRESSION EMSAM TRANSDERMAL PATCH 24 HOUR (selegiline) 3 MARPLAN ORAL TABLET (isocarboxazid) 3 QL (6 tablets per 1 day) NARDIL ORAL TABLET (phenelzine sulfate) 3 PARNATE ORAL TABLET (tranylcypromine sulfate) 3 phenelzine sulfate oral tablet 1 or 1b* tranylcypromine sulfate oral tablet 1 or 1b* *N-METHYL-D-ASPARTIC ACID (NMDA) RECEPTOR ANTAGONISTS*** - DRUGS FOR DEPRESSION SPRAVATO (56 MG DOSE) NASAL SOLUTION THERAPY PACK 4 PA; LD; QL (4 kits per 28 days) (esketamine hcl) SPRAVATO (84 MG DOSE) NASAL SOLUTION THERAPY PACK 4 PA; LD; QL (4 kits per 28 days) (esketamine hcl) *SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)*** - DRUGS FOR DEPRESSION citalopram hydrobromide oral solution 1 or 1b* QL (20 mL per 1 day) citalopram hydrobromide oral tablet 10 mg, 20 mg 1 or 1b* citalopram hydrobromide oral tablet 40 mg 1 or 1b* QL (1 tablet per 1 day) escitalopram oxalate oral solution 1 or 1b* QL (20 mL per 1 day) escitalopram oxalate oral tablet 10 mg, 5 mg 1 or 1b* escitalopram oxalate oral tablet 20 mg 1 or 1b* QL (1 tablet per 1 day) fluoxetine hcl oral capsule 10 mg 1 or 1b* fluoxetine hcl oral capsule 20 mg 1 or 1b* QL (4 capsules per 1 day) fluoxetine hcl oral capsule 40 mg 1 or 1b* QL (2 capsules per 1 day) fluoxetine hcl oral capsule delayed release 1 or 1b* QL (4 capsules per 28 days) fluoxetine hcl oral solution 1 or 1b* QL (20 mL per 1 day) fluoxetine hcl oral tablet 10 mg 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 42 Coverage Requirements and Prescription Drug Name Drug Tier Limits fluoxetine hcl oral tablet 20 mg 1 or 1b* QL (4 tablets per 1 day) FLUOXETINE HCL ORAL TABLET 60 MG 3 QL (1 tablet per 1 day) fluvoxamine maleate er oral capsule extended release 24 hour 1 or 1b* QL (2 capsules per 1 day) fluvoxamine maleate oral tablet 100 mg 1 or 1b* QL (3 tablet per 1 day) fluvoxamine maleate oral tablet 25 mg, 50 mg 1 or 1b* paroxetine hcl er oral tablet extended release 24 hour 12.5 mg 1 or 1b* paroxetine hcl er oral tablet extended release 24 hour 25 mg, 37.5 mg 1 or 1b* QL (2 tablets per 1 day) paroxetine hcl oral tablet 10 mg, 20 mg 1 or 1b* paroxetine hcl oral tablet 30 mg 1 or 1b* QL (2 tablets per 1 day) paroxetine hcl oral tablet 40 mg 1 or 1b* QL (1.5 tablet per 1 day) PAXIL ORAL SUSPENSION (paroxetine hcl) 3 ST; QL (30 mL per 1 day) PEXEVA ORAL TABLET 10 MG, 20 MG (paroxetine mesylate) 3 ST PEXEVA ORAL TABLET 30 MG (paroxetine mesylate) 3 ST; QL (2 tablets per 1 day) PEXEVA ORAL TABLET 40 MG (paroxetine mesylate) 3 ST; QL (1.5 tablet per 1 day) sertraline hcl oral concentrate 1 or 1b* QL (10 mL per 1 day) sertraline hcl oral tablet 100 mg 1 or 1b* QL (2 tablets per 1 day) sertraline hcl oral tablet 25 mg, 50 mg 1 or 1b* *SEROTONIN MODULATORS*** - DRUGS FOR DEPRESSION nefazodone hcl oral tablet 1 or 1b* trazodone hcl oral tablet 1 or 1a* TRINTELLIX ORAL TABLET 10 MG, 5 MG (vortioxetine hbr) 3 TRINTELLIX ORAL TABLET 20 MG (vortioxetine hbr) 3 QL (1 tablet per 1 day) *SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)*** - DRUGS FOR DEPRESSION DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 3 ST; QL (1 tablet per 1 day) HOUR 100 MG DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 3 ST HOUR 50 MG desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg 1 or 1b* QL (1 tablet per 1 day) desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg, 50 mg 1 or 1b* duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg 1 or 1b* QL (2 capsules per 1 day) duloxetine hcl oral capsule delayed release particles 30 mg 1 or 1b* duloxetine hcl oral capsule delayed release particles 40 mg 1 or 1b* QL (3 capsule per 1 day) FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 ST; QL (1 capsule per 1 day) (levomilnacipran hcl) FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY 3 ST; QL (28 pack per 365 days) PACK (levomilnacipran hcl) venlafaxine hcl er oral capsule extended release 24 hour 150 mg 1 or 1b* QL (1 capsule per 1 day) venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg 1 or 1b* venlafaxine hcl er oral tablet extended release 24 hour 150 mg, 225 mg 1 or 1b* QL (1 tablet per 1 day) venlafaxine hcl er oral tablet extended release 24 hour 37.5 mg, 75 mg 1 or 1b* venlafaxine hcl oral tablet 1 or 1b* QL (3 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 43 Coverage Requirements and Prescription Drug Name Drug Tier Limits *TRICYCLIC AGENTS*** - DRUGS FOR DEPRESSION amitriptyline hcl oral tablet 1 or 1a* amoxapine oral tablet 100 mg 1 or 1b* QL (4 tablets per 1 day) amoxapine oral tablet 150 mg 1 or 1b* QL (2 tablets per 1 day) amoxapine oral tablet 25 mg, 50 mg 1 or 1b* clomipramine hcl oral capsule 1 or 1b* desipramine hcl oral tablet 1 or 1b* doxepin hcl oral capsule 1 or 1b* doxepin hcl oral concentrate 1 or 1b* imipramine hcl oral tablet 1 or 1b* imipramine pamoate oral capsule 1 or 1b* NORPRAMIN ORAL TABLET (desipramine hcl) 3 nortriptyline hcl oral capsule 1 or 1b* nortriptyline hcl oral solution 1 or 1b* PAMELOR ORAL CAPSULE (nortriptyline hcl) 3 protriptyline hcl oral tablet 1 or 1b* trimipramine maleate oral capsule 1 or 1b* *ANTIDIABETICS* - HORMONES *ALPHA-GLUCOSIDASE INHIBITORS*** - DRUGS FOR DIABETES acarbose oral tablet 1 or 1b* QL (3 tablets per 1 day) miglitol oral tablet 1 or 1b* QL (3 tablets per 1 day) PRECOSE ORAL TABLET (acarbose) 3 QL (3 tablets per 1 day) *ANTIDIABETIC - AMYLIN ANALOGS*** - DRUGS FOR DIABETES SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (4 pens per 30 days) (pramlintide acetate) SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (2 boxes per 30 days) (pramlintide acetate) *BIGUANIDES*** - DRUGS FOR DIABETES metformin hcl er oral tablet extended release 24 hour 1 or 1b* metformin hcl oral solution 1 or 1b* PA; QL (2 bottles per 30 days) metformin hcl oral tablet 1 or 1b* RIOMET ORAL SOLUTION (metformin hcl) 3 PA; QL (2 bottles per 30 days) *DIABETIC OTHER*** - DRUGS FOR DIABETES BAQSIMI ONE PACK NASAL POWDER (glucagon) 3 QL (2 packs per 30 days) BAQSIMI TWO PACK NASAL POWDER (glucagon) 3 QL (1 pack per 30 days) diazoxide oral suspension 1 or 1b* GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 2 QL (2 kits per 30 days) (glucagon hcl (rdna)) GLUCAGON EMERGENCY INJECTION KIT 1 or 1b* QL (2 kits per 30 days) GLUCAGON EMERGENCY INJECTION SOLUTION 3 RECONSTITUTED GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION AUTO- 3 QL (2 packs per 30 days) INJECTOR (glucagon) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 44 Coverage Requirements and Prescription Drug Name Drug Tier Limits GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION AUTO- 3 QL (2 packs per 30 days) INJECTOR (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 QL (2 packs per 30 days) (glucagon) PROGLYCEM ORAL SUSPENSION (diazoxide) 3 ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 (dasiglucagon hcl) ZEGALOGUE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 (dasiglucagon hcl) *DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS*** - DRUGS FOR DIABETES alogliptin benzoate oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) JANUVIA ORAL TABLET (sitagliptin phosphate) 2 ST; QL (1 tablet per 1 day) *DIPEPTIDYL PEPTIDASE-4 INHIBITOR-BIGUANIDE COMBINATIONS*** - DRUGS FOR DIABETES alogliptin-metformin hcl oral tablet 1 or 1b* ST; QL (2 tablets per 1 day) JANUMET ORAL TABLET (sitagliptin-metformin hcl) 2 ST; QL (2 tablets per 1 day) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100- 2 ST; QL (1 tablet per 1 day) 1000 MG (sitagliptin-metformin hcl) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50- 2 ST; QL (2 tablets per 1 day) 1000 MG, 50-500 MG (sitagliptin-metformin hcl) *DOPAMINE RECEPTOR AGONISTS - ERGOT DERIVATIVES*** - DRUGS FOR DIABETES CYCLOSET ORAL TABLET (bromocriptine mesylate) 3 *DPP-4 INHIBITOR-THIAZOLIDINEDIONE COMBINATIONS*** - DRUGS FOR DIABETES alogliptin-pioglitazone oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *HUMAN INSULIN*** - DRUGS FOR DIABETES BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 QL (30 mL per 30 days) INJECTOR (insulin glargine) HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 QL (30 mL per 30 days) INJECTOR (insulin lispro) HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 QL (30 mL per 30 days) INJECTOR (insulin lispro) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION 2 QL (30 mL per 30 days) PEN-INJECTOR (insulin lispro prot & lispro) HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (insulin lispro 2 QL (30 mL per 30 days) prot & lispro) HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION 2 QL (30 mL per 30 days) PEN-INJECTOR (insulin lispro prot & lispro) HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (insulin lispro 2 QL (30 mL per 30 days) prot & lispro) HUMALOG SUBCUTANEOUS SOLUTION (insulin lispro) 2 QL (30 mL per 30 days) HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE (insulin lispro) 2 QL (30 mL per 30 days) HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- 2 QL (30 mL per 30 days) INJECTOR (insulin nph isophane & regular)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 45 Coverage Requirements and Prescription Drug Name Drug Tier Limits HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (insulin nph isophane 2 QL (30 mL per 30 days) & regular) HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN- 2 QL (30 mL per 30 days) INJECTOR (insulin nph human (isophane)) HUMULIN N SUBCUTANEOUS SUSPENSION (insulin nph human 2 QL (30 mL per 30 days) (isophane)) HUMULIN R INJECTION SOLUTION (insulin regular human) 2 QL (30 mL per 30 days) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS 2 PA; QL (20 mL per 30 days) SOLUTION (insulin regular human) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 PA; QL (18 mL per 30 days) INJECTOR (insulin regular human) LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- 2 QL (30 mL per 30 days) INJECTOR (insulin detemir) LEVEMIR SUBCUTANEOUS SOLUTION (insulin detemir) 2 QL (30 mL per 30 days) MYXREDLIN INTRAVENOUS SOLUTION (insulin regular(human) in 3 nacl) TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 QL (12 mL per 30 days) INJECTOR (insulin glargine) TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (13.5 mL per 30 days) (insulin glargine) TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- 2 QL (30 mL per 30 days) INJECTOR 100 UNIT/ML (insulin degludec) TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- 2 QL (18 mL per 30 days) INJECTOR 200 UNIT/ML (insulin degludec) TRESIBA SUBCUTANEOUS SOLUTION (insulin degludec) 2 QL (30 mL per 30 days) *INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)*** - DRUGS FOR DIABETES OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION 2 ST; QL (1 pen per 28 days) PEN-INJECTOR (semaglutide) OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- 2 ST; QL (2 pens per 28 days) INJECTOR 2 MG/1.5ML (semaglutide) OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- 2 ST; QL (1 unit per 28 days) INJECTOR 4 MG/3ML (semaglutide) RYBELSUS ORAL TABLET 14 MG, 7 MG (semaglutide) 2 ST; QL (1 carton per 30 days) RYBELSUS ORAL TABLET 3 MG (semaglutide) 2 ST; QL (1 carton per 1 fill) TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 2 ST; QL (4 pens per 28 days) MG/0.5ML, 1.5 MG/0.5ML (dulaglutide) TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 3 2 ST; QL (4 syringes per 28 days) MG/0.5ML, 4.5 MG/0.5ML (dulaglutide) VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR (liraglutide) 2 ST; QL (1 box per 30 days) *INSULIN-INCRETIN MIMETIC COMBINATIONS*** - DRUGS FOR DIABETES SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR (insulin 2 QL (5 pen per 25 days) glargine-lixisenatide) XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR (insulin 2 QL (5 pen per 30 days) degludec-liraglutide)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 46 Coverage Requirements and Prescription Drug Name Drug Tier Limits *MEGLITINIDE ANALOGUES*** - DRUGS FOR DIABETES nateglinide oral tablet 1 or 1b* QL (3 tablets per 1 day) repaglinide oral tablet 0.5 mg, 1 mg 1 or 1b* QL (4 tablets per 1 day) repaglinide oral tablet 2 mg 1 or 1b* QL (8 tablets per 1 day) *PROGESTERONE RECEPTOR ANTAGONISTS*** - DRUGS FOR DIABETES KORLYM ORAL TABLET (mifepristone) 4 PA; LD *SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS*** - DRUGS FOR DIABETES GLYXAMBI ORAL TABLET (empagliflozin-linagliptin) 2 QL (1 tablet per 1 day) *SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS*** - DRUGS FOR DIABETES FARXIGA ORAL TABLET (dapagliflozin propanediol) 2 ST; QL (1 tablet per 1 day) JARDIANCE ORAL TABLET (empagliflozin) 2 ST; QL (1 tablet per 1 day) *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR- BIGUANIDE COMB*** - DRUGS FOR DIABETES SYNJARDY ORAL TABLET (empagliflozin-metformin hcl) 2 ST; QL (2 tablets per 1 day) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10- 2 ST; QL (2 tablets per 1 day) 1000 MG, 12.5-1000 MG, 5-1000 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 25- 2 ST; QL (1 tablet per 1 day) 1000 MG (empagliflozin-metformin hcl) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10- 2 ST; QL (1 tablet per 1 day) 1000 MG, 10-500 MG, 5-500 MG (dapagliflozin-metformin hcl) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5- 2 ST; QL (2 tablet per 1 day) 1000 MG (dapagliflozin-metformin hcl) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 2 ST; QL (2 tablets per 1 day) MG (dapagliflozin-metformin hcl) *SULFONYLUREA-BIGUANIDE COMBINATIONS*** - DRUGS FOR DIABETES glipizide-metformin hcl oral tablet 1 or 1b* ST glyburide-metformin oral tablet 1 or 1b* ST *SULFONYLUREAS*** - DRUGS FOR DIABETES AMARYL ORAL TABLET (glimepiride) 3 ST glimepiride oral tablet 1 or 1b* ST glipizide er oral tablet extended release 24 hour 1 or 1a* ST glipizide oral tablet 1 or 1a* ST glipizide xl oral tablet extended release 24 hour 1 or 1a* ST GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 ST (glipizide) glyburide micronized oral tablet 1 or 1b* ST glyburide oral tablet 1 or 1b* ST GLYNASE ORAL TABLET (glyburide micronized) 3 ST tolbutamide oral tablet 1 or 1b* ST

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 47 Coverage Requirements and Prescription Drug Name Drug Tier Limits *SULFONYLUREA-THIAZOLIDINEDIONE COMBINATIONS*** - DRUGS FOR DIABETES DUETACT ORAL TABLET (pioglitazone hcl-glimepiride) 3 ST; QL (1 tablet per 1 day) pioglitazone hcl-glimepiride oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *THIAZOLIDINEDIONE-BIGUANIDE COMBINATIONS*** - DRUGS FOR DIABETES ACTOPLUS MET ORAL TABLET (pioglitazone hcl-metformin hcl) 3 ST; QL (3 tablet per 1 day) pioglitazone hcl-metformin hcl oral tablet 1 or 1b* ST; QL (3 tablets per 1 day) *THIAZOLIDINEDIONES*** - DRUGS FOR DIABETES pioglitazone hcl oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *ANTIDIARRHEAL/PROBIOTIC AGENTS* - DRUGS FOR THE STOMACH *ANTIDIARRHEAL - CHLORIDE CHANNEL ANTAGONISTS*** - DRUGS FOR DIARRHEA MYTESI ORAL TABLET DELAYED RELEASE (crofelemer) 3 PA; LD; QL (2 tablets per 1 day) *ANTIDIARRHEAL/PROBIOTIC COMBINATIONS*** - DRUGS FOR DIARRHEA RESTORA RX ORAL CAPSULE (lactobacillus casei-folic acid) 3 *ANTIPERISTALTIC AGENTS*** - DRUGS FOR DIARRHEA diphenoxylate-atropine oral liquid 1 or 1b* diphenoxylate-atropine oral tablet 1 or 1b* LOMOTIL ORAL TABLET (diphenoxylate-atropine) 3 loperamide hcl oral capsule 1 or 1b* MOTOFEN ORAL TABLET (difenoxin-atropine) 3 *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING *ANTIDOTE COMBINATIONS*** - DRUGS FOR OVERDOSE OR POISONING DUODOTE INTRAMUSCULAR SOLUTION AUTO-INJECTOR 3 (atropine-pralidoxime chloride) NITHIODOTE INTRAVENOUS KIT (sodium nitrite-sod thiosulfate) 3 *ANTIDOTES - CHELATING AGENTS*** - DRUGS FOR OVERDOSE OR POISONING CHEMET ORAL CAPSULE (succimer) 3 deferasirox granules oral packet 4 PA; SP deferasirox oral packet 4 PA; SP deferasirox oral tablet 180 mg 4 SP deferasirox oral tablet 360 mg, 90 mg 4 PA; SP deferasirox oral tablet soluble 4 PA; SP deferiprone oral tablet 4 PA EXJADE ORAL TABLET SOLUBLE (deferasirox) 4 PA; LD; SP FERRIPROX ORAL SOLUTION (deferiprone) 4 PA; LD FERRIPROX ORAL TABLET (deferiprone) 4 PA; LD FERRIPROX TWICE-A-DAY ORAL TABLET (deferiprone) 4 PA; LD

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 48 Coverage Requirements and Prescription Drug Name Drug Tier Limits JADENU ORAL TABLET (deferasirox) 4 PA; LD; SP JADENU SPRINKLE ORAL PACKET (deferasirox) 4 PA; LD; SP PENTETATE CALCIUM TRISODIUM COMBINATION SOLUTION 3 PENTETATE ZINC TRISODIUM COMBINATION SOLUTION 3 *ANTIDOTES AND SPECIFIC ANTAGONISTS*** - DRUGS FOR OVERDOSE OR POISONING ACETADOTE INTRAVENOUS SOLUTION (acetylcysteine) 3 acetylcysteine intravenous solution 1 or 1b* ANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED (coag fact 3 xa inactivated-zhzo) BAL IN OIL INTRAMUSCULAR SOLUTION 3 BRIDION INTRAVENOUS SOLUTION (sugammadex sodium) 3 CALCIUM DISODIUM VERSENATE INJECTION SOLUTION 3 CYANOKIT INTRAVENOUS SOLUTION RECONSTITUTED 3 (hydroxocobalamin) deferoxamine mesylate injection solution reconstituted 4 SP DESFERAL INJECTION SOLUTION RECONSTITUTED (deferoxamine 4 SP mesylate) DIGIFAB INTRAVENOUS SOLUTION RECONSTITUTED (digoxin 3 immune fab) fomepizole intravenous solution 1 or 1b* PRAXBIND INTRAVENOUS SOLUTION (idarucizumab) 3 PROTOPAM CHLORIDE INTRAVENOUS SOLUTION 3 RECONSTITUTED (pralidoxime chloride) PROVAYBLUE INTRAVENOUS SOLUTION (methylene blue (antidote)) 3 RADIOGARDASE ORAL CAPSULE (prussian blue insoluble) 3 SODIUM NITRITE INTRAVENOUS SOLUTION 3 PA; LD; QL (20 packets per 30 VISTOGARD ORAL PACKET (uridine triacetate) 3 days) *BENZODIAZEPINE ANTAGONISTS*** - DRUGS FOR OVERDOSE OR POISONING flumazenil intravenous solution 1 or 1b* *OPIOID ANTAGONISTS*** - DRUGS FOR OVERDOSE OR POISONING naloxone hcl injection solution 1 or 1b* QL (6 vial per 90 days) naloxone hcl injection solution cartridge 1 or 1b* QL (6 syringe per 90 days) naloxone hcl injection solution prefilled syringe 1 or 1b* QL (6 syringe per 90 days) naltrexone hcl oral tablet 1 or 1b* NARCAN NASAL LIQUID (naloxone hcl) 2 QL (6 nasal spray per 90 days) VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 4 SP; QL (1 vial per 28 days) (naltrexone)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 49 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIEMETICS* - DRUGS FOR THE STOMACH *5-HT3 RECEPTOR ANTAGONISTS*** - DRUGS FOR VOMITING AND NAUSEA ALOXI INTRAVENOUS SOLUTION (palonosetron hcl) 3 PA granisetron hcl intravenous solution 1 or 1b* granisetron hcl oral tablet 1 or 1b* QL (10 tablets per 30 days) ondansetron hcl injection solution 1 or 1b* ondansetron hcl oral solution 1 or 1b* QL (8 mL per 1 day) ondansetron hcl oral tablet 24 mg 1 or 1b* QL (8 tablet per 30 days) ondansetron hcl oral tablet 4 mg 1 or 1b* QL (48 tablets per 30 days) ondansetron hcl oral tablet 8 mg 1 or 1b* QL (24 tablets per 30 days) ondansetron oral tablet dispersible 4 mg 1 or 1b* QL (48 tablets per 30 days) ondansetron oral tablet dispersible 8 mg 1 or 1b* QL (24 tablets per 30 days) PALONOSETRON HCL INTRAVENOUS SOLUTION 0.25 MG/2ML 3 PA palonosetron hcl intravenous solution 0.25 mg/5ml 1 or 1b* PA palonosetron hcl intravenous solution prefilled syringe 1 or 1b* PA SANCUSO TRANSDERMAL PATCH (granisetron) 3 QL (4 patches per 28 days) SUSTOL SUBCUTANEOUS PREFILLED SYRINGE (granisetron) 3 ZOFRAN ORAL TABLET (ondansetron hcl) 3 QL (48 tablets per 30 days) ZUPLENZ ORAL FILM 4 MG (ondansetron) 3 QL (48 films per 30 days) ZUPLENZ ORAL FILM 8 MG (ondansetron) 3 QL (24 films per 30 days) *ANTIEMETIC COMBINATIONS*** - DRUGS FOR VOMITING AND NAUSEA AKYNZEO INTRAVENOUS SOLUTION (fosnetupitant-palonosetron) 3 PA; QL (5 vials per 30 days) AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; QL (5 vials per 30 days) (fosnetupitant-palonosetron) AKYNZEO ORAL CAPSULE (netupitant-palonosetron) 3 QL (5 capsules per 25 days) BONJESTA ORAL TABLET EXTENDED RELEASE (doxylamine- 3 PA; QL (4 tablet per 1 day) pyridoxine) doxylamine-pyridoxine oral tablet delayed release 1 or 1b* PA; QL (4 tablet per 1 day) *ANTIEMETICS - ANTICHOLINERGIC*** - DRUGS FOR VOMITING AND NAUSEA DIMENHYDRINATE INJECTION SOLUTION 3 meclizine hcl oral tablet 1 or 1a* meclizine hcl oral tablet chewable 1 or 1a* scopolamine transdermal patch 72 hour 1 or 1b* TIGAN INTRAMUSCULAR SOLUTION (trimethobenzamide hcl) 3 trimethobenzamide hcl oral capsule 1 or 1b* *ANTIEMETICS - ANTIDOPAMINERGIC*** - DRUGS FOR VOMITING AND NAUSEA BARHEMSYS INTRAVENOUS SOLUTION (amisulpride (antiemetic)) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 50 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIEMETICS - MISCELLANEOUS*** - DRUGS FOR VOMITING AND NAUSEA dronabinol oral capsule 1 or 1b* MARINOL ORAL CAPSULE (dronabinol) 3 SYNDROS ORAL SOLUTION (dronabinol) 3 *SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS*** - DRUGS FOR VOMITING AND NAUSEA aprepitant oral 1 or 1b* QL (15 capsules per 25 days) aprepitant oral capsule 125 mg 1 or 1b* QL (5 capsules per 25 days) aprepitant oral capsule 40 mg 1 or 1b* QL (1 capsule per 1 fill) aprepitant oral capsule 80 & 125 mg 1 or 1b* QL (15 capsules per 25 days) aprepitant oral capsule 80 mg 1 or 1b* QL (10 capsules per 25 days) CINVANTI INTRAVENOUS EMULSION (aprepitant) 3 PA; QL (5 vials per 30 days) EMEND ORAL SUSPENSION RECONSTITUTED (aprepitant) 3 QL (15 kit per 30 days) fosaprepitant dimeglumine intravenous solution reconstituted 1 or 1b* PA; QL (5 vial per 30 days) VARUBI (180 MG DOSE) ORAL TABLET THERAPY PACK (rolapitant 3 QL (4 capsules per 28 days) hcl) *ANTIFUNGALS* - DRUGS FOR INFECTIONS *ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)*** - ANTIBIOTICS CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 3 (caspofungin acetate) CASPOFUNGIN ACETATE INTRAVENOUS SOLUTION 3 RECONSTITUTED ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 3 (anidulafungin) micafungin sodium intravenous solution reconstituted 1 or 1b* MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 3 (micafungin sodium) *ANTIFUNGALS*** - DRUGS FOR FUNGUS ABELCET INTRAVENOUS SUSPENSION (amphotericin b lipid) 3 AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 3 (amphotericin b liposome) amphotericin b intravenous solution reconstituted 1 or 1b* ANCOBON ORAL CAPSULE (flucytosine) 3 PA flucytosine oral capsule 1 or 1b* PA griseofulvin microsize oral suspension 1 or 1b* griseofulvin microsize oral tablet 1 or 1b* griseofulvin ultramicrosize oral tablet 1 or 1b* nystatin oral tablet 1 or 1b* terbinafine hcl oral tablet 1 or 1b* QL (1 tablet per 1 day) *IMIDAZOLES*** - DRUGS FOR FUNGUS ketoconazole oral tablet 1 or 1b* QL (2 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 51 Coverage Requirements and Prescription Drug Name Drug Tier Limits *TRIAZOLES*** - DRUGS FOR FUNGUS CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; QL (1 vial per 1 day) (isavuconazonium sulfate) CRESEMBA ORAL CAPSULE (isavuconazonium sulfate) 3 PA; QL (2 capsules per 1 day) DIFLUCAN ORAL SUSPENSION RECONSTITUTED 10 MG/ML 3 QL (40 mL per 1 day) (fluconazole) DIFLUCAN ORAL SUSPENSION RECONSTITUTED 40 MG/ML 3 QL (10 mL per 1 day) (fluconazole) DIFLUCAN ORAL TABLET 100 MG (fluconazole) 3 QL (4 tablet per 1 day) DIFLUCAN ORAL TABLET 150 MG, 200 MG (fluconazole) 3 QL (2 tablets per 1 day) DIFLUCAN ORAL TABLET 50 MG (fluconazole) 3 QL (8 tablet per 1 day) fluconazole in sodium chloride intravenous solution 1 or 1b* fluconazole oral suspension reconstituted 10 mg/ml 1 or 1b* QL (40 mL per 1 day) fluconazole oral suspension reconstituted 40 mg/ml 1 or 1b* QL (10 mL per 1 day) fluconazole oral tablet 100 mg 1 or 1b* QL (4 tablet per 1 day) fluconazole oral tablet 150 mg, 200 mg 1 or 1b* QL (2 tablets per 1 day) fluconazole oral tablet 50 mg 1 or 1b* QL (8 tablet per 1 day) itraconazole oral capsule 1 or 1b* PA; QL (4.2 capsules per 1 day) itraconazole oral solution 1 or 1b* PA; QL (20 mL per 1 day) NOXAFIL INTRAVENOUS SOLUTION (posaconazole) 3 NOXAFIL ORAL SUSPENSION (posaconazole) 3 PA; QL (20 mL per 1 day) NOXAFIL ORAL TABLET DELAYED RELEASE (posaconazole) 3 PA; QL (8 tablet per 1 day) posaconazole oral tablet delayed release 1 or 1b* PA; QL (8 tablet per 1 day) SPORANOX ORAL CAPSULE (itraconazole) 3 PA; QL (4.2 capsules per 1 day) SPORANOX ORAL SOLUTION (itraconazole) 3 PA; QL (20 mL per 1 day) SPORANOX PULSEPAK ORAL CAPSULE (itraconazole) 3 PA; QL (4.2 capsules per 1 day) TOLSURA ORAL CAPSULE 3 PA; QL (126 capsules per 30 days) VFEND ORAL SUSPENSION RECONSTITUTED (voriconazole) 3 PA; QL (10 mL per 1 day) VFEND ORAL TABLET 200 MG (voriconazole) 3 PA; QL (2 tablets per 1 day) VFEND ORAL TABLET 50 MG (voriconazole) 3 PA; QL (4 tablet per 1 day) voriconazole intravenous solution reconstituted 1 or 1b* voriconazole oral suspension reconstituted 1 or 1b* PA; QL (10 mL per 1 day) voriconazole oral tablet 200 mg 1 or 1b* PA; QL (2 tablets per 1 day) voriconazole oral tablet 50 mg 1 or 1b* PA; QL (4 tablet per 1 day) *ANTIHISTAMINES* - DRUGS FOR THE LUNGS *ANTIHISTAMINES - ALKYLAMINES*** - DRUGS FOR ALLERGIES ryclora oral solution 1 or 1b* *ANTIHISTAMINES - ETHANOLAMINES*** - DRUGS FOR ALLERGIES carbinoxamine maleate oral solution 1 or 1b* carbinoxamine maleate oral tablet 1 or 1b* CLEMASTINE FUMARATE ORAL SYRUP 3 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 52 Coverage Requirements and Prescription Drug Name Drug Tier Limits clemastine fumarate oral tablet 1 or 1b* diphen oral elixir 1 or 1a* QL (4 mL per 1 day) di-phen oral elixir 1 or 1a* QL (4 mL per 1 day) diphenhydramine hcl injection solution 1 or 1b* diphenhydramine hcl oral elixir 1 or 1a* QL (4 mL per 1 day) KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 3 QL (40 mL per 1 day) (carbinoxamine maleate) RYVENT ORAL TABLET (carbinoxamine maleate) 1 or 1b* QL (4 tablets per 1 day) *ANTIHISTAMINES - NON-SEDATING*** - DRUGS FOR ALLERGIES cetirizine hcl oral solution 1 or 1b* CLARINEX ORAL TABLET (desloratadine) 3 ST; QL (1 tablet per 1 day) desloratadine oral tablet 1 or 1b* QL (1 tablet per 1 day) desloratadine oral tablet dispersible 1 or 1b* QL (1 tablet per 1 day) levocetirizine dihydrochloride oral solution 1 or 1b* QL (10 mL per 1 day) levocetirizine dihydrochloride oral tablet 1 or 1b* QL (1 tablet per 1 day) QUZYTTIR INTRAVENOUS SOLUTION (cetirizine hcl) 3 *ANTIHISTAMINES - PHENOTHIAZINES*** - DRUGS FOR ALLERGIES PHENERGAN INJECTION SOLUTION (promethazine hcl) 3 promethazine hcl injection solution 1 or 1a* promethazine hcl oral solution 1 or 1a* promethazine hcl oral syrup 1 or 1a* promethazine hcl oral tablet 12.5 mg, 50 mg 1 or 1a* promethazine hcl oral tablet 25 mg 1 or 1a* QL (4 tablets per 1 day) promethazine hcl rectal suppository 1 or 1b* promethegan rectal suppository 1 or 1b* *ANTIHISTAMINES - PIPERIDINES*** - DRUGS FOR ALLERGIES cyproheptadine hcl oral syrup 1 or 1b* cyproheptadine hcl oral tablet 1 or 1b* *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART *ACL INHIB-INTESTINAL CHOLESTEROL ABSORPTION INHIB COMB*** - DRUGS FOR CHOLESTEROL NEXLIZET ORAL TABLET (bempedoic acid-ezetimibe) 3 PA; QL (1 tablet per 1 day) *ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORS*** - DRUGS FOR CHOLESTEROL NEXLETOL ORAL TABLET (bempedoic acid) 3 PA; QL (1 tablet per 1 day) *ANGIOPOIETIN-LIKE PROTEIN 3 (ANGPTL3) INHIBITORS*** - DRUGS FOR CHOLESTEROL EVKEEZA INTRAVENOUS SOLUTION (evinacumab-dgnb) 4 PA; LD *ANTIHYPERLIPIDEMICS - MISC.*** - DRUGS FOR CHOLESTEROL icosapent ethyl oral capsule 1 or 1b* PA; QL (4 capsule per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 53 Coverage Requirements and Prescription Drug Name Drug Tier Limits omega-3-acid ethyl esters oral capsule 1 or 1b* PA; QL (4 capsule per 1 day) VASCEPA ORAL CAPSULE 0.5 GM (icosapent ethyl) 2 PA; QL (8 capsules per 1 day) VASCEPA ORAL CAPSULE 1 GM (icosapent ethyl) 2 PA; QL (4 capsule per 1 day) *BILE ACID SEQUESTRANTS*** - DRUGS FOR CHOLESTEROL cholestyramine light oral packet 1 or 1b* QL (24 grams per 1 day) cholestyramine light oral powder 1 or 1b* QL (24 grams per 1 day) cholestyramine oral packet 1 or 1b* QL (6 packets per 1 day) cholestyramine oral powder 1 or 1b* QL (54 gm per 1 day) colesevelam hcl oral packet 1 or 1b* QL (1 packet per 1 day) colesevelam hcl oral tablet 1 or 1b* QL (6 tablets per 1 day) COLESTID FLAVORED ORAL GRANULES (colestipol hcl) 3 QL (30 grams per 1 day) COLESTID FLAVORED ORAL PACKET (colestipol hcl) 3 QL (30 grams per 1 day) COLESTID ORAL GRANULES (colestipol hcl) 3 QL (30 grams per 1 day) COLESTID ORAL PACKET (colestipol hcl) 3 QL (30 grams per 1 day) COLESTID ORAL TABLET (colestipol hcl) 3 QL (16 tablets per 1 day) colestipol hcl oral granules 1 or 1b* QL (30 grams per 1 day) colestipol hcl oral packet 1 or 1b* QL (30 grams per 1 day) colestipol hcl oral tablet 1 or 1b* QL (16 tablets per 1 day) prevalite oral packet 1 or 1b* QL (24 grams per 1 day) prevalite oral powder 1 or 1b* QL (24 grams per 1 day) QUESTRAN LIGHT ORAL POWDER (cholestyramine light) 3 QL (24 grams per 1 day) QUESTRAN ORAL PACKET (cholestyramine) 3 QL (6 packets per 1 day) QUESTRAN ORAL POWDER (cholestyramine) 3 QL (54 gm per 1 day) *FIBRIC ACID DERIVATIVES*** - DRUGS FOR CHOLESTEROL fenofibrate micronized oral capsule 1 or 1b* QL (1 capsule per 1 day) fenofibrate oral capsule 1 or 1b* QL (1 capsule per 1 day) fenofibrate oral tablet 1 or 1b* QL (1 tablet per 1 day) fenofibric acid oral capsule delayed release 1 or 1b* QL (1 capsule per 1 day) fenofibric acid oral tablet 1 or 1b* QL (1 tablet per 1 day) FENOGLIDE ORAL TABLET (fenofibrate) 3 ST; QL (1 tablet per 1 day) FIBRICOR ORAL TABLET (fenofibric acid) 3 ST; QL (1 tablet per 1 day) gemfibrozil oral tablet 1 or 1b* QL (2 tablets per 1 day) LIPOFEN ORAL CAPSULE (fenofibrate) 3 ST; QL (1 capsule per 1 day) LOPID ORAL TABLET (gemfibrozil) 3 ST; QL (2 tablets per 1 day) TRICOR ORAL TABLET (fenofibrate) 3 ST; QL (1 tablet per 1 day) TRILIPIX ORAL CAPSULE DELAYED RELEASE (choline fenofibrate) 3 ST; QL (1 capsule per 1 day) *HMG COA REDUCTASE INHIBITORS*** - DRUGS FOR CHOLESTEROL atorvastatin calcium oral tablet 10 mg, 20 mg 1 or 1b*; $0 atorvastatin calcium oral tablet 40 mg 1 or 1b* atorvastatin calcium oral tablet 80 mg 1 or 1b* QL (1 tablet per 1 day) fluvastatin sodium er oral tablet extended release 24 hour 1 or 1b*; $0 QL (1 tablet per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 54 Coverage Requirements and Prescription Drug Name Drug Tier Limits fluvastatin sodium oral capsule 1 or 1b*; $0 lovastatin oral tablet 10 mg, 20 mg 1 or 1b*; $0 lovastatin oral tablet 40 mg 1 or 1b*; $0 QL (2 tablets per 1 day) pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg 1 or 1b*; $0 pravastatin sodium oral tablet 80 mg 1 or 1b*; $0 QL (1 tablet per 1 day) rosuvastatin calcium oral tablet 10 mg, 5 mg 1 or 1b*; $0 rosuvastatin calcium oral tablet 20 mg 1 or 1b* rosuvastatin calcium oral tablet 40 mg 1 or 1b* QL (1 tablet per 1 day) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 or 1b*; $0 simvastatin oral tablet 80 mg 1 or 1b* PA; QL (1 tablet per 1 day) *INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB*** - DRUGS FOR CHOLESTEROL ezetimibe-simvastatin oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS*** - DRUGS FOR CHOLESTEROL ezetimibe oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS*** - DRUGS FOR CHOLESTEROL JUXTAPID ORAL CAPSULE (lomitapide mesylate) 3 PA; LD *NICOTINIC ACID DERIVATIVES*** - DRUGS FOR CHOLESTEROL niacin (antihyperlipidemic) oral tablet 1 or 1b* ST; QL (12 tablets per 1 day) niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 750 mg 1 or 1b* ST; QL (2 tablets per 1 day) niacin er (antihyperlipidemic) oral tablet extended release 500 mg 1 or 1b* ST; QL (1 tablet per 1 day) niacor oral tablet 1 or 1b* ST; QL (12 tablets per 1 day) NIASPAN ORAL TABLET EXTENDED RELEASE 1000 MG, 750 MG 3 ST; QL (2 tablets per 1 day) (niacin (antihyperlipidemic)) NIASPAN ORAL TABLET EXTENDED RELEASE 500 MG (niacin 3 ST; QL (1 tablet per 1 day) (antihyperlipidemic)) *PCSK9 INHIBITORS*** - DRUGS FOR CHOLESTEROL PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 PA; QL (2 injection per 28 days) (alirocumab) REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION 3 PA; QL (1 injector per 30 days) CARTRIDGE (evolocumab) REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 PA; QL (2 syringe per 28 days) (evolocumab) REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO- 3 PA; QL (2 syringe per 28 days) INJECTOR (evolocumab) *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART *ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS*** - DRUGS FOR HIGH BLOOD PRESSURE amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 5-40 mg 1 or 1b* QL (1 capsule per 1 day) amlodipine besy-benazepril hcl oral capsule 2.5-10 mg, 5-10 mg, 5-20 mg 1 or 1b* PRESTALIA ORAL TABLET 14-10 MG (perindopril arg-amlodipine) 3 QL (1 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 55 Coverage Requirements and Prescription Drug Name Drug Tier Limits PRESTALIA ORAL TABLET 3.5-2.5 MG, 7-5 MG (perindopril arg- 3 amlodipine) TARKA ORAL TABLET EXTENDED RELEASE (trandolapril-verapamil 3 QL (1 tablet per 1 day) hcl) trandolapril-verapamil hcl er oral tablet extended release 1-240 mg 1 or 1b* trandolapril-verapamil hcl er oral tablet extended release 2-180 mg, 2-240 mg, 1 or 1b* QL (1 tablet per 1 day) 4-240 mg *ACE INHIBITORS & THIAZIDE/THIAZIDE-LIKE*** - DRUGS FOR HIGH BLOOD PRESSURE ACCURETIC ORAL TABLET (quinapril-hydrochlorothiazide) 3 QL (2 tablets per 1 day) benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 5-6.25 mg 1 or 1b* benazepril-hydrochlorothiazide oral tablet 20-12.5 mg, 20-25 mg 1 or 1b* QL (1 tablet per 1 day) enalapril-hydrochlorothiazide oral tablet 1 or 1b* QL (2 tablets per 1 day) fosinopril sodium-hctz oral tablet 10-12.5 mg 1 or 1b* QL (2 tablets per 1 day) fosinopril sodium-hctz oral tablet 20-12.5 mg 1 or 1b* QL (4 tablets per 1 day) lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg 1 or 1b* lisinopril-hydrochlorothiazide oral tablet 20-12.5 mg 1 or 1b* QL (4 tablets per 1 day) lisinopril-hydrochlorothiazide oral tablet 20-25 mg 1 or 1b* QL (2 tablets per 1 day) LOTENSIN HCT ORAL TABLET 10-12.5 MG (benazepril- 3 hydrochlorothiazide) LOTENSIN HCT ORAL TABLET 20-12.5 MG, 20-25 MG (benazepril- 3 QL (1 tablet per 1 day) hydrochlorothiazide) quinapril-hydrochlorothiazide oral tablet 1 or 1b* QL (2 tablets per 1 day) VASERETIC ORAL TABLET (enalapril-hydrochlorothiazide) 3 QL (2 tablets per 1 day) ZESTORETIC ORAL TABLET 10-12.5 MG (lisinopril- 3 hydrochlorothiazide) ZESTORETIC ORAL TABLET 20-12.5 MG (lisinopril- 3 QL (4 tablets per 1 day) hydrochlorothiazide) ZESTORETIC ORAL TABLET 20-25 MG (lisinopril-hydrochlorothiazide) 3 QL (2 tablets per 1 day) *ACE INHIBITORS*** - DRUGS FOR HIGH BLOOD PRESSURE benazepril hcl oral tablet 1 or 1a* QL (2 tablets per 1 day) captopril oral tablet 1 or 1b* QL (3 tablets per 1 day) enalapril maleate oral tablet 1 or 1b* QL (2 tablets per 1 day) enalaprilat intravenous injectable 1 or 1b* EPANED ORAL SOLUTION (enalapril maleate) 3 QL (40 mg per 1 day) fosinopril sodium oral tablet 1 or 1b* QL (2 tablets per 1 day) lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 or 1a* lisinopril oral tablet 30 mg, 40 mg 1 or 1a* QL (2 tablets per 1 day) LOTENSIN ORAL TABLET (benazepril hcl) 3 QL (2 tablets per 1 day) moexipril hcl oral tablet 15 mg 1 or 1b* QL (4 tablets per 1 day) moexipril hcl oral tablet 7.5 mg 1 or 1b* QL (2 tablets per 1 day) perindopril erbumine oral tablet 1 or 1b* QL (2 tablets per 1 day) QBRELIS ORAL SOLUTION (lisinopril) 3 QL (40 mg per 1 day) quinapril hcl oral tablet 1 or 1b* QL (2 tablets per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 56 Coverage Requirements and Prescription Drug Name Drug Tier Limits ramipril oral capsule 1 or 1b* QL (2 capsules per 1 day) trandolapril oral tablet 1 or 1b* QL (2 tablets per 1 day) *AGENTS FOR PHEOCHROMOCYTOMA*** - DRUGS FOR HIGH BLOOD PRESSURE DEMSER ORAL CAPSULE (metyrosine) 3 PA; QL (16 capsules per 1 day) DIBENZYLINE ORAL CAPSULE (phenoxybenzamine hcl) 3 PA; QL (12 capsules per 1 day) metyrosine oral capsule 1 or 1b* PA; QL (16 capsules per 1 day) phenoxybenzamine hcl oral capsule 1 or 1b* PA; QL (12 capsules per 1 day) phentolamine mesylate injection solution reconstituted 1 or 1b* *ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER COMB*** - DRUGS FOR HIGH BLOOD PRESSURE amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-320 mg 1 or 1b* QL (1 tablet per 1 day) amlodipine besylate-valsartan oral tablet 5-160 mg 1 or 1b* amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-40 mg 1 or 1b* QL (1 tablet per 1 day) amlodipine-olmesartan oral tablet 5-20 mg 1 or 1b* telmisartan-amlodipine oral tablet 40-10 mg, 80-10 mg, 80-5 mg 1 or 1b* QL (1 tablet per 1 day) telmisartan-amlodipine oral tablet 40-5 mg 1 or 1b* TWYNSTA ORAL TABLET 40-10 MG, 80-10 MG, 80-5 MG (telmisartan- 3 QL (1 tablet per 1 day) amlodipine) TWYNSTA ORAL TABLET 40-5 MG (telmisartan-amlodipine) 3 *ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE- LIKE*** - DRUGS FOR HIGH BLOOD PRESSURE candesartan cilexetil-hctz oral tablet 16-12.5 mg 1 or 1b* QL (2 tablets per 1 day) candesartan cilexetil-hctz oral tablet 32-12.5 mg, 32-25 mg 1 or 1b* QL (1 tablet per 1 day) EDARBYCLOR ORAL TABLET (azilsartan-chlorthalidone) 3 QL (1 tablet per 1 day) irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg 1 or 1b* QL (2 tablets per 1 day) irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg 1 or 1b* QL (1 tablet per 1 day) losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg 1 or 1b* QL (1 tablet per 1 day) losartan potassium-hctz oral tablet 50-12.5 mg 1 or 1b* olmesartan medoxomil-hctz oral tablet 20-12.5 mg 1 or 1b* olmesartan medoxomil-hctz oral tablet 40-12.5 mg, 40-25 mg 1 or 1b* QL (1 tablet per 1 day) telmisartan-hctz oral tablet 40-12.5 mg 1 or 1b* telmisartan-hctz oral tablet 80-12.5 mg 1 or 1b* QL (2 tablets per 1 day) telmisartan-hctz oral tablet 80-25 mg 1 or 1b* QL (1 tablet per 1 day) valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg 1 or 1b* valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg 1 or 1b* QL (1 tablet per 1 day) *ANGIOTENSIN II RECEPTOR ANTAGONISTS*** - DRUGS FOR HIGH BLOOD PRESSURE candesartan cilexetil oral tablet 16 mg, 4 mg, 8 mg 1 or 1b* QL (2 tablets per 1 day) candesartan cilexetil oral tablet 32 mg 1 or 1b* QL (1 tablet per 1 day) EDARBI ORAL TABLET 40 MG (azilsartan medoxomil) 3 EDARBI ORAL TABLET 80 MG (azilsartan medoxomil) 3 QL (1 tablet per 1 day) irbesartan oral tablet 150 mg, 75 mg 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 57 Coverage Requirements and Prescription Drug Name Drug Tier Limits irbesartan oral tablet 300 mg 1 or 1b* QL (1 tablet per 1 day) losartan potassium oral tablet 100 mg 1 or 1b* QL (1 tablet per 1 day) losartan potassium oral tablet 25 mg, 50 mg 1 or 1b* QL (2 tablets per 1 day) olmesartan medoxomil oral tablet 20 mg 1 or 1b* olmesartan medoxomil oral tablet 40 mg 1 or 1b* QL (1 tablet per 1 day) olmesartan medoxomil oral tablet 5 mg 1 or 1b* QL (2 tablets per 1 day) telmisartan oral tablet 20 mg, 40 mg 1 or 1b* telmisartan oral tablet 80 mg 1 or 1b* QL (2 tablets per 1 day) valsartan oral tablet 160 mg 1 or 1b* QL (2 tablets per 1 day) valsartan oral tablet 320 mg 1 or 1b* QL (1 tablet per 1 day) valsartan oral tablet 40 mg, 80 mg 1 or 1b* QL (3 tablet per 1 day) *ANGIOTENSIN II RECEPTOR ANT-CA CHANNEL BLOCKER- THIAZIDES*** - DRUGS FOR HIGH BLOOD PRESSURE amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320- 1 or 1b* QL (1 tablet per 1 day) 25 mg, 5-160-25 mg amlodipine-valsartan-hctz oral tablet 5-160-12.5 mg 1 or 1b* olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg 1 or 1b* olmesartan-amlodipine-hctz oral tablet 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 1 or 1b* QL (1 tablet per 1 day) mg, 40-5-25 mg *ANTIADRENERGICS - CENTRALLY ACTING*** - DRUGS FOR HIGH BLOOD PRESSURE CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY (clonidine) 3 CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY (clonidine) 3 CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY (clonidine) 3 clonidine hcl oral tablet 1 or 1a* QL (4 tablets per 1 day) clonidine transdermal patch weekly 1 or 1b* guanfacine hcl oral tablet 1 or 1b* methyldopa oral tablet 250 mg 1 or 1b* methyldopa oral tablet 500 mg 1 or 1b* QL (6 tablets per 1 day) *ANTIADRENERGICS - PERIPHERALLY ACTING*** - DRUGS FOR HIGH BLOOD PRESSURE CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG (doxazosin mesylate) 3 QL (1 tablet per 1 day) CARDURA ORAL TABLET 8 MG (doxazosin mesylate) 3 QL (2 tablets per 1 day) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg 1 or 1b* QL (1 tablet per 1 day) doxazosin mesylate oral tablet 8 mg 1 or 1b* QL (2 tablets per 1 day) MINIPRESS ORAL CAPSULE (prazosin hcl) 3 prazosin hcl oral capsule 1 or 1b* terazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 or 1b* QL (1 capsule per 1 day) terazosin hcl oral capsule 10 mg 1 or 1b* QL (2 capsules per 1 day) *ANTIHYPERTENSIVES - MISC.*** - DRUGS FOR HIGH BLOOD PRESSURE VECAMYL ORAL TABLET (mecamylamine hcl) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 58 Coverage Requirements and Prescription Drug Name Drug Tier Limits *BETA BLOCKER & DIURETIC COMBINATIONS*** - DRUGS FOR HIGH BLOOD PRESSURE atenolol-chlorthalidone oral tablet 1 or 1b* QL (1 tablet per 1 day) bisoprolol-hydrochlorothiazide oral tablet 1 or 1b* QL (2 tablets per 1 day) DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (2 tablets per 1 day) (metoprolol-hydrochlorothiazide) metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 50-25 mg 1 or 1b* QL (2 tablets per 1 day) metoprolol-hydrochlorothiazide oral tablet 100-50 mg 1 or 1b* QL (1 tablet per 1 day) TENORETIC 100 ORAL TABLET (atenolol-chlorthalidone) 3 QL (1 tablet per 1 day) TENORETIC 50 ORAL TABLET (atenolol-chlorthalidone) 3 QL (1 tablet per 1 day) ZIAC ORAL TABLET (bisoprolol-hydrochlorothiazide) 3 QL (2 tablets per 1 day) *DIRECT RENIN INHIBITORS & THIAZIDE/THIAZIDE-LIKE COMB*** - DRUGS FOR HIGH BLOOD PRESSURE TEKTURNA HCT ORAL TABLET 150-12.5 MG (aliskiren- 3 hydrochlorothiazide) TEKTURNA HCT ORAL TABLET 150-25 MG, 300-12.5 MG, 300-25 MG 3 QL (1 tablet per 1 day) (aliskiren-hydrochlorothiazide) *DIRECT RENIN INHIBITORS*** - DRUGS FOR HIGH BLOOD PRESSURE aliskiren fumarate oral tablet 150 mg 1 or 1b* aliskiren fumarate oral tablet 300 mg 1 or 1b* QL (1 tablet per 1 day) *DOPAMINE D1 RECEPTOR AGONISTS*** - DRUGS FOR HIGH BLOOD PRESSURE CORLOPAM INTRAVENOUS SOLUTION (fenoldopam mesylate) 3 *SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)*** - DRUGS FOR HIGH BLOOD PRESSURE eplerenone oral tablet 1 or 1b* INSPRA ORAL TABLET (eplerenone) 3 *VASODILATORS*** - DRUGS FOR HIGH BLOOD PRESSURE hydralazine hcl injection solution 1 or 1b* hydralazine hcl oral tablet 1 or 1b* minoxidil oral tablet 1 or 1b* NIPRIDE RTU INTRAVENOUS SOLUTION (nitroprusside sodium-nacl) 3 nitroprusside sodium intravenous solution 1 or 1b* sodium nitroprusside intravenous solution 1 or 1b* *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS *ANTI-INFECTIVE AGENTS - MISC.*** - DRUGS FOR INFECTIONS AEMCOLO ORAL TABLET DELAYED RELEASE (rifamycin sodium) 3 PA; QL (12 tablets per 30 days) bacitracin intramuscular solution reconstituted 1 or 1b* FLAGYL ORAL CAPSULE (metronidazole) 3 FLAGYL ORAL TABLET (metronidazole) 3 IMPAVIDO ORAL CAPSULE (miltefosine) 3 PA; QL (84 capsules per 1 fill) metronidazole in nacl intravenous solution 5-0.79 mg/ml-%, 500-0.79 1 or 1b* mg/100ml-%

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 59 Coverage Requirements and Prescription Drug Name Drug Tier Limits METRONIDAZOLE IN NACL INTRAVENOUS SOLUTION 500-0.74 3 MG/100ML-% metronidazole oral capsule 1 or 1a* metronidazole oral tablet 1 or 1a* NEBUPENT INHALATION SOLUTION RECONSTITUTED 3 (pentamidine isethionate) PENTAM INJECTION SOLUTION RECONSTITUTED (pentamidine 4 isethionate) pentamidine isethionate inhalation solution reconstituted 1 or 1b* pentamidine isethionate injection solution reconstituted 4 PRIMSOL ORAL SOLUTION (trimethoprim hcl) 3 tinidazole oral tablet 250 mg 1 or 1b* QL (5 tablets per 28 days) tinidazole oral tablet 500 mg 1 or 1b* QL (20 tablets per 1 fill) trimethoprim oral tablet 1 or 1a* XIFAXAN ORAL TABLET 200 MG (rifaximin) 3 PA; QL (9 tablets per 30 days) XIFAXAN ORAL TABLET 550 MG (rifaximin) 3 PA; QL (126 tablet per 252 days) *ANTI-INFECTIVE MISC. - COMBINATIONS*** - ANTIBIOTICS BACTRIM DS ORAL TABLET (sulfamethoxazole-trimethoprim) 3 BACTRIM ORAL TABLET (sulfamethoxazole-trimethoprim) 3 sulfamethoxazole-trimethoprim intravenous solution 1 or 1b* sulfamethoxazole-trimethoprim oral suspension 1 or 1a* sulfamethoxazole-trimethoprim oral tablet 1 or 1a* sulfatrim pediatric oral suspension 1 or 1a* *ANTIPROTOZOAL AGENTS*** - DRUGS FOR PARASITES ALINIA ORAL SUSPENSION RECONSTITUTED (nitazoxanide) 3 ALINIA ORAL TABLET (nitazoxanide) 3 atovaquone oral suspension 1 or 1b* LAMPIT ORAL TABLET (nifurtimox) 3 MEPRON ORAL SUSPENSION (atovaquone) 3 nitazoxanide oral tablet 1 or 1b* *CARBAPENEM COMBINATIONS*** - ANTIBIOTICS imipenem-cilastatin intravenous solution reconstituted 1 or 1b* PRIMAXIN IV INTRAVENOUS SOLUTION RECONSTITUTED 3 (imipenem-cilastatin) RECARBRIO INTRAVENOUS SOLUTION RECONSTITUTED 3 (imipenem-cilastatin-relebactam) VABOMERE INTRAVENOUS SOLUTION RECONSTITUTED 3 (meropenem-vaborbactam) *CARBAPENEMS*** - ANTIBIOTICS ertapenem sodium injection solution reconstituted 1 or 1b* INVANZ INJECTION SOLUTION RECONSTITUTED (ertapenem 3 sodium) meropenem intravenous solution reconstituted 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 60 Coverage Requirements and Prescription Drug Name Drug Tier Limits MEROPENEM-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 RECONSTITUTED *CHLORAMPHENICALS*** - ANTIBIOTICS chloramphenicol sod succinate intravenous solution reconstituted 1 or 1b* *CYCLIC LIPOPEPTIDES*** - ANTIBIOTICS CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED 3 (daptomycin) CUBICIN RF INTRAVENOUS SOLUTION RECONSTITUTED 3 (daptomycin) DAPTOMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 350 3 MG daptomycin intravenous solution reconstituted 500 mg 1 or 1b* *GLYCOPEPTIDES*** - ANTIBIOTICS DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED 3 (dalbavancin hcl) FIRVANQ ORAL SOLUTION RECONSTITUTED (vancomycin hcl) 3 PA; QL (1200 mL per 30 days) ORBACTIV INTRAVENOUS SOLUTION RECONSTITUTED 3 (oritavancin diphosphate) VANCOCIN HCL ORAL CAPSULE (vancomycin hcl) 3 PA; QL (240 capsules per 30 days) VANCOCIN ORAL CAPSULE (vancomycin hcl) 3 PA; QL (240 capsules per 30 days) VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS SOLUTION 3 VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 3 VANCOMYCIN HCL INTRAVENOUS SOLUTION 3 vancomycin hcl intravenous solution reconstituted 1 gm, 1000 mg, 500 mg 1 or 1b* QL (2 vials per 1 day) VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 3 1.25 GM, 1.5 GM, 250 MG vancomycin hcl intravenous solution reconstituted 10 gm, 100 gm, 5 gm, 750 1 or 1b* mg vancomycin hcl oral capsule 1 or 1b* PA; QL (240 capsules per 30 days) VANCOMYCIN HCL ORAL SOLUTION RECONSTITUTED 3 PA; QL (1200 mL per 30 days) VIBATIV INTRAVENOUS SOLUTION RECONSTITUTED (telavancin 3 hcl) *LEPROSTATICS*** - ANTIBIOTICS dapsone oral tablet 1 or 1b* *LINCOSAMIDES*** - ANTIBIOTICS CLEOCIN ORAL CAPSULE (clindamycin hcl) 3 CLEOCIN ORAL SOLUTION RECONSTITUTED (clindamycin palmitate 3 hcl) CLEOCIN PHOSPHATE INJECTION SOLUTION (clindamycin 3 QL (20 mL per 1 day) phosphate) clindamycin hcl oral capsule 1 or 1b* clindamycin palmitate hcl oral solution reconstituted 1 or 1b* clindamycin phosphate in d5w intravenous solution 1 or 1b* CLINDAMYCIN PHOSPHATE IN NACL INTRAVENOUS SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 61 Coverage Requirements and Prescription Drug Name Drug Tier Limits clindamycin phosphate injection solution 1 or 1b* QL (20 mL per 1 day) LINCOCIN INJECTION SOLUTION (lincomycin hcl) 3 lincomycin hcl injection solution 1 or 1b* *MONOBACTAMS*** - ANTIBIOTICS AZACTAM INJECTION SOLUTION RECONSTITUTED (aztreonam) 3 aztreonam injection solution reconstituted 1 or 1b* CAYSTON INHALATION SOLUTION RECONSTITUTED (aztreonam 4 LD; SP; QL (84 vials per 28 days) lysine) *OXAZOLIDINONES*** - ANTIBIOTICS linezolid in sodium chloride intravenous solution 1 or 1b* linezolid intravenous solution 1 or 1b* linezolid oral suspension reconstituted 1 or 1b* PA; QL (900 mL per 30 days) linezolid oral tablet 1 or 1b* PA; QL (28 tablet per 30 days) SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED (tedizolid 3 phosphate) SIVEXTRO ORAL TABLET (tedizolid phosphate) 3 PA; QL (6 tablet per 30 days) ZYVOX INTRAVENOUS SOLUTION (linezolid) 3 ZYVOX ORAL SUSPENSION RECONSTITUTED (linezolid) 3 PA; QL (900 mL per 30 days) ZYVOX ORAL TABLET (linezolid) 3 PA; QL (28 tablet per 30 days) *PLEUROMUTILINS*** - ANTIBIOTICS XENLETA INTRAVENOUS SOLUTION (lefamulin acetate) 3 LD XENLETA ORAL TABLET (lefamulin acetate) 3 PA; LD; QL (10 tablets per 30 days) *POLYMYXINS*** - ANTIBIOTICS colistimethate sodium (cba) injection solution reconstituted 1 or 1b* COLY-MYCIN M INJECTION SOLUTION RECONSTITUTED 3 (colistimethate sodium) polymyxin b sulfate injection solution reconstituted 1 or 1b* *STREPTOGRAMIN COMBINATIONS*** - ANTIBIOTICS SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED 3 (quinupristin-dalfopristin) *URINARY ANTI-INFECTIVES*** - ANTIBIOTICS fosfomycin tromethamine oral packet 1 or 1b* QL (1 pack per 1 fill) HIPREX ORAL TABLET (methenamine hippurate) 3 MACROBID ORAL CAPSULE (nitrofurantoin monohyd macro) 3 QL (14 capsules per 1 fill) MACRODANTIN ORAL CAPSULE (nitrofurantoin macrocrystal) 3 QL (4 capsules per 1 day) methenamine hippurate oral tablet 1 or 1b* MONUROL ORAL PACKET (fosfomycin tromethamine) 3 QL (1 pack per 1 fill) nitrofurantoin macrocrystal oral capsule 1 or 1b* QL (4 capsules per 1 day) nitrofurantoin monohyd macro oral capsule 1 or 1b* QL (14 capsules per 1 fill) nitrofurantoin oral suspension 1 or 1b* QL (80 mL per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 62 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIMALARIALS* - DRUGS FOR INFECTIONS *ANTIMALARIAL COMBINATIONS*** - DRUGS FOR PARASITES atovaquone-proguanil hcl oral tablet 1 or 1b* COARTEM ORAL TABLET (artemether-lumefantrine) 3 MALARONE ORAL TABLET (atovaquone-proguanil hcl) 3 *ANTIMALARIALS*** - DRUGS FOR PARASITES ARAKODA ORAL TABLET (tafenoquine succinate) 3 QL (56 tablets per 1 year) ARTESUNATE INTRAVENOUS SOLUTION RECONSTITUTED 3 chloroquine phosphate oral tablet 1 or 1a* DARAPRIM ORAL TABLET (pyrimethamine) 3 PA; LD; QL (3 tablets per 1 day) hydroxychloroquine sulfate oral tablet 1 or 1b* QL (90 tablets per 30 days) KRINTAFEL ORAL TABLET (tafenoquine succinate) 3 QL (2 tablets per 1 fill) mefloquine hcl oral tablet 1 or 1b* QL (5 tablets per 28 days) PRIMAQUINE PHOSPHATE ORAL TABLET 3 pyrimethamine oral tablet 1 or 1b* PA; QL (3 tablets per 1 day) QUALAQUIN ORAL CAPSULE (quinine sulfate) 3 PA; QL (60 capsule per 365 days) quinine sulfate oral capsule 1 or 1b* PA; QL (60 capsule per 365 days) *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES *ANTIMYASTHENIC/CHOLINERGIC AGENTS*** - DRUGS FOR NERVES AND MUSCLES BLOXIVERZ INTRAVENOUS SOLUTION (neostigmine methylsulfate) 3 FIRDAPSE ORAL TABLET (amifampridine phosphate) 4 PA; LD; QL (8 tablets per 1 day) MESTINON ORAL SOLUTION (pyridostigmine bromide) 3 MESTINON ORAL TABLET (pyridostigmine bromide) 3 MESTINON ORAL TABLET EXTENDED RELEASE (pyridostigmine 3 bromide) NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION 3 pyridostigmine bromide er oral tablet extended release 1 or 1b* pyridostigmine bromide oral solution 1 or 1b* pyridostigmine bromide oral tablet 1 or 1b* REGONOL INTRAVENOUS SOLUTION (pyridostigmine bromide) 3 RUZURGI ORAL TABLET (amifampridine) 4 PA; LD; QL (10 tablets per 1 day) *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS *ANTIMYCOBACTERIAL AGENTS*** - ANTIBIOTICS CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 3 (capreomycin sulfate) cycloserine oral capsule 1 or 1b* ethambutol hcl oral tablet 1 or 1b* isoniazid injection solution 1 or 1a* isoniazid oral syrup 1 or 1a* isoniazid oral tablet 1 or 1a*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 63 Coverage Requirements and Prescription Drug Name Drug Tier Limits MYAMBUTOL ORAL TABLET (ethambutol hcl) 3 MYCOBUTIN ORAL CAPSULE (rifabutin) 3 PASER ORAL PACKET (aminosalicylic acid) 3 PRETOMANID ORAL TABLET 3 PRIFTIN ORAL TABLET (rifapentine) 2 pyrazinamide oral tablet 1 or 1b* rifabutin oral capsule 1 or 1b* RIFADIN INTRAVENOUS SOLUTION RECONSTITUTED (rifampin) 3 rifampin intravenous solution reconstituted 1 or 1b* rifampin oral capsule 1 or 1b* SIRTURO ORAL TABLET (bedaquiline fumarate) 3 TRECATOR ORAL TABLET (ethionamide) 3 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR CANCER *ALKYLATING AGENTS*** - DRUGS FOR CANCER BELRAPZO INTRAVENOUS SOLUTION (bendamustine hcl) 3 PA; LD; SP BENDEKA INTRAVENOUS SOLUTION (bendamustine hcl) 3 PA; LD; SP busulfan intravenous solution 1 or 1b* SP BUSULFEX INTRAVENOUS SOLUTION (busulfan) 3 SP carboplatin intravenous solution 1 or 1b* SP cisplatin intravenous solution 1 or 1b* SP CISPLATIN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP MYLERAN ORAL TABLET (busulfan) 2; OC oxaliplatin intravenous solution 1 or 1b* SP oxaliplatin intravenous solution reconstituted 1 or 1b* SP paraplatin intravenous solution 1 or 1b* SP TEPADINA INJECTION SOLUTION RECONSTITUTED (thiotepa) 3 SP thiotepa injection solution reconstituted 1 or 1b* SP TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (bendamustine hcl) ZEPZELCA INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (lurbinectedin) *ANDROGEN BIOSYNTHESIS INHIBITORS*** - DRUGS FOR CANCER abiraterone acetate oral tablet 250 mg 1 or 1b*; OC PA; SP; QL (4 tablet per 1 day) abiraterone acetate oral tablet 500 mg 1 or 1b*; OC PA; SP; QL (2 tablets per 1 day) PA; LD; SP; QL (4 tablets per 1 YONSA ORAL TABLET (abiraterone acetate) 3; OC day) ZYTIGA ORAL TABLET 250 MG (abiraterone acetate) 3; OC PA; LD; SP; QL (4 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 ZYTIGA ORAL TABLET 500 MG (abiraterone acetate) 3; OC day) *ANTIADRENALS*** - DRUGS FOR CANCER LYSODREN ORAL TABLET (mitotane) 2; OC LD; QL (38 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 64 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIANDROGENS*** - DRUGS FOR CANCER bicalutamide oral tablet 1 or 1b*; OC CASODEX ORAL TABLET (bicalutamide) 3; OC PA; LD; SP; QL (4 tablets per 1 ERLEADA ORAL TABLET (apalutamide) 2; OC day) flutamide oral capsule 1 or 1b*; OC NILANDRON ORAL TABLET (nilutamide) 3; OC QL (1 tablet per 1 day) nilutamide oral tablet 1 or 1b*; OC QL (1 tablet per 1 day) PA; LD; SP; QL (4 tablets per 1 NUBEQA ORAL TABLET (darolutamide) 3; OC day) PA; LD; SP; QL (4 capsules per 1 XTANDI ORAL CAPSULE (enzalutamide) 2; OC day) PA; LD; SP; QL (4 tablets per 1 XTANDI ORAL TABLET 40 MG (enzalutamide) 2; OC day) PA; LD; SP; QL (2 tablets per 1 XTANDI ORAL TABLET 80 MG (enzalutamide) 2; OC day) *ANTIESTROGENS*** - DRUGS FOR CANCER FARESTON ORAL TABLET (toremifene citrate) 3; OC QL (1 tablet per 1 day) SOLTAMOX ORAL SOLUTION (tamoxifen citrate) 2; OC; $0 tamoxifen citrate oral tablet 1 or 1b*; OC; $0 toremifene citrate oral tablet 1 or 1b*; OC QL (1 tablet per 1 day) *ANTIMETABOLITES*** - DRUGS FOR CANCER ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED (pemetrexed 3 PA; SP disodium) ARRANON INTRAVENOUS SOLUTION (nelarabine) 3 SP azacitidine injection suspension reconstituted 1 or 1b* PA; SP capecitabine oral tablet 1 or 1b*; OC PA; SP cladribine intravenous solution 1 or 1b* SP clofarabine intravenous solution 1 or 1b* SP CLOLAR INTRAVENOUS SOLUTION (clofarabine) 3 SP cytarabine (pf) injection solution 1 or 1b* SP cytarabine injection solution 1 or 1b* SP DACOGEN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (decitabine) decitabine intravenous solution reconstituted 1 or 1b* SP floxuridine injection solution reconstituted 1 or 1b* SP fludarabine phosphate intravenous solution 1 or 1b* SP fludarabine phosphate intravenous solution reconstituted 1 or 1b* SP fluorouracil intravenous solution 1 or 1b* SP FOLOTYN INTRAVENOUS SOLUTION (pralatrexate) 3 SP GEMCITABINE HCL INTRAVENOUS SOLUTION 3 SP gemcitabine hcl intravenous solution reconstituted 1 or 1b* SP INFUGEM INTRAVENOUS SOLUTION (gemcitabine hcl-nacl) 3 SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 65 Coverage Requirements and Prescription Drug Name Drug Tier Limits mercaptopurine oral tablet 1 or 1b*; OC methotrexate oral tablet 1 or 1b*; OC methotrexate sodium (pf) injection solution 1 or 1b* methotrexate sodium injection solution 1 or 1b* methotrexate sodium injection solution reconstituted 1 or 1b* methotrexate sodium oral tablet 1 or 1b*; OC PA; LD; SP; QL (14 tablets per 28 ONUREG ORAL TABLET (azacitidine) 3; OC days) PURIXAN ORAL SUSPENSION (mercaptopurine) 3; OC PA; LD TABLOID ORAL TABLET (thioguanine) 2; OC TREXALL ORAL TABLET (methotrexate sodium) 2; OC VIDAZA INJECTION SUSPENSION RECONSTITUTED (azacitidine) 3 PA; LD; SP XATMEP ORAL SOLUTION (methotrexate) 3; OC PA; SP XELODA ORAL TABLET (capecitabine) 3; OC PA; LD; SP *ANTINEOPLASTIC - ALK INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (8 capsule per 1 ALECENSA ORAL CAPSULE (alectinib hcl) 3; OC day) ALUNBRIG ORAL TABLET 180 MG (brigatinib) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (6 tablets per 1 ALUNBRIG ORAL TABLET 30 MG (brigatinib) 3; OC day) PA; LD; SP; QL (2 tablets per 1 ALUNBRIG ORAL TABLET 90 MG (brigatinib) 3; OC day) PA; LD; SP; QL (1 pack per 30 ALUNBRIG ORAL TABLET THERAPY PACK (brigatinib) 3; OC days) LORBRENA ORAL TABLET 100 MG (lorlatinib) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (3 tablets per 1 LORBRENA ORAL TABLET 25 MG (lorlatinib) 3; OC day) PA; LD; SP; QL (4 capsules per 1 XALKORI ORAL CAPSULE (crizotinib) 2; OC day) PA; LD; SP; QL (3 capsules per 1 ZYKADIA ORAL TABLET (ceritinib) 3; OC day) *ANTINEOPLASTIC - ANTI-BCMA ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER BLENREP INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (belantamab mafodotin-blmf) *ANTINEOPLASTIC - ANTI-CCR4 ANTIBODIES*** - DRUGS FOR CANCER POTELIGEO INTRAVENOUS SOLUTION (mogamulizumab-kpkc) 3 LD; SP *ANTINEOPLASTIC - ANTI-CD19 ANTIBODIES*** - DRUGS FOR CANCER MONJUVI INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD (tafasitamab-cxix) *ANTINEOPLASTIC - ANTI-CD19 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER ZYNLONTA INTRAVENOUS SOLUTION RECONSTITUTED 3 LD (loncastuximab tesirine-lpyl) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 66 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTINEOPLASTIC - ANTI-CD20 ANTIBODIES*** - DRUGS FOR CANCER ARZERRA INTRAVENOUS CONCENTRATE (ofatumumab) 3 PA; LD; SP GAZYVA INTRAVENOUS SOLUTION (obinutuzumab) 3 PA; LD; SP RIABNI INTRAVENOUS SOLUTION (rituximab-arrx) 3 PA; LD; SP RITUXAN INTRAVENOUS SOLUTION (rituximab) 3 PA; LD; SP RUXIENCE INTRAVENOUS SOLUTION (rituximab-pvvr) 3 PA; SP TRUXIMA INTRAVENOUS SOLUTION (rituximab-abbs) 3 PA; SP *ANTINEOPLASTIC - ANTI-CD22 ANTIBODIES*** - DRUGS FOR CANCER LUMOXITI INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (moxetumomab pasudotox-tdfk) *ANTINEOPLASTIC - ANTI-CD22 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER BESPONSA INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (inotuzumab ozogamicin) *ANTINEOPLASTIC - ANTI-CD30 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER ADCETRIS INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (brentuximab vedotin) *ANTINEOPLASTIC - ANTI-CD33 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (gemtuzumab ozogamicin) *ANTINEOPLASTIC - ANTI-CD38 ANTIBODIES*** - DRUGS FOR CANCER DARZALEX INTRAVENOUS SOLUTION (daratumumab) 3 PA; LD; SP SARCLISA INTRAVENOUS SOLUTION (isatuximab-irfc) 3 PA; LD; SP *ANTINEOPLASTIC - ANTI-CD79B ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER POLIVY INTRAVENOUS SOLUTION RECONSTITUTED (polatuzumab 3 PA; LD; SP vedotin-piiq) *ANTINEOPLASTIC - ANTI-CTLA-4 ANTIBODIES*** - DRUGS FOR CANCER YERVOY INTRAVENOUS SOLUTION (ipilimumab) 3 PA; LD; SP *ANTINEOPLASTIC - ANTI-GD2 ANTIBODIES*** - DRUGS FOR CANCER DANYELZA INTRAVENOUS SOLUTION (naxitamab-gqgk) 3 PA; LD UNITUXIN INTRAVENOUS SOLUTION (dinutuximab) 3 LD *ANTINEOPLASTIC - ANTI-HER2 AGENTS*** - DRUGS FOR CANCER HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 3 LD; SP (trastuzumab) HERZUMA INTRAVENOUS SOLUTION RECONSTITUTED 3 LD; SP (trastuzumab-pkrb)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 67 Coverage Requirements and Prescription Drug Name Drug Tier Limits KANJINTI INTRAVENOUS SOLUTION RECONSTITUTED 3 LD; SP (trastuzumab-anns) MARGENZA INTRAVENOUS SOLUTION (margetuximab-cmkb) 3 PA; LD OGIVRI INTRAVENOUS SOLUTION RECONSTITUTED (trastuzumab- 3 LD; SP dkst) ONTRUZANT INTRAVENOUS SOLUTION RECONSTITUTED 3 LD; SP (trastuzumab-dttb) PERJETA INTRAVENOUS SOLUTION (pertuzumab) 3 PA; LD; SP TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (trastuzumab-qyyp) TUKYSA ORAL TABLET (tucatinib) 3; OC PA; LD; QL (4 tablets per 1 day) *ANTINEOPLASTIC - ANTI-NECTIN-4 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER PADCEV INTRAVENOUS SOLUTION RECONSTITUTED (enfortumab 3 PA; LD; SP vedotin-ejfv) *ANTINEOPLASTIC - ANTI-PD-1 ANTIBODIES*** - DRUGS FOR CANCER JEMPERLI INTRAVENOUS SOLUTION (dostarlimab-gxly) 3 LD; SP KEYTRUDA INTRAVENOUS SOLUTION (pembrolizumab) 3 PA; LD; SP LIBTAYO INTRAVENOUS SOLUTION (cemiplimab-rwlc) 3 PA; LD OPDIVO INTRAVENOUS SOLUTION (nivolumab) 3 PA; LD; SP *ANTINEOPLASTIC - ANTI-PD-L1 ANTIBODIES*** - DRUGS FOR CANCER BAVENCIO INTRAVENOUS SOLUTION (avelumab) 3 PA; LD IMFINZI INTRAVENOUS SOLUTION (durvalumab) 3 PA; LD; SP TECENTRIQ INTRAVENOUS SOLUTION (atezolizumab) 3 PA; LD; SP *ANTINEOPLASTIC - ANTI-SLAMF7 ANTIBODIES*** - DRUGS FOR CANCER EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (elotuzumab) *ANTINEOPLASTIC - AUTOLOGOUS CELLULAR IMMUNOTHERAPY*** - DRUGS FOR CANCER PROVENGE INTRAVENOUS SUSPENSION (sipuleucel-t) 4 PA; LD *ANTINEOPLASTIC - BCL-2 INHIBITORS*** - DRUGS FOR CANCER VENCLEXTA ORAL TABLET 10 MG (venetoclax) 3; OC PA; LD; QL (2 tablets per 1 day) VENCLEXTA ORAL TABLET 100 MG (venetoclax) 3; OC PA; LD; QL (6 tablet per 1 day) VENCLEXTA ORAL TABLET 50 MG (venetoclax) 3; OC PA; LD; QL (1 tablet per 1 day) VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 pack per 365 days) (venetoclax) *ANTINEOPLASTIC - BCR-ABL KINASE INHIBITORS*** - DRUGS FOR CANCER BOSULIF ORAL TABLET 100 MG (bosutinib) 2; OC PA; SP; QL (4 tablet per 1 day) BOSULIF ORAL TABLET 400 MG, 500 MG (bosutinib) 2; OC PA; SP; QL (1 tablet per 1 day) ICLUSIG ORAL TABLET 10 MG, 30 MG, 45 MG (ponatinib hcl) 2; OC PA; LD; QL (1 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 68 Coverage Requirements and Prescription Drug Name Drug Tier Limits ICLUSIG ORAL TABLET 15 MG (ponatinib hcl) 2; OC PA; LD; QL (2 tablets per 1 day) imatinib mesylate oral tablet 1 or 1b*; OC PA; SP; QL (2 tablets per 1 day) SPRYCEL ORAL TABLET (dasatinib) 2; OC PA; SP; QL (1 tablet per 1 day) TASIGNA ORAL CAPSULE (nilotinib hcl) 2; OC PA; SP; QL (4 capsules per 1 day) *ANTINEOPLASTIC - BISPECIFIC T-CELL ENGAGERS*** - DRUGS FOR CANCER BLINCYTO INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (blinatumomab) *ANTINEOPLASTIC - BRAF KINASE INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (6 capsules per 1 BRAFTOVI ORAL CAPSULE (encorafenib) 3; OC day) PA; LD; SP; QL (4 capsule per 1 TAFINLAR ORAL CAPSULE (dabrafenib mesylate) 3; OC day) ZELBORAF ORAL TABLET (vemurafenib) 2; OC PA; LD; SP; QL (8 tablet per 1 day) *ANTINEOPLASTIC - BTK INHIBITORS*** - DRUGS FOR CANCER BRUKINSA ORAL CAPSULE (zanubrutinib) 3; OC PA; LD; QL (4 capsules per 1 day) CALQUENCE ORAL CAPSULE (acalabrutinib) 3; OC PA; LD; QL (1 capsule per 1 day) IMBRUVICA ORAL CAPSULE 140 MG (ibrutinib) 3; OC PA; LD; QL (3 capsule per 1 day) IMBRUVICA ORAL CAPSULE 70 MG (ibrutinib) 3; OC PA; LD; QL (1 tablet per 1 day) IMBRUVICA ORAL TABLET (ibrutinib) 3; OC PA; LD; QL (1 tablet per 1 day) *ANTINEOPLASTIC - EGFR INHIBITORS*** - DRUGS FOR CANCER ERBITUX INTRAVENOUS SOLUTION (cetuximab) 3 PA; SP erlotinib hcl oral tablet 100 mg, 150 mg 1 or 1b*; OC PA; SP; QL (1 tablet per 1 day) erlotinib hcl oral tablet 25 mg 1 or 1b*; OC PA; SP; QL (3 tablets per 1 day) GILOTRIF ORAL TABLET (afatinib dimaleate) 3; OC PA; LD; QL (1 tablet per 1 day) IRESSA ORAL TABLET (gefitinib) 2; OC PA; LD; SP; QL (1 tablet per 1 day) PORTRAZZA INTRAVENOUS SOLUTION (necitumumab) 3 LD; SP TAGRISSO ORAL TABLET (osimertinib mesylate) 3; OC PA; LD; SP; QL (1 tablet per 1 day) TARCEVA ORAL TABLET 100 MG, 150 MG (erlotinib hcl) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (3 tablets per 1 TARCEVA ORAL TABLET 25 MG (erlotinib hcl) 3; OC day) VECTIBIX INTRAVENOUS SOLUTION (panitumumab) 3 PA; SP VIZIMPRO ORAL TABLET (dacomitinib) 3; OC PA; LD; SP; QL (1 tablet per 1 day) *ANTINEOPLASTIC - FGFR KINASE INHIBITORS*** - DRUGS FOR CANCER BALVERSA ORAL TABLET 3 MG (erdafitinib) 3; OC PA; LD; QL (3 tablets per 1 day) BALVERSA ORAL TABLET 4 MG (erdafitinib) 3; OC PA; LD; QL (2 tablets per 1 day) BALVERSA ORAL TABLET 5 MG (erdafitinib) 3; OC PA; LD; QL (1 tablet per 1 day) PEMAZYRE ORAL TABLET (pemigatinib) 3; OC PA; LD; QL (14 tablets per 21 days) *ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS*** - DRUGS FOR CANCER DAURISMO ORAL TABLET 100 MG (glasdegib maleate) 3; OC PA; LD; SP; QL (1 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 69 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; LD; SP; QL (2 tablets per 1 DAURISMO ORAL TABLET 25 MG (glasdegib maleate) 3; OC day) PA; LD; SP; QL (1 capsule per 1 ERIVEDGE ORAL CAPSULE (vismodegib) 2; OC day) PA; LD; SP; QL (1 capsule per 1 ODOMZO ORAL CAPSULE (sonidegib phosphate) 3; OC day) *ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS*** - DRUGS FOR CANCER BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (belinostat) PA; LD; SP; QL (1 capsule per 1 FARYDAK ORAL CAPSULE (panobinostat lactate) 3; OC day) ISTODAX (OVERFILL) INTRAVENOUS SOLUTION 3 PA; LD; SP RECONSTITUTED (romidepsin) ROMIDEPSIN INTRAVENOUS SOLUTION 3 PA; SP ZOLINZA ORAL CAPSULE (vorinostat) 2; OC PA; SP; QL (4 capsule per 1 day) *ANTINEOPLASTIC - HORMONAL AND RELATED AGENT COMBINATIONS*** - DRUGS FOR CANCER LEUPROLIDE ACETATE-BUPIVACAINE INTRAMUSCULAR 3 SOLUTION *ANTINEOPLASTIC - IMMUNOMODULATORS*** - DRUGS FOR CANCER PA; LD; SP; QL (21 capsules per 28 POMALYST ORAL CAPSULE (pomalidomide) 3; OC days) *ANTINEOPLASTIC - MEK INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (3 tablets per 1 COTELLIC ORAL TABLET (cobimetinib fumarate) 3; OC day) KOSELUGO ORAL CAPSULE 10 MG (selumetinib sulfate) 3; OC PA; LD; QL (8 capsules per 1 day) KOSELUGO ORAL CAPSULE 25 MG (selumetinib sulfate) 3; OC PA; LD; QL (4 capsules per 1 day) PA; LD; SP; QL (3 tablets per 1 MEKINIST ORAL TABLET 0.5 MG (trametinib dimethyl sulfoxide) 3; OC day) MEKINIST ORAL TABLET 2 MG (trametinib dimethyl sulfoxide) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (6 tablets per 1 MEKTOVI ORAL TABLET (binimetinib) 3; OC day) *ANTINEOPLASTIC - MET INHIBITORS*** - DRUGS FOR CANCER TABRECTA ORAL TABLET (capmatinib hcl) 3; OC PA; SP; QL (4 tablets per 1 day) *ANTINEOPLASTIC - METHYLTRANSFERASE INHIBITORS*** - DRUGS FOR CANCER TAZVERIK ORAL TABLET (tazemetostat hbr) 3; OC PA; LD; QL (8 tablets per 1 day) *ANTINEOPLASTIC - MTOR KINASE INHIBITORS*** - DRUGS FOR CANCER AFINITOR DISPERZ ORAL TABLET SOLUBLE (everolimus) 3; OC PA; SP AFINITOR ORAL TABLET 10 MG (everolimus) 2; OC PA; SP AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG (everolimus) 3; OC PA; SP everolimus oral tablet 1 or 1b*; OC PA; SP temsirolimus intravenous solution 1 or 1b* PA; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 70 Coverage Requirements and Prescription Drug Name Drug Tier Limits TORISEL INTRAVENOUS SOLUTION (temsirolimus) 3 PA; SP *ANTINEOPLASTIC - MULTIKINASE INHIBITORS*** - DRUGS FOR CANCER CABOMETYX ORAL TABLET (cabozantinib s-malate) 3; OC PA; LD; SP; QL (1 tablet per 1 day) CAPRELSA ORAL TABLET 100 MG (vandetanib) 2; OC PA; LD; QL (3 tablet per 1 day) CAPRELSA ORAL TABLET 300 MG (vandetanib) 2; OC PA; LD; QL (1 tablet per 1 day) PA; LD; SP; QL (1 dose-pack per COMETRIQ (100 MG DAILY DOSE) ORAL KIT (cabozantinib s-malate) 3; OC 56 days) PA; LD; SP; QL (1 dose pack per COMETRIQ (140 MG DAILY DOSE) ORAL KIT (cabozantinib s-malate) 3; OC 28 days) PA; LD; SP; QL (1 dose pack per COMETRIQ (60 MG DAILY DOSE) ORAL KIT (cabozantinib s-malate) 3; OC 28 days) FOTIVDA ORAL CAPSULE (tivozanib hcl) 3; OC LD lapatinib ditosylate oral tablet 1 or 1b*; OC PA; SP; QL (6 tablet per 1 day) PA; LD; SP; QL (6 tablets per 1 NERLYNX ORAL TABLET (neratinib maleate) 3; OC day) NEXAVAR ORAL TABLET (sorafenib tosylate) 2; OC PA; LD; SP; QL (4 tablet per 1 day) QINLOCK ORAL TABLET (ripretinib) 3; OC PA; LD; QL (3 tablets per 1 day) RYDAPT ORAL CAPSULE (midostaurin) 3; OC PA; SP; QL (8 capsules per 1 day) PA; LD; SP; QL (84 tablets per 28 STIVARGA ORAL TABLET (regorafenib) 2; OC days) PA; LD; SP; QL (1 capsule per 1 SUTENT ORAL CAPSULE (sunitinib malate) 2; OC day) TEPMETKO ORAL TABLET (tepotinib hcl) 3; OC PA; LD; QL (2 tablets per 1 day) TURALIO ORAL CAPSULE (pexidartinib hcl) 3; OC PA; LD; QL (4 tablets per 1 day) TYKERB ORAL TABLET (lapatinib ditosylate) 3; OC PA; LD; SP; QL (6 tablet per 1 day) UKONIQ ORAL TABLET (umbralisib tosylate) 3; OC PA; LD; QL (4 tablets per 1 day) VOTRIENT ORAL TABLET (pazopanib hcl) 2; OC PA; LD; SP; QL (4 tablet per 1 day) XOSPATA ORAL TABLET (gilteritinib fumarate) 3; OC PA; LD; QL (3 tablets per 1 day) *ANTINEOPLASTIC - PDGFR-ALPHA INHIBITORS*** - DRUGS FOR CANCER AYVAKIT ORAL TABLET (avapritinib) 3; OC PA; LD; QL (1 tablet per 1 day) *ANTINEOPLASTIC - PROTEASOME INHIBITORS*** - DRUGS FOR CANCER BORTEZOMIB INTRAVENOUS SOLUTION RECONSTITUTED 3 PA KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (carfilzomib) PA; LD; SP; QL (3 capsule per 28 NINLARO ORAL CAPSULE (ixazomib citrate) 3; OC days) VELCADE INJECTION SOLUTION RECONSTITUTED (bortezomib) 3 PA; SP *ANTINEOPLASTIC - RET INHIBITORS*** - DRUGS FOR CANCER GAVRETO ORAL CAPSULE (pralsetinib) 3; OC PA; LD; QL (4 capsules per 1 day) PA; LD; SP; QL (6 capsules per 1 RETEVMO ORAL CAPSULE 40 MG (selpercatinib) 3; OC day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 71 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; LD; SP; QL (4 capsules per 1 RETEVMO ORAL CAPSULE 80 MG (selpercatinib) 3; OC day) *ANTINEOPLASTIC - TROPOMYOSIN RECEPTOR KINASE INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (1 capsule per 1 ROZLYTREK ORAL CAPSULE 100 MG (entrectinib) 3; OC day) PA; LD; SP; QL (3 capsules per 1 ROZLYTREK ORAL CAPSULE 200 MG (entrectinib) 3; OC day) PA; LD; SP; QL (2 tablets per 1 VITRAKVI ORAL CAPSULE 100 MG (larotrectinib sulfate) 3; OC day) PA; LD; SP; QL (6 tablets per 1 VITRAKVI ORAL CAPSULE 25 MG (larotrectinib sulfate) 3; OC day) VITRAKVI ORAL SOLUTION (larotrectinib sulfate) 3; OC PA; LD; SP; QL (10 mL per 1 day) *ANTINEOPLASTIC - XPO1 INHIBITORS*** - DRUGS FOR CANCER XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (selinexor) XPOVIO (40 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (selinexor) XPOVIO (40 MG TWICE WEEKLY) ORAL TABLET THERAPY 3; OC PA; LD; QL (1 carton per 28 days) PACK (selinexor) XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (selinexor) XPOVIO (60 MG TWICE WEEKLY) ORAL TABLET THERAPY 3; OC PA; LD; QL (1 pack per 1 week) PACK (selinexor) XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (selinexor) XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET THERAPY 3; OC PA; LD; QL (1 pack per 1 week) PACK (selinexor) *ANTINEOPLASTIC ANTIBIOTICS*** - DRUGS FOR CANCER adriamycin intravenous solution 1 or 1b* SP adriamycin intravenous solution reconstituted 1 or 1b* SP bleomycin sulfate injection solution reconstituted 1 or 1b* SP COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (dactinomycin) dactinomycin intravenous solution reconstituted 1 or 1b* SP DAUNORUBICIN HCL INTRAVENOUS SOLUTION 3 SP DOXIL INTRAVENOUS INJECTABLE (doxorubicin hcl liposomal) 3 PA; SP doxorubicin hcl intravenous solution 1 or 1b* SP doxorubicin hcl intravenous solution reconstituted 1 or 1b* SP doxorubicin hcl liposomal intravenous injectable 1 or 1b* PA; SP ELLENCE INTRAVENOUS SOLUTION (epirubicin hcl) 3 PA; SP epirubicin hcl intravenous solution 1 or 1b* PA; SP IDAMYCIN PFS INTRAVENOUS SOLUTION (idarubicin hcl) 3 SP idarubicin hcl intravenous solution 1 or 1b* SP JELMYTO SOLUTION RECONSTITUTED (mitomycin) 3 PA; LD * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 72 Coverage Requirements and Prescription Drug Name Drug Tier Limits mitomycin intravenous solution reconstituted 1 or 1b* SP MITOMYCIN INTRAVESICAL SOLUTION PREFILLED SYRINGE 3 mitoxantrone hcl intravenous concentrate 1 or 1b* SP mutamycin intravenous solution reconstituted 1 or 1b* SP valrubicin intravesical solution 1 or 1b* SP VALSTAR INTRAVESICAL SOLUTION (valrubicin) 3 LD; SP *ANTINEOPLASTIC -ANTIBODY FOR RADIOPHARMACEUTICAL THERAPY*** - DRUGS FOR CANCER ZEVALIN Y-90 INTRAVENOUS KIT (ibritumomab tiuxetan for y-90) 3 PA; LD *ANTINEOPLASTIC ANTIBODY-DRUG COMPLEXES*** - DRUGS FOR CANCER ENHERTU INTRAVENOUS SOLUTION RECONSTITUTED (fam- 3 PA; LD; SP trastuzumab deruxtec-nxki) KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED (ado- 3 PA; LD; SP trastuzumab emtansine) *ANTINEOPLASTIC COMBINATIONS*** - DRUGS FOR CANCER DARZALEX FASPRO SUBCUTANEOUS SOLUTION (daratumumab- 3 PA; LD; SP hyaluronidase-fihj) HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION (trastuzumab- 3 LD; SP hyaluronidase-oysk) PA; LD; SP; QL (5 tablets per 28 INQOVI ORAL TABLET (decitabine-cedazuridine) 3; OC days) KISQALI FEMARA (400 MG DOSE) ORAL TABLET THERAPY PACK 2; OC PA; SP; QL (0.04 unit per 1 day) (ribociclib-letrozole) KISQALI FEMARA (600 MG DOSE) ORAL TABLET THERAPY PACK 2; OC PA; SP; QL (0.04 unit per 1 day) (ribociclib-letrozole) KISQALI FEMARA(200 MG DOSE) ORAL TABLET THERAPY PACK 2; OC PA; SP; QL (0.04 unit per 1 day) (ribociclib-letrozole) LONSURF ORAL TABLET (trifluridine-tipiracil) 3; OC PA; LD; SP PHESGO SUBCUTANEOUS SOLUTION (pertuz-trastuz-hyaluron-zzxf) 3 PA; LD; SP RITUXAN HYCELA SUBCUTANEOUS SOLUTION (rituximab- 3 LD; SP hyaluronidase human) VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 3 LD; SP (daunorubicin-cytarabine lipo) *ANTINEOPLASTIC ENZYMES*** - DRUGS FOR CANCER ASPARLAS INTRAVENOUS SOLUTION (calaspargase pegol-mknl) 3 PA; LD; SP ERWINASE INJECTION SOLUTION RECONSTITUTED (asparaginase 3 PA; LD; SP erwinia chrysanth) ERWINAZE INJECTION SOLUTION RECONSTITUTED (asparaginase 3 PA; LD; SP erwinia chrysanth) ONCASPAR INJECTION SOLUTION (pegaspargase) 3 PA; SP *ANTINEOPLASTIC RADIOPHARMACEUTICALS*** - DRUGS FOR CANCER AZEDRA DOSIMETRIC INTRAVENOUS SOLUTION (iobenguane i 4 PA; LD 131)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 73 Coverage Requirements and Prescription Drug Name Drug Tier Limits AZEDRA THERAPEUTIC INTRAVENOUS SOLUTION (iobenguane i 4 PA; LD 131) LUTATHERA INTRAVENOUS SOLUTION (lutetium lu 177 dotatate) 3 PA; LD QUADRAMET INTRAVENOUS SOLUTION (samarium sm 153 3 lexidronam) STRONTIUM CHLORIDE SR-89 INTRAVENOUS SOLUTION 3 XOFIGO INTRAVENOUS SOLUTION (radium ra 223 dichloride) 3 PA; LD *ANTINEOPLASTICS - INTERLEUKINS*** - DRUGS FOR CANCER ELZONRIS INTRAVENOUS SOLUTION (tagraxofusp-erzs) 3 PA; LD PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; SP (aldesleukin) *ANTINEOPLASTICS - PHOTOACTIVATED AGENTS*** - DRUGS FOR CANCER PHOTOFRIN INTRAVENOUS SOLUTION RECONSTITUTED 3 (porfimer sodium) UVADEX INJECTION SOLUTION (methoxsalen (photopheresis)) 3 *ANTINEOPLASTICS MISC.*** - DRUGS FOR CANCER ACTIMMUNE SUBCUTANEOUS SOLUTION (interferon gamma-1b) 4 PA; LD; SP ALFERON N INJECTION SOLUTION (interferon alfa-n3) 4 SP arsenic trioxide intravenous solution 1 or 1b* SP dacarbazine intravenous solution reconstituted 1 or 1b* SP HYDREA ORAL CAPSULE (hydroxyurea) 3; OC hydroxyurea oral capsule 1 or 1b*; OC INTRON A INJECTION SOLUTION (interferon alfa-2b) 4 LD; SP INTRON A INJECTION SOLUTION RECONSTITUTED (interferon alfa- 4 LD; SP 2b) MATULANE ORAL CAPSULE (procarbazine hcl) 2; OC LD NIPENT INTRAVENOUS SOLUTION RECONSTITUTED (pentostatin) 3 SP SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3 PA; LD (omacetaxine mepesuccinate) TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED (bcg 4 SP live) TRISENOX INTRAVENOUS SOLUTION (arsenic trioxide) 3 LD; SP *AROMATASE INHIBITORS*** - DRUGS FOR CANCER anastrozole oral tablet 1 or 1b*; OC; $0 QL (1 tablet per 1 day) AROMASIN ORAL TABLET (exemestane) 3; OC QL (2 tablets per 1 day) exemestane oral tablet 1 or 1b*; OC; $0 QL (2 tablets per 1 day) FEMARA ORAL TABLET (letrozole) 3; OC QL (1 tablet per 1 day) letrozole oral tablet 1 or 1b*; OC; $0 QL (1 tablet per 1 day) *CARBOXYPEPTIDASE ENZYME AGENTS*** - DRUGS FOR CANCER VORAXAZE INTRAVENOUS SOLUTION RECONSTITUTED 3 LD (glucarpidase)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 74 Coverage Requirements and Prescription Drug Name Drug Tier Limits *CARDIAC PROTECTIVE AGENTS*** - DRUGS FOR CANCER dexrazoxane hcl intravenous solution reconstituted 1 or 1b* SP TOTECT INTRAVENOUS SOLUTION RECONSTITUTED (dexrazoxane 3 SP hcl) *CHEMOTHERAPY ADJUNCTS - HYPERURICEMIA AGENTS*** - DRUGS FOR CANCER ELITEK INTRAVENOUS SOLUTION RECONSTITUTED (rasburicase) 3 PA; SP *CHEMOTHERAPY ADJUNCTS - KERATINOCYTE GROWTH FACTORS*** - DRUGS FOR CANCER KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 4 (palifermin) *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (21 capsules per 28 IBRANCE ORAL CAPSULE (palbociclib) 2; OC days) PA; LD; SP; QL (21 tablets per 28 IBRANCE ORAL TABLET 100 MG, 75 MG (palbociclib) 2; OC days) IBRANCE ORAL TABLET 125 MG (palbociclib) 2; OC PA; LD; SP; QL (1 tablet per 1 day) KISQALI (200 MG DOSE) ORAL TABLET THERAPY PACK (ribociclib 2; OC PA; SP; QL (3 tablets per 1 day) succinate) KISQALI (400 MG DOSE) ORAL TABLET THERAPY PACK (ribociclib 2; OC PA; SP; QL (3 tablets per 1 day) succinate) KISQALI (600 MG DOSE) ORAL TABLET THERAPY PACK (ribociclib 2; OC PA; SP; QL (3 tablets per 1 day) succinate) PA; LD; SP; QL (2 tablets per 1 VERZENIO ORAL TABLET (abemaciclib) 3; OC day) *ESTROGEN RECEPTOR ANTAGONIST*** - DRUGS FOR CANCER FASLODEX INTRAMUSCULAR SOLUTION (fulvestrant) 3 PA; SP fulvestrant intramuscular solution 1 or 1b* PA; SP *ESTROGENS-ANTINEOPLASTIC*** - DRUGS FOR CANCER EMCYT ORAL CAPSULE (estramustine phosphate sodium) 2; OC PA *FOLIC ACID ANTAGONISTS RESCUE AGENTS*** - DRUGS FOR CANCER KHAPZORY INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (levoleucovorin) leucovorin calcium injection solution 1 or 1b* leucovorin calcium injection solution reconstituted 1 or 1b* leucovorin calcium oral tablet 1 or 1b* levoleucovorin calcium intravenous solution reconstituted 1 or 1b* PA levoleucovorin calcium pf intravenous solution 1 or 1b* *GONADOTROPIN RELEASING HORMONE (GNRH) ANTAGONISTS*** - DRUGS FOR CANCER FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION 3 PA; SP; QL (2 units per 310 days) RECONSTITUTED (degarelix acetate) FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 3 PA; SP; QL (1 kit per 28 days) (degarelix acetate)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 75 Coverage Requirements and Prescription Drug Name Drug Tier Limits ORGOVYX ORAL TABLET (relugolix) 3; OC PA; LD; QL (1 tablet per 1 day) *IMIDAZOTETRAZINES*** - DRUGS FOR CANCER TEMODAR INTRAVENOUS SOLUTION RECONSTITUTED 2 PA; SP (temozolomide) TEMODAR ORAL CAPSULE (temozolomide) 3; OC PA; SP; QL (2 capsules per 1 day) temozolomide oral capsule 100 mg, 140 mg, 180 mg, 250 mg 1 or 1b*; OC PA; SP; QL (2 capsules per 1 day) temozolomide oral capsule 20 mg 1 or 1b*; OC PA; SP; QL (4 capsule per 1 day) temozolomide oral capsule 5 mg 1 or 1b*; OC PA; SP; QL (3 capsule per 1 day) *ISOCITRATE DEHYDROGENASE-1 (IDH1) INHIBITORS*** - DRUGS FOR CANCER TIBSOVO ORAL TABLET (ivosidenib) 3; OC PA; LD; QL (2 tablets per 1 day) *ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS*** - DRUGS FOR CANCER IDHIFA ORAL TABLET 100 MG (enasidenib mesylate) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 IDHIFA ORAL TABLET 50 MG (enasidenib mesylate) 3; OC day) *JANUS ASSOCIATED KINASE (JAK) INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (4 capsules per 1 INREBIC ORAL CAPSULE (fedratinib hcl) 3; OC day) PA; LD; SP; QL (2 tablets per 1 JAKAFI ORAL TABLET (ruxolitinib phosphate) 2; OC day) *LHRH ANALOGS*** - DRUGS FOR CANCER ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide acetate (3 month)) 3 PA; SP; QL (1 syringe per 84 days) PA; SP; QL (1 syringe per 112 ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide acetate (4 month)) 3 days) PA; SP; QL (1 syringe per 168 ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide acetate (6 month)) 3 days) ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide acetate) 3 PA; SP; QL (1 syringe per 28 days) leuprolide acetate injection kit 1 or 1b* PA; SP LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG PA; SP; QL (1 syringe kit per 28 4 (leuprolide acetate) days) LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG 2 SP; QL (1 kit per 28 days) (leuprolide acetate) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG 4 PA; SP; QL (1 kit per 84 days) (leuprolide acetate (3 month)) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG 2 SP; QL (1 kit per 84 days) (leuprolide acetate (3 month)) LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT (leuprolide 2 SP; QL (1 kit per 112 days) acetate (4 month)) LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT (leuprolide 2 SP; QL (1 syringe kit per 168 days) acetate (6 month)) TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION 3 PA; SP; QL (1 vial per 84 days) RECONSTITUTED 11.25 MG (triptorelin pamoate) TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION PA; SP; QL (1 syringe per 168 3 RECONSTITUTED 22.5 MG (triptorelin pamoate) days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 76 Coverage Requirements and Prescription Drug Name Drug Tier Limits TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION 3 PA; SP; QL (1 kit per 28 days) RECONSTITUTED 3.75 MG (triptorelin pamoate) PA; LD; SP; QL (1 implant per 365 VANTAS SUBCUTANEOUS KIT (histrelin acetate) 3 days) ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG (goserelin acetate) 3 PA; SP; QL (1 EA per 84 days) ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG (goserelin acetate) 3 PA; SP; QL (1 unit per 28 days) *MITOTIC INHIBITORS*** - DRUGS FOR CANCER ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 3 PA; LD; SP (paclitaxel protein-bound part) DOCETAXEL INTRAVENOUS CONCENTRATE 3 PA; SP DOCETAXEL INTRAVENOUS SOLUTION 3 PA; SP ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (etoposide phosphate) etoposide intravenous solution 1 or 1b* SP etoposide oral capsule 1 or 1b*; OC SP HALAVEN INTRAVENOUS SOLUTION (eribulin mesylate) 3 PA; SP IXEMPRA KIT INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; SP (ixabepilone) JEVTANA INTRAVENOUS SOLUTION (cabazitaxel) 3 PA; LD; SP MARQIBO INTRAVENOUS SUSPENSION (vincristine sulfate liposome) 3 LD NAVELBINE INTRAVENOUS SOLUTION (vinorelbine tartrate) 3 SP paclitaxel intravenous concentrate 1 or 1b* SP TENIPOSIDE INTRAVENOUS SOLUTION 3 SP toposar intravenous solution 1 or 1b* SP vinblastine sulfate intravenous solution 1 or 1b* SP vincristine sulfate intravenous solution 1 or 1b* SP vinorelbine tartrate intravenous solution 1 or 1b* SP *MYELOPROTECTIVE AGENTS*** - DRUGS FOR CANCER COSELA INTRAVENOUS SOLUTION RECONSTITUTED (trilaciclib 3 LD dihydrochloride) *NITROGEN MUSTARDS*** - DRUGS FOR CANCER ALKERAN INTRAVENOUS SOLUTION RECONSTITUTED (melphalan 3 SP hcl) ALKERAN ORAL TABLET (melphalan) 3; OC SP cyclophosphamide injection solution reconstituted 1 or 1b* SP CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION 3 SP cyclophosphamide oral capsule 1 or 1b*; OC SP CYCLOPHOSPHAMIDE ORAL TABLET 3; OC EVOMELA INTRAVENOUS SOLUTION RECONSTITUTED 3 LD; SP (melphalan hcl) IFEX INTRAVENOUS SOLUTION RECONSTITUTED (ifosfamide) 3 SP ifosfamide intravenous solution 1 or 1b* SP ifosfamide intravenous solution reconstituted 1 gm 1 or 1b* SP IFOSFAMIDE INTRAVENOUS SOLUTION RECONSTITUTED 3 GM 3 SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 77 Coverage Requirements and Prescription Drug Name Drug Tier Limits LEUKERAN ORAL TABLET (chlorambucil) 2; OC melphalan hcl intravenous solution reconstituted 1 or 1b* SP melphalan oral tablet 1 or 1b*; OC SP PEPAXTO INTRAVENOUS SOLUTION RECONSTITUTED (melphalan 3 LD flufenamide hcl) *NITROSOUREAS*** - DRUGS FOR CANCER BICNU INTRAVENOUS SOLUTION RECONSTITUTED (carmustine) 3 SP carmustine intravenous solution reconstituted 1 or 1b* SP GLEOSTINE ORAL CAPSULE (lomustine) 3; OC PA GLIADEL WAFER IMPLANT WAFER (carmustine in polifeprosan) 3 ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED 3 LD; SP (streptozocin) *ONCOLYTIC VIRAL AGENTS - HSV1*** - DRUGS FOR CANCER IMLYGIC INTRALESIONAL SUSPENSION (talimogene laherparepvec) 3 LD *PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS*** - DRUGS FOR CANCER ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED (copanlisib 3 PA; LD hcl) COPIKTRA ORAL CAPSULE (duvelisib) 3; OC PA; LD; QL (2 tablets per 1 day) PIQRAY (200 MG DAILY DOSE) ORAL TABLET THERAPY PACK 3; OC PA; SP; QL (1 pack per 28 days) (alpelisib) PIQRAY (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 3; OC PA; SP; QL (1 pack per 28 days) (alpelisib) PIQRAY (300 MG DAILY DOSE) ORAL TABLET THERAPY PACK 3; OC PA; SP; QL (1 pack per 28 days) (alpelisib) PA; LD; SP; QL (2 tablets per 1 ZYDELIG ORAL TABLET (idelalisib) 3; OC day) *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (4 tablets per 1 LYNPARZA ORAL TABLET (olaparib) 3; OC day) RUBRACA ORAL TABLET 200 MG, 300 MG (rucaparib camsylate) 3; OC PA; LD; SP; QL (4 tablet per 1 day) PA; LD; SP; QL (4 tablets per 1 RUBRACA ORAL TABLET 250 MG (rucaparib camsylate) 3; OC day) PA; LD; SP; QL (3 capsules per 1 TALZENNA ORAL CAPSULE 0.25 MG (talazoparib tosylate) 3; OC day) PA; LD; SP; QL (1 capsule per 1 TALZENNA ORAL CAPSULE 1 MG (talazoparib tosylate) 3; OC day) ZEJULA ORAL CAPSULE (niraparib tosylate) 3; OC PA; LD; QL (3 capsules per 1 day) *PROGESTINS-ANTINEOPLASTIC*** - DRUGS FOR CANCER hydroxyprogesterone caproate intramuscular solution 1 or 1b* PA; LD megestrol acetate oral suspension 1 or 1b*; OC megestrol acetate oral tablet 1 or 1b*; OC *RETINOIDS*** - DRUGS FOR CANCER tretinoin oral capsule 1 or 1b*; OC

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 78 Coverage Requirements and Prescription Drug Name Drug Tier Limits *SELECTIVE RETINOID X RECEPTOR AGONISTS*** - DRUGS FOR CANCER bexarotene oral capsule 1 or 1b*; OC PA; SP; QL (10 capsules per 1 day) *TETRAHYDROISOQUINOLINES*** - DRUGS FOR CANCER YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED 3 LD; SP (trabectedin) *TOPOISOMERASE I INHIBITORS - ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER TRODELVY INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD (sacituzumab govitecan-hziy) *TOPOISOMERASE I INHIBITORS*** - DRUGS FOR CANCER CAMPTOSAR INTRAVENOUS SOLUTION (irinotecan hcl) 3 SP HYCAMTIN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (topotecan hcl) HYCAMTIN ORAL CAPSULE (topotecan hcl) 2; OC PA; SP irinotecan hcl intravenous solution 1 or 1b* SP ONIVYDE INTRAVENOUS INJECTABLE (irinotecan hcl liposome) 3 LD TOPOTECAN HCL INTRAVENOUS SOLUTION 3 SP topotecan hcl intravenous solution reconstituted 1 or 1b* SP *URINARY TRACT PROTECTIVE AGENTS*** - DRUGS FOR CANCER ETHYOL INTRAVENOUS SOLUTION RECONSTITUTED (amifostine) 3 PA; SP mesna intravenous solution 1 or 1b* PA MESNEX INTRAVENOUS SOLUTION (mesna) 3 PA MESNEX ORAL TABLET (mesna) 2 PA *VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS*** - DRUGS FOR CANCER AVASTIN INTRAVENOUS SOLUTION (bevacizumab) 3 PA; LD; SP CYRAMZA INTRAVENOUS SOLUTION (ramucirumab) 3 PA; LD; SP PA; LD; SP; QL (6 tablets per 1 INLYTA ORAL TABLET 1 MG (axitinib) 2; OC day) INLYTA ORAL TABLET 5 MG (axitinib) 2; OC PA; LD; SP; QL (4 tablet per 1 day) LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (30 capsules per 30 3; OC (lenvatinib mesylate) days) LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (1 pack per 30 3; OC (lenvatinib mesylate) days) LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (60 capsules per 30 3; OC (lenvatinib mesylate) days) LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (1 pack per 30 3; OC (lenvatinib mesylate) days) LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (60 capsules per 30 3; OC (lenvatinib mesylate) days) LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (90 capsules per 30 3; OC (lenvatinib mesylate) days) LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (30 capsules per 30 3; OC (lenvatinib mesylate) days) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 79 Coverage Requirements and Prescription Drug Name Drug Tier Limits LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (1 pack per 30 3; OC (lenvatinib mesylate) days) MVASI INTRAVENOUS SOLUTION (bevacizumab-awwb) 3 PA; LD; SP ZALTRAP INTRAVENOUS SOLUTION (ziv-aflibercept) 3 PA; LD; SP ZIRABEV INTRAVENOUS SOLUTION (bevacizumab-bvzr) 3 PA; LD; SP *ANTIPARKINSON AND RELATED THERAPY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM *ADENOSINE RECEPTOR ANTAGONIST*** - DRUGS FOR PARKINSON NOURIANZ ORAL TABLET (istradefylline) 4 PA; LD; SP; QL (1 tablet per 1 day) *ANTIPARKINSON ANTICHOLINERGICS*** - DRUGS FOR PARKINSON benztropine mesylate injection solution 1 or 1a* benztropine mesylate oral tablet 1 or 1a* COGENTIN INJECTION SOLUTION (benztropine mesylate) 3 trihexyphenidyl hcl oral solution 1 or 1a* trihexyphenidyl hcl oral tablet 1 or 1a* *ANTIPARKINSON DOPAMINERGICS*** - DRUGS FOR PARKINSON amantadine hcl oral capsule 1 or 1b* QL (4 capsule per 1 day) amantadine hcl oral syrup 1 or 1b* QL (40 mL per 1 day) amantadine hcl oral tablet 1 or 1b* QL (4 tablet per 1 day) bromocriptine mesylate oral capsule 1 or 1b* bromocriptine mesylate oral tablet 1 or 1b* GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 137 MG 3 PA; LD; QL (2 capsules per 1 day) (amantadine hcl) GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 68.5 3 PA; LD MG (amantadine hcl) INBRIJA INHALATION CAPSULE (levodopa) 4 PA; LD; QL (5 kits per 30 days) OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY PACK 3 PA; LD; QL (2 tablets per 1 day) (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 129 3 PA; LD MG (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 193 3 PA; LD; QL (1 tablet per 1 day) MG, 258 MG (amantadine hcl) PARLODEL ORAL CAPSULE (bromocriptine mesylate) 3 PARLODEL ORAL TABLET (bromocriptine mesylate) 3 *ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS*** - DRUGS FOR PARKINSON AZILECT ORAL TABLET (rasagiline mesylate) 3 rasagiline mesylate oral tablet 1 or 1b* selegiline hcl oral capsule 1 or 1b* selegiline hcl oral tablet 1 or 1b* XADAGO ORAL TABLET 100 MG (safinamide mesylate) 3 PA; QL (1 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 80 Coverage Requirements and Prescription Drug Name Drug Tier Limits XADAGO ORAL TABLET 50 MG (safinamide mesylate) 3 PA; QL (2 tablets per 1 day) ZELAPAR ORAL TABLET DISPERSIBLE (selegiline hcl) 3 PA; QL (2 tablets per 1 day) *CENTRAL/PERIPHERAL COMT INHIBITORS*** - DRUGS FOR PARKINSON TASMAR ORAL TABLET (tolcapone) 3 PA; QL (6 tablet per 1 day) tolcapone oral tablet 1 or 1b* PA; QL (6 tablet per 1 day) *DECARBOXYLASE INHIBITORS*** - DRUGS FOR PARKINSON carbidopa oral tablet 1 or 1b* LODOSYN ORAL TABLET (carbidopa) 3 *LEVODOPA COMBINATIONS*** - DRUGS FOR PARKINSON carbidopa-levodopa er oral tablet extended release 1 or 1b* carbidopa-levodopa oral tablet 1 or 1b* carbidopa-levodopa oral tablet dispersible 1 or 1b* carbidopa-levodopa-entacapone oral tablet 1 or 1b* DUOPA ENTERAL SUSPENSION (carbidopa-levodopa) 3 PA; LD; SP RYTARY ORAL CAPSULE EXTENDED RELEASE (carbidopa- 3 levodopa) SINEMET ORAL TABLET (carbidopa-levodopa) 3 STALEVO 100 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 125 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 150 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 200 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 50 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 75 ORAL TABLET (carbidopa-levodopa-entacapone) 3 *NONERGOLINE DOPAMINE RECEPTOR AGONISTS*** - DRUGS FOR PARKINSON APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE (apomorphine 4 PA; LD; SP; QL (2 mL per 1 day) hcl) KYNMOBI SUBLINGUAL FILM (apomorphine hcl) 3 PA; LD; QL (5 films per 1 day) MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (1 tablet per 1 day) (pramipexole dihydrochloride) MIRAPEX ORAL TABLET (pramipexole dihydrochloride) 3 QL (3 tablet per 1 day) NEUPRO TRANSDERMAL PATCH 24 HOUR (rotigotine) 3 QL (1 patch per 1 day) pramipexole dihydrochloride er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) pramipexole dihydrochloride oral tablet 1 or 1b* QL (3 tablet per 1 day) ropinirole hcl er oral tablet extended release 24 hour 1 or 1b* ropinirole hcl oral tablet 1 or 1b* *PERIPHERAL COMT INHIBITORS*** - DRUGS FOR PARKINSON COMTAN ORAL TABLET (entacapone) 3 QL (8 tablet per 1 day) entacapone oral tablet 1 or 1b* QL (8 tablet per 1 day) ONGENTYS ORAL CAPSULE 25 MG (opicapone) 3 PA; QL (1 tablet per 1 day) ONGENTYS ORAL CAPSULE 50 MG (opicapone) 3 PA; QL (6 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 81 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIPSYCHOTICS/ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM *ANTIMANIC AGENTS*** - DRUGS FOR SEVERE MENTAL DISORDERS lithium carbonate er oral tablet extended release 1 or 1a* lithium carbonate oral capsule 1 or 1a* lithium carbonate oral tablet 1 or 1a* *ANTIPSYCHOTICS - MISC.*** - DRUGS FOR SEVERE MENTAL DISORDERS CAPLYTA ORAL CAPSULE (lumateperone tosylate) 3 ST; QL (1 capsule per 1 day) EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 3 QL (8 capsules per 1 day) MG, 200 MG (carbamazepine (antipsychotic)) EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 300 3 QL (5 capsules per 1 day) MG (carbamazepine (antipsychotic)) GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 3 (ziprasidone mesylate) LATUDA ORAL TABLET 120 MG (lurasidone hcl) 3 QL (1 tablet per 1 day) LATUDA ORAL TABLET 20 MG, 40 MG, 60 MG (lurasidone hcl) 3 LATUDA ORAL TABLET 80 MG (lurasidone hcl) 3 QL (2 tablets per 1 day) PA; LD; SP; QL (1 capsule per 1 NUPLAZID ORAL CAPSULE (pimavanserin tartrate) 4 day) NUPLAZID ORAL TABLET (pimavanserin tartrate) 4 PA; LD; SP; QL (1 tablet per 1 day) VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG (cariprazine hcl) 3 ST VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG (cariprazine hcl) 3 ST; QL (1 capsule per 1 day) VRAYLAR ORAL CAPSULE THERAPY PACK (cariprazine hcl) 3 ST; QL (1 pack per 1 year) ziprasidone hcl oral capsule 20 mg, 40 mg 1 or 1b* ziprasidone hcl oral capsule 60 mg, 80 mg 1 or 1b* QL (2 capsules per 1 day) ziprasidone mesylate intramuscular solution reconstituted 1 or 1b* *BENZISOXAZOLES*** - DRUGS FOR SEVERE MENTAL DISORDERS FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG, 6 MG (iloperidone) 3 ST FANAPT ORAL TABLET 10 MG, 12 MG, 8 MG (iloperidone) 3 ST; QL (2 tablets per 1 day) FANAPT TITRATION PACK ORAL TABLET (iloperidone) 3 ST; QL (1 pack per 1 year) INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED 3 QL (1 syringe per 28 days) SYRINGE (paliperidone palmitate) INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED 3 QL (1 syringe per 90 days) SYRINGE (paliperidone palmitate) paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg 1 or 1b* paliperidone er oral tablet extended release 24 hour 6 mg 1 or 1b* QL (2 tablets per 1 day) paliperidone er oral tablet extended release 24 hour 9 mg 1 or 1b* QL (1 tablet per 1 day) PERSERIS SUBCUTANEOUS PREFILLED SYRINGE (risperidone) 3 QL (1 syringe per 30 days) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION 2 QL (2 injections per 1 day) RECONSTITUTED ER 12.5 MG (risperidone microspheres)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 82 Coverage Requirements and Prescription Drug Name Drug Tier Limits RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 25 MG, 37.5 MG, 50 MG (risperidone 2 QL (2 injections per 28 days) microspheres) risperidone oral solution 1 or 1b* ST; QL (8 mL per 1 day) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 or 1b* QL (2 tablets per 1 day) risperidone oral tablet 3 mg, 4 mg 1 or 1b* QL (4 tablets per 1 day) risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 or 1b* QL (2 tablets per 1 day) risperidone oral tablet dispersible 3 mg, 4 mg 1 or 1b* QL (4 tablets per 1 day) *BUTYROPHENONES*** - DRUGS FOR SEVERE MENTAL DISORDERS HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 MG/ML 3 QL (5 injections per 30 days) (haloperidol decanoate) HALDOL DECANOATE INTRAMUSCULAR SOLUTION 50 MG/ML 3 QL (5 ampules per 30 days) (haloperidol decanoate) HALDOL INJECTION SOLUTION (haloperidol lactate) 3 haloperidol decanoate intramuscular solution 100 mg/ml 1 or 1b* QL (5 injections per 30 days) haloperidol decanoate intramuscular solution 50 mg/ml 1 or 1b* QL (5 ampules per 30 days) haloperidol lactate injection solution 1 or 1b* haloperidol lactate oral concentrate 1 or 1b* haloperidol oral tablet 1 or 1b* *DIBENZODIAZEPINES*** - DRUGS FOR SEVERE MENTAL DISORDERS clozapine oral tablet 100 mg 1 or 1b* QL (9 tablets per 1 day) clozapine oral tablet 200 mg 1 or 1b* QL (4 tablets per 1 day) clozapine oral tablet 25 mg, 50 mg 1 or 1b* clozapine oral tablet dispersible 100 mg 1 or 1b* QL (9 tablets per 1 day) clozapine oral tablet dispersible 12.5 mg, 25 mg 1 or 1b* clozapine oral tablet dispersible 150 mg 1 or 1b* QL (6 tablets per 1 day) clozapine oral tablet dispersible 200 mg 1 or 1b* QL (4 tablets per 1 day) VERSACLOZ ORAL SUSPENSION (clozapine) 3 QL (18 mL per 1 day) *DIBENZO-OXEPINO PYRROLES*** - DRUGS FOR SEVERE MENTAL DISORDERS asenapine maleate sublingual tablet sublingual 10 mg 1 or 1b* QL (2 tablets per 1 day) asenapine maleate sublingual tablet sublingual 2.5 mg, 5 mg 1 or 1b* SECUADO TRANSDERMAL PATCH 24 HOUR (asenapine) 3 ST; QL (1 patch per 1 day) *DIBENZOTHIAZEPINES*** - DRUGS FOR SEVERE MENTAL DISORDERS quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg 1 or 1b* quetiapine fumarate er oral tablet extended release 24 hour 300 mg, 400 mg, 1 or 1b* QL (2 tablets per 1 day) 50 mg quetiapine fumarate oral tablet 100 mg, 25 mg, 50 mg 1 or 1b* quetiapine fumarate oral tablet 200 mg 1 or 1b* QL (3 tablets per 1 day) quetiapine fumarate oral tablet 300 mg, 400 mg 1 or 1b* QL (2 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 83 Coverage Requirements and Prescription Drug Name Drug Tier Limits *DIBENZOXAZEPINES*** - DRUGS FOR SEVERE MENTAL DISORDERS ADASUVE INHALATION AEROSOL POWDER BREATH 3 ACTIVATED (loxapine) loxapine succinate oral capsule 1 or 1b* *DIHYDROINDOLONES*** - DRUGS FOR SEVERE MENTAL DISORDERS molindone hcl oral tablet 1 or 1b* *PHENOTHIAZINES*** - DRUGS FOR SEVERE MENTAL DISORDERS chlorpromazine hcl injection solution 1 or 1b* chlorpromazine hcl oral tablet 1 or 1b* compro rectal suppository 1 or 1b* fluphenazine decanoate injection solution 1 or 1b* fluphenazine hcl injection solution 1 or 1b* fluphenazine hcl oral concentrate 1 or 1b* fluphenazine hcl oral elixir 1 or 1b* fluphenazine hcl oral tablet 1 or 1b* perphenazine oral tablet 1 or 1b* prochlorperazine edisylate injection solution 1 or 1b* prochlorperazine maleate oral tablet 1 or 1a* prochlorperazine rectal suppository 1 or 1b* thioridazine hcl oral tablet 1 or 1b* trifluoperazine hcl oral tablet 1 or 1b* *QUINOLINONE DERIVATIVES*** - DRUGS FOR SEVERE MENTAL DISORDERS ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 3 (aripiprazole) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION 3 QL (1 injection per 30 days) RECONSTITUTED ER (aripiprazole) ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 10 MG, 15 3 ST MG, 2 MG, 5 MG (aripiprazole) ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 20 MG, 30 3 ST; QL (1 tablet per 1 day) MG (aripiprazole) ABILIFY MYCITE ORAL TABLET 10 MG, 15 MG, 2 MG, 5 MG 3 ST (aripiprazole) ABILIFY MYCITE ORAL TABLET 20 MG, 30 MG (aripiprazole) 3 ST; QL (1 tablet per 1 day) ABILIFY MYCITE STARTER KIT ORAL TABLET 10 MG, 15 MG, 2 3 ST MG, 5 MG (aripiprazole) ABILIFY MYCITE STARTER KIT ORAL TABLET 20 MG, 30 MG 3 ST; QL (1 tablet per 1 day) (aripiprazole) aripiprazole oral solution 1 or 1b* QL (30 mL per 1 day) aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 5 mg 1 or 1b* aripiprazole oral tablet 20 mg, 30 mg 1 or 1b* QL (1 tablet per 1 day) aripiprazole oral tablet dispersible 10 mg 1 or 1b* QL (3 tablets per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 84 Coverage Requirements and Prescription Drug Name Drug Tier Limits aripiprazole oral tablet dispersible 15 mg 1 or 1b* QL (2 tablets per 1 day) ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE 3 QL (1 syringe per 1 fill) (aripiprazole lauroxil) ARISTADA INTRAMUSCULAR PREFILLED SYRINGE (aripiprazole 3 lauroxil) REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG 3 ST (brexpiprazole) REXULTI ORAL TABLET 3 MG, 4 MG (brexpiprazole) 3 ST; QL (1 tablet per 1 day) *THIENBENZODIAZEPINES*** - DRUGS FOR SEVERE MENTAL DISORDERS olanzapine intramuscular solution reconstituted 1 or 1b* olanzapine oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg 1 or 1b* olanzapine oral tablet 15 mg, 20 mg 1 or 1b* QL (1 tablets per 1 day) olanzapine oral tablet dispersible 10 mg, 5 mg 1 or 1b* olanzapine oral tablet dispersible 15 mg 1 or 1b* QL (1 tablets per 1 day) olanzapine oral tablet dispersible 20 mg 1 or 1b* QL (1 tablet per 1 day) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION 3 RECONSTITUTED (olanzapine pamoate) *THIOXANTHENES*** - DRUGS FOR SEVERE MENTAL DISORDERS thiothixene oral capsule 1 or 1b* *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS *ANTISEPTICS & DISINFECTANTS*** - ANTISEPTICS AND DISINFECTANTS FORMALDEHYDE EXTERNAL SOLUTION 3 GLUTARALDEHYDE EXTERNAL SOLUTION 2 *CHLORINE ANTISEPTICS*** - ANTISEPTICS AND DISINFECTANTS BENZALKONIUM CHLORIDE EXTERNAL SOLUTION 3 *IODINE ANTISEPTICS*** - ANTISEPTICS AND DISINFECTANTS IODINE TINCTURE EXTERNAL TINCTURE 3 IODOFLEX EXTERNAL PAD (cadexomer iodine) 3 IODOSORB EXTERNAL GEL (cadexomer iodine) 3 *ANTIVIRALS* - DRUGS FOR INFECTIONS *ANTIRETROVIRAL COMBINATIONS*** - DRUGS FOR VIRAL INFECTIONS abacavir sulfate-lamivudine oral tablet 1 or 1b* QL (1 tablet per 1 day) abacavir-lamivudine-zidovudine oral tablet 1 or 1b* QL (2 tablets per 1 day) BIKTARVY ORAL TABLET (bictegravir-emtricitab-tenofov) 2 QL (1 tablet per 1 day) CABENUVA INTRAMUSCULAR SUSPENSION EXTENDED 3 PA; LD; QL (1 kit per 28 days) RELEASE 400 & 600 MG/2ML CABENUVA INTRAMUSCULAR SUSPENSION EXTENDED PA; LD; QL (1 kit per 1 one-time 3 RELEASE 600 & 900 MG/3ML fill) CIMDUO ORAL TABLET (lamivudine-tenofovir) 3 QL (1 tablet per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 85 Coverage Requirements and Prescription Drug Name Drug Tier Limits COMBIVIR ORAL TABLET (lamivudine-zidovudine) 3 QL (2 tablets per 1 day) COMPLERA ORAL TABLET (emtricitab-rilpivir-tenofovir) 3 PA; QL (1 tablet per 1 day) DELSTRIGO ORAL TABLET (doravirin-lamivudin-tenofov df) 3 QL (1 tablet per 1 day) DESCOVY ORAL TABLET (emtricitabine-tenofovir af) 2; $0 QL (1 tablet per 1 day) DOVATO ORAL TABLET (dolutegravir-lamivudine) 2 QL (1 tablet per 1 day) efavirenz-emtricitab-tenofovir oral tablet 1 or 1b* QL (1 tablet per 1 day) efavirenz-lamivudine-tenofovir oral tablet 1 or 1b* QL (1 tablet per 1 day) emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, 167-250 mg 1 or 1b* QL (1 tablet per 1 day) emtricitabine-tenofovir df oral tablet 200-300 mg 1 or 1b*; $0 QL (1 tablet per 1 day) EPZICOM ORAL TABLET (abacavir sulfate-lamivudine) 3 QL (1 tablet per 1 day) EVOTAZ ORAL TABLET (atazanavir-cobicistat) 3 QL (1 tablet per 1 day) GENVOYA ORAL TABLET (elviteg-cobic-emtricit-tenofaf) 2 QL (1 tablet per 1 day) JULUCA ORAL TABLET (dolutegravir-rilpivirine) 3 PA; QL (1 tablet per 1 day) KALETRA ORAL SOLUTION (lopinavir-ritonavir) 3 QL (16 mL per 1 day) KALETRA ORAL TABLET 100-25 MG (lopinavir-ritonavir) 2 QL (10 tablets per 1 day) KALETRA ORAL TABLET 200-50 MG (lopinavir-ritonavir) 2 QL (4 tablets per 1 day) lamivudine-zidovudine oral tablet 1 or 1b* QL (2 tablets per 1 day) lopinavir-ritonavir oral solution 1 or 1b* QL (16 mL per 1 day) lopinavir-ritonavir oral tablet 100-25 mg 1 or 1b* QL (10 tablets per 1 day) lopinavir-ritonavir oral tablet 200-50 mg 1 or 1b* QL (4 tablets per 1 day) ODEFSEY ORAL TABLET (emtricitab-rilpivir-tenofov af) 2 QL (1 tablet per 1 day) PREZCOBIX ORAL TABLET (darunavir-cobicistat) 3 QL (1 tablet per 1 day) STRIBILD ORAL TABLET (elviteg-cobic-emtricit-tenofdf) 2 QL (1 tablet per 1 day) SYMTUZA ORAL TABLET (darun-cobic-emtricit-tenofaf) 3 QL (1 tablet per 1 day) TEMIXYS ORAL TABLET (lamivudine-tenofovir) 3 QL (1 tablet per 1 day) TRIUMEQ ORAL TABLET (abacavir-dolutegravir-lamivud) 2 QL (1 tablet per 1 day) TRIZIVIR ORAL TABLET (abacavir-lamivudine-zidovudine) 3 QL (2 tablets per 1 day) TRUVADA ORAL TABLET (emtricitabine-tenofovir df) 2 ST; QL (1 tablet per 1 day) *ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY INHIBITOR)*** - DRUGS FOR VIRAL INFECTIONS SELZENTRY ORAL SOLUTION (maraviroc) 3 QL (62 mL per 1 day) SELZENTRY ORAL TABLET 150 MG, 300 MG (maraviroc) 2 QL (4 tablets per 1 day) SELZENTRY ORAL TABLET 25 MG (maraviroc) 2 QL (8 tablets per 1 day) SELZENTRY ORAL TABLET 75 MG (maraviroc) 2 QL (2 tablets per 1 day) *ANTIRETROVIRALS - CD4-DIRECTED POST-ATTACHMENT INHIBITOR*** - DRUGS FOR VIRAL INFECTIONS TROGARZO INTRAVENOUS SOLUTION (ibalizumab-uiyk) 3 PA; LD; QL (8 vials per 28 days) *ANTIRETROVIRALS - FUSION INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 2 PA; LD; QL (60 vials per 30 days) (enfuvirtide)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 86 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIRETROVIRALS - GP120-DIRECTED ATTACHMENT INHIBITOR*** - DRUGS FOR VIRAL INFECTIONS RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HOUR 3 PA; QL (2 tablets per 1 day) (fostemsavir tromethamine) *ANTIRETROVIRALS - INTEGRASE INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS ISENTRESS HD ORAL TABLET (raltegravir potassium) 3 QL (2 tablets per 1 day) ISENTRESS ORAL PACKET (raltegravir potassium) 3 QL (2 packets per 1 day) ISENTRESS ORAL TABLET (raltegravir potassium) 2 QL (4 tablets per 1 day) ISENTRESS ORAL TABLET CHEWABLE 100 MG (raltegravir 2 QL (6 tablets per 1 day) potassium) ISENTRESS ORAL TABLET CHEWABLE 25 MG (raltegravir potassium) 2 QL (24 tablets per 1 day) TIVICAY ORAL TABLET 10 MG (dolutegravir sodium) 3 QL (4 tablets per 1 day) TIVICAY ORAL TABLET 25 MG, 50 MG (dolutegravir sodium) 3 QL (2 tablets per 1 day) TIVICAY PD ORAL TABLET SOLUBLE (dolutegravir sodium) 3 QL (12 tablets per 1 day) *ANTIRETROVIRALS - PROTEASE INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS APTIVUS ORAL CAPSULE (tipranavir) 2 PA; QL (4 capsules per 1 day) atazanavir sulfate oral capsule 150 mg, 200 mg 1 or 1b* QL (2 capsules per 1 day) atazanavir sulfate oral capsule 300 mg 1 or 1b* QL (1 capsule per 1 day) CRIXIVAN ORAL CAPSULE (indinavir sulfate) 2 QL (6 capsules per 1 day) fosamprenavir calcium oral tablet 1 or 1b* QL (4 tablets per 1 day) INVIRASE ORAL TABLET (saquinavir mesylate) 2 QL (4 tablets per 1 day) LEXIVA ORAL SUSPENSION (fosamprenavir calcium) 2 QL (60 mL per 1 day) LEXIVA ORAL TABLET (fosamprenavir calcium) 3 QL (4 tablets per 1 day) NORVIR ORAL PACKET (ritonavir) 3 QL (12 packets per 1 day) NORVIR ORAL SOLUTION (ritonavir) 2 QL (16 mL per 1 day) NORVIR ORAL TABLET (ritonavir) 3 QL (12 tablets per 1 day) PREZISTA ORAL SUSPENSION (darunavir ethanolate) 2 QL (14 mL per 1 day) PREZISTA ORAL TABLET 150 MG (darunavir ethanolate) 2 QL (6 tablets per 1 day) PREZISTA ORAL TABLET 600 MG (darunavir ethanolate) 2 QL (2 tablets per 1 day) PREZISTA ORAL TABLET 75 MG (darunavir ethanolate) 2 QL (10 tablets per 1 day) PREZISTA ORAL TABLET 800 MG (darunavir ethanolate) 2 QL (1 tablet per 1 day) REYATAZ ORAL CAPSULE 150 MG, 200 MG (atazanavir sulfate) 3 QL (2 capsules per 1 day) REYATAZ ORAL CAPSULE 300 MG (atazanavir sulfate) 3 QL (1 capsule per 1 day) REYATAZ ORAL PACKET (atazanavir sulfate) 2 QL (5 packets per 1 day) ritonavir oral tablet 1 or 1b* QL (12 tablets per 1 day) VIRACEPT ORAL TABLET 250 MG (nelfinavir mesylate) 2 QL (10 tablets per 1 day) VIRACEPT ORAL TABLET 625 MG (nelfinavir mesylate) 2 QL (4 tablets per 1 day) *ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS EDURANT ORAL TABLET (rilpivirine hcl) 2 PA; QL (1 tablet per 1 day) efavirenz oral capsule 200 mg 1 or 1b* QL (4 capsules per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 87 Coverage Requirements and Prescription Drug Name Drug Tier Limits efavirenz oral capsule 50 mg 1 or 1b* QL (12 capsules per 1 day) efavirenz oral tablet 1 or 1b* QL (1 tablet per 1 day) etravirine oral tablet 100 mg 1 or 1b* PA; QL (4 tablets per 1 day) etravirine oral tablet 200 mg 1 or 1b* PA; QL (2 tablets per 1 day) INTELENCE ORAL TABLET 100 MG (etravirine) 2 PA; QL (4 tablets per 1 day) INTELENCE ORAL TABLET 200 MG (etravirine) 2 PA; QL (2 tablets per 1 day) INTELENCE ORAL TABLET 25 MG (etravirine) 2 PA; QL (16 tablets per 1 day) nevirapine er oral tablet extended release 24 hour 100 mg 1 or 1b* QL (3 tablets per 1 day) nevirapine er oral tablet extended release 24 hour 400 mg 1 or 1b* QL (1 tablet per 1 day) nevirapine oral suspension 1 or 1b* QL (40 mL per 1 day) nevirapine oral tablet 1 or 1b* QL (2 tablets per 1 day) PIFELTRO ORAL TABLET (doravirine) 3 QL (1 tablet per 1 day) SUSTIVA ORAL CAPSULE 200 MG (efavirenz) 3 QL (4 capsules per 1 day) SUSTIVA ORAL CAPSULE 50 MG (efavirenz) 3 QL (12 capsules per 1 day) SUSTIVA ORAL TABLET (efavirenz) 3 QL (1 tablet per 1 day) VIRAMUNE ORAL SUSPENSION (nevirapine) 3 QL (40 mL per 1 day) VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (1 tablet per 1 day) (nevirapine) *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- PURINES*** - DRUGS FOR VIRAL INFECTIONS abacavir sulfate oral solution 1 or 1b* QL (32 mL per 1 day) abacavir sulfate oral tablet 1 or 1b* QL (2 tablets per 1 day) ZIAGEN ORAL SOLUTION (abacavir sulfate) 3 QL (32 mL per 1 day) ZIAGEN ORAL TABLET (abacavir sulfate) 3 QL (2 tablets per 1 day) *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- PYRIMIDINES*** - DRUGS FOR VIRAL INFECTIONS emtricitabine oral capsule 1 or 1b*; $0 QL (1 capsule per 1 day) EMTRIVA ORAL CAPSULE (emtricitabine) 3 QL (1 capsule per 1 day) EMTRIVA ORAL SOLUTION (emtricitabine) 2 QL (29 mL per 1 day) EPIVIR ORAL SOLUTION (lamivudine) 3 QL (32 mL per 1 day) EPIVIR ORAL TABLET 150 MG (lamivudine) 3 QL (2 tablets per 1 day) EPIVIR ORAL TABLET 300 MG (lamivudine) 3 QL (1 tablet per 1 day) lamivudine oral solution 1 or 1b* QL (32 mL per 1 day) lamivudine oral tablet 150 mg 1 or 1b* QL (2 tablets per 1 day) lamivudine oral tablet 300 mg 1 or 1b* QL (1 tablet per 1 day) *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- THYMIDINES*** - DRUGS FOR VIRAL INFECTIONS RETROVIR INTRAVENOUS SOLUTION (zidovudine) 2 RETROVIR ORAL CAPSULE (zidovudine) 3 QL (6 capsules per 1 day) RETROVIR ORAL SYRUP (zidovudine) 3 QL (64 mL per 1 day) stavudine oral capsule 15 mg, 20 mg 1 or 1b* QL (4 capsules per 1 day) stavudine oral capsule 30 mg, 40 mg 1 or 1b* QL (2 capsules per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 88 Coverage Requirements and Prescription Drug Name Drug Tier Limits zidovudine oral capsule 1 or 1b* QL (6 capsules per 1 day) zidovudine oral syrup 1 or 1b* QL (64 mL per 1 day) zidovudine oral tablet 1 or 1b* QL (2 tablets per 1 day) *ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS tenofovir disoproxil fumarate oral tablet 1 or 1b*; $0 QL (1 tablet per 1 day) VIREAD ORAL POWDER (tenofovir disoproxil fumarate) 2 QL (8 grams per 1 day) VIREAD ORAL TABLET (tenofovir disoproxil fumarate) 2 QL (1 tablet per 1 day) *ANTIRETROVIRALS ADJUVANTS*** - DRUGS FOR VIRAL INFECTIONS TYBOST ORAL TABLET (cobicistat) 3 QL (1 tablet per 1 day) *CMV AGENTS*** - DRUGS FOR VIRAL INFECTIONS cidofovir intravenous solution 1 or 1b* foscarnet sodium intravenous solution 1 or 1b* FOSCAVIR INTRAVENOUS SOLUTION (foscarnet sodium) 3 GANCICLOVIR INTRAVENOUS SOLUTION 4 SP GANCICLOVIR SODIUM INTRAVENOUS SOLUTION 4 SP ganciclovir sodium intravenous solution reconstituted 4 SP PREVYMIS INTRAVENOUS SOLUTION (letermovir) 4 PA; SP; QL (1 vial per 1 day) PREVYMIS ORAL TABLET (letermovir) 4 PA; SP; QL (1 tablet per 1 day) VALCYTE ORAL SOLUTION RECONSTITUTED (valganciclovir hcl) 3 VALCYTE ORAL TABLET (valganciclovir hcl) 3 valganciclovir hcl oral solution reconstituted 1 or 1b* valganciclovir hcl oral tablet 1 or 1b* *HEPATITIS B AGENTS*** - DRUGS FOR VIRAL INFECTIONS adefovir dipivoxil oral tablet 4 SP; QL (1 tablet per 1 day) BARACLUDE ORAL SOLUTION (entecavir) 4 QL (20 mL per 1 day) entecavir oral tablet 4 QL (1 tablet per 1 day) EPIVIR HBV ORAL SOLUTION (lamivudine) 4 QL (20 mL per 1 day) EPIVIR HBV ORAL TABLET (lamivudine) 4 QL (1 tablet per 1 day) HEPSERA ORAL TABLET (adefovir dipivoxil) 4 SP; QL (1 tablet per 1 day) lamivudine oral tablet 1 or 1b* QL (1 tablet per 1 day) VEMLIDY ORAL TABLET (tenofovir alafenamide fumarate) 4 SP; QL (1 tablet per 1 day) *HEPATITIS C AGENT - COMBINATIONS*** - DRUGS FOR VIRAL INFECTIONS EPCLUSA ORAL TABLET (sofosbuvir-velpatasvir) 4 PA; SP; QL (1 tablet per 1 day) HARVONI ORAL PACKET 33.75-150 MG (ledipasvir-sofosbuvir) 4 PA; QL (1 packet per 1 day) HARVONI ORAL PACKET 45-200 MG (ledipasvir-sofosbuvir) 4 PA; QL (2 packets per 1 day) HARVONI ORAL TABLET 45-200 MG (ledipasvir-sofosbuvir) 4 PA; QL (1 tablet per 1 day) HARVONI ORAL TABLET 90-400 MG (ledipasvir-sofosbuvir) 4 PA; SP; QL (1 tablet per 1 day) VOSEVI ORAL TABLET (sofosbuv-velpatasv-voxilaprev) 4 PA; SP; QL (1 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 89 Coverage Requirements and Prescription Drug Name Drug Tier Limits *HEPATITIS C AGENTS*** - DRUGS FOR VIRAL INFECTIONS PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML 4 LD; SP; QL (2 syringe per 28 days) (peginterferon alfa-2a) PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML (peginterferon 4 LD; SP; QL (4 vials per 28 days) alfa-2a) ribavirin oral capsule 4 SP ribavirin oral tablet 4 SP *HERPES AGENTS - PURINE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS acyclovir oral capsule 1 or 1b* acyclovir oral suspension 1 or 1b* acyclovir oral tablet 1 or 1b* acyclovir sodium intravenous solution 1 or 1b* valacyclovir hcl oral tablet 1 gm 1 or 1b* QL (30 tablets per 1 fill) valacyclovir hcl oral tablet 500 mg 1 or 1b* QL (60 tablets per 1 fill) ZOVIRAX ORAL SUSPENSION (acyclovir) 3 *HERPES AGENTS - THYMIDINE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS famciclovir oral tablet 125 mg, 250 mg 1 or 1b* QL (60 tablets per 1 fill) famciclovir oral tablet 500 mg 1 or 1b* QL (21 tablets per 1 fill) *INFLUENZA AGENTS*** - DRUGS FOR VIRAL INFECTIONS rimantadine hcl oral tablet 1 or 1b* *NEURAMINIDASE INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS oseltamivir phosphate oral capsule 30 mg 1 or 1b* QL (20 capsule per 90 days) oseltamivir phosphate oral capsule 45 mg, 75 mg 1 or 1b* QL (10 capsule per 90 days) oseltamivir phosphate oral suspension reconstituted 1 or 1b* QL (180 mL per 90 days) RAPIVAB INTRAVENOUS SOLUTION (peramivir) 3 RELENZA DISKHALER INHALATION AEROSOL POWDER 2 QL (1 package per 90 days) BREATH ACTIVATED (zanamivir) TAMIFLU ORAL CAPSULE 30 MG (oseltamivir phosphate) 3 QL (20 capsule per 90 days) TAMIFLU ORAL CAPSULE 45 MG, 75 MG (oseltamivir phosphate) 3 QL (10 capsule per 90 days) TAMIFLU ORAL SUSPENSION RECONSTITUTED (oseltamivir 3 QL (180 mL per 90 days) phosphate) *PA ENDONUCLEASE INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK (baloxavir 3 QL (1 dose pack per 90 days) marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK (baloxavir 3 QL (1 dose pack per 90 days) marboxil) *RSV AGENTS - NUCLEOSIDE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS ribavirin inhalation solution reconstituted 1 or 1b* VIRAZOLE INHALATION SOLUTION RECONSTITUTED (ribavirin) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 90 Coverage Requirements and Prescription Drug Name Drug Tier Limits *BETA BLOCKERS* - DRUGS FOR THE HEART *ALPHA-BETA BLOCKERS*** - DRUGS FOR HIGH BLOOD PRESSURE carvedilol oral tablet 12.5 mg, 3.125 mg, 6.25 mg 1 or 1b* QL (2 tablets per 1 day) carvedilol oral tablet 25 mg 1 or 1b* QL (4 tablets per 1 day) carvedilol phosphate er oral capsule extended release 24 hour 1 or 1b* QL (1 capsule per 1 day) labetalol hcl oral tablet 1 or 1b* QL (8 tablets per 1 day) LABETALOL HCL-DEXTROSE INTRAVENOUS SOLUTION 3 LABETALOL HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 *BETA BLOCKERS CARDIO-SELECTIVE*** - DRUGS FOR HIGH BLOOD PRESSURE acebutolol hcl oral capsule 200 mg 1 or 1b* QL (6 capsules per 1 day) acebutolol hcl oral capsule 400 mg 1 or 1b* QL (3 capsules per 1 day) atenolol oral tablet 1 or 1a* QL (2 tablets per 1 day) betaxolol hcl oral tablet 10 mg 1 or 1b* QL (1 tablet per 1 day) betaxolol hcl oral tablet 20 mg 1 or 1b* QL (2 tablets per 1 day) bisoprolol fumarate oral tablet 10 mg 1 or 1b* QL (2 tablets per 1 day) bisoprolol fumarate oral tablet 5 mg 1 or 1b* QL (1 tablet per 1 day) BREVIBLOC IN NACL INTRAVENOUS SOLUTION (esmolol hcl- 3 sodium chloride) BREVIBLOC INTRAVENOUS SOLUTION (esmolol hcl) 3 BREVIBLOC PREMIXED DS INTRAVENOUS SOLUTION (esmolol hcl- 3 sodium chloride) BREVIBLOC PREMIXED INTRAVENOUS SOLUTION (esmolol hcl- 3 sodium chloride) BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 5 MG (nebivolol hcl) 2 QL (1 tablet per 1 day) BYSTOLIC ORAL TABLET 20 MG (nebivolol hcl) 2 QL (2 tablets per 1 day) esmolol hcl intravenous solution 100 mg/10ml 1 or 1b* ESMOLOL HCL INTRAVENOUS SOLUTION 2000 MG/100ML, 2500 3 MG/250ML ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 esmolol hcl-sodium chloride intravenous solution 1 or 1b* KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 3 QL (1 capsule per 1 day) 100 MG, 25 MG, 50 MG (metoprolol succinate) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 3 QL (2 capsules per 1 day) 200 MG (metoprolol succinate) metoprolol succinate er oral tablet extended release 24 hour 1 or 1b* metoprolol tartrate intravenous solution 1 or 1a* metoprolol tartrate oral tablet 100 mg 1 or 1a* QL (4 tablets per 1 day) metoprolol tartrate oral tablet 25 mg, 37.5 mg, 50 mg, 75 mg 1 or 1a* QL (2 tablets per 1 day) *BETA BLOCKERS NON-SELECTIVE*** - DRUGS FOR HIGH BLOOD PRESSURE HEMANGEOL ORAL SOLUTION (propranolol hcl) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 91 Coverage Requirements and Prescription Drug Name Drug Tier Limits INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 QL (1 capsule per 1 day) (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 QL (1 capsule per 1 day) (propranolol hcl sr beads) nadolol oral tablet 20 mg 1 or 1b* QL (1 tablet per 1 day) nadolol oral tablet 40 mg 1 or 1b* QL (3 tablets per 1 day) nadolol oral tablet 80 mg 1 or 1b* QL (4 tablets per 1 day) pindolol oral tablet 1 or 1b* QL (6 tablets per 1 day) propranolol hcl er oral capsule extended release 24 hour 120 mg 1 or 1b* QL (2 capsules per 1 day) propranolol hcl er oral capsule extended release 24 hour 160 mg 1 or 1b* QL (4 capsules per 1 day) propranolol hcl er oral capsule extended release 24 hour 60 mg, 80 mg 1 or 1b* QL (1 capsule per 1 day) propranolol hcl intravenous solution 1 or 1b* propranolol hcl oral solution 20 mg/5ml 1 or 1b* QL (20 mL per 1 day) propranolol hcl oral solution 40 mg/5ml 1 or 1b* QL (80 mL per 1 day) propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg 1 or 1b* QL (4 tablets per 1 day) propranolol hcl oral tablet 80 mg 1 or 1b* QL (8 tablets per 1 day) sorine oral tablet 120 mg, 80 mg 1 or 1b* QL (3 tablets per 1 day) sorine oral tablet 160 mg 1 or 1b* QL (4 tablets per 1 day) sorine oral tablet 240 mg 1 or 1b* QL (2 tablets per 1 day) sotalol hcl (af) oral tablet 1 or 1b* SOTALOL HCL INTRAVENOUS SOLUTION 3 sotalol hcl oral tablet 120 mg, 80 mg 1 or 1b* QL (3 tablets per 1 day) sotalol hcl oral tablet 160 mg 1 or 1b* QL (4 tablets per 1 day) sotalol hcl oral tablet 240 mg 1 or 1b* QL (2 tablets per 1 day) SOTYLIZE ORAL SOLUTION (sotalol hcl) 3 timolol maleate oral tablet 10 mg, 5 mg 1 or 1b* QL (6 tablets per 1 day) timolol maleate oral tablet 20 mg 1 or 1b* QL (3 tablets per 1 day) *CALCIUM CHANNEL BLOCKERS* - DRUGS FOR THE HEART *CALCIUM CHANNEL BLOCKERS*** - DRUGS FOR HIGH BLOOD PRESSURE amlodipine besylate oral tablet 10 mg 1 or 1b* QL (1 tablet per 1 day) amlodipine besylate oral tablet 2.5 mg, 5 mg 1 or 1b* CALAN SR ORAL TABLET EXTENDED RELEASE (verapamil hcl) 3 QL (2 tablets per 1 day) CARDENE IV INTRAVENOUS SOLUTION (nicardipine hcl in nacl) 3 CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 3 (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG (diltiazem hcl) 3 QL (3 tablet per 1 day) CARDIZEM ORAL TABLET 30 MG, 60 MG (diltiazem hcl) 3 cartia xt oral capsule extended release 24 hour 120 mg, 180 mg 1 or 1b* cartia xt oral capsule extended release 24 hour 240 mg, 300 mg 1 or 1b* QL (1 capsule per 1 day) CLEVIPREX INTRAVENOUS EMULSION (clevidipine) 3 CONJUPRI ORAL TABLET 2.5 MG (levamlodipine maleate) 3 ST

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 92 Coverage Requirements and Prescription Drug Name Drug Tier Limits CONJUPRI ORAL TABLET 5 MG (levamlodipine maleate) 3 ST; QL (1 tablet per 1 day) diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 1 or 1b* 360 mg diltiazem hcl er beads oral capsule extended release 24 hour 240 mg, 300 mg, 1 or 1b* QL (1 capsule per 1 day) 420 mg diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 1 or 1b* 180 mg diltiazem hcl er coated beads oral capsule extended release 24 hour 240 mg, 1 or 1b* QL (1 capsule per 1 day) 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg 1 or 1b* diltiazem hcl er coated beads oral tablet extended release 24 hour 240 mg, 300 1 or 1b* QL (1 tablet per 1 day) mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 1 or 1b* QL (2 capsules per 1 day) diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg 1 or 1b* diltiazem hcl er oral capsule extended release 24 hour 240 mg 1 or 1b* QL (1 capsule per 1 day) diltiazem hcl intravenous solution 1 or 1b* DILTIAZEM HCL INTRAVENOUS SOLUTION RECONSTITUTED 3 diltiazem hcl oral tablet 120 mg 1 or 1b* QL (3 tablet per 1 day) diltiazem hcl oral tablet 30 mg, 60 mg 1 or 1b* diltiazem hcl oral tablet 90 mg 1 or 1b* QL (4 tablet per 1 day) DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION 3 DILTIAZEM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg 1 or 1b* dilt-xr oral capsule extended release 24 hour 240 mg 1 or 1b* QL (1 capsule per 1 day) felodipine er oral tablet extended release 24 hour 10 mg 1 or 1b* QL (1 tablet per 1 day) felodipine er oral tablet extended release 24 hour 2.5 mg, 5 mg 1 or 1b* isradipine oral capsule 2.5 mg 1 or 1b* QL (2 capsules per 1 day) isradipine oral capsule 5 mg 1 or 1b* QL (4 capsule per 1 day) KATERZIA ORAL SUSPENSION (amlodipine benzoate) 3 QL (300 mL per 30 days) matzim la oral tablet extended release 24 hour 180 mg 1 or 1b* matzim la oral tablet extended release 24 hour 240 mg, 300 mg, 360 mg, 420 1 or 1b* QL (1 tablet per 1 day) mg NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION 3 NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE nicardipine hcl intravenous solution 1 or 1b* nicardipine hcl oral capsule 20 mg 1 or 1b* QL (6 capsule per 1 day) nicardipine hcl oral capsule 30 mg 1 or 1b* QL (4 capsule per 1 day) nifedipine er oral tablet extended release 24 hour 30 mg 1 or 1b* nifedipine er oral tablet extended release 24 hour 60 mg, 90 mg 1 or 1b* QL (1 tablet per 1 day) nifedipine er osmotic release oral tablet extended release 24 hour 30 mg 1 or 1b* nifedipine er osmotic release oral tablet extended release 24 hour 60 mg, 90 1 or 1b* QL (1 tablet per 1 day) mg nifedipine oral capsule 1 or 1b* QL (4 capsule per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 93 Coverage Requirements and Prescription Drug Name Drug Tier Limits nimodipine oral capsule 1 or 1b* QL (12 capsule per 1 day) nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 8.5 mg 1 or 1b* nisoldipine er oral tablet extended release 24 hour 25.5 mg, 30 mg, 34 mg, 40 1 or 1b* QL (1 tablet per 1 day) mg NYMALIZE ORAL SOLUTION (nimodipine) 3 QL (60 mL per 1 day) PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 3 MG (nifedipine) PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 60 3 QL (1 tablet per 1 day) MG, 90 MG (nifedipine) SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 MG, 8.5 3 MG (nisoldipine) SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 34 MG 3 QL (1 tablet per 1 day) (nisoldipine) taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 360 mg 1 or 1b* taztia xt oral capsule extended release 24 hour 240 mg, 300 mg 1 or 1b* QL (1 capsule per 1 day) tiadylt er oral capsule extended release 24 hour 120 mg, 180 mg, 360 mg 1 or 1b* tiadylt er oral capsule extended release 24 hour 240 mg, 300 mg, 420 mg 1 or 1b* QL (1 capsule per 1 day) TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 3 180 MG, 360 MG (diltiazem hcl er beads) TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG, 3 QL (1 capsule per 1 day) 300 MG, 420 MG (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 1 or 1b* mg verapamil hcl er oral capsule extended release 24 hour 200 mg, 300 mg, 360 1 or 1b* QL (1 capsule per 1 day) mg verapamil hcl er oral capsule extended release 24 hour 240 mg 1 or 1b* QL (2 capsules per 1 day) verapamil hcl er oral tablet extended release 1 or 1b* QL (2 tablets per 1 day) verapamil hcl intravenous solution 1 or 1b* verapamil hcl oral tablet 120 mg, 80 mg 1 or 1b* QL (4 tablet per 1 day) verapamil hcl oral tablet 40 mg 1 or 1b* QL (3 tablet per 1 day) VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 3 MG, 180 MG (verapamil hcl) VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG 3 QL (2 capsules per 1 day) (verapamil hcl) VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 360 MG 3 QL (1 capsule per 1 day) (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 3 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 3 QL (1 capsule per 1 day) MG, 300 MG (verapamil hcl) *CARDIOTONICS* - DRUGS FOR THE HEART *CARDIAC GLYCOSIDES*** - DRUGS FOR THE HEART digitek oral tablet 1 or 1b* digox oral tablet 1 or 1b* digoxin injection solution 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 94 Coverage Requirements and Prescription Drug Name Drug Tier Limits digoxin oral solution 1 or 1b* digoxin oral tablet 1 or 1b* LANOXIN INJECTION SOLUTION (digoxin) 3 LANOXIN ORAL TABLET (digoxin) 2 LANOXIN PEDIATRIC INJECTION SOLUTION (digoxin) 2 *INOTROPES*** - DRUGS FOR SERIOUS ALLERGIC REACTION dobutamine hcl intravenous solution 1 or 1b* DOBUTAMINE IN D5W INTRAVENOUS SOLUTION 3 dopamine hcl intravenous solution 1 or 1b* DOPAMINE IN D5W INTRAVENOUS SOLUTION 3 milrinone lactate in dextrose intravenous solution 1 or 1b* milrinone lactate intravenous solution 1 or 1b* *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART *CALCIUM CHANNEL BLOCKER & HMG COA REDUCTASE INHIBIT COMB*** - DRUGS FOR CHOLESTEROL amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 1 or 1b* QL (1 tablet per 1 day) 5-80 mg amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 1 or 1b* 5-20 mg, 5-40 mg CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5- 3 QL (1 tablet per 1 day) 80 MG (amlodipine-atorvastatin) CADUET ORAL TABLET 5-10 MG, 5-20 MG, 5-40 MG (amlodipine- 3 atorvastatin) *CARDIOPLEGIC SOLUTIONS*** - DRUGS FOR THE HEART ADENOCAINE INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 (cardioplegic soln) PLEGISOL PERFUSION SOLUTION (cardioplegic soln) 3 *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** - DRUGS FOR HIGH BLOOD PRESSURE ENTRESTO ORAL TABLET 24-26 MG (sacubitril-valsartan) 2 QL (6 tablets per 1 day) ENTRESTO ORAL TABLET 49-51 MG, 97-103 MG (sacubitril-valsartan) 2 QL (2 tablets per 1 day) *NITRATE & VASODILATOR COMBINATIONS*** - DRUGS FOR HIGH BLOOD PRESSURE BIDIL ORAL TABLET (isosorb dinitrate-hydralazine) 2 *PROSTAGLANDIN - IMPOTENCE AGENTS*** - DRUGS FOR THE HEART CAVERJECT IMPULSE INTRACAVERNOSAL KIT (alprostadil 3 PA (vasodilator)) CAVERJECT INTRACAVERNOSAL SOLUTION RECONSTITUTED 3 PA (alprostadil (vasodilator)) EDEX INTRACAVERNOSAL KIT (alprostadil (vasodilator)) 3 PA MUSE URETHRAL PELLET (alprostadil (vasodilator)) 3 PA *PROSTAGLANDIN VASODILATORS*** - DRUGS FOR HIGH BLOOD PRESSURE epoprostenol sodium intravenous solution reconstituted 4 PA; LD; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 95 Coverage Requirements and Prescription Drug Name Drug Tier Limits FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (epoprostenol sodium) ORENITRAM ORAL TABLET EXTENDED RELEASE (treprostinil 4 PA; LD; SP diolamine) REMODULIN INJECTION SOLUTION (treprostinil) 4 PA; LD; SP treprostinil injection solution 4 PA; LD; SP TYVASO INHALATION SOLUTION (treprostinil) 4 PA; LD; SP; QL (1 kit per 28 days) TYVASO REFILL INHALATION SOLUTION (treprostinil) 4 PA; LD; SP; QL (1 kit per 28 days) TYVASO STARTER INHALATION SOLUTION (treprostinil) 4 PA; LD; SP; QL (1 kit per 28 days) VELETRI INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (epoprostenol sodium) VENTAVIS INHALATION SOLUTION (iloprost) 4 PA; LD; SP; QL (9 mL per 1 day) *PULM HYPERTEN-SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC)*** - DRUGS FOR HIGH BLOOD PRESSURE PA; LD; SP; QL (3 tablets per 1 ADEMPAS ORAL TABLET (riociguat) 4 day) *PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS*** - DRUGS FOR HIGH BLOOD PRESSURE ambrisentan oral tablet 4 PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 bosentan oral tablet 4 day) OPSUMIT ORAL TABLET (macitentan) 4 PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 TRACLEER ORAL TABLET (bosentan) 4 day) PA; LD; SP; QL (2 tablets per 1 TRACLEER ORAL TABLET SOLUBLE (bosentan) 4 day) *PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS*** - DRUGS FOR HIGH BLOOD PRESSURE alyq oral tablet 4 PA; SP; QL (2 tablets per 1 day) sildenafil citrate intravenous solution 4 PA; SP; QL (3 vial per 1 day) sildenafil citrate oral suspension reconstituted 4 PA; SP; QL (6 mL per 1 day) sildenafil citrate oral tablet 4 PA; SP; QL (3 tablets per 1 day) tadalafil (pah) oral tablet 4 PA; SP; QL (2 tablets per 1 day) *PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST*** - DRUGS FOR HIGH BLOOD PRESSURE PA; LD; SP; QL (2 tablets per 1 UPTRAVI ORAL TABLET (selexipag) 4 day) PA; LD; SP; QL (1 pack per 365 UPTRAVI ORAL TABLET THERAPY PACK (selexipag) 4 days) *SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS*** - DRUGS FOR THE HEART sildenafil citrate oral tablet 1 or 1b* PA tadalafil oral tablet 10 mg, 20 mg 1 or 1b* PA tadalafil oral tablet 2.5 mg, 5 mg 1 or 1b* PA; QL (30 tablets per 30 days) vardenafil hcl oral tablet 1 or 1b* PA

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 96 Coverage Requirements and Prescription Drug Name Drug Tier Limits vardenafil hcl oral tablet dispersible 1 or 1b* PA *SEPTAL AGENTS - ABLATION** - DRUGS FOR THE HEART ABLYSINOL INTRA-ARTERIAL SOLUTION (dehydrated alcohol) 3 *SINUS NODE INHIBITORS** - DRUGS FOR HIGH BLOOD PRESSURE CORLANOR ORAL SOLUTION (ivabradine hcl) 3 PA; QL (4 ampules per 1 day) CORLANOR ORAL TABLET (ivabradine hcl) 2 PA; QL (2 tablets per 1 day) *TRANSTHYRETIN STABILIZERS*** - DRUGS FOR THE HEART PA; LD; SP; QL (1 capsule per 1 VYNDAMAX ORAL CAPSULE (tafamidis) 4 day) PA; LD; SP; QL (4 capsules per 1 VYNDAQEL ORAL CAPSULE (tafamidis meglumine (cardiac)) 4 day) *CEPHALOSPORINS* - DRUGS FOR INFECTIONS *CEPHALOSPORIN COMBINATIONS*** - ANTIBIOTICS AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED (ceftazidime- 3 avibactam) ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED 3 (ceftolozane-tazobactam) *CEPHALOSPORINS - 1ST GENERATION*** - ANTIBIOTICS cefadroxil oral capsule 1 or 1b* cefadroxil oral suspension reconstituted 1 or 1b* cefadroxil oral tablet 1 or 1b* CEFAZOLIN IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg 1 or 1b* CEFAZOLIN SODIUM INJECTION SOLUTION RECONSTITUTED 3 100 GM, 300 GM CEFAZOLIN SODIUM INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE cefazolin sodium intravenous solution reconstituted 1 or 1b* CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 RECONSTITUTED cephalexin oral capsule 1 or 1a* cephalexin oral suspension reconstituted 1 or 1a* cephalexin oral tablet 1 or 1a* KEFLEX ORAL CAPSULE (cephalexin) 3 *CEPHALOSPORINS - 2ND GENERATION*** - ANTIBIOTICS CEFACLOR ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 cefaclor oral capsule 1 or 1b* cefaclor oral suspension reconstituted 1 or 1b* CEFOTAN INJECTION SOLUTION RECONSTITUTED (cefotetan 3 disodium) cefotetan disodium injection solution reconstituted 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 97 Coverage Requirements and Prescription Drug Name Drug Tier Limits CEFOTETAN DISODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 RECONSTITUTED cefoxitin sodium injection solution reconstituted 1 or 1b* cefoxitin sodium intravenous solution reconstituted 1 or 1b* CEFOXITIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 RECONSTITUTED cefprozil oral suspension reconstituted 1 or 1b* cefprozil oral tablet 1 or 1b* cefuroxime axetil oral tablet 1 or 1b* cefuroxime sodium injection solution reconstituted 1 or 1b* cefuroxime sodium intravenous solution reconstituted 1 or 1b* *CEPHALOSPORINS - 3RD GENERATION*** - ANTIBIOTICS cefdinir oral capsule 1 or 1b* QL (20 capsules per 1 fill) cefdinir oral suspension reconstituted 125 mg/5ml 1 or 1b* QL (240 mL per 1 fill) cefdinir oral suspension reconstituted 250 mg/5ml 1 or 1b* QL (120 mL per 1 fill) cefixime oral capsule 1 or 1b* QL (10 capsules per 1 fill) cefixime oral suspension reconstituted 100 mg/5ml 1 or 1b* QL (200 mL per 1 fill) cefixime oral suspension reconstituted 200 mg/5ml 1 or 1b* QL (100 mL per 1 fill) cefotaxime sodium injection solution reconstituted 1 or 1b* cefpodoxime proxetil oral suspension reconstituted 1 or 1b* cefpodoxime proxetil oral tablet 1 or 1b* CEFTAZIDIME AND DEXTROSE INTRAVENOUS SOLUTION 3 RECONSTITUTED ceftazidime injection solution reconstituted 1 or 1b* ceftriaxone sodium in dextrose intravenous solution 1 or 1b* QL (3000 mL per 30 days) ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 500 mg 1 or 1b* QL (60 vials per 30 fills) CEFTRIAXONE SODIUM INJECTION SOLUTION 3 RECONSTITUTED 100 GM ceftriaxone sodium injection solution reconstituted 250 mg 1 or 1b* QL (1 vial per 30 fills) ceftriaxone sodium intravenous solution reconstituted 1 gm, 2 gm 1 or 1b* QL (60 vials per 30 days) ceftriaxone sodium intravenous solution reconstituted 10 gm 1 or 1b* CEFTRIAXONE SODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 QL (60 IV Bags per 30 days) RECONSTITUTED FORTAZ INJECTION SOLUTION RECONSTITUTED (ceftazidime) 3 FORTAZ INTRAVENOUS SOLUTION RECONSTITUTED (ceftazidime) 3 SUPRAX ORAL CAPSULE (cefixime) 3 QL (10 capsules per 1 fill) SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 3 QL (200 mL per 1 fill) (cefixime) SUPRAX ORAL SUSPENSION RECONSTITUTED 200 MG/5ML 3 QL (100 mL per 1 fill) (cefixime) SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML 3 QL (40 mL per 1 fill) (cefixime) SUPRAX ORAL TABLET CHEWABLE 100 MG (cefixime) 3 QL (40 tablets per 1 fill) SUPRAX ORAL TABLET CHEWABLE 200 MG (cefixime) 3 QL (20 tablets per 1 fill) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 98 Coverage Requirements and Prescription Drug Name Drug Tier Limits tazicef injection solution reconstituted 1 or 1b* TAZICEF INTRAVENOUS SOLUTION (ceftazidime sodium in dextrose) 3 tazicef intravenous solution reconstituted 1 or 1b* *CEPHALOSPORINS - 4TH GENERATION*** - ANTIBIOTICS cefepime hcl injection solution reconstituted 1 or 1b* CEFEPIME HCL INTRAVENOUS SOLUTION 3 CEFEPIME HCL INTRAVENOUS SOLUTION RECONSTITUTED 3 CEFEPIME-DEXTROSE INTRAVENOUS SOLUTION 3 RECONSTITUTED *CEPHALOSPORINS - 5TH GENERATION*** - ANTIBIOTICS TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED (ceftaroline 3 fosamil) *CEPHALOSPORINS - SIDEROPHORES*** - ANTIBIOTICS FETROJA INTRAVENOUS SOLUTION RECONSTITUTED (cefiderocol 3 sulfate tosylate) *CONTRACEPTIVES* - DRUGS FOR WOMEN *BIPHASIC CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS azurette oral tablet 1 or 1b*; $0 bekyree oral tablet 1 or 1b*; $0 desogestrel-ethinyl estradiol oral tablet 1 or 1b*; $0 kariva oral tablet 1 or 1b*; $0 LO LOESTRIN FE ORAL TABLET (norethin-eth estrad-fe biphas) 2 MIRCETTE ORAL TABLET (desogestrel-ethinyl estradiol) 3 pimtrea oral tablet 1 or 1b*; $0 simliya oral tablet 1 or 1b*; $0 viorele oral tablet 1 or 1b*; $0 volnea oral tablet 1 or 1b*; $0 *COMBINATION CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS afirmelle oral tablet 1 or 1a*; $0 altavera oral tablet 1 or 1a*; $0 alyacen 1/35 oral tablet 1 or 1a*; $0 apri oral tablet 1 or 1a*; $0 aubra eq oral tablet 1 or 1a*; $0 aubra oral tablet 1 or 1a*; $0 aurovela 1.5/30 oral tablet 1 or 1a*; $0 aurovela 1/20 oral tablet 1 or 1a*; $0 aurovela 24 fe oral tablet 1 or 1a*; $0 aurovela fe 1.5/30 oral tablet 1 or 1a*; $0 aurovela fe 1/20 oral tablet 1 or 1a*; $0 aviane oral tablet 1 or 1a*; $0 ayuna oral tablet 1 or 1a*; $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 99 Coverage Requirements and Prescription Drug Name Drug Tier Limits BALCOLTRA ORAL TABLET (levonorgest-eth estrad-fe bisg) 3 balziva oral tablet 1 or 1a*; $0 BEYAZ ORAL TABLET (drospiren-eth estrad-levomefol) 3 blisovi 24 fe oral tablet 1 or 1a*; $0 blisovi fe 1.5/30 oral tablet 1 or 1a*; $0 blisovi fe 1/20 oral tablet 1 or 1a*; $0 briellyn oral tablet 1 or 1a*; $0 charlotte 24 fe oral tablet chewable 1 or 1a*; $0 chateal eq oral tablet 1 or 1a*; $0 chateal oral tablet 1 or 1a*; $0 cryselle-28 oral tablet 1 or 1a*; $0 cyclafem 1/35 oral tablet 1 or 1a*; $0 cyred eq oral tablet 1 or 1a*; $0 cyred oral tablet 1 or 1a*; $0 dasetta 1/35 oral tablet 1 or 1a*; $0 delyla oral tablet 1 or 1a*; $0 desogestrel-ethinyl estradiol oral tablet 1 or 1a*; $0 drospiren-eth estrad-levomefol oral tablet 1 or 1b*; $0 drospirenone-ethinyl estradiol oral tablet 1 or 1b*; $0 elinest oral tablet 1 or 1a*; $0 emoquette oral tablet 1 or 1a*; $0 enskyce oral tablet 1 or 1a*; $0 estarylla oral tablet 1 or 1a*; $0 ethynodiol diac-eth estradiol oral tablet 1 or 1a*; $0 FALESSA ORAL KIT (levonorgestrel-eth estrad & fa) 3 falmina oral tablet 1 or 1a*; $0 femynor oral tablet 1 or 1a*; $0 gemmily oral capsule 1 or 1b*; $0 GENERESS FE ORAL TABLET CHEWABLE (norethin-eth estradiol-fe) 3 hailey 1.5/30 oral tablet 1 or 1a*; $0 hailey 24 fe oral tablet 1 or 1a*; $0 hailey fe 1.5/30 oral tablet 1 or 1a*; $0 hailey fe 1/20 oral tablet 1 or 1a*; $0 isibloom oral tablet 1 or 1a*; $0 jasmiel oral tablet 1 or 1b*; $0 juleber oral tablet 1 or 1a*; $0 junel 1.5/30 oral tablet 1 or 1a*; $0 junel 1/20 oral tablet 1 or 1a*; $0 junel fe 1.5/30 oral tablet 1 or 1a*; $0 junel fe 1/20 oral tablet 1 or 1a*; $0 junel fe 24 oral tablet 1 or 1a*; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 100 Coverage Requirements and Prescription Drug Name Drug Tier Limits kaitlib fe oral tablet chewable 1 or 1b*; $0 kalliga oral tablet 1 or 1a*; $0 kelnor 1/35 oral tablet 1 or 1a*; $0 kelnor 1/50 oral tablet 1 or 1a*; $0 kurvelo oral tablet 1 or 1a*; $0 larin 1.5/30 oral tablet 1 or 1a*; $0 larin 1/20 oral tablet 1 or 1a*; $0 larin 24 fe oral tablet 1 or 1a*; $0 larin fe 1.5/30 oral tablet 1 or 1a*; $0 larin fe 1/20 oral tablet 1 or 1a*; $0 larissia oral tablet 1 or 1a*; $0 layolis fe oral tablet chewable 1 or 1b*; $0 lessina oral tablet 1 or 1a*; $0 levonorgestrel-ethinyl estrad oral tablet 1 or 1a*; $0 levora 0.15/30 (28) oral tablet 1 or 1a*; $0 lillow oral tablet 1 or 1a*; $0 loestrin 1.5/30 (21) oral tablet 1 or 1a*; $0 loestrin 1/20 (21) oral tablet 1 or 1a*; $0 loestrin fe 1.5/30 oral tablet 1 or 1a*; $0 loestrin fe 1/20 oral tablet 1 or 1a*; $0 loryna oral tablet 1 or 1b*; $0 low-ogestrel oral tablet 1 or 1a*; $0 lo-zumandimine oral tablet 1 or 1b*; $0 lutera oral tablet 1 or 1a*; $0 marlissa oral tablet 1 or 1a*; $0 merzee oral capsule 1 or 1b*; $0 mibelas 24 fe oral tablet chewable 1 or 1a*; $0 microgestin 1.5/30 oral tablet 1 or 1a*; $0 microgestin 1/20 oral tablet 1 or 1a*; $0 microgestin 24 fe oral tablet 1 or 1a*; $0 microgestin fe 1.5/30 oral tablet 1 or 1a*; $0 microgestin fe 1/20 oral tablet 1 or 1a*; $0 mili oral tablet 1 or 1a*; $0 MINASTRIN 24 FE ORAL TABLET CHEWABLE (norethin ace-eth 3 estrad-fe) mono-linyah oral tablet 1 or 1a*; $0 necon 0.5/35 (28) oral tablet 1 or 1a*; $0 NEXTSTELLIS ORAL TABLET (drospirenone-estetrol) 3 nikki oral tablet 1 or 1b*; $0 norethin ace-eth estrad-fe oral capsule 1 or 1b*; $0 norethin ace-eth estrad-fe oral tablet 1 or 1a*; $0 norethin ace-eth estrad-fe oral tablet chewable 1 or 1a*; $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 101 Coverage Requirements and Prescription Drug Name Drug Tier Limits norethindrone acet-ethinyl est oral tablet 1 or 1a*; $0 norethin-eth estradiol-fe oral tablet chewable 1 or 1b*; $0 norgestimate-eth estradiol oral tablet 1 or 1a*; $0 nortrel 0.5/35 (28) oral tablet 1 or 1a*; $0 nortrel 1/35 (21) oral tablet 1 or 1a*; $0 nortrel 1/35 (28) oral tablet 1 or 1a*; $0 nymyo oral tablet 1 or 1a*; $0 ocella oral tablet 1 or 1b*; $0 orsythia oral tablet 1 or 1a*; $0 philith oral tablet 1 or 1a*; $0 pirmella 1/35 oral tablet 1 or 1a*; $0 portia-28 oral tablet 1 or 1a*; $0 previfem oral tablet 1 or 1a*; $0 reclipsen oral tablet 1 or 1a*; $0 SAFYRAL ORAL TABLET (drospiren-eth estrad-levomefol) 3 sprintec 28 oral tablet 1 or 1a*; $0 sronyx oral tablet 1 or 1a*; $0 syeda oral tablet 1 or 1b*; $0 tarina 24 fe oral tablet 1 or 1a*; $0 tarina fe 1/20 eq oral tablet 1 or 1a*; $0 tarina fe 1/20 oral tablet 1 or 1a*; $0 TAYTULLA ORAL CAPSULE (norethin ace-eth estrad-fe) 3 TYBLUME ORAL TABLET CHEWABLE (levonorgestrel-ethinyl estrad) 3 tydemy oral tablet 1 or 1b*; $0 vestura oral tablet 1 or 1b*; $0 vienva oral tablet 1 or 1a*; $0 vyfemla oral tablet 1 or 1a*; $0 vylibra oral tablet 1 or 1a*; $0 wera oral tablet 1 or 1a*; $0 wymzya fe oral tablet chewable 1 or 1b*; $0 YASMIN 28 ORAL TABLET (drospirenone-ethinyl estradiol) 3 YAZ ORAL TABLET (drospirenone-ethinyl estradiol) 3 zarah oral tablet 1 or 1b*; $0 zovia 1/35 (28) oral tablet 1 or 1a*; $0 zovia 1/35e (28) oral tablet 1 or 1a*; $0 zumandimine oral tablet 1 or 1b*; $0 *COMBINATION CONTRACEPTIVES - TRANSDERMAL*** - BIRTH CONTROL PILLS TWIRLA TRANSDERMAL PATCH WEEKLY (levonorgestrel-eth 3 estradiol) xulane transdermal patch weekly 1 or 1b*; $0 zafemy transdermal patch weekly 1 or 1b*; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 102 Coverage Requirements and Prescription Drug Name Drug Tier Limits *COMBINATION CONTRACEPTIVES - VAGINAL*** - BIRTH CONTROL PILLS ANNOVERA VAGINAL RING (segesterone-ethinyl estradiol) 3 eluryng vaginal ring 1 or 1b*; $0 etonogestrel-ethinyl estradiol vaginal ring 1 or 1b*; $0 NUVARING VAGINAL RING (etonogestrel-ethinyl estradiol) 3 *CONTINUOUS CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS amethyst oral tablet 1 or 1b*; $0 dolishale oral tablet 1 or 1b*; $0 levonorgestrel-ethinyl estrad oral tablet 1 or 1b*; $0 *COPPER CONTRACEPTIVES - IUD*** - BIRTH CONTROL PILLS PARAGARD INTRAUTERINE COPPER INTRAUTERINE 3 INTRAUTERINE DEVICE (copper) *EMERGENCY CONTRACEPTIVES*** - BIRTH CONTROL PILLS aftera oral tablet 1 or 1b*; $0 econtra ez oral tablet 1 or 1b*; $0 econtra one-step oral tablet 1 or 1b*; $0 ELLA ORAL TABLET (ulipristal acetate) 3; $0 levonorgestrel oral tablet 1 or 1b*; $0 my choice oral tablet 1 or 1b*; $0 my way oral tablet 1 or 1b*; $0 new day oral tablet 1 or 1b*; $0 opcicon one-step oral tablet 1 or 1b*; $0 option 2 oral tablet 1 or 1b*; $0 preventeza oral tablet 1 or 1b*; $0 react oral tablet 1 or 1b*; $0 take action oral tablet 1 or 1b*; $0 *EXTENDED-CYCLE CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS amethia oral tablet 1 or 1b*; $0 ashlyna oral tablet 1 or 1b*; $0 camrese lo oral tablet 1 or 1b*; $0 camrese oral tablet 1 or 1b*; $0 daysee oral tablet 1 or 1b*; $0 fayosim oral tablet 1 or 1b*; $0 iclevia oral tablet 1 or 1b*; $0 introvale oral tablet 1 or 1b*; $0 jaimiess oral tablet 1 or 1b*; $0 jolessa oral tablet 1 or 1b*; $0 levonorgest-eth est & eth est oral tablet 1 or 1b*; $0 levonorgest-eth estrad 91-day oral tablet 1 or 1b*; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 103 Coverage Requirements and Prescription Drug Name Drug Tier Limits lojaimiess oral tablet 1 or 1b*; $0 LOSEASONIQUE ORAL TABLET (levonorgest-eth estrad 91-day) 3 QUARTETTE ORAL TABLET (levonorgest-eth estrad 91-day) 3 rivelsa oral tablet 1 or 1b*; $0 SEASONIQUE ORAL TABLET (levonorgest-eth estrad 91-day) 3 setlakin oral tablet 1 or 1b*; $0 simpesse oral tablet 1 or 1b*; $0 *FOUR PHASE CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS NATAZIA ORAL TABLET (estradiol valerate-dienogest) 3 *PROGESTIN CONTRACEPTIVES - IMPLANTS*** - BIRTH CONTROL PILLS NEXPLANON SUBCUTANEOUS IMPLANT (etonogestrel) 4 LD; SP *PROGESTIN CONTRACEPTIVES - INJECTABLE*** - BIRTH CONTROL PILLS DEPO-PROVERA INTRAMUSCULAR SUSPENSION 3 (medroxyprogesterone acetate) DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED 3 SYRINGE (medroxyprogesterone acetate) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION 3; $0 PREFILLED SYRINGE (medroxyprogesterone acetate) medroxyprogesterone acetate intramuscular suspension 1 or 1b*; $0 medroxyprogesterone acetate intramuscular suspension prefilled syringe 1 or 1b*; $0 *PROGESTIN CONTRACEPTIVES - IUD*** - BIRTH CONTROL PILLS KYLEENA INTRAUTERINE INTRAUTERINE DEVICE (levonorgestrel) 4 LD; SP LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 3 LD; SP (levonorgestrel) MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 3 LD; SP (levonorgestrel) SKYLA INTRAUTERINE INTRAUTERINE DEVICE (levonorgestrel) 3 LD; SP *PROGESTIN CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS camila oral tablet 1 or 1b*; $0 deblitane oral tablet 1 or 1b*; $0 errin oral tablet 1 or 1b*; $0 heather oral tablet 1 or 1b*; $0 incassia oral tablet 1 or 1b*; $0 jencycla oral tablet 1 or 1b*; $0 lyleq oral tablet 1 or 1b*; $0 lyza oral tablet 1 or 1b*; $0 nora-be oral tablet 1 or 1b*; $0 norethindrone oral tablet 1 or 1b*; $0 norlyda oral tablet 1 or 1b*; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 104 Coverage Requirements and Prescription Drug Name Drug Tier Limits norlyroc oral tablet 1 or 1b*; $0 sharobel oral tablet 1 or 1b*; $0 SLYND ORAL TABLET (drospirenone) 3 tulana oral tablet 1 or 1b*; $0 *TRIPHASIC CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS alyacen 7/7/7 oral tablet 1 or 1a*; $0 aranelle oral tablet 1 or 1a*; $0 caziant oral tablet 1 or 1a*; $0 cyclafem 7/7/7 oral tablet 1 or 1a*; $0 dasetta 7/7/7 oral tablet 1 or 1a*; $0 enpresse-28 oral tablet 1 or 1a*; $0 ESTROSTEP FE ORAL TABLET (norethindron-ethinyl estrad-fe) 3 leena oral tablet 1 or 1a*; $0 levonest oral tablet 1 or 1a*; $0 levonorg-eth estrad triphasic oral tablet 1 or 1a*; $0 norgestim-eth estrad triphasic oral tablet 1 or 1b*; $0 nortrel 7/7/7 oral tablet 1 or 1a*; $0 nylia 7/7/7 oral tablet 1 or 1a*; $0 pirmella 7/7/7 oral tablet 1 or 1a*; $0 tilia fe oral tablet 1 or 1b*; $0 tri femynor oral tablet 1 or 1b*; $0 tri-estarylla oral tablet 1 or 1b*; $0 tri-legest fe oral tablet 1 or 1b*; $0 tri-linyah oral tablet 1 or 1b*; $0 tri-lo-estarylla oral tablet 1 or 1b*; $0 tri-lo-marzia oral tablet 1 or 1b*; $0 tri-lo-mili oral tablet 1 or 1b*; $0 tri-lo-sprintec oral tablet 1 or 1b*; $0 tri-mili oral tablet 1 or 1b*; $0 tri-nymyo oral tablet 1 or 1b*; $0 tri-previfem oral tablet 1 or 1b*; $0 tri-sprintec oral tablet 1 or 1b*; $0 trivora (28) oral tablet 1 or 1a*; $0 tri-vylibra lo oral tablet 1 or 1b*; $0 tri-vylibra oral tablet 1 or 1b*; $0 velivet oral tablet 1 or 1a*; $0 *CORTICOSTEROIDS* - HORMONES *GLUCOCORTICOSTEROIDS*** - DRUGS FOR INFLAMMATION ALKINDI SPRINKLE ORAL CAPSULE SPRINKLE (hydrocortisone) 3 PA; LD budesonide er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) budesonide oral capsule delayed release particles 1 or 1b* QL (3 capsule per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 105 Coverage Requirements and Prescription Drug Name Drug Tier Limits CORTEF ORAL TABLET (hydrocortisone) 3 decadron oral tablet 1 or 1a* DEPO-MEDROL INJECTION SUSPENSION (methylprednisolone acetate) 3 DEXABLISS ORAL TABLET THERAPY PACK 3 DEXAMETHASONE INTENSOL ORAL CONCENTRATE 2 (dexamethasone) dexamethasone oral elixir 1 or 1a* dexamethasone oral solution 1 or 1a* dexamethasone oral tablet 1 or 1a* dexamethasone oral tablet therapy pack 1 or 1b* DEXAMETHASONE SOD PHOS-NACL INTRAVENOUS SOLUTION 3 dexamethasone sod phosphate pf injection solution 1 or 1b* DEXAMETHASONE SOD PHOSPHATE PF INJECTION SOLUTION 3 PREFILLED SYRINGE DEXAMETHASONE SODIUM PHOSPHATE INJECTION SOLUTION 3 10 MG/ML, 4 MG/ML dexamethasone sodium phosphate injection solution 100 mg/10ml, 120 1 or 1b* mg/30ml, 20 mg/5ml DXEVO 11-DAY ORAL TABLET THERAPY PACK (dexamethasone) 3 ENTOCORT EC ORAL CAPSULE DELAYED RELEASE PARTICLES 3 QL (3 capsule per 1 day) (budesonide) HEMADY ORAL TABLET (dexamethasone) 3 PA; QL (2 tablets per 1 day) hydrocortisone oral tablet 1 or 1b* KENALOG INJECTION SUSPENSION (triamcinolone acetonide) 3 KENALOG-80 INJECTION SUSPENSION (triamcinolone acetonide) 3 MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG 3 (methylprednisolone) MEDROL ORAL TABLET 2 MG (methylprednisolone) 2 MEDROL ORAL TABLET THERAPY PACK (methylprednisolone) 3 methylprednisolone oral tablet 1 or 1a* methylprednisolone oral tablet therapy pack 1 or 1a* methylprednisolone sodium succ injection solution reconstituted 1 or 1b* MILLIPRED ORAL TABLET (prednisolone) 3 ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, 30 MG 3 QL (2 tablets per 1 day) (prednisolone sodium phosphate) ORAPRED ODT ORAL TABLET DISPERSIBLE 15 MG (prednisolone 3 sodium phosphate) ORTIKOS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 QL (1 capsule per 1 day) (budesonide) PEDIAPRED ORAL SOLUTION (prednisolone sodium phosphate) 3 prednisolone oral solution 1 or 1a* prednisolone sodium phosphate oral solution 1 or 1a* prednisolone sodium phosphate oral tablet dispersible 10 mg, 30 mg 1 or 1a* QL (2 tablets per 1 day) prednisolone sodium phosphate oral tablet dispersible 15 mg 1 or 1a*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 106 Coverage Requirements and Prescription Drug Name Drug Tier Limits PREDNISONE INTENSOL ORAL CONCENTRATE (prednisone) 3 prednisone oral solution 1 or 1a* prednisone oral tablet 1 or 1a* prednisone oral tablet therapy pack 1 or 1a* SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 3 (hydrocortisone sod succinate) SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 3 (methylprednisolone sodium succ) taperdex 12-day oral tablet therapy pack 1 or 1b* taperdex 6-day oral tablet therapy pack 1 or 1b* taperdex 7-day oral tablet therapy pack 1 or 1b* UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR (budesonide) 3 PA; QL (1 tablet per 1 day) ZCORT 7-DAY ORAL TABLET THERAPY PACK 3 ZILRETTA INTRA-ARTICULAR SUSPENSION RECONSTITUTED 4 PA; LD; QL (1 injection per 1 knee) ER (triamcinolone acetonide) *MINERALOCORTICOIDS*** - DRUGS FOR INFLAMMATION fludrocortisone acetate oral tablet 1 or 1b* *STEROID COMBINATIONS*** - DRUGS FOR INFLAMMATION BSP 0820 INJECTION KIT 3 CELESTONE SOLUSPAN INJECTION SUSPENSION (betamethasone 3 sod phos & acet) *COUGH/COLD/ALLERGY* - DRUGS FOR THE LUNGS *ANTITUSSIVE - NONNARCOTIC*** - DRUGS FOR ALLERGIES benzonatate oral capsule 1 or 1b* TESSALON PERLES ORAL CAPSULE (benzonatate) 3 *ANTITUSSIVE - OPIOID*** - DRUGS FOR COUGH AND COLD HYCODAN ORAL SYRUP (hydrocodone-homatropine) 3 hydrocodone-homatropine oral syrup 1 or 1a* hydrocodone-homatropine oral tablet 1 or 1a* hydromet oral syrup 1 or 1a* *ANTITUSSIVE-EXPECTORANT*** - DRUGS FOR COUGH AND COLD CODITUSSIN AC ORAL LIQUID 3 g tussin ac oral solution 1 or 1a* guaiatussin ac oral syrup 1 or 1a* guaifenesin ac oral syrup 1 or 1a* guaifenesin-codeine oral solution 1 or 1a* MAR-COF CG EXPECTORANT ORAL LIQUID (guaifenesin-codeine) 2 maxi-tuss ac oral solution 1 or 1a* M-CLEAR WC ORAL SOLUTION 2 NINJACOF-XG ORAL LIQUID (guaifenesin-codeine) 3 trymine cg oral liquid 1 or 1a* virtussin a/c oral solution 1 or 1a* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 107 Coverage Requirements and Prescription Drug Name Drug Tier Limits virtussin ac w/alc oral liquid 1 or 1a* *ANTITUSSIVE-EXPECTORANTS-DECONGESTANT*** - DRUGS FOR COUGH AND COLD CODITUSSIN DAC ORAL LIQUID 3 TUSNEL C ORAL SYRUP (pseudoephedrine-codeine-gg) 2 VIRTUSSIN DAC ORAL SOLUTION 2 *DECONGESTANT & ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 3 ST; QL (2 tablets per 1 day) HOUR (desloratadine-pseudoephedrine) promethazine vc oral syrup 1 or 1b* QL (120 mL per 1 fill) promethazine-phenylephrine oral syrup 1 or 1b* QL (120 mL per 1 fill) *DECONGESTANT W/ EXPECTORANT*** - DRUGS FOR COUGH AND COLD GILPHEX TR ORAL TABLET (phenylephrine-guaifenesin) 3 *IODINE EXPECTORANTS*** - DRUGS FOR COUGH AND COLD SSKI ORAL SOLUTION (potassium iodide (expectorant)) 3 *MISC. RESPIRATORY INHALANTS*** - DRUGS FOR ALLERGIES HYPERSAL INHALATION NEBULIZATION SOLUTION (sodium 3 chloride) sodium chloride inhalation nebulization solution 1 or 1b* *MUCOLYTICS*** - DRUGS FOR THE LUNGS acetylcysteine inhalation solution 1 or 1b* *NON-NARC ANTITUSSIVE-ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD promethazine-dm oral syrup 1 or 1a* QL (120 mL per 1 fill) *NON-NARC ANTITUSSIVE-DECONGESTANT- ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD pseudoeph-bromphen-dm oral syrup 1 or 1b* *OPIOID ANTITUSSIVE-ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD hydrocod polst-cpm polst er oral suspension extended release 1 or 1b* QL (120 mL per 1 fill) promethazine-codeine oral solution 1 or 1a* QL (120 mL per 1 fill) promethazine-codeine oral syrup 1 or 1a* QL (120 mL per 1 fill) TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 HOUR 2 (hydrocod polst-chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 (chlorpheniramine-codeine) TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE (codeine 3 polst-chlorphen polst) *OPIOID ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD CAPCOF ORAL SYRUP 3 HISTEX-AC ORAL SYRUP (phenyleph-triprolidine-codeine) 3 MAR-COF BP ORAL LIQUID (pseudoeph-bromphen-cod) 3 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 108 Coverage Requirements and Prescription Drug Name Drug Tier Limits MAXI-TUSS CD ORAL LIQUID 2 M-END PE ORAL LIQUID (phenylephrine-bromphen-codeine) 3 POLY-TUSSIN AC ORAL LIQUID 2 promethazine vc/codeine oral syrup 1 or 1b* QL (120 mL per 1 fill) promethazine-phenyleph-codeine oral syrup 1 or 1b* QL (120 mL per 1 fill) PRO-RED AC ORAL SYRUP (phenyleph-dexchlorphen-codeine) 3 RYDEX ORAL LIQUID (pseudoeph-bromphen-cod) 2 *DERMATOLOGICALS* - DRUGS FOR THE SKIN *ACNE ANTIBIOTICS*** - DRUGS FOR THE SKIN CLEOCIN-T EXTERNAL LOTION (clindamycin phosphate) 3 ST; QL (4 mL per 1 day) clindacin etz external swab 1 or 1b* QL (2 pads per 1 day) clindacin-p external swab 1 or 1b* QL (2 pads per 1 day) clindamycin phosphate external foam 1 or 1b* QL (100 grams per 30 days) clindamycin phosphate external gel 1 or 1b* QL (60 grams per 30 days) clindamycin phosphate external lotion 1 or 1b* QL (4 mL per 1 day) clindamycin phosphate external solution 1 or 1b* QL (4 mL per 1 day) clindamycin phosphate external swab 1 or 1b* QL (2 pads per 1 day) dapsone external gel 1 or 1b* ST; QL (60 grams per 30 days) ery external pad 1 or 1b* QL (2 pads per 1 day) ERYGEL EXTERNAL GEL (erythromycin) 3 QL (60 grams per 30 days) erythromycin external gel 1 or 1b* QL (60 grams per 30 days) erythromycin external solution 1 or 1b* EVOCLIN EXTERNAL FOAM (clindamycin phosphate) 3 ST; QL (100 grams per 30 days) KLARON EXTERNAL LOTION (sulfacetamide sodium (acne)) 3 sulfacetamide sodium (acne) external lotion 1 or 1b* *ACNE COMBINATIONS*** - DRUGS FOR THE SKIN adapalene-benzoyl peroxide external gel 1 or 1b* PA; QL (45 grams per 30 days) BENZAMYCIN EXTERNAL GEL (benzoyl peroxide-erythromycin) 3 ST; QL (46.6 grams per 30 days) benzoyl peroxide-erythromycin external gel 1 or 1b* QL (2 packets per 1 day) clindamycin phos-benzoyl perox external gel 1.2-5 % 1 or 1b* QL (45 grams per 30 days) clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 % 1 or 1b* QL (50 grams per 30 days) clindamycin-tretinoin external gel 1 or 1b* neuac external gel 1 or 1b* QL (45 grams per 30 days) ONEXTON EXTERNAL GEL (clindamycin phos-benzoyl perox) 2 QL (50 grams per 30 days) sulfacetamide sod-sulfur wash external liquid 1 or 1b* PA TAROXIA EXTERNAL GEL 3 *ACNE PRODUCTS*** - DRUGS FOR THE SKIN ABSORICA LD ORAL CAPSULE (isotretinoin micronized) 3 PA ABSORICA ORAL CAPSULE (isotretinoin) 3 PA accutane oral capsule 2 PA adapalene external cream 1 or 1b* PA; QL (1.5 grams per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 109 Coverage Requirements and Prescription Drug Name Drug Tier Limits adapalene external gel 1 or 1b* PA; QL (45 grams per 30 days) adapalene external pad 1 or 1b* PA AKLIEF EXTERNAL CREAM (trifarotene) 3 ST; QL (1 pump per 30 days) amnesteem oral capsule 2 PA ARAZLO EXTERNAL LOTION (tazarotene) 3 ST; QL (45 grams per 30 days) avita external cream 1 or 1b* PA; QL (45 grams per 30 days) avita external gel 1 or 1b* PA; QL (45 grams per 30 days) bp wash external liquid 1 or 1b* claravis oral capsule 2 PA isotretinoin oral capsule 2 PA myorisan oral capsule 2 PA tretinoin external cream 1 or 1b* PA; QL (45 grams per 30 days) tretinoin external gel 1 or 1b* PA; QL (45 grams per 30 days) tretinoin microsphere external gel 1 or 1b* PA; QL (45 grams per 30 days) tretinoin microsphere pump external gel 1 or 1b* PA; QL (45 grams per 30 days) zenatane oral capsule 2 PA *AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTS*** - DRUGS FOR THE SKIN VEREGEN EXTERNAL OINTMENT (sinecatechins) 3 *AGENTS FOR FACIAL WRINKLES - RETINOIDS*** - DRUGS FOR THE SKIN refissa external cream 1 or 1b* PA; QL (40 grams per 30 days) RENOVA EXTERNAL CREAM (tretinoin (facial wrinkles)) 3 PA; QL (40 grams per 30 days) RENOVA PUMP EXTERNAL CREAM (tretinoin (facial wrinkles)) 3 PA; QL (44 grams per 30 days) tretinoin (emollient) external cream 1 or 1b* PA; QL (40 grams per 30 days) *ANTIBIOTIC STEROID COMBINATIONS - TOPICAL*** - DRUGS FOR THE SKIN NEO-SYNALAR EXTERNAL CREAM (neomycin-fluocinolone) 3 *ANTIBIOTICS - TOPICAL*** - DRUGS FOR THE SKIN ALTABAX EXTERNAL OINTMENT (retapamulin) 2 QL (30 grams per 1 fill) CENTANY EXTERNAL OINTMENT (mupirocin) 3 QL (30 grams per 1 fill) gentamicin sulfate external cream 1 or 1b* QL (30 grams per 1 fill) gentamicin sulfate external ointment 1 or 1b* QL (30 grams per 1 fill) mupirocin calcium external cream 1 or 1b* QL (30 grams per 1 fill) mupirocin external ointment 1 or 1b* QL (30 grams per 1 fill) XEPI EXTERNAL CREAM (ozenoxacin) 3 QL (45 grams per 1 fill) *ANTIFUNGALS - TOPICAL COMBINATIONS*** - DRUGS FOR THE SKIN clotrimazole-betamethasone external cream 1 or 1b* QL (120 grams per 30 days) clotrimazole-betamethasone external lotion 1 or 1b* QL (120 mL per 30 days) miconazole-zinc oxide-petrolat external ointment 1 or 1b* QL (50 grams per 30 days) nystatin-triamcinolone external cream 1 or 1b* QL (120 grams per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 110 Coverage Requirements and Prescription Drug Name Drug Tier Limits nystatin-triamcinolone external ointment 1 or 1b* QL (120 grams per 30 days) VUSION EXTERNAL OINTMENT (miconazole-zinc oxide-petrolat) 3 QL (50 grams per 30 days) *ANTIFUNGALS - TOPICAL*** - DRUGS FOR THE SKIN ciclopirox external gel 1 or 1b* QL (100 grams per 30 days) ciclopirox external shampoo 1 or 1b* QL (120 mL per 30 days) ciclopirox external solution 1 or 1b* QL (7 mL per 30 days) ciclopirox olamine external cream 1 or 1b* QL (90 grams per 30 days) ciclopirox olamine external suspension 1 or 1b* QL (60 mL per 30 days) LOPROX EXTERNAL CREAM (ciclopirox olamine) 3 ST; QL (90 grams per 30 days) LOPROX EXTERNAL SHAMPOO (ciclopirox) 3 QL (120 mL per 30 days) LOPROX EXTERNAL SUSPENSION (ciclopirox olamine) 3 ST; QL (60 mL per 30 days) MENTAX EXTERNAL CREAM (butenafine hcl) 3 ST; QL (30 grams per 30 days) naftifine hcl external cream 1 % 1 or 1b* ST; QL (90 grams per 30 days) naftifine hcl external cream 2 % 1 or 1b* QL (60 grams per 30 days) naftifine hcl external gel 1 or 1b* ST; QL (90 grams per 30 days) NAFTIN EXTERNAL GEL 1 % (naftifine hcl) 3 ST; QL (90 grams per 30 days) NAFTIN EXTERNAL GEL 2 % (naftifine hcl) 3 ST; QL (60 grams per 30 days) nyamyc external powder 1 or 1b* QL (30 grams per 30 days) nystatin external cream 1 or 1b* QL (120 grams per 30 days) nystatin external ointment 1 or 1b* QL (120 grams per 30 days) nystatin external powder 1 or 1b* QL (30 grams per 30 days) nystop external powder 1 or 1b* QL (30 grams per 30 days) *ANTI-INFLAMMATORY AGENTS - TOPICAL*** - DRUGS FOR THE SKIN diclofenac sodium external gel 1 or 1b* QL (1000 gm per 30 days) *ANTI-INFLAMMATORY COMBINATIONS - TOPICAL*** - DRUGS FOR THE SKIN ziclopro combination therapy pack 1 or 1b* *ANTINEOPLASTIC ALKYLATING AGENTS - TOPICAL*** - DRUGS FOR THE SKIN VALCHLOR EXTERNAL GEL (mechlorethamine hcl (topical)) 3 PA; LD; QL (1 tube per 30 days) *ANTINEOPLASTIC ANTIMETABOLITES - TOPICAL*** - DRUGS FOR THE SKIN CARAC EXTERNAL CREAM (fluorouracil) 3 ST; QL (30 gm per 365 days) EFUDEX EXTERNAL CREAM (fluorouracil) 3 ST; QL (40 gm per 365 days) FLUOROPLEX EXTERNAL CREAM (fluorouracil) 3 ST; QL (60 gm per 365 days) fluorouracil external cream 0.5 % 1 or 1b* ST; QL (30 gm per 365 days) fluorouracil external cream 5 % 1 or 1b* QL (40 gm per 365 days) fluorouracil external solution 1 or 1b* QL (10 mL per 365 days) *ANTINEOPLASTIC RETINOIDS - TOPICAL*** - DRUGS FOR THE SKIN PANRETIN EXTERNAL GEL (alitretinoin) 3 SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 111 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIPRURITICS - TOPICAL*** - DRUGS FOR THE SKIN doxepin hcl external cream 1 or 1b* PA; QL (1 tube per 1 fill) *ANTIPSORIATICS - SYSTEMIC*** - DRUGS FOR THE SKIN acitretin oral capsule 1 or 1b* COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PA; LD; SP; QL (2 syringes per 28 4 PREFILLED SYRINGE (secukinumab) days) COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS SOLUTION PA; LD; SP; QL (2 pens per 28 4 AUTO-INJECTOR (secukinumab) days) COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION 4 PA; LD; SP; QL (1 pen per 28 days) AUTO-INJECTOR (secukinumab) COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (1 syringe per 28 4 (secukinumab) days) methoxsalen rapid oral capsule 1 or 1b*; OC SP SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 84 days) KIT (risankizumab-rzaa) SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 PA; SP; QL (1 carton per 84 days) (risankizumab-rzaa) SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (1 carton per 84 days) (risankizumab-rzaa) SORIATANE ORAL CAPSULE (acitretin) 3 STELARA SUBCUTANEOUS SOLUTION (ustekinumab) 4 PA; SP; QL (1 vial per 84 days) STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (1 syringe per 84 days) (ustekinumab) TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; SP; QL (1 autoinjector per 56 4 (guselkumab) days) TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (1 syringe per 47 days) (guselkumab) *ANTIPSORIATICS*** - DRUGS FOR THE SKIN calcipotriene external cream 1 or 1b* QL (120 grams per 30 days) calcipotriene external foam 1 or 1b* QL (120 grams per 30 days) calcipotriene external ointment 1 or 1b* QL (120 grams per 30 days) calcipotriene external solution 1 or 1b* QL (60 mL per 30 days) calcitrene external ointment 1 or 1b* QL (120 grams per 30 days) calcitriol external ointment 1 or 1b* QL (800 grams per 28 days) DOVONEX EXTERNAL CREAM (calcipotriene) 3 QL (120 grams per 30 days) SORILUX EXTERNAL FOAM (calcipotriene) 3 QL (120 grams per 30 days) tazarotene external cream 1 or 1b* QL (30 grams per 30 days) TAZORAC EXTERNAL CREAM (tazarotene) 2 QL (30 grams per 30 days) TAZORAC EXTERNAL GEL 0.05 % (tazarotene) 2 QL (30 grams per 30 days) TAZORAC EXTERNAL GEL 0.1 % (tazarotene) 2 QL (1 gram per 1 day) *ANTISEBORRHEIC COMBINATIONS*** - DRUGS FOR THE SKIN PROMISEB EXTERNAL CREAM (antiseborrheic products, misc.) 3 SODIUM SULFACETAMIDE-BAKUCHIOL EXTERNAL LIQUID 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 112 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTISEBORRHEIC PRODUCTS*** - DRUGS FOR THE SKIN selenium sulfide external lotion 1 or 1a* QL (120 mL per 30 days) *ANTIVIRAL TOPICAL COMBINATIONS*** - DRUGS FOR THE SKIN XERESE EXTERNAL CREAM (acyclovir-hydrocortisone) 3 PA; QL (5 gm per 30 days) *ANTIVIRALS - TOPICAL*** - DRUGS FOR THE SKIN acyclovir external cream 1 or 1b* PA; QL (5 gm per 30 days) acyclovir external ointment 1 or 1b* QL (30 gm per 30 days) DENAVIR EXTERNAL CREAM (penciclovir) 3 PA; QL (5 gm per 30 days) ZOVIRAX EXTERNAL OINTMENT (acyclovir) 3 QL (30 gm per 30 days) *ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE SKIN DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 4 SP; QL (2 syringes per 28 days) (dupilumab) DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 SP; QL (2 syringes per 28 days) (dupilumab) *BURN PRODUCTS*** - DRUGS FOR THE SKIN mafenide acetate external packet 1 or 1b* SILVADENE EXTERNAL CREAM (silver sulfadiazine) 3 silver sulfadiazine external cream 1 or 1a* ssd external cream 1 or 1a* SULFAMYLON EXTERNAL CREAM (mafenide acetate) 3 SULFAMYLON EXTERNAL PACKET (mafenide acetate) 3 *CORTICOSTEROIDS - TOPICAL*** - DRUGS FOR THE SKIN ala-cort external cream 1 or 1a* QL (454 grams per 30 days) alclometasone dipropionate external cream 1 or 1b* QL (60 grams per 30 days) alclometasone dipropionate external ointment 1 or 1b* QL (2 grams per 1 day) amcinonide external cream 3 ST; QL (60 grams per 30 days) amcinonide external lotion 3 ST; QL (60 mL per 30 days) beser external lotion 1 or 1b* QL (120 mL per 30 days) betamethasone dipropionate aug external cream 1 or 1b* QL (50 grams per 30 days) betamethasone dipropionate aug external gel 1 or 1b* QL (50 grams per 30 days) betamethasone dipropionate aug external lotion 1 or 1b* QL (60 mL per 30 days) betamethasone dipropionate aug external ointment 1 or 1b* QL (50 grams per 30 days) betamethasone dipropionate external cream 1 or 1b* QL (45 grams per 30 days) betamethasone dipropionate external lotion 1 or 1b* QL (60 mL per 30 days) betamethasone dipropionate external ointment 1 or 1b* QL (45 grams per 30 days) betamethasone valerate external cream 1 or 1b* QL (45 grams per 30 days) betamethasone valerate external foam 3 ST; QL (100 grams per 30 days) betamethasone valerate external lotion 1 or 1b* ST; QL (60 mL per 30 days) betamethasone valerate external ointment 1 or 1b* QL (45 grams per 30 days) clobetasol prop emollient base external cream 1 or 1b* QL (60 grams per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 113 Coverage Requirements and Prescription Drug Name Drug Tier Limits clobetasol propionate e external cream 1 or 1b* QL (60 grams per 30 days) clobetasol propionate emulsion external foam 1 or 1b* QL (100 grams per 30 days) clobetasol propionate external cream 1 or 1b* QL (60 grams per 30 days) clobetasol propionate external foam 1 or 1b* QL (100 mL per 30 days) clobetasol propionate external gel 1 or 1b* QL (60 grams per 30 days) clobetasol propionate external liquid 1 or 1b* QL (125 mL per 30 days) clobetasol propionate external lotion 1 or 1b* QL (118 mL per 30 days) clobetasol propionate external ointment 1 or 1b* QL (60 grams per 30 days) clobetasol propionate external shampoo 1 or 1b* QL (3.94 mL per 1 day) clobetasol propionate external solution 1 or 1b* QL (50 mL per 30 days) clocortolone pivalate external cream 3 ST; QL (90 grams per 30 days) clodan external shampoo 1 or 1b* QL (3.94 mL per 1 day) desonide external cream 1 or 1b* QL (60 grams per 30 days) desonide external gel 1 or 1b* QL (2 grams per 1 day) desonide external lotion 1 or 1b* QL (118 mL per 30 days) desonide external ointment 1 or 1b* QL (60 grams per 30 days) desoximetasone external cream 3 ST; QL (100 grams per 30 days) desoximetasone external gel 3 ST; QL (60 grams per 30 days) desoximetasone external liquid 3 ST; QL (100 mL per 30 days) desoximetasone external ointment 3 ST; QL (100 grams per 30 days) desrx external gel 1 or 1b* QL (2 grams per 1 day) diflorasone diacetate external cream 3 ST; QL (60 grams per 30 days) diflorasone diacetate external ointment 3 ST; QL (60 grams per 30 days) fluocinolone acetonide body external oil 1 or 1b* ST; QL (120 mL per 30 days) fluocinolone acetonide external cream 0.01 % 1 or 1b* QL (60 grams per 30 days) fluocinolone acetonide external cream 0.025 % 1 or 1b* QL (120 grams per 30 days) fluocinolone acetonide external ointment 1 or 1b* QL (120 grams per 30 days) fluocinolone acetonide external solution 1 or 1b* QL (90 mL per 30 days) fluocinolone acetonide scalp external oil 1 or 1b* QL (120 mL per 30 days) fluocinonide emulsified base external cream 1 or 1b* QL (60 grams per 30 days) fluocinonide external cream 1 or 1b* QL (120 grams per 30 days) fluocinonide external gel 1 or 1b* QL (60 grams per 30 days) fluocinonide external ointment 1 or 1b* QL (60 grams per 30 days) fluocinonide external solution 1 or 1b* QL (60 mL per 30 days) flurandrenolide external cream 3 ST; QL (120 grams per 30 days) flurandrenolide external lotion 3 ST; QL (120 mL per 30 days) flurandrenolide external ointment 3 ST; QL (60 grams per 30 days) fluticasone propionate external cream 1 or 1b* QL (60 grams per 30 days) fluticasone propionate external lotion 1 or 1b* QL (120 mL per 30 days) fluticasone propionate external ointment 1 or 1b* QL (60 grams per 30 days) halcinonide external cream 3 ST; QL (60 grams per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 114 Coverage Requirements and Prescription Drug Name Drug Tier Limits halobetasol propionate external cream 1 or 1b* QL (50 grams per 30 days) halobetasol propionate external ointment 1 or 1b* QL (50 grams per 30 days) hydrocortisone butyr lipo base external cream 3 ST; QL (60 grams per 30 days) hydrocortisone butyrate external cream 3 ST; QL (60 grams per 30 days) hydrocortisone butyrate external lotion 3 ST; QL (3.94 mL per 1 day) hydrocortisone butyrate external ointment 3 ST; QL (60 grams per 30 days) hydrocortisone butyrate external solution 3 ST; QL (60 mL per 30 days) hydrocortisone external cream 1 or 1a* QL (454 grams per 30 days) hydrocortisone external lotion 1 or 1a* QL (118 mL per 30 days) hydrocortisone external ointment 1 or 1a* QL (454 grams per 30 days) hydrocortisone valerate external cream 3 ST; QL (60 grams per 30 days) hydrocortisone valerate external ointment 3 ST; QL (60 grams per 30 days) mometasone furoate external cream 1 or 1b* QL (50 grams per 30 days) mometasone furoate external ointment 1 or 1b* QL (50 grams per 30 days) mometasone furoate external solution 1 or 1b* QL (60 mL per 30 days) nolix external lotion 3 ST; QL (120 mL per 30 days) prednicarbate external ointment 1 or 1b* QL (60 grams per 30 days) tovet external foam 1 or 1b* QL (100 grams per 30 days) triamcinolone acetonide external aerosol solution 3 ST; QL (100 grams per 30 days) triamcinolone acetonide external cream 1 or 1a* QL (454 grams per 30 days) triamcinolone acetonide external lotion 1 or 1a* QL (60 mL per 30 days) triamcinolone acetonide external ointment 0.025 %, 0.1 % 1 or 1a* QL (454 grams per 30 days) triamcinolone acetonide external ointment 0.05 % 3 ST; QL (430 grams per 30 days) triamcinolone acetonide external ointment 0.5 % 1 or 1a* QL (30 grams per 30 days) triderm external cream 1 or 1a* QL (454 grams per 30 days) tritocin external ointment 3 QL (430 grams per 30 days) *DEPIGMENTING AGENTS*** - DRUGS FOR THE SKIN blanche external cream 1 or 1b* *DEPIGMENTING COMBINATIONS*** - DRUGS FOR THE SKIN TRI-LUMA EXTERNAL CREAM (fluocin-hydroquinone-tretinoin) 3 *EMOLLIENT COMBINATIONS*** - DRUGS FOR THE SKIN LACTIC ACID E EXTERNAL CREAM 3 *EMOLLIENT/KERATOLYTIC AGENTS*** - DRUGS FOR THE SKIN CEROVEL EXTERNAL LOTION (urea) 3 *EMOLLIENTS*** - DRUGS FOR THE SKIN ammonium lactate external cream 1 or 1b* QL (450 grams per 30 days) ammonium lactate external lotion 1 or 1b* LACTIC ACID EXTERNAL LOTION 3 *ENZYMES - TOPICAL*** - DRUGS FOR THE SKIN SANTYL EXTERNAL OINTMENT (collagenase) 3 QL (30 grams per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 115 Coverage Requirements and Prescription Drug Name Drug Tier Limits *GLABELLAR LINES (FROWN LINES) AGENTS*** - DRUGS FOR THE SKIN BOTOX COSMETIC INTRAMUSCULAR SOLUTION 4 PA RECONSTITUTED (onabotulinumtoxina (cosmetic)) *IMIDAZOLE-RELATED ANTIFUNGALS - TOPICAL*** - DRUGS FOR THE SKIN clotrimazole external cream 1 or 1b* QL (1 gram per 1 day) clotrimazole external solution 1 or 1b* QL (60 mL per 30 days) econazole nitrate external cream 1 or 1b* QL (85 grams per 30 days) ECOZA EXTERNAL FOAM (econazole nitrate) 3 ST; QL (70 grams per 30 days) ERTACZO EXTERNAL CREAM (sertaconazole nitrate) 3 ST; QL (60 grams per 30 days) EXELDERM EXTERNAL CREAM (sulconazole nitrate) 3 ST; QL (60 grams per 30 days) EXELDERM EXTERNAL SOLUTION (sulconazole nitrate) 3 ST; QL (60 mL per 30 days) EXTINA EXTERNAL FOAM (ketoconazole) 3 QL (100 grams per 30 days) JUBLIA EXTERNAL SOLUTION (efinaconazole) 3 QL (4 mL per 1 day) ketoconazole external cream 1 or 1b* QL (120 grams per 30 days) ketoconazole external foam 1 or 1b* QL (100 grams per 30 days) ketoconazole external shampoo 1 or 1b* QL (120 mL per 30 days) luliconazole external cream 1 or 1b* ST; QL (60 grams per 30 days) LUZU EXTERNAL CREAM (luliconazole) 3 ST; QL (60 grams per 30 days) oxiconazole nitrate external cream 1 or 1b* QL (60 grams per 30 days) OXISTAT EXTERNAL CREAM (oxiconazole nitrate) 3 ST; QL (60 grams per 30 days) OXISTAT EXTERNAL LOTION (oxiconazole nitrate) 3 ST; QL (60 mL per 30 days) sulconazole nitrate external cream 1 or 1b* ST; QL (60 grams per 30 days) sulconazole nitrate external solution 1 or 1b* ST; QL (60 mL per 30 days) XOLEGEL EXTERNAL GEL (ketoconazole) 3 QL (45 grams per 30 days) *IMMUNOMODULATORS IMIDAZOQUINOLINAMINES - TOPICAL*** - DRUGS FOR THE SKIN ALDARA EXTERNAL CREAM (imiquimod) 3 ST; QL (48 packet per 365 days) imiquimod external cream 3.75 % 1 or 1b* ST; QL (28 units per 28 days) imiquimod external cream 5 % 1 or 1b* QL (48 packet per 365 days) imiquimod pump external cream 1 or 1b* ST; QL (1 pump bottle per 28 days) ZYCLARA EXTERNAL CREAM (imiquimod) 3 ST; QL (28 units per 28 days) ZYCLARA PUMP EXTERNAL CREAM 2.5 % (imiquimod) 3 ST; QL (1 pump bottle per 28 days) ZYCLARA PUMP EXTERNAL CREAM 3.75 % (imiquimod) 3 ST; QL (1 bottle per 28 days) *KERATOLYTIC/ANTIMITOTIC AGENTS*** - DRUGS FOR THE SKIN ACNESIC EXTERNAL GEL (salicylic acid) 3 CONDYLOX EXTERNAL GEL (podofilox) 3 podofilox external solution 1 or 1b* *LOCAL ANESTHETICS - TOPICAL*** - DRUGS FOR THE SKIN glydo external prefilled syringe 1 or 1b* lidocaine external ointment 1 or 1b* QL (5 grams per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 116 Coverage Requirements and Prescription Drug Name Drug Tier Limits lidocaine external patch 1 or 1b* PA; QL (3 patches per 1 day) lidocaine hcl external solution 1 or 1b* QL (10 mL per 1 day) lidocaine hcl urethral/mucosal external gel 1 or 1b* lidocaine hcl urethral/mucosal external prefilled syringe 1 or 1b* QUTENZA (4 PATCH) EXTERNAL KIT (capsaicin-cleansing gel) 3 LD *MACROLIDE IMMUNOSUPPRESSANTS - TOPICAL*** - DRUGS FOR THE SKIN pimecrolimus external cream 1 or 1b* ST; QL (100 grams per 90 days) tacrolimus external ointment 1 or 1b* ST; QL (100 grams per 90 days) *MELANOCORTIN RECEPTOR AGONISTS (UV PROTECTIVE)*** - DRUGS FOR THE SKIN PA; LD; QL (1 implant per 2 SCENESSE SUBCUTANEOUS IMPLANT (afamelanotide acetate) 3 monthss) *MICROTUBULE INHIBITORS - TOPICAL*** - DRUGS FOR THE SKIN KLISYRI EXTERNAL OINTMENT (tirbanibulin) 3 ST; QL (5 packets per 1 fill) *MISC. DERMATOLOGICAL PRODUCTS*** - DRUGS FOR THE SKIN ILIDERM EXTERNAL EMULSION 3 *MISC. TOPICAL*** - DRUGS FOR THE SKIN BORIC ACID EXTERNAL GRANULES 3 QBREXZA EXTERNAL PAD (glycopyrronium tosylate) 3 PA; QL (1 cloth per 1 day) *ORNITHINE DECARBOXYLASE (ODC) INHIBITORS - TOPICAL*** - DRUGS FOR THE SKIN VANIQA EXTERNAL CREAM (eflornithine hcl) 3 *OXABOROLE-RELATED ANTIFUNGALS - TOPICAL*** - DRUGS FOR THE SKIN tavaborole external solution 1 or 1b* ST; QL (1 bottle per 30 days) *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL*** - DRUGS FOR THE SKIN EUCRISA EXTERNAL OINTMENT (crisaborole) 3 ST; QL (100 grams per 30 days) *PHOTODYNAMIC THERAPY AGENTS - TOPICAL*** - DRUGS FOR THE SKIN AMELUZ EXTERNAL GEL (aminolevulinic acid hcl) 3 LEVULAN KERASTICK EXTERNAL SOLUTION RECONSTITUTED 3 (aminolevulinic acid hcl) *PROSTAGLANDINS - TOPICAL*** - DRUGS FOR THE SKIN bimatoprost external solution 1 or 1b* LATISSE EXTERNAL SOLUTION (bimatoprost) 3 *ROSACEA AGENTS*** - DRUGS FOR THE SKIN azelaic acid external gel 1 or 1b* QL (50 grams per 30 days) FINACEA EXTERNAL FOAM (azelaic acid) 2 QL (1.67 grams per 1 day) ivermectin external cream 1 or 1b* QL (45 grams per 30 days) METROCREAM EXTERNAL CREAM (metronidazole) 3 ST; QL (45 grams per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 117 Coverage Requirements and Prescription Drug Name Drug Tier Limits metronidazole external cream 1 or 1b* QL (45 grams per 30 days) metronidazole external gel 0.75 % 1 or 1b* QL (45 grams per 30 days) metronidazole external gel 1 % 1 or 1b* QL (55 grams per 30 days) metronidazole external lotion 1 or 1b* QL (59 mL per 30 days) MIRVASO EXTERNAL GEL (brimonidine tartrate) 3 QL (30 grams per 30 days) NORITATE EXTERNAL CREAM (metronidazole) 3 ST; QL (60 grams per 30 days) RHOFADE EXTERNAL CREAM (oxymetazoline hcl) 3 QL (60 grams per 30 days) rosadan external cream 1 or 1b* QL (45 grams per 30 days) rosadan external gel 1 or 1b* QL (45 grams per 30 days) SOOLANTRA EXTERNAL CREAM (ivermectin) 2 QL (45 grams per 30 days) ZILXI EXTERNAL FOAM (minocycline hcl micronized) 3 ST; QL (1 gram per 1 day) *SCABICIDES & PEDICULICIDES*** - DRUGS FOR THE SKIN crotan external lotion 1 or 1b* QL (60 mL per 30 days) ivermectin external lotion 1 or 1b* QL (120 grams per 30 days) lindane external shampoo 1 or 1b* QL (60 mL per 30 days) malathion external lotion 1 or 1b* QL (4 mL per 1 day) NATROBA EXTERNAL SUSPENSION (spinosad) 3 QL (120 mL per 7 days) OVIDE EXTERNAL LOTION (malathion) 3 QL (4 mL per 1 day) permethrin external cream 1 or 1b* QL (120 grams per 30 days) spinosad external suspension 1 or 1b* QL (120 mL per 7 days) SULFURATED LIME EXTERNAL SOLUTION 3 *SEBORRHEIC KERATOSIS PRODUCTS** - DRUGS FOR THE SKIN ESKATA EXTERNAL SOLUTION (hydrogen peroxide) 3 *STEROID-LOCAL ANESTHETIC COMBINATIONS*** - DRUGS FOR THE SKIN EPIFOAM EXTERNAL FOAM (pramoxine-hc) 3 PRAMOSONE EXTERNAL CREAM (pramoxine-hc) 2 PRAMOSONE EXTERNAL LOTION (pramoxine-hc) 2 *TAR PRODUCTS*** - DRUGS FOR THE SKIN coal tar external solution 1 or 1b* *TISSUE REPLACEMENTS*** - DRUGS FOR THE SKIN AFFINITY EXTERNAL SHEET (amniotic membrane allograft) 3 AMNIOFIX INJECTION SUSPENSION RECONSTITUTED (amniotic 3 membrane allograft) AMNIOTEXT EXTERNAL SHEET (amniotic membrane allograft) 3 AMPHENOL-40 INJECTION SUSPENSION RECONSTITUTED 3 APLIGRAF EXTERNAL DISK (cultured skin substitute) 3 BIOVANCE EXTERNAL SHEET (amniotic membrane allograft) 3 EPICORD EXTERNAL SHEET (umbilical cord allograft) 3 EPIFIX EXTERNAL DISK (amniotic membrane allograft) 3 EPIFIX EXTERNAL SHEET (amniotic membrane allograft) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 118 Coverage Requirements and Prescription Drug Name Drug Tier Limits EPIFIX MICRONIZED INJECTION SUSPENSION RECONSTITUTED 3 (amniotic membrane allograft) KARDIAMEMBRANE EXTERNAL SHEET (amniotic membrane 3 allograft) NEOX 100 EXTERNAL SHEET (amniotic membrane allograft) 3 NEOX CORD 1K EXTERNAL SHEET (amniotic membrane allograft) 3 NOVACHOR EXTERNAL SHEET (chorion membrane allograft) 3 NUSHIELD EXTERNAL DISK (amniotic membrane allograft) 3 NUSHIELD EXTERNAL SHEET (amniotic membrane allograft) 3 PALINGEN FLOW INJECTION INJECTABLE (amniotic memb-fluid 3 allograft) PALINGEN HYDROMEMBRANE EXTERNAL SHEET (amniotic 3 membrane allograft) PALINGEN INOVOFLO INJECTION INJECTABLE (amniotic fluid 3 allograft) PALINGEN MEMBRANE EXTERNAL SHEET (amniotic membrane 3 allograft) PALINGEN XPLUS HYDROMEMBRANE EXTERNAL SHEET 3 (amniotic membrane allograft) PALINGEN XPLUS MEMBRANE EXTERNAL SHEET (amniotic 3 membrane allograft) STRAVIX EXTERNAL SHEET (amniotic membrane allograft) 3 TRUSKIN EXTERNAL SHEET (skin allograft (human)) 3 *TOPICAL ANESTHETIC COMBINATIONS*** - DRUGS FOR THE SKIN CETACAINE EXTERNAL GEL (butamben-tetracaine-benzocaine) 3 FLEXIN EXTERNAL PATCH 3 lidocaine-prilocaine external kit 1 or 1b* QL (1 kit per 30 days) PRILO PATCH II EXTERNAL KIT (lidocaine-prilocaine) 3 REAL HEAL-I EXTERNAL KIT (lidocaine-prilocaine-dressing) 3 VENIPUNCTURE PX1 PHLEBOTOMY EXTERNAL KIT (lidocaine hcl- 3 blood collection) *TOPICAL ANESTHETIC GASES*** - DRUGS FOR THE SKIN CRYODOSE TA EXTERNAL AEROSOL (pentafluoroprop-tetrafluoroeth) 3 *TOPICAL SELECTIVE RETINOID X RECEPTOR AGONISTS*** - DRUGS FOR THE SKIN TARGRETIN EXTERNAL GEL (bexarotene) 2 PA; SP *TOPICAL STEROID COMBINATIONS*** - DRUGS FOR THE SKIN calcipotriene-betameth diprop external ointment 1 or 1b* ST; QL (400 grams per 28 days) calcipotriene-betameth diprop external suspension 1 or 1b* ST; QL (420 grams per 28 days) DUOBRII EXTERNAL LOTION (halobetasol prop-tazarotene) 3 PA; QL (200 grams per 30 days) ENSTILAR EXTERNAL FOAM (calcipotriene-betameth diprop) 3 QL (420 grams per 28 days) TACLONEX EXTERNAL OINTMENT (calcipotriene-betameth diprop) 3 ST; QL (400 grams per 28 days) TACLONEX EXTERNAL SUSPENSION (calcipotriene-betameth diprop) 3 ST; QL (420 grams per 28 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 119 Coverage Requirements and Prescription Drug Name Drug Tier Limits *TYPE II 5-ALPHA REDUCTASE INHIBITORS*** - DRUGS FOR THE SKIN finasteride oral tablet 1 or 1b* PROPECIA ORAL TABLET (finasteride) 3 *WOUND CARE - GROWTH FACTOR AGENTS*** - DRUGS FOR THE SKIN REGRANEX EXTERNAL GEL (becaplermin) 3 *WOUND DRESSINGS*** - DRUGS FOR THE SKIN KENDALL HYDROGEL WOUND DRESS EXTERNAL (hydroactive 3 dressings) TEGADERM AG MESH EXTERNAL PAD (silver) 2 WOUNDGELHA MATRIX EXTERNAL GEL (hyaluronate sodium) 3 *DIAGNOSTIC PRODUCTS* *DIAGNOSTIC TESTS*** ACCU-CHEK AVIVA PLUS IN VITRO STRIP (glucose blood) 2 QL (204 strips per 30 days) ACCU-CHEK COMPACT PLUS IN VITRO STRIP (glucose blood) 2 QL (204 strips per 30 days) ACCU-CHEK GUIDE IN VITRO STRIP (glucose blood) 2 QL (204 strips per 30 days) ACCU-CHEK SMARTVIEW IN VITRO STRIP (glucose blood) 2 QL (204 strips per 30 days) ACCUTREND GLUCOSE IN VITRO STRIP (glucose blood) 2 QL (204 strips per 30 days) ONETOUCH ULTRA IN VITRO STRIP (glucose blood) 2 ST; QL (204 strips per 30 days) ONETOUCH VERIO IN VITRO STRIP (glucose blood) 2 QL (204 strips per 30 days) *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH *DIGESTIVE ENZYMES*** - DRUGS FOR THE STOMACH CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 2 QL (25 capsules per 1 day) (pancrelipase (lip-prot-amyl)) PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 3 ST; QL (25 capsules per 1 day) (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 3 ST; QL (25 capsules per 1 day) (pancrelipase (lip-prot-amyl)) SUCRAID ORAL SOLUTION (sacrosidase) 4 PA; LD; QL (4 bottles per 30 days) VIOKACE ORAL TABLET (pancrelipase (lip-prot-amyl)) 2 QL (25 tablets per 1 day) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 2 QL (25 capsules per 1 day) (pancrelipase (lip-prot-amyl)) *DIURETICS* - DRUGS FOR THE HEART *CARBONIC ANHYDRASE INHIBITORS*** - DRUGS FOR HIGH BLOOD PRESSURE acetazolamide er oral capsule extended release 12 hour 1 or 1b* acetazolamide oral tablet 1 or 1b* acetazolamide sodium injection solution reconstituted 1 or 1b* KEVEYIS ORAL TABLET (dichlorphenamide) 4 PA; LD; QL (4 tablet per 1 day) methazolamide oral tablet 1 or 1b* *DIURETIC COMBINATIONS*** - DRUGS FOR HIGH BLOOD PRESSURE ALDACTAZIDE ORAL TABLET 25-25 MG (spironolactone-hctz) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 120 Coverage Requirements and Prescription Drug Name Drug Tier Limits ALDACTAZIDE ORAL TABLET 50-50 MG (spironolactone-hctz) 3 QL (4 tablets per 1 day) amiloride-hydrochlorothiazide oral tablet 1 or 1b* MAXZIDE ORAL TABLET (triamterene-hctz) 3 MAXZIDE-25 ORAL TABLET (triamterene-hctz) 3 spironolactone-hctz oral tablet 1 or 1b* triamterene-hctz oral capsule 1 or 1a* triamterene-hctz oral tablet 1 or 1a* *LOOP DIURETICS*** - DRUGS FOR HIGH BLOOD PRESSURE bumetanide injection solution 1 or 1b* bumetanide oral tablet 1 or 1b* BUMEX ORAL TABLET (bumetanide) 3 EDECRIN ORAL TABLET (ethacrynic acid) 3 ethacrynate sodium intravenous solution reconstituted 1 or 1b* ethacrynic acid oral tablet 1 or 1b* FUROSEMIDE IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 furosemide injection solution 1 or 1a* furosemide oral solution 1 or 1a* furosemide oral tablet 1 or 1a* LASIX ORAL TABLET (furosemide) 3 SODIUM EDECRIN INTRAVENOUS SOLUTION RECONSTITUTED 3 (ethacrynate sodium) torsemide oral tablet 1 or 1b* *OSMOTIC DIURETICS*** - DRUGS FOR HIGH BLOOD PRESSURE mannitol intravenous solution 1 or 1b* osmitrol intravenous solution 1 or 1b* *POTASSIUM SPARING DIURETICS*** - DRUGS FOR HIGH BLOOD PRESSURE ALDACTONE ORAL TABLET 100 MG (spironolactone) 3 QL (4 tablets per 1 day) ALDACTONE ORAL TABLET 25 MG, 50 MG (spironolactone) 3 amiloride hcl oral tablet 1 or 1b* CAROSPIR ORAL SUSPENSION (spironolactone) 3 QL (20 mL per 1 day) spironolactone oral tablet 100 mg 1 or 1a* QL (4 tablets per 1 day) spironolactone oral tablet 25 mg, 50 mg 1 or 1a* triamterene oral capsule 1 or 1b* *THIAZIDES AND THIAZIDE-LIKE DIURETICS*** - DRUGS FOR HIGH BLOOD PRESSURE chlorothiazide sodium intravenous solution reconstituted 1 or 1b* chlorthalidone oral tablet 1 or 1a* DIURIL ORAL SUSPENSION (chlorothiazide) 3 hydrochlorothiazide oral capsule 1 or 1a* hydrochlorothiazide oral tablet 12.5 mg, 25 mg 1 or 1a* hydrochlorothiazide oral tablet 50 mg 1 or 1a* QL (2 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 121 Coverage Requirements and Prescription Drug Name Drug Tier Limits indapamide oral tablet 1 or 1b* metolazone oral tablet 1 or 1b* SODIUM DIURIL INTRAVENOUS SOLUTION RECONSTITUTED 3 (chlorothiazide sodium) *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES *ABORTIFACIENT - PROGESTERONE RECEPTOR ANTAGONISTS*** - DRUGS FOR WOMEN MIFEPREX ORAL TABLET (mifepristone) 3 mifepristone oral tablet 1 or 1b* *ADENOSINE DEAMINASE SCID TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS REVCOVI INTRAMUSCULAR SOLUTION (elapegademase-lvlr) 4 PA; LD *BISPHOSPHONATES*** - DRUGS FOR MENOPAUSE AND BONE LOSS ACTONEL ORAL TABLET 150 MG (risedronate sodium) 3 QL (1 tablet per 30 days) ACTONEL ORAL TABLET 35 MG (risedronate sodium) 3 QL (4 tablets per 28 days) alendronate sodium oral solution 1 or 1b* QL (10.72 mg per 1 day) alendronate sodium oral tablet 10 mg, 5 mg 1 or 1b* QL (1 tablet per 1 day) alendronate sodium oral tablet 35 mg, 70 mg 1 or 1b* QL (4 tablets per 28 days) ATELVIA ORAL TABLET DELAYED RELEASE (risedronate sodium) 3 QL (4 tablets per 28 days) BINOSTO ORAL TABLET EFFERVESCENT (alendronate sodium) 3 QL (4 tablets per 28 days) BONIVA ORAL TABLET (ibandronate sodium) 3 ST; QL (1 tablet per 28 days) FOSAMAX ORAL TABLET (alendronate sodium) 3 QL (4 tablets per 28 days) FOSAMAX PLUS D ORAL TABLET (alendronate-cholecalciferol) 2 QL (4 tablets per 28 days) ibandronate sodium intravenous solution 1 or 1b* ibandronate sodium oral tablet 1 or 1b* QL (1 tablet per 28 days) pamidronate disodium intravenous solution 30 mg/10ml, 90 mg/10ml 4 SP PAMIDRONATE DISODIUM INTRAVENOUS SOLUTION 6 MG/ML 4 SP RECLAST INTRAVENOUS SOLUTION (zoledronic acid) 4 PA; SP; QL (100 mL per 375 days) risedronate sodium oral tablet 150 mg 1 or 1b* QL (1 tablet per 30 days) risedronate sodium oral tablet 30 mg, 5 mg 1 or 1b* QL (1 tablet per 1 day) risedronate sodium oral tablet 35 mg 1 or 1b* QL (4 tablets per 28 days) risedronate sodium oral tablet delayed release 1 or 1b* QL (4 tablets per 28 days) zoledronic acid intravenous concentrate 1 or 1b* PA; SP ZOLEDRONIC ACID INTRAVENOUS SOLUTION 4 MG/100ML 1 or 1b* PA; SP zoledronic acid intravenous solution 5 mg/100ml 4 PA; SP; QL (100 mL per 375 days) *CALCIMIMETIC AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS cinacalcet hcl oral tablet 30 mg, 60 mg 4 PA; QL (2 tablets per 1 day) cinacalcet hcl oral tablet 90 mg 4 PA; QL (4 tablets per 1 day) PARSABIV INTRAVENOUS SOLUTION (etelcalcetide hcl) 4 PA SENSIPAR ORAL TABLET 30 MG, 60 MG (cinacalcet hcl) 4 PA; QL (2 tablets per 1 day) SENSIPAR ORAL TABLET 90 MG (cinacalcet hcl) 4 PA; QL (4 tablets per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 122 Coverage Requirements and Prescription Drug Name Drug Tier Limits *CALCITONINS*** - DRUGS FOR MENOPAUSE AND BONE LOSS calcitonin (salmon) injection solution 4 calcitonin (salmon) nasal solution 1 or 1b* QL (1 bottle per 30 days) MIACALCIN INJECTION SOLUTION (calcitonin (salmon)) 4 *CARNITINE REPLENISHER - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS CARNITOR INTRAVENOUS SOLUTION (levocarnitine) 3 CARNITOR ORAL SOLUTION (levocarnitine) 3 CARNITOR ORAL TABLET (levocarnitine) 3 CARNITOR SF ORAL SOLUTION (levocarnitine) 3 levocarnitine oral solution 1 or 1b* levocarnitine oral tablet 1 or 1b* levocarnitine sf oral solution 1 or 1b* *CORTICOTROPIN*** - HORMONES ACTHAR INJECTION GEL (corticotropin) 4 PA; LD; SP *CORTISOL SYNTHESIS INHIBITORS*** - HORMONES ISTURISA ORAL TABLET 1 MG, 5 MG (osilodrostat phosphate) 4 PA; LD; QL (4 tablets per 1 day) ISTURISA ORAL TABLET 10 MG (osilodrostat phosphate) 4 PA; LD; QL (6 tablets per 1 day) *DOPAMINE RECEPTOR AGONISTS*** - DRUGS FOR WOMEN cabergoline oral tablet 1 or 1b* QL (16 tablets per 28 days) *FABRY DISEASE - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (agalsidase beta) PA; LD; QL (14 capsules per 30 GALAFOLD ORAL CAPSULE (migalastat hcl) 4 days) *GAA DEFICIENCY TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (alglucosidase alfa) *GNRH/LHRH ANTAGONISTS*** - DRUGS FOR WOMEN CETROTIDE SUBCUTANEOUS KIT (cetrorelix acetate) 4 PA; SP GANIRELIX ACETATE SUBCUTANEOUS SOLUTION PREFILLED 4 PA; SP SYRINGE ORILISSA ORAL TABLET 150 MG (elagolix sodium) 3 PA; QL (1 tablet per 1 day) ORILISSA ORAL TABLET 200 MG (elagolix sodium) 3 PA; QL (2 tablets per 1 day) *GROWTH HORMONE RECEPTOR ANTAGONISTS*** - DRUGS FOR GROWTH SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; SP; QL (1 vial per 1 day) (pegvisomant) *GROWTH HORMONE RELEASING HORMONES (GHRH)*** - DRUGS FOR GROWTH EGRIFTA SV SUBCUTANEOUS SOLUTION RECONSTITUTED PA; LD; QL (1 package per 30 4 (tesamorelin acetate) days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 123 Coverage Requirements and Prescription Drug Name Drug Tier Limits *GROWTH HORMONES*** - DRUGS FOR GROWTH GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION 4 PA; SP; QL (1 syringe per 1 day) RECONSTITUTED (somatropin) GENOTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; SP; QL (1 vial per 1 day) (somatropin) HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 5 4 PA; SP; QL (1 vial per 1 day) MG, 6 MG (somatropin) HUMATROPE INJECTION SOLUTION RECONSTITUTED 24 MG 4 PA; SP; QL (1 injection per 1 day) (somatropin) SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG 4 PA; LD; QL (1 vial per 1 day) (somatropin (non-refrigerated)) SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 5 MG, 6 4 PA; LD; QL (1 solution per 1 day) MG (somatropin (non-refrigerated)) ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; SP; QL (1 injection per 1 day) (somatropin (non-refrigerated)) *HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS** - DRUGS FOR MENOPAUSE AND BONE LOSS XURIDEN ORAL PACKET (uridine triacetate) 3 PA; LD; QL (4 packets per 1 day) *HEREDITARY TYROSINEMIA TYPE 1 (HT-1) TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS nitisinone oral capsule 4 PA; SP NITYR ORAL TABLET (nitisinone) 4 PA; LD ORFADIN ORAL CAPSULE (nitisinone) 4 PA; LD ORFADIN ORAL SUSPENSION (nitisinone) 4 PA; LD *HOMOCYSTINURIA TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS CYSTADANE ORAL POWDER (betaine) 3 LD *HYPERAMMONEMIA TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS CARBAGLU ORAL TABLET (carglumic acid) 4 PA; LD *HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS*** - DRUGS FOR MENOPAUSE AND BONE LOSS calcitriol intravenous solution 1 or 1b* PA calcitriol oral capsule 1 or 1b* PA calcitriol oral solution 1 or 1b* PA doxercalciferol intravenous solution 1 or 1b* PA doxercalciferol oral capsule 1 or 1b* PA HECTOROL INTRAVENOUS SOLUTION (doxercalciferol) 3 PA paricalcitol intravenous solution 1 or 1b* PA paricalcitol oral capsule 1 or 1b* PA RAYALDEE ORAL CAPSULE EXTENDED RELEASE (calcifediol) 3 PA; QL (2 tablets per 1 day) ROCALTROL ORAL CAPSULE (calcitriol) 3 PA ROCALTROL ORAL SOLUTION (calcitriol) 3 PA ZEMPLAR INTRAVENOUS SOLUTION (paricalcitol) 3 PA ZEMPLAR ORAL CAPSULE (paricalcitol) 3 PA * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 124 Coverage Requirements and Prescription Drug Name Drug Tier Limits *HYPOPHOSPHATASIA (HPP) AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS STRENSIQ SUBCUTANEOUS SOLUTION (asfotase alfa) 4 PA; LD *INSULIN-LIKE GROWTH FACTOR-1 RECEPTOR INHIBITORS(IGF-1R)*** - DRUGS FOR THYROID TEPEZZA INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; QL (8 fills per 168 days) (teprotumumab-trbw) *INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)*** - HORMONES INCRELEX SUBCUTANEOUS SOLUTION (mecasermin) 4 PA; LD; SP *LEPTIN ANALOGUES*** - HORMONES MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD (metreleptin) *LHRH/GNRH AGONIST ANALOG COMBINATIONS*** - DRUGS FOR WOMEN LUPANETA PACK COMBINATION KIT 11.25 & 5 MG (leuprolide & 4 PA; SP; QL (1 kit per 84 days) norethindrone) LUPANETA PACK COMBINATION KIT 3.75 & 5 MG (leuprolide & 4 PA; SP; QL (1 kit per 28 days) norethindrone) *LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS*** - DRUGS FOR WOMEN FENSOLVI (6 MONTH) SUBCUTANEOUS KIT (leuprolide acetate (6 PA; LD; SP; QL (1 kit per 24 3 month)) weekss) LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 4 PA; SP; QL (1 kit per 28 days) 15 MG (leuprolide acetate) LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 7.5 MG PA; SP; QL (1 syringe kit per 28 4 (leuprolide acetate) days) LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 11.25 MG 4 PA; SP; QL (1 kit per 12 weekss) (PED) (leuprolide acetate (3 month)) LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 30 MG 4 PA; SP; QL (1 kit per 84 days) (PED) (leuprolide acetate (3 month)) PA; LD; SP; QL (1 kit per 365 SUPPRELIN LA SUBCUTANEOUS KIT (histrelin acetate (cpp)) 4 days) SYNAREL NASAL SOLUTION (nafarelin acetate) 4 PA; SP; QL (5 bottle per 30 days) TRIPTODUR INTRAMUSCULAR SUSPENSION RECONSTITUTED 4 PA; LD; QL (1 vial per 168 days) ER (triptorelin pamoate) *LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS KANUMA INTRAVENOUS SOLUTION (sebelipase alfa) 3 PA; LD; SP *MOLYBDENUM COFACTOR DEFICIENCY (MOCD) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS NULIBRY INTRAVENOUS SOLUTION RECONSTITUTED 4 LD (fosdenopterin hydrobromide) *MUCOPOLYSACCHARIDOSIS I (MPS I) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS ALDURAZYME INTRAVENOUS SOLUTION (laronidase) 4 PA; LD; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 125 Coverage Requirements and Prescription Drug Name Drug Tier Limits *MUCOPOLYSACCHARIDOSIS II (MPS II) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS ELAPRASE INTRAVENOUS SOLUTION (idursulfase) 4 PA; LD; SP *MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS VIMIZIM INTRAVENOUS SOLUTION (elosulfase alfa) 4 PA; LD; SP *MUCOPOLYSACCHARIDOSIS VI (MPS VI) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS NAGLAZYME INTRAVENOUS SOLUTION (galsulfase) 4 PA; LD; SP *MUCOPOLYSACCHARIDOSIS VII (MPS VII) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS MEPSEVII INTRAVENOUS SOLUTION (vestronidase alfa-vjbk) 4 PA; LD *OVULATION STIMULANTS-GONADOTROPINS*** - DRUGS FOR WOMEN CHORIONIC GONADOTROPIN INTRAMUSCULAR SOLUTION 4 PA; SP RECONSTITUTED GONAL-F INJECTION SOLUTION RECONSTITUTED (follitropin alfa) 4 PA; SP GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION (follitropin 4 PA; SP alfa) GONAL-F RFF SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; SP (follitropin alfa) MENOPUR SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; SP (menotropins) NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 4 PA; SP (chorionic gonadotropin) OVIDREL SUBCUTANEOUS INJECTABLE (choriogonadotropin alfa) 4 PA; SP PREGNYL INTRAMUSCULAR SOLUTION RECONSTITUTED 4 PA; SP (chorionic gonadotropin) *OVULATION STIMULANTS-SYNTHETIC*** - DRUGS FOR WOMEN clomiphene citrate oral tablet 1 or 1b* PA *PARATHYROID HORMONE AND DERIVATIVES*** - DRUGS FOR MENOPAUSE AND BONE LOSS FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR (teriparatide 4 SP; QL (1 pen per 28 days) (recombinant)) NATPARA SUBCUTANEOUS CARTRIDGE (parathyroid hormone PA; LD; SP; QL (2 cartridge per 30 3 (recomb)) days) TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS SOLUTION 4 PA; SP; QL (1 pen per 28 days) PEN-INJECTOR *PHENYLKETONURIA TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS KUVAN ORAL PACKET (sapropterin dihydrochloride) 4 PA; LD; SP KUVAN ORAL TABLET (sapropterin dihydrochloride) 4 PA; LD; SP PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 4 PA; LD; SP MG/0.5ML, 2.5 MG/0.5ML (pegvaliase-pqpz) PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 PA; LD; SP; QL (1 syringe per 1 4 MG/ML (pegvaliase-pqpz) day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 126 Coverage Requirements and Prescription Drug Name Drug Tier Limits sapropterin dihydrochloride oral packet 4 PA; SP sapropterin dihydrochloride oral tablet 4 PA; SP *RANK LIGAND (RANKL) INHIBITORS*** - DRUGS FOR MENOPAUSE AND BONE LOSS PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QL (2 injections per 365 3 (denosumab) days) XGEVA SUBCUTANEOUS SOLUTION (denosumab) 3 PA; SP; QL (1 vial per 28 days) *SCLEROSTIN INHIBITORS*** - DRUGS FOR MENOPAUSE AND BONE LOSS EVENITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 30 days) (romosozumab-aqqg) *SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)*** - DRUGS FOR MENOPAUSE AND BONE LOSS EVISTA ORAL TABLET (raloxifene hcl) 3; $0 OSPHENA ORAL TABLET (ospemifene) 3 PA; QL (1 tablet per 1 day) raloxifene hcl oral tablet 1 or 1b*; $0 *SELECTIVE VASOPRESSIN V2-RECEPTOR ANTAGONISTS*** - HORMONES JYNARQUE ORAL TABLET (tolvaptan) 4 PA; LD; QL (4 tablets per 1 day) JYNARQUE ORAL TABLET THERAPY PACK (tolvaptan) 4 PA; LD; QL (1 carton per 28 days) SAMSCA ORAL TABLET 15 MG (tolvaptan) 3 PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 SAMSCA ORAL TABLET 30 MG (tolvaptan) 3 day) tolvaptan oral tablet 15 mg 1 or 1b* PA; QL (1 tablet per 1 day) tolvaptan oral tablet 30 mg 1 or 1b* PA; QL (2 tablets per 1 day) *SOMATOSTATIC AGENTS*** - DRUGS FOR GROWTH MYCAPSSA ORAL CAPSULE DELAYED RELEASE (octreotide acetate) 4 PA; LD; QL (4 capsules per 1 day) octreotide acetate injection solution 4 PA; SP SANDOSTATIN INJECTION SOLUTION (octreotide acetate) 4 PA; SP SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 30 MG 4 PA; SP; QL (1 kit per 28 days) (octreotide acetate) SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 20 MG 4 PA; SP; QL (2 kits per 28 days) (octreotide acetate) SIGNIFOR LAR INTRAMUSCULAR SUSPENSION 4 PA; LD; QL (1 kit per 28 days) RECONSTITUTED ER (pasireotide pamoate) SIGNIFOR SUBCUTANEOUS SOLUTION (pasireotide diaspartate) 4 PA; LD; QL (2 mL per 1 day) SOMATULINE DEPOT SUBCUTANEOUS SOLUTION (lanreotide PA; LD; SP; QL (1 syringe/vial per 4 acetate) 28 days) *UREA CYCLE DISORDER - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS AMMONUL INTRAVENOUS SOLUTION (sod benz-sod phenylacet) 3 BUPHENYL ORAL POWDER (sodium phenylbutyrate) 3 PA; LD; QL (25 GM per 1 day) BUPHENYL ORAL TABLET (sodium phenylbutyrate) 3 PA; LD; QL (40 tablets per 1 day) CITRULLINE EASY ORAL TABLET EXTENDED RELEASE 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 127 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; LD; SP; QL (17.5 mL per 1 RAVICTI ORAL LIQUID (glycerol phenylbutyrate) 3 day) sod benz-sod phenylacet intravenous solution 1 or 1b* sodium phenylbutyrate oral powder 1 or 1b* PA; QL (25 GM per 1 day) sodium phenylbutyrate oral tablet 1 or 1b* PA; QL (40 tablets per 1 day) *V1A/V2-ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS*** - HORMONES VAPRISOL INTRAVENOUS SOLUTION (conivaptan hcl in dextrose) 3 *VASOPRESSIN*** - HORMONES DDAVP INJECTION SOLUTION (desmopressin acetate) 3 DDAVP ORAL TABLET 0.1 MG (desmopressin acetate) 3 DDAVP ORAL TABLET 0.2 MG (desmopressin acetate) 3 QL (6 tablets per 1 day) DDAVP PF INJECTION SOLUTION (desmopressin acetate) 3 desmopressin ace spray refrig nasal solution 1 or 1b* desmopressin acetate injection solution 1 or 1b* desmopressin acetate oral tablet 0.1 mg 1 or 1b* desmopressin acetate oral tablet 0.2 mg 1 or 1b* QL (6 tablets per 1 day) desmopressin acetate pf injection solution 1 or 1b* desmopressin acetate spray nasal solution 1 or 1b* NOCDURNA SUBLINGUAL TABLET SUBLINGUAL (desmopressin 4 PA; QL (1 tablet per 1 day) acetate) STIMATE NASAL SOLUTION (desmopressin acetate) 3 PA; QL (5 mL per 30 days) VASOSTRICT INTRAVENOUS SOLUTION (vasopressin) 3 *X-LINKED HYPOPHOSPHATEMIA (XLH) TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS CRYSVITA SUBCUTANEOUS SOLUTION (burosumab-twza) 4 PA; LD; SP *ESTROGENS* - HORMONES *ESTROGEN & ANDROGEN*** - DRUGS FOR WOMEN est estrogens-methyltest oral tablet 1 or 1b* *ESTROGEN & PROGESTIN*** - DRUGS FOR WOMEN ACTIVELLA ORAL TABLET (estradiol-norethindrone acet) 3 amabelz oral tablet 1 or 1b* ANGELIQ ORAL TABLET (drospirenone-estradiol) 3 BIJUVA ORAL CAPSULE (estradiol-progesterone) 2 QL (1 capsule per 1 day) CLIMARA PRO TRANSDERMAL PATCH WEEKLY (estradiol- 2 QL (4 patch per 28 days) levonorgestrel) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY (estradiol- 2 QL (8 patch per 28 days) norethindrone acet) estradiol-norethindrone acet oral tablet 1 or 1b* FEMHRT ORAL TABLET (norethindrone-eth estradiol) 3 fyavolv oral tablet 1 or 1b* jinteli oral tablet 1 or 1b* mimvey oral tablet 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 128 Coverage Requirements and Prescription Drug Name Drug Tier Limits norethindrone-eth estradiol oral tablet 1 or 1b* PREFEST ORAL TABLET (estradiol-norgestimate) 3 PREMPHASE ORAL TABLET (conj estrog-medroxyprogest ace) 2 PREMPRO ORAL TABLET (conj estrog-medroxyprogest ace) 2 *ESTROGEN-PROGESTIN-GNRH ANTAGONIST*** - DRUGS FOR WOMAN ORIAHNN ORAL CAPSULE THERAPY PACK (elagolix-estradiol- 3 PA; QL (1 carton per 28 days) norethind) *ESTROGENS*** - DRUGS FOR WOMEN ALORA TRANSDERMAL PATCH TWICE WEEKLY (estradiol) 3 QL (8 patch per 28 days) CLIMARA TRANSDERMAL PATCH WEEKLY (estradiol) 3 QL (4 patches per 28 days) DELESTROGEN INTRAMUSCULAR OIL (estradiol valerate) 3 DEPO-ESTRADIOL INTRAMUSCULAR OIL (estradiol cypionate) 3 DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 2 QL (1 packet per 1 day) MG/0.75GM, 1 MG/GM (estradiol) DIVIGEL TRANSDERMAL GEL 1.25 MG/1.25GM (estradiol) 2 QL (30 packets per 30 days) dotti transdermal patch twice weekly 1 or 1b* QL (8 patch per 28 days) ELESTRIN TRANSDERMAL GEL (estradiol) 3 QL (1 pump per 30 days) ESTRADIOL IMPLANT PELLET 3 estradiol oral tablet 1 or 1b* estradiol transdermal patch twice weekly 1 or 1b* QL (8 patch per 28 days) estradiol transdermal patch weekly 1 or 1b* QL (4 patches per 28 days) estradiol valerate intramuscular oil 1 or 1b* ESTROGEL TRANSDERMAL GEL (estradiol) 3 QL (1 pump per 30 days) EVAMIST TRANSDERMAL SOLUTION (estradiol) 2 QL (2 bottles per 30 days) lyllana transdermal patch twice weekly 1 or 1b* QL (8 patch per 28 days) MENEST ORAL TABLET (esterified estrogens) 2 MENOSTAR TRANSDERMAL PATCH WEEKLY (estradiol) 3 QL (4 patch per 28 days) PREMARIN INJECTION SOLUTION RECONSTITUTED (estrogens 2 conjugated) PREMARIN ORAL TABLET (estrogens conjugated) 2 QL (1 tablet per 1 day) *ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB*** - DRUGS FOR WOMEN DUAVEE ORAL TABLET (conj estrogens-bazedoxifene) 3 PA; QL (1 tablet per 1 day) *FLUOROQUINOLONES* - DRUGS FOR INFECTIONS *FLUOROQUINOLONES*** - ANTIBIOTICS BAXDELA INTRAVENOUS SOLUTION RECONSTITUTED 3 (delafloxacin meglumine) BAXDELA ORAL TABLET (delafloxacin meglumine) 3 PA; QL (28 tablets per 30 days) CIPRO ORAL SUSPENSION RECONSTITUTED (ciprofloxacin) 3 QL (3 bottle per 30 days) CIPRO ORAL TABLET (ciprofloxacin hcl) 3 QL (28 tablets per 30 days) ciprofloxacin hcl oral tablet 1 or 1b* QL (28 tablets per 30 days) ciprofloxacin in d5w intravenous solution 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 129 Coverage Requirements and Prescription Drug Name Drug Tier Limits levofloxacin in d5w intravenous solution 1 or 1b* levofloxacin intravenous solution 1 or 1b* levofloxacin oral solution 1 or 1b* QL (480 mL per 30 days) levofloxacin oral tablet 1 or 1b* QL (14 tablets per 30 days) moxifloxacin hcl in nacl intravenous solution 1 or 1b* MOXIFLOXACIN HCL INTRAVENOUS SOLUTION 3 moxifloxacin hcl oral tablet 1 or 1b* QL (21 tablet per 30 days) ofloxacin oral tablet 1 or 1b* QL (28 tablet per 30 days) *GASTROINTESTINAL AGENTS - MISC.* - DRUGS FOR THE STOMACH *BILE ACID SYNTHESIS DISORDER AGENTS*** - DRUGS FOR THE STOMACH CHOLBAM ORAL CAPSULE (cholic acid) 3 PA; LD; QL (4 capsule per 1 day) *FARNESOID X RECEPTOR (FXR) AGONISTS*** - DRUGS FOR THE STOMACH OCALIVA ORAL TABLET (obeticholic acid) 4 PA; LD; SP; QL (1 tablet per 1 day) *GALLSTONE SOLUBILIZING AGENTS*** - DRUGS FOR THE STOMACH CHENODAL ORAL TABLET (chenodiol) 3 PA; LD; QL (7 tablets per 1 day) URSO 250 ORAL TABLET (ursodiol) 3 URSO FORTE ORAL TABLET (ursodiol) 3 ursodiol oral capsule 1 or 1b* ursodiol oral tablet 1 or 1b* *GASTROINTESTINAL ANTIALLERGY AGENTS*** - DRUGS FOR THE STOMACH cromolyn sodium oral concentrate 1 or 1b* GASTROCROM ORAL CONCENTRATE (cromolyn sodium) 3 *GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS*** - DRUGS FOR IRRITABLE BOWEL SYNDROME lubiprostone oral capsule 1 or 1b* QL (2 capsules per 1 day) *GASTROINTESTINAL STIMULANTS*** - DRUGS FOR THE STOMACH DEXPANTHENOL INJECTION SOLUTION 3 GIMOTI NASAL SOLUTION (metoclopramide hcl) 3 PA; QL (1 bottle per 4 weekss) metoclopramide hcl injection solution 1 or 1a* metoclopramide hcl oral solution 1 or 1a* QL (60 mL per 1 day) metoclopramide hcl oral tablet 10 mg 1 or 1a* QL (6 tablets per 1 day) metoclopramide hcl oral tablet 5 mg 1 or 1a* QL (12 tablets per 1 day) METOCLOPRAMIDE HCL ORAL TABLET DISPERSIBLE 10 MG 3 ST; QL (6 tablets per 1 day) metoclopramide hcl oral tablet dispersible 5 mg 1 or 1a* ST; QL (12 tablets per 1 day) REGLAN ORAL TABLET 10 MG (metoclopramide hcl) 3 QL (6 tablets per 1 day) REGLAN ORAL TABLET 5 MG (metoclopramide hcl) 3 QL (12 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 130 Coverage Requirements and Prescription Drug Name Drug Tier Limits *GLUCAGON-LIKE PEPTIDE-2 (GLP-2) ANALOGS*** - DRUGS FOR THE STOMACH GATTEX SUBCUTANEOUS KIT (teduglutide (rdna)) 3 PA; LD; SP *IBS AGENT - GUANYLATE CYCLASE-C (GC-C) AGONISTS*** - DRUGS FOR CONSTIPATION LINZESS ORAL CAPSULE (linaclotide) 2 QL (1 capsule per 1 day) *IBS AGENT - MU-OPIOID RECEPTOR AGONISTS*** - DRUGS FOR IRRITABLE BOWEL SYNDROME VIBERZI ORAL TABLET (eluxadoline) 2 QL (2 tablets per 1 day) *IBS AGENT - SELECTIVE 5-HT3 RECEPTOR ANTAGONISTS*** - DRUGS FOR IRRITABLE BOWEL SYNDROME alosetron hcl oral tablet 1 or 1b* PA; QL (2 tablets per 1 day) LOTRONEX ORAL TABLET (alosetron hcl) 3 PA; QL (2 tablets per 1 day) *INFLAMMATORY BOWEL AGENTS*** - DRUGS FOR INFLAMMATORY BOWEL DISEASE APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 ST; QL (4 capsule per 1 day) (mesalamine) AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 QL (8 tablet per 1 day) (sulfasalazine) AZULFIDINE ORAL TABLET (sulfasalazine) 3 QL (8 tablet per 1 day) balsalazide disodium oral capsule 1 or 1b* QL (9 capsule per 1 day) CANASA RECTAL SUPPOSITORY (mesalamine) 3 QL (1 suppository per 1 day) DELZICOL ORAL CAPSULE DELAYED RELEASE (mesalamine) 3 ST; QL (6 tablets per 1 day) DIPENTUM ORAL CAPSULE (olsalazine sodium) 3 ST; QL (4 capsule per 1 day) mesalamine er oral capsule extended release 24 hour 1 or 1b* QL (4 capsules per 1 day) mesalamine oral capsule delayed release 1 or 1b* QL (6 tablets per 1 day) mesalamine oral tablet delayed release 1.2 gm 1 or 1b* QL (4 tablets per 1 day) mesalamine oral tablet delayed release 800 mg 1 or 1b* QL (6 tablet per 1 day) mesalamine rectal enema 1 or 1b* QL (60 mL per 1 day) mesalamine rectal suppository 1 or 1b* QL (1 suppository per 1 day) mesalamine-cleanser rectal kit 1 or 1b* QL (1 kit per 28 days) PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG 2 QL (16 capsule per 1 day) (mesalamine) PENTASA ORAL CAPSULE EXTENDED RELEASE 500 MG 2 QL (8 capsule per 1 day) (mesalamine) ROWASA RECTAL KIT (mesalamine-cleanser) 3 QL (1 kit per 28 days) SFROWASA RECTAL ENEMA (mesalamine) 3 QL (60 mL per 1 day) sulfasalazine oral tablet 1 or 1b* QL (8 tablet per 1 day) sulfasalazine oral tablet delayed release 1 or 1b* QL (8 tablet per 1 day) *INTEGRIN RECEPTOR ANTAGONISTS*** - DRUGS FOR INFLAMMATORY BOWEL DISEASE ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP; QL (1 vial per 56 days) (vedolizumab)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 131 Coverage Requirements and Prescription Drug Name Drug Tier Limits *INTERLEUKIN ANTAGONISTS*** - DRUGS FOR INFLAMMATORY BOWEL DISEASE PA; LD; SP; QL (4 vial per 365 STELARA INTRAVENOUS SOLUTION (ustekinumab) 4 days) *INTESTINAL ACIDIFIERS*** - DRUGS FOR THE STOMACH enulose oral solution 1 or 1b* generlac oral solution 1 or 1b* lactulose encephalopathy oral solution 1 or 1b* *PERIPHERAL OPIOID RECEPTOR ANTAGONISTS*** - DRUGS FOR THE STOMACH alvimopan oral capsule 1 or 1b* ENTEREG ORAL CAPSULE (alvimopan) 3 MOVANTIK ORAL TABLET (naloxegol oxalate) 2 QL (1 tablet per 1 day) RELISTOR ORAL TABLET (methylnaltrexone bromide) 3 ST; QL (3 tablets per 1 day) RELISTOR SUBCUTANEOUS SOLUTION (methylnaltrexone bromide) 3 ST; QL (1 syringe per 1 day) SYMPROIC ORAL TABLET (naldemedine tosylate) 3 ST; QL (1 tablet per 1 day) *PHOSPHATE BINDER AGENTS*** - DRUGS FOR THE STOMACH AURYXIA ORAL TABLET (ferric citrate) 3 ST; QL (9 tablets per 1 day) calcium acetate (phos binder) oral capsule 1 or 1b* QL (12 capsules per 1 day) calcium acetate (phos binder) oral tablet 1 or 1b* QL (12 tablets per 1 day) calcium acetate oral tablet 1 or 1b* QL (12 tablets per 1 day) FOSRENOL ORAL PACKET (lanthanum carbonate) 3 ST; QL (3 stick packs per 1 day) FOSRENOL ORAL TABLET CHEWABLE (lanthanum carbonate) 3 ST; QL (3 tablets per 1 day) lanthanum carbonate oral tablet chewable 1 or 1b* QL (3 tablets per 1 day) PHOSLYRA ORAL SOLUTION (calcium acetate (phos binder)) 3 ST; QL (60 mL per 1 day) RENVELA ORAL PACKET 0.8 GM (sevelamer carbonate) 3 ST; QL (6 packets per 1 day) RENVELA ORAL PACKET 2.4 GM (sevelamer carbonate) 3 ST; QL (3 packets per 1 day) RENVELA ORAL TABLET (sevelamer carbonate) 3 ST; QL (9 tablets per 1 day) sevelamer carbonate oral packet 0.8 gm 1 or 1b* QL (6 packets per 1 day) sevelamer carbonate oral packet 2.4 gm 1 or 1b* QL (3 packets per 1 day) sevelamer carbonate oral tablet 1 or 1b* QL (9 tablets per 1 day) sevelamer hcl oral tablet 400 mg 1 or 1b* QL (15 tablets per 1 day) sevelamer hcl oral tablet 800 mg 1 or 1b* QL (9 tablets per 1 day) VELPHORO ORAL TABLET CHEWABLE (sucroferric oxyhydroxide) 2 QL (3 tablets per 1 day) *TRYPTOPHAN HYDROXYLASE INHIBITORS*** - DRUGS FOR DIARRHEA XERMELO ORAL TABLET (telotristat etiprate) 4 PA; LD; QL (3 tablets per 1 day) *TUMOR NECROSIS FACTOR ALPHA BLOCKERS*** - DRUGS FOR INFLAMMATORY BOWEL DISEASE INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (infliximab-dyyb) REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (infliximab)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 132 Coverage Requirements and Prescription Drug Name Drug Tier Limits *GENERAL ANESTHETICS* - DRUGS FOR PAIN AND FEVER *ANESTHETICS - MISC.*** - DRUGS FOR SEDATION AMIDATE INTRAVENOUS SOLUTION (etomidate) 3 ANESTHESIA S/I-40A INTRAVENOUS KIT 3 ANESTHESIA S/I-40H INTRAVENOUS KIT 3 ANESTHESIA S/I-40S INTRAVENOUS KIT 3 DIPRIVAN INTRAVENOUS EMULSION (propofol) 3 etomidate intravenous solution 1 or 1b* fresenius propoven intravenous emulsion 1 or 1b* KETALAR INJECTION SOLUTION (ketamine hcl) 3 ketamine hcl injection solution 1 or 1b* KETAMINE HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE propofol intravenous emulsion 1 or 1b* propofol-lipuro intravenous emulsion 1 or 1b* *BARBITURATE ANESTHETICS*** - DRUGS FOR SEDATION BREVITAL SODIUM INJECTION SOLUTION RECONSTITUTED 3 (methohexital sodium) METHOHEXITAL SODIUM INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE *VOLATILE ANESTHETICS*** - DRUGS FOR SEDATION desflurane inhalation solution 1 or 1b* FORANE INHALATION SOLUTION (isoflurane) 3 isoflurane inhalation solution 1 or 1b* sevoflurane inhalation solution 1 or 1b* SUPRANE INHALATION SOLUTION (desflurane) 3 terrell inhalation solution 1 or 1b* ULTANE INHALATION SOLUTION (sevoflurane) 3 *GENITOURINARY AGENTS - MISCELLANEOUS* - DRUGS FOR THE URINARY SYSTEM *5-ALPHA REDUCTASE INHIBITORS*** - DRUGS FOR THE PROSTATE dutasteride oral capsule 1 or 1b* QL (1 capsule per 1 day) finasteride oral tablet 1 or 1b* QL (1 tablet per 1 day) PROSCAR ORAL TABLET (finasteride) 3 QL (1 tablet per 1 day) *ALPHA 1-ADRENOCEPTOR ANTAGONISTS*** - DRUGS FOR THE PROSTATE alfuzosin hcl er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (1 tablet per 1 day) (doxazosin mesylate) silodosin oral capsule 1 or 1b* QL (1 capsule per 1 day) tamsulosin hcl oral capsule 1 or 1b* QL (2 capsules per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 133 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTI-INFECTIVE GENITOURINARY IRRIGANTS*** - DRUGS FOR THE URINARY SYSTEM neomycin-polymyxin b gu irrigation solution 1 or 1b* *CITRATES*** - DRUGS FOR INFECTIONS pot & sod cit-cit ac oral solution 1 or 1b* potassium citrate er oral tablet extended release 1 or 1b* UROCIT-K 10 ORAL TABLET EXTENDED RELEASE (potassium 3 citrate) UROCIT-K 15 ORAL TABLET EXTENDED RELEASE (potassium 3 citrate) UROCIT-K 5 ORAL TABLET EXTENDED RELEASE (potassium citrate) 3 *CYSTINOSIS AGENTS*** - DRUGS FOR THE URINARY SYSTEM CYSTAGON ORAL CAPSULE (cysteamine bitartrate) 4 LD; SP PROCYSBI ORAL CAPSULE DELAYED RELEASE (cysteamine 4 ST; LD bitartrate) PROCYSBI ORAL PACKET (cysteamine bitartrate) 4 ST; LD *GENITOURINARY IRRIGANTS*** - DRUGS FOR THE URINARY SYSTEM acetic acid irrigation solution 1 or 1b* aminoacetic acid irrigation solution 1 or 1b* argyle sterile saline irrigation solution 1 or 1b* curity sterile saline irrigation solution 1 or 1b* glycine irrigation solution 1 or 1b* glycine urologic irrigation solution 1 or 1b* RENACIDIN IRRIGATION SOLUTION (citric ac-gluconolact-mg carb) 3 RESECTISOL IRRIGATION SOLUTION (mannitol (gu irrigant)) 3 sodium chloride irrigation solution 1 or 1b* SORBITOL IRRIGATION SOLUTION 3 SORBITOL-MANNITOL IRRIGATION SOLUTION 3 *INTERSTITIAL CYSTITIS AGENTS*** - DRUGS FOR THE URINARY SYSTEM ELMIRON ORAL CAPSULE (pentosan polysulfate sodium) 3 QL (3 capsules per 1 day) RIMSO-50 INTRAVESICAL SOLUTION (dimethyl sulfoxide) 3 *PHOSPHATES*** - DRUGS FOR INFECTIONS K-PHOS NO 2 ORAL TABLET (pot & sod ac phosphates) 3 *PROSTATIC HYPERTROPHY AGENT COMBINATIONS*** - DRUGS FOR THE PROSTATE dutasteride-tamsulosin hcl oral capsule 1 or 1b* QL (1 capsule per 1 day) JALYN ORAL CAPSULE (dutasteride-tamsulosin hcl) 3 QL (1 capsule per 1 day) *SMALL INTERFERING RIBONUCLEIC ACID AGENTS (SIRNA)*** - DRUGS FOR THE URINARY SYSTEM OXLUMO SUBCUTANEOUS SOLUTION (lumasiran sodium) 4 PA; LD

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 134 Coverage Requirements and Prescription Drug Name Drug Tier Limits *URINARY STONE AGENTS*** - DRUGS FOR THE URINARY SYSTEM LITHOSTAT ORAL TABLET (acetohydroxamic acid) 3 THIOLA EC ORAL TABLET DELAYED RELEASE 100 MG (tiopronin) 3 PA; LD; QL (10 tablet per 1 day) THIOLA EC ORAL TABLET DELAYED RELEASE 300 MG (tiopronin) 3 PA; LD; QL (3 tablet per 1 day) THIOLA ORAL TABLET (tiopronin) 3 PA; LD; QL (10 tablet per 1 day) tiopronin oral tablet 1 or 1b* PA; QL (10 tablet per 1 day) *VESICOURETERAL REFLUX (VUR) AGENT COMBINATIONS*** - DRUGS FOR THE URINARY SYSTEM DEFLUX INJECTION PREFILLED SYRINGE (dextranomer-hyaluronic 3 acid) *GOUT AGENTS* - DRUGS FOR PAIN AND FEVER *GOUT AGENT COMBINATIONS*** - GOUT DRUGS colchicine-probenecid oral tablet 1 or 1b* *GOUT AGENTS*** - GOUT DRUGS allopurinol oral tablet 1 or 1a* allopurinol sodium intravenous solution reconstituted 1 or 1b* ALOPRIM INTRAVENOUS SOLUTION RECONSTITUTED 3 (allopurinol sodium) colchicine oral tablet 2 QL (2.3 tablet per 1 day) febuxostat oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) GLOPERBA ORAL SOLUTION (colchicine) 3 ST; QL (2 bottles per 30 days) PA; LD; SP; QL (0.08 mL per 1 KRYSTEXXA INTRAVENOUS SOLUTION (pegloticase) 4 day) ZYLOPRIM ORAL TABLET (allopurinol) 3 *URICOSURICS*** - GOUT DRUGS probenecid oral tablet 1 or 1b* *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD *AMINOLEVULINATE SYNTHASE 1-DIRECTED SIRNA*** - DRUGS FOR THE BLOOD GIVLAARI SUBCUTANEOUS SOLUTION (givosiran sodium) 4 PA; LD *ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE BLOOD HEMLIBRA SUBCUTANEOUS SOLUTION (emicizumab-kxwh) 4 PA; LD; SP *ANTIHEMOPHILIC PRODUCTS*** - DRUGS TO PREVENT BLEEDING ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophil factor (rahf-pfm)) ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP AFSTYLA INTRAVENOUS KIT (antihemophil fact single chain) 4 PA; LD; SP ALPHANATE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophilic factor-vwf) ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor ix)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 135 Coverage Requirements and Prescription Drug Name Drug Tier Limits ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor ix (rfixfc)) BENEFIX INTRAVENOUS KIT (coagulation factor ix (recomb)) 4 PA; LD; SP COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor x (human)) CORIFACT INTRAVENOUS KIT (factor xiii concentrate human) 4 PA; LD; SP ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED (antihem 4 PA; LD; SP fact (bdd-rfviiifc)) ESPEROCT INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemoph fact rcmb gpeg-exei) FEIBA INTRAVENOUS SOLUTION RECONSTITUTED (antiinhibitor 4 PA; LD; SP coagulant cmplx) FIBRYGA INTRAVENOUS SOLUTION RECONSTITUTED (fibrinogen 4 PA; LD concentrate (human)) HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophilic factor) HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophilic factor-vwf) IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor ix (rix-fp)) IXINITY INTRAVENOUS SOLUTION RECONSTITUTED (coagulation 4 PA; LD; SP factor ix (recomb)) JIVI INTRAVENOUS SOLUTION RECONSTITUTED (ahf (bdd-rfviii 4 PA; LD; SP peg-aucl)) KCENTRA INTRAVENOUS KIT (prothrombin complex conc human) 3 KOATE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophilic factor) KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophilic factor) KOGENATE FS INTRAVENOUS KIT (antihem factor recomb (rfviii)) 4 PA; LD; SP KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophil factor (rahf-pfm)) MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor ix) NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 4 LD; SP (antihemophil fact bd truncated) NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor viia recomb) NUWIQ INTRAVENOUS KIT (antihem fact (bdd-rfviii,sim)) 4 PA; LD; SP NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED (antihem fact 4 PA; LD; SP (bdd-rfviii,sim)) OBIZUR INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED (factor 4 PA; LD; SP ix complex) REBINYN INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor ix glycopeg)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 136 Coverage Requirements and Prescription Drug Name Drug Tier Limits RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihem factor recomb (rfviii)) RIASTAP INTRAVENOUS SOLUTION RECONSTITUTED (fibrinogen 3 PA; LD concentrate (human)) RIXUBIS INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP SEVENFACT INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor viia-jncw) TRETTEN INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor xiii a-sub) VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED (von 4 PA; LD; SP willebrand factor (recomb)) WILATE INTRAVENOUS KIT (antihemophilic factor-vwf) 4 PA; LD; SP XYNTHA INTRAVENOUS KIT (antihem fact (bdd-rfviii,mor)) 4 PA; LD; SP XYNTHA SOLOFUSE INTRAVENOUS KIT (antihem fact (bdd- 4 PA; LD; SP rfviii,mor)) *ANTI-VON WILLEBRAND FACTOR AGENTS*** - DRUGS FOR THE BLOOD CABLIVI INJECTION KIT (caplacizumab-yhdp) 4 PA; LD *BRADYKININ B2 RECEPTOR ANTAGONISTS*** - DRUGS FOR THE BLOOD PA; LD; SP; QL (24 syringes per 30 FIRAZYR SUBCUTANEOUS SOLUTION (icatibant acetate) 4 days) PA; SP; QL (24 syringes per 30 icatibant acetate subcutaneous solution 4 days) *C1 INHIBITORS*** - DRUGS FOR THE BLOOD PA; LD; SP; QL (24 vials per 30 BERINERT INTRAVENOUS KIT (c1 esterase inhibitor (human)) 4 days) CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED (c1 esterase PA; LD; SP; QL (20 vials per 30 4 inhibitor (human)) days) HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 2000 PA; LD; SP; QL (24 vials per 28 4 UNIT (c1 esterase inhibitor (human)) days) HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 3000 PA; LD; SP; QL (16 vials per 28 4 UNIT (c1 esterase inhibitor (human)) days) RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED (c1 PA; LD; SP; QL (16 vials per 30 4 esterase inhibitor (recomb)) days) *COMPLEMENT INHIBITORS*** - DRUGS FOR THE BLOOD EMPAVELI SUBCUTANEOUS SOLUTION (pegcetacoplan) 4 PA; LD; QL (9 vials per 28 days) SOLIRIS INTRAVENOUS SOLUTION (eculizumab) 4 PA; LD; SP ULTOMIRIS INTRAVENOUS SOLUTION 1100 MG/11ML PA; LD; SP; QL (3 vials per 56 4 (ravulizumab-cwvz) days) ULTOMIRIS INTRAVENOUS SOLUTION 300 MG/3ML (ravulizumab- PA; LD; SP; QL (12 vials per 56 4 cwvz) days) *DIRECT-ACTING P2Y12 INHIBITORS*** - DRUGS FOR THE BLOOD BRILINTA ORAL TABLET (ticagrelor) 2 QL (2 tablets per 1 day) KENGREAL INTRAVENOUS SOLUTION RECONSTITUTED 3 (cangrelor tetrasodium) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 137 Coverage Requirements and Prescription Drug Name Drug Tier Limits *GLYCOPROTEIN IIB/IIIA RECEPTOR INHIBITORS*** - DRUGS FOR THE BLOOD AGGRASTAT INTRAVENOUS CONCENTRATE (tirofiban hcl) 3 AGGRASTAT INTRAVENOUS SOLUTION (tirofiban hcl in nacl) 3 eptifibatide intravenous solution 1 or 1b* *HEMATORHEOLOGIC AGENTS*** - DRUGS FOR THE BLOOD pentoxifylline er oral tablet extended release 1 or 1b* *HEMIN*** - DRUGS FOR THE BLOOD PANHEMATIN INTRAVENOUS SOLUTION RECONSTITUTED 3 (hemin) *HUMAN PROTEIN C*** - DRUGS FOR THE BLOOD CEPROTIN INTRAVENOUS SOLUTION RECONSTITUTED (protein c 4 LD; SP concentrate (human)) *PHOSPHODIESTERASE III INHIBITORS*** - DRUGS FOR THE BLOOD cilostazol oral tablet 1 or 1b* *PLASMA EXPANDERS*** - DRUGS FOR THE BLOOD HESPAN INTRAVENOUS SOLUTION (hetastarch-nacl) 3 hetastarch-nacl intravenous solution 1 or 1b* HEXTEND INTRAVENOUS SOLUTION (hetastarch in lact electrolyte) 3 lmd in d5w intravenous solution 1 or 1b* lmd in nacl intravenous solution 1 or 1b* *PLASMA KALLIKREIN INHIBITORS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE BLOOD PA; LD; SP; QL (1 syringe per 28 TAKHZYRO SUBCUTANEOUS SOLUTION (lanadelumab-flyo) 4 days) *PLASMA KALLIKREIN INHIBITORS*** - DRUGS FOR THE BLOOD PA; LD; SP; QL (48 vials per 30 KALBITOR SUBCUTANEOUS SOLUTION (ecallantide) 4 days) ORLADEYO ORAL CAPSULE (berotralstat hcl) 4 PA; LD; QL (1 capsule per 1 day) *PLASMA PROTEINS*** - DRUGS FOR THE BLOOD ALBUKED 25 INTRAVENOUS SOLUTION (albumin human) 3 ALBUKED 5 INTRAVENOUS SOLUTION (albumin human) 3 ALBUMIN HUMAN INTRAVENOUS SOLUTION 3 ALBUMINEX INTRAVENOUS SOLUTION (albumin human-kjda) 3 ALBUMIN-ZLB INTRAVENOUS SOLUTION 3 ALBURX INTRAVENOUS SOLUTION 3 ALBUTEIN INTRAVENOUS SOLUTION (albumin human) 3 FLEXBUMIN INTRAVENOUS SOLUTION (albumin human) 3 HUMAN ALBUMIN GRIFOLS INTRAVENOUS SOLUTION (albumin 3 human) KEDBUMIN INTRAVENOUS SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 138 Coverage Requirements and Prescription Drug Name Drug Tier Limits OCTAPLAS BLOOD GROUP A INTRAVENOUS SOLUTION (plasma 3 human) OCTAPLAS BLOOD GROUP AB INTRAVENOUS SOLUTION (plasma 3 human) OCTAPLAS BLOOD GROUP B INTRAVENOUS SOLUTION (plasma 3 human) OCTAPLAS BLOOD GROUP O INTRAVENOUS SOLUTION (plasma 3 human) PLASBUMIN-25 INTRAVENOUS SOLUTION (albumin human) 3 PLASBUMIN-5 INTRAVENOUS SOLUTION (albumin human) 3 PLASMANATE INTRAVENOUS SOLUTION (plasma protein fraction) 3 THROMBATE III INTRAVENOUS SOLUTION RECONSTITUTED 3 (antithrombin iii (human)) *PLATELET AGGREGATION INHIBITOR COMBINATIONS*** - DRUGS FOR THE BLOOD aspirin-dipyridamole er oral capsule extended release 12 hour 1 or 1b* QL (2 capsules per 1 day) ASPIRIN-OMEPRAZOLE ORAL TABLET DELAYED RELEASE 3 PA; QL (1 tablet per 1 day) YOSPRALA ORAL TABLET DELAYED RELEASE (aspirin-omeprazole) 3 PA; QL (1 tablet per 1 day) *PLATELET AGGREGATION INHIBITORS*** - DRUGS FOR THE BLOOD dipyridamole oral tablet 1 or 1b* DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR (aspirin) 3 PA; QL (1 capsule per 1 day) *PROTAMINE*** - DRUGS FOR THE BLOOD protamine sulfate intravenous solution 1 or 1b* *PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS*** - DRUGS FOR THE BLOOD ZONTIVITY ORAL TABLET (vorapaxar sulfate) 3 PA; QL (1 tablet per 1 day) *QUINAZOLINE AGENTS*** - DRUGS FOR THE BLOOD AGRYLIN ORAL CAPSULE (anagrelide hcl) 3 anagrelide hcl oral capsule 1 or 1b* *SPLEEN TYROSINE KINASE (SYK) INHIBITORS*** - DRUGS FOR THE BLOOD TAVALISSE ORAL TABLET (fostamatinib disodium) 4 PA; LD; QL (2 tablets per 1 day) *THIENOPYRIDINE DERIVATIVES*** - DRUGS FOR THE BLOOD clopidogrel bisulfate oral tablet 300 mg 1 or 1b* clopidogrel bisulfate oral tablet 75 mg 1 or 1b* QL (1 tablet per 1 day) prasugrel hcl oral tablet 10 mg 1 or 1b* QL (1 tablet per 1 day) prasugrel hcl oral tablet 5 mg 1 or 1b* *THROMBOLYTIC AGENT - MISC*** - DRUGS FOR THE BLOOD DEFITELIO INTRAVENOUS SOLUTION (defibrotide sodium) 4 *TISSUE PLASMINOGEN ACTIVATORS*** - DRUGS FOR THE BLOOD ACTIVASE INTRAVENOUS SOLUTION RECONSTITUTED (alteplase) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 139 Coverage Requirements and Prescription Drug Name Drug Tier Limits CATHFLO ACTIVASE INJECTION SOLUTION RECONSTITUTED 3 (alteplase) RETAVASE HALF-KIT INTRAVENOUS KIT (reteplase) 3 RETAVASE INTRAVENOUS KIT (reteplase) 3 TNKASE INTRAVENOUS KIT (tenecteplase) 3 *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION *AGENTS FOR GAUCHER DISEASE*** - DRUGS FOR NUTRITION CERDELGA ORAL CAPSULE (eliglustat tartrate) 4 PA; LD; SP CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (imiglucerase) ELELYSO INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (taliglucerase alfa) miglustat oral capsule 4 PA; SP VPRIV INTRAVENOUS SOLUTION RECONSTITUTED (velaglucerase 4 PA; LD; SP alfa) *AMINO ACIDS*** - DRUGS FOR NUTRITION ENDARI ORAL PACKET (glutamine (sickle cell)) 4 PA; LD *COBALAMIN COMBINATIONS*** - DRUGS FOR NUTRITION LIPO-B INTRAMUSCULAR SOLUTION 3 NEURIN-SL SUBLINGUAL TABLET SUBLINGUAL 3 *COBALAMINS*** - DRUGS FOR NUTRITION cyanocobalamin injection solution 1000 mcg/ml 1 or 1a* CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML 3 hydroxocobalamin acetate intramuscular solution 1 or 1b* METHYLCOBALAMIN INJECTION SOLUTION RECONSTITUTED 3 *CXCR4 RECEPTOR ANTAGONIST*** - DRUGS FOR NUTRITION MOZOBIL SUBCUTANEOUS SOLUTION (plerixafor) 4 PA; LD; SP *CYTOTOXIC AGENTS*** - DRUGS FOR NUTRITION DROXIA ORAL CAPSULE (hydroxyurea) 2 SIKLOS ORAL TABLET (hydroxyurea) 3 PA; SP *ERYTHROID MATURATION AGENTS*** - DRUGS FOR NUTRITION REBLOZYL SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (luspatercept-aamt) *ERYTHROPOIESIS-STIMULATING AGENTS (ESAS)*** - DRUGS FOR NUTRITION ARANESP (ALBUMIN FREE) INJECTION SOLUTION (darbepoetin 4 PA; SP; QL (4 vials per 28 days) alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 4 PA; SP; QL (4 syringes per 28 days) MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 60 MCG/0.3ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED 4 PA; SP; QL (4 syringes per 30 days) SYRINGE 500 MCG/ML (darbepoetin alfa)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 140 Coverage Requirements and Prescription Drug Name Drug Tier Limits EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 4 PA; SP; QL (12 mL per 28 days) 3000 UNIT/ML, 4000 UNIT/ML (epoetin alfa) EPOGEN INJECTION SOLUTION 20000 UNIT/ML (epoetin alfa) 4 PA; SP; QL (24 vials per 28 days) MIRCERA INJECTION SOLUTION PREFILLED SYRINGE (methoxy PA; LD; QL (2 syringes per 28 4 peg-epoetin beta) days) PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 4 PA; SP; QL (12 mL per 28 days) 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML (epoetin alfa) PROCRIT INJECTION SOLUTION 20000 UNIT/ML (epoetin alfa) 4 PA; SP; QL (24 vials per 28 days) RETACRIT INJECTION SOLUTION (epoetin alfa-epbx) 4 PA; SP; QL (12 mL per 28 days) *FOLIC ACID/FOLATE COMBINATIONS*** - DRUGS FOR NUTRITION fa-vitamin b-6-vitamin b-12 oral tablet 1 or 1b* FOLGARD RX ORAL TABLET (folic acid-vit b6-vit b12) 3 foltabs 800 oral tablet 1 or 1b*; $0 millguard oral tablet 1 or 1b*; $0 *FOLIC ACID/FOLATES*** - DRUGS FOR NUTRITION cvs folic acid oral tablet 1 or 1a*; $0 fa-8 oral capsule 1 or 1b*; $0 folate oral tablet 1 or 1a*; $0 folic acid injection solution 1 or 1a* folic acid oral capsule 1 or 1b*; $0 folic acid oral tablet 1 mg 1 or 1a* folic acid oral tablet 400 mcg, 800 mcg 1 or 1a*; $0 gnp folic acid oral tablet 1 or 1a*; $0 hm folic acid oral tablet 1 or 1a*; $0 kp folic acid oral tablet 1 or 1a*; $0 px folic acid oral tablet 1 or 1a*; $0 qc folic acid oral tablet 1 or 1a*; $0 ra folic acid oral tablet 1 or 1a*; $0 sm folic acid oral tablet 1 or 1a*; $0 yl folic acid oral tablet 1 or 1a*; $0 *GRANULOCYTE COLONY-STIMULATING FACTORS (G-CSF)*** - DRUGS FOR NUTRITION FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 28 days) (pegfilgrastim-jmdb) GRANIX SUBCUTANEOUS SOLUTION (tbo-filgrastim) 4 PA; SP GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE (tbo- 4 PA; SP filgrastim) NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT PA; SP; QL (2 injectors/kits per 28 4 (pegfilgrastim) days) NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 28 days) (pegfilgrastim) NEUPOGEN INJECTION SOLUTION (filgrastim) 4 PA; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 141 Coverage Requirements and Prescription Drug Name Drug Tier Limits NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 4 PA; SP (filgrastim) NIVESTYM INJECTION SOLUTION (filgrastim-aafi) 4 PA; SP NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 4 PA; SP (filgrastim-aafi) NYVEPRIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 28 days) (pegfilgrastim-apgf) UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 28 days) (pegfilgrastim-cbqv) ZARXIO INJECTION SOLUTION PREFILLED SYRINGE (filgrastim- 4 PA; SP sndz) ZIEXTENZO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (2 injections per 28 4 (pegfilgrastim-bmez) days) *GRANULOCYTE/MACROPHAGE COLONY-STIMULATING FACTOR(GM-CSF)*** - DRUGS FOR NUTRITION LEUKINE INJECTION SOLUTION RECONSTITUTED (sargramostim) 4 PA; SP *HEMOGLOBIN S (HBS) POLYMERIZATION INHIBITORS*** - DRUGS FOR NUTRITION PA; LD; SP; QL (3 tablets per 1 OXBRYTA ORAL TABLET (voxelotor) 4 day) *IRON COMBINATIONS*** - DRUGS FOR NUTRITION foltrin oral capsule 1 or 1b* *IRON*** - DRUGS FOR NUTRITION ACCRUFER ORAL CAPSULE (ferric maltol) 3 FERAHEME INTRAVENOUS SOLUTION (ferumoxytol) 4 PA; SP; QL (2 vials per 6 days) FERRLECIT INTRAVENOUS SOLUTION (na ferric gluc cplx in sucrose) 4 PA; SP; QL (16 vials per 8 weekss) INFED INJECTION SOLUTION (iron dextran) 4 PA; SP INJECTAFER INTRAVENOUS SOLUTION (ferric carboxymaltose) 4 PA; SP; QL (2 vials per 14 days) MONOFERRIC INTRAVENOUS SOLUTION (ferric derisomaltose) 3 PA; SP; QL (1 vial per 1 day) na ferric gluc cplx in sucrose intravenous solution 4 SP TRIFERIC HEMODIALYSIS PACKET (ferric pyrophosphate citrate) 4 PA TRIFERIC HEMODIALYSIS SOLUTION (ferric pyrophosphate citrate) 4 PA VENOFER INTRAVENOUS SOLUTION (iron sucrose) 4 PA; SP; QL (15 mL per 71 days) *SELECTIN BLOCKERS*** - DRUGS FOR NUTRITION ADAKVEO INTRAVENOUS SOLUTION (crizanlizumab-tmca) 4 PA; SP *THROMBOPOIETIN (TPO) RECEPTOR AGONISTS*** - DRUGS FOR NUTRITION PA; LD; SP; QL (60 tablets per 30 DOPTELET ORAL TABLET (avatrombopag maleate) 4 days) MULPLETA ORAL TABLET (lusutrombopag) 4 PA; SP; QL (1 tablet per 1 day) NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 125 MCG 4 PA (romiplostim) NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 250 MCG, 4 PA; SP 500 MCG (romiplostim) PROMACTA ORAL PACKET 12.5 MG (eltrombopag olamine) 4 PA; LD; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 142 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; LD; SP; QL (3 dose-packs per 1 PROMACTA ORAL PACKET 25 MG (eltrombopag olamine) 4 day) PROMACTA ORAL TABLET 12.5 MG, 25 MG (eltrombopag olamine) 4 PA; LD; SP PA; LD; SP; QL (3 tablets per 1 PROMACTA ORAL TABLET 50 MG (eltrombopag olamine) 4 day) PROMACTA ORAL TABLET 75 MG (eltrombopag olamine) 4 PA; LD; SP; QL (1 tablet per 1 day) *HEMOSTATICS* - DRUGS FOR THE BLOOD *HEMOSTATIC COMBINATIONS - TOPICAL*** - DRUGS TO PREVENT BLEEDING ARTISS EXTERNAL SOLUTION (fibrin sealant component) 3 THROMBI-GEL 10 EXTERNAL PAD (thrombin-cmc-cacl-gelatin) 3 THROMBI-GEL 100 EXTERNAL PAD (thrombin-cmc-cacl-gelatin) 3 THROMBI-GEL 40 EXTERNAL PAD (thrombin-cmc-cacl-gelatin) 3 THROMBI-PAD EXTERNAL PAD (thrombin-cmc-cacl) 3 TISSEEL EXTERNAL KIT (fibrin sealant component) 3 TISSEEL EXTERNAL SOLUTION (fibrin sealant component) 3 *HEMOSTATICS - SYSTEMIC*** - DRUGS TO PREVENT BLEEDING AMICAR ORAL SOLUTION (aminocaproic acid) 3 QL (120 mL per 1 day) AMICAR ORAL TABLET 1000 MG (aminocaproic acid) 3 AMICAR ORAL TABLET 500 MG (aminocaproic acid) 3 QL (60 tablets per 1 day) aminocaproic acid intravenous solution 1 or 1b* aminocaproic acid oral solution 1 or 1b* QL (120 mL per 1 day) aminocaproic acid oral tablet 1000 mg 1 or 1b* aminocaproic acid oral tablet 500 mg 1 or 1b* QL (60 tablets per 1 day) CYKLOKAPRON INTRAVENOUS SOLUTION (tranexamic acid) 3 LYSTEDA ORAL TABLET (tranexamic acid) 3 QL (6 tablets per 1 day) tranexamic acid intravenous solution 1 or 1b* tranexamic acid oral tablet 1 or 1b* QL (6 tablets per 1 day) TRANEXAMIC ACID-NACL INTRAVENOUS SOLUTION 3 *HEMOSTATICS - TOPICAL*** - DRUGS TO PREVENT BLEEDING ACTIFOAM COLLAGEN SPONGE EXTERNAL (absorbable collagen 3 hemostat) AVITENE EXTERNAL PAD (microfibrillar coll hemostat) 3 AVITENE FLOUR EXTERNAL POWDER (microfibrillar coll hemostat) 3 ENDO AVITENE EXTERNAL (absorbable collagen hemostat) 3 GEL-FLOW NT EXTERNAL PREFILLED SYRINGE (gelatin 3 absorbable) GELFOAM COMPRESSED SIZE 100 EXTERNAL (gelatin absorbable) 3 GELFOAM DENTAL PACK SIZE 4 EXTERNAL (gelatin absorbable) 3 GELFOAM MOUTH/THROAT POWDER (gelatin absorbable) 3 GELFOAM SPONGE EXTERNAL (gelatin absorbable) 3 GELFOAM SPONGE SIZE 100 EXTERNAL (gelatin absorbable) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 143 Coverage Requirements and Prescription Drug Name Drug Tier Limits GELFOAM SPONGE SIZE 200 EXTERNAL (gelatin absorbable) 3 GELFOAM SPONGE SIZE 50 EXTERNAL (gelatin absorbable) 3 INSTAT EXTERNAL PAD (absorbable collagen hemostat) 3 INTERCEED (TC7) EXTERNAL PAD (oxidized cellulose) 3 INTERCEED EXTERNAL PAD (oxidized cellulose) 3 RECOTHROM EXTERNAL SOLUTION RECONSTITUTED (thrombin 3 (recombinant)) RECOTHROM SPRAY KIT EXTERNAL SOLUTION 3 RECONSTITUTED (thrombin (recombinant)) SURGICEL FIBRILLAR EXTERNAL PAD (oxidized cellulose) 3 SURGICEL NU-KNIT EXTERNAL PAD (oxidized cellulose) 3 SYRINGE AVITENE EXTERNAL (absorbable collagen hemostat) 3 TACHOSIL EXTERNAL PATCH (absorbable fibrin sealant) 3 THROMBIN-JMI EPISTAXIS EXTERNAL KIT (thrombin) 3 THROMBIN-JMI EXTERNAL KIT (thrombin) 3 THROMBIN-JMI EXTERNAL SOLUTION RECONSTITUTED 3 (thrombin) THROMBOGEN EXTERNAL KIT (thrombin) 3 THROMBOGEN EXTERNAL SOLUTION RECONSTITUTED 3 (thrombin) ULTRAFOAM SPONGE 2X6.25X7CM EXTERNAL (microfibrillar coll 3 hemostat) ULTRAFOAM SPONGE 8X12.5X1CM EXTERNAL (microfibrillar coll 3 hemostat) ULTRAFOAM SPONGE 8X12.5X3CM EXTERNAL (microfibrillar coll 3 hemostat) ULTRAFOAM SPONGE 8X25X1CM EXTERNAL (microfibrillar coll 3 hemostat) ULTRAFOAM SPONGE 8X6.25X1CM EXTERNAL (microfibrillar coll 3 hemostat) *HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS* - DRUGS FOR THE NERVOUS SYSTEM *BARBITURATE HYPNOTICS*** - DRUGS FOR INSOMNIA NEMBUTAL INJECTION SOLUTION (pentobarbital sodium) 3 pentobarbital sodium injection solution 1 or 1b* phenobarbital oral elixir 1 or 1b* QL (100 mL per 1 day) phenobarbital oral tablet 100 mg 1 or 1b* QL (4 tablets per 1 day) phenobarbital oral tablet 15 mg 1 or 1b* QL (800 tablets per 30 days) phenobarbital oral tablet 16.2 mg 1 or 1b* QL (741 tablets per 30 days) phenobarbital oral tablet 30 mg 1 or 1b* QL (400 tablets per 30 days) phenobarbital oral tablet 32.4 mg 1 or 1b* QL (370 tablets per 30 days) phenobarbital oral tablet 60 mg 1 or 1b* QL (200 tablets per 30 days) phenobarbital oral tablet 64.8 mg 1 or 1b* QL (185 tablets per 30 days) phenobarbital oral tablet 97.2 mg 1 or 1b* QL (123 tablets per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 144 Coverage Requirements and Prescription Drug Name Drug Tier Limits phenobarbital sodium injection solution 1 or 1b* *BENZODIAZEPINE HYPNOTICS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN BYFAVO INTRAVENOUS SOLUTION RECONSTITUTED 4 (remimazolam besylate) DORAL ORAL TABLET (quazepam) 3 ST; QL (1 tablet per 1 day) estazolam oral tablet 1 or 1b* QL (1 tablet per 1 day) flurazepam hcl oral capsule 1 or 1b* QL (1 capsule per 1 day) HALCION ORAL TABLET (triazolam) 3 QL (1 tablet per 1 day) midazolam hcl (pf) injection solution 1 or 1b* midazolam hcl injection solution 1 or 1b* midazolam hcl oral syrup 1 or 1b* QL (10 mL per 1 fill) MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS 3 SOLUTION MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS 3 SOLUTION PREFILLED SYRINGE MIDAZOLAM INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE quazepam oral tablet 1 or 1b* QL (1 tablet per 1 day) RESTORIL ORAL CAPSULE (temazepam) 3 QL (1 capsule per 1 day) temazepam oral capsule 1 or 1b* QL (1 capsule per 1 day) triazolam oral tablet 1 or 1b* QL (1 tablet per 1 day) *HYPNOTICS - TRICYCLIC AGENTS*** - DRUGS FOR INSOMNIA doxepin hcl oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) SILENOR ORAL TABLET (doxepin hcl) 3 ST; QL (1 tablet per 1 day) *NON-BENZODIAZEPINE - GABA-RECEPTOR MODULATORS*** - DRUGS FOR INSOMNIA EDLUAR SUBLINGUAL TABLET SUBLINGUAL (zolpidem tartrate) 3 ST; QL (1 tablet per 1 day) eszopiclone oral tablet 1 or 1b* QL (1 tablet per 1 day) zaleplon oral capsule 1 or 1b* QL (1 capsule per 1 day) zolpidem tartrate er oral tablet extended release 1 or 1b* ST; QL (1 tablet per 1 day) zolpidem tartrate oral tablet 1 or 1b* QL (1 tablet per 1 day) zolpidem tartrate sublingual tablet sublingual 1 or 1b* ST; QL (1 tablet per 1 day) ZOLPIMIST ORAL SOLUTION (zolpidem tartrate) 3 ST; QL (1 bottle per 30 days) *OREXIN RECEPTOR ANTAGONISTS*** - DRUGS FOR INSOMNIA BELSOMRA ORAL TABLET (suvorexant) 3 ST; QL (1 tablet per 1 day) DAYVIGO ORAL TABLET (lemborexant) 3 ST; QL (1 tablet per 1 day) *SELECTIVE ALPHA2-ADRENORECEPTOR AGONIST SEDATIVES*** - DRUGS FOR INSOMNIA dexmedetomidine hcl in nacl intravenous solution 1 or 1b* DEXMEDETOMIDINE HCL IN NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 145 Coverage Requirements and Prescription Drug Name Drug Tier Limits DEXMEDETOMIDINE HCL INTRAVENOUS SOLUTION 1000 3 MCG/10ML, 400 MCG/4ML dexmedetomidine hcl intravenous solution 200 mcg/2ml 1 or 1b* DEXMEDETOMIDINE HCL-DEXTROSE INTRAVENOUS SOLUTION 3 PRECEDEX INTRAVENOUS SOLUTION (dexmedetomidine hcl) 3 *SELECTIVE MELATONIN RECEPTOR AGONISTS*** - DRUGS FOR INSOMNIA HETLIOZ LQ ORAL SUSPENSION (tasimelteon) 4 LD HETLIOZ ORAL CAPSULE (tasimelteon) 4 PA; LD; QL (1 capsule per 1 day) ramelteon oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *LAXATIVES* - DRUGS FOR THE STOMACH *BOWEL EVACUANT COMBINATIONS*** - DRUGS TO PREVENT CONSTIPATION CLENPIQ ORAL SOLUTION (sod picosulfate-mag ox-cit acd) 3 QL (320 mL per 30 days) gavilyte-c oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) gavilyte-g oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) gavilyte-n with flavor pack oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) GOLYTELY ORAL SOLUTION RECONSTITUTED (peg 3350-kcl- 3 QL (4000 grams per 30 days) nabcb-nacl-nasulf) MOVIPREP ORAL SOLUTION RECONSTITUTED (peg-kcl-nacl-nasulf- 3 QL (1 gram per 30 days) na asc-c) NULYTELY LEMON-LIME ORAL SOLUTION RECONSTITUTED 3 QL (4000 grams per 30 days) (peg 3350-kcl-na bicarb-nacl) peg 3350-kcl-na bicarb-nacl oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) peg-3350/electrolytes oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) peg-3350/electrolytes/ascorbat oral solution reconstituted 1 or 1b*; $0 QL (1 gram per 30 days) peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 1 or 1b*; $0 QL (1 gram per 30 days) peg-prep oral kit 1 or 1b*; $0 QL (1 kit per 30 days) PLENVU ORAL SOLUTION RECONSTITUTED (peg-kcl-nacl-nasulf-na 3 QL (1 gram per 30 days) asc-c) SUPREP BOWEL PREP KIT ORAL SOLUTION (na sulfate-k sulfate-mg 2 QL (1 kit per 30 days) sulf) *LAXATIVES - MISCELLANEOUS*** - DRUGS TO PREVENT CONSTIPATION clearlax oral powder 1 or 1b*; $0 constulose oral solution 1 or 1b* cvs purelax oral packet 1 or 1b*; $0 cvs purelax oral powder 1 or 1b*; $0 eq clearlax oral powder 1 or 1b*; $0 eql clearlax oral powder 1 or 1b*; $0 gavilax oral powder 1 or 1b*; $0 gentlelax oral powder 1 or 1b*; $0 glycolax oral powder 1 or 1b*; $0 gnp clearlax oral packet 1 or 1b*; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 146 Coverage Requirements and Prescription Drug Name Drug Tier Limits gnp clearlax oral powder 1 or 1b*; $0 goodsense clearlax oral powder 1 or 1b*; $0 healthylax oral packet 1 or 1b*; $0 hm clearlax oral packet 1 or 1b*; $0 hm clearlax oral powder 1 or 1b*; $0 kls laxaclear oral powder 1 or 1b*; $0 KRISTALOSE ORAL PACKET (lactulose) 3 LACTULOSE ORAL PACKET 1 or 1b* lactulose oral solution 1 or 1b* mm clearlax oral powder 1 or 1b*; $0 peg 3350 oral packet 1 or 1b*; $0 peg 3350 oral powder 1 or 1b*; $0 polyethylene glycol 3350 oral packet 1 or 1b*; $0 polyethylene glycol 3350 oral powder 1 or 1b*; $0 qc natura-lax oral powder 1 or 1b*; $0 ra laxative oral powder 1 or 1b*; $0 sb polyethylene glycol 3350 oral powder 1 or 1b*; $0 sm clearlax oral powder 1 or 1b*; $0 smooth lax oral packet 1 or 1b*; $0 smooth lax oral powder 1 or 1b*; $0 *LUBRICANT LAXATIVES*** - DRUGS TO PREVENT CONSTIPATION mineral oil heavy oral oil 1 or 1b* *SALINE LAXATIVE MIXTURES*** - DRUGS TO PREVENT CONSTIPATION OSMOPREP ORAL TABLET (sod phos mono-sod phos dibasic) 3 QL (32 tablet per 30 days) *SALINE LAXATIVES*** - DRUGS TO PREVENT CONSTIPATION citrate of magnesia oral solution 1 or 1a*; $0 citroma oral solution 1 or 1a*; $0 cvs citrate of magnesia oral solution 1 or 1a*; $0 cvs magnesium citrate oral solution 1 or 1a*; $0 cvs milk of magnesia oral suspension 1 or 1b*; $0 dulcolax milk of magnesia oral suspension 1 or 1b*; $0 dulcolax oral suspension 1 or 1b*; $0 eq magnesium citrate oral solution 1 or 1a*; $0 eql magnesium citrate oral solution 1 or 1a*; $0 eql milk of magnesia oral suspension 1 or 1b*; $0 gnp milk of magnesia oral suspension 1 or 1b*; $0 goodsense magnesium citrate oral solution 1 or 1a*; $0 hm magnesium citrate oral solution 1 or 1a*; $0 hm milk of magnesia oral suspension 1 or 1b*; $0 magnesium citrate oral solution 1 or 1a*; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 147 Coverage Requirements and Prescription Drug Name Drug Tier Limits milk of magnesia concentrate oral suspension 1 or 1b*; $0 milk of magnesia oral suspension 1 or 1b*; $0 phillips milk of magnesia oral suspension 1 or 1b*; $0 px milk of magnesia oral suspension 1 or 1b*; $0 qc magnesium citrate oral solution 1 or 1a*; $0 qc milk of magnesia oral suspension 1 or 1b*; $0 ra milk of magnesia oral suspension 1 or 1b*; $0 sb magnesium citrate oral solution 1 or 1a*; $0 sb milk of magnesia oral suspension 1 or 1b*; $0 sm magnesium citrate oral solution 1 or 1a*; $0 sm milk of magnesia oral suspension 1 or 1b*; $0 *STIMULANT LAXATIVES*** - DRUGS TO PREVENT CONSTIPATION alophen oral tablet delayed release 1 or 1a*; $0 bisacodyl ec oral tablet delayed release 1 or 1a*; $0 CASCARA SAGRADA ORAL FLUID EXTRACT 3 correctol oral tablet delayed release 1 or 1a*; $0 cvs bisacodyl oral tablet delayed release 1 or 1a*; $0 cvs c-lax laxative oral tablet delayed release 1 or 1a*; $0 cvs gentle laxative oral tablet delayed release 1 or 1a*; $0 cvs gentle laxative womens oral tablet delayed release 1 or 1a*; $0 eq gentle laxative oral tablet delayed release 1 or 1a*; $0 eql gentle laxative oral tablet delayed release 1 or 1a*; $0 eql laxative oral tablet delayed release 1 or 1a*; $0 ex-lax ultra oral tablet delayed release 1 or 1a*; $0 feenamint oral tablet delayed release 1 or 1a*; $0 gentle laxative oral tablet delayed release 1 or 1a*; $0 gnp gentle laxative oral tablet delayed release 1 or 1a*; $0 gnp womens gentle laxative oral tablet delayed release 1 or 1a*; $0 goodsense bisacodyl ec oral tablet delayed release 1 or 1a*; $0 goodsense womens laxative oral tablet delayed release 1 or 1a*; $0 hm laxative oral tablet delayed release 1 or 1a*; $0 kp bisacodyl oral tablet delayed release 1 or 1a*; $0 laxative oral tablet delayed release 1 or 1a*; $0 px laxative oral tablet delayed release 1 or 1a*; $0 qc gentle laxative oral tablet delayed release 1 or 1a*; $0 ra laxative oral tablet delayed release 1 or 1a*; $0 ra womens laxative oral tablet delayed release 1 or 1a*; $0 sb bisacodyl laxative ec oral tablet delayed release 1 or 1a*; $0 sb gentle lax-women oral tablet delayed release 1 or 1a*; $0 sm gentle laxative oral tablet delayed release 1 or 1a*; $0 womans laxative oral tablet delayed release 1 or 1a*; $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 148 Coverage Requirements and Prescription Drug Name Drug Tier Limits womens laxative oral tablet delayed release 1 or 1a*; $0 *LOCAL ANESTHETICS-PARENTERAL* - DRUGS FOR PAIN AND FEVER *LOCAL ANESTHETIC & SYMPATHOMIMETIC*** - DRUGS FOR SEDATION articadent dental injection solution cartridge 3 bupivacaine-epinephrine (pf) injection solution 1 or 1b* bupivacaine-epinephrine injection solution 1 or 1b* lidocaine-epinephrine injection solution 1 or 1b* MARCAINE/EPINEPHRINE INJECTION SOLUTION (bupivacaine- 3 epinephrine) MARCAINE/EPINEPHRINE PF INJECTION SOLUTION (bupivacaine- 3 epinephrine) ORABLOC INJECTION SOLUTION CARTRIDGE (articaine- 3 epinephrine) sensorcaine/epinephrine injection solution 1 or 1b* sensorcaine-mpf/epinephrine injection solution 0.25% -1:200000, 0.5% - 1 or 1b* 1:200000 SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 0.75- 3 1:200000 % (bupivacaine-epinephrine) XYLOCAINE/EPINEPHRINE INJECTION SOLUTION (lidocaine- 3 epinephrine) XYLOCAINE-MPF/EPINEPHRINE INJECTION SOLUTION (lidocaine- 3 epinephrine) *LOCAL ANESTHETIC COMBINATIONS*** - DRUGS FOR SEDATION LIDOCAINE-SODIUM BICARBONATE INJECTION SOLUTION 3 PREFILLED SYRINGE POINT OF CARE LM-2.5 INJECTION KIT (lidocaine hcl-bupivacaine 3 hcl) *LOCAL ANESTHETICS - AMIDES*** - DRUGS FOR SEDATION BUPIVACAINE FISIOPHARMA INJECTION SOLUTION 3 bupivacaine hcl (pf) injection solution 1 or 1b* bupivacaine hcl injection solution 1 or 1b* BUPIVACAINE HCL-NACL EPIDURAL SOLUTION 3 BUPIVACAINE HCL-NACL EPIDURAL SOLUTION PREFILLED 3 SYRINGE bupivacaine in dextrose intrathecal solution 1 or 1b* bupivacaine spinal intrathecal solution 1 or 1b* CARBOCAINE INJECTION SOLUTION (mepivacaine hcl) 3 CARBOCAINE PRESERVATIVE-FREE INJECTION SOLUTION 3 (mepivacaine hcl) lidocaine hcl (pf) injection solution 1 or 1b* lidocaine hcl injection solution 1 or 1b* LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 149 Coverage Requirements and Prescription Drug Name Drug Tier Limits lidocaine hcl intradermal jet-injector 1 or 1b* LIDOCAINE IN DEXTROSE SOLUTION 3 MARCAINE INJECTION SOLUTION (bupivacaine hcl) 3 MARCAINE PRESERVATIVE FREE INJECTION SOLUTION 3 (bupivacaine hcl) MARCAINE SPINAL INTRATHECAL SOLUTION (bupivacaine in 3 dextrose) MONOJECT BONE MARROW BIOPSY INJECTION KIT (lidocaine hcl) 3 NAROPIN INJECTION SOLUTION (ropivacaine hcl) 3 polocaine injection solution 1 or 1b* polocaine-mpf injection solution 1 or 1b* ropivacaine hcl injection solution 1 or 1b* ROPIVACAINE HCL-NACL EPIDURAL SOLUTION 3 sensorcaine injection solution 1 or 1b* sensorcaine-mpf injection solution 1 or 1b* XARACOLL IMPLANT IMPLANT (bupivacaine hcl) 3 XYLOCAINE INJECTION SOLUTION (lidocaine hcl) 3 XYLOCAINE-MPF INJECTION SOLUTION (lidocaine hcl) 3 ZINGO INTRADERMAL JET-INJECTOR (lidocaine hcl) 3 *LOCAL ANESTHETICS - ESTERS*** - DRUGS FOR SEDATION chloroprocaine hcl (pf) injection solution 1 or 1b* CLOROTEKAL INTRATHECAL SOLUTION (chloroprocaine hcl) 3 NESACAINE INJECTION SOLUTION (chloroprocaine hcl) 3 NESACAINE-MPF INJECTION SOLUTION (chloroprocaine hcl) 3 *MACROLIDES* - DRUGS FOR INFECTIONS *AZITHROMYCIN*** - ANTIBIOTICS azithromycin intravenous solution reconstituted 1 or 1b* azithromycin oral packet 1 or 1b* QL (2 packets per 30 days) azithromycin oral suspension reconstituted 100 mg/5ml 1 or 1b* QL (15 ML per 30 days) azithromycin oral suspension reconstituted 200 mg/5ml 1 or 1b* QL (15 mL per 30 days) azithromycin oral tablet 250 mg 1 or 1b* QL (6 tablets per 30 days) azithromycin oral tablet 500 mg 1 or 1b* QL (3 tablets per 30 days) azithromycin oral tablet 600 mg 1 or 1b* QL (8 tablet per 28 days) ZITHROMAX INTRAVENOUS SOLUTION RECONSTITUTED 3 (azithromycin) ZITHROMAX ORAL PACKET (azithromycin) 3 QL (2 packets per 30 days) ZITHROMAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 3 QL (15 ML per 30 days) (azithromycin) ZITHROMAX ORAL SUSPENSION RECONSTITUTED 200 MG/5ML 3 QL (15 mL per 30 days) (azithromycin) ZITHROMAX ORAL TABLET 250 MG (azithromycin) 3 QL (6 tablets per 30 days) ZITHROMAX ORAL TABLET 500 MG (azithromycin) 3 QL (3 tablets per 30 days) ZITHROMAX TRI-PAK ORAL TABLET (azithromycin) 3 QL (3 tablets per 30 days) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 150 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZITHROMAX Z-PAK ORAL TABLET (azithromycin) 3 QL (6 tablets per 30 days) *CLARITHROMYCIN*** - ANTIBIOTICS clarithromycin er oral tablet extended release 24 hour 1 or 1b* clarithromycin oral suspension reconstituted 1 or 1b* QL (300 mL per 1 fill) clarithromycin oral tablet 1 or 1b* QL (28 tablets per 1 fill) *ERYTHROMYCINS*** - ANTIBIOTICS ery-tab oral tablet delayed release 1 or 1b* ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION 3 RECONSTITUTED (erythromycin lactobionate) erythrocin stearate oral tablet 1 or 1b* erythromycin base oral capsule delayed release particles 1 or 1b* erythromycin base oral tablet 1 or 1b* erythromycin base oral tablet delayed release 1 or 1b* erythromycin ethylsuccinate oral suspension reconstituted 1 or 1b* erythromycin ethylsuccinate oral tablet 1 or 1b* erythromycin oral tablet delayed release 1 or 1b* *FIDAXOMICIN*** - ANTIBIOTICS DIFICID ORAL SUSPENSION RECONSTITUTED (fidaxomicin) 3 DIFICID ORAL TABLET (fidaxomicin) 3 *MEDICAL DEVICES AND SUPPLIES* - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT *CERVICAL CAPS*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT FEMCAP VAGINAL DEVICE (cervical caps) 2; $0 *CONDOMS - FEMALE*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT FC FEMALE CONDOM (condoms - female) 2; $0 QL (12 units per 1 fill) FC2 FEMALE CONDOM (condoms - female) 2; $0 QL (12 units per 1 fill) *DENTAL DESENSITIZING PRODUCTS*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT REMESENSE DENTAL (dental desensitizing product) 3 *DENTIFRICES*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT MI PASTE DENTAL PASTE (dentifrices) 3 MI PASTE PLUS DENTAL PASTE (dentifrices) 3 *DIAPHRAGMS*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT CAYA VAGINAL DIAPHRAGM (diaphragm arc-spring) 2; $0 OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM (diaphragms) 3 WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide seal)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 151 Coverage Requirements and Prescription Drug Name Drug Tier Limits WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide seal) *GLUCOSE MONITORING TEST SUPPLIES*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT 1ST TIER UNILET COMFORTOUCH 2 QL (204 lancets per 30 days) ACCU-CHEK FASTCLIX LANCET KIT (lancets misc.) 2 QL (200 units per 30 days) ACCU-CHEK FASTCLIX LANCETS (lancets) 2 QL (204 lancets per 30 days) ACCU-CHEK MULTICLIX LANCETS (lancets) 2 QL (204 lancets per 30 days) ACCU-CHEK SAFE-T PRO LANCETS (lancets) 2 QL (204 lancets per 30 days) ACCU-CHEK SOFTCLIX LANCET DEV KIT (lancets misc.) 2 QL (200 units per 30 days) ACCU-CHEK SOFTCLIX LANCETS (lancets) 2 QL (204 lancets per 30 days) ACTI-LANCE 28G 2 QL (204 lancets per 30 days) ACTI-LANCE LITE LANCETS 28G 2 QL (204 lancets per 30 days) ACTI-LANCE SPECIAL LANCETS 17G 2 QL (204 lancets per 30 days) ACTI-LANCE UNIVERSAL 23G 2 QL (204 lancets per 30 days) ADVANCED MOBILE LANCET 2 QL (204 lancets per 30 days) ADVOCATE LANCETS (lancets) 2 QL (204 lancets per 30 days) ADVOCATE LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) ADVOCATE SAFETY LANCETS (lancets) 2 QL (204 lancets per 30 days) ADVOCATE SAFETY LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) AGAMATRIX ULTRA-THIN LANCETS (lancets) 2 QL (204 lancets per 30 days) AIMSCO TWIST LANCETS 32G 2 QL (204 lancets per 30 days) AIMSCO TWIST LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) AQUALANCE LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) ASSURE COMFORT LANCETS 28G 2 QL (204 lancets per 30 days) ASSURE HAEMOLANCE PLUS HIGH (lancets) 2 QL (204 lancets per 30 days) ASSURE HAEMOLANCE PLUS LOW (lancets) 2 QL (204 lancets per 30 days) ASSURE HAEMOLANCE PLUS MICRO (lancets) 2 QL (204 lancets per 30 days) ASSURE HAEMOLANCE PLUS NORMAL (lancets) 2 QL (204 lancets per 30 days) ASSURE HAEMOLANCE PLUS PED (lancets) 2 QL (204 lancets per 30 days) ASSURE LANCE LANCETS (lancets) 2 QL (204 lancets per 30 days) ASSURE LANCE LANCETS 21G (lancets) 2 QL (204 lancets per 30 days) ASSURE LANCE PLUS SAFETY 25G (lancets) 2 QL (204 lancets per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 152 Coverage Requirements and Prescription Drug Name Drug Tier Limits ASSURE LANCE PLUS SAFETY 30G (lancets) 2 QL (204 lancets per 30 days) ASSURE LANCE SAFETY LANCET 28G (lancets) 2 QL (204 lancets per 30 days) AURORA LANCET SUPER THIN 30G 2 QL (204 lancets per 30 days) AURORA LANCET THIN 23G 2 QL (204 lancets per 30 days) AUTOLET II CLINISAFE KIT (lancets misc.) 2 QL (200 units per 30 days) AUTOLET LITE CLINISAFE KIT (lancets misc.) 2 QL (200 units per 30 days) AUTOLET LITE STARTER PACK KIT (lancets misc.) 2 QL (200 units per 30 days) AUTOLET PLATFORMS (lancets misc.) 2 QL (200 units per 30 days) BD LANCET ULTRAFINE 30G (lancets) 2 QL (204 lancets per 30 days) BD LANCET ULTRAFINE 33G (lancets) 2 QL (204 lancets per 30 days) BD MICROTAINER LANCETS (lancets) 2 QL (204 lancets per 30 days) CAREONE LANCET SUPER THIN 30G (lancets) 2 QL (204 lancets per 30 days) CAREONE LANCET THIN 23G 2 QL (204 lancets per 30 days) CARESENS LANCETS (lancets) 2 QL (204 lancets per 30 days) CARETOUCH SAFETY LANCETS (lancets) 2 QL (204 lancets per 30 days) CARETOUCH SAFETY LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) CARETOUCH TWIST LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) CARETOUCH TWIST LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) CARETOUCH TWIST LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) CLEANLET LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) CLEVER CHEK LANCETS (lancets) 2 QL (204 lancets per 30 days) CLEVER CHOICE LANCETS 21G (lancets) 2 QL (204 lancets per 30 days) CLEVER CHOICE LANCETS 23G (lancets) 2 QL (204 lancets per 30 days) CLEVER CHOICE LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) COAGUCHEK LANCETS (lancets) 2 QL (204 lancets per 30 days) COMFORT ASSURED LANCETS 28G 2 QL (204 lancets per 30 days) COMFORT ASSURED LANCETS 33G 2 QL (204 lancets per 30 days) COMFORT LANCETS 2 QL (204 lancets per 30 days) COMFORT TOUCH LANCETS 31G (lancets) 2 QL (204 lancets per 30 days) COMFORT TOUCH PLUS LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) CVS LANCETS 21G 2 QL (204 lancets per 30 days) CVS LANCETS MICRO THIN 33G 2 QL (204 lancets per 30 days) CVS LANCETS ORIGINAL 2 QL (204 lancets per 30 days) CVS LANCETS THIN 26G 2 QL (204 lancets per 30 days) CVS LANCETS ULTRA THIN 30G 2 QL (204 lancets per 30 days) CVS LANCETS ULTRA-THIN 30G 2 QL (204 lancets per 30 days) CVS ULTRA THIN LANCETS 2 QL (204 lancets per 30 days) DEXCOM G4 PLAT PED RCV/SHARE DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) DEXCOM G4 PLAT PED RECEIVER DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 153 Coverage Requirements and Prescription Drug Name Drug Tier Limits DEXCOM G4 PLATINUM RCV/SHARE DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) DEXCOM G4 PLATINUM RECEIVER DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) DEXCOM G4 PLATINUM TRANSMITTER (continuous blood gluc 2 PA transmit) DEXCOM G4 SENSOR (continuous blood gluc sensor) 2 PA DEXCOM G5 MOB/G4 PLAT SENSOR (continuous blood gluc sensor) 2 PA; QL (5 units per 30 days) DEXCOM G5 MOBILE RECEIVER DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) DEXCOM G5 MOBILE TRANSMITTER (continuous blood gluc transmit) 2 PA; QL (1 unit per 90 days) DEXCOM G5 RECEIVER KIT DEVICE (continuous blood gluc receiver) 2 PA; QL (1 unit per 365 days) DEXCOM G6 RECEIVER DEVICE (continuous blood gluc receiver) 2 PA; QL (1 unit per 365 days) DEXCOM G6 SENSOR (continuous blood gluc sensor) 2 PA; QL (3 units per 30 days) DEXCOM G6 TRANSMITTER (continuous blood gluc transmit) 2 PA; QL (1 unit per 90 days) DIATHRIVE LANCET ULTRA THIN 30 (lancets) 2 QL (204 lancets per 30 days) DIATHRIVE LANCETS (lancets) 2 QL (204 lancets per 30 days) DROPLET LANCETS ULTRA THIN 30G (lancets) 2 QL (204 lancets per 30 days) DROPLET PERSONAL LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) DRUG MART LANCETS THIN 26G 2 QL (204 lancets per 30 days) DRUG MART ON-THE-GO LANCET 30G (lancets) 2 QL (204 lancets per 30 days) DRUG MART UNILET LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) DRUG MART UNILET LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) DRUG MART UNILET LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) EASY COMFORT LANCETS 2 QL (204 lancets per 30 days) EASY COMFORT LANCETS TWIST TOP 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 21G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 23G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 28G/TWIST (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 30G/TWIST (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 32G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 32G/TWIST (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 33G/TWIST (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH SAFETY LANCETS 21G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH SAFETY LANCETS 23G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH SAFETY LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH SAFETY LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) EMBRACE LANCETS ULTRA THIN 30G (lancets) 2 QL (204 lancets per 30 days) ENLITE GLUCOSE SENSOR (continuous blood gluc sensor) 3 PA

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 154 Coverage Requirements and Prescription Drug Name Drug Tier Limits EQL COLOR LANCETS 21G 2 QL (204 lancets per 30 days) EQL COLOR LANCETS MICRO 33G 2 QL (204 lancets per 30 days) EQL SUPER THIN LANCETS 30G 2 QL (204 lancets per 30 days) EQL THIN LANCETS 26G 2 QL (204 lancets per 30 days) EVERSENSE SENSOR/HOLDER (continuous blood gluc sensor) 3 PA EVERSENSE SMART TRANSMITTER (continuous blood gluc transmit) 3 PA; QL (1 unit per 365 days) E-Z JECT LANCET MICRO-THIN 33G (lancets) 2 QL (204 lancets per 30 days) E-Z JECT LANCET SUPER THIN 30G (lancets) 2 QL (204 lancets per 30 days) E-Z JECT LANCETS (lancets) 2 QL (204 lancets per 30 days) E-Z JECT LANCETS 21G (lancets) 2 QL (204 lancets per 30 days) E-Z JECT LANCETS THIN 26G (lancets) 2 QL (204 lancets per 30 days) EZ-LETS LANCETS 21G (lancets) 2 QL (204 lancets per 30 days) EZ-LETS LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) EZ-LETS LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) EZ-LETS LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) FIFTY50 SAFETY SEAL LANCETS (lancets) 2 QL (204 lancets per 30 days) FIFTY50 UNILET LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) FINE 30 (lancets) 2 QL (204 lancets per 30 days) FINGERSTIX LANCETS (lancets) 2 QL (204 lancets per 30 days) FORA LANCETS (lancets) 2 QL (204 lancets per 30 days) FREDS PHARMACY UNILET LANC 28G 2 QL (204 lancets per 30 days) FREDS PHARMACY UNILET LANC 30G 2 QL (204 lancets per 30 days) FREESTYLE LANCETS (lancets) 2 QL (204 lancets per 30 days) FREESTYLE LIBRE 14 DAY READER DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) FREESTYLE LIBRE 14 DAY SENSOR (continuous blood gluc sensor) 2 PA; QL (2 units per 28 days) FREESTYLE LIBRE 2 READER DEVICE (continuous blood gluc 2 PA; QL (1 reader per 1 year) receiver) FREESTYLE LIBRE 2 SENSOR (continuous blood gluc sensor) 2 PA; QL (2 units per 28 days) FREESTYLE LIBRE READER DEVICE (continuous blood gluc receiver) 2 PA; QL (1 unit per 365 days) FREESTYLE LIBRE SENSOR SYSTEM (continuous blood gluc sensor) 2 PA; QL (2 units per 28 days) FREESTYLE UNISTICK II LANCETS (lancets) 2 QL (204 lancets per 30 days) GENTEEL BUTTERFLY TOUCH LANCET (lancets) 2 QL (204 lancets per 30 days) GENTEEL CONTACT TIPS (BLUE) (lancets misc.) 2 QL (200 units per 30 days) GENTEEL CONTACT TIPS (CLEAR) (lancets misc.) 2 QL (200 units per 30 days) GENTEEL CONTACT TIPS (GREEN) (lancets misc.) 2 QL (200 units per 30 days) GENTEEL CONTACT TIPS (ORANGE) (lancets misc.) 2 QL (200 units per 30 days) GENTEEL CONTACT TIPS (RAINBOW) (lancets misc.) 2 QL (200 units per 30 days) GENTEEL CONTACT TIPS (VIOLET) (lancets misc.) 2 QL (200 units per 30 days) GENTEEL CONTACT TIPS (YELLOW) (lancets misc.) 2 QL (200 units per 30 days) GENTEEL LANCING KIT (BLUE) KIT (lancets misc.) 2 QL (200 units per 30 days) GENTEEL NOZZLES (lancets misc.) 2 QL (200 units per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 155 Coverage Requirements and Prescription Drug Name Drug Tier Limits GENTLE-LET GP LANCETS (lancets) 2 QL (204 lancets per 30 days) GENTLE-LET LANCETS (lancets) 2 QL (204 lancets per 30 days) GENTLE-LET PLATFORMS (lancets misc.) 2 QL (200 units per 30 days) GLOBAL INJECT EASE LANCETS 28G 2 QL (204 lancets per 30 days) GLOBAL INJECT EASE LANCETS 30G 2 QL (204 lancets per 30 days) GLUCOCOM LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) GLUCOCOM LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) GLUCOCOM LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) GNP LANCETS 21G 2 QL (204 lancets per 30 days) GNP LANCETS MICRO THIN 33G 2 QL (204 lancets per 30 days) GNP LANCETS SUPER THIN 30G 2 QL (204 lancets per 30 days) GNP LANCETS THIN 2 QL (204 lancets per 30 days) GNP LANCETS THIN 26G 2 QL (204 lancets per 30 days) GOJJI STERILE LANCETS (lancets) 2 QL (204 lancets per 30 days) GOODSENSE COLOR LANCETS 33G 2 QL (204 lancets per 30 days) GOODSENSE LANCETS 26G UNIV 2 QL (204 lancets per 30 days) GOODSENSE LANCETS 30G 2 QL (204 lancets per 30 days) GOODSENSE LANCETS 30G UNIV 2 QL (204 lancets per 30 days) GOODSENSE LANCETS 33G 2 QL (204 lancets per 30 days) GOODSENSE LANCETS 33G UNIV 2 QL (204 lancets per 30 days) GUARDIAN CONNECT TRANSMITTER (continuous blood gluc transmit) 3 PA; QL (2 units per 365 days) GUARDIAN LINK 3 TRANSMITTER (continuous blood gluc transmit) 3 PA GUARDIAN REAL-TIME REPLACE PED DEVICE (continuous blood 3 PA; QL (1 unit per 365 days) gluc receiver) GUARDIAN SENSOR (3) (continuous blood gluc sensor) 3 PA; QL (5 units per 30 days) GUARDIAN SENSOR 3 3 PA; QL (5 units per 30 days) HAEMOLANCE (lancets) 2 QL (204 lancets per 30 days) HAEMOLANCE LOW FLOW LANCETS (lancets) 2 QL (204 lancets per 30 days) HAEMOLANCE PLUS (lancets) 2 QL (204 lancets per 30 days) HAEMOLANCE PLUS HIGH FLOW (lancets) 2 QL (204 lancets per 30 days) HAEMOLANCE PLUS LOW FLOW (lancets) 2 QL (204 lancets per 30 days) HAEMOLANCE PLUS MAX FLOW (lancets) 2 QL (204 lancets per 30 days) HAEMOLANCE PLUS PEDIATRIC FLOW (lancets) 2 QL (204 lancets per 30 days) HEALTHY ACCENTS UNILET LANCETS 2 QL (204 lancets per 30 days) H-E-B INCONTROL LANCETS 28G 2 QL (204 lancets per 30 days) H-E-B INCONTROL LANCETS 30G 2 QL (204 lancets per 30 days) H-E-B INCONTROL LANCETS 33G 2 QL (204 lancets per 30 days) HYPOLANCE AST LANCING KIT (lancets misc.) 2 QL (200 units per 30 days) HY-VEE LANCETS (lancets) 2 QL (204 lancets per 30 days) HY-VEE THIN LANCETS 2 QL (204 lancets per 30 days) IN TOUCH STERILE LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) KINNEY LANCETS 2 QL (204 lancets per 30 days) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 156 Coverage Requirements and Prescription Drug Name Drug Tier Limits KINNEY THIN LANCETS 2 QL (204 lancets per 30 days) KROGER HEALTHPRO LANCET 26G (lancets) 2 QL (204 lancets per 30 days) KROGER LANCETS 2 QL (204 lancets per 30 days) KROGER LANCETS 21G 2 QL (204 lancets per 30 days) KROGER LANCETS MICRO THIN 33G 2 QL (204 lancets per 30 days) KROGER LANCETS SUPER THIN 2 QL (204 lancets per 30 days) KROGER LANCETS THIN 2 QL (204 lancets per 30 days) KROGER LANCETS THIN 26G 2 QL (204 lancets per 30 days) KROGER LANCETS ULTRATHIN 30G 2 QL (204 lancets per 30 days) LANCET TRANSPORTER CASE 2 QL (200 units per 30 days) LANCETS 2 QL (204 lancets per 30 days) LANCETS 30G 2 QL (204 lancets per 30 days) LANCETS 33G 2 QL (204 lancets per 30 days) LANCETS MICRO THIN 33G 2 QL (204 lancets per 30 days) LANCETS SUPER THIN 28G 2 QL (204 lancets per 30 days) LANCETS THIN 2 QL (204 lancets per 30 days) LANCETS ULTRA THIN (lancets) 2 QL (204 lancets per 30 days) LANCETS ULTRA THIN 30G 2 QL (204 lancets per 30 days) LIBERTY MEDICAL LANCETS (lancets) 2 QL (204 lancets per 30 days) LIFESCAN UNISTIK 2 (lancets) 2 QL (204 lancets per 30 days) LIFESCAN UNISTIK II LANCETS (lancets) 2 QL (204 lancets per 30 days) LITE TOUCH LANCETS 2 QL (204 lancets per 30 days) LITETOUCH LANCETS (lancets) 2 QL (204 lancets per 30 days) LIVE BETTER LANCET SUPER THIN 2 QL (204 lancets per 30 days) LIVE BETTER LANCET ULTRA THIN 2 QL (204 lancets per 30 days) LONGS LANCETS STANDARD 2 QL (204 lancets per 30 days) LONGS LANCETS THIN 2 QL (204 lancets per 30 days) LONGS LANCETS ULTRA THIN 2 QL (204 lancets per 30 days) MEDICHOICE SAFETY LANCET 2 QL (204 lancets per 30 days) MEDICHOICE SAFETY LANCET EXTRA 2 QL (204 lancets per 30 days) MEDICHOICE SAFETY LANCET NORM 2 QL (204 lancets per 30 days) MEDISENSE THIN LANCETS (lancets) 2 QL (204 lancets per 30 days) MEDLANCE EXTRA 21G (lancets) 2 QL (204 lancets per 30 days) MEDLANCE LITE 25G (lancets) 2 QL (204 lancets per 30 days) MEDLANCE PLUS EXTRA 21G (lancets) 2 QL (204 lancets per 30 days) MEDLANCE PLUS LANCETS (lancets) 2 QL (204 lancets per 30 days) MEDLANCE PLUS LITE 25G (lancets) 2 QL (204 lancets per 30 days) MEDLANCE PLUS SPECIAL 0.8MM (lancets) 2 QL (204 lancets per 30 days) MEDLANCE PLUS SUPERLITE 30G (lancets) 2 QL (204 lancets per 30 days) MEDLANCE PLUS UNIVERSAL 21G (lancets) 2 QL (204 lancets per 30 days) MEDLANCE UNIVERSAL 21G (lancets) 2 QL (204 lancets per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 157 Coverage Requirements and Prescription Drug Name Drug Tier Limits MEIJER LANCETS (lancets) 2 QL (204 lancets per 30 days) MEIJER LANCETS THIN (lancets) 2 QL (204 lancets per 30 days) MEIJER LANCETS UNIVERSAL 21G (lancets) 2 QL (204 lancets per 30 days) MEIJER LANCETS UNIVERSAL 30G (lancets) 2 QL (204 lancets per 30 days) MEIJER LANCETS UNIVERSAL 33G (lancets) 2 QL (204 lancets per 30 days) MEIJER SUPER THIN LANCETS (lancets) 2 QL (204 lancets per 30 days) MICROLET LANCETS (lancets) 2 QL (204 lancets per 30 days) MINILINK REAL-TIME TRANSMITTER (continuous blood gluc 3 PA transmit) MINIMED 630G GUARDIAN PRESS (continuous blood gluc transmit) 3 PA MINIMED GUARDIAN LINK 3 (continuous blood gluc transmit) 3 PA MM TWIST LANCETS (lancets) 2 QL (204 lancets per 30 days) MONOLET LANCETS (lancets) 2 QL (204 lancets per 30 days) MONOLET OPD LANCETS (lancets) 2 QL (204 lancets per 30 days) MONOLETTOR SAFETY LANCETS (lancets) 2 QL (204 lancets per 30 days) MPD SAFETY LANCET 21G 2 QL (204 lancets per 30 days) MPD SAFETY LANCET 23G 2 QL (204 lancets per 30 days) MPD SAFETY LANCET 28G 2 QL (204 lancets per 30 days) MPD SAFETY LANCET 30G 2 QL (204 lancets per 30 days) MULTI-LANCET DEVICE 2 KIT (lancets misc.) 2 QL (200 units per 30 days) MYGLUCOHEALTH LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) NOVA SAFETY LANCETS 23G (lancets) 2 QL (204 lancets per 30 days) NOVA SAFETY LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) NOVA SUREFLEX LANCETS (lancets) 2 QL (204 lancets per 30 days) ONETOUCH CLUB LANCETS FINE PT (lancets) 2 QL (204 lancets per 30 days) ONETOUCH DELICA LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) ONETOUCH DELICA LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) ONETOUCH DELICA PLUS LANCET30G (lancets) 2 QL (204 lancets per 30 days) ONETOUCH DELICA PLUS LANCET33G (lancets) 2 QL (204 lancets per 30 days) ONETOUCH FINEPOINT LANCETS (lancets) 2 QL (204 lancets per 30 days) ONETOUCH SURESOFT LANCING DEV (lancets misc.) 2 QL (200 units per 30 days) ONETOUCH ULTRASOFT LANCETS (lancets) 2 QL (204 lancets per 30 days) PARADIGM REAL-TIME TRANSMITTER (continuous blood gluc 3 PA transmit) PC LANCETS SUPER THIN 30G 2 QL (204 lancets per 30 days) PENLET II BLOOD SAMPLER KIT (lancets misc.) 2 QL (200 units per 30 days) PENLET II REPLACEMENT CAP (lancets misc.) 2 QL (200 units per 30 days) PERFECT LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) PERFECT LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) PHARMACIST CHOICE LANCETS (lancets) 2 QL (204 lancets per 30 days) PHARMACY COUNTER LANCETS (lancets) 2 QL (204 lancets per 30 days) PIP LANCETS 28G 2 QL (204 lancets per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 158 Coverage Requirements and Prescription Drug Name Drug Tier Limits PIP LANCETS 30G 2 QL (204 lancets per 30 days) PRECISION THINS GP LANCETS (lancets) 2 QL (204 lancets per 30 days) PREFERRED PLUS LANCETS COLORED 2 QL (204 lancets per 30 days) PREFERRED PLUS LANCETS THIN 2 QL (204 lancets per 30 days) PRO COMFORT LANCETS 30G 2 QL (204 lancets per 30 days) PRO COMFORT LANCETS 31G 2 QL (204 lancets per 30 days) PRODIGY LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) PRODIGY SAFETY LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) PRODIGY TWIST TOP LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) PSS SELECT GP LANCETS (lancets) 2 QL (204 lancets per 30 days) PSS SELECT PLATFORMS (lancets misc.) 2 QL (200 units per 30 days) PSS SELECT SAFETY LANCETS (lancets) 2 QL (204 lancets per 30 days) PURE COMFORT LANCETS 30G 2 QL (204 lancets per 30 days) PX LANCETS MICROTHIN 33G 2 QL (204 lancets per 30 days) PX LANCETS ULTRA THIN 2 QL (204 lancets per 30 days) PX LANCETS ULTRA THIN 28G 2 QL (204 lancets per 30 days) QC LANCETS SUPER THIN 30G 2 QL (204 lancets per 30 days) QC LANCETS ULTRA THIN 2 QL (204 lancets per 30 days) QC UNILET LANCETS 28G 2 QL (204 lancets per 30 days) QC UNILET LANCETS MICRO THIN 2 QL (204 lancets per 30 days) RA E-ZJECT LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) RA E-ZJECT LANCETS THIN 26G (lancets) 2 QL (204 lancets per 30 days) RA E-ZJECT LANCETS THIN 28G (lancets) 2 QL (204 lancets per 30 days) RA E-ZJECT LANCETS ULTRA THIN (lancets) 2 QL (204 lancets per 30 days) READYLANCE SAFETY LANCETS (lancets) 2 QL (204 lancets per 30 days) REALITY LANCETS 2 QL (204 lancets per 30 days) REALITY TRIGGER LANCETS 2 QL (204 lancets per 30 days) RELION LANCETS MICRO-THIN 33G (lancets) 2 QL (204 lancets per 30 days) RELION LANCETS THIN 26G (lancets) 2 QL (204 lancets per 30 days) RELION LANCETS ULTRA-THIN 30G (lancets) 2 QL (204 lancets per 30 days) RELION LANCING DEVICE KIT (lancets misc.) 2 QL (200 units per 30 days) RELION ULTRA THIN LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) RELION ULTRA THIN PLUS LANCETS (lancets) 2 QL (204 lancets per 30 days) REXALL LANCETS ULTRA THIN 30G (lancets) 2 QL (204 lancets per 30 days) RIGHTEST ALTERNATE SITE ADAPT (lancets misc.) 2 QL (200 units per 30 days) RIGHTEST GL300 LANCETS (lancets) 2 QL (204 lancets per 30 days) SAFE-T-LANCE (lancets) 2 QL (204 lancets per 30 days) SAFE-T-LANCE PLUS (lancets) 2 QL (204 lancets per 30 days) SAFETY LANCET 30G/PRESSURE ACT 2 QL (204 lancets per 30 days) SAFETY LANCETS (lancets) 2 QL (204 lancets per 30 days) SAFETY LANCETS 21G (lancets) 2 QL (204 lancets per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 159 Coverage Requirements and Prescription Drug Name Drug Tier Limits SAFETY LANCETS 28G 2 QL (204 lancets per 30 days) SAPS HEALTH TWIST TOP LANCETS 2 QL (204 lancets per 30 days) SAPS TWIST TOP LANCETS 2 QL (204 lancets per 30 days) SAPSCARE TWIST TOP LANCETS 2 QL (204 lancets per 30 days) SB LANCETS THIN 2 QL (204 lancets per 30 days) SB LANCETS ULTRA THIN 2 QL (204 lancets per 30 days) SELECT-LITE DEVICE/LANCETS KIT 2 QL (200 units per 30 days) SHOPKO ON-THE-GO LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) SHOPKO UNILET LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) SHOPKO UNILET LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) SINGLE-LET (lancets) 2 QL (204 lancets per 30 days) SM LANCETS 33G 2 QL (204 lancets per 30 days) SMART SENSE COLOR LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) SMART SENSE STANDARD LANCETS (lancets) 2 QL (204 lancets per 30 days) SMART SENSE SUPER THIN LANCETS (lancets) 2 QL (204 lancets per 30 days) SMART SENSE THIN LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) SMARTEST LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) SOLUS V2 LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) SOLUS V2 TWIST LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) STERILANCE PA (lancets misc.) 2 QL (200 units per 30 days) STERILANCE TL (lancets) 2 QL (204 lancets per 30 days) SUPER THIN LANCETS 2 QL (204 lancets per 30 days) SURE COMFORT LANCETS 18G 2 QL (204 lancets per 30 days) SURE COMFORT LANCETS 21G 2 QL (204 lancets per 30 days) SURE COMFORT LANCETS 23G 2 QL (204 lancets per 30 days) SURE COMFORT LANCETS 28G 2 QL (204 lancets per 30 days) SURE COMFORT LANCETS 30G 2 QL (204 lancets per 30 days) SURE-LANCE FLAT LANCETS (lancets) 2 QL (204 lancets per 30 days) SURE-LANCE LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) SURE-LANCE THIN LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) SURE-LANCE ULTRA THIN LANCETS (lancets) 2 QL (204 lancets per 30 days) SURELITE LANCETS (lancets) 2 QL (204 lancets per 30 days) SURE-TOUCH LANCETS UNIVERSAL (lancets) 2 QL (204 lancets per 30 days) TECHLITE AST LANCETS (lancets) 2 QL (204 lancets per 30 days) TECHLITE LANCETS (lancets) 2 QL (204 lancets per 30 days) TECHLITE LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) TGT LANCET MICRO THIN 33G 2 QL (204 lancets per 30 days) TGT LANCET THIN 26G 2 QL (204 lancets per 30 days) TGT LANCET ULTRA THIN 30G 2 QL (204 lancets per 30 days) THINLETS GP LANCETS (lancets) 2 QL (204 lancets per 30 days) TODAYS HEALTH THIN LANCETS 28G 2 QL (204 lancets per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 160 Coverage Requirements and Prescription Drug Name Drug Tier Limits TODAYS HEALTH THIN LANCETS 30G 2 QL (204 lancets per 30 days) TOPCARE LANCETS MICRO-THIN 33G 2 QL (204 lancets per 30 days) TRAVEL LANCETS 2 QL (204 lancets per 30 days) TRAVEL LANCETS ADVANCED 28G (lancets) 2 QL (204 lancets per 30 days) TRUE COMFORT TWIST TOP LANCETS 2 QL (204 lancets per 30 days) TRUEPLUS LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) TRUEPLUS LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) TRUEPLUS LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) TRUEPLUS LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) TRUEPLUS SAFETY LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) ULTILET CLASSIC LANCETS (lancets) 2 QL (204 lancets per 30 days) ULTILET LANCETS (lancets) 2 QL (204 lancets per 30 days) ULTILET SAFETY LANCETS (lancets) 2 QL (204 lancets per 30 days) ULTILET SAFETY LANCETS 23G (lancets) 2 QL (204 lancets per 30 days) ULTRA THIN LANCETS 31G 2 QL (204 lancets per 30 days) ULTRA-CARE LANCETS 30G 2 QL (204 lancets per 30 days) ULTRA-THIN II AUTO LANCET (lancets) 2 QL (204 lancets per 30 days) ULTRA-THIN II LANCETS (lancets) 2 QL (204 lancets per 30 days) UNILET COMFORTOUCH LANCET (lancets) 2 QL (204 lancets per 30 days) UNILET EXCELITE (lancets) 2 QL (204 lancets per 30 days) UNILET EXCELITE II (lancets) 2 QL (204 lancets per 30 days) UNILET G.P. LANCET (lancets) 2 QL (204 lancets per 30 days) UNILET G.P. SUPERLITE LANCET (lancets) 2 QL (204 lancets per 30 days) UNILET GP 28 ULTRA THIN (lancets) 2 QL (204 lancets per 30 days) UNILET LANCET (lancets) 2 QL (204 lancets per 30 days) UNILET MICRO-THIN 33G (lancets) 2 QL (204 lancets per 30 days) UNILET SUPERLITE LANCET (lancets) 2 QL (204 lancets per 30 days) UNILET SUPER-THIN 30G (lancets) 2 QL (204 lancets per 30 days) UNILET ULTRA-THIN 28G (lancets) 2 QL (204 lancets per 30 days) UNISTIK 1 (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 2 (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 2 COMFORT (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 2 EXTRA (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 2 NEONATAL (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 2 NORMAL (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 2 SUPER (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 3 (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 3 COMFORT (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 3 EXTRA (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 3 GENTLE (lancets) 2 QL (204 lancets per 30 days) UNISTIK 3 NEONATAL (lancets misc.) 2 QL (200 units per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 161 Coverage Requirements and Prescription Drug Name Drug Tier Limits UNISTIK 3 NORMAL (lancets misc.) 2 QL (200 units per 30 days) UNISTIK CZT COMFORT (lancets misc.) 2 QL (200 units per 30 days) UNISTIK CZT NORMAL (lancets misc.) 2 QL (200 units per 30 days) UNISTIK NORMAL (lancets misc.) 2 QL (200 units per 30 days) UNISTIK PRO SAFETY LANCET (lancets) 2 QL (204 lancets per 30 days) UNISTIK SAFETY LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) UNISTIK SAFETY LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) UNISTIK TOUCH SAFETY LANC 21G (lancets) 2 QL (204 lancets per 30 days) UNISTIK TOUCH SAFETY LANC 23G (lancets) 2 QL (204 lancets per 30 days) UNISTIK TOUCH SAFETY LANC 28G (lancets) 2 QL (204 lancets per 30 days) UNISTIK TOUCH SAFETY LANC 30G (lancets) 2 QL (204 lancets per 30 days) UNIVERSAL 1 LANCETS THIN 26G (lancets) 2 QL (204 lancets per 30 days) UNIVERSAL 1 LANCETS THIN 33G (lancets) 2 QL (204 lancets per 30 days) UNIVERSAL 1 LANCETS ULTRA THIN (lancets) 2 QL (204 lancets per 30 days) VALUE PLUS LANCET STANDARD 21G 2 QL (204 lancets per 30 days) VALUE PLUS LANCETS SUPER THIN 2 QL (204 lancets per 30 days) VALUE PLUS LANCETS THIN 26G 2 QL (204 lancets per 30 days) VALUMARK LANCET SUPER THIN 30G 2 QL (204 lancets per 30 days) VALUMARK LANCET ULTRA THIN 28G 2 QL (204 lancets per 30 days) VIDA MIA UNILET LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) VIDA MIA UNILET LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) VIVAGUARD LANCETS (lancets) 2 QL (204 lancets per 30 days) WALGREENS ADV TRAVEL LANCETS 2 QL (204 lancets per 30 days) WALGREENS LANCETS (lancets) 2 QL (204 lancets per 30 days) WALGREENS LANCETS MICRO THIN 2 QL (204 lancets per 30 days) WALGREENS LANCETS SUPER THIN 2 QL (204 lancets per 30 days) WALGREENS THIN LANCETS (lancets) 2 QL (204 lancets per 30 days) WALGREENS ULTRA THIN LANCETS (lancets) 2 QL (204 lancets per 30 days) *INSULIN ADMINISTRATION SUPPLIES*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT OMNIPOD 5 PACK (insulin disposable pump) 2 PA; QL (15 pods per 30 days) OMNIPOD DASH 5 PACK PODS (insulin disposable pump) 2 PA; QL (15 pods per 30 days) OMNIPOD STARTER KIT (insulin disposable pump) 2 PA; QL (1 unit per 4 yearss) *NEEDLES & SYRINGES*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT 1ST TIER UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) 1ST TIER UNIFINE PENTIPS PLUS 3 ST; QL (200 needles per 30 days) ABOUTTIME PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) ADVOCATE INSULIN PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ADVOCATE INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ASSURE ID INSULIN SAFETY SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ASSURE ID SAFETY PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 162 Coverage Requirements and Prescription Drug Name Drug Tier Limits AURORA PEN NEEDLES 3 ST; QL (200 needles per 30 days) AURORA UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) BD AUTOSHIELD (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD AUTOSHIELD DUO (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD INSULIN SYR ULTRAFINE II (insulin syringe-needle u-100) 2 ST; QL (200 syringes per 30 days) BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 2 QL (200 syringes per 30 days) ML, 27.5G X 5/8" 2 ML (insulin syringe-needle u-100) BD INSULIN SYRINGE 27G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 2 ST; QL (200 syringes per 30 days) 1/2" 0.5 ML, 29G X 1/2" 1 ML (insulin syringe-needle u-100) BD INSULIN SYRINGE HALF-UNIT (insulin syringe-needle u-100) 2 QL (200 syringes per 30 days) BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML (insulin syringe- 2 QL (200 syringes per 30 days) needle u-100) BD INSULIN SYRINGE MICROFINE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 2 ST; QL (200 syringes per 30 days) ML (insulin syringe-needle u-100) BD INSULIN SYRINGE U/F (insulin syringe-needle u-100) 2 ST; QL (200 syringes per 30 days) BD INSULIN SYRINGE U/F 1/2UNIT (insulin syringe-needle u-100) 2 ST; QL (200 syringes per 30 days) BD INSULIN SYRINGE U-100 1 ML (insulin syringes (disposable)) 2 ST; QL (200 syringes per 30 days) BD INSULIN SYRINGE U-500 (insulin syringe/needle u-500) 2 QL (200 syringes per 30 days) BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.5 ML, 31G X 5/16" 0.5 ML 2 ST; QL (200 syringes per 30 days) (insulin syringe-needle u-100) BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.3 ML (insulin 2 QL (200 syringes per 30 days) syringe-needle u-100) BD PEN NEEDLE MICRO U/F (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD PEN NEEDLE MINI U/F (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD PEN NEEDLE NANO 2ND GEN (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD PEN NEEDLE NANO U/F (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD PEN NEEDLE ORIGINAL U/F (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD PEN NEEDLE SHORT U/F (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 2 ST; QL (200 syringes per 30 days) 31G X 5/16" 0.3 ML (insulin syringe-needle u-100) BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 1 ML (insulin 2 QL (200 syringes per 30 days) syringe-needle u-100) BD SAFETY-LOK INSULIN SYRINGE (insulin syringe-needle u-100) 2 ST; QL (200 syringes per 30 days) BD VEO INSULIN SYR U/F 1/2UNIT (insulin syringe-needle u-100) 2 ST; QL (200 syringes per 30 days) BD VEO INSULIN SYRINGE U/F 31G X 15/64" 0.3 ML, 31G X 15/64" 2 ST; QL (200 syringes per 30 days) 0.5 ML (insulin syringe-needle u-100) BD VEO INSULIN SYRINGE U/F 31G X 15/64" 1 ML (insulin syringe- 2 QL (200 syringes per 30 days) needle u-100) CAREFINE PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) CAREONE INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) CAREONE UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) CAREONE UNIFINE PENTIPS PLUS 3 ST; QL (200 needles per 30 days) CARETOUCH INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 163 Coverage Requirements and Prescription Drug Name Drug Tier Limits CARETOUCH PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) CLEVER CHOICE COMFORT EZ (insulin pen needle) 3 ST; QL (200 needles per 30 days) CLICKFINE PEN NEEDLES 3 ST; QL (200 needles per 30 days) COMFORT ASSIST INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) COMFORT EZ INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) COMFORT EZ MICRO PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) COMFORT EZ PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) COMFORT EZ SHORT PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) COMFORT TOUCH INSULIN PEN NEED (insulin pen needle) 3 ST; QL (200 needles per 30 days) DIATHRIVE PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) DROPLET INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 15/64" 0.3 ML, 30G X 15/64" 1 ML, 30G X 5/16" 0.3 ML, 30G 3 ST; QL (200 syringes per 30 days) X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) DROPLET INSULIN SYRINGE 30G X 15/64" 0.5 ML (insulin syringe- 3 QL (200 syringes per 30 days) needle u-100) DROPLET MICRON (insulin pen needle) 3 QL (200 needles per 30 days) DROPLET PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) DROPSAFE SAFETY PEN NEEDLES 3 ST; QL (200 needles per 30 days) DRUG MART UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) DRUG MART UNIFINE PENTIPS PLUS 3 ST; QL (200 needles per 30 days) EASY COMFORT INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) EASY COMFORT PEN NEEDLES 3 ST; QL (200 needles per 30 days) EASY GLIDE PEN NEEDLES 3 ST; QL (200 needles per 30 days) EASY TOUCH FLIPLOCK INSULIN SY (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) EASY TOUCH INSULIN SAFETY SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) EASY TOUCH INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) EASY TOUCH PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) EASY TOUCH SAFETY PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) EASY TOUCH SHEATHLOCK SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) EQL INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) EXEL COMFORT POINT INSULIN SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) EXEL COMFORT POINT PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) FIFTY50 PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) FIFTY50 SUPERIOR COMFORT SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) FREDS PHARMACY UNIFINE PENTIP+ 3 ST; QL (200 needles per 30 days) FREDS PHARMACY UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) FREESTYLE PRECISION INS SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) GLOBAL EASE INJECT PEN NEEDLES 3 ST; QL (200 needles per 30 days) GLOBAL EASY GLIDE INSULIN SYR 31G X 15/64" 0.3 ML, 31G X 3 ST; QL (200 syringes per 30 days) 15/64" 0.5 ML, 31G X 5/16" 0.3 ML

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 164 Coverage Requirements and Prescription Drug Name Drug Tier Limits GLOBAL EASY GLIDE INSULIN SYR 31G X 15/64" 1 ML 3 QL (200 syringes per 30 days) GLOBAL EASY GLIDE PEN NEEDLES 3 ST; QL (200 needles per 30 days) GLOBAL INJECT EASE INSULIN SYR 3 ST; QL (200 syringes per 30 days) GLOBAL INSULIN SYRINGES 3 ST; QL (200 syringes per 30 days) GLUCOPRO INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) GNP CLICKFINE PEN NEEDLES 3 ST; QL (200 needles per 30 days) GNP INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) GNP ULTICARE PEN NEEDLES 3 ST; QL (200 needles per 30 days) GNP ULTRA COM INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) GOODSENSE CLICKFINE PEN NEEDLE 3 ST; QL (200 needles per 30 days) GOODSENSE PEN NEEDLE PENFINE (insulin pen needle) 3 ST; QL (200 needles per 30 days) HEALTHWISE INSULIN SYR/NEEDLE 3 ST; QL (200 syringes per 30 days) HEALTHWISE MICRON PEN NEEDLES 3 ST; QL (200 needles per 30 days) HEALTHWISE MINI PEN NEEDLES 3 ST; QL (200 needles per 30 days) HEALTHWISE PEN NEEDLES 3 ST; QL (200 needles per 30 days) HEALTHWISE SHORT PEN NEEDLES 3 ST; QL (200 needles per 30 days) HEALTHWISE UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) HEALTHY ACCENTS UNIFINE PENTIP 3 ST; QL (200 needles per 30 days) H-E-B INCONTROL PEN NEEDLES 3 ST; QL (200 needles per 30 days) H-E-B INCONTROL UNIFINE PENTIP (insulin pen needle) 3 ST; QL (200 needles per 30 days) HM ULTICARE INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) HM ULTICARE MINI PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) HM ULTICARE SHORT PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) INSULIN SYRINGE/NEEDLE 3 ST; QL (200 syringes per 30 days) INSULIN SYRINGE-NEEDLE U-100 3 ST; QL (200 syringes per 30 days) INSUPEN PEN NEEDLES 3 ST; QL (200 needles per 30 days) INSUPEN SENSITIVE (insulin pen needle) 3 ST; QL (200 needles per 30 days) INSUPEN ULTRAFIN (insulin pen needle) 3 ST; QL (200 needles per 30 days) KINRAY INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) KMART VALU INSULIN SYRINGE 29G 3 ST; QL (200 syringes per 30 days) KMART VALU INSULIN SYRINGE 30G 3 ST; QL (200 syringes per 30 days) KROGER INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) KROGER PEN NEEDLES 3 ST; QL (200 needles per 30 days) LEADER INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) LEADER UNIFINE PENTIPS (insulin pen needle) 3 ST; QL (200 needles per 30 days) LEADER UNIFINE PENTIPS PLUS (insulin pen needle) 3 ST; QL (200 needles per 30 days) LITETOUCH INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) LITETOUCH PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) LONGS INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) MAGELLAN INSULIN SAFETY SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 165 Coverage Requirements and Prescription Drug Name Drug Tier Limits MARATHON MEDICAL PENTIPS (insulin pen needle) 3 ST; QL (200 needles per 30 days) MAXICOMFORT II PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) MAXI-COMFORT INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) MAXI-COMFORT SAFETY PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) MAXICOMFORT SYR 27G X 1/2" (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) MEDIC INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) MEDICINE SHOPPE PEN NEEDLES 3 ST; QL (200 needles per 30 days) MEIJER PEN NEEDLES 3 ST; QL (200 needles per 30 days) MICRODOT PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) MM INSULIN SYRINGE/NEEDLE 3 ST; QL (200 syringes per 30 days) MM PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) MONOJECT INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) MONOJECT ULTRA COMFORT SYRINGE (insulin syringe-needle u- 3 ST; QL (200 syringes per 30 days) 100) MS INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) NOVOFINE (insulin pen needle) 3 ST; QL (200 needles per 30 days) NOVOFINE AUTOCOVER (insulin pen needle) 3 ST; QL (200 needles per 30 days) NOVOFINE PLUS (insulin pen needle) 3 ST; QL (200 needles per 30 days) NOVOTWIST (insulin pen needle) 3 ST; QL (200 needles per 30 days) PC UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) PEN NEEDLES 3 ST; QL (200 needles per 30 days) PEN NEEDLES 1/2" 3 ST; QL (200 needles per 30 days) PEN NEEDLES 5/16" 3 ST; QL (200 needles per 30 days) PENTIPS (insulin pen needle) 3 ST; QL (200 needles per 30 days) PRECISION SUREDOSE PLUS SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 3 ST; QL (200 syringes per 30 days) ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML (insulin syringe-needle u-100) PRECISION SURE-DOSE SYRINGE 30G X 3/8" 0.5 ML (insulin syringe- 3 QL (200 syringes per 30 days) needle u-100) PREFERRED PLUS INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) PREFERRED PLUS UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) PREVENT SAFETY PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) PRO COMFORT INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) PRO COMFORT PEN NEEDLES 3 ST; QL (200 needles per 30 days) PRODIGY INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) PURE COMFORT PEN NEEDLE 3 ST; QL (200 needles per 30 days) PX EXTRA SHORT PEN NEEDLES 3 ST; QL (200 needles per 30 days) PX INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) PX MINI PEN NEEDLES 3 ST; QL (200 needles per 30 days) PX PEN NEEDLE 3 ST; QL (200 needles per 30 days) PX SHORTLENGTH PEN NEEDLES 3 ST; QL (200 needles per 30 days) QC PEN NEEDLES 3 ST; QL (200 needles per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 166 Coverage Requirements and Prescription Drug Name Drug Tier Limits QC UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) RA INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) RA PEN NEEDLES 3 ST; QL (200 needles per 30 days) REALITY INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) RELION INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) RELION MINI PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) RELION PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) RELION SHORT PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) SAFETY INSULIN SYRINGES 3 ST; QL (200 syringes per 30 days) SB INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) SECURESAFE INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) SECURESAFE SAFETY PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) SHOPKO UNIFINE PENTIPS (insulin pen needle) 3 ST; QL (200 needles per 30 days) SHOPKO UNIFINE PENTIPS PLUS (insulin pen needle) 3 ST; QL (200 needles per 30 days) SURE COMFORT INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) SURE COMFORT PEN NEEDLES 3 ST; QL (200 needles per 30 days) SURE-FINE PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) SURE-JECT INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) TECHLITE INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) TECHLITE PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) TODAYS HEALTH MINI PEN NEEDLES 3 ST; QL (200 needles per 30 days) TODAYS HEALTH PEN NEEDLES 3 ST; QL (200 needles per 30 days) TODAYS HEALTH SHORT PEN NEEDLE 3 ST; QL (200 needles per 30 days) TOPCARE CLICKFINE PEN NEEDLES 3 ST; QL (200 needles per 30 days) TOPCARE ULTRA COMFORT INS SYR 3 ST; QL (200 syringes per 30 days) TRUE COMFORT INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) TRUE COMFORT PEN NEEDLES 3 ST; QL (200 needles per 30 days) TRUE COMFORT PRO INSULIN SYR 3 ST; QL (200 syringes per 30 days) TRUE COMFORT PRO PEN NEEDLES 3 ST; QL (200 needles per 30 days) TRUEPLUS 5-BEVEL PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) TRUEPLUS INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) TRUEPLUS PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTICARE INSULIN SAFETY SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTICARE INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTICARE MICRO PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTICARE MINI PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTICARE PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTICARE SHORT PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTIGUARD SAFEPACK PEN NEEDLE 3 ST; QL (200 needles per 30 days) ULTIGUARD SAFEPACK SYR/NEEDLE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTILET INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 167 Coverage Requirements and Prescription Drug Name Drug Tier Limits ULTILET INSULIN SYRINGE SHORT (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTILET PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTRA COMFORT INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) ULTRA FLO INSULIN PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTRA FLO INSULIN SYR 1/2 UNIT (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTRA FLO INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTRA THIN PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTRACARE INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) ULTRACARE PEN NEEDLES 3 ST; QL (200 needles per 30 days) ULTRA-COMFORT INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) ULTRA-THIN II INS SYR SHORT (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTRA-THIN II INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTRA-THIN II MINI PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTRA-THIN II PEN NEEDLE SHORT (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTRA-THIN II PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) UNIFINE PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) UNIFINE PENTIPS (insulin pen needle) 3 ST; QL (200 needles per 30 days) UNIFINE PENTIPS PLUS (insulin pen needle) 3 ST; QL (200 needles per 30 days) UNIFINE SAFECONTROL PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) VALUE HEALTH INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) VALUMARK PEN NEEDLES 3 ST; QL (200 needles per 30 days) VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML, 29G X 5/16" 1 ML, 30G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin 3 ST; QL (200 syringes per 30 days) syringe-needle u-100) VANISHPOINT INSULIN SYRINGE 30G X 3/16" 0.5 ML, 30G X 3/16" 1 3 QL (200 syringes per 30 days) ML (insulin syringe-needle u-100) VIDA MIA UNIFINE PENTIPS (insulin pen needle) 3 ST; QL (200 needles per 30 days) VP INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) WEGMANS UNIFINE PENTIPS PLUS 3 ST; QL (200 needles per 30 days) *MIGRAINE PRODUCTS* - DRUGS FOR THE NERVOUS SYSTEM *CALCITONIN GENE-RELATED PEPTIDE RECEPTOR ANTAG (CGRP)*** - DRUGS FOR MIGRAINE HEADACHES NURTEC ORAL TABLET DISPERSIBLE (rimegepant sulfate) 2 PA; QL (8 tablets per 30 days) *CGRP RECEPTOR ANTAGONISTS - MONOCOLONAL ANTIBODIES*** - DRUGS FOR MIGRAINE HEADACHES AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 QL (1 autoinjector per 30 days) (erenumab-aooe) EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION 3 QL (1 syringe per 30 days) PREFILLED SYRINGE (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 QL (1 pen per 30 days) (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 QL (1 syringe per 30 days) (galcanezumab-gnlm)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 168 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ERGOT COMBINATIONS*** - DRUGS FOR MIGRAINE HEADACHES ergotamine-caffeine oral tablet 1 or 1b* migergot rectal suppository 1 or 1b* *MIGRAINE PRODUCTS*** - DRUGS FOR MIGRAINE HEADACHES dihydroergotamine mesylate injection solution 1 or 1b* PA *SELECTIVE SEROTONIN AGONIST-NSAID COMBINATIONS*** - DRUGS FOR MIGRAINE HEADACHES sumatriptan-naproxen sodium oral tablet 1 or 1b* ST; QL (9 tablets per 30 days) *SELECTIVE SEROTONIN AGONISTS 5-HT(1)*** - DRUGS FOR MIGRAINE HEADACHES almotriptan malate oral tablet 1 or 1b* QL (9 tablets per 30 days) eletriptan hydrobromide oral tablet 1 or 1b* QL (9 tablets per 30 days) frovatriptan succinate oral tablet 1 or 1b* ST; QL (9 tablets per 30 days) naratriptan hcl oral tablet 1 or 1b* QL (9 tablets per 30 days) rizatriptan benzoate oral tablet 1 or 1b* QL (9 tablets per 30 days) rizatriptan benzoate oral tablet dispersible 1 or 1b* QL (9 tablets per 30 days) sumatriptan nasal solution 1 or 1b* QL (6 nasal inhalers per 30 days) sumatriptan succinate oral tablet 1 or 1b* QL (9 tablets per 30 days) sumatriptan succinate refill subcutaneous solution cartridge 1 or 1b* QL (6 cartridges per 30 days) sumatriptan succinate subcutaneous solution 1 or 1b* QL (5 vials per 30 days) sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml 1 or 1b* QL (6 syringes (2 ML) per 30 days) sumatriptan succinate subcutaneous solution auto-injector 6 mg/0.5ml 1 or 1b* QL (6 cartridges (2ml) per 30 days) ST; QL (6 nasal inhalers per 30 zolmitriptan nasal solution 1 or 1b* days) zolmitriptan oral tablet 1 or 1b* QL (9 tablets per 30 days) zolmitriptan oral tablet dispersible 1 or 1b* QL (9 tablets per 30 days) *MINERALS & ELECTROLYTES* - DRUGS FOR NUTRITION *BICARBONATES*** - DRUGS FOR NUTRITION SODIUM ACETATE INTRAVENOUS SOLUTION 3 sodium bicarbonate intravenous solution 1 or 1b* THAM INTRAVENOUS SOLUTION (tromethamine) 3 *CALCIUM COMBINATIONS*** - DRUGS FOR NUTRITION CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION 3 *CALCIUM*** - DRUGS FOR NUTRITION CALCIUM GLUCONATE INTRAVENOUS SOLUTION 3 *ELECTROLYTES & DEXTROSE*** - DRUGS FOR NUTRITION DEXTROSE 5%/ELECTROLYTE #48 INTRAVENOUS SOLUTION 3 dextrose in lactated ringers intravenous solution 1 or 1b* DEXTROSE-NACL INTRAVENOUS SOLUTION 10-0.2 %, 2.5-0.45 % 3 dextrose-nacl intravenous solution 10-0.45 %, 5-0.2 %, 5-0.33 %, 5-0.45 %, 5- 1 or 1b* 0.9 %

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 169 Coverage Requirements and Prescription Drug Name Drug Tier Limits dextrose-sodium chloride intravenous solution 2.5-0.45 %, 5-0.45 %, 5-0.9 % 1 or 1b* DEXTROSE-SODIUM CHLORIDE INTRAVENOUS SOLUTION 5- 3 0.225 %, 5-0.3 % ELLIOTTS B INTRATHECAL SOLUTION (intrathecal elec-dextrose) 3 IONOSOL-MB IN D5W INTRAVENOUS SOLUTION (electrolyte-mb in 3 dextrose) ISOLYTE-P IN D5W INTRAVENOUS SOLUTION (electrolyte-p in 3 dextrose) kcl in dextrose-nacl intravenous solution 10-5-0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 1 or 1b* 40-5-0.45 meq/l-%-% KCL IN DEXTROSE-NACL INTRAVENOUS SOLUTION 20-5-0.225 3 MEQ/L-%-%, 40-5-0.9 MEQ/L-%-% KCL-LACTATED RINGERS-D5W INTRAVENOUS SOLUTION 3 NORMOSOL-M IN D5W INTRAVENOUS SOLUTION (electrolyte-m in 3 dextrose) NORMOSOL-R IN D5W INTRAVENOUS SOLUTION (electrolyte-r in 3 dextrose) potassium chloride in dextrose intravenous solution 1 or 1b* *ELECTROLYTES PARENTERAL*** - DRUGS FOR NUTRITION ISOLYTE-S INTRAVENOUS SOLUTION (electrolyte-s) 3 ISOLYTE-S PH 7.4 INTRAVENOUS SOLUTION (electrolyte-s (ph 7.4)) 3 KCL (IN NACL 0.9%) INTRAVENOUS SOLUTION 3 lactated ringers intravenous solution 1 or 1b* NORMOSOL-R INTRAVENOUS SOLUTION (electrolyte-r) 3 NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION (electrolyte-r (ph 3 7.4)) PLASMA-LYTE 148 INTRAVENOUS SOLUTION (electrolyte-148) 3 PLASMA-LYTE A INTRAVENOUS SOLUTION (electrolyte-a) 3 POTASSIUM CHLORIDE IN NACL INTRAVENOUS SOLUTION 20- 3 0.45 MEQ/L-%, 40-0.9 MEQ/L-% potassium chloride in nacl intravenous solution 20-0.9 meq/l-% 1 or 1b* ringers intravenous solution 1 or 1b* TPN ELECTROLYTES INTRAVENOUS CONCENTRATE (parenteral 3 electrolytes) *FLUORIDE COMBINATIONS*** - DRUGS FOR NUTRITION FLORIVA ORAL LIQUID (sodium fluoride-vitamin d) 3 *FLUORIDE*** - DRUGS FOR NUTRITION fluoritab oral solution 1 or 1a*; $0 nafrinse drops oral solution 1 or 1a*; $0 nafrinse oral tablet chewable 1 or 1a*; $0 sodium fluoride oral solution 0.5 mg/ml 1 or 1b*; $0 QL (2 mL per 1 day) sodium fluoride oral solution 1.1 (0.5 f) mg/ml 1 or 1a*; $0 QL (2 mL per 1 day) sodium fluoride oral tablet 1 or 1a*; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 170 Coverage Requirements and Prescription Drug Name Drug Tier Limits sodium fluoride oral tablet chewable 1 or 1a*; $0 *MAGNESIUM*** - DRUGS FOR NUTRITION MAGNESIUM SULFATE IN D5W INTRAVENOUS SOLUTION 3 MAGNESIUM SULFATE INTRAVENOUS SOLUTION 3 *MANGANESE*** - DRUGS FOR NUTRITION manganese chloride intravenous solution 1 or 1b* *PHOSPHATE*** - DRUGS FOR NUTRITION K-PHOS ORAL TABLET (potassium phosphate monobasic) 2 K-PHOS-NEUTRAL ORAL TABLET (k phos mono-sod phos di & mono) 3 phosphorous oral tablet 1 or 1b* phospho-trin 250 neutral oral tablet 1 or 1b* POTASSIUM PHOSPHATES INTRAVENOUS SOLUTION 15 3 MMOLE/5ML, 150 MMOLE/50ML potassium phosphates intravenous solution 45 mmole/15ml 1 or 1b* potassium phosphates(66 meq k) intravenous solution 1 or 1b* POTASSIUM PHOSPHATES(71 MEQ K) INTRAVENOUS SOLUTION 3 sodium phosphates intravenous solution 1 or 1b* virt-phos 250 neutral oral tablet 1 or 1b* *POTASSIUM*** - DRUGS FOR NUTRITION klor-con 10 oral tablet extended release 1 or 1b* klor-con m10 oral tablet extended release 1 or 1a* klor-con m15 oral tablet extended release 1 or 1a* klor-con m20 oral tablet extended release 1 or 1a* klor-con oral packet 1 or 1b* klor-con oral tablet extended release 1 or 1b* K-TAB ORAL TABLET EXTENDED RELEASE (potassium chloride) 3 potassium acetate intravenous solution 1 or 1b* potassium chloride crys er oral tablet extended release 1 or 1a* potassium chloride er oral capsule extended release 1 or 1b* potassium chloride er oral tablet extended release 1 or 1b* POTASSIUM CHLORIDE INTRAVENOUS SOLUTION 10 MEQ/100ML, 10 MEQ/50ML, 20 MEQ/100ML, 20 MEQ/50ML, 40 3 MEQ/100ML potassium chloride intravenous solution 2 meq/ml 1 or 1b* potassium chloride oral packet 1 or 1b* potassium chloride oral solution 1 or 1b* *SODIUM*** - DRUGS FOR NUTRITION monoject flush syringe intravenous solution 1 or 1b* QL (200 syringes per 30 days) monoject sodium chloride flush intravenous solution 1 or 1b* normal saline flush intravenous solution 1 or 1b* sodium chloride flush intravenous solution 1 or 1b* sodium chloride injection solution 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 171 Coverage Requirements and Prescription Drug Name Drug Tier Limits sodium chloride intravenous solution 1 or 1b* *TRACE MINERAL COMBINATIONS*** - DRUGS FOR NUTRITION THE LIQUILIFT TRACE INTRAVENOUS KIT (trace minerals cr-cu-mn- 3 se-zn) TRALEMENT INTRAVENOUS SOLUTION (trace minerals cu-mn-se-zn) 3 *TRACE MINERALS*** - DRUGS FOR NUTRITION chromic chloride intravenous solution 1 or 1b* cupric chloride intravenous solution 1 or 1b* SELENIOUS ACID INTRAVENOUS SOLUTION 3 *ZINC*** - DRUGS FOR NUTRITION GALZIN ORAL CAPSULE (zinc acetate (oral)) 3 WILZIN ORAL CAPSULE (zinc acetate (oral)) 3 zinc chloride intravenous solution 1 or 1b* zinc sulfate intravenous solution 1 or 1b* *MISCELLANEOUS THERAPEUTIC CLASSES* - VITAMINS AND MINERALS *ANTILEPROTICS*** - VITAMINS AND MINERALS PA; LD; SP; QL (1 capsule per 1 THALOMID ORAL CAPSULE 100 MG, 50 MG (thalidomide) 2; OC day) PA; LD; SP; QL (2 capsules per 1 THALOMID ORAL CAPSULE 150 MG, 200 MG (thalidomide) 2; OC day) *B-LYMPHOCYTE STIMULATOR (BLYS)-SPECIFIC INHIBITORS*** - VITAMINS AND MINERALS BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (belimumab) BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; SP; QL (4 autoinjectors per 4 (belimumab) 28 days) BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (4 pens per 28 4 (belimumab) days) *CHELATING AGENTS*** - VITAMINS AND MINERALS clovique oral capsule 1 or 1b* PA; SP; QL (8 capsules per 1 day) DEPEN TITRATABS ORAL TABLET (penicillamine) 3 PA; QL (8 tablets per 1 day) EDETATE DISODIUM INTRAVENOUS SOLUTION 3 penicillamine oral capsule 1 or 1b* PA; QL (8 capsules per 1 day) penicillamine oral tablet 1 or 1b* PA; QL (8 tablets per 1 day) trientine hcl oral capsule 1 or 1b* PA; SP; QL (8 capsules per 1 day) *CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) SOLUTIONS*** - VITAMINS AND MINERALS PHOXILLUM B22K4/0 INTRAVENOUS SOLUTION 3 PHOXILLUM BK4/2.5 INTRAVENOUS SOLUTION 3 PRISMASOL B22GK 4/0 INTRAVENOUS SOLUTION (bicarb-dextrose-k 3 (crrt)) PRISMASOL BGK 0/2.5 INTRAVENOUS SOLUTION (bicarb-dextrose- 3 ca (crrt))

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 172 Coverage Requirements and Prescription Drug Name Drug Tier Limits PRISMASOL BGK 2/0 INTRAVENOUS SOLUTION (bicarb-dextrose-k 3 (crrt)) PRISMASOL BGK 2/3.5 INTRAVENOUS SOLUTION (bicarb-dextrose-k- 3 ca (crrt)) PRISMASOL BGK 4/0/1.2 INTRAVENOUS SOLUTION (bicarb-dextose- 3 k-mg (crrt)) PRISMASOL BGK 4/2.5 INTRAVENOUS SOLUTION (bicarb-dextrose-k- 3 ca (crrt)) PRISMASOL BK 0/0/1.2 INTRAVENOUS SOLUTION (bicarb-mg (crrt)) 3 *CYCLOSPORINE ANALOGS*** - VITAMINS AND MINERALS cyclosporine intravenous solution 1 or 1b* SP cyclosporine modified oral capsule 1 or 1b* cyclosporine modified oral solution 1 or 1b* cyclosporine oral capsule 1 or 1b* gengraf oral capsule 1 or 1b* gengraf oral solution 1 or 1b* LUPKYNIS ORAL CAPSULE (voclosporin) 4 PA; LD; QL (6 capsules per 1 day) NEORAL ORAL CAPSULE (cyclosporine modified) 3 NEORAL ORAL SOLUTION (cyclosporine modified) 3 SANDIMMUNE INTRAVENOUS SOLUTION (cyclosporine) 3 SP SANDIMMUNE ORAL CAPSULE (cyclosporine) 3 SANDIMMUNE ORAL SOLUTION (cyclosporine) 3 *ENZYMES*** - VITAMINS AND MINERALS AMPHADASE INJECTION SOLUTION (hyaluronidase bovine) 3 HYLENEX INJECTION SOLUTION (hyaluronidase human) 3 VITRASE INJECTION SOLUTION (hyaluronidase ovine) 3 XIAFLEX INJECTION SOLUTION RECONSTITUTED (collagenase 4 PA; LD clostrid histolyt) *FARNESYLTRANSFERASE INHIBITORS*** - VITAMINS AND MINERALS ZOKINVY ORAL CAPSULE (lonafarnib) 4 PA; LD; QL (4 capsules per 1 day) *FECAL INCONTINENCE BULKING AGENT - COMBINATIONS*** - VITAMINS AND MINERALS SOLESTA INJECTION GEL (dextranomer-sodium hyaluronate) 4 LD; SP *IMMUNE GLOBULIN IMMUNOSUPPRESSANTS*** - VITAMINS AND MINERALS ATGAM INTRAVENOUS INJECTABLE (lymphocyte,anti-thymo imm 3 SP glob) THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (anti-thymocyte glob (rabbit)) *IMMUNOMODULATORS FOR MYELODYSPLASTIC SYNDROMES*** - VITAMINS AND MINERALS PA; LD; SP; QL (1 capsule per 1 REVLIMID ORAL CAPSULE (lenalidomide) 2; OC day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 173 Coverage Requirements and Prescription Drug Name Drug Tier Limits *INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS*** - VITAMINS AND MINERALS CELLCEPT INTRAVENOUS INTRAVENOUS SOLUTION 3 SP RECONSTITUTED (mycophenolate mofetil hcl) CELLCEPT ORAL CAPSULE (mycophenolate mofetil) 3 CELLCEPT ORAL SUSPENSION RECONSTITUTED (mycophenolate 3 mofetil) CELLCEPT ORAL TABLET (mycophenolate mofetil) 3 mycophenolate mofetil hcl intravenous solution reconstituted 1 or 1b* SP mycophenolate mofetil intravenous solution reconstituted 1 or 1b* SP mycophenolate mofetil oral capsule 1 or 1b* mycophenolate mofetil oral suspension reconstituted 1 or 1b* mycophenolate mofetil oral tablet 1 or 1b* mycophenolate sodium oral tablet delayed release 1 or 1b* MYFORTIC ORAL TABLET DELAYED RELEASE (mycophenolate 3 sodium) *INTERLEUKIN-6 (IL-6) ANTAGONISTS*** - VITAMINS AND MINERALS SYLVANT INTRAVENOUS SOLUTION RECONSTITUTED (siltuximab) 4 PA; LD; SP *IRRIGATION SOLUTIONS*** - VITAMINS AND MINERALS argyle sterile water irrigation solution 1 or 1b* lactated ringers irrigation solution 1 or 1b* physiolyte irrigation solution 1 or 1b* physiosol irrigation irrigation solution 1 or 1b* ringers irrigation irrigation solution 1 or 1b* sterile water for irrigation irrigation solution 1 or 1b* tis-u-sol irrigation solution 1 or 1b* water for irrigation, sterile irrigation solution 1 or 1b* *MACROLIDE IMMUNOSUPPRESSANTS*** - VITAMINS AND MINERALS ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 (tacrolimus) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 (tacrolimus) everolimus oral tablet 1 or 1b* PROGRAF INTRAVENOUS SOLUTION (tacrolimus) 2 SP PROGRAF ORAL CAPSULE (tacrolimus) 3 PROGRAF ORAL PACKET (tacrolimus) 3 RAPAMUNE ORAL SOLUTION (sirolimus) 3 RAPAMUNE ORAL TABLET (sirolimus) 3 sirolimus oral solution 1 or 1b* sirolimus oral tablet 1 or 1b* tacrolimus oral capsule 1 or 1b* ZORTRESS ORAL TABLET (everolimus) 3 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 174 Coverage Requirements and Prescription Drug Name Drug Tier Limits *MISCELLANEOUS THERAPEUTIC CLASSES*** - VITAMINS AND MINERALS NEXAVIR INJECTION SOLUTION (liver derivative complex) 3 *MONOCLONAL ANTIBODIES*** - VITAMINS AND MINERALS ENSPRYNG SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (1 syringe per 28 4 (satralizumab-mwge) days) GAMIFANT INTRAVENOUS SOLUTION (emapalumab-lzsg) 3 PA; LD; SP SIMULECT INTRAVENOUS SOLUTION RECONSTITUTED 3 (basiliximab) UPLIZNA INTRAVENOUS SOLUTION (inebilizumab-cdon) 4 PA; LD; QL (30 mL per 180 days) *PERITONEAL DIALYSIS SOLUTIONS*** - VITAMINS AND MINERALS DELFLEX-LC/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DELFLEX-LC/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DELFLEX-LC/4.25% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DELFLEX-SM/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 2 (peritoneal dialysis solutions) DELFLEX-SM/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DIANEAL LOW CALCIUM/1.5% DEX INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) DIANEAL LOW CALCIUM/2.5% DEX INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) DIANEAL LOW CALCIUM/4.25% DEX INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) DIANEAL PD-2/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DIANEAL PD-2/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DIANEAL PD-2/4.25% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) EXTRANEAL INTRAPERITONEAL SOLUTION (icodextrin-electrolytes) 3 ULTRABAG/DIANEAL PD-2/1.5% DEX INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) ULTRABAG/DIANEAL PD-2/2.5% DEX INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) ULTRABAG/DIANEAL PD-2/4.25%DEX INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) ULTRABAG/DIANEAL/1.5% DEXTROSE INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) ULTRABAG/DIANEAL/2.5% DEXTROSE INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) ULTRABAG/DIANEAL/4.25% DEX INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 175 Coverage Requirements and Prescription Drug Name Drug Tier Limits *POTASSIUM REMOVING AGENTS*** - VITAMINS AND MINERALS LOKELMA ORAL PACKET (sodium zirconium cyclosilicate) 3 sodium polystyrene sulfonate oral powder 1 or 1b* sps oral suspension 1 or 1b* VELTASSA ORAL PACKET (patiromer sorbitex calcium) 3 LD *PROSTAGLANDINS*** - VITAMINS AND MINERALS alprostadil injection solution 1 or 1b* PROSTIN VR INJECTION SOLUTION (alprostadil) 3 *PURINE ANALOGS*** - VITAMINS AND MINERALS AZASAN ORAL TABLET (azathioprine) 3 azathioprine oral tablet 1 or 1b* AZATHIOPRINE SODIUM INJECTION SOLUTION 3 RECONSTITUTED IMURAN ORAL TABLET (azathioprine) 3 *SCLEROSING AGENTS*** - VITAMINS AND MINERALS ASCLERA INTRAVENOUS SOLUTION (polidocanol) 3 ETHAMOLIN INTRAVENOUS SOLUTION (ethanolamine oleate) 3 sodium tetradecyl sulfate intravenous solution 1 or 1b* SOTRADECOL INTRAVENOUS SOLUTION 1 % (sodium tetradecyl 3 sulfate) sotradecol intravenous solution 3 % 1 or 1b* VARITHENA INTRAVENOUS FOAM (polidocanol) 3 LD *SELECTIVE T-CELL COSTIMULATION BLOCKERS*** - VITAMINS AND MINERALS NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED (belatacept) 3 PA; SP *MOUTH/THROAT/DENTAL AGENTS* - DRUGS FOR THE MOUTH AND THROAT *ANESTHETICS TOPICAL ORAL*** - DRUGS FOR THE MOUTH AND THROAT lidocaine hcl mouth/throat solution 1 or 1a* QL (10 mL per 1 day) lidocaine viscous hcl mouth/throat solution 1 or 1a* QL (10 mL per 1 day) *ANTI-INFECTIVES - THROAT*** - DRUGS FOR THE MOUTH AND THROAT clotrimazole mouth/throat troche 1 or 1b* QL (5 tablet per 1 day) nystatin mouth/throat suspension 1 or 1b* QL (750 mL per 30 days) ORAVIG BUCCAL TABLET (miconazole) 3 *ANTISEPTICS - MOUTH/THROAT*** - DRUGS FOR THE MOUTH AND THROAT chlorhexidine gluconate mouth/throat solution 1 or 1a* QL (480 mL per 30 days) PERIDEX MOUTH/THROAT SOLUTION (chlorhexidine gluconate) 3 QL (480 mL per 30 days) periogard mouth/throat solution 1 or 1a* QL (480 mL per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 176 Coverage Requirements and Prescription Drug Name Drug Tier Limits *DENTAL PRODUCTS - COMBINATIONS*** - DRUGS FOR THE MOUTH AND THROAT fluoridex sensitivity relief dental paste 1 or 1b* NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION 3 RECONSTITUTED (sodium fluoride-phosphoric acd) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE (sod fluoride- 3 potassium nitrate) PREVIDENT 5000 SENSITIVE DENTAL PASTE (sod fluoride-potassium 3 nitrate) sodium fluoride 5000 enamel dental paste 1 or 1b* sodium fluoride 5000 sensitive dental paste 1 or 1b* *FLUORIDE DENTAL PRODUCTS*** - DRUGS FOR THE MOUTH AND THROAT cavarest dental gel 1 or 1b* clinpro 5000 dental paste 1 or 1b* denta 5000 plus dental cream 1 or 1b* dentagel dental gel 1 or 1a* easygel dental gel 1 or 1b* fluoridex daily renewal mouth/throat concentrate 1 or 1b* fluoridex dental paste 1 or 1b* fluoridex enhanced whitening dental paste 1 or 1b* NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION 3 RECONSTITUTED (sodium fluoride) NAFRINSE WEEKLY MOUTH/THROAT SOLUTION 3 RECONSTITUTED (sodium fluoride) PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE (sodium fluoride) 3 PREVIDENT 5000 DRY MOUTH DENTAL GEL (sodium fluoride) 3 PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE (sodium 3 fluoride) PREVIDENT 5000 PLUS DENTAL CREAM (sodium fluoride) 3 PREVIDENT DENTAL GEL (sodium fluoride) 3 PREVIDENT MOUTH/THROAT SOLUTION (sodium fluoride) 3 sf 5000 plus dental cream 1 or 1b* sf dental gel 1 or 1a* sodium fluoride 5000 plus dental cream 1 or 1b* sodium fluoride 5000 ppm dental cream 1 or 1b* sodium fluoride 5000 ppm dental paste 1 or 1b* sodium fluoride dental cream 1 or 1b* sodium fluoride dental gel 1 or 1b* sodium fluoride mouth/throat solution 1 or 1a* *SALIVA STIMULANTS*** - DRUGS FOR THE MOUTH AND THROAT cevimeline hcl oral capsule 1 or 1b* EVOXAC ORAL CAPSULE (cevimeline hcl) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 177 Coverage Requirements and Prescription Drug Name Drug Tier Limits pilocarpine hcl oral tablet 1 or 1b* QL (4 tablets per 1 day) SALAGEN ORAL TABLET (pilocarpine hcl) 3 QL (4 tablets per 1 day) *STEROIDS - MOUTH/THROAT/DENTAL*** - DRUGS FOR THE MOUTH AND THROAT oralone mouth/throat paste 1 or 1b* triamcinolone acetonide mouth/throat paste 1 or 1b* *MULTIVITAMINS* - DRUGS FOR NUTRITION *B-COMPLEX VITAMINS*** - DRUGS FOR NUTRITION b complex oral tablet 1 or 1b*; $0 b complex-b12 oral tablet 1 or 1b*; $0 B-COMPLEX INJECTION INJECTABLE 3 b-complex/b-12 oral tablet 1 or 1b*; $0 ra b-complex oral tablet 1 or 1b*; $0 ra b-complex with b-12 oral tablet 1 or 1b*; $0 vitamin b complex oral tablet 1 or 1b*; $0 vitamin b-complex oral tablet 1 or 1b*; $0 vitamin-b complex oral tablet 1 or 1b*; $0 *B-COMPLEX W/ C & CALCIUM*** - DRUGS FOR NUTRITION gnp b-complex plus vitamin c oral tablet 1 or 1b*; $0 qc b-complex/vitamin c oral tablet 1 or 1b*; $0 *B-COMPLEX W/ C & FOLIC ACID*** - DRUGS FOR NUTRITION b complex-c-folic acid oral tablet 1 or 1b*; $0 b-complex balanced oral tablet 1 or 1b*; $0 b-complex/vitamin c oral tablet 1 or 1b*; $0 dialyvite 800 oral tablet 1 or 1b*; $0 eql super b complex/vitamin c oral tablet 1 or 1b*; $0 FULL SPECTRUM B/VITAMIN C ORAL TABLET 2; $0 hm vitamin b complex/vitamin c oral tablet 1 or 1b*; $0 kp b complex-c oral tablet 1 or 1b*; $0 nephro vitamins oral tablet 1 or 1b*; $0 NEPHRO-VITE ORAL TABLET (b complex-c-folic acid) 2; $0 px b complex/vitamin c oral tablet 1 or 1b*; $0 renal multivitamin formula oral tablet 1 or 1b*; $0 renal vitamin oral tablet 1 or 1b*; $0 renal-vite oral tablet 1 or 1b*; $0 rena-vite oral tablet 1 or 1b*; $0 sm b super vitamin complex oral tablet 1 or 1b*; $0 SM B-COMPLEX/VITAMIN C ORAL TABLET 2; $0 stress formula oral tablet 1 or 1b*; $0 super b complex/fa/vit c oral tablet 1 or 1b*; $0 super b-complex/vit c/fa oral tablet 1 or 1b*; $0 VITALINE BIOTIN FORTE ORAL TABLET (b complex-c-folic acid) 2; $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 178 Coverage Requirements and Prescription Drug Name Drug Tier Limits WEST-VITE W/FOLIC ACID ORAL TABLET 2; $0 *B-COMPLEX W/ C*** - DRUGS FOR NUTRITION allbee/c oral tablet 1 or 1b*; $0 b complex-c oral tablet 1 or 1b*; $0 b-complex-c oral tablet 1 or 1b*; $0 better b complex oral tablet 1 or 1b*; $0 cvs b complex plus c oral tablet 1 or 1b*; $0 cvs super b complex/c oral tablet 1 or 1b*; $0 hm b complex/c oral tablet 1 or 1b*; $0 sm super b complex/c oral tablet 1 or 1b*; $0 sm vitamin b complex/vitamin c oral tablet 1 or 1b*; $0 super b complex/vitamin c oral tablet 1 or 1b*; $0 super b-complex + vitamin c oral tablet 1 or 1b*; $0 vitamin b + c complex oral tablet 1 or 1b*; $0 *B-COMPLEX W/ C-BIOTIN-E & FOLIC ACID*** - DRUGS FOR NUTRITION B COMPLEX-C-BIOTIN-E-FA ORAL TABLET 2; $0 *B-COMPLEX W/ FOLIC ACID*** - DRUGS FOR NUTRITION b complex formula 1 oral tablet 1 or 1b*; $0 b complex plus oral tablet 1 or 1b*; $0 kobee oral tablet 1 or 1b*; $0 sm balanced b-100 oral tablet 1 or 1b*; $0 sm balanced b-50 oral tablet 1 or 1b*; $0 super b complex maxi oral tablet 1 or 1b*; $0 *B-COMPLEX W/BIOTIN & FOLIC ACID*** - DRUGS FOR NUTRITION b complex 100 tr oral tablet extended release 1 or 1b*; $0 b complex-biotin-fa oral tablet 1 or 1b*; $0 b-100 b-complex oral tablet 1 or 1b*; $0 b-100 complex cr oral tablet extended release 1 or 1b*; $0 b-100 tr oral tablet extended release 1 or 1b*; $0 b-50 complex oral tablet extended release 1 or 1b*; $0 balance b-50 oral tablet 1 or 1b*; $0 balanced b complex oral tablet 1 or 1b*; $0 balanced b-100 oral tablet extended release 1 or 1b*; $0 balanced b-50/fa oral tablet 1 or 1b*; $0 b-compleet-100 oral tablet 1 or 1b*; $0 b-compleet-50 oral tablet 1 or 1b*; $0 b-complex oral tablet 1 or 1b*; $0 big 100 (biotin) oral tablet 1 or 1b*; $0 big 100 oral tablet 1 or 1b*; $0 complex b-50 prolonged release oral tablet extended release 1 or 1b*; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 179 Coverage Requirements and Prescription Drug Name Drug Tier Limits endur-b oral tablet extended release 1 or 1b*; $0 eql b complex 50 oral tablet 1 or 1b*; $0 eql b-100 complex oral tablet extended release 1 or 1b*; $0 gnp b-100 complex oral tablet extended release 1 or 1b*; $0 gnp b-50 complex oral tablet extended release 1 or 1b*; $0 hm vitamin b100 complex oral tablet 1 or 1b*; $0 hm vitamin b50 complex oral tablet 1 or 1b*; $0 qc b50 prolonged release oral tablet extended release 1 or 1b*; $0 quin b strong b-25 oral tablet 1 or 1b*; $0 ra balanced b-100 cr oral tablet extended release 1 or 1b*; $0 ra balanced b-100 oral tablet 1 or 1b*; $0 ra balanced b-50 oral tablet 1 or 1b*; $0 ra balanced b-50 tr oral tablet extended release 1 or 1b*; $0 sm b100 complex oral tablet 1 or 1b*; $0 sm b-complex oral tablet 1 or 1b*; $0 super b-100 oral tablet 1 or 1b*; $0 super b-50 oral tablet 1 or 1b*; $0 super b-complex oral tablet 1 or 1b*; $0 super dec b-100 oral tablet 1 or 1b*; $0 super quints b-50 oral tablet 1 or 1b*; $0 yl balanced b-100 oral tablet 1 or 1b*; $0 *BIOFLAVONOID PRODUCTS*** - DRUGS FOR NUTRITION ADRENAL C FORMULA ORAL TABLET (bioflavonoid products) 3 *MULTIPLE VITAMINS & FLUORIDE-FOLIC ACID*** - DRUGS FOR NUTRITION MULTIVITAMIN/FLUORIDE ORAL TABLET CHEWABLE 3 *MULTIPLE VITAMINS W/ IRON*** - DRUGS FOR NUTRITION daily multiple vitamins/iron oral tablet 1 or 1b*; $0 daily vitamin formula+iron oral tablet 1 or 1b*; $0 daily vite multivitamin/iron oral tablet 1 or 1b*; $0 daily-vitamin/iron oral tablet 1 or 1b*; $0 hm one daily/iron oral tablet 1 or 1b*; $0 multi-day plus iron oral tablet 1 or 1b*; $0 multiple vitamins/iron oral tablet 1 or 1b*; $0 multivitamin plus iron adult oral tablet 1 or 1b*; $0 multi-vitamin/iron oral tablet 1 or 1b*; $0 nat-rul daily-vite+iron oral tablet 1 or 1b*; $0 one daily multivitamin/iron oral tablet 1 or 1b*; $0 one-daily multi-vitamin/iron oral tablet 1 or 1b*; $0 one-daily/iron oral tablet 1 or 1b*; $0 qc daily multivitamins/iron oral tablet 1 or 1b*; $0 sm multiple vitamins/iron oral tablet 1 or 1b*; $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 180 Coverage Requirements and Prescription Drug Name Drug Tier Limits stress b complex/iron oral tablet 1 or 1b*; $0 stress formula/iron oral tablet 1 or 1b*; $0 tab-a-vite/iron oral tablet 1 or 1b*; $0 TAB-A-VITE/IRON/BETA CAROTENE ORAL TABLET (multiple 2; $0 vitamins-iron) *MULTIPLE VITAMINS W/ MINERALS & CALCIUM-FOLIC ACID*** - DRUGS FOR NUTRITION FOLGARD OS ORAL TABLET (multiple vit-min-calcium-fa) 3 *MULTIPLE VITAMINS W/ MINERALS & FLUORIDE-IRON-FOLIC ACID*** - DRUGS FOR NUTRITION QUFLORA FE ORAL TABLET CHEWABLE (multi vit-min-fluoride-fe-fa) 3 *MULTIPLE VITAMINS W/ MINERALS*** - DRUGS FOR NUTRITION one daily multivitamin adult oral tablet 1 or 1b*; $0 tab-a-vite oral tablet 1 or 1b*; $0 VENEXA ORAL TABLET (multiple vitamins-minerals) 3 VITRANOL FE ORAL TABLET (multiple vitamins-minerals) 3 ZYVANA ORAL CAPSULE 3 *MULTIVITAMINS*** - DRUGS FOR NUTRITION anti-oxidant oral tablet 1 or 1b*; $0 daily multiple vitamins oral tablet 1 or 1b*; $0 daily value multivitamin oral tablet 1 or 1b*; $0 daily vitamin oral tablet 1 or 1b*; $0 daily vitamins oral tablet 1 or 1b*; $0 daily vite oral tablet 1 or 1b*; $0 daily vites oral tablet 1 or 1b*; $0 daily-vitamin oral tablet 1 or 1b*; $0 daily-vite multivitamin oral tablet 1 or 1b*; $0 daily-vite oral tablet 1 or 1b*; $0 ESTROFACTORS ORAL TABLET (multiple vitamin) 2; $0 gnp essential one daily oral tablet 1 or 1b*; $0 healthy hair/skin/nails oral tablet 1 or 1b*; $0 HIGH POTENCY MULTIVITAMIN ORAL TABLET 2; $0 INFUVITE ADULT INTRAVENOUS INJECTABLE (multiple vitamin) 3 M.V.I. ADULT INTRAVENOUS INJECTABLE (multiple vitamin) 3 multi vitamin daily oral tablet 1 or 1b*; $0 MULTI VITAMIN ORAL TABLET 2; $0 MULTI VITAMIN W/D-3 ORAL TABLET 2; $0 multi-day oral tablet 1 or 1b*; $0 multiple vitamin-folic acid oral tablet 1 or 1b*; $0 multiple vitamins essential oral tablet 1 or 1b*; $0 multiple vitamins oral tablet 1 or 1b*; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 181 Coverage Requirements and Prescription Drug Name Drug Tier Limits MULTIVITAMIN ADULT ORAL TABLET 3; $0 multi-vitamin daily oral tablet 1 or 1b*; $0 multivitamin iron-free oral tablet 1 or 1b*; $0 MULTIVITAMIN ORAL TABLET 2; $0 multi-vitamin oral tablet 1 or 1b*; $0 NEOMULTIVITE ORAL TABLET (multiple vitamin) 2; $0 OMNICAP ORAL TABLET 2; $0 once daily oral tablet 1 or 1b*; $0 ONE DAILY ESSENTIAL ORAL TABLET (multiple vitamin) 2; $0 one daily oral tablet 1 or 1b*; $0 ONE-A-DAY ESSENTIAL ORAL TABLET (multiple vitamin) 2; $0 ONE-A-DAY MENS ORAL TABLET (multiple vitamin) 2; $0 one-daily multi vitamins oral tablet 1 or 1b*; $0 one-daily multi-vitamin oral tablet 1 or 1b*; $0 qc essentials oral tablet 1 or 1b*; $0 QUINTABS ORAL TABLET 2; $0 sm multiple vitamins essential oral tablet 1 or 1b*; $0 stresstabs energy oral tablet 1 or 1b*; $0 tab-a-vite/beta carotene oral tablet 1 or 1b*; $0 THERA ORAL TABLET (multiple vitamin) 2; $0 thera-mill oral tablet 1 or 1b*; $0 thera-tabs oral tablet 1 or 1b*; $0 THEREMS ORAL TABLET (multiple vitamin) 2; $0 vit e-vit c-beta carotene oral tablet 1 or 1b*; $0 vitalee oral tablet 1 or 1b*; $0 *PED MULTI VITAMINS W/FL & FE*** - DRUGS FOR NUTRITION multi-vit/iron/fluoride oral solution 1 or 1b* multi-vitamin/fluoride/iron oral solution 1 or 1b* POLY-VI-FLOR/IRON ORAL SUSPENSION (ped multivitamins-fl-iron) 3 POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE (ped multivitamins- 3 fl-iron) QUFLORA FE PEDIATRIC ORAL LIQUID (ped multivitamins-fl-iron) 3 *PED MV W/ FLUORIDE*** - DRUGS FOR NUTRITION FLORIVA PLUS ORAL SOLUTION (pediatric multivitamins-fl) 3 multivitamin/fluoride oral solution 1 or 1b*; $0 multi-vitamin/fluoride oral solution 1 or 1b*; $0 multivitamin/fluoride oral tablet chewable 1 or 1b*; $0 POLY-VI-FLOR ORAL SUSPENSION (pediatric multivitamins-fl) 3 POLY-VI-FLOR ORAL TABLET CHEWABLE (pediatric multivitamins- 3 fl) QUFLORA GUMMIES ORAL TABLET CHEWABLE (pediatric 2 multivitamins-fl)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 182 Coverage Requirements and Prescription Drug Name Drug Tier Limits QUFLORA PEDIATRIC ORAL SOLUTION (pediatric multivitamins-fl) 3 QUFLORA PEDIATRIC ORAL TABLET CHEWABLE (pediatric 3 multivitamins-fl) *PED VITAMINS ACD & FA W/ FLUORIDE*** - DRUGS FOR NUTRITION TRI-VI-FLOR ORAL SUSPENSION (ped vit a-c-d-methylfolate-fl) 3 TRI-VI-FLORO ORAL SUSPENSION 3 *PED VITAMINS ACD W/ FLUORIDE*** - DRUGS FOR NUTRITION adc/f (0.5mg/ml) oral solution 1 or 1b*; $0 multivitamin select/fluoride oral solution 1 or 1b*; $0 tri-vite/fluoride oral solution 1 or 1b*; $0 vitamins acd-fluoride oral solution 1 or 1b*; $0 *PEDIATRIC MULTIPLE VITAMINS & MINERALS W/ FLUORIDE*** - DRUGS FOR NUTRITION FLORIVA ORAL TABLET CHEWABLE (ped multiple vit-minerals-fl) 3 *PEDIATRIC MULTIPLE VITAMINS*** - DRUGS FOR NUTRITION INFUVITE PEDIATRIC INTRAVENOUS SOLUTION (pediatric multiple 3 vitamins) M.V.I. PEDIATRIC INTRAVENOUS SOLUTION RECONSTITUTED 3 (pediatric multiple vitamins) *PRENATAL MV & MIN W/FE-FA*** - DRUGS FOR NUTRITION ATABEX EC ORAL TABLET DELAYED RELEASE (prenatal vit-dss-fe 3 QL (1 tablet per 1 day) cbn-fa) ATABEX OB ORAL TABLET (prenatal vit w/ fe bisg-fa) 3 QL (1 tablet per 1 day) AZESCHEW PRENATAL/POSTNATAL ORAL TABLET CHEWABLE 3 ST; QL (1 tablet per 1 day) AZESCO ORAL TABLET 3 ST; QL (1 tablet per 1 day) CITRANATAL B-CALM ORAL (prenat w/o a fecbnfeglu-fa &b6) 3 QL (3 EA per 1 day) CITRANATAL BLOOM ORAL TABLET (prenatal-dss-fecb-fegl-fa) 3 ST; QL (2 tablets per 1 day) CITRANATAL RX ORAL TABLET (prenat w/o a-fecb-fegl-dss-fa) 3 ST; QL (1 tablet per 1 day) CLASSIC PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) C-NATE DHA ORAL CAPSULE 3 QL (1 capsule per 1 day) COMPLETENATE ORAL TABLET CHEWABLE 2 QL (1 tablet per 1 day) CO-NATAL FA ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) CONCEPT DHA ORAL CAPSULE (prenat-fefum-fepo-fa-omega 3) 3 QL (1 capsule per 1 day) CONCEPT OB ORAL CAPSULE (prenat w/o a vit-fefum-fepo-fa) 3 QL (1 capsule per 1 day) CVS PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) DUET DHA 400 ORAL (prenat-fepoly-fered-fa-omega 3) 3 ST; QL (2 units per 1 day) DUET DHA BALANCED ORAL (prenat-fepoly-fered-fa-omega 3) 3 ST; QL (2 units per 1 day) elite-ob oral tablet 1 or 1b* QL (1 tablet per 1 day) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa-omega) 3 ST; QL (1 capsule per 1 day) EQL PRENATAL FORMULA ORAL TABLET 2; $0 QL (1 tablet per 1 day) FOLIVANE-OB ORAL CAPSULE (prenat w/o a vit-fefum-fepo-fa) 2 QL (1 capsule per 1 day) GNP PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 183 Coverage Requirements and Prescription Drug Name Drug Tier Limits HM ONE DAILY PRENATAL ORAL 2; $0 QL (1 EA per 1 day) HM PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) inatal gt oral tablet 1 or 1b* QL (1 tablet per 1 day) JENLIVA PRENATAL/POSTNATAL ORAL CAPSULE 2 QL (1 capsule per 1 day) KOSHER PRENATAL PLUS IRON ORAL TABLET 3 ST; QL (1 tablet per 1 day) KP PRENATAL MULTIVITAMINS ORAL TABLET 2; $0 QL (1 tablet per 1 day) KPN PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) M-NATAL PLUS ORAL TABLET 3 QL (1 tablet per 1 day) MULTI PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) MYNATAL ORAL CAPSULE (prenatal multivit-min-fe-fa) 3 QL (1 capsule per 1 day) MYNATAL PLUS ORAL TABLET 2 QL (1 tablet per 1 day) MYNATAL-Z ORAL TABLET 2 QL (1 tablet per 1 day) NATACHEW ORAL TABLET CHEWABLE (prenatal vit-fe fum-fe bisg- 3 ST; QL (1 tablet per 1 day) fa) NATALVIT ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) NEEVO DHA ORAL CAPSULE (prenat w/oa-fefum-methf-omegas) 3 ST; QL (1 capsule per 1 day) NEONATAL COMPLETE ORAL TABLET 3 ST; QL (1 tablet per 1 day) NEONATAL FE ORAL TABLET 3 ST; QL (1 tablet per 1 day) NEONATAL PLUS ORAL TABLET (prenatal vit-fe fumarate-fa) 3 ST; QL (1 tablet per 1 day) NEONATAL VITAMIN ORAL TABLET (prenatal vit-fe fumarate-fa) 2; $0 QL (1 tablet per 1 day) NESTABS DHA ORAL (prenat-w/oa-fe bisgly-fa-omega) 3 ST; QL (2 tablets per 1 day) NESTABS ORAL TABLET (prenat-fe bisgly-fa-w/o vit a) 3 ST; QL (2 tablets per 1 day) NIVA-PLUS ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) OB COMPLETE ONE ORAL CAPSULE (prenat-fecbn-feaspgl-fa-fish) 3 ST; QL (1 capsule per 1 day) OB COMPLETE ORAL TABLET (prenatal vit-iron carbonyl-fa) 3 ST; QL (1 tablet per 1 day) OB COMPLETE PETITE ORAL CAPSULE (prenat-fecbn-feaspgl-fa- 3 ST; QL (1 capsule per 1 day) omega) OB COMPLETE PREMIER ORAL TABLET (prenatal-fe cbn-fe asp gly- 3 ST; QL (1 tablet per 1 day) fa) OB COMPLETE/DHA ORAL CAPSULE (prenat-fecbn-feaspgl-fa-omega) 3 ST; QL (1 capsule per 1 day) OBSTETRIX DHA ORAL (prenatal-fecbn-fa-dss-omega 3) 3 QL (1 EA per 1 day) OBSTETRIX EC ORAL TABLET (prenatal vit-dss-fe cbn-fa) 3 QL (1 tablet per 1 day) O-CAL PRENATAL ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) ONE VITE WOMENS ORAL TABLET 2; $0 QL (1 tablet per 1 day) ONE VITE WOMENS PLUS ORAL TABLET 3 QL (1 tablet per 1 day) ONE-A-DAY WOMENS PRENATAL ORAL (prenatal vit-fe fum-fa-omega) 2; $0 QL (1 EA per 1 day) PERRY PRENATAL ORAL CAPSULE (prenatal vit-fe fumarate-fa) 2; $0 QL (1 capsule per 1 day) PNV TABS 20-1 ORAL TABLET 3 ST; QL (1 tablet per 1 day) PNV TABS 29-1 ORAL TABLET 2 QL (1 tablet per 1 day) PNV-OMEGA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) pnv-select oral tablet 1 or 1b* QL (1 tablet per 1 day) PREGENNA ORAL TABLET 3 ST; QL (1 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 184 Coverage Requirements and Prescription Drug Name Drug Tier Limits PRENA1 PEARL ORAL CAPSULE EXTENDED RELEASE 3 ST; QL (1 capsule per 1 day) PRENARA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) prenatabs rx oral tablet 1 or 1a* QL (1 tablet per 1 day) PRENATAL 19 ORAL TABLET 3 QL (1 tablet per 1 day) prenatal 19 oral tablet chewable 1 or 1a* QL (1 tablet per 1 day) PRENATAL 19 ORAL TABLET CHEWABLE 29-1 MG 3 QL (1 tablet per 1 day) PRENATAL COMPLETE ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRE-NATAL FORMULA ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRENATAL FORTE ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRENATAL ONE DAILY ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRENATAL ORAL TABLET 27-0.8 MG, 28-0.8 MG 2; $0 QL (1 tablet per 1 day) PRENATAL ORAL TABLET 27-1 MG 2 QL (1 tablet per 1 day) PRENATAL PLUS IRON ORAL TABLET 2 QL (1 tablet per 1 day) PRENATAL VITAMIN AND MINERAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRENATAL VITAMIN ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRENATAL VITAMIN PLUS LOW IRON ORAL TABLET 2 QL (1 tablet per 1 day) PRENATAL VITAMINS ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRENATAL/IRON ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRENATAL-U ORAL CAPSULE (prenatal w/o a vit-fe fum-fa) 2 QL (1 capsule per 1 day) PRENATE ELITE ORAL TABLET (prenatal-feaspgly-methylfol-fa) 3 ST; QL (1 tablet per 1 day) PRENATRIX ORAL TABLET (prenatal vit-fe fumarate-fa) 3 ST; QL (1 tablet per 1 day) PRENATRYL ORAL TABLET (prenatal vit-fe fumarate-fa) 3 ST; QL (1 tablet per 1 day) PRENATVITE COMPLETE ORAL TABLET 3 ST; QL (1 tablet per 1 day) PRENATVITE PLUS ORAL TABLET 3 ST; QL (1 tablet per 1 day) PRENATVITE RX ORAL TABLET 3 ST; QL (1 tablet per 1 day) PREPLUS ORAL TABLET 2 QL (1 tablet per 1 day) PRETAB ORAL TABLET 2 QL (1 tablet per 1 day) PRIMACARE ORAL CAPSULE (pren-fe-meth-fa-omeg w/o a) 3 ST; QL (1 capsule per 1 day) PROVIDA OB ORAL CAPSULE (prenat w/o a vit-fefum-fepo-fa) 3 QL (1 capsule per 1 day) PX PRENATAL MULTIVITAMINS ORAL TABLET 2; $0 QL (1 tablet per 1 day) QC PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) RA PRENATAL FORMULA ORAL TABLET 2; $0 QL (1 tablet per 1 day) RA PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) RELNATE DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) SELECT-OB ORAL TABLET CHEWABLE (prenatal vit-fe psac cmplx-fa) 3 ST; QL (1 tablet per 1 day) SE-NATAL 19 ORAL TABLET 2 QL (1 tablet per 1 day) SE-NATAL 19 ORAL TABLET CHEWABLE 2 QL (1 tablet per 1 day) SM ONE DAILY PRENATAL ORAL 2; $0 QL (1 EA per 1 day) SM PRENATAL VITAMINS ORAL TABLET 2; $0 QL (1 tablet per 1 day) TARON-C DHA ORAL CAPSULE (prenat-fefum-fepo-fa-omega 3) 3 QL (1 capsule per 1 day) THRIVITE RX ORAL TABLET 2 QL (1 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 185 Coverage Requirements and Prescription Drug Name Drug Tier Limits TRICARE ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) TRICARE PRENATAL DHA ONE ORAL CAPSULE (prenatal-fefum-fa- 3 ST; QL (1 capsule per 1 day) dss-fish oil) TRINATAL RX 1 ORAL TABLET 2 QL (1 tablet per 1 day) trinate oral tablet 1 or 1a* QL (1 tablet per 1 day) TRINAZ ORAL TABLET 3 ST; QL (1 tablet per 1 day) VINATE DHA RF ORAL CAPSULE (prenat w/oa-fefum-methf-omegas) 3 ST; QL (1 capsule per 1 day) VINATE II ORAL TABLET (prenatal vit w/ fe bisg-fa) 2 QL (1 tablet per 1 day) VINATE ONE ORAL TABLET (prenatal vit-fe fumarate-fa) 2 QL (1 tablet per 1 day) VIRT-C DHA ORAL CAPSULE 3 QL (1 capsule per 1 day) VIRT-NATE DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) VIRT-PN PLUS ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) VITAFOL GUMMIES ORAL TABLET CHEWABLE (prenatal vit-fe 3 QL (1 tablet per 1 day) phos-fa-omega) VITAFOL-NANO ORAL TABLET (prenatal-fe fum-methf-fa w/o a) 3 ST; QL (1 tablet per 1 day) VITAFOL-OB ORAL TABLET (prenatal vit-fe fumarate-fa) 3 ST; QL (1 tablet per 1 day) VITAPEARL ORAL CAPSULE EXTENDED RELEASE (prenat-fefum- 3 ST; QL (1 capsule per 1 day) fered-fa-dha w/oa) VITATHELY WITH GINGER ORAL TABLET (prenatal vit-fe fumarate- 3 ST; QL (1 tablet per 1 day) fa) VIVA DHA ORAL CAPSULE (prenatal vit-fe fum-fa-omega) 3 ST; QL (1 capsule per 1 day) VP-PNV-DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) WESTAB PLUS ORAL TABLET 3 QL (1 tablet per 1 day) ZALVIT ORAL TABLET 3 ST; QL (1 tablet per 1 day) ZATEAN-PN PLUS ORAL CAPSULE (prenat w/o a-fe-methf-fa-omega) 3 ST; QL (1 capsule per 1 day) *PRENATAL MV & MIN W/FE-FA-CA-OMEGA 3 FISH OIL*** - DRUGS FOR NUTRITION COMPLETE NATAL DHA ORAL 3 TRIVEEN-DUO DHA ORAL (prenat-febis-fepro-fa-ca-omega) 2 *PRENATAL MV & MIN W/FE-FA-DHA*** - DRUGS FOR NUTRITION CITRANATAL 90 DHA ORAL (prenat w/o a-fecbgl-dss-fa-dha) 3 ST; QL (1 EA per 1 day) CITRANATAL ASSURE ORAL (prenat w/o a-fecbgl-dss-fa-dha) 3 ST; QL (2 units per 1 day) CITRANATAL BLOOM DHA ORAL (prenat w/o a-fecbgl-dss-fa-dha) 3 ST; QL (1 EA per 1 day) CITRANATAL DHA ORAL (prenat w/o a-fecbgl-dss-fa-dha) 3 ST; QL (2 units per 1 day) CITRANATAL ESSENCE ORAL THERAPY PACK (prenat w/o a-fecbgl- 3 fa-dha) CITRANATAL HARMONY ORAL CAPSULE (prenat-fefmcb-dss-fa-dha 3 ST; QL (1 capsule per 1 day) w/o a) CITRANATAL MEDLEY ORAL CAPSULE (prenat-fecb-fefum-fa-dha w/o 3 ST; QL (1 capsule per 1 day) a) ENFAMIL EXPECTA ORAL (prenatal mv-min-fe fum-fa-dha) 2; $0 QL (1 EA per 1 day) NEONATAL + DHA ORAL 3 ST; QL (1 tablet per 1 day) NESTABS ONE ORAL CAPSULE (prenat-fe-methylfol-dha w/o a) 3 ST; QL (1 capsule per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 186 Coverage Requirements and Prescription Drug Name Drug Tier Limits OBSTETRIX ONE ORAL CAPSULE (prenat-fe-methyl-dss-dha w/o a) 3 QL (1 capsule per 1 day) pnv-dha oral capsule 1 or 1b* ST; QL (1 capsule per 1 day) PNV-DHA+DOCUSATE ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) PREGEN DHA ORAL CAPSULE 3 ST; QL (1 tablet per 1 day) PRENA 1 TRUE ORAL 3 QL (2 tablets per 1 day) PRENAISSANCE ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) PRENAISSANCE PLUS ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) PRENATAL MULTIVITAMIN + DHA ORAL (prenatal mv-min-fe fum-fa- 2; $0 QL (1 EA per 1 day) dha) PRENATE DHA ORAL CAPSULE (prenat-feasp-meth-fa-dha w/o a) 3 ST; QL (1 capsule per 1 day) PRENATE ENHANCE ORAL CAPSULE (prenat w/o a-fe-methfol-fa-dha) 3 ST; QL (1 capsule per 1 day) PRENATE ESSENTIAL ORAL CAPSULE (prenat-feasp-meth-fa-dha w/o 3 ST; QL (1 capsule per 1 day) a) PRENATE MINI ORAL CAPSULE (prenat-fecbn-feasp-meth-fa-dha) 3 ST; QL (1 capsule per 1 day) PRENATE PIXIE ORAL CAPSULE (prenat-feasp-meth-fa-dha w/o a) 3 ST; QL (1 capsule per 1 day) PRENATE RESTORE ORAL CAPSULE (prenat w/o a-fe-methfol-fa-dha) 3 ST; QL (1 capsule per 1 day) SELECT-OB+DHA ORAL (prenatal vit-fepoly-fa-dha) 3 ST; QL (2 units per 1 day) TARON-PREX ORAL CAPSULE (prenat-fefum-dss-fa-dha w/o a) 3 QL (1 capsule per 1 day) TRISTART DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) TRISTART FREE ORAL CAPSULE (prenat w/o a-fecbn-meth-fa-dha) 3 TRISTART ONE ORAL CAPSULE (prenat w/o a-fecbn-meth-fa-dha) 3 ST; QL (1 capsule per 1 day) VIRT-PN DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) VITAFOL FE+ ORAL CAPSULE (prenat-fe poly-methfol-fa-dha) 3 ST; QL (2 capsules per 1 day) VITAFOL ULTRA ORAL CAPSULE (prenat-fe poly-methfol-fa-dha) 3 ST; QL (1 capsule per 1 day) VITAFOL-OB+DHA ORAL (prenatal mv-min-fe fum-fa-dha) 3 ST; QL (2 units per 1 day) VITAFOL-ONE ORAL CAPSULE (prenatal vit-fepoly-fa-dha) 3 ST; QL (1 capsule per 1 day) VITAMEDMD ONE RX/QUATREFOLIC ORAL CAPSULE (prenat w/o 3 ST; QL (1 capsule per 1 day) a-fe-methfol-fa-dha) VITATRUE ORAL (prenat-fechel-fa-dha w/o vit a) 3 ST; QL (2 tablets per 1 day) WESTGEL DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) ZATEAN-PN DHA ORAL CAPSULE (prenat w/o a-fe-methfol-fa-dha) 3 ST; QL (1 capsule per 1 day) *PRENATAL MV & MINERALS W/FA WITHOUT IRON*** - DRUGS FOR NUTRITION PRENATE ORAL TABLET CHEWABLE (prenat mv-min-methylfolate-fa) 3 ST; QL (1 tablet per 1 day) *PRENATAL VITAMINS*** - DRUGS FOR NUTRITION NEONATAL 19 ORAL TABLET 3 ST; QL (1 tablet per 1 day) PREMESISRX ORAL TABLET (prenatal ca-b6-b12-fa-ginger) 2 ST; QL (1 tablet per 1 day) PRENA1 ORAL TABLET CHEWABLE 2 ST; QL (1 tablet per 1 day) PRENATE AM ORAL TABLET (prenatal ca-b6-b12-fa-ginger) 3 ST; QL (1 tablet per 1 day) VITAFOL STRIPS ORAL FILM (prenatal-b6-b12-d3-folic acid) 3 QL (1 EA per 1 day) VITAMEDMD REDICHEW RX ORAL TABLET CHEWABLE (prenat- 3 ST; QL (1 tablet per 1 day) b2-b6-b12-d3-fa)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 187 Coverage Requirements and Prescription Drug Name Drug Tier Limits *VITAMINS A & D*** - DRUGS FOR NUTRITION COD LIVER OIL ORAL OIL 3 *VITAMINS W/ LIPOTROPICS*** - DRUGS FOR NUTRITION ACTIFLOVIT EAR HEALTH ORAL TABLET (vitamins-lipotropics) 2; $0 b-100 complex oral tablet 1 or 1b*; $0 b-100 cr oral tablet extended release 1 or 1b*; $0 b-100 oral tablet 1 or 1b*; $0 b-50 oral tablet 1 or 1b*; $0 balance b-100 oral tablet 1 or 1b*; $0 balanced b-100 complex cr oral tablet extended release 1 or 1b*; $0 balanced b-100 oral tablet 1 or 1b*; $0 balanced b-50 complex oral tablet 1 or 1b*; $0 complex b-100 oral tablet extended release 1 or 1b*; $0 complex b-100-inositol oral tablet extended release 1 or 1b*; $0 cvs balanced b50 oral tablet 1 or 1b*; $0 cvs inner ear plus oral tablet 1 or 1b*; $0 ear health formula oral tablet 1 or 1b*; $0 ear health plus oral tablet 1 or 1b*; $0 inner ear plus oral tablet 1 or 1b*; $0 lipo flavonoid plus oral tablet 1 or 1b*; $0 lipoflavovit oral tablet 1 or 1b*; $0 LIPOTRIAD ORAL TABLET (vitamins-lipotropics) 2; $0 mega multiple/chelated mineral oral tablet 1 or 1b*; $0 nat-rul b-50 oral tablet 1 or 1b*; $0 px b-50 oral tablet 1 or 1b*; $0 risanoid plus oral tablet 1 or 1b*; $0 super stress b-complex cr oral tablet extended release 1 or 1b*; $0 ultra b-100 complex oral tablet 1 or 1b*; $0 *MUSCULOSKELETAL THERAPY AGENTS* - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES *CENTRAL MUSCLE RELAXANTS*** - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES baclofen intrathecal solution 4 baclofen oral tablet 10 mg, 5 mg 1 or 1b* QL (3 tablets per 1 day) baclofen oral tablet 20 mg 1 or 1b* QL (4 tablets per 1 day) carisoprodol oral tablet 1 or 1b* QL (4 tablets per 1 day) chlorzoxazone oral tablet 375 mg, 750 mg 1 or 1b* ST; QL (4 tablets per 1 day) chlorzoxazone oral tablet 500 mg 1 or 1b* QL (4 tablets per 1 day) cyclobenzaprine hcl oral tablet 1 or 1b* QL (3 tablets per 1 day) fexmid oral tablet 1 or 1b* ST; QL (3 tablets per 1 day) GABLOFEN INTRATHECAL SOLUTION (baclofen) 4

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 188 Coverage Requirements and Prescription Drug Name Drug Tier Limits GABLOFEN INTRATHECAL SOLUTION PREFILLED SYRINGE 4 (baclofen) LIORESAL INTRATHECAL SOLUTION (baclofen) 3 lorzone oral tablet 1 or 1b* ST; QL (4 tablets per 1 day) metaxalone oral tablet 1 or 1b* ST; QL (4 tablets per 1 day) methocarbamol injection solution 1 or 1b* methocarbamol oral tablet 500 mg 1 or 1b* QL (8 tablets per 1 day) methocarbamol oral tablet 750 mg 1 or 1b* QL (6 tablets per 1 day) orphenadrine citrate er oral tablet extended release 12 hour 1 or 1b* QL (2 tablets per 1 day) orphenadrine citrate injection solution 1 or 1b* ROBAXIN INJECTION SOLUTION (methocarbamol) 3 ST SKELAXIN ORAL TABLET (metaxalone) 3 ST; QL (4 tablets per 1 day) SOMA ORAL TABLET (carisoprodol) 3 ST; QL (4 tablets per 1 day) tizanidine hcl oral capsule 2 mg 1 or 1b* QL (4 capsules per 1 day) tizanidine hcl oral capsule 4 mg 1 or 1b* QL (9 capsules per 1 day) tizanidine hcl oral capsule 6 mg 1 or 1b* QL (6 capsules per 1 day) tizanidine hcl oral tablet 2 mg 1 or 1b* QL (4 tablets per 1 day) tizanidine hcl oral tablet 4 mg 1 or 1b* QL (9 tablets per 1 day) ZANAFLEX ORAL CAPSULE 2 MG (tizanidine hcl) 3 ST; QL (4 capsules per 1 day) ZANAFLEX ORAL CAPSULE 4 MG (tizanidine hcl) 3 ST; QL (9 capsules per 1 day) ZANAFLEX ORAL CAPSULE 6 MG (tizanidine hcl) 3 ST; QL (6 capsules per 1 day) ZANAFLEX ORAL TABLET (tizanidine hcl) 3 ST; QL (9 tablets per 1 day) *DIRECT MUSCLE RELAXANTS*** - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES DANTRIUM INTRAVENOUS SOLUTION RECONSTITUTED 3 (dantrolene sodium) DANTRIUM ORAL CAPSULE (dantrolene sodium) 3 dantrolene sodium intravenous solution reconstituted 1 or 1b* dantrolene sodium oral capsule 1 or 1b* revonto intravenous solution reconstituted 1 or 1b* RYANODEX INTRAVENOUS SUSPENSION RECONSTITUTED 3 (dantrolene sodium) *MUSCLE RELAXANT COMBINATIONS*** - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES carisoprodol-aspirin-codeine oral tablet 1 or 1b* QL (40 tablets per 30 days) CYCLOPAK COMBINATION THERAPY PACK (cyclobenz-lido-prilo- 3 swall spr) orphenadrine-asa-caffeine oral tablet 1 or 1b* ST orphengesic forte oral tablet 1 or 1b* ST *VISCOSUPPLEMENTS*** - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES DUROLANE INTRA-ARTICULAR PREFILLED SYRINGE (sodium 4 PA hyaluronate (viscosup))

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 189 Coverage Requirements and Prescription Drug Name Drug Tier Limits EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (sodium hyaluronate (viscosup)) GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE (cross-linked 4 SP hyaluronate) GELSYN-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 SP (sodium hyaluronate (viscosup)) HYALGAN INTRA-ARTICULAR SOLUTION (sodium hyaluronate 4 PA (viscosup)) HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (sodium hyaluronate (viscosup)) HYMOVIS INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA; LD; SP (hyaluronan) MONOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (hyaluronan) ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED 4 PA SYRINGE (hyaluronan) SUPARTZ FX INTRA-ARTICULAR SOLUTION PREFILLED 4 SYRINGE (sodium hyaluronate (viscosup)) SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (hylan) SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED 4 PA SYRINGE (hylan) TRILURON INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA; SP (sodium hyaluronate (viscosup)) VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 SP (sodium hyaluronate (viscosup)) *NASAL AGENTS - SYSTEMIC AND TOPICAL* - DRUGS FOR THE NOSE *ANTIHISTAMINE-STEROID*** - ALLERGY azelastine-fluticasone nasal suspension 1 or 1b* QL (1 bottle per 30 days) DYMISTA NASAL SUSPENSION (azelastine-fluticasone) 3 QL (1 bottle per 30 days) *NASAL ANESTHETICS*** - ALLERGY GOPRELTO NASAL SOLUTION 3 NUMBRINO NASAL SOLUTION (cocaine hcl (nasal anesthetic)) 3 *NASAL ANTICHOLINERGICS*** - ALLERGY ipratropium bromide nasal solution 0.03 % 1 or 1b* QL (2 bottles per 30 days) ipratropium bromide nasal solution 0.06 % 1 or 1b* QL (1 mL per 1 day) *NASAL ANTIHISTAMINES*** - ALLERGY azelastine hcl nasal solution 0.1 %, 137 mcg/spray 1 or 1b* QL (1 package per 25 days) azelastine hcl nasal solution 0.15 % 1 or 1b* QL (1 bottle per 25 days) olopatadine hcl nasal solution 1 or 1b* QL (1 bottle per 30 days) PATANASE NASAL SOLUTION (olopatadine hcl) 3 QL (1 bottle per 30 days) *NASAL STEROIDS*** - ALLERGY flunisolide nasal solution 3 ST; QL (1 bottle per 30 days) fluticasone propionate nasal suspension 1 or 1a* QL (1 bottle per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 190 Coverage Requirements and Prescription Drug Name Drug Tier Limits mometasone furoate nasal suspension 3 ST; QL (1 bottle per 30 days) PROPEL MINI NASAL IMPLANT (mometasone furoate) 3 PROPEL NASAL IMPLANT (mometasone furoate) 3 *NEUROMUSCULAR AGENTS* - DRUGS FOR NERVES AND MUSCLES *BENZATHIAZOLES*** - DRUGS FOR NERVES AND MUSCLES RILUTEK ORAL TABLET (riluzole) 4 SP; QL (4 tablets per 1 day) riluzole oral tablet 4 SP; QL (4 tablets per 1 day) TIGLUTIK ORAL SUSPENSION (riluzole) 4 LD *DEPOLARIZING MUSCLE RELAXANTS*** - DRUGS FOR NERVES AND MUSCLES ANECTINE INJECTION SOLUTION (succinylcholine chloride) 3 QUELICIN INJECTION SOLUTION (succinylcholine chloride) 3 SUCCINYLCHOLINE CHLORIDE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE *MUSCULAR DYSTROPHY AGENTS*** - DRUGS FOR NERVES AND MUSCLES AMONDYS 45 INTRAVENOUS SOLUTION 4 LD EXONDYS 51 INTRAVENOUS SOLUTION (eteplirsen) 4 PA; LD VILTEPSO INTRAVENOUS SOLUTION (viltolarsen) 4 PA; LD VYONDYS 53 INTRAVENOUS SOLUTION (golodirsen) 4 PA; LD *NEUROMUSCULAR BLOCKING AGENT - NEUROTOXINS*** - DRUGS FOR NERVES AND MUSCLES BOTOX INJECTION SOLUTION RECONSTITUTED 4 PA; SP (onabotulinumtoxina) DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED 4 PA; SP (abobotulinumtoxina) MYOBLOC INTRAMUSCULAR SOLUTION (rimabotulinumtoxinb) 4 PA; SP XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 4 PA; LD; SP (incobotulinumtoxina) *NONDEPOLARIZING MUSCLE RELAXANTS*** - DRUGS FOR NERVES AND MUSCLES atracurium besylate intravenous solution 1 or 1b* cisatracurium besylate (pf) intravenous solution 1 or 1b* cisatracurium besylate intravenous solution 1 or 1b* NIMBEX INTRAVENOUS SOLUTION (cisatracurium besylate) 3 pancuronium bromide intravenous solution 1 or 1b* rocuronium bromide intravenous solution 1 or 1b* ROCURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE VECURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE vecuronium bromide intravenous solution reconstituted 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 191 Coverage Requirements and Prescription Drug Name Drug Tier Limits *SPINAL MUSCULAR ATROPHY-SMN2 SPLICING MODIFIERS*** - DRUGS FOR NERVES AND MUSCLES EVRYSDI ORAL SOLUTION RECONSTITUTED (risdiplam) 4 PA; LD; QL (5 mg per 1 day) *NUTRIENTS* - DRUGS FOR NUTRITION *AMINO ACID MIXTURES*** - DRUGS FOR NUTRITION AMINOPROTECT INTRAVENOUS SOLUTION (amino acid infusion) 3 AMINOSYN II INTRAVENOUS SOLUTION (amino acid infusion) 3 AMINOSYN-PF INTRAVENOUS SOLUTION (amino acid infusion) 3 CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION (amino 3 ac elect-calc in d5w) CLINIMIX E/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION (amino 3 ac elect-calc in d10w) CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION (amino 3 ac elect-calc in d5w) CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION (amino ac 3 elect-calc in d15w) CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION (amino ac 3 elect-calc in d20w) CLINIMIX E/DEXTROSE (8/10) INTRAVENOUS SOLUTION 3 CLINIMIX E/DEXTROSE (8/14) INTRAVENOUS SOLUTION 3 CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION (amino 3 acid infusion in d10w) CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION (amino 3 acid infusion in d5w) CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION (amino acid 3 infusion in d15w) CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION (amino acid 3 infusion in d20w) CLINIMIX/DEXTROSE (6/5) INTRAVENOUS SOLUTION 3 CLINIMIX/DEXTROSE (8/10) INTRAVENOUS SOLUTION 3 CLINIMIX/DEXTROSE (8/14) INTRAVENOUS SOLUTION 3 clinisol sf intravenous solution 1 or 1b* FREAMINE HBC INTRAVENOUS SOLUTION (amino acid infusion) 3 FREAMINE III INTRAVENOUS SOLUTION (amino acid infusion) 3 plenamine intravenous solution 1 or 1b* PREMASOL INTRAVENOUS SOLUTION (amino acid infusion) 3 PROCALAMINE INTRAVENOUS SOLUTION (amino acd electrolyte 3 infusion) PROSOL INTRAVENOUS SOLUTION (amino acid infusion) 3 TRAVASOL INTRAVENOUS SOLUTION (amino acid infusion) 3 TROPHAMINE INTRAVENOUS SOLUTION (amino acid infusion) 3 *AMINO ACIDS-SINGLE*** - DRUGS FOR NUTRITION ARGININE HCL INJECTION SOLUTION 3 ELCYS INTRAVENOUS SOLUTION (cysteine hcl) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 192 Coverage Requirements and Prescription Drug Name Drug Tier Limits GLUTATHIONE INJECTION SOLUTION 3 GLUTATHIONE INTRAVENOUS SOLUTION 3 GLYCINE INJECTION SOLUTION 3 LYSINE HCL INJECTION SOLUTION 3 n-acetyl-l-cysteine oral capsule 1 or 1b* TAURINE INJECTION SOLUTION 3 *CARBOHYDRATES*** - DRUGS FOR NUTRITION dextrose intravenous solution 10 %, 250 mg/ml, 5 %, 70 % 1 or 1b* DEXTROSE INTRAVENOUS SOLUTION 20 %, 40 % 3 *LIPIDS*** - DRUGS FOR NUTRITION CLINOLIPID INTRAVENOUS EMULSION (fat emulsion plant based) 3 PA; LD; SP; QL (2 bottles per 30 DOJOLVI ORAL LIQUID (triheptanoin) 4 days) INTRALIPID INTRAVENOUS EMULSION (fat emulsion plant based) 3 NUTRILIPID INTRAVENOUS EMULSION (fat emulsion plant based) 3 OMEGAVEN INTRAVENOUS EMULSION (fish oil triglyceride based) 3 SMOFLIPID INTRAVENOUS EMULSION (fat emul fish oil/plant based) 3 *LIPOTROPIC COMBINATIONS*** - DRUGS FOR NUTRITION LIPO INTRAMUSCULAR SOLUTION 3 LIPO-C INTRAMUSCULAR SOLUTION 3 *PROTEIN COMBINATIONS*** - DRUGS FOR NUTRITION TRI-AMINO INJECTION SOLUTION 3 *PROTEIN-CARBOHYDRATE-LIPID WITH ELECTROLYTE COMBINATIONS*** - DRUGS FOR NUTRITION KABIVEN INTRAVENOUS EMULSION (amino ac-dext-lipid-electrolyt) 3 PERIKABIVEN INTRAVENOUS EMULSION (amino ac-dext-lipid- 3 electrolyt) *OPHTHALMIC AGENTS* - DRUGS FOR THE EYE *ALPHA ADRENERGIC AGONIST & CARBONIC ANHYDRASE INHIB COMB*** - DRUGS FOR GLAUCOMA SIMBRINZA OPHTHALMIC SUSPENSION (brinzolamide-brimonidine) 2 QL (8 mL per 30 days) *BETA-BLOCKERS - OPHTHALMIC COMBINATIONS*** - DRUGS FOR GLAUCOMA COMBIGAN OPHTHALMIC SOLUTION (brimonidine tartrate-timolol) 2 QL (15 mL per 30 days) dorzolamide hcl-timolol mal ophthalmic solution 1 or 1b* QL (10 mL per 30 days) dorzolamide hcl-timolol mal pf ophthalmic solution 1 or 1b* QL (12 mL per 30 days) *BETA-BLOCKERS - OPHTHALMIC*** - DRUGS FOR GLAUCOMA betaxolol hcl ophthalmic solution 1 or 1b* QL (0.5 mL per 1 day) BETIMOL OPHTHALMIC SOLUTION (timolol hemihydrate) 3 QL (15 mL per 30 days) BETOPTIC-S OPHTHALMIC SUSPENSION (betaxolol hcl) 2 QL (15 mL per 30 days) carteolol hcl ophthalmic solution 1 or 1a* levobunolol hcl ophthalmic solution 1 or 1b* timolol maleate ocudose ophthalmic solution 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 193 Coverage Requirements and Prescription Drug Name Drug Tier Limits timolol maleate ophthalmic gel forming solution 1 or 1b* QL (5 mL per 30 days) timolol maleate ophthalmic solution 0.25 %, 0.5 % 1 or 1b* QL (20 mL per 30 days) timolol maleate ophthalmic solution 0.5 % (daily) 1 or 1b* QL (5 mL per 30 days) timolol maleate pf ophthalmic solution 1 or 1b* QL (20 mL per 30 days) TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 % (timolol 3 QL (18 mL per 30 days) maleate) TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.5 % (timolol 3 QL (20 mL per 30 days) maleate) TIMOPTIC OPHTHALMIC SOLUTION (timolol maleate) 3 QL (20 mL per 30 days) TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION (timolol 3 QL (5 mL per 30 days) maleate) *CYCLOPLEGIC MYDRIATIC COMBINATIONS*** - DRUGS FOR THE EYE CYCLOMYDRIL OPHTHALMIC SOLUTION (cyclopentolate- 3 phenylephrine) *CYCLOPLEGIC MYDRIATICS*** - DRUGS FOR THE EYE altafrin ophthalmic solution 1 or 1b* atropine sulfate ophthalmic ointment 1 or 1b* QL (3.5 grams per 30 days) ATROPINE SULFATE OPHTHALMIC SOLUTION 0.01 % 3 ATROPINE SULFATE OPHTHALMIC SOLUTION 1 % 3 QL (30 mL per 30 days) CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 2 % (cyclopentolate hcl) 3 CYCLOGYL OPHTHALMIC SOLUTION 1 % (cyclopentolate hcl) 3 QL (15 mL per 30 days) cyclopentolate hcl ophthalmic solution 0.5 %, 2 % 1 or 1b* cyclopentolate hcl ophthalmic solution 1 % 1 or 1b* QL (15 mL per 30 days) ISOPTO ATROPINE OPHTHALMIC SOLUTION (atropine sulfate) 3 QL (30 mL per 30 days) MYDRIACYL OPHTHALMIC SOLUTION (tropicamide) 3 PHENYLEPHRINE HCL INTRAOCULAR SOLUTION PREFILLED 3 SYRINGE phenylephrine hcl ophthalmic solution 1 or 1b* tropicamide ophthalmic solution 1 or 1b* *LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG*** - ANTI-INFECTIVE/ANTI-INFLAMMATORIES XIIDRA OPHTHALMIC SOLUTION (lifitegrast) 2 QL (2 vial per 1 day) *MIOTICS - DIRECT ACTING*** - DRUGS FOR GLAUCOMA ISOPTO CARPINE OPHTHALMIC SOLUTION (pilocarpine hcl) 3 MIOCHOL-E INTRAOCULAR SOLUTION RECONSTITUTED 3 (acetylcholine chloride) MIOSTAT INTRAOCULAR SOLUTION (carbachol) 3 pilocarpine hcl ophthalmic solution 1 or 1b* *OPHTHALMIC ADRENERGIC AGENTS*** - DRUGS FOR THE EYE EPINEPHRINE HCL INTRAOCULAR SOLUTION PREFILLED 3 SYRINGE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 194 Coverage Requirements and Prescription Drug Name Drug Tier Limits *OPHTHALMIC ANTIALLERGIC*** - DRUGS FOR ITCHY EYE azelastine hcl ophthalmic solution 1 or 1b* QL (1 bottle per 24 days) cromolyn sodium ophthalmic solution 1 or 1a* QL (1 bottle per 30 days) epinastine hcl ophthalmic solution 1 or 1b* QL (1 bottle per 30 days) *OPHTHALMIC ANTIBIOTICS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES AZASITE OPHTHALMIC SOLUTION (azithromycin) 3 bacitracin ophthalmic ointment 1 or 1b* QL (7 grams per 30 days) BESIVANCE OPHTHALMIC SUSPENSION (besifloxacin hcl) 3 CILOXAN OPHTHALMIC OINTMENT (ciprofloxacin hcl) 3 QL (3.5 grams per 30 days) CILOXAN OPHTHALMIC SOLUTION (ciprofloxacin hcl) 3 ciprofloxacin hcl ophthalmic solution 1 or 1a* erythromycin ophthalmic ointment 1 or 1a* QL (3.5 grams per 30 days) gatifloxacin ophthalmic solution 1 or 1b* gentak ophthalmic ointment 1 or 1a* QL (7 grams per 30 days) gentamicin sulfate ophthalmic solution 1 or 1a* QL (10 mL per 30 days) levofloxacin ophthalmic solution 1 or 1b* MITOMYCIN INTRAOCULAR SOLUTION PREFILLED SYRINGE 3 MITOSOL OPHTHALMIC KIT (mitomycin) 3 MOXEZA OPHTHALMIC SOLUTION (moxifloxacin hcl) 3 QL (3 mL per 30 days) moxifloxacin hcl (2x day) ophthalmic solution 1 or 1b* QL (3 mL per 30 days) MOXIFLOXACIN HCL INTRAOCULAR SOLUTION 3 MOXIFLOXACIN HCL INTRAOCULAR SOLUTION PREFILLED 3 SYRINGE moxifloxacin hcl ophthalmic solution 1 or 1b* QL (1 vial per 30 days) OCUFLOX OPHTHALMIC SOLUTION (ofloxacin) 3 QL (10 mL per 30 days) ofloxacin ophthalmic solution 1 or 1a* QL (10 mL per 30 days) tobramycin ophthalmic solution 1 or 1a* QL (20 mL per 30 days) TOBREX OPHTHALMIC OINTMENT (tobramycin) 3 QL (3.5 grams per 30 days) TOBREX OPHTHALMIC SOLUTION (tobramycin) 3 QL (20 mL per 30 days) VIGAMOX OPHTHALMIC SOLUTION (moxifloxacin hcl) 3 QL (1 vial per 30 days) ZYMAXID OPHTHALMIC SOLUTION (gatifloxacin) 3 *OPHTHALMIC ANTIFUNGAL*** - DRUGS FOR THE EYE NATACYN OPHTHALMIC SUSPENSION (natamycin) 3 *OPHTHALMIC ANTI-INFECTIVE COMBINATIONS*** - ANTI- INFECTIVE/ANTI-INFLAMMATORIES ak-poly-bac ophthalmic ointment 1 or 1a* bacitracin-polymyxin b ophthalmic ointment 1 or 1a* neomycin-bacitracin zn-polymyx ophthalmic ointment 1 or 1b* neomycin-polymyxin-gramicidin ophthalmic solution 1 or 1b* QL (10 mL per 30 days) neo-polycin ophthalmic ointment 1 or 1b* polycin ophthalmic ointment 1 or 1a*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 195 Coverage Requirements and Prescription Drug Name Drug Tier Limits polymyxin b-trimethoprim ophthalmic solution 1 or 1a* QL (10 mL per 30 days) POLYTRIM OPHTHALMIC SOLUTION (polymyxin b-trimethoprim) 3 QL (10 mL per 30 days) *OPHTHALMIC ANTISEPTICS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION 3 (povidone-iodine) *OPHTHALMIC ANTIVIRALS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES trifluridine ophthalmic solution 1 or 1b* QL (7.5 mL per 30 days) ZIRGAN OPHTHALMIC GEL (ganciclovir) 3 QL (5 gram per 7 days) *OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS*** - DRUGS FOR GLAUCOMA AZOPT OPHTHALMIC SUSPENSION (brinzolamide) 3 QL (15 ML per 30 days) brinzolamide ophthalmic suspension 1 or 1b* QL (15 mL per 30 days) dorzolamide hcl ophthalmic solution 1 or 1b* QL (10 mL per 30 days) TRUSOPT OPHTHALMIC SOLUTION (dorzolamide hcl) 3 QL (10 mL per 30 days) *OPHTHALMIC DIAGNOSTIC PRODUCTS*** - DRUGS FOR THE EYE ak-fluor intravenous solution 10 % 1 or 1b* AK-FLUOR INTRAVENOUS SOLUTION 25 % 3 altafluor benox ophthalmic solution 1 or 1b* FLUORESCEIN SODIUM/BENOXINATE OPHTHALMIC SOLUTION 3 fluorescein-benoxinate ophthalmic solution 1 or 1b* FLUORESCITE INTRAVENOUS SOLUTION (fluorescein sodium) 3 fluor-i-strips a.t. ophthalmic strip 1 or 1b* FLURA-SAFE OPHTHALMIC SOLUTION (fluorexon-benoxinate) 3 PAREMYD OPHTHALMIC SOLUTION (hydroxyamphetamine- 3 tropicamide) proparacaine-fluorescein ophthalmic solution 1 or 1b* *OPHTHALMIC IMMUNOMODULATORS*** - ANTI- INFECTIVE/ANTI-INFLAMMATORIES RESTASIS MULTIDOSE OPHTHALMIC EMULSION (cyclosporine) 2 QL (1 bottle per 28 days) RESTASIS OPHTHALMIC EMULSION (cyclosporine) 2 QL (2 vials per 1 day) *OPHTHALMIC IRRIGATION SOLUTIONS*** - DRUGS FOR THE EYE balanced salt intraocular solution 1 or 1b* BSS INTRAOCULAR SOLUTION (ophth irr soln-intraocular) 3 BSS PLUS INTRAOCULAR SOLUTION (ophth irr soln-intraocular) 3 *OPHTHALMIC KINASE INHIBITORS - COMBINATIONS*** - DRUGS FOR GLAUCOMA ROCKLATAN OPHTHALMIC SOLUTION (netarsudil-latanoprost) 3 QL (2.5 mL per 30 days) *OPHTHALMIC LOCAL ANESTHETIC - COMBINATIONS*** - DRUGS FOR THE EYE LIDOCAINE-EPINEPHRINE INTRAOCULAR SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 196 Coverage Requirements and Prescription Drug Name Drug Tier Limits LIDOCAINE-PHENYLEPHRINE INTRAOCULAR SOLUTION 3 LIDOCAINE-PHENYLEPHRINE-BSS INTRAOCULAR SOLUTION 3 PREFILLED SYRINGE *OPHTHALMIC LOCAL ANESTHETICS*** - DRUGS FOR THE EYE AKTEN OPHTHALMIC GEL (lidocaine hcl) 3 ALCAINE OPHTHALMIC SOLUTION (proparacaine hcl) 3 proparacaine hcl ophthalmic solution 1 or 1b* tetracaine hcl ophthalmic solution 1 or 1b* *OPHTHALMIC NERVE GROWTH FACTORS*** - DRUGS FOR THE EYE OXERVATE OPHTHALMIC SOLUTION (cenegermin-bkbj) 4 PA; LD; QL (2 vials per 1 day) *OPHTHALMIC NONSTEROIDAL ANTI-INFLAMMATORY AGENTS*** - ANTI-INFECTIVE/ANTI-INFLAMMATORIES ACULAR LS OPHTHALMIC SOLUTION (ketorolac tromethamine) 3 QL (5 mL per 30 days) ACULAR OPHTHALMIC SOLUTION (ketorolac tromethamine) 3 QL (5 mL per 30 days) ACUVAIL OPHTHALMIC SOLUTION (ketorolac tromethamine) 3 QL (1 box per 30 days) bromfenac sodium (once-daily) ophthalmic solution 1 or 1b* QL (1.7 mL per 30 days) BROMSITE OPHTHALMIC SOLUTION (bromfenac sodium) 3 QL (5 mL per 30 days) diclofenac sodium ophthalmic solution 1 or 1b* QL (5 mL per 30 days) flurbiprofen sodium ophthalmic solution 1 or 1b* QL (2.5 mL per 30 days) ILEVRO OPHTHALMIC SUSPENSION (nepafenac) 2 QL (3 mL per 30 days) ketorolac tromethamine ophthalmic solution 1 or 1b* QL (5 mL per 30 days) NEVANAC OPHTHALMIC SUSPENSION (nepafenac) 3 QL (3 mL per 30 days) PROLENSA OPHTHALMIC SOLUTION (bromfenac sodium) 3 QL (3 mL per 30 days) *OPHTHALMIC PHOTODYNAMIC THERAPY AGENTS*** - DRUGS FOR THE EYE VISUDYNE INTRAVENOUS SOLUTION RECONSTITUTED 4 LD; SP (verteporfin) *OPHTHALMIC PHOTOENHANCER COMBINATIONS*** - DRUGS FOR THE EYE PHOTREXA VISCOUS OPHTHALMIC SOLUTION PREFILLED 3 SYRINGE (riboflavin 5-phosphate-dextran) PHOTREXA-PHOTREXA VISCOUS KIT OPHTHALMIC SOLUTION 3 PREFILLED SYRINGE (riboflav5 & riboflav5-dextran) *OPHTHALMIC RHO KINASE INHIBITORS*** - DRUGS FOR GLAUCOMA RHOPRESSA OPHTHALMIC SOLUTION (netarsudil dimesylate) 3 QL (2.5 mL per 30 days) *OPHTHALMIC SELECTIVE ALPHA ADRENERGIC AGONISTS*** - DRUGS FOR GLAUCOMA ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % (brimonidine tartrate) 2 QL (15 mL per 30 days) ALPHAGAN P OPHTHALMIC SOLUTION 0.15 % (brimonidine tartrate) 3 QL (15 mL per 30 days) apraclonidine hcl ophthalmic solution 1 or 1b* brimonidine tartrate ophthalmic solution 1 or 1b* QL (15 mL per 30 days) IOPIDINE OPHTHALMIC SOLUTION (apraclonidine hcl) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 197 Coverage Requirements and Prescription Drug Name Drug Tier Limits *OPHTHALMIC STEROID COMBINATIONS*** - ANTI- INFECTIVE/ANTI-INFLAMMATORIES bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 or 1b* BLEPHAMIDE OPHTHALMIC SUSPENSION (sulfacetamide- 3 QL (15 mL per 30 days) prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT (sulfacetamide- 3 prednisolone) DEXAMETHASONE-MOXIFLOXACIN INTRAOCULAR SOLUTION 3 DEXAMETH-MOXIFLOX-KETOROLAC INTRAOCULAR 3 SOLUTION MAXITROL OPHTHALMIC OINTMENT (neomycin-polymyxin- 3 dexameth) MAXITROL OPHTHALMIC SUSPENSION (neomycin-polymyxin- 3 dexameth) neomycin-polymyxin-dexameth ophthalmic ointment 1 or 1a* neomycin-polymyxin-dexameth ophthalmic suspension 1 or 1a* neomycin-polymyxin-hc ophthalmic suspension 1 or 1b* neo-polycin hc ophthalmic ointment 1 or 1b* PRED-G OPHTHALMIC SUSPENSION (gentamicin-prednisolone acet) 3 PRED-G S.O.P. OPHTHALMIC OINTMENT (gentamicin-prednisolone 3 acet) sulfacetamide-prednisolone ophthalmic solution 1 or 1a* QL (15 mL per 30 days) TOBRADEX OPHTHALMIC OINTMENT (tobramycin-dexamethasone) 2 TOBRADEX OPHTHALMIC SUSPENSION (tobramycin-dexamethasone) 3 QL (10 mL per 30 days) TOBRADEX ST OPHTHALMIC SUSPENSION (tobramycin- 3 QL (10 mL per 30 days) dexamethasone) tobramycin-dexamethasone ophthalmic suspension 1 or 1b* QL (10 mL per 30 days) TRIAMCINOLONE-MOXIFLOXACIN INTRAOCULAR SUSPENSION 3 ZYLET OPHTHALMIC SUSPENSION (loteprednol-tobramycin) 2 *OPHTHALMIC STEROIDS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES ALREX OPHTHALMIC SUSPENSION (loteprednol etabonate) 3 dexamethasone sodium phosphate ophthalmic solution 1 or 1b* DEXTENZA OPHTHALMIC INSERT (dexamethasone) 3 DEXYCU INTRAOCULAR SUSPENSION (dexamethasone) 3 DUREZOL OPHTHALMIC EMULSION (difluprednate) 2 QL (10 mL per 30 days) FLAREX OPHTHALMIC SUSPENSION (fluorometholone acetate) 3 fluorometholone ophthalmic suspension 1 or 1b* FML FORTE OPHTHALMIC SUSPENSION (fluorometholone) 3 FML LIQUIFILM OPHTHALMIC SUSPENSION (fluorometholone) 3 FML OPHTHALMIC OINTMENT (fluorometholone) 3 ILUVIEN INTRAVITREAL IMPLANT (fluocinolone acetonide) 4 PA; LD; SP INVELTYS OPHTHALMIC SUSPENSION (loteprednol etabonate) 3 QL (5.6 mL per 30 days) LOTEMAX OPHTHALMIC GEL (loteprednol etabonate) 3 QL (10 grams per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 198 Coverage Requirements and Prescription Drug Name Drug Tier Limits LOTEMAX OPHTHALMIC OINTMENT (loteprednol etabonate) 3 QL (7 grams per 30 days) LOTEMAX OPHTHALMIC SUSPENSION (loteprednol etabonate) 3 QL (30 mL per 30 days) LOTEMAX SM OPHTHALMIC GEL (loteprednol etabonate) 3 QL (10 grams per 30 days) loteprednol etabonate ophthalmic gel 1 or 1b* QL (10 grams per 30 days) loteprednol etabonate ophthalmic suspension 1 or 1b* QL (30 mL per 30 days) MAXIDEX OPHTHALMIC SUSPENSION (dexamethasone) 3 OZURDEX INTRAVITREAL IMPLANT (dexamethasone) 3 PA; LD; SP PRED MILD OPHTHALMIC SUSPENSION (prednisolone acetate) 3 prednisolone acetate ophthalmic suspension 1 or 1b* QL (20 mL per 30 days) PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC SOLUTION 3 QL (20 mL per 30 days) RETISERT INTRAVITREAL IMPLANT (fluocinolone acetonide) 3 PA; LD; SP TRIESENCE INTRAOCULAR SUSPENSION (triamcinolone acetonide) 3 YUTIQ INTRAVITREAL IMPLANT (fluocinolone acetonide) 3 PA; LD *OPHTHALMIC SULFONAMIDES*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES BLEPH-10 OPHTHALMIC SOLUTION (sulfacetamide sodium) 3 QL (15 mL per 30 days) sulfacetamide sodium ophthalmic ointment 1 or 1b* QL (3.5 grams per 30 days) sulfacetamide sodium ophthalmic solution 1 or 1b* QL (15 mL per 30 days) *OPHTHALMIC SURGICAL AIDS - COMBINATIONS*** - DRUGS FOR THE EYE DISCOVISC INTRAOCULAR SOLUTION (na chondroit sulf-na hyaluron) 3 DUOVISC INTRAOCULAR KIT (na hyalur & na chond-na hyalur) 3 OMIDRIA INTRAOCULAR SOLUTION (phenylephrine-ketorolac) 3 VISCOAT INTRAOCULAR SOLUTION (na chondroit sulf-na hyaluron) 3 *OPHTHALMIC SURGICAL AIDS*** - DRUGS FOR THE EYE AMVISC INTRAOCULAR SOLUTION (sodium hyaluronate) 4 AMVISC PLUS INTRAOCULAR SOLUTION (sodium hyaluronate) 4 CELLUGEL INTRAOCULAR SOLUTION (hypromellose) 3 HEALON DUET PRO INTRAOCULAR SOLUTION PREFILLED 4 SYRINGE (sodium hyaluronate) HEALON GV INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON GV PRO INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON PRO INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON5 INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON5 PRO INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HYALURONIDASE (INTRAOCULAR) INTRAOCULAR SOLUTION 3 MEMBRANEBLUE OPHTHALMIC SOLUTION (trypan blue) 3 ocucoat viscoadherent intraocular solution 1 or 1b* PROVISC INTRAOCULAR SOLUTION (sodium hyaluronate) 4 TISSUEBLUE INTRAOCULAR SOLUTION PREFILLED SYRINGE 3 (brilliant blue g)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 199 Coverage Requirements and Prescription Drug Name Drug Tier Limits VISIONBLUE OPHTHALMIC SOLUTION (trypan blue) 3 *OPHTHALMICS - BLEPHAROPTOSIS AGENTS** - DRUGS FOR THE EYE UPNEEQ OPHTHALMIC SOLUTION (oxymetazoline hcl) 3 PA; QL (30 containers per 30 days) *OPHTHALMICS - CYSTINOSIS AGENTS** - DRUGS FOR THE EYE CYSTADROPS OPHTHALMIC SOLUTION (cysteamine hcl) 4 PA; LD; QL (4 bottles per 28 days) CYSTARAN OPHTHALMIC SOLUTION (cysteamine hcl) 3 PA; LD; QL (60 mL per 28 days) *PROSTAGLANDINS - OPHTHALMIC*** - DRUGS FOR GLAUCOMA bimatoprost ophthalmic solution 1 or 1b* PA; LD; SP; QL (2 applicators per 1 DURYSTA INTRAOCULAR IMPLANT (bimatoprost) 4 lifetime) latanoprost ophthalmic solution 1 or 1b* QL (5 mL per 30 days) LUMIGAN OPHTHALMIC SOLUTION (bimatoprost) 2 QL (7.5 mL per 30 days) travoprost (bak free) ophthalmic solution 1 or 1b* QL (5 mL per 30 days) VYZULTA OPHTHALMIC SOLUTION (latanoprostene bunod) 3 QL (5 mL per 30 days) XELPROS OPHTHALMIC EMULSION (latanoprost) 3 QL (5 mL per 30 days) ZIOPTAN OPHTHALMIC SOLUTION (tafluprost) 3 QL (9 mL per 30 days) *VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) ANTAGONISTS*** - DRUGS FOR THE EYE BEOVU INTRAVITREAL SOLUTION (brolucizumab-dbll) 4 PA; LD; SP BEVACIZUMAB INTRAOCULAR SOLUTION PREFILLED SYRINGE 3 PA EYLEA INTRAVITREAL SOLUTION (aflibercept) 4 PA; LD; SP EYLEA INTRAVITREAL SOLUTION PREFILLED SYRINGE 4 PA; LD (aflibercept) LUCENTIS INTRAVITREAL SOLUTION (ranibizumab) 4 PA; LD; SP LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 4 PA; LD; SP (ranibizumab) *OTIC AGENTS* - DRUGS FOR THE EAR *OTIC AGENTS - MISCELLANEOUS*** - WAX REMOVAL acetic acid otic solution 1 or 1b* *OTIC ANALGESIC COMBINATIONS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES PRAMOTIC OTIC LIQUID (pramoxine-chloroxylenol) 3 *OTIC ANTI-INFECTIVES*** - ANTIBIOTICS CETRAXAL OTIC SOLUTION (ciprofloxacin hcl) 3 QL (28 containers per 1 fill) ciprofloxacin hcl otic solution 1 or 1b* QL (28 containers per 1 fill) ofloxacin otic solution 1 or 1b* QL (10 mL per 1 fill) OTIPRIO INTRATYMPANIC SUSPENSION (ciprofloxacin) 3 *OTIC STEROID-ANTI-INFECTIVE COMBINATIONS*** - ANTI- INFECTIVE/ANTI-INFLAMMATORIES CIPRO HC OTIC SUSPENSION (ciprofloxacin-hydrocortisone) 3 QL (10 mL per 1 fill) CIPRODEX OTIC SUSPENSION (ciprofloxacin-dexamethasone) 3 QL (7.5 mL per 1 fill) ciprofloxacin-dexamethasone otic suspension 1 or 1b* QL (7.5 mL per 1 fill) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 200 Coverage Requirements and Prescription Drug Name Drug Tier Limits ciprofloxacin-fluocinolone pf otic solution 1 or 1b* QL (28 vials per 1 fill) CORTISPORIN-TC OTIC SUSPENSION (neomycin-colist-hc-thonzonium) 3 neomycin-polymyxin-hc otic solution 1 or 1b* neomycin-polymyxin-hc otic suspension 1 or 1b* OTOVEL OTIC SOLUTION (ciprofloxacin-fluocinolone) 3 QL (28 vials per 1 fill) *OTIC STEROIDS*** - ANTI-INFECTIVE/ANTI-INFLAMMATORIES DERMOTIC OTIC OIL (fluocinolone acetonide) 3 flac otic oil 1 or 1b* fluocinolone acetonide otic oil 1 or 1b* hydrocortisone-acetic acid otic solution 1 or 1b* QL (10 mL per 1 fill) *OXYTOCICS* - HORMONES *ABORTIFACIENTS/CERVICAL RIPENING - PROSTAGLANDINS*** - DRUGS FOR WOMEN carboprost tromethamine intramuscular solution 1 or 1b* CERVIDIL VAGINAL INSERT (dinoprostone) 3 HEMABATE INTRAMUSCULAR SOLUTION (carboprost tromethamine) 3 PREPIDIL VAGINAL GEL (dinoprostone) 3 PROSTIN E2 VAGINAL SUPPOSITORY (dinoprostone) 3 *OXYTOCICS*** - DRUGS FOR WOMEN methergine oral tablet 1 or 1b* methylergonovine maleate injection solution 1 or 1b* methylergonovine maleate oral tablet 1 or 1b* oxytocin injection solution 1 or 1b* OXYTOCIN-LACTATED RINGERS INTRAVENOUS SOLUTION 3 OXYTOCIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 PITOCIN INJECTION SOLUTION (oxytocin) 3 *PASSIVE IMMUNIZING AND TREATMENT AGENTS* - BIOLOGICAL AGENTS *ANTITOXINS-ANTIVENINS*** - BIOLOGICAL AGENTS ANASCORP INTRAVENOUS SOLUTION RECONSTITUTED 3 (centruroides (scorpion) im fab) ANAVIP INTRAVENOUS SOLUTION RECONSTITUTED (crotalidae 3 immune fab (equine)) ANTIVENIN LATRODECTUS MACTANS INJECTION KIT 3 ANTIVENIN MICRURUS FULVIUS INTRAVENOUS SOLUTION 3 RECONSTITUTED CROFAB INTRAVENOUS SOLUTION RECONSTITUTED (crotalidae 3 polyval immune fab) *ANTIVIRAL MONOCLONAL ANTIBODIES*** - BIOLOGICAL AGENTS SOTROVIMAB INTRAVENOUS SOLUTION 4 SYNAGIS INTRAMUSCULAR SOLUTION (palivizumab) 4 PA; LD; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 201 Coverage Requirements and Prescription Drug Name Drug Tier Limits *BACTERIAL MONOCLONAL ANTIBODIES*** - BIOLOGICAL AGENTS ZINPLAVA INTRAVENOUS SOLUTION (bezlotoxumab) 3 PA *IMMUNE SERUMS*** - BIOLOGICAL AGENTS ASCENIV INTRAVENOUS SOLUTION (immune globulin (human)-slra) 4 PA; LD; SP BIVIGAM INTRAVENOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP CUTAQUIG SUBCUTANEOUS SOLUTION (immune globulin (human)- 4 PA; LD; SP hipp) CUVITRU SUBCUTANEOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP CYTOGAM INTRAVENOUS INJECTABLE (cytomegalovirus immune 4 SP glob) FLEBOGAMMA DIF INTRAVENOUS SOLUTION (immune globulin 4 PA; LD; SP (human)) GAMASTAN INTRAMUSCULAR INJECTABLE (immune globulin 4 PA; LD; SP (human)) GAMMAGARD INJECTION SOLUTION (immune globulin (human)) 4 PA; LD; SP GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION 4 PA; LD; SP RECONSTITUTED (immune globulin (human)) GAMMAKED INJECTION SOLUTION (immune globulin (human)) 4 PA; LD; SP GAMMAPLEX INTRAVENOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP GAMUNEX-C INJECTION SOLUTION (immune globulin (human)) 4 PA; LD; SP HEPAGAM B INJECTION SOLUTION (hepatitis b immune globulin) 4 SP HIZENTRA SUBCUTANEOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; SP (immune globulin (human)) HYPERHEP B INTRAMUSCULAR SOLUTION (hepatitis b immune 4 LD; SP globulin) HYPERRAB INJECTION SOLUTION (rabies immune globulin) 4 SP HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED LD; SP; QL (2 syringes per 365 4 SYRINGE (rho d immune globulin) days) HYPERTET S/D INTRAMUSCULAR INJECTABLE (tetanus immune 3 globulin) IMOGAM RABIES-HT INJECTION SOLUTION (rabies immune 4 SP globulin) KEDRAB INJECTION SOLUTION 4 SP MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR 4 SP; QL (2 syringes per 365 days) SOLUTION PREFILLED SYRINGE (rho d immune globulin) NABI-HB INTRAMUSCULAR SOLUTION (hepatitis b immune globulin) 4 LD; SP OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 GM/200ML, 25 4 PA; LD; SP GM/500ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) OCTAGAM INTRAVENOUS SOLUTION 30 GM/300ML (immune 4 PA; LD globulin (human)) PANZYGA INTRAVENOUS SOLUTION (immune globulin (human)-ifas) 4 PA; LD; SP PRIVIGEN INTRAVENOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 202 Coverage Requirements and Prescription Drug Name Drug Tier Limits RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION 4 SP; QL (2 syringes per 365 days) PREFILLED SYRINGE (rho d immune globulin) RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE (rho d 4 LD; SP; QL (2 fills per 365 days) immune globulin) VARIZIG INTRAMUSCULAR SOLUTION (varicella-zoster immune glob) 3 WINRHO SDF INJECTION SOLUTION (rho d immune globulin) 4 SP; QL (2 fills per 365 days) XEMBIFY SUBCUTANEOUS SOLUTION (immune globulin (human)- 4 PA; LD; SP klhw) *MONOCLONAL ANTIBODY - COMBINATIONS*** - BIOLOGICAL AGENTS REGEN-COV INTRAVENOUS SOLUTION (casirivimab-imdevimab) 4 *PASSIVE IMMUNIZING AGENTS - COMBINATIONS*** - BIOLOGICAL AGENTS HYQVIA SUBCUTANEOUS KIT (immune globulin-hyaluronidase) 4 PA; LD; SP *PENICILLINS* - DRUGS FOR INFECTIONS *AMINOPENICILLINS*** - ANTIBIOTICS amoxicillin oral capsule 1 or 1a* amoxicillin oral suspension reconstituted 1 or 1a* QL (500 mL per 1 fill) amoxicillin oral tablet 1 or 1a* amoxicillin oral tablet chewable 1 or 1a* ampicillin oral capsule 1 or 1a* ampicillin sodium injection solution reconstituted 1 or 1b* ampicillin sodium intravenous solution reconstituted 1 or 1b* *NATURAL PENICILLINS*** - ANTIBIOTICS BICILLIN L-A INTRAMUSCULAR SUSPENSION (penicillin g 3 benzathine) PENICILLIN G POT IN DEXTROSE INTRAVENOUS SOLUTION 3 penicillin g potassium injection solution reconstituted 1 or 1b* PENICILLIN G PROCAINE INTRAMUSCULAR SUSPENSION 3 penicillin g sodium injection solution reconstituted 1 or 1b* penicillin v potassium oral solution reconstituted 1 or 1b* penicillin v potassium oral tablet 1 or 1b* pfizerpen injection solution reconstituted 1 or 1b* *PENICILLIN COMBINATIONS*** - ANTIBIOTICS amoxicillin-pot clavulanate er oral tablet extended release 12 hour 1 or 1b* QL (40 tablets per 1 fill) amoxicillin-pot clavulanate oral suspension reconstituted 1 or 1b* amoxicillin-pot clavulanate oral tablet 1 or 1b* amoxicillin-pot clavulanate oral tablet chewable 1 or 1b* ampicillin-sulbactam sodium injection solution reconstituted 1 or 1b* ampicillin-sulbactam sodium intravenous solution reconstituted 1 or 1b* AUGMENTIN ES-600 ORAL SUSPENSION RECONSTITUTED 3 (amoxicillin-pot clavulanate) AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 2 MG/5ML (amoxicillin-pot clavulanate) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 203 Coverage Requirements and Prescription Drug Name Drug Tier Limits AUGMENTIN ORAL SUSPENSION RECONSTITUTED 250-62.5 3 MG/5ML (amoxicillin-pot clavulanate) AUGMENTIN ORAL TABLET (amoxicillin-pot clavulanate) 3 BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION (penicillin g 3 benzathine & proc) BICILLIN C-R INTRAMUSCULAR SUSPENSION (penicillin g 3 benzathine & proc) piperacillin sod-tazobactam so intravenous solution reconstituted 1 or 1b* UNASYN INJECTION SOLUTION RECONSTITUTED (ampicillin- 3 sulbactam sodium) UNASYN INTRAVENOUS SOLUTION RECONSTITUTED (ampicillin- 3 sulbactam sodium) ZOSYN INTRAVENOUS SOLUTION (piperacillin-tazobactam in dex) 3 *PENICILLINASE-RESISTANT PENICILLINS*** - ANTIBIOTICS dicloxacillin sodium oral capsule 1 or 1b* NAFCILLIN SODIUM IN DEXTROSE INTRAVENOUS SOLUTION 3 nafcillin sodium injection solution reconstituted 1 or 1b* nafcillin sodium intravenous solution reconstituted 1 or 1b* OXACILLIN SODIUM IN DEXTROSE INTRAVENOUS SOLUTION 3 oxacillin sodium injection solution reconstituted 1 or 1b* oxacillin sodium intravenous solution reconstituted 1 or 1b* *PROGESTINS* - HORMONES *PROGESTINS*** - DRUGS FOR WOMEN AYGESTIN ORAL TABLET (norethindrone acetate) 3 hydroxyprogesterone caproate intramuscular oil 4 PA; SP; QL (25 mL per 21 weekss) PA; LD; SP; QL (25 mL per 21 MAKENA INTRAMUSCULAR OIL (hydroxyprogesterone caproate) 4 weekss) MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; SP; QL (25 mL per 21 4 (hydroxyprogesterone caproate) weekss) medroxyprogesterone acetate oral tablet 1 or 1a* QL (1 tablet per 1 day) megestrol acetate oral suspension 1 or 1b*; OC norethindrone acetate oral tablet 1 or 1b* progesterone intramuscular oil 1 or 1b* progesterone oral capsule 100 mg 1 or 1b* QL (2 capsules per 1 day) progesterone oral capsule 200 mg 1 or 1b* QL (1 capsule per 1 day) PROVERA ORAL TABLET (medroxyprogesterone acetate) 3 QL (1 tablet per 1 day) *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* - DRUGS FOR THE NERVOUS SYSTEM *AGENTS FOR OPIOID WITHDRAWAL*** - DRUGS FOR THE NERVOUS SYSTEM LUCEMYRA ORAL TABLET (lofexidine hcl) 3 QL (16 tablets per 1 day) *ALCOHOL DETERRENTS*** - DRUGS FOR THE NERVOUS SYSTEM acamprosate calcium oral tablet delayed release 1 or 1b* QL (6 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 204 Coverage Requirements and Prescription Drug Name Drug Tier Limits disulfiram oral tablet 1 or 1b* *ANTI-CATAPLECTIC AGENTS*** - DRUGS FOR SLEEP DISORDER XYREM ORAL SOLUTION (sodium oxybate) 3 PA; LD; QL (18 mL per 1 day) *ANTIDEMENTIA AGENT COMBINATIONS*** - DRUGS FOR ALZHEIMER'S DISEASE NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 2 (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 QL (1 capsule per 1 day) (memantine hcl-donepezil hcl) *ANTISENSE OLIGONUCLEOTIDE (ASO) INHIBITOR AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; QL (4 syringes per 28 4 (inotersen sodium) days) *BENZODIAZEPINES & TRICYCLIC AGENTS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN chlordiazepoxide-amitriptyline oral tablet 1 or 1b* *CHOLINOMIMETICS - ACHE INHIBITORS*** - DRUGS FOR ALZHEIMER'S DISEASE ARICEPT ORAL TABLET 10 MG, 23 MG (donepezil hcl) 3 QL (1 tablet per 1 day) ARICEPT ORAL TABLET 5 MG (donepezil hcl) 3 donepezil hcl oral tablet 10 mg, 23 mg 1 or 1b* QL (1 tablet per 1 day) donepezil hcl oral tablet 5 mg 1 or 1b* donepezil hcl oral tablet dispersible 1 or 1b* QL (1 tablet per 1 day) EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24HR, 9.5 3 ST; QL (1 patch per 1 day) MG/24HR (rivastigmine) EXELON TRANSDERMAL PATCH 24 HOUR 4.6 MG/24HR 3 ST; QL (1 gram per 1 day) (rivastigmine) galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 1 or 1b* QL (1 capsule per 1 day) mg galantamine hydrobromide er oral capsule extended release 24 hour 8 mg 1 or 1b* galantamine hydrobromide oral solution 1 or 1b* galantamine hydrobromide oral tablet 12 mg, 8 mg 1 or 1b* QL (2 tablets per 1 day) galantamine hydrobromide oral tablet 4 mg 1 or 1b* RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 16 3 QL (1 capsule per 1 day) MG, 24 MG (galantamine hydrobromide) RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 8 3 MG (galantamine hydrobromide) rivastigmine tartrate oral capsule 1.5 mg, 3 mg 1 or 1b* rivastigmine tartrate oral capsule 4.5 mg, 6 mg 1 or 1b* QL (2 capsules per 1 day) rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 9.5 mg/24hr 1 or 1b* QL (1 patch per 1 day) rivastigmine transdermal patch 24 hour 4.6 mg/24hr 1 or 1b* QL (1 gram per 1 day) *FIBROMYALGIA AGENT - SNRIS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN SAVELLA ORAL TABLET (milnacipran hcl) 2 QL (2 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 205 Coverage Requirements and Prescription Drug Name Drug Tier Limits SAVELLA TITRATION PACK ORAL (milnacipran hcl) 2 QL (1 pack per 365 days) *MELANOCORTIN RECEPTOR AGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM VYLEESI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; QL (4 autoinjectors per 30 3 (bremelanotide acetate) days) *MOVEMENT DISORDER DRUG THERAPY*** - DRUGS FOR THE NERVOUS SYSTEM PA; LD; SP; QL (4 tablets per 1 AUSTEDO ORAL TABLET (deutetrabenazine) 4 day) INGREZZA ORAL CAPSULE 40 MG (valbenazine tosylate) 4 PA; LD INGREZZA ORAL CAPSULE 60 MG, 80 MG (valbenazine tosylate) 4 PA; LD; QL (1 capsule per 1 day) INGREZZA ORAL CAPSULE THERAPY PACK (valbenazine tosylate) 4 PA; LD; QL (1 pack per 1 year) tetrabenazine oral tablet 12.5 mg 1 or 1b* PA; SP; QL (8 tablets per 1 day) tetrabenazine oral tablet 25 mg 1 or 1b* PA; SP; QL (4 tablets per 1 day) PA; LD; SP; QL (8 tablets per 1 XENAZINE ORAL TABLET 12.5 MG (tetrabenazine) 3 day) PA; LD; SP; QL (4 tablets per 1 XENAZINE ORAL TABLET 25 MG (tetrabenazine) 3 day) *MS AGENTS - PYRIMIDINE SYNTHESIS INHIBITORS*** - DRUGS FOR MULTIPLE SCLEROSIS AUBAGIO ORAL TABLET (teriflunomide) 4 PA; LD; SP; QL (1 tablet per 1 day) *MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES*** - DRUGS FOR MULTIPLE SCLEROSIS MAVENCLAD (10 TABS) ORAL TABLET THERAPY PACK PA; LD; SP; QL (2 packs per 46 4 (cladribine) weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (4 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (5 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (6 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (7 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (8 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (9 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) *MULTIPLE SCLEROSIS AGENTS - INTERFERONS*** - DRUGS FOR MULTIPLE SCLEROSIS BETASERON SUBCUTANEOUS KIT (interferon beta-1b) 4 SP; QL (15 kits per 30 days) REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 PA; SP; QL (12 ML per 28 days) (interferon beta-1a) REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION 4 PA; SP; QL (4.2 ML per 28 days) AUTO-INJECTOR (interferon beta-1a) REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP (interferon beta-1a)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 206 Coverage Requirements and Prescription Drug Name Drug Tier Limits REBIF TITRATION PACK SUBCUTANEOUS SOLUTION 4 PA; SP PREFILLED SYRINGE (interferon beta-1a) *MULTIPLE SCLEROSIS AGENTS - MONOCLONAL ANTIBODIES*** - DRUGS FOR MULTIPLE SCLEROSIS KESIMPTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; SP; QL (1 syringe per 28 4 (ofatumumab) days) PA; LD; SP; QL (3 vials per 365 LEMTRADA INTRAVENOUS SOLUTION (alemtuzumab) 4 days) TYSABRI INTRAVENOUS CONCENTRATE (natalizumab) 4 PA; LD; SP; QL (1 vial per 28 days) *MULTIPLE SCLEROSIS AGENTS - NRF2 PATHWAY ACTIVATORS*** - DRUGS FOR MULTIPLE SCLEROSIS PA; LD; SP; QL (14 capsules per dimethyl fumarate oral capsule delayed release 120 mg 4 365 days) PA; LD; SP; QL (2 capsules per 1 dimethyl fumarate oral capsule delayed release 240 mg 4 day) dimethyl fumarate starter pack oral 4 PA; SP; QL (1 kit per 365 days) *MULTIPLE SCLEROSIS AGENTS - POTASSIUM CHANNEL BLOCKERS*** - DRUGS FOR MULTIPLE SCLEROSIS AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR PA; LD; SP; QL (2 tablets per 1 4 (dalfampridine) day) dalfampridine er oral tablet extended release 12 hour 4 PA; SP; QL (2 tablets per 1 day) *MULTIPLE SCLEROSIS AGENTS*** - DRUGS FOR MULTIPLE SCLEROSIS COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 PA; LD; SP; QL (1 syringe per 1 4 MG/ML (glatiramer acetate) day) COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 PA; LD; SP; QL (12 ML per 28 4 MG/ML (glatiramer acetate) days) *N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTS*** - DRUGS FOR ALZHEIMER'S DISEASE memantine hcl er oral capsule extended release 24 hour 14 mg, 7 mg 1 or 1b* memantine hcl er oral capsule extended release 24 hour 21 mg, 28 mg 1 or 1b* QL (1 capsule per 1 day) memantine hcl oral solution 1 or 1b* QL (10 mL per 1 day) memantine hcl oral tablet 10 mg 1 or 1b* QL (2 tablets per 1 day) memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg 1 or 1b* QL (1 tablet per 1 day) memantine hcl oral tablet 5 mg 1 or 1b* NAMENDA TITRATION PAK ORAL TABLET (memantine hcl) 3 QL (1 tablet per 1 day) *PHENOTHIAZINES & TRICYCLIC AGENTS*** - DRUGS FOR DEPRESSION perphenazine-amitriptyline oral tablet 1 or 1b* *POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN GRALISE ORAL TABLET 300 MG (gabapentin (once-daily)) 2 PA GRALISE ORAL TABLET 600 MG (gabapentin (once-daily)) 2 PA; QL (3 tablets per 1 day) LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 165 3 PA MG, 82.5 MG (pregabalin)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 207 Coverage Requirements and Prescription Drug Name Drug Tier Limits LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 330 3 PA; QL (2 tablets per 1 day) MG (pregabalin) pregabalin er oral tablet extended release 24 hour 165 mg, 82.5 mg 1 or 1b* PA pregabalin er oral tablet extended release 24 hour 330 mg 1 or 1b* PA; QL (2 tablets per 1 day) *PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS - SSRIS*** - DRUGS FOR DEPRESSION fluoxetine hcl (pmdd) oral tablet 10 mg 1 or 1b* fluoxetine hcl (pmdd) oral tablet 20 mg 1 or 1b* QL (4 tablets per 1 day) *PSEUDOBULBAR AFFECT AGENT COMBINATIONS*** - DRUGS FOR SEVERE MENTAL DISORDERS NUEDEXTA ORAL CAPSULE (dextromethorphan-quinidine) 3 PA; QL (2 capsules per 1 day) *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*** - DRUGS FOR SEVERE MENTAL DISORDERS ergoloid mesylates oral tablet 1 or 1b* QL (3 tablets per 1 day) pimozide oral tablet 1 or 1b* *RESTLESS LEG SYNDROME (RLS) AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM HORIZANT ORAL TABLET EXTENDED RELEASE (gabapentin 3 PA; QL (2 tablets per 1 day) enacarbil) *SEROTONIN 1A RECEPT AGONIST/SEROTONIN 2A RECEPT ANTAG*** - DRUGS FOR THE NERVOUS SYSTEM ADDYI ORAL TABLET (flibanserin) 3 PA; QL (1 tablet per 1 day) *SMALL INTERFERING RIBONUCLEIC ACID (SIRNA) AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM ONPATTRO INTRAVENOUS SOLUTION (patisiran sodium) 4 PA; LD; QL (0.72 mL per 1 day) *SMOKING DETERRENTS*** - DRUGS FOR DEPRESSION bupropion hcl er (smoking det) oral tablet extended release 12 hour 1 or 1b*; $0 PA; QL (2 tablets per 1 day) CHANTIX CONTINUING MONTH PAK ORAL TABLET (varenicline 3; $0 PA; QL (2 tablet per 1 day) tartrate) CHANTIX ORAL TABLET 0.5 MG (varenicline tartrate) 3; $0 PA; QL (2 tablets per 1 day) CHANTIX ORAL TABLET 1 MG (varenicline tartrate) 3; $0 PA; QL (2 tablet per 1 day) CHANTIX STARTING MONTH PAK ORAL TABLET (varenicline PA; QL (1 starting month pack per 3; $0 tartrate) 365 days) cvs nicotine mouth/throat gum 1 or 1b*; $0 cvs nicotine mouth/throat lozenge 1 or 1b*; $0 cvs nicotine polacrilex mouth/throat gum 1 or 1b*; $0 cvs nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 cvs nicotine transdermal patch 24 hour 1 or 1b*; $0 eq nicotine mouth/throat lozenge 1 or 1b*; $0 eq nicotine polacrilex mouth/throat gum 1 or 1b*; $0 eq nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 eq nicotine step 3 transdermal patch 24 hour 1 or 1b*; $0 eq nicotine transdermal patch 24 hour 1 or 1b*; $0 eql nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 208 Coverage Requirements and Prescription Drug Name Drug Tier Limits gnp nicotine mini mouth/throat lozenge 1 or 1b*; $0 gnp nicotine mouth/throat gum 1 or 1b*; $0 gnp nicotine polacrilex mouth/throat gum 1 or 1b*; $0 gnp nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 gnp nicotine transdermal patch 24 hour 1 or 1b*; $0 goodsense nicotine mouth/throat gum 1 or 1b*; $0 goodsense nicotine mouth/throat lozenge 1 or 1b*; $0 habitrol transdermal patch 24 hour 1 or 1b*; $0 hm nicotine polacrilex mouth/throat gum 1 or 1b*; $0 hm nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 hm nicotine transdermal patch 24 hour 1 or 1b*; $0 kls quit2 mouth/throat gum 1 or 1b*; $0 kls quit2 mouth/throat lozenge 1 or 1b*; $0 kls quit4 mouth/throat gum 1 or 1b*; $0 kls quit4 mouth/throat lozenge 1 or 1b*; $0 NICODERM CQ TRANSDERMAL PATCH 24 HOUR (nicotine) 2; $0 NICORETTE MINI MOUTH/THROAT LOZENGE (nicotine polacrilex) 2; $0 NICORETTE MOUTH/THROAT GUM (nicotine polacrilex) 2; $0 NICORETTE MOUTH/THROAT LOZENGE (nicotine polacrilex) 2; $0 NICORETTE STARTER KIT MOUTH/THROAT GUM (nicotine 2; $0 polacrilex) nicotine mini mouth/throat lozenge 1 or 1b*; $0 nicotine polacrilex mini mouth/throat lozenge 1 or 1b*; $0 nicotine polacrilex mouth/throat gum 1 or 1b*; $0 nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 nicotine step 1 transdermal patch 24 hour 1 or 1b*; $0 nicotine step 2 transdermal patch 24 hour 1 or 1b*; $0 nicotine step 3 transdermal patch 24 hour 1 or 1b*; $0 NICOTINE TRANSDERMAL KIT 2; $0 nicotine transdermal patch 24 hour 1 or 1b*; $0 NICOTROL INHALATION INHALER (nicotine) 3; $0 PA NICOTROL NS NASAL SOLUTION (nicotine) 3; $0 PA px stop smoking aid mouth/throat gum 1 or 1b*; $0 px stop smoking aid mouth/throat lozenge 1 or 1b*; $0 qc nicotine transdermal system transdermal patch 24 hour 1 or 1b*; $0 ra mini nicotine mouth/throat lozenge 1 or 1b*; $0 ra nicotine gum mouth/throat gum 1 or 1b*; $0 ra nicotine mouth/throat gum 1 or 1b*; $0 ra nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 ra nicotine transdermal patch 24 hour 1 or 1b*; $0 sm nicotine mouth/throat gum 1 or 1b*; $0 sm nicotine mouth/throat lozenge 1 or 1b*; $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 209 Coverage Requirements and Prescription Drug Name Drug Tier Limits sm nicotine polacrilex mouth/throat gum 1 or 1b*; $0 sm nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 sm nicotine transdermal patch 24 hour 1 or 1b*; $0 thrive mouth/throat gum 1 or 1b*; $0 *SPHINGOSINE 1-PHOSPHATE (S1P) RECEPTOR MODULATORS*** - DRUGS FOR MULTIPLE SCLEROSIS GILENYA ORAL CAPSULE (fingolimod hcl) 4 PA; SP; QL (1 capsule per 1 day) PA; LD; SP; QL (4 tablets per 1 MAYZENT ORAL TABLET 0.25 MG (siponimod fumarate) 4 day) MAYZENT ORAL TABLET 2 MG (siponimod fumarate) 4 PA; LD; SP; QL (1 tablet per 1 day) MAYZENT STARTER PACK ORAL TABLET THERAPY PACK PA; LD; SP; QL (1 pack per 1 one 4 (siponimod fumarate) time fill) ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK 4 PA; LD; SP; QL (1 pack per 1 fill) (ozanimod hcl) PA; LD; SP; QL (1 capsule per 1 ZEPOSIA ORAL CAPSULE (ozanimod hcl) 4 day) ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK 4 PA; LD; SP; QL (1 pack per 1 fill) (ozanimod hcl) *THIENBENZODIAZEPINES & SSRIS*** - DRUGS FOR SEVERE MENTAL DISORDERS olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-50 mg 1 or 1b* QL (1 capsule per 1 day) olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6-25 mg 1 or 1b* SYMBYAX ORAL CAPSULE (olanzapine-fluoxetine hcl) 3 *VASOMOTOR SYMPTOM AGENTS - SSRIS*** - DRUGS FOR THE NERVOUS SYSTEM paroxetine mesylate oral capsule 1 or 1b* *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS *ALPHA-PROTEINASE INHIBITOR (HUMAN)*** - DRUGS FOR ASTHMA/COPD ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (alpha1-proteinase inhibitor) GLASSIA INTRAVENOUS SOLUTION (alpha1-proteinase inhibitor) 4 PA; LD; SP PROLASTIN-C INTRAVENOUS SOLUTION (alpha1-proteinase 4 PA; LD inhibitor) PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD (alpha1-proteinase inhibitor) ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED (alpha1- 4 PA; LD; SP proteinase inhibitor) *CFTR POTENTIATORS*** - DRUGS FOR CYSTIC FIBROSIS KALYDECO ORAL PACKET 25 MG (ivacaftor) 4 PA; LD; QL (2 packets per 1 day) KALYDECO ORAL PACKET 50 MG, 75 MG (ivacaftor) 4 PA; LD; QL (2 packet per 1 day) KALYDECO ORAL TABLET (ivacaftor) 4 PA; LD; QL (2 tablets per 1 day) *CYSTIC FIBROSIS AGENT - COMBINATIONS*** - DRUGS FOR CYSTIC FIBROSIS ORKAMBI ORAL PACKET (lumacaftor-ivacaftor) 4 PA; LD; QL (2 packets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 210 Coverage Requirements and Prescription Drug Name Drug Tier Limits ORKAMBI ORAL TABLET (lumacaftor-ivacaftor) 4 PA; LD; QL (4 tablet per 1 day) SYMDEKO ORAL TABLET THERAPY PACK (tezacaftor-ivacaftor) 4 PA; LD; QL (1 carton per 28 days) TRIKAFTA ORAL TABLET THERAPY PACK (elexacaftor-tezacaftor- 4 PA; LD; QL (1 carton per 28 days) ivacaft) *CYSTIC FIBROSIS AGENTS - MISCELLANEOUS*** - DRUGS FOR CYSTIC FIBROSIS PA; LD; SP; QL (560 tablets per 28 BRONCHITOL INHALATION CAPSULE (mannitol (cystic fibrosis)) 4 days) BRONCHITOL TOLERANCE TEST INHALATION CAPSULE 4 PA; LD; SP; QL (1 test per 1 fill) (mannitol (cystic fibrosis)) *HYDROLYTIC ENZYMES*** - DRUGS FOR THE LUNGS PULMOZYME INHALATION SOLUTION (dornase alfa) 4 LD; SP; QL (150 mL per 30 days) *PLEURAL SCLEROSING AGENTS*** - DRUGS FOR THE LUNGS SCLEROSOL INTRAPLEURAL INTRAPLEURAL AEROSOL 3 POWDER (talc) STERILE TALC POWDER INTRAPLEURAL SUSPENSION 3 RECONSTITUTED (talc) STERITALC INTRAPLEURAL POWDER (talc) 3 *PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS*** - DRUGS FOR THE LUNGS PA; LD; SP; QL (2 capsules per 1 OFEV ORAL CAPSULE (nintedanib esylate) 4 day) *PULMONARY FIBROSIS AGENTS*** - DRUGS FOR THE LUNGS PA; LD; SP; QL (9 capsule per 1 ESBRIET ORAL CAPSULE (pirfenidone) 4 day) PA; LD; SP; QL (9 tablets per 1 ESBRIET ORAL TABLET 267 MG (pirfenidone) 4 day) PA; LD; SP; QL (3 tablets per 1 ESBRIET ORAL TABLET 801 MG (pirfenidone) 4 day) *RESPIRATORY AGENTS - MISC.*** - DRUGS FOR THE LUNGS CUROSURF INTRATRACHEAL SUSPENSION (poractant alfa) 3 INFASURF INTRATRACHEAL SUSPENSION (calfactant in nacl) 3 SURVANTA INTRATRACHEAL SUSPENSION (beractant in nacl) 3 *SULFONAMIDES* - DRUGS FOR INFECTIONS *SULFONAMIDES*** - ANTIBIOTICS SULFADIAZINE ORAL TABLET 3 *TETRACYCLINES* - DRUGS FOR INFECTIONS *AMINOMETHYLCYCLINES*** - ANTIBIOTICS NUZYRA INTRAVENOUS SOLUTION RECONSTITUTED 3 LD (omadacycline tosylate) NUZYRA ORAL TABLET (omadacycline tosylate) 3 PA; LD; QL (30 tablets per 30 days) *FLUOROCYCLINES*** - ANTIBIOTICS XERAVA INTRAVENOUS SOLUTION RECONSTITUTED 3 (eravacycline dihydrochloride)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 211 Coverage Requirements and Prescription Drug Name Drug Tier Limits *GLYCYLCYCLINES*** - ANTIBIOTICS TIGECYCLINE INTRAVENOUS SOLUTION RECONSTITUTED 3 TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 3 (tigecycline) *TETRACYCLINES*** - ANTIBIOTICS coremino oral tablet extended release 24 hour 1 or 1b* ST demeclocycline hcl oral tablet 1 or 1b* doxy 100 intravenous solution reconstituted 1 or 1b* QL (2 vials per 1 day) doxycycline hyclate intravenous solution reconstituted 1 or 1b* QL (2 vials per 1 day) doxycycline hyclate oral capsule 100 mg 1 or 1b* QL (2 capsules per 1 day) doxycycline hyclate oral capsule 50 mg 1 or 1b* doxycycline hyclate oral tablet 100 mg, 20 mg, 50 mg 1 or 1b* QL (2 tablets per 1 day) doxycycline hyclate oral tablet 150 mg 1 or 1b* ST; QL (1 tablet per 1 day) doxycycline hyclate oral tablet 75 mg 1 or 1b* ST; QL (2 tablets per 1 day) doxycycline hyclate oral tablet delayed release 1 or 1b* ST; QL (2 tablets per 1 day) doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg 1 or 1b* QL (2 capsules per 1 day) doxycycline monohydrate oral capsule 150 mg 1 or 1b* doxycycline monohydrate oral suspension reconstituted 1 or 1b* QL (600 mL per 30 days) doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg 1 or 1b* QL (2 tablets per 1 day) doxycycline monohydrate oral tablet 150 mg 1 or 1b* MINOCIN INTRAVENOUS SOLUTION RECONSTITUTED 3 (minocycline hcl) minocycline hcl er oral tablet extended release 24 hour 1 or 1b* ST minocycline hcl oral capsule 1 or 1b* minocycline hcl oral tablet 1 or 1b* mondoxyne nl oral capsule 1 or 1b* QL (2 capsules per 1 day) morgidox oral capsule 1 or 1b* QL (2 capsules per 1 day) tetracycline hcl oral capsule 1 or 1b* *THYROID AGENTS* - HORMONES *ANTITHYROID AGENTS - RADIOPHARMACEUTICALS*** - DRUGS FOR THYROID SODIUM IODIDE I-131 ORAL SOLUTION 3 *ANTITHYROID AGENTS*** - DRUGS FOR THYROID methimazole oral tablet 1 or 1a* propylthiouracil oral tablet 1 or 1b* TAPAZOLE ORAL TABLET (methimazole) 3 *THYROID HORMONES*** - DRUGS FOR THYROID ARMOUR THYROID ORAL TABLET (thyroid) 3 CYTOMEL ORAL TABLET (liothyronine sodium) 3 euthyrox oral tablet 1 or 1b* levo-t oral tablet 1 or 1b* LEVOTHYROXINE SODIUM INTRAVENOUS SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 212 Coverage Requirements and Prescription Drug Name Drug Tier Limits LEVOTHYROXINE SODIUM INTRAVENOUS SOLUTION 3 RECONSTITUTED levothyroxine sodium oral capsule 1 or 1b* levothyroxine sodium oral tablet 1 or 1a* levoxyl oral tablet 1 or 1a* liothyronine sodium intravenous solution 1 or 1b* liothyronine sodium oral tablet 1 or 1b* NATURE-THROID ORAL TABLET (thyroid) 3 np thyroid oral tablet 1 or 1a* SYNTHROID ORAL TABLET (levothyroxine sodium) 3 THYQUIDITY ORAL SOLUTION (levothyroxine sodium) 3 TIROSINT ORAL CAPSULE (levothyroxine sodium) 3 TIROSINT-SOL ORAL SOLUTION (levothyroxine sodium) 3 TRIOSTAT INTRAVENOUS SOLUTION (liothyronine sodium) 3 unithroid oral tablet 1 or 1a* WESTHROID ORAL TABLET (thyroid) 3 WP THYROID ORAL TABLET (thyroid) 3 *TOXOIDS* - BIOLOGICAL AGENTS *TOXOID COMBINATIONS*** - VACCINES ADACEL INTRAMUSCULAR SUSPENSION (tetanus-diphth-acell 3; $0 pertussis) BOOSTRIX INTRAMUSCULAR SUSPENSION (tetanus-diphth-acell 3; $0 pertussis) DAPTACEL INTRAMUSCULAR SUSPENSION (diphth-acell pertussis- 3; $0 tetanus) DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR 3; $0 SUSPENSION INFANRIX INTRAMUSCULAR SUSPENSION (diphth-acell pertussis- 3; $0 tetanus) KINRIX INTRAMUSCULAR SUSPENSION (dtap-ipv vaccine) 3; $0 PEDIARIX INTRAMUSCULAR SUSPENSION (dtap-hepatitis b recomb- 3; $0 ipv) PENTACEL INTRAMUSCULAR SUSPENSION RECONSTITUTED 3; $0 (dtap-ipv-hib vaccine) QUADRACEL INTRAMUSCULAR SUSPENSION (dtap-ipv vaccine) 3; $0 TDVAX INTRAMUSCULAR SUSPENSION (tetanus-diphtheria toxoids td) 3; $0 TENIVAC INTRAMUSCULAR INJECTABLE (tetanus-diphtheria toxoids 3; $0 td) TETANUS-DIPHTHERIA TOXOIDS TD INTRAMUSCULAR 3; $0 SUSPENSION VAXELIS INTRAMUSCULAR SUSPENSION (dtap-ipv-hib-hepatitis b 3 recmb) VAXELIS INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 3 (dtap-ipv-hib-hepatitis b recmb)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 213 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS* - DRUGS FOR THE STOMACH *ANTICHOLINERGIC COMBINATIONS*** - DRUGS FOR STOMACH CRAMPS chlordiazepoxide-clidinium oral capsule 1 or 1b* LIBRAX ORAL CAPSULE (chlordiazepoxide-clidinium) 3 phenohytro oral elixir 1 or 1b* phenohytro oral tablet 1 or 1b* *ANTISPASMODICS*** - DRUGS FOR STOMACH CRAMPS BENTYL INTRAMUSCULAR SOLUTION (dicyclomine hcl) 3 dicyclomine hcl intramuscular solution 1 or 1b* dicyclomine hcl oral capsule 1 or 1a* dicyclomine hcl oral solution 1 or 1a* dicyclomine hcl oral tablet 1 or 1a* *BELLADONNA ALKALOIDS*** - DRUGS FOR STOMACH CRAMPS ATROPEN INTRAMUSCULAR SOLUTION AUTO-INJECTOR 3 (atropine sulfate) atropine sulfate injection solution prefilled syringe 1 or 1b* ATROPINE SULFATE INTRAVENOUS SOLUTION 3 ATROPINE SULFATE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE hyoscyamine sulfate er oral tablet extended release 12 hour 1 or 1b* hyoscyamine sulfate sl sublingual tablet sublingual 1 or 1b* hyoscyamine sulfate sublingual tablet sublingual 1 or 1b* *H-2 ANTAGONISTS*** - DRUGS FOR ULCERS AND STOMACH ACID cimetidine hcl oral solution 1 or 1b* cimetidine oral tablet 200 mg 1 or 1b* QL (2 tablets per 1 day) cimetidine oral tablet 300 mg, 400 mg 1 or 1b* QL (4 tablets per 1 day) cimetidine oral tablet 800 mg 1 or 1b* QL (3 tablets per 1 day) famotidine intravenous solution 1 or 1b* famotidine oral suspension reconstituted 1 or 1b* QL (5 mL per 1 day) famotidine oral tablet 20 mg 1 or 1b* QL (4 tablets per 1 day) famotidine oral tablet 40 mg 1 or 1b* QL (2 tablets per 1 day) famotidine premixed intravenous solution 1 or 1b* nizatidine oral capsule 150 mg 1 or 1b* QL (2 capsules per 1 day) nizatidine oral capsule 300 mg 1 or 1b* QL (1 capsule per 1 day) nizatidine oral solution 1 or 1b* QL (20 mL per 1 day) PEPCID ORAL TABLET 20 MG (famotidine) 3 QL (4 tablets per 1 day) PEPCID ORAL TABLET 40 MG (famotidine) 3 QL (2 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 214 Coverage Requirements and Prescription Drug Name Drug Tier Limits *MISC. ANTI-ULCER*** - DRUGS FOR ULCERS AND STOMACH ACID CARAFATE ORAL SUSPENSION (sucralfate) 3 CARAFATE ORAL TABLET (sucralfate) 3 sucralfate oral suspension 1 or 1b* sucralfate oral tablet 1 or 1b* *PROTON PUMP INHIBITORS*** - DRUGS FOR ULCERS AND STOMACH ACID DEXILANT ORAL CAPSULE DELAYED RELEASE (dexlansoprazole) 2 ST; QL (1 capsule per 1 day) esomeprazole sodium intravenous solution reconstituted 1 or 1b* NEXIUM I.V. INTRAVENOUS SOLUTION RECONSTITUTED 3 (esomeprazole sodium) omeprazole oral capsule delayed release 1 or 1b* pantoprazole sodium intravenous solution reconstituted 1 or 1b* pantoprazole sodium oral tablet delayed release 1 or 1b* PROTONIX INTRAVENOUS SOLUTION RECONSTITUTED 3 (pantoprazole sodium) *QUATERNARY ANTICHOLINERGICS*** - DRUGS FOR STOMACH CRAMPS CUVPOSA ORAL SOLUTION (glycopyrrolate) 3 GLYCATE ORAL TABLET (glycopyrrolate) 3 PA glycopyrrolate injection solution 1 or 1b* glycopyrrolate oral tablet 1 mg, 2 mg 1 or 1b* GLYCOPYRROLATE ORAL TABLET 1.5 MG 3 PA GLYCOPYRROLATE PF INJECTION SOLUTION PREFILLED 3 SYRINGE GLYRX-PF INJECTION SOLUTION (glycopyrrolate) 3 GLYRX-PF INJECTION SOLUTION PREFILLED SYRINGE 3 (glycopyrrolate) methscopolamine bromide oral tablet 1 or 1b* *ULCER ANTI-INFECTIVE W/ BISMUTH COMBINATIONS*** - DRUGS FOR ULCERS AND STOMACH ACID HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 ST; QL (1 pack per 1 fill) PYLERA ORAL CAPSULE (bis subcit-metronid-tetracyc) 3 ST; QL (1 pack per 1 fill) *ULCER ANTI-INFECTIVE W/ PROTON PUMP INHIBITORS*** - DRUGS FOR ULCERS AND STOMACH ACID amoxicill-clarithro-lansopraz oral 1 or 1b* ST; QL (1 pack per 1 fill) OMECLAMOX-PAK ORAL (amoxicill-clarithro-omeprazole) 3 ST; QL (1 pack per 1 fill) TALICIA ORAL CAPSULE DELAYED RELEASE (amoxicill-rifabutin- 3 ST; QL (1 pack per 1 fill) omeprazole) *ULCER DRUGS - PROSTAGLANDINS*** - DRUGS FOR ULCERS AND STOMACH ACID CYTOTEC ORAL TABLET (misoprostol) 3 misoprostol oral tablet 1 or 1a*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 215 Coverage Requirements and Prescription Drug Name Drug Tier Limits *URINARY ANTISPASMODICS* - DRUGS FOR THE URINARY SYSTEM *URINARY ANTISPASMODIC - ANTIMUSCARINIC (ANTICHOLINERGIC)*** - DRUGS FOR THE BLADDER darifenacin hydrobromide er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg 1 or 1b* QL (2 tablets per 1 day) oxybutynin chloride er oral tablet extended release 24 hour 5 mg 1 or 1b* QL (1 tablet per 1 day) oxybutynin chloride oral syrup 1 or 1b* QL (20 mL per 1 day) oxybutynin chloride oral tablet 1 or 1b* QL (4 tablets per 1 day) solifenacin succinate oral tablet 1 or 1b* QL (1 tablet per 1 day) tolterodine tartrate er oral capsule extended release 24 hour 1 or 1b* QL (1 capsule per 1 day) tolterodine tartrate oral tablet 1 or 1b* QL (2 tablets per 1 day) TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (1 tablet per 1 day) (fesoterodine fumarate) trospium chloride er oral capsule extended release 24 hour 1 or 1b* QL (1 capsule per 1 day) trospium chloride oral tablet 1 or 1b* QL (2 tablets per 1 day) *URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS*** - DRUGS FOR THE BLADDER MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (1 tablet per 1 day) (mirabegron) *URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS*** - DRUGS FOR THE BLADDER bethanechol chloride oral tablet 1 or 1b* *URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS*** - DRUGS FOR THE BLADDER flavoxate hcl oral tablet 1 or 1b* *VACCINES* - BIOLOGICAL AGENTS *BACTERIAL VACCINES*** - VACCINES ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED 3; $0 (haemophilus b polysac conj vac) BCG VACCINE INJECTION INJECTABLE 3; $0 BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 3; $0 (meningococcal b recomb omv adj) BIOTHRAX INTRAMUSCULAR SUSPENSION (anthrax vaccine 3 adsorbed) HIBERIX INJECTION SOLUTION RECONSTITUTED (haemophilus b 3; $0 polysac conj vac) MENACTRA INTRAMUSCULAR INJECTABLE (meningococcal a c 3; $0 y&w-135 conj) MENQUADFI INTRAMUSCULAR INJECTABLE (meningococcal a c 3; $0 y&w-135 conj) MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED 3; $0 (meningococcal a c y&w-135 olig) PEDVAX HIB INTRAMUSCULAR SUSPENSION (haemophilus b polysac 3; $0 conj vac)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 216 Coverage Requirements and Prescription Drug Name Drug Tier Limits PNEUMOVAX 23 INJECTION INJECTABLE (pneumococcal vac 2; $0 polyvalent) PREVNAR 13 INTRAMUSCULAR SUSPENSION (pneumococcal 13-val 2; $0 conj vacc) TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED 3; $0 SYRINGE (meningococcal b vac (recomb)) TYPHIM VI INTRAMUSCULAR SOLUTION (typhoid vi polysaccharide 3 vacc) VAXCHORA ORAL SUSPENSION RECONSTITUTED (cholera vac live 3 attenuated) *VIRAL VACCINE COMBINATIONS*** - VACCINES M-M-R II INJECTION SOLUTION RECONSTITUTED (measles, mumps 3; $0 & rubella vac) PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED 3; $0 (measles-mumps-rubella-varicell) TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 3; $0 (hepatitis a-hep b recomb vac) *VIRAL VACCINES*** - VACCINES AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) (influenza vac split quad) AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac split quad) ENGERIX-B INJECTION SUSPENSION (hepatitis b vac recombinant) 3; $0 FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2; $0 QL (1 fill per 180 days) (influenza vac a&b surf ant adj) FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE 2; $0 QL (1 fill per 180 days) (influenza vac a&b sa adj quad) FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac split quad) FLUBLOK QUADRIVALENT INTRAMUSCULAR SOLUTION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac recomb ha quad) FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) (influenza vac subunit quad) FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac subunit quad) FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac split quad) FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) (influenza vac split quad) FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac split quad) GARDASIL 9 INTRAMUSCULAR SUSPENSION (hpv 9-valent recomb 2; $0 vaccine) GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED 2; $0 SYRINGE (hpv 9-valent recomb vaccine) HAVRIX INTRAMUSCULAR SUSPENSION (hepatitis a vaccine) 3; $0 HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 3; $0 (hepatitis b vac recomb adj) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 217 Coverage Requirements and Prescription Drug Name Drug Tier Limits IMOVAX RABIES INTRAMUSCULAR INJECTABLE (rabies virus 3 vaccine, hdc) IPOL INJECTION INJECTABLE (poliovirus vaccine inactivated) 3; $0 IXIARO INTRAMUSCULAR SUSPENSION (japanese encephalitis vac 3 inac) RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED 3 (rabies vaccine, pcec) RECOMBIVAX HB INJECTION SUSPENSION (hepatitis b vac 3; $0 recombinant) ROTARIX ORAL SUSPENSION RECONSTITUTED (rotavirus vaccine 3; $0 live oral) ROTATEQ ORAL SOLUTION (rotavirus vac live pentavalent) 3; $0 SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 3; $0 (zoster vac recomb adjuvanted) STAMARIL INJECTION SUSPENSION RECONSTITUTED 3 VAQTA INTRAMUSCULAR SUSPENSION (hepatitis a vaccine) 3; $0 VARIVAX SUBCUTANEOUS INJECTABLE (varicella virus vaccine live) 3; $0 YF-VAX SUBCUTANEOUS INJECTABLE (yellow fever vaccine) 3 *VAGINAL AND RELATED PRODUCTS* - DRUGS FOR WOMEN *IMIDAZOLE-RELATED ANTIFUNGALS*** - DRUGS FOR INFECTIONS GYNAZOLE-1 VAGINAL CREAM (butoconazole nitrate (1 dose)) 3 miconazole 3 vaginal suppository 1 or 1b* terconazole vaginal cream 0.4 % 1 or 1b* QL (90 grams per 30 days) terconazole vaginal cream 0.8 % 1 or 1b* QL (40 grams per 30 days) terconazole vaginal suppository 1 or 1b* QL (6 suppositories per 30 days) *MISCELLANEOUS VAGINAL PRODUCTS*** - DRUGS FOR WOMEN INTRAROSA VAGINAL INSERT (prasterone) 3 ST; QL (1 insert per 1 day) *SPERMICIDES*** - BIRTH CONTROL PILLS ENCARE VAGINAL SUPPOSITORY (nonoxynol-9) 2; $0 OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL (nonoxynol-9) 2; $0 SHUR-SEAL CONTRACEPTIVE VAGINAL GEL (nonoxynol-9) 2; $0 TODAY SPONGE VAGINAL (nonoxynol-9) 2; $0 VCF VAGINAL CONTRACEPTIVE VAGINAL FILM (nonoxynol-9) 2; $0 VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM (nonoxynol-9) 2; $0 VCF VAGINAL CONTRACEPTIVE VAGINAL GEL (nonoxynol-9) 2; $0 *VAGINAL ANTI-INFECTIVES*** - DRUGS FOR INFECTIONS CLEOCIN VAGINAL CREAM (clindamycin phosphate) 3 CLEOCIN VAGINAL SUPPOSITORY (clindamycin phosphate) 2 clindamycin phosphate vaginal cream 1 or 1b* CLINDESSE VAGINAL CREAM (clindamycin phosphate (1 dose)) 3 metronidazole vaginal gel 1 or 1b* NUVESSA VAGINAL GEL (metronidazole) 3 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 218 Coverage Requirements and Prescription Drug Name Drug Tier Limits vandazole vaginal gel 1 or 1b* *VAGINAL CONTRACEPTIVE PH MODULATOR - COMBINATIONS*** - DRUGS FOR WOMEN PHEXXI VAGINAL GEL (lactic ac-citric ac-pot bitart) 3 *VAGINAL ESTROGENS*** - DRUGS FOR WOMEN estradiol vaginal cream 1 or 1b* estradiol vaginal tablet 1 or 1b* QL (18 tablet per 28 days) ESTRING VAGINAL RING (estradiol) 3 QL (1 ring per 90 days) FEMRING VAGINAL RING (estradiol acetate) 3 QL (1 ring per 90 days) IMVEXXY MAINTENANCE PACK VAGINAL INSERT 10 MCG 3 QL (18 inserts per 28 days) (estradiol) IMVEXXY MAINTENANCE PACK VAGINAL INSERT 4 MCG 3 QL (18 packs per 28 days) (estradiol) IMVEXXY STARTER PACK VAGINAL INSERT 10 MCG (estradiol) 3 QL (18 inserts per 28 days) IMVEXXY STARTER PACK VAGINAL INSERT 4 MCG (estradiol) 3 QL (18 packs per 28 days) PREMARIN VAGINAL CREAM (estrogens, conjugated) 2 QL (1 gm per 1 day) yuvafem vaginal tablet 1 or 1b* QL (18 tablet per 28 days) *VAGINAL PROGESTINS*** - DRUGS FOR WOMEN CRINONE VAGINAL GEL 4 % (progesterone) 4 SP CRINONE VAGINAL GEL 8 % (progesterone) 4 PA; SP; QL (1 applicator per 1 day) ENDOMETRIN VAGINAL INSERT (progesterone) 3 PA *VASOPRESSORS* - DRUGS FOR THE HEART *ANAPHYLAXIS THERAPY AGENTS*** - DRUGS FOR SERIOUS ALLERGIC REACTION ADRENALIN INJECTION SOLUTION (epinephrine) 3 epinephrine (anaphylaxis) injection solution 1 or 1b* epinephrine injection solution auto-injector 1 or 1b* QL (2 pens per 1 fill) SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 2 QL (2 syringes per 1 fill) (epinephrine) *NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS*** - DRUGS FOR SERIOUS ALLERGIC REACTION droxidopa oral capsule 100 mg 1 or 1b* PA; SP; QL (3 capsules per 1 day) droxidopa oral capsule 200 mg, 300 mg 1 or 1b* PA; SP; QL (6 capsules per 1 day) PA; LD; SP; QL (3 capsules per 1 NORTHERA ORAL CAPSULE 100 MG (droxidopa) 3 day) PA; LD; SP; QL (6 capsules per 1 NORTHERA ORAL CAPSULE 200 MG, 300 MG (droxidopa) 3 day) *VASOPRESSORS*** - DRUGS FOR SERIOUS ALLERGIC REACTION AKOVAZ INTRAVENOUS SOLUTION (ephedrine sulfate (pressors)) 3 BIORPHEN INTRAVENOUS SOLUTION (phenylephrine hcl (pressors)) 3 EMERPHED INTRAVENOUS SOLUTION (ephedrine sulfate (pressors)) 3 EPHEDRINE SULFATE (PRESSORS) INJECTION SOLUTION 3 PREFILLED SYRINGE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 219 Coverage Requirements and Prescription Drug Name Drug Tier Limits EPHEDRINE SULFATE INTRAVENOUS SOLUTION 3 EPHEDRINE SULFATE-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE EPINEPHRINE HCL-NACL INTRAVENOUS SOLUTION 3 EPINEPHRINE INTRAVENOUS SOLUTION 3 EPINEPHRINE INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 EPINEPHRINE PF INJECTION SOLUTION 3 EPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 3 EPINEPHRINE-NACL INTRAVENOUS SOLUTION 3 GIAPREZA INTRAVENOUS SOLUTION (angiotensin ii acetate) 3 LEVOPHED INTRAVENOUS SOLUTION (norepinephrine bitartrate) 3 midodrine hcl oral tablet 1 or 1b* NOREPINEPHRINE (BASE)-DEXTROSE INTRAVENOUS SOLUTION 3 norepinephrine bitartrate intravenous solution 1 or 1b* NOREPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 3 NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS 3 SOLUTION PHENYLEPHRINE HCL INTRAVENOUS SOLUTION 3 PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 3 PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE VAZCULEP INTRAVENOUS SOLUTION (phenylephrine hcl (pressors)) 3 *VITAMINS* - DRUGS FOR NUTRITION *VITAMIN A*** - DRUGS FOR NUTRITION AQUASOL A INTRAMUSCULAR SOLUTION (vitamin a) 3 *VITAMIN B-1*** - DRUGS FOR NUTRITION thiamine hcl injection solution 1 or 1b* *VITAMIN B-6*** - DRUGS FOR NUTRITION pyridoxine hcl injection solution 1 or 1b* *VITAMIN C*** - DRUGS FOR NUTRITION ASCOR INTRAVENOUS SOLUTION (ascorbic acid) 3 *VITAMIN D*** - DRUGS FOR NUTRITION DRISDOL ORAL CAPSULE (ergocalciferol) 3 ergocalciferol oral capsule 1 or 1a* vitamin d (ergocalciferol) oral capsule 1 or 1a* *VITAMIN K*** - DRUGS FOR NUTRITION MEPHYTON ORAL TABLET (phytonadione) 3 phytonadione injection solution 1 or 1b* phytonadione oral tablet 1 or 1b* vitamin k1 injection solution 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 220 Index 1ST TIER UNIFINE PENTIPS...... 162 ACTIFOAM COLLAGEN SPONGE AGRYLIN...... 139 1ST TIER UNIFINE PENTIPS ...... 143 AIMOVIG...... 168 PLUS...... 162 ACTI-LANCE 28G...... 152 AIMSCO TWIST LANCETS 32G... 152 1ST TIER UNILET ACTI-LANCE LITE LANCETS AIMSCO TWIST LANCETS 33G... 152 COMFORTOUCH...... 152 28G...... 152 ak-fluor...... 196 abacavir sulfate...... 88 ACTI-LANCE SPECIAL LANCETS AK-FLUOR...... 196 abacavir sulfate-lamivudine...... 85 17G...... 152 AKLIEF...... 110 abacavir-lamivudine-zidovudine...... 85 ACTI-LANCE UNIVERSAL 23G....152 AKOVAZ...... 219 ABELCET...... 51 ACTIMMUNE...... 74 ak-poly-bac...... 195 ABILIFY MAINTENA...... 84 ACTIVASE...... 139 AKTEN...... 197 ABILIFY MYCITE...... 84 ACTIVELLA...... 128 AKYNZEO...... 50 ABILIFY MYCITE ACTONEL...... 122 ala-cort...... 113 MAINTENANCE KIT...... 84 ACTOPLUS MET...... 48 albendazole...... 30 ABILIFY MYCITE STARTER KIT..84 ACULAR...... 197 ALBENZA...... 30 abiraterone acetate...... 64 ACULAR LS...... 197 ALBUKED 25...... 138 ABLYSINOL...... 97 ACUVAIL...... 197 ALBUKED 5...... 138 ABOUTTIME PEN NEEDLE...... 162 acyclovir...... 90, 113 ALBUMIN HUMAN...... 138 ABRAXANE...... 77 acyclovir sodium...... 90 ALBUMINEX...... 138 ABSORICA...... 109 ADACEL...... 213 ALBUMIN-ZLB...... 138 ABSORICA LD...... 109 ADAKVEO...... 142 ALBURX...... 138 ACACIA...... 15 adapalene...... 109, 110 ALBUTEIN...... 138 acamprosate calcium...... 204 adapalene-benzoyl peroxide...... 109 albuterol sulfate...... 34 acarbose...... 44 ADASUVE...... 84 albuterol sulfate hfa...... 34 ACCOLATE...... 35 adc/f (0.5mg/ml)...... 183 ALCAINE...... 197 ACCRUFER...... 142 ADCETRIS...... 67 alclometasone dipropionate...... 113 ACCU-CHEK AVIVA PLUS...... 120 ADDYI...... 208 ALDACTAZIDE...... 120, 121 ACCU-CHEK COMPACT PLUS.... 120 adefovir dipivoxil...... 89 ALDACTONE...... 121 ACCU-CHEK FASTCLIX LANCET ADEMPAS...... 96 ALDARA...... 116 ...... 152 ADENOCAINE...... 95 ALDER...... 15 ACCU-CHEK FASTCLIX adenosine...... 32 ALDURAZYME...... 125 LANCETS...... 152 ADHANSIA XR...... 13 ALECENSA...... 66 ACCU-CHEK GUIDE...... 120 ADIPEX-P...... 12 alendronate sodium...... 122 ACCU-CHEK MULTICLIX ADRENAL C FORMULA...... 180 ALFENTANIL HCL...... 26 LANCETS...... 152 ADRENALIN...... 219 ALFERON N...... 74 ACCU-CHEK SAFE-T PRO adriamycin...... 72 alfuzosin hcl er...... 133 LANCETS...... 152 adult aspirin regimen...... 23 ALIMTA...... 65 ACCU-CHEK SMARTVIEW...... 120 ADVAIR DISKUS...... 33 ALINIA...... 60 ACCU-CHEK SOFTCLIX LANCET ADVAIR HFA...... 33 ALIQOPA...... 78 DEV...... 152 ADVANCED MOBILE LANCET....152 aliskiren fumarate...... 59 ACCU-CHEK SOFTCLIX ADVATE...... 135 ALKERAN...... 77 LANCETS...... 152 ADVOCATE INSULIN PEN ALKINDI SPRINKLE...... 105 ACCURETIC...... 56 NEEDLES...... 162 allbee/c...... 179 accutane...... 109 ADVOCATE INSULIN SYRINGE.. 162 allopurinol...... 135 ACCUTREND GLUCOSE...... 120 ADVOCATE LANCETS...... 152 allopurinol sodium...... 135 acebutolol hcl...... 91 ADVOCATE LANCETS 30G...... 152 almotriptan malate...... 169 ACETADOTE...... 49 ADVOCATE SAFETY LANCETS.. 152 alogliptin benzoate...... 45 acetaminophen...... 22 ADVOCATE SAFETY LANCETS alogliptin-metformin hcl...... 45 acetaminophen-codeine...... 25 26G...... 152 alogliptin-pioglitazone...... 45 acetaminophen-codeine #2...... 25 ADYNOVATE...... 135 alophen...... 148 acetaminophen-codeine #3...... 25 ADZENYS ER...... 11 ALOPRIM...... 135 acetaminophen-codeine #4...... 25 ADZENYS XR-ODT...... 11 ALORA...... 129 acetazolamide...... 120 AEMCOLO...... 59 alosetron hcl...... 131 acetazolamide er...... 120 AFFINITY...... 118 ALOXI...... 50 acetazolamide sodium...... 120 AFINITOR...... 70 ALPHAGAN P...... 197 acetic acid...... 134, 200 AFINITOR DISPERZ...... 70 ALPHANATE...... 135 acetylcysteine...... 49, 108 afirmelle...... 99 ALPHANINE SD...... 135 acitretin...... 112 AFLURIA QUADRIVALENT...... 217 alprazolam...... 32 ACNESIC...... 116 AFSTYLA...... 135 alprazolam er...... 31 ACREMONIUM...... 15 aftera...... 103 ALPRAZOLAM INTENSOL...... 32 ACTHAR...... 123 AGAMATRIX ULTRA-THIN alprazolam xr...... 32 ACTHIB...... 216 LANCETS...... 152 ALPROLIX...... 136 ACTIFLOVIT EAR HEALTH...... 188 AGGRASTAT...... 138 alprostadil...... 176 221 ALREX...... 198 ampicillin sodium...... 203 armodafinil...... 13 ALTABAX...... 110 ampicillin-sulbactam sodium...... 203 ARMOUR THYROID...... 212 altafluor benox...... 196 AMPYRA...... 207 ARNUITY ELLIPTA...... 35 altafrin...... 194 AMVISC...... 199 AROMASIN...... 74 altavera...... 99 AMVISC PLUS...... 199 ARRANON...... 65 ALTERNARIA...... 15 anagrelide hcl...... 139 arsenic trioxide...... 74 ALUNBRIG...... 66 ANALPRAM-HC...... 30 ARTESUNATE...... 63 alvimopan...... 132 ANASCORP...... 201 articadent dental...... 149 alyacen 1/35...... 99 anastrozole...... 74 ARTISS...... 143 alyacen 7/7/7...... 105 ANAVIP...... 201 ARZERRA...... 67 alyq...... 96 ANCOBON...... 51 ASCENIV...... 202 amabelz...... 128 ANDEXXA...... 49 ASCLERA...... 176 amantadine hcl...... 80 ANDRODERM...... 29 ascomp-codeine...... 25 AMARYL...... 47 ANECTINE...... 191 ASCOR...... 220 AMBISOME...... 51 ANESTHESIA S/I-40A...... 133 asenapine maleate...... 83 ambrisentan...... 96 ANESTHESIA S/I-40H...... 133 ashlyna...... 103 amcinonide...... 113 ANESTHESIA S/I-40S...... 133 ASPARLAS...... 73 AMELUZ...... 117 ANGELIQ...... 128 ASPERGILLUS FUMIGATUS...... 15 AMERICAN BEECH...... 15 ANGIOMAX...... 37 aspirin...... 23 AMERICAN COCKROACH...... 15 ANJESO...... 21 aspirin 81...... 23 AMERICAN ELM...... 15 ANNOVERA...... 103 aspirin adult low dose...... 23 amethia...... 103 ANORO ELLIPTA...... 33 aspirin adult low strength...... 23 amethyst...... 103 anti-oxidant...... 181 aspirin childrens...... 23 AMICAR...... 143 ANTIVENIN LATRODECTUS aspirin ec...... 23 AMIDATE...... 133 MACTANS...... 201 aspirin ec adult low strength...... 23 amikacin sulfate...... 19 ANTIVENIN MICRURUS aspirin ec low dose...... 23 amiloride hcl...... 121 FULVIUS...... 201 aspirin ec low strength...... 23 amiloride-hydrochlorothiazide...... 121 ANUSOL-HC...... 30 aspirin low dose...... 23 aminoacetic acid...... 134 APADAZ...... 28 aspirin low strength...... 23 aminocaproic acid...... 143 apap-caff-dihydrocodeine...... 25 aspirin-dipyridamole er...... 139 aminophylline...... 36 APLENZIN...... 42 ASPIRIN-OMEPRAZOLE...... 139 AMINOPROTECT...... 192 APLIGRAF...... 118 ASSURE COMFORT LANCETS AMINOSYN II...... 192 APOKYN...... 81 28G...... 152 AMINOSYN-PF...... 192 apraclonidine hcl...... 197 ASSURE HAEMOLANCE PLUS amiodarone hcl...... 33 aprepitant...... 51 HIGH...... 152 AMIODARONE HCL IN apri...... 99 ASSURE HAEMOLANCE PLUS DEXTROSE...... 33 APRISO...... 131 LOW...... 152 amitriptyline hcl...... 44 APTENSIO XR...... 13 ASSURE HAEMOLANCE PLUS amlodipine besy-benazepril hcl...... 55 APTIOM...... 38 MICRO...... 152 amlodipine besylate...... 92 APTIVUS...... 87 ASSURE HAEMOLANCE PLUS amlodipine besylate-valsartan...... 57 AQUALANCE LANCETS 30G...... 152 NORMAL...... 152 amlodipine-atorvastatin...... 95 AQUASOL A...... 220 ASSURE HAEMOLANCE PLUS amlodipine-olmesartan...... 57 ARAKODA...... 63 PED...... 152 amlodipine-valsartan-hctz...... 58 ARALAST NP...... 210 ASSURE ID INSULIN SAFETY ammonium lactate...... 115 aranelle...... 105 SYR...... 162 AMMONUL...... 127 ARANESP (ALBUMIN FREE)...... 140 ASSURE ID SAFETY PEN amnesteem...... 110 ARAVA...... 22 NEEDLES...... 162 AMNIOFIX...... 118 ARAZLO...... 110 ASSURE LANCE LANCETS...... 152 AMNIOTEXT...... 118 ARCALYST...... 20 ASSURE LANCE LANCETS 21G... 152 AMONDYS 45...... 191 arformoterol tartrate...... 34 ASSURE LANCE PLUS SAFETY amoxapine...... 44 ARGATROBAN...... 38 25G...... 152 amoxicill-clarithro-lansopraz...... 215 ARGATROBAN IN SODIUM ASSURE LANCE PLUS SAFETY amoxicillin...... 203 CHLORIDE...... 37 30G...... 153 amoxicillin-pot clavulanate...... 203 ARGININE HCL...... 192 ASSURE LANCE SAFETY amoxicillin-pot clavulanate er...... 203 argyle sterile saline...... 134 LANCET 28G...... 153 AMPHADASE...... 173 argyle sterile water...... 174 ASTAGRAF XL...... 174 AMPHENOL-40...... 118 ARICEPT...... 205 ATABEX EC...... 183 amphetamine er...... 11 ARIKAYCE...... 19 ATABEX OB...... 183 amphetamine sulfate...... 11 aripiprazole...... 84, 85 atazanavir sulfate...... 87 amphetamine-dextroamphet er...... 11 ARISTADA...... 85 ATELVIA...... 122 amphetamine-dextroamphetamine...... 11 ARISTADA INITIO...... 85 atenolol...... 91 amphotericin b...... 51 ARIXTRA...... 37 atenolol-chlorthalidone...... 59 ampicillin...... 203 ARIZONA CYPRESS...... 15 ATGAM...... 173 222 atomoxetine hcl...... 11 b complex...... 178 BD INSULIN SYR ULTRAFINE II. 163 atorvastatin calcium...... 54 b complex 100 tr...... 179 BD INSULIN SYRINGE...... 163 atovaquone...... 60 b complex formula 1...... 179 BD INSULIN SYRINGE HALF- atovaquone-proguanil hcl...... 63 b complex plus...... 179 UNIT...... 163 atracurium besylate...... 191 b complex-b12...... 178 BD INSULIN SYRINGE ATROPEN...... 214 b complex-biotin-fa...... 179 MICROFINE...... 163 atropine sulfate...... 194, 214 b complex-c...... 179 BD INSULIN SYRINGE U/F...... 163 ATROPINE SULFATE...... 194, 214 B COMPLEX-C-BIOTIN-E-FA...... 179 BD INSULIN SYRINGE U/F ATROVENT HFA...... 35 b complex-c-folic acid...... 178 1/2UNIT...... 163 AUBAGIO...... 206 b-100...... 188 BD INSULIN SYRINGE U-500...... 163 aubra...... 99 b-100 b-complex...... 179 BD INSULIN SYRINGE aubra eq...... 99 b-100 complex...... 188 ULTRAFINE...... 163 AUGMENTIN...... 203, 204 b-100 complex cr...... 179 BD LANCET ULTRAFINE 30G...... 153 AUGMENTIN ES-600...... 203 b-100 cr...... 188 BD LANCET ULTRAFINE 33G...... 153 AUREOBASIDIUM...... 15 b-100 tr...... 179 BD MICROTAINER LANCETS...... 153 AUREOBASIDIUM PULLULANS....15 b-50...... 188 BD PEN NEEDLE MICRO U/F...... 163 AURORA LANCET SUPER THIN b-50 complex...... 179 BD PEN NEEDLE MINI U/F...... 163 30G...... 153 bac...... 22 BD PEN NEEDLE NANO 2ND GEN AURORA LANCET THIN 23G...... 153 bacitracin...... 59, 195 ...... 163 AURORA PEN NEEDLES...... 163 bacitracin-polymyxin b...... 195 BD PEN NEEDLE NANO U/F...... 163 AURORA UNIFINE PENTIPS...... 163 bacitra-neomycin-polymyxin-hc...... 198 BD PEN NEEDLE ORIGINAL U/F.163 aurovela 1.5/30...... 99 baclofen...... 188 BD PEN NEEDLE SHORT U/F...... 163 aurovela 1/20...... 99 BACTRIM...... 60 BD SAFETYGLIDE INSULIN aurovela 24 fe...... 99 BACTRIM DS...... 60 SYRINGE...... 163 aurovela fe 1.5/30...... 99 BAHIA...... 15 BD SAFETY-LOK INSULIN aurovela fe 1/20...... 99 BAL IN OIL...... 49 SYRINGE...... 163 AURYXIA...... 132 balance b-100...... 188 BD VEO INSULIN SYR U/F AUSTEDO...... 206 balance b-50...... 179 1/2UNIT...... 163 AUSTRALIAN PINE...... 15 balanced b complex...... 179 BD VEO INSULIN SYRINGE U/F.. 163 AUTOLET II CLINISAFE...... 153 balanced b-100...... 179, 188 bekyree...... 99 AUTOLET LITE CLINISAFE...... 153 balanced b-100 complex cr...... 188 BELBUCA...... 28 AUTOLET LITE STARTER PACK153 balanced b-50 complex...... 188 BELEODAQ...... 70 AUTOLET PLATFORMS...... 153 balanced b-50/fa...... 179 BELRAPZO...... 64 AVASTIN...... 79 balanced salt...... 196 BELSOMRA...... 145 aviane...... 99 BALCOLTRA...... 100 benazepril hcl...... 56 avita...... 110 BALD CYPRESS...... 15 benazepril-hydrochlorothiazide...... 56 AVITENE...... 143 balsalazide disodium...... 131 BENDEKA...... 64 AVITENE FLOUR...... 143 BALVERSA...... 69 BENEFIX...... 136 AVYCAZ...... 97 balziva...... 100 BENLYSTA...... 172 AYGESTIN...... 204 BANZEL...... 38 BENTYL...... 214 ayuna...... 99 BAQSIMI ONE PACK...... 44 BENZALKONIUM CHLORIDE...... 85 AYVAKIT...... 71 BAQSIMI TWO PACK...... 44 BENZAMYCIN...... 109 azacitidine...... 65 BARACLUDE...... 89 BENZHYDROCODONE- AZACTAM...... 62 BARHEMSYS...... 50 ACETAMINOPHEN...... 28 AZASAN...... 176 BASAGLAR KWIKPEN...... 45 BENZNIDAZOLE...... 30 AZASITE...... 195 BAVENCIO...... 68 benzonatate...... 107 azathioprine...... 176 BAXDELA...... 129 benzoyl peroxide-erythromycin...... 109 AZATHIOPRINE SODIUM...... 176 BAYBERRY (WAX MYRTLE)...... 15 benzphetamine hcl...... 12 AZEDRA DOSIMETRIC...... 73 bayer advanced aspirin reg st...... 23 benztropine mesylate...... 80 AZEDRA THERAPEUTIC...... 74 bayer aspirin...... 23 BEOVU...... 200 azelaic acid...... 117 bayer aspirin ec low dose...... 23 BERINERT...... 137 azelastine hcl...... 190, 195 bayer low dose...... 23 BERMUDA GRASS...... 15 azelastine-fluticasone...... 190 BCG VACCINE...... 216 beser...... 113 AZESCHEW b-compleet-100...... 179 BESIVANCE...... 195 PRENATAL/POSTNATAL...... 183 b-compleet-50...... 179 BESPONSA...... 67 AZESCO...... 183 B-COMPLEX...... 178 BETADINE OPHTHALMIC PREP 196 AZILECT...... 80 b-complex...... 179 betamethasone dipropionate...... 113 azithromycin...... 150 b-complex balanced...... 178 betamethasone dipropionate aug...... 113 AZOPT...... 196 b-complex/b-12...... 178 betamethasone valerate...... 113 aztreonam...... 62 b-complex/vitamin c...... 178 BETASERON...... 206 AZULFIDINE...... 131 b-complex-c...... 179 betaxolol hcl...... 91, 193 AZULFIDINE EN-TABS...... 131 BD AUTOSHIELD...... 163 bethanechol chloride...... 216 azurette...... 99 BD AUTOSHIELD DUO...... 163 BETHKIS...... 19 223 BETIMOL...... 193 briellyn...... 100 calcitonin (salmon)...... 123 BETOPTIC-S...... 193 BRILINTA...... 137 calcitrene...... 112 better b complex...... 179 brimonidine tartrate...... 197 calcitriol...... 112, 124 BEVACIZUMAB...... 200 brinzolamide...... 196 calcium acetate...... 132 bexarotene...... 79 BRIVIACT...... 38 calcium acetate (phos binder)...... 132 BEXSERO...... 216 BROME...... 15 CALCIUM DISODIUM BEYAZ...... 100 bromfenac sodium (once-daily)...... 197 VERSENATE...... 49 bicalutamide...... 65 bromocriptine mesylate...... 80 CALCIUM GLUCONATE...... 169 BICILLIN C-R...... 204 BROMSITE...... 197 CALCIUM GLUCONATE-NACL...169 BICILLIN C-R 900/300...... 204 BRONCHITOL...... 211 CALDOLOR...... 21 BICILLIN L-A...... 203 BRONCHITOL TOLERANCE CALIFORNIA PEPPER TREE...... 15 BICNU...... 78 TEST...... 211 CALQUENCE...... 69 BIDIL...... 95 BROVANA...... 34 camila...... 104 big 100...... 179 BRUKINSA...... 69 CAMPTOSAR...... 79 big 100 (biotin)...... 179 BSP 0820...... 107 camrese...... 103 BIJUVA...... 128 BSS...... 196 camrese lo...... 103 BIKTARVY...... 85 BSS PLUS...... 196 CANASA...... 131 BILTRICIDE...... 30 budesonide...... 35, 105 CANCIDAS...... 51 bimatoprost...... 117, 200 budesonide er...... 105 candesartan cilexetil...... 57 BINOSTO...... 122 budesonide-formoterol fumarate...... 33 candesartan cilexetil-hctz...... 57 BIORPHEN...... 219 bumetanide...... 121 CANDIDA ALBICANS EXTRACT...15 BIOTHRAX...... 216 BUMEX...... 121 CAPASTAT SULFATE...... 63 BIOVANCE...... 118 BUNAVAIL...... 28 CAPCOF...... 108 bisacodyl ec...... 148 bupap...... 22 capecitabine...... 65 bisoprolol fumarate...... 91 BUPHENYL...... 127 CAPLYTA...... 82 bisoprolol-hydrochlorothiazide...... 59 BUPIVACAINE FISIOPHARMA....149 CAPRELSA...... 71 BIVALIRUDIN RTU...... 37 bupivacaine hcl...... 149 captopril...... 56 BIVALIRUDIN-SODIUM bupivacaine hcl (pf)...... 149 CARAC...... 111 CHLORIDE...... 37 BUPIVACAINE HCL-NACL...... 149 CARAFATE...... 215 BIVIGAM...... 202 bupivacaine in dextrose...... 149 CARBAGLU...... 124 BLACK WILLOW...... 15 bupivacaine spinal...... 149 carbamazepine...... 38, 39 blanche...... 115 bupivacaine-epinephrine...... 149 carbamazepine er...... 38 BLENREP...... 66 bupivacaine-epinephrine (pf)...... 149 carbidopa...... 81 bleomycin sulfate...... 72 BUPRENEX...... 28 carbidopa-levodopa...... 81 BLEPH-10...... 199 buprenorphine...... 29 carbidopa-levodopa er...... 81 BLEPHAMIDE...... 198 buprenorphine hcl...... 28, 29 carbidopa-levodopa-entacapone...... 81 BLEPHAMIDE S.O.P...... 198 buprenorphine hcl-naloxone hcl...... 29 carbinoxamine maleate...... 52 BLINCYTO...... 69 bupropion hcl...... 42 CARBOCAINE...... 149 blisovi 24 fe...... 100 bupropion hcl er (smoking det)...... 208 CARBOCAINE PRESERVATIVE- blisovi fe 1.5/30...... 100 bupropion hcl er (sr)...... 42 FREE...... 149 blisovi fe 1/20...... 100 bupropion hcl er (xl)...... 42 carboplatin...... 64 BLOXIVERZ...... 63 buspirone hcl...... 31 carboprost tromethamine...... 201 BONIVA...... 122 busulfan...... 64 CARDENE IV...... 92 BONJESTA...... 50 BUSULFEX...... 64 CARDIZEM...... 92 BOOSTRIX...... 213 butalbital-acetaminophen...... 22, 23 CARDIZEM LA...... 92 BORIC ACID...... 117 butalbital-apap-caff-cod...... 25 CARDURA...... 58 BORTEZOMIB...... 71 butalbital-apap-caffeine...... 23 CARDURA XL...... 133 bosentan...... 96 butalbital-asa-caff-codeine...... 25 CAREFINE PEN NEEDLES...... 163 BOSULIF...... 68 butalbital-aspirin-caffeine...... 23 CAREONE INSULIN SYRINGE..... 163 BOTOX...... 191 butorphanol tartrate...... 29 CAREONE LANCET SUPER THIN BOTOX COSMETIC...... 116 BUTRANS...... 29 30G...... 153 BOTRYTIS...... 15 BYFAVO...... 145 CAREONE LANCET THIN 23G.....153 bp wash...... 110 BYSTOLIC...... 91 CAREONE UNIFINE PENTIPS...... 163 BRAFTOVI...... 69 CABENUVA...... 85 CAREONE UNIFINE PENTIPS BREO ELLIPTA...... 33 cabergoline...... 123 PLUS...... 163 BRETYLIUM TOSYLATE...... 33 CABLIVI...... 137 CARESENS LANCETS...... 153 BREVIBLOC...... 91 CABOMETYX...... 71 CARETOUCH INSULIN SYRINGE BREVIBLOC IN NACL...... 91 CADUET...... 95 ...... 163 BREVIBLOC PREMIXED...... 91 CAFCIT...... 12 CARETOUCH PEN NEEDLES...... 164 BREVIBLOC PREMIXED DS...... 91 caffeine citrate...... 12 CARETOUCH SAFETY LANCETS153 BREVITAL SODIUM...... 133 CALAN SR...... 92 CARETOUCH SAFETY LANCETS BREZTRI AEROSPHERE...... 33 calcipotriene...... 112 26G...... 153 BRIDION...... 49 calcipotriene-betameth diprop...... 119 224 CARETOUCH TWIST LANCETS cefuroxime axetil...... 98 ciprofloxacin hcl...... 129, 195, 200 28G...... 153 cefuroxime sodium...... 98 ciprofloxacin in d5w...... 129 CARETOUCH TWIST LANCETS celecoxib...... 20 ciprofloxacin-dexamethasone...... 200 30G...... 153 CELESTONE SOLUSPAN...... 107 ciprofloxacin-fluocinolone pf...... 201 CARETOUCH TWIST LANCETS CELLCEPT...... 174 cisatracurium besylate...... 191 33G...... 153 CELLCEPT INTRAVENOUS...... 174 cisatracurium besylate (pf)...... 191 carisoprodol...... 188 CELLUGEL...... 199 cisplatin...... 64 carisoprodol-aspirin-codeine...... 189 CELONTIN...... 41 CISPLATIN...... 64 carmustine...... 78 CENTANY...... 110 citalopram hydrobromide...... 42 CARNITOR...... 123 cephalexin...... 97 CITRANATAL 90 DHA...... 186 CARNITOR SF...... 123 CEPROTIN...... 138 CITRANATAL ASSURE...... 186 CAROSPIR...... 121 CERDELGA...... 140 CITRANATAL B-CALM...... 183 carteolol hcl...... 193 CEREBYX...... 41 CITRANATAL BLOOM...... 183 cartia xt...... 92 CEREZYME...... 140 CITRANATAL BLOOM DHA...... 186 carvedilol...... 91 CEROVEL...... 115 CITRANATAL DHA...... 186 carvedilol phosphate er...... 91 CERVIDIL...... 201 CITRANATAL ESSENCE...... 186 CASCARA SAGRADA...... 148 CETACAINE...... 119 CITRANATAL HARMONY...... 186 CASODEX...... 65 cetirizine hcl...... 53 CITRANATAL MEDLEY...... 186 CASPOFUNGIN ACETATE...... 51 CETRAXAL...... 200 CITRANATAL RX...... 183 CAT HAIR EXTRACT...... 15 CETROTIDE...... 123 citrate of magnesia...... 147 cataflam...... 21 cevimeline hcl...... 177 citroma...... 147 CATAPRES-TTS-1...... 58 CHANTIX...... 208 CITRULLINE EASY...... 127 CATAPRES-TTS-2...... 58 CHANTIX CONTINUING MONTH CLADOSPORIUM CATAPRES-TTS-3...... 58 PAK...... 208 CLADOSPORIOIDES...... 15 CATHFLO ACTIVASE...... 140 CHANTIX STARTING MONTH CLADOSPORIUM CATTLE EPITHELIUM...... 15 PAK...... 208 SPHAEROSPERMUM...... 15 cavarest...... 177 charlotte 24 fe...... 100 cladribine...... 65 CAVERJECT...... 95 chateal...... 100 claravis...... 110 CAVERJECT IMPULSE...... 95 chateal eq...... 100 CLARINEX...... 53 CAYA...... 151 CHEMET...... 48 CLARINEX-D 12 HOUR...... 108 CAYSTON...... 62 CHENODAL...... 130 clarithromycin...... 151 caziant...... 105 childrens aspirin...... 23 clarithromycin er...... 151 CEDAR ELM...... 15 chloramphenicol sod succinate...... 61 CLASSIC PRENATAL...... 183 cefaclor...... 97 chlordiazepoxide hcl...... 32 CLEANLET LANCETS 28G...... 153 CEFACLOR ER...... 97 chlordiazepoxide-amitriptyline...... 205 clearlax...... 146 cefadroxil...... 97 chlordiazepoxide-clidinium...... 214 CLEMASTINE FUMARATE...... 52 CEFAZOLIN IN SODIUM chlorhexidine gluconate...... 176 clemastine fumarate...... 53 CHLORIDE...... 97 chloroprocaine hcl (pf)...... 150 CLENPIQ...... 146 cefazolin sodium...... 97 chloroquine phosphate...... 63 CLEOCIN...... 61, 218 CEFAZOLIN SODIUM...... 97 chlorothiazide sodium...... 121 CLEOCIN PHOSPHATE...... 61 CEFAZOLIN SODIUM- chlorpromazine hcl...... 84 CLEOCIN-T...... 109 DEXTROSE...... 97 chlorthalidone...... 121 CLEVER CHEK LANCETS...... 153 cefdinir...... 98 chlorzoxazone...... 188 CLEVER CHOICE COMFORT EZ 164 cefepime hcl...... 99 CHOLBAM...... 130 CLEVER CHOICE LANCETS 21G 153 CEFEPIME HCL...... 99 cholestyramine...... 54 CLEVER CHOICE LANCETS 23G 153 CEFEPIME-DEXTROSE...... 99 cholestyramine light...... 54 CLEVER CHOICE LANCETS 28G 153 cefixime...... 98 CHORIONIC GONADOTROPIN... 126 CLEVIPREX...... 92 CEFOTAN...... 97 chromic chloride...... 172 CLICKFINE PEN NEEDLES...... 164 cefotaxime sodium...... 98 ciclopirox...... 111 CLIMARA...... 129 cefotetan disodium...... 97 ciclopirox olamine...... 111 CLIMARA PRO...... 128 CEFOTETAN DISODIUM- cidofovir...... 89 clindacin etz...... 109 DEXTROSE...... 98 cilostazol...... 138 clindacin-p...... 109 cefoxitin sodium...... 98 CILOXAN...... 195 clindamycin hcl...... 61 CEFOXITIN SODIUM-DEXTROSE.98 CIMDUO...... 85 clindamycin palmitate hcl...... 61 cefpodoxime proxetil...... 98 cimetidine...... 214 clindamycin phos-benzoyl perox...... 109 cefprozil...... 98 cimetidine hcl...... 214 clindamycin phosphate...... 62, 109, 218 ceftazidime...... 98 cinacalcet hcl...... 122 clindamycin phosphate in d5w...... 61 CEFTAZIDIME AND DEXTROSE...98 CINQAIR...... 35 CLINDAMYCIN PHOSPHATE IN ceftriaxone sodium...... 98 CINRYZE...... 137 NACL...... 61 CEFTRIAXONE SODIUM...... 98 CINVANTI...... 51 clindamycin-tretinoin...... 109 ceftriaxone sodium in dextrose...... 98 CIPRO...... 129 CLINDESSE...... 218 CEFTRIAXONE SODIUM- CIPRO HC...... 200 CLINIMIX E/DEXTROSE (2.75/5)..192 DEXTROSE...... 98 CIPRODEX...... 200 CLINIMIX E/DEXTROSE (4.25/10) 192 225 CLINIMIX E/DEXTROSE (4.25/5)..192 COMETRIQ (100 MG DAILY COTEMPLA XR-ODT...... 13 CLINIMIX E/DEXTROSE (5/15).....192 DOSE)...... 71 CREON...... 120 CLINIMIX E/DEXTROSE (5/20).....192 COMETRIQ (140 MG DAILY CRESEMBA...... 52 CLINIMIX E/DEXTROSE (8/10).....192 DOSE)...... 71 CRINONE...... 219 CLINIMIX E/DEXTROSE (8/14).....192 COMETRIQ (60 MG DAILY CRIXIVAN...... 87 CLINIMIX/DEXTROSE (4.25/10)... 192 DOSE)...... 71 CROFAB...... 201 CLINIMIX/DEXTROSE (4.25/5)..... 192 COMFORT ASSIST INSULIN cromolyn sodium...... 34, 130, 195 CLINIMIX/DEXTROSE (5/15)...... 192 SYRINGE...... 164 crotan...... 118 CLINIMIX/DEXTROSE (5/20)...... 192 COMFORT ASSURED LANCETS CRYODOSE TA...... 119 CLINIMIX/DEXTROSE (6/5)...... 192 28G...... 153 cryselle-28...... 100 CLINIMIX/DEXTROSE (8/10)...... 192 COMFORT ASSURED LANCETS CRYSVITA...... 128 CLINIMIX/DEXTROSE (8/14)...... 192 33G...... 153 CUBICIN...... 61 clinisol sf...... 192 COMFORT EZ INSULIN CUBICIN RF...... 61 CLINOLIPID...... 193 SYRINGE...... 164 cupric chloride...... 172 clinpro 5000...... 177 COMFORT EZ MICRO PEN curity sterile saline...... 134 clobazam...... 38 NEEDLES...... 164 CUROSURF...... 211 clobetasol prop emollient base...... 113 COMFORT EZ PEN NEEDLES...... 164 CURVULARIA...... 16 clobetasol propionate...... 114 COMFORT EZ SHORT PEN CUTAQUIG...... 202 clobetasol propionate e...... 114 NEEDLES...... 164 CUVITRU...... 202 clobetasol propionate emulsion...... 114 COMFORT LANCETS...... 153 CUVPOSA...... 215 clocortolone pivalate...... 114 COMFORT TOUCH INSULIN PEN cvs aspirin...... 23 clodan...... 114 NEED...... 164 cvs aspirin adult low dose...... 23 clofarabine...... 65 COMFORT TOUCH LANCETS cvs aspirin adult low strength...... 23 CLOLAR...... 65 31G...... 153 cvs aspirin ec...... 23 clomiphene citrate...... 126 COMFORT TOUCH PLUS cvs aspirin low dose...... 23 clomipramine hcl...... 44 LANCETS 30G...... 153 cvs aspirin low strength...... 23 clonazepam...... 38 COMPLERA...... 86 cvs b complex plus c...... 179 clonidine...... 58 COMPLETE NATAL DHA...... 186 cvs balanced b50...... 188 clonidine hcl...... 58 COMPLETENATE...... 183 cvs bisacodyl...... 148 clonidine hcl (analgesia)...... 22 complex b-100...... 188 cvs citrate of magnesia...... 147 clonidine hcl er...... 11 complex b-100-inositol...... 188 cvs c-lax laxative...... 148 clopidogrel bisulfate...... 139 complex b-50 prolonged release...... 179 cvs folic acid...... 141 clorazepate dipotassium...... 32 compro...... 84 cvs gentle laxative...... 148 CLOROTEKAL...... 150 COMTAN...... 81 cvs gentle laxative womens...... 148 clotrimazole...... 116, 176 CO-NATAL FA...... 183 cvs inner ear plus...... 188 clotrimazole-betamethasone...... 110 CONCEPT DHA...... 183 CVS LANCETS 21G...... 153 clovique...... 172 CONCEPT OB...... 183 CVS LANCETS MICRO THIN 33G153 clozapine...... 83 CONDYLOX...... 116 CVS LANCETS ORIGINAL...... 153 C-NATE DHA...... 183 CONJUPRI...... 92, 93 CVS LANCETS THIN 26G...... 153 COAGADEX...... 136 constulose...... 146 CVS LANCETS ULTRA THIN 30G 153 COAGUCHEK LANCETS...... 153 CONTRAVE...... 13 CVS LANCETS ULTRA-THIN 30G153 coal tar...... 118 CONZIP...... 26 cvs magnesium citrate...... 147 COARTEM...... 63 COPAXONE...... 207 cvs milk of magnesia...... 147 COCKLEBUR...... 15 COPIKTRA...... 78 cvs nicotine...... 208 COD LIVER OIL...... 188 coremino...... 212 cvs nicotine polacrilex...... 208 CODEINE SULFATE...... 26 CORIFACT...... 136 CVS PRENATAL...... 183 codeine sulfate...... 26 CORLANOR...... 97 cvs purelax...... 146 CODITUSSIN AC...... 107 CORLOPAM...... 59 cvs super b complex/c...... 179 CODITUSSIN DAC...... 108 CORN POLLEN...... 16 CVS ULTRA THIN LANCETS...... 153 COGENTIN...... 80 correctol...... 148 cyanocobalamin...... 140 colchicine...... 135 CORTEF...... 106 CYANOCOBALAMIN...... 140 colchicine-probenecid...... 135 CORTENEMA...... 30 CYANOKIT...... 49 colesevelam hcl...... 54 CORTIFOAM...... 30 cyclafem 1/35...... 100 COLESTID...... 54 CORTISPORIN-TC...... 201 cyclafem 7/7/7...... 105 COLESTID FLAVORED...... 54 CORVERT...... 33 cyclobenzaprine hcl...... 188 colestipol hcl...... 54 COSELA...... 77 CYCLOGYL...... 194 colistimethate sodium (cba)...... 62 COSENTYX...... 112 CYCLOMYDRIL...... 194 COLY-MYCIN M...... 62 COSENTYX (300 MG DOSE)...... 112 CYCLOPAK...... 189 COMBIGAN...... 193 COSENTYX SENSOREADY (300 cyclopentolate hcl...... 194 COMBIPATCH...... 128 MG)...... 112 cyclophosphamide...... 77 COMBIVENT RESPIMAT...... 33 COSENTYX SENSOREADY PEN.. 112 CYCLOPHOSPHAMIDE...... 77 COMBIVIR...... 86 COSMEGEN...... 72 cycloserine...... 63 COTELLIC...... 70 CYCLOSET...... 45 226 cyclosporine...... 173 deferiprone...... 48 DEXCOM G4 PLATINUM cyclosporine modified...... 173 deferoxamine mesylate...... 49 RECEIVER...... 154 CYKLOKAPRON...... 143 DEFITELIO...... 139 DEXCOM G4 PLATINUM cyproheptadine hcl...... 53 DEFLUX...... 135 TRANSMITTER...... 154 CYRAMZA...... 79 DELESTROGEN...... 129 DEXCOM G4 SENSOR...... 154 cyred...... 100 DELFLEX-LC/1.5% DEXTROSE... 175 DEXCOM G5 MOB/G4 PLAT cyred eq...... 100 DELFLEX-LC/2.5% DEXTROSE... 175 SENSOR...... 154 CYSTADANE...... 124 DELFLEX-LC/4.25% DEXTROSE. 175 DEXCOM G5 MOBILE CYSTADROPS...... 200 DELFLEX-SM/1.5% DEXTROSE...175 RECEIVER...... 154 CYSTAGON...... 134 DELFLEX-SM/2.5% DEXTROSE...175 DEXCOM G5 MOBILE CYSTARAN...... 200 DELSTRIGO...... 86 TRANSMITTER...... 154 cytarabine...... 65 delyla...... 100 DEXCOM G5 RECEIVER KIT...... 154 cytarabine (pf)...... 65 DELZICOL...... 131 DEXCOM G6 RECEIVER...... 154 CYTOGAM...... 202 demeclocycline hcl...... 212 DEXCOM G6 SENSOR...... 154 CYTOMEL...... 212 DEMEROL...... 26 DEXCOM G6 TRANSMITTER...... 154 CYTOTEC...... 215 DEMSER...... 57 DEXILANT...... 215 dacarbazine...... 74 DENAVIR...... 113 DEXMEDETOMIDINE HCL...... 146 DACOGEN...... 65 denta 5000 plus...... 177 dexmedetomidine hcl...... 146 dactinomycin...... 72 dentagel...... 177 dexmedetomidine hcl in nacl...... 145 daily multiple vitamins...... 181 DEPEN TITRATABS...... 172 DEXMEDETOMIDINE HCL IN daily multiple vitamins/iron...... 180 DEPO-ESTRADIOL...... 129 NACL...... 145 daily value multivitamin...... 181 DEPO-MEDROL...... 106 DEXMEDETOMIDINE HCL- daily vitamin...... 181 DEPO-PROVERA...... 104 DEXTROSE...... 146 daily vitamin formula+iron...... 180 DEPO-SUBQ PROVERA 104...... 104 dexmethylphenidate hcl...... 13 daily vitamins...... 181 DEPO-TESTOSTERONE...... 29 dexmethylphenidate hcl er...... 13 daily vite...... 181 DERMOTIC...... 201 DEXPANTHENOL...... 130 daily vite multivitamin/iron...... 180 DESCOVY...... 86 dexrazoxane hcl...... 75 daily vites...... 181 DESFERAL...... 49 DEXTENZA...... 198 daily-vitamin...... 181 desflurane...... 133 dextroamphetamine sulfate...... 11 daily-vitamin/iron...... 180 desipramine hcl...... 44 dextroamphetamine sulfate er...... 11 daily-vite...... 181 desloratadine...... 53 dextrose...... 193 daily-vite multivitamin...... 181 desmopressin ace spray refrig...... 128 DEXTROSE...... 193 dalfampridine er...... 207 desmopressin acetate...... 128 DEXTROSE 5%/ELECTROLYTE DALIRESP...... 35 desmopressin acetate pf...... 128 #48...... 169 DALVANCE...... 61 desmopressin acetate spray...... 128 dextrose in lactated ringers...... 169 danazol...... 29 desogestrel-ethinyl estradiol...... 99, 100 DEXTROSE-NACL...... 169 DANDELION...... 16 desonide...... 114 dextrose-nacl...... 169 DANTRIUM...... 189 desoximetasone...... 114 dextrose-sodium chloride...... 170 dantrolene sodium...... 189 desrx...... 114 DEXTROSE-SODIUM CHLORIDE170 DANYELZA...... 67 DESVENLAFAXINE ER...... 43 DEXYCU...... 198 dapsone...... 61, 109 desvenlafaxine succinate er...... 43 DIACOMIT...... 39 DAPTACEL...... 213 DEXABLISS...... 106 dialyvite 800...... 178 DAPTOMYCIN...... 61 dexamethasone...... 106 DIANEAL LOW CALCIUM/1.5% daptomycin...... 61 DEXAMETHASONE INTENSOL...106 DEX...... 175 DARAPRIM...... 63 DEXAMETHASONE SOD PHOS- DIANEAL LOW CALCIUM/2.5% darifenacin hydrobromide er...... 216 NACL...... 106 DEX...... 175 DARZALEX...... 67 dexamethasone sod phosphate pf...... 106 DIANEAL LOW CALCIUM/4.25% DARZALEX FASPRO...... 73 DEXAMETHASONE SOD DEX...... 175 dasetta 1/35...... 100 PHOSPHATE PF...... 106 DIANEAL PD-2/1.5% DEXTROSE.175 dasetta 7/7/7...... 105 DEXAMETHASONE SODIUM DIANEAL PD-2/2.5% DEXTROSE.175 DAUNORUBICIN HCL...... 72 PHOSPHATE...... 106 DIANEAL PD-2/4.25% DEXTROSE DAURISMO...... 69, 70 dexamethasone sodium phosphate106, 198 ...... 175 DAYPRO...... 21 DEXAMETHASONE- DIASTAT ACUDIAL...... 38 daysee...... 103 MOXIFLOXACIN...... 198 DIASTAT PEDIATRIC...... 38 DAYTRANA...... 13 DEXAMETH-MOXIFLOX- DIATHRIVE LANCET ULTRA DAYVIGO...... 145 KETOROLAC...... 198 THIN 30...... 154 DDAVP...... 128 DEXCOM G4 PLAT PED DIATHRIVE LANCETS...... 154 DDAVP PF...... 128 RCV/SHARE...... 153 DIATHRIVE PEN NEEDLE...... 164 deblitane...... 104 DEXCOM G4 PLAT PED diazepam...... 32, 38 decadron...... 106 RECEIVER...... 153 DIAZEPAM...... 32 decitabine...... 65 DEXCOM G4 PLATINUM diazepam intensol...... 32 deferasirox...... 48 RCV/SHARE...... 154 diazoxide...... 44 deferasirox granules...... 48 DIBENZYLINE...... 57 227 diclofenac potassium...... 21 dorzolamide hcl...... 196 DURAGESIC-50...... 26 diclofenac sodium...... 21, 111, 197 dorzolamide hcl-timolol mal...... 193 DURAGESIC-75...... 26 diclofenac sodium er...... 21 dorzolamide hcl-timolol mal pf...... 193 duramorph...... 26 diclofenac-misoprostol...... 20 dotti...... 129 DUREZOL...... 198 dicloxacillin sodium...... 204 DOVATO...... 86 DURLAZA...... 139 dicyclomine hcl...... 214 DOVONEX...... 112 DUROLANE...... 189 diethylpropion hcl...... 12 doxazosin mesylate...... 58 DURYSTA...... 200 diethylpropion hcl er...... 12 doxepin hcl...... 44, 112, 145 DUST MITE MIXED ALLERGEN DIFICID...... 151 doxercalciferol...... 124 EXT...... 18 diflorasone diacetate...... 114 DOXIL...... 72 dutasteride...... 133 DIFLUCAN...... 52 doxorubicin hcl...... 72 dutasteride-tamsulosin hcl...... 134 diflunisal...... 23 doxorubicin hcl liposomal...... 72 DUTOPROL...... 59 DIGIFAB...... 49 doxy 100...... 212 DXEVO 11-DAY...... 106 digitek...... 94 doxycycline hyclate...... 212 DYANAVEL XR...... 11 digox...... 94 doxycycline monohydrate...... 212 DYMISTA...... 190 digoxin...... 94, 95 doxylamine-pyridoxine...... 50 DYSPORT...... 191 dihydroergotamine mesylate...... 169 DRECHSLERA...... 16 ear health formula...... 188 DILANTIN...... 41 DRISDOL...... 220 ear health plus...... 188 DILANTIN INFATABS...... 41 dronabinol...... 51 EASTERN COTTONWOOD...... 16 DILATRATE-SR...... 31 droperidol...... 31 EASY COMFORT INSULIN DILAUDID...... 26 DROPLET INSULIN SYRINGE...... 164 SYRINGE...... 164 diltiazem hcl...... 93 DROPLET LANCETS ULTRA EASY COMFORT LANCETS...... 154 DILTIAZEM HCL...... 93 THIN 30G...... 154 EASY COMFORT LANCETS diltiazem hcl er...... 93 DROPLET MICRON...... 164 TWIST TOP...... 154 diltiazem hcl er beads...... 93 DROPLET PEN NEEDLES...... 164 EASY COMFORT PEN NEEDLES.164 diltiazem hcl er coated beads...... 93 DROPLET PERSONAL LANCETS EASY GLIDE PEN NEEDLES...... 164 DILTIAZEM HCL-DEXTROSE...... 93 30G...... 154 EASY TOUCH FLIPLOCK DILTIAZEM HCL-SODIUM DROPSAFE SAFETY PEN INSULIN SY...... 164 CHLORIDE...... 93 NEEDLES...... 164 EASY TOUCH INSULIN SAFETY dilt-xr...... 93 drospiren-eth estrad-levomefol...... 100 SYR...... 164 DIMENHYDRINATE...... 50 drospirenone-ethinyl estradiol...... 100 EASY TOUCH INSULIN SYRINGE dimethyl fumarate...... 207 DROXIA...... 140 ...... 164 dimethyl fumarate starter pack...... 207 droxidopa...... 219 EASY TOUCH LANCETS 21G...... 154 DIPENTUM...... 131 DRUG MART LANCETS THIN EASY TOUCH LANCETS 23G...... 154 diphen...... 53 26G...... 154 EASY TOUCH LANCETS 26G...... 154 di-phen...... 53 DRUG MART ON-THE-GO EASY TOUCH LANCETS 28G...... 154 diphenhydramine hcl...... 53 LANCET 30G...... 154 EASY TOUCH LANCETS diphenoxylate-atropine...... 48 DRUG MART UNIFINE PENTIPS. 164 28G/TWIST...... 154 DIPHTHERIA-TETANUS DRUG MART UNIFINE PENTIPS EASY TOUCH LANCETS 30G...... 154 TOXOIDS DT...... 213 PLUS...... 164 EASY TOUCH LANCETS DIPRIVAN...... 133 DRUG MART UNILET LANCETS 30G/TWIST...... 154 dipyridamole...... 139 28G...... 154 EASY TOUCH LANCETS 32G...... 154 DISCOVISC...... 199 DRUG MART UNILET LANCETS EASY TOUCH LANCETS disopyramide phosphate...... 32 30G...... 154 32G/TWIST...... 154 disulfiram...... 205 DRUG MART UNILET LANCETS EASY TOUCH LANCETS DIURIL...... 121 33G...... 154 33G/TWIST...... 154 divalproex sodium...... 41 DSUVIA...... 26 EASY TOUCH PEN NEEDLES...... 164 divalproex sodium er...... 41 DUAVEE...... 129 EASY TOUCH SAFETY LANCETS DIVIGEL...... 129 DUET DHA 400...... 183 21G...... 154 dobutamine hcl...... 95 DUET DHA BALANCED...... 183 EASY TOUCH SAFETY LANCETS DOBUTAMINE IN D5W...... 95 DUETACT...... 48 23G...... 154 DOCETAXEL...... 77 dulcolax...... 147 EASY TOUCH SAFETY LANCETS dofetilide...... 33 dulcolax milk of magnesia...... 147 26G...... 154 DOG EPITHELIUM...... 16 duloxetine hcl...... 43 EASY TOUCH SAFETY LANCETS DOG FENNEL...... 16 DUOBRII...... 119 28G...... 154 DOJOLVI...... 193 DUODOTE...... 48 EASY TOUCH SAFETY PEN dolishale...... 103 DUOPA...... 81 NEEDLES...... 164 donepezil hcl...... 205 DUOVISC...... 199 EASY TOUCH SHEATHLOCK dopamine hcl...... 95 DUPIXENT...... 113 SYRINGE...... 164 DOPAMINE IN D5W...... 95 DURACLON...... 22 easygel...... 177 DOPRAM...... 12 DURAGESIC-100...... 26 ec-naproxen...... 21 DOPTELET...... 142 DURAGESIC-12...... 26 econazole nitrate...... 116 DORAL...... 145 DURAGESIC-25...... 26 econtra ez...... 103 228 econtra one-step...... 103 endur-b...... 180 EQL COLOR LANCETS 21G...... 155 ecotrin low strength...... 23 ENFAMIL EXPECTA...... 186 EQL COLOR LANCETS MICRO ECOZA...... 116 ENGERIX-B...... 217 33G...... 155 EDARBI...... 57 ENHERTU...... 73 eql gentle laxative...... 148 EDARBYCLOR...... 57 ENLITE GLUCOSE SENSOR...... 154 EQL INSULIN SYRINGE...... 164 EDECRIN...... 121 enoxaparin sodium...... 37 eql laxative...... 148 EDETATE DISODIUM...... 172 enpresse-28...... 105 eql magnesium citrate...... 147 EDEX...... 95 enskyce...... 100 eql milk of magnesia...... 147 EDLUAR...... 145 ENSPRYNG...... 175 eql nicotine polacrilex...... 208 EDURANT...... 87 ENSTILAR...... 119 EQL PRENATAL FORMULA...... 183 efavirenz...... 87, 88 entacapone...... 81 eql super b complex/vitamin c...... 178 efavirenz-emtricitab-tenofovir...... 86 entecavir...... 89 EQL SUPER THIN LANCETS 30G 155 efavirenz-lamivudine-tenofovir...... 86 ENTEREG...... 132 EQL THIN LANCETS 26G...... 155 EFUDEX...... 111 ENTOCORT EC...... 106 EQUETRO...... 82 EGRIFTA SV...... 123 ENTRESTO...... 95 ERAXIS...... 51 ELAPRASE...... 126 ENTYVIO...... 131 ERBITUX...... 69 ELCYS...... 192 enulose...... 132 ergocalciferol...... 220 ELELYSO...... 140 ENVARSUS XR...... 174 ergoloid mesylates...... 208 ELEPSIA XR...... 39 EPANED...... 56 ergotamine-caffeine...... 169 ELESTRIN...... 129 EPCLUSA...... 89 ERIVEDGE...... 70 eletriptan hydrobromide...... 169 EPHEDRINE SULFATE...... 220 ERLEADA...... 65 ELIGARD...... 76 EPHEDRINE SULFATE erlotinib hcl...... 69 elinest...... 100 (PRESSORS)...... 219 errin...... 104 ELIQUIS...... 36 EPHEDRINE SULFATE-NACL...... 220 ERTACZO...... 116 ELIQUIS DVT/PE STARTER EPICOCCUM...... 16 ertapenem sodium...... 60 PACK...... 36 EPICOCCUM NIGRUM...... 16 ERWINASE...... 73 ELITEK...... 75 EPICORD...... 118 ERWINAZE...... 73 elite-ob...... 183 EPIDIOLEX...... 39 ery...... 109 ELIXOPHYLLIN...... 36 EPIFIX...... 118 ERYGEL...... 109 ELLA...... 103 EPIFIX MICRONIZED...... 119 ery-tab...... 151 ELLENCE...... 72 EPIFOAM...... 118 ERYTHROCIN LACTOBIONATE.151 ELLIOTTS B...... 170 epinastine hcl...... 195 erythrocin stearate...... 151 ELMIRON...... 134 epinephrine...... 219 erythromycin...... 109, 151, 195 ELOCTATE...... 136 EPINEPHRINE...... 220 erythromycin base...... 151 eluryng...... 103 epinephrine (anaphylaxis)...... 219 erythromycin ethylsuccinate...... 151 ELZONRIS...... 74 EPINEPHRINE HCL...... 194 ESBRIET...... 211 EMBRACE LANCETS ULTRA EPINEPHRINE HCL-NACL...... 220 escitalopram oxalate...... 42 THIN 30G...... 154 EPINEPHRINE PF...... 220 esgic...... 23 EMCYT...... 75 EPINEPHRINE-DEXTROSE...... 220 ESKATA...... 118 EMEND...... 51 EPINEPHRINE-NACL...... 220 esmolol hcl...... 91 EMERPHED...... 219 epirubicin hcl...... 72 ESMOLOL HCL...... 91 EMGALITY...... 168 epitol...... 39 esmolol hcl-sodium chloride...... 91 EMGALITY (300 MG DOSE)...... 168 EPIVIR...... 88 esomeprazole sodium...... 215 emoquette...... 100 EPIVIR HBV...... 89 ESPEROCT...... 136 EMPAVELI...... 137 eplerenone...... 59 est estrogens-methyltest...... 128 EMPLICITI...... 68 EPOGEN...... 141 estarylla...... 100 EMSAM...... 42 epoprostenol sodium...... 95 estazolam...... 145 emtricitabine...... 88 eptifibatide...... 138 ESTRADIOL...... 129 emtricitabine-tenofovir df...... 86 EPZICOM...... 86 estradiol...... 129, 219 EMTRIVA...... 88 eq aspirin...... 24 estradiol valerate...... 129 EMVERM...... 30 eq aspirin adult low dose...... 24 estradiol-norethindrone acet...... 128 enalapril maleate...... 56 eq aspirin low dose...... 24 ESTRING...... 219 enalaprilat...... 56 eq clearlax...... 146 ESTROFACTORS...... 181 enalapril-hydrochlorothiazide...... 56 eq gentle laxative...... 148 ESTROGEL...... 129 ENBRACE HR...... 183 eq magnesium citrate...... 147 ESTROSTEP FE...... 105 ENBREL...... 22 eq nicotine...... 208 eszopiclone...... 145 ENBREL MINI...... 22 eq nicotine polacrilex...... 208 ethacrynate sodium...... 121 ENBREL SURECLICK...... 22 eq nicotine step 3...... 208 ethacrynic acid...... 121 ENCARE...... 218 eql aspirin ec...... 24 ethambutol hcl...... 63 ENDARI...... 140 eql aspirin low dose...... 24 ETHAMOLIN...... 176 ENDO AVITENE...... 143 eql b complex 50...... 180 ethosuximide...... 41 endocet...... 28 eql b-100 complex...... 180 ethynodiol diac-eth estradiol...... 100 ENDOMETRIN...... 219 eql clearlax...... 146 ETHYOL...... 79 229 etodolac...... 21 FASENRA PEN...... 35 FLAGYL...... 59 etodolac er...... 21 FASLODEX...... 75 FLAREX...... 198 etomidate...... 133 fa-vitamin b-6-vitamin b-12...... 141 flavoxate hcl...... 216 etonogestrel-ethinyl estradiol...... 103 fayosim...... 103 FLEBOGAMMA DIF...... 202 ETOPOPHOS...... 77 FC FEMALE CONDOM...... 151 flecainide acetate...... 33 etoposide...... 77 FC2 FEMALE CONDOM...... 151 FLEXBUMIN...... 138 etravirine...... 88 febuxostat...... 135 FLEXIN...... 119 EUCRISA...... 117 feenamint...... 148 FLOLAN...... 96 EUFLEXXA...... 190 FEIBA...... 136 FLORIVA...... 170, 183 euthyrox...... 212 felbamate...... 40 FLORIVA PLUS...... 182 EVAMIST...... 129 FELDENE...... 21 FLOVENT DISKUS...... 36 EVEKEO ODT...... 12 felodipine er...... 93 FLOVENT HFA...... 36 EVENITY...... 127 FEMARA...... 74 floxuridine...... 65 everolimus...... 70, 174 FEMCAP...... 151 FLUAD...... 217 EVERSENSE SENSOR/HOLDER...155 FEMHRT...... 128 FLUAD QUADRIVALENT...... 217 EVERSENSE SMART FEMRING...... 219 FLUARIX QUADRIVALENT...... 217 TRANSMITTER...... 155 femynor...... 100 FLUBLOK QUADRIVALENT...... 217 EVISTA...... 127 fenofibrate...... 54 FLUCELVAX QUADRIVALENT... 217 EVKEEZA...... 53 fenofibrate micronized...... 54 fluconazole...... 52 EVOCLIN...... 109 fenofibric acid...... 54 fluconazole in sodium chloride...... 52 EVOMELA...... 77 FENOGLIDE...... 54 flucytosine...... 51 EVOTAZ...... 86 fenoprofen calcium...... 21 fludarabine phosphate...... 65 EVOXAC...... 177 FENSOLVI (6 MONTH)...... 125 fludrocortisone acetate...... 107 EVRYSDI...... 192 fentanyl...... 26 FLULAVAL QUADRIVALENT...... 217 EXEL COMFORT POINT fentanyl citrate...... 26 flumazenil...... 49 INSULIN SYR...... 164 FENTANYL CITRATE...... 26 flunisolide...... 190 EXEL COMFORT POINT PEN FENTANYL CITRATE (PF)...... 26 fluocinolone acetonide...... 114, 201 NEEDLE...... 164 fentanyl citrate (pf)...... 26 fluocinolone acetonide body...... 114 EXELDERM...... 116 FENTANYL CITRATE PF...... 26 fluocinolone acetonide scalp...... 114 EXELON...... 205 FENTANYL CITRATE-NACL...... 26 fluocinonide...... 114 exemestane...... 74 FENTANYL CIT-ROPIVACAINE- fluocinonide emulsified base...... 114 EXJADE...... 48 NACL...... 25 FLUORESCEIN ex-lax ultra...... 148 FENTANYL-BUPIVACAINE- SODIUM/BENOXINATE...... 196 EXONDYS 51...... 191 NACL...... 25 fluorescein-benoxinate...... 196 EXTINA...... 116 FENTORA...... 26 FLUORESCITE...... 196 EXTRANEAL...... 175 FERAHEME...... 142 fluoridex...... 177 EYLEA...... 200 FERRIPROX...... 48 fluoridex daily renewal...... 177 E-Z JECT LANCET MICRO-THIN FERRIPROX TWICE-A-DAY...... 48 fluoridex enhanced whitening...... 177 33G...... 155 FERRLECIT...... 142 fluoridex sensitivity relief...... 177 E-Z JECT LANCET SUPER THIN FETROJA...... 99 fluor-i-strips a.t...... 196 30G...... 155 FETZIMA...... 43 fluoritab...... 170 E-Z JECT LANCETS...... 155 FETZIMA TITRATION...... 43 fluorometholone...... 198 E-Z JECT LANCETS 21G...... 155 fexmid...... 188 FLUOROPLEX...... 111 E-Z JECT LANCETS THIN 26G.....155 FIBRICOR...... 54 fluorouracil...... 65, 111 ezetimibe...... 55 FIBRYGA...... 136 fluoxetine hcl...... 42, 43 ezetimibe-simvastatin...... 55 FIFTY50 PEN NEEDLES...... 164 FLUOXETINE HCL...... 43 EZ-LETS LANCETS 21G...... 155 FIFTY50 SAFETY SEAL fluoxetine hcl (pmdd)...... 208 EZ-LETS LANCETS 26G...... 155 LANCETS...... 155 fluphenazine decanoate...... 84 EZ-LETS LANCETS 28G...... 155 FIFTY50 SUPERIOR COMFORT fluphenazine hcl...... 84 EZ-LETS LANCETS 30G...... 155 SYR...... 164 flurandrenolide...... 114 fa-8...... 141 FIFTY50 UNILET LANCETS 33G..155 FLURA-SAFE...... 196 FABRAZYME...... 123 FINACEA...... 117 flurazepam hcl...... 145 FALESSA...... 100 finasteride...... 120, 133 flurbiprofen...... 21 falmina...... 100 FINE 30...... 155 flurbiprofen sodium...... 197 famciclovir...... 90 FINGERSTIX LANCETS...... 155 flutamide...... 65 famotidine...... 214 FINTEPLA...... 39 fluticasone propionate...... 114, 190 famotidine premixed...... 214 FIRAZYR...... 137 fluticasone-salmeterol...... 33 FANAPT...... 82 FIRDAPSE...... 63 fluvastatin sodium...... 55 FANAPT TITRATION PACK...... 82 FIRE ANT...... 16 fluvastatin sodium er...... 54 FARESTON...... 65 FIRMAGON...... 75 fluvoxamine maleate...... 43 FARXIGA...... 47 FIRMAGON (240 MG DOSE)...... 75 fluvoxamine maleate er...... 43 FARYDAK...... 70 FIRVANQ...... 61 FLUZONE QUADRIVALENT...... 217 FASENRA...... 35 flac...... 201 FML...... 198 230 FML FORTE...... 198 FUROSEMIDE IN SODIUM GENTEEL CONTACT TIPS FML LIQUIFILM...... 198 CHLORIDE...... 121 (CLEAR)...... 155 FOCALIN...... 13 FUSARIUM...... 16 GENTEEL CONTACT TIPS folate...... 141 FUZEON...... 86 (GREEN)...... 155 FOLGARD OS...... 181 fyavolv...... 128 GENTEEL CONTACT TIPS FOLGARD RX...... 141 FYCOMPA...... 38 (ORANGE)...... 155 folic acid...... 141 g tussin ac...... 107 GENTEEL CONTACT TIPS FOLIVANE-OB...... 183 gabapentin...... 39 (RAINBOW)...... 155 FOLOTYN...... 65 GABLOFEN...... 188, 189 GENTEEL CONTACT TIPS foltabs 800...... 141 GALAFOLD...... 123 (VIOLET)...... 155 foltrin...... 142 galantamine hydrobromide...... 205 GENTEEL CONTACT TIPS fomepizole...... 49 galantamine hydrobromide er...... 205 (YELLOW)...... 155 fondaparinux sodium...... 37 GALZIN...... 172 GENTEEL LANCING KIT (BLUE) 155 FORA LANCETS...... 155 GAMASTAN...... 202 GENTEEL NOZZLES...... 155 FORANE...... 133 GAMIFANT...... 175 gentle laxative...... 148 FORMALDEHYDE...... 85 GAMMAGARD...... 202 gentlelax...... 146 formoterol fumarate...... 34 GAMMAGARD S/D LESS IGA...... 202 GENTLE-LET GP LANCETS...... 156 FORTAZ...... 98 GAMMAKED...... 202 GENTLE-LET LANCETS...... 156 FORTEO...... 126 GAMMAPLEX...... 202 GENTLE-LET PLATFORMS...... 156 FOSAMAX...... 122 GAMUNEX-C...... 202 GENVOYA...... 86 FOSAMAX PLUS D...... 122 GANCICLOVIR...... 89 GEODON...... 82 fosamprenavir calcium...... 87 GANCICLOVIR SODIUM...... 89 GERMAN COCKROACH...... 16 fosaprepitant dimeglumine...... 51 ganciclovir sodium...... 89 GIAPREZA...... 220 foscarnet sodium...... 89 GANIRELIX ACETATE...... 123 GILENYA...... 210 FOSCAVIR...... 89 GARDASIL 9...... 217 GILOTRIF...... 69 fosfomycin tromethamine...... 62 GASTROCROM...... 130 GILPHEX TR...... 108 fosinopril sodium...... 56 gatifloxacin...... 195 GIMOTI...... 130 fosinopril sodium-hctz...... 56 GATTEX...... 131 GIVLAARI...... 135 fosphenytoin sodium...... 41 gavilax...... 146 GLASSIA...... 210 FOSRENOL...... 132 gavilyte-c...... 146 GLEOSTINE...... 78 FOTIVDA...... 71 gavilyte-g...... 146 GLIADEL WAFER...... 78 FRAGMIN...... 37 gavilyte-n with flavor pack...... 146 glimepiride...... 47 FREAMINE HBC...... 192 GAVRETO...... 71 glipizide...... 47 FREAMINE III...... 192 GAZYVA...... 67 glipizide er...... 47 FREDS PHARMACY UNIFINE GEL-FLOW NT...... 143 glipizide xl...... 47 PENTIP+...... 164 GELFOAM...... 143 glipizide-metformin hcl...... 47 FREDS PHARMACY UNIFINE GELFOAM COMPRESSED SIZE GLOBAL EASE INJECT PEN PENTIPS...... 164 100...... 143 NEEDLES...... 164 FREDS PHARMACY UNILET GELFOAM DENTAL PACK SIZE 4 GLOBAL EASY GLIDE INSULIN LANC 28G...... 155 ...... 143 SYR...... 164, 165 FREDS PHARMACY UNILET GELFOAM SPONGE...... 143 GLOBAL EASY GLIDE PEN LANC 30G...... 155 GELFOAM SPONGE SIZE 100...... 143 NEEDLES...... 165 FREESTYLE LANCETS...... 155 GELFOAM SPONGE SIZE 200...... 144 GLOBAL INJECT EASE INSULIN FREESTYLE LIBRE 14 DAY GELFOAM SPONGE SIZE 50...... 144 SYR...... 165 READER...... 155 GEL-ONE...... 190 GLOBAL INJECT EASE FREESTYLE LIBRE 14 DAY GELSYN-3...... 190 LANCETS 28G...... 156 SENSOR...... 155 GEMCITABINE HCL...... 65 GLOBAL INJECT EASE FREESTYLE LIBRE 2 READER....155 gemcitabine hcl...... 65 LANCETS 30G...... 156 FREESTYLE LIBRE 2 SENSOR.....155 gemfibrozil...... 54 GLOBAL INSULIN SYRINGES...... 165 FREESTYLE LIBRE READER...... 155 gemmily...... 100 GLOPERBA...... 135 FREESTYLE LIBRE SENSOR GENERESS FE...... 100 GLUCAGEN HYPOKIT...... 44 SYSTEM...... 155 generlac...... 132 GLUCAGON EMERGENCY...... 44 FREESTYLE PRECISION INS SYR gengraf...... 173 GLUCOCOM LANCETS 28G...... 156 ...... 164 GENOTROPIN...... 124 GLUCOCOM LANCETS 30G...... 156 FREESTYLE UNISTICK II GENOTROPIN MINIQUICK...... 124 GLUCOCOM LANCETS 33G...... 156 LANCETS...... 155 gentak...... 195 GLUCOPRO INSULIN SYRINGE..165 fresenius propoven...... 133 gentamicin in saline...... 19 GLUCOTROL XL...... 47 frovatriptan succinate...... 169 gentamicin sulfate...... 19, 110, 195 GLUTARALDEHYDE...... 85 FULL SPECTRUM B/VITAMIN C.178 GENTEEL BUTTERFLY TOUCH GLUTATHIONE...... 193 FULPHILA...... 141 LANCET...... 155 glyburide...... 47 fulvestrant...... 75 GENTEEL CONTACT TIPS glyburide micronized...... 47 furosemide...... 121 (BLUE)...... 155 glyburide-metformin...... 47 GLYCATE...... 215 231 glycine...... 134 GOODSENSE LANCETS 33G HEALON...... 199 GLYCINE...... 193 UNIV...... 156 HEALON DUET PRO...... 199 glycine urologic...... 134 goodsense magnesium citrate...... 147 HEALON GV...... 199 glycolax...... 146 goodsense nicotine...... 209 HEALON GV PRO...... 199 glycopyrrolate...... 215 GOODSENSE PEN NEEDLE HEALON PRO...... 199 GLYCOPYRROLATE...... 215 PENFINE...... 165 HEALON5...... 199 GLYCOPYRROLATE PF...... 215 goodsense womens laxative...... 148 HEALON5 PRO...... 199 glydo...... 116 GOPRELTO...... 190 HEALTHWISE INSULIN GLYNASE...... 47 GRALISE...... 207 SYR/NEEDLE...... 165 GLYRX-PF...... 215 granisetron hcl...... 50 HEALTHWISE MICRON PEN GLYXAMBI...... 47 GRANIX...... 141 NEEDLES...... 165 gnp adult aspirin low strength...... 24 GRASS POLLEN(K-O-R-T-SWT HEALTHWISE MINI PEN gnp aspirin...... 24 VERN)...... 16 NEEDLES...... 165 gnp aspirin low dose...... 24 GRASTEK...... 16 HEALTHWISE PEN NEEDLES...... 165 gnp b-100 complex...... 180 griseofulvin microsize...... 51 HEALTHWISE SHORT PEN gnp b-50 complex...... 180 griseofulvin ultramicrosize...... 51 NEEDLES...... 165 gnp b-complex plus vitamin c...... 178 guaiatussin ac...... 107 HEALTHWISE UNIFINE PENTIPS gnp clearlax...... 146, 147 guaifenesin ac...... 107 ...... 165 GNP CLICKFINE PEN NEEDLES. 165 guaifenesin-codeine...... 107 HEALTHY ACCENTS UNIFINE gnp essential one daily...... 181 guanfacine hcl...... 58 PENTIP...... 165 gnp folic acid...... 141 guanfacine hcl er...... 11 HEALTHY ACCENTS UNILET gnp gentle laxative...... 148 GUARDIAN CONNECT LANCETS...... 156 GNP INSULIN SYRINGE...... 165 TRANSMITTER...... 156 healthy hair/skin/nails...... 181 GNP LANCETS 21G...... 156 GUARDIAN LINK 3 healthylax...... 147 GNP LANCETS MICRO THIN 33G TRANSMITTER...... 156 heather...... 104 ...... 156 GUARDIAN REAL-TIME h-e-b aspirin...... 24 GNP LANCETS SUPER THIN 30G 156 REPLACE PED...... 156 H-E-B INCONTROL LANCETS GNP LANCETS THIN...... 156 GUARDIAN SENSOR (3)...... 156 28G...... 156 GNP LANCETS THIN 26G...... 156 GUARDIAN SENSOR 3...... 156 H-E-B INCONTROL LANCETS gnp milk of magnesia...... 147 GVOKE HYPOPEN 1-PACK...... 44 30G...... 156 gnp nicotine...... 209 GVOKE HYPOPEN 2-PACK...... 45 H-E-B INCONTROL LANCETS gnp nicotine mini...... 209 GVOKE PFS...... 45 33G...... 156 gnp nicotine polacrilex...... 209 GYNAZOLE-1...... 218 H-E-B INCONTROL PEN GNP PRENATAL...... 183 habitrol...... 209 NEEDLES...... 165 GNP ULTICARE PEN NEEDLES...165 HACKBERRY...... 16 H-E-B INCONTROL UNIFINE GNP ULTRA COM INSULIN HAEGARDA...... 137 PENTIP...... 165 SYRINGE...... 165 HAEMOLANCE...... 156 HECTOROL...... 124 gnp womens gentle laxative...... 148 HAEMOLANCE LOW FLOW HELIDAC THERAPY...... 215 GOCOVRI...... 80 LANCETS...... 156 HEMABATE...... 201 GOJJI STERILE LANCETS...... 156 HAEMOLANCE PLUS...... 156 HEMADY...... 106 GOLDENROD...... 16 HAEMOLANCE PLUS HIGH HEMANGEOL...... 91 GOLYTELY...... 146 FLOW...... 156 HEMLIBRA...... 135 GONAL-F...... 126 HAEMOLANCE PLUS LOW HEMOFIL M...... 136 GONAL-F RFF...... 126 FLOW...... 156 HEPAGAM B...... 202 GONAL-F RFF REDIJECT...... 126 HAEMOLANCE PLUS MAX heparin (porcine) in nacl...... 37 GONITRO...... 31 FLOW...... 156 HEPARIN (PORCINE) IN NACL...... 37 goodsense aspirin...... 24 HAEMOLANCE PLUS heparin lock flush...... 37 goodsense aspirin adult low st...... 24 PEDIATRIC FLOW...... 156 HEPARIN SOD (PORCINE) IN goodsense aspirin adults...... 24 hailey 1.5/30...... 100 D5W...... 37 goodsense aspirin low dose...... 24 hailey 24 fe...... 100 heparin sod (porcine) in d5w...... 37 goodsense bisacodyl ec...... 148 hailey fe 1.5/30...... 100 heparin sodium (porcine)...... 37 goodsense clearlax...... 147 hailey fe 1/20...... 100 HEPARIN SODIUM (PORCINE)...... 37 GOODSENSE CLICKFINE PEN HALAVEN...... 77 heparin sodium (porcine) pf...... 37 NEEDLE...... 165 halcinonide...... 114 HEPARIN SODIUM (PORCINE) GOODSENSE COLOR LANCETS HALCION...... 145 PF...... 37 33G...... 156 HALDOL...... 83 heparin sodium lock flush...... 37 GOODSENSE LANCETS 26G HALDOL DECANOATE...... 83 HEPLISAV-B...... 217 UNIV...... 156 halobetasol propionate...... 115 HEPSERA...... 89 GOODSENSE LANCETS 30G...... 156 haloperidol...... 83 HERCEPTIN...... 67 GOODSENSE LANCETS 30G haloperidol decanoate...... 83 HERCEPTIN HYLECTA...... 73 UNIV...... 156 haloperidol lactate...... 83 HERZUMA...... 67 GOODSENSE LANCETS 33G...... 156 HARVONI...... 89 HESPAN...... 138 HAVRIX...... 217 hetastarch-nacl...... 138 232 HETLIOZ...... 146 HUMULIN N KWIKPEN...... 46 IDELVION...... 136 HETLIOZ LQ...... 146 HUMULIN R...... 46 IDHIFA...... 76 HEXTEND...... 138 HUMULIN R U-500 IFEX...... 77 HIBERIX...... 216 (CONCENTRATED)...... 46 ifosfamide...... 77 HIGH POTENCY HUMULIN R U-500 KWIKPEN...... 46 IFOSFAMIDE...... 77 MULTIVITAMIN...... 181 HYALGAN...... 190 ILARIS...... 20 HIPREX...... 62 HYALURONIDASE ILEVRO...... 197 HISTEX-AC...... 108 (INTRAOCULAR)...... 199 ILIDERM...... 117 HIZENTRA...... 202 HYCAMTIN...... 79 ILUVIEN...... 198 hm adult aspirin...... 24 HYCODAN...... 107 imatinib mesylate...... 69 hm aspirin...... 24 hydralazine hcl...... 59 IMBRUVICA...... 69 hm aspirin ec...... 24 HYDREA...... 74 IMCIVREE...... 13 hm aspirin ec low dose...... 24 hydrochlorothiazide...... 121 IMFINZI...... 68 hm b complex/c...... 179 hydrocod polst-cpm polst er...... 108 imipenem-cilastatin...... 60 hm clearlax...... 147 hydrocodone bitartrate er...... 26 imipramine hcl...... 44 hm folic acid...... 141 hydrocodone-acetaminophen...... 26 imipramine pamoate...... 44 hm laxative...... 148 hydrocodone-homatropine...... 107 imiquimod...... 116 hm magnesium citrate...... 147 hydrocodone-ibuprofen...... 26 imiquimod pump...... 116 hm milk of magnesia...... 147 hydrocortisone...... 30, 106, 115 IMLYGIC...... 78 hm nicotine...... 209 hydrocortisone (perianal)...... 30 IMOGAM RABIES-HT...... 202 hm nicotine polacrilex...... 209 hydrocortisone ace-pramoxine...... 30 IMOVAX RABIES...... 218 HM ONE DAILY PRENATAL...... 184 hydrocortisone butyr lipo base...... 115 IMPAVIDO...... 59 hm one daily/iron...... 180 hydrocortisone butyrate...... 115 IMURAN...... 176 HM PRENATAL...... 184 hydrocortisone valerate...... 115 IMVEXXY MAINTENANCE PACK HM ULTICARE INSULIN hydrocortisone-acetic acid...... 201 ...... 219 SYRINGE...... 165 hydromet...... 107 IMVEXXY STARTER PACK...... 219 HM ULTICARE MINI PEN hydromorphone hcl...... 26 IN TOUCH STERILE LANCETS NEEDLES...... 165 hydromorphone hcl er...... 26 30G...... 156 HM ULTICARE SHORT PEN HYDROMORPHONE HCL PF...... 27 inatal gt...... 184 NEEDLES...... 165 hydromorphone hcl pf...... 27 INBRIJA...... 80 hm vitamin b complex/vitamin c...... 178 HYDROMORPHONE HCL-NACL...27 incassia...... 104 hm vitamin b100 complex...... 180 hydroxocobalamin acetate...... 140 INCRELEX...... 125 hm vitamin b50 complex...... 180 hydroxychloroquine sulfate...... 63 indapamide...... 122 HONEY BEE VENOM...... 16 hydroxyprogesterone caproate...... 78, 204 INDERAL XL...... 92 HONEY BEE VENOM PROTEIN.....16 hydroxyurea...... 74 indomethacin...... 21 HORIZANT...... 208 hydroxyzine hcl...... 31 indomethacin er...... 21 HORSE EPITHELIUM...... 16 hydroxyzine pamoate...... 31 indomethacin sodium...... 21 HUMALOG...... 45 HYLENEX...... 173 INFANRIX...... 213 HUMALOG JUNIOR KWIKPEN..... 45 HYMOVIS...... 190 INFASURF...... 211 HUMALOG KWIKPEN...... 45 hyoscyamine sulfate...... 214 INFED...... 142 HUMALOG MIX 50/50...... 45 hyoscyamine sulfate er...... 214 INFLECTRA...... 132 HUMALOG MIX 50/50 KWIKPEN.. 45 hyoscyamine sulfate sl...... 214 INFUGEM...... 65 HUMALOG MIX 75/25...... 45 HYPERHEP B...... 202 INFUMORPH 200...... 27 HUMALOG MIX 75/25 KWIKPEN.. 45 HYPERRAB...... 202 INFUMORPH 500...... 27 HUMAN ALBUMIN GRIFOLS...... 138 HYPERRHO S/D...... 202 INFUVITE ADULT...... 181 HUMATE-P...... 136 HYPERSAL...... 108 INFUVITE PEDIATRIC...... 183 HUMATIN...... 19 HYPERTET S/D...... 202 INGREZZA...... 206 HUMATROPE...... 124 HYPOLANCE AST LANCING...... 156 INJECTAFER...... 142 HUMIRA...... 20 HYQVIA...... 203 INLYTA...... 79 HUMIRA PEDIATRIC CROHNS HY-VEE LANCETS...... 156 inner ear plus...... 188 START...... 20 HY-VEE THIN LANCETS...... 156 INNOPRAN XL...... 92 HUMIRA PEN...... 20 ibandronate sodium...... 122 INQOVI...... 73 HUMIRA PEN-CD/UC/HS IBRANCE...... 75 INREBIC...... 76 STARTER...... 20 ibu...... 21 INSPRA...... 59 HUMIRA PEN-PEDIATRIC UC ibuprofen...... 21 INSTAT...... 144 START...... 20 ibuprofen lysine...... 21 INSULIN SYRINGE...... 165 HUMIRA PEN-PS/UV/ADOL HS ibutilide fumarate...... 33 INSULIN SYRINGE/NEEDLE...... 165 START...... 20 icatibant acetate...... 137 INSULIN SYRINGE-NEEDLE U- HUMIRA PEN-PSOR/UVEIT iclevia...... 103 100...... 165 STARTER...... 20 ICLUSIG...... 68, 69 INSUPEN PEN NEEDLES...... 165 HUMULIN 70/30...... 46 icosapent ethyl...... 53 INSUPEN SENSITIVE...... 165 HUMULIN 70/30 KWIKPEN...... 45 IDAMYCIN PFS...... 72 INSUPEN ULTRAFIN...... 165 HUMULIN N...... 46 idarubicin hcl...... 72 INTELENCE...... 88 233 INTERCEED...... 144 JEMPERLI...... 68 ketorolac tromethamine...... 21, 197 INTERCEED (TC7)...... 144 jencycla...... 104 KEVEYIS...... 120 INTRALIPID...... 193 JENLIVA KEYTRUDA...... 68 INTRAROSA...... 218 PRENATAL/POSTNATAL...... 184 KHAPZORY...... 75 INTRON A...... 74 JEVTANA...... 77 KINNEY LANCETS...... 156 introvale...... 103 jinteli...... 128 KINNEY THIN LANCETS...... 157 INVANZ...... 60 JIVI...... 136 KINRAY INSULIN SYRINGE...... 165 INVEGA SUSTENNA...... 82 JOHNSON GRASS...... 16 KINRIX...... 213 INVEGA TRINZA...... 82 jolessa...... 103 KISQALI (200 MG DOSE)...... 75 INVELTYS...... 198 JORNAY PM...... 13, 14 KISQALI (400 MG DOSE)...... 75 INVIRASE...... 87 JUBLIA...... 116 KISQALI (600 MG DOSE)...... 75 IODINE TINCTURE...... 85 juleber...... 100 KISQALI FEMARA (400 MG IODOFLEX...... 85 JULUCA...... 86 DOSE)...... 73 IODOSORB...... 85 JUNE GRASS POLLEN KISQALI FEMARA (600 MG IONOSOL-MB IN D5W...... 170 STANDARDIZED...... 16 DOSE)...... 73 IOPIDINE...... 197 junel 1.5/30...... 100 KISQALI FEMARA(200 MG IPOL...... 218 junel 1/20...... 100 DOSE)...... 73 ipratropium bromide...... 35, 190 junel fe 1.5/30...... 100 KLARON...... 109 ipratropium-albuterol...... 33 junel fe 1/20...... 100 KLISYRI...... 117 irbesartan...... 57, 58 junel fe 24...... 100 klor-con...... 171 irbesartan-hydrochlorothiazide...... 57 JUXTAPID...... 55 klor-con 10...... 171 IRESSA...... 69 JYNARQUE...... 127 klor-con m10...... 171 irinotecan hcl...... 79 KABIVEN...... 193 klor-con m15...... 171 ISENTRESS...... 87 KADCYLA...... 73 klor-con m20...... 171 ISENTRESS HD...... 87 kaitlib fe...... 101 kls aspirin low dose...... 24 isibloom...... 100 KALBITOR...... 138 kls laxaclear...... 147 isoflurane...... 133 KALETRA...... 86 kls quit2...... 209 ISOLYTE-P IN D5W...... 170 kalliga...... 101 kls quit4...... 209 ISOLYTE-S...... 170 KALYDECO...... 210 KMART VALU INSULIN ISOLYTE-S PH 7.4...... 170 KANJINTI...... 68 SYRINGE 29G...... 165 isoniazid...... 63 KANUMA...... 125 KMART VALU INSULIN isoproterenol hcl...... 34 KAPOK...... 16 SYRINGE 30G...... 165 ISOPROTERENOL-SODIUM KAPSPARGO SPRINKLE...... 91 KOATE...... 136 CHLORIDE...... 34 KAPVAY...... 11 KOATE-DVI...... 136 ISOPTO ATROPINE...... 194 KARBINAL ER...... 53 kobee...... 179 ISOPTO CARPINE...... 194 KARDIAMEMBRANE...... 119 KOCHIA...... 16 ISORDIL TITRADOSE...... 31 kariva...... 99 KOGENATE FS...... 136 isosorbide dinitrate...... 31 KATERZIA...... 93 KORLYM...... 47 isosorbide mononitrate...... 31 KCENTRA...... 136 KOSELUGO...... 70 isosorbide mononitrate er...... 31 KCL (IN NACL 0.9%)...... 170 KOSHER PRENATAL PLUS IRON184 isotretinoin...... 110 kcl in dextrose-nacl...... 170 KOVALTRY...... 136 isradipine...... 93 KCL IN DEXTROSE-NACL...... 170 kp aspirin...... 24 ISTODAX (OVERFILL)...... 70 KCL-LACTATED RINGERS-D5W 170 kp b complex-c...... 178 ISTURISA...... 123 KEDBUMIN...... 138 kp bisacodyl...... 148 ISUPREL...... 34 KEDRAB...... 202 kp folic acid...... 141 itraconazole...... 52 KEFLEX...... 97 KP PRENATAL MULTIVITAMINS ivermectin...... 31, 117, 118 kelnor 1/35...... 101 ...... 184 IXEMPRA KIT...... 77 kelnor 1/50...... 101 K-PHOS...... 171 IXIARO...... 218 KENALOG...... 106 K-PHOS NO 2...... 134 IXINITY...... 136 KENALOG-80...... 106 K-PHOS-NEUTRAL...... 171 JADENU...... 49 KENDALL HYDROGEL WOUND KPN PRENATAL...... 184 JADENU SPRINKLE...... 49 DRESS...... 120 KRINTAFEL...... 63 jaimiess...... 103 KENGREAL...... 137 KRISTALOSE...... 147 JAKAFI...... 76 KEPIVANCE...... 75 KROGER HEALTHPRO LANCET JALYN...... 134 KESIMPTA...... 207 26G...... 157 jantoven...... 36 KETALAR...... 133 KROGER INSULIN SYRINGE...... 165 JANUMET...... 45 ketamine hcl...... 133 KROGER LANCETS...... 157 JANUMET XR...... 45 KETAMINE HCL...... 133 KROGER LANCETS 21G...... 157 JANUVIA...... 45 KETAMINE HCL-SODIUM KROGER LANCETS MICRO JARDIANCE...... 47 CHLORIDE...... 133 THIN 33G...... 157 jasmiel...... 100 ketoconazole...... 51, 116 KROGER LANCETS SUPER THIN JATENZO...... 29 ketoprofen...... 21 ...... 157 JELMYTO...... 72 ketoprofen er...... 21 KROGER LANCETS THIN...... 157 234 KROGER LANCETS THIN 26G.....157 LENVIMA (12 MG DAILY DOSE)... 79 LIDOCAINE-PHENYLEPHRINE...197 KROGER LANCETS ULTRATHIN LENVIMA (14 MG DAILY DOSE)... 79 LIDOCAINE-PHENYLEPHRINE- 30G...... 157 LENVIMA (18 MG DAILY DOSE)... 79 BSS...... 197 KROGER PEN NEEDLES...... 165 LENVIMA (20 MG DAILY DOSE)... 79 lidocaine-prilocaine...... 119 KRYSTEXXA...... 135 LENVIMA (24 MG DAILY DOSE)... 79 LIDOCAINE-SODIUM K-TAB...... 171 LENVIMA (4 MG DAILY DOSE)..... 79 BICARBONATE...... 149 kurvelo...... 101 LENVIMA (8 MG DAILY DOSE)..... 80 LIFESCAN UNISTIK 2...... 157 KUVAN...... 126 lessina...... 101 LIFESCAN UNISTIK II LANCETS 157 KYLEENA...... 104 letrozole...... 74 LILETTA (52 MG)...... 104 KYNMOBI...... 81 leucovorin calcium...... 75 lillow...... 101 KYPROLIS...... 71 LEUKERAN...... 78 LINCOCIN...... 62 labetalol hcl...... 91 LEUKINE...... 142 lincomycin hcl...... 62 LABETALOL HCL-DEXTROSE...... 91 leuprolide acetate...... 76 lindane...... 118 LABETALOL HCL-SODIUM LEUPROLIDE ACETATE- linezolid...... 62 CHLORIDE...... 91 BUPIVACAINE...... 70 linezolid in sodium chloride...... 62 lactated ringers...... 170, 174 levalbuterol hcl...... 34 LINZESS...... 131 LACTIC ACID...... 115 levalbuterol tartrate...... 34 LIORESAL...... 189 LACTIC ACID E...... 115 LEVEMIR...... 46 liothyronine sodium...... 213 LACTULOSE...... 147 LEVEMIR FLEXTOUCH...... 46 LIPO...... 193 lactulose...... 147 levetiracetam...... 39 lipo flavonoid plus...... 188 lactulose encephalopathy...... 132 levetiracetam er...... 39 LIPO-B...... 140 lamivudine...... 88, 89 LEVETIRACETAM IN NACL...... 39 LIPO-C...... 193 lamivudine-zidovudine...... 86 levobunolol hcl...... 193 LIPOFEN...... 54 lamotrigine...... 39 levocarnitine...... 123 lipoflavovit...... 188 lamotrigine er...... 39 levocarnitine sf...... 123 LIPOTRIAD...... 188 lamotrigine starter kit-blue...... 39 levocetirizine dihydrochloride...... 53 lisinopril...... 56 lamotrigine starter kit-green...... 39 levofloxacin...... 130, 195 lisinopril-hydrochlorothiazide...... 56 lamotrigine starter kit-orange...... 39 levofloxacin in d5w...... 130 LITE TOUCH LANCETS...... 157 LAMPIT...... 60 levoleucovorin calcium...... 75 LITETOUCH INSULIN SYRINGE.165 LANCET TRANSPORTER CASE.. 157 levoleucovorin calcium pf...... 75 LITETOUCH LANCETS...... 157 LANCETS...... 157 levonest...... 105 LITETOUCH PEN NEEDLES...... 165 LANCETS 30G...... 157 levonorgest-eth est & eth est...... 103 lithium carbonate...... 82 LANCETS 33G...... 157 levonorgest-eth estrad 91-day...... 103 lithium carbonate er...... 82 LANCETS MICRO THIN 33G...... 157 levonorgestrel...... 103 LITHOSTAT...... 135 LANCETS SUPER THIN 28G...... 157 levonorgestrel-ethinyl estrad...... 101, 103 LIVE BETTER LANCET SUPER LANCETS THIN...... 157 levonorg-eth estrad triphasic...... 105 THIN...... 157 LANCETS ULTRA THIN...... 157 LEVOPHED...... 220 LIVE BETTER LANCET ULTRA LANCETS ULTRA THIN 30G...... 157 levora 0.15/30 (28)...... 101 THIN...... 157 LANOXIN...... 95 levorphanol tartrate...... 27 lmd in d5w...... 138 LANOXIN PEDIATRIC...... 95 levo-t...... 212 lmd in nacl...... 138 lanthanum carbonate...... 132 LEVOTHYROXINE SODIUM.212, 213 LO LOESTRIN FE...... 99 lapatinib ditosylate...... 71 levothyroxine sodium...... 213 LODINE...... 21 larin 1.5/30...... 101 levoxyl...... 213 LODOSYN...... 81 larin 1/20...... 101 LEVULAN KERASTICK...... 117 loestrin 1.5/30 (21)...... 101 larin 24 fe...... 101 LEXIVA...... 87 loestrin 1/20 (21)...... 101 larin fe 1.5/30...... 101 LIBERTY MEDICAL LANCETS....157 loestrin fe 1.5/30...... 101 larin fe 1/20...... 101 LIBRAX...... 214 loestrin fe 1/20...... 101 larissia...... 101 LIBTAYO...... 68 lojaimiess...... 104 LASIX...... 121 lidocaine...... 116, 117 LOKELMA...... 176 latanoprost...... 200 LIDOCAINE (ANORECTAL)...... 30 LOMAIRA...... 12 LATISSE...... 117 lidocaine hcl...... 117, 149, 150, 176 LOMOTIL...... 48 LATUDA...... 82 LIDOCAINE HCL...... 149 LONGS INSULIN SYRINGE...... 165 laxative...... 148 LIDOCAINE HCL (CARDIAC)...... 32 LONGS LANCETS STANDARD.....157 layolis fe...... 101 lidocaine hcl (cardiac)...... 32 LONGS LANCETS THIN...... 157 LEADER INSULIN SYRINGE...... 165 LIDOCAINE HCL (CARDIAC) PF...32 LONGS LANCETS ULTRA THIN..157 LEADER UNIFINE PENTIPS...... 165 lidocaine hcl (cardiac) pf...... 32 LONHALA MAGNAIR REFILL LEADER UNIFINE PENTIPS PLUS lidocaine hcl (pf)...... 149 KIT...... 35 ...... 165 lidocaine hcl urethral/mucosal...... 117 LONHALA MAGNAIR STARTER leena...... 105 lidocaine in d5w...... 32 KIT...... 35 leflunomide...... 22 LIDOCAINE IN DEXTROSE...... 150 LONSURF...... 73 LEMTRADA...... 207 lidocaine viscous hcl...... 176 loperamide hcl...... 48 LENSCALE...... 16 lidocaine-epinephrine...... 149 LOPID...... 54 LENVIMA (10 MG DAILY DOSE)... 79 LIDOCAINE-EPINEPHRINE...... 196 lopinavir-ritonavir...... 86 235 LOPROX...... 111 MARCAINE...... 150 medroxyprogesterone acetate...... 104, 204 lorazepam...... 32 MARCAINE PRESERVATIVE mefenamic acid...... 21 lorazepam intensol...... 32 FREE...... 150 mefloquine hcl...... 63 LORBRENA...... 66 MARCAINE SPINAL...... 150 mega multiple/chelated mineral...... 188 loryna...... 101 MARCAINE/EPINEPHRINE...... 149 megestrol acetate...... 78, 204 lorzone...... 189 MARCAINE/EPINEPHRINE PF.....149 meijer aspirin ec...... 24 losartan potassium...... 58 MAR-COF BP...... 108 MEIJER LANCETS...... 158 losartan potassium-hctz...... 57 MAR-COF CG EXPECTORANT....107 MEIJER LANCETS THIN...... 158 LOSEASONIQUE...... 104 MARGENZA...... 68 MEIJER LANCETS UNIVERSAL LOTEMAX...... 198, 199 MARINOL...... 51 21G...... 158 LOTEMAX SM...... 199 marlissa...... 101 MEIJER LANCETS UNIVERSAL LOTENSIN...... 56 MARPLAN...... 42 30G...... 158 LOTENSIN HCT...... 56 MARQIBO...... 77 MEIJER LANCETS UNIVERSAL loteprednol etabonate...... 199 MATULANE...... 74 33G...... 158 LOTRONEX...... 131 matzim la...... 93 MEIJER PEN NEEDLES...... 166 lovastatin...... 55 MAVENCLAD (10 TABS)...... 206 MEIJER SUPER THIN LANCETS. 158 low-ogestrel...... 101 MAVENCLAD (4 TABS)...... 206 MEKINIST...... 70 loxapine succinate...... 84 MAVENCLAD (5 TABS)...... 206 MEKTOVI...... 70 lo-zumandimine...... 101 MAVENCLAD (6 TABS)...... 206 MELALEUCA...... 16 lubiprostone...... 130 MAVENCLAD (7 TABS)...... 206 meloxicam...... 21 LUCEMYRA...... 204 MAVENCLAD (8 TABS)...... 206 melphalan...... 78 LUCENTIS...... 200 MAVENCLAD (9 TABS)...... 206 melphalan hcl...... 78 luliconazole...... 116 MAXICOMFORT II PEN NEEDLE166 memantine hcl...... 207 LUMIGAN...... 200 MAXI-COMFORT INSULIN memantine hcl er...... 207 LUMIZYME...... 123 SYRINGE...... 166 MEMBRANEBLUE...... 199 LUMOXITI...... 67 MAXI-COMFORT SAFETY PEN MENACTRA...... 216 LUPANETA PACK...... 125 NEEDLE...... 166 M-END PE...... 109 LUPKYNIS...... 173 MAXICOMFORT SYR 27G X 1/2".166 MENEST...... 129 LUPRON DEPOT (1-MONTH)...... 76 MAXIDEX...... 199 MENOPUR...... 126 LUPRON DEPOT (3-MONTH)...... 76 MAXITROL...... 198 MENOSTAR...... 129 LUPRON DEPOT (4-MONTH)...... 76 maxi-tuss ac...... 107 MENQUADFI...... 216 LUPRON DEPOT (6-MONTH)...... 76 MAXI-TUSS CD...... 109 MENTAX...... 111 LUPRON DEPOT-PED (1-MONTH) MAXZIDE...... 121 MENVEO...... 216 ...... 125 MAXZIDE-25...... 121 meperidine hcl...... 27 LUPRON DEPOT-PED (3-MONTH) MAYZENT...... 210 MEPHYTON...... 220 ...... 125 MAYZENT STARTER PACK...... 210 meprobamate...... 31 LUTATHERA...... 74 M-CLEAR WC...... 107 MEPRON...... 60 lutera...... 101 MEADOW FESCUE GRASS MEPSEVII...... 126 LUZU...... 116 POLLEN...... 16 mercaptopurine...... 66 lyleq...... 104 meclizine hcl...... 50 meropenem...... 60 lyllana...... 129 meclofenamate sodium...... 21 MEROPENEM-SODIUM LYNPARZA...... 78 MEDIC INSULIN SYRINGE...... 166 CHLORIDE...... 61 LYRICA CR...... 207, 208 MEDICHOICE SAFETY LANCET 157 merzee...... 101 LYSINE HCL...... 193 MEDICHOICE SAFETY LANCET mesalamine...... 131 LYSODREN...... 64 EXTRA...... 157 mesalamine er...... 131 LYSTEDA...... 143 MEDICHOICE SAFETY LANCET mesalamine-cleanser...... 131 lyza...... 104 NORM...... 157 mesna...... 79 M.V.I. ADULT...... 181 MEDICINE SHOPPE PEN MESNEX...... 79 M.V.I. PEDIATRIC...... 183 NEEDLES...... 166 MESQUITE...... 16 MACROBID...... 62 MEDISENSE THIN LANCETS...... 157 MESTINON...... 63 MACRODANTIN...... 62 MEDLANCE EXTRA 21G...... 157 metaxalone...... 189 mafenide acetate...... 113 MEDLANCE LITE 25G...... 157 metformin hcl...... 44 MAGELLAN INSULIN SAFETY MEDLANCE PLUS EXTRA 21G.... 157 metformin hcl er...... 44 SYR...... 165 MEDLANCE PLUS LANCETS...... 157 METHADONE HCL...... 27 magnesium citrate...... 147 MEDLANCE PLUS LITE 25G...... 157 methadone hcl...... 27 MAGNESIUM SULFATE...... 171 MEDLANCE PLUS SPECIAL methadone hcl intensol...... 27 MAGNESIUM SULFATE IN D5W. 171 0.8MM...... 157 METHADOSE...... 27 MAKENA...... 204 MEDLANCE PLUS SUPERLITE methadose...... 27 MALARONE...... 63 30G...... 157 METHADOSE SUGAR-FREE...... 27 malathion...... 118 MEDLANCE PLUS UNIVERSAL methazolamide...... 120 manganese chloride...... 171 21G...... 157 methenamine hippurate...... 62 mannitol...... 121 MEDLANCE UNIVERSAL 21G...... 157 methergine...... 201 MARATHON MEDICAL PENTIPS166 MEDROL...... 106 methimazole...... 212 236 methocarbamol...... 189 millguard...... 141 MONOLETTOR SAFETY METHOHEXITAL SODIUM...... 133 MILLIPRED...... 106 LANCETS...... 158 methotrexate...... 66 milrinone lactate...... 95 mono-linyah...... 101 methotrexate sodium...... 66 milrinone lactate in dextrose...... 95 MONONINE...... 136 methotrexate sodium (pf)...... 66 mimvey...... 128 MONOVISC...... 190 methoxsalen rapid...... 112 MINASTRIN 24 FE...... 101 montelukast sodium...... 35 methscopolamine bromide...... 215 mineral oil heavy...... 147 MONUROL...... 62 METHYLCOBALAMIN...... 140 MINILINK REAL-TIME morgidox...... 212 methyldopa...... 58 TRANSMITTER...... 158 MORPHINE SULFATE...... 27 methylergonovine maleate...... 201 MINIMED 630G GUARDIAN morphine sulfate...... 27 METHYLIN...... 14 PRESS...... 158 morphine sulfate (concentrate)...... 27 methylphenidate hcl...... 14 MINIMED GUARDIAN LINK 3...... 158 morphine sulfate (pf)...... 27 methylphenidate hcl er...... 14 MINIPRESS...... 58 MORPHINE SULFATE (PF)...... 27 METHYLPHENIDATE HCL ER...... 14 minitran...... 31 morphine sulfate er...... 27 methylphenidate hcl er (cd)...... 14 MINOCIN...... 212 morphine sulfate er beads...... 27 methylphenidate hcl er (la)...... 14 minocycline hcl...... 212 MORPHINE SULFATE-NACL...... 27 methylphenidate hcl er (xr)...... 14 minocycline hcl er...... 212 MOTOFEN...... 48 methylprednisolone...... 106 minoxidil...... 59 MOUNTAIN CEDAR...... 16 methylprednisolone sodium succ...... 106 MIOCHOL-E...... 194 MOUSE EPITHELIUM...... 16 metoclopramide hcl...... 130 MIOSTAT...... 194 MOVANTIK...... 132 METOCLOPRAMIDE HCL...... 130 MIRAPEX...... 81 MOVIPREP...... 146 metolazone...... 122 MIRAPEX ER...... 81 MOXEZA...... 195 metoprolol succinate er...... 91 MIRCERA...... 141 MOXIFLOXACIN HCL...... 130, 195 metoprolol tartrate...... 91 MIRCETTE...... 99 moxifloxacin hcl...... 130, 195 metoprolol-hydrochlorothiazide...... 59 MIRENA (52 MG)...... 104 moxifloxacin hcl (2x day)...... 195 METROCREAM...... 117 mirtazapine...... 41 moxifloxacin hcl in nacl...... 130 metronidazole...... 60, 118, 218 MIRVASO...... 118 MOZOBIL...... 140 metronidazole in nacl...... 59 misoprostol...... 215 MPD SAFETY LANCET 21G...... 158 METRONIDAZOLE IN NACL...... 60 MITE (D. FARINAE)...... 16 MPD SAFETY LANCET 23G...... 158 metyrosine...... 57 MITE (D. PTERONYSSINUS)...... 16 MPD SAFETY LANCET 28G...... 158 mexiletine hcl...... 32 mitigo...... 27 MPD SAFETY LANCET 30G...... 158 MI PASTE...... 151 mitomycin...... 73 MS INSULIN SYRINGE...... 166 MI PASTE PLUS...... 151 MITOMYCIN...... 73, 195 MUCOR...... 16, 17 MIACALCIN...... 123 MITOSOL...... 195 MUGWORT...... 17 mibelas 24 fe...... 101 mitoxantrone hcl...... 73 MULPLETA...... 142 micafungin sodium...... 51 MIXED ASPERGILLUS...... 18 MULTAQ...... 33 miconazole 3...... 218 MIXED FEATHERS...... 19 MULTI PRENATAL...... 184 miconazole-zinc oxide-petrolat...... 110 MIXED RAGWEED...... 16 MULTI VITAMIN...... 181 MICRHOGAM ULTRA- MIXED VESPID VENOM multi vitamin daily...... 181 FILTERED PLUS...... 202 PROTEIN...... 16 MULTI VITAMIN W/D-3...... 181 MICRODOT PEN NEEDLE...... 166 mm clearlax...... 147 multi-day...... 181 microgestin 1.5/30...... 101 MM INSULIN SYRINGE/NEEDLE 166 multi-day plus iron...... 180 microgestin 1/20...... 101 MM PEN NEEDLES...... 166 MULTI-LANCET DEVICE 2...... 158 microgestin 24 fe...... 101 MM TWIST LANCETS...... 158 multiple vitamin-folic acid...... 181 microgestin fe 1.5/30...... 101 M-M-R II...... 217 multiple vitamins...... 181 microgestin fe 1/20...... 101 M-NATAL PLUS...... 184 multiple vitamins essential...... 181 MICROLET LANCETS...... 158 modafinil...... 14 multiple vitamins/iron...... 180 MIDAZOLAM...... 145 moexipril hcl...... 56 multi-vit/iron/fluoride...... 182 midazolam hcl...... 145 molindone hcl...... 84 MULTIVITAMIN...... 182 midazolam hcl (pf)...... 145 mometasone furoate...... 115, 191 multi-vitamin...... 182 MIDAZOLAM HCL-SODIUM mondoxyne nl...... 212 MULTIVITAMIN ADULT...... 182 CHLORIDE...... 145 MONJUVI...... 66 multi-vitamin daily...... 182 MIDAZOLAM-SODIUM MONOFERRIC...... 142 multivitamin iron-free...... 182 CHLORIDE...... 145 MONOJECT BONE MARROW multivitamin plus iron adult...... 180 midodrine hcl...... 220 BIOPSY...... 150 multivitamin select/fluoride...... 183 MIFEPREX...... 122 monoject flush syringe...... 171 MULTIVITAMIN/FLUORIDE...... 180 mifepristone...... 122 MONOJECT INSULIN SYRINGE..166 multivitamin/fluoride...... 182 migergot...... 169 monoject sodium chloride flush...... 171 multi-vitamin/fluoride...... 182 miglitol...... 44 MONOJECT ULTRA COMFORT multi-vitamin/fluoride/iron...... 182 miglustat...... 140 SYRINGE...... 166 multi-vitamin/iron...... 180 mili...... 101 MONOLET LANCETS...... 158 mupirocin...... 110 milk of magnesia...... 148 MONOLET OPD LANCETS...... 158 mupirocin calcium...... 110 milk of magnesia concentrate...... 148 MUSE...... 95 237 mutamycin...... 73 NATURE-THROID...... 213 NICORETTE...... 209 MVASI...... 80 NAVELBINE...... 77 NICORETTE MINI...... 209 my choice...... 103 NAYZILAM...... 38 NICORETTE STARTER KIT...... 209 my way...... 103 NEBUPENT...... 60 NICOTINE...... 209 MYALEPT...... 125 necon 0.5/35 (28)...... 101 nicotine...... 209 MYAMBUTOL...... 64 NEEVO DHA...... 184 nicotine mini...... 209 MYCAMINE...... 51 nefazodone hcl...... 43 nicotine polacrilex...... 209 MYCAPSSA...... 127 NEMBUTAL...... 144 nicotine polacrilex mini...... 209 MYCOBUTIN...... 64 NEOMULTIVITE...... 182 nicotine step 1...... 209 mycophenolate mofetil...... 174 neomycin sulfate...... 19 nicotine step 2...... 209 mycophenolate mofetil hcl...... 174 neomycin-bacitracin zn-polymyx...... 195 nicotine step 3...... 209 mycophenolate sodium...... 174 neomycin-polymyxin b gu...... 134 NICOTROL...... 209 MYDAYIS...... 11 neomycin-polymyxin-dexameth...... 198 NICOTROL NS...... 209 MYDRIACYL...... 194 neomycin-polymyxin-gramicidin...... 195 nifedipine...... 93 MYFORTIC...... 174 neomycin-polymyxin-hc...... 198, 201 nifedipine er...... 93 MYGLUCOHEALTH LANCETS NEONATAL + DHA...... 186 nifedipine er osmotic release...... 93 30G...... 158 NEONATAL 19...... 187 nikki...... 101 MYLERAN...... 64 NEONATAL COMPLETE...... 184 NILANDRON...... 65 MYLOTARG...... 67 NEONATAL FE...... 184 nilutamide...... 65 MYNATAL...... 184 NEONATAL PLUS...... 184 NIMBEX...... 191 MYNATAL PLUS...... 184 NEONATAL VITAMIN...... 184 nimodipine...... 94 MYNATAL-Z...... 184 neo-polycin...... 195 NINJACOF-XG...... 107 MYOBLOC...... 191 neo-polycin hc...... 198 NINLARO...... 71 myorisan...... 110 NEOPROFEN...... 22 NIPENT...... 74 MYRBETRIQ...... 216 NEORAL...... 173 NIPRIDE RTU...... 59 MYTESI...... 48 NEOSTIGMINE nisoldipine er...... 94 MYXREDLIN...... 46 METHYLSULFATE...... 63 nitazoxanide...... 60 na ferric gluc cplx in sucrose...... 142 NEO-SYNALAR...... 110 NITHIODOTE...... 48 NABI-HB...... 202 NEOX 100...... 119 nitisinone...... 124 nabumetone...... 21 NEOX CORD 1K...... 119 NITRO-BID...... 31 n-acetyl-l-cysteine...... 193 nephro vitamins...... 178 NITRO-DUR...... 31 nadolol...... 92 NEPHRO-VITE...... 178 nitrofurantoin...... 62 nafcillin sodium...... 204 NERLYNX...... 71 nitrofurantoin macrocrystal...... 62 NAFCILLIN SODIUM IN NESACAINE...... 150 nitrofurantoin monohyd macro...... 62 DEXTROSE...... 204 NESACAINE-MPF...... 150 NITROGLYCERIN...... 31 nafrinse...... 170 NESTABS...... 184 nitroglycerin...... 31 NAFRINSE DAILY ACIDULATED 177 NESTABS DHA...... 184 nitroglycerin in d5w...... 31 NAFRINSE DAILY/NEUTRAL...... 177 NESTABS ONE...... 186 NITROLINGUAL...... 31 nafrinse drops...... 170 neuac...... 109 NITROMIST...... 31 NAFRINSE WEEKLY...... 177 NEULASTA...... 141 nitroprusside sodium...... 59 naftifine hcl...... 111 NEULASTA ONPRO...... 141 NITROSTAT...... 31 NAFTIN...... 111 NEUPOGEN...... 141, 142 NITYR...... 124 NAGLAZYME...... 126 NEUPRO...... 81 NIVA-PLUS...... 184 nalbuphine hcl...... 29 NEURIN-SL...... 140 NIVESTYM...... 142 naloxone hcl...... 49 NEVANAC...... 197 nizatidine...... 214 naltrexone hcl...... 49 nevirapine...... 88 NOCDURNA...... 128 NAMENDA TITRATION PAK...... 207 nevirapine er...... 88 nolix...... 115 NAMZARIC...... 205 new day...... 103 nora-be...... 104 naproxen...... 22 NEXAVAR...... 71 NOREPINEPHRINE (BASE)- naproxen sodium...... 22 NEXAVIR...... 175 DEXTROSE...... 220 naratriptan hcl...... 169 NEXIUM I.V...... 215 norepinephrine bitartrate...... 220 NARCAN...... 49 NEXLETOL...... 53 NOREPINEPHRINE-DEXTROSE..220 NARDIL...... 42 NEXLIZET...... 53 NOREPINEPHRINE-SODIUM NAROPIN...... 150 NEXPLANON...... 104 CHLORIDE...... 220 NATACHEW...... 184 NEXTERONE...... 33 norethin ace-eth estrad-fe...... 101 NATACYN...... 195 NEXTSTELLIS...... 101 norethindrone...... 104 NATALVIT...... 184 niacin (antihyperlipidemic)...... 55 norethindrone acetate...... 204 NATAZIA...... 104 niacin er (antihyperlipidemic)...... 55 norethindrone acet-ethinyl est...... 102 nateglinide...... 47 niacor...... 55 norethindrone-eth estradiol...... 129 NATPARA...... 126 NIASPAN...... 55 norethin-eth estradiol-fe...... 102 NATROBA...... 118 nicardipine hcl...... 93 norgestimate-eth estradiol...... 102 nat-rul b-50...... 188 NICARDIPINE HCL IN NACL...... 93 norgestim-eth estrad triphasic...... 105 nat-rul daily-vite+iron...... 180 NICODERM CQ...... 209 NORITATE...... 118 238 norlyda...... 104 OBSTETRIX EC...... 184 ONETOUCH DELICA PLUS norlyroc...... 105 OBSTETRIX ONE...... 187 LANCET30G...... 158 normal saline flush...... 171 O-CAL PRENATAL...... 184 ONETOUCH DELICA PLUS NORMOSOL-M IN D5W...... 170 OCALIVA...... 130 LANCET33G...... 158 NORMOSOL-R...... 170 ocella...... 102 ONETOUCH FINEPOINT NORMOSOL-R IN D5W...... 170 OCTAGAM...... 202 LANCETS...... 158 NORMOSOL-R PH 7.4...... 170 OCTAPLAS BLOOD GROUP A..... 139 ONETOUCH SURESOFT NORPACE...... 32 OCTAPLAS BLOOD GROUP AB...139 LANCING DEV...... 158 NORPACE CR...... 32 OCTAPLAS BLOOD GROUP B...... 139 ONETOUCH ULTRA...... 120 NORPRAMIN...... 44 OCTAPLAS BLOOD GROUP O..... 139 ONETOUCH ULTRASOFT NORTHERA...... 219 octreotide acetate...... 127 LANCETS...... 158 nortrel 0.5/35 (28)...... 102 ocucoat viscoadherent...... 199 ONETOUCH VERIO...... 120 nortrel 1/35 (21)...... 102 OCUFLOX...... 195 ONEXTON...... 109 nortrel 1/35 (28)...... 102 ODACTRA...... 19 ONGENTYS...... 81 nortrel 7/7/7...... 105 ODEFSEY...... 86 ONIVYDE...... 79 nortriptyline hcl...... 44 ODOMZO...... 70 ONPATTRO...... 208 NORVIR...... 87 OFEV...... 211 ONTRUZANT...... 68 NOURIANZ...... 80 OFIRMEV...... 22 ONUREG...... 66 NOVA SAFETY LANCETS 23G..... 158 ofloxacin...... 130, 195, 200 opcicon one-step...... 103 NOVA SAFETY LANCETS 28G..... 158 OGIVRI...... 68 OPDIVO...... 68 NOVA SUREFLEX LANCETS...... 158 olanzapine...... 85 OPSUMIT...... 96 NOVACHOR...... 119 olanzapine-fluoxetine hcl...... 210 option 2...... 103 NOVAREL...... 126 OLINVYK...... 28 OPTIONS GYNOL II NOVOEIGHT...... 136 OLIVE TREE...... 17 CONTRACEPTIVE...... 218 NOVOFINE...... 166 olmesartan medoxomil...... 58 ORABLOC...... 149 NOVOFINE AUTOCOVER...... 166 olmesartan medoxomil-hctz...... 57 ORALAIR...... 19 NOVOFINE PLUS...... 166 olmesartan-amlodipine-hctz...... 58 oralone...... 178 NOVOSEVEN RT...... 136 olopatadine hcl...... 190 ORAPRED ODT...... 106 NOVOTWIST...... 166 OMECLAMOX-PAK...... 215 ORAVIG...... 176 NOXAFIL...... 52 omega-3-acid ethyl esters...... 54 ORBACTIV...... 61 np thyroid...... 213 OMEGAVEN...... 193 ORCHARD GRASS POLLEN...... 17 NPLATE...... 142 omeprazole...... 215 ORENITRAM...... 96 NUBEQA...... 65 OMIDRIA...... 199 ORFADIN...... 124 NUCALA...... 35 OMNICAP...... 182 ORGOVYX...... 76 NUCYNTA...... 27, 28 OMNIFLEX DIAPHRAGM...... 151 ORIAHNN...... 129 NUEDEXTA...... 208 OMNIPOD 5 PACK...... 162 ORILISSA...... 123 NULIBRY...... 125 OMNIPOD DASH 5 PACK PODS... 162 ORKAMBI...... 210, 211 NULOJIX...... 176 OMNIPOD STARTER...... 162 ORLADEYO...... 138 NULYTELY LEMON-LIME...... 146 ONCASPAR...... 73 orphenadrine citrate...... 189 NUMBRINO...... 190 once daily...... 182 orphenadrine citrate er...... 189 NUPLAZID...... 82 ondansetron...... 50 orphenadrine-asa-caffeine...... 189 NURTEC...... 168 ondansetron hcl...... 50 orphengesic forte...... 189 NUSHIELD...... 119 one daily...... 182 orsythia...... 102 NUTRILIPID...... 193 ONE DAILY ESSENTIAL...... 182 ORTHOVISC...... 190 NUVARING...... 103 one daily multivitamin adult...... 181 ORTIKOS...... 106 NUVESSA...... 218 one daily multivitamin/iron...... 180 oseltamivir phosphate...... 90 NUWIQ...... 136 ONE VITE WOMENS...... 184 osmitrol...... 121 NUZYRA...... 211 ONE VITE WOMENS PLUS...... 184 OSMOLEX ER...... 80 nyamyc...... 111 ONE-A-DAY ESSENTIAL...... 182 OSMOPREP...... 147 nylia 7/7/7...... 105 ONE-A-DAY MENS...... 182 OSPHENA...... 127 NYMALIZE...... 94 ONE-A-DAY WOMENS OTEZLA...... 22 nymyo...... 102 PRENATAL...... 184 OTIPRIO...... 200 nystatin...... 51, 111, 176 one-daily multi vitamins...... 182 OTOVEL...... 201 nystatin-triamcinolone...... 110, 111 one-daily multi-vitamin...... 182 OTREXUP...... 19 nystop...... 111 one-daily multi-vitamin/iron...... 180 OVIDE...... 118 NYVEPRIA...... 142 one-daily/iron...... 180 OVIDREL...... 126 OB COMPLETE...... 184 ONETOUCH CLUB LANCETS oxacillin sodium...... 204 OB COMPLETE ONE...... 184 FINE PT...... 158 OXACILLIN SODIUM IN OB COMPLETE PETITE...... 184 ONETOUCH DELICA LANCETS DEXTROSE...... 204 OB COMPLETE PREMIER...... 184 30G...... 158 oxaliplatin...... 64 OB COMPLETE/DHA...... 184 ONETOUCH DELICA LANCETS oxandrolone...... 29 OBIZUR...... 136 33G...... 158 oxaprozin...... 22 OBSTETRIX DHA...... 184 OXAYDO...... 28 239 oxazepam...... 32 PAMIDRONATE DISODIUM...... 122 PERENNIAL RYE GRASS OXBRYTA...... 142 PANCREAZE...... 120 POLLEN...... 17 oxcarbazepine...... 39 pancuronium bromide...... 191 PERFECT LANCETS 28G...... 158 OXERVATE...... 197 PANHEMATIN...... 138 PERFECT LANCETS 30G...... 158 oxiconazole nitrate...... 116 PANRETIN...... 111 PERFOROMIST...... 34 OXISTAT...... 116 pantoprazole sodium...... 215 PERIDEX...... 176 OXLUMO...... 134 PANZYGA...... 202 PERIKABIVEN...... 193 OXTELLAR XR...... 39, 40 PARADIGM REAL-TIME perindopril erbumine...... 56 oxybutynin chloride...... 216 TRANSMITTER...... 158 periogard...... 176 oxybutynin chloride er...... 216 PARAGARD INTRAUTERINE PERJETA...... 68 oxycodone hcl...... 28 COPPER...... 103 permethrin...... 118 oxycodone hcl er...... 28 paraplatin...... 64 perphenazine...... 84 oxycodone-acetaminophen...... 28 PAREMYD...... 196 perphenazine-amitriptyline...... 207 OXYCONTIN...... 28 paricalcitol...... 124 PERRY PRENATAL...... 184 oxymorphone hcl...... 28 PARLODEL...... 80 PERSERIS...... 82 oxymorphone hcl er...... 28 PARNATE...... 42 PERTZYE...... 120 oxytocin...... 201 paromomycin sulfate...... 19 PEXEVA...... 43 OXYTOCIN-LACTATED paroxetine hcl...... 43 pfizerpen...... 203 RINGERS...... 201 paroxetine hcl er...... 43 PHARMACIST CHOICE OXYTOCIN-SODIUM CHLORIDE201 paroxetine mesylate...... 210 LANCETS...... 158 OZEMPIC (0.25 OR 0.5 MG/DOSE). 46 PARSABIV...... 122 PHARMACY COUNTER OZEMPIC (1 MG/DOSE)...... 46 PASER...... 64 LANCETS...... 158 OZURDEX...... 199 PATANASE...... 190 phendimetrazine tartrate...... 12 pacerone...... 33 PAXIL...... 43 phendimetrazine tartrate er...... 12 paclitaxel...... 77 PC LANCETS SUPER THIN 30G... 158 phenelzine sulfate...... 42 PADCEV...... 68 PC UNIFINE PENTIPS...... 166 PHENERGAN...... 53 PALFORZIA (12 MG DAILY PEDIAPRED...... 106 phenobarbital...... 144 DOSE)...... 17 PEDIARIX...... 213 phenobarbital sodium...... 145 PALFORZIA (120 MG DAILY PEDVAX HIB...... 216 phenohytro...... 214 DOSE)...... 17 peg 3350...... 147 phenoxybenzamine hcl...... 57 PALFORZIA (160 MG DAILY peg 3350-kcl-na bicarb-nacl...... 146 phentermine hcl...... 12 DOSE)...... 17 peg-3350/electrolytes...... 146 phentolamine mesylate...... 57 PALFORZIA (20 MG DAILY peg-3350/electrolytes/ascorbat...... 146 PHENYLEPHRINE HCL...... 194, 220 DOSE)...... 17 PEGASYS...... 90 phenylephrine hcl...... 194 PALFORZIA (200 MG DAILY peg-kcl-nacl-nasulf-na asc-c...... 146 PHENYLEPHRINE HCL-NACL.....220 DOSE)...... 17 peg-prep...... 146 PHENYTEK...... 41 PALFORZIA (240 MG DAILY PEMAZYRE...... 69 phenytoin...... 41 DOSE)...... 17 PEN NEEDLES...... 166 phenytoin infatabs...... 41 PALFORZIA (3 MG DAILY DOSE). 17 PEN NEEDLES 1/2"...... 166 phenytoin sodium...... 41 PALFORZIA (300 MG PEN NEEDLES 5/16"...... 166 phenytoin sodium extended...... 41 MAINTENANCE)...... 17 penicillamine...... 172 PHESGO...... 73 PALFORZIA (300 MG PENICILLIN G POT IN PHEXXI...... 219 TITRATION)...... 17 DEXTROSE...... 203 philith...... 102 PALFORZIA (40 MG DAILY penicillin g potassium...... 203 phillips milk of magnesia...... 148 DOSE)...... 17 PENICILLIN G PROCAINE...... 203 PHOMA EXIGUA...... 17 PALFORZIA (6 MG DAILY DOSE). 17 penicillin g sodium...... 203 PHOSLYRA...... 132 PALFORZIA (80 MG DAILY penicillin v potassium...... 203 phosphorous...... 171 DOSE)...... 17 PENICILLIUM NOTATUM...... 17 phospho-trin 250 neutral...... 171 PALFORZIA INITIAL PENLET II BLOOD SAMPLER...... 158 PHOTOFRIN...... 74 ESCALATION...... 17 PENLET II REPLACEMENT CAP.158 PHOTREXA VISCOUS...... 197 PALINGEN FLOW...... 119 PENTACEL...... 213 PHOTREXA-PHOTREXA PALINGEN HYDROMEMBRANE.119 PENTAM...... 60 VISCOUS KIT...... 197 PALINGEN INOVOFLO...... 119 pentamidine isethionate...... 60 PHOXILLUM B22K4/0...... 172 PALINGEN MEMBRANE...... 119 PENTASA...... 131 PHOXILLUM BK4/2.5...... 172 PALINGEN XPLUS pentazocine-naloxone hcl...... 29 physiolyte...... 174 HYDROMEMBRANE...... 119 PENTETATE CALCIUM physiosol irrigation...... 174 PALINGEN XPLUS MEMBRANE..119 TRISODIUM...... 49 phytonadione...... 220 paliperidone er...... 82 PENTETATE ZINC TRISODIUM.... 49 PIFELTRO...... 88 PALONOSETRON HCL...... 50 PENTIPS...... 166 pilocarpine hcl...... 178, 194 palonosetron hcl...... 50 pentobarbital sodium...... 144 pimecrolimus...... 117 PALYNZIQ...... 126 pentoxifylline er...... 138 pimozide...... 208 PAMELOR...... 44 PEPAXTO...... 78 pimtrea...... 99 pamidronate disodium...... 122 PEPCID...... 214 pindolol...... 92 240 pioglitazone hcl...... 48 POTELIGEO...... 66 PRENATAL ONE DAILY...... 185 pioglitazone hcl-glimepiride...... 48 PRALUENT...... 55 PRENATAL PLUS IRON...... 185 pioglitazone hcl-metformin hcl...... 48 pramipexole dihydrochloride...... 81 PRENATAL VITAMIN...... 185 PIP LANCETS 28G...... 158 pramipexole dihydrochloride er...... 81 PRENATAL VITAMIN AND PIP LANCETS 30G...... 159 PRAMOSONE...... 118 MINERAL...... 185 piperacillin sod-tazobactam so...... 204 PRAMOTIC...... 200 PRENATAL VITAMIN PLUS LOW PIQRAY (200 MG DAILY DOSE).....78 prasugrel hcl...... 139 IRON...... 185 PIQRAY (250 MG DAILY DOSE).....78 pravastatin sodium...... 55 PRENATAL VITAMINS...... 185 PIQRAY (300 MG DAILY DOSE).....78 PRAXBIND...... 49 PRENATAL/IRON...... 185 pirmella 1/35...... 102 praziquantel...... 31 PRENATAL-U...... 185 pirmella 7/7/7...... 105 prazosin hcl...... 58 PRENATE...... 187 piroxicam...... 22 PRECEDEX...... 146 PRENATE AM...... 187 PITOCIN...... 201 PRECISION SUREDOSE PLUS PRENATE DHA...... 187 PLASBUMIN-25...... 139 SYR...... 166 PRENATE ELITE...... 185 PLASBUMIN-5...... 139 PRECISION SURE-DOSE PRENATE ENHANCE...... 187 PLASMA-LYTE 148...... 170 SYRINGE...... 166 PRENATE ESSENTIAL...... 187 PLASMA-LYTE A...... 170 PRECISION THINS GP LANCETS 159 PRENATE MINI...... 187 PLASMANATE...... 139 PRECOSE...... 44 PRENATE PIXIE...... 187 PLEGISOL...... 95 PRED MILD...... 199 PRENATE RESTORE...... 187 plenamine...... 192 PRED-G...... 198 PRENATRIX...... 185 PLENITY...... 12 PRED-G S.O.P...... 198 PRENATRYL...... 185 PLENITY WELCOME KIT...... 12 prednicarbate...... 115 PRENATVITE COMPLETE...... 185 PLENVU...... 146 prednisolone...... 106 PRENATVITE PLUS...... 185 PNEUMOVAX 23...... 217 prednisolone acetate...... 199 PRENATVITE RX...... 185 PNV TABS 20-1...... 184 prednisolone sodium phosphate...... 106 PREPIDIL...... 201 PNV TABS 29-1...... 184 PREDNISOLONE SODIUM PREPLUS...... 185 pnv-dha...... 187 PHOSPHATE...... 199 PRESTALIA...... 55, 56 PNV-DHA+DOCUSATE...... 187 prednisone...... 107 PRETAB...... 185 PNV-OMEGA...... 184 PREDNISONE INTENSOL...... 107 PRETOMANID...... 64 pnv-select...... 184 PREFERRED PLUS INSULIN prevalite...... 54 podofilox...... 116 SYRINGE...... 166 PREVENT SAFETY PEN POINT OF CARE LM-2.5...... 149 PREFERRED PLUS LANCETS NEEDLES...... 166 POLIVY...... 67 COLORED...... 159 preventeza...... 103 polocaine...... 150 PREFERRED PLUS LANCETS PREVIDENT...... 177 polocaine-mpf...... 150 THIN...... 159 PREVIDENT 5000 BOOSTER polycin...... 195 PREFERRED PLUS UNIFINE PLUS...... 177 polyethylene glycol 3350...... 147 PENTIPS...... 166 PREVIDENT 5000 DRY MOUTH... 177 polymyxin b sulfate...... 62 PREFEST...... 129 PREVIDENT 5000 ENAMEL polymyxin b-trimethoprim...... 196 pregabalin...... 40 PROTECT...... 177 POLYTRIM...... 196 pregabalin er...... 208 PREVIDENT 5000 ORTHO POLY-TUSSIN AC...... 109 PREGEN DHA...... 187 DEFENSE...... 177 POLY-VI-FLOR...... 182 PREGENNA...... 184 PREVIDENT 5000 PLUS...... 177 POLY-VI-FLOR/IRON...... 182 PREGNYL...... 126 PREVIDENT 5000 SENSITIVE...... 177 POMALYST...... 70 PREMARIN...... 129, 219 previfem...... 102 portia-28...... 102 PREMASOL...... 192 PREVNAR 13...... 217 PORTRAZZA...... 69 PREMESISRX...... 187 PREVYMIS...... 89 posaconazole...... 52 PREMPHASE...... 129 PREZCOBIX...... 86 pot & sod cit-cit ac...... 134 PREMPRO...... 129 PREZISTA...... 87 potassium acetate...... 171 PRENA 1 TRUE...... 187 PRIALT...... 25 POTASSIUM CHLORIDE...... 171 PRENA1...... 187 PRIFTIN...... 64 potassium chloride...... 171 PRENA1 PEARL...... 185 PRILO PATCH II...... 119 potassium chloride crys er...... 171 PRENAISSANCE...... 187 PRIMACARE...... 185 potassium chloride er...... 171 PRENAISSANCE PLUS...... 187 PRIMAQUINE PHOSPHATE...... 63 potassium chloride in dextrose...... 170 PRENARA...... 185 PRIMAXIN IV...... 60 POTASSIUM CHLORIDE IN prenatabs rx...... 185 primidone...... 40 NACL...... 170 PRENATAL...... 185 PRIMSOL...... 60 potassium chloride in nacl...... 170 PRENATAL 19...... 185 PRISMASOL B22GK 4/0...... 172 potassium citrate er...... 134 prenatal 19...... 185 PRISMASOL BGK 0/2.5...... 172 POTASSIUM PHOSPHATES...... 171 PRENATAL COMPLETE...... 185 PRISMASOL BGK 2/0...... 173 potassium phosphates...... 171 PRE-NATAL FORMULA...... 185 PRISMASOL BGK 2/3.5...... 173 potassium phosphates(66 meq k)...... 171 PRENATAL FORTE...... 185 PRISMASOL BGK 4/0/1.2...... 173 POTASSIUM PHOSPHATES(71 PRENATAL MULTIVITAMIN + PRISMASOL BGK 4/2.5...... 173 MEQ K)...... 171 DHA...... 187 PRISMASOL BK 0/0/1.2...... 173 241 PRIVET...... 17 PRO-RED AC...... 109 QC LANCETS ULTRA THIN...... 159 PRIVIGEN...... 202 PROSCAR...... 133 qc magnesium citrate...... 148 PRO COMFORT INSULIN PROSOL...... 192 qc milk of magnesia...... 148 SYRINGE...... 166 PROSTIN E2...... 201 qc natura-lax...... 147 PRO COMFORT LANCETS 30G....159 PROSTIN VR...... 176 qc nicotine transdermal system...... 209 PRO COMFORT LANCETS 31G....159 protamine sulfate...... 139 QC PEN NEEDLES...... 166 PRO COMFORT PEN NEEDLES...166 PROTONIX...... 215 QC PRENATAL...... 185 PROAIR DIGIHALER...... 34 PROTOPAM CHLORIDE...... 49 QC UNIFINE PENTIPS...... 167 PROAIR HFA...... 34 protriptyline hcl...... 44 QC UNILET LANCETS 28G...... 159 PROAIR RESPICLICK...... 34 PROVAYBLUE...... 49 QC UNILET LANCETS MICRO probenecid...... 135 PROVENGE...... 68 THIN...... 159 PROBUPHINE IMPLANT KIT...... 29 PROVENTIL HFA...... 34 QDOLO...... 28 procainamide hcl...... 32 PROVERA...... 204 QINLOCK...... 71 PROCALAMINE...... 192 PROVIDA OB...... 185 QSYMIA...... 12 PROCARDIA XL...... 94 PROVISC...... 199 QUADRACEL...... 213 procentra...... 12 pseudoeph-bromphen-dm...... 108 QUADRAMET...... 74 prochlorperazine...... 84 PSS SELECT GP LANCETS...... 159 QUALAQUIN...... 63 prochlorperazine edisylate...... 84 PSS SELECT PLATFORMS...... 159 QUARTETTE...... 104 prochlorperazine maleate...... 84 PSS SELECT SAFETY LANCETS..159 quazepam...... 145 PROCRIT...... 141 PULMICORT FLEXHALER...... 36 QUDEXY XR...... 40 PROCTOCORT...... 30 PULMOZYME...... 211 QUEEN PALM...... 17 PROCTOFOAM HC...... 30 PURE COMFORT LANCETS 30G. 159 QUELICIN...... 191 procto-med hc...... 30 PURE COMFORT PEN NEEDLE...166 QUESTRAN...... 54 procto-pak...... 30 PURIXAN...... 66 QUESTRAN LIGHT...... 54 proctozone-hc...... 30 px aspirin...... 24 quetiapine fumarate...... 83 PROCYSBI...... 134 px b complex/vitamin c...... 178 quetiapine fumarate er...... 83 PRODIGY INSULIN SYRINGE...... 166 px b-50...... 188 QUFLORA FE...... 181 PRODIGY LANCETS 28G...... 159 px enteric aspirin...... 24 QUFLORA FE PEDIATRIC...... 182 PRODIGY SAFETY LANCETS 26G PX EXTRA SHORT PEN QUFLORA GUMMIES...... 182 ...... 159 NEEDLES...... 166 QUFLORA PEDIATRIC...... 183 PRODIGY TWIST TOP LANCETS px folic acid...... 141 QUILLICHEW ER...... 14 28G...... 159 PX INSULIN SYRINGE...... 166 QUILLIVANT XR...... 14 PROFILNINE...... 136 PX LANCETS MICROTHIN 33G... 159 quin b strong b-25...... 180 progesterone...... 204 PX LANCETS ULTRA THIN...... 159 quinapril hcl...... 56 PROGLYCEM...... 45 PX LANCETS ULTRA THIN 28G.. 159 quinapril-hydrochlorothiazide...... 56 PROGRAF...... 174 px laxative...... 148 quinidine gluconate er...... 32 PROLASTIN-C...... 210 px milk of magnesia...... 148 quinidine sulfate...... 32 PROLENSA...... 197 PX MINI PEN NEEDLES...... 166 quinine sulfate...... 63 PROLEUKIN...... 74 PX PEN NEEDLE...... 166 QUINTABS...... 182 PROLIA...... 127 PX PRENATAL MULTIVITAMINS QUTENZA (4 PATCH)...... 117 PROMACTA...... 142, 143 ...... 185 QUZYTTIR...... 53 promethazine hcl...... 53 PX SHORTLENGTH PEN QVAR REDIHALER...... 36 promethazine vc...... 108 NEEDLES...... 166 ra aspirin...... 24 promethazine vc/codeine...... 109 px stop smoking aid...... 209 ra aspirin adult low dose...... 24 promethazine-codeine...... 108 PYLERA...... 215 ra aspirin adult low strength...... 24 promethazine-dm...... 108 pyrazinamide...... 64 ra aspirin childrens...... 24 promethazine-phenyleph-codeine...... 109 pyridostigmine bromide...... 63 ra aspirin ec...... 24 promethazine-phenylephrine...... 108 pyridostigmine bromide er...... 63 ra aspirin ec adult low st...... 24 promethegan...... 53 pyridoxine hcl...... 220 ra balanced b-100...... 180 PROMISEB...... 112 pyrimethamine...... 63 ra balanced b-100 cr...... 180 propafenone hcl...... 33 QBRELIS...... 56 ra balanced b-50...... 180 propafenone hcl er...... 33 QBREXZA...... 117 ra balanced b-50 tr...... 180 proparacaine hcl...... 197 qc aspirin...... 24 ra b-complex...... 178 proparacaine-fluorescein...... 196 qc aspirin low dose...... 24 ra b-complex with b-12...... 178 PROPECIA...... 120 qc b50 prolonged release...... 180 RA E-ZJECT LANCETS 28G...... 159 PROPEL...... 191 qc b-complex/vitamin c...... 178 RA E-ZJECT LANCETS THIN 26G PROPEL MINI...... 191 qc childrens aspirin...... 24 ...... 159 propofol...... 133 qc daily multivitamins/iron...... 180 RA E-ZJECT LANCETS THIN 28G propofol-lipuro...... 133 qc enteric aspirin...... 24 ...... 159 propranolol hcl...... 92 qc essentials...... 182 RA E-ZJECT LANCETS ULTRA propranolol hcl er...... 92 qc folic acid...... 141 THIN...... 159 propylthiouracil...... 212 qc gentle laxative...... 148 ra folic acid...... 141 PROQUAD...... 217 QC LANCETS SUPER THIN 30G...159 RA INSULIN SYRINGE...... 167 242 ra laxative...... 147, 148 RELION LANCETS MICRO-THIN RIFADIN...... 64 ra milk of magnesia...... 148 33G...... 159 rifampin...... 64 ra mini nicotine...... 209 RELION LANCETS THIN 26G...... 159 RIGHTEST ALTERNATE SITE ra nicotine...... 209 RELION LANCETS ULTRA-THIN ADAPT...... 159 ra nicotine gum...... 209 30G...... 159 RIGHTEST GL300 LANCETS...... 159 ra nicotine polacrilex...... 209 RELION LANCING DEVICE...... 159 RILUTEK...... 191 ra pain relief aspirin...... 25 RELION MINI PEN NEEDLES...... 167 riluzole...... 191 RA PEN NEEDLES...... 167 RELION PEN NEEDLES...... 167 rimantadine hcl...... 90 RA PRENATAL...... 185 RELION SHORT PEN NEEDLES...167 RIMSO-50...... 134 RA PRENATAL FORMULA...... 185 RELION ULTRA THIN LANCETS ringers...... 170 ra womens laxative...... 148 30G...... 159 ringers irrigation...... 174 RABAVERT...... 218 RELION ULTRA THIN PLUS RINVOQ...... 19 RABBIT EPITHELIUM...... 17 LANCETS...... 159 RIOMET...... 44 RADIOGARDASE...... 49 RELISTOR...... 132 risanoid plus...... 188 RAGWITEK...... 17 RELNATE DHA...... 185 risedronate sodium...... 122 raloxifene hcl...... 127 REMERON...... 42 RISPERDAL CONSTA...... 82, 83 ramelteon...... 146 REMERON SOLTAB...... 42 risperidone...... 83 ramipril...... 57 REMESENSE...... 151 RITALIN...... 15 RANEXA...... 31 REMICADE...... 132 RITALIN LA...... 14, 15 ranolazine er...... 31 remifentanil hcl...... 28 ritonavir...... 87 RAPAMUNE...... 174 REMODULIN...... 96 RITUXAN...... 67 RAPIVAB...... 90 RENACIDIN...... 134 RITUXAN HYCELA...... 73 rasagiline mesylate...... 80 renal multivitamin formula...... 178 rivastigmine...... 205 RASUVO...... 20 renal vitamin...... 178 rivastigmine tartrate...... 205 RAVICTI...... 128 renal-vite...... 178 rivelsa...... 104 RAYALDEE...... 124 rena-vite...... 178 RIXUBIS...... 137 RAZADYNE ER...... 205 RENOVA...... 110 rizatriptan benzoate...... 169 react...... 103 RENOVA PUMP...... 110 ROBAXIN...... 189 READYLANCE SAFETY RENVELA...... 132 ROCALTROL...... 124 LANCETS...... 159 repaglinide...... 47 ROCKLATAN...... 196 REAL HEAL-I...... 119 REPATHA...... 55 rocuronium bromide...... 191 REALITY INSULIN SYRINGE...... 167 REPATHA PUSHTRONEX ROCURONIUM BROMIDE...... 191 REALITY LANCETS...... 159 SYSTEM...... 55 ROMIDEPSIN...... 70 REALITY TRIGGER LANCETS....159 REPATHA SURECLICK...... 55 ropinirole hcl...... 81 REBIF...... 206 RESECTISOL...... 134 ropinirole hcl er...... 81 REBIF REBIDOSE...... 206 RESTASIS...... 196 ropivacaine hcl...... 150 REBIF REBIDOSE TITRATION RESTASIS MULTIDOSE...... 196 ROPIVACAINE HCL-NACL...... 150 PACK...... 206 RESTORA RX...... 48 rosadan...... 118 REBIF TITRATION PACK...... 207 RESTORIL...... 145 rosuvastatin calcium...... 55 REBINYN...... 136 RETACRIT...... 141 ROTARIX...... 218 REBLOZYL...... 140 RETAVASE...... 140 ROTATEQ...... 218 RECARBRIO...... 60 RETAVASE HALF-KIT...... 140 ROUGH MARSH ELDER...... 17 RECLAST...... 122 RETEVMO...... 71, 72 ROWASA...... 131 reclipsen...... 102 RETISERT...... 199 roweepra...... 40 RECOMBINATE...... 137 RETROVIR...... 88 ROXICODONE...... 28 RECOMBIVAX HB...... 218 REVCOVI...... 122 ROZLYTREK...... 72 RECOTHROM...... 144 REVLIMID...... 173 RUBRACA...... 78 RECOTHROM SPRAY KIT...... 144 revonto...... 189 RUCONEST...... 137 RECTIV...... 30 REXALL LANCETS ULTRA THIN rufinamide...... 40 RED MAPLE...... 17 30G...... 159 RUKOBIA...... 87 RED MULBERRY...... 17 REXULTI...... 85 RUSSIAN THISTLE...... 17 RED TOP GRASS POLLEN...... 17 REYATAZ...... 87 RUXIENCE...... 67 REDITREX...... 20 RHIZOPUS...... 17 RUZURGI...... 63 refissa...... 110 RHOFADE...... 118 RYANODEX...... 189 REGEN-COV...... 203 RHOGAM ULTRA-FILTERED RYBELSUS...... 46 REGLAN...... 130 PLUS...... 203 ryclora...... 52 REGONOL...... 63 RHOPHYLAC...... 203 RYDAPT...... 71 REGRANEX...... 120 RHOPRESSA...... 197 RYDEX...... 109 relafen...... 22 RIABNI...... 67 RYTARY...... 81 RELENZA DISKHALER...... 90 RIASTAP...... 137 RYTHMOL SR...... 33 RELEXXII...... 14 ribavirin...... 90 RYVENT...... 53 RELION INSULIN SYRINGE...... 167 RIDAURA...... 20 SACCHAROMYCES CEREVISIAE.17 rifabutin...... 64 SAFE-T-LANCE...... 159 243 SAFE-T-LANCE PLUS...... 159 SEREVENT DISKUS...... 34 sm folic acid...... 141 SAFETY INSULIN SYRINGES...... 167 SEROSTIM...... 124 sm gentle laxative...... 148 SAFETY LANCET 30G/PRESSURE sertraline hcl...... 43 SM LANCETS 33G...... 160 ACT...... 159 setlakin...... 104 sm magnesium citrate...... 148 SAFETY LANCETS...... 159 sevelamer carbonate...... 132 sm milk of magnesia...... 148 SAFETY LANCETS 21G...... 159 sevelamer hcl...... 132 sm multiple vitamins essential...... 182 SAFETY LANCETS 28G...... 160 SEVENFACT...... 137 sm multiple vitamins/iron...... 180 SAFYRAL...... 102 sevoflurane...... 133 sm nicotine...... 209, 210 SALAGEN...... 178 sf...... 177 sm nicotine polacrilex...... 210 SAMSCA...... 127 sf 5000 plus...... 177 SM ONE DAILY PRENATAL...... 185 SANCUSO...... 50 SFROWASA...... 131 SM PRENATAL VITAMINS...... 185 SANDIMMUNE...... 173 SHAGBARK HICKORY...... 17 sm super b complex/c...... 179 SANDOSTATIN...... 127 sharobel...... 105 sm vitamin b complex/vitamin c...... 179 SANDOSTATIN LAR DEPOT...... 127 SHEEP SORREL...... 17 SMART SENSE COLOR LANCETS SANTYL...... 115 SHINGRIX...... 218 33G...... 160 sapropterin dihydrochloride...... 127 SHOPKO ON-THE-GO LANCETS SMART SENSE STANDARD SAPS HEALTH TWIST TOP 30G...... 160 LANCETS...... 160 LANCETS...... 160 SHOPKO UNIFINE PENTIPS...... 167 SMART SENSE SUPER THIN SAPS TWIST TOP LANCETS...... 160 SHOPKO UNIFINE PENTIPS LANCETS...... 160 SAPSCARE TWIST TOP PLUS...... 167 SMART SENSE THIN LANCETS LANCETS...... 160 SHOPKO UNILET LANCETS 28G.160 26G...... 160 SARCLISA...... 67 SHOPKO UNILET LANCETS 30G.160 SMARTEST LANCETS 28G...... 160 SAVELLA...... 205 SHORT RAGWEED POLLEN EXT. 17 SMOFLIPID...... 193 SAVELLA TITRATION PACK...... 206 SHUR-SEAL CONTRACEPTIVE...218 smooth lax...... 147 SAXENDA...... 12 SIGNIFOR...... 127 sod benz-sod phenylacet...... 128 sb aspirin...... 25 SIGNIFOR LAR...... 127 SODIUM ACETATE...... 169 sb aspirin adult low strength...... 25 SIKLOS...... 140 SODIUM BICARBONATE...... 30 sb aspirin ec...... 25 sildenafil citrate...... 96 sodium bicarbonate...... 169 sb bisacodyl laxative ec...... 148 SILENOR...... 145 sodium chloride...... 108, 134, 171, 172 sb childrens aspirin...... 25 silodosin...... 133 sodium chloride flush...... 171 sb gentle lax-women...... 148 SILVADENE...... 113 SODIUM CITRATE LOCK FLUSH. 36 SB INSULIN SYRINGE...... 167 silver sulfadiazine...... 113 SODIUM DIURIL...... 122 SB LANCETS THIN...... 160 SIMBRINZA...... 193 SODIUM EDECRIN...... 121 SB LANCETS ULTRA THIN...... 160 simliya...... 99 sodium fluoride...... 170, 171, 177 sb low dose asa ec...... 25 simpesse...... 104 sodium fluoride 5000 enamel...... 177 sb magnesium citrate...... 148 SIMPONI ARIA...... 20 sodium fluoride 5000 plus...... 177 sb milk of magnesia...... 148 SIMULECT...... 175 sodium fluoride 5000 ppm...... 177 sb polyethylene glycol 3350...... 147 simvastatin...... 55 sodium fluoride 5000 sensitive...... 177 SCENESSE...... 117 SINEMET...... 81 SODIUM IODIDE I-131...... 212 SCLEROSOL INTRAPLEURAL.....211 SINGLE-LET...... 160 SODIUM NITRITE...... 49 scopolamine...... 50 sirolimus...... 174 sodium nitroprusside...... 59 SEASONIQUE...... 104 SIRTURO...... 64 sodium phenylbutyrate...... 128 SECUADO...... 83 SIVEXTRO...... 62 sodium phosphates...... 171 SECURESAFE INSULIN SYRINGE SKELAXIN...... 189 sodium polystyrene sulfonate...... 176 ...... 167 SKYLA...... 104 SODIUM SULFACETAMIDE- SECURESAFE SAFETY PEN SKYRIZI...... 112 BAKUCHIOL...... 112 NEEDLES...... 167 SKYRIZI (150 MG DOSE)...... 112 sodium tetradecyl sulfate...... 176 SELECT-LITE DEVICE/LANCETS SKYRIZI PEN...... 112 SOLESTA...... 173 ...... 160 SLYND...... 105 solifenacin succinate...... 216 SELECT-OB...... 185 sm aspirin...... 25 SOLIQUA...... 46 SELECT-OB+DHA...... 187 sm aspirin adult low strength...... 25 SOLIRIS...... 137 selegiline hcl...... 80 sm aspirin ec...... 25 SOLOSEC...... 19 SELENIOUS ACID...... 172 sm aspirin ec low strength...... 25 SOLTAMOX...... 65 selenium sulfide...... 113 sm aspirin low dose...... 25 SOLU-CORTEF...... 107 SELZENTRY...... 86 sm aspirin tri-buffered...... 23 SOLU-MEDROL...... 107 SE-NATAL 19...... 185 sm b super vitamin complex...... 178 SOLUS V2 LANCETS 28G...... 160 SENSIPAR...... 122 sm b100 complex...... 180 SOLUS V2 TWIST LANCETS 30G.160 sensorcaine...... 150 sm balanced b-100...... 179 SOMA...... 189 sensorcaine/epinephrine...... 149 sm balanced b-50...... 179 SOMATULINE DEPOT...... 127 sensorcaine-mpf...... 150 sm b-complex...... 180 SOMAVERT...... 123 sensorcaine-mpf/epinephrine...... 149 SM B-COMPLEX/VITAMIN C...... 178 SOOLANTRA...... 118 SENSORCAINE- sm childrens aspirin...... 25 SORBITOL...... 134 MPF/EPINEPHRINE...... 149 sm clearlax...... 147 SORBITOL-MANNITOL...... 134 244 SORIATANE...... 112 subvenite starter kit-orange...... 40 SUSTOL...... 50 SORILUX...... 112 SUCCINYLCHOLINE CHLORIDE191 SUTENT...... 71 sorine...... 92 SUCRAID...... 120 SWEET GUM...... 18 SORREL/DOCK MIX...... 19 sucralfate...... 215 SWEET VERNAL GRASS SOTALOL HCL...... 92 SUFENTANIL CITRATE...... 28 POLLEN...... 18 sotalol hcl...... 92 SULAR...... 94 syeda...... 102 sotalol hcl (af)...... 92 sulconazole nitrate...... 116 SYLVANT...... 174 SOTRADECOL...... 176 sulfacetamide sodium...... 199 SYMBICORT...... 33 sotradecol...... 176 sulfacetamide sodium (acne)...... 109 SYMBYAX...... 210 SOTROVIMAB...... 201 sulfacetamide sod-sulfur wash...... 109 SYMDEKO...... 211 SOTYLIZE...... 92 sulfacetamide-prednisolone...... 198 SYMJEPI...... 219 spinosad...... 118 SULFADIAZINE...... 211 SYMLINPEN 120...... 44 SPINY PIGWEED...... 17 sulfamethoxazole-trimethoprim...... 60 SYMLINPEN 60...... 44 SPIRIVA HANDIHALER...... 35 SULFAMYLON...... 113 SYMPAZAN...... 38 SPIRIVA RESPIMAT...... 35 sulfasalazine...... 131 SYMPROIC...... 132 spironolactone...... 121 sulfatrim pediatric...... 60 SYMTUZA...... 86 spironolactone-hctz...... 121 SULFURATED LIME...... 118 SYNAGIS...... 201 SPORANOX...... 52 sulindac...... 22 SYNAREL...... 125 SPORANOX PULSEPAK...... 52 sumatriptan...... 169 SYNDROS...... 51 SPRAVATO (56 MG DOSE)...... 42 sumatriptan succinate...... 169 SYNERCID...... 62 SPRAVATO (84 MG DOSE)...... 42 sumatriptan succinate refill...... 169 SYNJARDY...... 47 sprintec 28...... 102 sumatriptan-naproxen sodium...... 169 SYNJARDY XR...... 47 SPRITAM...... 40 SUNOSI...... 13 SYNRIBO...... 74 SPRYCEL...... 69 SUPARTZ FX...... 190 SYNTHROID...... 213 sps...... 176 super b complex maxi...... 179 SYNVISC...... 190 sronyx...... 102 super b complex/fa/vit c...... 178 SYNVISC ONE...... 190 ssd...... 113 super b complex/vitamin c...... 179 SYRINGE AVITENE...... 144 SSKI...... 108 super b-100...... 180 tab-a-vite...... 181 st joseph aspirin...... 25 super b-50...... 180 tab-a-vite/beta carotene...... 182 st joseph low dose...... 25 super b-complex...... 180 tab-a-vite/iron...... 181 STALEVO 100...... 81 super b-complex + vitamin c...... 179 TAB-A-VITE/IRON/BETA STALEVO 125...... 81 super b-complex/vit c/fa...... 178 CAROTENE...... 181 STALEVO 150...... 81 super dec b-100...... 180 TABLOID...... 66 STALEVO 200...... 81 super quints b-50...... 180 TABRECTA...... 70 STALEVO 50...... 81 super stress b-complex cr...... 188 TACHOSIL...... 144 STALEVO 75...... 81 SUPER THIN LANCETS...... 160 TACLONEX...... 119 STAMARIL...... 218 SUPPRELIN LA...... 125 tacrolimus...... 117, 174 stavudine...... 88 SUPRANE...... 133 tadalafil...... 96 STELARA...... 112, 132 SUPRAX...... 98 tadalafil (pah)...... 96 STEMPHYLIUM...... 17 SUPREP BOWEL PREP KIT...... 146 TAFINLAR...... 69 STERILANCE PA...... 160 SURE COMFORT INSULIN TAGRISSO...... 69 STERILANCE TL...... 160 SYRINGE...... 167 take action...... 103 STERILE TALC POWDER...... 211 SURE COMFORT LANCETS 18G. 160 TAKHZYRO...... 138 sterile water for irrigation...... 174 SURE COMFORT LANCETS 21G. 160 TALICIA...... 215 STERITALC...... 211 SURE COMFORT LANCETS 23G. 160 TALL RAGWEED...... 18 STIMATE...... 128 SURE COMFORT LANCETS 28G. 160 TALZENNA...... 78 STIOLTO RESPIMAT...... 33 SURE COMFORT LANCETS 30G. 160 TAMIFLU...... 90 STIVARGA...... 71 SURE COMFORT PEN NEEDLES.167 tamoxifen citrate...... 65 STRAVIX...... 119 SURE-FINE PEN NEEDLES...... 167 tamsulosin hcl...... 133 STRENSIQ...... 125 SURE-JECT INSULIN SYRINGE...167 TAPAZOLE...... 212 streptomycin sulfate...... 19 SURE-LANCE FLAT LANCETS.... 160 taperdex 12-day...... 107 stress b complex/iron...... 181 SURE-LANCE LANCETS 26G...... 160 taperdex 6-day...... 107 stress formula...... 178 SURE-LANCE THIN LANCETS taperdex 7-day...... 107 stress formula/iron...... 181 28G...... 160 TARCEVA...... 69 stresstabs energy...... 182 SURE-LANCE ULTRA THIN TARGRETIN...... 119 STRIBILD...... 86 LANCETS...... 160 tarina 24 fe...... 102 STRIVERDI RESPIMAT...... 34 SURELITE LANCETS...... 160 tarina fe 1/20...... 102 STROMECTOL...... 31 SURE-TOUCH LANCETS tarina fe 1/20 eq...... 102 STRONTIUM CHLORIDE SR-89..... 74 UNIVERSAL...... 160 TARKA...... 56 SUBLOCADE...... 29 SURGICEL FIBRILLAR...... 144 TARON-C DHA...... 185 subvenite...... 40 SURGICEL NU-KNIT...... 144 TARON-PREX...... 187 subvenite starter kit-blue...... 40 SURVANTA...... 211 TAROXIA...... 109 subvenite starter kit-green...... 40 SUSTIVA...... 88 TASIGNA...... 69 245 TASMAR...... 81 theophylline...... 36 TODAYS HEALTH MINI PEN TAURINE...... 193 theophylline er...... 36 NEEDLES...... 167 tavaborole...... 117 THEOPHYLLINE IN D5W...... 36 TODAYS HEALTH PEN NEEDLES TAVALISSE...... 139 THERA...... 182 ...... 167 TAYTULLA...... 102 thera-mill...... 182 TODAYS HEALTH SHORT PEN tazarotene...... 112 thera-tabs...... 182 NEEDLE...... 167 tazicef...... 99 THEREMS...... 182 TODAYS HEALTH THIN TAZICEF...... 99 thiamine hcl...... 220 LANCETS 28G...... 160 TAZORAC...... 112 THINLETS GP LANCETS...... 160 TODAYS HEALTH THIN taztia xt...... 94 THIOLA...... 135 LANCETS 30G...... 161 TAZVERIK...... 70 THIOLA EC...... 135 tolbutamide...... 47 TDVAX...... 213 thioridazine hcl...... 84 tolcapone...... 81 TECENTRIQ...... 68 thiotepa...... 64 TOLSURA...... 52 TECHLITE AST LANCETS...... 160 thiothixene...... 85 tolterodine tartrate...... 216 TECHLITE INSULIN SYRINGE.... 167 thrive...... 210 tolterodine tartrate er...... 216 TECHLITE LANCETS...... 160 THRIVITE RX...... 185 tolvaptan...... 127 TECHLITE LANCETS 30G...... 160 THROMBATE III...... 139 TOPCARE CLICKFINE PEN TECHLITE PEN NEEDLES...... 167 THROMBI-GEL 10...... 143 NEEDLES...... 167 TEFLARO...... 99 THROMBI-GEL 100...... 143 TOPCARE LANCETS MICRO- TEGADERM AG MESH...... 120 THROMBI-GEL 40...... 143 THIN 33G...... 161 TEGSEDI...... 205 THROMBIN-JMI...... 144 TOPCARE ULTRA COMFORT TEKTURNA HCT...... 59 THROMBIN-JMI EPISTAXIS...... 144 INS SYR...... 167 telmisartan...... 58 THROMBI-PAD...... 143 topiramate...... 40 telmisartan-amlodipine...... 57 THROMBOGEN...... 144 topiramate er...... 40 telmisartan-hctz...... 57 THYMOGLOBULIN...... 173 toposar...... 77 temazepam...... 145 THYQUIDITY...... 213 TOPOTECAN HCL...... 79 TEMIXYS...... 86 tiadylt er...... 94 topotecan hcl...... 79 TEMODAR...... 76 tiagabine hcl...... 41 toremifene citrate...... 65 temozolomide...... 76 TIAZAC...... 94 TORISEL...... 71 temsirolimus...... 70 TIBSOVO...... 76 torsemide...... 121 tencon...... 23 TICE BCG...... 74 TOTECT...... 75 TENIPOSIDE...... 77 TIGAN...... 50 TOUJEO MAX SOLOSTAR...... 46 TENIVAC...... 213 TIGECYCLINE...... 212 TOUJEO SOLOSTAR...... 46 tenofovir disoproxil fumarate...... 89 TIGLUTIK...... 191 tovet...... 115 TENORETIC 100...... 59 tilia fe...... 105 TOVIAZ...... 216 TENORETIC 50...... 59 timolol maleate...... 92, 194 TPN ELECTROLYTES...... 170 TEPADINA...... 64 timolol maleate ocudose...... 193 TRACLEER...... 96 TEPEZZA...... 125 timolol maleate pf...... 194 TRALEMENT...... 172 TEPMETKO...... 71 TIMOPTIC...... 194 tramadol hcl...... 28 terazosin hcl...... 58 TIMOPTIC OCUDOSE...... 194 tramadol hcl er...... 28 terbinafine hcl...... 51 TIMOPTIC-XE...... 194 tramadol hcl er (biphasic)...... 28 terbutaline sulfate...... 34 TIMOTHY GRASS POLLEN tramadol-acetaminophen...... 29 terconazole...... 218 ALLERGEN...... 18 trandolapril...... 57 TERIPARATIDE tinidazole...... 60 trandolapril-verapamil hcl er...... 56 (RECOMBINANT)...... 126 tiopronin...... 135 tranexamic acid...... 143 terrell...... 133 TIROSINT...... 213 TRANEXAMIC ACID-NACL...... 143 TESSALON PERLES...... 107 TIROSINT-SOL...... 213 tranylcypromine sulfate...... 42 TESTOPEL...... 29 TISSEEL...... 143 TRAVASOL...... 192 testosterone...... 30 TISSUEBLUE...... 199 TRAVEL LANCETS...... 161 testosterone cypionate...... 29 tis-u-sol...... 174 TRAVEL LANCETS ADVANCED testosterone enanthate...... 30 TIVICAY...... 87 28G...... 161 TETANUS-DIPHTHERIA TIVICAY PD...... 87 travoprost (bak free)...... 200 TOXOIDS TD...... 213 tizanidine hcl...... 189 TRAZIMERA...... 68 tetrabenazine...... 206 TNKASE...... 140 trazodone hcl...... 43 tetracaine hcl...... 197 TOBI PODHALER...... 19 TREANDA...... 64 tetracycline hcl...... 212 TOBRADEX...... 198 TRECATOR...... 64 TGT LANCET MICRO THIN 33G. 160 TOBRADEX ST...... 198 TRELEGY ELLIPTA...... 34 TGT LANCET THIN 26G...... 160 tobramycin...... 19, 195 TRELSTAR MIXJECT...... 76, 77 TGT LANCET ULTRA THIN 30G..160 tobramycin sulfate...... 19 TREMFYA...... 112 THALOMID...... 172 tobramycin-dexamethasone...... 198 treprostinil...... 96 THAM...... 169 TOBREX...... 195 TRESIBA...... 46 THE LIQUILIFT TRACE...... 172 TODAY SPONGE...... 218 TRESIBA FLEXTOUCH...... 46 THEO-24...... 36 tretinoin...... 78, 110 246 tretinoin (emollient)...... 110 tri-vylibra...... 105 ULTICARE MICRO PEN tretinoin microsphere...... 110 tri-vylibra lo...... 105 NEEDLES...... 167 tretinoin microsphere pump...... 110 TRIZIVIR...... 86 ULTICARE MINI PEN NEEDLES. 167 TRETTEN...... 137 TRODELVY...... 79 ULTICARE PEN NEEDLES...... 167 TREXALL...... 66 TROGARZO...... 86 ULTICARE SHORT PEN trezix...... 25 TROKENDI XR...... 40 NEEDLES...... 167 tri femynor...... 105 TROPHAMINE...... 192 ULTIGUARD SAFEPACK PEN triamcinolone acetonide...... 115, 178 tropicamide...... 194 NEEDLE...... 167 TRIAMCINOLONE- trospium chloride...... 216 ULTIGUARD SAFEPACK MOXIFLOXACIN...... 198 trospium chloride er...... 216 SYR/NEEDLE...... 167 TRI-AMINO...... 193 TRUE COMFORT INSULIN ULTILET CLASSIC LANCETS...... 161 triamterene...... 121 SYRINGE...... 167 ULTILET INSULIN SYRINGE...... 167 triamterene-hctz...... 121 TRUE COMFORT PEN NEEDLES 167 ULTILET INSULIN SYRINGE triazolam...... 145 TRUE COMFORT PRO INSULIN SHORT...... 168 tri-buffered aspirin...... 23 SYR...... 167 ULTILET LANCETS...... 161 TRICARE...... 186 TRUE COMFORT PRO PEN ULTILET PEN NEEDLE...... 168 TRICARE PRENATAL DHA ONE.186 NEEDLES...... 167 ULTILET SAFETY LANCETS...... 161 TRICHOPHYTON...... 18 TRUE COMFORT TWIST TOP ULTILET SAFETY LANCETS 23G161 TRICHOPHYTON LANCETS...... 161 ULTIVA...... 28 MENTAGROPHYTES...... 18 TRUEPLUS 5-BEVEL PEN ULTOMIRIS...... 137 TRICOR...... 54 NEEDLES...... 167 ultra b-100 complex...... 188 triderm...... 115 TRUEPLUS INSULIN SYRINGE....167 ULTRA COMFORT INSULIN trientine hcl...... 172 TRUEPLUS LANCETS 26G...... 161 SYRINGE...... 168 TRIESENCE...... 199 TRUEPLUS LANCETS 28G...... 161 ULTRA FLO INSULIN PEN tri-estarylla...... 105 TRUEPLUS LANCETS 30G...... 161 NEEDLES...... 168 TRIFERIC...... 142 TRUEPLUS LANCETS 33G...... 161 ULTRA FLO INSULIN SYR 1/2 trifluoperazine hcl...... 84 TRUEPLUS PEN NEEDLES...... 167 UNIT...... 168 trifluridine...... 196 TRUEPLUS SAFETY LANCETS ULTRA FLO INSULIN SYRINGE..168 trihexyphenidyl hcl...... 80 28G...... 161 ULTRA THIN LANCETS 31G...... 161 TRIKAFTA...... 211 TRULICITY...... 46 ULTRA THIN PEN NEEDLES...... 168 tri-legest fe...... 105 TRUMENBA...... 217 ULTRABAG/DIANEAL PD-2/1.5% tri-linyah...... 105 TRUSKIN...... 119 DEX...... 175 TRILIPIX...... 54 TRUSOPT...... 196 ULTRABAG/DIANEAL PD-2/2.5% tri-lo-estarylla...... 105 TRUVADA...... 86 DEX...... 175 tri-lo-marzia...... 105 TRUXIMA...... 67 ULTRABAG/DIANEAL PD- tri-lo-mili...... 105 trymine cg...... 107 2/4.25%DEX...... 175 tri-lo-sprintec...... 105 TUKYSA...... 68 ULTRABAG/DIANEAL/1.5% TRI-LUMA...... 115 tulana...... 105 DEXTROSE...... 175 TRILURON...... 190 TURALIO...... 71 ULTRABAG/DIANEAL/2.5% trimethobenzamide hcl...... 50 TUSNEL C...... 108 DEXTROSE...... 175 trimethoprim...... 60 TUSSICAPS...... 108 ULTRABAG/DIANEAL/4.25% DEX tri-mili...... 105 TUXARIN ER...... 108 ...... 175 trimipramine maleate...... 44 TUZISTRA XR...... 108 ULTRACARE INSULIN SYRINGE 168 TRINATAL RX 1...... 186 TWINRIX...... 217 ULTRA-CARE LANCETS 30G...... 161 trinate...... 186 TWIRLA...... 102 ULTRACARE PEN NEEDLES...... 168 TRINAZ...... 186 TWYNSTA...... 57 ULTRA-COMFORT INSULIN TRINTELLIX...... 43 TYBLUME...... 102 SYRINGE...... 168 tri-nymyo...... 105 TYBOST...... 89 ULTRAFOAM SPONGE TRIOSTAT...... 213 tydemy...... 102 2X6.25X7CM...... 144 tri-previfem...... 105 TYGACIL...... 212 ULTRAFOAM SPONGE TRIPTODUR...... 125 TYKERB...... 71 8X12.5X1CM...... 144 TRISENOX...... 74 TYPHIM VI...... 217 ULTRAFOAM SPONGE tri-sprintec...... 105 TYSABRI...... 207 8X12.5X3CM...... 144 TRISTART DHA...... 187 TYVASO...... 96 ULTRAFOAM SPONGE TRISTART FREE...... 187 TYVASO REFILL...... 96 8X25X1CM...... 144 TRISTART ONE...... 187 TYVASO STARTER...... 96 ULTRAFOAM SPONGE tritocin...... 115 UCERIS...... 30, 107 8X6.25X1CM...... 144 TRIUMEQ...... 86 UDENYCA...... 142 ULTRA-THIN II AUTO LANCET.. 161 TRIVEEN-DUO DHA...... 186 UKONIQ...... 71 ULTRA-THIN II INS SYR SHORT.168 TRI-VI-FLOR...... 183 ULTANE...... 133 ULTRA-THIN II INSULIN TRI-VI-FLORO...... 183 ULTICARE INSULIN SAFETY SYRINGE...... 168 tri-vite/fluoride...... 183 SYR...... 167 ULTRA-THIN II LANCETS...... 161 trivora (28)...... 105 ULTICARE INSULIN SYRINGE....167 247 ULTRA-THIN II MINI PEN UROCIT-K 15...... 134 VECURONIUM BROMIDE...... 191 NEEDLE...... 168 UROCIT-K 5...... 134 vecuronium bromide...... 191 ULTRA-THIN II PEN NEEDLE URSO 250...... 130 VELCADE...... 71 SHORT...... 168 URSO FORTE...... 130 VELETRI...... 96 ULTRA-THIN II PEN NEEDLES....168 ursodiol...... 130 velivet...... 105 UNASYN...... 204 UVADEX...... 74 VELPHORO...... 132 UNIFINE PEN NEEDLES...... 168 VABOMERE...... 60 VELTASSA...... 176 UNIFINE PENTIPS...... 168 valacyclovir hcl...... 90 VEMLIDY...... 89 UNIFINE PENTIPS PLUS...... 168 VALCHLOR...... 111 VENCLEXTA...... 68 UNIFINE SAFECONTROL PEN VALCYTE...... 89 VENCLEXTA STARTING PACK.....68 NEEDLE...... 168 valganciclovir hcl...... 89 VENEXA...... 181 UNILET COMFORTOUCH valproate sodium...... 41 VENIPUNCTURE PX1 LANCET...... 161 valproic acid...... 41 PHLEBOTOMY...... 119 UNILET EXCELITE...... 161 valrubicin...... 73 venlafaxine hcl...... 43 UNILET EXCELITE II...... 161 valsartan...... 58 venlafaxine hcl er...... 43 UNILET G.P. LANCET...... 161 valsartan-hydrochlorothiazide...... 57 VENOFER...... 142 UNILET G.P. SUPERLITE VALSTAR...... 73 VENOMIL HONEY BEE VENOM... 18 LANCET...... 161 VALTOCO 10 MG DOSE...... 38 VENOMIL MIXED VESPID UNILET GP 28 ULTRA THIN...... 161 VALTOCO 15 MG DOSE...... 38 VENOM...... 18 UNILET LANCET...... 161 VALTOCO 20 MG DOSE...... 38 VENOMIL WASP VENOM...... 18 UNILET MICRO-THIN 33G...... 161 VALTOCO 5 MG DOSE...... 38 VENOMIL WHITE FACED UNILET SUPERLITE LANCET..... 161 VALUE HEALTH INSULIN HORNET...... 18 UNILET SUPER-THIN 30G...... 161 SYRINGE...... 168 VENOMIL YELLOW HORNET UNILET ULTRA-THIN 28G...... 161 VALUE PLUS LANCET VENOM...... 18 UNISTIK 1...... 161 STANDARD 21G...... 162 VENOMIL YELLOW JACKET UNISTIK 2...... 161 VALUE PLUS LANCETS SUPER VENOM...... 18 UNISTIK 2 COMFORT...... 161 THIN...... 162 VENTAVIS...... 96 UNISTIK 2 EXTRA...... 161 VALUE PLUS LANCETS THIN VENTOLIN HFA...... 34 UNISTIK 2 NEONATAL...... 161 26G...... 162 verapamil hcl...... 94 UNISTIK 2 NORMAL...... 161 VALUMARK LANCET SUPER verapamil hcl er...... 94 UNISTIK 2 SUPER...... 161 THIN 30G...... 162 VEREGEN...... 110 UNISTIK 3...... 161 VALUMARK LANCET ULTRA VERELAN...... 94 UNISTIK 3 COMFORT...... 161 THIN 28G...... 162 VERELAN PM...... 94 UNISTIK 3 EXTRA...... 161 VALUMARK PEN NEEDLES...... 168 VERSACLOZ...... 83 UNISTIK 3 GENTLE...... 161 VANCOCIN...... 61 VERZENIO...... 75 UNISTIK 3 NEONATAL...... 161 VANCOCIN HCL...... 61 vestura...... 102 UNISTIK 3 NORMAL...... 162 VANCOMYCIN HCL...... 61 VFEND...... 52 UNISTIK CZT COMFORT...... 162 vancomycin hcl...... 61 VIBATIV...... 61 UNISTIK CZT NORMAL...... 162 VANCOMYCIN HCL IN VIBERZI...... 131 UNISTIK NORMAL...... 162 DEXTROSE...... 61 VICTOZA...... 46 UNISTIK PRO SAFETY LANCET. 162 VANCOMYCIN HCL IN NACL...... 61 VIDA MIA UNIFINE PENTIPS...... 168 UNISTIK SAFETY LANCETS 28G 162 vandazole...... 219 VIDA MIA UNILET LANCETS 28G UNISTIK SAFETY LANCETS 30G 162 VANIQA...... 117 ...... 162 UNISTIK TOUCH SAFETY LANC VANISHPOINT INSULIN VIDA MIA UNILET LANCETS 30G 21G...... 162 SYRINGE...... 168 ...... 162 UNISTIK TOUCH SAFETY LANC VANTAS...... 77 VIDAZA...... 66 23G...... 162 VAPRISOL...... 128 vienva...... 102 UNISTIK TOUCH SAFETY LANC VAQTA...... 218 vigabatrin...... 41 28G...... 162 vardenafil hcl...... 96, 97 vigadrone...... 41 UNISTIK TOUCH SAFETY LANC VARITHENA...... 176 VIGAMOX...... 195 30G...... 162 VARIVAX...... 218 VILTEPSO...... 191 unithroid...... 213 VARIZIG...... 203 VIMIZIM...... 126 UNITUXIN...... 67 VARUBI (180 MG DOSE)...... 51 VIMPAT...... 40 UNIVERSAL 1 LANCETS THIN VASCEPA...... 54 VINATE DHA RF...... 186 26G...... 162 VASERETIC...... 56 VINATE II...... 186 UNIVERSAL 1 LANCETS THIN VASOSTRICT...... 128 VINATE ONE...... 186 33G...... 162 VAXCHORA...... 217 vinblastine sulfate...... 77 UNIVERSAL 1 LANCETS ULTRA VAXELIS...... 213 vincristine sulfate...... 77 THIN...... 162 VAZCULEP...... 220 vinorelbine tartrate...... 77 UPLIZNA...... 175 VCF VAGINAL VIOKACE...... 120 UPNEEQ...... 200 CONTRACEPTIVE...... 218 viorele...... 99 UPTRAVI...... 96 VECAMYL...... 58 VIRACEPT...... 87 UROCIT-K 10...... 134 VECTIBIX...... 69 VIRAMUNE...... 88 248 VIRAMUNE XR...... 88 VYNDAQEL...... 97 XEMBIFY...... 203 VIRAZOLE...... 90 VYONDYS 53...... 191 XENAZINE...... 206 VIREAD...... 89 VYVANSE...... 12 XENICAL...... 13 VIRT-C DHA...... 186 VYXEOS...... 73 XENLETA...... 62 VIRT-NATE DHA...... 186 VYZULTA...... 200 XEOMIN...... 191 virt-phos 250 neutral...... 171 WAKIX...... 13 XEPI...... 110 VIRT-PN DHA...... 187 WALGREENS ADV TRAVEL XERAVA...... 211 VIRT-PN PLUS...... 186 LANCETS...... 162 XERESE...... 113 virtussin a/c...... 107 WALGREENS LANCETS...... 162 XERMELO...... 132 virtussin ac w/alc...... 108 WALGREENS LANCETS MICRO XGEVA...... 127 VIRTUSSIN DAC...... 108 THIN...... 162 XIAFLEX...... 173 VISCO-3...... 190 WALGREENS LANCETS SUPER XIFAXAN...... 60 VISCOAT...... 199 THIN...... 162 XIGDUO XR...... 47 VISIONBLUE...... 200 WALGREENS THIN LANCETS.....162 XIIDRA...... 194 VISTARIL...... 31 WALGREENS ULTRA THIN XOFIGO...... 74 VISTOGARD...... 49 LANCETS...... 162 XOFLUZA (40 MG DOSE)...... 90 VISUDYNE...... 197 warfarin sodium...... 36 XOFLUZA (80 MG DOSE)...... 90 vit e-vit c-beta carotene...... 182 WASP VENOM PROTEIN...... 18 XOLAIR...... 34 VITAFOL FE+...... 187 water for irrigation, sterile...... 174 XOLEGEL...... 116 VITAFOL GUMMIES...... 186 WEGMANS UNIFINE PENTIPS XOPENEX HFA...... 34 VITAFOL STRIPS...... 187 PLUS...... 168 XOSPATA...... 71 VITAFOL ULTRA...... 187 WEGOVY...... 13 XPOVIO (100 MG ONCE VITAFOL-NANO...... 186 wera...... 102 WEEKLY)...... 72 VITAFOL-OB...... 186 WESTAB PLUS...... 186 XPOVIO (40 MG ONCE WEEKLY).72 VITAFOL-OB+DHA...... 187 WESTERN JUNIPER...... 18 XPOVIO (40 MG TWICE VITAFOL-ONE...... 187 WESTGEL DHA...... 187 WEEKLY)...... 72 vitalee...... 182 WESTHROID...... 213 XPOVIO (60 MG ONCE WEEKLY).72 VITALINE BIOTIN FORTE...... 178 WEST-VITE W/FOLIC ACID...... 179 XPOVIO (60 MG TWICE VITAMEDMD ONE WHITE BIRCH...... 18 WEEKLY)...... 72 RX/QUATREFOLIC...... 187 WHITE FACED HORNET VENOM.18 XPOVIO (80 MG ONCE WEEKLY).72 VITAMEDMD REDICHEW RX...... 187 WHITE MULBERRY...... 18 XPOVIO (80 MG TWICE vitamin b + c complex...... 179 WHITE OAK...... 18 WEEKLY)...... 72 vitamin b complex...... 178 WHITE PINE...... 18 XTANDI...... 65 vitamin b-complex...... 178 WHITE-FACED HORNET VENOM 18 xulane...... 102 vitamin d (ergocalciferol)...... 220 WIDE-SEAL DIAPHRAGM 60...... 151 XULTOPHY...... 46 vitamin k1...... 220 WIDE-SEAL DIAPHRAGM 65...... 151 XURIDEN...... 124 vitamin-b complex...... 178 WIDE-SEAL DIAPHRAGM 70...... 152 XYLOCAINE...... 150 vitamins acd-fluoride...... 183 WIDE-SEAL DIAPHRAGM 75...... 152 XYLOCAINE/EPINEPHRINE...... 149 VITAPEARL...... 186 WIDE-SEAL DIAPHRAGM 80...... 152 XYLOCAINE-MPF...... 150 VITATHELY WITH GINGER...... 186 WIDE-SEAL DIAPHRAGM 85...... 152 XYLOCAINE-MPF/EPINEPHRINE VITATRUE...... 187 WIDE-SEAL DIAPHRAGM 90...... 152 ...... 149 VITRAKVI...... 72 WIDE-SEAL DIAPHRAGM 95...... 152 XYNTHA...... 137 VITRANOL FE...... 181 WILATE...... 137 XYNTHA SOLOFUSE...... 137 VITRASE...... 173 WILZIN...... 172 XYREM...... 205 VIVA DHA...... 186 WINRHO SDF...... 203 YASMIN 28...... 102 VIVAGUARD LANCETS...... 162 womans laxative...... 148 YAZ...... 102 VIVITROL...... 49 womens laxative...... 149 YELLOW DOCK...... 18 VIZIMPRO...... 69 WOUNDGELHA MATRIX...... 120 YELLOW HORNET VENOM volnea...... 99 WP THYROID...... 213 PROTEIN...... 18 VONVENDI...... 137 wymzya fe...... 102 YELLOW JACKET VENOM VORAXAZE...... 74 XADAGO...... 80, 81 PROTEIN...... 18 voriconazole...... 52 XALKORI...... 66 YERVOY...... 67 VOSEVI...... 89 XARACOLL...... 150 YF-VAX...... 218 VOTRIENT...... 71 XARELTO...... 36, 37 yl balanced b-100...... 180 VP INSULIN SYRINGE...... 168 XARELTO STARTER PACK...... 37 yl folic acid...... 141 VP-PNV-DHA...... 186 XATMEP...... 66 YONDELIS...... 79 VPRIV...... 140 XCOPRI...... 41 YONSA...... 64 VRAYLAR...... 82 XCOPRI (250 MG DAILY DOSE).....40 YOSPRALA...... 139 VUSION...... 111 XCOPRI (350 MG DAILY DOSE).....40 YUPELRI...... 35 vyfemla...... 102 XELJANZ...... 19 YUTIQ...... 199 VYLEESI...... 206 XELJANZ XR...... 19 yuvafem...... 219 vylibra...... 102 XELODA...... 66 zafemy...... 102 VYNDAMAX...... 97 XELPROS...... 200 zafirlukast...... 35 249 zaleplon...... 145 zovia 1/35e (28)...... 102 ZALTRAP...... 80 ZOVIRAX...... 90, 113 ZALVIT...... 186 ZUBSOLV...... 29 ZANAFLEX...... 189 ZULRESSO...... 42 ZANOSAR...... 78 zumandimine...... 102 zarah...... 102 ZUPLENZ...... 50 ZARXIO...... 142 ZYCLARA...... 116 ZATEAN-PN DHA...... 187 ZYCLARA PUMP...... 116 ZATEAN-PN PLUS...... 186 ZYDELIG...... 78 ZCORT 7-DAY...... 107 ZYKADIA...... 66 zebutal...... 23 ZYLET...... 198 ZEGALOGUE...... 45 ZYLOPRIM...... 135 ZEJULA...... 78 ZYMAXID...... 195 ZELAPAR...... 81 ZYNLONTA...... 66 ZELBORAF...... 69 ZYPREXA RELPREVV...... 85 ZEMAIRA...... 210 ZYTIGA...... 64 ZEMDRI...... 19 ZYVANA...... 181 ZEMPLAR...... 124 ZYVOX...... 62 zenatane...... 110 ZENPEP...... 120 zenzedi...... 12 ZEPOSIA...... 210 ZEPOSIA 7-DAY STARTER PACK210 ZEPOSIA STARTER KIT...... 210 ZEPZELCA...... 64 ZERBAXA...... 97 ZESTORETIC...... 56 ZEVALIN Y-90...... 73 ZIAC...... 59 ZIAGEN...... 88 ziclopro...... 111 zidovudine...... 89 ZIEXTENZO...... 142 ZILRETTA...... 107 ZILXI...... 118 zinc chloride...... 172 zinc sulfate...... 172 ZINGO...... 150 ZINPLAVA...... 202 ZIOPTAN...... 200 ziprasidone hcl...... 82 ziprasidone mesylate...... 82 ZIRABEV...... 80 ZIRGAN...... 196 ZITHROMAX...... 150 ZITHROMAX TRI-PAK...... 150 ZITHROMAX Z-PAK...... 151 ZOFRAN...... 50 ZOKINVY...... 173 ZOLADEX...... 77 zoledronic acid...... 122 ZOLEDRONIC ACID...... 122 ZOLINZA...... 70 zolmitriptan...... 169 zolpidem tartrate...... 145 zolpidem tartrate er...... 145 ZOLPIMIST...... 145 zonisamide...... 40 ZONTIVITY...... 139 ZORBTIVE...... 124 ZORTRESS...... 174 ZOSYN...... 204 zovia 1/35 (28)...... 102 250 Most plans include our home delivery program at no extra cost to you. Find out more by going online to anthem.com/ca or call 866-297-1013.

For information about your pharmacy benefit, log in at

anthem.com/ca.

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

Speech and hearing impaired (TDD/TTY) users Call 1-800-221-6915, Monday through Friday, 8:30 a.m. to 5 p.m.ET.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans. Rev. 11/18