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ACA Preventive Drug List Effective January 1, 2021

Recommendations by United States Preventive Services Task Force (USPSTF), Health Resources and Services Administration (HRSA), and Advisory Committee on Immunization Practices (ACIP, adopted by the Centers for Disease Control)

In accordance with requirements put forth through the Affordable Care Act (ACA), your employer has elected to provide evidence-based Preventive Drug coverage at $0. Below is the list of preventive medications that may be available under your ACA Preventive Drug coverage. This list is subject to the terms of your health plans and may change, based on ACA guidelines updates.

The drugs listed below are grouped into broad categories. Each category includes an alphabetical list of drugs. Please verify with your plan if a must be tried before the brand version of a drug is filled. Please refer to your benefit materials for coverage details and the plan website for current information as this list will be reviewed periodically and is subject to change.

Generic prescription drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Reference brands may not themselves be covered, please check your benefit. Some generic products have no reference brand. Brand prescription drugs are shown in all capital letters followed by the generic name. Generic medicines are available for many of the brand-name drugs listed though may not be available in all strengths. ASPIRIN stannous fluoride gel 0.4% (Gel-Kam) aspirin chew tab 81 mg aspirin tab delayed release 81 mg Supplements & Combinations sodium fluoride chew tab 0.25 mg f (from 0.55 mg BOWEL PREPARATION naf) peg 3350-kcl-sod bicarb-nacl for soln 420 gm sodium fluoride chew tab 0.5 mg f (from 1.1 mg (Nulytely/flavor pack) naf) peg 3350-kcl-na bicarb-nacl-na sulfate for soln sodium fluoride chew tab 1 mg f (from 2.2 mg naf) 236 gm (Golytely) sodium fluoride soln 0.125 mg/drop f (0.275 mg/ drop naf) PRIMARY PREVENTION sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml anastrozole tab 1 mg (Arimidex) naf) ARIMIDEX – anastrozole tab 1 mg EVISTA – hcl tab 60 mg FOLIC ACID SUPPLEMENTS raloxifene hcl tab 60 mg (Evista) folic acid cap 0.8 mg SOLTAMOX – citrate oral soln 10 mg/5ml folic acid tab 400 mcg (base equivalent) folic acid tab 800 mcg tamoxifen citrate tab 10 mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) HUMAN IMMUNODEFICIENCY VIRUS PREEXPOSURE PROPHYLAXIS FLUORIDE (HIV PREP) Dental Products & Combinations TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg sodium fluoride cream 1.1% (Prevident 5000 plus) sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) INFANT EYE OINTMENT sodium fluoride paste 1.1% (Prevident 5000 boost) (FOR NEWBORNS) sodium fluoride rinse 0.02% erythromycin ophth oint 5 mg/gm sodium fluoride rinse 0.0221% (0.01% f) sodium fluoride rinse 0.05% IRON SUPPLEMENTS sodium fluoride-potassium nitrate paste 1.1-5% carbonyl iron susp 15 mg/1.25ml (elemental iron) (Prevident 5000 sensi) FER-IN-SOL – ferrous sulfate soln 75 mg/ml stannous fluoride conc 0.63% (15 mg/ml elemental fe)

Generic Drugs = bold Brand Drugs = ALL CAPITAL LETTERS

6756-A (NONNR version) © Prime Therapeutics LLC 09/20 Product names listed are the property of their respective owners. Page 1 of 7 IRON SUPPLEMENTS (CONTINUED) BOOSTRIX – tet tox-diph-acell pertuss ad inj 5-2.5- FERROUS SULFATE – ferrous sulfate liquid 220 mg/ 18.5 lf-lf-mcg/0.5ml 5ml (44 mg/5ml elemental fe) DAPTACEL – diph, acellular pert & tet tox inj 15 lf- ferrous sulfate elixir 220 mg/5ml (44 mg/5ml 23 mcg-5 lf/0.5ml elemental fe) DIPHTHERIA/TETANUS TOXOID – diphtheria-tetanus ferrous sulfate soln 75 mg/ml (15 mg/ml elemental tox adsorbed (dt) im inj 25-5 unit/0.5ml fe) ENGERIX-B – b vaccine (recombinant) FERROUS SULFATE – ferrous sulfate syrup 300 mg/ 10 mcg/0.5ml 5ml (60 mg/5ml elemental fe) ENGERIX-B – hepatitis b vaccine (recombinant) ICAR PEDIATRIC – carbonyl iron susp 15 mg/1.25ml 20 mcg/ml (elemental iron) ENGERIX-B – hepatitis b vaccine (recombinant) susp IRON UP – polysaccharide iron complex liquid 15 mg/ 10 mcg/0.5ml 0.5ml (fe equiv) ENGERIX-B – hepatitis b vaccine (recombinant) susp NOVAFERRUM PEDIATRIC DROP – polysaccharide 20 mcg/ml iron complex liquid 15 mg/ml (fe equiv) FLUAD – influenza vac type a&b surface ant adj susp pref syr 0.5 ml SINGLE AGENT STATINS FLUAD QUADRIVALENT – influenza vac type a&b surface ant adj quad pref syr 0.5 ml lovastatin tab 20 mg FLUARIX QUADRIVALENT – influenza virus vac split lovastatin tab 40 mg quadrivalent susp pref syr 0.5ml pravastatin sodium tab 10 mg FLUBLOK QUADRIVALENT – influenza vac recomb pravastatin sodium tab 20 mg (Pravachol) ha quad pf soln pref syr 0.5 ml pravastatin sodium tab 40 mg (Pravachol) FLUCELVAX QUADRIVALENT – influenza vac tissue- pravastatin sodium tab 80 mg (Pravachol) cultured subunit quadrivalent im susp simvastatin tab 10 mg (Zocor) FLUCELVAX QUADRIVALENT – influenza vac tiss- simvastatin tab 20 mg (Zocor) cult subunt quad susp pref syr 0.5 ml simvastatin tab 40 mg (Zocor) FLULAVAL QUADRIVALENT – influenza virus vaccine split quadrivalent im inj TOBACCO CESSATION FLULAVAL QUADRIVALENT – influenza virus vac generic Rx nicotine gum, lozenges, patches split quadrivalent susp pref syr 0.5ml bupropion hcl (smoking deterrent) tab er 12hr FLUZONE HIGH-DOSE PF – influenza virus vac split 150 mg high-dose pf susp pref syr 0.5ml CHANTIX – varenicline tartrate tab 0.5 mg (base FLUZONE HIGH-DOSE PF – influenza vac split high- equiv) dose quad pf susp pref syr 0.7 ml CHANTIX – varenicline tartrate tab 1 mg (base equiv) FLUZONE QUADRIVALENT – influenza virus vaccine CHANTIX CONTINUING MONTH – varenicline tartrate split quadrivalent im inj tab 1 mg (base equiv) FLUZONE QUADRIVALENT – influenza virus vaccine CHANTIX STARTING MONTH PACK – varenicline split quadrivalent inj 0.5 ml tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack FLUZONE QUADRIVALENT – influenza virus vac split NICOTROL INHALER – nicotine inhaler system 10 mg quadrivalent susp pref syr 0.25 ml (4 mg delivered) FLUZONE QUADRIVALENT – influenza virus vac split NICOTROL NS – nicotine nasal spray 10 mg/ml quadrivalent susp pref syr 0.5ml (0.5 mg/spray) GARDASIL 9 – human papillomavirus (hpv) 9-valent recomb vac im susp VACCINES GARDASIL 9 – human papillomavirus (hpv) 9-valent ACTHIB – haemophilus b polysaccharide conjugate recomb vac susp pref syr vaccine for inj HAVRIX – hepatitis a vaccine inj susp 720 el ADACEL – tet tox-diph-acell pertuss ad inj 5-2-15.5 lf- unit/0.5ml lf-mcg/0.5ml HAVRIX – hepatitis a vaccine inj susp 1440 el unit/ml AFLURIA QUADRIVALENT – influenza virus vaccine HEPLISAV-B – hepatitis b vaccine recomb adjuvanted split quadrivalent im inj pref syr 20 mcg/0.5ml AFLURIA QUADRIVALENT – influenza virus vac split HIBERIX – haemophilus b polysaccharide conjugate quadrivalent susp pref syr 0.25 ml vac for inj 10 mcg AFLURIA QUADRIVALENT – influenza virus vac split INFANRIX – diph, acellular pert & tet tox inj 25 lf- quadrivalent susp pref syr 0.5ml 58 mcg-10 lf/0.5ml BEXSERO – meningococcal vac b (recomb omv IPOL INACTIVATED IPV – poliovirus vaccine, ipv adjuv) inj prefilled syringe injection

Generic Drugs = bold Brand Drugs = ALL CAPITAL LETTERS

6756-A (NONNR version) © Prime Therapeutics LLC 09/20 Product names listed are the property of their respective owners. Page 2 of 7 VACCINES (CONTINUED) VAQTA – hepatitis a vaccine inj susp 50 unit/ml KINRIX – diph-tetanus tox ad-acell pert & polio virus, VARIVAX – varicella virus vac live for subcutaneous ipv vac inj inj 1350 pfu/0.5ml M-M-R II – measles-mumps-rubella virus vaccines for ZOSTAVAX – zoster vaccine live for subcutaneous inj soln susp 19400 unit/0.65ml MENACTRA – meningococcal (a, c, y, and w-135) conjugate vaccine inj MENQUADFI – meningococcal (a, c, y, and w-135) conjugate vaccine inj MENVEO – meningococcal (a, c, y, and w-135) oligo conj vac for inj PEDIARIX – diph-tetanus tox-acell pert-hepatitis b- polio ipv vac inj PEDVAX HIB – haemophilus b polysaccharide conj vac im susp 7.5 mcg/0.5 ml PENTACEL – diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp PNEUMOVAX 23 – pneumococcal vaccine polyvalent inj 25 mcg/0.5ml PNEUMOVAX 23/1 DOSE – pneumococcal vaccine polyvalent inj 25 mcg/0.5ml PREVNAR 13 – pneumococcal 13-valent conjugate vaccine inj PROQUAD – measles-mumps-rubella-varicella virus vaccines for susp QUADRACEL – diph-tetanus tox ad-acell pert & polio virus, ipv vac inj RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 10 mcg/ml RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 40 mcg/ml ROTARIX – rotavirus vaccine, live for oral susp ROTATEQ – rotavirus vaccine, live oral pentavalent soln SHINGRIX – zoster vac recombinant adjuvanted for im inj 50 mcg/0.5ml TDVAX – tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml TENIVAC – tetanus-diphtheria toxoids (td) inj 5-2 lfu TRUMENBA – meningococcal group b vac (recomb) im susp prefilled syr TWINRIX – hep a-hep b vaccine susp pref syr 720- 20 elu-mcg/ml VAQTA – hepatitis a vaccine inj susp 25 unit/0.5ml

Generic Drugs = bold Brand Drugs = ALL CAPITAL LETTERS

6756-A (NONNR version) © Prime Therapeutics LLC 09/20 Product names listed are the property of their respective owners. Page 3 of 7 Recommendation on Contraceptives by Health Resources and Services Administration (HRSA)

Eligible benefit plans include coverage under the Affordable Care Act for the following contraceptives to be covered at $0. To determine cost share for medications not listed below, log onto your account at MyPrime.com. Please refer to your benefit materials for coverage details and the plan website for current information as this publication is subject to change. This list will be reviewed periodically and is subject to change.

Generic prescription drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Reference brands may not themselves be covered, please check your benefit. Some generic products have no reference brand. Brand prescription drugs are shown in all capital letters followed by the generic name. Generic medicines are available for many of the brand-name drugs listed though may not be available in all strengths.

CONTRACEPTIVES VCF Vaginal Contraceptive gel - nonoxynol-9 gel 4% Barrier Method Types Cervical Caps Sponge FEMCAP – cervical cap 22 mm TODAY SPONGE – nonoxynol-9 vaginal sponge FEMCAP – cervical cap 26 mm 1000 mg FEMCAP – cervical cap 30 mm Emergency Method Types Diaphragms Emergency Ella CAYA – diaphragm arc-spring ELLA – ulipristal acetate tab 30 mg OMNIFLEX DIAPHRAGM – diaphragms WIDE-SEAL SILICONE DIAPHR – diaphragm wide Emergency Progestin seal 60 mm WIDE-SEAL SILICONE DIAPHR – diaphragm wide Aftera - tab 1.5 mg (Plan B One- seal 65 mm Step) WIDE-SEAL SILICONE DIAPHR – diaphragm wide Econtra Ez - levonorgestrel tab 1.5 mg (Plan B seal 70 mm One-Step) WIDE-SEAL SILICONE DIAPHR – diaphragm wide Econtra One-Step - levonorgestrel tab 1.5 mg (Plan seal 75 mm B One-Step) WIDE-SEAL SILICONE DIAPHR – diaphragm wide levonorgestrel tab 1.5 mg (Plan B One-Step) seal 80 mm My Choice - levonorgestrel tab 1.5 mg (Plan B One- WIDE-SEAL SILICONE DIAPHR – diaphragm wide Step) seal 85 mm My Way - levonorgestrel tab 1.5 mg (Plan B One- WIDE-SEAL SILICONE DIAPHR – diaphragm wide Step) seal 90 mm New Day - levonorgestrel tab 1.5 mg (Plan B One- WIDE-SEAL SILICONE DIAPHR – diaphragm wide Step) seal 95 mm Opcicon One-Step - levonorgestrel tab 1.5 mg (Plan B One-Step) Female Condom Option 2 - levonorgestrel tab 1.5 mg (Plan B One- Step) FC FEMALE CONDOM – condoms - female Preventeza - levonorgestrel tab 1.5 mg (Plan B FC2 FEMALE CONDOM – condoms - female One-Step) React - levonorgestrel tab 1.5 mg (Plan B One- Spermicide Step) ENCARE – nonoxynol-9 vaginal suppos 100 mg Take Action - levonorgestrel tab 1.5 mg (Plan B OPTIONS CONCEPTROL VAGINAL – nonoxynol-9 One-Step) gel 4% OPTIONS GYNOL II VAGINAL – nonoxynol-9 gel 3% SHUR-SEAL – nonoxynol-9 gel 2% Hormonal Method Types VCF VAGINAL CONTRACEPTIVE – nonoxynol-9 film 28% Injectable Progestin VCF VAGINAL CONTRACEPTIVE – nonoxynol-9 medroxyprogesterone acetate im susp 150 mg/ml foam 12.5% (Depo-provera contrac)

Generic Drugs = bold Brand Drugs = ALL CAPITAL LETTERS

6756-A (NONNR version) © Prime Therapeutics LLC 09/20 Product names listed are the property of their respective owners. Page 4 of 7 Hormonal Method Types Cyred - desogestrel & ethinyl tab 0.15 mg-30 mcg Injectable Progestin (continued) Cyred Eq - desogestrel & ethinyl estradiol tab medroxyprogesterone acetate im susp prefilled syr 0.15 mg-30 mcg 150 mg/ml (Depo-provera contrac) Dasetta 7/7/7 - norethindrone-eth estradiol tab 0.5- 35/0.75-35/1-35 mg-mcg CONTRACEPTIVES Delyla - levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg Oral Combined desogest-eth estrad & eth estrad tab 0.15-0.02/ Afirmelle - levonorgestrel & ethinyl estradiol tab 0.01 mg(21/5) (Mircette) 0.1 mg-20 mcg desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg Altavera - levonorgestrel & ethinyl estradiol tab drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz) 0.15 mg-30 mcg drospirenone-ethinyl estradiol tab 3-0.03 mg Alyacen 7/7/7 - norethindrone-eth estradiol tab 0.5- (Yasmin 28) 35/0.75-35/1-35 mg-mcg drospirenone-ethinyl estrad-levomefolate tab 3- Apri - desogestrel & ethinyl estradiol tab 0.15 mg- 0.02-0.451 mg (Beyaz) 30 mcg drospirenone-ethinyl estrad-levomefolate tab 3- Aubra - levonorgestrel & ethinyl estradiol tab 0.03-0.451 mg (Safyral) 0.1 mg-20 mcg Elinest - norgestrel & ethinyl estradiol tab 0.3 mg- Aubra Eq - levonorgestrel & ethinyl estradiol tab 30 mcg 0.1 mg-20 mcg Emoquette - desogestrel & ethinyl estradiol tab Aurovela 1/20 - norethindrone ace & ethinyl 0.15 mg-30 mcg estradiol tab 1 mg-20 mcg (Loestrin 1/20-21) Enpresse-28 - levonorgestrel-eth estra tab 0.05- Aurovela 1.5/30 - norethindrone ace & ethinyl 30/0.075-40/0.125-30mg-mcg estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) Enskyce - desogestrel & ethinyl estradiol tab Aurovela 24 Fe - norethindrone ace-ethinyl 0.15 mg-30 mcg estradiol-fe tab 1 mg-20 mcg (24) Estarylla - norgestimate & ethinyl estradiol tab Aurovela Fe 1/20 - norethindrone ace & ethinyl 0.25 mg-35 mcg estradiol-fe tab 1 mg-20 mcg (Loestrin Fe 1/20) ethynodiol diacetate & ethinyl estradiol tab 1 mg- Aurovela Fe 1.5/30 - norethindrone ace & ethinyl 35 mcg estradiol-fe tab 1.5 mg-30 mcg (Loestrin Fe ethynodiol diacetate & ethinyl estradiol tab 1 mg- 1.5/30) 50 mcg Aviane - levonorgestrel & ethinyl estradiol tab Falmina - levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 0.1 mg-20 mcg Ayuna - levonorgestrel & ethinyl estradiol tab Femynor - norgestimate & ethinyl estradiol tab 0.15 mg-30 mcg 0.25 mg-35 mcg Azurette - desogest-eth estrad & eth estrad tab Gianvi - drospirenone-ethinyl estradiol tab 3- 0.15-0.02/0.01 mg(21/5) (Mircette) 0.02 mg (Yaz) Bekyree - desogest-eth estrad & eth estrad tab Hailey 1.5/30 - norethindrone ace & ethinyl 0.15-0.02/0.01 mg(21/5) (Mircette) estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) Blisovi 24 Fe - norethindrone ace-ethinyl estradiol- Hailey 24 Fe - norethindrone ace-ethinyl estradiol- fe tab 1 mg-20 mcg (24) fe tab 1 mg-20 mcg (24) Blisovi Fe 1/20 - norethindrone ace & ethinyl Isibloom - desogestrel & ethinyl estradiol tab estradiol-fe tab 1 mg-20 mcg (Loestrin Fe 1/20) 0.15 mg-30 mcg Blisovi Fe 1.5/30 - norethindrone ace & ethinyl Jasmiel - drospirenone-ethinyl estradiol tab estradiol-fe tab 1.5 mg-30 mcg (Loestrin Fe 3-0.02 mg (Yaz) 1.5/30) Juleber - desogestrel & ethinyl estradiol tab Caziant - desogest-ethin est tab 0.1-0.025/0.125- 0.15 mg-30 mcg 0.025/0.15-0.025mg-mg Junel 1/20 - norethindrone ace & ethinyl estradiol Chateal - levonorgestrel & ethinyl estradiol tab tab 1 mg-20 mcg (Loestrin 1/20-21) 0.15 mg-30 mcg Junel 1.5/30 - norethindrone ace & ethinyl estradiol Chateal Eq - levonorgestrel & ethinyl estradiol tab tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) 0.15 mg-30 mcg Junel Fe 1/20 - norethindrone ace & ethinyl Cryselle-28 - norgestrel & ethinyl estradiol tab estradiol-fe tab 1 mg-20 mcg (Loestrin Fe 1/20) 0.3 mg-30 mcg Junel Fe 1.5/30 - norethindrone ace & ethinyl Cyclafem 7/7/7 - norethindrone-eth estradiol tab estradiol-fe tab 1.5 mg-30 mcg (Loestrin Fe 0.5-35/0.75-35/1-35 mg-mcg 1.5/30)

Generic Drugs = bold Brand Drugs = ALL CAPITAL LETTERS

6756-A (NONNR version) © Prime Therapeutics LLC 09/20 Product names listed are the property of their respective owners. Page 5 of 7 CONTRACEPTIVES Mibelas 24 Fe - norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24) (Minastrin 24 Fe) Oral Combined (continued) Microgestin 1/20 - norethindrone ace & ethinyl Junel Fe 24 - norethindrone ace-ethinyl estradiol-fe estradiol tab 1 mg-20 mcg (Loestrin 1/20-21) tab 1 mg-20 mcg (24) Microgestin 1.5/30 - norethindrone ace & ethinyl Kaitlib Fe - norethindrone & ethinyl estradiol-fe estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) chew tab 0.8 mg-25 mcg (Generess Fe) Microgestin Fe - norethindrone ace & ethinyl Kalliga - desogestrel & ethinyl estradiol tab estradiol-fe tab 1 mg-20 mcg (Loestrin Fe 1/20) 0.15 mg- 30 mcg Microgestin Fe 1.5/30 - norethindrone ace & ethinyl Kariva - desogest-eth estrad & eth estrad tab 0.15- estradiol-fe tab 1.5 mg-30 mcg (Loestrin Fe 0.02/0.01 mg(21/5) (Mircette) 1.5/30) Kelnor 1/35 - ethynodiol diacetate & ethinyl Mili - norgestimate & ethinyl estradiol tab 0.25 mg- estradiol tab 1 mg-35 mcg 35 mc Kelnor 1/50 - ethynodiol diacetate & ethinyl Mono-Linyah - norgestimate & ethinyl estradiol tab estradiol tab 1 mg-50 mcg 0.25 mg-35 mcg Kurvelo - levonorgestrel & ethinyl estradiol tab Nikki - drospirenone-ethinyl estradiol tab 0.15 mg-30 mcg 3-0.02 mg (Yaz) Larin 1/20 - norethindrone ace & ethinyl estradiol norethindrone & ethinyl estradiol-fe chew tab tab 1 mg-20 mcg (Loestrin 1/20-21) 0.4 mg-35 mcg Larin 1.5/30 - norethindrone ace & ethinyl estradiol norethindrone & ethinyl estradiol-fe chew tab tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) 0.8 mg-25 mcg (Generess Fe) Larin 24 Fe - norethindrone ace-ethinyl estradiol-fe norethindrone ace & ethinyl estradiol tab 1 mg- tab 1 mg-20 mcg (24) 20 mcg (Loestrin 1/20-21) Larin Fe 1/20 - norethindrone ace & ethinyl norethindrone ace & ethinyl estradiol tab 1.5 mg- estradiol-fe tab 1 mg-20 mcg (Loestrin Fe 1/20) 30 mcg (Loestrin 1.5/30-21) Larin Fe 1.5/30 - norethindrone ace & ethinyl norethindrone ace & ethinyl estradiol-fe tab 1 mg- estradiol-fe tab 1.5 mg-30 mcg (Loestrin Fe 20 mcg (Loestrin Fe 1/20) 1.5/30) norethindrone ace & ethinyl estradiol-fe tab Larissia - levonorgestrel & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin Fe 1.5/30) 0.1 mg-20 mcg norethindrone ace-ethinyl estradiol-fe tab 1 mg- Layolis Fe - norethindrone & ethinyl estradiol-fe 20 mcg (24) chew tab 0.8 mg-25 mcg (Generess Fe) norethindrone ace-eth estradiol-fe chew tab 1 mg- Lessina - levonorgestrel & ethinyl estradiol tab 20 mcg (24) (Minastrin 24 Fe) 0.1 mg-20 mcg norgestimate & ethinyl estradiol tab 0.25 mg- Levonest - levonorgestrel-eth estra tab 0.05- 35 mcg 30/0.075-40/0.125-30mg-mcg norgestimate-eth estrad tab 0.18-25/0.215-25/ levonorgestrel & ethinyl estradiol tab 0.1 mg- 0.25-25 mg-mcg 20 mcg norgestimate-eth estrad tab 0.18-35/0.215-35/0.25- levonorgestrel & ethinyl estradiol tab 0.15 mg- 35 mg-mcg 30 mcg Nortrel 7/7/7 - norethindrone-eth estradiol tab 0.5- levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125- 35/0.75-35/1-35 mg-mcg 30mg-mcg Ocella - drospirenone-ethinyl estradiol tab Levora 0.15/30-28 - levonorgestrel & ethinyl 3-0.03 mg (Yasmin 28) estradiol tab 0.15 mg-30 mcg Orsythia - levonorgestrel & ethinyl estradiol tab Lillow - levonorgestrel & ethinyl estradiol tab 0.15 0.1 mg-20 mcg mg-30 mcg Pimtrea - desogest-eth estrad & eth estrad tab Loryna - drospirenone-ethinyl estradiol tab 0.15-0.02/0.01 mg(21/5) (Mircette) 3-0.02 mg (Yaz) Pirmella 7/7/7 - norethindrone-eth estradiol tab 0.5- Low-Ogestrel - norgestrel & ethinyl estradiol tab 35/0.75-35/1-35 mg-mcg 0.3 mg-30 mcg Portia-28 - levonorgestrel & ethinyl estradiol tab Lo-Zumandimine - drospirenone-ethinyl estradiol 0.15 mg-30 mcg tab 3-0.02 mg (Yaz) Previfem - norgestimate & ethinyl estradiol tab Lutera - levonorgestrel & ethinyl estradiol tab 0.25 mg-35 mcg 0.1 mg-20 mcg Reclipsen - desogestrel & ethinyl estradiol tab Marlissa - levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 0.15 mg-30 mcg Simliya - desogest-eth estrad & eth estrad tab 0.15- Melodetta 24 Fe - norethindrone ace-eth estradiol- 0.02/0.01 mg(21/5) (Mircette) fe chew tab 1 mg-20 mcg (24) (Minastrin 24 Fe)

Generic Drugs = bold Brand Drugs = ALL CAPITAL LETTERS

6756-A (NONNR version) © Prime Therapeutics LLC 09/20 Product names listed are the property of their respective owners. Page 6 of 7 CONTRACEPTIVES Wymzya Fe - norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg Oral Combined (continued) Zarah - drospirenone-ethinyl estradiol tab Sprintec 28 - norgestimate & ethinyl estradiol tab 3-0.03 mg (Yasmin 28) 0.25 mg-35 mcg Zovia 1/35E - ethynodiol diacetate & ethinyl Sronyx - levonorgestrel & ethinyl estradiol tab estradiol tab 1 mg-35 mcg 0.1 mg-20 mcg Zumandimine - drospirenone-ethinyl estradiol tab Syeda - drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28) 3-0.03 mg (Yasmin 28) Tarina 24 Fe - norethindrone ace-ethinyl estradiol- Oral Extended Continuous fe tab 1 mg-20 mcg (24) Tarina Fe 1/20 - norethindrone ace & ethinyl Amethyst - levonorgestrel-ethinyl estradiol estradiol-fe tab 1 mg-20 mcg (Loestrin Fe 1/20) (continuous) tab 90-20 mcg Tarina Fe 1/20 Eq - norethindrone ace & ethinyl levonorgestrel-ethinyl estradiol (continuous) tab estradiol-fe tab 1 mg-20 mcg (Loestrin Fe 1/20) 90-20 mcg Tilia Fe - norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep Fe) Oral Progestin Tri-Estarylla - norgestimate-eth estrad tab 0.18- Camila - norethindrone tab 0.35 mg (Ortho 35/0.215-35/0.25-35 mg-mcg Micronor) Tri Femynor - norgestimate-eth estrad tab 0.18- Deblitane - norethindrone tab 0.35 mg (Ortho 35/0.215-35/0.25-35 mg-mcg Micronor) Tri-Legest Fe - norethindrone ac-ethinyl estrad-fe Errin - norethindrone tab 0.35 mg (Ortho Micronor) tab 1-20/1-30/1-35 mg-mcg (Estrostep Fe) Heather - norethindrone tab 0.35 mg (Ortho Tri-Linyah - norgestimate-eth estrad tab 0.18- Micronor) 35/0.215-35/0.25-35 mg-mcg Incassia - norethindrone tab 0.35 mg (Ortho Tri-Lo-Estarylla - norgestimate-eth estrad tab 0.18- Micronor) 25/0.215-25/0.25-25 mg-mcg Jencycla - norethindrone tab 0.35 mg (Ortho Tri-Lo-Marzia - norgestimate-eth estrad tab 0.18- Micronor) 25/0.215-25/0.25-25 mg-mcg Lyza - norethindrone tab 0.35 mg (Ortho Micronor) Tri-Lo-Mili - norgestimate-eth estrad tab 0.18- Nora-Be - norethindrone tab 0.35 mg (Ortho 25/0.215-25/0.25-25 mg-mcg Micronor) Tri-Lo-Sprintec - norgestimate-eth estrad tab 0.18- norethindrone tab 0.35 mg (Ortho Micronor) 25/0.215-25/0.25-25 mg-mcg Norlyda - norethindrone tab 0.35 mg (Ortho Tri-Mili - norgestimate-eth estrad tab 0.18-35/0.215- Micronor) 35/0.25-35 mg-mcg Norlyroc - norethindrone tab 0.35 mg (Ortho Tri-Previfem - norgestimate-eth estrad tab 0.18- Micronor) 35/0.215-35/0.25-35 mg-mcg Sharobel - norethindrone tab 0.35 mg (Ortho Tri-Sprintec - norgestimate-eth estrad tab 0.18- Micronor) 35/0.215-35/0.25-35 mg-mcg Tulana - norethindrone tab 0.35 mg (Ortho Trivora-28 - levonorgestrel-eth estra tab 0.05- Micronor) 30/0.075-40/0.125-30mg-mcg Tri-Vylibra - norgestimate-eth estrad tab 0.18- 35/0.215-35/0.25-35 mg-mcg Tri-Vylibra Lo - norgestimate-eth estrad tab 0.18- 25/0.215-25/0.25-25 mg-mcg Tydemy - drospirenone-ethinyl estrad- levomefolate tab 3-0.03-0.451 mg (Safyral) Velivet - desogest-ethin est tab 0.1-0.025/0.125- 0.025/0.15-0.025mg-mg Vienva - levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg Viorele - desogest-eth estrad & eth estrad tab 0.15- 0.02/0.01 mg(21/5) (Mircette) Volnea - desogest-eth estrad & eth estrad tab 0.15- 0.02/0.01 mg(21/5) (Mircette) Vylibra - norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg

Generic Drugs = bold Brand Drugs = ALL CAPITAL LETTERS

6756-A (NONNR version) © Prime Therapeutics LLC 09/20 Product names listed are the property of their respective owners. Page 7 of 7