UnitedHealthcare Community Plan of Indiana Drug List February 2021

This document can be used as a searchable tool, by using the function CTRL+F, to find items on the preferred drug list (PDL) Please pay close attention to DRUG LABEL NAME, which shows either a brand version or a generic version of the drug. Important: many branded versions of drugs are nonpreferred on the UHC Community Plan of Indiana PDL, if the generically available version is available. For example, ABILIFY is brand name and is nonpreferred while ARIPIPRAZOLE is the available generic and is preferred). Information regarding formulary status, whether prior authorization is required, and other utilization management edits is contained in the right sided columns for each drug name in each row. This document is not listed in alphabetical order by drug name, rather drugs are grouped together by drug class. It is advised to use the search tool to find a drug name, brand or generic, that you are looking to locate. This list is a representative list of drug coverage and coverage changes may occur after publication. This list represents drugs covered under the pharmacy benefit and does not reflect medical benefit drugs or their coverage. CMS approved manufacturers are covered under the Medicaid program (“approved labelers”). The Indiana Preferred Diabetes Supply List (PDSL) aligns with the Indiana state covered list per FSSA and are not represented in this document. Please refer to the Indiana State Medicaid website at https://inm- providerportal.optum.com/providerportal/faces/PreLogin.jsp , click on “Preferred Products”, then “Preferred Diabetic Supply List” for a list of preferred blood glucose monitors, test strips and information relation to the manufacturers and customer assistance for each manufacturer. UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) CEFADROXIL CEFADROXIL CAP 500MG 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEFADROXIL CAP 500 MG P N N Y N CEFADROXIL CEFADROXIL SUS 250/5ML 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEFADROXIL FOR SUSP 250 MG/5ML P N N Y N CEFADROXIL CEFADROXIL SUS 500/5ML 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEFADROXIL FOR SUSP 500 MG/5ML P N N Y N CEFADROXIL CEFADROXIL TAB 1GM 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEFADROXIL TAB 1 GM P N N Y N CEPHALEXIN CEPHALEXIN CAP 250MG 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN CAP 250 MG P N N Y N CEPHALEXIN CEPHALEXIN CAP 500MG 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN CAP 500 MG P N N Y N CEPHALEXIN CEPHALEXIN CAP 750MG 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN CAP 750 MG P N N Y N CEPHALEXIN CEPHALEXIN SUS 125/5ML 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN FOR SUSP 125 MG/5ML P N N Y N CEPHALEXIN CEPHALEXIN SUS 250/5ML 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN FOR SUSP 250 MG/5ML P N N Y N CEPHALEXIN CEPHALEXIN TAB 250MG 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN TAB 250 MG NP Y N N N CEPHALEXIN CEPHALEXIN TAB 500MG 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN TAB 500 MG NP Y N Y N KEFLEX KEFLEX CAP 750MG 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN CAP 750 MG NP Y N Y N CEFACLOR CEFACLOR CAP 250MG 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFACLOR CAP 250 MG P N N Y N CEFACLOR CEFACLOR CAP 500MG 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFACLOR CAP 500 MG P N N Y N CEFACLOR CEFACLOR SUS 125/5ML 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFACLOR FOR SUSP 125 MG/5ML P N N Y N CEFACLOR CEFACLOR SUS 375/5ML 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFACLOR FOR SUSP 375 MG/5ML P N N Y N CEFACLOR ER CEFACLOR ER TAB 500MG 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFACLOR MONOHYDRATE TAB ER 12HR 500 MG NP Y N Y N CEFPROZIL CEFPROZIL SUS 125/5ML 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPROZIL FOR SUSP 125 MG/5ML P N N Y N CEFPROZIL CEFPROZIL SUS 250/5ML 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPROZIL FOR SUSP 250 MG/5ML P N N Y N CEFPROZIL CEFPROZIL TAB 250MG 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPROZIL TAB 250 MG P N N Y N CEFPROZIL CEFPROZIL TAB 500MG 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPROZIL TAB 500 MG P N N Y N CEFUROXIME AXETIL CEFUROXIME TAB 250MG 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFUROXIME AXETIL TAB 250 MG P N N Y N CEFUROXIME AXETIL CEFUROXIME TAB 500MG 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFUROXIME AXETIL TAB 500 MG P N N Y N CEFDINIR CEFDINIR CAP 300MG 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFDINIR CAP 300 MG P N N Y N CEFDINIR CEFDINIR SUS 125/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFDINIR FOR SUSP 125 MG/5ML P N N Y N CEFDINIR CEFDINIR SUS 250/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFDINIR FOR SUSP 250 MG/5ML P N N Y N CEFIXIME CEFIXIME CAP 400MG 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFIXIME CAP 400 MG P N N Y N CEFIXIME CEFIXIME SUS 100/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFIXIME FOR SUSP 100 MG/5ML NP Y N Y Y CEFIXIME CEFIXIME SUS 200/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFIXIME FOR SUSP 200 MG/5ML NP Y N Y Y CEFPODOXIME PROXETIL CEFPODO PROX SUS 100/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPODOXIME PROXETIL FOR SUSP 100 MG/5ML NP Y NYN CEFPODOXIME PROXETIL CEFPODO PROX SUS 50MG/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPODOXIME PROXETIL FOR SUSP 50 MG/5ML NP Y NYN CEFPODOXIME PROXETIL CEFPODOXIME TAB 100MG 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPODOXIME PROXETIL TAB 100 MG NP Y N Y N CEFPODOXIME PROXETIL CEFPODOXIME TAB 200MG 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPODOXIME PROXETIL TAB 200 MG NP Y N Y N SUPRAX SUPRAX CAP 400MG 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFIXIME CAP 400 MG NP Y N Y N SUPRAX SUPRAX CHW 100MG 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFIXIME CHEW TAB 100 MG NP Y N N N SUPRAX SUPRAX SUS 100/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFIXIME FOR SUSP 100 MG/5ML NP Y N Y Y SUPRAX SUPRAX SUS 200/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFIXIME FOR SUSP 200 MG/5ML NP Y N Y Y AVODART AVODART CAP 0.5MG 5-ALPHA-REDUCTASE INHIBITORS DUTASTERIDE CAP 0.5 MG NP Y N Y N DUTASTERIDE DUTASTERIDE CAP 0.5MG 5-ALPHA-REDUCTASE INHIBITORS DUTASTERIDE CAP 0.5 MG NP Y N Y N DUTASTERIDE/TAMSULOSIN HYDROCHLORDUTAST/TAMSU CAP 0.5-0.4 5-ALPHA-REDUCTASE INHIBITORS DUTASTERIDE-TAMSULOSIN HCL CAP 0.5-0.4 MG NP Y N Y N FINASTERIDE FINASTERIDE TAB 5MG 5-ALPHA-REDUCTASE INHIBITORS FINASTERIDE TAB 5 MG P N N Y N JALYN JALYN CAP 5-ALPHA-REDUCTASE INHIBITORS DUTASTERIDE-TAMSULOSIN HCL CAP 0.5-0.4 MG NP Y N Y N PROSCAR PROSCAR TAB 5MG 5-ALPHA-REDUCTASE INHIBITORS FINASTERIDE TAB 5 MG NP Y N Y N ANZEMET ANZEMET TAB 50MG 5-HT3 RECEPTOR ANTAGONISTS DOLASETRON MESYLATE TAB 50 MG NP Y N Y N GRANISETRON HCL GRANISETRON TAB 1MG 5-HT3 RECEPTOR ANTAGONISTS GRANISETRON HCL TAB 1 MG NP Y N Y N ONDANSETRON HCL ONDANSETRON SOL 4MG/5ML 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON HCL ORAL SOLN 4 MG/5ML NP Y N Y N ONDANSETRON HCL ONDANSETRON TAB 24MG 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON HCL TAB 24 MG P N N Y N ONDANSETRON HYDROCHLORIDE ONDANSETRON TAB 4MG 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON HCL TAB 4 MG P N N Y N

Confidential 2/19/2021 Page 1 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ONDANSETRON HYDROCHLORIDE ONDANSETRON TAB 8MG 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON HCL TAB 8 MG P N N Y N ONDANSETRON ODT ONDANSETRON TAB 4MG ODT 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG P N N Y N SANCUSO SANCUSO DIS 3.1MG 5-HT3 RECEPTOR ANTAGONISTS GRANISETRON TD PATCH 3.1 MG/24HR (CONTAINS 34.3 MG) NP Y N Y N ZOFRAN ZOFRAN TAB 4MG 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON HCL TAB 4 MG NP Y N Y N ZUPLENZ ZUPLENZ MIS 4MG 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON ORAL SOLUBLE FILM 4 MG NP Y N Y N AMMONIUM CHLORIDE AMMONIUM GRA CHLORIDE ACIDIFYING AGENTS AMMONIUM CHLORIDE GRANULES NP Y N N N K-PHOS NO 2 K-PHOS TAB NO 2 ACIDIFYING AGENTS POTASSIUM & SODIUM ACID PHOSPHATES TAB 305-700 MG NP Y N N N RIMANTADINE HYDROCHLORIDE RIMANTADINE TAB 100MG ADAMANTANE ANTIVIRALS RIMANTADINE HYDROCHLORIDE TAB 100 MG P N N Y N AMANTADINE HCL AMANTADINE CAP 100MG ADAMANTANES (CNS) AMANTADINE HCL CAP 100 MG P N N Y N AMANTADINE HCL AMANTADINE SYP 50MG/5ML ADAMANTANES (CNS) AMANTADINE HCL SYRUP 50 MG/5ML P N N Y N AMANTADINE HCL AMANTADINE TAB 100MG ADAMANTANES (CNS) AMANTADINE HCL TAB 100 MG NP Y N N N AMANTADINE HYDROCHLORIDE AMANTADINE TAB 100MG ADAMANTANES (CNS) AMANTADINE HCL TAB 100 MG NP Y N N N GOCOVRI GOCOVRI CAP 68.5MG ADAMANTANES (CNS) AMANTADINE HCL CAP ER 24HR 68.5 MG (BASE EQUIVALENT) NP Y N Y N OSMOLEX ER OSMOLEX ER TAB ADAMANTANES (CNS) AMANTADINE HCL TAB ER 24HR PAK 129 MG & 193 MG (322 MG DOSE) NP Y N Y N OSMOLEX ER OSMOLEX ER TAB 129MG ADAMANTANES (CNS) AMANTADINE HCL TAB ER 24HR 129 MG (BASE EQUIVALENT) NP Y N Y N AIRDUO DIGIHALER 113/14 AIRDUO DGHLR INH 113-14 ADRENALS FLUTICASONE-SALMETEROL AER POWDER BA 113-14 MCG/ACT W/SENSOR NP Y N Y N AIRDUO DIGIHALER 232/14 AIRDUO DGHLR INH 232-14 ADRENALS FLUTICASONE-SALMETEROL AER POWDER BA 232-14 MCG/ACT W/SENSOR NP Y N Y N AIRDUO DIGIHALER 55/14 AIRDUO DGHLR INH 55-14 ADRENALS FLUTICASONE-SALMETEROL AER POWDER BA 55-14 MCG/ACT W/ SENSOR NP Y N Y N AIRDUO RESPICLICK 113/14 AIRDUO RESPI INH 113-14 ADRENALS FLUTICASONE-SALMETEROL AER POWDER BA 113-14 MCG/ACT NP Y N Y N AIRDUO RESPICLICK 232/14 AIRDUO RESPI INH 232-14 ADRENALS FLUTICASONE-SALMETEROL AER POWDER BA 232-14 MCG/ACT NP Y N Y N AIRDUO RESPICLICK 55/14 AIRDUO RESPI INH 55-14 ADRENALS FLUTICASONE-SALMETEROL AER POWDER BA 55-14 MCG/ACT NP Y N Y N ALKINDI SPRINKLE ALKINDI SPRI CAP 0.5MG ADRENALS HYDROCORTISONE CAP SPRINKLE 0.5 MG NP Y N Y N ALKINDI SPRINKLE ALKINDI SPRI CAP 2MG ADRENALS HYDROCORTISONE CAP SPRINKLE 2 MG NP Y N Y N ALKINDI SPRINKLE ALKINDI SPRI CAP 5MG ADRENALS HYDROCORTISONE CAP SPRINKLE 5 MG NP Y N Y N ALVESCO ALVESCO AER 80MCG ADRENALS CICLESONIDE INHAL AEROSOL 80 MCG/ACT NP Y N N N ARMONAIR DIGIHALER ARMONAIR DIG AER 55MCG ADRENALS FLUTICASONE PROPIONATE AER POW BA 55 MCG/ACT WITH SENSOR NP Y N Y N ARNUITY ELLIPTA ARNUITY ELPT INH 50MCG ADRENALS FLUTICASONE FUROATE AEROSOL POWDER BREATH ACTIV 50 MCG/ACT P N N Y N ASMANEX HFA ASMANEX HFA AER 200 MCG ADRENALS MOMETASONE FUROATE INHAL AEROSOL SUSPENSION 200 MCG/ACT P N N Y Y ASMANEX HFA ASMANEX HFA AER 50MCG ADRENALS MOMETASONE FUROATE INHAL AEROSOL SUSPENSION 50 MCG/ACT P N N Y Y ASMANEX TWISTHALER 120 METERED DOSASMANEX 120 AER 220MCG ADRENALS MOMETASONE FUROATE INHAL POWD 220 MCG/INH (BREATH ACTIVATED) NP Y N Y N ASMANEX TWISTHALER 14 METERED DOSEASMANEX 14 AER 220MCG ADRENALS MOMETASONE FUROATE INHAL POWD 220 MCG/INH (BREATH ACTIVATED) NP Y N Y N ASMANEX TWISTHALER 30 METERED DOSEASMANEX 30 AER 110MCG ADRENALS MOMETASONE FUROATE INHAL POWD 110 MCG/INH (BREATH ACTIVATED) NP Y N Y N ASMANEX TWISTHALER 60 METERED DOSEASMANEX 60 AER 220MCG ADRENALS MOMETASONE FUROATE INHAL POWD 220 MCG/INH (BREATH ACTIVATED) NP Y N Y N ASMANEX TWISTHALER 7 METERED DOSES ASMANEX 7 AER 110MCG ADRENALS MOMETASONE FUROATE INHAL POWD 110 MCG/INH (BREATH ACTIVATED) NP Y N Y N BREO ELLIPTA BREO ELLIPTA INH 100-25 ADRENALS FLUTICASONE FUROATE-VILANTEROL AERO POWD BA 100-25 MCG/INH NP Y N Y N BREZTRI AEROSPHERE BREZTRI AERO AER SPHERE ADRENALS BUDESONIDE-GLYCOPYRROLATE-FORMOTEROL AERS 160-9-4.8 MCG/ACT NP Y N Y N BUDESONIDE BUDESONIDE CAP 3MG DR ADRENALS BUDESONIDE DELAYED RELEASE PARTICLES CAP 3 MG P Y N Y N BUDESONIDE BUDESONIDE SUS 0.25MG/2 ADRENALS BUDESONIDE INHALATION SUSP 0.25 MG/2ML P N N Y Y BUDESONIDE ER BUDESONIDE TAB ER 9MG ADRENALS BUDESONIDE TAB ER 24HR 9 MG NP Y N Y N BUDESONIDE/FORMOTEROL FUMARATE D BUDES/FORMOT AER 80-4.5 ADRENALS BUDESONIDE-FORMOTEROL FUMARATE DIHYD AEROSOL 80-4.5 MCG/ACT NP Y N Y Y CONTRAST ALLERGY PREMED PACK CONTR ALLRGY KIT PREMD PK ADRENALS PREDNISONE TAB 3 X 50 MG & DIPHENHYDRAMINE CAP 1 X 50 MG KIT NP Y N Y N CORTEF CORTEF TAB 10MG ADRENALS HYDROCORTISONE TAB 10 MG NP Y N Y N CORTEF CORTEF TAB 20MG ADRENALS HYDROCORTISONE TAB 20 MG NP Y N Y N CORTEF CORTEF TAB 5MG ADRENALS HYDROCORTISONE TAB 5 MG NP Y N Y N DECADRON DECADRON TAB 0.5MG ADRENALS DEXAMETHASONE TAB 0.5 MG P N N N N DECADRON DECADRON TAB 4MG ADRENALS DEXAMETHASONE TAB 4 MG P N N Y N DECADRON DECADRON TAB 6MG ADRENALS DEXAMETHASONE TAB 6 MG P N N Y N DEXABLISS DEXABLISS TAB 1.5MG ADRENALS DEXAMETHASONE TAB THERAPY PACK 1.5 MG (39) NP Y N Y N

Confidential 2/19/2021 Page 2 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) DEXAMETHASON TAB 0.75MG DEXAMETHASON TAB 0.75MG ADRENALS DEXAMETHASONE TAB 0.75 MG P N N N N DEXAMETHASONE DEXAMETHASON ELX 0.5/5ML ADRENALS DEXAMETHASONE ELIXIR 0.5 MG/5ML P N N Y N DEXAMETHASONE DEXAMETHASON TAB 0.5MG ADRENALS DEXAMETHASONE TAB 0.5 MG P N N N N DEXAMETHASONE DEXAMETHASON TAB 1.5MG ADRENALS DEXAMETHASONE TAB 1.5 MG P N N Y N DEXAMETHASONE DEXAMETHASON TAB 4MG ADRENALS DEXAMETHASONE TAB 4 MG P N N Y N DEXAMETHASONE DEXAMETHASON TAB 6MG ADRENALS DEXAMETHASONE TAB 6 MG P N N Y N DEXAMETHASONE 10-DAY DOSE PACK DEXAMETHASON TAB 10-DAY ADRENALS DEXAMETHASONE TAB THERAPY PACK 1.5 MG (35) NP Y N N N DEXAMETHASONE 13-DAY DOSE PACK DEXAMETHASON TAB 13-DAY ADRENALS DEXAMETHASONE TAB THERAPY PACK 1.5 MG (51) NP Y N N N DEXAMETHASONE INTENSOL DEXAMETHASON CON 1MG/ML ADRENALS DEXAMETHASONE CONC 1 MG/ML P N N N N DULERA DULERA AER 50-5MCG ADRENALS MOMETASONE FUROATE-FORMOTEROL FUMARATE AEROSOL 50-5 MCG/ACT NP Y N Y N DXEVO 11-DAY DXEVO 11-DAY PAK 1.5MG ADRENALS DEXAMETHASONE TAB THERAPY PACK 1.5 MG (39) NP Y N Y N EMFLAZA EMFLAZA SUS 22.75/ML ADRENALS DEFLAZACORT SUSP 22.75 MG/ML NP Y N Y N EMFLAZA EMFLAZA TAB 18MG ADRENALS DEFLAZACORT TAB 18 MG NP Y N N N EMFLAZA EMFLAZA TAB 6MG ADRENALS DEFLAZACORT TAB 6 MG NP Y N Y N ENTOCORT EC ENTOCORT EC CAP 3MG DR ADRENALS BUDESONIDE DELAYED RELEASE PARTICLES CAP 3 MG NP Y N Y N FLOVENT DISKUS FLOVENT DISK AER 50MCG ADRENALS FLUTICASONE PROPIONATE AER POW BA 50 MCG/BLISTER NP Y N Y N FLOVENT HFA FLOVENT HFA AER 110MCG ADRENALS FLUTICASONE PROPIONATE HFA INHAL AER 110 MCG/ACT (125/VALVE) NP Y N Y N FLOVENT HFA FLOVENT HFA AER 220MCG ADRENALS FLUTICASONE PROPIONATE HFA INHAL AER 220 MCG/ACT (250/VALVE) NP Y N Y N FLOVENT HFA FLOVENT HFA AER 44MCG ADRENALS FLUTICASONE PROPIONATE HFA INHAL AERO 44 MCG/ACT (50/VALVE) NP Y N Y N FLUDROCORTISONE ACETATE FLUDROCORT TAB 0.1MG ADRENALS FLUDROCORTISONE ACETATE TAB 0.1 MG P N N Y N FLUTICASONE PROPIONATE/SALMETEROL FLUTIC/SALME INH 55/14 ADRENALS FLUTICASONE-SALMETEROL AER POWDER BA 55-14 MCG/ACT P N N Y N HEMADY HEMADY TAB 20MG ADRENALS DEXAMETHASONE TAB 20 MG NP Y N Y N HIDEX 6-DAY HIDEX 6-DAY PAK 1.5MG ADRENALS DEXAMETHASONE TAB THERAPY PACK 1.5 MG (21) NP Y N N N HYDROCORTISONE HYDROCORT TAB 10MG ADRENALS HYDROCORTISONE TAB 10 MG P N N Y N HYDROCORTISONE HYDROCORT TAB 20MG ADRENALS HYDROCORTISONE TAB 20 MG P N N Y N HYDROCORTISONE HYDROCORT TAB 5MG ADRENALS HYDROCORTISONE TAB 5 MG P N N Y N MEDROL MEDROL TAB 2MG ADRENALS METHYLPREDNISOLONE TAB 2 MG P N N N N MEDROL MEDROL TAB 32MG ADRENALS METHYLPREDNISOLONE TAB 32 MG NP Y N Y N MEDROL MEDROL TAB 4MG ADRENALS METHYLPREDNISOLONE TAB 4 MG NP Y N Y N MEDROL MEDROL TAB 8MG ADRENALS METHYLPREDNISOLONE TAB 8 MG NP Y N Y N MEDROL DOSEPAK MEDROL TAB 4MG ADRENALS METHYLPREDNISOLONE TAB THERAPY PACK 4 MG (21) NP Y N Y N METHYLPREDNISOLONE METHYLPRED TAB 32MG ADRENALS METHYLPREDNISOLONE TAB 32 MG P N N Y N METHYLPREDNISOLONE METHYLPRED TAB 4MG ADRENALS METHYLPREDNISOLONE TAB 4 MG P N N Y N METHYLPREDNISOLONE METHYLPRED TAB 8MG ADRENALS METHYLPREDNISOLONE TAB 8 MG P N N Y N MILLIPRED MILLIPRED TAB 5MG ADRENALS PREDNISOLONE TAB 5 MG NP Y N Y N MILLIPRED DP MILLIPRED DP PAK 5MG ADRENALS PREDNISOLONE TAB THERAPY PACK 5 MG (48) NP Y N N N ORAPRED ODT ORAPRED ODT TAB 10MG ADRENALS PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 10 MG (BASE EQ) NP Y N Y N ORAPRED ODT ORAPRED ODT TAB 15MG ADRENALS PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 15 MG (BASE EQ) NP Y N Y N ORAPRED ODT ORAPRED ODT TAB 30MG ADRENALS PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 30 MG (BASE EQ) NP Y N N N ORTIKOS ORTIKOS CAP 6MG ER ADRENALS BUDESONIDE CAP ER 24HR 6 MG NP Y N Y N PEDIAPRED PEDIAPRED SOL 5MG/5ML ADRENALS PREDNISOLONE SOD PHOSPH ORAL SOLN 6.7 MG/5ML (5 MG/5ML BASE) NP Y N Y N PREDNISOLONE PREDNISOLONE SOL 15MG/5ML ADRENALS PREDNISOLONE SYRUP 15 MG/5ML (USP SOLUTION EQUIVALENT) P N N Y N PREDNISOLONE SODIUM PHOSPHATE PRED SOD PHO SOL 5MG/5ML ADRENALS PREDNISOLONE SOD PHOSPH ORAL SOLN 6.7 MG/5ML (5 MG/5ML BASE) P N N Y N PREDNISOLONE SODIUM PHOSPHATE PREDNISOLONE SOL 10MG/5ML ADRENALS PREDNISOLONE SOD PHOSPHATE ORAL SOLN 10 MG/5ML (BASE EQUIV) NP Y N Y N PREDNISOLONE SODIUM PHOSPHATE PREDNISOLONE SOL 20MG/5ML ADRENALS PREDNISOLONE SOD PHOSPHATE ORAL SOLN 20 MG/5ML (BASE EQUIV) NP Y N Y N PREDNISOLONE SODIUM PHOSPHATE PREDNISOLONE SOL 25MG/5ML ADRENALS PREDNISOLONE SODIUM PHOSPHATE ORAL SOLN 25 MG/5ML (BASE EQ) NP Y N Y N PREDNISOLONE SODIUM PHOSPHATE ODT PREDNISOLONE TAB 10MG ODT ADRENALS PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 10 MG (BASE EQ) NP Y NYN PREDNISOLONE SODIUM PHOSPHATE ODT PREDNISOLONE TAB 15MG ODT ADRENALS PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 15 MG (BASE EQ) NP Y NYN

Confidential 2/19/2021 Page 3 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) PREDNISOLONE SODIUM PHOSPHATE ODT PREDNISOLONE TAB 30MG ODT ADRENALS PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 30 MG (BASE EQ) NP Y NNN PREDNISONE PREDNISONE PAK 10MG ADRENALS PREDNISONE TAB THERAPY PACK 10 MG (21) P N N Y N PREDNISONE PREDNISONE PAK 5MG ADRENALS PREDNISONE TAB THERAPY PACK 5 MG (21) P N N N N PREDNISONE PREDNISONE SOL 5MG/5ML ADRENALS PREDNISONE ORAL SOLN 5 MG/5ML P N N Y N PREDNISONE PREDNISONE TAB 10MG ADRENALS PREDNISONE TAB 10 MG P N N Y N PREDNISONE PREDNISONE TAB 1MG ADRENALS PREDNISONE TAB 1 MG P N N Y N PREDNISONE PREDNISONE TAB 20MG ADRENALS PREDNISONE TAB 20 MG P N N Y N PREDNISONE INTENSOL PREDNISONE CON 5MG/ML ADRENALS PREDNISONE CONC 5 MG/ML NP Y N Y N PULMICORT PULMICORT SUS 0.25MG/2 ADRENALS BUDESONIDE INHALATION SUSP 0.25 MG/2ML NP Y N Y Y PULMICORT FLEXHALER PULMICORT INH 180MCG ADRENALS BUDESONIDE INHAL AERO POWD 180 MCG/ACT (BREATH ACTIVATED) NP Y N Y N PULMICORT FLEXHALER PULMICORT INH 90MCG ADRENALS BUDESONIDE INHAL AERO POWD 90 MCG/ACT (BREATH ACTIVATED) NP Y N Y N QVAR REDIHALER QVAR REDIHA AER 80MCG ADRENALS BECLOMETHASONE DIPROP HFA BREATH ACT INH AER 80 MCG/ACT P N N Y N QVAR REDIHALER QVAR REDIHAL AER 40MCG ADRENALS BECLOMETHASONE DIPROP HFA BREATH ACT INH AER 40 MCG/ACT P N N Y N RAYOS RAYOS TAB 1MG ADRENALS PREDNISONE TAB DELAYED RELEASE 1 MG NP Y N Y N RAYOS RAYOS TAB 5MG ADRENALS PREDNISONE TAB DELAYED RELEASE 5 MG NP Y N Y N SYMBICORT SYMBICORT AER 80-4.5 ADRENALS BUDESONIDE-FORMOTEROL FUMARATE DIHYD AEROSOL 80-4.5 MCG/ACT NP Y N Y Y TAPERDEX 12-DAY TAPERDEX PAK 12-DAY ADRENALS DEXAMETHASONE TAB THERAPY PACK 1.5 MG (49) NP Y N Y N TAPERDEX 6-DAY TAPERDEX PAK 6 DAY ADRENALS DEXAMETHASONE TAB THERAPY PACK 1.5 MG (21) NP Y N N N TAPERDEX 7-DAY TAPERDEX PAK 7-DAY ADRENALS DEXAMETHASONE TAB THERAPY PACK 1.5 MG (27) NP Y N Y N TRELEGY ELLIPTA TRELEGY AER ELLIPTA ADRENALS FLUTICASONE-UMECLIDINIUM-VILANTEROL AEPB 100-62.5-25 MCG/INH NP Y N Y N UCERIS UCERIS TAB 9MG ADRENALS BUDESONIDE TAB ER 24HR 9 MG NP Y N Y N ZCORT 7-DAY ZCORT 7-DAY TAB 1.5MG ADRENALS DEXAMETHASONE TAB THERAPY PACK 1.5 MG (25) NP Y N Y N DISULFIRAM DISULFIRAM TAB 250MG ALCOHOL DETERRENTS DISULFIRAM TAB 250 MG P N N Y N DISULFIRAM DISULFIRAM TAB 500MG ALCOHOL DETERRENTS DISULFIRAM TAB 500 MG P N N N N ALKA-SELTZER HEARTBURN RELIEF ALKA SELTZER TAB HEARTBRN ALKALINIZING AGENTS SODIUM BICARBONATE-CITRIC ACID EFFER TAB 1940-1000 MG NPYNNN CYTRA K CRYSTALS CYTRA K GRA CRYSTALS ALKALINIZING AGENTS POTASSIUM CITRATE & CITRIC ACID POWDER PACK 3300-1002 MG NP Y N N N CYTRA-2 CYTRA-2 SOL ALKALINIZING AGENTS SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML P N N N N E-Z-GAS II E-Z-GAS II GRA ALKALINIZING AGENTS SOD BICARB-CITRIC ACID-SIMETH GRAN PACK 2.21-1.53-0.04 GM NP Y N N N ORACIT ORACIT SOL ALKALINIZING AGENTS SODIUM CITRATE & CITRIC ACID SOLN 490-640 MG/5ML NP Y N N N POTASSIUM CITRATE POT CITRATE GRA ALKALINIZING AGENTS POTASSIUM CITRATE GRANULES NP Y N N N POTASSIUM CITRATE ER POT CITRATE TAB 1080MG ALKALINIZING AGENTS POTASSIUM CITRATE TAB ER 10 MEQ (1080 MG) P N N Y N POTASSIUM CITRATE ER POT CITRATE TAB 540MG ER ALKALINIZING AGENTS POTASSIUM CITRATE TAB ER 5 MEQ (540 MG) P N N N N POTASSIUM CITRATE MONOHYDRATE POT CITRATE GRA MONOHYDR ALKALINIZING AGENTS POTASSIUM CITRATE GRANULES NP Y N N N POTASSIUM CITRATE/CITRIC ACID K CITRATE SOL CITR ACD ALKALINIZING AGENTS POTASSIUM CITRATE & CITRIC ACID SOLN 1100-334 MG/5ML P N NNN POTASSIUM CITRATE/SODIUM CITRATE/CITK/NA CITRATE SOL CITR ACD ALKALINIZING AGENTS POT & SOD CITRATES W/ CIT AC SOLN 550-500-334 MG/5ML NP Y N N N SODIUM ACETATE TRIHYDRATE SODIUM ACETA GRA ALKALINIZING AGENTS SODIUM ACETATE GRANULES NP Y N N N SODIUM CITRATE SOD CITRATE CRY ALKALINIZING AGENTS SODIUM CITRATE CRYSTALS NP Y N N N SODIUM CITRATE ANHYDROUS SOD CITRATE GRA ALKALINIZING AGENTS SODIUM CITRATE GRANULES (BULK) NP Y N N N SODIUM CITRATE DIHYDRATE SODIUM CITRA GRA DIHYDRAT ALKALINIZING AGENTS SODIUM CITRATE DIHYDRATE GRANULES NP Y N N N SODIUM CITRATE/CITRIC ACID SOD CITRATE SOL CITR ACD ALKALINIZING AGENTS SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML P N N N N SODIUM LACTATE SOD LACTATE SOL 60% ALKALINIZING AGENTS SODIUM LACTATE SOLN 60% NP Y N N N TRICITRATES TRICITRATES SOL ALKALINIZING AGENTS POT & SOD CITRATES W/ CIT AC SOLN 550-500-334 MG/5ML NP Y N N N UROCIT-K 10 UROCIT-K 10 TAB ALKALINIZING AGENTS POTASSIUM CITRATE TAB ER 10 MEQ (1080 MG) NP Y N Y N UROCIT-K 15 UROCIT-K 15 TAB ALKALINIZING AGENTS POTASSIUM CITRATE TAB ER 15 MEQ (1620 MG) NP Y N N N UROCIT-K 5 UROCIT-K 5 TAB ALKALINIZING AGENTS POTASSIUM CITRATE TAB ER 5 MEQ (540 MG) NP Y N N N GRASTEK GRASTEK SUB 2800BAU ALLERGENIC EXTRACTS (THERAPEUTIC) TIMOTHY GRASS POLLEN ALLERGEN EXT SL TAB 2800 BAU NP Y N Y N ODACTRA ODACTRA SUB ALLERGENIC EXTRACTS (THERAPEUTIC) *DUST MITE MIXED EXT SL TAB 12 SQ-HDM*** NP Y N Y N ORALAIR ORALAIR SUB 300 IR ALLERGENIC EXTRACTS (THERAPEUTIC) *GRASS MIXED POLLEN EXT SL TAB 300 IR (INDEX OF REACTIVITY)* NP Y N YN

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ORALAIR ADULT STARTER PACK ORALAIR ADLT SUB 300 IR ALLERGENIC EXTRACTS (THERAPEUTIC) *GRASS MIXED POLLEN EXT SL TAB 300 IR (INDEX OF REACTIVITY)* NP Y N Y N ORALAIR CHILDREN/ADOLESCENTS STARTEORALAIR CHLD SUB 100 IR ALLERGENIC EXTRACTS (THERAPEUTIC) *GRASS MIXED POLLEN EXT SL TAB 100 IR (INDEX OF REACTIVITY)* NP Y N Y Y RAGWITEK RAGWITEK SUB ALLERGENIC EXTRACTS (THERAPEUTIC) SHORT RAGWEED POLLEN ALLERGEN EXTRACT SL TAB 12 AMB A 1-U NP Y N Y N LAMISIL LAMISIL TAB 250MG ALLYLAMINE ANTIFUNGALS TERBINAFINE HCL TAB 250 MG NP Y N Y N TERBINAFINE HCL TERBINAFINE TAB 250MG ALLYLAMINE ANTIFUNGALS TERBINAFINE HCL TAB 250 MG P N N Y N TERBINAFINE HYDROCHLORIDE TERBINAFINE TAB 250MG ALLYLAMINE ANTIFUNGALS TERBINAFINE HCL TAB 250 MG P N N Y N GNP TERBINAFINE HYDROCHLORIDE TERBINAFINE CRE 1% ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) TERBINAFINE HCL CREAM 1% P N N N N LAMISIL AT LAMISIL AT CRE 1% ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) TERBINAFINE HCL CREAM 1% P N N N N NAFTIFINE HCL NAFTIFINE CRE HCL 1% ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) NAFTIFINE HCL CREAM 1% NP Y N N N NAFTIFINE HYDROCHLORIDE NAFTIFINE CRE HCL 2% ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) NAFTIFINE HCL CREAM 2% NP Y N N N NAFTIN NAFTIN CRE 2% ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) NAFTIFINE HCL CREAM 2% NP Y N N N ONYCHO-MED ONYCHO-MED KIT 250MG-2% ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) TERBINAFINE HCL POWD 250 MG & MICONAZOLE NITRATE SOLN 2% KIT NP Y N Y N RA ANTIFUNGAL FOOT CARE ANTIFUNGAL CRE FOOT 1% ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) TERBINAFINE HCL CREAM 1% P N N N N ADRENALIN ADRENALIN INJ 1MG/ML ALPHA- AND BETA-ADRENERGIC AGONISTS EPINEPHRINE INJ 1 MG/ML (1:1000) NP Y N Y N ADYPHREN AMP KIT ADYPHREN AMP KIT 1MG/ML ALPHA- AND BETA-ADRENERGIC AGONISTS *EPINEPHRINE INJ KIT 1 MG/ML (1:1000)** NP Y N Y N ADYPHREN II ADYPHREN II KIT ALPHA- AND BETA-ADRENERGIC AGONISTS *EPINEPHRINE INJ KIT 1 MG/ML (1:1000)** NP Y N Y N ADYPHREN KIT ADYPHREN KIT ALPHA- AND BETA-ADRENERGIC AGONISTS *EPINEPHRINE INJ KIT 1 MG/ML (1:1000)** NP Y N Y N ASTHMANEFRIN REFILL ASTHMANEFRIN NEB 2.25% ALPHA- AND BETA-ADRENERGIC AGONISTS RACEPINEPHRINE HCL SOLN NEBU 2.25% (BASE EQUIVALENT)NPYNNN AUVI-Q AUVI-Q INJ 0.1MG ALPHA- AND BETA-ADRENERGIC AGONISTS EPINEPHRINE SOLUTION AUTO-INJECTOR 0.1 MG/0.1ML NP Y N Y N EPINEPHRINE EPINEPHRINE INJ 0.15MG ALPHA- AND BETA-ADRENERGIC AGONISTS EPINEPHRINE SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML (1:2000) P NNYN EPINEPHRINE EPINEPHRINE INJ 0.1MG/ML ALPHA- AND BETA-ADRENERGIC AGONISTS EPINEPHRINE IV SOLN 1 MG/10ML (0.1 MG/ML) NP Y N N N EPINEPHRINE PROFESSIONAL EPINEPHR PRO KIT 1MG/ML ALPHA- AND BETA-ADRENERGIC AGONISTS *EPINEPHRINE INJ KIT 1 MG/ML (1:1000)** NP Y N Y N EPINEPHRINESNAP-EMS EPINEPHRINE KIT 1MG/ML ALPHA- AND BETA-ADRENERGIC AGONISTS *EPINEPHRINE INJ KIT 1 MG/ML (1:1000)** NP Y N Y N EPINEPHRINESNAP-V EPINPHEPHRIN KIT SNAP-V ALPHA- AND BETA-ADRENERGIC AGONISTS *EPINEPHRINE INJ KIT 1 MG/ML (1:1000)** NP Y N Y N EPIPEN 2-PAK EPIPEN 2-PAK INJ 0.3MG ALPHA- AND BETA-ADRENERGIC AGONISTS EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (1:1000) NP YNYN EPIPEN-JR 2-PAK EPIPEN-JR INJ 0.15MG ALPHA- AND BETA-ADRENERGIC AGONISTS EPINEPHRINE SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML (1:2000) NP Y N Y N EPISNAP EPISNAP KIT ALPHA- AND BETA-ADRENERGIC AGONISTS *EPINEPHRINE INJ KIT 1 MG/ML (1:1000)** NP Y N Y N NORTHERA NORTHERA CAP 100MG ALPHA- AND BETA-ADRENERGIC AGONISTS DROXIDOPA CAP 100 MG NP Y N Y N NORTHERA NORTHERA CAP 300MG ALPHA- AND BETA-ADRENERGIC AGONISTS DROXIDOPA CAP 300 MG NP Y N Y N S2 S2 NEB 2.25% ALPHA- AND BETA-ADRENERGIC AGONISTS RACEPINEPHRINE HCL SOLN NEBU 2.25% (BASE EQUIVALENT) NP Y N N N LUCEMYRA LUCEMYRA TAB 0.18MG ALPHA-ADRENERGIC AGONISTS LOFEXIDINE HCL TAB 0.18 MG (BASE EQUIVALENT) NP Y N Y N MIDODRINE HCL MIDODRINE TAB 2.5MG ALPHA-ADRENERGIC AGONISTS MIDODRINE HCL TAB 2.5 MG P N N Y N ALPHAGAN P ALPHAGAN P SOL 0.1% ALPHA-ADRENERGIC AGONISTS (EENT) BRIMONIDINE TARTRATE OPHTH SOLN 0.1% NP Y N Y N ALPHAGAN P ALPHAGAN P SOL 0.15% ALPHA-ADRENERGIC AGONISTS (EENT) BRIMONIDINE TARTRATE OPHTH SOLN 0.15% NP Y N Y N BRIMONIDE/DORZOLAMIDE P-F BRIMO/DORZO SOL 0.15-2% ALPHA-ADRENERGIC AGONISTS (EENT) BRIMONIDINE TARTRATE-DORZOLAMIDE HCL OPHTH SOLN 0.15-2% NP Y N Y N BRIMONIDINE TARTRATE BRIMONIDINE SOL 0.15% ALPHA-ADRENERGIC AGONISTS (EENT) BRIMONIDINE TARTRATE OPHTH SOLN 0.15% P N N Y N BRIMONIDINE TARTRATE BRIMONIDINE SOL 0.2% OP ALPHA-ADRENERGIC AGONISTS (EENT) BRIMONIDINE TARTRATE OPHTH SOLN 0.2% P N N Y N COMBIGAN COMBIGAN SOL 0.2/0.5% ALPHA-ADRENERGIC AGONISTS (EENT) BRIMONIDINE TARTRATE-TIMOLOL MALEATE OPHTH SOLN 0.2-0.5% NP Y N Y N LUMIFY LUMIFY DRO 0.025% ALPHA-ADRENERGIC AGONISTS (EENT) BRIMONIDINE TARTRATE OPHTH SOLN 0.025% NP Y N Y N SIMBRINZA SIMBRINZA SUS 1-0.2% ALPHA-ADRENERGIC AGONISTS (EENT) BRINZOLAMIDE-BRIMONIDINE TARTRATE OPHTH SUSP 1-0.2% NP Y N Y N TIMOLOL/BRIMONIDE/DORZOLAMIDE TIM/BRIM/DOR SOL ALPHA-ADRENERGIC AGONISTS (EENT) TIMOLOL-BRIMONIDINE-DORZOLAMIDE OPHTH SOLN 0.5-0.15-2% NP Y N Y N CARDURA CARDURA TAB 1MG ALPHA-ADRENERGIC BLOCKING AGENTS DOXAZOSIN MESYLATE TAB 1 MG NP Y N Y N CARDURA XL CARDURA XL TAB 4MG ALPHA-ADRENERGIC BLOCKING AGENTS DOXAZOSIN MESYLATE TAB ER 24 HR 4 MG (BASE EQUIV) NP Y N N N DOXAZOSIN DOXAZOSIN TAB 2MG ALPHA-ADRENERGIC BLOCKING AGENTS DOXAZOSIN MESYLATE TAB 2 MG P N N Y N DOXAZOSIN MESYLATE DOXAZOSIN TAB 1MG ALPHA-ADRENERGIC BLOCKING AGENTS DOXAZOSIN MESYLATE TAB 1 MG P N N Y N MINIPRESS MINIPRESS CAP 1MG ALPHA-ADRENERGIC BLOCKING AGENTS PRAZOSIN HCL CAP 1 MG NP Y N N N PRAZOSIN HCL PRAZOSIN HCL CAP 1MG ALPHA-ADRENERGIC BLOCKING AGENTS PRAZOSIN HCL CAP 1 MG P N N N N TERAZOSIN HCL TERAZOSIN CAP 10MG ALPHA-ADRENERGIC BLOCKING AGENTS TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT) P N N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) TERAZOSIN HCL TERAZOSIN CAP 1MG ALPHA-ADRENERGIC BLOCKING AGENTS TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT) P N N Y N TERAZOSIN HYDROCHLORIDE TERAZOSIN CAP 2MG ALPHA-ADRENERGIC BLOCKING AGENTS TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT) P N N Y N ACARBOSE ACARBOSE TAB 25MG ALPHA-GLUCOSIDASE INHIBITORS ACARBOSE TAB 25 MG P N N Y N MIGLITOL MIGLITOL TAB 25MG ALPHA-GLUCOSIDASE INHIBITORS MIGLITOL TAB 25 MG NP Y N Y N MIGLITOL MIGLITOL TAB 50MG ALPHA-GLUCOSIDASE INHIBITORS MIGLITOL TAB 50 MG NP Y N Y N PRECOSE PRECOSE TAB 25MG ALPHA-GLUCOSIDASE INHIBITORS ACARBOSE TAB 25 MG NP Y N Y N PAROMOMYCIN SULFATE PAROMOMYCIN CAP 250MG AMEBICIDES PAROMOMYCIN SULFATE CAP 250 MG P N N Y N ARIKAYCE ARIKAYCE SUS AMINOGLYCOSIDE ANTIBIOTICS AMIKACIN SULFATE LIPOSOME INHAL SUSP 590 MG/8.4ML (BASE EQ) NP Y N Y N BETHKIS BETHKIS NEB 300/4ML AMINOGLYCOSIDE ANTIBIOTICS TOBRAMYCIN NEBU SOLN 300 MG/4ML NP Y N Y N GENTAMICIN SULFATE GENTAMICIN INJ 40MG/ML AMINOGLYCOSIDE ANTIBIOTICS GENTAMICIN SULFATE INJ 40 MG/ML P N N N N GENTAMICIN SULFATE PEDIATRIC GENTAMICIN INJ 10MG/ML AMINOGLYCOSIDE ANTIBIOTICS GENTAMICIN SULFATE INJ 10 MG/ML P N N N N KITABIS PAK KITABIS PAK NEB 300/5ML AMINOGLYCOSIDE ANTIBIOTICS TOBRAMYCIN NEBU SOLN 300 MG/5ML NP Y N Y N NEOMYCIN SULFATE NEOMYCIN TAB 500MG AMINOGLYCOSIDE ANTIBIOTICS NEOMYCIN SULFATE TAB 500 MG P N N Y N TOBI TOBI NEB 300/5ML AMINOGLYCOSIDE ANTIBIOTICS TOBRAMYCIN NEBU SOLN 300 MG/5ML NP Y N Y N TOBI PODHALER TOBI PODHALR CAP 28MG AMINOGLYCOSIDE ANTIBIOTICS TOBRAMYCIN INHAL CAP 28 MG NP Y N Y N TOBRAMYCIN TOBRAMYCIN NEB 300/4ML AMINOGLYCOSIDE ANTIBIOTICS TOBRAMYCIN NEBU SOLN 300 MG/4ML P Y N Y N TOBRAMYCIN TOBRAMYCIN NEB 300/5ML AMINOGLYCOSIDE ANTIBIOTICS TOBRAMYCIN NEBU SOLN 300 MG/5ML NP Y N Y N NUZYRA NUZYRA TAB 150MG AMINOMETHYLCYCLINES OMADACYCLINE TOSYLATE TAB 150 MG (BASE EQUIVALENT) P Y N Y N SEYSARA SEYSARA TAB 60MG AMINOMETHYLCYCLINES SARECYCLINE HCL TAB 60 MG (BASE EQUIVALENT) NP Y N Y N AMOXICILLIN AMOXICILLIN CAP 250MG AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN (TRIHYDRATE) CAP 250 MG P N N Y N AMOXICILLIN AMOXICILLIN CAP 500MG AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN (TRIHYDRATE) CAP 500 MG P N N Y N AMOXICILLIN AMOXICILLIN CHW 125MG AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN (TRIHYDRATE) CHEW TAB 125 MG P N N Y N AMOXICILLIN AMOXICILLIN SUS 125/5ML AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML P N N Y N AMOXICILLIN AMOXICILLIN SUS 200/5ML AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML P N N Y N AMOXICILLIN AMOXICILLIN SUS 250/5ML AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML P N N Y N AMOXICILLIN AMOXICILLIN SUS 400/5ML AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML P N N Y N AMOXICILLIN AMOXICILLIN TAB 500MG AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN (TRIHYDRATE) TAB 500 MG NP Y N Y N AMOXICILLIN AMOXICILLIN TAB 875MG AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN (TRIHYDRATE) TAB 875 MG P N N Y N AMOXICILLIN/CLAVULANATE POTASSIUM AMOX/K CLAV CHW 200MG AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN & K CLAVULANATE CHEW TAB 200-28.5 MG P N N Y N AMOXICILLIN/CLAVULANATE POTASSIUM AMOX/K CLAV CHW 400MG AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN & K CLAVULANATE CHEW TAB 400-57 MGPNNYN AMOXICILLIN/CLAVULANATE POTASSIUM AMOX/K CLAV SUS 200/5ML AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML P N N Y N AMOXICILLIN/CLAVULANATE POTASSIUM AMOX/K CLAV SUS 250/5ML AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML P N N Y N AMOXICILLIN/CLAVULANATE POTASSIUM AMOX/K CLAV SUS 400/5ML AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML P N N Y N AMOXICILLIN/CLAVULANATE POTASSIUM AMOX/K CLAV SUS 600/5ML AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML P N N Y N AMOXICILLIN/CLAVULANATE POTASSIUM AMOX/K CLAV TAB 250-125 AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN & K CLAVULANATE TAB 250-125 MG P NNYN AMOXICILLIN/CLAVULANATE POTASSIUM AMOX/K CLAV TAB 500-125 AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN & K CLAVULANATE TAB 500-125 MG P NNYN AMOXICILLIN/CLAVULANATE POTASSIUM AMOX/K CLAV TAB 875-125 AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN & K CLAVULANATE TAB 875-125 MG P NNYN AMOXICILLIN/CLAVULANATE POTASSIUM EAMOX-POT CLA TAB ER AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN & K CLAVULANATE TAB ER 12HR 1000-62.5 MG NP Y N Y N AMPICILLIN AMPICILLIN CAP 500MG AMINOPENICILLIN ANTIBIOTICS AMPICILLIN CAP 500 MG P N N Y N AUGMENTIN AUGMENTIN SUS 125/5ML AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN & K CLAVULANATE FOR SUSP 125-31.25 MG/5ML NP Y N Y N AUGMENTIN AUGMENTIN SUS 250/5ML AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML NP Y N Y N AUGMENTIN AUGMENTIN TAB 500MG AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN & K CLAVULANATE TAB 500-125 MG NP Y N Y N AUGMENTIN ES-600 AUGMENTIN SUS ES-600 AMINOPENICILLIN ANTIBIOTICS AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML NP Y N Y N BUPHENYL BUPHENYL TAB 500MG AMMONIA DETOXICANTS SODIUM PHENYLBUTYRATE TAB 500 MG NP Y N Y N CARBAGLU CARBAGLU TAB 200MG AMMONIA DETOXICANTS CARGLUMIC ACID TAB 200 MG P Y N N N CHOLAC SYP 10GM/15 CHOLAC SYP 10GM/15 AMMONIA DETOXICANTS LACTULOSE (ENCEPHALOPATHY) SYRUP 10 GM/15ML P N N N N CONSTULOSE CONSTULOSE SOL 10GM/15 AMMONIA DETOXICANTS LACTULOSE SOLUTION 10 GM/15ML P N N Y N ENULOSE ENULOSE SOL 10GM/15 AMMONIA DETOXICANTS LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML P N N Y N

Confidential 2/19/2021 Page 6 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) GENERLAC GENERLAC SOL 10GM/15 AMMONIA DETOXICANTS LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML P N N Y N KRISTALOSE KRISTALOSE PAK 10GM AMMONIA DETOXICANTS LACTULOSE ORAL CRYSTAL PACKET 10 GM NP Y N Y N KRISTALOSE KRISTALOSE PAK 20GM AMMONIA DETOXICANTS LACTULOSE ORAL CRYSTAL PACKET 20 GM NP Y N Y N LACTULOSE LACTULOSE PAK 10GM AMMONIA DETOXICANTS LACTULOSE ORAL CRYSTAL PACKET 10 GM NP Y N Y N LACTULOSE LACTULOSE SOL 10GM/15 AMMONIA DETOXICANTS LACTULOSE SOLUTION 10 GM/15ML P N N Y N LITHOSTAT LITHOSTAT TAB 250MG AMMONIA DETOXICANTS ACETOHYDROXAMIC ACID TAB 250 MG NP Y N N N RAVICTI RAVICTI LIQ 1.1GM/ML AMMONIA DETOXICANTS GLYCEROL PHENYLBUTYRATE LIQUID 1.1 GM/ML P Y N Y N SODIUM PHENYLBUTYRATE SODIUM PHENY TAB 500MG AMMONIA DETOXICANTS SODIUM PHENYLBUTYRATE TAB 500 MG NP Y N Y N ADDERALL ADDERALL TAB 5MG AMPHETAMINES AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG NP Y N Y Y ADDERALL XR ADDERALL XR CAP 20MG AMPHETAMINES AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG NP Y N Y Y ADDERALL XR ADDERALL XR CAP 5MG AMPHETAMINES AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG NP Y N Y Y ADZENYS ER ADZENYS ER SUS 1.25MG AMPHETAMINES AMPHETAMINE EXTENDED RELEASE SUSP 1.25 MG/ML P N N Y Y ADZENYS XR-ODT ADZENYS XR TAB 3.1MG AMPHETAMINES AMPHETAMINE TAB EXTENDED RELEASE DISINTEGRATING 3.1 MG P N N Y Y AMPHETAMINE ER AMPHETAMI ER SUS 1.25/ML AMPHETAMINES AMPHETAMINE EXTENDED RELEASE SUSP 1.25 MG/ML P N N Y Y AMPHETAMINE SULFATE AMPHETAMINE TAB 10MG AMPHETAMINES AMPHETAMINE SULFATE TAB 10 MG P N N Y Y AMPHETAMINE SULFATE AMPHETAMINE TAB 5MG AMPHETAMINES AMPHETAMINE SULFATE TAB 5 MG P N N Y Y AMPHETAMINE/DEXTROAMPHETAMINE AMPHET/DEXTR CAP 20MG ER AMPHETAMINES AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG P N N Y Y AMPHETAMINE/DEXTROAMPHETAMINE AMPHET/DEXTR CAP 5MG ER AMPHETAMINES AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG P N N Y Y AMPHETAMINE/DEXTROAMPHETAMINE AMPHET/DEXTR TAB 5MG AMPHETAMINES AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG P N N Y Y DESOXYN DESOXYN TAB 5MG AMPHETAMINES METHAMPHETAMINE HCL TAB 5 MG NP Y N N Y DEXEDRINE DEXEDRINE CAP 5MG CR AMPHETAMINES DEXTROAMPHETAMINE SULFATE CAP ER 24HR 5 MG NP Y N Y Y DEXTROAMPHETAMINE SULFATE DEXTROAMPHET SOL 5MG/5ML AMPHETAMINES DEXTROAMPHETAMINE SULFATE ORAL SOLUTION 5 MG/5ML P N N Y Y DEXTROAMPHETAMINE SULFATE DEXTROAMPHET TAB 10MG AMPHETAMINES DEXTROAMPHETAMINE SULFATE TAB 10 MG P N N Y Y DEXTROAMPHETAMINE SULFATE DEXTROAMPHET TAB 5MG AMPHETAMINES DEXTROAMPHETAMINE SULFATE TAB 5 MG P N N Y Y DEXTROAMPHETAMINE SULFATE ER DEXTROAMPHET CAP 5MG ER AMPHETAMINES DEXTROAMPHETAMINE SULFATE CAP ER 24HR 5 MG P N N Y Y DYANAVEL XR DYANAVEL XR SUS 2.5MG/ML AMPHETAMINES AMPHETAMINE EXTENDED RELEASE SUSP 2.5 MG/ML P N N Y Y EVEKEO EVEKEO TAB 10MG AMPHETAMINES AMPHETAMINE SULFATE TAB 10 MG NP Y N Y Y EVEKEO EVEKEO TAB 5MG AMPHETAMINES AMPHETAMINE SULFATE TAB 5 MG NP Y N Y Y EVEKEO ODT EVEKEO ODT TAB 5MG AMPHETAMINES AMPHETAMINE SULFATE ORALLY DISINTEGRATING TAB 5 MG P N N Y Y METHAMPHETAMINE HCL METHAMPHETAM TAB 5MG AMPHETAMINES METHAMPHETAMINE HCL TAB 5 MG P N N N Y MYDAYIS MYDAYIS CAP 12.5MG AMPHETAMINES AMPHETAMINE-DEXTROAMPHETAMINE 3-BEAD CAP ER 24HR 12.5 MG P N N Y Y PROCENTRA PROCENTRA SOL 5MG/5ML AMPHETAMINES DEXTROAMPHETAMINE SULFATE ORAL SOLUTION 5 MG/5ML NP Y N Y Y VYVANSE VYVANSE CAP 10MG AMPHETAMINES LISDEXAMFETAMINE DIMESYLATE CAP 10 MG P N N Y Y ZENZEDI ZENZEDI TAB 10MG AMPHETAMINES DEXTROAMPHETAMINE SULFATE TAB 10 MG NP Y N Y Y ZENZEDI ZENZEDI TAB 2.5MG AMPHETAMINES DEXTROAMPHETAMINE SULFATE TAB 2.5 MG P N N Y Y ZENZEDI ZENZEDI TAB 5MG AMPHETAMINES DEXTROAMPHETAMINE SULFATE TAB 5 MG NP Y N Y Y ZENZEDI ZENZEDI TAB 7.5MG AMPHETAMINES DEXTROAMPHETAMINE SULFATE TAB 7.5 MG P N N Y Y SYMLINPEN 120 SYMLNPEN 120 INJ 1000MCG AMYLINOMIMETICS PRAMLINTIDE ACETATE PEN-INJ 2700 MCG/2.7ML (1000 MCG/ML) P Y N Y N SYMLINPEN 60 SYMLINPEN 60 INJ 1000MCG AMYLINOMIMETICS PRAMLINTIDE ACETATE PEN-INJ 1500 MCG/1.5ML (1000 MCG/ML) P Y N Y N ALLZITAL ALLZITAL TAB 25-325MG ANALGESICS AND ANTIPYRETICS, MISC. BUTALBITAL-ACETAMINOPHEN TAB 25-325 MG NP Y N Y N AMINOFEN AMINOFEN TAB 325MG ANALGESICS AND ANTIPYRETICS, MISC. ACETAMINOPHEN TAB 325 MG P N N N N BAC BAC TAB ANALGESICS AND ANTIPYRETICS, MISC. BUTALBITAL-ACETAMINOPHEN-CAFFEINE TAB 50-325-40 MG P N N Y N BUPAP BUPAP TAB 50-300MG ANALGESICS AND ANTIPYRETICS, MISC. BUTALBITAL-ACETAMINOPHEN TAB 50-300 MG NP Y N N N BUTALBITAL/ACETAMINOPHEN BUTAL/ACETAM TAB 25-325MG ANALGESICS AND ANTIPYRETICS, MISC. BUTALBITAL-ACETAMINOPHEN TAB 25-325 MG NP Y N Y N BUTALBITAL/ACETAMINOPHEN BUTAL/APAP TAB 50-325MG ANALGESICS AND ANTIPYRETICS, MISC. BUTALBITAL-ACETAMINOPHEN TAB 50-325 MG P N N Y N BUTALBITAL/ACETAMINOPHEN BUTALB/ACETA TAB 50-300MG ANALGESICS AND ANTIPYRETICS, MISC. BUTALBITAL-ACETAMINOPHEN TAB 50-300 MG NP Y N N N BUTALBITAL/ACETAMINOPHEN/CAFFEINE BUT/APAP/CAF CAP ANALGESICS AND ANTIPYRETICS, MISC. BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-300-40 MG NP Y N N N CHILDRENS ACETAMINOPHEN CHILD APAP TAB 80MG ANALGESICS AND ANTIPYRETICS, MISC. ACETAMINOPHEN DISINTEGRATING TAB 80 MG NP Y N N N

Confidential 2/19/2021 Page 7 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) CHILDRENS APAP CHILDRENS CHW APAP ANALGESICS AND ANTIPYRETICS, MISC. ACETAMINOPHEN CHEW TAB 80 MG P N N N Y FIORICET FIORICET CAP ANALGESICS AND ANTIPYRETICS, MISC. BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-300-40 MG NP Y N N N GABACAINE GABACAINE PAK ANALGESICS AND ANTIPYRETICS, MISC. *GABAPENTIN CAP 300 MG & LIDOCAINE PATCH 5% THERAPY PACK*** NP Y N Y N ILARIS ILARIS INJ 150MG/ML ANALGESICS AND ANTIPYRETICS, MISC. CANAKINUMAB SUBCUTANEOUS INJ 150 MG/ML P Y N Y N LYRICA CR LYRICA CR TAB 330MG ANALGESICS AND ANTIPYRETICS, MISC. PREGABALIN TAB ER 24HR 330 MG NP Y N Y N LYRICA CR LYRICA CR TAB 82.5MG ANALGESICS AND ANTIPYRETICS, MISC. PREGABALIN TAB ER 24HR 82.5 MG NP Y N Y N NEURAPTINE NEURAPTINE CRE 10% ANALGESICS AND ANTIPYRETICS, MISC. GABAPENTIN CREAM 10% NP Y N Y N TENCON TENCON TAB 50-325MG ANALGESICS AND ANTIPYRETICS, MISC. BUTALBITAL-ACETAMINOPHEN TAB 50-325 MG P N N Y N ANADROL-50 ANADROL-50 TAB 50MG ANDROGENS OXYMETHOLONE TAB 50 MG NP Y N N N ANDRODERM ANDRODERM DIS 2MG/24HR ANDROGENS TESTOSTERONE TD PATCH 24HR 2 MG/24HR NP Y N Y N ANDROGEL ANDROGEL GEL 1%(25MG) ANDROGENS TESTOSTERONE TD GEL 25 MG/2.5GM (1%) NP Y N Y N ANDROGEL ANDROGEL GEL 1.62% ANDROGENS TESTOSTERONE TD GEL 20.25 MG/1.25GM (1.62%) NP Y N Y N DANAZOL DANAZOL CAP 200MG ANDROGENS DANAZOL CAP 200 MG P N N Y N DANAZOL DANAZOL CAP 50MG ANDROGENS DANAZOL CAP 50 MG P N N Y N DEPO-TESTOSTERONE DEPO-TESTOST INJ 100MG/ML ANDROGENS TESTOSTERONE CYPIONATE IM INJ IN OIL 100 MG/ML NP Y N N N DEPO-TESTOSTERONE DEPO-TESTOST INJ 200MG/ML ANDROGENS TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML NP Y N Y N JATENZO JATENZO CAP 158MG ANDROGENS TESTOSTERONE UNDECANOATE CAP 158 MG NP Y N Y N JATENZO JATENZO CAP 237MG ANDROGENS TESTOSTERONE UNDECANOATE CAP 237 MG NP Y N Y N METHITEST METHITEST TAB 10MG ANDROGENS METHYLTESTOSTERONE ORAL TAB 10 MG NP Y N Y N METHYLTESTOSTERONE METHYLTESTOS CAP 10MG ANDROGENS METHYLTESTOSTERONE CAP 10 MG NP Y N Y N NATESTO NATESTO GEL 5.5MG ANDROGENS TESTOSTERONE NASAL GEL 5.5 MG/ACT NP Y N Y N OXANDROLONE OXANDROLONE TAB 10MG ANDROGENS OXANDROLONE TAB 10 MG NP Y N Y N OXANDROLONE OXANDROLONE TAB 2.5MG ANDROGENS OXANDROLONE TAB 2.5 MG NP Y N Y N STRIANT STRIANT MIS 30MG ANDROGENS TESTOSTERONE BUCCAL MUCOADHESIVE SYSTEM 30 MG NP Y N N N TESTIM TESTIM GEL 1%(50MG) ANDROGENS TESTOSTERONE TD GEL 50 MG/5GM (1%) NP Y N Y N TESTOSTERONE TESTOSTERONE GEL 1%(25MG) ANDROGENS TESTOSTERONE TD GEL 25 MG/2.5GM (1%) P Y N Y N TESTOSTERONE TESTOSTERONE GEL 1.62% ANDROGENS TESTOSTERONE TD GEL 20.25 MG/1.25GM (1.62%) NP Y N Y N TESTOSTERONE CYPIONATE TESTOST CYP INJ 100MG/ML ANDROGENS TESTOSTERONE CYPIONATE IM INJ IN OIL 100 MG/ML P N N N N TESTOSTERONE CYPIONATE TESTOST CYP INJ 200MG/ML ANDROGENS TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML P N N Y N TESTOSTERONE ENANTHATE TESTOST ENAN INJ 200MG/ML ANDROGENS TESTOSTERONE ENANTHATE IM INJ IN OIL 200 MG/ML P N N Y N TESTOSTERONE PUMP TESTOSTERONE GEL PUMP 1% ANDROGENS TESTOSTERONE TD GEL 12.5 MG/ACT (1%) P Y N Y N TESTOSTERONE TOPICAL SOLUTION TESTOSTERONE SOL 30MG/ACT ANDROGENS TESTOSTERONE TD SOLN 30 MG/ACT NP Y N Y N VOGELXO VOGELXO GEL 1%(50MG) ANDROGENS TESTOSTERONE TD GEL 50 MG/5GM (1%) NP Y N Y N XYOSTED XYOSTED INJ 50/0.5 ANDROGENS TESTOSTERONE ENANTHATE SOLUTION AUTO-INJECTOR 50 MG/0.5ML NP Y N Y N ATACAND ATACAND TAB 32MG ANGIOTENSIN II RECEPTOR ANTAGONISTS CANDESARTAN CILEXETIL TAB 32 MG NP Y N Y N ATACAND ATACAND TAB 4MG ANGIOTENSIN II RECEPTOR ANTAGONISTS CANDESARTAN CILEXETIL TAB 4 MG NP Y N Y N ATACAND HCT ATACAND HCT TAB 16-12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 16-12.5 MG NPYNYN ATACAND HCT ATACAND HCT TAB 32-12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 32-12.5 MG NPYNYN AVALIDE AVALIDE TAB 150-12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG NP Y N Y N AVAPRO AVAPRO TAB 75MG ANGIOTENSIN II RECEPTOR ANTAGONISTS IRBESARTAN TAB 75 MG NP Y N Y N BENICAR BENICAR TAB 20MG ANGIOTENSIN II RECEPTOR ANTAGONISTS OLMESARTAN MEDOXOMIL TAB 20 MG NP Y N Y N BENICAR BENICAR TAB 5MG ANGIOTENSIN II RECEPTOR ANTAGONISTS OLMESARTAN MEDOXOMIL TAB 5 MG NP Y N Y N BENICAR HCT BENICAR HCT TAB 20-12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG NP YNYN CANDESARTAN CILEXETIL CANDESARTAN TAB 32MG ANGIOTENSIN II RECEPTOR ANTAGONISTS CANDESARTAN CILEXETIL TAB 32 MG NP Y N Y N CANDESARTAN CILEXETIL CANDESARTAN TAB 4MG ANGIOTENSIN II RECEPTOR ANTAGONISTS CANDESARTAN CILEXETIL TAB 4 MG NP Y N Y N CANDESARTAN CILEXETIL/HYDROCHLOROTCANDESA/HCTZ TAB 16-12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 16-12.5 MG NP Y N Y N CANDESARTAN CILEXETIL/HYDROCHLOROTCANDESA/HCTZ TAB 32-12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 32-12.5 MG NP Y N Y N COZAAR COZAAR TAB 25MG ANGIOTENSIN II RECEPTOR ANTAGONISTS LOSARTAN POTASSIUM TAB 25 MG NP Y N Y N

Confidential 2/19/2021 Page 8 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) DIOVAN DIOVAN TAB 320MG ANGIOTENSIN II RECEPTOR ANTAGONISTS VALSARTAN TAB 320 MG NP Y N Y N DIOVAN DIOVAN TAB 40MG ANGIOTENSIN II RECEPTOR ANTAGONISTS VALSARTAN TAB 40 MG NP Y N Y N DIOVAN HCT DIOVAN HCT TAB 80/12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG NP Y N Y N EDARBI EDARBI TAB 40MG ANGIOTENSIN II RECEPTOR ANTAGONISTS AZILSARTAN MEDOXOMIL TAB 40 MG NP Y N Y N EDARBYCLOR EDARBYCLOR TAB 40-12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS AZILSARTAN MEDOXOMIL-CHLORTHALIDONE TAB 40-12.5 MG NP Y N Y N HYZAAR HYZAAR TAB 50-12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG NP Y N Y N IRBESARTAN IRBESARTAN TAB 75MG ANGIOTENSIN II RECEPTOR ANTAGONISTS IRBESARTAN TAB 75 MG NP Y N Y N IRBESARTAN/HYDROCHLOROTHIAZIDE IRBESAR/HCTZ TAB 150-12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG NP Y N Y N LOSARTAN POTASSIUM LOSARTAN POT TAB 25MG ANGIOTENSIN II RECEPTOR ANTAGONISTS LOSARTAN POTASSIUM TAB 25 MG P N N Y N LOSARTAN POTASSIUM/HYDROCHLOROTH LOSARTAN/HCT TAB 50-12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG P N N Y N MICARDIS MICARDIS TAB 20MG ANGIOTENSIN II RECEPTOR ANTAGONISTS TELMISARTAN TAB 20 MG NP Y N Y N MICARDIS HCT MICARDIS HCT TAB 40/12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG NP Y N Y N OLMESARTAN MEDOXOMIL OLMESA MEDOX TAB 20MG ANGIOTENSIN II RECEPTOR ANTAGONISTS OLMESARTAN MEDOXOMIL TAB 20 MG NP Y N Y N OLMESARTAN MEDOXOMIL OLMESA MEDOX TAB 5MG ANGIOTENSIN II RECEPTOR ANTAGONISTS OLMESARTAN MEDOXOMIL TAB 5 MG NP Y N Y N OLMESARTAN MEDOXOMIL/HYDROCHLOR OLM MED/HCTZ TAB 20-12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG NP Y N Y N TELMISARTAN TELMISARTAN TAB 20MG ANGIOTENSIN II RECEPTOR ANTAGONISTS TELMISARTAN TAB 20 MG NP Y N Y N TELMISARTAN/HYDROCHLOROTHIAZIDE TELMISA/HCTZ TAB 40-12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG NP Y N Y N VALSARTAN VALSARTAN TAB 320MG ANGIOTENSIN II RECEPTOR ANTAGONISTS VALSARTAN TAB 320 MG NP Y N Y N VALSARTAN VALSARTAN TAB 40MG ANGIOTENSIN II RECEPTOR ANTAGONISTS VALSARTAN TAB 40 MG NP Y N Y N VALSARTAN/HYDROCHLOROTHIAZIDE VALSART/HCTZ TAB 80-12.5 ANGIOTENSIN II RECEPTOR ANTAGONISTS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG NP Y N Y N PRESTALIA PRESTALIA TAB 3.5-2.5 ANGIOTENSIN-CONVERT.ENZYME INHIB(HYPOTN) PERINDOPRIL ARGININE-AMLODIPINE BESYLATE TAB 3.5-2.5 MGNPYNYN ACCUPRIL ACCUPRIL TAB 5MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS QUINAPRIL HCL TAB 5 MG NP Y N Y N ACCURETIC ACCURETIC TAB 10-12.5 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG NP Y N Y N ACCURETIC ACCURETIC TAB 20-12.5 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG NP Y N Y N ALTACE ALTACE CAP 1.25MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS RAMIPRIL CAP 1.25 MG P N N Y N ALTACE ALTACE CAP 2.5MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS RAMIPRIL CAP 2.5 MG NP Y N Y N BENAZEPRIL HCL BENAZEPRIL TAB 40MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS BENAZEPRIL HCL TAB 40 MG P N N Y N BENAZEPRIL HCL BENAZEPRIL TAB 5MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS BENAZEPRIL HCL TAB 5 MG P N N Y N BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE BENAZEP/HCTZ TAB 20-25MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG P N N Y N BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE BENAZEP/HCTZ TAB 5-6.25 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG P N N Y N BENAZEPRIL HYDROCHLORIDE BENAZEPRIL TAB 20MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS BENAZEPRIL HCL TAB 20 MG P N N Y N BENAZEPRIL HYDROCHLORIDE/HYDROCHLOBENAZEP/HCTZ TAB 10-12.5 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG P N N Y N CAPTOPRIL CAPTOPRIL TAB 100MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS CAPTOPRIL TAB 100 MG P N N Y N CAPTOPRIL CAPTOPRIL TAB 12.5MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS CAPTOPRIL TAB 12.5 MG P N N Y N CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPR/HCTZ TAB 25-15MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-15 MG P N N Y N CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPR/HCTZ TAB 25-25MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-25 MG P N N Y N ENALAPRIL MALEATE ENALAPRIL TAB 2.5MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ENALAPRIL MALEATE TAB 2.5 MG P N N Y N ENALAPRIL MALEATE/HYDROCHLOROTHIAZENALAPR/HCTZ TAB 5-12.5MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 5-12.5 MG P N N Y N EPANED EPANED SOL 1MG/ML ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ENALAPRIL MALEATE ORAL SOLN 1 MG/ML P N N Y Y FOSINOPRIL SODIUM FOSINOPRIL TAB 10MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS FOSINOPRIL SODIUM TAB 10 MG P N N Y N FOSINOPRIL SODIUM/HYDROCHLOROTHIAZFOSINOP/HCTZ TAB 10/12.5 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG P N N Y N FOSINOPRIL SODIUM/HYDROCHLOROTHIAZFOSINOP/HCTZ TAB 20/12.5 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG P N N Y N LISINOPRIL LISINOPRIL TAB 2.5MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS LISINOPRIL TAB 2.5 MG P N N Y N LISINOPRIL LISINOPRIL TAB 30MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS LISINOPRIL TAB 30 MG P N N Y N LISINOPRIL/HYDROCHLOROTHIAZIDE LISINOP/HCTZ TAB 10-12.5 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG P N N Y N LISINOPRIL/HYDROCHLOROTHIAZIDE LISINOP/HCTZ TAB 20-12.5 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG P N N Y N LOTENSIN LOTENSIN TAB 10MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS BENAZEPRIL HCL TAB 10 MG NP Y N Y N LOTENSIN LOTENSIN TAB 40MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS BENAZEPRIL HCL TAB 40 MG NP Y N Y N

Confidential 2/19/2021 Page 9 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) LOTENSIN HCT LOTENSIN HCT TAB 10-12.5 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG NP Y N YN LOTENSIN HCT LOTENSIN HCT TAB 20-25MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG NP Y N Y N MAVIK MAVIK TAB 4MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS TRANDOLAPRIL TAB 4 MG NP Y N Y N MOEXIPRIL HCL MOEXIPRIL TAB 15MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS MOEXIPRIL HCL TAB 15 MG NP Y N Y N MOEXIPRIL HCL MOEXIPRIL TAB 7.5MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS MOEXIPRIL HCL TAB 7.5 MG NP Y N Y N PERINDOPRIL ERBUMINE PERINDOPRIL TAB 2MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS PERINDOPRIL ERBUMINE TAB 2 MG NP Y N Y N PRINIVIL PRINIVIL TAB 10MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS LISINOPRIL TAB 10 MG NP Y N Y N QBRELIS QBRELIS SOL 1MG/ML ANGIOTENSIN-CONVERTING ENZYME INHIBITORS LISINOPRIL ORAL SOLN 1 MG/ML NP Y N N N QUINAPRIL HCL QUINAPRIL TAB 5MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS QUINAPRIL HCL TAB 5 MG P N N Y N QUINAPRIL HYDROCHLORIDE QUINAPRIL TAB 5MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS QUINAPRIL HCL TAB 5 MG P N N Y N QUINAPRIL/HYDROCHLOROTHIAZIDE QNAPRIL/HCTZ TAB 10-12.5 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG P N N Y N QUINAPRIL/HYDROCHLOROTHIAZIDE QNAPRIL/HCTZ TAB 20-12.5 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG P N N Y N RAMIPRIL RAMIPRIL CAP 1.25MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS RAMIPRIL CAP 1.25 MG P N N Y N TRANDOLAPRIL TRANDOLAPRIL TAB 1MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS TRANDOLAPRIL TAB 1 MG P N N Y N TRANDOLAPRIL TRANDOLAPRIL TAB 4MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS TRANDOLAPRIL TAB 4 MG P N N Y N VASERETIC VASERETIC TAB 10-25MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 10-25 MG NP YNYN VASOTEC VASOTEC TAB 2.5MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ENALAPRIL MALEATE TAB 2.5 MG NP Y N Y N ZESTORETIC ZESTORETIC TAB 10-12.5 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG NP Y N Y N ZESTORETIC ZESTORETIC TAB 20-12.5 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG NP Y N Y N ZESTRIL ZESTRIL TAB 2.5MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS LISINOPRIL TAB 2.5 MG NP Y N Y N ZESTRIL ZESTRIL TAB 30MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS LISINOPRIL TAB 30 MG NP Y N Y N ALBENDAZOLE ALBENDAZOLE TAB 200MG ANTHELMINTICS ALBENDAZOLE TAB 200 MG P N N Y N ALBENZA ALBENZA TAB 200MG ANTHELMINTICS ALBENDAZOLE TAB 200 MG NP Y N Y N BILTRICIDE BILTRICIDE TAB 600MG ANTHELMINTICS PRAZIQUANTEL TAB 600 MG NP Y N Y N CVS PINWORM TREATMENT CVS PINWORM SUS 50MG/ML ANTHELMINTICS PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV) P N N Y N EGATEN EGATEN TAB 250MG ANTHELMINTICS TRICLABENDAZOLE TAB 250 MG NP Y N Y N EMVERM EMVERM CHW 100MG ANTHELMINTICS MEBENDAZOLE CHEW TAB 100 MG NP Y N Y N IVERMECTIN IVERMECTIN TAB 3MG ANTHELMINTICS IVERMECTIN TAB 3 MG P N N Y N PIN-AWAY PIN-AWAY SUS 144MG/ML ANTHELMINTICS PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV) P N N Y N PINWORM MEDICINE PINWORM MED SUS 144MG/ML ANTHELMINTICS PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV) P N N Y N PRAZIQUANTEL PRAZIQUANTEL TAB 600MG ANTHELMINTICS PRAZIQUANTEL TAB 600 MG P Y N Y N REESES PINWORM MEDICINE PINWORM TAB MEDICINE ANTHELMINTICS PYRANTEL PAMOATE TAB 180 MG P N N Y N REESES PINWORM MEDICINE REESES MED SUS PINWORM ANTHELMINTICS PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV) P N N Y N STROMECTOL STROMECTOL TAB 3MG ANTHELMINTICS IVERMECTIN TAB 3 MG NP Y N Y N ALAWAY ALAWAY DRO 0.025%OP ANTIALLERGIC AGENTS KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) P N N N N ALAWAY CHILDRENS ALLERGY EYE ITCH RELALAWAY CHILD DRO 0.025%OP ANTIALLERGIC AGENTS KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) P N N N N ALOCRIL ALOCRIL SOL 2% ANTIALLERGIC AGENTS NEDOCROMIL SODIUM OPHTH SOLN 2% NP Y N N N ALOMIDE ALOMIDE SOL 0.1% OP ANTIALLERGIC AGENTS LODOXAMIDE TROMETHAMINE OPHTH SOLN 0.1% NP Y N N N AZELASTINE HCL AZELASTINE DRO 0.05% ANTIALLERGIC AGENTS AZELASTINE HCL OPHTH SOLN 0.05% P N Y N N AZELASTINE HCL AZELASTINE SPR 0.15% ANTIALLERGIC AGENTS AZELASTINE HCL NASAL SPRAY 0.15% (205.5 MCG/SPRAY) NP Y N Y N AZELASTINE HYDROCHLORIDE AZELASTINE SPR 0.1% ANTIALLERGIC AGENTS AZELASTINE HCL NASAL SPRAY 0.1% (137 MCG/SPRAY) P N N Y N AZELASTINE HYDROCHLORIDE/FLUTICASONAZEL/FLUTIC SPR 137-50 ANTIALLERGIC AGENTS AZELASTINE HCL-FLUTICASONE PROP NASAL SPRAY 137-50 MCG/ACT NP Y N Y N BEPREVE BEPREVE DRO 1.5% ANTIALLERGIC AGENTS BEPOTASTINE BESILATE OPHTH SOLN 1.5% NP Y N Y N CLARITIN EYE CLARITIN EYE DRO 0.025%OP ANTIALLERGIC AGENTS KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) P N N N N CROMOLYN SODIUM CROMOLYN SOD SOL 4% OP ANTIALLERGIC AGENTS CROMOLYN SODIUM OPHTH SOLN 4% P N N Y N CROMOLYN SODIUM CROMOLYN SOD SPR 5.2/ACT ANTIALLERGIC AGENTS CROMOLYN SODIUM NASAL AEROSOL SOLN 5.2 MG/ACT (4%) P N N N Y DERMACINRX AZENASE PAK AZENASE PAK MIS 137-50 ANTIALLERGIC AGENTS AZELASTINE SOL 137 MCG/ACT & FLUTICASONE SUS 50 MCG/ACT THPK NP Y NYN DYMISTA DYMISTA SPR 137-50 ANTIALLERGIC AGENTS AZELASTINE HCL-FLUTICASONE PROP NASAL SPRAY 137-50 MCG/ACT NP Y N Y N

Confidential 2/19/2021 Page 10 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) EPINASTINE HCL EPINASTINE DRO 0.05% ANTIALLERGIC AGENTS EPINASTINE HCL OPHTH SOLN 0.05% NP Y N N N KP KETOTIFEN FUMARATE KETOTIF FUM DRO 0.025%OP ANTIALLERGIC AGENTS KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) P N N N N LASTACAFT LASTACAFT SOL 0.25% ANTIALLERGIC AGENTS ALCAFTADINE OPHTH SOLN 0.25% NP Y N N N NASALCROM NASALCROM SPR 5.2/ACT ANTIALLERGIC AGENTS CROMOLYN SODIUM NASAL AEROSOL SOLN 5.2 MG/ACT (4%) P N N N Y OLOPATADINE HYDROCHLORIDE OLOPATADINE DRO 0.1% ANTIALLERGIC AGENTS OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT) P N N Y N OLOPATADINE HYDROCHLORIDE OLOPATADINE SPR 0.6% ANTIALLERGIC AGENTS OLOPATADINE HCL NASAL SOLN 0.6% NP Y N Y N OPTIVAR OPTIVAR DRO 0.05% ANTIALLERGIC AGENTS AZELASTINE HCL OPHTH SOLN 0.05% NP Y N N N PATADAY PATADAY SOL 0.1% ANTIALLERGIC AGENTS OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT) P N N Y N PATADAY EXTRA STRENGTH PATADAY SOL 0.7% ANTIALLERGIC AGENTS OLOPATADINE HCL OPHTH SOLN 0.7% (BASE EQUIVALENT) NP Y N Y N PATANASE PATANASE SPR 0.6% ANTIALLERGIC AGENTS OLOPATADINE HCL NASAL SOLN 0.6% NP Y N Y N RA ANTIHISTAMINE EYE DROPS ANTIHISTAMIN DRO 0.025%OP ANTIALLERGIC AGENTS KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) P N N N N ZADITOR ZADITOR DRO 0.025%OP ANTIALLERGIC AGENTS KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) P N N N N ZERVIATE ZERVIATE DRO 0.24% ANTIALLERGIC AGENTS CETIRIZINE HCL OPHTH SOLN 0.24% (BASE EQUIV) NP Y N Y N AK-POLY-BAC AK-POLY-BAC OIN OP ANTIBACTERIALS (EENT) BACITRACIN-POLYMYXIN B OPHTH OINT P N N Y N AZASITE AZASITE SOL 1% ANTIBACTERIALS (EENT) AZITHROMYCIN OPHTH SOLN 1% NP Y N Y N BACITRACIN BACITRACIN OIN OP ANTIBACTERIALS (EENT) BACITRACIN OPHTH OINT 500 UNIT/GM P N N Y N BACITRACIN/POLYMYXIN B BACIT/POLYMY OIN OP ANTIBACTERIALS (EENT) BACITRACIN-POLYMYXIN B OPHTH OINT P N N Y N BESIVANCE BESIVANCE SUS 0.6% ANTIBACTERIALS (EENT) BESIFLOXACIN HCL OPHTH SUSP 0.6% (BASE EQUIV) NP Y N Y N BLEPH-10 BLEPH-10 SOL 10% OP ANTIBACTERIALS (EENT) SULFACETAMIDE SODIUM OPHTH SOLN 10% NP Y N Y N CETRAXAL CETRAXAL SOL 0.2% ANTIBACTERIALS (EENT) CIPROFLOXACIN HCL OTIC SOLN 0.2% (BASE EQUIVALENT) NP Y N Y N CILOXAN CILOXAN OIN 0.3% OP ANTIBACTERIALS (EENT) CIPROFLOXACIN HCL OPHTH OINT 0.3% NP Y N Y N CIPROFLOXACIN CIPROFLOXACN SOL 0.2% ANTIBACTERIALS (EENT) CIPROFLOXACIN HCL OTIC SOLN 0.2% (BASE EQUIVALENT) NP Y N Y N CIPROFLOXACIN HYDROCHLORIDE CIPROFLOXACN SOL 0.3% OP ANTIBACTERIALS (EENT) CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT) P N N Y N ERYTHROMYCIN ERYTHROMYCIN OIN 5MG/GM ANTIBACTERIALS (EENT) ERYTHROMYCIN OPHTH OINT 5 MG/GM P N N Y N GATIFLOXACIN GATIFLOXACIN SOL 0.5% ANTIBACTERIALS (EENT) GATIFLOXACIN OPHTH SOLN 0.5% NP Y N Y N GENTAK GENTAK OIN 0.3% OP ANTIBACTERIALS (EENT) GENTAMICIN SULFATE OPHTH OINT 0.3% P N N Y N GENTAMICIN SULFATE GENTAMICIN SOL 0.3% OP ANTIBACTERIALS (EENT) GENTAMICIN SULFATE OPHTH SOLN 0.3% P N N Y N KLARITY-A KLARITY-A DRO 1% ANTIBACTERIALS (EENT) AZITHROMYCIN OPHTH SOLN 1% NP Y N Y N LEVOFLOXACIN LEVOFLOXACIN SOL 0.5% ANTIBACTERIALS (EENT) LEVOFLOXACIN OPHTH SOLN 0.5% NP Y N N N MITOSOL MITOSOL KIT 0.2MG ANTIBACTERIALS (EENT) MITOMYCIN FOR OPHTH SOLN KIT 0.2 MG NP Y N N N MOXEZA MOXEZA SOL 0.5% ANTIBACTERIALS (EENT) MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQ) (2 TIMES DAILY) NP Y N Y N MOXIFLOXACIN HYDROCHLORIDE MOXIFLOXACIN SOL HCL 0.5% ANTIBACTERIALS (EENT) MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV) NP Y N Y N NEOMYCIN/POLYMYXIN/BACITRACIN ZINC NEO/BAC/POLY OIN OP ANTIBACTERIALS (EENT) NEOMYCIN-BACITRAC ZN-POLYMYX 5(3.5)MG-400UNT-10000UNT OP OIN P N N N N NEOMYCIN/POLYMYXIN/GRAMICIDIN NEO/POLY/GRA SOL OP ANTIBACTERIALS (EENT) NEOMYCIN-POLYMY-GRAMICID OP SOL 1.75-10000-0.025MG-UNT-MG/ML P N N N N NEO-POLYCIN NEO-POLYCIN OIN OP ANTIBACTERIALS (EENT) NEOMYCIN-BACITRAC ZN-POLYMYX 5(3.5)MG-400UNT-10000UNT OP OIN P N N N N OCUFLOX OCUFLOX DRO 0.3% OP ANTIBACTERIALS (EENT) OFLOXACIN OPHTH SOLN 0.3% NP Y N Y N OFLOXACIN OFLOXACIN DRO 0.3% OP ANTIBACTERIALS (EENT) OFLOXACIN OPHTH SOLN 0.3% P N N Y N OTOVEL OTOVEL DRO ANTIBACTERIALS (EENT) CIPROFLOXACIN-FLUOCINOLONE ACETON (PF) OTIC SOLN 0.3-0.025% NP Y N Y N POLYCIN POLYCIN OIN OP ANTIBACTERIALS (EENT) BACITRACIN-POLYMYXIN B OPHTH OINT P N N Y N POLYMYXIN B SULFATE/TRIMETHOPRIM SUPOLYMYXIN B/ SOL TRIMETHP ANTIBACTERIALS (EENT) POLYMYXIN B-TRIMETHOPRIM OPHTH SOLN 10000 UNIT/ML-0.1% P N N Y N POLYTRIM POLYTRIM SOL OP ANTIBACTERIALS (EENT) POLYMYXIN B-TRIMETHOPRIM OPHTH SOLN 10000 UNIT/ML-0.1% NP Y N Y N SODIUM SULFACETAMIDE SOD SULFACET SOL 10% OP ANTIBACTERIALS (EENT) SULFACETAMIDE SODIUM OPHTH SOLN 10% P N N Y N TOBRAMYCIN SULFATE TOBRAMYCIN SOL 0.3% OP ANTIBACTERIALS (EENT) TOBRAMYCIN OPHTH SOLN 0.3% P N N Y N TOBREX TOBREX OIN 0.3% OP ANTIBACTERIALS (EENT) TOBRAMYCIN OPHTH OINT 0.3% NP Y N Y N TRIMETHOPRIM SULFATE/POLYMYXIN B SUTRIMETHOPRIM SOL POLYMYXN ANTIBACTERIALS (EENT) POLYMYXIN B-TRIMETHOPRIM OPHTH SOLN 10000 UNIT/ML-0.1% P N N Y N VIGAMOX VIGAMOX DRO 0.5% ANTIBACTERIALS (EENT) MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV) NP Y N Y N ZYMAXID ZYMAXID SOL 0.5% ANTIBACTERIALS (EENT) GATIFLOXACIN OPHTH SOLN 0.5% NP Y N Y N ACANYA ACANYA GEL 1.2-2.5% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE GEL 1.2-2.5% NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ADAPALENE/BENZOYL PEROXIDE/CLINDAMADAP/BENZ/ GEL CLINDAMY ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) ADAPALENE-BENZOYL PEROXIDE-CLINDAMYCIN GEL 0.3-2.5-1% NP Y N Y N ALTABAX ALTABAX OIN 1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) RETAPAMULIN OINT 1% NP Y N Y N AMZEEQ AMZEEQ AER 4% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) MINOCYCLINE HCL MICRONIZED FOAM 4% NP Y N Y N BENZACLIN BENZACLIN GEL 1-5% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE GEL 1-5% NP Y N Y N BENZAMYCIN BENZAMYCIN GEL 5-3% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) BENZOYL PEROXIDE-ERYTHROMYCIN GEL 5-3% NP Y N Y N BENZOYL PEROXIDE/CLINDAMYCIN/NIACINBENZ/CLIN/ GEL NIACIN ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN-BENZOYL PEROXIDE-NIACINAMIDE GEL 1-2.5-4% NP Y N Y N BENZOYL PEROXIDE/CLINDAMYCIN/NIACINBENZ/CLINDA/ GEL NIA/TRET ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) BENZ PER-CLINDAMYCIN-NIACINAMID-TRETINOIN GEL 2.5-1-2-0.025% NP Y N YN CENTANY CENTANY OIN 2% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) MUPIROCIN OINT 2% NP Y N Y N CENTANY AT CENTANY AT KIT 2% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) MUPIROCIN OINT KIT 2% NP Y N N N CLEOCIN CLEOCIN CRE 2% VAG ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE VAGINAL CREAM 2% NP Y N Y N CLEOCIN CLEOCIN SUP 100MG ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE VAGINAL SUPPOS 100 MG NP Y N Y N CLEOCIN-T CLEOCIN-T LOT 1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE LOTION 1% NP Y N Y N CLINDACIN ETZ CLINDACIN KIT ETZ 1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) *CLINDAMYCIN PHOSPHATE SWAB 1% & CLEANSER KIT*** NP Y N N N CLINDACIN ETZ PLEDGETS CLINDACIN MIS ETZ 1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE SWAB 1% P N N Y N CLINDACIN PAC CLINDACIN KIT PAC 1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) *CLINDAMYCIN PHOSPHATE SWAB 1% & CLEANSER KIT*** NP Y N N N CLINDACIN-P CLINDACIN-P PAD 1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE SWAB 1% P N N Y N CLINDAGEL CLINDAGEL GEL 1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE GEL 1% NP Y N Y N CLINDAMYCIN PHOSPHATE CLINDAMYCIN AER 1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE FOAM 1% NP Y N Y N CLINDAMYCIN PHOSPHATE CLINDAMYCIN CRE 2% VAG ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE VAGINAL CREAM 2% P N N Y N CLINDAMYCIN PHOSPHATE CLINDAMYCIN GEL 1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE GEL 1% NP Y N Y N CLINDAMYCIN PHOSPHATE CLINDAMYCIN LOT 1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE LOTION 1% P N N Y N CLINDAMYCIN PHOSPHATE CLINDAMYCIN SOL 1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE SOLN 1% P N N Y N CLINDAMYCIN PHOSPHATE/BENZOYL PEROCLINDAMY/BEN GEL 1.2-5% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPH-BENZOYL PEROXIDE (REFRIG) GEL 1.2 (1)-5% NP Y N Y N CLINDAMYCIN PHOSPHATE/NIACINAMIDE CLINDAMYCIN LOT NIACIN ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE-NIACINAMIDE LOTION 1-4% NP Y N Y N CLINDAMYCIN PHOSPHATE/NIACINAMIDE/CLIND/NIACIN CRE TRETINOI ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOS-NIACINAMIDE-TRETINOIN CREAM 1-4-0.025% NP Y N Y N CLINDAMYCIN/BENZOYL PEROXIDE CLINDAMY/BEN GEL 1-5% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE GEL 1-5% NP Y N Y N CLINDESSE CLINDESSE CRE 2% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE (ONE DOSE) VAGINAL CREAM 2% NP Y N Y N CURAD TRIPLE ANTIBIOTIC CURAD TRIPLE OIN ANTIBIOT ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** P N N NN DEOXIA DEOXIA GEL ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE-NIACINAMIDE GEL 1-4% NP Y N Y N DEOXIA DEOXIA LOT ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE-NIACINAMIDE LOTION 1-4% NP Y N Y N DERMACINRX CLORHEXACIN DERMACINRX KIT 4-2-5% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) *CHLORHEXIDINE SOL 4%-MUPIROCIN ON 2%-DIMETH CR 5%-TAPE KIT* NP Y N N N ERY ERY PAD 2% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) ERYTHROMYCIN PADS 2% NP Y N Y N ERYGEL ERYGEL GEL 2% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) ERYTHROMYCIN GEL 2% NP Y N Y N ERYTHROMYCIN ERYTHROMYCIN SOL 2% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) ERYTHROMYCIN SOLN 2% P N N Y N ERYTHROMYCIN/BENZOYL PEROXIDE ERY/BENZOYL GEL 5-3% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) BENZOYL PEROXIDE-ERYTHROMYCIN GEL 5-3% NPYNYN EVOCLIN EVOCLIN AER 1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE FOAM 1% NP Y N Y N GENTAMICIN SULFATE GENTAMICIN CRE 0.1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) GENTAMICIN SULFATE CREAM 0.1% P N N Y N GENTAMICIN SULFATE GENTAMICIN OIN 0.1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) GENTAMICIN SULFATE OINT 0.1% P N N Y N KLARON KLARON LOT 10% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) SULFACETAMIDE SODIUM LOTION 10% (ACNE) NP Y N Y N METROLOTION METROLOTION LOT 0.75% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) METRONIDAZOLE LOTION 0.75% NP Y N Y N METRONIDAZOLE METRONIDAZOL CRE 0.75% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) METRONIDAZOLE CREAM 0.75% P N N Y N METRONIDAZOLE METRONIDAZOL GEL 1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) METRONIDAZOLE GEL 1% P N N Y N METRONIDAZOLE VAGINAL METRONIDAZOL GEL 0.75%VAG ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) METRONIDAZOLE VAGINAL GEL 0.75% P N N Y N MUPIROCIN MUPIROCIN CRE 2% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) MUPIROCIN CALCIUM CREAM 2% NP Y N Y N MUPIROCIN MUPIROCIN OIN 2% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) MUPIROCIN OINT 2% P N N Y N NEUAC NEUAC GEL 1.2-5% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPH-BENZOYL PEROXIDE (REFRIG) GEL 1.2 (1)-5% NP YNYN NEUAC KIT NEUAC KIT 1.2-5% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) *CLINDAMYCIN-BENZOYL PEROX GEL 1.2-5% & MOISTURIZER CR KIT** NP Y N N N NUCARACLINPAK NUCARACLINPA KIT ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) *CLINDAMYCIN PHOSPHATE GEL 1% & MOISTURIZER KIT*** NP Y N Y N

Confidential 2/19/2021 Page 12 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) NUSRUGEPAK SURGICAL PREP/CAREPAK NUSURGEPAK KIT SURGICAL ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) *CHLORHEXIDINE SOL 4%-MUPIROCIN ON 2%-DIMETH CR 5%-TAPE KIT* NP Y N N N NUVESSA NUVESSA GEL 1.3% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) METRONIDAZOLE VAGINAL GEL 1.3% NP Y N Y N ONEXTON ONEXTON GEL 1.2-3.75 ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE GEL 1.2-3.75% NP Y N Y N OVACE PLUS OVACE PLUS AER 9.8% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) SULFACETAMIDE SODIUM FOAM 9.8% NP Y N Y N OVACE PLUS OVACE PLUS CRE 10% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) SULFACETAMIDE SODIUM CREAM 10% NP Y N N N OVACE PLUS WASH OVACE PLUS GEL 10% WASH ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) SULFACETAMIDE SODIUM CLEANSING GEL 10% NP Y N N N OVACE PLUS WASH OVACE PLUS LIQ 10% WASH ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) SULFACETAMIDE SODIUM LIQUID 10% P N N N N OVACE WASH OVACE WASH LIQ 10% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) SULFACETAMIDE SODIUM LIQUID 10% P N N N N ROSADAN ROSADAN CRE 0.75% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) METRONIDAZOLE CREAM 0.75% P N N Y N ROSADAN KIT ROSADAN KIT 0.75% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) METRONIDAZOLE GEL 0.75% W/ CLEANSER KIT NP Y N N N SODIUM SULFACETAMIDE SOD SULFACET GEL 10% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) SULFACETAMIDE SODIUM CLEANSING GEL 10% NP Y N N N SODIUM SULFACETAMIDE WASH SODIUM SULFA LIQ 10% WASH ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) SULFACETAMIDE SODIUM LIQUID 10% P N N N N SULFACETAMIDE SODIUM SULFACETAMID LOT 10% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) SULFACETAMIDE SODIUM LOTION 10% (ACNE) NP Y N Y N TARDEOXIA TARDEOXIA CRE ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) CLINDAMYCIN PHOS-NIACINAMIDE-TRETINOIN CREAM 1-4-0.025% NP Y N Y N VANDAZOLE VANDAZOLE GEL 0.75% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) METRONIDAZOLE VAGINAL GEL 0.75% P N N Y N XEPI XEPI CRE 1% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) OZENOXACIN CREAM 1% NP Y N Y N ZILXI ZILXI AER 1.5% ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) MINOCYCLINE HCL MICRONIZED FOAM 1.5% NP Y N Y N BENZTROPINE MESYLATE BENZTROPINE TAB 0.5MG ANTICHOLINERGIC AGENTS (CNS) BENZTROPINE MESYLATE TAB 0.5 MG P N N Y N BENZTROPINE MESYLATE BENZTROPINE TAB 1MG ANTICHOLINERGIC AGENTS (CNS) BENZTROPINE MESYLATE TAB 1 MG P N N Y N BENZTROPINE MESYLATE BENZTROPINE TAB 2MG ANTICHOLINERGIC AGENTS (CNS) BENZTROPINE MESYLATE TAB 2 MG P N N Y N TRIHEXYPHENIDYL HCL TRIHEXYPHEN SOL 0.4MG/ML ANTICHOLINERGIC AGENTS (CNS) TRIHEXYPHENIDYL HCL ORAL SOLN 0.4 MG/ML P N N Y N TRIHEXYPHENIDYL HYDROCHLORIDE TRIHEXYPHEN TAB 2MG ANTICHOLINERGIC AGENTS (CNS) TRIHEXYPHENIDYL HCL TAB 2 MG P N N Y N TRIHEXYPHENIDYL HYDROCHLORIDE TRIHEXYPHEN TAB 5MG ANTICHOLINERGIC AGENTS (CNS) TRIHEXYPHENIDYL HCL TAB 5 MG P N N Y N ARIXTRA ARIXTRA INJ 10/0.8ML ANTICOAGULANTS, MISCELLANEOUS FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML NP Y N Y N ARIXTRA ARIXTRA INJ 2.5/0.5 ANTICOAGULANTS, MISCELLANEOUS FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML NP Y N N N ARIXTRA ARIXTRA INJ 5/0.4ML ANTICOAGULANTS, MISCELLANEOUS FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML NP Y N Y N ARIXTRA ARIXTRA INJ 7.5/0.6 ANTICOAGULANTS, MISCELLANEOUS FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML NP Y N Y N FONDAPARINUX SODIUM FONDAPARINUX INJ 10/0.8ML ANTICOAGULANTS, MISCELLANEOUS FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML NP Y N Y N FONDAPARINUX SODIUM FONDAPARINUX INJ 2.5/0.5 ANTICOAGULANTS, MISCELLANEOUS FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML NP Y N N N FONDAPARINUX SODIUM FONDAPARINUX INJ 5/0.4ML ANTICOAGULANTS, MISCELLANEOUS FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML NP Y N Y N FONDAPARINUX SODIUM FONDAPARINUX INJ 7.5/0.6 ANTICOAGULANTS, MISCELLANEOUS FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML NP Y N Y N APTIOM APTIOM TAB 200MG ANTICONVULSANTS, MISCELLANEOUS ESLICARBAZEPINE ACETATE TAB 200 MG NP Y N Y N APTIOM APTIOM TAB 600MG ANTICONVULSANTS, MISCELLANEOUS ESLICARBAZEPINE ACETATE TAB 600 MG NP Y N Y N BANZEL BANZEL SUS 40MG/ML ANTICONVULSANTS, MISCELLANEOUS RUFINAMIDE SUSP 40 MG/ML NP Y N Y N BANZEL BANZEL TAB 200MG ANTICONVULSANTS, MISCELLANEOUS RUFINAMIDE TAB 200 MG P Y N Y N BANZEL BANZEL TAB 400MG ANTICONVULSANTS, MISCELLANEOUS RUFINAMIDE TAB 400 MG P Y N Y N BRIVIACT BRIVIACT SOL 10MG/ML ANTICONVULSANTS, MISCELLANEOUS BRIVARACETAM ORAL SOLN 10 MG/ML NP Y N Y N BRIVIACT BRIVIACT TAB 10MG ANTICONVULSANTS, MISCELLANEOUS BRIVARACETAM TAB 10 MG NP Y N Y N CARBAMAZEPINE CARBAMAZEPIN TAB 200MG ANTICONVULSANTS, MISCELLANEOUS CARBAMAZEPINE TAB 200 MG P N N N N CARBAMAZEPINE ER CARBAMAZEPIN CAP 100MG ER ANTICONVULSANTS, MISCELLANEOUS CARBAMAZEPINE CAP ER 12HR 100 MG P N N N N CARBATROL CARBATROL CAP 100MG ANTICONVULSANTS, MISCELLANEOUS CARBAMAZEPINE CAP ER 12HR 100 MG P N N N N DEPAKOTE DEPAKOTE TAB 125MG DR ANTICONVULSANTS, MISCELLANEOUS DIVALPROEX SODIUM TAB DELAYED RELEASE 125 MG NP Y N N N DEPAKOTE ER DEPAKOTE ER TAB 250MG ANTICONVULSANTS, MISCELLANEOUS DIVALPROEX SODIUM TAB ER 24 HR 250 MG NP Y N N N DEPAKOTE SPRINKLES DEPAKOTE SPR CAP 125MG ANTICONVULSANTS, MISCELLANEOUS DIVALPROEX SODIUM CAP DELAYED RELEASE SPRINKLE 125 MG NP Y N NN DIACOMIT DIACOMIT CAP 250MG ANTICONVULSANTS, MISCELLANEOUS STIRIPENTOL CAP 250 MG NP Y N Y N DIACOMIT DIACOMIT CAP 500MG ANTICONVULSANTS, MISCELLANEOUS STIRIPENTOL CAP 500 MG NP Y N Y N DIVALPROEX SODIUM DIVALPROEX CAP 125MG ANTICONVULSANTS, MISCELLANEOUS DIVALPROEX SODIUM CAP DELAYED RELEASE SPRINKLE 125 MG P N N N N DIVALPROEX SODIUM DR DIVALPROEX TAB 125MG DR ANTICONVULSANTS, MISCELLANEOUS DIVALPROEX SODIUM TAB DELAYED RELEASE 125 MG P N N N N

Confidential 2/19/2021 Page 13 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) DIVALPROEX SODIUM ER DIVALPROEX TAB 250MG ER ANTICONVULSANTS, MISCELLANEOUS DIVALPROEX SODIUM TAB ER 24 HR 250 MG P N N N N EPIDIOLEX EPIDIOLEX SOL 100MG/ML ANTICONVULSANTS, MISCELLANEOUS CANNABIDIOL SOLN 100 MG/ML NP Y N Y N EPITOL EPITOL TAB 200MG ANTICONVULSANTS, MISCELLANEOUS CARBAMAZEPINE TAB 200 MG P N N N N EQUETRO EQUETRO CAP 100MG ANTICONVULSANTS, MISCELLANEOUS CARBAMAZEPINE (ANTIPSYCHOTIC) CAP ER 12HR 100 MG P N N Y N EQUETRO EQUETRO CAP 200MG ANTICONVULSANTS, MISCELLANEOUS CARBAMAZEPINE (ANTIPSYCHOTIC) CAP ER 12HR 200 MG P N N Y N EQUETRO EQUETRO CAP 300MG ANTICONVULSANTS, MISCELLANEOUS CARBAMAZEPINE (ANTIPSYCHOTIC) CAP ER 12HR 300 MG P N N Y N FANATREX FUSEPAQ FANATREX SUS 25MG/ML ANTICONVULSANTS, MISCELLANEOUS *GABAPENTIN ORAL SUSP 25 MG/ML (CMPD KIT)** NP Y N Y N FELBAMATE FELBAMATE SUS 600/5ML ANTICONVULSANTS, MISCELLANEOUS FELBAMATE SUSP 600 MG/5ML P N N Y Y FELBAMATE FELBAMATE TAB 400MG ANTICONVULSANTS, MISCELLANEOUS FELBAMATE TAB 400 MG P N N Y N FELBATOL FELBATOL SUS 600/5ML ANTICONVULSANTS, MISCELLANEOUS FELBAMATE SUSP 600 MG/5ML NP Y N Y Y FELBATOL FELBATOL TAB 400MG ANTICONVULSANTS, MISCELLANEOUS FELBAMATE TAB 400 MG NP Y N Y N FINTEPLA FINTEPLA SOL 2.2MG/ML ANTICONVULSANTS, MISCELLANEOUS FENFLURAMINE HCL ORAL SOLN 2.2 MG/ML NP Y N Y N FYCOMPA FYCOMPA SUS 0.5MG/ML ANTICONVULSANTS, MISCELLANEOUS PERAMPANEL SUSP 0.5 MG/ML NP Y N Y N FYCOMPA FYCOMPA TAB 2MG ANTICONVULSANTS, MISCELLANEOUS PERAMPANEL TAB 2 MG NP Y N Y N GABAPENTIN GABAPENTIN CAP 100MG ANTICONVULSANTS, MISCELLANEOUS GABAPENTIN CAP 100 MG P N N Y N GABAPENTIN GABAPENTIN CAP 400MG ANTICONVULSANTS, MISCELLANEOUS GABAPENTIN CAP 400 MG P N N Y N GABAPENTIN GABAPENTIN SOL 300/6ML ANTICONVULSANTS, MISCELLANEOUS GABAPENTIN ORAL SOLN 250 MG/5ML NP Y N Y N GABAPENTIN GABAPENTIN TAB 800MG ANTICONVULSANTS, MISCELLANEOUS GABAPENTIN TAB 800 MG P N N Y N GABITRIL GABITRIL TAB 16MG ANTICONVULSANTS, MISCELLANEOUS TIAGABINE HCL TAB 16 MG NP Y N Y Y GABITRIL GABITRIL TAB 2MG ANTICONVULSANTS, MISCELLANEOUS TIAGABINE HCL TAB 2 MG NP Y N Y Y GABITRIL GABITRIL TAB 4MG ANTICONVULSANTS, MISCELLANEOUS TIAGABINE HCL TAB 4 MG NP Y N Y Y HORIZANT HORIZANT TAB 300MG ER ANTICONVULSANTS, MISCELLANEOUS GABAPENTIN ENACARBIL TAB ER 300 MG NP Y N Y N KEPPRA KEPPRA SOL 100MG/ML ANTICONVULSANTS, MISCELLANEOUS LEVETIRACETAM ORAL SOLN 100 MG/ML NP Y N Y Y KEPPRA KEPPRA TAB 250MG ANTICONVULSANTS, MISCELLANEOUS LEVETIRACETAM TAB 250 MG NP Y N Y N KEPPRA KEPPRA TAB 500MG ANTICONVULSANTS, MISCELLANEOUS LEVETIRACETAM TAB 500 MG NP Y N Y N KEPPRA KEPPRA TAB 750MG ANTICONVULSANTS, MISCELLANEOUS LEVETIRACETAM TAB 750 MG NP Y N Y N KEPPRA XR KEPPRA XR TAB 500MG ANTICONVULSANTS, MISCELLANEOUS LEVETIRACETAM TAB ER 24HR 500 MG NP Y N Y N KEPPRA XR KEPPRA XR TAB 750MG ANTICONVULSANTS, MISCELLANEOUS LEVETIRACETAM TAB ER 24HR 750 MG NP Y N N N LAMICTAL LAMICTAL TAB 25MG ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB 25 MG NP Y N N N LAMICTAL CHEWABLE DISPERSIBLE LAMICTAL CHW 5MG ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB CHEWABLE DISPERSIBLE 5 MG NP Y N N N LAMICTAL ODT LAMICTAL ODT KIT ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB DISINT 21 X 25 MG & 7 X 50 MG TITRATION KIT P N N N N LAMICTAL STARTER/NOT TAKING CARBAM LAMICTAL KIT START 49 ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB 25 MG (42) & 100 MG (7) STARTER KIT NP Y N N N LAMICTAL STARTER/TAKING CARBAMAZEP LAMICTAL KIT START 98 ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB 84 X 25 MG & 14 X 100 MG STARTER KIT NP Y N N N LAMICTAL STARTER/TAKING VALPROATE LAMICTAL KIT START 35 ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB 35 X 25 MG STARTER KIT NPYNNN LAMICTAL XR LAMICTAL XR TAB 25MG ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB ER 24HR 25 MG NP Y N N N LAMOTRIGINE LAMOTRIGINE TAB 25MG ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB 25 MG P N N N N LAMOTRIGINE ER LAMOTRIGINE TAB 25MG ER ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB ER 24HR 25 MG P N N N N LAMOTRIGINE ODT LAMOTRIGINE TAB 25MG ODT ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE ORALLY DISINTEGRATING TAB 25 MG P N N N N LAMOTRIGINE STARTER KIT/BLUE LAMOTRIGINE KIT START 35 ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB 35 X 25 MG STARTER KIT P N N N N LAMOTRIGINE STARTER KIT/GREEN LAMOTRIGINE KIT START 98 ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB 84 X 25 MG & 14 X 100 MG STARTER KIT P N N N N LAMOTRIGINE STARTER KIT/ORANGE LAMOTRIGINE KIT START 49 ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB 25 MG (42) & 100 MG (7) STARTER KIT P N N N N LAMOTRIGINE TITRATION LAMOTRIGINE KIT ODT ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB DISINT 25 (14) & 50 MG (14) & 100 MG (7) KIT P N N N N LEVETIRACETAM LEVETIRACETA SOL 100MG/ML ANTICONVULSANTS, MISCELLANEOUS LEVETIRACETAM ORAL SOLN 100 MG/ML P N N Y Y LEVETIRACETAM LEVETIRACETA TAB 250MG ANTICONVULSANTS, MISCELLANEOUS LEVETIRACETAM TAB 250 MG P N N Y N LEVETIRACETAM LEVETIRACETA TAB 500MG ANTICONVULSANTS, MISCELLANEOUS LEVETIRACETAM TAB 500 MG P N N Y N LEVETIRACETAM LEVETIRACETA TAB 750MG ANTICONVULSANTS, MISCELLANEOUS LEVETIRACETAM TAB 750 MG P N N Y N LEVETIRACETAM ER LEVETIRACETA TAB 500MG ER ANTICONVULSANTS, MISCELLANEOUS LEVETIRACETAM TAB ER 24HR 500 MG NP Y N Y N LEVETIRACETAM ER LEVETIRACETA TAB 750MG ER ANTICONVULSANTS, MISCELLANEOUS LEVETIRACETAM TAB ER 24HR 750 MG NP Y N N N

Confidential 2/19/2021 Page 14 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) LYRICA LYRICA CAP 225MG ANTICONVULSANTS, MISCELLANEOUS PREGABALIN CAP 225 MG NP Y N Y N LYRICA LYRICA CAP 25MG ANTICONVULSANTS, MISCELLANEOUS PREGABALIN CAP 25 MG NP Y N Y N LYRICA LYRICA SOL 20MG/ML ANTICONVULSANTS, MISCELLANEOUS PREGABALIN SOLN 20 MG/ML NP Y N Y N NEURONTIN NEURONTIN CAP 100MG ANTICONVULSANTS, MISCELLANEOUS GABAPENTIN CAP 100 MG NP Y N Y N NEURONTIN NEURONTIN CAP 400MG ANTICONVULSANTS, MISCELLANEOUS GABAPENTIN CAP 400 MG NP Y N Y N NEURONTIN NEURONTIN SOL 250/5ML ANTICONVULSANTS, MISCELLANEOUS GABAPENTIN ORAL SOLN 250 MG/5ML NP Y N Y N NEURONTIN NEURONTIN TAB 800MG ANTICONVULSANTS, MISCELLANEOUS GABAPENTIN TAB 800 MG NP Y N Y N OXCARBAZEPINE OXCARBAZEPIN TAB 150MG ANTICONVULSANTS, MISCELLANEOUS OXCARBAZEPINE TAB 150 MG P N N N N OXTELLAR XR OXTELLAR XR TAB 150MG ANTICONVULSANTS, MISCELLANEOUS OXCARBAZEPINE TAB ER 24HR 150 MG P N N N N POTASSIUM BROMIDE POT BROMIDE GRA ANTICONVULSANTS, MISCELLANEOUS POTASSIUM BROMIDE GRANULES NP Y N N N PREGABALIN PREGABALIN CAP 225MG ANTICONVULSANTS, MISCELLANEOUS PREGABALIN CAP 225 MG P N N Y N PREGABALIN PREGABALIN CAP 25MG ANTICONVULSANTS, MISCELLANEOUS PREGABALIN CAP 25 MG P N N Y N PREGABALIN PREGABALIN SOL 20MG/ML ANTICONVULSANTS, MISCELLANEOUS PREGABALIN SOLN 20 MG/ML P N N Y N QUDEXY XR QUDEXY XR CAP 25/24HR ANTICONVULSANTS, MISCELLANEOUS TOPIRAMATE CAP ER 24HR SPRINKLE 25 MG NP Y N Y N ROWEEPRA ROWEEPRA TAB 500MG ANTICONVULSANTS, MISCELLANEOUS LEVETIRACETAM TAB 500 MG P N N Y N RUFINAMIDE RUFINAMIDE SUS 40MG/ML ANTICONVULSANTS, MISCELLANEOUS RUFINAMIDE SUSP 40 MG/ML P Y N Y N SABRIL SABRIL TAB 500MG ANTICONVULSANTS, MISCELLANEOUS VIGABATRIN TAB 500 MG NP Y N Y N SPRITAM SPRITAM TAB 250MG ANTICONVULSANTS, MISCELLANEOUS LEVETIRACETAM TAB DISINTEGRATING SOLUBLE 250 MG NP Y N N N SUBVENITE SUBVENITE TAB 25MG ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB 25 MG P N N N N SUBVENITE STARTER KIT/BLUE SUBVENITE KIT START 35 ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB 35 X 25 MG STARTER KIT P N N N N SUBVENITE STARTER KIT/GREEN SUBVENITE KIT START 98 ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB 84 X 25 MG & 14 X 100 MG STARTER KIT P N N N N SUBVENITE STARTER KIT/ORANGE SUBVENITE KIT START 49 ANTICONVULSANTS, MISCELLANEOUS LAMOTRIGINE TAB 25 MG (42) & 100 MG (7) STARTER KIT P N N N N TEGRETOL TEGRETOL SUS 100/5ML ANTICONVULSANTS, MISCELLANEOUS CARBAMAZEPINE SUSP 100 MG/5ML P N N N N TEGRETOL TEGRETOL TAB 200MG ANTICONVULSANTS, MISCELLANEOUS CARBAMAZEPINE TAB 200 MG NP Y N N N TEGRETOL-XR TEGRETOL-XR TAB 100MG ANTICONVULSANTS, MISCELLANEOUS CARBAMAZEPINE TAB ER 12HR 100 MG P N N N N TEGRETOL-XR TEGRETOL-XR TAB 400MG ANTICONVULSANTS, MISCELLANEOUS CARBAMAZEPINE TAB ER 12HR 400 MG NP Y N N N TIAGABINE HYDROCHLORIDE TIAGABINE TAB 16MG ANTICONVULSANTS, MISCELLANEOUS TIAGABINE HCL TAB 16 MG P Y N Y Y TIAGABINE HYDROCHLORIDE TIAGABINE TAB 2MG ANTICONVULSANTS, MISCELLANEOUS TIAGABINE HCL TAB 2 MG P Y N Y Y TIAGABINE HYDROCHLORIDE TIAGABINE TAB 4MG ANTICONVULSANTS, MISCELLANEOUS TIAGABINE HCL TAB 4 MG P Y N Y Y TOPAMAX TOPAMAX TAB 25MG ANTICONVULSANTS, MISCELLANEOUS TOPIRAMATE TAB 25 MG NP Y N N N TOPAMAX SPRINKLE TOPAMAX SPR CAP 15MG ANTICONVULSANTS, MISCELLANEOUS TOPIRAMATE SPRINKLE CAP 15 MG NP Y N N N TOPIRAMATE TOPIRAMATE TAB 25MG ANTICONVULSANTS, MISCELLANEOUS TOPIRAMATE TAB 25 MG P N N N N TOPIRAMATE ER TOPIRAMATE CAP ER 25MG ANTICONVULSANTS, MISCELLANEOUS TOPIRAMATE CAP ER 24HR SPRINKLE 25 MG P N N Y N TRILEPTAL TRILEPTAL TAB 150MG ANTICONVULSANTS, MISCELLANEOUS OXCARBAZEPINE TAB 150 MG NP Y N N N TROKENDI XR TROKENDI XR CAP 25MG ANTICONVULSANTS, MISCELLANEOUS TOPIRAMATE CAP ER 24HR 25 MG P N N Y N VALPROATE SODIUM VALPROATE INJ 500/5ML ANTICONVULSANTS, MISCELLANEOUS VALPROATE SODIUM INJ 100 MG/ML P N N N N VALPROIC ACID VALPROIC ACD SOL 250/5ML ANTICONVULSANTS, MISCELLANEOUS VALPROATE SODIUM ORAL SOLN 250 MG/5ML (BASE EQUIV) P N N N N VIGABATRIN VIGABATRIN PAK 500MG ANTICONVULSANTS, MISCELLANEOUS VIGABATRIN POWD PACK 500 MG P Y N Y N VIGABATRIN VIGABATRIN TAB 500MG ANTICONVULSANTS, MISCELLANEOUS VIGABATRIN TAB 500 MG NP Y N Y N VIMPAT VIMPAT SOL 10MG/ML ANTICONVULSANTS, MISCELLANEOUS LACOSAMIDE ORAL SOLUTION 10 MG/ML NP Y N Y Y VIMPAT VIMPAT TAB 50MG ANTICONVULSANTS, MISCELLANEOUS LACOSAMIDE TAB 50 MG P Y N Y Y XCOPRI XCOPRI PAK 12.5-25 ANTICONVULSANTS, MISCELLANEOUS CENOBAMATE TAB TITRATION PACK 14 X 12.5 MG & 14 X 25 MG NP Y N Y N XCOPRI XCOPRI TAB 150MG ANTICONVULSANTS, MISCELLANEOUS CENOBAMATE TAB 150 MG NP Y N Y N XCOPRI XCOPRI TAB 50MG ANTICONVULSANTS, MISCELLANEOUS CENOBAMATE TAB 50 MG NP Y N Y N ZONEGRAN ZONEGRAN CAP 100MG ANTICONVULSANTS, MISCELLANEOUS ZONISAMIDE CAP 100 MG NP Y N Y N ZONEGRAN ZONEGRAN CAP 25MG ANTICONVULSANTS, MISCELLANEOUS ZONISAMIDE CAP 25 MG NP Y N Y N ZONISAMIDE ZONISAMIDE CAP 100MG ANTICONVULSANTS, MISCELLANEOUS ZONISAMIDE CAP 100 MG P N N Y N ZONISAMIDE ZONISAMIDE CAP 25MG ANTICONVULSANTS, MISCELLANEOUS ZONISAMIDE CAP 25 MG P N N Y N

Confidential 2/19/2021 Page 15 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) AMOXAPINE TAB 150MG AMOXAPINE TAB 150MG ANTIDEPRESSANTS AMOXAPINE TAB 150 MG P N N Y N APLENZIN APLENZIN TAB 174MG ANTIDEPRESSANTS, MISCELLANEOUS BUPROPION HBR TAB ER 24HR 174 MG P N N Y N BUPROPION HCL BUPROPION TAB 75MG ANTIDEPRESSANTS, MISCELLANEOUS BUPROPION HCL TAB 75 MG P N N Y N BUPROPION HYDROCHLORIDE ER (SR) BUPROPION TAB 100MG SR ANTIDEPRESSANTS, MISCELLANEOUS BUPROPION HCL TAB ER 12HR 100 MG P N N Y N BUPROPION HYDROCHLORIDE ER (SR) BUPROPION TAB 150MG SR ANTIDEPRESSANTS, MISCELLANEOUS BUPROPION HCL (SMOKING DETERRENT) TAB ER 12HR 150 MG P N N N N BUPROPION HYDROCHLORIDE ER (XL) BUPROPN HCL TAB 150MG XL ANTIDEPRESSANTS, MISCELLANEOUS BUPROPION HCL TAB ER 24HR 150 MG P N N Y N FORFIVO XL FORFIVO XL TAB 450MG ANTIDEPRESSANTS, MISCELLANEOUS BUPROPION HCL TAB ER 24HR 450 MG P N N Y N MIRTAZAPINE MIRTAZAPINE TAB 7.5MG ANTIDEPRESSANTS, MISCELLANEOUS MIRTAZAPINE TAB 7.5 MG P N N Y N MIRTAZAPINE ODT MIRTAZAPINE TAB 15MG ODT ANTIDEPRESSANTS, MISCELLANEOUS MIRTAZAPINE ORALLY DISINTEGRATING TAB 15 MG P N N Y N REMERON REMERON TAB 15MG ANTIDEPRESSANTS, MISCELLANEOUS MIRTAZAPINE TAB 15 MG NP Y N Y N REMERON SOLTAB REMERON SLTB TAB 15MG ANTIDEPRESSANTS, MISCELLANEOUS MIRTAZAPINE ORALLY DISINTEGRATING TAB 15 MG NP Y N Y N SPRAVATO 56MG DOSE SPRAVATO SOL 56MG DOS ANTIDEPRESSANTS, MISCELLANEOUS ESKETAMINE HCL NASAL SOLN 28 MG/DEVICE X 2 (56 MG DOSE PACK) P N N Y Y SPRAVATO 84MG DOSE SPRAVATO SOL 84MG DOS ANTIDEPRESSANTS, MISCELLANEOUS ESKETAMINE HCL NASAL SOLN 28 MG/DEVICE X 3 (84 MG DOSE PACK) P N N Y Y WELLBUTRIN SR WELLBUTRIN TAB 100MG SR ANTIDEPRESSANTS, MISCELLANEOUS BUPROPION HCL TAB ER 12HR 100 MG NP Y N Y N WELLBUTRIN XL WELLBUTRIN TAB XL 150MG ANTIDEPRESSANTS, MISCELLANEOUS BUPROPION HCL TAB ER 24HR 150 MG NP Y N Y N ZULRESSO ZULRESSO INJ 100/20ML ANTIDEPRESSANTS, MISCELLANEOUS BREXANOLONE IV SOLN 100 MG/20ML (5 MG/ML) P N N N N CYCLOSET CYCLOSET TAB 0.8MG ANTIDIABETIC AGENTS, MISCELLANEOUS BROMOCRIPTINE MESYLATE TAB 0.8 MG (BASE EQUIVALENT) NP Y N N N KORLYM KORLYM TAB 300MG ANTIDIABETIC AGENTS, MISCELLANEOUS MIFEPRISTONE TAB 300 MG P Y N Y N ABATINEX ABATINEX CAP 680MG ANTIDIARRHEA AGENTS *LACTOBACILLUS CAP** P N N N N LOMOTIL LOMOTIL TAB 2.5MG ANTIDIARRHEA AGENTS DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG NP Y N Y N LOPERAMIDE HCL LOPERAMIDE CAP 2MG ANTIDIARRHEA AGENTS LOPERAMIDE HCL CAP 2 MG P N N Y N LOPERAMIDE HYDROCHLORIDE LOPERAMIDE LIQ 1MG/5ML ANTIDIARRHEA AGENTS LOPERAMIDE HCL LIQ 1 MG/5ML (0.2 MG/ML) P N N Y N LOPERAMIDE HYDROCHLORIDE LOPERAMIDE LIQ 1MG/7.5 ANTIDIARRHEA AGENTS LOPERAMIDE HCL LIQ 1 MG/7.5ML NP Y N N N MOTOFEN MOTOFEN TAB 1-0.025 ANTIDIARRHEA AGENTS DIFENOXIN W/ ATROPINE TAB 1-0.025 MG NP Y N Y N MYTESI MYTESI TAB 125MG ANTIDIARRHEA AGENTS CROFELEMER TAB DELAYED RELEASE 125 MG P Y N Y N XERMELO XERMELO TAB 250MG ANTIDIARRHEA AGENTS TELOTRISTAT ETHYL TAB 250 MG (AS TELOTRISTAT ETIPRATE) NP Y N Y N ACETYLCYSTEINE ACETYLCYST SOL 10% ANTIDOTES ACETYLCYSTEINE INHAL SOLN 10% P N N Y N ACETYLCYSTEINE ACETYLCYST SOL 20% ANTIDOTES ACETYLCYSTEINE INHAL SOLN 20% P N N N N LEUCOVORIN CALCIUM LEUCOVOR CA TAB 10MG ANTIDOTES LEUCOVORIN CALCIUM TAB 10 MG P N N N N LEUCOVORIN CALCIUM LEUCOVOR CA TAB 15MG ANTIDOTES LEUCOVORIN CALCIUM TAB 15 MG P N N Y N LEUCOVORIN CALCIUM LEUCOVOR CA TAB 25MG ANTIDOTES LEUCOVORIN CALCIUM TAB 25 MG P N N Y N LEUCOVORIN CALCIUM LEUCOVOR CA TAB 5MG ANTIDOTES LEUCOVORIN CALCIUM TAB 5 MG P N N Y N DRONABINOL DRONABINOL CAP 2.5MG ANTIEMETICS, MISCELLANEOUS DRONABINOL CAP 2.5 MG P Y N Y N MARINOL MARINOL CAP 2.5MG ANTIEMETICS, MISCELLANEOUS DRONABINOL CAP 2.5 MG NP Y N Y N SCOPOLAMINE SCOPOLAMINE DIS 1MG/3DAY ANTIEMETICS, MISCELLANEOUS SCOPOLAMINE TD PATCH 72HR 1 MG/3DAYS NP Y N Y N SYNDROS SYNDROS SOL 5MG/ML ANTIEMETICS, MISCELLANEOUS DRONABINOL SOLN 5 MG/ML NP Y N N N TRANSDERM SCOP TRANSDERM SC DIS 1MG/3DAY ANTIEMETICS, MISCELLANEOUS SCOPOLAMINE TD PATCH 72HR 1 MG/3DAYS NP Y N Y N ANASTROZOLE ANASTROZOLE TAB 1MG ANTIESTROGENS ANASTROZOLE TAB 1 MG P N N Y N ARIMIDEX ARIMIDEX TAB 1MG ANTIESTROGENS ANASTROZOLE TAB 1 MG NP Y N Y N AROMASIN AROMASIN TAB 25MG ANTIESTROGENS EXEMESTANE TAB 25 MG NP Y N Y N EXEMESTANE EXEMESTANE TAB 25MG ANTIESTROGENS EXEMESTANE TAB 25 MG P N N Y N FEMARA FEMARA TAB 2.5MG ANTIESTROGENS LETROZOLE TAB 2.5 MG NP Y N Y N KISQALI FEMARA 200 DOSE KISQALI 200 PAK FEMARA ANTIESTROGENS RIBOCICLIB 200 MG DOSE (200 MG TAB) & LETROZOLE 2.5 MG TBPK NP Y N Y N KISQALI FEMARA 400 DOSE KISQALI 400 PAK FEMARA ANTIESTROGENS RIBOCICLIB 400 MG DOSE (200 MG TAB) & LETROZOLE 2.5 MG TBPK NP Y N Y N KISQALI FEMARA 600 DOSE KISQALI 600 PAK FEMARA ANTIESTROGENS RIBOCICLIB 600 MG DOSE (200 MG TAB) & LETROZOLE 2.5 MG TBPK NP Y N Y N LETROZOLE LETROZOLE TAB 2.5MG ANTIESTROGENS LETROZOLE TAB 2.5 MG P N N Y N ESBRIET ESBRIET CAP 267MG ANTIFIBROTIC AGENTS PIRFENIDONE CAP 267 MG P Y N Y N ESBRIET ESBRIET TAB 801MG ANTIFIBROTIC AGENTS PIRFENIDONE TAB 801 MG P Y N Y N

Confidential 2/19/2021 Page 16 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) OFEV OFEV CAP 100MG ANTIFIBROTIC AGENTS NINTEDANIB ESYLATE CAP 100 MG (BASE EQUIVALENT) P Y N Y N GRISEOFULVIN MICROSIZE GRISEOFULVIN SUS 125/5ML ANTIFUNGALS, MISCELLANEOUS GRISEOFULVIN MICROSIZE SUSP 125 MG/5ML P N N Y N GRISEOFULVIN MICROSIZE GRISEOFULVIN TAB MICR 500 ANTIFUNGALS, MISCELLANEOUS GRISEOFULVIN MICROSIZE TAB 500 MG P N N Y N GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN TAB ULTR 125 ANTIFUNGALS, MISCELLANEOUS GRISEOFULVIN ULTRAMICROSIZE TAB 125 MG P N N Y N GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN TAB ULTR 250 ANTIFUNGALS, MISCELLANEOUS GRISEOFULVIN ULTRAMICROSIZE TAB 250 MG P N N Y N ORGOVYX ORGOVYX TAB 120MG ANTIGONADTROPINS RELUGOLIX TAB 120 MG NP Y N Y N ORIAHNN ORIAHNN CAP ANTIGONADTROPINS ELAGOLIX-ESTRAD-NORETH 300-1-0.5MG & ELAGOLIX 300MG CAP PACK NP Y N Y N ORILISSA ORILISSA TAB 150MG ANTIGONADTROPINS ELAGOLIX SODIUM TAB 150 MG (BASE EQUIV) P Y N Y N ORILISSA ORILISSA TAB 200MG ANTIGONADTROPINS ELAGOLIX SODIUM TAB 200 MG (BASE EQUIV) P Y N Y N ALLOPURINOL ALLOPURINOL TAB 100MG ANTIGOUT AGENTS ALLOPURINOL TAB 100 MG P N N Y N ALLOPURINOL ALLOPURINOL TAB 300MG ANTIGOUT AGENTS ALLOPURINOL TAB 300 MG P N N Y N COLCHICINE COLCHICINE CAP 0.6MG ANTIGOUT AGENTS COLCHICINE CAP 0.6 MG NP Y N Y N COLCRYS COLCRYS TAB 0.6MG ANTIGOUT AGENTS COLCHICINE TAB 0.6 MG NP Y N Y N FEBUXOSTAT FEBUXOSTAT TAB 40MG ANTIGOUT AGENTS FEBUXOSTAT TAB 40 MG P N Y Y N GLOPERBA GLOPERBA SOL 0.6/5ML ANTIGOUT AGENTS COLCHICINE ORAL SOLN 0.6 MG/5ML NP Y N Y N MITIGARE MITIGARE CAP 0.6MG ANTIGOUT AGENTS COLCHICINE CAP 0.6 MG P N N Y N ULORIC ULORIC TAB 40MG ANTIGOUT AGENTS FEBUXOSTAT TAB 40 MG NP Y N Y N ZYLOPRIM ZYLOPRIM TAB 100MG ANTIGOUT AGENTS ALLOPURINOL TAB 100 MG NP Y N Y N ZYLOPRIM ZYLOPRIM TAB 300MG ANTIGOUT AGENTS ALLOPURINOL TAB 300 MG NP Y N Y N BONJESTA BONJESTA TAB 20-20MG ANTIHISTAMINES (GI DRUGS) DOXYLAMINE-PYRIDOXINE TAB ER 20-20 MG NP Y N Y N DICLEGIS DICLEGIS TAB 10-10MG ANTIHISTAMINES (GI DRUGS) DOXYLAMINE-PYRIDOXINE TAB DELAYED RELEASE 10-10 MG NP Y N Y N DIMENHYDRINATE DIMENHYDRIN TAB 50MG ANTIHISTAMINES (GI DRUGS) DIMENHYDRINATE TAB 50 MG P N N N N DOXYLAMINE SUCCINATE/PYRIDOXINE HYDDOXYL/PYRID TAB 10-10MG ANTIHISTAMINES (GI DRUGS) DOXYLAMINE-PYRIDOXINE TAB DELAYED RELEASE 10-10 MG NP Y N Y N MECLIZINE HCL MECLIZINE TAB 12.5MG ANTIHISTAMINES (GI DRUGS) MECLIZINE HCL TAB 12.5 MG P N N Y N MECLIZINE HCL MECLIZINE TAB 25MG ANTIHISTAMINES (GI DRUGS) MECLIZINE HCL TAB 25 MG P N N N N MECLIZINE HYDROCHLORIDE MECLIZINE TAB 50MG ANTIHISTAMINES (GI DRUGS) MECLIZINE HCL TAB 50 MG NP Y N N N TIGAN TIGAN CAP 300MG ANTIHISTAMINES (GI DRUGS) TRIMETHOBENZAMIDE HCL CAP 300 MG NP Y N Y N TRIMETHOBENZAMIDE HYDROCHLORIDE TRIMETHOBENZ CAP 300MG ANTIHISTAMINES (GI DRUGS) TRIMETHOBENZAMIDE HCL CAP 300 MG P N N Y N BD GLUCOSE BD GLUCOSE CHW 5GM ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS GLUCOSE CHEW TAB 5 GM NP Y N N N DEX4 FAST ACTING GLUCOSE DEX4 GLUCOSE LIQ ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS GLUCOSE ORAL LIQUID 15 GM/59ML NP Y N N N DEX4 FAST ACTING GLUCOSE GO-POUCH DEX4 GLUCOSE GEL ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS GLUCOSE GEL 15 GM/33GM NP Y N N N DIAZOXIDE DIAZOXIDE SUS 50MG/ML ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS DIAZOXIDE SUSP 50 MG/ML NP Y N N N DEXAMETH PHO SOL 0.1% OP DEXAMETH PHO SOL 0.1% OP ANTI-INFLAMMATORY AGENTS (EENT) DEXAMETHASONE SODIUM PHOSPHATE OPHTH SOLN 0.1% P N NNN ALOSETRON HYDROCHLORIDE ALOSETRON TAB 0.5MG ANTI-INFLAMMATORY AGENTS (GI DRUGS) ALOSETRON HCL TAB 0.5 MG (BASE EQUIV) NP Y N N N APRISO APRISO CAP 0.375GM ANTI-INFLAMMATORY AGENTS (GI DRUGS) MESALAMINE CAP ER 24HR 0.375 GM NP Y N Y N ASACOL HD ASACOL HD TAB 800MG ANTI-INFLAMMATORY AGENTS (GI DRUGS) MESALAMINE TAB DELAYED RELEASE 800 MG NP Y N Y N BALSALAZIDE DISODIUM BALSALAZIDE CAP 750MG ANTI-INFLAMMATORY AGENTS (GI DRUGS) BALSALAZIDE DISODIUM CAP 750 MG P N N Y N CANASA CANASA SUP 1000MG ANTI-INFLAMMATORY AGENTS (GI DRUGS) MESALAMINE SUPPOS 1000 MG NP Y N Y N COLAZAL COLAZAL CAP 750MG ANTI-INFLAMMATORY AGENTS (GI DRUGS) BALSALAZIDE DISODIUM CAP 750 MG NP Y N Y N DELZICOL DELZICOL CAP 400MG ANTI-INFLAMMATORY AGENTS (GI DRUGS) MESALAMINE CAP DR 400 MG NP Y N Y N DIPENTUM DIPENTUM CAP 250MG ANTI-INFLAMMATORY AGENTS (GI DRUGS) OLSALAZINE SODIUM CAP 250 MG NP Y N Y N LIALDA LIALDA TAB 1.2GM ANTI-INFLAMMATORY AGENTS (GI DRUGS) MESALAMINE TAB DELAYED RELEASE 1.2 GM NP Y N Y N LOTRONEX LOTRONEX TAB 0.5MG ANTI-INFLAMMATORY AGENTS (GI DRUGS) ALOSETRON HCL TAB 0.5 MG (BASE EQUIV) NP Y N N N MESALAMINE MESALAMINE ENE 4GM ANTI-INFLAMMATORY AGENTS (GI DRUGS) MESALAMINE ENEMA 4 GM P N N Y N MESALAMINE MESALAMINE KIT 4GM ANTI-INFLAMMATORY AGENTS (GI DRUGS) *MESALAMINE RECTAL ENEMA 4 GM & CLEANSER WIPE KIT** NP Y N Y N MESALAMINE MESALAMINE SUP 1000MG ANTI-INFLAMMATORY AGENTS (GI DRUGS) MESALAMINE SUPPOS 1000 MG P N N Y N MESALAMINE DR MESALAMINE CAP 400MG DR ANTI-INFLAMMATORY AGENTS (GI DRUGS) MESALAMINE CAP DR 400 MG P N N Y N MESALAMINE DR MESALAMINE TAB 1.2GM ANTI-INFLAMMATORY AGENTS (GI DRUGS) MESALAMINE TAB DELAYED RELEASE 1.2 GM NP Y N Y N

Confidential 2/19/2021 Page 17 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) MESALAMINE DR MESALAMINE TAB 800MG DR ANTI-INFLAMMATORY AGENTS (GI DRUGS) MESALAMINE TAB DELAYED RELEASE 800 MG NP Y N Y N MESALAMINE ER MESALAMINE CAP 0.375GM ANTI-INFLAMMATORY AGENTS (GI DRUGS) MESALAMINE CAP ER 24HR 0.375 GM NP Y N Y N PENTASA PENTASA CAP 250MG CR ANTI-INFLAMMATORY AGENTS (GI DRUGS) MESALAMINE CAP ER 250 MG NP Y N Y N PENTASA PENTASA CAP 500MG CR ANTI-INFLAMMATORY AGENTS (GI DRUGS) MESALAMINE CAP ER 500 MG NP Y N Y N ROWASA ROWASA KIT 4GM ANTI-INFLAMMATORY AGENTS (GI DRUGS) *MESALAMINE RECTAL ENEMA 4 GM & CLEANSER WIPE KIT** NP Y N Y N SFROWASA SFROWASA ENE 4GM ANTI-INFLAMMATORY AGENTS (GI DRUGS) MESALAMINE SULFITE-FREE (SF) ENEMA 4 GM/60ML P N N Y N NUCALA NUCALA INJ 100MG/ML ANTI-INFLAMMATORY AGENTS (RESPIRATORY) MEPOLIZUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML P YNYN CORDRAN 24X3 TAP SML 24IN CORDRAN 24X3 TAP SML 24IN ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS) FLURANDRENOLIDE TAPE 4 MCG/SQCM NP Y N Y N EUCRISA EUCRISA OIN 2% ANTI-INFLAMMATORY AGENTS, MISC (SKIN) CRISABOROLE OINT 2% P N Y Y N JUXTAPID JUXTAPID CAP 5MG ANTILIPEMIC AGENTS, MISCELLANEOUS LOMITAPIDE MESYLATE CAP 5 MG (BASE EQUIV) NP Y N Y N LOVAZA LOVAZA CAP 1GM ANTILIPEMIC AGENTS, MISCELLANEOUS OMEGA-3-ACID ETHYL ESTERS CAP 1 GM NP Y N Y N NEXLETOL NEXLETOL TAB 180MG ANTILIPEMIC AGENTS, MISCELLANEOUS BEMPEDOIC ACID TAB 180 MG NP Y N Y N NEXLIZET NEXLIZET TAB 180/10MG ANTILIPEMIC AGENTS, MISCELLANEOUS BEMPEDOIC ACID-EZETIMIBE TAB 180-10 MG NP Y N Y N NIACIN ER NIACIN ER TAB 1000MG ANTILIPEMIC AGENTS, MISCELLANEOUS NIACIN TAB ER 1000 MG (ANTIHYPERLIPIDEMIC) P N N Y N NIACIN ER NIACIN ER TAB 500MG ANTILIPEMIC AGENTS, MISCELLANEOUS NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC) P N N Y N NIACIN ER NIACIN ER TAB 750MG ANTILIPEMIC AGENTS, MISCELLANEOUS NIACIN TAB ER 750 MG (ANTIHYPERLIPIDEMIC) P N N Y N NIASPAN NIASPAN TAB 1000 ER ANTILIPEMIC AGENTS, MISCELLANEOUS NIACIN TAB ER 1000 MG (ANTIHYPERLIPIDEMIC) NP Y N Y N NIASPAN NIASPAN TAB 500MG ER ANTILIPEMIC AGENTS, MISCELLANEOUS NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC) NP Y N Y N NIASPAN NIASPAN TAB 750MG ER ANTILIPEMIC AGENTS, MISCELLANEOUS NIACIN TAB ER 750 MG (ANTIHYPERLIPIDEMIC) NP Y N Y N OMEGA-3 RX COMPLETE OMEGA-3 RX PAK COMPLETE ANTILIPEMIC AGENTS, MISCELLANEOUS *OMEGA-3-ACID ETHYL EST CAP 1GM & MULTIVIT/MINERAL TAB THPK* NP Y N Y N OMEGA-3-ACID ETHYL ESTERS OMEGA-3-ACID CAP 1GM ANTILIPEMIC AGENTS, MISCELLANEOUS OMEGA-3-ACID ETHYL ESTERS CAP 1 GM P Y N Y N POLICOSANOL POLICOSANOL CAP 10MG ANTILIPEMIC AGENTS, MISCELLANEOUS POLICOSANOL CAP 10 MG NP Y N N N VASCAZEN VASCAZEN CAP 1GM ANTILIPEMIC AGENTS, MISCELLANEOUS OMEGA-3-ACID ETHYL ESTERS (DIETARY MANAGEMENT) CAP 1 GM NP Y N N N VASCEPA VASCEPA CAP 0.5GM ANTILIPEMIC AGENTS, MISCELLANEOUS ICOSAPENT ETHYL CAP 0.5 GM NP Y N Y N VASCEPA VASCEPA CAP 1GM ANTILIPEMIC AGENTS, MISCELLANEOUS ICOSAPENT ETHYL CAP 1 GM NP Y N Y N ZYNCOL ZYNCOL TAB 30MG ANTILIPEMIC AGENTS, MISCELLANEOUS POLICOSANOL TAB 30 MG NP Y N N N ARAKODA ARAKODA TAB 100MG ANTIMALARIALS TAFENOQUINE SUCCINATE TAB 100 MG (BASE EQUIVALENT) NP Y N Y N ATOVAQUONE/PROGUANIL HCL ATOVAQ/PROGU TAB 250-100 ANTIMALARIALS ATOVAQUONE-PROGUANIL HCL TAB 250-100 MG NP Y N Y N ATOVAQUONE/PROGUANIL HCL ATOVAQ/PROGU TAB 62.5-25 ANTIMALARIALS ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG NP Y N Y N CHLOROQUINE PHOSPHATE CHLOROQUINE TAB 250MG ANTIMALARIALS CHLOROQUINE PHOSPHATE TAB 250 MG P N N Y N CHLOROQUINE PHOSPHATE CHLOROQUINE TAB 500MG ANTIMALARIALS CHLOROQUINE PHOSPHATE TAB 500 MG P N N Y N DARAPRIM DARAPRIM TAB 25MG ANTIMALARIALS PYRIMETHAMINE TAB 25 MG NP Y N Y N HYDROXYCHLOROQUINE SULFATE HYDROXYCHLOR TAB 200MG ANTIMALARIALS HYDROXYCHLOROQUINE SULFATE TAB 200 MG P N N Y N KRINTAFEL KRINTAFEL TAB 150MG ANTIMALARIALS TAFENOQUINE SUCCINATE TAB 150 MG (BASE EQUIVALENT) P N N Y N MALARONE MALARONE TAB 250-100 ANTIMALARIALS ATOVAQUONE-PROGUANIL HCL TAB 250-100 MG NP Y N Y N MALARONE MALARONE TAB 62.5-25 ANTIMALARIALS ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG NP Y N Y N MEFLOQUINE HCL MEFLOQUINE TAB 250MG ANTIMALARIALS MEFLOQUINE HCL TAB 250 MG P N N Y N PLAQUENIL PLAQUENIL TAB 200MG ANTIMALARIALS HYDROXYCHLOROQUINE SULFATE TAB 200 MG NP Y N Y N PRIMAQUINE PHOSPHATE PRIMAQUINE TAB 26.3MG ANTIMALARIALS PRIMAQUINE PHOSPHATE TAB 26.3 MG (15 MG BASE) P N N N N PYRIMETHAMINE PYRIMETHAMIN TAB 25MG ANTIMALARIALS PYRIMETHAMINE TAB 25 MG P Y N Y N PYRIMETHAMINE/LEUCOVORIN PYRIME/LEUCO CAP 12.5/2.5 ANTIMALARIALS PYRIMETHAMINE-LEUCOVORIN CAP 12.5-2.5 MG NP Y N Y N QUALAQUIN QUALAQUIN CAP 324MG ANTIMALARIALS QUININE SULFATE CAP 324 MG NP Y N N N LITHIUM LITHIUM SOL 8MEQ/5ML ANTIMANIC AGENTS LITHIUM ORAL SOLUTION 8 MEQ/5ML P N N N N LITHIUM CARBONATE LITHIUM CARB CAP 150MG ANTIMANIC AGENTS LITHIUM CARBONATE CAP 150 MG P N N N N LITHIUM CARBONATE ER LITHIUM CARB TAB 300MG ER ANTIMANIC AGENTS LITHIUM CARBONATE TAB ER 300 MG P N N N N LITHOBID LITHOBID TAB 300MG CR ANTIMANIC AGENTS LITHIUM CARBONATE TAB ER 300 MG NP Y N N N CAFERGOT CAFERGOT TAB 1-100MG ANTIMIGRAINE AGENTS, MISCELLANEOUS ERGOTAMINE W/ CAFFEINE TAB 1-100 MG NP Y N Y N ERGOTAMINE TARTRATE/CAFFEINE ERGOT/CAFFEN TAB 1-100MG ANTIMIGRAINE AGENTS, MISCELLANEOUS ERGOTAMINE W/ CAFFEINE TAB 1-100 MG P N N Y N

Confidential 2/19/2021 Page 18 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) MIGERGOT MIGERGOT SUP 2/100 ANTIMIGRAINE AGENTS, MISCELLANEOUS ERGOTAMINE W/ CAFFEINE SUPPOS 2-100 MG P N N Y N DARIFENACIN HYDROBROMIDE ER DARIFENACIN TAB 7.5MG ANTIMUSCARINICS DARIFENACIN HYDROBROMIDE TAB ER 24HR 7.5 MG (BASE EQUIV) NP Y N Y N DETROL DETROL TAB 1MG ANTIMUSCARINICS TOLTERODINE TARTRATE TAB 1 MG NP Y N Y N DETROL LA DETROL LA CAP 2MG ANTIMUSCARINICS TOLTERODINE TARTRATE CAP ER 24HR 2 MG NP Y N Y N DITROPAN XL DITROPAN XL TAB 5MG ANTIMUSCARINICS OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG NP Y N Y N ENABLEX ENABLEX TAB 7.5MG ANTIMUSCARINICS DARIFENACIN HYDROBROMIDE TAB ER 24HR 7.5 MG (BASE EQUIV) NP Y N Y N GELNIQUE GELNIQUE GEL 10% ANTIMUSCARINICS OXYBUTYNIN CHLORIDE TD GEL 10% NP Y N Y N OXYBUTYNIN CHLORIDE OXYBUTYNIN SYP 5MG/5ML ANTIMUSCARINICS OXYBUTYNIN CHLORIDE SYRUP 5 MG/5ML P N N Y N OXYBUTYNIN CHLORIDE OXYBUTYNIN TAB 5MG ANTIMUSCARINICS OXYBUTYNIN CHLORIDE TAB 5 MG P N N Y N OXYBUTYNIN CHLORIDE ER OXYBUTYNIN TAB 15MG ER ANTIMUSCARINICS OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG P N N Y N OXYBUTYNIN CHLORIDE ER OXYBUTYNIN TAB 5MG ER ANTIMUSCARINICS OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG P N N Y N OXYTROL OXYTROL DIS 3.9MG/24 ANTIMUSCARINICS OXYBUTYNIN TD PATCH TWICE WEEKLY 3.9 MG/24HR NP Y N Y N SOLIFENACIN SUCCINATE SOLIFENACIN TAB 5MG ANTIMUSCARINICS SOLIFENACIN SUCCINATE TAB 5 MG NP Y N Y N TOLTERODINE TARTRATE TOLTERODINE TAB 1MG ANTIMUSCARINICS TOLTERODINE TARTRATE TAB 1 MG P N Y Y N TOLTERODINE TARTRATE ER TOLTERODINE CAP 2MG ER ANTIMUSCARINICS TOLTERODINE TARTRATE CAP ER 24HR 2 MG NP Y N Y N TOVIAZ TOVIAZ TAB 4MG ANTIMUSCARINICS FESOTERODINE FUMARATE TAB ER 24HR 4 MG NP Y N Y N TROSPIUM CHLORIDE TROSPIUM CL TAB 20MG ANTIMUSCARINICS TROSPIUM CHLORIDE TAB 20 MG P N Y Y N TROSPIUM CHLORIDE ER TROSPIUM CHL CAP 60MG ER ANTIMUSCARINICS TROSPIUM CHLORIDE CAP ER 24HR 60 MG NP Y N Y N VESICARE VESICARE TAB 5MG ANTIMUSCARINICS SOLIFENACIN SUCCINATE TAB 5 MG NP Y N Y N ANASPAZ ANASPAZ TAB 0.125MG ANTIMUSCARINICS/ANTISPASMODICS HYOSCYAMINE SULFATE TAB DISINT 0.125 MG P N N Y N ANORO ELLIPTA ANORO ELLIPT AER 62.5-25 ANTIMUSCARINICS/ANTISPASMODICS UMECLIDINIUM-VILANTEROL AERO POWD BA 62.5-25 MCG/INH NP Y N Y N ATROPINE SULFATE ATROPINE SUL INJ 0.4MG/ML ANTIMUSCARINICS/ANTISPASMODICS ATROPINE SULFATE IV SOLN 0.4 MG/ML NP Y N N N ATROVENT HFA ATROVENT HFA AER 17MCG ANTIMUSCARINICS/ANTISPASMODICS IPRATROPIUM BROMIDE HFA INHAL AEROSOL 17 MCG/ACT P N N Y N BEVESPI AEROSPHERE BEVESPI AER 9-4.8MCG ANTIMUSCARINICS/ANTISPASMODICS GLYCOPYRROLATE-FORMOTEROL FUMARATE AEROSOL 9-4.8 MCG/ACT NP Y N Y N CHLORDIAZEPOXIDE HCL/CLIDINIUM BROMCHLORD/CLIDI CAP 5-2.5MG ANTIMUSCARINICS/ANTISPASMODICS CHLORDIAZEPOXIDE HCL-CLIDINIUM BROMIDE CAP 5-2.5 MG NP Y N Y N CHLORDIAZEPOXIDE HYDROCHLORIDE/CLIDCHLORD/CLIDI CAP 5-2.5MG ANTIMUSCARINICS/ANTISPASMODICS CHLORDIAZEPOXIDE HCL-CLIDINIUM BROMIDE CAP 5-2.5 MG NP Y N Y N CUVPOSA CUVPOSA SOL 1MG/5ML ANTIMUSCARINICS/ANTISPASMODICS GLYCOPYRROLATE ORAL SOLN 1 MG/5ML NP Y N Y N DICYCLOMINE HYDROCHLORIDE DICYCLOMINE CAP 10MG ANTIMUSCARINICS/ANTISPASMODICS DICYCLOMINE HCL CAP 10 MG P N N Y N DICYCLOMINE HYDROCHLORIDE DICYCLOMINE SOL 10MG/5ML ANTIMUSCARINICS/ANTISPASMODICS DICYCLOMINE HCL ORAL SOLN 10 MG/5ML P N N N N DICYCLOMINE HYDROCHLORIDE DICYCLOMINE TAB 20MG ANTIMUSCARINICS/ANTISPASMODICS DICYCLOMINE HCL TAB 20 MG P N N Y N DUAKLIR PRESSAIR DUAKLIR AER 400/12 ANTIMUSCARINICS/ANTISPASMODICS ACLIDINIUM BR-FORMOTEROL FUM AERO POW BR ACT 400-12 MCG/ACTNPYNYN ED-SPAZ ED-SPAZ TAB 0.125MG ANTIMUSCARINICS/ANTISPASMODICS HYOSCYAMINE SULFATE TAB DISINT 0.125 MG P N N Y N GLYCATE GLYCATE TAB 1.5MG ANTIMUSCARINICS/ANTISPASMODICS GLYCOPYRROLATE TAB 1.5 MG NP Y N N N GLYCOPYRROLATE GLYCOPYRROL TAB 1MG ANTIMUSCARINICS/ANTISPASMODICS GLYCOPYRROLATE TAB 1 MG P N N N N GLYCOPYRROLATE GLYCOPYRROLA TAB 1.5MG ANTIMUSCARINICS/ANTISPASMODICS GLYCOPYRROLATE TAB 1.5 MG NP Y N N N GLYRX-PF GLYRX-PF INJ 1MG/5ML ANTIMUSCARINICS/ANTISPASMODICS GLYCOPYRROLATE INJ PF SOLN PREF SYR 1 MG/5ML (0.2 MG/ML) NP Y N N N HYOSCYAMINE SULFATE HYOSCYAMINE ELX 0.125/5 ANTIMUSCARINICS/ANTISPASMODICS HYOSCYAMINE SULFATE ELIXIR 0.125 MG/5ML P N N Y N HYOSCYAMINE SULFATE HYOSCYAMINE TAB 0.125MG ANTIMUSCARINICS/ANTISPASMODICS HYOSCYAMINE SULFATE TAB 0.125 MG P N N Y N HYOSCYAMINE SULFATE ER HYOSCYAMINE TAB 0.375 ER ANTIMUSCARINICS/ANTISPASMODICS HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG P N N Y N INCRUSE ELLIPTA INCRUSE ELPT INH 62.5MCG ANTIMUSCARINICS/ANTISPASMODICS UMECLIDINIUM BR AERO POWD BREATH ACT 62.5 MCG/INH (BASE EQ)PNNYN IPRATROPIUM BROMIDE IPRATROPIUM SOL 0.02%INH ANTIMUSCARINICS/ANTISPASMODICS IPRATROPIUM BROMIDE INHAL SOLN 0.02% P N N Y N IPRATROPIUM BROMIDE IPRATROPIUM SPR 0.03% ANTIMUSCARINICS/ANTISPASMODICS IPRATROPIUM BROMIDE NASAL SOLN 0.03% (21 MCG/SPRAY) P N N Y N IPRATROPIUM BROMIDE IPRATROPIUM SPR 0.06% ANTIMUSCARINICS/ANTISPASMODICS IPRATROPIUM BROMIDE NASAL SOLN 0.06% (42 MCG/SPRAY) P N N Y N LEVBID LEVBID TAB 0.375 ER ANTIMUSCARINICS/ANTISPASMODICS HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG P N N Y N LEVSIN LEVSIN TAB 0.125MG ANTIMUSCARINICS/ANTISPASMODICS HYOSCYAMINE SULFATE TAB 0.125 MG NP Y N Y N LEVSIN/SL LEVSIN/SL SUB 0.125MG ANTIMUSCARINICS/ANTISPASMODICS HYOSCYAMINE SULFATE SL TAB 0.125 MG NP Y N Y N LIBRAX LIBRAX CAP 5-2.5MG ANTIMUSCARINICS/ANTISPASMODICS CHLORDIAZEPOXIDE HCL-CLIDINIUM BROMIDE CAP 5-2.5 MG NP Y N Y N LONHALA MAGNAIR REFILL KIT LONHALA MAGN SOL 25MCG ANTIMUSCARINICS/ANTISPASMODICS GLYCOPYRROLATE INHAL SOLUTION 25 MCG/ML NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) LONHALA MAGNAIR STARTER KIT LONHALA MAGN SOL 25MCG ANTIMUSCARINICS/ANTISPASMODICS GLYCOPYRROLATE INHAL SOLUTION 25 MCG/ML NP Y N Y N METHSCOPOLAMINE BROMIDE METHSCOPOLAM TAB 2.5MG ANTIMUSCARINICS/ANTISPASMODICS METHSCOPOLAMINE BROMIDE TAB 2.5 MG NP Y N N N NULEV NULEV TAB 0.125MG ANTIMUSCARINICS/ANTISPASMODICS HYOSCYAMINE SULFATE TAB DISINT 0.125 MG P N N Y N OSCIMIN OSCIMIN TAB 0.125MG ANTIMUSCARINICS/ANTISPASMODICS HYOSCYAMINE SULFATE TAB 0.125 MG P N N Y N OSCIMIN SR OSCIMIN SR TAB 0.375MG ANTIMUSCARINICS/ANTISPASMODICS HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG P N N Y N PROPANTHELINE BROMIDE PROPANTHELIN TAB 15MG ANTIMUSCARINICS/ANTISPASMODICS PROPANTHELINE BROMIDE TAB 15 MG NP Y N Y N SEEBRI NEOHALER SEEBRI NEOHA CAP 15.6MCG ANTIMUSCARINICS/ANTISPASMODICS GLYCOPYRROLATE INHAL CAP 15.6 MCG NP Y N Y N SPIRIVA HANDIHALER SPIRIVA CAP HANDIHLR ANTIMUSCARINICS/ANTISPASMODICS TIOTROPIUM BROMIDE MONOHYDRATE INHAL CAP 18 MCG (BASE EQUIV) NP Y N Y N SPIRIVA RESPIMAT SPIRIVA AER 1.25MCG ANTIMUSCARINICS/ANTISPASMODICS TIOTROPIUM BROMIDE MONOHYDRATE INHAL AEROSOL 1.25 MCG/ACT NP Y N Y N SPIRIVA RESPIMAT SPIRIVA SPR 2.5MCG ANTIMUSCARINICS/ANTISPASMODICS TIOTROPIUM BROMIDE MONOHYDRATE INHAL AEROSOL 2.5 MCG/ACT NP YNYN STIOLTO RESPIMAT STIOLTO AER 2.5-2.5 ANTIMUSCARINICS/ANTISPASMODICS TIOTROPIUM BR-OLODATEROL INHAL AERO SOLN 2.5-2.5 MCG/ACT P NNYN SYMAX DUOTAB SYMAX DUOTAB TAB ANTIMUSCARINICS/ANTISPASMODICS HYOSCYAMINE SULFATE TAB ER 0.375 MG (0.125 MG IR/0.25 MG ER) NP Y N N N SYMAX-SR SYMAX-SR TAB 0.375MG ANTIMUSCARINICS/ANTISPASMODICS HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG P N N Y N TUDORZA PRESSAIR TUDORZA PRES AER 400/ACT ANTIMUSCARINICS/ANTISPASMODICS ACLIDINIUM BROMIDE AEROSOL POWD BREATH ACTIVATED 400 MCG/ACT NP Y N Y N YUPELRI YUPELRI SOL ANTIMUSCARINICS/ANTISPASMODICS REVEFENACIN INHALATION SOLUTION 175 MCG/3ML NP Y N Y N DAPSONE DAPSONE TAB 100MG ANTIMYCOBACTERIALS, MISCELLANEOUS DAPSONE TAB 100 MG P N N Y N DAPSONE DAPSONE TAB 25MG ANTIMYCOBACTERIALS, MISCELLANEOUS DAPSONE TAB 25 MG P N N Y N ABIRATERONE ACETATE ABIRATERONE TAB 250MG ANTINEOPLASTIC AGENTS ABIRATERONE ACETATE TAB 250 MG P Y N Y N ABIRATERONE ACETATE ABIRATERONE TAB 500MG ANTINEOPLASTIC AGENTS ABIRATERONE ACETATE TAB 500 MG NP Y N Y N AFINITOR AFINITOR TAB 10MG ANTINEOPLASTIC AGENTS EVEROLIMUS TAB 10 MG P Y N Y N AFINITOR AFINITOR TAB 2.5MG ANTINEOPLASTIC AGENTS EVEROLIMUS TAB 2.5 MG NP Y N Y N AFINITOR AFINITOR TAB 7.5MG ANTINEOPLASTIC AGENTS EVEROLIMUS TAB 7.5 MG NP Y N N N AFINITOR DISPERZ AFINITOR DIS TAB 2MG ANTINEOPLASTIC AGENTS EVEROLIMUS TAB FOR ORAL SUSP 2 MG P Y N Y N ALECENSA ALECENSA CAP 150MG ANTINEOPLASTIC AGENTS ALECTINIB HCL CAP 150 MG (BASE EQUIVALENT) P Y N Y N ALKERAN ALKERAN TAB 2MG ANTINEOPLASTIC AGENTS MELPHALAN TAB 2 MG NP Y N N N ALUNBRIG ALUNBRIG PAK ANTINEOPLASTIC AGENTS BRIGATINIB TAB INITIATION THERAPY PACK 90 MG & 180 MG P Y N Y N ALUNBRIG ALUNBRIG TAB 30MG ANTINEOPLASTIC AGENTS BRIGATINIB TAB 30 MG P Y N Y N ALUNBRIG ALUNBRIG TAB 90MG ANTINEOPLASTIC AGENTS BRIGATINIB TAB 90 MG P Y N Y N AYVAKIT AYVAKIT TAB 100MG ANTINEOPLASTIC AGENTS AVAPRITINIB TAB 100 MG NP Y N Y N BALVERSA BALVERSA TAB 3MG ANTINEOPLASTIC AGENTS ERDAFITINIB TAB 3 MG P Y N Y N BALVERSA BALVERSA TAB 4MG ANTINEOPLASTIC AGENTS ERDAFITINIB TAB 4 MG P Y N Y N BALVERSA BALVERSA TAB 5MG ANTINEOPLASTIC AGENTS ERDAFITINIB TAB 5 MG P Y N Y N BEXAROTENE BEXAROTENE CAP 75MG ANTINEOPLASTIC AGENTS BEXAROTENE CAP 75 MG P Y N N N BICALUTAMIDE BICALUTAMIDE TAB 50MG ANTINEOPLASTIC AGENTS BICALUTAMIDE TAB 50 MG P N N Y N BOSULIF BOSULIF TAB 100MG ANTINEOPLASTIC AGENTS BOSUTINIB TAB 100 MG P Y N Y N BOSULIF BOSULIF TAB 400MG ANTINEOPLASTIC AGENTS BOSUTINIB TAB 400 MG P Y N Y N BRAFTOVI BRAFTOVI CAP 75MG ANTINEOPLASTIC AGENTS ENCORAFENIB CAP 75 MG NP Y N Y N BRUKINSA BRUKINSA CAP 80MG ANTINEOPLASTIC AGENTS ZANUBRUTINIB CAP 80 MG P Y N Y N CABOMETYX CABOMETYX TAB 20MG ANTINEOPLASTIC AGENTS CABOZANTINIB S-MALATE TAB 20 MG (BASE EQUIVALENT) P Y N Y N CALQUENCE CALQUENCE CAP 100MG ANTINEOPLASTIC AGENTS ACALABRUTINIB CAP 100 MG P Y N Y N CAPECITABINE CAPECITABINE TAB 150MG ANTINEOPLASTIC AGENTS CAPECITABINE TAB 150 MG P Y N N N CAPRELSA CAPRELSA TAB 100MG ANTINEOPLASTIC AGENTS VANDETANIB TAB 100 MG P Y N Y N CAPRELSA CAPRELSA TAB 300MG ANTINEOPLASTIC AGENTS VANDETANIB TAB 300 MG P Y N Y N CASODEX CASODEX TAB 50MG ANTINEOPLASTIC AGENTS BICALUTAMIDE TAB 50 MG NP Y N Y N COMETRIQ COMETRIQ KIT 100MG ANTINEOPLASTIC AGENTS CABOZANTINIB S-MAL CAP 1 X 80 MG & 1 X 20 MG (100 DOSE) KIT P Y N Y N COMETRIQ COMETRIQ KIT 140MG ANTINEOPLASTIC AGENTS CABOZANTINIB S-MAL CAP 1 X 80 MG & 3 X 20 MG (140 DOSE) KIT P Y N Y N COMETRIQ COMETRIQ KIT 60MG ANTINEOPLASTIC AGENTS CABOZANTINIB S-MALATE CAP 3 X 20 MG (60 MG DOSE) KIT P Y N Y N COPIKTRA COPIKTRA CAP 15MG ANTINEOPLASTIC AGENTS DUVELISIB CAP 15 MG NP Y N Y N

Confidential 2/19/2021 Page 20 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) COTELLIC COTELLIC TAB 20MG ANTINEOPLASTIC AGENTS COBIMETINIB FUMARATE TAB 20 MG (BASE EQUIVALENT) P Y N Y N CYCLOPHOSPHAMIDE CYCLOPHOSPH CAP 25MG ANTINEOPLASTIC AGENTS CYCLOPHOSPHAMIDE CAP 25 MG P N N N N DAURISMO DAURISMO TAB 100MG ANTINEOPLASTIC AGENTS GLASDEGIB MALEATE TAB 100 MG (BASE EQUIVALENT) P Y N Y N DAURISMO DAURISMO TAB 25MG ANTINEOPLASTIC AGENTS GLASDEGIB MALEATE TAB 25 MG (BASE EQUIVALENT) P Y N Y N DROXIA DROXIA CAP 200MG ANTINEOPLASTIC AGENTS HYDROXYUREA CAP 200 MG P N N N N DROXIA DROXIA CAP 400MG ANTINEOPLASTIC AGENTS HYDROXYUREA CAP 400 MG P N N Y N EMCYT EMCYT CAP 140MG ANTINEOPLASTIC AGENTS ESTRAMUSTINE PHOSPHATE SODIUM CAP 140 MG NP Y N Y N ERIVEDGE ERIVEDGE CAP 150MG ANTINEOPLASTIC AGENTS VISMODEGIB CAP 150 MG P Y N Y N ERLEADA ERLEADA TAB 60MG ANTINEOPLASTIC AGENTS APALUTAMIDE TAB 60 MG P Y N Y N ERLOTINIB HYDROCHLORIDE ERLOTINIB TAB 100MG ANTINEOPLASTIC AGENTS ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT) P Y N Y N ERLOTINIB HYDROCHLORIDE ERLOTINIB TAB 25MG ANTINEOPLASTIC AGENTS ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT) P Y N Y N ETOPOSIDE ETOPOSIDE CAP 50MG ANTINEOPLASTIC AGENTS ETOPOSIDE CAP 50 MG P N N N N EVEROLIMUS EVEROLIMUS TAB 2.5MG ANTINEOPLASTIC AGENTS EVEROLIMUS TAB 2.5 MG P Y N Y N EVEROLIMUS EVEROLIMUS TAB 7.5MG ANTINEOPLASTIC AGENTS EVEROLIMUS TAB 7.5 MG P Y N N N FARYDAK FARYDAK CAP 10MG ANTINEOPLASTIC AGENTS PANOBINOSTAT LACTATE CAP 10 MG (BASE EQUIVALENT) P Y N Y N FLUTAMIDE FLUTAMIDE CAP 125MG ANTINEOPLASTIC AGENTS FLUTAMIDE CAP 125 MG P N N Y N GAVRETO GAVRETO CAP 100MG ANTINEOPLASTIC AGENTS PRALSETINIB CAP 100 MG NP Y N Y N GILOTRIF GILOTRIF TAB 20MG ANTINEOPLASTIC AGENTS AFATINIB DIMALEATE TAB 20 MG (BASE EQUIVALENT) P Y N Y N GLEEVEC GLEEVEC TAB 100MG ANTINEOPLASTIC AGENTS IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT) NP Y N Y N GLEEVEC GLEEVEC TAB 400MG ANTINEOPLASTIC AGENTS IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT) NP Y N Y N GLEOSTINE GLEOSTINE CAP 10MG ANTINEOPLASTIC AGENTS LOMUSTINE CAP 10 MG P N N N N HYCAMTIN HYCAMTIN CAP 0.25MG ANTINEOPLASTIC AGENTS TOPOTECAN HCL CAP 0.25 MG (BASE EQUIV) P Y N N N HYDREA HYDREA CAP 500MG ANTINEOPLASTIC AGENTS HYDROXYUREA CAP 500 MG NP Y N Y N HYDROXYUREA HYDROXYUREA CAP 500MG ANTINEOPLASTIC AGENTS HYDROXYUREA CAP 500 MG P N N Y N IBRANCE IBRANCE CAP 75MG ANTINEOPLASTIC AGENTS PALBOCICLIB CAP 75 MG P Y N Y N ICLUSIG ICLUSIG TAB 10MG ANTINEOPLASTIC AGENTS PONATINIB HCL TAB 10 MG (BASE EQUIV) NP Y N N N ICLUSIG ICLUSIG TAB 15MG ANTINEOPLASTIC AGENTS PONATINIB HCL TAB 15 MG (BASE EQUIV) P Y N Y N ICLUSIG ICLUSIG TAB 45MG ANTINEOPLASTIC AGENTS PONATINIB HCL TAB 45 MG (BASE EQUIV) P Y N Y N IDHIFA IDHIFA TAB 50MG ANTINEOPLASTIC AGENTS ENASIDENIB MESYLATE TAB 50 MG (BASE EQUIVALENT) P Y N Y N IMATINIB MESYLATE IMATINIB MES TAB 100MG ANTINEOPLASTIC AGENTS IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT) P Y N Y N IMATINIB MESYLATE IMATINIB MES TAB 400MG ANTINEOPLASTIC AGENTS IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT) P Y N Y N IMBRUVICA IMBRUVICA CAP 140MG ANTINEOPLASTIC AGENTS IBRUTINIB CAP 140 MG P Y N Y N IMBRUVICA IMBRUVICA CAP 70MG ANTINEOPLASTIC AGENTS IBRUTINIB CAP 70 MG P Y N Y N INLYTA INLYTA TAB 1MG ANTINEOPLASTIC AGENTS AXITINIB TAB 1 MG P Y N Y N INLYTA INLYTA TAB 5MG ANTINEOPLASTIC AGENTS AXITINIB TAB 5 MG P Y N Y N INQOVI INQOVI TAB 35-100MG ANTINEOPLASTIC AGENTS DECITABINE-CEDAZURIDINE TAB 35-100 MG NP Y N Y N INREBIC INREBIC CAP 100MG ANTINEOPLASTIC AGENTS FEDRATINIB HCL CAP 100 MG NP Y N Y N INTRON A INTRON A INJ 18MU ANTINEOPLASTIC AGENTS INTERFERON ALFA-2B INJ 6000000 UNIT/ML P Y N N N IRESSA IRESSA TAB 250MG ANTINEOPLASTIC AGENTS GEFITINIB TAB 250 MG P Y N Y N JAKAFI JAKAFI TAB 5MG ANTINEOPLASTIC AGENTS RUXOLITINIB PHOSPHATE TAB 5 MG (BASE EQUIVALENT) P Y N Y N KISQALI KISQALI TAB 200DOSE ANTINEOPLASTIC AGENTS RIBOCICLIB SUCCINATE TAB PACK 200 MG DAILY DOSE NP Y N Y N KISQALI KISQALI TAB 400DOSE ANTINEOPLASTIC AGENTS RIBOCICLIB SUCCINATE TAB PACK 400 MG DAILY DOSE (200 MG TAB) NP Y N Y N KOSELUGO KOSELUGO CAP 10MG ANTINEOPLASTIC AGENTS SELUMETINIB SULFATE CAP 10 MG NP Y N Y N KOSELUGO KOSELUGO CAP 25MG ANTINEOPLASTIC AGENTS SELUMETINIB SULFATE CAP 25 MG NP Y N Y N LAPATINIB DITOSYLATE LAPATINIB TAB 250MG ANTINEOPLASTIC AGENTS LAPATINIB DITOSYLATE TAB 250 MG (BASE EQUIV) P Y N Y N LENVIMA 10 MG DAILY DOSE LENVIMA CAP 10 MG ANTINEOPLASTIC AGENTS LENVATINIB CAP THERAPY PACK 10 MG (10 MG DAILY DOSE) P Y N Y N LENVIMA 12MG DAILY DOSE LENVIMA CAP 12MG ANTINEOPLASTIC AGENTS LENVATINIB CAP THERAPY PACK 3 X 4 MG (12 MG DAILY DOSE) P Y N Y N LENVIMA 14 MG DAILY DOSE LENVIMA CAP 14 MG ANTINEOPLASTIC AGENTS LENVATINIB CAP THERAPY PACK 10 & 4 MG (14 MG DAILY DOSE) P Y N Y N

Confidential 2/19/2021 Page 21 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) LENVIMA 18 MG DAILY DOSE LENVIMA CAP 18 MG ANTINEOPLASTIC AGENTS LENVATINIB CAP THER PACK 10 MG & 2 X 4 MG (18 MG DAILY DOSE) PYNYN LENVIMA 20 MG DAILY DOSE LENVIMA CAP 20 MG ANTINEOPLASTIC AGENTS LENVATINIB CAP THERAPY PACK 2 X 10 MG (20 MG DAILY DOSE) P Y N Y N LENVIMA 24 MG DAILY DOSE LENVIMA CAP 24 MG ANTINEOPLASTIC AGENTS LENVATINIB CAP THER PACK 2 X 10 MG & 4 MG (24 MG DAILY DOSE) PYNYN LENVIMA 4 MG DAILY DOSE LENVIMA CAP 4MG ANTINEOPLASTIC AGENTS LENVATINIB CAP THERAPY PACK 4 MG (4 MG DAILY DOSE) P Y N Y N LENVIMA 8 MG DAILY DOSE LENVIMA CAP 8 MG ANTINEOPLASTIC AGENTS LENVATINIB CAP THERAPY PACK 2 X 4 MG (8 MG DAILY DOSE) P Y N Y N LEUKERAN LEUKERAN TAB 2MG ANTINEOPLASTIC AGENTS CHLORAMBUCIL TAB 2 MG P N N N N LONSURF LONSURF TAB 15-6.14 ANTINEOPLASTIC AGENTS TRIFLURIDINE-TIPIRACIL TAB 15-6.14 MG P Y N Y N LORBRENA LORBRENA TAB 100MG ANTINEOPLASTIC AGENTS LORLATINIB TAB 100 MG NP Y N Y N LORBRENA LORBRENA TAB 25MG ANTINEOPLASTIC AGENTS LORLATINIB TAB 25 MG NP Y N Y N LYNPARZA LYNPARZA TAB 100MG ANTINEOPLASTIC AGENTS OLAPARIB TAB 100 MG P Y N Y N LYSODREN LYSODREN TAB 500MG ANTINEOPLASTIC AGENTS MITOTANE TAB 500 MG P N N Y N MATULANE MATULANE CAP 50MG ANTINEOPLASTIC AGENTS PROCARBAZINE HCL CAP 50 MG P N N N N MEKINIST MEKINIST TAB 0.5MG ANTINEOPLASTIC AGENTS TRAMETINIB DIMETHYL SULFOXIDE TAB 0.5 MG (BASE EQUIVALENT) P Y N Y N MEKINIST MEKINIST TAB 2MG ANTINEOPLASTIC AGENTS TRAMETINIB DIMETHYL SULFOXIDE TAB 2 MG (BASE EQUIVALENT) P Y N Y N MEKTOVI MEKTOVI TAB 15MG ANTINEOPLASTIC AGENTS BINIMETINIB TAB 15 MG NP Y N Y N MELPHALAN MELPHALAN TAB 2MG ANTINEOPLASTIC AGENTS MELPHALAN TAB 2 MG P N N N N MERCAPTOPURINE MERCAPTOPUR TAB 50MG ANTINEOPLASTIC AGENTS MERCAPTOPURINE TAB 50 MG P N N Y N METHOTREXATE METHOTREXATE TAB 2.5MG ANTINEOPLASTIC AGENTS METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV) P N N N N MYLERAN MYLERAN TAB 2MG ANTINEOPLASTIC AGENTS BUSULFAN TAB 2 MG P N N N N NERLYNX NERLYNX TAB 40MG ANTINEOPLASTIC AGENTS NERATINIB MALEATE TAB 40 MG (BASE EQUIVALENT) NP Y N Y N NEXAVAR NEXAVAR TAB 200MG ANTINEOPLASTIC AGENTS SORAFENIB TOSYLATE TAB 200 MG (BASE EQUIVALENT) P Y N Y N NILANDRON NILANDRON TAB 150MG ANTINEOPLASTIC AGENTS NILUTAMIDE TAB 150 MG NP Y N Y N NILUTAMIDE NILUTAMIDE TAB 150MG ANTINEOPLASTIC AGENTS NILUTAMIDE TAB 150 MG NP Y N Y N NINLARO NINLARO CAP 2.3MG ANTINEOPLASTIC AGENTS IXAZOMIB CITRATE CAP 2.3 MG (BASE EQUIVALENT) P Y N Y N NUBEQA NUBEQA TAB 300MG ANTINEOPLASTIC AGENTS DAROLUTAMIDE TAB 300 MG P Y N Y N ODOMZO ODOMZO CAP 200MG ANTINEOPLASTIC AGENTS SONIDEGIB PHOSPHATE CAP 200 MG (BASE EQUIVALENT) P Y N Y N ONUREG ONUREG TAB 200MG ANTINEOPLASTIC AGENTS AZACITIDINE TAB 200 MG NP Y N Y N PEMAZYRE PEMAZYRE TAB 4.5MG ANTINEOPLASTIC AGENTS PEMIGATINIB TAB 4.5 MG NP Y N Y N PIQRAY 200MG DAILY DOSE PIQRAY 200MG TAB DOSE ANTINEOPLASTIC AGENTS ALPELISIB TAB THERAPY PACK 200 MG DAILY DOSE P Y N Y N PIQRAY 250MG DAILY DOSE PIQRAY 250MG TAB DOSE ANTINEOPLASTIC AGENTS ALPELISIB TAB PACK 250 MG DAILY DOSE (200 MG & 50 MG TABS) P Y N Y N PIQRAY 300MG DAILY DOSE PIQRAY 300MG TAB DOSE ANTINEOPLASTIC AGENTS ALPELISIB TAB PACK 300 MG DAILY DOSE (2X150 MG TAB) P Y N Y N POMALYST POMALYST CAP 1MG ANTINEOPLASTIC AGENTS POMALIDOMIDE CAP 1 MG P Y N Y N PURIXAN PURIXAN SUS 20MG/ML ANTINEOPLASTIC AGENTS MERCAPTOPURINE SUSP 2000 MG/100ML (20 MG/ML) NP Y N Y N QINLOCK QINLOCK TAB 50MG ANTINEOPLASTIC AGENTS RIPRETINIB TAB 50 MG NP Y N Y N RETEVMO RETEVMO CAP 40MG ANTINEOPLASTIC AGENTS SELPERCATINIB CAP 40 MG NP Y N Y N RETEVMO RETEVMO CAP 80MG ANTINEOPLASTIC AGENTS SELPERCATINIB CAP 80 MG NP Y N Y N REVLIMID REVLIMID CAP 2.5MG ANTINEOPLASTIC AGENTS LENALIDOMIDE CAPS 2.5 MG P Y N Y N ROZLYTREK ROZLYTREK CAP 100MG ANTINEOPLASTIC AGENTS ENTRECTINIB CAP 100 MG P Y N Y N ROZLYTREK ROZLYTREK CAP 200MG ANTINEOPLASTIC AGENTS ENTRECTINIB CAP 200 MG P Y N Y N RUBRACA RUBRACA TAB 200MG ANTINEOPLASTIC AGENTS RUCAPARIB CAMSYLATE TAB 200 MG (BASE EQUIVALENT) P Y N Y N RUBRACA RUBRACA TAB 250MG ANTINEOPLASTIC AGENTS RUCAPARIB CAMSYLATE TAB 250 MG (BASE EQUIVALENT) P Y N Y N RYDAPT RYDAPT CAP 25MG ANTINEOPLASTIC AGENTS MIDOSTAURIN CAP 25 MG P Y N Y N SIKLOS SIKLOS TAB 1000MG ANTINEOPLASTIC AGENTS HYDROXYUREA TAB 1000 MG NP Y N Y N SIKLOS SIKLOS TAB 100MG ANTINEOPLASTIC AGENTS HYDROXYUREA TAB 100 MG NP Y N Y N SPRYCEL SPRYCEL TAB 20MG ANTINEOPLASTIC AGENTS DASATINIB TAB 20 MG P Y N Y N SPRYCEL SPRYCEL TAB 50MG ANTINEOPLASTIC AGENTS DASATINIB TAB 50 MG P Y N Y N STIVARGA STIVARGA TAB 40MG ANTINEOPLASTIC AGENTS REGORAFENIB TAB 40 MG P Y N Y N SUTENT SUTENT CAP 12.5MG ANTINEOPLASTIC AGENTS SUNITINIB MALATE CAP 12.5 MG (BASE EQUIVALENT) P Y N Y N

Confidential 2/19/2021 Page 22 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) SUTENT SUTENT CAP 37.5MG ANTINEOPLASTIC AGENTS SUNITINIB MALATE CAP 37.5 MG (BASE EQUIVALENT) P Y N N N SYNRIBO SYNRIBO INJ 3.5MG ANTINEOPLASTIC AGENTS OMACETAXINE MEPESUCCINATE FOR INJ 3.5 MG NP Y N N N TABLOID TABLOID TAB 40MG ANTINEOPLASTIC AGENTS THIOGUANINE TAB 40 MG P N N N N TABRECTA TABRECTA TAB 150MG ANTINEOPLASTIC AGENTS CAPMATINIB HCL TAB 150 MG NP Y N Y N TAFINLAR TAFINLAR CAP 50MG ANTINEOPLASTIC AGENTS DABRAFENIB MESYLATE CAP 50 MG (BASE EQUIVALENT) P Y N Y N TAGRISSO TAGRISSO TAB 40MG ANTINEOPLASTIC AGENTS OSIMERTINIB MESYLATE TAB 40 MG (BASE EQUIVALENT) NP Y N Y N TALZENNA TALZENNA CAP 0.25MG ANTINEOPLASTIC AGENTS TALAZOPARIB TOSYLATE CAP 0.25 MG (BASE EQUIVALENT) NP Y N Y N TALZENNA TALZENNA CAP 1MG ANTINEOPLASTIC AGENTS TALAZOPARIB TOSYLATE CAP 1 MG (BASE EQUIVALENT) NP Y N Y N TARCEVA TARCEVA TAB 100MG ANTINEOPLASTIC AGENTS ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT) NP Y N Y N TARCEVA TARCEVA TAB 25MG ANTINEOPLASTIC AGENTS ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT) NP Y N Y N TARGRETIN TARGRETIN CAP 75MG ANTINEOPLASTIC AGENTS BEXAROTENE CAP 75 MG NP Y N N N TASIGNA TASIGNA CAP 150MG ANTINEOPLASTIC AGENTS NILOTINIB HCL CAP 150 MG (BASE EQUIVALENT) P Y N Y N TASIGNA TASIGNA CAP 50MG ANTINEOPLASTIC AGENTS NILOTINIB HCL CAP 50 MG (BASE EQUIVALENT) P Y N Y N TAZVERIK TAZVERIK TAB 200MG ANTINEOPLASTIC AGENTS TAZEMETOSTAT HBR TAB 200 MG NP Y N Y N TEMODAR TEMODAR CAP 100MG ANTINEOPLASTIC AGENTS TEMOZOLOMIDE CAP 100 MG NP Y N N N TEMODAR TEMODAR CAP 180MG ANTINEOPLASTIC AGENTS TEMOZOLOMIDE CAP 180 MG NP Y N Y N TEMODAR TEMODAR CAP 20MG ANTINEOPLASTIC AGENTS TEMOZOLOMIDE CAP 20 MG NP Y N Y N TEMOZOLOMIDE TEMOZOLOMIDE CAP 100MG ANTINEOPLASTIC AGENTS TEMOZOLOMIDE CAP 100 MG P Y N N N TEMOZOLOMIDE TEMOZOLOMIDE CAP 180MG ANTINEOPLASTIC AGENTS TEMOZOLOMIDE CAP 180 MG P Y N Y N TEMOZOLOMIDE TEMOZOLOMIDE CAP 20MG ANTINEOPLASTIC AGENTS TEMOZOLOMIDE CAP 20 MG P Y N Y N TEMOZOLOMIDE TEMOZOLOMIDE CAP 5MG ANTINEOPLASTIC AGENTS TEMOZOLOMIDE CAP 5 MG P Y N Y N TIBSOVO TIBSOVO TAB 250MG ANTINEOPLASTIC AGENTS IVOSIDENIB TAB 250 MG P Y N Y N TRETINOIN TRETINOIN CAP 10MG ANTINEOPLASTIC AGENTS TRETINOIN CAP 10 MG P N N N N TREXALL TREXALL TAB 5MG ANTINEOPLASTIC AGENTS METHOTREXATE SODIUM TAB 5 MG (BASE EQUIV) NP Y N N N TUKYSA TUKYSA TAB 150MG ANTINEOPLASTIC AGENTS TUCATINIB TAB 150 MG NP Y N Y N TUKYSA TUKYSA TAB 50MG ANTINEOPLASTIC AGENTS TUCATINIB TAB 50 MG NP Y N Y N TURALIO TURALIO CAP 200MG ANTINEOPLASTIC AGENTS PEXIDARTINIB HCL CAP 200 MG (BASE EQUIVALENT) P Y N Y N TYKERB TYKERB TAB 250MG ANTINEOPLASTIC AGENTS LAPATINIB DITOSYLATE TAB 250 MG (BASE EQUIV) NP Y N Y N VENCLEXTA VENCLEXTA TAB 100MG ANTINEOPLASTIC AGENTS VENETOCLAX TAB 100 MG P Y N Y N VENCLEXTA VENCLEXTA TAB 10MG ANTINEOPLASTIC AGENTS VENETOCLAX TAB 10 MG P Y N Y N VENCLEXTA VENCLEXTA TAB 50MG ANTINEOPLASTIC AGENTS VENETOCLAX TAB 50 MG P Y N Y N VENCLEXTA STARTING PACK VENCLEXTA TAB START PK ANTINEOPLASTIC AGENTS VENETOCLAX TAB THERAPY STARTER PACK 10 & 50 & 100 MG P Y N Y N VERZENIO VERZENIO TAB 50MG ANTINEOPLASTIC AGENTS ABEMACICLIB TAB 50 MG P Y N Y N VIZIMPRO VIZIMPRO TAB 15MG ANTINEOPLASTIC AGENTS DACOMITINIB TAB 15 MG NP Y N Y N VOTRIENT VOTRIENT TAB 200MG ANTINEOPLASTIC AGENTS PAZOPANIB HCL TAB 200 MG (BASE EQUIV) P Y N Y N XALKORI XALKORI CAP 200MG ANTINEOPLASTIC AGENTS CRIZOTINIB CAP 200 MG P Y N Y N XATMEP XATMEP SOL 2.5MG/ML ANTINEOPLASTIC AGENTS METHOTREXATE ORAL SOLN 2.5 MG/ML NP Y N Y N XELODA XELODA TAB 150MG ANTINEOPLASTIC AGENTS CAPECITABINE TAB 150 MG NP Y N N N XOSPATA XOSPATA TAB 40MG ANTINEOPLASTIC AGENTS GILTERITINIB FUMARATE TABLET 40 MG (BASE EQUIVALENT) NP Y N Y N XPOVIO 100 MG ONCE WEEKLY XPOVIO PAK 100MG ANTINEOPLASTIC AGENTS SELINEXOR TAB THERAPY PACK 20 MG (100 MG ONCE WEEKLY) NP Y N Y N XPOVIO 40 MG ONCE WEEKLY XPOVIO PAK 40MG ANTINEOPLASTIC AGENTS SELINEXOR TAB THERAPY PACK 20 MG (40 MG ONCE WEEKLY) NP Y N Y N XPOVIO 60 MG ONCE WEEKLY XPOVIO PAK 60MG ANTINEOPLASTIC AGENTS SELINEXOR TAB THERAPY PACK 20 MG (60 MG ONCE WEEKLY) NP Y N Y N XPOVIO 80 MG TWICE WEEKLY XPOVIO PAK 80MG ANTINEOPLASTIC AGENTS SELINEXOR TAB THERAPY PACK 20 MG (80 MG TWICE WEEKLY) NP Y N Y N XTANDI XTANDI CAP 40MG ANTINEOPLASTIC AGENTS ENZALUTAMIDE CAP 40 MG NP Y N Y N YONSA YONSA TAB 125MG ANTINEOPLASTIC AGENTS ABIRATERONE ACETATE TAB 125 MG NP Y N Y N ZEJULA ZEJULA CAP 100MG ANTINEOPLASTIC AGENTS NIRAPARIB TOSYLATE CAP 100 MG (BASE EQUIVALENT) P Y N Y N ZELBORAF ZELBORAF TAB 240MG ANTINEOPLASTIC AGENTS VEMURAFENIB TAB 240 MG P Y N Y N ZOLINZA ZOLINZA CAP 100MG ANTINEOPLASTIC AGENTS VORINOSTAT CAP 100 MG P Y N Y N

Confidential 2/19/2021 Page 23 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ZYDELIG ZYDELIG TAB 100MG ANTINEOPLASTIC AGENTS IDELALISIB TAB 100 MG P Y N Y N ZYKADIA ZYKADIA TAB 150MG ANTINEOPLASTIC AGENTS CERITINIB TAB 150 MG P Y N Y N ZYTIGA ZYTIGA TAB 250MG ANTINEOPLASTIC AGENTS ABIRATERONE ACETATE TAB 250 MG NP Y N Y N ZYTIGA ZYTIGA TAB 500MG ANTINEOPLASTIC AGENTS ABIRATERONE ACETATE TAB 500 MG NP Y N Y N CALCITONIN-SALMON CALCITONIN SPR 200/ACT ANTIPARATHYROID AGENTS CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT P N N Y N CINACALCET HYDROCHLORIDE CINACALCET TAB 30MG ANTIPARATHYROID AGENTS CINACALCET HCL TAB 30 MG (BASE EQUIV) P Y N Y N CINACALCET HYDROCHLORIDE CINACALCET TAB 90MG ANTIPARATHYROID AGENTS CINACALCET HCL TAB 90 MG (BASE EQUIV) P Y N Y N MIACALCIN MIACALCIN SPR 200/ACT ANTIPARATHYROID AGENTS CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT NP Y N Y N SENSIPAR SENSIPAR TAB 30MG ANTIPARATHYROID AGENTS CINACALCET HCL TAB 30 MG (BASE EQUIV) NP Y N Y N SENSIPAR SENSIPAR TAB 90MG ANTIPARATHYROID AGENTS CINACALCET HCL TAB 90 MG (BASE EQUIV) NP Y N Y N ALINIA ALINIA SUS 100/5ML ANTIPROTOZOALS, MISCELLANEOUS NITAZOXANIDE FOR SUSP 100 MG/5ML P N N Y Y ALINIA ALINIA TAB 500MG ANTIPROTOZOALS, MISCELLANEOUS NITAZOXANIDE TAB 500 MG NP Y N Y N ATOVAQUONE ATOVAQUONE SUS 750/5ML ANTIPROTOZOALS, MISCELLANEOUS ATOVAQUONE SUSP 750 MG/5ML P Y N Y N BENZNIDAZOLE BENZNIDAZOLE TAB 100MG ANTIPROTOZOALS, MISCELLANEOUS BENZNIDAZOLE TAB 100 MG P N N Y N BENZNIDAZOLE BENZNIDAZOLE TAB 12.5MG ANTIPROTOZOALS, MISCELLANEOUS BENZNIDAZOLE TAB 12.5 MG P N N Y N FLAGYL FLAGYL CAP 375MG ANTIPROTOZOALS, MISCELLANEOUS METRONIDAZOLE CAP 375 MG NP Y N Y N FLAGYL FLAGYL TAB 500MG ANTIPROTOZOALS, MISCELLANEOUS METRONIDAZOLE TAB 500 MG NP Y N Y N IMPAVIDO IMPAVIDO CAP 50MG ANTIPROTOZOALS, MISCELLANEOUS MILTEFOSINE CAP 50 MG P Y N Y N LAMPIT LAMPIT TAB 120MG ANTIPROTOZOALS, MISCELLANEOUS NIFURTIMOX TAB 120 MG NP Y N Y N LAMPIT LAMPIT TAB 30MG ANTIPROTOZOALS, MISCELLANEOUS NIFURTIMOX TAB 30 MG NP Y N Y N MEPRON MEPRON SUS ANTIPROTOZOALS, MISCELLANEOUS ATOVAQUONE SUSP 750 MG/5ML NP Y N Y N METRONIDAZOLE METRONIDAZOL CAP 375MG ANTIPROTOZOALS, MISCELLANEOUS METRONIDAZOLE CAP 375 MG NP Y N Y N METRONIDAZOLE METRONIDAZOL TAB 250MG ANTIPROTOZOALS, MISCELLANEOUS METRONIDAZOLE TAB 250 MG P N N Y N METRONIDAZOLE METRONIDAZOL TAB 500MG ANTIPROTOZOALS, MISCELLANEOUS METRONIDAZOLE TAB 500 MG P N N Y N METRONIDAZOLE BENZOATE/SYRSPEND SFMETRONIDAZOL SUS 50MG/ML ANTIPROTOZOALS, MISCELLANEOUS *METRONIDAZOLE BENZOATE FOR SUSP 50 MG/ML (CMPD KIT)* NP Y N N N NEBUPENT NEBUPENT INH 300MG ANTIPROTOZOALS, MISCELLANEOUS PENTAMIDINE ISETHIONATE FOR NEBULIZATION SOLN 300 MG NP Y N N N NITAZOXANIDE NITAZOXANIDE TAB 500MG ANTIPROTOZOALS, MISCELLANEOUS NITAZOXANIDE TAB 500 MG P N N Y N PENTAMIDINE ISETHIONATE PENTAMIDINE INH 300MG ANTIPROTOZOALS, MISCELLANEOUS PENTAMIDINE ISETHIONATE FOR NEBULIZATION SOLN 300 MG P NNNN SOLOSEC SOLOSEC GRA 2GM ANTIPROTOZOALS, MISCELLANEOUS SECNIDAZOLE GRANULES PACKET 2 GM NP Y N Y N TINIDAZOLE TINIDAZOLE TAB 250MG ANTIPROTOZOALS, MISCELLANEOUS TINIDAZOLE TAB 250 MG NP Y N N N TINIDAZOLE TINIDAZOLE TAB 500MG ANTIPROTOZOALS, MISCELLANEOUS TINIDAZOLE TAB 500 MG NP Y N Y N ENOVARX-LIDOCAINE HCL LIDOCAINE CRE 5% ANTIPRURITICS AND LOCAL ANESTHETICS *LIDOCAINE HCL CREAM 5% (COMPOUND KIT)** NP Y N N N LEVATIO PATCH LEVATIO PAD 0.3-5% ANTIPRURITICS AND LOCAL ANESTHETICS CAPSAICIN-MENTHOL TOPICAL PATCH 0.03-5% NP Y N N N LEVIGOLT LEVIGOLT CRE 4-1% ANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE-MENTHOL CREAM 4-1% NP Y N N N LEVIGOSP LEVIGOSP SPR 2.5-0.13 ANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE-BENZALKONIUM LIQUID 2.5-0.13% NP Y N N N LIDOCAINE LIDOCAINE CRE 3% ANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE CREAM 3% P N N Y N LIDOCAINE LIDOCAINE OIN 5% ANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE OINT 5% NP Y N Y N LIDOCAINE LIDOCAINE PAD 4% ANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE PATCH 4% NP Y N N N LIDOCAINE LIDOCAINE PAD 5% ANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE PATCH 5% P Y N Y N LIDOCAINE HCL LIDOCAINE GEL 2% ANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE HCL URETHRAL/MUCOSAL GEL PREFILLED SYRINGE 2% P N N Y N LIDOCAINE HCL LIDOCAINE SOL 4% ANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE HCL SOLN 4% NP Y N N N LIDOCAINE TOPICAL ANESTHETIC LIDOCAINE CRE 4% ANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE CREAM 4% P N N Y N LIDOCANNA LIDOCANNA PAD 4% ANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE PATCH 4% NP Y N N N LIDODERM LIDODERM DIS 5% ANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE PATCH 5% NP Y N Y N LIDODOSE LIDODOSE GEL 3% ANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE HCL GEL 3% NP Y N N N PRUDOXIN PRUDOXIN CRE 5% ANTIPRURITICS AND LOCAL ANESTHETICS DOXEPIN HCL CREAM 5% NP Y N Y N XOLIDO XOLIDO CRE 2% ANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE HCL CREAM 2% NP Y N N N ZONALON ZONALON CRE 5% ANTIPRURITICS AND LOCAL ANESTHETICS DOXEPIN HCL CREAM 5% NP Y N Y N

Confidential 2/19/2021 Page 24 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ADASUVE ADASUVE INH 10MG ANTIPSYCHOTICS, MISCELLANEOUS LOXAPINE AEROSOL POWDER BREATH ACTIVATED 10 MG P N N N N LOXAPINE SUCCINATE LOXAPINE CAP 5MG ANTIPSYCHOTICS, MISCELLANEOUS LOXAPINE SUCCINATE CAP 5 MG P N N Y Y MOLINDONE HYDROCHLORIDE MOLINDONE TAB HCL 25MG ANTIPSYCHOTICS, MISCELLANEOUS MOLINDONE HCL TAB 25 MG P N N Y N MOLINDONE HYDROCHLORIDE MOLINDONE TAB HCL 5MG ANTIPSYCHOTICS, MISCELLANEOUS MOLINDONE HCL TAB 5 MG P N N Y N PIMOZIDE PIMOZIDE TAB 1MG ANTIPSYCHOTICS, MISCELLANEOUS PIMOZIDE TAB 1 MG P N N Y N PIMOZIDE PIMOZIDE TAB 2MG ANTIPSYCHOTICS, MISCELLANEOUS PIMOZIDE TAB 2 MG P N N Y N TEGSEDI TEGSEDI INJ 284/1.5 ANTISENSE OLIGONUCLEOTIDES INOTERSEN SOD SUBCUTANEOUS PREF SYR 284 MG/1.5ML (BASE EQ) P Y N Y N CABLIVI CABLIVI KIT 11MG ANTITHROMBOTIC AGENTS, MISCELLANEOUS CAPLACIZUMAB-YHDP FOR INJ KIT 11 MG P Y N Y N IOSAT IOSAT TAB 130MG ANTITHYROID AGENTS POTASSIUM IODIDE TAB 130 MG NP Y N N N METHIMAZOLE METHIMAZOLE TAB 10MG ANTITHYROID AGENTS METHIMAZOLE TAB 10 MG P N N Y N METHIMAZOLE METHIMAZOLE TAB 5MG ANTITHYROID AGENTS METHIMAZOLE TAB 5 MG P N N Y N PROPYLTHIOURACIL PROPYLTHIOUR TAB 50MG ANTITHYROID AGENTS PROPYLTHIOURACIL TAB 50 MG P N N Y N TAPAZOLE TAPAZOLE TAB 10MG ANTITHYROID AGENTS METHIMAZOLE TAB 10 MG NP Y N Y N TAPAZOLE TAPAZOLE TAB 5MG ANTITHYROID AGENTS METHIMAZOLE TAB 5 MG NP Y N Y N HYPERTET S/D HYPERTET S/D INJ 250/ML ANTITOXINS AND IMMUNE GLOBULINS TETANUS IMMUNE GLOBULIN (HUMAN) INJ 250 UNIT/ML P N N Y N CYCLOSERINE CYCLOSERINE CAP 250MG ANTITUBERCULOSIS AGENTS CYCLOSERINE CAP 250 MG P N N Y N ETHAMBUTOL HYDROCHLORIDE ETHAMBUTOL TAB 100MG ANTITUBERCULOSIS AGENTS ETHAMBUTOL HCL TAB 100 MG P N N N N ETHAMBUTOL HYDROCHLORIDE ETHAMBUTOL TAB 400MG ANTITUBERCULOSIS AGENTS ETHAMBUTOL HCL TAB 400 MG P N N Y N ISONIAZID ISONIAZID SYP 50MG/5ML ANTITUBERCULOSIS AGENTS ISONIAZID SYRUP 50 MG/5ML P N N Y N ISONIAZID ISONIAZID TAB 100MG ANTITUBERCULOSIS AGENTS ISONIAZID TAB 100 MG P N N Y N ISONIAZID ISONIAZID TAB 300MG ANTITUBERCULOSIS AGENTS ISONIAZID TAB 300 MG P N N Y N MYAMBUTOL MYAMBUTOL TAB 400MG ANTITUBERCULOSIS AGENTS ETHAMBUTOL HCL TAB 400 MG NP Y N Y N MYCOBUTIN MYCOBUTIN CAP 150MG ANTITUBERCULOSIS AGENTS RIFABUTIN CAP 150 MG NP Y N Y N PASER PASER GRA 4GM ANTITUBERCULOSIS AGENTS AMINOSALICYLIC ACID ER GRANULES PACKET 4 GM P N N Y N PRETOMANID PRETOMANID TAB 200MG ANTITUBERCULOSIS AGENTS PRETOMANID TAB 200 MG NP Y N Y N PRIFTIN PRIFTIN TAB 150MG ANTITUBERCULOSIS AGENTS RIFAPENTINE TAB 150 MG P N N Y N PYRAZINAMIDE PYRAZINAMIDE TAB 500MG ANTITUBERCULOSIS AGENTS PYRAZINAMIDE TAB 500 MG P N N Y N RIFABUTIN RIFABUTIN CAP 150MG ANTITUBERCULOSIS AGENTS RIFABUTIN CAP 150 MG P N N Y N RIFAMPIN RIFAMPIN CAP 300MG ANTITUBERCULOSIS AGENTS RIFAMPIN CAP 300 MG P N N Y N RIFAMPIN/SYRSPEND SF PH4 RIFAMPIN SUS 25MG/ML ANTITUBERCULOSIS AGENTS *RIFAMPIN SUSP 25 MG/ML (COMPOUND KIT)** NP Y N Y N SIRTURO SIRTURO TAB 100MG ANTITUBERCULOSIS AGENTS BEDAQUILINE FUMARATE TAB 100 MG (BASE EQUIV) P N N Y N SIRTURO SIRTURO TAB 20MG ANTITUBERCULOSIS AGENTS BEDAQUILINE FUMARATE TAB 20 MG (BASE EQUIV) P N N Y N TRECATOR TRECATOR TAB 250MG ANTITUBERCULOSIS AGENTS ETHIONAMIDE TAB 250 MG P N N Y N HYDROCODONE BITARTRATE/HOMATROPI HYDROC/HOMAT TAB 5-1.5MG ANTITUSSIVES HYDROCODONE W/ HOMATROPINE TAB 5-1.5 MG P N N Y Y HYDROCODONE POLISTIREX/CHLORPHENIRHYD POL/CPM SUS 10-8/5ML ANTITUSSIVES HYDROCOD POLST-CHLORPHEN POLST ER SUSP 10-8 MG/5ML NP Y N Y Y HYDROCODONE/HOMATROPINE HYDROCOD/HOM SYP 5-1.5/5 ANTITUSSIVES HYDROCODONE W/ HOMATROPINE SYRUP 5-1.5 MG/5ML P N N Y Y HYDROMET HYDROMET SYP 5-1.5/5 ANTITUSSIVES HYDROCODONE W/ HOMATROPINE SYRUP 5-1.5 MG/5ML P N N Y Y PROMETHAZINE HYDROCHLORIDE/DEXTROPROMETHAZINE SOL DM ANTITUSSIVES PROMETHAZINE-DM SYRUP 6.25-15 MG/5ML P N N Y Y PROMETHAZINE VC/CODEINE PROMETH VC/ SYP CODEINE ANTITUSSIVES PROMETHAZINE-PHENYLEPHRINE-CODEINE SYRUP 6.25-5-10 MG/5ML P N N Y Y PROMETHAZINE/CODEINE PROMETH/COD SOL 6.25-10 ANTITUSSIVES PROMETHAZINE W/ CODEINE SYRUP 6.25-10 MG/5ML P N N Y Y PROMETHAZINE/PHENYLEPHRINE/CODEIN PROMETH/PE/ SYP CODEINE ANTITUSSIVES PROMETHAZINE-PHENYLEPHRINE-CODEINE SYRUP 6.25-5-10 MG/5ML P NNYY TRIFLURIDINE TRIFLURIDINE SOL 1% OP ANTIVIRALS (EENT) TRIFLURIDINE OPHTH SOLN 1% P N N Y N ZIRGAN ZIRGAN GEL 0.15% ANTIVIRALS (EENT) GANCICLOVIR OPHTH GEL 0.15% NP Y N Y N ACYCLOVIR ACYCLOVIR CRE 5% ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) ACYCLOVIR CREAM 5% NP Y N Y N ACYCLOVIR ACYCLOVIR OIN 5% ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) ACYCLOVIR OINT 5% NP Y N Y N DENAVIR DENAVIR CRE 1% ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) PENCICLOVIR CREAM 1% NP Y N N N DOCOSANOL DOCOSANOL CRE 10% ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) DOCOSANOL CREAM 10% NP Y N N N XERESE XERESE CRE 5-1% ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) ACYCLOVIR-HYDROCORTISONE CREAM 5-1% NP Y N Y N

Confidential 2/19/2021 Page 25 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ZOVIRAX ZOVIRAX CRE 5% ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) ACYCLOVIR CREAM 5% NP Y N Y N ZOVIRAX ZOVIRAX OIN 5% ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) ACYCLOVIR OINT 5% NP Y N Y N FAVIPIRAVIR FAVIPIRAVIR TAB 200MG ANTIVIRALS, MISCELLANEOUS FAVIPIRAVIR TAB 200 MG NP Y N Y N PREVYMIS PREVYMIS TAB 240MG ANTIVIRALS, MISCELLANEOUS LETERMOVIR TAB 240 MG NP Y N Y N XOFLUZA XOFLUZA TAB 20MG ANTIVIRALS, MISCELLANEOUS BALOXAVIR MARBOXIL TAB THERAPY PACK 2 X 20 MG (40 MG DOSE) NP Y N Y N AMBIEN AMBIEN TAB 5MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC ZOLPIDEM TARTRATE TAB 5 MG NP Y N Y N AMBIEN CR AMBIEN CR TAB 6.25MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC ZOLPIDEM TARTRATE TAB ER 6.25 MG NP Y N Y N BELSOMRA BELSOMRA TAB 5MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC SUVOREXANT TAB 5 MG P N N Y N BUSPIRONE HCL BUSPIRONE TAB 15MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC BUSPIRONE HCL TAB 15 MG P N N Y N BUSPIRONE HCL BUSPIRONE TAB 30MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC BUSPIRONE HCL TAB 30 MG P N N Y N BUSPIRONE HYDROCHLORIDE BUSPIRONE TAB 5MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC BUSPIRONE HCL TAB 5 MG P N N Y N CHLORAL HYDRATE CHLORAL CRY HYDRATE ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC CHLORAL HYDRATE CRYSTALS NP Y N N N DAYVIGO DAYVIGO TAB 5MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC LEMBOREXANT TAB 5 MG P N N Y Y DROPERIDOL DROPERIDOL INJ 2.5MG/ML ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC DROPERIDOL INJ 2.5 MG/ML P N N N N EDLUAR EDLUAR SUB 5MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC ZOLPIDEM TARTRATE SL TAB 5 MG P N N Y N ESZOPICLONE ESZOPICLONE TAB 1MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC ESZOPICLONE TAB 1 MG P N N Y N HETLIOZ HETLIOZ CAP 20MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC TASIMELTEON CAPSULE 20 MG P N N Y N HYDROXYZINE HCL HYDROXYZ HCL INJ 25MG/ML ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC HYDROXYZINE HCL IM SOLN 25 MG/ML P N N N N HYDROXYZINE HCL HYDROXYZ HCL SYP 10MG/5ML ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC HYDROXYZINE HCL SYRUP 10 MG/5ML P N N Y N HYDROXYZINE HCL HYDROXYZ HCL TAB 50MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC HYDROXYZINE HCL TAB 50 MG P N N Y N HYDROXYZINE HYDROCHLORIDE HYDROXYZ HCL INJ 50MG/ML ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC HYDROXYZINE HCL IM SOLN 50 MG/ML P N N N N HYDROXYZINE HYDROCHLORIDE HYDROXYZ HCL TAB 10MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC HYDROXYZINE HCL TAB 10 MG P N N Y N HYDROXYZINE PAMOATE HYDROXYZ PAM CAP 25MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC HYDROXYZINE PAMOATE CAP 25 MG P N N Y N KLS RAPID RELEASE ACETAMIOPHEN PM EXRAPID RELEAS TAB 25-500MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC DIPHENHYDRAMINE-ACETAMINOPHEN TAB 25-500 MG (SLEEP) NP Y N N N LUNESTA LUNESTA TAB 1MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC ESZOPICLONE TAB 1 MG NP Y N Y N RAMELTEON RAMELTEON TAB 8MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC RAMELTEON TAB 8 MG P N N Y N ROZEREM ROZEREM TAB 8MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC RAMELTEON TAB 8 MG NP Y N Y N ZALEPLON ZALEPLON CAP 5MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC ZALEPLON CAP 5 MG P N N Y N ZOLPIDEM TARTRATE ZOLPIDEM TAB 5MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC ZOLPIDEM TARTRATE TAB 5 MG P N N Y N ZOLPIDEM TARTRATE ER ZOLPIDEM ER TAB 6.25MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC ZOLPIDEM TARTRATE TAB ER 6.25 MG P N N Y N ZOLPIMIST ZOLPIMIST SPR 5MG ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC ZOLPIDEM TARTRATE ORAL SPRAY 5 MG/ACT P N N Y N ABILIFY ABILIFY TAB 20MG ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE TAB 20 MG NP Y N Y N ABILIFY ABILIFY TAB 2MG ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE TAB 2 MG NP Y N Y N ABILIFY ABILIFY TAB 5MG ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE TAB 5 MG NP Y N Y N ABILIFY MAINTENA ABILIFY MAIN INJ 300MG ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE IM FOR ER SUSP PREFILLED SYRINGE 300 MG P N N Y Y ABILIFY MYCITE ABILIFY MYCI TAB 2MG ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE TAB 2 MG WITH SENSOR P N N Y N ARIPIPRAZOLE ARIPIPRAZOLE SOL 1MG/ML ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE ORAL SOLUTION 1 MG/ML P N N Y N ARIPIPRAZOLE ARIPIPRAZOLE TAB 20MG ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE TAB 20 MG P N N Y N ARIPIPRAZOLE ARIPIPRAZOLE TAB 2MG ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE TAB 2 MG P N N Y N ARIPIPRAZOLE ARIPIPRAZOLE TAB 5MG ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE TAB 5 MG P N N Y N ARIPIPRAZOLE ODT ARIPIPRAZOLE TAB 10MG ODT ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE ORALLY DISINTEGRATING TAB 10 MG P N N Y N ARISTADA ARISTADA INJ 1064MG ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE LAUROXIL IM ER SUSP PREFILLED SYR 1064 MG/3.9ML P N N Y Y ARISTADA ARISTADA INJ 441MG/1. ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE LAUROXIL IM ER SUSP PREFILLED SYR 441 MG/1.6ML P N N Y Y ARISTADA ARISTADA INJ 662MG/2 ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE LAUROXIL IM ER SUSP PREFILLED SYR 662 MG/2.4ML P N N Y Y ARISTADA ARISTADA INJ 882MG/3 ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE LAUROXIL IM ER SUSP PREFILLED SYR 882 MG/3.2ML P N N Y Y ARISTADA INITIO ARISTADA INJ INITIO ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE LAUROXIL IM ER SUSP PREFILLED SYR 675 MG/2.4ML P N N Y Y ASENAPINE MALEATE SL ASENAPINE SUB 2.5MG ATYPICAL ANTIPSYCHOTICS ASENAPINE MALEATE SL TAB 2.5 MG (BASE EQUIV) P N N Y N CAPLYTA CAPLYTA CAP 42MG ATYPICAL ANTIPSYCHOTICS LUMATEPERONE TOSYLATE CAP 42 MG P N N Y Y

Confidential 2/19/2021 Page 26 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) CLOZAPINE CLOZAPINE TAB 100MG ATYPICAL ANTIPSYCHOTICS CLOZAPINE TAB 100 MG P N N Y Y CLOZAPINE CLOZAPINE TAB 25MG ATYPICAL ANTIPSYCHOTICS CLOZAPINE TAB 25 MG P N N Y Y CLOZAPINE ODT CLOZAPINE TAB 100/ODT ATYPICAL ANTIPSYCHOTICS CLOZAPINE ORALLY DISINTEGRATING TAB 100 MG P N N Y Y CLOZAPINE ODT CLOZAPINE TAB 12.5/ODT ATYPICAL ANTIPSYCHOTICS CLOZAPINE ORALLY DISINTEGRATING TAB 12.5 MG P N N Y Y CLOZARIL CLOZARIL TAB 100MG ATYPICAL ANTIPSYCHOTICS CLOZAPINE TAB 100 MG NP Y N Y Y CLOZARIL CLOZARIL TAB 25MG ATYPICAL ANTIPSYCHOTICS CLOZAPINE TAB 25 MG NP Y N Y Y FANAPT FANAPT TAB 1MG ATYPICAL ANTIPSYCHOTICS ILOPERIDONE TAB 1 MG P N N Y Y FANAPT TITRATION PACK FANAPT PAK ATYPICAL ANTIPSYCHOTICS ILOPERIDONE TAB 1 MG & 2 MG & 4 MG & 6 MG TITRATION PAK P N N Y Y GEODON GEODON CAP 20MG ATYPICAL ANTIPSYCHOTICS ZIPRASIDONE HCL CAP 20 MG NP Y N Y Y GEODON GEODON CAP 60MG ATYPICAL ANTIPSYCHOTICS ZIPRASIDONE HCL CAP 60 MG NP Y N Y Y GEODON GEODON INJ 20MG ATYPICAL ANTIPSYCHOTICS ZIPRASIDONE MESYLATE FOR INJ 20 MG (BASE EQUIVALENT) NP Y N N Y INVEGA INVEGA TAB 1.5MG ATYPICAL ANTIPSYCHOTICS PALIPERIDONE TAB ER 24HR 1.5 MG NP Y N Y N INVEGA INVEGA TAB 6MG ATYPICAL ANTIPSYCHOTICS PALIPERIDONE TAB ER 24HR 6 MG NP Y N Y N INVEGA SUSTENNA INVEGA SUST INJ 117/0.75 ATYPICAL ANTIPSYCHOTICS PALIPERIDONE PALMITATE ER SUSP PREF SYR 117 MG/0.75ML P N N Y Y INVEGA SUSTENNA INVEGA SUST INJ 156MG/ML ATYPICAL ANTIPSYCHOTICS PALIPERIDONE PALMITATE ER SUSP PREF SYR 156 MG/ML P N N Y Y INVEGA SUSTENNA INVEGA SUST INJ 234/1.5 ATYPICAL ANTIPSYCHOTICS PALIPERIDONE PALMITATE ER SUSP PREF SYR 234 MG/1.5ML P N N Y Y INVEGA SUSTENNA INVEGA SUST INJ 39/0.25 ATYPICAL ANTIPSYCHOTICS PALIPERIDONE PALMITATE ER SUSP PREF SYR 39 MG/0.25ML P N N Y Y INVEGA SUSTENNA INVEGA SUST INJ 78/0.5ML ATYPICAL ANTIPSYCHOTICS PALIPERIDONE PALMITATE ER SUSP PREF SYR 78 MG/0.5ML P N N Y Y INVEGA TRINZA INVEGA TRINZ INJ 273MG ATYPICAL ANTIPSYCHOTICS PALIPERIDONE PALMITATE ER SUSP PREF SYR 273 MG/0.875ML P N N Y Y INVEGA TRINZA INVEGA TRINZ INJ 410MG ATYPICAL ANTIPSYCHOTICS PALIPERIDONE PALMITATE ER SUSP PREF SYR 410 MG/1.315ML P N N Y Y INVEGA TRINZA INVEGA TRINZ INJ 546MG ATYPICAL ANTIPSYCHOTICS PALIPERIDONE PALMITATE ER SUSP PREF SYR 546 MG/1.75ML P N N Y Y INVEGA TRINZA INVEGA TRINZ INJ 819MG ATYPICAL ANTIPSYCHOTICS PALIPERIDONE PALMITATE ER SUSP PREF SYR 819 MG/2.625ML P N N Y Y LATUDA LATUDA TAB 20MG ATYPICAL ANTIPSYCHOTICS LURASIDONE HCL TAB 20 MG P N N Y Y LATUDA LATUDA TAB 80MG ATYPICAL ANTIPSYCHOTICS LURASIDONE HCL TAB 80 MG P N N Y Y NUPLAZID NUPLAZID CAP 34MG ATYPICAL ANTIPSYCHOTICS PIMAVANSERIN TARTRATE CAP 34 MG (BASE EQUIVALENT) P N N Y N OLANZAPINE OLANZAPINE INJ 10MG ATYPICAL ANTIPSYCHOTICS OLANZAPINE FOR IM INJ 10 MG P N N N N OLANZAPINE OLANZAPINE TAB 10MG ATYPICAL ANTIPSYCHOTICS OLANZAPINE TAB 10 MG P N N Y N OLANZAPINE OLANZAPINE TAB 2.5MG ATYPICAL ANTIPSYCHOTICS OLANZAPINE TAB 2.5 MG P N N Y N OLANZAPINE OLANZAPINE TAB 20MG ATYPICAL ANTIPSYCHOTICS OLANZAPINE TAB 20 MG P N N Y N OLANZAPINE ODT OLANZAPINE TAB 10MG ODT ATYPICAL ANTIPSYCHOTICS OLANZAPINE ORALLY DISINTEGRATING TAB 10 MG P N N Y N OLANZAPINE ODT OLANZAPINE TAB 20MG ODT ATYPICAL ANTIPSYCHOTICS OLANZAPINE ORALLY DISINTEGRATING TAB 20 MG P N N Y N OLANZAPINE ODT OLANZAPINE TAB 5MG ODT ATYPICAL ANTIPSYCHOTICS OLANZAPINE ORALLY DISINTEGRATING TAB 5 MG P N N Y N PALIPERIDONE ER PALIPERIDONE TAB ER 1.5MG ATYPICAL ANTIPSYCHOTICS PALIPERIDONE TAB ER 24HR 1.5 MG P N N Y N PALIPERIDONE ER PALIPERIDONE TAB ER 6MG ATYPICAL ANTIPSYCHOTICS PALIPERIDONE TAB ER 24HR 6 MG P N N Y N PERSERIS PERSERIS INJ 90MG ATYPICAL ANTIPSYCHOTICS RISPERIDONE SUBCUTANEOUS FOR ER SUSP PREFILLED SYR 90 MG P N N Y Y QUETIAPINE FUMARATE QUETIAPINE TAB 25MG ATYPICAL ANTIPSYCHOTICS QUETIAPINE FUMARATE TAB 25 MG P N N Y N QUETIAPINE FUMARATE QUETIAPINE TAB 300MG ATYPICAL ANTIPSYCHOTICS QUETIAPINE FUMARATE TAB 300 MG P N N Y N QUETIAPINE FUMARATE ER QUETIAPINE TAB 150MG ER ATYPICAL ANTIPSYCHOTICS QUETIAPINE FUMARATE TAB ER 24HR 150 MG P N N Y N QUETIAPINE FUMARATE ER QUETIAPINE TAB 300MG ER ATYPICAL ANTIPSYCHOTICS QUETIAPINE FUMARATE TAB ER 24HR 300 MG P N N Y N QUETIAPINE FUMARATE ER QUETIAPINE TAB 400MG ER ATYPICAL ANTIPSYCHOTICS QUETIAPINE FUMARATE TAB ER 24HR 400 MG P N N Y N QUETIAPINE FUMARATE ER QUETIAPINE TAB 50MG ER ATYPICAL ANTIPSYCHOTICS QUETIAPINE FUMARATE TAB ER 24HR 50 MG P N N Y N REXULTI REXULTI TAB 0.25MG ATYPICAL ANTIPSYCHOTICS BREXPIPRAZOLE TAB 0.25 MG P N N Y Y RISPERDAL RISPERDAL SOL 1MG/ML ATYPICAL ANTIPSYCHOTICS RISPERIDONE SOLN 1 MG/ML NP Y N Y N RISPERDAL RISPERDAL TAB 0.5MG ATYPICAL ANTIPSYCHOTICS RISPERIDONE TAB 0.5 MG NP Y N Y N RISPERDAL CONSTA RISPERDAL INJ 12.5MG ATYPICAL ANTIPSYCHOTICS RISPERIDONE MICROSPHERES FOR IM EXTENDED REL SUSP 12.5 MG P N N Y Y RISPERIDONE RISPERIDONE SOL 1MG/ML ATYPICAL ANTIPSYCHOTICS RISPERIDONE SOLN 1 MG/ML P N N Y N RISPERIDONE RISPERIDONE TAB 0.25MG ATYPICAL ANTIPSYCHOTICS RISPERIDONE TAB 0.25 MG P N N Y N RISPERIDONE ODT RISPERIDONE TAB 0.25 ODT ATYPICAL ANTIPSYCHOTICS RISPERIDONE ORALLY DISINTEGRATING TAB 0.25 MG P N N Y N

Confidential 2/19/2021 Page 27 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) SAPHRIS SAPHRIS SUB 2.5MG ATYPICAL ANTIPSYCHOTICS ASENAPINE MALEATE SL TAB 2.5 MG (BASE EQUIV) NP Y N Y N SECUADO SECUADO DIS 3.8MG ATYPICAL ANTIPSYCHOTICS ASENAPINE TD PATCH 24 HR 3.8 MG/24HR P N N Y Y SEROQUEL SEROQUEL TAB 25MG ATYPICAL ANTIPSYCHOTICS QUETIAPINE FUMARATE TAB 25 MG NP Y N Y N SEROQUEL SEROQUEL TAB 300MG ATYPICAL ANTIPSYCHOTICS QUETIAPINE FUMARATE TAB 300 MG NP Y N Y N SEROQUEL XR SEROQUEL XR TAB 150MG ATYPICAL ANTIPSYCHOTICS QUETIAPINE FUMARATE TAB ER 24HR 150 MG NP Y N Y N SEROQUEL XR SEROQUEL XR TAB 300MG ATYPICAL ANTIPSYCHOTICS QUETIAPINE FUMARATE TAB ER 24HR 300 MG NP Y N Y N SEROQUEL XR SEROQUEL XR TAB 400MG ATYPICAL ANTIPSYCHOTICS QUETIAPINE FUMARATE TAB ER 24HR 400 MG NP Y N Y N SEROQUEL XR SEROQUEL XR TAB 50MG ATYPICAL ANTIPSYCHOTICS QUETIAPINE FUMARATE TAB ER 24HR 50 MG NP Y N Y N VERSACLOZ VERSACLOZ SUS 50MG/ML ATYPICAL ANTIPSYCHOTICS CLOZAPINE SUSP 50 MG/ML P N N Y Y VRAYLAR VRAYLAR CAP 1.5-3MG ATYPICAL ANTIPSYCHOTICS CARIPRAZINE HCL CAP THERAPY PACK 1.5 MG (1) & 3 MG (6) P N N Y N VRAYLAR VRAYLAR CAP 1.5MG ATYPICAL ANTIPSYCHOTICS CARIPRAZINE HCL CAP 1.5 MG (BASE EQUIVALENT) P N N Y Y VRAYLAR VRAYLAR CAP 3MG ATYPICAL ANTIPSYCHOTICS CARIPRAZINE HCL CAP 3 MG (BASE EQUIVALENT) P N N Y Y ZIPRASIDONE HCL ZIPRASIDONE CAP 20MG ATYPICAL ANTIPSYCHOTICS ZIPRASIDONE HCL CAP 20 MG P N N Y Y ZIPRASIDONE HCL ZIPRASIDONE CAP 60MG ATYPICAL ANTIPSYCHOTICS ZIPRASIDONE HCL CAP 60 MG P N N Y Y ZIPRASIDONE MESYLATE ZIPRASIDONE INJ 20MG ATYPICAL ANTIPSYCHOTICS ZIPRASIDONE MESYLATE FOR INJ 20 MG (BASE EQUIVALENT) P N N N Y ZYPREXA ZYPREXA INJ 10MG ATYPICAL ANTIPSYCHOTICS OLANZAPINE FOR IM INJ 10 MG NP Y N N N ZYPREXA ZYPREXA TAB 10MG ATYPICAL ANTIPSYCHOTICS OLANZAPINE TAB 10 MG NP Y N Y N ZYPREXA ZYPREXA TAB 2.5MG ATYPICAL ANTIPSYCHOTICS OLANZAPINE TAB 2.5 MG NP Y N Y N ZYPREXA ZYPREXA TAB 20MG ATYPICAL ANTIPSYCHOTICS OLANZAPINE TAB 20 MG NP Y N Y N ZYPREXA RELPREVV ZYPREXA RELP INJ 210MG ATYPICAL ANTIPSYCHOTICS OLANZAPINE PAMOATE FOR EXTENDED REL IM SUSP 210 MG (BASE EQ) P N N Y Y ZYPREXA RELPREVV ZYPREXA RELP INJ 405MG ATYPICAL ANTIPSYCHOTICS OLANZAPINE PAMOATE FOR EXTENDED REL IM SUSP 405 MG (BASE EQ) P N N Y Y ZYPREXA ZYDIS ZYPREXA ZYDI TAB 10MG ATYPICAL ANTIPSYCHOTICS OLANZAPINE ORALLY DISINTEGRATING TAB 10 MG NP Y N Y N ZYPREXA ZYDIS ZYPREXA ZYDI TAB 20MG ATYPICAL ANTIPSYCHOTICS OLANZAPINE ORALLY DISINTEGRATING TAB 20 MG NP Y N Y N ZYPREXA ZYDIS ZYPREXA ZYDI TAB 5MG ATYPICAL ANTIPSYCHOTICS OLANZAPINE ORALLY DISINTEGRATING TAB 5 MG NP Y N Y N CHANTIX CHANTIX TAB 0.5MG AUTONOMIC DRUGS, MISCELLANEOUS VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV) P N N N Y CHANTIX CONTINUING MONTH PAK CHANTIX PAK 1MG AUTONOMIC DRUGS, MISCELLANEOUS VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV) P N N N Y CHANTIX STARTING MONTH PAK CHANTIX PAK 0.5& 1MG AUTONOMIC DRUGS, MISCELLANEOUS VARENICLINE TARTRATE TAB 0.5 MG X 11 & TAB 1 MG X 42 PACK P N N N Y COMMIT COMMIT LOZ 2MG AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE POLACRILEX LOZENGE 2 MG NP Y N N Y GOODSENSE NICOTINE GUM NICOTINE GUM 4MG AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE POLACRILEX GUM 4 MG P N N N Y GOODSENSE NICOTINE POLACRILEX NICOTINE POL LOZ 4MG MINT AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE POLACRILEX LOZENGE 4 MG P N N N Y GOODSENSE NICOTINE POLACRILEX GUM NICOTINE GUM 2MG AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE POLACRILEX GUM 2 MG P N N N Y NICODERM CQ NICODERM CQ DIS 7MG/24HR AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE TD PATCH 24HR 7 MG/24HR P N N N Y NICORETTE NICORETTE GUM 2MG ORIG AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE POLACRILEX GUM 2 MG P N N N Y NICORETTE NICORETTE GUM 2MGFRUIT AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE POLACRILEX GUM 2 MG NP Y N N Y NICORETTE MINI NICORETTE LOZ 2MG MINT AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE POLACRILEX LOZENGE 2 MG P N N N Y NICORETTE STARTER KIT NICORETTE ST GUM 2MG AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE POLACRILEX GUM 2 MG P N N N Y NICOTINE NICOTINE DIS 14MG/24H AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE TD PATCH 24HR 14 MG/24HR P N N N Y NICOTINE MINI LOZENGE NICOTINE LOZ MINI 2MG AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE POLACRILEX LOZENGE 2 MG P N N N Y NICOTINE POLACRILEX REFILL NICOTINE POL GUM 2MG REF AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE POLACRILEX GUM 2 MG P N N N Y NICOTINE STEP 1 NICOTINE DIS STEP 1 AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE TD PATCH 24HR 21 MG/24HR P N N N Y NICOTINE STEP 3 NICOTINE DIS 7MG/24HR AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE TD PATCH 24HR 7 MG/24HR P N N N Y NICOTINE TRANSDERMAL SYSTEM NICOTINE SYS KIT TRANSDER AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE TD PATCH 24 HR KIT 21-14-7 MG/24HR NP YNNN NICOTINE TRANSDERMAL SYSTEM NICOTINE TD DIS 7MG/24HR AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE TD PATCH 24HR 7 MG/24HR P N N N Y NICOTINE TRANSDERMAL SYSTEM STEP 1 NICOTINE TD DIS 21MG/24H AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE TD PATCH 24HR 21 MG/24HR P N N N Y NICOTINE TRANSDERMAL SYSTEM STEP 1/CNICOTINE TD DIS STEP 1 AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE TD PATCH 24HR 21 MG/24HR P N N N Y NICOTINE TRANSDERMAL SYSTEM STEP 2 NICOTINE TD DIS 14MG/24H AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE TD PATCH 24HR 14 MG/24HR P N N N Y NICOTINE TRANSDERMAL SYSTSTEM STEP 3NICOTINE TD DIS STEP 3 AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE TD PATCH 24HR 7 MG/24HR P N N N Y NICOTROL INHALER NICOTROL INH AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE INHALER SYSTEM 10 MG (4 MG DELIVERED) NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) NICOTROL NS NICOTROL NS SPR 10MG/ML AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE NASAL SPRAY 10 MG/ML (0.5 MG/SPRAY) NP Y N Y N THRIVE THRIVE GUM 2MG MINT AUTONOMIC DRUGS, MISCELLANEOUS NICOTINE POLACRILEX GUM 2 MG P N N N Y CRESEMBA CRESEMBA CAP 186 MG AZOLE ANTIFUNGALS ISAVUCONAZONIUM SULFATE CAP 186 MG (ISAVUCONAZOLE 100 MG) NP Y N Y N DIFLUCAN DIFLUCAN SUS 10MG/ML AZOLE ANTIFUNGALS FLUCONAZOLE FOR SUSP 10 MG/ML NP Y N Y N DIFLUCAN DIFLUCAN SUS 40MG/ML AZOLE ANTIFUNGALS FLUCONAZOLE FOR SUSP 40 MG/ML NP Y N Y N DIFLUCAN DIFLUCAN TAB 200MG AZOLE ANTIFUNGALS FLUCONAZOLE TAB 200 MG NP Y N Y N DIFLUCAN DIFLUCAN TAB 50MG AZOLE ANTIFUNGALS FLUCONAZOLE TAB 50 MG NP Y N Y N FLUCONAZOLE FLUCONAZOLE SUS 10MG/ML AZOLE ANTIFUNGALS FLUCONAZOLE FOR SUSP 10 MG/ML P N N Y N FLUCONAZOLE FLUCONAZOLE SUS 40MG/ML AZOLE ANTIFUNGALS FLUCONAZOLE FOR SUSP 40 MG/ML P N N Y N FLUCONAZOLE FLUCONAZOLE TAB 200MG AZOLE ANTIFUNGALS FLUCONAZOLE TAB 200 MG P N N Y N FLUCONAZOLE FLUCONAZOLE TAB 50MG AZOLE ANTIFUNGALS FLUCONAZOLE TAB 50 MG P N N Y N ITRACONAZOLE ITRACONAZOLE CAP 100MG AZOLE ANTIFUNGALS ITRACONAZOLE CAP 100 MG P Y N Y N ITRACONAZOLE ITRACONAZOLE SOL 10MG/ML AZOLE ANTIFUNGALS ITRACONAZOLE ORAL SOLN 10 MG/ML P Y N Y N KETOCONAZOLE KETOCONAZOLE TAB 200MG AZOLE ANTIFUNGALS KETOCONAZOLE TAB 200 MG P N N Y N NOXAFIL NOXAFIL SUS 40MG/ML AZOLE ANTIFUNGALS POSACONAZOLE SUSP 40 MG/ML NP Y N N N NOXAFIL NOXAFIL TAB 100MG AZOLE ANTIFUNGALS POSACONAZOLE TAB DELAYED RELEASE 100 MG NP Y N Y N POSACONAZOLE DR POSACONAZOLE TAB 100MG DR AZOLE ANTIFUNGALS POSACONAZOLE TAB DELAYED RELEASE 100 MG NP Y N Y N SPORANOX SPORANOX CAP 100MG AZOLE ANTIFUNGALS ITRACONAZOLE CAP 100 MG NP Y N Y N SPORANOX SPORANOX SOL 10MG/ML AZOLE ANTIFUNGALS ITRACONAZOLE ORAL SOLN 10 MG/ML NP Y N Y N SPORANOX PULSEPAK SPORANOX CAP PULSEPAK AZOLE ANTIFUNGALS ITRACONAZOLE CAP 100 MG NP Y N Y N TOLSURA TOLSURA CAP 65MG AZOLE ANTIFUNGALS ITRACONAZOLE CAP 65 MG NP Y N Y N VFEND VFEND SUS 40MG/ML AZOLE ANTIFUNGALS VORICONAZOLE FOR SUSP 40 MG/ML NP Y N Y N VFEND VFEND TAB 50MG AZOLE ANTIFUNGALS VORICONAZOLE TAB 50 MG NP Y N Y N VORICONAZOLE VORICONAZOLE SUS 40MG/ML AZOLE ANTIFUNGALS VORICONAZOLE FOR SUSP 40 MG/ML NP Y N Y N VORICONAZOLE VORICONAZOLE TAB 50MG AZOLE ANTIFUNGALS VORICONAZOLE TAB 50 MG P Y N Y N ORAVIG ORAVIG TAB 50MG AZOLES (SKIN AND MUCOUS MEMBRANE) MICONAZOLE BUCCAL TAB 50 MG (MOUTH-THROAT) NP Y N Y N MYSOLINE MYSOLINE TAB 250MG BARBITURATES (ANTICONVULSANTS) PRIMIDONE TAB 250 MG NP Y N Y N MYSOLINE MYSOLINE TAB 50MG BARBITURATES (ANTICONVULSANTS) PRIMIDONE TAB 50 MG NP Y N Y N PRIMIDONE PRIMIDONE TAB 250MG BARBITURATES (ANTICONVULSANTS) PRIMIDONE TAB 250 MG P N N Y N PRIMIDONE PRIMIDONE TAB 50MG BARBITURATES (ANTICONVULSANTS) PRIMIDONE TAB 50 MG P N N Y N AMYTAL SODIUM AMYTAL SOD INJ 500MG BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) AMOBARBITAL SODIUM FOR INJ 500 MG P N N N N NEMBUTAL SODIUM NEMBUTAL SOD INJ 50MG/ML BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) PENTOBARBITAL SODIUM INJ 50 MG/ML NP Y N N N PENTOBARBITAL SODIUM PENTOBARB INJ 50MG/ML BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) PENTOBARBITAL SODIUM INJ 50 MG/ML P N N N N PHENOBARB ELX 20/5ML PHENOBARB ELX 20/5ML BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) PHENOBARBITAL ELIXIR 20 MG/5ML P N N N N PHENOBARBITAL PHENOBARB TAB 15MG BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) PHENOBARBITAL TAB 15 MG P N N N N PHENOBARBITAL SODIUM PHENOBARB INJ 65MG/ML BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) PHENOBARBITAL SODIUM INJ 65 MG/ML P N N N N CLOBAZAM CLOBAZAM SUS 2.5MG/ML BENZODIAZEPINES (ANTICONVULSANTS) CLOBAZAM SUSPENSION 2.5 MG/ML P N N Y N CLOBAZAM CLOBAZAM TAB 10MG BENZODIAZEPINES (ANTICONVULSANTS) CLOBAZAM TAB 10 MG P N N Y N CLOBAZAM CLOBAZAM TAB 20MG BENZODIAZEPINES (ANTICONVULSANTS) CLOBAZAM TAB 20 MG P N N Y N CLONAZEPAM CLONAZEPAM TAB 0.5MG BENZODIAZEPINES (ANTICONVULSANTS) CLONAZEPAM TAB 0.5 MG P N N Y N CLONAZEPAM ODT CLONAZEP ODT TAB 0.125MG BENZODIAZEPINES (ANTICONVULSANTS) CLONAZEPAM ORALLY DISINTEGRATING TAB 0.125 MG P N N Y N KLONOPIN KLONOPIN TAB 0.5MG BENZODIAZEPINES (ANTICONVULSANTS) CLONAZEPAM TAB 0.5 MG NP Y N Y N NAYZILAM NAYZILAM SPR 5MG BENZODIAZEPINES (ANTICONVULSANTS) MIDAZOLAM NASAL SPRAY SOLN 5 MG/0.1 ML P Y N Y N ONFI ONFI SUS 2.5MG/ML BENZODIAZEPINES (ANTICONVULSANTS) CLOBAZAM SUSPENSION 2.5 MG/ML NP Y N Y N ONFI ONFI TAB 10MG BENZODIAZEPINES (ANTICONVULSANTS) CLOBAZAM TAB 10 MG NP Y N Y N ONFI ONFI TAB 20MG BENZODIAZEPINES (ANTICONVULSANTS) CLOBAZAM TAB 20 MG NP Y N Y N SYMPAZAN SYMPAZAN MIS 20MG BENZODIAZEPINES (ANTICONVULSANTS) CLOBAZAM ORAL FILM 20 MG P N N Y N SYMPAZAN SYMPAZAN MIS 5MG BENZODIAZEPINES (ANTICONVULSANTS) CLOBAZAM ORAL FILM 5 MG P N N Y N

Confidential 2/19/2021 Page 29 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) VALTOCO VALTOCO SPR 5MG BENZODIAZEPINES (ANTICONVULSANTS) DIAZEPAM NASAL SPRAY 5 MG/0.1 ML NP Y N Y N ALPRAZOLAM ALPRAZOLAM TAB 0.25MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) ALPRAZOLAM TAB 0.25 MG P N N Y N ALPRAZOLAM ER ALPRAZOLAM TAB 0.5MG ER BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) ALPRAZOLAM TAB ER 24HR 0.5 MG P N N Y N ALPRAZOLAM INTENSOL ALPRAZOLAM CON 1 MG/ML BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) ALPRAZOLAM CONC 1 MG/ML P N N Y N ALPRAZOLAM ODT ALPRAZOLAM TAB 0.25 ODT BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG P N N Y N ALPRAZOLAM XR ALPRAZOLAM TAB 0.5MG XR BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) ALPRAZOLAM TAB ER 24HR 0.5 MG P N N Y N ATIVAN ATIVAN INJ 2MG/ML BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) LORAZEPAM INJ 2 MG/ML NP Y N N N CHLORDIAZEPOXIDE HCL CHLORDIAZEP CAP 5MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) CHLORDIAZEPOXIDE HCL CAP 5 MG P N N Y N CHLORDIAZEPOXIDE HYDROCHLORIDE CHLORDIAZEP CAP 25MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) CHLORDIAZEPOXIDE HCL CAP 25 MG P N N Y N CLORAZEPATE DIPOTASSIUM CLORAZ DIPOT TAB 3.75MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) CLORAZEPATE DIPOTASSIUM TAB 3.75 MG P N N Y N DIASTAT ACUDIAL DIASTAT ACDL GEL 5-10MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG NP Y N Y N DIASTAT PEDIATRIC DIASTAT PED GEL 2.5M GEL BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG NP Y NYN DIAZEPAM DIAZEPAM SOL 5MG/5ML BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) DIAZEPAM ORAL SOLN 1 MG/ML P N N N N DIAZEPAM DIAZEPAM TAB 2MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) DIAZEPAM TAB 2 MG P N N Y N DIAZEPAM INTENSOL DIAZEPAM CON 5MG/ML BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) DIAZEPAM CONC 5 MG/ML P N N Y N DIAZEPAM RECTAL GEL DIAZEPAM GEL 10MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG P N N Y N DIAZEPAM RECTAL GEL DIAZEPAM GEL 2.5MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG P N N Y N DORAL DORAL TAB 15MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) QUAZEPAM TAB 15 MG NP Y N Y N ESTAZOLAM ESTAZOLAM TAB 1MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) ESTAZOLAM TAB 1 MG P N N Y N FLURAZEPAM HCL FLURAZEPAM CAP 15MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) FLURAZEPAM HCL CAP 15 MG P N N Y N GENE-XENE TAB 15MG GENE-XENE TAB 15MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) CLORAZEPATE DIPOTASSIUM TAB 15 MG P N N Y N GENE-XENE TAB 3.75MG GENE-XENE TAB 3.75MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) CLORAZEPATE DIPOTASSIUM TAB 3.75 MG P N N Y N GENE-XENE TAB 7.5MG GENE-XENE TAB 7.5MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) CLORAZEPATE DIPOTASSIUM TAB 7.5 MG P N N Y N HALCION HALCION TAB 0.25MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) TRIAZOLAM TAB 0.25 MG NP Y N Y N LORAZEPAM LORAZEPAM TAB 0.5MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) LORAZEPAM TAB 0.5 MG P N N Y N LORAZEPAM INTENSOL LORAZEPAM CON 2MG/ML BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) LORAZEPAM CONC 2 MG/ML P N N N N MIDAZOLAM MIDAZOLAM SOL 100MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) MIDAZOLAM IV SOLN 100 MG/100ML P N N N N MIDAZOLAM HCL MIDAZOLAM SYP 2MG/ML BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) MIDAZOLAM HCL SYRUP 2 MG/ML (BASE EQUIVALENT) P N N N N MIDAZOLAM HYDROCHLORIDE MIDAZOLAM INJ 2MG/2ML BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) MIDAZOLAM HCL INJ 2 MG/2ML (BASE EQUIVALENT) P N N N N MIDAZOLAM HYDROCHLORIDE/SODIUM CHMIDAZOL/NACL SOL 50/50ML BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) MIDAZOLAM HCL 50 MG/50ML-SODIUM CHLORIDE 0.9% IV SOLN P N N N N MIDAZOLAM/SYRSPEND SF PH4 MIDAZOLAM SUS 1MG/ML BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) *MIDAZOLAM SUSP 1 MG/ML (COMPOUND KIT)**PNNNN MKO MELT DOSE PACK MKO MELT PK TRO 3-25-2MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) MIDAZOLAM-KETAMINE HCL-ONDANSETRON HCL TROCHE 3-25-2 MG NP Y N Y N OXAZEPAM OXAZEPAM CAP 10MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) OXAZEPAM CAP 10 MG P N N Y N QUAZEPAM QUAZEPAM TAB 15MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) QUAZEPAM TAB 15 MG P N N Y N RESTORIL RESTORIL CAP 7.5MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) TEMAZEPAM CAP 7.5 MG NP Y N Y N TEMAZEPAM TEMAZEPAM CAP 7.5MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) TEMAZEPAM CAP 7.5 MG P N N Y N TRANXENE T TRANXENE T TAB 7.5MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) CLORAZEPATE DIPOTASSIUM TAB 7.5 MG NP Y N Y N TRIAZOLAM TRIAZOLAM TAB 0.125MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) TRIAZOLAM TAB 0.125 MG P N N Y N VALIUM VALIUM TAB 2MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) DIAZEPAM TAB 2 MG NP Y N Y N XANAX XANAX TAB 0.25MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) ALPRAZOLAM TAB 0.25 MG NP Y N Y N XANAX XR XANAX XR TAB 0.5MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) ALPRAZOLAM TAB ER 24HR 0.5 MG NP Y N Y N ACEBUTOLOL HCL ACEBUTOLOL CAP 200MG BETA-ADRENERGIC BLOCKING AGENTS ACEBUTOLOL HCL CAP 200 MG P N N Y N ACEBUTOLOL HCL ACEBUTOLOL CAP 400MG BETA-ADRENERGIC BLOCKING AGENTS ACEBUTOLOL HCL CAP 400 MG P N N Y N ATENOLOL ATENOLOL TAB 100MG BETA-ADRENERGIC BLOCKING AGENTS ATENOLOL TAB 100 MG P N N Y N ATENOLOL ATENOLOL TAB 25MG BETA-ADRENERGIC BLOCKING AGENTS ATENOLOL TAB 25 MG P N N Y N ATENOLOL ATENOLOL TAB 50MG BETA-ADRENERGIC BLOCKING AGENTS ATENOLOL TAB 50 MG P N N Y N ATENOLOL/CHLORTHALIDONE ATENOL/CHLOR TAB 50-25MG BETA-ADRENERGIC BLOCKING AGENTS ATENOLOL & CHLORTHALIDONE TAB 50-25 MG P N N Y N ATENOLOL/SYRSPEND SF PH4 ATENOLOL SUS 1GM/ML BETA-ADRENERGIC BLOCKING AGENTS *ATENOLOL ORAL SUSPENSION 1 MG/ML (CMPD KIT)** NP Y NYN

Confidential 2/19/2021 Page 30 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) BETAPACE BETAPACE TAB 80MG BETA-ADRENERGIC BLOCKING AGENTS SOTALOL HCL TAB 80 MG NP Y N Y N BETAPACE AF BETAPACE AF TAB 80MG BETA-ADRENERGIC BLOCKING AGENTS SOTALOL HCL (AFIB/AFL) TAB 80 MG NP Y N Y N BETAXOLOL HCL BETAXOLOL TAB 10MG BETA-ADRENERGIC BLOCKING AGENTS BETAXOLOL HCL TAB 10 MG P N N Y N BISOPROLOL FUMARATE BISOPROL FUM TAB 5MG BETA-ADRENERGIC BLOCKING AGENTS BISOPROLOL FUMARATE TAB 5 MG P N N Y N BISOPROLOL FUMARATE/HYDROCHLOROT BISOPRL/HCTZ TAB 2.5/6.25 BETA-ADRENERGIC BLOCKING AGENTS BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG P N N Y N BYSTOLIC BYSTOLIC TAB 2.5MG BETA-ADRENERGIC BLOCKING AGENTS NEBIVOLOL HCL TAB 2.5 MG (BASE EQUIVALENT) NP Y N Y N BYSTOLIC BYSTOLIC TAB 20MG BETA-ADRENERGIC BLOCKING AGENTS NEBIVOLOL HCL TAB 20 MG (BASE EQUIVALENT) NP Y N Y N CARVEDILOL CARVEDILOL TAB 25MG BETA-ADRENERGIC BLOCKING AGENTS CARVEDILOL TAB 25 MG P N N Y N CARVEDILOL CARVEDILOL TAB 3.125MG BETA-ADRENERGIC BLOCKING AGENTS CARVEDILOL TAB 3.125 MG P N N Y N CARVEDILOL PHOSPHATE CARVEDILOL CAP 10MG ER BETA-ADRENERGIC BLOCKING AGENTS CARVEDILOL PHOSPHATE CAP ER 24HR 10 MG NP Y N N N COREG COREG TAB 25MG BETA-ADRENERGIC BLOCKING AGENTS CARVEDILOL TAB 25 MG NP Y N Y N COREG COREG TAB 3.125MG BETA-ADRENERGIC BLOCKING AGENTS CARVEDILOL TAB 3.125 MG NP Y N Y N COREG CR COREG CR CAP 10MG BETA-ADRENERGIC BLOCKING AGENTS CARVEDILOL PHOSPHATE CAP ER 24HR 10 MG NP Y N N N CORGARD CORGARD TAB 20MG BETA-ADRENERGIC BLOCKING AGENTS NADOLOL TAB 20 MG NP Y N Y N CORGARD CORGARD TAB 40MG BETA-ADRENERGIC BLOCKING AGENTS NADOLOL TAB 40 MG NP Y N Y N CORGARD CORGARD TAB 80MG BETA-ADRENERGIC BLOCKING AGENTS NADOLOL TAB 80 MG NP Y N Y N DUTOPROL DUTOPROL TAB 100-12.5 BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL & HYDROCHLOROTHIAZIDE TAB ER 24HR 100-12.5 MG NP Y N Y N DUTOPROL DUTOPROL TAB 25-12.5 BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL & HYDROCHLOROTHIAZIDE TAB ER 24HR 25-12.5 MG NP Y N Y N HEMANGEOL HEMANGEOL SOL 4.28/ML BETA-ADRENERGIC BLOCKING AGENTS PROPRANOLOL HCL ORAL SOLN 4.28 MG/ML (3.75 MG/ML BASE EQUIV) P N N NN INDERAL LA INDERAL LA CAP 60MG BETA-ADRENERGIC BLOCKING AGENTS PROPRANOLOL HCL CAP ER 24HR 60 MG NP Y N N N INDERAL XL INDERAL XL CAP 80MG BETA-ADRENERGIC BLOCKING AGENTS PROPRANOLOL HCL SUSTAINED-RELEASE BEADS CAP ER 24HR 80 MG P N N N N INNOPRAN XL INNOPRAN XL CAP 80MG BETA-ADRENERGIC BLOCKING AGENTS PROPRANOLOL HCL SUSTAINED-RELEASE BEADS CAP ER 24HR 80 MG P N N N N KAPSPARGO SPRINKLE KAPSPARGO CAP 200MG BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL SUCC CAP ER 24HR SPRINKLE 200 MG (TARTRATE EQUIV) NP Y N Y N KAPSPARGO SPRINKLE KAPSPARGO CAP 25MG BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL SUCC CAP ER 24HR SPRINKLE 25 MG (TARTRATE EQUIV) NP Y N Y N LABETALOL HYDROCHLORIDE LABETALOL TAB 100MG BETA-ADRENERGIC BLOCKING AGENTS LABETALOL HCL TAB 100 MG P N N Y N LABETALOL HYDROCHLORIDE LABETALOL TAB 200MG BETA-ADRENERGIC BLOCKING AGENTS LABETALOL HCL TAB 200 MG P N N Y N LABETALOL HYDROCHLORIDE LABETALOL TAB 300MG BETA-ADRENERGIC BLOCKING AGENTS LABETALOL HCL TAB 300 MG P N N Y N LOPRESSOR LOPRESSOR TAB 100MG BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL TARTRATE TAB 100 MG NP Y N Y N LOPRESSOR LOPRESSOR TAB 50MG BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL TARTRATE TAB 50 MG NP Y N Y N METOPROLOL SUCCINATE ER METOPROLOL TAB 200MG ER BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV) P N N Y N METOPROLOL SUCCINATE ER METOPROLOL TAB 25MG ER BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV) P N N Y N METOPROLOL TARTRATE METOPROL TAR TAB 100MG BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL TARTRATE TAB 100 MG P N N Y N METOPROLOL TARTRATE METOPROL TAR TAB 25MG BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL TARTRATE TAB 25 MG P N N Y N METOPROLOL TARTRATE METOPROL TAR TAB 50MG BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL TARTRATE TAB 50 MG P N N Y N METOPROLOL TARTRATE METOPROLOL TAB 37.5MG BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL TARTRATE TAB 37.5 MG NP Y N N N METOPROLOL/HYDROCHLOROTHIAZIDE METOPRL/HCTZ TAB 100-50MG BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-50 MG NP Y N Y N METOPROLOL/HYDROCHLOROTHIAZIDE METOPRL/HCTZ TAB 50-25MG BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL & HYDROCHLOROTHIAZIDE TAB 50-25 MG NP Y N Y N NADOLOL NADOLOL TAB 20MG BETA-ADRENERGIC BLOCKING AGENTS NADOLOL TAB 20 MG NP Y N Y N NADOLOL NADOLOL TAB 40MG BETA-ADRENERGIC BLOCKING AGENTS NADOLOL TAB 40 MG NP Y N Y N NADOLOL NADOLOL TAB 80MG BETA-ADRENERGIC BLOCKING AGENTS NADOLOL TAB 80 MG NP Y N Y N PINDOLOL PINDOLOL TAB 10MG BETA-ADRENERGIC BLOCKING AGENTS PINDOLOL TAB 10 MG NP Y N Y N PINDOLOL PINDOLOL TAB 5MG BETA-ADRENERGIC BLOCKING AGENTS PINDOLOL TAB 5 MG NP Y N Y N PROPRANOLOL HCL PROPRANOLOL TAB 40MG BETA-ADRENERGIC BLOCKING AGENTS PROPRANOLOL HCL TAB 40 MG P N N N N PROPRANOLOL HCL ER PROPRANOLOL CAP 120MG ER BETA-ADRENERGIC BLOCKING AGENTS PROPRANOLOL HCL CAP ER 24HR 120 MG P N N N N PROPRANOLOL HYDROCHLORIDE PROPRANOLOL TAB 10MG BETA-ADRENERGIC BLOCKING AGENTS PROPRANOLOL HCL TAB 10 MG P N N N N PROPRANOLOL HYDROCHLORIDE ER PROPRANOLOL CAP 60MG ER BETA-ADRENERGIC BLOCKING AGENTS PROPRANOLOL HCL CAP ER 24HR 60 MG P N N N N PROPRANOLOL/HYDROCHLOROTHIAZIDE PROPRAN/HCTZ TAB 40/25 BETA-ADRENERGIC BLOCKING AGENTS PROPRANOLOL & HYDROCHLOROTHIAZIDE TAB 40-25 MG P N N Y N SORINE SORINE TAB 80MG BETA-ADRENERGIC BLOCKING AGENTS SOTALOL HCL TAB 80 MG P N N Y N

Confidential 2/19/2021 Page 31 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) SOTALOL HCL (AF) SOTALOL AF TAB 80MG BETA-ADRENERGIC BLOCKING AGENTS SOTALOL HCL (AFIB/AFL) TAB 80 MG P N N Y N SOTALOL HCL AF SOTALOL AF TAB 160MG BETA-ADRENERGIC BLOCKING AGENTS SOTALOL HCL (AFIB/AFL) TAB 160 MG P N N Y N SOTALOL HYDROCHLORIDE SOTALOL TAB 80MG BETA-ADRENERGIC BLOCKING AGENTS SOTALOL HCL TAB 80 MG P N N Y N SOTYLIZE SOTYLIZE SOL 5MG/ML BETA-ADRENERGIC BLOCKING AGENTS SOTALOL HCL ORAL SOLUTION 5 MG/ML NP Y N Y N TENORETIC 100 TENORETIC TAB 100 BETA-ADRENERGIC BLOCKING AGENTS ATENOLOL & CHLORTHALIDONE TAB 100-25 MG NP Y N Y N TENORETIC 50 TENORETIC TAB 50 BETA-ADRENERGIC BLOCKING AGENTS ATENOLOL & CHLORTHALIDONE TAB 50-25 MG NP Y N Y N TENORMIN TENORMIN TAB 100MG BETA-ADRENERGIC BLOCKING AGENTS ATENOLOL TAB 100 MG NP Y N Y N TENORMIN TENORMIN TAB 25MG BETA-ADRENERGIC BLOCKING AGENTS ATENOLOL TAB 25 MG NP Y N Y N TENORMIN TENORMIN TAB 50MG BETA-ADRENERGIC BLOCKING AGENTS ATENOLOL TAB 50 MG NP Y N Y N TIMOLOL MALEATE TIMOLOL MAL TAB 5MG BETA-ADRENERGIC BLOCKING AGENTS TIMOLOL MALEATE TAB 5 MG NP Y N Y N TOPROL XL TOPROL XL TAB 200MG BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV) NP Y N Y N TOPROL XL TOPROL XL TAB 25MG BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV) NP Y N Y N ZIAC ZIAC TAB 2.5/6.25 BETA-ADRENERGIC BLOCKING AGENTS BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG NP Y N Y N BETAXOLOL HCL BETAXOLOL SOL 0.5% OP BETA-ADRENERGIC BLOCKING AGENTS (EENT) BETAXOLOL HCL OPHTH SOLN 0.5% P N N Y N BETIMOL BETIMOL SOL 0.25% BETA-ADRENERGIC BLOCKING AGENTS (EENT) TIMOLOL OPHTH SOLN 0.25% NP Y N Y N BETOPTIC-S BETOPTIC-S SUS 0.25% OP BETA-ADRENERGIC BLOCKING AGENTS (EENT) BETAXOLOL HCL OPHTH SUSP 0.25% NP Y N Y N CARTEOLOL HCL CARTEOLOL SOL 1% OP BETA-ADRENERGIC BLOCKING AGENTS (EENT) CARTEOLOL HCL OPHTH SOLN 1% P N N N N ISTALOL ISTALOL SOL 0.5% OP BETA-ADRENERGIC BLOCKING AGENTS (EENT) TIMOLOL MALEATE OPHTH SOLN 0.5% (ONCE-DAILY) NP Y N Y N LEVOBUNOLOL HCL LEVOBUNOLOL SOL 0.5% OP BETA-ADRENERGIC BLOCKING AGENTS (EENT) LEVOBUNOLOL HCL OPHTH SOLN 0.5% P N N Y N TIMOLOL MALEATE TIMOLOL MAL SOL 0.5% OP BETA-ADRENERGIC BLOCKING AGENTS (EENT) TIMOLOL MALEATE OPHTH SOLN 0.5% P N N Y N TIMOLOL MALEATE OPHTHALMIC GEL FOR TIMOLOL GEL SOL 0.25% OP BETA-ADRENERGIC BLOCKING AGENTS (EENT) TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25% NP Y N Y N TIMOLOL/BRIMONIDINE/DORZOLAMIDE/LATIMOL/BRIM SOL DORZ/LAT BETA-ADRENERGIC BLOCKING AGENTS (EENT) TIMOLOL-BRIMON-DORZOL-LATANOPROST OPH SOLN 0.5-0.15-2-0.005% NP Y N YN TIMOPTIC TIMOPTIC SOL 0.25% OP BETA-ADRENERGIC BLOCKING AGENTS (EENT) TIMOLOL MALEATE OPHTH SOLN 0.25% NP Y N Y N TIMOPTIC TIMOPTIC SOL 0.5% OP BETA-ADRENERGIC BLOCKING AGENTS (EENT) TIMOLOL MALEATE OPHTH SOLN 0.5% NP Y N Y N TIMOPTIC OCUDOSE TIMOPTIC OCU SOL 0.25% OP BETA-ADRENERGIC BLOCKING AGENTS (EENT) TIMOLOL MALEATE PRESERVATIVE FREE OPHTH SOLN 0.25% NP Y N Y N TIMOPTIC-XE TIMOPTIC-XE SOL 0.25% OP BETA-ADRENERGIC BLOCKING AGENTS (EENT) TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25% NP Y N Y N FORTAMET FORTAMET TAB 1000MG BIGUANIDES METFORMIN HCL TAB ER 24HR OSMOTIC 1000 MG NP Y N Y N FORTAMET FORTAMET TAB 500MG BIGUANIDES METFORMIN HCL TAB ER 24HR OSMOTIC 500 MG NP Y N Y N GLUMETZA GLUMETZA TAB 1000MG BIGUANIDES METFORMIN HCL TAB ER 24HR MODIFIED RELEASE 1000 MG NP Y N Y N GLUMETZA GLUMETZA TAB 500MG BIGUANIDES METFORMIN HCL TAB ER 24HR MODIFIED RELEASE 500 MG NP Y N N N METFORMIN HYDROCHLORIDE METFORMIN SOL 500/5ML BIGUANIDES METFORMIN HCL ORAL SOLN 500 MG/5ML NP Y N Y N METFORMIN HYDROCHLORIDE METFORMIN TAB 500MG BIGUANIDES METFORMIN HCL TAB 500 MG P N N Y N METFORMIN HYDROCHLORIDE METFORMIN TAB 850MG BIGUANIDES METFORMIN HCL TAB 850 MG P N N Y N METFORMIN HYDROCHLORIDE ER METFORMIN TAB 1000 ER BIGUANIDES METFORMIN HCL TAB ER 24HR MODIFIED RELEASE 1000 MG NP Y N Y N METFORMIN HYDROCHLORIDE ER METFORMIN TAB 500MG ER BIGUANIDES METFORMIN HCL TAB ER 24HR 500 MG P N N Y N METFORMIN HYDROCHLORIDE ER METFORMIN TAB 750MG ER BIGUANIDES METFORMIN HCL TAB ER 24HR 750 MG P N N N N METFORMIN HYDROCHLORIDE ER METFORMIN ER TAB 1000MG BIGUANIDES METFORMIN HCL TAB ER 24HR OSMOTIC 1000 MG P Y N Y N RIOMET RIOMET SOL BIGUANIDES METFORMIN HCL ORAL SOLN 500 MG/5ML NP Y N Y N RIOMET ER RIOMET ER SUS 500/5ML BIGUANIDES METFORMIN HCL FOR ORAL ER SUSP 500 MG/5ML NP Y N Y N COLESEVELAM HYDROCHLORIDE COLESEVELAM PAK 3.75 BILE ACID SEQUESTRANTS COLESEVELAM HCL PACKET FOR SUSP 3.75 GM NP Y N N N COLESEVELAM HYDROCHLORIDE COLESEVELAM TAB 625MG BILE ACID SEQUESTRANTS COLESEVELAM HCL TAB 625 MG NP Y N Y N COLESTID COLESTID GRA 5GM BILE ACID SEQUESTRANTS COLESTIPOL HCL GRANULES 5 GM NP Y N Y N COLESTID COLESTID TAB 1GM BILE ACID SEQUESTRANTS COLESTIPOL HCL TAB 1 GM NP Y N Y N COLESTID FLAVORED COLESTID FLA GRA 5GM BILE ACID SEQUESTRANTS COLESTIPOL HCL GRANULES 5 GM NP Y N Y N COLESTIPOL HCL COLESTIPOL TAB 1GM BILE ACID SEQUESTRANTS COLESTIPOL HCL TAB 1 GM NP Y N Y N WELCHOL WELCHOL PAK 3.75GM BILE ACID SEQUESTRANTS COLESEVELAM HCL PACKET FOR SUSP 3.75 GM NP Y N N N WELCHOL WELCHOL TAB 625MG BILE ACID SEQUESTRANTS COLESEVELAM HCL TAB 625 MG NP Y N Y N TAVALISSE TAVALISSE TAB 100MG BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC. FOSTAMATINIB DISODIUM TAB 100 MG (BASE EQUIVALENT) NP Y N Y N

Confidential 2/19/2021 Page 32 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ACTONEL ACTONEL TAB 150MG BONE RESORPTION INHIBITORS RISEDRONATE SODIUM TAB 150 MG NP Y N N N ACTONEL ACTONEL TAB 35MG BONE RESORPTION INHIBITORS RISEDRONATE SODIUM TAB 35 MG NP Y N Y N ALENDRONATE SODIUM ALENDRONATE SOL 70/75ML BONE RESORPTION INHIBITORS ALENDRONATE SODIUM ORAL SOLN 70 MG/75ML P N N Y N ALENDRONATE SODIUM ALENDRONATE TAB 35MG BONE RESORPTION INHIBITORS ALENDRONATE SODIUM TAB 35 MG P N N Y N ALENDRONATE SODIUM ALENDRONATE TAB 5MG BONE RESORPTION INHIBITORS ALENDRONATE SODIUM TAB 5 MG P N N Y N ATELVIA ATELVIA TAB BONE RESORPTION INHIBITORS RISEDRONATE SODIUM TAB DELAYED RELEASE 35 MG NP Y N N N BINOSTO BINOSTO TAB 70MG BONE RESORPTION INHIBITORS ALENDRONATE SODIUM EFFERVESCENT TAB 70 MG NP Y N Y N BONIVA BONIVA TAB 150MG BONE RESORPTION INHIBITORS IBANDRONATE SODIUM TAB 150 MG (BASE EQUIVALENT) NP Y N N N FOSAMAX FOSAMAX TAB 70MG BONE RESORPTION INHIBITORS ALENDRONATE SODIUM TAB 70 MG NP Y N Y N FOSAMAX PLUS D FOSAMAX + D TAB 70-2800 BONE RESORPTION INHIBITORS ALENDRONATE SODIUM-CHOLECALCIFEROL TAB 70-2800 MG-UNIT NP Y N Y N IBANDRONATE SODIUM IBANDRONATE TAB 150MG BONE RESORPTION INHIBITORS IBANDRONATE SODIUM TAB 150 MG (BASE EQUIVALENT) NP Y N N N RISEDRONATE SODIUM RISEDRONATE TAB 150MG BONE RESORPTION INHIBITORS RISEDRONATE SODIUM TAB 150 MG NP Y N N N RISEDRONATE SODIUM RISEDRONATE TAB 35MG BONE RESORPTION INHIBITORS RISEDRONATE SODIUM TAB 35 MG NP Y N Y N RISEDRONATE SODIUM RISEDRONATE TAB 5MG BONE RESORPTION INHIBITORS RISEDRONATE SODIUM TAB 5 MG NP Y N Y N RISEDRONATE SODIUM DR RISEDRON SOD TAB 35MG DR BONE RESORPTION INHIBITORS RISEDRONATE SODIUM TAB DELAYED RELEASE 35 MG NP Y N N N HALDOL HALDOL INJ 5MG/ML BUTYROPHENONES HALOPERIDOL LACTATE INJ 5 MG/ML NP Y N N N HALDOL DECANOATE 100 HALDOL DECAN INJ 100MG/ML BUTYROPHENONES HALOPERIDOL DECANOATE IM SOLN 100 MG/ML NP Y N N Y HALOPERIDOL HALOPERIDOL CON 2MG/ML BUTYROPHENONES HALOPERIDOL LACTATE ORAL CONC 2 MG/ML P N N N N HALOPERIDOL HALOPERIDOL TAB 0.5MG BUTYROPHENONES HALOPERIDOL TAB 0.5 MG P N N Y N HALOPERIDOL DECANOATE HALOPER DEC INJ 50MG/ML BUTYROPHENONES HALOPERIDOL DECANOATE IM SOLN 50 MG/ML P N N N Y HALOPERIDOL LACTATE HALOPERIDOL INJ 5MG/ML BUTYROPHENONES HALOPERIDOL LACTATE INJ 5 MG/ML P N N N N AIMOVIG AIMOVIG INJ 70MG/ML CALCITONIN GENE-RELATED PEPTIDE ANTAG. ERENUMAB-AOOE SUBCUTANEOUS SOLN AUTO-INJECTOR 70 MG/ML P Y N Y N AJOVY AJOVY INJ 225/1.5 CALCITONIN GENE-RELATED PEPTIDE ANTAG. FREMANEZUMAB-VFRM SUBCUTANEOUS SOLN AUTO-INJ 225 MG/1.5ML NP Y NYN EMGALITY EMGALITY INJ 100MG/ML CALCITONIN GENE-RELATED PEPTIDE ANTAG. GALCANEZUMAB-GNLM SUBCUTANEOUS SOLN PREFILLED SYR 100 MG/ML P Y N Y N EMGALITY EMGALITY INJ 120MG/ML CALCITONIN GENE-RELATED PEPTIDE ANTAG. GALCANEZUMAB-GNLM SUBCUTANEOUS SOLN AUTO-INJECTOR 120 MG/ML P Y N Y N NURTEC NURTEC TAB 75MG ODT CALCITONIN GENE-RELATED PEPTIDE ANTAG. RIMEGEPANT SULFATE TAB DISINT 75 MG P Y N Y N UBRELVY UBRELVY TAB 50MG CALCITONIN GENE-RELATED PEPTIDE ANTAG. UBROGEPANT TAB 50 MG NP Y N Y N CALAN SR CALAN SR TAB 120MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. VERAPAMIL HCL TAB ER 120 MG NP Y N Y N CALAN SR CALAN SR TAB 180MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. VERAPAMIL HCL TAB ER 180 MG NP Y N Y N CARDIZEM CARDIZEM TAB 120MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL TAB 120 MG NP Y N Y N CARDIZEM CARDIZEM TAB 30MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL TAB 30 MG NP Y N Y N CARDIZEM CARDIZEM TAB 60MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL TAB 60 MG NP Y N Y N CARDIZEM CD CARDIZEM CD CAP 120MG/24 CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG NP Y N Y N CARDIZEM LA CARDIZEM LA TAB 120MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS TAB ER 24HR 120 MG NP Y N Y N CARDIZEM LA CARDIZEM LA TAB 180MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS TAB ER 24HR 180 MG NP Y N Y N CARDIZEM LA CARDIZEM LA TAB 240MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS TAB ER 24HR 240 MG NP Y N Y N CARDIZEM LA CARDIZEM LA TAB 300MG/24 CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS TAB ER 24HR 300 MG NP Y N N N CARTIA XT CARTIA XT CAP 120/24HR CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG P N N Y N DILTIAZEM CD DILTIAZEM CAP 240MG CD CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG P N N Y N DILTIAZEM HCL DILTIAZEM TAB 120MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL TAB 120 MG P N N Y N DILTIAZEM HCL DILTIAZEM TAB 30MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL TAB 30 MG P N N Y N DILTIAZEM HCL DILTIAZEM TAB 60MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL TAB 60 MG P N N Y N DILTIAZEM HCL DILTIAZEM TAB 90MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL TAB 90 MG P N N Y N DILTIAZEM HCL CD DILTIAZEM CAP 360MG CD CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS CAP ER 24HR 360 MG P N N YN DILTIAZEM HCL ER DILTIAZEM CAP 120MG ER CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL CAP ER 24HR 120 MG P N N Y N DILTIAZEM HCL ER DILTIAZEM CAP 60MG ER CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL CAP ER 12HR 60 MG P N N Y N DILTIAZEM HCL ER DILTIAZEM ER TAB 180MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS TAB ER 24HR 180 MG NP Y N Y N DILTIAZEM HCL ER DILTIAZEM ER TAB 240MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS TAB ER 24HR 240 MG NP Y N Y N

Confidential 2/19/2021 Page 33 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) DILTIAZEM HCL ER DILTIAZEM ER TAB 300MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS TAB ER 24HR 300 MG NP Y N N N DILTIAZEM HCL ER DILTIAZEM ER TAB 360MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS TAB ER 24HR 360 MG NP Y N Y N DILT-XR DILT-XR CAP 120MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL CAP ER 24HR 120 MG P N N Y N MATZIM LA MATZIM LA TAB 180MG/24 CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS TAB ER 24HR 180 MG NP Y N Y N MATZIM LA MATZIM LA TAB 240MG/24 CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS TAB ER 24HR 240 MG NP Y N Y N MATZIM LA MATZIM LA TAB 300MG/24 CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS TAB ER 24HR 300 MG NP Y N N N MATZIM LA MATZIM LA TAB 360MG/24 CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL COATED BEADS TAB ER 24HR 360 MG NP Y N Y N TARKA TARKA TAB 2-180 CR CALCIUM-CHANNEL BLOCKING AGENTS, MISC. TRANDOLAPRIL-VERAPAMIL HCL TAB ER 2-180 MG NP Y N Y N TARKA TARKA TAB 2-240 CR CALCIUM-CHANNEL BLOCKING AGENTS, MISC. TRANDOLAPRIL-VERAPAMIL HCL TAB ER 2-240 MG NP Y N Y N TAZTIA XT TAZTIA XT CAP 120MG/24 CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 120 MG PNNYN TIADYLT ER TIADYLT CAP 120MG/24 CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 120 MGPNNYN TIAZAC TIAZAC CAP 120MG/24 CALCIUM-CHANNEL BLOCKING AGENTS, MISC. DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 120 MG NP Y NYN TRANDOLAPRIL/VERAPAMIL HCL ER TRANDO/VERAP TAB 1-240 ER CALCIUM-CHANNEL BLOCKING AGENTS, MISC. TRANDOLAPRIL-VERAPAMIL HCL TAB ER 1-240 MG NP Y N Y N TRANDOLAPRIL/VERAPAMIL HCL ER TRANDO/VERAP TAB 2-180 ER CALCIUM-CHANNEL BLOCKING AGENTS, MISC. TRANDOLAPRIL-VERAPAMIL HCL TAB ER 2-180 MG NP Y N Y N VERAPAMIL HCL VERAPAMIL TAB 40MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. VERAPAMIL HCL TAB 40 MG P N N Y N VERAPAMIL HCL VERAPAMIL TAB 80MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. VERAPAMIL HCL TAB 80 MG P N N Y N VERAPAMIL HCL CR VERAPAMIL TAB 240MG CR CALCIUM-CHANNEL BLOCKING AGENTS, MISC. VERAPAMIL HCL TAB ER 240 MG P N N Y N VERAPAMIL HCL ER VERAPAMIL CAP 100MG ER CALCIUM-CHANNEL BLOCKING AGENTS, MISC. VERAPAMIL HCL CAP ER 24HR 100 MG NP Y N Y N VERAPAMIL HCL ER VERAPAMIL TAB 120MG ER CALCIUM-CHANNEL BLOCKING AGENTS, MISC. VERAPAMIL HCL TAB ER 120 MG P N N Y N VERAPAMIL HCL ER VERAPAMIL TAB 180MG ER CALCIUM-CHANNEL BLOCKING AGENTS, MISC. VERAPAMIL HCL TAB ER 180 MG P N N Y N VERAPAMIL HYDROCHLORIDE VERAPAMIL TAB 120MG CALCIUM-CHANNEL BLOCKING AGENTS, MISC. VERAPAMIL HCL TAB 120 MG P N N Y N VERAPAMIL HYDROCHLORIDE ER VERAPAMIL CAP 200MG ER CALCIUM-CHANNEL BLOCKING AGENTS, MISC. VERAPAMIL HCL CAP ER 24HR 200 MG NP Y N Y N VERELAN VERELAN CAP 120MG SR CALCIUM-CHANNEL BLOCKING AGENTS, MISC. VERAPAMIL HCL CAP ER 24HR 120 MG NP Y N Y N VERELAN PM VERELAN PM CAP 100MG ER CALCIUM-CHANNEL BLOCKING AGENTS, MISC. VERAPAMIL HCL CAP ER 24HR 100 MG NP Y N Y N ACETAZOLAMIDE ACETAZOLAMID TAB 125MG CARBONIC ANHYDRASE INHIBITORS (EENT) ACETAZOLAMIDE TAB 125 MG P N N Y N ACETAZOLAMIDE ER ACETAZOLAMID CAP 500MG ER CARBONIC ANHYDRASE INHIBITORS (EENT) ACETAZOLAMIDE CAP ER 12HR 500 MG P N N Y N AZOPT AZOPT SUS 1% OP CARBONIC ANHYDRASE INHIBITORS (EENT) BRINZOLAMIDE OPHTH SUSP 1% NP Y N N N COSOPT COSOPT SOL 22.3-6.8 CARBONIC ANHYDRASE INHIBITORS (EENT) DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 22.3-6.8 MG/ML NP Y NYN COSOPT PF COSOPT PF SOL 2%-0.5% CARBONIC ANHYDRASE INHIBITORS (EENT) DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOL 22.3-6.8 MG/ML PFNPYNNN DORZOLAMIDE HCL DORZOLAMIDE SOL 2% OP CARBONIC ANHYDRASE INHIBITORS (EENT) DORZOLAMIDE HCL OPHTH SOLN 2% P N N Y N DORZOLAMIDE HCL/TIMOLOL MALEATE DORZOL/TIMOL SOL 22.3-6.8 CARBONIC ANHYDRASE INHIBITORS (EENT) DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 22.3-6.8 MG/ML P N N Y N DORZOLAMIDE HYDROCHLORIDE/TIMOLOLDORZOL/TIMOL SOL 2%-0.5% CARBONIC ANHYDRASE INHIBITORS (EENT) DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOL 22.3-6.8 MG/ML PF NP Y N N N METHAZOLAMIDE METHAZOLAMID TAB 25MG CARBONIC ANHYDRASE INHIBITORS (EENT) METHAZOLAMIDE TAB 25 MG P N N Y N METHAZOLAMIDE METHAZOLAMID TAB 50MG CARBONIC ANHYDRASE INHIBITORS (EENT) METHAZOLAMIDE TAB 50 MG P N N Y N TRUSOPT TRUSOPT SOL 2% OP CARBONIC ANHYDRASE INHIBITORS (EENT) DORZOLAMIDE HCL OPHTH SOLN 2% NP Y N Y N KEVEYIS KEVEYIS TAB 50MG CARBONIC ANHYDRASE INHIBITORS (MISC.) DICHLORPHENAMIDE TAB 50 MG NP Y N Y N CORLANOR CORLANOR SOL 5MG/5ML CARDIAC DRUGS, MISCELLANEOUS IVABRADINE HCL ORAL SOLN 5 MG/5ML (BASE EQUIV) NP Y N Y N CORLANOR CORLANOR TAB 5MG CARDIAC DRUGS, MISCELLANEOUS IVABRADINE HCL TAB 5 MG (BASE EQUIV) NP Y N Y N RANEXA RANEXA TAB 500MG CARDIAC DRUGS, MISCELLANEOUS RANOLAZINE TAB ER 12HR 500 MG NP Y N Y N RANOLAZINE ER RANOLAZINE TAB 500MG ER CARDIAC DRUGS, MISCELLANEOUS RANOLAZINE TAB ER 12HR 500 MG P N Y Y N VYNDAMAX VYNDAMAX CAP 61MG CARDIAC DRUGS, MISCELLANEOUS TAFAMIDIS CAP 61 MG P Y N Y N VYNDAQEL VYNDAQEL CAP 20MG CARDIAC DRUGS, MISCELLANEOUS TAFAMIDIS MEGLUMINE (CARDIAC) CAP 20 MG P Y N Y N DIGITEK DIGITEK TAB 0.125MG CARDIOTONIC AGENTS DIGOXIN TAB 125 MCG (0.125 MG) P N N Y N DIGITEK DIGITEK TAB 0.25MG CARDIOTONIC AGENTS DIGOXIN TAB 250 MCG (0.25 MG) P N N Y N DIGOX DIGOX TAB 0.125MG CARDIOTONIC AGENTS DIGOXIN TAB 125 MCG (0.125 MG) P N N Y N DIGOX DIGOX TAB 0.25MG CARDIOTONIC AGENTS DIGOXIN TAB 250 MCG (0.25 MG) P N N Y N DIGOXIN DIGOXIN SOL 50MCG/ML CARDIOTONIC AGENTS DIGOXIN ORAL SOLN 0.05 MG/ML P N N N N DIGOXIN DIGOXIN TAB 0.125MG CARDIOTONIC AGENTS DIGOXIN TAB 125 MCG (0.125 MG) P N N Y N

Confidential 2/19/2021 Page 34 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) DIGOXIN DIGOXIN TAB 0.25MG CARDIOTONIC AGENTS DIGOXIN TAB 250 MCG (0.25 MG) P N N Y N LANOXIN LANOXIN TAB 0.0625MG CARDIOTONIC AGENTS DIGOXIN TAB 62.5 MCG (0.0625 MG) NP Y N Y N LANOXIN LANOXIN TAB 0.25MG CARDIOTONIC AGENTS DIGOXIN TAB 250 MCG (0.25 MG) P N N Y N COMTAN COMTAN TAB 200MG CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. ENTACAPONE TAB 200 MG NP Y N Y N ENTACAPONE ENTACAPONE TAB 200MG CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. ENTACAPONE TAB 200 MG P N N Y N ONGENTYS ONGENTYS CAP 25MG CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. OPICAPONE CAP 25 MG NP Y N N N ONGENTYS ONGENTYS CAP 50MG CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. OPICAPONE CAP 50 MG NP Y N Y N TASMAR TASMAR TAB 100MG CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. TOLCAPONE TAB 100 MG NP Y N Y N TOLCAPONE TOLCAPONE TAB 100MG CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. TOLCAPONE TAB 100 MG P N N Y N RETIN-A RETIN-A CRE 0.025% CELL STIMULANTS AND PROLIFERANTS TRETINOIN CREAM 0.025% NP Y N Y N RETIN-A MICRO RETIN-A MICR GEL 0.04% CELL STIMULANTS AND PROLIFERANTS TRETINOIN MICROSPHERE GEL 0.04% NP Y N Y Y RETIN-A MICRO RETIN-A MICR GEL 0.06% CELL STIMULANTS AND PROLIFERANTS TRETINOIN MICROSPHERE GEL 0.06% NP Y N Y N RETIN-A MICRO PUMP RETIN-A MICR GEL 0.04%PMP CELL STIMULANTS AND PROLIFERANTS TRETINOIN MICROSPHERE GEL 0.04% NP Y N Y Y RETIN-A MICRO PUMP RETIN-A MICR GEL 0.08% CELL STIMULANTS AND PROLIFERANTS TRETINOIN MICROSPHERE GEL 0.08% NP Y N Y N TARDIMAXIA TARDIMAXIA GEL CELL STIMULANTS AND PROLIFERANTS NIACINAMIDE-SPIRONOLACTONE-TRETINOIN GEL 2-5-0.025% NP Y N Y N TAROXIA TAROXIA CRE CELL STIMULANTS AND PROLIFERANTS NIACINAMIDE-TRETINOIN CREAM 4-0.025% NP Y N Y N TRETINOIN TRETINOIN CRE 0.025% CELL STIMULANTS AND PROLIFERANTS TRETINOIN CREAM 0.025% P N Y Y N TRETINOIN TRETINOIN GEL 0.01% CELL STIMULANTS AND PROLIFERANTS TRETINOIN GEL 0.01% NP Y N Y N TRETINOIN TRETINOIN GEL 0.05% CELL STIMULANTS AND PROLIFERANTS TRETINOIN GEL 0.05% NP Y N Y N TRETINOIN MICROSPHERE PUMP TRETINOIN GEL 0.04%PMP CELL STIMULANTS AND PROLIFERANTS TRETINOIN MICROSPHERE GEL 0.04% NP Y N Y Y VARDIMAXIA VARDIMAXIA GEL CELL STIMULANTS AND PROLIFERANTS NIACINAMIDE-SPIRONOLACTONE-TRETINOIN GEL 2-5-0.05% NP Y N Y N VAROXIA VAROXIA CRE CELL STIMULANTS AND PROLIFERANTS NIACINAMIDE-TRETINOIN CREAM 4-0.05% NP Y N Y N CATAPRES-TTS-1 CATAPRES-TTS DIS 0.1/24HR CENTRAL ALPHA-AGONISTS CLONIDINE TD PATCH WEEKLY 0.1 MG/24HR NP Y N Y N CATAPRES-TTS-2 CATAPRES-TTS DIS 0.2/24HR CENTRAL ALPHA-AGONISTS CLONIDINE TD PATCH WEEKLY 0.2 MG/24HR NP Y N Y N CATAPRES-TTS-3 CATAPRES-TTS DIS 0.3/24HR CENTRAL ALPHA-AGONISTS CLONIDINE TD PATCH WEEKLY 0.3 MG/24HR NP Y N Y N CLONIDINE HCL CLONIDINE DIS 0.1/24HR CENTRAL ALPHA-AGONISTS CLONIDINE TD PATCH WEEKLY 0.1 MG/24HR P N N Y N CLONIDINE HCL CLONIDINE DIS 0.3/24HR CENTRAL ALPHA-AGONISTS CLONIDINE TD PATCH WEEKLY 0.3 MG/24HR P N N Y N CLONIDINE HCL ER CLONIDINE TAB 0.1MG ER CENTRAL ALPHA-AGONISTS CLONIDINE HCL TAB ER 12HR 0.1 MG P N N Y N CLONIDINE HYDROCHLORIDE CLONIDINE TAB 0.1MG CENTRAL ALPHA-AGONISTS CLONIDINE HCL TAB 0.1 MG P N N Y Y CLONIDINE HYDROCHLORIDE CLONIDINE TAB 0.2MG CENTRAL ALPHA-AGONISTS CLONIDINE HCL TAB 0.2 MG P N N Y Y CLONIDINE HYDROCHLORIDE CLONIDINE TAB 0.3MG CENTRAL ALPHA-AGONISTS CLONIDINE HCL TAB 0.3 MG P N N Y Y GUANFACINE HCL GUANFACINE TAB 1MG CENTRAL ALPHA-AGONISTS GUANFACINE HCL TAB 1 MG P N N N N GUANFACINE HYDROCHLORIDE GUANFACINE TAB 1MG CENTRAL ALPHA-AGONISTS GUANFACINE HCL TAB 1 MG P N N N N KAPVAY KAPVAY TAB 0.1 MG CENTRAL ALPHA-AGONISTS CLONIDINE HCL TAB ER 12HR 0.1 MG NP Y N Y N METHYLDOPA METHYLDOPA TAB 250MG CENTRAL ALPHA-AGONISTS METHYLDOPA TAB 250 MG P N N Y N METHYLDOPA METHYLDOPA TAB 500MG CENTRAL ALPHA-AGONISTS METHYLDOPA TAB 500 MG P N N Y N METHYLDOPA/HYDROCHLOROTHIAZIDE METHYLD/HCTZ TAB 250/15 CENTRAL ALPHA-AGONISTS METHYLDOPA & HYDROCHLOROTHIAZIDE TAB 250-15 MG P N N Y N ACAMPROSATE CALCIUM DR ACAMPRO CAL TAB 333MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. ACAMPROSATE CALCIUM TAB DELAYED RELEASE 333 MG P NNYN ATOMOXETINE ATOMOXETINE CAP 10MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. ATOMOXETINE HCL CAP 10 MG (BASE EQUIV) P N N Y N ATOMOXETINE ATOMOXETINE CAP 60MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. ATOMOXETINE HCL CAP 60 MG (BASE EQUIV) P N N Y N GUANFACINE ER GUANFACINE TAB 1MG ER CENTRAL NERVOUS SYSTEM AGENTS, MISC. GUANFACINE HCL TAB ER 24HR 1 MG (BASE EQUIV) P N N Y N INTUNIV INTUNIV TAB 1MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. GUANFACINE HCL TAB ER 24HR 1 MG (BASE EQUIV) NP Y N Y N MEMANTINE HCL TITRATION PAK MEMANT TITRA PAK 5-10MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. MEMANTINE HCL TAB 28 X 5 MG & 21 X 10 MG TITRATION PACK P N N Y N MEMANTINE HYDROCHLORIDE MEMANTINE SOL 10MG/5ML CENTRAL NERVOUS SYSTEM AGENTS, MISC. MEMANTINE HCL ORAL SOLUTION 2 MG/ML P N N Y N MEMANTINE HYDROCHLORIDE MEMANTINE TAB HCL 5MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. MEMANTINE HCL TAB 5 MG P N N Y N MEMANTINE HYDROCHLORIDE ER MEMANTINE HC CAP 7MG ER CENTRAL NERVOUS SYSTEM AGENTS, MISC. MEMANTINE HCL CAP ER 24HR 7 MG P N N Y N NAMENDA NAMENDA TAB 5MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. MEMANTINE HCL TAB 5 MG NP Y N Y N NAMENDA TITRATION PAK NAMENDA TAB 5-10MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. MEMANTINE HCL TAB 28 X 5 MG & 21 X 10 MG TITRATION PACK NP Y N Y N

Confidential 2/19/2021 Page 35 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) NAMENDA XR NAMENDA XR CAP 7MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. MEMANTINE HCL CAP ER 24HR 7 MG NP Y N Y N NAMENDA XR TITRATION PACK NAMENDA XR CAP TITRATIO CENTRAL NERVOUS SYSTEM AGENTS, MISC. MEMANTINE HCL CAP ER 24HR 7 MG & 14 MG & 21 MG & 28 MG PACK P N N Y N NAMZARIC NAMZARIC CAP CENTRAL NERVOUS SYSTEM AGENTS, MISC. MEMANTINE-DONEPEZIL CAP ER 24HR 7 & 14 & 21 & 28-10 MG PACK P N N Y N NAMZARIC NAMZARIC CAP 7-10MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. MEMANTINE HCL-DONEPEZIL HCL CAP ER 24HR 7-10 MG P N N Y N NOURIANZ NOURIANZ TAB 20MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. ISTRADEFYLLINE TAB 20 MG NP Y N Y N NUEDEXTA NUEDEXTA CAP 20-10MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. DEXTROMETHORPHAN HBR-QUINIDINE SULFATE CAP 20-10 MG P Y N Y N RILUTEK RILUTEK TAB 50MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. RILUZOLE TAB 50 MG NP Y N Y N RILUZOLE RILUZOLE TAB 50MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. RILUZOLE TAB 50 MG P N N Y N STRATTERA STRATTERA CAP 10MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. ATOMOXETINE HCL CAP 10 MG (BASE EQUIV) NP Y N Y N STRATTERA STRATTERA CAP 60MG CENTRAL NERVOUS SYSTEM AGENTS, MISC. ATOMOXETINE HCL CAP 60 MG (BASE EQUIV) NP Y N Y N TIGLUTIK TIGLUTIK SUS 50/10ML CENTRAL NERVOUS SYSTEM AGENTS, MISC. RILUZOLE SUSP 50 MG/10ML NP Y N Y N XYREM XYREM SOL 500MG/ML CENTRAL NERVOUS SYSTEM AGENTS, MISC. SODIUM OXYBATE ORAL SOLUTION 500 MG/ML P N N Y Y XYWAV XYWAV SOL 0.5GM/ML CENTRAL NERVOUS SYSTEM AGENTS, MISC. CALCIUM, MAG, POTASSIUM, & SOD OXYBATES ORAL SOLN 500 MG/ML NP YNYN AMRIX AMRIX CAP 15MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CYCLOBENZAPRINE HCL CAP ER 24HR 15 MG NP Y N Y N CARISOPRODOL CARISOPRODOL TAB 250MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CARISOPRODOL TAB 250 MG NP Y N Y N CARISOPRODOL/ASPIRIN/CODEINE CARISOPRODOL TAB ASA/COD CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CARISOPRODOL W/ ASPIRIN & CODEINE TAB 200-325-16 MG NP Y N Y N CHLORZOXAZONE CHLORZOXAZON TAB 250MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CHLORZOXAZONE TAB 250 MG NP Y N Y N CHLORZOXAZONE CHLORZOXAZON TAB 375MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CHLORZOXAZONE TAB 375 MG NP Y N N N CHLORZOXAZONE CHLORZOXAZON TAB 500MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CHLORZOXAZONE TAB 500 MG P N N Y N CYCLO/GABA10/300 PACK CYCLO/GABA PAK 10/300 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CYCLOBENZAPRINE TAB 10 MG & GABAPENTIN CAP 300 MG THERA PACK NP Y N N N CYCLOBENZAPRINE HYDROCHLORIDE CYCLOBENZAPR TAB 5MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CYCLOBENZAPRINE HCL TAB 5 MG P N N Y N CYCLOBENZAPRINE HYDROCHLORIDE CYCLOBENZAPR TAB 7.5MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CYCLOBENZAPRINE HCL TAB 7.5 MG NP Y N N N CYCLOBENZAPRINE HYDROCHLORIDE ER CYCLOBENZAPR CAP 15MG ER CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CYCLOBENZAPRINE HCL CAP ER 24HR 15 MG NP Y N Y N CYCLOPAK CYCLOPAK PAK CENTRALLY ACTING SKELETAL MUSCLE RELAXNT *CYCLOBEN TAB 5 MG & LIDO-PRILO 2.5-2.5% CR &SWALLOW SPRAY** NP Y NNN CYCLOPHENE RAPIDPAQ CYCLOPHENE CRE RAPIDPAQ CENTRALLY ACTING SKELETAL MUSCLE RELAXNT *CYCLOBENZAPRINE HCL TD CREAM 5% (COMPOUND KIT)** NP Y N N N ENOVARX-CYCLOBENZAPRINE HCL CYCLOBENZAPR CRE 20MG/GM CENTRALLY ACTING SKELETAL MUSCLE RELAXNT *CYCLOBENZAPRINE HCL TD CREAM 20 MG/GM (COMPOUND KIT)** NP Y N N N FEXMID FEXMID TAB 7.5MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CYCLOBENZAPRINE HCL TAB 7.5 MG NP Y N N N LORZONE LORZONE TAB 375MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CHLORZOXAZONE TAB 375 MG NP Y N N N METAXALL CP METAXALL CP KIT 0.025% CENTRALLY ACTING SKELETAL MUSCLE RELAXNT METAXALONE TAB 800 MG & CAPSAICIN CR 0.025% KIT NP Y N N N METAXALONE METAXALONE TAB 400MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT METAXALONE TAB 400 MG NP Y N N N METAXALONE METAXALONE TAB 800MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT METAXALONE TAB 800 MG NP Y N Y N METHOCARBAMOL METHOCARBAM TAB 500MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT METHOCARBAMOL TAB 500 MG P N N Y N METHOCARBAMOL METHOCARBAM TAB 750MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT METHOCARBAMOL TAB 750 MG P N N Y N NOPIOID-LMC KIT NOPIOID-LMC MIS KIT CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CYCLOBEN TAB 7.5 MG & LIDOCAINE-MENTHOL PATCH 4-4% THER PACK NP Y N Y N ROBAXIN-750 ROBAXIN-750 TAB 750MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT METHOCARBAMOL TAB 750 MG NP Y N Y N SKELAXIN SKELAXIN TAB 800MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT METAXALONE TAB 800 MG NP Y N Y N SOMA SOMA TAB 250MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CARISOPRODOL TAB 250 MG NP Y N Y N TABRADOL FUSEPAQ TABRADOL SUS 1MG/ML CENTRALLY ACTING SKELETAL MUSCLE RELAXNT *CYCLOBENZAPRINE HCL W/ MSM ORAL SUSP 1 MG/ML (CMPD KIT)** NP Y N Y N TABRADOL RAPIDPAQ TABRADOL SUS RAPIDPAQ CENTRALLY ACTING SKELETAL MUSCLE RELAXNT *CYCLOBENZAPRINE HCL W/ MSM ORAL SUSP 1 MG/ML (CMPD KIT)** NP Y N Y N TIZANIDINE HCL TIZANIDINE CAP 2MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT TIZANIDINE HCL CAP 2 MG (BASE EQUIVALENT) NP Y N Y N TIZANIDINE HCL TIZANIDINE CAP 4MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT TIZANIDINE HCL CAP 4 MG (BASE EQUIVALENT) NP Y N N N TIZANIDINE HCL TIZANIDINE TAB 2MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT) P N N Y N TIZANIDINE HYDROCHLORIDE TIZANIDINE TAB 4MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT) P N NYN VANADOM VANADOM TAB 350MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT CARISOPRODOL TAB 350 MG NP Y N Y N ZANAFLEX ZANAFLEX CAP 2MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT TIZANIDINE HCL CAP 2 MG (BASE EQUIVALENT) NP Y N Y N ZANAFLEX ZANAFLEX CAP 4MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT TIZANIDINE HCL CAP 4 MG (BASE EQUIVALENT) NP Y N N N ZANAFLEX ZANAFLEX TAB 4MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT) NP Y N Y N CHENODAL CHENODAL TAB 250MG CHOLELITHOLYTIC AGENTS CHENODIOL TAB 250 MG NP Y N N N

Confidential 2/19/2021 Page 36 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) RELTONE RELTONE CAP 200MG CHOLELITHOLYTIC AGENTS URSODIOL CAP 200 MG NP Y N Y N RELTONE RELTONE CAP 400MG CHOLELITHOLYTIC AGENTS URSODIOL CAP 400 MG NP Y N Y N URSO 250 URSO 250 TAB 250MG CHOLELITHOLYTIC AGENTS URSODIOL TAB 250 MG NP Y N N N URSO FORTE URSO FORTE TAB 500MG CHOLELITHOLYTIC AGENTS URSODIOL TAB 500 MG NP Y N N N URSODIOL URSODIOL CAP 300MG CHOLELITHOLYTIC AGENTS URSODIOL CAP 300 MG P N N Y N URSODIOL URSODIOL TAB 250MG CHOLELITHOLYTIC AGENTS URSODIOL TAB 250 MG P N N N N URSODIOL/SYRSPEND SF PH4 URSODIOL SUS 30MG/ML CHOLELITHOLYTIC AGENTS *URSODIOL SUSP 30 MG/ML (COMPOUND KIT)** NP Y N Y N EZETIMIBE EZETIMIBE TAB 10MG CHOLESTEROL ABSORPTION INHIBITORS EZETIMIBE TAB 10 MG P Y N Y N ZETIA ZETIA TAB 10MG CHOLESTEROL ABSORPTION INHIBITORS EZETIMIBE TAB 10 MG NP Y N Y N DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE CAP 100MG CLASS IA ANTIARRHYTHMICS DISOPYRAMIDE PHOSPHATE CAP 100 MG P N N Y N DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE CAP 150MG CLASS IA ANTIARRHYTHMICS DISOPYRAMIDE PHOSPHATE CAP 150 MG P N N Y N NORPACE NORPACE CAP 100MG CLASS IA ANTIARRHYTHMICS DISOPYRAMIDE PHOSPHATE CAP 100 MG NP Y N Y N NORPACE NORPACE CAP 150MG CLASS IA ANTIARRHYTHMICS DISOPYRAMIDE PHOSPHATE CAP 150 MG NP Y N Y N NORPACE CR NORPACE CAP 100MG CR CLASS IA ANTIARRHYTHMICS DISOPYRAMIDE PHOSPHATE CAP ER 12HR 100 MG P N N N N QUINIDINE GLUCONATE CR QUINIDINE GL TAB 324MG CR CLASS IA ANTIARRHYTHMICS QUINIDINE GLUCONATE TAB ER 324 MG P N N Y N QUINIDINE GLUCONATE ER QUINIDINE GL TAB 324MG ER CLASS IA ANTIARRHYTHMICS QUINIDINE GLUCONATE TAB ER 324 MG P N N Y N QUINIDINE SULFATE QUINIDINE SU TAB 200MG CLASS IA ANTIARRHYTHMICS QUINIDINE SULFATE TAB 200 MG P N N Y N QUINIDINE SULFATE QUINIDINE SU TAB 300MG CLASS IA ANTIARRHYTHMICS QUINIDINE SULFATE TAB 300 MG P N N Y N QUINIDINE SULFATE DIHYDRATE QUINIDINE CRY SULFATE CLASS IA ANTIARRHYTHMICS QUINIDINE SULFATE CRYSTALS NP Y N N N MEXILETINE HCL MEXILETINE CAP 150MG CLASS IB ANTIARRHYTHMICS MEXILETINE HCL CAP 150 MG P N N Y N MEXILETINE HCL MEXILETINE CAP 200MG CLASS IB ANTIARRHYTHMICS MEXILETINE HCL CAP 200 MG P N N Y N MEXILETINE HCL MEXILETINE CAP 250MG CLASS IB ANTIARRHYTHMICS MEXILETINE HCL CAP 250 MG P N N Y N FLECAINIDE ACETATE FLECAINIDE TAB 50MG CLASS IC ANTIARRHYTHMICS FLECAINIDE ACETATE TAB 50 MG P N N Y N PROPAFENONE HCL PROPAFENONE TAB 150MG CLASS IC ANTIARRHYTHMICS PROPAFENONE HCL TAB 150 MG P N N Y N PROPAFENONE HCL PROPAFENONE TAB 225MG CLASS IC ANTIARRHYTHMICS PROPAFENONE HCL TAB 225 MG P N N Y N PROPAFENONE HYDROCHLORIDE ER PROPAFENONE CAP 225MG ER CLASS IC ANTIARRHYTHMICS PROPAFENONE HCL CAP ER 12HR 225 MG NP Y N Y N PROPAFENONE HYDROCHLORIDE ER PROPAFENONE CAP 325MG ER CLASS IC ANTIARRHYTHMICS PROPAFENONE HCL CAP ER 12HR 325 MG NP Y N Y N PROPAFENONE HYDROCHLORIDE ER PROPAFENONE CAP 425MG ER CLASS IC ANTIARRHYTHMICS PROPAFENONE HCL CAP ER 12HR 425 MG NP Y N N N RYTHMOL SR RYTHMOL SR CAP 225MG CLASS IC ANTIARRHYTHMICS PROPAFENONE HCL CAP ER 12HR 225 MG NP Y N Y N RYTHMOL SR RYTHMOL SR CAP 325MG CLASS IC ANTIARRHYTHMICS PROPAFENONE HCL CAP ER 12HR 325 MG NP Y N Y N RYTHMOL SR RYTHMOL SR CAP 425MG CLASS IC ANTIARRHYTHMICS PROPAFENONE HCL CAP ER 12HR 425 MG NP Y N N N AMIODARONE HYDROCHLORIDE AMIODARONE TAB 100MG CLASS III ANTIARRHYTHMICS AMIODARONE HCL TAB 100 MG NP Y N Y N AMIODARONE HYDROCHLORIDE AMIODARONE TAB 200MG CLASS III ANTIARRHYTHMICS AMIODARONE HCL TAB 200 MG P N N Y N AMIODARONE HYDROCHLORIDE AMIODARONE TAB 400MG CLASS III ANTIARRHYTHMICS AMIODARONE HCL TAB 400 MG P N N Y N DOFETILIDE DOFETILIDE CAP 125MCG CLASS III ANTIARRHYTHMICS DOFETILIDE CAP 125 MCG (0.125 MG) P N N Y N MULTAQ MULTAQ TAB 400MG CLASS III ANTIARRHYTHMICS DRONEDARONE HCL TAB 400 MG (BASE EQUIVALENT) NP Y N Y N PACERONE PACERONE TAB 100MG CLASS III ANTIARRHYTHMICS AMIODARONE HCL TAB 100 MG NP Y N Y N PACERONE PACERONE TAB 200MG CLASS III ANTIARRHYTHMICS AMIODARONE HCL TAB 200 MG NP Y N Y N PACERONE PACERONE TAB 400MG CLASS III ANTIARRHYTHMICS AMIODARONE HCL TAB 400 MG NP Y N Y N TIKOSYN TIKOSYN CAP 125MCG CLASS III ANTIARRHYTHMICS DOFETILIDE CAP 125 MCG (0.125 MG) NP Y N Y N BERINERT BERINERT INJ 500UNIT COMPLEMENT INHIBITORS C1 ESTERASE INHIBITOR (HUMAN) FOR IV INJ KIT 500 UNIT NP Y N N N CINRYZE CINRYZE SOL 500 UNIT COMPLEMENT INHIBITORS C1 ESTERASE INHIBITOR (HUMAN) FOR IV INJ 500 UNIT NP Y N N N FIRAZYR FIRAZYR INJ 30MG/3ML COMPLEMENT INHIBITORS ICATIBANT ACETATE INJ 30 MG/3ML (BASE EQUIVALENT) NP Y N Y N HAEGARDA HAEGARDA INJ 2000UNIT COMPLEMENT INHIBITORS C1 ESTERASE INHIBITOR (HUMAN) FOR SUBCUTANEOUS INJ 2000 UNIT P Y N Y N HAEGARDA HAEGARDA INJ 3000UNIT COMPLEMENT INHIBITORS C1 ESTERASE INHIBITOR (HUMAN) FOR SUBCUTANEOUS INJ 3000 UNIT P Y N Y N ICATIBANT ACETATE ICATIBANT INJ 30MG/3ML COMPLEMENT INHIBITORS ICATIBANT ACETATE INJ 30 MG/3ML (BASE EQUIVALENT) P Y N Y N ORLADEYO ORLADEYO CAP 110MG COMPLEMENT INHIBITORS BEROTRALSTAT HCL CAP 110 MG NP Y N Y N RUCONEST RUCONEST INJ 2100UNIT COMPLEMENT INHIBITORS C1 ESTERASE INHIBITOR (RECOMBINANT) FOR IV INJ 2100 UNIT P Y N Y N

Confidential 2/19/2021 Page 37 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) TAKHZYRO TAKHZYRO INJ 300/2ML COMPLEMENT INHIBITORS LANADELUMAB-FLYO INJ 300 MG/2ML (150 MG/ML) NP Y N Y N AFIRMELLE AFIRMELLE TAB 0.1-0.02 CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG P N N Y N AFTERA AFTERA TAB 1.5MG CONTRACEPTIVES LEVONORGESTREL TAB 1.5 MG P N N Y N ALTAVERA ALTAVERA TAB CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N ALYACEN 1/35 ALYACEN TAB 1/35 CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG P N N Y N ALYACEN 7/7/7 ALYACEN TAB 7/7/7 CONTRACEPTIVES NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG P N N Y N AMETHIA AMETHIA TAB CONTRACEPTIVES LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) NP Y N Y N AMETHIA LO AMETHIA LO TAB CONTRACEPTIVES LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7) NP Y N Y N AMETHYST AMETHYST TAB 90-20MCG CONTRACEPTIVES LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) TAB 90-20 MCG NP Y N Y N ANNOVERA ANNOVERA MIS CONTRACEPTIVES SEGESTERONE ACE-ETHINYL ESTRADIOL VA RING 0.15-0.013 MG/24HR NP Y N Y N APRI APRI TAB CONTRACEPTIVES DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N ARANELLE ARANELLE TAB CONTRACEPTIVES NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG P N N Y N ASHLYNA ASHLYNA TAB CONTRACEPTIVES LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) NP Y N Y N AUBRA AUBRA TAB 0.1-0.02 CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG P N N Y N AUBRA EQ AUBRA EQ TAB 0.1-0.02 CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG P N N Y N AUROVELA 1.5/30 AUROVELA TAB 1.5/30 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG P N N Y N AUROVELA 1/20 AUROVELA TAB 1/20 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG P N N Y N AUROVELA 24 FE AUROVELA 24 TAB FE 1/20 CONTRACEPTIVES NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24) NP Y N Y N AUROVELA FE 1.5/30 AUROVELA FE TAB 1.5/30 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG P N N Y N AUROVELA FE 1/20 AUROVELA FE TAB 1/20 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG P N N Y N AVIANE AVIANE TAB CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG P N N Y N AYUNA AYUNA TAB CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N AZURETTE AZURETTE TAB 28 DAY CONTRACEPTIVES DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) P N N Y N BALCOLTRA BALCOLTRA TAB 0.1-20 CONTRACEPTIVES LEVONORGESTREL-ETHINYL ESTRADIOL-FE TAB 0.1 MG-20 MCG (21) NP Y N Y N BALZIVA BALZIVA TAB CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG P N N Y N BEKYREE BEKYREE TAB CONTRACEPTIVES DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) P N N Y N BEYAZ BEYAZ TAB CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.02-0.451 MG NP Y N Y N BLISOVI 24 FE BLISOVI 24 TAB FE 1/20 CONTRACEPTIVES NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24) NP Y N Y N BLISOVI FE 1.5/30 BLISOVI FE TAB 1.5/30 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG P N N Y N BLISOVI FE 1/20 BLISOVI FE TAB 1/20 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG P N N Y N BRIELLYN BRIELLYN TAB CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG P N N Y N CAMILA CAMILA TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG P N N Y N CAMRESE CAMRESE TAB CONTRACEPTIVES LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) NP Y N Y N CAMRESE LO CAMRESE LO TAB CONTRACEPTIVES LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7) NP Y N Y N CAZIANT CAZIANT PAK CONTRACEPTIVES DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG P N N Y N CESIA CESIA PAK CONTRACEPTIVES DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG P N N Y N CHARLOTTE 24 FE CHARLOTTE 24 CHW FE 1/20 CONTRACEPTIVES NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24) NP Y N Y N CHATEAL CHATEAL TAB 0.15/30 CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N CHATEAL EQ CHATEAL EQ TAB 0.15/30 CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N CRYSELLE-28 CRYSELLE-28 TAB 28 TABS CONTRACEPTIVES NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG P N N Y N CYCLAFEM 1/35 CYCLAFEM TAB 1/35 CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG P N N Y N CYCLAFEM 7/7/7 CYCLAFEM TAB 7/7/7 CONTRACEPTIVES NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG P N N Y N CYRED CYRED TAB CONTRACEPTIVES DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N CYRED EQ CYRED EQ TAB CONTRACEPTIVES DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N DASETTA 1/35 DASETTA TAB 1/35 CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG P N N Y N DASETTA 7/7/7 DASETTA TAB 7/7/7 CONTRACEPTIVES NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG P N N Y N DAYSEE DAYSEE TAB CONTRACEPTIVES LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) NP Y N Y N DEBLITANE DEBLITANE TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG P N N Y N

Confidential 2/19/2021 Page 38 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) DELYLA DELYLA TAB 0.1-0.02 CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG P N N Y N DESOGESTREL/ETHINYL ESTRADIOL DESO/ETHINYL TAB ESTRADIO CONTRACEPTIVES DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N DROSPIRENONE/ETHINYL ESTRADIOL DROSPIR/ETHI TAB 3-0.02MG CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG NP Y N Y N DROSPIRENONE/ETHINYL ESTRADIOL/LEVODROSPIRE/ETH TAB ESTR/LEV CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.02-0.451 MG NP Y N Y N ECONTRA EZ ECONTRA EZ TAB 1.5MG CONTRACEPTIVES LEVONORGESTREL TAB 1.5 MG P N N Y N ECONTRA ONE-STEP ECONTRA OS TAB 1.5MG CONTRACEPTIVES LEVONORGESTREL TAB 1.5 MG P N N Y N ELINEST ELINEST TAB CONTRACEPTIVES NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG P N N Y N ELLA ELLA TAB 30MG CONTRACEPTIVES ULIPRISTAL ACETATE TAB 30 MG NP Y N Y N ELURYNG ELURYNG MIS CONTRACEPTIVES ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.120-0.015 MG/24HR P N N Y N EMOQUETTE EMOQUETTE TAB CONTRACEPTIVES DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N ENPRESSE-28 ENPRESSE-28 TAB CONTRACEPTIVES LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG P N N Y N ENSKYCE ENSKYCE TAB CONTRACEPTIVES DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N ERRIN ERRIN TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG P N N Y N ESTARYLLA ESTARYLLA TAB 0.25-35 CONTRACEPTIVES NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG P N N Y N ESTROSTEP FE ESTROSTEP FE TAB CONTRACEPTIVES NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG NP Y N Y N ETHYNODIOL DIACETATE/ETHINYL ESTRAD ETHY ETH EST TAB 1-35 CONTRACEPTIVES ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG P NNYN ETONOGESTREL/ETHINYL ESTRADIOL ETONOGESTREL MIS ETHY EST CONTRACEPTIVES ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.120-0.015 MG/24HR PNNYN FALESSA FALESSA KIT CONTRACEPTIVES *LEVONORGEST-ETH ESTRAD TAB 0.1 MG-20 MCG & FA TAB 1 MG KIT* NP Y N Y N FALMINA FALMINA TAB CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG P N N Y N FAYOSIM FAYOSIM TAB CONTRACEPTIVES LEVONOR-ETH EST TAB 0.15-0.02/0.025/0.03 MG Ð EST 0.01 MG NP Y N Y N FEMYNOR FEMYNOR TAB 0.25-35 CONTRACEPTIVES NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG P N N Y N GEMMILY GEMMILY CAP 1/20 CONTRACEPTIVES NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE CAP 1 MG-20 MCG (24) NP Y N Y N GENERESS FE GENERESS FE CHW CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.8 MG-25 MCG NP Y N Y N GIANVI GIANVI TAB 3-0.02MG CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG NP Y N Y N HAILEY 1.5/30 HAILEY TAB 1.5/30 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG P N N Y N HAILEY 24 FE HAILEY 24 TAB FE CONTRACEPTIVES NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24) NP Y N Y N HAILEY FE 1.5/30 HAILEY FE TAB 1.5/30 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG P N N Y N HAILEY FE 1/20 HAILEY FE TAB 1/20 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG P N N Y N HEATHER HEATHER TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG P N N Y N ICLEVIA ICLEVIA TAB CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG P N N Y N INCASSIA INCASSIA TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG P N N Y N INTROVALE INTROVALE TAB CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG P N N Y N ISIBLOOM ISIBLOOM TAB CONTRACEPTIVES DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N JAIMIESS JAIMIESS TAB CONTRACEPTIVES LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) NP Y N Y N JASMIEL JASMIEL TAB 3-0.02MG CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG NP Y N Y N JENCYCLA JENCYCLA TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG P N N Y N JOLESSA JOLESSA TAB CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG P N N Y N JULEBER JULEBER TAB CONTRACEPTIVES DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N JUNEL 1.5/30 JUNEL 1.5/30 TAB CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG P N N Y N JUNEL 1/20 JUNEL 1/20 TAB CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG P N N Y N JUNEL FE 1.5/30 JUNEL FE TAB 1.5/30 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG P N N Y N JUNEL FE 1/20 JUNEL FE TAB 1/20 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG P N N Y N JUNEL FE 24 JUNEL FE 24 TAB 1/20 CONTRACEPTIVES NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24) NP Y N Y N KAITLIB FE KAITLIB FE CHW CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.8 MG-25 MCG NP Y N Y N KALLIGA KALLIGA TAB CONTRACEPTIVES DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N KARIVA KARIVA TAB 28 DAY CONTRACEPTIVES DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) P N N Y N KELNOR 1/35 KELNOR TAB 1/35 CONTRACEPTIVES ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG P N N Y N KELNOR 1/50 KELNOR 1/50 TAB CONTRACEPTIVES ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-50 MCG P N N Y N

Confidential 2/19/2021 Page 39 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) KURVELO KURVELO TAB 0.15/30 CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N LARIN 1.5/30 LARIN TAB 1.5/30 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG P N N Y N LARIN 1/20 LARIN TAB 1/20 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG P N N Y N LARIN 24 FE LARIN 24 TAB FE 1/20 CONTRACEPTIVES NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24) NP Y N Y N LARIN FE 1.5/30 LARIN FE TAB 1.5/30 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG P N N Y N LARIN FE 1/20 LARIN FE TAB 1/20 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG P N N Y N LARISSIA LARISSIA TAB CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG P N N Y N LAYOLIS FE LAYOLIS FE CHW CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.8 MG-25 MCG NP Y N Y N LEENA LEENA TAB CONTRACEPTIVES NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG P N N Y N LESSINA LESSINA TAB CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG P N N Y N LEVONEST LEVONEST TAB CONTRACEPTIVES LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG P N N Y N LEVONORGESTREL LEVONORGESTR TAB 1.5MG CONTRACEPTIVES LEVONORGESTREL TAB 1.5 MG P N N Y N LEVONORGESTREL AND ETHINYL ESTRADIOLEVONOR/ETHI TAB ESTRADIO CONTRACEPTIVES LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7) NP Y N Y N LEVONORGESTREL/ETHINYL ESTRADIOL LEVONOR/ETHI TAB 0.1-0.02 CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG P N N Y N LEVONORGESTREL/ETHINYL ESTRADIOL LEVONOR/ETHI TAB ESTRADIO CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG P N N Y N LEVONORGESTREL/ETHINYL ESTRADIOL LEVONOR/ETHI TAB ESTRADIO CONTRACEPTIVES LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) NP Y N Y N LEVORA 0.15/30-28 LEVORA-28 TAB 0.15/30 CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N LILLOW LILLOW TAB 0.15/30 CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N LO LOESTRIN FE LO LOESTRIN TAB 1-10-10 CONTRACEPTIVES NORETHIN-ETH ESTRADIOL-FE TAB 1 MG-10 MCG (24)/10 MCG (2) NP Y N Y N LOESTRIN 1.5/30-21 LOESTRIN 21 TAB 1.5/30 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG NP Y N Y N LOESTRIN 1/20-21 LOESTRIN TAB 1/20-21 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG NP Y N Y N LOESTRIN FE 1.5/30 LOESTRIN FE TAB 1.5/30 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG NP Y N Y N LOESTRIN FE 1/20 LOESTRIN FE TAB 1/20 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG NP Y N Y N LOJAIMIESS LOJAIMIESS TAB CONTRACEPTIVES LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7) NP Y N Y N LORYNA LORYNA TAB 3-0.02MG CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG NP Y N Y N LOSEASONIQUE LOSEASONIQUE TAB CONTRACEPTIVES LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7) NP Y N Y N LOW-OGESTREL LOW-OGESTREL TAB CONTRACEPTIVES NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG P N N Y N LO-ZUMANDIMINE LO-ZUMANDIMI TAB 3-0.02MG CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG NP Y N Y N LUTERA LUTERA TAB CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG P N N Y N LYLEQ LYLEQ TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG P N N Y N LYZA LYZA TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG P N N Y N MARLISSA MARLISSA TAB 0.15/30 CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N MELODETTA 24 FE MELODETTA CHW 24 FE CONTRACEPTIVES NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24) NP Y N Y N MERZEE MERZEE CAP 1/20 CONTRACEPTIVES NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE CAP 1 MG-20 MCG (24) NP Y N Y N MIBELAS 24 FE MIBELAS 24 CHW FE CONTRACEPTIVES NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24) NP Y N Y N MICROGESTIN 1.5/30 MICROGESTIN TAB 1.5/30 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG P N N Y N MICROGESTIN 1/20 MICROGESTIN TAB 1/20 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG P N N Y N MICROGESTIN 24 FE MICRGSTIN 24 TAB FE 1/20 CONTRACEPTIVES NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24) NP Y N Y N MICROGESTIN FE 1.5/30 MICROGESTIN TAB FE1.5/30 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG P N N Y N MICROGESTIN FE 1/20 MICROGESTIN TAB FE 1/20 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG P N N Y N MILI MILI TAB 0.25/35 CONTRACEPTIVES NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG P N N Y N MINASTRIN 24 FE MINASTRIN 24 CHW FE CONTRACEPTIVES NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24) NP Y N Y N MIRCETTE MIRCETTE TAB 28 DAY CONTRACEPTIVES DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) NP Y N Y N MONO-LINYAH MONO-LINYAH TAB 0.25-35 CONTRACEPTIVES NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG P N N Y N MY CHOICE MY CHOICE TAB 1.5MG CONTRACEPTIVES LEVONORGESTREL TAB 1.5 MG P N N Y N MY WAY MY WAY TAB 1.5MG CONTRACEPTIVES LEVONORGESTREL TAB 1.5 MG P N N Y N NATAZIA NATAZIA TAB CONTRACEPTIVES ESTRADIOL VALERATE-DIENOGEST TAB 3 MG /2-2 MG/2-3 MG/1 MG NP Y N Y N NECON 0.5/35-28 NECON TAB 0.5/35 CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG P N N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) NECON 1/35 NECON TAB 1/35 CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG P N N Y N NEW DAY NEW DAY TAB 1.5MG CONTRACEPTIVES LEVONORGESTREL TAB 1.5 MG P N N Y N NIKKI NIKKI TAB 3-0.02MG CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG NP Y N Y N NORA-BE NORA-BE TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG P N N Y N NORETHINDRONE NORETHINDRON TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG P N N Y N NORETHINDRONE & ETHINYL ESTRADIOL F NORETH/ETHIN CHW FE CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.8 MG-25 MCG NP Y N Y N NORETHINDRONE ACETATE/ETHINYL ESTRANORETH/ETHIN TAB 1/20 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG P N N Y N NORETHINDRONE ACETATE/ETHINYL ESTRANORE/ETH/FER CAP 1/20 CONTRACEPTIVES NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE CAP 1 MG-20 MCG (24) NP Y N Y N NORETHINDRONE ACETATE/ETHINYL ESTRANORETH/ETHIN TAB FE 1/20 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG P N N Y N NORETHINDRONE/ETHINYL ESTRADIOL/FERNORE/ETH/FER CHW 0.4MG-35 CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.4 MG-35 MCG NP Y N Y N NORGESTIMATE/ETHINYL ESTRADIOL NORGEST/ETHI TAB 0.25/35 CONTRACEPTIVES NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG P N N Y N NORGESTIMATE/ETHINYL ESTRADIOL NORGEST/ETHI TAB ESTRADIO CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCGNPYNYN NORLYDA NORLYDA TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG P N N Y N NORLYROC NORLYROC TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG P N N Y N NORTREL 0.5/35 (28) NORTREL TAB 0.5/35 CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG P N N Y N NORTREL 1/35 NORTREL TAB 1/35 CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG P N N Y N NORTREL 7/7/7 NORTREL TAB 7/7/7 CONTRACEPTIVES NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG P N N Y N NUVARING NUVARING MIS CONTRACEPTIVES ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.120-0.015 MG/24HR NP Y N Y N NYLIA 7/7/7 NYLIA TAB 7/7/7 CONTRACEPTIVES NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG P N N Y N NYMYO NYMYO TAB 0.25-35 CONTRACEPTIVES NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG P N N Y N OCELLA OCELLA TAB 3-0.03MG CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG NP Y N Y N OPCICON ONE-STEP OPCICON TAB 1.5MG CONTRACEPTIVES LEVONORGESTREL TAB 1.5 MG P N N Y N OPTION 2 OPTION 2 TAB 1.5MG CONTRACEPTIVES LEVONORGESTREL TAB 1.5 MG P N N Y N ORSYTHIA ORSYTHIA TAB CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG P N N Y N ORTHO MICRONOR ORTHO MICRON TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG NP Y N Y N ORTHO TRI-CYCLEN LO ORTHO TRI- TAB CYCLN LO CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG NP Y N Y N PHILITH PHILITH TAB 0.4-35 CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG P N N Y N PIMTREA PIMTREA TAB CONTRACEPTIVES DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) P N N Y N PIRMELLA 1/35 PIRMELLA TAB 1/35 CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG P N N Y N PIRMELLA 7/7/7 PIRMELLA TAB 7/7/7 CONTRACEPTIVES NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG P N N Y N PLAN B ONE-STEP PLAN B TAB 1.5MG CONTRACEPTIVES LEVONORGESTREL TAB 1.5 MG P N N Y N PORTIA-28 PORTIA-28 TAB CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N PREVENTEZA PREVENTEZA TAB 1.5MG CONTRACEPTIVES LEVONORGESTREL TAB 1.5 MG P N N Y N PREVIFEM PREVIFEM TAB CONTRACEPTIVES NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG P N N Y N QUARTETTE QUARTETTE TAB CONTRACEPTIVES LEVONOR-ETH EST TAB 0.15-0.02/0.025/0.03 MG Ð EST 0.01 MG NP Y N Y N REACT REACT TAB 1.5MG CONTRACEPTIVES LEVONORGESTREL TAB 1.5 MG P N N Y N RECLIPSEN RECLIPSEN TAB CONTRACEPTIVES DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N RIVELSA RIVELSA TAB CONTRACEPTIVES LEVONOR-ETH EST TAB 0.15-0.02/0.025/0.03 MG Ð EST 0.01 MG NP Y N Y N SAFYRAL SAFYRAL TAB CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.03-0.451 MG NP Y N Y N SEASONIQUE SEASONIQUE TAB CONTRACEPTIVES LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) NP Y N Y N SETLAKIN SETLAKIN TAB CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG P N N Y N SHAROBEL SHAROBEL TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG P N N Y N SIMLIYA SIMLIYA TAB 28 DAY CONTRACEPTIVES DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) P N N Y N SIMPESSE SIMPESSE TAB CONTRACEPTIVES LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) NP Y N Y N SLYND SLYND TAB 4MG CONTRACEPTIVES DROSPIRENONE TAB 4 MG NP Y N Y N SOLIA SOLIA TAB CONTRACEPTIVES DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG P N N Y N SPRINTEC 28 SPRINTEC 28 TAB 28 DAY CONTRACEPTIVES NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG P N N Y N SRONYX SRONYX TAB CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG P N N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) SYEDA SYEDA TAB 3-0.03MG CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG NP Y N Y N TAKE ACTION TAKE ACTION TAB 1.5MG CONTRACEPTIVES LEVONORGESTREL TAB 1.5 MG P N N Y N TARINA 24 FE TARINA 24 FE TAB CONTRACEPTIVES NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24) NP Y N Y N TARINA FE 1/20 TARINA FE TAB 1/20 CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG P N N Y N TARINA FE 1/20 EQ TARINA FE TAB 1/20 EQ CONTRACEPTIVES NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG P N N Y N TAYTULLA TAYTULLA CAP 1MG/20MC CONTRACEPTIVES NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE CAP 1 MG-20 MCG (24) NP Y N Y N TILIA FE TILIA FE TAB CONTRACEPTIVES NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG P N N Y N TRI FEMYNOR TRI FEMYNOR TAB CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG P N N Y N TRI-ESTARYLLA TRI-ESTARYLL TAB CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG P N N Y N TRI-LEGEST FE TRI-LEGEST TAB FE CONTRACEPTIVES NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG P N N Y N TRI-LINYAH TRI-LINYAH TAB CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG P N N Y N TRI-LO-ESTARYLLA TRI-LO TAB ESTARYLL CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG NP Y N Y N TRI-LO-MARZIA TRI-LO- TAB MARZIA CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG NP Y N Y N TRI-LO-MILI TRI-LO-MILI TAB CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG NP Y N Y N TRI-LO-SPRINTEC TRI-LO- TAB SPRINTEC CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG NP Y N Y N TRI-MILI TRI-MILI TAB CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG P N N Y N TRINESSA TRINESSA TAB CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG P N N Y N TRI-NYMYO TRI-NYMYO TAB CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG P N N Y N TRI-PREVIFEM TRI-PREVIFEM TAB CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG P N N Y N TRI-SPRINTEC TRI-SPRINTEC TAB CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG P N N Y N TRIVORA-28 TRIVORA-28 TAB CONTRACEPTIVES LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG P N N Y N TRI-VYLIBRA TRI-VYLIBRA TAB CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG P N N Y N TRI-VYLIBRA LO TRI-VYLIBRA TAB LO CONTRACEPTIVES NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG NP Y N Y N TULANA TULANA TAB 0.35MG CONTRACEPTIVES NORETHINDRONE TAB 0.35 MG P N N Y N TWIRLA TWIRLA DIS 120-30 CONTRACEPTIVES LEVONORGESTREL-ETHINYL ESTRADIOL TD PTWK 120-30 MCG/24HR NP Y N Y N TYBLUME TYBLUME TAB 0.1-0.02 CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG P N N Y N TYDEMY TYDEMY TAB CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.03-0.451 MG NP Y N Y N VELIVET VELIVET PAK CONTRACEPTIVES DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG P N N Y N VIENVA VIENVA TAB 0.1-20 CONTRACEPTIVES LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG P N N Y N VIORELE VIORELE TAB CONTRACEPTIVES DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) P N N Y N VOLNEA VOLNEA TAB CONTRACEPTIVES DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) P N N Y N VYFEMLA VYFEMLA TAB 0.4-35 CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG P N N Y N VYLIBRA VYLIBRA TAB 0.25-35 CONTRACEPTIVES NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG P N N Y N WERA WERA TAB 0.5/35 CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG P N N Y N WYMZYA FE WYMZYA FE CHW 0.4MG-35 CONTRACEPTIVES NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.4 MG-35 MCG NP Y N Y N XULANE XULANE DIS 150-35 CONTRACEPTIVES NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR P N N Y N YASMIN 28 YASMIN 28 TAB 3-0.03MG CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG NP Y N Y N YAZ YAZ TAB 3-0.02MG CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG NP Y N Y N ZARAH ZARAH TAB 3-0.03MG CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG NP Y N Y N ZOVIA 1/35 ZOVIA 1/35 TAB CONTRACEPTIVES ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG P N N Y N ZOVIA 1/35E ZOVIA 1/35E TAB CONTRACEPTIVES ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG P N N Y N ZUMANDIMINE ZUMANDIMINE TAB 3-0.03MG CONTRACEPTIVES DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG NP Y N Y N ALREX ALREX SUS 0.2% CORTICOSTEROIDS (EENT) LOTEPREDNOL ETABONATE OPHTH SUSP 0.2% NP Y N Y N BECONASE AQ BECONASE AQ SUS 0.042% CORTICOSTEROIDS (EENT) BECLOMETHASONE DIPROPIONATE MONOHYD NASAL SUSP 42 MCG/SPRAY NP Y N Y N BLEPHAMIDE BLEPHAMIDE SUS OP CORTICOSTEROIDS (EENT) SULFACETAMIDE SODIUM-PREDNISOLONE OPHTH SUSP 10-0.2% NP Y N Y N BLEPHAMIDE S.O.P. BLEPHAMIDE OIN S.O.P. CORTICOSTEROIDS (EENT) SULFACETAMIDE SODIUM-PREDNISOLONE OPHTH OINT 10-0.2% NP Y N Y N BUDESONIDE NASAL SPRAY BUDESONIDE SUS 32MCG CORTICOSTEROIDS (EENT) BUDESONIDE NASAL SUSP 32 MCG/ACT NP Y N Y N CIPRO HC CIPRO HC SUS OTIC CORTICOSTEROIDS (EENT) CIPROFLOXACIN-HYDROCORTISONE OTIC SUSP 0.2-1% NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) CIPRODEX CIPRODEX SUS 0.3-0.1% CORTICOSTEROIDS (EENT) CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP 0.3-0.1% NP Y N Y N CIPROFLOXACIN/DEXAMETHASONE CIPRO/DEXA SUS 0.3-0.1% CORTICOSTEROIDS (EENT) CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP 0.3-0.1% P Y N Y N CLARISPRAY CLARISPRAY SPR 50MCG CORTICOSTEROIDS (EENT) FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT P N N Y N CORTISPORIN-TC CORTISPORIN SUS -TC OTIC CORTICOSTEROIDS (EENT) NEOMYCIN-COLISTIN-HC-THONZONIUM OTIC SUSP 3.3-3-10-0.5 MG/ML NP Y N Y N DERMACINRX TICANASE PAK TICANASE PAK 50-2.7 CORTICOSTEROIDS (EENT) FLUTICASONE NASAL SUSP 50 MCG/ACT &SOD CHLOR 2.7% SPRAY THPKNPYNYN DEXAMETHASONE SODIUM PHOSPHATE DEXAMETH PHO SOL 0.1% OP CORTICOSTEROIDS (EENT) DEXAMETHASONE SODIUM PHOSPHATE OPHTH SOLN 0.1% P N N N N DUREZOL DUREZOL EMU 0.05% CORTICOSTEROIDS (EENT) DIFLUPREDNATE OPHTH EMULSION 0.05% NP Y N Y N EYSUVIS EYSUVIS DRO 0.25% CORTICOSTEROIDS (EENT) LOTEPREDNOL ETABONATE OPHTH SUSP 0.25% NP Y N Y N FLAREX FLAREX SUS 0.1% OP CORTICOSTEROIDS (EENT) FLUOROMETHOLONE ACETATE OPHTH SUSP 0.1% NP Y N Y N FLONASE ALLERGY RELIEF FLONASE ALGY SPR 50MCG CORTICOSTEROIDS (EENT) FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT P N N Y N FLONASE SENSIMIST FLONASE SENS SUS 27.5MCG CORTICOSTEROIDS (EENT) FLUTICASONE FUROATE NASAL SUSP 27.5 MCG/SPRAY NP Y N N N FLUNISOLIDE FLUNISOLIDE SPR 0.025% CORTICOSTEROIDS (EENT) FLUNISOLIDE NASAL SOLN 25 MCG/ACT (0.025%) NP Y N Y N FLUOCINOLONE ACETONIDE FLUOCIN ACET OIL 0.01% CORTICOSTEROIDS (EENT) FLUOCINOLONE ACETONIDE (OTIC) OIL 0.01% NP Y N N N FLUOROMETHOLONE FLUOROMETHOL SUS 0.1% OP CORTICOSTEROIDS (EENT) FLUOROMETHOLONE OPHTH SUSP 0.1% P N N Y N FLUTICASONE PROPIONATE FLUTICASONE SPR 50MCG CORTICOSTEROIDS (EENT) FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT P N N Y N FML FML OIN 0.1% OP CORTICOSTEROIDS (EENT) FLUOROMETHOLONE OPHTH OINT 0.1% NP Y N Y N FML FORTE FML FORTE SUS 0.25% OP CORTICOSTEROIDS (EENT) FLUOROMETHOLONE OPHTH SUSP 0.25% NP Y N Y N FML LIQUIFILM FML LIQUIFLM SUS 0.1% OP CORTICOSTEROIDS (EENT) FLUOROMETHOLONE OPHTH SUSP 0.1% NP Y N Y N HYDROCORTISONE/ACETIC ACID HC/ACET ACID SOL OTIC CORTICOSTEROIDS (EENT) HYDROCORTISONE W/ ACETIC ACID OTIC SOLN 1-2% P N N Y N INVELTYS INVELTYS SUS 1% CORTICOSTEROIDS (EENT) LOTEPREDNOL ETABONATE OPHTH SUSP 1% NP Y N Y N KLARITY-L KLARITY-L DRO 0.2% CORTICOSTEROIDS (EENT) LOTEPREDNOL ETABONATE OPHTH EMULSION 0.2% NP Y N Y N LOTEMAX LOTEMAX OIN 0.5% CORTICOSTEROIDS (EENT) LOTEPREDNOL ETABONATE OPHTH OINT 0.5% NP Y N N N LOTEMAX LOTEMAX SUS 0.5% CORTICOSTEROIDS (EENT) LOTEPREDNOL ETABONATE OPHTH SUSP 0.5% NP Y N Y N LOTEMAX SM LOTEMAX SM GEL 0.38% CORTICOSTEROIDS (EENT) LOTEPREDNOL ETABONATE OPHTH GEL 0.38% NP Y N Y N LOTEPREDNOL ETABONATE LOTEPREDNOL SUS 0.5% CORTICOSTEROIDS (EENT) LOTEPREDNOL ETABONATE OPHTH SUSP 0.5% NP Y N Y N MAXIDEX MAXIDEX SUS 0.1% OP CORTICOSTEROIDS (EENT) DEXAMETHASONE OPHTH SUSP 0.1% NP Y N N N MAXITROL MAXITROL SUS 0.1% OP CORTICOSTEROIDS (EENT) NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH SUSP 0.1% NP Y N Y N MOMETASONE FUROATE MOMETASONE SPR 50MCG CORTICOSTEROIDS (EENT) MOMETASONE FUROATE NASAL SUSP 50 MCG/ACT NP Y N Y N NASACORT ALLERGY 24HR NASACORT ALR SPR 55MCG/AC CORTICOSTEROIDS (EENT) TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT PNNYN NASONEX NASONEX SPR 50MCG/AC CORTICOSTEROIDS (EENT) MOMETASONE FUROATE NASAL SUSP 50 MCG/ACT NP Y N Y N NEOMYCIN/POLYMYXIN/BACITRACIN/HYDRNEO/POLY/BAC OIN /HC 1%OP CORTICOSTEROIDS (EENT) BACITRACIN-POLYMYXIN-NEOMYCIN-HC OPHTH OINT 1% P N N Y N NEOMYCIN/POLYMYXIN/DEXAMETHASONENEO/POLY/DEX SUS 0.1% OP CORTICOSTEROIDS (EENT) NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH SUSP 0.1% P N N Y N NEOMYCIN/POLYMYXIN/HC NEO/POLY/HC SOL 1% OTIC CORTICOSTEROIDS (EENT) NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1% P N N Y N NEO-POLYCIN HC NEO-POLYCIN OIN HC 1%OP CORTICOSTEROIDS (EENT) BACITRACIN-POLYMYXIN-NEOMYCIN-HC OPHTH OINT 1% P N N Y N OMNARIS OMNARIS SPR CORTICOSTEROIDS (EENT) CICLESONIDE NASAL SUSP 50 MCG/ACT NP Y N Y N PRED FORTE PRED FORTE SUS 1% OP CORTICOSTEROIDS (EENT) PREDNISOLONE ACETATE OPHTH SUSP 1% NP Y N Y N PRED MILD PRED MILD SUS 0.12% OP CORTICOSTEROIDS (EENT) PREDNISOLONE ACETATE OPHTH SUSP 0.12% NP Y N Y N PRED-G PRED-G SUS OP CORTICOSTEROIDS (EENT) GENTAMICIN-PREDNISOLONE ACE OPHTH SUSP 0.3-1% NP Y N Y N PRED-G S.O.P. PRED-G S.O.P OIN OP CORTICOSTEROIDS (EENT) GENTAMICIN-PREDNISOLONE ACE OPHTH OINT 0.3-0.6% P N N N N PREDNISOLONE ACETATE P-F PREDNISOLONE SUS 1% CORTICOSTEROIDS (EENT) PREDNISOLONE ACETATE OPHTH SUSP 1% P N N Y N PREDNISOLONE ACETATE/MOXIFLOXACIN/ PRED MOXIFLO SUS BROMFEN CORTICOSTEROIDS (EENT) PREDNISOLONE ACE-MOXIFLOXACIN-BROMFENAC OP SUSP 1-0.5-0.075% NP Y N Y N PREDNISOLONE ACETATE/MOXIFLOXACIN/ PREDNI/MOXI/ DRO NEPAFENA CORTICOSTEROIDS (EENT) PREDNISOLONE-MOXIFLOXACIN-NEPAFENAC OPHTH SUSP 1-0.5-0.1% NP Y N Y N PREDNISOLONE ACETATE/NEPAFENAC PRED/NEPAFEN DRO 1-0.1% CORTICOSTEROIDS (EENT) PREDNISOLONE ACETATE-NEPAFENAC OPHTH SUSP 1-0.1% NP Y N YN PREDNISOLONE SODIUM PHOSPHATE PRED SOD PHO SOL 1% OP CORTICOSTEROIDS (EENT) PREDNISOLONE SODIUM PHOSPHATE OPHTH SOLN 1% P N N N N PREDNISOLONE SODIUM PHOSPHATE/GAT PRED-GAT-BRO INJ CORTICOSTEROIDS (EENT) PREDNISOLONE-GATIFLOXACIN-BROMFENAC OPHTH SOLN 1-0.5-0.075% NP Y N Y N PREDNISOLONE SODIUM PHOSPHATE/MOXPRED MOXIFLO SOL 1-0.5% CORTICOSTEROIDS (EENT) PREDNISOLONE-MOXIFLOXACIN OPTH SOLN 1-0.5% NP Y N N N PREDNISOLONE/BROMFENAC PREDNIS/BROM SUS 1-0.075% CORTICOSTEROIDS (EENT) PREDNISOLONE-BROMFENAC OPHTH SUSP 1-0.075% NP Y N Y N PREDNISOLONE/GATIFLOXACIN/BROMFEN PRED-GATIFL- SUS BROMFENA CORTICOSTEROIDS (EENT) PREDNISOLONE-GATIFLOXACIN-BROMFENAC OPHTH SUSP 1-0.5-0.075% NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) PREDNISOLONE-GATIFLOXACIN PRED-GATI SUS 1-0.5% CORTICOSTEROIDS (EENT) PREDNISOLONE-GATIFLOXACIN OPHTH SUSP 1-0.5% NP Y N Y N QNASL QNASL AER 80MCG CORTICOSTEROIDS (EENT) BECLOMETHASONE DIPROPIONATE NASAL AEROSOL 80 MCG/ACT NP Y N Y N QNASL CHILDRENS QNASL CHILD SPR 40MCG CORTICOSTEROIDS (EENT) BECLOMETHASONE DIPROPIONATE NASAL AEROSOL 40 MCG/ACT NP Y N Y N RHINOCORT ALLERGY RHINOCORT SUS ALLERGY CORTICOSTEROIDS (EENT) BUDESONIDE NASAL SUSP 32 MCG/ACT NP Y N Y N SULFACETAMIDE SODIUM/PREDNISOLONE SULF/PRED NA SOL OP CORTICOSTEROIDS (EENT) SULFACETAMIDE SODIUM-PREDNISOLONE OPHTH SOLN 10-0.23(0.25)% P N N N N TOBRADEX TOBRADEX OIN 0.3-0.1% CORTICOSTEROIDS (EENT) TOBRAMYCIN-DEXAMETHASONE OPHTH OINT 0.3-0.1% P N N Y N TOBRADEX TOBRADEX SUS 0.3-0.1% CORTICOSTEROIDS (EENT) TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1% NP Y N Y N TOBRADEX ST TOBRADEX ST SUS 0.3-0.05 CORTICOSTEROIDS (EENT) TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.05% NP Y N Y N TOBRAMYCIN/DEXAMETHASONE TOBRA/DEXAME SUS 0.3-0.1% CORTICOSTEROIDS (EENT) TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1% P N N Y N TRIAMCINOLONE ACETONIDE TRIAMCINOLON AER 55MCG/AC CORTICOSTEROIDS (EENT) TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT P N N Y N XHANCE XHANCE MIS 93MCG CORTICOSTEROIDS (EENT) FLUTICASONE PROPIONATE NASAL EXHALER SUSP 93 MCG/ACT NP Y N Y N ZETONNA ZETONNA AER 37MCG CORTICOSTEROIDS (EENT) CICLESONIDE NASAL AEROSOL SOLN 37 MCG/ACT (50 MCG/VALVE) NP Y N Y N ZYLET ZYLET SUS 0.5-0.3% CORTICOSTEROIDS (EENT) LOTEPREDNOL ETABONATE-TOBRAMYCIN OPHTH SUSP 0.5-0.3% NP Y N Y N ALCLOMETASONE DIPROPIONATE ALCLOMETASON CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) ALCLOMETASONE DIPROPIONATE CREAM 0.05% NP YNYN AMCINONIDE AMCINONIDE CRE 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) AMCINONIDE CREAM 0.1% NP Y N N N AMCINONIDE AMCINONIDE LOT 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) AMCINONIDE LOTION 0.1% NP Y N Y N AMCINONIDE AMCINONIDE OIN 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) AMCINONIDE OINT 0.1% P N N N N AUGMENTED BETAMETHASONE DIPROPIO AUG BETAMET CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) BETAMETHASONE DIPROPIONATE AUGMENTED CREAM 0.05% P N N Y N AUGMENTED BETAMETHASONE DIPROPIO AUG BETAMET GEL 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) BETAMETHASONE DIPROPIONATE AUGMENTED GEL 0.05% P N N Y N AUGMENTED BETAMETHASONE DIPROPIO AUG BETAMET OIN 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) BETAMETHASONE DIPROPIONATE AUGMENTED OINT 0.05% P N N Y N BETAMETHASONE DIPROPIONATE BETA DIPROP GEL 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) BETAMETHASONE DIPROPIONATE AUGMENTED GEL 0.05% P N N Y N BETAMETHASONE DIPROPIONATE BETAMETH DIP CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) BETAMETHASONE DIPROPIONATE CREAM 0.05% NP YNYN BETAMETHASONE DIPROPIONATE BETAMETH DIP LOT 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) BETAMETHASONE DIPROPIONATE LOTION 0.05% P NNNN BETAMETHASONE DIPROPIONATE BETAMETH DIP OIN 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) BETAMETHASONE DIPROPIONATE OINT 0.05% P N N YN BETAMETHASONE VALERATE BETAMETH VAL AER 0.12% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) BETAMETHASONE VALERATE AEROSOL FOAM 0.12% NP Y NYN BETAMETHASONE VALERATE BETAMETH VAL CRE 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) BETAMETHASONE VALERATE CREAM 0.1% (BASE EQUIVALENT) P N N Y N BETAMETHASONE VALERATE BETAMETH VAL LOT 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) BETAMETHASONE VALERATE LOTION 0.1% (BASE EQUIVALENT) P N N N N CALCIPOTRIENE ANHYDROUS/CLOBETASOLCALCIPOTRIEN SOL CLOBETAS CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CALCIPOTRIENE-CLOBETASOL PROPIONATE SOLN 0.005-0.05% NP Y N Y N CLOBETASOL PROPIONATE CLOBETASOL AER 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOBETASOL PROPIONATE FOAM 0.05% NP Y N Y N CLOBETASOL PROPIONATE CLOBETASOL CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOBETASOL PROPIONATE CREAM 0.05% NP Y N Y N CLOBETASOL PROPIONATE CLOBETASOL SOL 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOBETASOL PROPIONATE SOLN 0.05% P N N Y N CLOBETASOL PROPIONATE CLOBETASOL SPR 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOBETASOL PROPIONATE SPRAY 0.05% NP Y N Y N CLOBETASOL PROPIONATE EMOLLIENT CLOBETASOL E CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOBETASOL PROPIONATE EMOLLIENT BASE CREAM 0.05% P N N Y N CLOBEX CLOBEX SPR 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOBETASOL PROPIONATE SPRAY 0.05% NP Y N Y N CLOCORTOLONE PIVALATE CLOCORTOLONE CRE 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOCORTOLONE PIVALATE CREAM 0.1% NP Y N Y N CLODAN CLODAN SHA 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOBETASOL PROPIONATE SHAMPOO 0.05% NP Y N Y N CLODERM CLODERM CRE 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOCORTOLONE PIVALATE CREAM 0.1% NP Y N Y N CORDRAN CORDRAN CRE 0.025% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLURANDRENOLIDE CREAM 0.025% NP Y N Y N CORDRAN CORDRAN CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLURANDRENOLIDE CREAM 0.05% NP Y N Y N CORDRAN CORDRAN OIN 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLURANDRENOLIDE OINT 0.05% NP Y N N N CORDRAN CORDRAN 80X3 TAP 4MCG/CM CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLURANDRENOLIDE TAPE 4 MCG/SQCM NP Y N Y N CUTIVATE CUTIVATE LOT 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLUTICASONE PROPIONATE LOTION 0.05% NP Y N Y N CVS CORTISONE INTENSE HEALING ANTI-IT CORT INTENSE CRE HEAL 1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE CREAM 1% P N N Y N DESONATE DESONATE GEL 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) DESONIDE GEL 0.05% NP Y N Y N DESONIDE DESONIDE CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) DESONIDE CREAM 0.05% NP Y N Y N DESONIDE DESONIDE GEL 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) DESONIDE GEL 0.05% NP Y N Y N DESONIDE DESONIDE LOT 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) DESONIDE LOTION 0.05% NP Y N Y N DESOWEN DESOWEN CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) DESONIDE CREAM 0.05% NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) DESOXIMETASONE DESOXIMETAS CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) DESOXIMETASONE CREAM 0.05% NP Y N Y N DESOXIMETASONE DESOXIMETASO SPR 0.25% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) DESOXIMETASONE SPRAY 0.25% NP Y N Y N DIFLORASONE DIACETATE DIFLORASONE CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) DIFLORASONE DIACETATE CREAM 0.05% NP Y N Y N DIFLORASONE DIACETATE DIFLORASONE OIN 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) DIFLORASONE DIACETATE OINT 0.05% NP Y N N N DIPROLENE DIPROLENE OIN 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) BETAMETHASONE DIPROPIONATE AUGMENTED OINT 0.05% NP Y N Y N DIPROLENE AF DIPROLENE AF CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) BETAMETHASONE DIPROPIONATE AUGMENTED CREAM 0.05% NP Y N Y N DUOBRII DUOBRII LOT CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HALOBETASOL PROPIONATE-TAZAROTENE LOTION 0.01-0.045% NP Y N Y N FLUOCINOLONE ACETONIDE FLUOCIN ACET CRE 0.01% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLUOCINOLONE ACETONIDE CREAM 0.01% NP Y N Y N FLUOCINOLONE ACETONIDE FLUOCIN ACET CRE 0.025% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLUOCINOLONE ACETONIDE CREAM 0.025% P N N Y N FLUOCINONIDE FLUOCINONIDE CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLUOCINONIDE CREAM 0.05% NP Y N Y N FLUOCINONIDE FLUOCINONIDE GEL 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLUOCINONIDE GEL 0.05% NP Y N Y N FLUOCINONIDE FLUOCINONIDE SOL 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLUOCINONIDE SOLN 0.05% P N N Y N FLUOCINONIDE EMULSIFIED BASE FLUOCINONIDE CRE E 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLUOCINONIDE EMULSIFIED BASE CREAM 0.05% P N N Y N FLURANDRENOLIDE FLURANDRENOL CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLURANDRENOLIDE CREAM 0.05% NP Y N Y N FLURANDRENOLIDE FLURANDRENOL OIN 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLURANDRENOLIDE OINT 0.05% NP Y N N N FLUTICASONE PROPIONATE FLUTICASONE CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLUTICASONE PROPIONATE CREAM 0.05% P N N Y N FLUTICASONE PROPIONATE FLUTICASONE LOT 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLUTICASONE PROPIONATE LOTION 0.05% NP Y N Y N HALCINONIDE HALCINONIDE CRE 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HALCINONIDE CREAM 0.1% NP Y N Y N HALOBETASOL PROPIONATE HALOBETASOL AER 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HALOBETASOL PROPIONATE FOAM 0.05% NP Y N Y N HALOBETASOL PROPIONATE HALOBETASOL CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HALOBETASOL PROPIONATE CREAM 0.05% P N N Y N HALOBETASOL PROPIONATE HALOBETASOL OIN 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HALOBETASOL PROPIONATE OINT 0.05% NP Y N Y N HALOG HALOG SOL 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HALCINONIDE SOLN 0.1% NP Y N Y N HYDROCORTISONE HYDROCORT CRE 0.5% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE CREAM 0.5% P N N Y N HYDROCORTISONE HYDROCORT CRE 1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE PERIANAL CREAM 1% NP Y N Y N HYDROCORTISONE HYDROCORT CRE 2.5% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE CREAM 2.5% P N N Y N HYDROCORTISONE HYDROCORT LOT 1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE LOTION 1% P N N Y N HYDROCORTISONE HYDROCORT LOT 2.5% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE LOTION 2.5% P N N Y N HYDROCORTISONE HYDROCORT OIN 2.5% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE OINT 2.5% P N N Y N HYDROCORTISONE BUTYRATE HC BUTYRATE CRE 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE BUTYRATE CREAM 0.1% NP Y N Y N HYDROCORTISONE BUTYRATE HC BUTYRATE OIN 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE BUTYRATE OINT 0.1% P N N Y N HYDROCORTISONE BUTYRATE HC BUTYRATE SOL 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE BUTYRATE SOLN 0.1% P N N Y N HYDROCORTISONE VALERATE HC VALERATE CRE 0.2% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE VALERATE CREAM 0.2% NP Y N Y N IMPEKLO IMPEKLO LOT 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOBETASOL PROPIONATE LOTION 0.15 MG/ACT (0.05%) NP Y N Y N IMPOYZ IMPOYZ CRE 0.025% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOBETASOL PROPIONATE CREAM 0.025% NP Y N Y N INSTACORT 5 INSTACORT 5 CRE 0.5% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE CREAM 0.5% P N N Y N KENALOG KENALOG AER SPRAY CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) TRIAMCINOLONE ACETONIDE AEROSOL SOLN 0.147 MG/GM NP Y N Y N KP HYDROCORTISONE MAXIMUM STRENGTHYDROCORT OIN 1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE OINT 1% P N N Y N LEXETTE LEXETTE AER 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HALOBETASOL PROPIONATE FOAM 0.05% NP Y N Y N LOCOID LOCOID LOT 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE BUTYRATE LOTION 0.1% NP Y N Y N MOMETASONE FUROATE MOMETASONE CRE 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) MOMETASONE FUROATE CREAM 0.1% P N N Y N MOMETASONE FUROATE MOMETASONE SOL 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) MOMETASONE FUROATE SOLUTION 0.1% (LOTION) P N N Y N NEO-SYNALAR NEO-SYNALAR CRE CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) NEOMYCIN SULFATE-FLUOCINOLONE ACETONIDE CREAM 0.5-0.025% NP Y N Y N NOLIX NOLIX CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLURANDRENOLIDE CREAM 0.05% NP Y N Y N NYSTATIN/TRIAMCINOLONE NYSTAT/TRIAM OIN CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-% NP YNYY NYSTATIN/TRIAMCINOLONE ACETONIDE NYSTAT/TRIAM CRE CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-% NP Y N Y Y OLUX OLUX AER 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOBETASOL PROPIONATE FOAM 0.05% NP Y N Y N OLUX-E OLUX-E AER 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOBETASOL PROPIONATE EMULSION FOAM 0.05% NP Y N Y N PANDEL PANDEL CRE 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE PROBUTATE CREAM 0.1% NP Y N N N

Confidential 2/19/2021 Page 45 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) PRAMOSONE PRAMOSONE LOT 1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) PRAMOXINE-HC LOTION 1-1% NP Y N N N PREDNICARBATE PREDNICARBAT CRE 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) PREDNICARBATE CREAM 0.1% P N N Y N PREDNICARBATE PREDNICARBAT OIN 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) PREDNICARBATE OINT 0.1% NP Y N N N PSORCON PSORCON CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) DIFLORASONE DIACETATE CREAM 0.05% NP Y N Y N QUINIXIL QUINIXIL PAK 0.1%-5% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) MOMETASONE FUROATE CREAM 0.1% & DIMETHICONE CREAM 5% THPKNPYNYN SANADERMRX SKIN REPAIR SOLUTION SANADERMRX KIT SKIN REP CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) *TRIAMCINOLONE ACET CR 0.1% & DIMETH CR 5% & SILICONE TAPE* NP Y N Y N SARNOL-HC SARNOL-HC LOT 1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE LOTION 1% P N N Y N SM HYDROCORTISONE HYDROCORT OIN 0.5% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE OINT 0.5% P N N N N SYNALAR SYNALAR CRE 0.025% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLUOCINOLONE ACETONIDE CREAM 0.025% NP Y N Y N SYNALAR SYNALAR SOL 0.01% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLUOCINOLONE ACETONIDE SOLN 0.01% NP Y N Y N TACLONEX TACLONEX SUS CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CALCIPOTRIENE-BETAMETHASONE DIPROPIONATE SUSP 0.005-0.064% NP Y N Y N TASOPROL TASOPROL KIT CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOBETASOL PROPIONATE CREAM 0.05% KIT NP Y N Y N TEMOVATE TEMOVATE CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOBETASOL PROPIONATE CREAM 0.05% NP Y N Y N TEXACORT TEXACORT SOL 2.5% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HYDROCORTISONE SOLN 2.5% NP Y N N N TOPICORT TOPICORT CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) DESOXIMETASONE CREAM 0.05% NP Y N Y N TOPICORT TOPICORT SPR 0.25% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) DESOXIMETASONE SPRAY 0.25% NP Y N Y N TOVET TOVET AER 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) CLOBETASOL PROPIONATE EMULSION FOAM 0.05% NP Y N Y N TRIAMCINOLONE ACETONIDE TRIAMCINOLON AER SPRAY CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) TRIAMCINOLONE ACETONIDE AEROSOL SOLN 0.147 MG/GM NP Y N Y N TRIAMCINOLONE ACETONIDE TRIAMCINOLON CRE 0.025% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) TRIAMCINOLONE ACETONIDE CREAM 0.025% P N N Y N TRIAMCINOLONE ACETONIDE TRIAMCINOLON CRE 0.5% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) TRIAMCINOLONE ACETONIDE CREAM 0.5% P N N Y N TRIAMCINOLONE ACETONIDE TRIAMCINOLON LOT 0.025% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) TRIAMCINOLONE ACETONIDE LOTION 0.025% P N N N N TRIAMCINOLONE ACETONIDE TRIAMCINOLON LOT 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) TRIAMCINOLONE ACETONIDE LOTION 0.1% P N N Y N TRIAMCINOLONE ACETONIDE TRIAMCINOLON OIN 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) TRIAMCINOLONE ACETONIDE OINT 0.05% NP Y N N N TRIAMCINOLONE ACETONIDE TRIAMCINOLON OIN 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) TRIAMCINOLONE ACETONIDE OINT 0.1% P N N Y N TRIDESILON TRIDESILON CRE 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) DESONIDE CREAM 0.05% NP Y N Y N TRILOCICLO TRILOCICLO KIT 0.1-8% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) TRIAMCINOLONE ACETONIDE OINT 0.1% & CICLOPIROX SOLN 8% KIT NP Y N N N ULTRAVATE ULTRAVATE LOT 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) HALOBETASOL PROPIONATE LOTION 0.05% NP Y N Y N VANOS VANOS CRE 0.1% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) FLUOCINONIDE CREAM 0.1% NP Y N Y N VERDESO VERDESO AER 0.05% CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) DESONIDE FOAM 0.05% NP Y N Y N JANTOVEN JANTOVEN TAB 1MG COUMARIN DERIVATIVES WARFARIN SODIUM TAB 1 MG P N N Y N JANTOVEN JANTOVEN TAB 2.5MG COUMARIN DERIVATIVES WARFARIN SODIUM TAB 2.5 MG P N N Y N JANTOVEN JANTOVEN TAB 2MG COUMARIN DERIVATIVES WARFARIN SODIUM TAB 2 MG P N N Y N JANTOVEN JANTOVEN TAB 4MG COUMARIN DERIVATIVES WARFARIN SODIUM TAB 4 MG P N N Y N JANTOVEN JANTOVEN TAB 6MG COUMARIN DERIVATIVES WARFARIN SODIUM TAB 6 MG P N N N N JANTOVEN JANTOVEN TAB 7.5MG COUMARIN DERIVATIVES WARFARIN SODIUM TAB 7.5 MG P N N Y N WARFARIN SODIUM WARFARIN TAB 1MG COUMARIN DERIVATIVES WARFARIN SODIUM TAB 1 MG P N N Y N WARFARIN SODIUM WARFARIN TAB 2.5MG COUMARIN DERIVATIVES WARFARIN SODIUM TAB 2.5 MG P N N Y N WARFARIN SODIUM WARFARIN TAB 2MG COUMARIN DERIVATIVES WARFARIN SODIUM TAB 2 MG P N N Y N WARFARIN SODIUM WARFARIN TAB 4MG COUMARIN DERIVATIVES WARFARIN SODIUM TAB 4 MG P N N Y N WARFARIN SODIUM WARFARIN TAB 6MG COUMARIN DERIVATIVES WARFARIN SODIUM TAB 6 MG P N N N N WARFARIN SODIUM WARFARIN TAB 7.5MG COUMARIN DERIVATIVES WARFARIN SODIUM TAB 7.5 MG P N N Y N CELEBREX CELEBREX CAP 50MG CYCLOOXYGENASE-2 (COX-2) INHIBITORS CELECOXIB CAP 50 MG NP Y N Y N CELECOXIB CELECOXIB CAP 50MG CYCLOOXYGENASE-2 (COX-2) INHIBITORS CELECOXIB CAP 50 MG P Y N Y N CREON CREON CAP 3000UNIT DIGESTANTS PANCRELIPASE (LIP-PROT-AMYL) DR CAP 3000-9500-15000 UNIT P N N N N PANCREATIN PANCREATIN TAB 325MG DIGESTANTS PANCREATIN TAB 325 MG NP Y N N N PANCREATIN 8X PANCREAT 8X TAB 900MG DIGESTANTS *DIGESTIVE ENZYME TAB*** NP Y N N N PANCREAZE PANCREAZE CAP 2600UNIT DIGESTANTS PANCRELIPASE (LIP-PROT-AMYL) DR CAP 2600-6200-10850 UNIT NP Y N N N VIOKACE VIOKACE TAB 10440 DIGESTANTS PANCRELIPASE (LIP-PROT-AMYL) TAB 10440-39150-39150 UNIT NP Y N N N

Confidential 2/19/2021 Page 46 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ZENPEP ZENPEP CAP 3000UNIT DIGESTANTS PANCRELIPASE (LIP-PROT-AMYL) DR CAP 3000-10000-14000 UNIT NP Y N N N ADALAT CC ADALAT CC TAB 60MG ER DIHYDROPYRIDINES NIFEDIPINE TAB ER 24HR 60 MG NP Y N Y N AFEDITAB CR AFEDITAB TAB 30MG CR DIHYDROPYRIDINES NIFEDIPINE TAB ER 24HR 30 MG P N N Y N AMLODIPINE BESYLATE AMLODIPINE TAB 2.5MG DIHYDROPYRIDINES AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT) P N N Y N AMLODIPINE BESYLATE/ATORVASTATIN CAAMLOD/ATORVA TAB 2.5-10MG DIHYDROPYRIDINES AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 2.5-10 MG NP Y N Y N AMLODIPINE BESYLATE/BENAZEPRIL HCL AMLOD/BENAZP CAP 5-40MG DIHYDROPYRIDINES AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG NP Y N Y N AMLODIPINE BESYLATE/BENAZEPRIL HYDR AMLOD/BENAZP CAP 2.5-10MG DIHYDROPYRIDINES AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG NP Y NYN AMLODIPINE BESYLATE/SYRSPEND SF PH4 AMLODIPINE SUS 1MG/ML DIHYDROPYRIDINES *AMLODIPINE BESYLATE ORAL SUSP 1 MG/ML (CMPD KIT) (BASE EQ)* NP Y N Y N AMLODIPINE BESYLATE/VALSARTAN AMLOD/VALSAR TAB 5-160MG DIHYDROPYRIDINES AMLODIPINE BESYLATE-VALSARTAN TAB 5-160 MG NP Y N N N AMLODIPINE/OLMESARTAN MEDOXOMIL AMLOD/OLMESA TAB 5-20MG DIHYDROPYRIDINES AMLODIPINE BESYLATE-OLMESARTAN MEDOXOMIL TAB 5-20 MG NP Y N N N AZOR AZOR TAB 5-20MG DIHYDROPYRIDINES AMLODIPINE BESYLATE-OLMESARTAN MEDOXOMIL TAB 5-20 MG NP Y N N N CADUET CADUET TAB 5-10MG DIHYDROPYRIDINES AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 5-10 MG NP Y N Y N CONJUPRI CONJUPRI TAB 2.5MG DIHYDROPYRIDINES LEVAMLODIPINE MALEATE TAB 2.5 MG NP Y N Y N CONSENSI CONSENSI TAB 2.5-200 DIHYDROPYRIDINES AMLODIPINE BESYLATE-CELECOXIB TAB 2.5-200 MG NP Y N Y N EXFORGE EXFORGE TAB 5-160MG DIHYDROPYRIDINES AMLODIPINE BESYLATE-VALSARTAN TAB 5-160 MG NP Y N N N EXFORGE HCT EXFORGEH/5- TAB 160-12.5 DIHYDROPYRIDINES AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE TAB 5-160-12.5 MG NP Y N N N FELODIPINE ER FELODIPINE TAB 2.5MG ER DIHYDROPYRIDINES FELODIPINE TAB ER 24HR 2.5 MG P N N Y N ISRADIPINE ISRADIPINE CAP 2.5MG DIHYDROPYRIDINES ISRADIPINE CAP 2.5 MG NP Y N Y N ISRADIPINE ISRADIPINE CAP 5MG DIHYDROPYRIDINES ISRADIPINE CAP 5 MG NP Y N Y N KATERZIA KATERZIA SUS 1MG/ML DIHYDROPYRIDINES AMLODIPINE BENZOATE ORAL SUSP 1 MG/ML (BASE EQUIVALENT) NP Y N Y N LOTREL LOTREL CAP 5-10MG DIHYDROPYRIDINES AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG NP Y N Y N NICARDIPINE HCL NICARDIPINE CAP 20MG DIHYDROPYRIDINES NICARDIPINE HCL CAP 20 MG NP Y N Y N NICARDIPINE HCL NICARDIPINE CAP 30MG DIHYDROPYRIDINES NICARDIPINE HCL CAP 30 MG NP Y N Y N NIFEDIPINE NIFEDIPINE CAP 10MG DIHYDROPYRIDINES NIFEDIPINE CAP 10 MG P N N Y N NIFEDIPINE ER NIFEDIPINE TAB 30MG ER DIHYDROPYRIDINES NIFEDIPINE TAB ER 24HR 30 MG P N N Y N NIMODIPINE NIMODIPINE CAP 30MG DIHYDROPYRIDINES NIMODIPINE CAP 30 MG P N N Y N NISOLDIPINE ER NISOLDIPINE TAB 20MG ER DIHYDROPYRIDINES NISOLDIPINE TAB ER 24HR 20 MG NP Y N Y N NISOLDIPINE ER NISOLDIPINE TAB 30MG ER DIHYDROPYRIDINES NISOLDIPINE TAB ER 24HR 30 MG NP Y N Y N NISOLDIPINE ER NISOLDIPINE TAB 8.5MG ER DIHYDROPYRIDINES NISOLDIPINE TAB ER 24HR 8.5 MG NP Y N N N NORVASC NORVASC TAB 2.5MG DIHYDROPYRIDINES AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT) NP Y N Y N NYMALIZE NYMALIZE SOL DIHYDROPYRIDINES NIMODIPINE ORAL SOLN 6 MG/ML P N N Y N OLMESARTAN MEDOXOMIL/AMLODIPINE/ OLM MED/AMLO TAB /HCTZ DIHYDROPYRIDINES OLMESARTAN-AMLODIPINE-HYDROCHLOROTHIAZIDE TAB 20-5-12.5 MGNPYNYN PROCARDIA PROCARDIA CAP 10MG DIHYDROPYRIDINES NIFEDIPINE CAP 10 MG NP Y N Y N PROCARDIA XL PROCARDIA XL TAB 30MG CR DIHYDROPYRIDINES NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG NP Y N Y N SULAR SULAR TAB 8.5MG DIHYDROPYRIDINES NISOLDIPINE TAB ER 24HR 8.5 MG NP Y N N N TELMISARTAN/AMLODIPINE TELMIS/AMLOD TAB 40-5MG DIHYDROPYRIDINES TELMISARTAN-AMLODIPINE TAB 40-5 MG NP Y N Y N TRIBENZOR TRIBENZOR20- TAB 5-12.5MG DIHYDROPYRIDINES OLMESARTAN-AMLODIPINE-HYDROCHLOROTHIAZIDE TAB 20-5-12.5 MG NP Y N Y N TWYNSTA TWYNSTA TAB 40-5MG DIHYDROPYRIDINES TELMISARTAN-AMLODIPINE TAB 40-5 MG NP Y N Y N ALOGLIPTIN ALOGLIPTIN TAB 6.25MG DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS ALOGLIPTIN BENZOATE TAB 6.25 MG (BASE EQUIV) P N Y Y N ALOGLIPTIN/METFORMIN HCL ALOGLIPTIN/ TAB METFORM DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS ALOGLIPTIN-METFORMIN HCL TAB 12.5-500 MGPNYYN ALOGLIPTIN/PIOGLITAZONE ALOG/PIOGLIT TAB 12.5-15 DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS ALOGLIPTIN-PIOGLITAZONE TAB 12.5-15 MG P N YYN JANUMET JANUMET TAB 50-500MG DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS SITAGLIPTIN-METFORMIN HCL TAB 50-500 MG NP Y N Y N JANUMET XR JANUMET XR TAB 50-1000 DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS SITAGLIPTIN-METFORMIN HCL TAB ER 24HR 50-1000 MG NP Y N Y N JANUMET XR JANUMET XR TAB 50-500MG DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS SITAGLIPTIN-METFORMIN HCL TAB ER 24HR 50-500 MG NP Y N Y N JANUVIA JANUVIA TAB 25MG DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS SITAGLIPTIN PHOSPHATE TAB 25 MG (BASE EQUIV) NP Y N Y N JENTADUETO JENTADUETO TAB 2.5-500 DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS LINAGLIPTIN-METFORMIN HCL TAB 2.5-500 MG NP Y N Y N JENTADUETO XR JENTADUETO TAB XR DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS LINAGLIPTIN-METFORMIN HCL TAB ER 24HR 2.5-1000 MG NP Y N Y N KAZANO KAZANO 12.5- TAB 500MG DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS ALOGLIPTIN-METFORMIN HCL TAB 12.5-500 MG NP Y N Y N

Confidential 2/19/2021 Page 47 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) KOMBIGLYZE XR KOMBIGLYZ XR TAB 2.5-1000 DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS SAXAGLIPTIN-METFORMIN HCL TAB ER 24HR 2.5-1000 MG NP Y N Y N KOMBIGLYZE XR KOMBIGLYZ XR TAB 5-500MG DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS SAXAGLIPTIN-METFORMIN HCL TAB ER 24HR 5-500 MG NP Y N YN NESINA NESINA TAB 6.25MG DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS ALOGLIPTIN BENZOATE TAB 6.25 MG (BASE EQUIV) NP Y N Y N ONGLYZA ONGLYZA TAB 2.5MG DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS SAXAGLIPTIN HCL TAB 2.5 MG (BASE EQUIV) NP Y N Y N OSENI OSENI TAB 12.5-15 DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS ALOGLIPTIN-PIOGLITAZONE TAB 12.5-15 MG NP Y N Y N TRADJENTA TRADJENTA TAB 5MG DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS LINAGLIPTIN TAB 5 MG NP Y N Y N ELIQUIS ELIQUIS TAB 2.5MG DIRECT FACTOR XA INHIBITORS APIXABAN TAB 2.5 MG P N N Y N ELIQUIS ELIQUIS TAB 5MG DIRECT FACTOR XA INHIBITORS APIXABAN TAB 5 MG P N N Y N ELIQUIS STARTER PACK ELIQUIS ST P TAB 5MG DIRECT FACTOR XA INHIBITORS APIXABAN TAB STARTER PACK 5 MG P N N Y N SAVAYSA SAVAYSA TAB 15MG DIRECT FACTOR XA INHIBITORS EDOXABAN TOSYLATE TAB 15 MG (BASE EQUIVALENT) P N N Y N XARELTO XARELTO TAB 10MG DIRECT FACTOR XA INHIBITORS RIVAROXABAN TAB 10 MG NP Y N Y N XARELTO XARELTO TAB 2.5MG DIRECT FACTOR XA INHIBITORS RIVAROXABAN TAB 2.5 MG NP Y N Y N XARELTO STARTER PACK XARELTO STAR TAB 15/20MG DIRECT FACTOR XA INHIBITORS RIVAROXABAN TAB STARTER THERAPY PACK 15 MG & 20 MG NP Y N Y N PRADAXA PRADAXA CAP 75MG DIRECT THROMBIN INHIBITORS DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ) NP Y N Y N HYDRALAZINE HCL HYDRALAZINE TAB 10MG DIRECT VASODILATORS HYDRALAZINE HCL TAB 10 MG P N N Y N HYDRALAZINE HYDROCHLORIDE HYDRALAZINE TAB 100MG DIRECT VASODILATORS HYDRALAZINE HCL TAB 100 MG P N N Y N HYDRALAZINE HYDROCHLORIDE HYDRALAZINE TAB 25MG DIRECT VASODILATORS HYDRALAZINE HCL TAB 25 MG P N N Y N HYDRALAZINE HYDROCHLORIDE HYDRALAZINE TAB 50MG DIRECT VASODILATORS HYDRALAZINE HCL TAB 50 MG P N N Y N MINOXIDIL MINOXIDIL TAB 10MG DIRECT VASODILATORS MINOXIDIL TAB 10 MG P N N Y N MINOXIDIL MINOXIDIL TAB 2.5MG DIRECT VASODILATORS MINOXIDIL TAB 2.5 MG P N N Y N DANTRIUM DANTRIUM CAP 25MG DIRECT-ACTING SKELETAL MUSCLE RELAXANTS DANTROLENE SODIUM CAP 25 MG NP Y N Y N DANTROLENE SODIUM DANTROLENE CAP 25MG DIRECT-ACTING SKELETAL MUSCLE RELAXANTS DANTROLENE SODIUM CAP 25 MG P N N Y N ACTEMRA ACTEMRA INJ 162/0.9 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS TOCILIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 162 MG/0.9ML NP Y N Y N ACTEMRA ACTPEN ACTEMRA INJ ACTPEN DISEASE-MODIFYING ANTIRHEUMATIC AGENTS TOCILIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 162 MG/0.9ML NP Y N Y N ARAVA ARAVA TAB 10MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS LEFLUNOMIDE TAB 10 MG NP Y N Y N CIMZIA CIMZIA KIT DISEASE-MODIFYING ANTIRHEUMATIC AGENTS CERTOLIZUMAB PEGOL FOR INJ KIT 2 X 200 MG P Y N Y N CIMZIA STARTER KIT CIMZIA KIT STARTER DISEASE-MODIFYING ANTIRHEUMATIC AGENTS CERTOLIZUMAB PEGOL INJ KIT 6 X 200 MG/ML P Y N Y N ENBREL ENBREL INJ 25MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ETANERCEPT SUBCUTANEOUS INJ 25 MG/0.5ML P Y N Y N ENBREL ENBREL INJ 25MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ETANERCEPT FOR SUBCUTANEOUS INJ 25 MG P Y N Y N ENBREL MINI ENBREL MINI INJ 50MG/ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ETANERCEPT SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML P Y N YN ENBREL SURECLICK ENBREL SRCLK INJ 50MG/ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ETANERCEPT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML P Y N Y N HUMIRA HUMIRA INJ 10/0.1ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ADALIMUMAB PREFILLED SYRINGE KIT 10 MG/0.1ML P Y N Y N HUMIRA HUMIRA KIT 40MG/0.8 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ADALIMUMAB PREFILLED SYRINGE KIT 40 MG/0.8ML P Y N Y N HUMIRA PEDIATRIC CROHNS DISEASE STARHUMIRA PEDIA INJ CROHNS DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ADALIMUMAB PREFILLED SYRINGE KIT 80 MG/0.8ML P Y N Y N HUMIRA PEN HUMIRA PEN INJ 40MG/0.8 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.8ML P Y N Y N HUMIRA PEN HUMIRA PEN INJ 80/0.8ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML P Y N Y N HUMIRA PEN-CD/UC/HS STARTER HUMIRA PEN INJ CD/UC/HS DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.8ML P Y N Y N HUMIRA PEN-CD/UC/HS STARTER HUMIRA PEN KIT CD/UC/HS DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML P Y N Y N HUMIRA PEN-PS/UV STARTER HUMIRA PEN INJ PS/UV DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.8ML P Y N Y N HUMIRA PEN-PS/UV STARTER HUMIRA PEN KIT PS/UV DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML & 40 MG/0.4ML P Y N Y N KEVZARA KEVZARA INJ 150/1.14 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS SARILUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/1.14ML P Y N Y N KINERET KINERET INJ DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ANAKINRA SUBCUTANEOUS SOLN PREFILLED SYRINGE 100 MG/0.67ML P Y N Y N LEFLUNOMIDE LEFLUNOMIDE TAB 10MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS LEFLUNOMIDE TAB 10 MG P N N Y N OLUMIANT OLUMIANT TAB 1MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS BARICITINIB TAB 1 MG P Y N Y N ORENCIA ORENCIA INJ 125MG/ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ABATACEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 125 MG/ML NP YNYN ORENCIA ORENCIA INJ 50/0.4ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ABATACEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 50 MG/0.4ML NP Y N Y N ORENCIA ORENCIA INJ 87.5/0.7 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ABATACEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 87.5 MG/0.7ML NP Y N Y N ORENCIA CLICKJECT ORENCIA CLCK INJ 125MG/ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ABATACEPT SUBCUTANEOUS SOLN AUTO-INJECTOR 125 MG/ML NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) OTEZLA OTEZLA TAB 10/20/30 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS APREMILAST TAB STARTER THERAPY PACK 10 MG & 20 MG & 30 MG P YNYN OTEZLA OTEZLA TAB 30MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS APREMILAST TAB 30 MG P Y N Y N OTREXUP OTREXUP INJ 10MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PF AUTO-INJECTOR 10 MG/0.4ML NP Y N Y N OTREXUP OTREXUP INJ 20MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PF AUTO-INJECTOR 20 MG/0.4ML NP Y N Y N RASUVO RASUVO INJ 10MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PF AUTO-INJECTOR 10 MG/0.2ML NP Y N Y N RASUVO RASUVO INJ 12.5MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PF AUTO-INJECTOR 12.5 MG/0.25ML NP Y N Y N RASUVO RASUVO INJ 15MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PF AUTO-INJECTOR 15 MG/0.3ML NP Y N Y N RASUVO RASUVO INJ 17.5MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PF AUTO-INJECTOR 17.5 MG/0.35ML NP Y N Y N RASUVO RASUVO INJ 20MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PF AUTO-INJECTOR 20 MG/0.4ML NP Y N Y N RASUVO RASUVO INJ 22.5MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PF AUTO-INJECTOR 22.5 MG/0.45ML NP Y N Y N RASUVO RASUVO INJ 25MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PF AUTO-INJECTOR 25 MG/0.5ML NP Y N Y N RASUVO RASUVO INJ 30MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PF AUTO-INJECTOR 30 MG/0.6ML NP Y N Y N RASUVO RASUVO INJ 7.5MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PF AUTO-INJECTOR 7.5 MG/0.15ML NP Y N Y N REDITREX REDITREX INJ 10/.4ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PREFILLED SYRINGE 10 MG/0.4ML NP Y N Y N REDITREX REDITREX INJ 12.5/0.5 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PREFILLED SYRINGE 12.5 MG/0.5ML NP Y N Y N REDITREX REDITREX INJ 15/.6ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PREFILLED SYRINGE 15 MG/0.6ML NP Y N Y N REDITREX REDITREX INJ 17.5/0.7 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PREFILLED SYRINGE 17.5 MG/0.7ML NP Y N Y N REDITREX REDITREX INJ 20/.8ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PREFILLED SYRINGE 20 MG/0.8ML NP Y N Y N REDITREX REDITREX INJ 22.5/0.9 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PREFILLED SYRINGE 22.5 MG/0.9ML NP Y N Y N REDITREX REDITREX INJ 25MG/ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PREFILLED SYRINGE 25 MG/ML NP Y N Y N REDITREX REDITREX INJ 7.5/.3ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS METHOTREXATE SOLN PREFILLED SYRINGE 7.5 MG/0.3ML NP Y N Y N RINVOQ RINVOQ TAB 15MG ER DISEASE-MODIFYING ANTIRHEUMATIC AGENTS UPADACITINIB TAB ER 24HR 15 MG NP Y N Y N SIMPONI SIMPONI INJ 100MG/ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS GOLIMUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 100 MG/ML NP Y N Y N SIMPONI SIMPONI INJ 50/0.5ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS GOLIMUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 50 MG/0.5ML NP Y N YN XELJANZ XELJANZ TAB 5MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS TOFACITINIB CITRATE TAB 5 MG (BASE EQUIVALENT) NP Y N Y N XELJANZ XR XELJANZ XR TAB 11MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTS TOFACITINIB CITRATE TAB ER 24HR 11 MG (BASE EQUIVALENT) NP Y NYN AMILOR/HCTZ TAB 5-50 AMILOR/HCTZ TAB 5-50 DIURETICS AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG P N N Y N EZIDE TAB 50MG EZIDE TAB 50MG DIURETICS HYDROCHLOROTHIAZIDE TAB 50 MG P N N Y N FUROSEMIDE TAB 40MG FUROSEMIDE TAB 40MG DIURETICS FUROSEMIDE TAB 40 MG P N N Y N CARBIDOPA CARBIDOPA TAB 25MG DOPAMINE PRECURSORS CARBIDOPA TAB 25 MG NP Y N Y N CARBIDOPA/LEVODOPA CARB/LEVO TAB 10-100MG DOPAMINE PRECURSORS CARBIDOPA & LEVODOPA TAB 10-100 MG P N N Y N CARBIDOPA/LEVODOPA ER CARB/LEVO ER TAB 25-100MG DOPAMINE PRECURSORS CARBIDOPA & LEVODOPA TAB ER 25-100 MG P N N Y N CARBIDOPA/LEVODOPA ER CARB/LEVO ER TAB 50-200MG DOPAMINE PRECURSORS CARBIDOPA & LEVODOPA TAB ER 50-200 MG P N N Y N CARBIDOPA/LEVODOPA/ENTACAPONE CARB/LEVO 50 TAB /ENTACAP DOPAMINE PRECURSORS CARBIDOPA-LEVODOPA-ENTACAPONE TABS 12.5-50-200 MG NP Y N Y N CARBIDOPA/LEVODOPA/ENTACAPONE CARB/LEVO 75 TAB /ENTACAP DOPAMINE PRECURSORS CARBIDOPA-LEVODOPA-ENTACAPONE TABS 18.75-75-200 MG NP Y N NN CARBIDOPA/LEVODOPA/ENTACAPONE CARB/LEVO150 TAB /ENTACAP DOPAMINE PRECURSORS CARBIDOPA-LEVODOPA-ENTACAPONE TABS 37.5-150-200 MG NP Y N YN DUOPA DUOPA SUS 4.63-20 DOPAMINE PRECURSORS CARBIDOPA-LEVODOPA ENTERAL SUSP 4.63-20 MG/ML NP Y N N N INBRIJA INBRIJA CAP 42MG DOPAMINE PRECURSORS LEVODOPA INHAL POWDER CAP 42 MG NP Y N Y N LODOSYN LODOSYN TAB 25MG DOPAMINE PRECURSORS CARBIDOPA TAB 25 MG NP Y N Y N RYTARY RYTARY CAP 195MG DOPAMINE PRECURSORS CARBIDOPA & LEVODOPA CAP ER 48.75-195 MG NP Y N Y N RYTARY RYTARY CAP 95MG DOPAMINE PRECURSORS CARBIDOPA & LEVODOPA CAP ER 23.75-95 MG NP Y N N N SINEMET SINEMET TAB 10-100MG DOPAMINE PRECURSORS CARBIDOPA & LEVODOPA TAB 10-100 MG NP Y N Y N STALEVO 100 STALEVO 100 TAB DOPAMINE PRECURSORS CARBIDOPA-LEVODOPA-ENTACAPONE TABS 25-100-200 MG NP Y N Y N STALEVO 125 STALEVO 125 TAB DOPAMINE PRECURSORS CARBIDOPA-LEVODOPA-ENTACAPONE TABS 31.25-125-200 MG NP Y N N N STALEVO 150 STALEVO 150 TAB DOPAMINE PRECURSORS CARBIDOPA-LEVODOPA-ENTACAPONE TABS 37.5-150-200 MG NP Y N Y N STALEVO 200 STALEVO 200 TAB DOPAMINE PRECURSORS CARBIDOPA-LEVODOPA-ENTACAPONE TABS 50-200-200 MG NP Y N N N STALEVO 50 STALEVO 50 TAB DOPAMINE PRECURSORS CARBIDOPA-LEVODOPA-ENTACAPONE TABS 12.5-50-200 MG NP Y N Y N STALEVO 75 STALEVO 75 TAB DOPAMINE PRECURSORS CARBIDOPA-LEVODOPA-ENTACAPONE TABS 18.75-75-200 MG NP Y N N N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) CEQUA CEQUA SOL 0.09% EENT ANTI-INFLAMMATORY AGENTS, MISC. CYCLOSPORINE (OPHTH) SOLN 0.09% (PF) NP Y N Y N CYCLOSPORINE IN KLARITY CYCLOSPORINE EMU 0.1% EENT ANTI-INFLAMMATORY AGENTS, MISC. CYCLOSPORINE (OPHTH) EMULSION 0.1% NP Y N Y N RESTASIS RESTASIS EMU 0.05% EENT ANTI-INFLAMMATORY AGENTS, MISC. CYCLOSPORINE (OPHTH) EMULSION 0.05% NP Y N Y N XIIDRA XIIDRA DRO 5% EENT ANTI-INFLAMMATORY AGENTS, MISC. LIFITEGRAST OPHTH SOLN 5% P Y N Y N ALTACHLORE ALTACHLORE OIN 5% OP EENT DRUGS, MISCELLANEOUS SODIUM CHLORIDE HYPERTONIC OPHTH OINT 5% P N N N N ALTACHLORE ALTACHLORE SOL 5% OP EENT DRUGS, MISCELLANEOUS SODIUM CHLORIDE HYPERTONIC OPHTH SOLN 5% P N N Y N ARTIFICIAL TEARS ARTIFICIAL SOL TEARS OP EENT DRUGS, MISCELLANEOUS HYPROMELLOSE OPHTH SOLN 0.4% P N N N N CYSTADROPS CYSTADROPS SOL 0.37% EENT DRUGS, MISCELLANEOUS CYSTEAMINE HCL OPHTH SOLN 0.37% (BASE EQUIVALENT) NP Y N Y N CYSTARAN CYSTARAN SOL 0.44% EENT DRUGS, MISCELLANEOUS CYSTEAMINE HCL OPHTH SOLN 0.44% (BASE EQUIVALENT) P Y N Y N HYPOTEARS HYPOTEARS OIN OP EENT DRUGS, MISCELLANEOUS *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** P N N Y N ACULAR ACULAR SOL 0.5% OP EENT NONSTEROIDAL ANTI-INFLAM. AGENTS KETOROLAC TROMETHAMINE OPHTH SOLN 0.5% NP Y N Y N ACULAR LS ACULAR LS SOL 0.4% EENT NONSTEROIDAL ANTI-INFLAM. AGENTS KETOROLAC TROMETHAMINE OPHTH SOLN 0.4% NP Y N N N ACUVAIL ACUVAIL SOL 0.45% EENT NONSTEROIDAL ANTI-INFLAM. AGENTS KETOROLAC TROMETHAMINE (PF) OPHTH SOLN 0.45% NP Y N Y N BROMFENAC BROMFENAC SOL 0.09% OP EENT NONSTEROIDAL ANTI-INFLAM. AGENTS BROMFENAC SODIUM OPHTH SOLN 0.09% (BASE EQUIV) (ONCE-DAILY) NP Y N N N BROMSITE BROMSITE DRO 0.075% EENT NONSTEROIDAL ANTI-INFLAM. AGENTS BROMFENAC SODIUM OPHTH SOLN 0.075% (BASE EQUIVALENT) NP Y N Y N DICLOFENAC SODIUM DICLOFENAC SOL 0.1% OP EENT NONSTEROIDAL ANTI-INFLAM. AGENTS DICLOFENAC SODIUM OPHTH SOLN 0.1% P N N Y N FLURBIPROFEN SODIUM FLURBIPROFEN SOL 0.03% OP EENT NONSTEROIDAL ANTI-INFLAM. AGENTS FLURBIPROFEN SODIUM OPHTH SOLN 0.03% P N N Y N ILEVRO ILEVRO DRO 0.3% OP EENT NONSTEROIDAL ANTI-INFLAM. AGENTS NEPAFENAC OPHTH SUSP 0.3% NP Y N Y N KETOROLAC TROMETHAMINE KETOROLAC SOL 0.4% EENT NONSTEROIDAL ANTI-INFLAM. AGENTS KETOROLAC TROMETHAMINE OPHTH SOLN 0.4% P N N N N KETOROLAC TROMETHAMINE KETOROLAC SOL 0.5% EENT NONSTEROIDAL ANTI-INFLAM. AGENTS KETOROLAC TROMETHAMINE OPHTH SOLN 0.5% P N N Y N NEVANAC NEVANAC SUS 0.1% EENT NONSTEROIDAL ANTI-INFLAM. AGENTS NEPAFENAC OPHTH SUSP 0.1% NP Y N Y N PROLENSA PROLENSA SOL 0.07% EENT NONSTEROIDAL ANTI-INFLAM. AGENTS BROMFENAC SODIUM OPHTH SOLN 0.07% (BASE EQUIVALENT) NP Y N Y N BROMELAIN BROMELAIN TAB 500MG ENZYMES BROMELAINS TAB 500 MG NP Y N N N BROMELAIN 2400 GDU BROMELAIN CAP 2400GDU ENZYMES BROMELAINS CAP 250 MG NP Y N N N PALYNZIQ PALYNZIQ INJ 2.5/0.5 ENZYMES PEGVALIASE-PQPZ SUBCUTANEOUS SOLN PREF SYRINGE 2.5 MG/0.5ML NP Y N Y N PALYNZIQ PALYNZIQ INJ 20MG/ML ENZYMES PEGVALIASE-PQPZ SUBCUTANEOUS SOLN PREF SYRINGE 20 MG/ML NP Y N Y N STRENSIQ STRENSIQ INJ 18/0.45 ENZYMES ASFOTASE ALFA SUBCUTANEOUS INJ 18 MG/0.45ML P Y N N N SUCRAID SUCRAID SOL 8500/ML ENZYMES SACROSIDASE SOLN 8500 UNIT/ML NP Y N N N BROMOCRIPTINE MESYLATE BROMOCRIPTIN CAP 5MG ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS BROMOCRIPTINE MESYLATE CAP 5 MG (BASE EQUIVALENT) NP Y N Y N BROMOCRIPTINE MESYLATE BROMOCRIPTIN TAB 2.5MG ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS BROMOCRIPTINE MESYLATE TAB 2.5 MG (BASE EQUIVALENT) NP Y N Y N CABERGOLINE CABERGOLINE TAB 0.5MG ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS CABERGOLINE TAB 0.5 MG P N N Y N PARLODEL PARLODEL CAP 5MG ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS BROMOCRIPTINE MESYLATE CAP 5 MG (BASE EQUIVALENT) NP Y N Y N PARLODEL PARLODEL TAB 2.5MG ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS BROMOCRIPTINE MESYLATE TAB 2.5 MG (BASE EQUIVALENT) NP Y N Y N E.E.S. 400 E.E.S. 400 TAB 400MG ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG P N N Y N E.E.S. GRANULES E.E.S. GRAN SUS 200/5ML ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML P N N Y N ERYPED 200 ERYPED SUS 200/5ML ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML P N N Y N ERYPED 400 ERYPED SUS 400/5ML ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 400 MG/5ML NP Y N Y N ERY-TAB ERY-TAB TAB 250MG EC ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN TAB DELAYED RELEASE 250 MG NP Y N Y N ERY-TAB ERY-TAB TAB 333MG EC ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN TAB DELAYED RELEASE 333 MG NP Y N Y N ERY-TAB ERY-TAB TAB 500MG EC ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN TAB DELAYED RELEASE 500 MG NP Y N Y N ERYTHROCIN STEARATE ERYTHROCIN TAB 250MG ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN STEARATE TAB 250 MG P N N Y N ERYTHROMYCIN ERYTHROMYCIN CAP 250MG EC ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN W/ DELAYED RELEASE PARTICLES CAP 250 MG P N N Y N ERYTHROMYCIN DR ERYTHROMYCIN TAB 333MG EC ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN TAB DELAYED RELEASE 333 MG P N N Y N ERYTHROMYCIN DR ERYTHROMYCIN TAB 500MG EC ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN TAB DELAYED RELEASE 500 MG P N N Y N ERYTHROMYCIN ETHYLSUCCINATE ERYTHROM ETH SUS 200/5ML ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML P N N Y N ERYTHROMYCIN ETHYLSUCCINATE ERYTHROM ETH SUS 400/5ML ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 400 MG/5ML P N N Y N ERYTHROMYCIN ETHYLSUCCINATE ERYTHROM ETH TAB 400MG ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG P N N Y N ERYTHROMYCIN STEARATE ERYTHROM ST TAB 250MG ERYTHROMYCIN ANTIBIOTICS ERYTHROMYCIN STEARATE TAB 250 MG P N N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) DUAVEE DUAVEE TAB 0.45-20 ESTROGEN AGONIST-ANTAGONISTS CONJUGATED ESTROGENS-BAZEDOXIFENE TAB 0.45-20 MG P N N Y N EVISTA EVISTA TAB 60MG ESTROGEN AGONIST-ANTAGONISTS RALOXIFENE HCL TAB 60 MG NP Y N Y N FARESTON FARESTON TAB 60MG ESTROGEN AGONIST-ANTAGONISTS TOREMIFENE CITRATE TAB 60 MG (BASE EQUIVALENT) NP Y N Y N OSPHENA OSPHENA TAB 60MG ESTROGEN AGONIST-ANTAGONISTS OSPEMIFENE TAB 60 MG NP Y N Y N RALOXIFENE HYDROCHLORIDE RALOXIFENE TAB 60MG ESTROGEN AGONIST-ANTAGONISTS RALOXIFENE HCL TAB 60 MG P N N Y N SOLTAMOX SOLTAMOX SOL 10MG/5ML ESTROGEN AGONIST-ANTAGONISTS TAMOXIFEN CITRATE ORAL SOLN 10 MG/5ML (BASE EQUIVALENT) NP Y N Y N TAMOXIFEN CITRATE TAMOXIFEN TAB 10MG ESTROGEN AGONIST-ANTAGONISTS TAMOXIFEN CITRATE TAB 10 MG (BASE EQUIVALENT) P N N Y N TAMOXIFEN CITRATE TAMOXIFEN TAB 20MG ESTROGEN AGONIST-ANTAGONISTS TAMOXIFEN CITRATE TAB 20 MG (BASE EQUIVALENT) P N N Y N TOREMIFENE CITRATE TOREMIFENE TAB 60MG ESTROGEN AGONIST-ANTAGONISTS TOREMIFENE CITRATE TAB 60 MG (BASE EQUIVALENT) P N N Y N ACTIVELLA ACTIVELLA TAB 1-0.5MG ESTROGENS ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG NP Y N Y N ALORA ALORA DIS 0.025MG ESTROGENS ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR NP Y N Y N AMABELZ AMABELZ TAB 0.5-0.1 ESTROGENS ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG NP Y N N N AMABELZ AMABELZ TAB 1-0.5MG ESTROGENS ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG NP Y N Y N ANGELIQ ANGELIQ TAB 0.25-0.5 ESTROGENS DROSPIRENONE-ESTRADIOL TAB 0.25-0.5 MG NP Y N N N BI-EST 50:50 COMPOUNDING KIT BI-EST 50:50 CRE ESTROGENS *ESTRIOL-ESTRADIOL CREAM (CMPD KIT)*** NP Y N Y N BI-EST 50:50 PROGESTERONE-TESTOSTEROBI-EST 50:50 CRE ESTROGENS *ESTRADIOL-ESTRIOL-TESTOST-PROGEST MICRO CREAM (CMPD KIT)*** NP Y N Y N BI-EST 80:20 PROGESTERONE COMPOUNDIBIEST/PROGES CRE ESTROGENS *ESTRADIOL-ESTRIOL-PROGESTERONE MICRONIZED CREAM (CMPD KIT)* NP Y N N N BIEST/PROGESTERONE BIEST/PROGES CRE ESTROGENS *ESTRADIOL-ESTRIOL-PROGESTERONE MICRONIZED CREAM (CMPD KIT)* NP Y N N N BIJUVA BIJUVA CAP 1-100MG ESTROGENS ESTRADIOL-PROGESTERONE CAP 1-100 MG NP Y N Y N CLIMARA CLIMARA DIS 0.025MG ESTROGENS ESTRADIOL TD PATCH WEEKLY 0.025 MG/24HR NP Y N Y N CLIMARA PRO CLIMARA PRO DIS WEEKLY ESTROGENS ESTRADIOL-LEVONORGESTREL TD PATCH WEEKLY 0.045-0.015 MG/DAY NP Y N N N COMBIPATCH COMBIPATCH DIS ESTROGENS ESTRADIOL-NORETHINDRONE ACE TD PTTW 0.05-0.14 MG/DAY NP Y N Y N DELESTROGEN DELESTROGEN INJ 10MG/ML ESTROGENS ESTRADIOL VALERATE IM IN OIL 10 MG/ML NP Y N Y N DEPO-ESTRADIOL DEPO-ESTRADI INJ 5MG/ML ESTROGENS ESTRADIOL CYPIONATE IM IN OIL 5 MG/ML P N N Y N DIVIGEL DIVIGEL GEL 0.25MG ESTROGENS ESTRADIOL TD GEL 0.25 MG/0.25GM (0.1%) NP Y N Y N DIVIGEL DIVIGEL GEL 0.5MG ESTROGENS ESTRADIOL TD GEL 0.5 MG/0.5GM (0.1%) NP Y N N N DIVIGEL DIVIGEL GEL 1.25MG ESTROGENS ESTRADIOL TD GEL 1.25 MG/1.25GM (0.1%) NP Y N Y N DOTTI DOTTI DIS 0.025MG ESTROGENS ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR NP Y N Y N ELESTRIN ELESTRIN GEL 0.06% ESTROGENS ESTRADIOL GEL 0.06% (0.52 MG/0.87 GM METERED-DOSE PUMP) NP Y N N N ESTRACE ESTRACE TAB 0.5MG ESTROGENS ESTRADIOL TAB 0.5 MG NP Y N Y N ESTRACE ESTRACE TAB 1MG ESTROGENS ESTRADIOL TAB 1 MG NP Y N Y N ESTRACE ESTRACE TAB 2MG ESTROGENS ESTRADIOL TAB 2 MG NP Y N Y N ESTRADIOL ESTRADIOL DIS 0.025MG ESTROGENS ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR NP Y N Y N ESTRADIOL ESTRADIOL TAB 0.5MG ESTROGENS ESTRADIOL TAB 0.5 MG P N N Y N ESTRADIOL ESTRADIOL TAB 10MCG ESTROGENS ESTRADIOL VAGINAL TAB 10 MCG P N N Y N ESTRADIOL ESTRADIOL TAB 1MG ESTROGENS ESTRADIOL TAB 1 MG P N N Y N ESTRADIOL ESTRADIOL TAB 2MG ESTROGENS ESTRADIOL TAB 2 MG P N N Y N ESTRADIOL VALERATE ESTRAD VAL INJ 20MG/ML ESTROGENS ESTRADIOL VALERATE IM IN OIL 20 MG/ML NP Y N Y N ESTRADIOL/NORETHINDRONE ACETATE ESTRA/NORETH TAB 0.5-0.1 ESTROGENS ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG NP Y N N N ESTRING ESTRING MIS 2MG ESTROGENS ESTRADIOL VAGINAL RING 2 MG (7.5 MCG/24HRS) NP Y N Y N ESTRIOL CONCENTRATE ESTRIOL CRE 10% ESTROGENS ESTRIOL (BULK) CREAM 10% NP Y N N N ESTRONE CONCENTRATE ESTRONE CRE 1% ESTROGENS ESTRONE (BULK) CREAM 1% NP Y N N N EVAMIST EVAMIST SPR 1.53MG ESTROGENS ESTRADIOL TRANSDERMAL SPRAY 1.53 MG/SPRAY NP Y N N N FEMHRT LOW DOSE FEMHRT TAB 0.5-2.5 ESTROGENS NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 0.5 MG-2.5 MCG NP Y N N N FEMRING FEMRING MIS 0.05/24H ESTROGENS ESTRADIOL ACETATE VAGINAL RING 0.05 MG/24HR NP Y N Y N FYAVOLV FYAVOLV TAB 0.5-2.5 ESTROGENS NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 0.5 MG-2.5 MCG NP Y N N N FYAVOLV FYAVOLV TAB 1-5 ESTROGENS NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 1 MG-5 MCG NP Y N Y N JINTELI JINTELI TAB 1MG-5MCG ESTROGENS NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 1 MG-5 MCG NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) LYLLANA LYLLANA DIS 0.025MG ESTROGENS ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR NP Y N Y N MENEST MENEST TAB 0.3MG ESTROGENS ESTERIFIED ESTROGENS TAB 0.3 MG NP Y N Y N MENOSTAR MENOSTAR DIS 14MCG ESTROGENS ESTRADIOL TD PATCH WEEKLY 14 MCG/24HR NP Y N Y N MIMVEY MIMVEY TAB 1-0.5MG ESTROGENS ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG NP Y N Y N MINIVELLE MINIVELLE DIS 0.025MG ESTROGENS ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR NP Y N Y N NORETHINDRONE ACETATE/ETHINYL ESTRANORETH/ETHIN TAB 0.5-2.5 ESTROGENS NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 0.5 MG-2.5 MCG NP Y N N N NORETHINDRONE ACETATE/ETHINYL ESTRANORETH/ETHIN TAB 1MG-5MCG ESTROGENS NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 1 MG-5 MCG NP Y N Y N PREFEST PREFEST TAB ESTROGENS ESTRADIOL TAB 1 MG(15)/ESTRAD-NORGESTIMATE TAB 1-0.09MG(15) NP Y N Y N PREMARIN PREMARIN TAB 0.3MG ESTROGENS ESTROGENS, CONJUGATED TAB 0.3 MG P N N Y N PREMARIN PREMARIN VAG CRE 0.625MG ESTROGENS ESTROGENS, CONJUGATED VAGINAL CREAM 0.625 MG/GM NP Y N Y N PREMPHASE PREMPHASE TAB ESTROGENS CONJ EST 0.625(14)/CONJ EST-MEDROXYPRO AC TAB 0.625-5MG(14) P N N Y N PREMPRO PREMPRO TAB 0.3-1.5 ESTROGENS CONJUGATED ESTROGEN-MEDROXYPROGEST ACETATE TAB 0.3-1.5 MG P N N Y N VAGIFEM VAGIFEM TAB 10MCG ESTROGENS ESTRADIOL VAGINAL TAB 10 MCG NP Y N Y N VIVELLE-DOT VIVELLE-DOT DIS 0.025MG ESTROGENS ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR NP Y N Y N YUVAFEM YUVAFEM TAB 10MCG ESTROGENS ESTRADIOL VAGINAL TAB 10 MCG P N N Y N CARBINOXAMINE MALEATE CARBINOXAMIN SOL 4MG/5ML ETHANOLAMINE DERIVATIVES CARBINOXAMINE MALEATE SOLN 4 MG/5ML NP Y N Y N CARBINOXAMINE MALEATE CARBINOXAMIN TAB 4MG ETHANOLAMINE DERIVATIVES CARBINOXAMINE MALEATE TAB 4 MG NP Y N Y N CARBINOXAMINE MALEATE CARBINOXAMIN TAB 6MG ETHANOLAMINE DERIVATIVES CARBINOXAMINE MALEATE TAB 6 MG NP Y N Y N CLEMASTINE FUMARATE CLEMASTINE TAB 1.34MG ETHANOLAMINE DERIVATIVES CLEMASTINE FUMARATE TAB 1.34 MG (1 MG BASE EQUIV) P N N Y N CLEMASTINE FUMARATE CLEMASTINE TAB 2.68MG ETHANOLAMINE DERIVATIVES CLEMASTINE FUMARATE TAB 2.68 MG P N N Y N ANTARA ANTARA CAP 30MG FIBRIC ACID DERIVATIVES FENOFIBRATE MICRONIZED CAP 30 MG NP Y N Y N FENOFIBRATE FENOFIBRATE CAP 50MG FIBRIC ACID DERIVATIVES FENOFIBRATE CAP 50 MG NP Y N N N FENOFIBRATE FENOFIBRATE TAB 40MG FIBRIC ACID DERIVATIVES FENOFIBRATE TAB 40 MG NP Y N Y N FENOFIBRATE FENOFIBRATE TAB 54MG FIBRIC ACID DERIVATIVES FENOFIBRATE TAB 54 MG P N Y Y N FENOFIBRATE MICRONIZED FENOFIBRATE CAP 67MG FIBRIC ACID DERIVATIVES FENOFIBRATE MICRONIZED CAP 67 MG P N Y Y N FENOFIBRIC ACID FENOFIBRIC TAB 35MG FIBRIC ACID DERIVATIVES FENOFIBRIC ACID TAB 35 MG NP Y N Y N FENOFIBRIC ACID DR FENOFIBRIC CAP 45MG DR FIBRIC ACID DERIVATIVES CHOLINE FENOFIBRATE CAP DR 45 MG (FENOFIBRIC ACID EQUIV) NP Y N Y N FENOGLIDE FENOGLIDE TAB 40MG FIBRIC ACID DERIVATIVES FENOFIBRATE TAB 40 MG NP Y N Y N FIBRICOR FIBRICOR TAB 35MG FIBRIC ACID DERIVATIVES FENOFIBRIC ACID TAB 35 MG NP Y N Y N GEMFIBROZIL GEMFIBROZIL TAB 600MG FIBRIC ACID DERIVATIVES GEMFIBROZIL TAB 600 MG P N N Y N LIPOFEN LIPOFEN CAP 50MG FIBRIC ACID DERIVATIVES FENOFIBRATE CAP 50 MG NP Y N N N LOPID LOPID TAB 600MG FIBRIC ACID DERIVATIVES GEMFIBROZIL TAB 600 MG NP Y N Y N TRICOR TRICOR TAB 48MG FIBRIC ACID DERIVATIVES FENOFIBRATE TAB 48 MG NP Y N Y N TRILIPIX TRILIPIX CAP 45MG FIBRIC ACID DERIVATIVES CHOLINE FENOFIBRATE CAP DR 45 MG (FENOFIBRIC ACID EQUIV) NP Y N Y N SAVELLA SAVELLA TAB 12.5MG FIBROMYALGIA AGENTS MILNACIPRAN HCL TAB 12.5 MG P N N N N SAVELLA TITRATION PACK SAVELLA MIS TITR PAK FIBROMYALGIA AGENTS MILNACIPRAN HCL TAB 12.5 MG (5) & 25 MG (8) & 50 MG (42) PAK P NNNN CYPROHEPTADINE HCL CYPROHEPTAD SYP 2MG/5ML FIRST GEN. ANTIHIST. DERIVATIVES, MISC. CYPROHEPTADINE HCL SYRUP 2 MG/5ML P N N N N CYPROHEPTADINE HYDROCHLORIDE CYPROHEPTAD TAB 4MG FIRST GEN. ANTIHIST. DERIVATIVES, MISC. CYPROHEPTADINE HCL TAB 4 MG P N N N N BACLOFEN BACLOFEN TAB 5MG GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT BACLOFEN TAB 5 MG P N N Y N ALVIMOPAN ALVIMOPAN CAP 12MG GI DRUGS, MISCELLANEOUS ALVIMOPAN CAP 12 MG NP Y N N N AMITIZA AMITIZA CAP 8MCG GI DRUGS, MISCELLANEOUS LUBIPROSTONE CAP 8 MCG NP Y N Y N CHOLBAM CHOLBAM CAP 50MG GI DRUGS, MISCELLANEOUS CHOLIC ACID CAP 50 MG P Y N Y N ENTEREG ENTEREG CAP 12MG GI DRUGS, MISCELLANEOUS ALVIMOPAN CAP 12 MG NP Y N N N GATTEX GATTEX KIT 5MG GI DRUGS, MISCELLANEOUS TEDUGLUTIDE (RDNA) FOR INJ KIT 5 MG P Y N Y N LINZESS LINZESS CAP 72MCG GI DRUGS, MISCELLANEOUS LINACLOTIDE CAP 72 MCG NP Y N Y N LUBIPROSTONE LUBIPROSTONE CAP 8MCG GI DRUGS, MISCELLANEOUS LUBIPROSTONE CAP 8 MCG NP Y N Y N MOTEGRITY MOTEGRITY TAB 1MG GI DRUGS, MISCELLANEOUS PRUCALOPRIDE SUCCINATE TAB 1 MG (BASE EQUIVALENT) P Y N Y N MOVANTIK MOVANTIK TAB 12.5MG GI DRUGS, MISCELLANEOUS NALOXEGOL OXALATE TAB 12.5 MG (BASE EQUIVALENT) P Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) OCALIVA OCALIVA TAB 5MG GI DRUGS, MISCELLANEOUS OBETICHOLIC ACID TAB 5 MG NP Y N Y N RELISTOR RELISTOR INJ 12/0.6ML GI DRUGS, MISCELLANEOUS METHYLNALTREXONE BROMIDE INJ 12 MG/0.6ML (20 MG/ML) NP Y N Y N RELISTOR RELISTOR INJ 8/0.4ML GI DRUGS, MISCELLANEOUS METHYLNALTREXONE BROMIDE INJ 8 MG/0.4ML (20 MG/ML) NP Y N Y N RELISTOR RELISTOR TAB 150MG GI DRUGS, MISCELLANEOUS METHYLNALTREXONE BROMIDE TAB 150 MG NP Y N Y N SYMPROIC SYMPROIC TAB 0.2MG GI DRUGS, MISCELLANEOUS NALDEMEDINE TOSYLATE TAB 0.2 MG (BASE EQUIVALENT) NP Y N Y N TRULANCE TRULANCE TAB 3MG GI DRUGS, MISCELLANEOUS PLECANATIDE TAB 3 MG P Y N Y N VIBERZI VIBERZI TAB 75MG GI DRUGS, MISCELLANEOUS ELUXADOLINE TAB 75 MG NP Y N Y N GLUCAGEN DIAGNOSTIC GLUCAGEN INJ 1MG GLYCOGENOLYTIC AGENTS GLUCAGON HCL (RDNA) DIAGNOSTIC FOR INJ 1 MG (BASE EQUIV) NP Y N N N GLUCAGEN HYPOKIT GLUCAGEN INJ HYPOKIT GLYCOGENOLYTIC AGENTS GLUCAGON HCL (RDNA) FOR INJ 1 MG (BASE EQUIV) P N N Y N GLUCAGON EMERGENCY KIT GLUCAGON KIT 1MG GLYCOGENOLYTIC AGENTS GLUCAGON (RDNA) FOR INJ KIT 1 MG P N N Y N GLUCAGON EMERGENCY KIT FOR LOW BLOGLUCAGON EMR SOL 1MG GLYCOGENOLYTIC AGENTS GLUCAGON HCL FOR INJ 1 MG P N N Y N FIRVANQ FIRVANQ SOL 25MG/ML GLYCOPEPTIDE ANTIBIOTICS VANCOMYCIN HCL FOR ORAL SOLN 25 MG/ML (BASE EQUIVALENT) P Y N Y N FIRVANQ FIRVANQ SOL 50MG/ML GLYCOPEPTIDE ANTIBIOTICS VANCOMYCIN HCL FOR ORAL SOLN 50 MG/ML (BASE EQUIVALENT) P Y N Y N VANCOCIN VANCOCIN CAP 250MG GLYCOPEPTIDE ANTIBIOTICS VANCOMYCIN HCL CAP 250 MG (BASE EQUIVALENT) NP Y N Y N VANCOCIN HCL VANCOCIN HCL CAP 125MG GLYCOPEPTIDE ANTIBIOTICS VANCOMYCIN HCL CAP 125 MG (BASE EQUIVALENT) NP Y N Y N VANCOMYCIN HYDROCHLORIDE VANCOMYCIN CAP 250MG GLYCOPEPTIDE ANTIBIOTICS VANCOMYCIN HCL CAP 250 MG (BASE EQUIVALENT) NP Y N Y N VANCOMYCIN HYDROCHLORIDE VANCOMYCIN SOL 250/5ML GLYCOPEPTIDE ANTIBIOTICS VANCOMYCIN HCL FOR ORAL SOLN 50 MG/ML (BASE EQUIVALENT) NP Y N Y N RIDAURA RIDAURA CAP 3MG GOLD COMPOUNDS AURANOFIN CAP 3 MG NP Y N Y N CHORIONIC GONADOTROPIN CHOR GONADOT INJ 10000UNT GONADOTROPINS CHORIONIC GONADOTROPIN FOR IM INJ 10000 UNIT P Y N N N ELIGARD ELIGARD INJ 22.5MG GONADOTROPINS LEUPROLIDE ACETATE (3 MONTH) FOR SUBCUTANEOUS INJ KIT 22.5MG NP Y N Y N ELIGARD ELIGARD INJ 30MG GONADOTROPINS LEUPROLIDE ACETATE (4 MONTH) FOR SUBCUTANEOUS INJ KIT 30 MG NP Y N Y N ELIGARD ELIGARD INJ 45MG GONADOTROPINS LEUPROLIDE ACETATE (6 MONTH) FOR SUBCUTANEOUS INJ KIT 45 MG NP Y N Y N ELIGARD ELIGARD INJ 7.5MG GONADOTROPINS LEUPROLIDE ACETATE FOR SUBCUTANEOUS INJ KIT 7.5 MG NP Y N Y N FENSOLVI FENSOLVI INJ 45MG GONADOTROPINS LEUPROLIDE ACET (6 MONTH) FOR INJ PEDIATRIC KIT 45 MG NP Y N Y N LEUPROLIDE ACETATE LEUPROLIDE INJ 1MG/0.2 GONADOTROPINS LEUPROLIDE ACETATE INJ KIT 5 MG/ML P Y N N N LUPANETA PACK LUPANETA KIT 11.25-5 GONADOTROPINS LEUPROLIDE (3 MON) INJ 11.25 MG & NORETHINDRONE TAB 5 MG KIT NP Y N Y N LUPANETA PACK LUPANETA KIT 3.75-5 GONADOTROPINS LEUPROLIDE (1 MON) INJ 3.75 MG & NORETHINDRONE TAB 5 MG KIT NP Y N N N LUPRON DEPOT (1-MONTH) LUPRON DEPOT INJ 3.75MG GONADOTROPINS LEUPROLIDE ACETATE FOR INJ KIT 3.75 MG P Y N Y N LUPRON DEPOT (3-MONTH) LUPRON DEPOT INJ 11.25MG GONADOTROPINS LEUPROLIDE ACETATE (3 MONTH) FOR INJ KIT 11.25 MG P Y N Y N LUPRON DEPOT (4-MONTH) LUPRON DEPOT INJ 30MG GONADOTROPINS LEUPROLIDE ACETATE (4 MONTH) FOR INJ KIT 30 MG P Y N Y N LUPRON DEPOT (6-MONTH) LUPRON DEPOT INJ 45MG GONADOTROPINS LEUPROLIDE ACETATE (6 MONTH) FOR INJ KIT 45 MG P Y N Y N LUPRON DEPOT-PED (1-MONTH) LUPR DEP-PED INJ 7.5MG GONADOTROPINS LEUPROLIDE ACETATE FOR INJ PEDIATRIC KIT 7.5 MG P Y N Y N LUPRON DEPOT-PED (3-MONTH) LUPR DEP-PED INJ 11.25MG GONADOTROPINS LEUPROLIDE ACETATE (3 MONTH) FOR INJ PEDIATRIC KIT 11.25 MG P Y N Y N NOVAREL NOVAREL INJ 5000UNIT GONADOTROPINS CHORIONIC GONADOTROPIN FOR IM INJ 5000 UNIT P Y N N N OVIDREL OVIDREL INJ GONADOTROPINS CHORIOGONADOTROPIN ALFA INJ 250 MCG/0.5ML P Y N N N PREGNYL W/DILUENT BENZYL ALCOHOL/NAPREGNYL INJ 10000UNT GONADOTROPINS CHORIONIC GONADOTROPIN FOR IM INJ 10000 UNIT P Y N N N SYNAREL SYNAREL SOL 2MG/ML GONADOTROPINS NAFARELIN ACETATE NASAL SOLN 2 MG/ML (200 MCG/ACT) (BASE EQ) NP Y N N N TRIPTODUR TRIPTODUR SUS 22.5MG GONADOTROPINS TRIPTORELIN PAMOATE FOR IM ER SUSP 22.5 MG (BASE EQUIV) NP Y N Y N CHEMET CHEMET CAP 100MG HEAVY METAL ANTAGONISTS SUCCIMER CAP 100 MG P N N Y N CLOVIQUE CLOVIQUE CAP 250MG HEAVY METAL ANTAGONISTS TRIENTINE HCL CAP 250 MG NP Y N N N CUPRIMINE CUPRIMINE CAP 250MG HEAVY METAL ANTAGONISTS PENICILLAMINE CAP 250 MG NP Y N N N DEFERASIROX DEFERASIROX TAB 125MG HEAVY METAL ANTAGONISTS DEFERASIROX TAB FOR ORAL SUSP 125 MG P Y N N N DEFERASIROX DEFERASIROX TAB 90MG HEAVY METAL ANTAGONISTS DEFERASIROX TAB 90 MG P Y N Y N DEFERIPRONE DEFERIPRONE TAB 500MG HEAVY METAL ANTAGONISTS DEFERIPRONE TAB 500 MG NP Y N Y N DEPEN TITRATABS DEPEN TITRA TAB 250MG HEAVY METAL ANTAGONISTS PENICILLAMINE TAB 250 MG NP Y N Y N EXJADE EXJADE TAB 125MG HEAVY METAL ANTAGONISTS DEFERASIROX TAB FOR ORAL SUSP 125 MG NP Y N N N FERRIPROX FERRIPROX SOL 100MG/ML HEAVY METAL ANTAGONISTS DEFERIPRONE ORAL SOLN 100 MG/ML NP Y N N N FERRIPROX FERRIPROX TAB 1000MG HEAVY METAL ANTAGONISTS DEFERIPRONE TAB 1000 MG NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) FERRIPROX FERRIPROX TAB 500MG HEAVY METAL ANTAGONISTS DEFERIPRONE TAB 500 MG NP Y N Y N JADENU JADENU TAB 90MG HEAVY METAL ANTAGONISTS DEFERASIROX TAB 90 MG NP Y N Y N JADENU SPRINKLE JADENU SPRKL GRA 90MG HEAVY METAL ANTAGONISTS DEFERASIROX GRANULES PACKET 90 MG NP Y N Y N PENICILLAMINE PENICILLAMIN TAB 250MG HEAVY METAL ANTAGONISTS PENICILLAMINE TAB 250 MG P Y N Y N SYPRINE SYPRINE CAP 250MG HEAVY METAL ANTAGONISTS TRIENTINE HCL CAP 250 MG NP Y N N N TRIENTINE HYDROCHLORIDE TRIENTINE CAP 250MG HEAVY METAL ANTAGONISTS TRIENTINE HCL CAP 250 MG NP Y N N N ARANESP ALBUMIN FREE ARANESP INJ 10MCG HEMATOPOIETIC AGENTS DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 10 MCG/0.4ML P Y N Y N ARANESP ALBUMIN FREE ARANESP INJ 25MCG HEMATOPOIETIC AGENTS DARBEPOETIN ALFA SOLN INJ 25 MCG/ML P Y N N N DOPTELET DOPTELET TAB 20MG HEMATOPOIETIC AGENTS AVATROMBOPAG MALEATE TAB 20 MG (BASE EQUIV) NP Y N Y N EPOGEN EPOGEN INJ 2000/ML HEMATOPOIETIC AGENTS EPOETIN ALFA INJ 2000 UNIT/ML NP Y N N N FULPHILA FULPHILA INJ 6/0.6ML HEMATOPOIETIC AGENTS PEGFILGRASTIM-JMDB SOLN PREFILLED SYRINGE 6 MG/0.6ML NP Y N N N GRANIX GRANIX INJ 300/1ML HEMATOPOIETIC AGENTS TBO-FILGRASTIM SUBCUTANEOUS INJ 300 MCG/ML NP Y N N N LEUKINE LEUKINE INJ 250MCG HEMATOPOIETIC AGENTS SARGRAMOSTIM LYOPHILIZED FOR INJ 250 MCG P Y N N N MIRCERA MIRCERA INJ 50MCG HEMATOPOIETIC AGENTS METHOXY PEG-EPOETIN BETA SOLN PREFILLED SYR 50 MCG/0.3ML NP Y N Y N MOZOBIL MOZOBIL INJ HEMATOPOIETIC AGENTS PLERIXAFOR SUBCUTANEOUS INJ 24 MG/1.2ML (20 MG/ML) P Y N Y N MULPLETA MULPLETA TAB 3MG HEMATOPOIETIC AGENTS LUSUTROMBOPAG TAB 3 MG P Y N Y N NEULASTA NEULASTA INJ 6MG/0.6M HEMATOPOIETIC AGENTS PEGFILGRASTIM SOLN PREFILLED SYRINGE 6 MG/0.6ML P Y N N N NEUPOGEN NEUPOGEN INJ 300MCG HEMATOPOIETIC AGENTS FILGRASTIM INJ 300 MCG/ML NP Y N N N NEUPOGEN NEUPOGEN INJ 480MCG HEMATOPOIETIC AGENTS FILGRASTIM INJ 480 MCG/1.6ML (300 MCG/ML) NP Y N Y N NIVESTYM NIVESTYM INJ 300MCG HEMATOPOIETIC AGENTS FILGRASTIM-AAFI INJ 300 MCG/ML NP Y N N N NYVEPRIA NYVEPRIA INJ 6/0.6ML HEMATOPOIETIC AGENTS PEGFILGRASTIM-APGF SOLN PREFILLED SYRINGE 6 MG/0.6ML NP Y N N N PROCRIT PROCRIT INJ 2000/ML HEMATOPOIETIC AGENTS EPOETIN ALFA INJ 2000 UNIT/ML NP Y N N N PROMACTA PROMACTA PAK 25MG HEMATOPOIETIC AGENTS ELTROMBOPAG OLAMINE POWDER PACK FOR SUSP 25 MG (BASE EQUIV) P Y N Y N PROMACTA PROMACTA TAB 12.5MG HEMATOPOIETIC AGENTS ELTROMBOPAG OLAMINE TAB 12.5 MG (BASE EQUIV) P Y N Y N PROMACTA PROMACTA TAB 50MG HEMATOPOIETIC AGENTS ELTROMBOPAG OLAMINE TAB 50 MG (BASE EQUIV) P Y N Y N RETACRIT RETACRIT INJ 2000UNIT HEMATOPOIETIC AGENTS EPOETIN ALFA-EPBX INJ 2000 UNIT/ML P Y N N N UDENYCA UDENYCA INJ 6MG/.6ML HEMATOPOIETIC AGENTS PEGFILGRASTIM-CBQV SOLN PREFILLED SYRINGE 6 MG/0.6ML NP Y N N N ZARXIO ZARXIO INJ 300/0.5 HEMATOPOIETIC AGENTS FILGRASTIM-SNDZ SOLN PREFILLED SYRINGE 300 MCG/0.5ML P Y N N N ZIEXTENZO ZIEXTENZO INJ 6/0.6ML HEMATOPOIETIC AGENTS PEGFILGRASTIM-BMEZ SOLN PREFILLED SYRINGE 6 MG/0.6ML NP Y N N N PENTOXIFYLLINE CR PENTOXIFYLLI TAB 400MG CR HEMORRHEOLOGIC AGENTS PENTOXIFYLLINE TAB ER 400 MG P N N Y N PENTOXIFYLLINE ER PENTOXIFYLLI TAB 400MG ER HEMORRHEOLOGIC AGENTS PENTOXIFYLLINE TAB ER 400 MG P N N Y N TRENTAL TAB 400MG TRENTAL TAB 400MG HEMORRHEOLOGIC AGENTS PENTOXIFYLLINE TAB 400MG NP Y N N N AMICAR AMICAR SOL 0.25/ML HEMOSTATICS AMINOCAPROIC ACID ORAL SOLN 0.25 GM/ML NP Y N Y N AMICAR AMICAR TAB 1000MG HEMOSTATICS AMINOCAPROIC ACID TAB 1000 MG NP Y N Y N AMICAR AMICAR TAB 500MG HEMOSTATICS AMINOCAPROIC ACID TAB 500 MG NP Y N Y N AMINOCAPROIC ACID AMINOCAPR AC TAB 1000MG HEMOSTATICS AMINOCAPROIC ACID TAB 1000 MG P N N Y N AMINOCAPROIC ACID AMINOCAPR AC TAB 500MG HEMOSTATICS AMINOCAPROIC ACID TAB 500 MG P N N Y N AMINOCAPROIC ACID AMINOCAPROIC SOL 0.25/ML HEMOSTATICS AMINOCAPROIC ACID ORAL SOLN 0.25 GM/ML P N N Y N LYSTEDA LYSTEDA TAB 650MG HEMOSTATICS TRANEXAMIC ACID TAB 650 MG NP Y N Y N RECOTHROM RECOTHROM SOL 5000UNIT HEMOSTATICS THROMBIN (RECOMBINANT) FOR SOLN 5000 UNIT NP Y N N N RECOTHROM/SPRAY APPLICATOR KIT RECOTHROM SOL 20000UNT HEMOSTATICS THROMBIN (RECOMBINANT) FOR SOLN 20000 UNIT NP Y N N N THROMBOGEN THROMBOGEN SOL 1000UNIT HEMOSTATICS THROMBIN FOR SOLN 1000 UNIT NP Y N N N TRANEXAMIC ACID TRANEX ACID TAB 650MG HEMOSTATICS TRANEXAMIC ACID TAB 650 MG P N N Y N ENOXAPARIN SODIUM ENOXAPARIN INJ 100MG/ML HEPARINS ENOXAPARIN SODIUM INJ 100 MG/ML P N N Y N ENOXAPARIN SODIUM ENOXAPARIN INJ 150MG/ML HEPARINS ENOXAPARIN SODIUM INJ 150 MG/ML P N N Y N ENOXAPARIN SODIUM ENOXAPARIN INJ 30/0.3ML HEPARINS ENOXAPARIN SODIUM INJ 30 MG/0.3ML P N N Y N ENOXAPARIN SODIUM ENOXAPARIN INJ 300/3ML HEPARINS ENOXAPARIN SODIUM INJ 300 MG/3ML P N N Y N ENOXAPARIN SODIUM ENOXAPARIN INJ 40/0.4ML HEPARINS ENOXAPARIN SODIUM INJ 40 MG/0.4ML P N N Y N

Confidential 2/19/2021 Page 54 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ENOXAPARIN SODIUM ENOXAPARIN INJ 60/0.6ML HEPARINS ENOXAPARIN SODIUM INJ 60 MG/0.6ML P N N Y N ENOXAPARIN SODIUM ENOXAPARIN INJ 80/0.8ML HEPARINS ENOXAPARIN SODIUM INJ 80 MG/0.8ML P N N Y N FRAGMIN FRAGMIN INJ 10000/ML HEPARINS DALTEPARIN SODIUM INJ 10000 UNIT/ML NP Y N N N HEPARIN SODIUM HEPARIN SOD INJ 1000/ML HEPARINS HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML P N N N N LOVENOX LOVENOX INJ 100MG/ML HEPARINS ENOXAPARIN SODIUM INJ 100 MG/ML NP Y N Y N LOVENOX LOVENOX INJ 150MG/ML HEPARINS ENOXAPARIN SODIUM INJ 150 MG/ML NP Y N Y N LOVENOX LOVENOX INJ 30/0.3ML HEPARINS ENOXAPARIN SODIUM INJ 30 MG/0.3ML NP Y N Y N LOVENOX LOVENOX INJ 300/3ML HEPARINS ENOXAPARIN SODIUM INJ 300 MG/3ML NP Y N Y N LOVENOX LOVENOX INJ 40/0.4ML HEPARINS ENOXAPARIN SODIUM INJ 40 MG/0.4ML NP Y N Y N LOVENOX LOVENOX INJ 60/0.6ML HEPARINS ENOXAPARIN SODIUM INJ 60 MG/0.6ML NP Y N Y N LOVENOX LOVENOX INJ 80/0.8ML HEPARINS ENOXAPARIN SODIUM INJ 80 MG/0.8ML NP Y N Y N CIMETIDINE CIMETIDINE TAB 300MG HISTAMINE H2-ANTAGONISTS CIMETIDINE TAB 300 MG P N N Y N CIMETIDINE CIMETIDINE TAB 400MG HISTAMINE H2-ANTAGONISTS CIMETIDINE TAB 400 MG P N N Y N CIMETIDINE CIMETIDINE TAB 800MG HISTAMINE H2-ANTAGONISTS CIMETIDINE TAB 800 MG P N N Y N CIMETIDINE 200 CIMETIDINE TAB 200MG HISTAMINE H2-ANTAGONISTS CIMETIDINE TAB 200 MG P N N Y N FAMOTIDINE FAMOTIDINE TAB 10MG HISTAMINE H2-ANTAGONISTS FAMOTIDINE TAB 10 MG P N N Y N NIZATIDINE NIZATIDINE CAP 150MG HISTAMINE H2-ANTAGONISTS NIZATIDINE CAP 150 MG NP Y N N N NIZATIDINE NIZATIDINE SOL 15MG/ML HISTAMINE H2-ANTAGONISTS NIZATIDINE ORAL SOLN 15 MG/ML NP Y N Y N FUZEON FUZEON INJ 90MG HIV ENTRY AND FUSION INHIBITORS ENFUVIRTIDE FOR INJ 90 MG P N N Y N RUKOBIA RUKOBIA TAB 600MG ER HIV ENTRY AND FUSION INHIBITORS FOSTEMSAVIR TROMETHAMINE TAB ER 12HR 600 MG NP Y N Y N SELZENTRY SELZENTRY SOL 20MG/ML HIV ENTRY AND FUSION INHIBITORS MARAVIROC ORAL SOLN 20 MG/ML P N N Y N SELZENTRY SELZENTRY TAB 25MG HIV ENTRY AND FUSION INHIBITORS MARAVIROC TAB 25 MG P N N Y N SELZENTRY SELZENTRY TAB 75MG HIV ENTRY AND FUSION INHIBITORS MARAVIROC TAB 75 MG P N N Y N BIKTARVY BIKTARVY TAB HIV INTEGRASE INHIBITOR ANTIRETROVIRALS BICTEGRAVIR-EMTRICITABINE-TENOFOVIR AF TAB 50-200-25 MG P Y N Y N DOVATO DOVATO TAB 50-300MG HIV INTEGRASE INHIBITOR ANTIRETROVIRALS DOLUTEGRAVIR SODIUM-LAMIVUDINE TAB 50-300 MG (BASE EQ) P N N YN GENVOYA GENVOYA TAB HIV INTEGRASE INHIBITOR ANTIRETROVIRALS ELVITEGRAV-COBIC-EMTRICITAB-TENOFOV AF TAB 150-150-200-10 MG P Y N Y N ISENTRESS ISENTRESS CHW 25MG HIV INTEGRASE INHIBITOR ANTIRETROVIRALS RALTEGRAVIR POTASSIUM CHEW TAB 25 MG (BASE EQUIV) P N N Y N ISENTRESS ISENTRESS TAB 400MG HIV INTEGRASE INHIBITOR ANTIRETROVIRALS RALTEGRAVIR POTASSIUM TAB 400 MG (BASE EQUIV) P N N Y N ISENTRESS HD ISENTRESS HD TAB 600MG HIV INTEGRASE INHIBITOR ANTIRETROVIRALS RALTEGRAVIR POTASSIUM TAB 600 MG (BASE EQUIV) P N N Y N JULUCA JULUCA TAB 50-25MG HIV INTEGRASE INHIBITOR ANTIRETROVIRALS DOLUTEGRAVIR SODIUM-RILPIVIRINE HCL TAB 50-25 MG (BASE EQ) PNNYN STRIBILD STRIBILD TAB HIV INTEGRASE INHIBITOR ANTIRETROVIRALS ELVITEGRAV-COBIC-EMTRICITAB-TENOFOVDF TAB 150-150-200-300 MG P Y N Y N TIVICAY TIVICAY TAB 10MG HIV INTEGRASE INHIBITOR ANTIRETROVIRALS DOLUTEGRAVIR SODIUM TAB 10 MG (BASE EQUIV) P N N Y N TIVICAY PD TIVICAY PD TAB 5MG HIV INTEGRASE INHIBITOR ANTIRETROVIRALS DOLUTEGRAVIR SODIUM TAB FOR ORAL SUSP 5 MG (BASE EQUIV) P N N YY COMPLERA COMPLERA TAB HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. EMTRICITABINE-RILPIVIRINE-TENOFOVIR DF TAB 200-25-300 MG P Y N Y N DELSTRIGO DELSTRIGO TAB HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. DORAVIRINE-LAMIVUDINE-TENOFOVIR DF TAB 100-300-300 MG P N N Y N EDURANT EDURANT TAB 25MG HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. RILPIVIRINE HCL TAB 25 MG (BASE EQUIVALENT) P N N Y N EFAVIRENZ EFAVIRENZ CAP 50MG HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. EFAVIRENZ CAP 50 MG P N N Y N EFAVIRENZ EFAVIRENZ TAB 600MG HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. EFAVIRENZ TAB 600 MG P N N Y N EFAVIRENZ/LAMIVUDINE/TENOFOVIR DISOEFAVIR/LAMIV TAB TENOFOVI HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. EFAVIRENZ-LAMIVUDINE-TENOFOVIR DF TAB 400-300-300 MG P N N Y N INTELENCE INTELENCE TAB 100MG HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. ETRAVIRINE TAB 100 MG P N N Y N INTELENCE INTELENCE TAB 25MG HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. ETRAVIRINE TAB 25 MG P N N Y N NEVIRAPINE NEVIRAPINE SUS 50MG/5ML HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. NEVIRAPINE SUSP 50 MG/5ML P N N Y N NEVIRAPINE NEVIRAPINE TAB 200MG HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. NEVIRAPINE TAB 200 MG P N N Y N NEVIRAPINE ER NEVIRAPINE TAB 100MG HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. NEVIRAPINE TAB ER 24HR 100 MG P N N Y N NEVIRAPINE ER NEVIRAPINE TAB 400MG ER HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. NEVIRAPINE TAB ER 24HR 400 MG P N N Y N PIFELTRO PIFELTRO TAB 100MG HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. DORAVIRINE TAB 100 MG NP Y N Y N SUSTIVA SUSTIVA CAP 50MG HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. EFAVIRENZ CAP 50 MG NP Y N Y N SUSTIVA SUSTIVA TAB 600MG HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. EFAVIRENZ TAB 600 MG NP Y N Y N

Confidential 2/19/2021 Page 55 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) SYMFI SYMFI TAB HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. EFAVIRENZ-LAMIVUDINE-TENOFOVIR DF TAB 600-300-300 MG NP Y N Y N SYMFI LO SYMFI LO TAB HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. EFAVIRENZ-LAMIVUDINE-TENOFOVIR DF TAB 400-300-300 MG NP Y N Y N VIRAMUNE VIRAMUNE SUS 50MG/5ML HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. NEVIRAPINE SUSP 50 MG/5ML P N N Y N VIRAMUNE XR VIRAMUNE XR TAB 400MG HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. NEVIRAPINE TAB ER 24HR 400 MG NP Y N Y N ABACAVIR ABACAVIR SOL 20MG/ML HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS ABACAVIR SULFATE SOLN 20 MG/ML (BASE EQUIV) P N N Y N ABACAVIR ABACAVIR TAB 300MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS ABACAVIR SULFATE TAB 300 MG (BASE EQUIV) P N N Y N ABACAVIR SULFATE/LAMIVUDINE ABACA/LAMIVU TAB 600-300 HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS ABACAVIR SULFATE-LAMIVUDINE TAB 600-300 MG P N N Y N ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDABACAV/LAMIV TAB /ZIDOVUD HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE TAB 300-150-300 MG P N N Y N ATRIPLA ATRIPLA TAB HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS EFAVIRENZ-EMTRICITABINE-TENOFOVIR DF TAB 600-200-300 MG NP Y N Y N CIMDUO CIMDUO TAB 300-300 HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS LAMIVUDINE-TENOFOVIR DISOPROXIL FUMARATE TAB 300-300 MG NP YNYN DESCOVY DESCOVY TAB 200/25MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS EMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TAB 200-25 MG NP Y N Y N DIDANOSINE DIDANOSINE CAP 200MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS DIDANOSINE DELAYED RELEASE CAPSULE 200 MG P N N Y N EFAVIRENZ/EMTRICITABINE/TENOFOVIR D EFAVIR/EMTRI TAB TENOFOVI HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS EFAVIRENZ-EMTRICITABINE-TENOFOVIR DF TAB 600-200-300 MG NP Y N Y N EMTRICITABINE EMTRICITABIN CAP 200MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS EMTRICITABINE CAPS 200 MG P N N Y N EMTRICITABINE/TENOFOVIR DISOPROXIL EMTR/TEN DF TAB 167-250 HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 167-250 MG P N N Y N EMTRICITABINE/TENOFOVIR DISOPROXIL F EMTR/TEN DF TAB 100-150 HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 100-150 MG P N N Y N EMTRIVA EMTRIVA CAP 200MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS EMTRICITABINE CAPS 200 MG NP Y N Y N EMTRIVA EMTRIVA SOL 10MG/ML HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS EMTRICITABINE SOLN 10 MG/ML P N N Y N EPIVIR HBV EPIVIR HBV SOL 5MG/ML HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS LAMIVUDINE ORAL SOLN 5 MG/ML (HBV) P N N Y N EPIVIR HBV EPIVIR HBV TAB 100MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS LAMIVUDINE TAB 100 MG (HBV) NP Y N Y N EPZICOM EPZICOM TAB 600-300 HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS ABACAVIR SULFATE-LAMIVUDINE TAB 600-300 MG NP Y N Y N LAMIVUDINE LAMIVUDINE SOL 10MG/ML HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS LAMIVUDINE ORAL SOLN 10 MG/ML P N N Y N LAMIVUDINE LAMIVUDINE TAB 150MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS LAMIVUDINE TAB 150 MG P N N Y N LAMIVUDINE LAMIVUDINE TAB 300MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS LAMIVUDINE TAB 300 MG P N N Y N LAMIVUDINE/ZIDOVUDINE LAMIVUD/ZIDO TAB 150-300 HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS LAMIVUDINE-ZIDOVUDINE TAB 150-300 MG P N N Y N ODEFSEY ODEFSEY TAB HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS EMTRICITABINE-RILPIVIRINE-TENOFOVIR AF TAB 200-25-25 MG P N N Y N RETROVIR RETROVIR CAP 100MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS ZIDOVUDINE CAP 100 MG NP Y N Y N RETROVIR RETROVIR SYP 50MG/5ML HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS ZIDOVUDINE SYRUP 10 MG/ML NP Y N Y N STAVUDINE STAVUDINE CAP 15MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS STAVUDINE CAP 15 MG P N N Y N TEMIXYS TEMIXYS TAB 300-300 HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS LAMIVUDINE-TENOFOVIR DISOPROXIL FUMARATE TAB 300-300 MG P NNYN TENOFOVIR DISOPROXIL FUMARATE TENOFOVIR TAB 300MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG P N N Y N TRIUMEQ TRIUMEQ TAB HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TAB 600-50-300 MG P N N Y N TRIZIVIR TRIZIVIR TAB HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE TAB 300-150-300 MG NP Y N Y N TRUVADA TRUVADA TAB 100-150 HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 100-150 MG P N N Y N TRUVADA TRUVADA TAB 200-300 HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG NP Y N Y N VIREAD VIREAD TAB 150MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS TENOFOVIR DISOPROXIL FUMARATE TAB 150 MG P N N Y N VIREAD VIREAD TAB 300MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG NP Y N Y N ZERIT ZERIT CAP 30MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS STAVUDINE CAP 30 MG NP Y N Y N ZIDOVUDINE ZIDOVUDINE CAP 100MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS ZIDOVUDINE CAP 100 MG P N N Y N ZIDOVUDINE ZIDOVUDINE SYP 50MG/5ML HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS ZIDOVUDINE SYRUP 10 MG/ML P N N Y N ZIDOVUDINE ZIDOVUDINE TAB 300MG HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS ZIDOVUDINE TAB 300 MG P N N Y N APTIVUS APTIVUS CAP 250MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS TIPRANAVIR CAP 250 MG P N N Y N APTIVUS APTIVUS SOL HIV PROTEASE INHIBITOR ANTIRETROVIRALS TIPRANAVIR ORAL SOLN 100 MG/ML P N N Y N ATAZANAVIR SULFATE ATAZANAVIR CAP 150MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS ATAZANAVIR SULFATE CAP 150 MG (BASE EQUIV) P N N Y N ATAZANAVIR SULFATE ATAZANAVIR CAP 300MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS ATAZANAVIR SULFATE CAP 300 MG (BASE EQUIV) P N N Y N CRIXIVAN CRIXIVAN CAP 200MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS INDINAVIR SULFATE CAP 200 MG P N N Y N CRIXIVAN CRIXIVAN CAP 400MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS INDINAVIR SULFATE CAP 400 MG P N N Y N EVOTAZ EVOTAZ TAB 300-150 HIV PROTEASE INHIBITOR ANTIRETROVIRALS ATAZANAVIR SULFATE-COBICISTAT TAB 300-150 MG (BASE EQUIV) P N NYN

Confidential 2/19/2021 Page 56 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) FOSAMPRENAVIR CALCIUM FOSAMPRENAVI TAB 700MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS FOSAMPRENAVIR CALCIUM TAB 700 MG (BASE EQUIV) P NNYN INVIRASE INVIRASE TAB 500MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS SAQUINAVIR MESYLATE TAB 500 MG P N N Y N KALETRA KALETRA SOL HIV PROTEASE INHIBITOR ANTIRETROVIRALS LOPINAVIR-RITONAVIR SOLN 400-100 MG/5ML (80-20 MG/ML) NP Y N Y N KALETRA KALETRA TAB 100-25MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS LOPINAVIR-RITONAVIR TAB 100-25 MG P N N Y N KALETRA KALETRA TAB 200-50MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS LOPINAVIR-RITONAVIR TAB 200-50 MG P N N Y N LEXIVA LEXIVA SUS 50MG/ML HIV PROTEASE INHIBITOR ANTIRETROVIRALS FOSAMPRENAVIR CALCIUM SUSP 50 MG/ML (BASE EQUIV) P N N Y N LEXIVA LEXIVA TAB 700MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS FOSAMPRENAVIR CALCIUM TAB 700 MG (BASE EQUIV) NP Y N Y N LOPINAVIR/RITONAVIR LOPIN/RITON SOL 80-20/ML HIV PROTEASE INHIBITOR ANTIRETROVIRALS LOPINAVIR-RITONAVIR SOLN 400-100 MG/5ML (80-20 MG/ML) P N N Y N NORVIR NORVIR SOL 80MG/ML HIV PROTEASE INHIBITOR ANTIRETROVIRALS RITONAVIR ORAL SOLN 80 MG/ML P N N Y N NORVIR NORVIR TAB 100MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS RITONAVIR TAB 100 MG NP Y N Y N PREZCOBIX PREZCOBIX TAB 800-150 HIV PROTEASE INHIBITOR ANTIRETROVIRALS DARUNAVIR-COBICISTAT TAB 800-150 MG P N N Y N PREZISTA PREZISTA SUS 100MG/ML HIV PROTEASE INHIBITOR ANTIRETROVIRALS DARUNAVIR ETHANOLATE SUSP 100 MG/ML (BASE EQUIV) P N N Y N PREZISTA PREZISTA TAB 150MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS DARUNAVIR ETHANOLATE TAB 150 MG (BASE EQUIV) P N N Y N PREZISTA PREZISTA TAB 75MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS DARUNAVIR ETHANOLATE TAB 75 MG (BASE EQUIV) P N N Y N PREZISTA PREZISTA TAB 800MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS DARUNAVIR ETHANOLATE TAB 800 MG (BASE EQUIV) P N N Y N REYATAZ REYATAZ CAP 150MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS ATAZANAVIR SULFATE CAP 150 MG (BASE EQUIV) NP Y N Y N REYATAZ REYATAZ CAP 300MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS ATAZANAVIR SULFATE CAP 300 MG (BASE EQUIV) NP Y N Y N RITONAVIR RITONAVIR TAB 100MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS RITONAVIR TAB 100 MG P N N Y N SYMTUZA SYMTUZA TAB HIV PROTEASE INHIBITOR ANTIRETROVIRALS DARUNAVIR-COBIC-EMTRICITAB-TENOFOV AF TAB 800-150-200-10 MG NP Y N Y N VIRACEPT VIRACEPT TAB 250MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS NELFINAVIR MESYLATE TAB 250 MG P N N Y N VIRACEPT VIRACEPT TAB 625MG HIV PROTEASE INHIBITOR ANTIRETROVIRALS NELFINAVIR MESYLATE TAB 625 MG P N N Y N ALTOPREV ALTOPREV TAB 20MG ER HMG-COA REDUCTASE INHIBITORS LOVASTATIN TAB ER 24HR 20 MG NP Y N Y N ATORVASTATIN CALCIUM ATORVASTATIN TAB 10MG HMG-COA REDUCTASE INHIBITORS ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) P N N Y N CRESTOR CRESTOR TAB 5MG HMG-COA REDUCTASE INHIBITORS ROSUVASTATIN CALCIUM TAB 5 MG NP Y N Y N EZALLOR SPRINKLE EZALLOR SPR CAP 5MG HMG-COA REDUCTASE INHIBITORS ROSUVASTATIN CALCIUM SPRINKLE CAP 5 MG (BASE EQUIVALENT) NP Y N Y N EZETIMIBE/SIMVASTATIN EZETIM/SIMVA TAB 10-10MG HMG-COA REDUCTASE INHIBITORS EZETIMIBE-SIMVASTATIN TAB 10-10 MG NP Y N Y N FLOLIPID FLOLIPID SUS 20MG/5ML HMG-COA REDUCTASE INHIBITORS SIMVASTATIN SUSP 20 MG/5ML (4 MG/ML) NP Y N Y N FLOLIPID FLOLIPID SUS 40MG/5ML HMG-COA REDUCTASE INHIBITORS SIMVASTATIN SUSP 40 MG/5ML (8 MG/ML) NP Y N Y N FLUVASTATIN FLUVASTATIN CAP 20MG HMG-COA REDUCTASE INHIBITORS FLUVASTATIN SODIUM CAP 20 MG (BASE EQUIVALENT) NP Y N Y N FLUVASTATIN FLUVASTATIN CAP 40MG HMG-COA REDUCTASE INHIBITORS FLUVASTATIN SODIUM CAP 40 MG (BASE EQUIVALENT) NP Y N N N FLUVASTATIN SODIUM ER FLUVASTATIN TAB 80MG ER HMG-COA REDUCTASE INHIBITORS FLUVASTATIN SODIUM TAB ER 24 HR 80 MG (BASE EQUIVALENT)NPYNNN LESCOL XL LESCOL XL TAB 80MG HMG-COA REDUCTASE INHIBITORS FLUVASTATIN SODIUM TAB ER 24 HR 80 MG (BASE EQUIVALENT) NP Y N N N LIPITOR LIPITOR TAB 10MG HMG-COA REDUCTASE INHIBITORS ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) NP Y N Y N LIVALO LIVALO TAB 1MG HMG-COA REDUCTASE INHIBITORS PITAVASTATIN CALCIUM TAB 1 MG NP Y N Y N LOVASTATIN LOVASTATIN TAB 10MG HMG-COA REDUCTASE INHIBITORS LOVASTATIN TAB 10 MG P N N Y Y LOVASTATIN LOVASTATIN TAB 40MG HMG-COA REDUCTASE INHIBITORS LOVASTATIN TAB 40 MG P N N Y Y PRAVACHOL PRAVACHOL TAB 20MG HMG-COA REDUCTASE INHIBITORS PRAVASTATIN SODIUM TAB 20 MG NP Y N Y N PRAVASTATIN SODIUM PRAVASTATIN TAB 10MG HMG-COA REDUCTASE INHIBITORS PRAVASTATIN SODIUM TAB 10 MG NP Y N Y N ROSUVASTATIN CALCIUM ROSUVASTATIN TAB 5MG HMG-COA REDUCTASE INHIBITORS ROSUVASTATIN CALCIUM TAB 5 MG P N N Y N SIMVASTATIN SIMVASTATIN TAB 5MG HMG-COA REDUCTASE INHIBITORS SIMVASTATIN TAB 5 MG P N N Y N VYTORIN VYTORIN TAB 10-10MG HMG-COA REDUCTASE INHIBITORS EZETIMIBE-SIMVASTATIN TAB 10-10 MG NP Y N Y N ZOCOR ZOCOR TAB 10MG HMG-COA REDUCTASE INHIBITORS SIMVASTATIN TAB 10 MG NP Y N Y N ZYPITAMAG ZYPITAMAG TAB 2MG HMG-COA REDUCTASE INHIBITORS PITAVASTATIN MAGNESIUM TAB 2 MG (BASE EQUIV) NP Y N Y N DILANTIN DILANTIN CAP 100MG HYDANTOINS PHENYTOIN SODIUM EXTENDED CAP 100 MG P N N Y N DILANTIN DILANTIN CAP 30MG HYDANTOINS PHENYTOIN SODIUM EXTENDED CAP 30 MG P N N N N DILANTIN INFATABS DILANTIN CHW 50MG HYDANTOINS PHENYTOIN CHEW TAB 50 MG P N N Y N DILANTIN-125 DILANTIN-125 SUS 125/5ML HYDANTOINS PHENYTOIN SUSP 125 MG/5ML NP Y N Y N PHENYTEK PHENYTEK CAP 200MG HYDANTOINS PHENYTOIN SODIUM EXTENDED CAP 200 MG NP Y N Y N

Confidential 2/19/2021 Page 57 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) PHENYTEK PHENYTEK CAP 300MG HYDANTOINS PHENYTOIN SODIUM EXTENDED CAP 300 MG P N N Y N PHENYTOIN PHENYTOIN CHW 50MG HYDANTOINS PHENYTOIN CHEW TAB 50 MG P N N Y N PHENYTOIN PHENYTOIN SUS 100/4ML HYDANTOINS PHENYTOIN SUSP 125 MG/5ML P N N Y N PHENYTOIN INFATABS PHENYTOIN CHW 50MG HYDANTOINS PHENYTOIN CHEW TAB 50 MG P N N Y N PHENYTOIN SODIUM EXTENDED PHENYTOIN EX CAP 100MG HYDANTOINS PHENYTOIN SODIUM EXTENDED CAP 100 MG P N N Y N CICLODAN CICLODAN SOL 8% HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE) CICLOPIROX SOLUTION 8% P N N Y N CICLOPIROX CICLOPIROX GEL 0.77% HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE) CICLOPIROX GEL 0.77% NP Y N N N CICLOPIROX CICLOPIROX SUS 0.77% HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE) CICLOPIROX OLAMINE SUSP 0.77% (BASE EQUIV) NP Y N Y N CICLOPIROX NAIL LACQUER CICLOPIROX SOL 8% HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE) CICLOPIROX SOLUTION 8% P N N Y N CICLOPIROX OLAMINE CICLOPIROX CRE 0.77% HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE) CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV) NP Y N YN CICLOPIROX TREATMENT CICLOPIROX KIT 8% HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE) CICLOPIROX SOLUTION KIT 8% NP Y N N N LOPROX LOPROX CRE 0.77% HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE) CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV) NP Y N Y N LOPROX LOPROX KIT 0.77% HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE) *CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV) & CLEANSER KIT*NPYNNN LOPROX LOPROX SUS 0.77% HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE) CICLOPIROX OLAMINE SUSP 0.77% (BASE EQUIV) NP Y N Y N VECAMYL VECAMYL TAB 2.5MG HYPOTENSIVE AGENTS, MISCELLANEOUS MECAMYLAMINE HCL TAB 2.5 MG NP Y N Y N ACTIMMUNE ACTIMMUNE INJ 2MU/0.5 IMMUNOMODULATORY AGENTS INTERFERON GAMMA-1B INJ 100 MCG/0.5ML (2000000 UNIT/0.5ML) P Y N N N AUBAGIO AUBAGIO TAB 7MG IMMUNOMODULATORY AGENTS TERIFLUNOMIDE TAB 7 MG P Y N Y N AVONEX AVONEX PREFL KIT 30MCG IMMUNOMODULATORY AGENTS INTERFERON BETA-1A IM PREFILLED SYRINGE KIT 30 MCG/0.5ML NP Y N Y N AVONEX PEN AVONEX PEN KIT 30MCG IMMUNOMODULATORY AGENTS INTERFERON BETA-1A IM AUTO-INJECTOR KIT 30 MCG/0.5ML NP Y N Y N BAFIERTAM BAFIERTAM CAP 95MG IMMUNOMODULATORY AGENTS MONOMETHYL FUMARATE CAPSULE DELAYED RELEASE 95 MG NP Y N Y N BETASERON BETASERON INJ 0.3MG IMMUNOMODULATORY AGENTS INTERFERON BETA-1B FOR INJ KIT 0.3 MG NP Y N N N COPAXONE COPAXONE INJ 20MG/ML IMMUNOMODULATORY AGENTS GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML NP Y N Y N COPAXONE COPAXONE INJ 40MG/ML IMMUNOMODULATORY AGENTS GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 40 MG/ML P Y N Y N DIMETHYL FUMARATE DIMETHYL FUM CAP 120MG DR IMMUNOMODULATORY AGENTS DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG P Y N Y N DIMETHYL FUMARATE STARTERPACK DIMETHYL FUM MIS STARTER IMMUNOMODULATORY AGENTS DIMETHYL FUMARATE CAPSULE DR STARTER PACK 120 MG & 240 MG P Y N Y N ENSPRYNG ENSPRYNG INJ IMMUNOMODULATORY AGENTS SATRALIZUMAB-MWGE SUBCUTANEOUS SOLN PREF SYRINGE 120 MG/ML NP Y N Y N EXTAVIA EXTAVIA INJ 0.3MG IMMUNOMODULATORY AGENTS INTERFERON BETA-1B FOR INJ KIT 0.3 MG NP Y N N N GILENYA GILENYA CAP 0.25MG IMMUNOMODULATORY AGENTS FINGOLIMOD HCL CAP 0.25 MG (BASE EQUIV) P Y N Y N GLATIRAMER ACETATE GLATIRAMER INJ 20MG/ML IMMUNOMODULATORY AGENTS GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML P Y N Y N GLATIRAMER ACETATE GLATIRAMER INJ 40MG/ML IMMUNOMODULATORY AGENTS GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 40 MG/ML P Y N Y N GLATOPA GLATOPA INJ 20MG/ML IMMUNOMODULATORY AGENTS GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML P Y N Y N GLATOPA GLATOPA INJ 40MG/ML IMMUNOMODULATORY AGENTS GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 40 MG/ML P Y N Y N KESIMPTA KESIMPTA INJ 20/.4ML IMMUNOMODULATORY AGENTS OFATUMUMAB SOLN AUTO-INJECTOR 20 MG/0.4ML NP Y N Y N MAYZENT MAYZENT TAB 0.25MG IMMUNOMODULATORY AGENTS SIPONIMOD FUMARATE TAB 0.25 MG (BASE EQUIV) P Y N Y N MAYZENT MAYZENT TAB 2MG IMMUNOMODULATORY AGENTS SIPONIMOD FUMARATE TAB 2 MG (BASE EQUIV) P Y N Y N MAYZENT STARTER PACK MAYZENT STAR PAK 0.25MG IMMUNOMODULATORY AGENTS SIPONIMOD FUMARATE TAB 0.25 MG (12) STARTER PACK P Y N Y N PLEGRIDY PLEGRIDY INJ PEN IMMUNOMODULATORY AGENTS PEGINTERFERON BETA-1A SOLN PEN-INJECTOR 125 MCG/0.5ML P Y N Y N PLEGRIDY STARTER PACK PLEGRIDY PEN INJ STARTER IMMUNOMODULATORY AGENTS PEGINTERFERON BETA-1A SOLN PEN-INJ 63 & 94 MCG/0.5ML PACK P Y NNN REBIF REBIF INJ 22/0.5 IMMUNOMODULATORY AGENTS INTERFERON BETA-1A SOLN PREF SYR 22 MCG/0.5ML (12MU/ML) NP Y N Y N REBIF REBIDOSE REBIF REBIDO INJ 22/0.5 IMMUNOMODULATORY AGENTS INTERFERON BETA-1A SOLN AUTO-INJ 22 MCG/0.5ML (12MU/ML) NP Y N Y N REBIF REBIDOSE TITRATION PACK REBIF REBIDO INJ TITRATN IMMUNOMODULATORY AGENTS INTERFERON BETA-1A AUTO-INJ 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML NP Y N Y N REBIF TITRATION PACK REBIF TITRTN INJ PACK IMMUNOMODULATORY AGENTS INTERFERON BETA-1A PREF SYR 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML NP Y NYN TECFIDERA TECFIDERA CAP 120MG IMMUNOMODULATORY AGENTS DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG NP Y N Y N TECFIDERA STARTER PACK TECFIDERA MIS STARTER IMMUNOMODULATORY AGENTS DIMETHYL FUMARATE CAPSULE DR STARTER PACK 120 MG & 240 MG NPYNYN THALOMID THALOMID CAP 100MG IMMUNOMODULATORY AGENTS THALIDOMIDE CAP 100 MG P Y N Y N THALOMID THALOMID CAP 50MG IMMUNOMODULATORY AGENTS THALIDOMIDE CAP 50 MG P Y N Y N VUMERITY VUMERITY CAP 231MG IMMUNOMODULATORY AGENTS DIROXIMEL FUMARATE CAPSULE DELAYED RELEASE 231 MG NP Y N Y N ZEPOSIA ZEPOSIA CAP .92MG IMMUNOMODULATORY AGENTS OZANIMOD HCL CAP 0.92 MG NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ZEPOSIA 7-DAY STARTER PACK ZEPOSIA 7DAY CAP STR PACK IMMUNOMODULATORY AGENTS OZANIMOD CAP PACK 4 X 0.23 MG & 3 X 0.46 MG NP Y N Y N ZEPOSIA STARTER KIT ZEPOSIA CAP STR KIT IMMUNOMODULATORY AGENTS OZANIMOD CAP PACK 4 X 0.23 MG & 3 X 0.46 MG & 30 X 0.92 MG NP Y NYN ASTAGRAF XL ASTAGRAF XL CAP 0.5MG IMMUNOSUPPRESSIVE AGENTS TACROLIMUS CAP ER 24HR 0.5 MG NP Y N Y N ASTAGRAF XL ASTAGRAF XL CAP 5MG IMMUNOSUPPRESSIVE AGENTS TACROLIMUS CAP ER 24HR 5 MG NP Y N N N AZASAN AZASAN TAB 75 MG IMMUNOSUPPRESSIVE AGENTS AZATHIOPRINE TAB 75 MG NP Y N N N AZATHIOPRINE AZATHIOPRINE TAB 50MG IMMUNOSUPPRESSIVE AGENTS AZATHIOPRINE TAB 50 MG P N N Y N BENLYSTA BENLYSTA INJ 200MG/ML IMMUNOSUPPRESSIVE AGENTS BELIMUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML NP Y N Y N CELLCEPT CELLCEPT CAP 250MG IMMUNOSUPPRESSIVE AGENTS MYCOPHENOLATE MOFETIL CAP 250 MG NP Y N Y N CELLCEPT CELLCEPT SUS 200MG/ML IMMUNOSUPPRESSIVE AGENTS MYCOPHENOLATE MOFETIL FOR ORAL SUSP 200 MG/ML NP Y N Y N CELLCEPT CELLCEPT TAB 500MG IMMUNOSUPPRESSIVE AGENTS MYCOPHENOLATE MOFETIL TAB 500 MG NP Y N Y N CYCLOSPORINE CYCLOSPORINE CAP 100MG IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE CAP 100 MG P N N Y N CYCLOSPORINE CYCLOSPORINE CAP 25MG IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE CAP 25 MG P N N Y N CYCLOSPORINE MODIFIED CYCLOSPORINE CAP 100MG MD IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE MODIFIED CAP 100 MG P N N Y N CYCLOSPORINE MODIFIED CYCLOSPORINE CAP 25MG MOD IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE MODIFIED CAP 25 MG P N N N N CYCLOSPORINE MODIFIED CYCLOSPORINE CAP 50MG MOD IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE MODIFIED CAP 50 MG P N N Y N ENVARSUS XR ENVARSUS XR TAB 0.75MG IMMUNOSUPPRESSIVE AGENTS TACROLIMUS TAB ER 24HR 0.75 MG NP Y N Y N ENVARSUS XR ENVARSUS XR TAB 4MG IMMUNOSUPPRESSIVE AGENTS TACROLIMUS TAB ER 24HR 4 MG NP Y N N N EVEROLIMUS EVEROLIMUS TAB 0.25MG IMMUNOSUPPRESSIVE AGENTS EVEROLIMUS TAB 0.25 MG P N N N N GENGRAF GENGRAF CAP 100MG IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE MODIFIED CAP 100 MG P N N Y N GENGRAF GENGRAF CAP 25MG IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE MODIFIED CAP 25 MG P N N N N GENGRAF GENGRAF SOL 100MG/ML IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE MODIFIED ORAL SOLN 100 MG/ML NP Y N N N IMURAN IMURAN TAB 50MG IMMUNOSUPPRESSIVE AGENTS AZATHIOPRINE TAB 50 MG NP Y N Y N MAVENCLAD MAVENCLAD PAK 10MG(4) IMMUNOSUPPRESSIVE AGENTS CLADRIBINE TAB THERAPY PACK 10 MG (4 TABS) NP Y N Y N MYCOPHENOLATE MOFETIL MYCOPHENOLAT CAP 250MG IMMUNOSUPPRESSIVE AGENTS MYCOPHENOLATE MOFETIL CAP 250 MG P N N Y N MYCOPHENOLATE MOFETIL MYCOPHENOLAT SUS 200MG/ML IMMUNOSUPPRESSIVE AGENTS MYCOPHENOLATE MOFETIL FOR ORAL SUSP 200 MG/ML P N N Y N MYCOPHENOLATE MOFETIL MYCOPHENOLAT TAB 500MG IMMUNOSUPPRESSIVE AGENTS MYCOPHENOLATE MOFETIL TAB 500 MG P N N Y N MYCOPHENOLIC ACID DR MYCOPHENOLIC TAB 180MG DR IMMUNOSUPPRESSIVE AGENTS MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV) P N N Y N MYCOPHENOLIC ACID DR MYCOPHENOLIC TAB 360MG DR IMMUNOSUPPRESSIVE AGENTS MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV) P N N Y N MYFORTIC MYFORTIC TAB 180MG IMMUNOSUPPRESSIVE AGENTS MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV) NP Y N Y N MYFORTIC MYFORTIC TAB 360MG IMMUNOSUPPRESSIVE AGENTS MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV) NP Y N Y N NEORAL NEORAL CAP 100MG IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE MODIFIED CAP 100 MG NP Y N Y N NEORAL NEORAL CAP 25MG IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE MODIFIED CAP 25 MG NP Y N N N PROGRAF PROGRAF CAP 0.5MG IMMUNOSUPPRESSIVE AGENTS TACROLIMUS CAP 0.5 MG NP Y N N N PROGRAF PROGRAF CAP 1MG IMMUNOSUPPRESSIVE AGENTS TACROLIMUS CAP 1 MG NP Y N Y N RAPAMUNE RAPAMUNE TAB 0.5MG IMMUNOSUPPRESSIVE AGENTS SIROLIMUS TAB 0.5 MG NP Y N Y N RAPAMUNE RAPAMUNE TAB 1MG IMMUNOSUPPRESSIVE AGENTS SIROLIMUS TAB 1 MG NP Y N Y N RAPAMUNE RAPAMUNE TAB 2MG IMMUNOSUPPRESSIVE AGENTS SIROLIMUS TAB 2 MG NP Y N N N SANDIMMUNE SANDIMMUNE CAP 100MG IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE CAP 100 MG NP Y N Y N SANDIMMUNE SANDIMMUNE CAP 25MG IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE CAP 25 MG NP Y N Y N SANDIMMUNE SANDIMMUNE SOL 100MG/ML IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE ORAL SOLN 100 MG/ML NP Y N N N SIROLIMUS SIROLIMUS TAB 0.5MG IMMUNOSUPPRESSIVE AGENTS SIROLIMUS TAB 0.5 MG P N N Y N SIROLIMUS SIROLIMUS TAB 1MG IMMUNOSUPPRESSIVE AGENTS SIROLIMUS TAB 1 MG P N N Y N SIROLIMUS SIROLIMUS TAB 2MG IMMUNOSUPPRESSIVE AGENTS SIROLIMUS TAB 2 MG P N N N N TACROLIMUS TACROLIMUS CAP 0.5MG IMMUNOSUPPRESSIVE AGENTS TACROLIMUS CAP 0.5 MG P N N N N TACROLIMUS TACROLIMUS CAP 1MG IMMUNOSUPPRESSIVE AGENTS TACROLIMUS CAP 1 MG P N N Y N ZORTRESS ZORTRESS TAB 0.25MG IMMUNOSUPPRESSIVE AGENTS EVEROLIMUS TAB 0.25 MG NP Y N N N ZORTRESS ZORTRESS TAB 1MG IMMUNOSUPPRESSIVE AGENTS EVEROLIMUS TAB 1 MG P N N N N ADLYXIN ADLYXIN INJ 20MCG INCRETIN MIMETICS LIXISENATIDE SOLN PEN-INJECTOR 20 MCG/0.2ML (100 MCG/ML) P N Y Y N

Confidential 2/19/2021 Page 59 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ADLYXIN STARTER PACK ADLYXIN INJ 10/20MCG INCRETIN MIMETICS LIXISENATIDE PEN-INJ STARTER KIT 10 MCG/0.2ML & 20 MCG/0.2ML P N Y Y N BYDUREON BCISE BYDUREON BC INJ 2/0.85ML INCRETIN MIMETICS EXENATIDE EXTENDED RELEASE SUSP AUTO-INJECTOR 2 MG/0.85ML NP Y N Y N BYDUREON PEN BYDUREON PEN INJ 2MG INCRETIN MIMETICS EXENATIDE EXTENDED RELEASE FOR SUSP PEN-INJECTOR 2 MG NP Y N Y N BYETTA BYETTA INJ 10MCG INCRETIN MIMETICS EXENATIDE SOLN PEN-INJECTOR 10 MCG/0.04ML NP Y N Y N BYETTA BYETTA INJ 5MCG INCRETIN MIMETICS EXENATIDE SOLN PEN-INJECTOR 5 MCG/0.02ML NP Y N Y N OZEMPIC OZEMPIC INJ 2/1.5ML INCRETIN MIMETICS SEMAGLUTIDE SOLN PEN-INJ 0.25 OR 0.5 MG/DOSE (2 MG/1.5ML) NP Y N Y N RYBELSUS RYBELSUS TAB 3MG INCRETIN MIMETICS SEMAGLUTIDE TAB 3 MG NP Y N Y N TRULICITY TRULICITY INJ 0.75/0.5 INCRETIN MIMETICS DULAGLUTIDE SOLN PEN-INJECTOR 0.75 MG/0.5ML P N Y Y N VICTOZA VICTOZA INJ 18MG/3ML INCRETIN MIMETICS LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML) P N Y Y N NOVOLIN 70/30 NOVOLIN INJ 70/30 INSULINS INSULIN NPH ISOPHANE & REGULAR HUMAN INJ 100 UNIT/ML (70-30) P N N Y N NOVOLIN N NOVOLIN N INJ U-100 INSULINS INSULIN NPH (HUMAN) (ISOPHANE) INJ 100 UNIT/ML P N N Y N NOVOLIN R NOVOLIN R INJ U-100 INSULINS INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML P N N Y N NOVOLOG NOVOLOG INJ 100/ML INSULINS INSULIN ASPART INJ 100 UNIT/ML NP Y N Y N RELION R RELION R INJ 100/ML INSULINS INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML P N N Y N DUPIXENT DUPIXENT INJ 200/1.14 INTERLEUKIN ANTAGONISTS DUPILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 200 MG/1.14ML NP Y N Y N FASENRA PEN FASENRA PEN INJ 30MG/ML INTERLEUKIN ANTAGONISTS BENRALIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 30 MG/ML P Y N Y N HUMULIN 70/30 HUMULIN INJ 70/30 INTERMEDIATE-ACTING INSULINS INSULIN NPH ISOPHANE & REGULAR HUMAN INJ 100 UNIT/ML (70-30) P N N Y N HUMULIN 70/30 KWIKPEN HUMULIN INJ 70/30KWP INTERMEDIATE-ACTING INSULINS INSULIN NPH & REGULAR SUSP PEN-INJ 100 UNIT/ML (70-30)NPYNYN HUMULIN N HUMULIN N INJ U-100 INTERMEDIATE-ACTING INSULINS INSULIN NPH (HUMAN) (ISOPHANE) INJ 100 UNIT/ML P N N Y N HUMULIN N KWIKPEN HUMULIN N INJ U-100KWP INTERMEDIATE-ACTING INSULINS INSULIN NPH (HUMAN) (ISOPHANE) SUSP PEN-INJECTOR 100 UNIT/ML NP Y N Y N NOVOLIN 70/30 NOVOLIN INJ 70/30 INTERMEDIATE-ACTING INSULINS INSULIN NPH ISOPHANE & REGULAR HUMAN INJ 100 UNIT/ML (70-30) P N N Y N NOVOLIN 70/30 FLEXPEN NOVOLIN INJ 70/30 FP INTERMEDIATE-ACTING INSULINS INSULIN NPH & REGULAR SUSP PEN-INJ 100 UNIT/ML (70-30)NPYNYN NOVOLIN 70/30 RELION NOVOLIN70/30 INJ RELION INTERMEDIATE-ACTING INSULINS INSULIN NPH ISOPHANE & REGULAR HUMAN INJ 100 UNIT/ML (70-30) P N N Y N NOVOLIN N NOVOLIN N INJ U-100 INTERMEDIATE-ACTING INSULINS INSULIN NPH (HUMAN) (ISOPHANE) INJ 100 UNIT/ML P N N Y N NOVOLIN N FLEXPEN NOVOLIN N INJ 100 UNIT INTERMEDIATE-ACTING INSULINS INSULIN NPH (HUMAN) (ISOPHANE) SUSP PEN-INJECTOR 100 UNIT/ML NP Y N Y N NOVOLIN N RELION NOVOLIN N INJ RELION INTERMEDIATE-ACTING INSULINS INSULIN NPH (HUMAN) (ISOPHANE) INJ 100 UNIT/ML P N N Y N ACETONE ACETONE SOL KETONES ACETONE SOLN NP Y N N N CHEMSTRIP-K CHEMSTRIP K TES KETONES ACETONE (URINE) TEST STRIP P N N Y N KETOCARE KETOCARE TES KETONES ACETONE (URINE) TEST STRIP P N N Y N KETONE KETONE TES KETONES ACETONE (URINE) TEST STRIP P N N Y N KETONE TEST STRIPS KETONE TEST TES KETONES ACETONE (URINE) TEST STRIP P N N Y N KETOSTIX KETOSTIX TES STRIP KETONES ACETONE (URINE) TEST STRIP P N N Y N RELION KETONE RELION KETON TES KETONES ACETONE (URINE) TEST STRIP P N N Y N RELION KETONE TEST STRIPS RELION TES KETONE KETONES ACETONE (URINE) TEST STRIP P N N Y N MYALEPT MYALEPT INJ 11.3MG LEPTINS METRELEPTIN FOR SUBCUTANEOUS INJ 11.3 MG NP Y N Y N ACCOLATE ACCOLATE TAB 10MG LEUKOTRIENE MODIFIERS ZAFIRLUKAST TAB 10 MG NP Y N Y N MONTELUKAST SODIUM MONTELUKAST TAB 10MG LEUKOTRIENE MODIFIERS MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV) P N N Y N SINGULAIR SINGULAIR TAB 10MG LEUKOTRIENE MODIFIERS MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV) NP Y N Y N ZAFIRLUKAST ZAFIRLUKAST TAB 10MG LEUKOTRIENE MODIFIERS ZAFIRLUKAST TAB 10 MG NP Y N Y N ZILEUTON ER ZILEUTON ER TAB 600MG LEUKOTRIENE MODIFIERS ZILEUTON TAB ER 12HR 600 MG NP Y N Y N ZYFLO ZYFLO TAB 600MG LEUKOTRIENE MODIFIERS ZILEUTON TAB 600 MG NP Y N N N CLEOCIN CLEOCIN CAP 150MG LINCOMYCIN ANTIBIOTICS CLINDAMYCIN HCL CAP 150 MG NP Y N Y N CLEOCIN CLEOCIN CAP 300MG LINCOMYCIN ANTIBIOTICS CLINDAMYCIN HCL CAP 300 MG NP Y N Y N CLEOCIN CLEOCIN CAP 75MG LINCOMYCIN ANTIBIOTICS CLINDAMYCIN HCL CAP 75 MG NP Y N Y N CLEOCIN PEDIATRIC GRANULES CLEOCIN PED SOL 75MG/5ML LINCOMYCIN ANTIBIOTICS CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV) NP Y N Y N CLINDAMYCIN HCL CLINDAMYCIN CAP 150MG LINCOMYCIN ANTIBIOTICS CLINDAMYCIN HCL CAP 150 MG P N N Y N CLINDAMYCIN HCL CLINDAMYCIN CAP 300MG LINCOMYCIN ANTIBIOTICS CLINDAMYCIN HCL CAP 300 MG P N N Y N CLINDAMYCIN HCL CLINDAMYCIN CAP 75MG LINCOMYCIN ANTIBIOTICS CLINDAMYCIN HCL CAP 75 MG NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) CLINDAMYCIN PALMITATE HCL CLINDAMYCIN SOL 75MG/5ML LINCOMYCIN ANTIBIOTICS CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV) P N N Y N BASAGLAR KWIKPEN BASAGLAR INJ 100UNIT LONG-ACTING INSULINS INSULIN GLARGINE SOLN PEN-INJECTOR 100 UNIT/ML P N N Y N LANTUS LANTUS INJ 100/ML LONG-ACTING INSULINS INSULIN GLARGINE INJ 100 UNIT/ML NP Y N Y N LANTUS SOLOSTAR LANTUS SOLOS INJ 100/ML LONG-ACTING INSULINS INSULIN GLARGINE SOLN PEN-INJECTOR 100 UNIT/ML NP Y N Y N LEVEMIR LEVEMIR INJ LONG-ACTING INSULINS INSULIN DETEMIR INJ 100 UNIT/ML NP Y N Y N LEVEMIR FLEXTOUCH LEVEMIR INJ FLEXTOUC LONG-ACTING INSULINS INSULIN DETEMIR SOLN PEN-INJECTOR 100 UNIT/ML NP Y N Y N SEMGLEE SEMGLEE INJ 100U/ML LONG-ACTING INSULINS INSULIN GLARGINE SOLN PEN-INJECTOR 100 UNIT/ML P N N Y N SEMGLEE SEMGLEE SOL 100U/ML LONG-ACTING INSULINS INSULIN GLARGINE INJ 100 UNIT/ML P N N Y N SOLIQUA 100/33 SOLIQUA INJ 100/33 LONG-ACTING INSULINS INSULIN GLARGINE-LIXISENATIDE SOL PEN-INJ 100-33 UNIT-MCG/ML P N Y Y N TOUJEO MAX SOLOSTAR TOUJEO MAX INJ 300IU/ML LONG-ACTING INSULINS INSULIN GLARGINE SOLN PEN-INJECTOR 300 UNIT/ML (2 UNIT DIAL) NP Y NYN TOUJEO SOLOSTAR TOUJEO SOLO INJ 300IU/ML LONG-ACTING INSULINS INSULIN GLARGINE SOLN PEN-INJECTOR 300 UNIT/ML (1 UNIT DIAL) NP Y N Y N TRESIBA TRESIBA INJ 100UNIT LONG-ACTING INSULINS INSULIN DEGLUDEC INJ 100 UNIT/ML NP Y N Y N TRESIBA FLEXTOUCH TRESIBA FLEX INJ 100UNIT LONG-ACTING INSULINS INSULIN DEGLUDEC SOLN PEN-INJECTOR 100 UNIT/ML NP Y N Y N XULTOPHY 100/3.6 XULTOPHY INJ 100/3.6 LONG-ACTING INSULINS INSULIN DEGLUDEC-LIRAGLUTIDE SOL PEN-INJ 100-3.6 UNIT-MG/ML NP Y N Y N BUMETANIDE BUMETANIDE TAB 0.5MG LOOP DIURETICS BUMETANIDE TAB 0.5 MG P N N Y N BUMETANIDE BUMETANIDE TAB 1MG LOOP DIURETICS BUMETANIDE TAB 1 MG P N N Y N BUMETANIDE BUMETANIDE TAB 2MG LOOP DIURETICS BUMETANIDE TAB 2 MG P N N Y N BUMEX BUMEX TAB 0.5MG LOOP DIURETICS BUMETANIDE TAB 0.5 MG NP Y N Y N EDECRIN EDECRIN TAB 25MG LOOP DIURETICS ETHACRYNIC ACID TAB 25 MG NP Y N Y N ETHACRYNIC ACID ETHACRYNIC TAB ACD 25MG LOOP DIURETICS ETHACRYNIC ACID TAB 25 MG NP Y N Y N FUROSEMIDE FUROSEMIDE SOL 8MG/ML LOOP DIURETICS FUROSEMIDE ORAL SOLN 8 MG/ML NP Y N N N FUROSEMIDE FUROSEMIDE TAB 20MG LOOP DIURETICS FUROSEMIDE TAB 20 MG P N N Y N FUROSEMIDE FUROSEMIDE TAB 80MG LOOP DIURETICS FUROSEMIDE TAB 80 MG P N N Y N LASIX LASIX TAB 20MG LOOP DIURETICS FUROSEMIDE TAB 20 MG NP Y N Y N LASIX LASIX TAB 80MG LOOP DIURETICS FUROSEMIDE TAB 80 MG NP Y N Y N TORSEMIDE TORSEMIDE TAB 100MG LOOP DIURETICS TORSEMIDE TAB 100 MG P N N Y N TORSEMIDE TORSEMIDE TAB 10MG LOOP DIURETICS TORSEMIDE TAB 10 MG P N N Y N TORSEMIDE TORSEMIDE TAB 20MG LOOP DIURETICS TORSEMIDE TAB 20 MG P N N Y N TORSEMIDE TORSEMIDE TAB 5MG LOOP DIURETICS TORSEMIDE TAB 5 MG P N N Y N CROMOLYN SODIUM CROMOLYN SOD CON 100/5ML MAST-CELL STABILIZERS CROMOLYN SODIUM ORAL CONC 100 MG/5ML NP Y N Y N CROMOLYN SODIUM CROMOLYN SOD NEB 20MG/2ML MAST-CELL STABILIZERS CROMOLYN SODIUM SOLN NEBU 20 MG/2ML P N N Y N GASTROCROM GASTROCROM CON 100/5ML MAST-CELL STABILIZERS CROMOLYN SODIUM ORAL CONC 100 MG/5ML NP Y N Y N NATEGLINIDE NATEGLINIDE TAB 60MG MEGLITINIDES NATEGLINIDE TAB 60 MG P N N Y N REPAGLINIDE REPAGLINIDE TAB 0.5MG MEGLITINIDES REPAGLINIDE TAB 0.5 MG P N N Y N REPAGLINIDE REPAGLINIDE TAB 2MG MEGLITINIDES REPAGLINIDE TAB 2 MG P N N Y N STARLIX STARLIX TAB 60MG MEGLITINIDES NATEGLINIDE TAB 60 MG NP Y N Y N ALDACTAZIDE ALDACTAZIDE TAB 25/25 MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG NP Y N Y N ALDACTAZIDE ALDACTAZIDE TAB 50/50 MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 50-50 MG NP Y N Y N ALDACTONE ALDACTONE TAB 25MG MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS SPIRONOLACTONE TAB 25 MG NP Y N Y N ALDACTONE ALDACTONE TAB 50MG MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS SPIRONOLACTONE TAB 50 MG NP Y N Y N CAROSPIR CAROSPIR SUS 25MG/5ML MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS SPIRONOLACTONE SUSP 25 MG/5ML NP Y N Y N EPLERENONE EPLERENONE TAB 25MG MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS EPLERENONE TAB 25 MG NP Y N Y N EPLERENONE EPLERENONE TAB 50MG MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS EPLERENONE TAB 50 MG NP Y N Y N INSPRA INSPRA TAB 25MG MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS EPLERENONE TAB 25 MG NP Y N Y N INSPRA INSPRA TAB 50MG MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS EPLERENONE TAB 50 MG NP Y N Y N SPIRONOLACTONE SPIRONOLACT TAB 25MG MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS SPIRONOLACTONE TAB 25 MG P N N Y N SPIRONOLACTONE SPIRONOLACT TAB 50MG MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS SPIRONOLACTONE TAB 50 MG P N N Y N SPIRONOLACTONE/HYDROCHLOROTHIAZIDSPIRONO/HCTZ TAB 25/25 MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG P N N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ISOPTO CARPINE ISOPTO CARP SOL 1% OP MIOTICS PILOCARPINE HCL OPHTH SOLN 1% NP Y N N N PHOSPHOLINE IODIDE PHOSPHOLINE SOL 0.125%OP MIOTICS ECHOTHIOPHATE IODIDE OPHTH FOR SOLN 0.125% P N N N N PILOCARPINE HCL PILOCARPINE SOL 1% OP MIOTICS PILOCARPINE HCL OPHTH SOLN 1% P N N N N PILOCARPINE HYDROCHLORIDE PILOCARPINE SOL 1% OP MIOTICS PILOCARPINE HCL OPHTH SOLN 1% P N N N N YELLOW MERC OIN 1% OP YELLOW MERC OIN 1% OP MISC. ANTI-INFECTIVES MERCURIC OXIDE, YELLOW OPHTH OINT 1% NP Y N N N CIMETIDINE TAB 400MG CIMETIDINE TAB 400MG MISC. GI DRUGS CIMETIDINE TAB 400 MG P N N Y N AZILECT AZILECT TAB 0.5MG MONOAMINE OXIDASE B INHIBITORS RASAGILINE MESYLATE TAB 0.5 MG (BASE EQUIV) NP Y N N N EMSAM EMSAM DIS 6MG/24HR MONOAMINE OXIDASE B INHIBITORS SELEGILINE TD PATCH 24HR 6 MG/24HR P N N Y N RASAGILINE MESYLATE RASAGILINE TAB 0.5MG MONOAMINE OXIDASE B INHIBITORS RASAGILINE MESYLATE TAB 0.5 MG (BASE EQUIV) NP Y N N N SELEGILINE HYDROCHLORIDE SELEGILINE CAP 5MG MONOAMINE OXIDASE B INHIBITORS SELEGILINE HCL CAP 5 MG P N N Y N XADAGO XADAGO TAB 50MG MONOAMINE OXIDASE B INHIBITORS SAFINAMIDE MESYLATE TAB 50 MG (BASE EQUIV) NP Y N Y N ZELAPAR ZELAPAR TAB 1.25MG MONOAMINE OXIDASE B INHIBITORS SELEGILINE HCL ORALLY DISINTEGRATING TAB 1.25 MG NP Y N N N MARPLAN MARPLAN TAB 10MG MONOAMINE OXIDASE INHIBITORS ISOCARBOXAZID TAB 10 MG P N N Y N NARDIL NARDIL TAB 15MG MONOAMINE OXIDASE INHIBITORS PHENELZINE SULFATE TAB 15 MG NP Y N Y N PARNATE PARNATE TAB 10MG MONOAMINE OXIDASE INHIBITORS TRANYLCYPROMINE SULFATE TAB 10 MG NP Y N Y N PHENELZINE SULFATE PHENELZINE TAB 15MG MONOAMINE OXIDASE INHIBITORS PHENELZINE SULFATE TAB 15 MG P N N Y N TRANYLCYPROMINE SULFATE TRANYLCYPROM TAB 10MG MONOAMINE OXIDASE INHIBITORS TRANYLCYPROMINE SULFATE TAB 10 MG P N N Y N CAYSTON CAYSTON INH 75MG MONOBACTAM ANTIBIOTICS AZTREONAM LYSINE FOR INHAL SOLN 75 MG (BASE EQUIVALENT) P Y N Y N SYNAGIS SYNAGIS INJ 50MG MONOCLONAL ANTIBODY ANTIVIRALS PALIVIZUMAB IM SOLN 50 MG/0.5ML P Y N N N HYPERSAL HYPERSAL NEB 3.5% MUCOLYTIC AGENTS SODIUM CHLORIDE SOLN NEBU 3.5% NP Y N N N HYPERSAL HYPERSAL NEB 7% MUCOLYTIC AGENTS SODIUM CHLORIDE SOLN NEBU 7% P N N N N NASAL MIST NASAL MIST AER 0.9% MUCOLYTIC AGENTS SODIUM CHLORIDE AERO SOLN 0.9% NP Y N N N PULMOZYME PULMOZYME SOL 1MG/ML MUCOLYTIC AGENTS DORNASE ALFA INHAL SOLN 1 MG/ML P Y N Y N SIMPLY SALINE BABY SIMPLY SALIN AER BABY MUCOLYTIC AGENTS SODIUM CHLORIDE AERO SOLN 0.9% NP Y N N N SODIUM CHLORIDE SOD CHLORIDE NEB 0.9% MUCOLYTIC AGENTS SODIUM CHLORIDE SOLN NEBU 0.9% P N N N N TYLOXAPOL TYLOXAPOL LIQ MUCOLYTIC AGENTS TYLOXAPOL (BULK) LIQUID NP Y N N N ATROPINE SULFATE ATROPINE SUL OIN 1% OP MYDRIATICS ATROPINE SULFATE OPHTH OINT 1% P N N N N ATROPINE SULFATE ATROPINE SUL SOL 1% OP MYDRIATICS ATROPINE SULFATE OPHTH SOLN 1% P N N Y N ATROPINE SULFATE MONOHYDRATE ATROPINE SUL SOL 0.01% MYDRIATICS ATROPINE SULFATE OPHTH SOLN 0.01% NP Y N Y N CYCLOGYL CYCLOGYL SOL 0.5% OP MYDRIATICS CYCLOPENTOLATE HCL OPHTH SOLN 0.5% NP Y N N N CYCLOGYL CYCLOGYL SOL 1% OP MYDRIATICS CYCLOPENTOLATE HCL OPHTH SOLN 1% NP Y N Y N CYCLOPENTOLATE HCL CYCLOPENTOL SOL 1% OP MYDRIATICS CYCLOPENTOLATE HCL OPHTH SOLN 1% P N N Y N CYCLOPENTOLATE HCL CYCLOPENTOL SOL 2% OP MYDRIATICS CYCLOPENTOLATE HCL OPHTH SOLN 2% NP Y N N N EPINEPHR HCL SOL 2% OP EPINEPHR HCL SOL 2% OP MYDRIATICS EPINEPHRINE HCL OPHTH SOLN 2% NP Y N N N ISOPTO ATROPINE ISOPTO ATROP SOL 1% OP MYDRIATICS ATROPINE SULFATE OPHTH SOLN 1% P N N Y N TROPICAMIDE/CYCLOPENTOLATE/PHENYLETROP-CYC-PE DRO 1-1-2.5 MYDRIATICS TROPICAMIDE-CYCLOPENTOLATE-PHENYLEPHRINE OPHTH SOLN 1-1-2.5% NP Y N Y N PENICILLIN V POTASSIUM PENICILLN VK SOL 125/5ML NATURAL PENICILLIN ANTIBIOTICS PENICILLIN V POTASSIUM FOR SOLN 125 MG/5ML P N N Y N PENICILLIN V POTASSIUM PENICILLN VK SOL 250/5ML NATURAL PENICILLIN ANTIBIOTICS PENICILLIN V POTASSIUM FOR SOLN 250 MG/5ML P N N Y N PENICILLIN V POTASSIUM PENICILLN VK TAB 250MG NATURAL PENICILLIN ANTIBIOTICS PENICILLIN V POTASSIUM TAB 250 MG P N N Y N OSELTAMIVIR PHOSPHATE OSELTAMIVIR CAP 30MG NEURAMINIDASE INHIBITOR ANTIVIRALS OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV) P N N Y N OSELTAMIVIR PHOSPHATE OSELTAMIVIR CAP 45MG NEURAMINIDASE INHIBITOR ANTIVIRALS OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV) P N N Y N OSELTAMIVIR PHOSPHATE OSELTAMIVIR SUS 6MG/ML NEURAMINIDASE INHIBITOR ANTIVIRALS OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV) P N N Y Y RELENZA DISKHALER RELENZA MIS DISKHALE NEURAMINIDASE INHIBITOR ANTIVIRALS ZANAMIVIR AERO POWDER BREATH ACTIVATED 5 MG/BLISTER PNNYN TAMIFLU TAMIFLU CAP 30MG NEURAMINIDASE INHIBITOR ANTIVIRALS OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV) NP Y N Y N TAMIFLU TAMIFLU CAP 45MG NEURAMINIDASE INHIBITOR ANTIVIRALS OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV) NP Y N Y N TAMIFLU TAMIFLU SUS 6MG/ML NEURAMINIDASE INHIBITOR ANTIVIRALS OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV) NP Y N Y Y AKYNZEO AKYNZEO CAP 300-0.5 NEUROKININ-1 RECEPTOR ANTAGONISTS NETUPITANT-PALONOSETRON CAP 300-0.5 MG NP Y N Y N APREPITANT APREPITANT CAP 40MG NEUROKININ-1 RECEPTOR ANTAGONISTS APREPITANT CAPSULE 40 MG P N N Y N

Confidential 2/19/2021 Page 62 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) APREPITANT APREPITANT CAP 80MG NEUROKININ-1 RECEPTOR ANTAGONISTS APREPITANT CAPSULE 80 MG P N N Y N APREPITANT APREPITANT PAK 80 & 125 NEUROKININ-1 RECEPTOR ANTAGONISTS APREPITANT CAPSULE THERAPY PACK 80 & 125 MG P N N Y N EMEND EMEND CAP 80MG NEUROKININ-1 RECEPTOR ANTAGONISTS APREPITANT CAPSULE 80 MG NP Y N Y N EMEND EMEND SUS 125MG NEUROKININ-1 RECEPTOR ANTAGONISTS APREPITANT FOR ORAL SUSP 125 MG (125 MG/5ML) NP Y N Y N EMEND TRIPACK EMEND TRIPAC PAK 80 & 125 NEUROKININ-1 RECEPTOR ANTAGONISTS APREPITANT CAPSULE THERAPY PACK 80 & 125 MG NP Y N Y N VARUBI VARUBI TAB 90MG NEUROKININ-1 RECEPTOR ANTAGONISTS ROLAPITANT HCL TAB THERAPY PACK 2 X 90 MG (BASE EQUIV) P N N Y N BIDIL BIDIL TAB NITRATES AND NITRITES ISOSORBIDE DINITRATE-HYDRALAZINE HCL TAB 20-37.5 MG NP Y N Y N DILATRATE SR DILATRATE SR CAP 40MG NITRATES AND NITRITES ISOSORBIDE DINITRATE CAP ER 40 MG NP Y N Y N ISORDIL TITRADOSE ISORDIL TAB 40MG NITRATES AND NITRITES ISOSORBIDE DINITRATE TAB 40 MG NP Y N Y N ISORDIL TITRADOSE ISORDIL TAB 5MG NITRATES AND NITRITES ISOSORBIDE DINITRATE TAB 5 MG NP Y N Y N ISOSORBIDE DINITRATE ISOSORB DIN TAB 10MG NITRATES AND NITRITES ISOSORBIDE DINITRATE TAB 10 MG P N N Y N ISOSORBIDE DINITRATE ISOSORB DIN TAB 20MG NITRATES AND NITRITES ISOSORBIDE DINITRATE TAB 20 MG P N N Y N ISOSORBIDE DINITRATE ISOSORB DIN TAB 30MG NITRATES AND NITRITES ISOSORBIDE DINITRATE TAB 30 MG P N N Y N ISOSORBIDE DINITRATE ISOSORB DIN TAB 5MG NITRATES AND NITRITES ISOSORBIDE DINITRATE TAB 5 MG P N N Y N ISOSORBIDE MONONITRATE ISOSORB MONO TAB 10MG NITRATES AND NITRITES ISOSORBIDE MONONITRATE TAB 10 MG P N N Y N ISOSORBIDE MONONITRATE ISOSORB MONO TAB 20MG NITRATES AND NITRITES ISOSORBIDE MONONITRATE TAB 20 MG P N N Y N ISOSORBIDE MONONITRATE ER ISOSORB MONO TAB 120MG ER NITRATES AND NITRITES ISOSORBIDE MONONITRATE TAB ER 24HR 120 MG P N N Y N ISOSORBIDE MONONITRATE ER ISOSORB MONO TAB 30MG ER NITRATES AND NITRITES ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG P N N Y N ISOSORBIDE MONONITRATE ER ISOSORB MONO TAB 60MG ER NITRATES AND NITRITES ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG P N N Y N MINITRAN MINITRAN DIS 0.1MG/HR NITRATES AND NITRITES NITROGLYCERIN TD PATCH 24HR 0.1 MG/HR P N N Y N NITRO-BID NITRO-BID OIN 2% NITRATES AND NITRITES NITROGLYCERIN OINT 2% P N N Y N NITRO-DUR NITRO-DUR DIS 0.1MG/HR NITRATES AND NITRITES NITROGLYCERIN TD PATCH 24HR 0.1 MG/HR P N N Y N NITROGLYCERIN NITROGLYCERN SUB 0.3MG NITRATES AND NITRITES NITROGLYCERIN SL TAB 0.3 MG P N N Y N NITROGLYCERIN NITROGLYCERN SUB 0.4MG NITRATES AND NITRITES NITROGLYCERIN SL TAB 0.4 MG P N N Y N NITROGLYCERIN ER NITROGLYCER CAP 2.5MG ER NITRATES AND NITRITES NITROGLYCERIN CAP ER 2.5 MG NP Y N N N NITROGLYCERIN LINGUAL NITROGLYCRN SPR 0.4MG NITRATES AND NITRITES NITROGLYCERIN TL SOLN 0.4 MG/SPRAY (400 MCG/SPRAY) P N N Y N NITROGLYCERIN TRANSDERMAL NITROGLYCER DIS 0.1MG/HR NITRATES AND NITRITES NITROGLYCERIN TD PATCH 24HR 0.1 MG/HR P N N Y N NITROLINGUAL PUMPSPRAY NITROLINGUAL SPR PUMPSPRA NITRATES AND NITRITES NITROGLYCERIN TL SOLN 0.4 MG/SPRAY (400 MCG/SPRAY) NP Y N Y N NITROMIST NITROMIST AER 400MCG NITRATES AND NITRITES NITROGLYCERIN LINGUAL AEROSOL 400 MCG/SPRAY NP Y N N N NITROSTAT NITROSTAT SUB 0.3MG NITRATES AND NITRITES NITROGLYCERIN SL TAB 0.3 MG NP Y N Y N NITROSTAT NITROSTAT SUB 0.4MG NITRATES AND NITRITES NITROGLYCERIN SL TAB 0.4 MG NP Y N Y N NITRO-TIME NITRO-TIME CAP 2.5MG CR NITRATES AND NITRITES NITROGLYCERIN CAP ER 2.5 MG NP Y N N N APOKYN APOKYN INJ 10MG/ML NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST APOMORPHINE HCL SOLN CARTRIDGE 30 MG/3ML NP Y N Y N KYNMOBI KYNMOBI MIS 10MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST APOMORPHINE HYDROCHLORIDE FILM 10 MG NP Y N Y N KYNMOBI TITRATION KIT KYNMOBI KIT TITRATIO NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST APOMORPHINE HCL FILM 10/15/20/25/30 MG TITRATION KIT NP Y N Y N MIRAPEX MIRAPEX TAB 0.125MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG NP Y N Y N MIRAPEX MIRAPEX TAB 0.5MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG NP Y N Y N MIRAPEX MIRAPEX TAB 0.75MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG NP Y N N N MIRAPEX MIRAPEX TAB 1MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG NP Y N Y N MIRAPEX ER MIRAPEX ER TAB 0.375MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST PRAMIPEXOLE DIHYDROCHLORIDE TAB ER 24HR 0.375 MG NP Y N Y N MIRAPEX ER MIRAPEX ER TAB 2.25MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST PRAMIPEXOLE DIHYDROCHLORIDE TAB ER 24HR 2.25 MG NP Y N N N NEUPRO NEUPRO DIS 1MG/24HR NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST ROTIGOTINE TD PATCH 24HR 1 MG/24HR NP Y N Y N PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE TAB 0.125MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG P N N Y N PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE TAB 0.5MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG PNNYN PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE TAB 0.75MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG P N N N N PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE TAB 1.5MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG PNNYN PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE TAB 1MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG P N N Y N PRAMIPEXOLE DIHYDROCHLORIDE ER PRAMIPEXOLE TAB 0.375 ER NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST PRAMIPEXOLE DIHYDROCHLORIDE TAB ER 24HR 0.375 MG NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) PRAMIPEXOLE DIHYDROCHLORIDE ER PRAMIPEXOLE TAB 2.25 ER NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST PRAMIPEXOLE DIHYDROCHLORIDE TAB ER 24HR 2.25 MG NP Y N N N ROPINIROLE ER ROPINIROLE TAB 2MG ER NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST ROPINIROLE HYDROCHLORIDE TAB ER 24HR 2 MG (BASE EQUIVALENT) NP Y N Y N ROPINIROLE ER ROPINIROLE TAB 6MG ER NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST ROPINIROLE HYDROCHLORIDE TAB ER 24HR 6 MG (BASE EQUIVALENT) NP Y N N N ROPINIROLE ER ROPINIROLE TAB 8MG ER NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST ROPINIROLE HYDROCHLORIDE TAB ER 24HR 8 MG (BASE EQUIVALENT) NP Y N Y N ROPINIROLE HCL ROPINIROLE TAB 0.5MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST ROPINIROLE HYDROCHLORIDE TAB 0.5 MG P N N Y N ROPINIROLE HCL ROPINIROLE TAB 4MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST ROPINIROLE HYDROCHLORIDE TAB 4 MG P N N Y N ROPINIROLE HYDROCHLORIDE ROPINIROLE TAB 0.25MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST ROPINIROLE HYDROCHLORIDE TAB 0.25 MG P N N Y N ROPINIROLE HYDROCHLORIDE ROPINIROLE TAB 4MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST ROPINIROLE HYDROCHLORIDE TAB 4 MG P N N Y N D.H.E. 45 D.H.E. 45 INJ 1MG/ML NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS DIHYDROERGOTAMINE MESYLATE INJ 1 MG/ML NP Y N Y N DIBENZYLINE DIBENZYLINE CAP 10MG NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS PHENOXYBENZAMINE HCL CAP 10 MG NP Y N Y N DIHYDROERGOTAMINE MESYLATE DIHYDROERGOT INJ 1MG/ML NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS DIHYDROERGOTAMINE MESYLATE INJ 1 MG/ML PNNYN DIHYDROERGOTAMINE MESYLATE DIHYDROERGOT SPR 4MG/ML NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS DIHYDROERGOTAMINE MESYLATE NASAL SPRAY 4 MG/ML NP Y N Y N ERGOLOID MESYLATES ERGOLOID MES TAB 1MG ORAL NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS ERGOLOID MESYLATES TAB 1 MG P N N Y N ERGOMAR ERGOMAR SUB 2MG NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS ERGOTAMINE TARTRATE SL TAB 2 MG NP Y N N N MIGRANAL MIGRANAL SPR 4MG/ML NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS DIHYDROERGOTAMINE MESYLATE NASAL SPRAY 4 MG/ML NP Y N Y N DICLOFENAC SODIUM DICLOFENAC GEL 1% NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) DICLOFENAC SODIUM GEL 1% P Y N Y N DICLOFENAC SODIUM DICLOFENAC GEL 3% NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) DICLOFENAC SODIUM (ACTINIC KERATOSES) GEL 3% NP Y N Y N DICLOFENAC SODIUM DICLOFENAC SOL 1.5% NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) DICLOFENAC SODIUM SOLN 1.5% NP Y N Y N DICLOFONO DICLOFONO GEL 1.6% NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) DICLOFENAC SODIUM GEL 1.6% NP Y N Y N DICLOTREX DICLOTREX PAK NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) DICLOFENAC SODIUM SOLN 1.5% & CAMPHOR-MENTHOL GEL 4-10% THPK NP YNYN ENOVARX-DICLOFENAC SODIU M ENOVARX CRE 2.5% NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) *DICLOFENAC SODIUM CREAM 2.5% (COMPOUNDING KIT)** NP Y N N N FROTEK FROTEK CRE 10% NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) KETOPROFEN CREAM 10% NP Y N Y N KETOROLAC 2% GEL KETOROLAC GEL 2% NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) *KETOROLAC TROMETHAMINE GEL 2% (CMPD KIT)** (BASE EQUIV) NP Y N N N ORMECA ORMECA KIT NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) DICLOFENAC GEL 3% & B6-FA-B12 TAB 46-0.4-1.1 MG KIT NP Y N Y N PENNSAID PENNSAID SOL 2% NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) DICLOFENAC SODIUM SOLN 2% NP Y N Y N VOLTAREN VOLTAREN GEL 1% NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) DICLOFENAC SODIUM GEL 1% P Y N Y N ACYCLOVIR ACYCLOVIR CAP 200MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS ACYCLOVIR CAP 200 MG P N N Y N ACYCLOVIR ACYCLOVIR SUS 200/5ML NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS ACYCLOVIR SUSP 200 MG/5ML P N N Y N ACYCLOVIR ACYCLOVIR TAB 400MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS ACYCLOVIR TAB 400 MG P N N Y N ACYCLOVIR ACYCLOVIR TAB 800MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS ACYCLOVIR TAB 800 MG P N N Y N ADEFOVIR DIPIVOXIL ADEFOV DIPIV TAB 10MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS ADEFOVIR DIPIVOXIL TAB 10 MG NP Y N Y N BARACLUDE BARACLUDE SOL NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS ENTECAVIR ORAL SOLN 0.05 MG/ML P N N Y N BARACLUDE BARACLUDE TAB 0.5MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS ENTECAVIR TAB 0.5 MG NP Y N Y N ENTECAVIR ENTECAVIR TAB 0.5MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS ENTECAVIR TAB 0.5 MG P N N Y N FAMCICLOVIR FAMCICLOVIR TAB 125MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS FAMCICLOVIR TAB 125 MG NP Y N Y N FAMCICLOVIR FAMCICLOVIR TAB 250MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS FAMCICLOVIR TAB 250 MG NP Y N Y N FAMCICLOVIR FAMCICLOVIR TAB 500MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS FAMCICLOVIR TAB 500 MG NP Y N Y N HEPSERA HEPSERA TAB 10MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS ADEFOVIR DIPIVOXIL TAB 10 MG NP Y N Y N RIBAVIRIN RIBAVIRIN INH 6GM NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS RIBAVIRIN FOR INHAL SOLN 6 GM NP Y N N N SITAVIG SITAVIG TAB 50MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS ACYCLOVIR BUCCAL TAB 50 MG NP Y N Y N VALACYCLOVIR HCL VALACYCLOVIR TAB 1GM NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS VALACYCLOVIR HCL TAB 1 GM P N N Y N VALACYCLOVIR HYDROCHLORIDE VALACYCLOVIR TAB 500MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS VALACYCLOVIR HCL TAB 500 MG P N N Y N VALCYTE VALCYTE SOL 50MG/ML NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS VALGANCICLOVIR HCL FOR SOLN 50 MG/ML (BASE EQUIV) NP Y N Y N VALCYTE VALCYTE TAB 450MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS VALGANCICLOVIR HCL TAB 450 MG (BASE EQUIVALENT) NP Y N Y N VALGANCICLOVIR VALGANCICLOV TAB 450MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS VALGANCICLOVIR HCL TAB 450 MG (BASE EQUIVALENT) P N N Y N VALGANCICLOVIR HYDROCHLORDE VALGANCICLOV SOL 50MG/ML NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS VALGANCICLOVIR HCL FOR SOLN 50 MG/ML (BASE EQUIV) NP Y N Y N VALTREX VALTREX TAB 500MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS VALACYCLOVIR HCL TAB 500 MG NP Y N Y N VEMLIDY VEMLIDY TAB 25MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS TENOFOVIR ALAFENAMIDE FUMARATE TAB 25 MG NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) VIRAZOLE VIRAZOLE INH 6GM NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS RIBAVIRIN FOR INHAL SOLN 6 GM NP Y N N N ACETAMINOPHEN/CAFFEINE/DIHYDROCODAPAP-CAFFEIN CAP DIHYDROC OPIATE AGONISTS ACETAMINOPHEN-CAFFEINE-DIHYDROCODEINE CAP 320.5-30-16 MG NP Y N Y N ACETAMINOPHEN/CODEINE APAP/CODEINE SOL 120-12/5 OPIATE AGONISTS ACETAMINOPHEN W/ CODEINE SOLN 120-12 MG/5ML P N N Y N ACETAMINOPHEN/CODEINE APAP/CODEINE TAB 300-15MG OPIATE AGONISTS ACETAMINOPHEN W/ CODEINE TAB 300-15 MG P N N Y N ACETAMINOPHEN/CODEINE APAP/CODEINE TAB 300-30MG OPIATE AGONISTS ACETAMINOPHEN W/ CODEINE TAB 300-30 MG P N N Y N ACETAMINOPHEN/CODEINE APAP/CODEINE TAB 300-60MG OPIATE AGONISTS ACETAMINOPHEN W/ CODEINE TAB 300-60 MG P N N Y N ACTIQ ACTIQ LOZ 200MCG OPIATE AGONISTS FENTANYL CITRATE LOZENGE ON A HANDLE 200 MCG NP Y N Y N APADAZ APADAZ TAB 4.08-325 OPIATE AGONISTS BENZHYDROCODONE HCL-ACETAMINOPHEN TAB 4.08-325 MG NP Y N Y N APADAZ APADAZ TAB 6.12-325 OPIATE AGONISTS BENZHYDROCODONE HCL-ACETAMINOPHEN TAB 6.12-325 MG NP Y N Y N APADAZ APADAZ TAB 8.16-325 OPIATE AGONISTS BENZHYDROCODONE HCL-ACETAMINOPHEN TAB 8.16-325 MG NP Y N Y N ASCOMP/CODEINE ASCOMP/COD CAP 30MG OPIATE AGONISTS BUTALBITAL-ASPIRIN-CAFF W/ CODEINE CAP 50-325-40-30 MG P N N Y N BUTALBITAL/ACETAMINOPHEN/CAFFEINE/ BUT/APAP/CAF CAP CODEINE OPIATE AGONISTS BUTALBITAL-ACETAMINOPHEN-CAFF W/ COD CAP 50-300-40-30 MG NP Y N Y N BUTALBITAL/ACETAMINOPHEN/CAFFEINE/ BUT/APAP/CAF CAP CODEINE OPIATE AGONISTS BUTALBITAL-ACETAMINOPHEN-CAFF W/ COD CAP 50-325-40-30 MG P N N Y N CODEINE SULFATE CODEINE SULF TAB 15MG OPIATE AGONISTS CODEINE SULFATE TAB 15 MG P N N Y N CODEINE SULFATE CODEINE SULF TAB 30MG OPIATE AGONISTS CODEINE SULFATE TAB 30 MG P N N Y N CODEINE SULFATE CODEINE SULF TAB 60MG OPIATE AGONISTS CODEINE SULFATE TAB 60 MG P N N Y N CODEINE/ACETAMINOPHEN CODEINE/APAP TAB 30-300MG OPIATE AGONISTS ACETAMINOPHEN W/ CODEINE TAB 300-30 MG P N N Y N CODEINE/ACETAMINOPHEN CODEINE/APAP TAB 60-300MG OPIATE AGONISTS ACETAMINOPHEN W/ CODEINE TAB 300-60 MG P N N Y N CONZIP CONZIP CAP 100MG OPIATE AGONISTS TRAMADOL HCL CAP ER 24HR BIPHASIC RELEASE 100 MG NP Y N Y N DILAUDID DILAUDID LIQ 1MG/ML OPIATE AGONISTS HYDROMORPHONE HCL LIQD 1 MG/ML NP Y N Y N DILAUDID DILAUDID TAB 2MG OPIATE AGONISTS HYDROMORPHONE HCL TAB 2 MG NP Y N Y N DILAUDID DILAUDID TAB 4MG OPIATE AGONISTS HYDROMORPHONE HCL TAB 4 MG NP Y N Y N DILAUDID DILAUDID TAB 8MG OPIATE AGONISTS HYDROMORPHONE HCL TAB 8 MG NP Y N Y N DURAGESIC DURAGESIC DIS 100MCG/H OPIATE AGONISTS FENTANYL TD PATCH 72HR 100 MCG/HR NP Y N Y N DURAGESIC DURAGESIC DIS 12MCG/HR OPIATE AGONISTS FENTANYL TD PATCH 72HR 12 MCG/HR NP Y N Y N ENDOCET ENDOCET TAB 10-325MG OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG P N N Y N ENDOCET ENDOCET TAB 2.5-325 OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 2.5-325 MG NP Y N Y N ENDOCET ENDOCET TAB 5-325MG OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG P N N Y N ENDOCET ENDOCET TAB 7.5-325 OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG P N N Y N FENTANYL FENTANYL DIS 100MCG/H OPIATE AGONISTS FENTANYL TD PATCH 72HR 100 MCG/HR P Y N Y N FENTANYL FENTANYL DIS 12MCG/HR OPIATE AGONISTS FENTANYL TD PATCH 72HR 12 MCG/HR P Y N Y N FENTANYL FENTANYL DIS 37.5MCG OPIATE AGONISTS FENTANYL TD PATCH 72HR 37.5 MCG/HR NP Y N Y N FENTANYL CITRATE FENTANYL CIT TAB 100MCG OPIATE AGONISTS FENTANYL CITRATE BUCCAL TAB 100 MCG (BASE EQUIV) NP Y N N N FENTANYL CITRATE ORAL TRANSMUCOSAL FENTANYL OT LOZ 200MCG OPIATE AGONISTS FENTANYL CITRATE LOZENGE ON A HANDLE 200 MCG NP Y N Y N FENTORA FENTORA TAB 100MCG OPIATE AGONISTS FENTANYL CITRATE BUCCAL TAB 100 MCG (BASE EQUIV) NP Y N N N FIORICET/CODEINE FIORICET CAP CODEINE OPIATE AGONISTS BUTALBITAL-ACETAMINOPHEN-CAFF W/ COD CAP 50-300-40-30 MG NP Y N Y N FORTIGAN CAP FORTIGAN CAP OPIATE AGONISTS MEPERIDINE W/ PROMETHAZINE CAP 50-25 MG NP Y N Y N HYDROCODONE BITARTRATE ER HYDROCODONE CAP 10MG ER OPIATE AGONISTS HYDROCODONE BITARTRATE CAP ER 12HR 10 MG NP Y N Y N HYDROCODONE BITARTRATE/ACETAMINOPHYDRO/ACETA SOL 10-325MG OPIATE AGONISTS HYDROCODONE-ACETAMINOPHEN SOLN 10-325 MG/15ML NP Y N Y N HYDROCODONE BITARTRATE/ACETAMINOPHYDROCO/APAP SOL 7.5-325 OPIATE AGONISTS HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML P N N Y N HYDROCODONE BITARTRATE/ACETAMINOPHYDROCO/APAP TAB 10-300MG OPIATE AGONISTS HYDROCODONE-ACETAMINOPHEN TAB 10-300 MG NP Y N Y N HYDROCODONE BITARTRATE/ACETAMINOPHYDROCO/APAP TAB 5-300MG OPIATE AGONISTS HYDROCODONE-ACETAMINOPHEN TAB 5-300 MG NP Y N Y N HYDROCODONE BITARTRATE/ACETAMINOPHYDROCO/APAP TAB 5-325MG OPIATE AGONISTS HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG P N N Y N HYDROCODONE BITARTRATE/ACETAMINOPHYDROCO/APAP TAB 7.5-300 OPIATE AGONISTS HYDROCODONE-ACETAMINOPHEN TAB 7.5-300 MG NP Y N Y N HYDROCODONE BITARTRATE/ACETAMINOPHYDROCO/APAP TAB 7.5-325 OPIATE AGONISTS HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG P N N Y N HYDROCODONE/ACETAMINOPHEN HYDROCO/APAP TAB 10-325MG OPIATE AGONISTS HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG P N N Y N HYDROCODONE/IBUPROFEN HYDROCOD/IBU TAB 10-200MG OPIATE AGONISTS HYDROCODONE-IBUPROFEN TAB 10-200 MG NP Y N Y N HYDROCODONE/IBUPROFEN HYDROCOD/IBU TAB 5-200MG OPIATE AGONISTS HYDROCODONE-IBUPROFEN TAB 5-200 MG NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) HYDROCODONE/IBUPROFEN HYDROCOD/IBU TAB 7.5-200 OPIATE AGONISTS HYDROCODONE-IBUPROFEN TAB 7.5-200 MG NP Y N Y N HYDROMORPHONE HCL HYDROMORPHON LIQ 1MG/ML OPIATE AGONISTS HYDROMORPHONE HCL LIQD 1 MG/ML P N N Y N HYDROMORPHONE HCL HYDROMORPHON SUP 3MG OPIATE AGONISTS HYDROMORPHONE HCL SUPPOS 3 MG P N N Y N HYDROMORPHONE HCL HYDROMORPHON TAB 2MG OPIATE AGONISTS HYDROMORPHONE HCL TAB 2 MG P N N Y N HYDROMORPHONE HCL HYDROMORPHON TAB 4MG OPIATE AGONISTS HYDROMORPHONE HCL TAB 4 MG P N N Y N HYDROMORPHONE HCL HYDROMORPHON TAB 8MG OPIATE AGONISTS HYDROMORPHONE HCL TAB 8 MG P N N Y N HYDROMORPHONE HCL ER HYDROMORPHON TAB 8MG ER OPIATE AGONISTS HYDROMORPHONE HCL TAB ER 24HR 8 MG NP Y N Y N HYSINGLA ER HYSINGLA ER TAB 20 MG OPIATE AGONISTS HYDROCODONE BITARTRATE TAB ER 24HR DETER 20 MG NP Y N Y N LAZANDA LAZANDA SPR 100MCG OPIATE AGONISTS FENTANYL CITRATE NASAL SPRAY 100 MCG/ACT (BASE EQUIV) NP Y N Y N LEVORPHANOL TARTRATE LEVORPHANOL TAB 2MG OPIATE AGONISTS LEVORPHANOL TARTRATE TAB 2 MG NP Y N Y N LEVORPHANOL TARTRATE LEVORPHANOL TAB 3MG OPIATE AGONISTS LEVORPHANOL TARTRATE TAB 3 MG NP Y N Y N LORTAB LORTAB ELX 10-300MG OPIATE AGONISTS HYDROCODONE-ACETAMINOPHEN SOLN 10-300 MG/15ML NP Y N Y N MEPERIDINE HCL MEPERIDINE SOL 50MG/5ML OPIATE AGONISTS MEPERIDINE HCL ORAL SOLN 50 MG/5ML NP Y N Y N MEPERIDINE HCL MEPERIDINE TAB 50MG OPIATE AGONISTS MEPERIDINE HCL TAB 50 MG NP Y N Y N METHADONE HCL METHADONE SOL 10MG/5ML OPIATE AGONISTS METHADONE HCL SOLN 10 MG/5ML NP Y N Y N METHADONE HCL METHADONE SOL 5MG/5ML OPIATE AGONISTS METHADONE HCL SOLN 5 MG/5ML NP Y N Y N METHADONE HCL METHADONE TAB 10MG OPIATE AGONISTS METHADONE HCL TAB 10 MG NP Y N Y N METHADONE HCL METHADONE TAB 5MG OPIATE AGONISTS METHADONE HCL TAB 5 MG NP Y N Y N METHADONE HCL INTENSOL METHADONE CON 10MG/ML OPIATE AGONISTS METHADONE HCL CONC 10 MG/ML NP Y N Y N METHADOSE METHADOSE CON 10MG/ML OPIATE AGONISTS METHADONE HCL CONC 10 MG/ML NP Y N Y N METHADOSE METHADOSE TAB 40MG OPIATE AGONISTS METHADONE HCL TAB FOR ORAL SUSP 40 MG NP Y N Y N METHADOSE SUGAR-FREE METHADOSE SF CON 10MG/ML OPIATE AGONISTS METHADONE HCL CONC 10 MG/ML NP Y N Y N MORPHINE SULFATE MORPHINE SUL SOL 100/5ML OPIATE AGONISTS MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML) P N N Y N MORPHINE SULFATE MORPHINE SUL SOL 10MG/5ML OPIATE AGONISTS MORPHINE SULFATE ORAL SOLN 10 MG/5ML P N N Y N MORPHINE SULFATE MORPHINE SUL SOL 20MG/5ML OPIATE AGONISTS MORPHINE SULFATE ORAL SOLN 20 MG/5ML P N N Y N MORPHINE SULFATE MORPHINE SUL SUP 10MG OPIATE AGONISTS MORPHINE SULFATE SUPPOS 10 MG P N N Y N MORPHINE SULFATE MORPHINE SUL SUP 20MG OPIATE AGONISTS MORPHINE SULFATE SUPPOS 20 MG P N N Y N MORPHINE SULFATE MORPHINE SUL SUP 5MG OPIATE AGONISTS MORPHINE SULFATE SUPPOS 5 MG P N N Y N MORPHINE SULFATE MORPHINE SUL TAB 15MG OPIATE AGONISTS MORPHINE SULFATE TAB 15 MG P N N Y N MORPHINE SULFATE MORPHINE SUL TAB 30MG OPIATE AGONISTS MORPHINE SULFATE TAB 30 MG P N N Y N MORPHINE SULFATE CR MORPHINE SUL TAB 60MG ER OPIATE AGONISTS MORPHINE SULFATE TAB ER 60 MG P Y N Y N MORPHINE SULFATE ER MORPHINE SUL CAP 10MG ER OPIATE AGONISTS MORPHINE SULFATE CAP ER 24HR 10 MG NP Y N Y N MORPHINE SULFATE ER MORPHINE SUL TAB 15MG ER OPIATE AGONISTS MORPHINE SULFATE TAB ER 15 MG P Y N Y N MS CONTIN MS CONTIN TAB 15MG ER OPIATE AGONISTS MORPHINE SULFATE TAB ER 15 MG NP Y N Y N NALOCET NALOCET TAB 2.5-300 OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 2.5-300 MG NP Y N Y N NUCYNTA NUCYNTA TAB 50MG OPIATE AGONISTS TAPENTADOL HCL TAB 50 MG NP Y N Y N NUCYNTA NUCYNTA TAB 75MG OPIATE AGONISTS TAPENTADOL HCL TAB 75 MG NP Y N Y N NUCYNTA ER NUCYNTA ER TAB 50MG OPIATE AGONISTS TAPENTADOL HCL TAB ER 12HR 50 MG NP Y N Y N OLINVYK OLINVYK SOL 2MG/2ML OPIATE AGONISTS OLICERIDINE FUMARATE IV SOLN 2 MG/2ML (1 MG/ML) NP Y N N N OPANA OPANA TAB 10MG OPIATE AGONISTS OXYMORPHONE HCL TAB 10 MG NP Y N Y N OXAYDO OXAYDO TAB 5MG OPIATE AGONISTS OXYCODONE HCL TAB 5 MG P N N Y N OXAYDO OXAYDO TAB 7.5MG OPIATE AGONISTS OXYCODONE HCL TAB 7.5 MG NP Y N Y N OXYCODONE HCL OXYCODONE CAP 5MG OPIATE AGONISTS OXYCODONE HCL CAP 5 MG NP Y N Y N OXYCODONE HCL ER OXYCODONE TAB 10MG ER OPIATE AGONISTS OXYCODONE HCL TAB ER 12HR DETER 10 MG NP Y N Y N OXYCODONE HYDROCHLORIDE OXYCODONE CAP HCL 5MG OPIATE AGONISTS OXYCODONE HCL CAP 5 MG NP Y N Y N OXYCODONE HYDROCHLORIDE OXYCODONE CON 100/5ML OPIATE AGONISTS OXYCODONE HCL CONC 100 MG/5ML (20 MG/ML) P N N Y N OXYCODONE HYDROCHLORIDE OXYCODONE SOL 5MG/5ML OPIATE AGONISTS OXYCODONE HCL SOLN 5 MG/5ML P N N Y N OXYCODONE HYDROCHLORIDE OXYCODONE TAB 10MG OPIATE AGONISTS OXYCODONE HCL TAB 10 MG P N N Y N

Confidential 2/19/2021 Page 66 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) OXYCODONE HYDROCHLORIDE OXYCODONE TAB 15MG OPIATE AGONISTS OXYCODONE HCL TAB 15 MG P N N Y N OXYCODONE HYDROCHLORIDE OXYCODONE TAB 20MG OPIATE AGONISTS OXYCODONE HCL TAB 20 MG P N N Y N OXYCODONE HYDROCHLORIDE OXYCODONE TAB 5MG OPIATE AGONISTS OXYCODONE HCL TAB 5 MG P N N Y N OXYCODONE HYDROCHLORIDE/ACETAMIN OXYCOD/ACETA SOL 10/300MG OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN SOLN 10-300 MG/5ML NP Y N N N OXYCODONE/ACETAMINOPHEN OXYCOD/APAP TAB 10-300MG OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 10-300 MG NP Y N Y N OXYCODONE/ACETAMINOPHEN OXYCOD/APAP TAB 10-325MG OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG P N N Y N OXYCODONE/ACETAMINOPHEN OXYCOD/APAP TAB 2.5-325 OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 2.5-325 MG NP Y N Y N OXYCODONE/ACETAMINOPHEN OXYCOD/APAP TAB 5-300MG OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 5-300 MG NP Y N Y N OXYCODONE/ACETAMINOPHEN OXYCOD/APAP TAB 5-325MG OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG P N N Y N OXYCODONE/ACETAMINOPHEN OXYCOD/APAP TAB 7.5-325 OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG P N N Y N OXYCODONE/ACETAMINOPHEN OXYCOD-APAP TAB 2.5-300 OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 2.5-300 MG NP Y N Y N OXYCODONE/ASPIRIN OXYCOD/ASA TAB OPIATE AGONISTS OXYCODONE-ASPIRIN TAB 4.8355-325 MG P N N Y N OXYCONTIN OXYCONTIN TAB 10MG CR OPIATE AGONISTS OXYCODONE HCL TAB ER 12HR DETER 10 MG NP Y N Y N OXYMORPHONE HYDROCHLORIDE OXYMORPHONE TAB HCL 10MG OPIATE AGONISTS OXYMORPHONE HCL TAB 10 MG NP Y N Y N OXYMORPHONE HYDROCHLORIDE OXYMORPHONE TAB HCL 5MG OPIATE AGONISTS OXYMORPHONE HCL TAB 5 MG NP Y N Y N OXYMORPHONE HYDROCHLORIDE ER OXYMORPHONE TAB 5MG ER OPIATE AGONISTS OXYMORPHONE HCL TAB ER 12HR 5 MG P Y N Y N OXYMORPHONE HYDROCHLORIDEER OXYMORPHONE TAB 40MG ER OPIATE AGONISTS OXYMORPHONE HCL TAB ER 12HR 40 MG P Y N Y N PERCOCET PERCOCET TAB 10-325MG OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG NP Y N Y N PERCOCET PERCOCET TAB 2.5-325 OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 2.5-325 MG NP Y N Y N PERCOCET PERCOCET TAB 5-325MG OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG NP Y N Y N PERCOCET PERCOCET TAB 7.5-325 OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG NP Y N Y N PROLATE PROLATE SOL 10/300MG OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN SOLN 10-300 MG/5ML NP Y N N N PROLATE PROLATE TAB 10-300MG OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 10-300 MG NP Y N Y N PROLATE PROLATE TAB 5-300MG OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 5-300 MG NP Y N Y N PROLATE PROLATE TAB 7.5-300 OPIATE AGONISTS OXYCODONE W/ ACETAMINOPHEN TAB 7.5-300 MG NP Y N Y N QDOLO QDOLO SOL 5MG/ML OPIATE AGONISTS TRAMADOL HCL ORAL SOLN 5 MG/ML NP Y N Y N ROXICODONE ROXICODONE TAB 15MG OPIATE AGONISTS OXYCODONE HCL TAB 15 MG NP Y N Y N ROXICODONE ROXICODONE TAB 30MG OPIATE AGONISTS OXYCODONE HCL TAB 30 MG NP Y N Y N ROXICODONE ROXICODONE TAB 5MG OPIATE AGONISTS OXYCODONE HCL TAB 5 MG NP Y N Y N SUBSYS SUBSYS SPR 100MCG OPIATE AGONISTS FENTANYL SUBLINGUAL SPRAY 100 MCG NP Y N Y N SUBSYS SUBSYS SPR 1200MCG OPIATE AGONISTS FENTANYL SUBLINGUAL SPRAY 1200 MCG (600 MCG X 2) NP Y N Y N SYNAPRYN FUSEPAQ SYNAPRYN SUS 10MG/ML OPIATE AGONISTS *TRAMADOL HCL FOR ORAL SUSP 10 MG/ML (COMPOUND KIT)*** NP Y N Y N TRAMADOL HCL TRAMADOL HCL TAB 50MG OPIATE AGONISTS TRAMADOL HCL TAB 50 MG P N N Y N TRAMADOL HCL ER TRAMADOL HCL TAB 100MG ER OPIATE AGONISTS TRAMADOL HCL TAB ER 24HR 100 MG NP Y N Y N TRAMADOL HYDROCHLORIDE TRAMADOL HCL TAB 100MG OPIATE AGONISTS TRAMADOL HCL TAB 100 MG NP Y N Y N TRAMADOL HYDROCHLORIDE/ACETAMINOTRAMADL/APAP TAB 37.5-325 OPIATE AGONISTS TRAMADOL-ACETAMINOPHEN TAB 37.5-325 MG NP Y N Y N TREZIX TREZIX CAP OPIATE AGONISTS ACETAMINOPHEN-CAFFEINE-DIHYDROCODEINE CAP 320.5-30-16 MG NP Y N Y N ULTRACET ULTRACET TAB 37.5-325 OPIATE AGONISTS TRAMADOL-ACETAMINOPHEN TAB 37.5-325 MG NP Y N Y N ULTRAM ULTRAM TAB 50MG OPIATE AGONISTS TRAMADOL HCL TAB 50 MG NP Y N Y N XODOL XODOL TAB 5-300MG OPIATE AGONISTS HYDROCODONE-ACETAMINOPHEN TAB 5-300 MG NP Y N Y N XTAMPZA ER XTAMPZA ER CAP 9MG OPIATE AGONISTS OXYCODONE CAP ER 12HR ABUSE-DETERRENT 9 MG NP Y N Y N ZOHYDRO ER ZOHYDRO ER CAP 10MG OPIATE AGONISTS HYDROCODONE BITARTRATE CAP ER 12HR 10 MG NP Y N Y N LIFEMS NALOXONE LIFEMS NALOX INJ 2MG/2ML OPIATE ANTAGONISTS NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML KIT NP Y N Y N NALOXONE HCL NALOXONE INJ 1MG/ML OPIATE ANTAGONISTS NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML NP Y N Y N NALOXONE HYDROCHLORIDE NALOXONE INJ 0.4MG/ML OPIATE ANTAGONISTS NALOXONE HCL INJ 0.4 MG/ML P N N Y N NALOXONE HYDROCHLORIDE NALOXONE INJ 2MG/2ML OPIATE ANTAGONISTS NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML P N N Y N NALTREXONE HCL NALTREXONE TAB 50MG OPIATE ANTAGONISTS NALTREXONE HCL TAB 50 MG P N N N N NALTREXONE HYDROCHLORIDE NALTREXONE TAB 50MG OPIATE ANTAGONISTS NALTREXONE HCL TAB 50 MG P N N N N

Confidential 2/19/2021 Page 67 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) NARCAN NARCAN SPR OPIATE ANTAGONISTS NALOXONE HCL NASAL SPRAY 4 MG/0.1ML P N N Y N BELBUCA BELBUCA MIS 75MCG OPIATE PARTIAL AGONISTS BUPRENORPHINE HCL BUCCAL FILM 75 MCG (BASE EQUIVALENT) NP Y N Y N BUNAVAIL BUNAVAIL MIS 2.1-0.3 OPIATE PARTIAL AGONISTS BUPRENORPHINE-NALOXONE BUCCAL FILM 2.1-0.3 MG (BASE EQUIV) NP Y N Y N BUNAVAIL BUNAVAIL MIS 4.2-0.7 OPIATE PARTIAL AGONISTS BUPRENORPHINE-NALOXONE BUCCAL FILM 4.2-0.7 MG (BASE EQUIV) NP Y N Y N BUPRENORPHINE BUPRENORPHIN DIS 5MCG/HR OPIATE PARTIAL AGONISTS BUPRENORPHINE TD PATCH WEEKLY 5 MCG/HR P Y N Y N BUPRENORPHINE HCL BUPRENORPHIN SUB 2MG OPIATE PARTIAL AGONISTS BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV) P N N Y N BUPRENORPHINE HCL BUPRENORPHIN SUB 8MG OPIATE PARTIAL AGONISTS BUPRENORPHINE HCL SL TAB 8 MG (BASE EQUIV) P N N Y N BUPRENORPHINE HCL/NALOXONE HCL BUPREN/NALOX SUB 2-0.5MG OPIATE PARTIAL AGONISTS BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2-0.5 MG (BASE EQUIV) NP Y N Y N BUPRENORPHINE HCL/NALOXONE HCL BUPREN/NALOX SUB 8-2MG OPIATE PARTIAL AGONISTS BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV) NP Y N Y N BUPRENORPHINE HYDROCHLORIDE/NALOXBUPREN/NALOX MIS 2-0.5MG OPIATE PARTIAL AGONISTS BUPRENORPHINE HCL-NALOXONE HCL SL FILM 2-0.5 MG (BASE EQUIV) P N N Y N BUPRENORPHINE HYDROCHLORIDE/NALOXBUPREN/NALOX MIS 8-2MG OPIATE PARTIAL AGONISTS BUPRENORPHINE HCL-NALOXONE HCL SL FILM 8-2 MG (BASE EQUIV) P N N Y N BUTORPHANOL TARTRATE BUTORPHANOL SOL 10MG/ML OPIATE PARTIAL AGONISTS BUTORPHANOL TARTRATE NASAL SOLN 10 MG/ML P N N Y N BUTRANS BUTRANS DIS 5MCG/HR OPIATE PARTIAL AGONISTS BUPRENORPHINE TD PATCH WEEKLY 5 MCG/HR NP Y N Y N PENTAZOCINE/NALOXONE HCL PENTAZ/NALOX TAB 50-0.5MG OPIATE PARTIAL AGONISTS PENTAZOCINE W/ NALOXONE TAB 50-0.5 MG P N N Y N SUBLOCADE SUBLOCADE INJ 100/0.5 OPIATE PARTIAL AGONISTS BUPRENORPHINE EXTENDED RELEASE SOLN PREF SYR 100 MG/0.5ML NP Y N Y N SUBLOCADE SUBLOCADE INJ 300/1.5 OPIATE PARTIAL AGONISTS BUPRENORPHINE EXTENDED RELEASE SOLN PREF SYR 300 MG/1.5ML NP Y N Y N SUBOXONE SUBOXONE MIS 2-0.5MG OPIATE PARTIAL AGONISTS BUPRENORPHINE HCL-NALOXONE HCL SL FILM 2-0.5 MG (BASE EQUIV) P N N Y N SUBOXONE SUBOXONE MIS 4-1MG OPIATE PARTIAL AGONISTS BUPRENORPHINE HCL-NALOXONE HCL SL FILM 4-1 MG (BASE EQUIV) NP Y N Y N SUBOXONE SUBOXONE MIS 8-2MG OPIATE PARTIAL AGONISTS BUPRENORPHINE HCL-NALOXONE HCL SL FILM 8-2 MG (BASE EQUIV) NP Y N Y N ZUBSOLV ZUBSOLV SUB 0.7-0.18 OPIATE PARTIAL AGONISTS BUPRENORPHINE HCL-NALOXONE HCL SL TAB 0.7-0.18 MG (BASE EQ) NP Y N Y N ZUBSOLV ZUBSOLV SUB 11.4-2.9 OPIATE PARTIAL AGONISTS BUPRENORPHINE HCL-NALOXONE HCL SL TAB 11.4-2.9 MG (BASE EQ) NP Y N Y N ZUBSOLV ZUBSOLV SUB 5.7-1.4 OPIATE PARTIAL AGONISTS BUPRENORPHINE HCL-NALOXONE HCL SL TAB 5.7-1.4 MG (BASE EQ) NP Y N Y N AZITHROMYCIN AZITHROMYCIN SUS 100/5ML OTHER MACROLIDE ANTIBIOTICS AZITHROMYCIN FOR SUSP 100 MG/5ML P N N Y N AZITHROMYCIN AZITHROMYCIN SUS 200/5ML OTHER MACROLIDE ANTIBIOTICS AZITHROMYCIN FOR SUSP 200 MG/5ML P N N Y N AZITHROMYCIN AZITHROMYCIN TAB 250MG OTHER MACROLIDE ANTIBIOTICS AZITHROMYCIN TAB 250 MG P N N Y N AZITHROMYCIN AZITHROMYCIN TAB 500MG OTHER MACROLIDE ANTIBIOTICS AZITHROMYCIN TAB 500 MG P N N Y N AZITHROMYCIN AZITHROMYCIN TAB 600MG OTHER MACROLIDE ANTIBIOTICS AZITHROMYCIN TAB 600 MG P N N Y N CLARITHROMYCIN CLARITHROMYC SUS 125/5ML OTHER MACROLIDE ANTIBIOTICS CLARITHROMYCIN FOR SUSP 125 MG/5ML P N N Y N CLARITHROMYCIN CLARITHROMYC TAB 250MG OTHER MACROLIDE ANTIBIOTICS CLARITHROMYCIN TAB 250 MG P N N Y N CLARITHROMYCIN ER CLARITHROMYC TAB 500MG ER OTHER MACROLIDE ANTIBIOTICS CLARITHROMYCIN TAB ER 24HR 500 MG P N N Y N DIFICID DIFICID SUS OTHER MACROLIDE ANTIBIOTICS FIDAXOMICIN FOR SUSP 40 MG/ML P N N Y N DIFICID DIFICID TAB 200MG OTHER MACROLIDE ANTIBIOTICS FIDAXOMICIN TAB 200 MG P Y N Y N ZITHROMAX ZITHROMAX SUS 100/5ML OTHER MACROLIDE ANTIBIOTICS AZITHROMYCIN FOR SUSP 100 MG/5ML NP Y N Y N ZITHROMAX ZITHROMAX SUS 200/5ML OTHER MACROLIDE ANTIBIOTICS AZITHROMYCIN FOR SUSP 200 MG/5ML NP Y N Y N ZITHROMAX ZITHROMAX TAB 250MG OTHER MACROLIDE ANTIBIOTICS AZITHROMYCIN TAB 250 MG NP Y N Y N ZITHROMAX ZITHROMAX TAB 500MG OTHER MACROLIDE ANTIBIOTICS AZITHROMYCIN TAB 500 MG NP Y N Y N ZITHROMAX TRI-PAK ZITHROMAX TAB TRI-PAK OTHER MACROLIDE ANTIBIOTICS AZITHROMYCIN TAB 500 MG NP Y N Y N ZITHROMAX Z-PAK ZITHROMAX TAB Z-PAK OTHER MACROLIDE ANTIBIOTICS AZITHROMYCIN TAB 250 MG NP Y N Y N AMPYRA AMPYRA TAB 10MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS DALFAMPRIDINE TAB ER 12HR 10 MG NP Y N Y N ARCALYST ARCALYST INJ 220MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS RILONACEPT FOR INJ 220 MG NP Y N Y N CYSTAGON CYSTAGON CAP 150MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS CYSTEAMINE BITARTRATE CAP 150 MG P N N Y N CYSTAGON CYSTAGON CAP 50MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS CYSTEAMINE BITARTRATE CAP 50 MG P N N Y N FIRDAPSE FIRDAPSE TAB 10MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS AMIFAMPRIDINE PHOSPHATE TAB 10 MG (BASE EQUIVALENT) NP Y N Y N NITISINONE NITISINONE CAP 10MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS NITISINONE CAP 10 MG NP Y N Y N NITISINONE NITISINONE CAP 2MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS NITISINONE CAP 2 MG NP Y N Y N NITISINONE NITISINONE CAP 5MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS NITISINONE CAP 5 MG NP Y N Y N NITYR NITYR TAB 10MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS NITISINONE TAB 10 MG P Y N Y N NITYR NITYR TAB 2MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS NITISINONE TAB 2 MG P Y N Y N

Confidential 2/19/2021 Page 68 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) NITYR NITYR TAB 5MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS NITISINONE TAB 5 MG P Y N Y N NUCEL NUCEL INJ 0.5ML OTHER MISCELLANEOUS THERAPEUTIC AGENTS *AMNIOTIC MEMBRANE-AMNIOTIC FLUID ALLOGRAFT INJ 0.5 ML*** NP Y N N N ORFADIN ORFADIN CAP 10MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS NITISINONE CAP 10 MG NP Y N Y N ORFADIN ORFADIN CAP 20MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS NITISINONE CAP 20 MG NP Y N Y N ORFADIN ORFADIN CAP 2MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS NITISINONE CAP 2 MG NP Y N Y N ORFADIN ORFADIN CAP 5MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS NITISINONE CAP 5 MG NP Y N Y N ORFADIN ORFADIN SUS 4MG/ML OTHER MISCELLANEOUS THERAPEUTIC AGENTS NITISINONE SUSP 4 MG/ML NP Y N Y N TYBOST TYBOST TAB 150MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS COBICISTAT TAB 150 MG P N N Y N ZAVESCA ZAVESCA CAP 100MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS MIGLUSTAT CAP 100 MG NP Y N Y N CHILDRENS MEDI-PROFEN MEDI-PROFEN SUS 100/5ML OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS IBUPROFEN SUSP 100 MG/5ML P N N N N DICLOFENAC DICLOFENAC CAP 35MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS DICLOFENAC CAP 35 MG NP Y N Y N DICLOFENAC EPOLAMINE DICLOFENAC DIS 1.3% OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS DICLOFENAC EPOLAMINE PATCH 1.3% NP Y N Y N DICLOFENAC POTASSIUM DICLOFEN POT TAB 50MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS DICLOFENAC POTASSIUM TAB 50 MG P N N Y N DICLOFENAC SODIUM DR DICLOFENAC TAB 25MG DR OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS DICLOFENAC SODIUM TAB DELAYED RELEASE 25 MG P N NYN DICLOFENAC SODIUM DR DICLOFENAC TAB 50MG DR OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG P N NYN DICLOFENAC SODIUM ER DICLOFENAC TAB 100MG ER OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS DICLOFENAC SODIUM TAB ER 24HR 100 MG P N N Y N DICLOFENAC SODIUM/MISOPROSTOL DICLO/MISOPR TAB 50-0.2MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS DICLOFENAC W/ MISOPROSTOL TAB DELAYED RELEASE 50-0.2 MG NP Y N Y N DICLOFENAC SODIUM/MISOPROSTOL DICLO/MISOPR TAB 75-0.2MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS DICLOFENAC W/ MISOPROSTOL TAB DELAYED RELEASE 75-0.2 MG NP Y N Y N DIFLUNISAL DIFLUNISAL TAB 500MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS DIFLUNISAL TAB 500 MG NP Y N Y N DUEXIS DUEXIS TAB 800-26.6 OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS IBUPROFEN-FAMOTIDINE TAB 800-26.6 MG NP Y N Y N ETODOLAC ETODOLAC CAP 200MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS ETODOLAC CAP 200 MG P N N Y N ETODOLAC ETODOLAC TAB 400MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS ETODOLAC TAB 400 MG P N N Y N ETODOLAC ETODOLAC TAB 500MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS ETODOLAC TAB 500 MG P N N Y N ETODOLAC ER ETODOLAC ER TAB 400MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS ETODOLAC TAB ER 24HR 400 MG NP Y N Y N ETODOLAC ER ETODOLAC ER TAB 600MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS ETODOLAC TAB ER 24HR 600 MG NP Y N Y N FELDENE FELDENE CAP 10MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS PIROXICAM CAP 10 MG NP Y N Y N FELDENE FELDENE CAP 20MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS PIROXICAM CAP 20 MG NP Y N Y N FENOPROFEN CALCIUM FENOPROFEN CAP 200MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS FENOPROFEN CALCIUM CAP 200 MG NP Y N N N FENOPROFEN CALCIUM FENOPROFEN TAB 600MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS FENOPROFEN CALCIUM TAB 600 MG NP Y N Y N FLECTOR FLECTOR PAD 1.3% OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS DICLOFENAC EPOLAMINE PATCH 1.3% NP Y N Y N FLURBIPROFEN FLURBIPROFEN TAB 100MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS FLURBIPROFEN TAB 100 MG NP Y N Y N FLURBIPROFEN FLURBIPROFEN TAB 50MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS FLURBIPROFEN TAB 50 MG NP Y N Y N GNP IBUPROFEN CHILDRENS IBUPROFEN CHW 100MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS IBUPROFEN CHEW TAB 100 MG P N N N Y GNP NAPROXEN NAPROXEN TAB 220MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN SODIUM TAB 220 MG P N N N N GOODSENSE IBUPROFEN IBUPROFEN CAP 200MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS IBUPROFEN CAP 200 MG NP Y N Y N GOODSENSE IBUPROFEN CHILDRENS IBUPROFEN SUS 100/5ML OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS IBUPROFEN SUSP 100 MG/5ML P N N N N GOODSENSE IBUPROFEN INFANTS IBUPROFEN DRO 50/1.25 OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS IBUPROFEN SUSP 40 MG/ML P N N N N GOODSENSE NAPROXEN SODIUM NAPROXEN SOD TAB 220MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN SODIUM TAB 220 MG P N N N N IBUPROFEN IBUPROFEN TAB 200MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS IBUPROFEN TAB 200 MG P N N N N IBUPROFEN IBUPROFEN TAB 400MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS IBUPROFEN TAB 400 MG P N N Y N IBUPROFEN IBUPROFEN TAB 600MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS IBUPROFEN TAB 600 MG P N N Y N IBUPROFEN IBUPROFEN TAB 800MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS IBUPROFEN TAB 800 MG P N N Y N INDOCIN INDOCIN SUP 50MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS INDOMETHACIN SUPPOS 50 MG NP Y N Y N INDOCIN INDOCIN SUS 25MG/5ML OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS INDOMETHACIN SUSP 25 MG/5ML NP Y N Y N INDOMETHACIN INDOMETHACIN CAP 20MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS INDOMETHACIN CAP 20 MG NP Y N Y N INDOMETHACIN INDOMETHACIN CAP 25MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS INDOMETHACIN CAP 25 MG P N N Y N INDOMETHACIN INDOMETHACIN CAP 50MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS INDOMETHACIN CAP 50 MG P N N Y N INDOMETHACIN ER INDOMETHACIN CAP 75MG ER OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS INDOMETHACIN CAP ER 75 MG NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) KETOPROFEN KETOPROFEN CAP 25MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS KETOPROFEN CAP 25 MG P N N Y N KETOPROFEN KETOPROFEN CAP 50MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS KETOPROFEN CAP 50 MG P N N Y N KETOPROFEN ER KETOPROFEN CAP 200MG ER OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS KETOPROFEN CAP ER 24HR 200 MG NP Y N Y N KETOROLAC TROMETHAMINE KETOR TROMET SPR 15.75MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS KETOROLAC TROMETHAMINE NASAL SPRAY 15.75 MG/SPRAY NP Y N N N KETOROLAC TROMETHAMINE KETOROLAC TAB 10MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS KETOROLAC TROMETHAMINE TAB 10 MG P N N Y N LODINE LODINE TAB 400MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS ETODOLAC TAB 400 MG NP Y N Y N MECLOFENAMATE SODIUM MECLOFEN SOD CAP 100MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS MECLOFENAMATE SODIUM CAP 100 MG NP Y N Y N MECLOFENAMATE SODIUM MECLOFEN SOD CAP 50MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS MECLOFENAMATE SODIUM CAP 50 MG NP Y N Y N MEDI-PROFEN MEDI-PROFEN CAP 200MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS IBUPROFEN CAP 200 MG NP Y N Y N MEDI-PROFEN MEDI-PROFEN TAB 200MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS IBUPROFEN TAB 200 MG P N N N N MEDIPROXEN MEDIPROXEN TAB 220MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN SODIUM TAB 220 MG P N N N N MEFENAMIC ACID MEFENAM ACID CAP 250MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS MEFENAMIC ACID CAP 250 MG NP Y N Y N MELOXICAM MELOXICAM CAP 5MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS MELOXICAM CAP 5 MG NP Y N Y N MELOXICAM MELOXICAM TAB 15MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS MELOXICAM TAB 15 MG P N N Y N MELOXICAM MELOXICAM TAB 7.5MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS MELOXICAM TAB 7.5 MG P N N Y N MOBIC MOBIC TAB 15MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS MELOXICAM TAB 15 MG NP Y N Y N MOBIC MOBIC TAB 7.5MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS MELOXICAM TAB 7.5 MG NP Y N Y N NABUMETONE NABUMETONE TAB 500MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NABUMETONE TAB 500 MG P N N Y N NABUMETONE NABUMETONE TAB 750MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NABUMETONE TAB 750 MG P N N Y N NALFON NALFON CAP 400MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS FENOPROFEN CALCIUM CAP 400 MG NP Y N N N NALFON NALFON TAB 600MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS FENOPROFEN CALCIUM TAB 600 MG NP Y N Y N NAPRELAN NAPRELAN TAB 375MG CR OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN SODIUM TAB ER 24HR 375 MG (BASE EQUIV) NP Y N N N NAPRELAN NAPRELAN TAB 500MG CR OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN SODIUM TAB ER 24HR 500 MG (BASE EQUIV) NP Y N Y N NAPROSYN NAPROSYN SUS 125/5ML OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN SUSP 125 MG/5ML NP Y N Y N NAPROXEN NAPROXEN TAB 250MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN TAB 250 MG P N N Y N NAPROXEN NAPROXEN TAB 375MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN TAB 375 MG P N N Y N NAPROXEN NAPROXEN TAB 500MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN TAB 500 MG P N N Y N NAPROXEN NAPROXEN DR TAB 375MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN TAB EC 375 MG P N N Y N NAPROXEN SODIUM NAPROXEN SOD TAB 275MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN SODIUM TAB 275 MG NP Y N Y N NAPROXEN SODIUM NAPROXEN SOD TAB 550MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN SODIUM TAB 550 MG NP Y N Y N NAPROXEN SODIUM CR NAPROXEN SOD TAB 375MG CR OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN SODIUM TAB ER 24HR 375 MG (BASE EQUIV)NPYNNN NAPROXEN SODIUM ER NAPROXEN SOD TAB 375MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN SODIUM TAB ER 24HR 375 MG (BASE EQUIV) NP YNNN NAPROXEN SODIUM ER NAPROXEN SOD TAB 500MG CR OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN SODIUM TAB ER 24HR 500 MG (BASE EQUIV)NPYNYN OXAPROZIN OXAPROZIN TAB 600MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS OXAPROZIN TAB 600 MG P N N Y N PIROXICAM PIROXICAM CAP 10MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS PIROXICAM CAP 10 MG P N N Y N PIROXICAM PIROXICAM CAP 20MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS PIROXICAM CAP 20 MG P N N Y N RA NAPROXEN SODIUM NAPROXEN SOD CAP 220MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN SODIUM CAP 220 MG NP Y N N N RELAFEN RELAFEN TAB 500MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NABUMETONE TAB 500 MG NP Y N Y N RELAFEN RELAFEN TAB 750MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NABUMETONE TAB 750 MG NP Y N Y N RELAFEN DS RELAFEN DS TAB 1000MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NABUMETONE TAB 1000 MG NP Y N Y N SULINDAC SULINDAC TAB 150MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS SULINDAC TAB 150 MG P N N Y N TOLMETIN SODIUM TOLMETIN SOD CAP 400MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS TOLMETIN SODIUM CAP 400 MG NP Y N Y N TOLMETIN SODIUM TOLMETIN SOD TAB 600MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS TOLMETIN SODIUM TAB 600 MG NP Y N Y N VIMOVO VIMOVO TAB 375-20MG OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS NAPROXEN-ESOMEPRAZOLE MAGNESIUM TAB DR 375-20 MG NP Y N Y N LINEZOLID LINEZOLID SUS 100/5ML OXAZOLIDINONE ANTIBIOTICS LINEZOLID FOR SUSP 100 MG/5ML P Y N Y N LINEZOLID LINEZOLID TAB 600MG OXAZOLIDINONE ANTIBIOTICS LINEZOLID TAB 600 MG P Y N N N SIVEXTRO SIVEXTRO TAB 200MG OXAZOLIDINONE ANTIBIOTICS TEDIZOLID PHOSPHATE TAB 200 MG NP Y N Y N ZYVOX ZYVOX SUS 100MG/5M OXAZOLIDINONE ANTIBIOTICS LINEZOLID FOR SUSP 100 MG/5ML NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ZYVOX ZYVOX TAB 600MG OXAZOLIDINONE ANTIBIOTICS LINEZOLID TAB 600 MG NP Y N N N ARICEPT ARICEPT TAB 5MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) DONEPEZIL HYDROCHLORIDE TAB 5 MG NP Y N Y N BETHANECHOL CHLORIDE BETHANECHOL TAB 5MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) BETHANECHOL CHLORIDE TAB 5 MG P N N N N CEVIMELINE HYDROCHLORIDE CEVIMELINE CAP 30MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) CEVIMELINE HCL CAP 30 MG NP Y N N N DONEPEZIL HCL DONEPEZIL TAB 10MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) DONEPEZIL HYDROCHLORIDE TAB 10 MG P N N Y N DONEPEZIL HYDROCHLORIDE DONEPEZIL TAB 5MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) DONEPEZIL HYDROCHLORIDE TAB 5 MG P N N Y N DONEPEZIL HYDROCHLORIDE ODT DONEPEZIL TAB ODT 5MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 5 MG P N N Y N EVOXAC EVOXAC CAP 30MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) CEVIMELINE HCL CAP 30 MG NP Y N N N EXELON EXELON DIS 4.6MG/24 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) RIVASTIGMINE TD PATCH 24HR 4.6 MG/24HR NP Y N Y N GALANTAMINE HYDROBROMIDE GALANTAMINE CAP 16MG ER PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) GALANTAMINE HYDROBROMIDE CAP ER 24HR 16 MG P N N Y N GALANTAMINE HYDROBROMIDE GALANTAMINE SOL 4MG/ML PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) GALANTAMINE HYDROBROMIDE ORAL SOLN 4 MG/ML P N N Y N GALANTAMINE HYDROBROMIDE GALANTAMINE TAB 4MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) GALANTAMINE HYDROBROMIDE TAB 4 MG P N N Y N GALANTAMINE HYDROBROMIDE ER GALANTAMINE CAP 8MG ER PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) GALANTAMINE HYDROBROMIDE CAP ER 24HR 8 MG P N N Y N GUANIDINE HCL GUANIDINE TAB 125MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) GUANIDINE HCL TAB 125 MG NP Y N N N MESTINON MESTINON SOL 60MG/5ML PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) PYRIDOSTIGMINE BROMIDE ORAL SOLN 60 MG/5ML NP Y N Y N MESTINON MESTINON TAB 60MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) PYRIDOSTIGMINE BROMIDE TAB 60 MG NP Y N Y N MESTINON TIMESPAN MESTINON TAB TIMESPAN PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) PYRIDOSTIGMINE BROMIDE TAB ER 180 MG NP Y N Y N NEOSTIGMINE METHYLSULFATE NEOSTIG METH INJ 5MG/5ML PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) NEOSTIGMINE METHYLSULFATE SOLN PREF SYR 5 MG/5ML (1 MG/ML) NP Y N N N PILOCARPINE HYDROCHLORIDE PILOCARPINE TAB 5MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) PILOCARPINE HCL TAB 5 MG P N N Y N PILOCARPINE HYDROCHLORIDE PILOCARPINE TAB 7.5MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) PILOCARPINE HCL TAB 7.5 MG P N N N N PYRIDOSTIGMINE BROMIDE PYRIDOSTIGM TAB 60MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) PYRIDOSTIGMINE BROMIDE TAB 60 MG P N N Y N PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMI SOL 60MG/5ML PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) PYRIDOSTIGMINE BROMIDE ORAL SOLN 60 MG/5ML P N N Y N PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMI TAB 30MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) PYRIDOSTIGMINE BROMIDE TAB 30 MG NP Y N Y N PYRIDOSTIGMINE BROMIDE ER PYRIDOSTIGMI TAB ER 180MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) PYRIDOSTIGMINE BROMIDE TAB ER 180 MG P NNYN RAZADYNE ER RAZADYNE ER CAP 8MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) GALANTAMINE HYDROBROMIDE CAP ER 24HR 8 MG NP Y N Y N RIVASTIGMINE TARTRATE RIVASTIGMINE CAP 1.5MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT) P N N Y N RIVASTIGMINE TRANSDERMAL SYSTEM RIVASTIGMINE DIS 4.6MG/24 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) RIVASTIGMINE TD PATCH 24HR 4.6 MG/24HR P N N Y N SALAGEN SALAGEN TAB 5MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) PILOCARPINE HCL TAB 5 MG NP Y N Y N SALAGEN SALAGEN TAB 7.5MG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) PILOCARPINE HCL TAB 7.5 MG NP Y N N N FORTEO FORTEO SOL 600/2.4 PARATHYROID AGENTS TERIPARATIDE (RECOMBINANT) SOLN PEN-INJ 600 MCG/2.4ML NP Y N Y N NATPARA NATPARA INJ 25MCG PARATHYROID AGENTS PARATHYROID HORMONE (RECOMBINANT) FOR INJ CARTRIDGE 25 MCG NP Y N Y N TERIPARATIDE TERIPARATIDE INJ PARATHYROID AGENTS TERIPARATIDE (RECOMBINANT) SOLN PEN-INJ 620 MCG/2.48ML NP Y N Y N TYMLOS TYMLOS INJ PARATHYROID AGENTS ABALOPARATIDE SUBCUTANEOUS SOLN PEN-INJECTOR 3120 MCG/1.56ML P Y N Y N PRALUENT PRALUENT INJ 75MG/ML PCSK9 INHIBITORS ALIROCUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 75 MG/ML NP Y N Y N REPATHA REPATHA INJ 140MG/ML PCSK9 INHIBITORS EVOLOCUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 140 MG/ML P Y N Y N REPATHA PUSHTRONEX SYSTEM REPATHA PUSH INJ 420/3.5 PCSK9 INHIBITORS EVOLOCUMAB SUBCUTANEOUS SOLN CARTRIDGE/INFUSOR 420 MG/3.5ML P Y N YN REPATHA SURECLICK REPATHA SURE INJ 140MG/ML PCSK9 INHIBITORS EVOLOCUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 140 MG/ML P Y N Y N CYCLACILLIN TAB 500MG CYCLACILLIN TAB 500MG PENICILLIN ANTIBIOTICS CYCLACILLIN TAB 500 MG NP Y N N N DICLOXACILLIN SODIUM DICLOXACILL CAP 250MG PENICILLINASE-RESISTANT PENICILLINS DICLOXACILLIN SODIUM CAP 250 MG P N N Y N DICLOXACILLIN SODIUM DICLOXACILL CAP 500MG PENICILLINASE-RESISTANT PENICILLINS DICLOXACILLIN SODIUM CAP 500 MG P N N Y N PROMETHAZINE HCL PROMETHAZINE SUP 12.5MG PHENOTHIAZINE DERIVATIVES PROMETHAZINE HCL SUPPOS 12.5 MG P N N Y N PROMETHAZINE HCL PROMETHAZINE SYP 6.25/5ML PHENOTHIAZINE DERIVATIVES PROMETHAZINE HCL SYRUP 6.25 MG/5ML P N N Y N PROMETHAZINE HCL PROMETHAZINE TAB 50MG PHENOTHIAZINE DERIVATIVES PROMETHAZINE HCL TAB 50 MG P N N Y N PROMETHAZINE HCL PLAIN PROMETHAZINE SOL 6.25/5ML PHENOTHIAZINE DERIVATIVES PROMETHAZINE HCL SYRUP 6.25 MG/5ML P N N Y N PROMETHAZINE HYDROCHLORIDE PROMETHAZINE SUP 25MG PHENOTHIAZINE DERIVATIVES PROMETHAZINE HCL SUPPOS 25 MG P N N Y N PROMETHAZINE HYDROCHLORIDE PROMETHAZINE TAB 12.5MG PHENOTHIAZINE DERIVATIVES PROMETHAZINE HCL TAB 12.5 MG P N N Y N PROMETHAZINE HYDROCHLORIDE PROMETHAZINE TAB 25MG PHENOTHIAZINE DERIVATIVES PROMETHAZINE HCL TAB 25 MG P N N Y N PROMETHAZINE VC PROMETH VC SYP 6.25-5/5 PHENOTHIAZINE DERIVATIVES PROMETHAZINE & PHENYLEPHRINE SYRUP 6.25-5 MG/5ML P N N Y Y

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) PROMETHAZINE/PHENYLEPHRINE PROMETH/PE SYP 6.25-5/5 PHENOTHIAZINE DERIVATIVES PROMETHAZINE & PHENYLEPHRINE SYRUP 6.25-5 MG/5ML P N N YY PROMETHEGAN PROMETHEGAN SUP 12.5MG PHENOTHIAZINE DERIVATIVES PROMETHAZINE HCL SUPPOS 12.5 MG P N N Y N PROMETHEGAN PROMETHEGAN SUP 50MG PHENOTHIAZINE DERIVATIVES PROMETHAZINE HCL SUPPOS 50 MG P N N Y N CHLORPROMAZINE HCL CHLORPROMAZ INJ 25MG/ML PHENOTHIAZINES CHLORPROMAZINE HCL INJ 25 MG/ML P N N N N CHLORPROMAZINE HCL CHLORPROMAZ TAB 10MG PHENOTHIAZINES CHLORPROMAZINE HCL TAB 10 MG P N N Y N COMPRO COMPRO SUP 25MG PHENOTHIAZINES PROCHLORPERAZINE SUPPOS 25 MG P N N N N FLUPHENAZINE DECANOATE FLUPHENAZ DE INJ 25MG/ML PHENOTHIAZINES FLUPHENAZINE DECANOATE INJ 25 MG/ML P N N N Y FLUPHENAZINE DECANOATE FLUPHENAZINE LIQ DECANOAT PHENOTHIAZINES FLUPHENAZINE DECANOATE (BULK) LIQUID NP Y N N N FLUPHENAZINE HCL FLUPHENAZINE CON 5MG/ML PHENOTHIAZINES FLUPHENAZINE HCL ORAL CONC 5 MG/ML P N N N Y FLUPHENAZINE HCL FLUPHENAZINE TAB 1MG PHENOTHIAZINES FLUPHENAZINE HCL TAB 1 MG P N N Y Y FLUPHENAZINE HYDROCHLORIDE FLUPHENAZINE ELX 2.5/5ML PHENOTHIAZINES FLUPHENAZINE HCL ELIXIR 2.5 MG/5ML P N N N Y PERPHENAZINE PERPHENAZINE TAB 2MG PHENOTHIAZINES PERPHENAZINE TAB 2 MG P N N Y Y PROCHLORPERAZINE PROCHLORPER SUP 25MG PHENOTHIAZINES PROCHLORPERAZINE SUPPOS 25 MG P N N N N PROCHLORPERAZINE EDISYLATE PROCHLORPER INJ 10MG/2ML PHENOTHIAZINES PROCHLORPERAZINE EDISYLATE INJ 10 MG/2ML P N N N N PROCHLORPERAZINE MALEATE PROCHLORPER TAB 5MG PHENOTHIAZINES PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT) P N N N N THIORIDAZINE HCL THIORIDAZINE TAB 10MG PHENOTHIAZINES THIORIDAZINE HCL TAB 10 MG P N N Y N TRIFLUOPERAZINE HCL TRIFLUOPERAZ TAB 10MG PHENOTHIAZINES TRIFLUOPERAZINE HCL TAB 10 MG (BASE EQUIVALENT) P N N Y N TRIFLUOPERAZINE HCL TRIFLUOPERAZ TAB 1MG PHENOTHIAZINES TRIFLUOPERAZINE HCL TAB 1 MG (BASE EQUIVALENT) P N N Y N AURYXIA AURYXIA TAB 210MG PHOSPHATE-REMOVING AGENTS FERRIC CITRATE TAB 1 GM (210 MG FERRIC IRON) NP Y N Y N FOSRENOL FOSRENOL CHW 500MG PHOSPHATE-REMOVING AGENTS LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL) NP Y N N N LANTHANUM CARBONATE LANTHANUM CHW 500MG PHOSPHATE-REMOVING AGENTS LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL) NP Y N N N RENAGEL RENAGEL TAB 800MG PHOSPHATE-REMOVING AGENTS SEVELAMER HCL TAB 800 MG NP Y N Y N RENVELA RENVELA TAB 800MG PHOSPHATE-REMOVING AGENTS SEVELAMER CARBONATE TAB 800 MG NP Y N Y N SEVELAMER CARBONATE SEVELAMER TAB 800MG PHOSPHATE-REMOVING AGENTS SEVELAMER CARBONATE TAB 800 MG P N Y Y N SEVELAMER HYDROCHLORIDE SEVELAMER TAB 400MG PHOSPHATE-REMOVING AGENTS SEVELAMER HCL TAB 400 MG NP Y N Y N SEVELAMER HYDROCHLORIDE SEVELAMER TAB 800MG PHOSPHATE-REMOVING AGENTS SEVELAMER HCL TAB 800 MG NP Y N Y N VELPHORO VELPHORO CHW 500MG PHOSPHATE-REMOVING AGENTS SUCROFERRIC OXYHYDROXIDE CHEW TAB 500 MG NP Y N Y N DALIRESP DALIRESP TAB 250MCG PHOSPHODIESTERASE TYPE 4 INHIBITORS ROFLUMILAST TAB 250 MCG NP Y N Y N ADCIRCA ADCIRCA TAB 20MG PHOSPHODIESTERASE TYPE 5 INHIBITORS TADALAFIL TAB 20 MG (PAH) NP Y N Y N ALYQ ALYQ TAB 20MG PHOSPHODIESTERASE TYPE 5 INHIBITORS TADALAFIL TAB 20 MG (PAH) NP Y N Y N CIALIS CIALIS TAB 5MG PHOSPHODIESTERASE TYPE 5 INHIBITORS TADALAFIL TAB 5 MG NP Y N Y N REVATIO REVATIO SUS 10MG/ML PHOSPHODIESTERASE TYPE 5 INHIBITORS SILDENAFIL CITRATE FOR SUSPENSION 10 MG/ML NP Y N Y N REVATIO REVATIO TAB 20MG PHOSPHODIESTERASE TYPE 5 INHIBITORS SILDENAFIL CITRATE TAB 20 MG NP Y N Y N SILDENAFIL CITRATE SILDENAFIL SUS 10MG/ML PHOSPHODIESTERASE TYPE 5 INHIBITORS SILDENAFIL CITRATE FOR SUSPENSION 10 MG/ML NP Y N Y N SILDENAFIL CITRATE SILDENAFIL TAB 20MG PHOSPHODIESTERASE TYPE 5 INHIBITORS SILDENAFIL CITRATE TAB 20 MG P Y N Y N TADALAFIL TADALAFIL TAB 20MG PHOSPHODIESTERASE TYPE 5 INHIBITORS TADALAFIL TAB 20 MG (PAH) NP Y N Y N TADALAFIL TADALAFIL TAB 5MG PHOSPHODIESTERASE TYPE 5 INHIBITORS TADALAFIL TAB 5 MG NP Y N Y N METHOXSALEN METHOXSALEN CAP 10MG PIGMENTING AGENTS METHOXSALEN RAPID CAP 10 MG P N N N N OXSORALEN ULTRA OXSORALEN-UL CAP 10MG PIGMENTING AGENTS METHOXSALEN RAPID CAP 10 MG NP Y N N N AHIST AHIST TAB 25MG PIPERAZINE DERIVATIVES CHLORCYCLIZINE HCL TAB 25 MG NP Y N N N STAHIST AD STAHIST AD TAB 25-60MG PIPERAZINE DERIVATIVES CHLORCYCLIZINE & PSEUDOEPHEDRINE TAB 25-60 MG NP Y N N N ACTHAR ACTHAR INJ 80UNIT PITUITARY CORTICOTROPIN INJ GEL 80 UNIT/ML NP Y N Y N DDAVP DDAVP SOL 0.01% PITUITARY DESMOPRESSIN ACETATE NASAL SOLN 0.01% (REFRIGERATED) P N N Y N DDAVP DDAVP TAB 0.1MG PITUITARY DESMOPRESSIN ACETATE TAB 0.1 MG NP Y N Y N DDAVP DDAVP TAB 0.2MG PITUITARY DESMOPRESSIN ACETATE TAB 0.2 MG NP Y N Y N DESMOPRESSIN ACETATE DESMOPRESSIN SPR 0.01% PITUITARY DESMOPRESSIN ACETATE NASAL SPRAY SOLN 0.01% (REFRIGERATED) P N N Y N DESMOPRESSIN ACETATE DESMOPRESSIN TAB 0.1MG PITUITARY DESMOPRESSIN ACETATE TAB 0.1 MG P N N Y N DESMOPRESSIN ACETATE DESMOPRESSIN TAB 0.2MG PITUITARY DESMOPRESSIN ACETATE TAB 0.2 MG P N N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) NOCDURNA NOCDURNA SUB 27.7MCG PITUITARY DESMOPRESSIN ACETATE SUBLINGUAL TAB 27.7 MCG P Y N Y N STIMATE STIMATE SOL 1.5MG/ML PITUITARY DESMOPRESSIN ACETATE NASAL SOLN 1.5 MG/ML NP Y N Y N MACRILEN MACRILEN PAK 60MG PITUITARY FUNCTION MACIMORELIN ACETATE PACK FOR ORAL SOLN 60 MG (BASE EQUIV) NP Y N Y N METOPIRONE METOPIRONE CAP 250MG PITUITARY FUNCTION METYRAPONE CAP 250 MG NP Y N N N BRILINTA BRILINTA TAB 60MG PLATELET-AGGREGATION INHIBITORS TICAGRELOR TAB 60 MG P Y N Y N BRILINTA BRILINTA TAB 90MG PLATELET-AGGREGATION INHIBITORS TICAGRELOR TAB 90 MG P Y N Y N CILOSTAZOL CILOSTAZOL TAB 50MG PLATELET-AGGREGATION INHIBITORS CILOSTAZOL TAB 50 MG P N N Y N CLOPIDOGREL CLOPIDOGREL TAB 300MG PLATELET-AGGREGATION INHIBITORS CLOPIDOGREL BISULFATE TAB 300 MG (BASE EQUIV) P N N Y N CLOPIDOGREL CLOPIDOGREL TAB 75MG PLATELET-AGGREGATION INHIBITORS CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV) P N N Y N DURLAZA DURLAZA CAP 162.5MG PLATELET-AGGREGATION INHIBITORS ASPIRIN CAPSULE ER 24HR 162.5 MG NP Y N Y N EFFIENT EFFIENT TAB 10MG PLATELET-AGGREGATION INHIBITORS PRASUGREL HCL TAB 10 MG (BASE EQUIV) NP Y N Y N EFFIENT EFFIENT TAB 5MG PLATELET-AGGREGATION INHIBITORS PRASUGREL HCL TAB 5 MG (BASE EQUIV) NP Y N Y N PLAVIX PLAVIX TAB 75MG PLATELET-AGGREGATION INHIBITORS CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV) NP Y N Y N PLETAL PLETAL TAB 50MG PLATELET-AGGREGATION INHIBITORS CILOSTAZOL TAB 50 MG NP Y N Y N PRASUGREL PRASUGREL TAB 10MG PLATELET-AGGREGATION INHIBITORS PRASUGREL HCL TAB 10 MG (BASE EQUIV) P Y N Y N PRASUGREL PRASUGREL TAB 5MG PLATELET-AGGREGATION INHIBITORS PRASUGREL HCL TAB 5 MG (BASE EQUIV) P Y N Y N YOSPRALA YOSPRALA TAB 81-40MG PLATELET-AGGREGATION INHIBITORS ASPIRIN-OMEPRAZOLE TAB DELAYED RELEASE 81-40 MG NP Y N Y N AGRYLIN AGRYLIN CAP 0.5MG PLATELET-REDUCING AGENTS ANAGRELIDE HCL CAP 0.5 MG NP Y N N N ANAGRELIDE HYDROCHLORIDE ANAGRELIDE CAP 0.5MG PLATELET-REDUCING AGENTS ANAGRELIDE HCL CAP 0.5 MG P N N N N XENLETA XENLETA TAB 600MG PLEUROMUTILINS LEFAMULIN ACETATE TAB 600 MG NP Y N Y N NYSTATIN NYSTATIN SUS 100000 POLYENE ANTIFUNGALS NYSTATIN SUSP 100000 UNIT/ML P N N Y N NYSTATIN NYSTATIN TAB 500000 POLYENE ANTIFUNGALS NYSTATIN TAB 500000 UNIT P N N Y N NYSTATIN NYSTATIN CRE 100000 POLYENES (SKIN AND MUCOUS MEMBRANE) NYSTATIN CREAM 100000 UNIT/GM P N N Y N NYSTATIN NYSTATIN OIN 100000 POLYENES (SKIN AND MUCOUS MEMBRANE) NYSTATIN OINT 100000 UNIT/GM P N N Y N LOKELMA LOKELMA PAK 10GM POTASSIUM-REMOVING AGENTS SODIUM ZIRCONIUM CYCLOSILICATE FOR SUSP PACKET 10 GM P Y N Y N LOKELMA LOKELMA PAK 5GM POTASSIUM-REMOVING AGENTS SODIUM ZIRCONIUM CYCLOSILICATE FOR SUSP PACKET 5 GM P Y N Y N SPS SPS SUS 15GM/60 POTASSIUM-REMOVING AGENTS SODIUM POLYSTYRENE SULFONATE ORAL SUSP 15 GM/60ML P N N Y N AMILORIDE HCL AMILORIDE TAB 5MG POTASSIUM-SPARING DIURETICS AMILORIDE HCL TAB 5 MG P N N Y N AMILORIDE/HYDROCHLOROTHIAZIDE AMILOR/HCTZ TAB 5-50 POTASSIUM-SPARING DIURETICS AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG P N N Y N DYRENIUM DYRENIUM CAP 50MG POTASSIUM-SPARING DIURETICS TRIAMTERENE CAP 50 MG NP Y N N N MAXZIDE MAXZIDE TAB 75-50 POTASSIUM-SPARING DIURETICS TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG NP Y N Y N MAXZIDE-25 MAXZIDE-25 TAB POTASSIUM-SPARING DIURETICS TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG NP Y N Y N TRIAMTERENE TRIAMTERENE CAP 50MG POTASSIUM-SPARING DIURETICS TRIAMTERENE CAP 50 MG NP Y N N N TRIAMTERENE/HYDROCHLOROTHIAZIDE TRIAMT/HCTZ CAP 37.5-25 POTASSIUM-SPARING DIURETICS TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG P N N Y N TRIAMTERENE/HYDROCHLOROTHIAZIDE TRIAMT/HCTZ TAB 75-50MG POTASSIUM-SPARING DIURETICS TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MGPNNYN AYGESTIN AYGESTIN TAB 5MG PROGESTINS NORETHINDRONE ACETATE TAB 5 MG NP Y N Y N CRINONE CRINONE GEL 4% VAG PROGESTINS PROGESTERONE VAGINAL GEL 4% NP Y N N N DEPO-PROVERA CONTRACEPTIVE DEPO-PROVERA INJ 150MG/ML PROGESTINS MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML NP Y N Y N DEPO-SUBQ PROVERA 104 DEPO-SQ PROV INJ 104 PROGESTINS MEDROXYPROGESTERONE ACETATE SUSP PREF SYR 104 MG/0.65ML NP Y N Y N FIRST-PROGESTERONE VGS 100 COMPOUNPROGESTERONE SUP VGS 100 PROGESTINS PROGESTERONE VAGINAL SUPPOSITORY 100 MG NP Y N N N FIRST-PROGESTERONE VGS 200 COMPOUNPROGESTERONE SUP VGS 200 PROGESTINS PROGESTERONE VAGINAL SUPPOSITORY 200 MG NP Y N N N MEDROXYPROGESTERONE ACETATE MEDROXYPR AC INJ 150MG/ML PROGESTINS MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML P N N Y N MEDROXYPROGESTERONE ACETATE MEDROXYPR AC TAB 10MG PROGESTINS MEDROXYPROGESTERONE ACETATE TAB 10 MG P N N Y N MEDROXYPROGESTERONE ACETATE MEDROXYPR AC TAB 2.5MG PROGESTINS MEDROXYPROGESTERONE ACETATE TAB 2.5 MG P N N Y N MEDROXYPROGESTERONE ACETATE MEDROXYPR AC TAB 5MG PROGESTINS MEDROXYPROGESTERONE ACETATE TAB 5 MG P N N Y N MEGESTROL ACETATE MEGESTROL SUS 625/5ML PROGESTINS MEGESTROL ACETATE SUSP 625 MG/5ML NP Y N Y N MEGESTROL ACETATE MEGESTROL AC SUS 400MG/10 PROGESTINS MEGESTROL ACETATE SUSP 40 MG/ML P N N Y N MEGESTROL ACETATE MEGESTROL AC TAB 20MG PROGESTINS MEGESTROL ACETATE TAB 20 MG P N N N N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) MEGESTROL ACETATE MEGESTROL AC TAB 40MG PROGESTINS MEGESTROL ACETATE TAB 40 MG P N N Y N NORETHINDRONE ACETATE NORETHIN ACE TAB 5MG PROGESTINS NORETHINDRONE ACETATE TAB 5 MG P N N Y N PROGESTERONE PROGESTERONE CAP 100MG PROGESTINS PROGESTERONE MICRONIZED CAP 100 MG P Y N Y N PROGESTERONE PROGESTERONE INJ 50MG/ML PROGESTINS PROGESTERONE IM IN OIL 50 MG/ML NP Y N N N PROGESTERONE CONCENTRATE PROGESTERONE CRE 40% PROGESTINS PROGESTERONE (BULK) CREAM 40% NP Y N N N PROMETRIUM PROMETRIUM CAP 100MG PROGESTINS PROGESTERONE MICRONIZED CAP 100 MG NP Y N Y N PROVERA PROVERA TAB 10MG PROGESTINS MEDROXYPROGESTERONE ACETATE TAB 10 MG NP Y N Y N PROVERA PROVERA TAB 2.5MG PROGESTINS MEDROXYPROGESTERONE ACETATE TAB 2.5 MG NP Y N Y N PROVERA PROVERA TAB 5MG PROGESTINS MEDROXYPROGESTERONE ACETATE TAB 5 MG NP Y N Y N METOCLOPRAMIDE HCL METOCLOPRAM TAB 5MG PROKINETIC AGENTS METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT) P N N Y N METOCLOPRAMIDE HYDROCHLORIDE METOCLOPRAM SOL 10/10ML PROKINETIC AGENTS METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML) (BASE EQUIV) PNNYN METOCLOPRAMIDE HYDROCHLORIDE METOCLOPRAM TAB 10MG PROKINETIC AGENTS METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT) P N N Y N METOCLOPRAMIDE ODT METOCLOPRAM TAB 5MG ODT PROKINETIC AGENTS METOCLOPRAMIDE HCL ORALLY DISINTEGRATING TAB 5 MG (BASE EQ) NP Y N Y N REGLAN REGLAN TAB 5MG PROKINETIC AGENTS METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT) NP Y N Y N ZELNORM ZELNORM TAB 6MG PROKINETIC AGENTS TEGASEROD MALEATE TAB 6 MG (BASE EQUIVALENT) NP Y N Y N ACTANOL ACTANOL TAB 2.5-60MG PROPYLAMINE DERIVATIVES TRIPROLIDINE & PSEUDOEPHEDRINE TAB 2.5-60 MG P N N N Y BIMATOPROST BIMATOPROST SOL 0.03% PROSTAGLANDIN ANALOGS BIMATOPROST OPHTH SOLN 0.03% NP Y N Y N LATANOPROST LATANOPROST SOL 0.005% PROSTAGLANDIN ANALOGS LATANOPROST OPHTH SOLN 0.005% P N N Y N LUMIGAN LUMIGAN SOL 0.01% PROSTAGLANDIN ANALOGS BIMATOPROST OPHTH SOLN 0.01% NP Y N Y N TIMOLOL/DORZOLAMIDE/LATANOPROST TIM/DORZ/LAT SOL PROSTAGLANDIN ANALOGS TIMOLOL-DORZOLAMIDE-LATANOPROST OPHTH SOLN 0.5-0.15-0.005% NPYNYN TIMOLOL/LATANOPROST TIMOL/LATAN SOL PROSTAGLANDIN ANALOGS LATANOPROST-TIMOLOL MALEATE OPHTH SOLN 0.005-0.5% NP Y N Y N TRAVATAN Z TRAVATAN Z DRO 0.004% PROSTAGLANDIN ANALOGS TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE) NP Y N Y N TRAVOPROST TRAVOPROST DRO 0.004% PROSTAGLANDIN ANALOGS TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE) NP Y N Y N VYZULTA VYZULTA SOL 0.024% PROSTAGLANDIN ANALOGS LATANOPROSTENE BUNOD OPHTH SOLN 0.024% NP Y N Y N XALATAN XALATAN SOL 0.005% PROSTAGLANDIN ANALOGS LATANOPROST OPHTH SOLN 0.005% NP Y N Y N XELPROS XELPROS EMU 0.005% PROSTAGLANDIN ANALOGS LATANOPROST OPHTH EMULSION 0.005% NP Y N Y N ZIOPTAN ZIOPTAN DRO 0.0015% PROSTAGLANDIN ANALOGS TAFLUPROST PRESERVATIVE FREE (PF) OPHTH SOLN 0.0015% NP Y N Y N CYTOTEC CYTOTEC TAB 100MCG PROSTAGLANDINS MISOPROSTOL TAB 100 MCG NP Y N Y N CYTOTEC CYTOTEC TAB 200MCG PROSTAGLANDINS MISOPROSTOL TAB 200 MCG NP Y N Y N MISOPROSTOL MISOPROSTOL TAB 100MCG PROSTAGLANDINS MISOPROSTOL TAB 100 MCG P N N Y N MISOPROSTOL MISOPROSTOL TAB 200MCG PROSTAGLANDINS MISOPROSTOL TAB 200 MCG P N N Y N CARAFATE CARAFATE SUS 1GM/10ML PROTECTANTS SUCRALFATE SUSP 1 GM/10ML P N N Y N CARAFATE CARAFATE TAB 1GM PROTECTANTS SUCRALFATE TAB 1 GM NP Y N Y N SUCRALFATE SUCRALFATE SUS 1GM/10ML PROTECTANTS SUCRALFATE SUSP 1 GM/10ML NP Y N Y N SUCRALFATE SUCRALFATE TAB 1GM PROTECTANTS SUCRALFATE TAB 1 GM P N N Y N MESNEX MESNEX TAB 400MG PROTECTIVE AGENTS MESNA TAB 400 MG P N N N N ALBUSTIX ALBUSTIX TES PROTEIN ALBUMIN (URINE) TEST STRIP NP Y N N N CHEMSTRIP MICRAL CHEMSTRIP TES MICRAL PROTEIN ALBUMIN (URINE) TEST STRIP NP Y N N N ACID REDUCER ACID REDUCER CAP 20.6MGDR PROTON-PUMP INHIBITORS OMEPRAZOLE MAGNESIUM CAP DR 20.6 MG (20 MG BASE EQUIV) P N N Y N ACID REDUCER ACID REDUCER TAB 20MG DR PROTON-PUMP INHIBITORS OMEPRAZOLE MAGNESIUM DELAYED RELEASE TAB 20 MG (BASE EQUIV) NP Y N Y N ACIPHEX ACIPHEX TAB 20MG PROTON-PUMP INHIBITORS RABEPRAZOLE SODIUM EC TAB 20 MG NP Y N Y N ACIPHEX SPRINKLE ACIPHEX SPR CAP 5MG PROTON-PUMP INHIBITORS RABEPRAZOLE SODIUM CAPSULE SPRINKLE DR 5 MG NP Y N Y N DEXILANT DEXILANT CAP 30MG DR PROTON-PUMP INHIBITORS DEXLANSOPRAZOLE CAP DELAYED RELEASE 30 MG NP Y N Y N EQ OMEPRAZOLE OMEPRAZOLE TAB 20MG DR PROTON-PUMP INHIBITORS OMEPRAZOLE DELAYED RELEASE TAB 20 MG NP Y N Y N ESOMEPRAZOLE MAGNESIUM ESOMEPRA MAG CAP 20MG DR PROTON-PUMP INHIBITORS ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ) NPYNYN ESOMEPRAZOLE MAGNESIUM ESOMEPRA MAG CAP 40MG DR PROTON-PUMP INHIBITORS ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ) NPYNYN ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE GRA 10MG DR PROTON-PUMP INHIBITORS ESOMEPRAZOLE MAGNESIUM FOR DELAYED RELEASE SUSP PACKET 10 MGP NNYY ESOMEPRAZOLE STRONTIUM ESOMEPRAZOLE CAP 49.3MG PROTON-PUMP INHIBITORS ESOMEPRAZOLE STRONTIUM CAP DELAYED RELEASE 49.3 MG NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) FIRST-LANSOPRAZOLE LANSOPRAZOLE SUS 3MG/ML PROTON-PUMP INHIBITORS *LANSOPRAZOLE SUSP 3 MG/ML (COMPOUND KIT)** NP Y N Y N LANSOPRAZOLE LANSOPRAZOLE CAP 15MG DR PROTON-PUMP INHIBITORS LANSOPRAZOLE CAP DELAYED RELEASE 15 MG P N N Y N LANSOPRAZOLE LANSOPRAZOLE TAB 15MG ODT PROTON-PUMP INHIBITORS LANSOPRAZOLE TAB DELAYED RELEASE ORALLY DISINTEGRATING 15 MG P N N Y Y LANSOPRAZOLE/AMOXICILLIN/CLARITHRO LANSOPR/AMOX MIS /CLARITH PROTON-PUMP INHIBITORS AMOXICILLIN CAP-CLARITHRO TAB-LANSOPRAZ CAP DR THERAPY PACK NP Y N Y N NEXIUM NEXIUM CAP 20MG PROTON-PUMP INHIBITORS ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ) NP Y N Y N NEXIUM NEXIUM CAP 40MG PROTON-PUMP INHIBITORS ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ) NP Y N Y N NEXIUM NEXIUM GRA 10MG DR PROTON-PUMP INHIBITORS ESOMEPRAZOLE MAGNESIUM FOR DELAYED RELEASE SUSP PACKET 10 MG NP Y N Y Y NEXIUM NEXIUM GRA 2.5MG DR PROTON-PUMP INHIBITORS ESOMEPRAZOLE MAGNESIUM FOR DELAYED RELEASE SUSP PACK 2.5 MG P N N Y Y NEXIUM 24HR NEXIUM 24HR CAP 20MG PROTON-PUMP INHIBITORS ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ) P Y N Y N NEXIUM 24HR NEXIUM 24HR TAB 20MG PROTON-PUMP INHIBITORS ESOMEPRAZOLE MAGNESIUM TAB DELAYED RELEASE 20 MG NP Y N Y N OMEPRAZOLE OMEPRAZOLE CAP 20MG PROTON-PUMP INHIBITORS OMEPRAZOLE CAP DELAYED RELEASE 20 MG P N N Y N OMEPRAZOLE OMEPRAZOLE TAB 20MG ODT PROTON-PUMP INHIBITORS OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG NP Y N Y N OMEPRAZOLE DR OMEPRAZOLE CAP 10MG PROTON-PUMP INHIBITORS OMEPRAZOLE CAP DELAYED RELEASE 10 MG P N N Y N OMEPRAZOLE DR OMEPRAZOLE CAP 40MG PROTON-PUMP INHIBITORS OMEPRAZOLE CAP DELAYED RELEASE 40 MG P N N Y N OMEPRAZOLE MAGNESIUM OMEPRAZOLE CAP 20.6MGDR PROTON-PUMP INHIBITORS OMEPRAZOLE MAGNESIUM CAP DR 20.6 MG (20 MG BASE EQUIV) P N N Y N OMEPRAZOLE ODT OMEPRAZOLE TAB ODT 20MG PROTON-PUMP INHIBITORS OMEPRAZOLE TABLET DELAYED RELEASE DISINTEGRATING 20 MG NP Y N Y N OMEPRAZOLE/SODIUM BICARBONATE OMEPRA/BICAR CAP 20-1100 PROTON-PUMP INHIBITORS OMEPRAZOLE-SODIUM BICARBONATE CAP 20-1100 MG NP Y N Y N PANTOPRAZOLE SODIUM PANTOPRAZOLE INJ SOD 40MG PROTON-PUMP INHIBITORS PANTOPRAZOLE SODIUM FOR IV SOLN 40 MG (BASE EQUIV) NP Y N Y N PANTOPRAZOLE SODIUM PANTOPRAZOLE TAB 20MG PROTON-PUMP INHIBITORS PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV) P N N Y N PANTOPRAZOLE SODIUM DR PANTOPRAZOLE TAB 40MG DR PROTON-PUMP INHIBITORS PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV) P N N Y N PREVACID PREVACID CAP 15MG DR PROTON-PUMP INHIBITORS LANSOPRAZOLE CAP DELAYED RELEASE 15 MG P N N Y N PREVACID PREVACID CAP 30MG DR PROTON-PUMP INHIBITORS LANSOPRAZOLE CAP DELAYED RELEASE 30 MG NP Y N Y N PREVACID SOLUTAB PREVACID TAB 15MG STB PROTON-PUMP INHIBITORS LANSOPRAZOLE TAB DELAYED RELEASE ORALLY DISINTEGRATING 15 MG NP Y N YY PRILOSEC OTC PRILOSEC OTC TAB 20MG PROTON-PUMP INHIBITORS OMEPRAZOLE MAGNESIUM DELAYED RELEASE TAB 20 MG (BASE EQUIV) NP Y N Y N PROTONIX PROTONIX TAB 20MG PROTON-PUMP INHIBITORS PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV) NP Y N Y N RABEPRAZOLE SODIUM RABEPRAZOLE TAB 20MG PROTON-PUMP INHIBITORS RABEPRAZOLE SODIUM EC TAB 20 MG NP Y N Y N RABEPRAZOLE SODIUM DR SPRINKLE RABEPRAZOLE CAP 10MG DR PROTON-PUMP INHIBITORS RABEPRAZOLE SODIUM CAPSULE SPRINKLE DR 10 MG NP Y N Y N ZEGERID ZEGERID CAP 20-1100 PROTON-PUMP INHIBITORS OMEPRAZOLE-SODIUM BICARBONATE CAP 20-1100 MG NP Y N Y N ANCOBON ANCOBON CAP 250MG PYRIMIDINE ANTIFUNGALS FLUCYTOSINE CAP 250 MG NP Y N Y N ANCOBON ANCOBON CAP 500MG PYRIMIDINE ANTIFUNGALS FLUCYTOSINE CAP 500 MG NP Y N Y N FLUCYTOSINE FLUCYTOSINE CAP 250MG PYRIMIDINE ANTIFUNGALS FLUCYTOSINE CAP 250 MG NP Y N Y N FLUCYTOSINE FLUCYTOSINE CAP 500MG PYRIMIDINE ANTIFUNGALS FLUCYTOSINE CAP 500 MG NP Y N Y N BAXDELA BAXDELA TAB 450MG QUINOLONE ANTIBIOTICS DELAFLOXACIN MEGLUMINE TAB 450 MG (BASE EQUIV) NP Y N Y N CIPRO CIPRO TAB 250MG QUINOLONE ANTIBIOTICS CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV) NP Y N Y N CIPRO CIPRO TAB 500MG QUINOLONE ANTIBIOTICS CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV) NP Y N Y N CIPRO CIPRO (10%) SUS 500MG/5 QUINOLONE ANTIBIOTICS CIPROFLOXACIN FOR ORAL SUSP 500 MG/5ML (10%) (10 GM/100ML) P N N Y N CIPRO CIPRO (5%) SUS 250MG/5 QUINOLONE ANTIBIOTICS CIPROFLOXACIN FOR ORAL SUSP 250 MG/5ML (5%) (5 GM/100ML) P N N Y N CIPROFLOXACIN HCL CIPROFLOXACN TAB 100MG QUINOLONE ANTIBIOTICS CIPROFLOXACIN HCL TAB 100 MG (BASE EQUIV) P N N Y N CIPROFLOXACIN HCL CIPROFLOXACN TAB 750MG QUINOLONE ANTIBIOTICS CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV) P N N Y N CIPROFLOXACIN HYDROCHLORIDE CIPROFLOXACN TAB 250MG QUINOLONE ANTIBIOTICS CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV) P N N Y N CIPROFLOXACIN HYDROCHLORIDE CIPROFLOXACN TAB 500MG QUINOLONE ANTIBIOTICS CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV) P N N Y N LEVAQUIN LEVAQUIN TAB 250MG QUINOLONE ANTIBIOTICS LEVOFLOXACIN TAB 250 MG NP Y N Y N LEVOFLOXACIN LEVOFLOXACIN SOL 25MG/ML QUINOLONE ANTIBIOTICS LEVOFLOXACIN ORAL SOLN 25 MG/ML NP Y N Y N LEVOFLOXACIN LEVOFLOXACIN TAB 250MG QUINOLONE ANTIBIOTICS LEVOFLOXACIN TAB 250 MG P N N Y N MOXIFLOXACIN HYDROCHLORIDE MOXIFLOXACIN TAB 400MG QUINOLONE ANTIBIOTICS MOXIFLOXACIN HCL TAB 400 MG (BASE EQUIV) NP Y N Y N OFLOXACIN OFLOXACIN TAB 300MG QUINOLONE ANTIBIOTICS OFLOXACIN TAB 300 MG P N N Y N ADMELOG ADMELOG INJ 100U/ML RAPID-ACTING INSULINS INSULIN LISPRO INJ 100 UNIT/ML P N N Y N ADMELOG SOLOSTAR ADMELOG SOLO INJ 100U/ML RAPID-ACTING INSULINS INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (1 UNIT DIAL) P Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ADMELOG SOLOSTAR ADMELOG SOLO INJ 100U/ML RAPID-ACTING INSULINS INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (1 UNIT DIAL) NP Y N Y N APIDRA APIDRA INJ U-100 RAPID-ACTING INSULINS INSULIN GLULISINE INJ 100 UNIT/ML NP Y N Y N APIDRA SOLOSTAR APIDRA INJ SOLOSTAR RAPID-ACTING INSULINS INSULIN GLULISINE SOLN PEN-INJECTOR INJ 100 UNIT/ML NP Y N Y N FIASP FIASP INJ 100/ML RAPID-ACTING INSULINS INSULIN ASPART (WITH NIACINAMIDE) INJ 100 UNIT/ML NP Y N Y N FIASP FLEXTOUCH FIASP FLEX INJ TOUCH RAPID-ACTING INSULINS INSULIN ASPART (WITH NIACINAMIDE) SOL PEN-INJ 100 UNIT/ML NP Y N Y N FIASP PENFILL FIASP PENFIL INJ U-100 RAPID-ACTING INSULINS INSULIN ASPART (WITH NIACINAMIDE) SOLN CARTRIDGE 100 UNIT/ML NP Y N Y N HUMALOG HUMALOG INJ 100/ML RAPID-ACTING INSULINS INSULIN LISPRO INJ 100 UNIT/ML NP Y N Y N HUMALOG JUNIOR KWIKPEN HUMALOG JR INJ 100/ML RAPID-ACTING INSULINS INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (0.5 UNIT DIAL) NPYNYN HUMALOG KWIKPEN HUMALOG KWIK INJ 100/ML RAPID-ACTING INSULINS INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (1 UNIT DIAL) NP Y N Y N HUMALOG MIX 50/50 HUMALOG MIX INJ 50/50 RAPID-ACTING INSULINS INSULIN LISPRO PROTAMINE & LISPRO INJ 100 UNIT/ML (50-50) P N N Y N HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX INJ 50/50KWP RAPID-ACTING INSULINS INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT/ML (50-50) NP Y N Y N HUMALOG MIX 75/25 HUMALOG MIX SUS 75/25 RAPID-ACTING INSULINS INSULIN LISPRO PROT & LISPRO INJ 100 UNIT/ML (75-25) P N N Y N HUMALOG MIX 75/25 KWIKPEN HUMALOG MIX INJ 75/25KWP RAPID-ACTING INSULINS INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT/ML (75-25) NP Y N Y N INSULIN ASPART INSULIN ASPA INJ 100/ML RAPID-ACTING INSULINS INSULIN ASPART INJ 100 UNIT/ML NP Y N Y N INSULIN ASPART FLEXPEN INSULIN ASPA INJ FLEXPEN RAPID-ACTING INSULINS INSULIN ASPART SOLN PEN-INJECTOR 100 UNIT/ML NP Y N Y N INSULIN ASPART PENFILL INSULIN ASPA INJ PENFILL RAPID-ACTING INSULINS INSULIN ASPART SOLN CARTRIDGE 100 UNIT/ML NP Y N Y N INSULIN ASPART PROTAMINE/INSULIN ASPINSULIN ASPA INJ 70/30 RAPID-ACTING INSULINS INSULIN ASPART PROT & ASPART (HUMAN) INJ 100 UNIT/ML (70-30) P N N Y N INSULIN ASPART PROTAMINE/INSULIN ASPINS ASP PROT INJ FLEXPEN RAPID-ACTING INSULINS INSULIN ASPART PROT & ASPART SUS PEN-INJ 100 UNIT/ML (70-30) NP Y N Y N INSULIN LISPRO INSULIN LISP INJ 100/ML RAPID-ACTING INSULINS INSULIN LISPRO INJ 100 UNIT/ML NP Y N Y N INSULIN LISPRO JUNIOR KWIKPEN INSULIN LISP INJ JUNIOR RAPID-ACTING INSULINS INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (0.5 UNIT DIAL) NP Y N Y N INSULIN LISPRO PROTAMINE/INSULIN LISPRINSULIN LISP INJ PROTAMIN RAPID-ACTING INSULINS INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT/ML (75-25) NP Y N Y N LYUMJEV LYUMJEV INJ 100UT/ML RAPID-ACTING INSULINS INSULIN LISPRO-AABC INJ 100 UNIT/ML NP Y N Y N LYUMJEV KWIKPEN LYUMJEV KWPN INJ 100UT/ML RAPID-ACTING INSULINS INSULIN LISPRO-AABC SOLN PEN-INJ 100 UNIT/ML (1 UNIT DIAL) NP Y N Y N NOVOLOG NOVOLOG INJ 100/ML RAPID-ACTING INSULINS INSULIN ASPART INJ 100 UNIT/ML NP Y N Y N NOVOLOG FLEXPEN NOVOLOG INJ FLEXPEN RAPID-ACTING INSULINS INSULIN ASPART SOLN PEN-INJECTOR 100 UNIT/ML NP Y N Y N NOVOLOG MIX 70/30 NOVOLOG MIX INJ 70/30 RAPID-ACTING INSULINS INSULIN ASPART PROT & ASPART (HUMAN) INJ 100 UNIT/ML (70-30) NP Y N Y N NOVOLOG MIX 70/30 PREFILLED FLEXPEN NOVOLOG MIX INJ FLEXPEN RAPID-ACTING INSULINS INSULIN ASPART PROT & ASPART SUS PEN-INJ 100 UNIT/ML (70-30) NP Y N Y N NOVOLOG PENFILL NOVOLOG INJ PENFILL RAPID-ACTING INSULINS INSULIN ASPART SOLN CARTRIDGE 100 UNIT/ML NP Y N Y N ALISKIREN ALISKIREN TAB 150MG RENIN INHIBITORS ALISKIREN FUMARATE TAB 150 MG (BASE EQUIVALENT) NP Y N Y N TEKTURNA TEKTURNA TAB 150MG RENIN INHIBITORS ALISKIREN FUMARATE TAB 150 MG (BASE EQUIVALENT) NP Y N Y N TEKTURNA HCT TEKTURNA HCT TAB 150-12.5 RENIN INHIBITORS ALISKIREN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG NP Y N N N ENTRESTO ENTRESTO TAB 24-26MG RENIN-ANGIOTEN.-ALDOST. SYS. INHIB, MISC SACUBITRIL-VALSARTAN TAB 24-26 MG P Y N Y N ADHANSIA XR ADHANSIA XR CAP 25MG RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL CAP ER 24HR 25 MG P N N Y Y APTENSIO XR APTENSIO XR CAP 10MG RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL CAP ER 24HR 10 MG (XR) NP Y N Y Y CONCERTA CONCERTA TAB 18MG RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 18 MG NP Y N Y Y CONCERTA CONCERTA TAB 36MG RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 36 MG NP Y N Y Y COTEMPLA XR-ODT COTEMPLA TAB 17.3MG RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE TAB EXTENDED RELEASE DISINTEGRATING 17.3 MG PNNYY COTEMPLA XR-ODT COTEMPLA TAB 8.6MG RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE TAB EXTENDED RELEASE DISINTEGRATING 8.6 MG P N NYY DAYTRANA DAYTRANA DIS 10MG/9HR RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE TD PATCH 10 MG/9HR P N N Y Y DEXMETHYLPHENIDATE HCL DEXMETHYLPH TAB 10MG RESPIRATORY AND CNS STIMULANTS DEXMETHYLPHENIDATE HCL TAB 10 MG P N N Y Y DEXMETHYLPHENIDATE HCL DEXMETHYLPH TAB 5MG RESPIRATORY AND CNS STIMULANTS DEXMETHYLPHENIDATE HCL TAB 5 MG P N N Y Y DEXMETHYLPHENIDATE HCL ER DEXMETHYLPHE CAP 5MG ER RESPIRATORY AND CNS STIMULANTS DEXMETHYLPHENIDATE HCL CAP ER 24 HR 5 MG P N N Y Y DEXMETHYLPHENIDATE HYDROCHLORIDE DEXMETHYLPH TAB 2.5MG RESPIRATORY AND CNS STIMULANTS DEXMETHYLPHENIDATE HCL TAB 2.5 MG P N N Y Y DEXMETHYLPHENIDATE HYDROCHLORIDE DEXMETHYLPHE CAP ER 25MG RESPIRATORY AND CNS STIMULANTS DEXMETHYLPHENIDATE HCL CAP ER 24 HR 25 MG PNNYY FOCALIN FOCALIN TAB 10MG RESPIRATORY AND CNS STIMULANTS DEXMETHYLPHENIDATE HCL TAB 10 MG NP Y N Y Y FOCALIN FOCALIN TAB 2.5MG RESPIRATORY AND CNS STIMULANTS DEXMETHYLPHENIDATE HCL TAB 2.5 MG NP Y N Y Y FOCALIN XR FOCALIN XR CAP 5MG RESPIRATORY AND CNS STIMULANTS DEXMETHYLPHENIDATE HCL CAP ER 24 HR 5 MG NP Y N Y Y JORNAY PM JORNAY PM CAP 20MG ER RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL CAP DELAYED ER 24HR 20 MG (PM) P N N Y Y

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) METADATE ER METADATE TAB 20MG ER RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL TAB ER 20 MG P N N Y Y METHYLIN METHYLIN SOL 10MG/5ML RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL SOLN 10 MG/5ML NP Y N Y Y METHYLIN METHYLIN SOL 5MG/5ML RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL SOLN 5 MG/5ML NP Y N Y Y METHYLPHENIDATE HYDROCHLORIDE METHYLPHENID SOL 10MG/5ML RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL SOLN 10 MG/5ML P N N Y Y METHYLPHENIDATE HYDROCHLORIDE METHYLPHENID SOL 5MG/5ML RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL SOLN 5 MG/5ML P N N Y Y METHYLPHENIDATE HYDROCHLORIDE METHYLPHENID TAB 5MG RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL TAB 5 MG P N N Y Y METHYLPHENIDATE HYDROCHLORIDE CD METHYLPHENID CAP 10MG RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL CAP ER 10 MG (CD) P N N Y Y METHYLPHENIDATE HYDROCHLORIDE ER METHYLPHENID TAB 10MG ER RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL TAB ER 10 MG P N N Y Y METHYLPHENIDATE HYDROCHLORIDE ER METHYLPHENID TAB 36MG ER RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 36 MG P N N Y Y METHYLPHENIDATE HYDROCHLORIDE ER (LMETHYLPHENID CAP 60MG LA RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL CAP ER 24HR 60 MG (LA) P N N Y Y QUILLICHEW ER QUILLICHEW CHW 20MG ER RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL CHEW TAB EXTENDED RELEASE 20 MG P N N Y Y QUILLICHEW ER QUILLICHEW CHW 30MG ER RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL CHEW TAB EXTENDED RELEASE 30 MG P N N Y Y QUILLIVANT XR QUILLIVANT SUS 25MG/5ML RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL FOR ER SUSP 25 MG/5ML (5 MG/ML) P N N Y Y RELEXXII RELEXXII TAB 72MG RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 72 MG P N N Y Y RITALIN RITALIN TAB 5MG RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL TAB 5 MG NP Y N Y Y RITALIN LA RITALIN LA CAP 10MG RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL CAP ER 24HR 10 MG (LA) NP Y N Y Y RITALIN LA RITALIN LA CAP 30MG RESPIRATORY AND CNS STIMULANTS METHYLPHENIDATE HCL CAP ER 24HR 30 MG (LA) NP Y N Y Y ELIXOPHYLLIN ELIXOPHYLLIN ELX 80/15ML RESPIRATORY SMOOTH MUSCLE RELAXANTS THEOPHYLLINE ELIXIR 80 MG/15ML P N N Y N THEO-24 THEO-24 CAP 100MG CR RESPIRATORY SMOOTH MUSCLE RELAXANTS THEOPHYLLINE CAP ER 24HR 100 MG P N N N N THEOPHYLLINE THEOPHYLLINE SOL 80/15ML RESPIRATORY SMOOTH MUSCLE RELAXANTS THEOPHYLLINE SOLN 80 MG/15ML P N N Y N THEOPHYLLINE CR THEOPHYLLINE TAB 300MG CR RESPIRATORY SMOOTH MUSCLE RELAXANTS THEOPHYLLINE TAB ER 12HR 300 MG P N N Y N THEOPHYLLINE ER THEOPHYLLINE TAB 300MG ER RESPIRATORY SMOOTH MUSCLE RELAXANTS THEOPHYLLINE TAB ER 12HR 300 MG P N N Y N THEOPHYLLINE ER THEOPHYLLINE TAB 450MG ER RESPIRATORY SMOOTH MUSCLE RELAXANTS THEOPHYLLINE TAB ER 12HR 450 MG P N N N N XOLAIR XOLAIR INJ 150MG/ML RESPIRATORY TRACT AGENTS, MISCELLANEOUS OMALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/ML P YNYN XOLAIR XOLAIR INJ 75/0.5 RESPIRATORY TRACT AGENTS, MISCELLANEOUS OMALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 75 MG/0.5ML P YNYN XOLAIR XOLAIR SOL 150MG RESPIRATORY TRACT AGENTS, MISCELLANEOUS OMALIZUMAB FOR INJ 150 MG P Y N Y N RHOPRESSA RHOPRESSA SOL 0.02% RHO KINASE INHIBITORS NETARSUDIL DIMESYLATE OPHTH SOLN 0.02% NP Y N Y N ROCKLATAN ROCKLATAN DRO RHO KINASE INHIBITORS NETARSUDIL DIMESYLATE-LATANOPROST OPHTH SOLN 0.02-0.005% NP Y N Y N AEMCOLO AEMCOLO TAB 194MG RIFAMYCIN ANTIBIOTICS RIFAMYCIN SODIUM TAB DELAYED RELEASE 194 MG (BASE EQUIV) NP Y N Y N XIFAXAN XIFAXAN TAB 200MG RIFAMYCIN ANTIBIOTICS RIFAXIMIN TAB 200 MG NP Y N Y N XIFAXAN XIFAXAN TAB 550MG RIFAMYCIN ANTIBIOTICS RIFAXIMIN TAB 550 MG NP Y N Y N BUTALBITAL/ASA/CAFFEINE BUT/ASA/CAFF CAP SALICYLATES BUTALBITAL-ASPIRIN-CAFFEINE CAP 50-325-40 MG P N N Y N BUTALBITAL/ASPIRIN/CAFFEINE BUT/ASA/CAFF CAP SALICYLATES BUTALBITAL-ASPIRIN-CAFFEINE CAP 50-325-40 MG P N N Y N NORGESIC FORTE NORGESIC TAB FORTE SALICYLATES ORPHENADRINE W/ ASPIRIN & CAFFEINE TAB 50-770-60 MG NP Y N Y N ORPHENADRINE CITRATE/ASPIRIN/CAFFEINORPH/ASA/CAF TAB SALICYLATES ORPHENADRINE W/ ASPIRIN & CAFFEINE TAB 50-770-60 MG NP Y N Y N CETIRIZINE HCL CETIRIZINE CHW 5MG SECOND GENERATION ANTIHISTAMINES CETIRIZINE HCL CHEW TAB 5 MG NP Y N Y N CETIRIZINE HCL CETIRIZINE TAB 5MG SECOND GENERATION ANTIHISTAMINES CETIRIZINE HCL TAB 5 MG P N N N Y CETIRIZINE HYDROCHLORIDE CETIRIZINE CHW 10MG SECOND GENERATION ANTIHISTAMINES CETIRIZINE HCL CHEW TAB 10 MG NP Y N Y N CETIRIZINE HYDROCHLORIDE CETIRIZINE TAB 10MG SECOND GENERATION ANTIHISTAMINES CETIRIZINE HCL TAB 10 MG P N N N N CETIRIZINE HYDROCHLORIDE CHILDRENS A CETIRIZINE SOL 1MG/ML SECOND GENERATION ANTIHISTAMINES CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) P N N Y Y DESLORATADINE DESLORATADIN TAB 5MG SECOND GENERATION ANTIHISTAMINES DESLORATADINE TAB 5 MG NP Y N Y N DESLORATADINE ODT DESLORATADIN TAB 2.5 ODT SECOND GENERATION ANTIHISTAMINES DESLORATADINE TAB ORALLY DISINTEGRATING 2.5 MG NP Y N N N DESLORATADINE ODT DESLORATADIN TAB 5MG ODT SECOND GENERATION ANTIHISTAMINES DESLORATADINE TAB ORALLY DISINTEGRATING 5 MG NP Y N Y N KP FEXOFENADINE HCL FEXOFENADINE TAB 60MG SECOND GENERATION ANTIHISTAMINES FEXOFENADINE HCL TAB 60 MG P N Y N N LEVOCETIRIZINE DIHYDROCHLORIDE LEVOCETIRIZI TAB 5MG SECOND GENERATION ANTIHISTAMINES LEVOCETIRIZINE DIHYDROCHLORIDE TAB 5 MG P N N Y N LORATADINE LORATADINE TAB 10MG SECOND GENERATION ANTIHISTAMINES LORATADINE TAB 10 MG P N N N N LORATADINE CHILDRENS LORATADINE CHW 5MG SECOND GENERATION ANTIHISTAMINES LORATADINE CHEW TAB 5 MG NP Y N N N LORATADINE CHILDRENS LORATADINE SOL 10/10ML SECOND GENERATION ANTIHISTAMINES LORATADINE SYRUP 5 MG/5ML P N N Y Y

Confidential 2/19/2021 Page 77 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) QC FEXOFENADINE HYDROCHLORIDE FEXOFENADINE TAB 180MG SECOND GENERATION ANTIHISTAMINES FEXOFENADINE HCL TAB 180 MG P N Y N N RA LORATADINE LORATADINE SYP 5MG/5ML SECOND GENERATION ANTIHISTAMINES LORATADINE SYRUP 5 MG/5ML P N N Y Y SM LORATA-DINE D LORATA-DINE TAB D 24HR SECOND GENERATION ANTIHISTAMINES LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG P N N N Y XYZAL ALLERGY 24HR XYZAL TAB 5MG SECOND GENERATION ANTIHISTAMINES LEVOCETIRIZINE DIHYDROCHLORIDE TAB 5 MG P N N Y N XYZAL ALLERGY 24HR CHILDRENS XYZAL 24HR SOL 2.5/5ML SECOND GENERATION ANTIHISTAMINES LEVOCETIRIZINE DIHYDROCHLORIDE SOLN 2.5 MG/5ML (0.5 MG/ML) NP Y N N N ZYRTEC ALLERGY ZYRTEC ALLGY TAB 10MG SECOND GENERATION ANTIHISTAMINES CETIRIZINE HCL TAB 10 MG P N N N N ZYRTEC CHILDRENS ALLERGY ZYRTEC CHILD SOL 5MG/5ML SECOND GENERATION ANTIHISTAMINES CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) P N N Y Y ZYRTEC-D ALLERGY/CONGESTION ZYRTEC-D TAB 5-120MG SECOND GENERATION ANTIHISTAMINES CETIRIZINE-PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG P N N Y Y CYMBALTA CYMBALTA CAP 20MG SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR DULOXETINE HCL ENTERIC COATED PELLETS CAP 20 MG (BASE EQ) NP YNYN DESVENLAFAXINE ER DESVENLAFAX TAB 100MG ER SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR DESVENLAFAXINE TAB ER 24HR 100 MG P N N Y N DESVENLAFAXINE ER DESVENLAFAX TAB 50MG ER SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR DESVENLAFAXINE TAB ER 24HR 50 MG P N N Y N DRIZALMA SPRINKLE DRIZALMA CAP 20MG DR SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR DULOXETINE HCL CAP DELAYED RELEASE SPRINKLE 20 MG (BASE EQ) P N N Y N DULOXETINE HCL DULOXETINE CAP 30MG SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR DULOXETINE HCL ENTERIC COATED PELLETS CAP 30 MG (BASE EQ) P N N Y N DULOXETINE HYDROCHLORIDE DULOXETINE CAP 20MG SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR DULOXETINE HCL ENTERIC COATED PELLETS CAP 20 MG (BASE EQ) P N N Y N EFFEXOR XR EFFEXOR XR CAP 150MG SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR VENLAFAXINE HCL CAP ER 24HR 150 MG (BASE EQUIVALENT) NP Y N YN EFFEXOR XR EFFEXOR XR CAP 37.5MG SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR VENLAFAXINE HCL CAP ER 24HR 37.5 MG (BASE EQUIVALENT) NP YNYN EFFEXOR XR EFFEXOR XR CAP 75MG SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR VENLAFAXINE HCL CAP ER 24HR 75 MG (BASE EQUIVALENT) NP Y N Y N FETZIMA FETZIMA CAP 20MG SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR LEVOMILNACIPRAN HCL CAP ER 24HR 20 MG (BASE EQUIVALENT) P N N Y N FETZIMA TITRATION PACK FETZIMA CAP TITRATIO SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR LEVOMILNACIPRAN HCL CAP ER 24HR 20 & 40 MG THERAPY PACK P N N Y N PRISTIQ PRISTIQ TAB 100MG SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR DESVENLAFAXINE SUCCINATE TAB ER 24HR 100 MG (BASE EQUIV) NP Y NYN PRISTIQ PRISTIQ TAB 25MG SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR DESVENLAFAXINE SUCCINATE TAB ER 24HR 25 MG (BASE EQUIV) NP Y N Y N VENLAFAXINE HCL ER VENLAFAXINE CAP 150MG ER SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR VENLAFAXINE HCL CAP ER 24HR 150 MG (BASE EQUIVALENT) P N N Y N VENLAFAXINE HCL ER VENLAFAXINE CAP 37.5 ER SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR VENLAFAXINE HCL CAP ER 24HR 37.5 MG (BASE EQUIVALENT) P N N Y N VENLAFAXINE HYDROCHLORIDE VENLAFAXINE TAB 25MG SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR VENLAFAXINE HCL TAB 25 MG (BASE EQUIVALENT)PNNYN VENLAFAXINE HYDROCHLORIDE ER VENLAFAXINE CAP 75MG ER SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR VENLAFAXINE HCL CAP ER 24HR 75 MG (BASE EQUIVALENT) P N N Y N ALFUZOSIN HCL ER ALFUZOSIN TAB 10MG ER SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT ALFUZOSIN HCL TAB ER 24HR 10 MG P N N Y N FLOMAX FLOMAX CAP 0.4MG SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT TAMSULOSIN HCL CAP 0.4 MG NP Y N Y N RAPAFLO RAPAFLO CAP 4MG SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT SILODOSIN CAP 4 MG NP Y N Y N SILODOSIN SILODOSIN CAP 4MG SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT SILODOSIN CAP 4 MG NP Y N Y N TAMSULOSIN HYDROCHLORIDE TAMSULOSIN CAP 0.4MG SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT TAMSULOSIN HCL CAP 0.4 MG P N N Y N UROXATRAL UROXATRAL TAB 10MG SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT ALFUZOSIN HCL TAB ER 24HR 10 MG NP Y N Y N ADVAIR DISKUS ADVAIR DISKU AER 100/50 SELECTIVE BETA-2-ADRENERGIC AGONISTS FLUTICASONE-SALMETEROL AER POWDER BA 100-50 MCG/DOSE NP Y NYN ADVAIR HFA ADVAIR HFA AER 45/21 SELECTIVE BETA-2-ADRENERGIC AGONISTS FLUTICASONE-SALMETEROL INHAL AEROSOL 45-21 MCG/ACT NP Y N Y N ALBUTEROL ALBUTEROL TAB 4MG SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE TAB 4 MG NP Y N Y N ALBUTEROL SULFATE ALBUTEROL NEB 0.083% SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML) P N N Y N ALBUTEROL SULFATE ALBUTEROL NEB 0.5% SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE SOLN NEBU 0.5% (5 MG/ML) P N N Y N ALBUTEROL SULFATE ALBUTEROL NEB 0.63MG/3 SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV) P N N Y Y ALBUTEROL SULFATE ALBUTEROL NEB 1.25MG/3 SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV) P N N Y Y ALBUTEROL SULFATE ALBUTEROL SYP 2MG/5ML SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE SYRUP 2 MG/5ML P N N Y N ALBUTEROL SULFATE ALBUTEROL TAB 2MG SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE TAB 2 MG NP Y N N N ALBUTEROL SULFATE ALBUTEROL TAB 4MG SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE TAB 4 MG NP Y N Y N ALBUTEROL SULFATE ER ALBUTEROL TAB 4MG ER SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE TAB ER 12HR 4 MG NP Y N N N ALBUTEROL SULFATE HFA ALBUTEROL AER HFA SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV) P N N Y N ARCAPTA NEOHALER ARCAPTA CAP 75MCG SELECTIVE BETA-2-ADRENERGIC AGONISTS INDACATEROL MALEATE INHAL POWDER CAP 75 MCG (BASE EQUIV) P N N Y N BROVANA BROVANA NEB 15MCG SELECTIVE BETA-2-ADRENERGIC AGONISTS ARFORMOTEROL TARTRATE SOLN NEBU 15 MCG/2ML (BASE EQUIV) NP Y N Y N COMBIVENT RESPIMAT COMBIVENT AER 20-100 SELECTIVE BETA-2-ADRENERGIC AGONISTS IPRATROPIUM-ALBUTEROL INHAL AEROSOL SOLN 20-100 MCG/ACT P N N Y N FLUTICASONE PROPIONATE/SALMETEROL FLUTIC/SALME AER 100/50 SELECTIVE BETA-2-ADRENERGIC AGONISTS FLUTICASONE-SALMETEROL AER POWDER BA 100-50 MCG/DOSE P Y N Y N IPRATROPIUM BROMIDE/ALBUTEROL SULF IPRATROPIUM/ SOL ALBUTER SELECTIVE BETA-2-ADRENERGIC AGONISTS IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML P N N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) LEVALBUTEROL LEVALBUTEROL NEB 1.25/0.5 SELECTIVE BETA-2-ADRENERGIC AGONISTS LEVALBUTEROL HCL SOLN NEBU CONC 1.25 MG/0.5ML (BASE EQUIV) P N Y Y N LEVALBUTEROL HCL LEVALBUTEROL NEB 0.31MG SELECTIVE BETA-2-ADRENERGIC AGONISTS LEVALBUTEROL HCL SOLN NEBU 0.31 MG/3ML (BASE EQUIV) P NYYN LEVALBUTEROL TARTRATE HFA LEVALBUTEROL AER 45/ACT SELECTIVE BETA-2-ADRENERGIC AGONISTS LEVALBUTEROL TARTRATE INHAL AEROSOL 45 MCG/ACT (BASE EQUIV) NP Y N Y N PERFOROMIST PERFOROMIST NEB 20MCG SELECTIVE BETA-2-ADRENERGIC AGONISTS FORMOTEROL FUMARATE SOLN NEBU 20 MCG/2ML NP Y N Y N PROAIR DIGIHALER PROAIR DIGIH AER 108MCG SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE AER POW BA 108 MCG/ACT WITH SENSOR NP Y N Y N PROAIR HFA PROAIR HFA AER SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV) NP Y N Y N PROAIR RESPICLICK PROAIR RESPI AER SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE AER POW BA 108 MCG/ACT (90 MCG BASE EQUIV) NP Y N Y N PROVENTIL HFA PROVENTIL AER HFA SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)NPYNYN SEREVENT DISKUS SEREVENT DIS AER 50MCG SELECTIVE BETA-2-ADRENERGIC AGONISTS SALMETEROL XINAFOATE AER POW BA 50 MCG/DOSE (BASE EQUIV) NP Y N Y N STRIVERDI RESPIMAT STRIVERDI AER 2.5MCG SELECTIVE BETA-2-ADRENERGIC AGONISTS OLODATEROL HCL INHAL AEROSOL SOLN 2.5 MCG/ACT (BASE EQUIV) P N N Y N TERBUTALINE SULFATE TERBUTALINE TAB 2.5MG SELECTIVE BETA-2-ADRENERGIC AGONISTS TERBUTALINE SULFATE TAB 2.5 MG NP Y N Y N UTIBRON NEOHALER UTIBRON CAP NEOHALER SELECTIVE BETA-2-ADRENERGIC AGONISTS INDACATEROL-GLYCOPYRROLATE INHAL CAP 27.5-15.6 MCG NP Y N Y N VENTOLIN HFA VENTOLIN HFA AER SELECTIVE BETA-2-ADRENERGIC AGONISTS ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV) NP Y N YN WIXELA INHUB WIXELA INHUB AER 100/50 SELECTIVE BETA-2-ADRENERGIC AGONISTS FLUTICASONE-SALMETEROL AER POWDER BA 100-50 MCG/DOSE P Y N Y N XOPENEX XOPENEX NEB 0.31MG SELECTIVE BETA-2-ADRENERGIC AGONISTS LEVALBUTEROL HCL SOLN NEBU 0.31 MG/3ML (BASE EQUIV) NP Y N Y N XOPENEX CONCENTRATE XOPENEX CONC NEB 1.25/0.5 SELECTIVE BETA-2-ADRENERGIC AGONISTS LEVALBUTEROL HCL SOLN NEBU CONC 1.25 MG/0.5ML (BASE EQUIV) NP Y N Y N XOPENEX HFA XOPENEX HFA AER SELECTIVE BETA-2-ADRENERGIC AGONISTS LEVALBUTEROL TARTRATE INHAL AEROSOL 45 MCG/ACT (BASE EQUIV) NP Y N Y N GEMTESA GEMTESA TAB 75MG SELECTIVE BETA-3-ADRENERGIC AGONISTS VIBEGRON TAB 75 MG NP Y N N N MYRBETRIQ MYRBETRIQ TAB 25MG SELECTIVE BETA-3-ADRENERGIC AGONISTS MIRABEGRON TAB ER 24 HR 25 MG NP Y N Y N ALMOTRIPTAN ALMOTRIPTAN TAB 6.25MG SELECTIVE SEROTONIN AGONISTS ALMOTRIPTAN MALATE TAB 6.25 MG NP Y N Y N ALMOTRIPTAN MALATE ALMOTRIP MAL TAB 6.25MG SELECTIVE SEROTONIN AGONISTS ALMOTRIPTAN MALATE TAB 6.25 MG NP Y N Y N AMERGE AMERGE TAB 1MG SELECTIVE SEROTONIN AGONISTS NARATRIPTAN HCL TAB 1 MG (BASE EQUIV) NP Y N Y N ELETRIPTAN HYDROBROMIDE ELETRIPTAN TAB 20MG SELECTIVE SEROTONIN AGONISTS ELETRIPTAN HYDROBROMIDE TAB 20 MG (BASE EQUIVALENT) NP Y N YN FROVA FROVA TAB 2.5MG SELECTIVE SEROTONIN AGONISTS FROVATRIPTAN SUCCINATE TAB 2.5 MG (BASE EQUIVALENT) NP Y N Y N FROVATRIPTAN SUCCINATE FROVATRIPTAN TAB 2.5MG SELECTIVE SEROTONIN AGONISTS FROVATRIPTAN SUCCINATE TAB 2.5 MG (BASE EQUIVALENT) NP Y N YN IMITREX IMITREX INJ 6MG/0.5 SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML NP Y N Y N IMITREX IMITREX SPR 20MG/ACT SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN NASAL SPRAY 20 MG/ACT NP Y N Y N IMITREX IMITREX SPR 5MG/ACT SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN NASAL SPRAY 5 MG/ACT NP Y N Y N IMITREX IMITREX TAB 25MG SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN SUCCINATE TAB 25 MG NP Y N Y N IMITREX STATDOSE SYSTEM IMITREX INJ 4MG/0.5 SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 4 MG/0.5ML NP Y N Y N MAXALT MAXALT TAB 10MG SELECTIVE SEROTONIN AGONISTS RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT) NP Y N Y N MAXALT-MLT MAXALT-MLT TAB 10MG SELECTIVE SEROTONIN AGONISTS RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ) NP Y N Y N MIGRAINE PACK MIGRAINE MIS PACK SELECTIVE SEROTONIN AGONISTS *SUMATRIPTAN TAB 50 MG & HOMEOPATHIC PROD GEL THERAPY PACK** NP Y N Y N NARATRIPTAN HCL NARATRIPTAN TAB 1MG SELECTIVE SEROTONIN AGONISTS NARATRIPTAN HCL TAB 1 MG (BASE EQUIV) P N Y Y N ONZETRA XSAIL ONZETRA XSAI MIS 11MG SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN SUCCINATE EXHALER POWDER 11 MG/NOSEPIECE NP Y N Y N RELPAX RELPAX TAB 20MG SELECTIVE SEROTONIN AGONISTS ELETRIPTAN HYDROBROMIDE TAB 20 MG (BASE EQUIVALENT) NP Y N Y N REYVOW REYVOW TAB 100MG SELECTIVE SEROTONIN AGONISTS LASMIDITAN SUCCINATE TAB 100 MG NP Y N Y N REYVOW REYVOW TAB 50MG SELECTIVE SEROTONIN AGONISTS LASMIDITAN SUCCINATE TAB 50 MG NP Y N Y N RIZATRIPTAN BENZOATE RIZATRIPTAN TAB 5MG SELECTIVE SEROTONIN AGONISTS RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT) P N N Y N RIZATRIPTAN BENZOATE ODT RIZATRIPTAN TAB 5MG ODT SELECTIVE SEROTONIN AGONISTS RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ) P N N Y N SUMANSETRON SUMANSETRON PAK SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN 50 MG & ONDANSETRON 4 MG TAB THERAPY PACK NP Y N N N SUMATRIPTAN SUMATRIPTAN SPR 20MG/ACT SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN NASAL SPRAY 20 MG/ACT P N N Y N SUMATRIPTAN SUMATRIPTAN SPR 5MG/ACT SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN NASAL SPRAY 5 MG/ACT P N N Y N SUMATRIPTAN SUCCINATE SUMATRIPTAN INJ 4MG/0.5 SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 4 MG/0.5MLPNNYN SUMATRIPTAN SUCCINATE SUMATRIPTAN INJ 6MG/0.5 SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML P N N Y N SUMATRIPTAN SUCCINATE SUMATRIPTAN TAB 25MG SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN SUCCINATE TAB 25 MG P N N Y N SUMATRIPTAN/NAPROXEN SODIUM SUMAT-NAPROX TAB 85-500MG SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN-NAPROXEN SODIUM TAB 85-500 MG NP Y N Y N TOSYMRA TOSYMRA SOL 10MG SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN NASAL SPRAY 10 MG/ACT NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) TREXIMET TREXIMET TAB 85-500MG SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN-NAPROXEN SODIUM TAB 85-500 MG NP Y N Y N ZEMBRACE SYMTOUCH ZEMBRACE SYM INJ 3/0.5ML SELECTIVE SEROTONIN AGONISTS SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 3 MG/0.5ML NP Y NYN ZOLMITRIPTAN ODT ZOLMITRIPTAN TAB 2.5 MG SELECTIVE SEROTONIN AGONISTS ZOLMITRIPTAN ORALLY DISINTEGRATING TAB 2.5 MG NP Y N Y N ZOMIG ZOMIG TAB 2.5MG SELECTIVE SEROTONIN AGONISTS ZOLMITRIPTAN TAB 2.5 MG NP Y N Y N ZOMIG ZMT ZOMIG ZMT TAB 2.5 MG SELECTIVE SEROTONIN AGONISTS ZOLMITRIPTAN ORALLY DISINTEGRATING TAB 2.5 MG NP Y N Y N BRISDELLE BRISDELLE CAP 7.5MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS PAROXETINE MESYLATE CAP 7.5 MG (BASE EQUIV) NP Y N Y N CELEXA CELEXA TAB 10MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS CITALOPRAM HYDROBROMIDE TAB 10 MG (BASE EQUIV) NP Y N Y N CELEXA CELEXA TAB 40MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS CITALOPRAM HYDROBROMIDE TAB 40 MG (BASE EQUIV) NP Y N Y N CITALOPRAM CITALOPRAM TAB 20MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS CITALOPRAM HYDROBROMIDE TAB 20 MG (BASE EQUIV) P N N Y N CITALOPRAM HYDROBROMIDE CITALOPRAM SOL 10MG/5ML SELECTIVE-SEROTONIN REUPTAKE INHIBITORS CITALOPRAM HYDROBROMIDE ORAL SOLN 10 MG/5ML P N N Y N CITALOPRAM HYDROBROMIDE CITALOPRAM TAB 10MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS CITALOPRAM HYDROBROMIDE TAB 10 MG (BASE EQUIV) P N N Y N CITALOPRAM HYDROBROMIDE CITALOPRAM TAB 40MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS CITALOPRAM HYDROBROMIDE TAB 40 MG (BASE EQUIV) P N N Y N ESCITALOPRAM OXALATE ESCITALOP OX SOL 10/10ML SELECTIVE-SEROTONIN REUPTAKE INHIBITORS ESCITALOPRAM OXALATE SOLN 5 MG/5ML (BASE EQUIV) P N N Y N ESCITALOPRAM OXALATE ESCITALOPRAM TAB 10MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS ESCITALOPRAM OXALATE TAB 10 MG (BASE EQUIV) P N N Y N ESCITALOPRAM OXALATE ESCITALOPRAM TAB 5MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS ESCITALOPRAM OXALATE TAB 5 MG (BASE EQUIV) P N N Y N FLUOXETINE DR FLUOXETINE CAP 90MG DR SELECTIVE-SEROTONIN REUPTAKE INHIBITORS FLUOXETINE HCL CAP DELAYED RELEASE 90 MG P N N Y N FLUOXETINE HCL FLUOXETINE CAP 20MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS FLUOXETINE HCL CAP 20 MG P N N Y N FLUOXETINE HCL FLUOXETINE SOL 20MG/5ML SELECTIVE-SEROTONIN REUPTAKE INHIBITORS FLUOXETINE HCL SOLUTION 20 MG/5ML P N N Y N FLUOXETINE HYDROCHLORIDE FLUOXETINE CAP 10MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS FLUOXETINE HCL CAP 10 MG P N N Y N FLUOXETINE HYDROCHLORIDE FLUOXETINE CAP 40MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS FLUOXETINE HCL CAP 40 MG P N N Y N FLUOXETINE HYDROCHLORIDE FLUOXETINE TAB 10MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS FLUOXETINE HCL TAB 10 MG P N N Y N FLUVOXAMINE MALEATE FLUVOXAMINE TAB 100MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS FLUVOXAMINE MALEATE TAB 100 MG P N N Y N FLUVOXAMINE MALEATE FLUVOXAMINE TAB 25MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS FLUVOXAMINE MALEATE TAB 25 MG P N N Y N FLUVOXAMINE MALEATE ER FLUVOXAMINE CAP 100MG ER SELECTIVE-SEROTONIN REUPTAKE INHIBITORS FLUVOXAMINE MALEATE CAP ER 24HR 100 MG P N N YN LEXAPRO LEXAPRO TAB 10MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS ESCITALOPRAM OXALATE TAB 10 MG (BASE EQUIV) NP Y N Y N LEXAPRO LEXAPRO TAB 5MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS ESCITALOPRAM OXALATE TAB 5 MG (BASE EQUIV) NP Y N Y N OLANZAPINE/FLUOXETINE OLANZA/FLUOX CAP 3-25MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS OLANZAPINE-FLUOXETINE HCL CAP 3-25 MG P N N Y Y PAROXETINE PAROXETINE CAP 7.5MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS PAROXETINE MESYLATE CAP 7.5 MG (BASE EQUIV) NP Y N Y N PAROXETINE HCL PAROXETINE TAB 30MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS PAROXETINE HCL TAB 30 MG P N N Y Y PAROXETINE HCL ER PAROXETIN ER TAB 12.5MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS PAROXETINE HCL TAB ER 24HR 12.5 MG P N N Y Y PAROXETINE HYDROCHLORIDE PAROXETINE TAB 10MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS PAROXETINE HCL TAB 10 MG P N N Y Y PAROXETINE HYDROCHLORIDE PAROXETINE TAB 20MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS PAROXETINE HCL TAB 20 MG P N N Y Y PAROXETINE HYDROCHLORIDE PAROXETINE TAB 30MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS PAROXETINE HCL TAB 30 MG P N N Y Y PAXIL PAXIL SUS 10MG/5ML SELECTIVE-SEROTONIN REUPTAKE INHIBITORS PAROXETINE HCL ORAL SUSP 10 MG/5ML (BASE EQUIV) P N N Y Y PAXIL PAXIL TAB 10MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS PAROXETINE HCL TAB 10 MG NP Y N Y Y PAXIL PAXIL TAB 20MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS PAROXETINE HCL TAB 20 MG NP Y N Y Y PAXIL PAXIL TAB 30MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS PAROXETINE HCL TAB 30 MG NP Y N Y Y PAXIL CR PAXIL CR TAB 12.5MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS PAROXETINE HCL TAB ER 24HR 12.5 MG NP Y N Y Y PEXEVA PEXEVA TAB 10MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS PAROXETINE MESYLATE TAB 10 MG (BASE EQUIV) P N N Y Y PROZAC PROZAC CAP 10MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS FLUOXETINE HCL CAP 10 MG NP Y N Y N PROZAC PROZAC CAP 20MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS FLUOXETINE HCL CAP 20 MG NP Y N Y N PROZAC PROZAC CAP 40MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS FLUOXETINE HCL CAP 40 MG NP Y N Y N SERTRALINE HCL SERTRALINE TAB 25MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS SERTRALINE HCL TAB 25 MG P N N Y N SERTRALINE HYDROCHLORIDE SERTRALINE CON 20MG/ML SELECTIVE-SEROTONIN REUPTAKE INHIBITORS SERTRALINE HCL ORAL CONCENTRATE FOR SOLUTION 20 MG/ML P N N Y N SERTRALINE HYDROCHLORIDE SERTRALINE TAB 100MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS SERTRALINE HCL TAB 100 MG P N N Y N SERTRALINE HYDROCHLORIDE SERTRALINE TAB 25MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS SERTRALINE HCL TAB 25 MG P N N Y N SYMBYAX SYMBYAX CAP 3-25MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS OLANZAPINE-FLUOXETINE HCL CAP 3-25 MG NP Y N Y Y ZOLOFT ZOLOFT CON 20MG/ML SELECTIVE-SEROTONIN REUPTAKE INHIBITORS SERTRALINE HCL ORAL CONCENTRATE FOR SOLUTION 20 MG/ML NP Y N Y N

Confidential 2/19/2021 Page 80 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ZOLOFT ZOLOFT TAB 100MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS SERTRALINE HCL TAB 100 MG NP Y N Y N ZOLOFT ZOLOFT TAB 25MG SELECTIVE-SEROTONIN REUPTAKE INHIBITORS SERTRALINE HCL TAB 25 MG NP Y N Y N NEFAZODONE HCL NEFAZODONE TAB 100MG SEROTONIN MODULATORS NEFAZODONE HCL TAB 100 MG P N N Y N NEFAZODONE HYDROCHLORIDE NEFAZODONE TAB 50MG SEROTONIN MODULATORS NEFAZODONE HCL TAB 50 MG P N N Y N TRAZODONE HYDROCHLORIDE TRAZODONE TAB 100MG SEROTONIN MODULATORS TRAZODONE HCL TAB 100 MG P N N Y N TRAZODONE HYDROCHLORIDE TRAZODONE TAB 50MG SEROTONIN MODULATORS TRAZODONE HCL TAB 50 MG P N N Y N TRINTELLIX TRINTELLIX TAB 5MG SEROTONIN MODULATORS VORTIOXETINE HBR TAB 5 MG (BASE EQUIV) P N N Y N VIIBRYD VIIBRYD TAB 10MG SEROTONIN MODULATORS VILAZODONE HCL TAB 10 MG P N N Y N VIIBRYD STARTER PACK VIIBRYD KIT STARTER SEROTONIN MODULATORS VILAZODONE HCL TAB STARTER KIT 10 (7) & 20 (23) MG P N N N N HUMULIN R HUMULIN R INJ U-100 SHORT-ACTING INSULINS INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML P N N Y N HUMULIN R U-500 KWIKPEN HUMULIN R INJ U-500 SHORT-ACTING INSULINS INSULIN REGULAR (HUMAN) SOLN PEN-INJECTOR 500 UNIT/ML NP Y N Y N NOVOLIN R NOVOLIN R INJ U-100 SHORT-ACTING INSULINS INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML P N N Y N NOVOLIN R FLEXPEN NOVOLIN R INJ 100 UNIT SHORT-ACTING INSULINS INSULIN REGULAR (HUMAN) SOLN PEN-INJECTOR 100 UNIT/ML NP Y N Y N NOVOLIN R RELION NOVOLIN R INJ RELION SHORT-ACTING INSULINS INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML P N N Y N CARISOPR/ASA TAB 200-325 CARISOPR/ASA TAB 200-325 SKELETAL MUSCLE RELAXANTS CARISOPRODOL W/ ASPIRIN TAB 200-325 MG NP Y N Y N CHLORZOXAZON TAB 500MG CHLORZOXAZON TAB 500MG SKELETAL MUSCLE RELAXANTS CHLORZOXAZONE TAB 500 MG P N N Y N ORPHENADRINE CITRATE CR ORPHENADRINE TAB 100MG CR SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS ORPHENADRINE CITRATE TAB ER 12HR 100 MG PNNYN ORPHENADRINE CITRATE ER ORPHENADRINE TAB 100MG ER SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS ORPHENADRINE CITRATE TAB ER 12HR 100 MG PNNYN ABSORICA ABSORICA CAP 10MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 10 MG NP Y N Y N ABSORICA ABSORICA CAP 20MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 20 MG NP Y N Y N ABSORICA ABSORICA CAP 25MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 25 MG NP Y N Y N ABSORICA ABSORICA CAP 30MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 30 MG NP Y N Y N ABSORICA ABSORICA CAP 35MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 35 MG NP Y N Y N ABSORICA LD ABSORICA LD CAP 16MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN MICRONIZED CAP 16 MG NP Y N Y N ABSORICA LD ABSORICA LD CAP 24MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN MICRONIZED CAP 24 MG NP Y N Y N ABSORICA LD ABSORICA LD CAP 8MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN MICRONIZED CAP 8 MG NP Y N Y N ACITRETIN ACITRETIN CAP 10MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ACITRETIN CAP 10 MG P Y N Y N ACZONE ACZONE GEL 5% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. DAPSONE GEL 5% NP Y N Y N ADAPALENE ADAPALENE CRE 0.1% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ADAPALENE CREAM 0.1% NP Y N Y N ADAPALENE ADAPALENE GEL 0.1% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ADAPALENE GEL 0.1% P N N Y N ADAPALENE PUMP ADAPALENE GEL PMP 0.3% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ADAPALENE GEL 0.3% NP Y N Y N ADAPALENE/BENZOYL PEROXIDE ADAPAL/BEN P GEL 0.1-2.5% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ADAPALENE-BENZOYL PEROXIDE GEL 0.1-2.5%NPYNYN AMNESTEEM AMNESTEEM CAP 10MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 10 MG P Y N Y N AMNESTEEM AMNESTEEM CAP 20MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 20 MG P Y N Y N AMNESTEEM AMNESTEEM CAP 40MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 40 MG P Y N Y N ARAZLO ARAZLO LOT 0.045% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. TAZAROTENE (ACNE) LOTION 0.045% NP Y N Y N CALCIPOTRIENE CALCIPOTRIEN AER 0.005% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. CALCIPOTRIENE FOAM 0.005% NP Y N Y N CALCIPOTRIENE CALCIPOTRIEN CRE 0.005% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. CALCIPOTRIENE CREAM 0.005% P N Y Y N CALCIPOTRIENE CALCIPOTRIEN OIN 0.005% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. CALCIPOTRIENE OINT 0.005% P N Y Y N CALCIPOTRIENE CALCIPOTRIEN SOL 0.005% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. CALCIPOTRIENE SOLN 0.005% (50 MCG/ML) P N N Y N CALCITRENE CALCITRENE OIN 0.005% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. CALCIPOTRIENE OINT 0.005% NP Y N Y N CALCITRIOL CALCITRIOL OIN 3MCG/GM SKIN AND MUCOUS MEMBRANE AGENTS, MISC. CALCITRIOL OINT 3 MCG/GM P N Y Y N CLARAVIS CLARAVIS CAP 10MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 10 MG P Y N Y N CLARAVIS CLARAVIS CAP 20MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 20 MG P Y N Y N CLARAVIS CLARAVIS CAP 30MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 30 MG P Y N Y N CLARAVIS CLARAVIS CAP 40MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 40 MG P Y N Y N CLINDAMYCIN PHOSPHATE/TRETINOIN CLINDAMYCIN GEL TRETINOI SKIN AND MUCOUS MEMBRANE AGENTS, MISC. CLINDAMYCIN PHOSPHATE-TRETINOIN GEL 1.2-0.025% NP Y N Y N COREMINO COREMINO TAB 45MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. MINOCYCLINE HCL TAB ER 24HR 45 MG NP Y N N N

Confidential 2/19/2021 Page 81 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) COSENTYX COSENTYX INJ 150MG/ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC. SECUKINUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/MLPYNYN COSENTYX COSENTYX INJ 300DOSE SKIN AND MUCOUS MEMBRANE AGENTS, MISC. SECUKINUMAB SUBCUTANEOUS PREF SYR 150 MG/ML (300 MG DOSE) PYNYN COSENTYX SENSOREADY PEN COSENTYX PEN INJ 150MG/ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC. SECUKINUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 150 MG/ML P Y N Y N COSENTYX SENSOREADY PEN COSENTYX PEN INJ 300DOSE SKIN AND MUCOUS MEMBRANE AGENTS, MISC. SECUKINUMAB SUBCUTANEOUS AUTO-INJ 150 MG/ML (300 MG DOSE) P Y N Y N DAPSONE DAPSONE GEL 5% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. DAPSONE GEL 5% NP Y N Y N DAPSONE/NIACINAMIDE DAPS/NIACINA GEL 6-4% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. DAPSONE-NIACINAMIDE GEL 6-4% NP Y N Y N DAPSONE/NIACINAMIDE/SPIRONOLACTONDAP/NIAC/SPI GEL 6-2-5% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. DAPSONE-NIACINAMIDE-SPIRONOLACTONE GEL 6-2-5% NP Y N Y N DIFFERIN DIFFERIN CRE 0.1% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ADAPALENE CREAM 0.1% NP Y N Y N DIFFERIN DIFFERIN GEL 0.1% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ADAPALENE GEL 0.1% P N N Y N DIFFERIN DIFFERIN LOT 0.1% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ADAPALENE LOTION 0.1% NP Y N Y N DOVONEX DOVONEX CRE 0.005% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. CALCIPOTRIENE CREAM 0.005% NP Y N Y N DOXYCYCLINE DOXYCYCLINE CAP 40MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. DOXYCYCLINE (ROSACEA) CAP DELAYED RELEASE 40 MG NP Y N N N DUPIXENT DUPIXENT INJ 300/2ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC. DUPILUMAB SUBCUTANEOUS SOLN PEN-INJECTOR 300 MG/2ML NP Y N Y N EFUDEX EFUDEX CRE 5% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. FLUOROURACIL CREAM 5% NP Y N Y N ELIDEL ELIDEL CRE 1% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. PIMECROLIMUS CREAM 1% NP Y N Y Y EPIDUO EPIDUO GEL 0.1-2.5% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ADAPALENE-BENZOYL PEROXIDE GEL 0.1-2.5% NP Y N Y N FINACEA FINACEA AER 15% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. AZELAIC ACID FOAM 15% NP Y N Y N FINACEA FINACEA GEL 15% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. AZELAIC ACID GEL 15% NP Y N Y N FLUOROURACIL FLUOROURACIL CRE 0.5% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. FLUOROURACIL CREAM 0.5% NP Y N Y N FLUOROURACIL FLUOROURACIL CRE 5% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. FLUOROURACIL CREAM 5% P N N Y N FLUOROURACIL FLUOROURACIL SOL 2% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. FLUOROURACIL SOLN 2% P N N N N ILUMYA ILUMYA SOL 100MG/ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC. TILDRAKIZUMAB-ASMN SUBCUTANEOUS SOLN PREF SYRINGE 100 MG/MLP YNYN IMIQUIMOD IMIQUIMOD CRE 5% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. IMIQUIMOD CREAM 5% P N N Y N IMIQUIMOD PUMP IMIQUIMOD CRE 3.75%PMP SKIN AND MUCOUS MEMBRANE AGENTS, MISC. IMIQUIMOD CREAM 3.75% NP Y N Y N ISOTRETINOIN ISOTRETINOIN CAP 10MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 10 MG P Y N Y N ISOTRETINOIN ISOTRETINOIN CAP 20MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 20 MG P Y N Y N ISOTRETINOIN ISOTRETINOIN CAP 30MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 30 MG P Y N Y N ISOTRETINOIN ISOTRETINOIN CAP 40MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 40 MG P Y N Y N ITHOXIA ITHOXIA CRE SKIN AND MUCOUS MEMBRANE AGENTS, MISC. NIACINAMIDE-TAZAROTENE CREAM 4-0.1% NP Y N Y N MINOCYCLINE HYDROCHLORIDE ER MINOCYCLINE TAB 45MG ER SKIN AND MUCOUS MEMBRANE AGENTS, MISC. MINOCYCLINE HCL TAB ER 24HR 45 MG NP Y N NN MINOCYCLINE HYDROCHLORIDEER MINOCYCLINE CAP 45MG ER SKIN AND MUCOUS MEMBRANE AGENTS, MISC. MINOCYCLINE HCL CAP ER 24HR 45 MG (BASE EQUIVALENT) NP Y N Y N MINOLIRA MINOLIRA TAB 105MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. MINOCYCLINE HCL TAB ER 24HR BIPHASIC RELEASE 105 MG NP Y N Y N MIRVASO MIRVASO GEL 0.33% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. BRIMONIDINE TARTRATE GEL 0.33% (BASE EQUIVALENT) NP Y N Y N MYORISAN MYORISAN CAP 10MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 10 MG P Y N Y N MYORISAN MYORISAN CAP 20MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 20 MG P Y N Y N MYORISAN MYORISAN CAP 30MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 30 MG P Y N Y N MYORISAN MYORISAN CAP 40MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 40 MG P Y N Y N ORACEA ORACEA CAP 40MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. DOXYCYCLINE (ROSACEA) CAP DELAYED RELEASE 40 MG NP Y N N N PANRETIN PANRETIN GEL 0.1% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ALITRETINOIN GEL 0.1% P Y N N N PIMECROLIMUS PIMECROLIMUS CRE 1% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. PIMECROLIMUS CREAM 1% P N Y Y Y PROTOPIC PROTOPIC OIN 0.03% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. TACROLIMUS OINT 0.03% NP Y N Y Y QBREXZA QBREXZA PAD 2.4% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. GLYCOPYRRONIUM TOSYLATE PAD 2.4% (BASE EQUIVALENT) NP Y N Y N RECTIV RECTIV OIN 0.4% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. NITROGLYCERIN OINT 0.4% P Y N Y N REGRANEX REGRANEX GEL 0.01% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. BECAPLERMIN GEL 0.01% P Y N Y N RHOFADE RHOFADE CRE 1% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. OXYMETAZOLINE HCL CREAM 1% NP Y N Y N SILIQ SILIQ INJ 210/1.5 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. BRODALUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 210 MG/1.5ML NPYNYN SKYRIZI SKYRIZI INJ 150DOSE SKIN AND MUCOUS MEMBRANE AGENTS, MISC. RISANKIZUMAB-RZAA SOL PREFILLED SYRINGE 2 X 75 MG/0.83ML KIT NP Y N Y N SOLODYN SOLODYN TAB 55MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. MINOCYCLINE HCL TAB ER 24HR 55 MG NP Y N N N

Confidential 2/19/2021 Page 82 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) SORIATANE SORIATANE CAP 10MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ACITRETIN CAP 10 MG NP Y N Y N STELARA STELARA INJ 45MG/0.5 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. USTEKINUMAB INJ 45 MG/0.5ML NP Y N Y N STELARA STELARA INJ 90MG/ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC. USTEKINUMAB SOLN PREFILLED SYRINGE 90 MG/ML NP Y N Y N TACROLIMUS TACROLIMUS OIN 0.03% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. TACROLIMUS OINT 0.03% P N Y Y Y TACROLIMUS MONOHYDRATE TACROLIMUS CRE MONOHYDR SKIN AND MUCOUS MEMBRANE AGENTS, MISC. TACROLIMUS CREAM 0.1% NP Y N Y N TALTZ TALTZ INJ 80MG/ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC. IXEKIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 80 MG/ML NP Y N Y N TARGRETIN TARGRETIN GEL 1% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. BEXAROTENE GEL 1% P Y N N N TAZAROTENE TAZAROTENE CRE 0.1% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. TAZAROTENE CREAM 0.1% NP Y N Y N TAZORAC TAZORAC CRE 0.05% SKIN AND MUCOUS MEMBRANE AGENTS, MISC. TAZAROTENE CREAM 0.05% NP Y N Y N TREMFYA TREMFYA INJ 100MG/ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC. GUSELKUMAB SOLN PEN-INJECTOR 100 MG/ML NP Y N Y N XIMINO XIMINO CAP 45MG ER SKIN AND MUCOUS MEMBRANE AGENTS, MISC. MINOCYCLINE HCL CAP ER 24HR 45 MG (BASE EQUIVALENT) NP Y N Y N ZENATANE ZENATANE CAP 10MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 10 MG P Y N Y N ZENATANE ZENATANE CAP 20MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 20 MG P Y N Y N ZENATANE ZENATANE CAP 30MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 30 MG P Y N Y N ZENATANE ZENATANE CAP 40MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ISOTRETINOIN CAP 40 MG P Y N Y N ZIANA ZIANA GEL SKIN AND MUCOUS MEMBRANE AGENTS, MISC. CLINDAMYCIN PHOSPHATE-TRETINOIN GEL 1.2-0.025% NP Y N Y N FARXIGA FARXIGA TAB 5MG SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB DAPAGLIFLOZIN PROPANEDIOL TAB 5 MG (BASE EQUIVALENT) P Y N Y N GLYXAMBI GLYXAMBI TAB 10-5 MG SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB EMPAGLIFLOZIN-LINAGLIPTIN TAB 10-5 MG NP Y N N N INVOKAMET INVOKAMET TAB 50-500MG SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB CANAGLIFLOZIN-METFORMIN HCL TAB 50-500 MG NP Y N Y N INVOKAMET XR INVOKAMET XR TAB 50-500MG SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB CANAGLIFLOZIN-METFORMIN HCL TAB ER 24HR 50-500 MG NP YNYN INVOKANA INVOKANA TAB 100MG SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB CANAGLIFLOZIN TAB 100 MG NP Y N Y N JARDIANCE JARDIANCE TAB 10MG SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB EMPAGLIFLOZIN TAB 10 MG NP Y N Y N QTERN QTERN TAB 5-5MG SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB DAPAGLIFLOZIN-SAXAGLIPTIN TAB 5-5 MG NP Y N Y N SEGLUROMET SEGLUROMET TAB 2.5-500 SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB ERTUGLIFLOZIN-METFORMIN HCL TAB 2.5-500 MG P N Y Y N STEGLATRO STEGLATRO TAB 15MG SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB ERTUGLIFLOZIN L-PYROGLUTAMIC ACID TAB 15 MG (BASE EQUIV) P N YYN STEGLATRO STEGLATRO TAB 5MG SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB ERTUGLIFLOZIN L-PYROGLUTAMIC ACID TAB 5 MG (BASE EQUIV) P N Y Y N STEGLUJAN STEGLUJAN TAB 5-100MG SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB ERTUGLIFLOZIN-SITAGLIPTIN TAB 5-100 MG NP Y N Y N SYNJARDY SYNJARDY TAB 5-500MG SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB EMPAGLIFLOZIN-METFORMIN HCL TAB 5-500 MG NP Y N Y N SYNJARDY XR SYNJARDY XR TAB 5-1000MG SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB EMPAGLIFLOZIN-METFORMIN HCL TAB ER 24HR 5-1000 MG NP Y NYN TRIJARDY XR TRIJARDY XR TAB SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN TAB ER 24HR 5-2.5-1000MG NPYNYN XIGDUO XR XIGDUO XR TAB 10-500MG SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB DAPAGLIFLOZIN-METFORMIN HCL TAB ER 24HR 10-500 MG NP Y N N N XIGDUO XR XIGDUO XR TAB 2.5-1000 SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB DAPAGLIFLOZIN-METFORMIN HCL TAB ER 24HR 2.5-1000 MG NP Y NYN XIGDUO XR XIGDUO XR TAB 5-500MG SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB DAPAGLIFLOZIN-METFORMIN HCL TAB ER 24HR 5-500 MG NP Y N Y N BYNFEZIA PEN BYNFEZIA PEN INJ 2500MCG SOMATOSTATIN AGONISTS OCTREOTIDE ACETATE SOLN PEN-INJECTOR 2500 MCG/ML (2.8 ML) NP Y N N N MYCAPSSA MYCAPSSA CAP 20MG SOMATOSTATIN AGONISTS OCTREOTIDE ACETATE CAP DELAYED RELEASE 20 MG NP Y N Y N OCTREOTIDE ACETATE OCTREOTIDE INJ 1000MCG SOMATOSTATIN AGONISTS OCTREOTIDE ACETATE INJ 1000 MCG/ML (1 MG/ML) P N N Y N OCTREOTIDE ACETATE OCTREOTIDE INJ 500MCG SOMATOSTATIN AGONISTS OCTREOTIDE ACETATE INJ 500 MCG/ML (0.5 MG/ML) P N N Y N OCTREOTIDE ACETATE OCTREOTIDE INJ 50MCG/ML SOMATOSTATIN AGONISTS OCTREOTIDE ACETATE INJ 50 MCG/ML (0.05 MG/ML) P N N N N SANDOSTATIN SANDOSTATIN INJ 500MCG SOMATOSTATIN AGONISTS OCTREOTIDE ACETATE INJ 500 MCG/ML (0.5 MG/ML) NP Y N Y N SANDOSTATIN SANDOSTATIN INJ 50MCG/ML SOMATOSTATIN AGONISTS OCTREOTIDE ACETATE INJ 50 MCG/ML (0.05 MG/ML) NP Y N N N SIGNIFOR SIGNIFOR INJ 0.3MG/ML SOMATOSTATIN AGONISTS PASIREOTIDE DIASPARTATE INJ 0.3 MG/ML (BASE EQUIV) P Y N Y N EGRIFTA SV EGRIFTA SV INJ 2MG SOMATOTROPIN AGONISTS TESAMORELIN ACETATE FOR INJ 2 MG (BASE EQUIV) NP Y N Y N GENOTROPIN GENOTROPIN INJ 5MG SOMATOTROPIN AGONISTS SOMATROPIN FOR SUBCUTANEOUS INJ 5 MG NP Y N N N GENOTROPIN MINIQUICK GENOTROPIN INJ 0.2MG SOMATOTROPIN AGONISTS SOMATROPIN FOR INJ 0.2 MG NP Y N N N HUMATROPE HUMATROPE INJ 6MG SOMATOTROPIN AGONISTS SOMATROPIN FOR INJ 6 MG (18 UNIT) NP Y N N N HUMATROPE COMBO PACK HUMATROPE INJ 5MG SOMATOTROPIN AGONISTS SOMATROPIN FOR INJ 5 MG NP Y N N N INCRELEX INCRELEX INJ 40MG/4ML SOMATOTROPIN AGONISTS MECASERMIN INJ 40 MG/4ML (10 MG/ML) P Y N N N NORDITROPIN CARTRIDGE NORDITROPIN INJ 5/1.5ML SOMATOTROPIN AGONISTS SOMATROPIN INJ 5 MG/1.5ML NP Y N N N

Confidential 2/19/2021 Page 83 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) NUTROPIN AQ NUSPIN 10 NUTROPIN AQ INJ 10MG/2ML SOMATOTROPIN AGONISTS SOMATROPIN SOLUTION PEN-INJECTOR 10 MG/2ML NP Y N N N NUTROPIN AQ NUSPIN 20 NUTROPIN AQ INJ 20MG/2ML SOMATOTROPIN AGONISTS SOMATROPIN SOLUTION PEN-INJECTOR 20 MG/2ML NP Y N N N NUTROPIN AQ NUSPIN 5 NUTROPIN AQ INJ NUSPIN 5 SOMATOTROPIN AGONISTS SOMATROPIN SOLUTION PEN-INJECTOR 5 MG/2ML NP Y N N N OMNITROPE OMNITROPE INJ 5.8MG SOMATOTROPIN AGONISTS SOMATROPIN FOR INJ 5.8 MG NP Y N N N SAIZEN SAIZEN INJ 5MG SOMATOTROPIN AGONISTS SOMATROPIN (NON-REFRIGERATED) FOR INJ 5 MG NP Y N N N SEROSTIM SEROSTIM INJ 4MG SOMATOTROPIN AGONISTS SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 4 MG NP Y N N N ZOMACTON ZOMACTON INJ 5MG SOMATOTROPIN AGONISTS SOMATROPIN FOR SUBCUTANEOUS INJ 5 MG P Y N N N ZORBTIVE ZORBTIVE INJ 8.8MG SOMATOTROPIN AGONISTS SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 8.8 MG NP Y N N N SOMAVERT SOMAVERT INJ 10MG SOMATOTROPIN ANTAGONISTS PEGVISOMANT FOR INJ 10 MG (AS PROTEIN) P Y N Y N CELONTIN CELONTIN CAP 300MG SUCCINIMIDES METHSUXIMIDE CAP 300 MG P N N Y N ETHOSUXIMIDE ETHOSUXIMIDE CAP 250MG SUCCINIMIDES ETHOSUXIMIDE CAP 250 MG P N N Y N ETHOSUXIMIDE ETHOSUXIMIDE SOL 250/5ML SUCCINIMIDES ETHOSUXIMIDE SOLN 250 MG/5ML P N N Y N ZARONTIN ZARONTIN CAP 250MG SUCCINIMIDES ETHOSUXIMIDE CAP 250 MG NP Y N Y N ZARONTIN ZARONTIN SOL 250/5ML SUCCINIMIDES ETHOSUXIMIDE SOLN 250 MG/5ML NP Y N Y N DIASTIX DIASTIX TES STRIPS SUGAR GLUCOSE URINE TEST-(GLUCOSE OXIDASE) STRIP NP Y N N N AZULFIDINE AZULFIDINE TAB 500MG SULFONAMIDE ANTIBIOTICS (SYSTEMIC) SULFASALAZINE TAB 500 MG NP Y N Y N AZULFIDINE EN-TABS AZULFIDINE TAB 500MG EN SULFONAMIDE ANTIBIOTICS (SYSTEMIC) SULFASALAZINE TAB DELAYED RELEASE 500 MG NP Y N Y N BACTRIM BACTRIM TAB 400-80MG SULFONAMIDE ANTIBIOTICS (SYSTEMIC) SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG NP Y N Y N BACTRIM DS BACTRIM DS TAB 800-160 SULFONAMIDE ANTIBIOTICS (SYSTEMIC) SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG NP Y N Y N SULFADIAZINE SULFADIAZINE TAB 500MG SULFONAMIDE ANTIBIOTICS (SYSTEMIC) SULFADIAZINE TAB 500 MG NP Y N Y N SULFAMETHOXAZOLE/TRIMETHOPRIM SMZ-TMP SUS 200-40/5 SULFONAMIDE ANTIBIOTICS (SYSTEMIC) SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML P N N Y N SULFAMETHOXAZOLE/TRIMETHOPRIM SMZ-TMP TAB 400-80MG SULFONAMIDE ANTIBIOTICS (SYSTEMIC) SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG P N N Y N SULFAMETHOXAZOLE/TRIMETHOPRIM DS SMZ/TMP DS TAB 800-160 SULFONAMIDE ANTIBIOTICS (SYSTEMIC) SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG P N N Y N SULFASALAZINE SULFASALAZIN TAB 500MG SULFONAMIDE ANTIBIOTICS (SYSTEMIC) SULFASALAZINE TAB 500 MG P N N Y N SULFATRIM PEDIATRIC SULFATRIM PD SUS 200-40/5 SULFONAMIDE ANTIBIOTICS (SYSTEMIC) SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML P NNYN SULFISOXIZOLE SULFISOXIZOL CRY SULFONAMIDE ANTIBIOTICS (SYSTEMIC) SULFISOXAZOLE CRYSTALS NP Y N N N AMARYL AMARYL TAB 1MG SULFONYLUREAS GLIMEPIRIDE TAB 1 MG NP Y N Y N AMARYL AMARYL TAB 2MG SULFONYLUREAS GLIMEPIRIDE TAB 2 MG NP Y N Y N GLIMEPIRIDE GLIMEPIRIDE TAB 1MG SULFONYLUREAS GLIMEPIRIDE TAB 1 MG P N N Y N GLIMEPIRIDE GLIMEPIRIDE TAB 2MG SULFONYLUREAS GLIMEPIRIDE TAB 2 MG P N N Y N GLIPIZIDE GLIPIZIDE TAB 5MG SULFONYLUREAS GLIPIZIDE TAB 5 MG P N N Y N GLIPIZIDE ER GLIPIZIDE ER TAB 10MG SULFONYLUREAS GLIPIZIDE TAB ER 24HR 10 MG P N N Y N GLIPIZIDE ER GLIPIZIDE ER TAB 2.5MG SULFONYLUREAS GLIPIZIDE TAB ER 24HR 2.5 MG P N N Y N GLIPIZIDE XL GLIPIZIDE XL TAB 10MG SULFONYLUREAS GLIPIZIDE TAB ER 24HR 10 MG P N N Y N GLIPIZIDE XL GLIPIZIDE XL TAB 2.5MG SULFONYLUREAS GLIPIZIDE TAB ER 24HR 2.5 MG P N N Y N GLIPIZIDE/METFORMIN HYDROCHLORIDE GLIP/METFORM TAB 2.5-250M SULFONYLUREAS GLIPIZIDE-METFORMIN HCL TAB 2.5-250 MG NP Y N Y N GLIPIZIDE/METFORMIN HYDROCHLORIDE GLIP/METFORM TAB 2.5-500M SULFONYLUREAS GLIPIZIDE-METFORMIN HCL TAB 2.5-500 MG NP Y N Y N GLUCOTROL GLUCOTROL TAB 10MG SULFONYLUREAS GLIPIZIDE TAB 10 MG NP Y N Y N GLUCOTROL XL GLUCOTROL XL TAB 10MG SULFONYLUREAS GLIPIZIDE TAB ER 24HR 10 MG NP Y N Y N GLUCOTROL XL GLUCOTROL XL TAB 2.5MG SULFONYLUREAS GLIPIZIDE TAB ER 24HR 2.5 MG NP Y N Y N GLUCOVANCE GLUCOVANCE TAB 2.5-500 SULFONYLUREAS GLYBURIDE-METFORMIN TAB 2.5-500 MG NP Y N Y N GLUCOVANCE GLUCOVANCE TAB 5-500MG SULFONYLUREAS GLYBURIDE-METFORMIN TAB 5-500 MG NP Y N Y N GLYBURIDE GLYBURIDE TAB 1.25MG SULFONYLUREAS GLYBURIDE TAB 1.25 MG P N N Y N GLYBURIDE GLYBURIDE TAB 2.5MG SULFONYLUREAS GLYBURIDE TAB 2.5 MG P N N Y N GLYBURIDE GLYBURIDE TAB 5MG SULFONYLUREAS GLYBURIDE TAB 5 MG P N N Y N GLYBURIDE MICRONIZED GLYBURID MCR TAB 1.5MG SULFONYLUREAS GLYBURIDE MICRONIZED TAB 1.5 MG P N N Y N GLYBURIDE/METFORMIN HCL GLYB/METFORM TAB 1.25-250 SULFONYLUREAS GLYBURIDE-METFORMIN TAB 1.25-250 MG P N N Y N GLYBURIDE/METFORMIN HCL GLYB/METFORM TAB 5-500MG SULFONYLUREAS GLYBURIDE-METFORMIN TAB 5-500 MG P N N Y N

Confidential 2/19/2021 Page 84 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) GLYBURIDE/METFORMIN HYDROCHLORIDEGLYB/METFORM TAB 1.25-250 SULFONYLUREAS GLYBURIDE-METFORMIN TAB 1.25-250 MG P N N Y N GLYBURIDE/METFORMIN HYDROCHLORIDEGLYB/METFORM TAB 2.5-500 SULFONYLUREAS GLYBURIDE-METFORMIN TAB 2.5-500 MG P N N Y N GLYBURIDE/METFORMIN HYDROCHLORIDEGLYB/METFORM TAB 5-500MG SULFONYLUREAS GLYBURIDE-METFORMIN TAB 5-500 MG P N N Y N GLYNASE GLYNASE TAB 1.5MG SULFONYLUREAS GLYBURIDE MICRONIZED TAB 1.5 MG NP Y N Y N TOLBUTAMIDE TOLBUTAMIDE TAB 500MG SULFONYLUREAS TOLBUTAMIDE TAB 500 MG NP Y N Y N ISOPROTEREN AER 131MCG ISOPROTEREN AER 131MCG SYMPATHOMIMETIC (ADRENERGIC) AGENTS ISOPROTERENOL HCL INHAL AEROSOL SOLN 131 MCG/ACT (2.5 MG/ML) NP Y N N N PSEUDOEPHEDRINE HCL PSEUDOEPHEDR SYP 30MG/5ML SYMPATHOMIMETIC (ADRENERGIC) AGENTS PSEUDOEPHEDRINE HCL SYRUP 30 MG/5ML P N N N Y SOBA PAIN RELIEVER/SINUS PAIN RELIEVE TAB SINUS SYMPATHOMIMETIC (ADRENERGIC) AGENTS PSEUDOEPHEDRINE W/ ACETAMINOPHEN TAB 30-500 MG PNNNN ACTICLATE ACTICLATE TAB 75MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE HYCLATE TAB 75 MG NP Y N Y N AVIDOXY AVIDOXY TAB 100MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE MONOHYDRATE TAB 100 MG NP Y N Y N AVIDOXY DK AVIDOXY DK KIT TETRACYCLINE ANTIBIOTICS *DOXYCYCLINE TAB 100 MG & SUNCREEN & SAL ACID WASH 2% KIT** NP Y N N N DEMECLOCYCLINE HCL DEMECLOCYCL TAB 150MG TETRACYCLINE ANTIBIOTICS DEMECLOCYCLINE HCL TAB 150 MG NP Y N Y N DEMECLOCYCLINE HCL DEMECLOCYCL TAB 300MG TETRACYCLINE ANTIBIOTICS DEMECLOCYCLINE HCL TAB 300 MG NP Y N Y N DEMECLOCYCLINE HYDROCHLORIDE DEMECLOCYCL TAB 150MG TETRACYCLINE ANTIBIOTICS DEMECLOCYCLINE HCL TAB 150 MG NP Y N Y N DEMECLOCYCLINE HYDROCHLORIDE DEMECLOCYCL TAB 300MG TETRACYCLINE ANTIBIOTICS DEMECLOCYCLINE HCL TAB 300 MG NP Y N Y N DOXYCYCLINE DOXYCYCLINE TAB 150MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE MONOHYDRATE TAB 150 MG NP Y N N N DOXYCYCLINE DOXYCYCLINE TAB 50MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE MONOHYDRATE TAB 50 MG NP Y N Y N DOXYCYCLINE DOXYCYCLINE TAB 75MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE MONOHYDRATE TAB 75 MG NP Y N Y N DOXYCYCLINE HYCLATE DOXYCYCL HYC CAP 100MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE HYCLATE CAP 100 MG P N N Y N DOXYCYCLINE HYCLATE DOXYCYCL HYC CAP 50MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE HYCLATE CAP 50 MG P N N Y N DOXYCYCLINE HYCLATE DOXYCYCLINE TAB 20MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE HYCLATE TAB 20 MG NP Y N N N DOXYCYCLINE HYCLATE DOXYCYCLINE TAB 75MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE HYCLATE TAB 75 MG NP Y N Y N DOXYCYCLINE HYCLATE DOXYCYCLINE TAB 80MG DR TETRACYCLINE ANTIBIOTICS DOXYCYCLINE HYCLATE TAB DELAYED RELEASE 80 MG NP Y N Y N DOXYCYCLINE HYCLATE DR DOXYCYCL HYC TAB 100MG DR TETRACYCLINE ANTIBIOTICS DOXYCYCLINE HYCLATE TAB DELAYED RELEASE 100 MG NP Y N Y N DOXYCYCLINE HYCLATE DR DOXYCYCL HYC TAB 200MG DR TETRACYCLINE ANTIBIOTICS DOXYCYCLINE HYCLATE TAB DELAYED RELEASE 200 MG NP Y N Y N DOXYCYCLINE HYCLATE DR DOXYCYCL HYC TAB 50MG DR TETRACYCLINE ANTIBIOTICS DOXYCYCLINE HYCLATE TAB DELAYED RELEASE 50 MG NP Y N Y N DOXYCYCLINE HYCLATE DR DOXYCYCL HYC TAB 75MG DR TETRACYCLINE ANTIBIOTICS DOXYCYCLINE HYCLATE TAB DELAYED RELEASE 75 MG NP Y N N N DOXYCYCLINE MONOHYDRATE DOXYCYC MONO CAP 100MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE MONOHYDRATE CAP 100 MG P N N Y N DOXYCYCLINE MONOHYDRATE DOXYCYC MONO CAP 50MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE MONOHYDRATE CAP 50 MG P N N Y N DOXYCYCLINE MONOHYDRATE DOXYCYC MONO CAP 75MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE MONOHYDRATE CAP 75 MG NP Y N N N DOXYCYCLINE MONOHYDRATE DOXYCYC MONO TAB 100MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE MONOHYDRATE TAB 100 MG NP Y N Y N DOXYCYCLINE MONOHYDRATE DOXYCYC MONO TAB 50MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE MONOHYDRATE TAB 50 MG NP Y N Y N DOXYCYCLINE MONOHYDRATE DOXYCYC MONO TAB 75MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE MONOHYDRATE TAB 75 MG NP Y N Y N MINOCYCLINE HCL MINOCYCLINE CAP 75MG TETRACYCLINE ANTIBIOTICS MINOCYCLINE HCL CAP 75 MG NP Y N N N MINOCYCLINE HCL MINOCYCLINE TAB 100MG TETRACYCLINE ANTIBIOTICS MINOCYCLINE HCL TAB 100 MG NP Y N Y N MINOCYCLINE HYDROCHLORIDE MINOCYCLINE CAP 100MG TETRACYCLINE ANTIBIOTICS MINOCYCLINE HCL CAP 100 MG P N N Y N MINOCYCLINE HYDROCHLORIDE MINOCYCLINE CAP 50MG TETRACYCLINE ANTIBIOTICS MINOCYCLINE HCL CAP 50 MG P N N Y N MINOCYCLINE HYDROCHLORIDE MINOCYCLINE CAP 75MG TETRACYCLINE ANTIBIOTICS MINOCYCLINE HCL CAP 75 MG NP Y N N N MINOCYCLINE HYDROCHLORIDE MINOCYCLINE TAB 100MG TETRACYCLINE ANTIBIOTICS MINOCYCLINE HCL TAB 100 MG NP Y N Y N MONDOXYNE NL MONDOXYNE NL CAP 100MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE MONOHYDRATE CAP 100 MG P N N Y N MONDOXYNE NL MONDOXYNE NL CAP 75MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE MONOHYDRATE CAP 75 MG NP Y N N N MORGIDOX 1X100MG MORGIDOX CAP 1X100MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE HYCLATE CAP 100 MG P N N Y N MORGIDOX 1X100MG MORGIDOX KIT 1X100MG TETRACYCLINE ANTIBIOTICS *DOXYCYCLINE HYCLATE CAP 1 X 100 MG W/ CLEANSER KIT* NP Y N N N MORGIDOX 2X100MG MORGIDOX CAP 2X100MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE HYCLATE CAP 100 MG P N N Y N MORGIDOX 2X100MG MORGIDOX KIT 2X100MG TETRACYCLINE ANTIBIOTICS *DOXYCYCLINE HYCLATE CAP 2 X 100 MG W/ CLEANSER KIT* NP Y N N N TARGADOX TARGADOX TAB 50MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE HYCLATE TAB 50 MG NP Y N N N TETRACYCLINE HYDROCHLORIDE TETRACYCLINE CAP 250MG TETRACYCLINE ANTIBIOTICS TETRACYCLINE HCL CAP 250 MG NP Y N Y Y TETRACYCLINE HYDROCHLORIDE TETRACYCLINE CAP 500MG TETRACYCLINE ANTIBIOTICS TETRACYCLINE HCL CAP 500 MG NP Y N Y Y

Confidential 2/19/2021 Page 85 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) VIBRAMYCIN VIBRAMYCIN CAP 100MG TETRACYCLINE ANTIBIOTICS DOXYCYCLINE HYCLATE CAP 100 MG NP Y N Y N VIBRAMYCIN VIBRAMYCIN SUS 25MG/5ML TETRACYCLINE ANTIBIOTICS DOXYCYCLINE MONOHYDRATE FOR SUSP 25 MG/5ML NP Y N N N DIURIL DIURIL SUS 250/5ML THIAZIDE DIURETICS CHLOROTHIAZIDE SUSP 250 MG/5ML P N N Y N HYDROCHLOROTHIAZIDE HYDROCHLOROT CAP 12.5MG THIAZIDE DIURETICS HYDROCHLOROTHIAZIDE CAP 12.5 MG P N N Y N HYDROCHLOROTHIAZIDE HYDROCHLOROT TAB 12.5MG THIAZIDE DIURETICS HYDROCHLOROTHIAZIDE TAB 12.5 MG P N N N N HYDROCHLOROTHIAZIDE HYDROCHLOROT TAB 25MG THIAZIDE DIURETICS HYDROCHLOROTHIAZIDE TAB 25 MG P N N Y N HYDROCHLOROTHIAZIDE HYDROCHLOROT TAB 50MG THIAZIDE DIURETICS HYDROCHLOROTHIAZIDE TAB 50 MG P N N Y N CHLORTHALIDONE CHLORTHALID TAB 25MG THIAZIDE-LIKE DIURETICS CHLORTHALIDONE TAB 25 MG P N N Y N CHLORTHALIDONE CHLORTHALID TAB 50MG THIAZIDE-LIKE DIURETICS CHLORTHALIDONE TAB 50 MG P N N Y N INDAPAMIDE INDAPAMIDE TAB 1.25MG THIAZIDE-LIKE DIURETICS INDAPAMIDE TAB 1.25 MG P N N Y N INDAPAMIDE INDAPAMIDE TAB 2.5MG THIAZIDE-LIKE DIURETICS INDAPAMIDE TAB 2.5 MG P N N Y N METOLAZONE METOLAZONE TAB 10MG THIAZIDE-LIKE DIURETICS METOLAZONE TAB 10 MG P N N Y N METOLAZONE METOLAZONE TAB 2.5MG THIAZIDE-LIKE DIURETICS METOLAZONE TAB 2.5 MG P N N Y N METOLAZONE METOLAZONE TAB 5MG THIAZIDE-LIKE DIURETICS METOLAZONE TAB 5 MG P N N Y N ACTOPLUS MET ACTOPLUS MET TAB 15-500MG THIAZOLIDINEDIONES PIOGLITAZONE HCL-METFORMIN HCL TAB 15-500 MG NP Y N Y N ACTOS ACTOS TAB 15MG THIAZOLIDINEDIONES PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV) NP Y N Y N AVANDIA AVANDIA TAB 2MG THIAZOLIDINEDIONES ROSIGLITAZONE MALEATE TAB 2 MG (BASE EQUIV) NP Y N N N DUETACT DUETACT TAB 30-2MG THIAZOLIDINEDIONES PIOGLITAZONE HCL-GLIMEPIRIDE TAB 30-2 MG NP Y N Y N PIOGLITAZONE HCL PIOGLITAZONE TAB 45MG THIAZOLIDINEDIONES PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV) P N N Y N PIOGLITAZONE HCL/METFORMIN HCL PIOGLITA/MET TAB 15-500MG THIAZOLIDINEDIONES PIOGLITAZONE HCL-METFORMIN HCL TAB 15-500 MG NP Y N Y N PIOGLITAZONE HCL-GLIMEPIRIDE PIOGLIT/GLIM TAB 30-2MG THIAZOLIDINEDIONES PIOGLITAZONE HCL-GLIMEPIRIDE TAB 30-2 MG NP Y N Y N PIOGLITAZONE HYDROCHLORIDE PIOGLITAZONE TAB 15MG THIAZOLIDINEDIONES PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV) P N N Y N THIOTHIXENE THIOTHIXENE CAP 1MG THIOXANTHENES THIOTHIXENE CAP 1 MG P N N Y N ARMOUR THYROID ARMOUR THYRO TAB 15MG THYROID AGENTS THYROID TAB 15 MG (1/4 GRAIN) NP Y N Y N ARMOUR THYROID ARMOUR THYRO TAB 30MG THYROID AGENTS THYROID TAB 30 MG (1/2 GRAIN) NP Y N Y N ARMOUR THYROID ARMOUR THYRO TAB 60MG THYROID AGENTS THYROID TAB 60 MG (1 GRAIN) NP Y N Y N ARMOUR THYROID ARMOUR THYRO TAB 90MG THYROID AGENTS THYROID TAB 90 MG (1 1/2 GRAIN) NP Y N Y N CYTOMEL CYTOMEL TAB 25MCG THYROID AGENTS LIOTHYRONINE SODIUM TAB 25 MCG NP Y N Y N CYTOMEL CYTOMEL TAB 50MCG THYROID AGENTS LIOTHYRONINE SODIUM TAB 50 MCG NP Y N Y N CYTOMEL CYTOMEL TAB 5MCG THYROID AGENTS LIOTHYRONINE SODIUM TAB 5 MCG NP Y N Y N EUTHYROX EUTHYROX TAB 25MCG THYROID AGENTS LEVOTHYROXINE SODIUM TAB 25 MCG P N N Y N LEVO-T LEVO-T TAB 25MCG THYROID AGENTS LEVOTHYROXINE SODIUM TAB 25 MCG P N N Y N LEVOTHYROXINE SODIUM LEVOTHYROXIN CAP 13MCG THYROID AGENTS LEVOTHYROXINE SODIUM CAP 13 MCG NP Y N Y N LEVOTHYROXINE SODIUM LEVOTHYROXIN TAB 25MCG THYROID AGENTS LEVOTHYROXINE SODIUM TAB 25 MCG P N N Y N LEVOXYL LEVOXYL TAB 25MCG THYROID AGENTS LEVOTHYROXINE SODIUM TAB 25 MCG P N N Y N LIOTHYRONINE SODIUM LIOTHYRONINE TAB 25MCG THYROID AGENTS LIOTHYRONINE SODIUM TAB 25 MCG P N N Y N LIOTHYRONINE SODIUM LIOTHYRONINE TAB 50MCG THYROID AGENTS LIOTHYRONINE SODIUM TAB 50 MCG P N N Y N LIOTHYRONINE SODIUM LIOTHYRONINE TAB 5MCG THYROID AGENTS LIOTHYRONINE SODIUM TAB 5 MCG P N N Y N NP THYROID 120 NP THYROID TAB 120MG THYROID AGENTS THYROID TAB 120 MG (2 GRAIN) NP Y N Y N NP THYROID 15 NP THYROID TAB 15MG THYROID AGENTS THYROID TAB 15 MG (1/4 GRAIN) NP Y N Y N NP THYROID 30 NP THYROID TAB 30MG THYROID AGENTS THYROID TAB 30 MG (1/2 GRAIN) NP Y N Y N NP THYROID 60 NP THYROID TAB 60MG THYROID AGENTS THYROID TAB 60 MG (1 GRAIN) NP Y N Y N NP THYROID 90 NP THYROID TAB 90MG THYROID AGENTS THYROID TAB 90 MG (1 1/2 GRAIN) NP Y N Y N SYNTHROID SYNTHROID TAB 25MCG THYROID AGENTS LEVOTHYROXINE SODIUM TAB 25 MCG NP Y N Y N SYNTHROID SYNTHROID TAB 50MCG THYROID AGENTS LEVOTHYROXINE SODIUM TAB 50 MCG P N N Y N THYQUIDITY THYQUIDITY SOL 100MCG THYROID AGENTS LEVOTHYROXINE SODIUM ORAL SOLUTION 100 MCG/5ML NP Y N N N THYROID THYROID TAB 65MG THYROID AGENTS THYROID TAB 65 MG NP Y N N N TIROSINT TIROSINT CAP 13MCG THYROID AGENTS LEVOTHYROXINE SODIUM CAP 13 MCG NP Y N Y N

Confidential 2/19/2021 Page 86 UnitedHealthcare Community Plan of Indiana Drug List, February 2021

Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) TIROSINT-SOL TIROSINT-SOL SOL 13MCG/ML THYROID AGENTS LEVOTHYROXINE SODIUM ORAL SOLUTION 13 MCG/ML NP Y N Y N UNITHROID UNITHROID TAB 25MCG THYROID AGENTS LEVOTHYROXINE SODIUM TAB 25 MCG P N N Y N WESTHROID WESTHROID TAB 32.5MG THYROID AGENTS THYROID TAB 32.5 MG NP Y N N N WP THYROID WP THYROID TAB 16.25MG THYROID AGENTS THYROID TAB 16.25 MG NP Y N N N ADACEL ADACEL INJ TOXOIDS TET TOX-DIPH-ACELL PERTUSS AD INJ 5-2-15.5 LF-LF-MCG/0.5ML P N N Y N BOOSTRIX BOOSTRIX INJ TOXOIDS TET TOX-DIPH-ACELL PERTUSS AD INJ 5-2.5-18.5 LF-LF-MCG/0.5ML P N N Y N DAPTACEL DAPTACEL INJ TOXOIDS DIPH, ACELLULAR PERT & TET TOX INJ 15 LF-23 MCG-5 LF/0.5ML P N N Y N DIPHTHERIA/TETANUS TOXOIDS ADSORBEDDIP/TET PED INJ 25-5LFU TOXOIDS DIPHTHERIA-TETANUS TOX ADSORBED (DT) IM INJ 25-5 UNIT/0.5ML P N N Y N INFANRIX INFANRIX INJ TOXOIDS DIPH, ACELLULAR PERT & TET TOX INJ 25 LF-58 MCG-10 LF/0.5ML P N N Y N KINRIX KINRIX INJ TOXOIDS DIPH-TETANUS TOX AD-ACELL PERT & POLIO VIRUS, IPV VAC INJ P N N Y N QUADRACEL QUADRACEL INJ TOXOIDS DIPH-TETANUS TOX AD-ACELL PERT & POLIO VIRUS, IPV VAC INJ P N N Y N TDVAX TDVAX INJ 2-2 LF TOXOIDS TETANUS-DIPHTHERIA TOXOIDS (TD) INJ 2-2 LF/0.5ML P N N Y N TENIVAC TENIVAC INJ 5-2LF TOXOIDS TETANUS-DIPHTHERIA TOXOIDS (TD) INJ 5-2 LFU P N N Y N TETANUS/DIPHTHERIA TOXOIDS-ADSORBEDTET/DIP TOX INJ 2-2 LF TOXOIDS TETANUS-DIPHTHERIA TOXOIDS (TD) INJ 2-2 LF/0.5ML P N N Y N AMITRIPTYLINE HCL AMITRIPTYLIN TAB 25MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS AMITRIPTYLINE HCL TAB 25 MG P N N Y N AMITRIPTYLINE HYDROCHLORIDE AMITRIPTYLIN TAB 10MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS AMITRIPTYLINE HCL TAB 10 MG P N N Y N AMOXAPINE AMOXAPINE TAB 25MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS AMOXAPINE TAB 25 MG P N N Y N AMOXAPINE AMOXAPINE TAB 50MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS AMOXAPINE TAB 50 MG P N N Y N ANAFRANIL ANAFRANIL CAP 25MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS CLOMIPRAMINE HCL CAP 25 MG NP Y N Y N ANAFRANIL ANAFRANIL CAP 50MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS CLOMIPRAMINE HCL CAP 50 MG NP Y N Y N ANAFRANIL ANAFRANIL CAP 75MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS CLOMIPRAMINE HCL CAP 75 MG NP Y N Y N CLOMIPRAMINE HCL CLOMIPRAMINE CAP 25MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS CLOMIPRAMINE HCL CAP 25 MG P N N Y N CLOMIPRAMINE HCL CLOMIPRAMINE CAP 50MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS CLOMIPRAMINE HCL CAP 50 MG P N N Y N CLOMIPRAMINE HCL CLOMIPRAMINE CAP 75MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS CLOMIPRAMINE HCL CAP 75 MG P N N Y N DESIPRAMINE HYDROCHLORIDE DESIPRAMINE TAB 100MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS DESIPRAMINE HCL TAB 100 MG P N N Y N DESIPRAMINE HYDROCHLORIDE DESIPRAMINE TAB 10MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS DESIPRAMINE HCL TAB 10 MG P N N Y N DESIPRAMINE HYDROCHLORIDE DESIPRAMINE TAB 25MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS DESIPRAMINE HCL TAB 25 MG P N N Y N DOXEPIN HCL DOXEPIN HCL CAP 10MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS DOXEPIN HCL CAP 10 MG P N N Y N DOXEPIN HCL DOXEPIN HCL CAP 50MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS DOXEPIN HCL CAP 50 MG P N N Y N DOXEPIN HCL DOXEPIN HCL CON 10MG/ML TRICYCLICS, OTHER NOREPI-RU INHIBITORS DOXEPIN HCL CONC 10 MG/ML P N N Y N DOXEPIN HYDROCHLORIDE DOXEPIN TAB 3MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS DOXEPIN HCL (SLEEP) TAB 3 MG (BASE EQUIV) P N N Y N DOXEPIN HYDROCHLORIDE DOXEPIN HCL CAP 25MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS DOXEPIN HCL CAP 25 MG P N N Y N IMIPRAMINE HCL IMIPRAM HCL TAB 10MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS IMIPRAMINE HCL TAB 10 MG P N N Y N IMIPRAMINE HCL IMIPRAM HCL TAB 25MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS IMIPRAMINE HCL TAB 25 MG P N N Y N IMIPRAMINE HCL IMIPRAM HCL TAB 50MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS IMIPRAMINE HCL TAB 50 MG P N N Y N IMIPRAMINE PAMOATE IMIPRAM PAM CAP 100MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS IMIPRAMINE PAMOATE CAP 100 MG P N N Y N IMIPRAMINE PAMOATE IMIPRAM PAM CAP 125MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS IMIPRAMINE PAMOATE CAP 125 MG P N N Y N IMIPRAMINE PAMOATE IMIPRAM PAM CAP 75MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS IMIPRAMINE PAMOATE CAP 75 MG P N N Y N MAPROTILINE HCL MAPROTILINE TAB 25MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS MAPROTILINE HCL TAB 25 MG P N N Y N NORPRAMIN NORPRAMIN TAB 10MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS DESIPRAMINE HCL TAB 10 MG NP Y N Y N NORPRAMIN NORPRAMIN TAB 25MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS DESIPRAMINE HCL TAB 25 MG NP Y N Y N NORTRIPTYLINE HCL NORTRIPTYLIN CAP 25MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS NORTRIPTYLINE HCL CAP 25 MG P N N Y N NORTRIPTYLINE HCL NORTRIPTYLIN CAP 75MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS NORTRIPTYLINE HCL CAP 75 MG P N N Y N NORTRIPTYLINE HCL NORTRIPTYLIN SOL 10MG/5ML TRICYCLICS, OTHER NOREPI-RU INHIBITORS NORTRIPTYLINE HCL SOLN 10 MG/5ML P N N Y N NORTRIPTYLINE HYDROCHLORIDE NORTRIPTYLIN CAP 10MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS NORTRIPTYLINE HCL CAP 10 MG P N N Y N NORTRIPTYLINE HYDROCHLORIDE NORTRIPTYLIN CAP 50MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS NORTRIPTYLINE HCL CAP 50 MG P N N Y N PAMELOR PAMELOR CAP 10MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS NORTRIPTYLINE HCL CAP 10 MG NP Y N Y N PAMELOR PAMELOR CAP 50MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS NORTRIPTYLINE HCL CAP 50 MG NP Y N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) PAMELOR PAMELOR CAP 75MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS NORTRIPTYLINE HCL CAP 75 MG NP Y N Y N PERPHENAZINE/AMITRIPTYLINE PERPHEN/AMIT TAB 2-10MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS PERPHENAZINE-AMITRIPTYLINE TAB 2-10 MG P N NNN PROTRIPTYLINE HCL PROTRIPTYLIN TAB 5MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS PROTRIPTYLINE HCL TAB 5 MG P N N Y N SILENOR SILENOR TAB 3MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS DOXEPIN HCL (SLEEP) TAB 3 MG (BASE EQUIV) NP Y N Y N TRIMIPRAMINE MALEATE TRIMIPRAMINE CAP 100MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS TRIMIPRAMINE MALEATE CAP 100 MG P N N Y N TRIMIPRAMINE MALEATE TRIMIPRAMINE CAP 25MG TRICYCLICS, OTHER NOREPI-RU INHIBITORS TRIMIPRAMINE MALEATE CAP 25 MG P N N Y N PROBENECID PROBENECID TAB 500MG URICOSURIC AGENTS PROBENECID TAB 500 MG P N N Y N PROBENECID/COLCHICINE PROBEN/COLCH TAB 500-0.5 URICOSURIC AGENTS COLCHICINE W/ PROBENECID TAB 0.5-500 MG NP Y N Y N MACROBID MACROBID CAP 100MG URINARY ANTI-INFECTIVES NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG NP Y N Y N MACRODANTIN MACRODANTIN CAP 25MG URINARY ANTI-INFECTIVES NITROFURANTOIN MACROCRYSTALLINE CAP 25 MG NP Y N Y N MACRODANTIN MACRODANTIN CAP 50MG URINARY ANTI-INFECTIVES NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG NP Y N Y N NITROFURANTOIN NITROFURANTN CAP 100MG URINARY ANTI-INFECTIVES NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG P N N Y N NITROFURANTOIN NITROFURANTN SUS 25MG/5ML URINARY ANTI-INFECTIVES NITROFURANTOIN SUSP 25 MG/5ML P N N Y Y NITROFURANTOIN MACROCRYSTALS NITROFUR MAC CAP 25MG URINARY ANTI-INFECTIVES NITROFURANTOIN MACROCRYSTALLINE CAP 25 MG P N N Y N NITROFURANTOIN MACROCRYSTALS NITROFUR MAC CAP 50MG URINARY ANTI-INFECTIVES NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG P N N Y N PRIMSOL PRIMSOL SOL 50MG/5ML URINARY ANTI-INFECTIVES TRIMETHOPRIM HCL ORAL SOLN 50 MG/5ML (BASE EQUIV) NP Y N Y N TRIMETHOPRIM TRIMETHOPRIM TAB 100MG URINARY ANTI-INFECTIVES TRIMETHOPRIM TAB 100 MG P N N Y N AFLURIA QUADRIVALENT 2020-2021 AFLURIA QUAD INJ 2020-21 VACCINES INFLUENZA VIRUS VACCINE SPLIT QUADRIVALENT IM INJ P N N Y N BEXSERO BEXSERO INJ VACCINES MENINGOCOCCAL VAC B (RECOMB OMV ADJUV) INJ PREFILLED SYRINGE P N N Y N ENGERIX-B ENGERIX-B INJ 10/0.5ML VACCINES HEPATITIS B VACCINE (RECOMBINANT) SUSP 10 MCG/0.5ML P N N Y N ENGERIX-B ENGERIX-B INJ 20MCG/ML VACCINES HEPATITIS B VACCINE (RECOMBINANT) SUSP 20 MCG/ML P N N Y N FLUAD 2020-2021 FLUAD INJ 2020-21 VACCINES INFLUENZA VAC TYPE A&B SURFACE ANT ADJ SUSP PREF SYR 0.5 ML P N N Y N FLUAD QUADRIVALENT INFLUENZA VACCINFLUAD QUADRI INJ 0.5ML VACCINES INFLUENZA VAC TYPE A&B SURFACE ANT ADJ QUAD PREF SYR 0.5 ML P N N Y N FLUARIX 2005-2006 FLUARIX INJ 05-06 VACCINES INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ NP Y N N N FLUARIX QUADRIVALENT 2020-2021 FLUARIX QUAD INJ 2020-21 VACCINES INFLUENZA VIRUS VAC SPLIT QUADRIVALENT SUSP PREF SYR 0.5ML P N N Y N FLUBLOK QUADRIVALENT 2020-2021 FLUBLOK QUAD INJ 2020-21 VACCINES INFLUENZA VAC RECOMB HA QUAD PF SOLN PREF SYR 0.5 ML P N N Y N FLUCELVAX QUADRIVALENT 2020-2021 FLUCLVX QUAD INJ 2020-21 VACCINES INFLUENZA VAC TISSUE-CULTURED SUBUNIT QUADRIVALENT IM SUSP P N N Y N FLULAVAL QUADRIVALENT 2020-2021 FLULAVAL QUA INJ 2020-21 VACCINES INFLUENZA VIRUS VAC SPLIT QUADRIVALENT SUSP PREF SYR 0.5ML P N N Y N FLUMIST QUADRIVALENT FLUMIST QUAD SUS 2020-21 VACCINES INFLUENZA VIRUS VACCINE LIVE QUADRIVALENT INTRANASAL SUSP P N N Y N FLUSHIELD INFLUENZA VIRUS VACCINE FLUSHIELD INJ 2001-02 VACCINES INFLUENZA VIRUS VACCINE SPLIT INJ P N N Y N FLUSHIELD INFLUENZA VIRUSVACCINE FLUSHIELD INJ SPLIT VACCINES INFLUENZA VIRUS VACCINE SPLIT INJ P N N Y N FLUVIRIN 2005-2006 FLUVIRIN INJ 2005-06 VACCINES INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN INJ NP Y N N N FLUVIRIN INJ INFLUENZA VIRUSVACCINE INJ VACCINES INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN INJ NP Y N N N FLUZONE PF 2005-2006 FLUZONE INJ PF 05-06 VACCINES INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ NP Y N N N FLUZONE HIGH-DOSE PF 2020-2021 FLUZONE HD INJ PF 20-21 VACCINES INFLUENZA VAC SPLIT HIGH-DOSE QUAD PF SUSP PREF SYR 0.7 ML P N N Y N FLUZONE QUADRIVALENT 2020-2021 FLUZONE QUAD INJ 2020-21 VACCINES INFLUENZA VIRUS VACCINE SPLIT QUADRIVALENT IM INJ P N N Y N FLUZONE SPLIT FLUZONE INJ SPLIT VACCINES INFLUENZA VIRUS VACCINE SPLIT INJ P N N Y N FLUZONE SUBVIRION FLUZONE INJ SPLIT VACCINES INFLUENZA VIRUS VACCINE SPLIT INJ P N N Y N GARDASIL 9 GARDASIL 9 INJ VACCINES HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT RECOMB VAC IM SUSP P N N Y N HAVRIX HAVRIX INJ 1440UNIT VACCINES HEPATITIS A VACCINE INJ SUSP 1440 EL UNIT/ML P N N Y N HAVRIX HAVRIX INJ 720UNIT VACCINES HEPATITIS A VACCINE INJ SUSP 720 EL UNIT/0.5ML P N N Y N HEPLISAV-B HEPLISAV-B INJ 20/0.5ML VACCINES HEPATITIS B VACCINE RECOMB ADJUVANTED PREF SYR 20 MCG/0.5ML P N N Y Y MENACTRA MENACTRA INJ VACCINES MENINGOCOCCAL (A, C, Y, AND W-135) CONJUGATE VACCINE INJ P N N Y N MENQUADFI MENQUADFI INJ VACCINES MENINGOCOCCAL (A, C, Y, AND W-135) CONJUGATE VACCINE INJ P N N Y N MENVEO MENVEO INJ VACCINES MENINGOCOCCAL (A, C, Y, AND W-135) OLIGO CONJ VAC FOR INJ P N N Y N M-M-R II M-M-R II INJ VACCINES MEASLES-MUMPS-RUBELLA VIRUS VACCINES FOR INJ SOLN P N N Y N PEDIARIX PEDIARIX INJ 0.5ML VACCINES DIPH-TETANUS TOX-ACELL PERT-HEPATITIS B-POLIO IPV VAC INJ P N N Y N PENTACEL PENTACEL INJ VACCINES DIPH-AC PER-TET TOX AD-POLIOV-HAEMOPH B POLY VAC FOR IM SUSP P N N Y N

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) PNEUMOVAX 23 PNEUMOVAX 23 INJ 25/0.5 VACCINES PNEUMOCOCCAL VACCINE POLYVALENT INJ 25 MCG/0.5ML P N N Y N PREVNAR 13 PREVNAR 13 INJ VACCINES PNEUMOCOCCAL 13-VALENT CONJUGATE VACCINE INJ P N N Y N PROQUAD PROQUAD INJ VACCINES MEASLES-MUMPS-RUBELLA-VARICELLA VIRUS VACCINES FOR SUSP P N N Y N RECOMBIVAX HB RECOMBIVA HB INJ 10MCG/ML VACCINES HEPATITIS B VACCINE (RECOMBINANT) SUSP 10 MCG/ML P N N Y N RECOMBIVAX HB RECOMBIVA HB INJ 5MCG/0.5 VACCINES HEPATITIS B VACCINE (RECOMBINANT) SUSP 5 MCG/0.5ML P N N Y N SHINGRIX SHINGRIX INJ 50/0.5ML VACCINES ZOSTER VAC RECOMBINANT ADJUVANTED FOR IM INJ 50 MCG/0.5ML P N N Y Y TRUMENBA TRUMENBA INJ VACCINES MENINGOCOCCAL GROUP B VAC (RECOMB) IM SUSP PREFILLED SYR P N N Y N TWINRIX TWINRIX INJ VACCINES HEP A-HEP B VACCINE SUSP PREF SYR 720-20 ELU-MCG/ML P N N Y N VAQTA VAQTA INJ 25/0.5ML VACCINES HEPATITIS A VACCINE INJ SUSP 25 UNIT/0.5ML P N N Y N VAQTA VAQTA INJ 50UNT/ML VACCINES HEPATITIS A VACCINE INJ SUSP 50 UNIT/ML P N N Y N VARIVAX VARIVAX INJ VACCINES VARICELLA VIRUS VAC LIVE FOR SUBCUTANEOUS INJ 1350 PFU/0.5ML P N N Y N VAXELIS VAXELIS INJ VACCINES DIPH-TET TOX-AC PERT AD-POLIO IPV-HIB-HEPATITIS B RECMB SUSP P N N Y N PETN TAB 80MG PETN TAB 80MG VASODILATING AGENTS PENTAERYTHRITOL TETRANITRATE TAB 80 MG NP Y N N N ADEMPAS ADEMPAS TAB 0.5MG VASODILATING AGENTS (RESPIRATORY TRACT) RIOCIGUAT TAB 0.5 MG P Y N Y N AMBRISENTAN AMBRISENTAN TAB 5MG VASODILATING AGENTS (RESPIRATORY TRACT) AMBRISENTAN TAB 5 MG P Y N Y N BOSENTAN BOSENTAN TAB 62.5MG VASODILATING AGENTS (RESPIRATORY TRACT) BOSENTAN TAB 62.5 MG P Y N Y N LETAIRIS LETAIRIS TAB 5MG VASODILATING AGENTS (RESPIRATORY TRACT) AMBRISENTAN TAB 5 MG NP Y N Y N OPSUMIT OPSUMIT TAB 10MG VASODILATING AGENTS (RESPIRATORY TRACT) MACITENTAN TAB 10 MG P Y N Y N ORENITRAM ORENITRAM TAB 0.125MG VASODILATING AGENTS (RESPIRATORY TRACT) TREPROSTINIL DIOLAMINE TAB ER 0.125 MG (BASE EQUIV) NP Y N NN ORENITRAM ORENITRAM TAB 2.5MG VASODILATING AGENTS (RESPIRATORY TRACT) TREPROSTINIL DIOLAMINE TAB ER 2.5 MG (BASE EQUIV) NP Y N Y N ORENITRAM ORENITRAM TAB 5MG VASODILATING AGENTS (RESPIRATORY TRACT) TREPROSTINIL DIOLAMINE TAB ER 5 MG (BASE EQUIV) NP Y N Y N TRACLEER TRACLEER TAB 32MG VASODILATING AGENTS (RESPIRATORY TRACT) BOSENTAN TAB FOR ORAL SUSP 32 MG P Y N Y N TRACLEER TRACLEER TAB 62.5MG VASODILATING AGENTS (RESPIRATORY TRACT) BOSENTAN TAB 62.5 MG NP Y N Y N UPTRAVI UPTRAVI TAB 200/800 VASODILATING AGENTS (RESPIRATORY TRACT) SELEXIPAG TAB THERAPY PACK 200 MCG (140) & 800 MCG (60) NP YNYN UPTRAVI UPTRAVI TAB 200MCG VASODILATING AGENTS (RESPIRATORY TRACT) SELEXIPAG TAB 200 MCG NP Y N Y N UPTRAVI UPTRAVI TAB 200MCG VASODILATING AGENTS (RESPIRATORY TRACT) SELEXIPAG TAB 200 MCG NP Y N Y N DIPYRIDAMOLE DIPYRIDAMOLE TAB 25MG VASODILATING AGENTS, MISCELLANEOUS DIPYRIDAMOLE TAB 25 MG P N N Y N DIPYRIDAMOLE DIPYRIDAMOLE TAB 50MG VASODILATING AGENTS, MISCELLANEOUS DIPYRIDAMOLE TAB 50 MG P N N Y N DIPYRIDAMOLE DIPYRIDAMOLE TAB 75MG VASODILATING AGENTS, MISCELLANEOUS DIPYRIDAMOLE TAB 75 MG P N N Y N NIACIN FLUSH FREE NIACIN CAP 500MG VASODILATING AGENTS, MISCELLANEOUS INOSITOL NIACINATE CAP 500 MG NP Y N N N NO FLUSH NIACIN NIACIN TAB 100MG VASODILATING AGENTS, MISCELLANEOUS INOSITOL NIACINATE TAB 100 MG (NIACIN EQUIV) NP Y N N N JYNARQUE JYNARQUE TAB 15MG VASOPRESSIN ANTAGONISTS TOLVAPTAN TAB 15 MG NP Y N N N JYNARQUE JYNARQUE TAB 15MG VASOPRESSIN ANTAGONISTS TOLVAPTAN TAB THERAPY PACK 15 MG NP Y N Y N SAMSCA SAMSCA TAB 15MG VASOPRESSIN ANTAGONISTS TOLVAPTAN TAB 15 MG NP Y N N N TOLVAPTAN TOLVAPTAN TAB 15MG VASOPRESSIN ANTAGONISTS TOLVAPTAN TAB 15 MG NP Y N N N AUSTEDO AUSTEDO TAB 6MG VESICULAR MONOAMINE TRANSPORT2 INHIBITOR DEUTETRABENAZINE TAB 6 MG NP Y N Y N AUSTEDO AUSTEDO TAB 9MG VESICULAR MONOAMINE TRANSPORT2 INHIBITOR DEUTETRABENAZINE TAB 9 MG NP Y N Y N INGREZZA INGREZZA CAP 40-80MG VESICULAR MONOAMINE TRANSPORT2 INHIBITOR VALBENAZINE TOSYLATE CAP THERAPY PACK 40 MG (7) & 80 MG (21) P Y N Y N INGREZZA INGREZZA CAP 40MG VESICULAR MONOAMINE TRANSPORT2 INHIBITOR VALBENAZINE TOSYLATE CAP 40 MG (BASE EQUIV) P Y N Y N TETRABENAZINE TETRABENAZIN TAB 12.5MG VESICULAR MONOAMINE TRANSPORT2 INHIBITOR TETRABENAZINE TAB 12.5 MG P Y N Y N XENAZINE XENAZINE TAB 12.5MG VESICULAR MONOAMINE TRANSPORT2 INHIBITOR TETRABENAZINE TAB 12.5 MG NP Y N Y N ARMODAFINIL ARMODAFINIL TAB 150MG WAKEFULNESS-PROMOTING AGENTS ARMODAFINIL TAB 150 MG P N N Y Y ARMODAFINIL ARMODAFINIL TAB 50MG WAKEFULNESS-PROMOTING AGENTS ARMODAFINIL TAB 50 MG P N N Y Y MODAFINIL MODAFINIL TAB 100MG WAKEFULNESS-PROMOTING AGENTS MODAFINIL TAB 100 MG P N N Y Y MODAFINIL MODAFINIL TAB 200MG WAKEFULNESS-PROMOTING AGENTS MODAFINIL TAB 200 MG P N N Y Y NUVIGIL NUVIGIL TAB 150MG WAKEFULNESS-PROMOTING AGENTS ARMODAFINIL TAB 150 MG NP Y N Y Y NUVIGIL NUVIGIL TAB 50MG WAKEFULNESS-PROMOTING AGENTS ARMODAFINIL TAB 50 MG NP Y N Y Y PROVIGIL PROVIGIL TAB 100MG WAKEFULNESS-PROMOTING AGENTS MODAFINIL TAB 100 MG NP Y N Y Y

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Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) PROVIGIL PROVIGIL TAB 200MG WAKEFULNESS-PROMOTING AGENTS MODAFINIL TAB 200 MG NP Y N Y Y SUNOSI SUNOSI TAB 75MG WAKEFULNESS-PROMOTING AGENTS SOLRIAMFETOL HCL TAB 75 MG (BASE EQUIV) P N N Y Y WAKIX WAKIX TAB 4.45MG WAKEFULNESS-PROMOTING AGENTS PITOLISANT HCL TAB 4.45 MG (BASE EQUIVALENT) P N N Y Y

Important Information: DRUG LABEL NAME shows either a brand version or a generic version of the drug GENERICS - many brand versions of drugs are nonpreferred on the UHC Community Plan of Indiana PDL (for example ABILIFY is brand name and is nonpreferred while ARIPIPRAZOLE is generic and is preferred). This list is a representative list of drug coverage and coverage changes may occur after publication This list represents drugs covered under the pharmacy benefit and does not reflect medical benefit drugs CMS approved manufacturers are covered under the Medicaid program Preferred Diabetes Supply List aligns with the Indiana state covered list per FSSA and are not represented in this list

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