Traditional Open Drug List

Drug list — Four Tier Drug Plan

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

Here are a few things to remember about the list:

o You and your doctor can use it as a guide to choose drugs that are best for you. Drugs that aren’t on this list may not be covered by your plan and may cost you more out of pocket.

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

o To help you see how the drug list works with your drug benefit, we've included some frequently asked questions (FAQ) about how the list is set up and what to do if a drug you take isn't on it.

o This booklet is updated on a quarterly basis. To view the most up-to-date list of drugs for your plan - including drugs that have been added, generic drugs and more - log in at anthem.com and choose Prescription Benefits.

If you have questions about your pharmacy benefits, we're here to help. Just call us at the Pharmacy Member Services number on your ID card.

05374MUMENABS Traditional Open Drug List

What is a drug list? The drug list, also called a formulary, is a list of prescription medicines your plan covers. It includes hundreds of brand-name and generic drugs approved by the U.S. Food & Drug Administration (FDA).

Is this a complete listing of all covered drugs? Yes, this is a complete listing of all the drugs on the drug list. But, it’s possible a drug(s) on this list may not be covered, depending on your plan’s design. Your coverage has limitations and exclusions, which means there are certain conditions that determine what’s covered by your plan and what isn’t. To find out more, read your Certificate/Evidence of Coverage or your Summary Plan Description, which you got when you signed up for your plan.

How can I find a drug on the list? The drugs are listed in alphabetical order based on the name of their drug class, also called therapeutic class. You can search the PDF drug list by:

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

The Notes column will tell you if you need preapproval before you can take the drug (called prior authorization or PA), or if you need to try other drugs first for your treatment (called step therapy or ST).

When I search the list, I see that each drug is on a tier. What are the tiers for? The drug list is set up in tiers or levels. We place drugs on different tiers based on how well they work to improve health, whether there are over-the-counter (OTC) options and their costs compared to other drugs used for the same type of treatment. Your share of the drug cost will depend on what tier a drug is on. The lower the tier, the lower your share of the cost. Here’s a breakdown of the tiers in your plan:

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

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

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

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

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

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

If my medicine isn’t on the drug list, what are my options? Here are a few things to think about:

o If you want to take a drug that’s not on the drug list, you may have to pay the full cost for it.

o You can also talk to your doctor or pharmacist to see if there’s another drug covered by your plan that will work just as well, or if generic or OTC drugs are an option. Only you and your doctor can decide what drugs are right for you.

o You can search for generic drugs at anthem.com. OTC drugs aren’t shown on the list.

o If a drug you’re taking isn’t covered, your doctor can ask us to review the coverage. This process is called preapproval or prior authorization. Your doctor can get the process started by calling the Pharmacy Member Services number on the back of your member ID card or by downloading a prior authorization form from our website and submitting it. If your request is approved, the amount you pay for the drug will depend on your plan’s benefit.

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

What’s the difference between brand-name and generic drugs? A brand-name drug is FDA-approved and usually available from only one manufacturer. It may be protected by a patent, which means it can only be made or sold by the company that has the patent.

A generic drug is also FDA-approved and has the same active ingredients as the brand-name drug. But a generic drug is usually available only after the patent on the brand-name drug ends. It may look different, but a generic drug works the same as the brand-name drug.

Online Pharmacy Resources Find your closest network pharmacy, get the most up-to-date coverage information on your drug list including details about pricing your medication, brands and generics, dosage/strength options, and much more — when you log in at anthem.com.

Does the drug list change, and how will I know if it does? Drugs on our list are reviewed on a regular basis. Sometimes, drugs are added, removed or moved to a different tier. We’ll let you know if a drug you take is taken off the list and, in some cases, if a drug you take is moved to a higher tier.

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

Does my plan cover preventive drugs? We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA).

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

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

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

Brand name drugs are in UPPER CASE, bold type.

Generic drugs are in lower case, plain type.

$0 = preventive drugs. For some members, this product may be covered at 100% with $0 cost share with a prescription from your provider if specified criteria are met.

DO = dose optimization. Usually, this means you may have to switch from taking a drug twice a day to taking it once a day at a higher strength.

LD = limited distribution. These drugs are available only through certain pharmacies or wholesalers, depending on what the manufacturer decides.

PA = prior authorization. You may need to get benefits approved before certain prescriptions can be filled.

QL = quantity limits. There are limits on the amount of medicine covered within a certain amount of time.

SP = specialty drugs. Specialty drugs are used to treat difficult, long-term conditions. You may need to get this drug through a specialty pharmacy.

ST = step therapy. You may need to use another recommended drug first before a prescribed drug is covered. Traditional Open Drug List Four-Tier

Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...... 3 *ALLERGENIC EXTRACTS/BIOLOGICALS MISC*...... 6 *AMEBICIDES*...... 11 *AMINOGLYCOSIDES*...... 11 *ANALGESICS - ANTI-INFLAMMATORY*...... 11 *ANALGESICS - NONNARCOTIC*...... 15 *ANALGESICS - OPIOID*...... 17 *ANDROGENS-ANABOLIC*...... 20 *ANORECTAL AND RELATED PRODUCTS*...... 21 *ANTACIDS*...... 21 *ANTHELMINTICS*...... 21 *ANTIANGINAL AGENTS*...... 22 *ANTIANXIETY AGENTS*...... 22 *ANTIARRHYTHMICS*...... 23 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS*...... 24 *ANTICOAGULANTS*...... 27 **...... 28 **...... 31 *ANTIDIABETICS*...... 34 *ANTIDIARRHEAL/PROBIOTIC AGENTS*...... 39 *ANTIDOTES AND SPECIFIC ANTAGONISTS*...... 40 *ANTIEMETICS*...... 41 *ANTIFUNGALS*...... 42 **...... 43 *ANTIHYPERLIPIDEMICS*...... 44 *ANTIHYPERTENSIVES*...... 46 *ANTI-INFECTIVE AGENTS - MISC.*...... 50 *ANTIMALARIALS*...... 52 *ANTIMYASTHENIC/CHOLINERGIC AGENTS*...... 53 *ANTIMYCOBACTERIAL AGENTS*...... 53 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...... 54 *ANTIPARKINSON AND RELATED THERAPY AGENTS*...... 66 */ANTIMANIC AGENTS*...... 68 *ANTISEPTICS & DISINFECTANTS*...... 71 *ANTIVIRALS*...... 71 *BETA BLOCKERS*...... 75 *CALCIUM CHANNEL BLOCKERS*...... 76 *CARDIOTONICS*...... 78 *CARDIOVASCULAR AGENTS - MISC.*...... 78 *CEPHALOSPORINS*...... 80 *CONTRACEPTIVES*...... 82 *CORTICOSTEROIDS*...... 86 *COUGH/COLD/ALLERGY*...... 88 *DERMATOLOGICALS*...... 89 *DIAGNOSTIC PRODUCTS*...... 99 *DIGESTIVE AIDS*...... 104 *DIURETICS*...... 104 *ENDOCRINE AND METABOLIC AGENTS - MISC.*...... 105 *ESTROGENS*...... 111 *FLUOROQUINOLONES*...... 112 *GASTROINTESTINAL AGENTS - MISC.*...... 112 *GENERAL ANESTHETICS*...... 115 *GENITOURINARY AGENTS - MISCELLANEOUS*...... 116 *GOUT AGENTS*...... 117 *HEMATOLOGICAL AGENTS - MISC.*...... 117 *HEMATOPOIETIC AGENTS*...... 121 *HEMOSTATICS*...... 124 *HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS*...... 125 1 *LAXATIVES*...... 126 *LOCAL ANESTHETICS-PARENTERAL*...... 128 *MACROLIDES*...... 130 *MEDICAL DEVICES AND SUPPLIES*...... 130 *MIGRAINE PRODUCTS*...... 146 *MINERALS & ELECTROLYTES*...... 148 *MISCELLANEOUS THERAPEUTIC CLASSES*...... 151 *MOUTH/THROAT/DENTAL AGENTS*...... 154 *MULTIVITAMINS*...... 155 *MUSCULOSKELETAL THERAPY AGENTS*...... 164 *NASAL AGENTS - SYSTEMIC AND TOPICAL*...... 165 *NEUROMUSCULAR AGENTS*...... 165 *NUTRIENTS*...... 166 *OPHTHALMIC AGENTS*...... 168 *OTIC AGENTS*...... 175 *OXYTOCICS*...... 175 *PASSIVE IMMUNIZING AND TREATMENT AGENTS*...... 176 *PENICILLINS*...... 177 *PROGESTINS*...... 178 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*...... 178 *RESPIRATORY AGENTS - MISC.*...... 184 *SULFONAMIDES*...... 184 *TETRACYCLINES*...... 185 *THYROID AGENTS*...... 186 *TOXOIDS*...... 186 *ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS*...... 187 *URINARY ANTISPASMODICS*...... 189 *VACCINES*...... 189 *VAGINAL AND RELATED PRODUCTS*...... 191 *VASOPRESSORS*...... 192 *VITAMINS*...... 193

2 Four-Tier Drug Name Tier Notes *AMPHETAMINE CURRENT AS OF 10/1/2021 MIXTURES*** ADDERALL ORAL Drug Name Tier Notes TABLET 10 MG, 12.5 MG, 3 ST; DO 15 MG, 5 MG, 7.5 MG *ADHD/ANTI- ADDERALL ORAL NARCOLEPSY/ANTI- 3 ST; QL OBESITY/ANOREXIANT TABLET 20 MG, 30 MG S* ADDERALL XR ORAL CAPSULE EXTENDED *ADHD AGENT - 3 ST; DO SELECTIVE ALPHA RELEASE 24 HOUR 10 ADRENERGIC MG, 15 MG, 5 MG AGONISTS*** ADDERALL XR ORAL clonidine hcl er oral tablet CAPSULE EXTENDED 1 or 1b* PA; QL 3 ST; QL extended release 12 hour RELEASE 24 HOUR 20 MG, 25 MG, 30 MG guanfacine hcl er oral tablet extended release 24 hour 1 1 or 1b* PA; DO amphetamine-dextroamphet er oral capsule extended mg, 2 mg 1 or 1b* PA; DO release 24 hour 10 mg, 15 guanfacine hcl er oral tablet mg, 5 mg extended release 24 hour 3 1 or 1b* PA; QL mg, 4 mg amphetamine-dextroamphet er oral capsule extended 1 or 1b* PA; QL INTUNIV ORAL TABLET release 24 hour 20 mg, 25 EXTENDED RELEASE 24 3 PA; DO mg, 30 mg HOUR 1 MG, 2 MG amphetamine- INTUNIV ORAL TABLET dextroamphetamine oral 1 or 1b* PA; DO EXTENDED RELEASE 24 3 PA; QL tablet 10 mg, 12.5 mg, 15 HOUR 3 MG, 4 MG mg, 5 mg, 7.5 mg KAPVAY ORAL TABLET amphetamine- EXTENDED RELEASE 12 3 PA; QL dextroamphetamine oral 1 or 1b* PA; QL HOUR tablet 20 mg, 30 mg *ADHD AGENT - MYDAYIS ORAL SELECTIVE CAPSULE EXTENDED 3 ST; QL NOREPINEPHRINE RELEASE 24 HOUR REUPTAKE INHIBITOR*** *AMPHETAMINES*** atomoxetine hcl oral capsule ADZENYS ER ORAL 1 or 1b* PA; DO 10 mg, 18 mg, 25 mg, 40 mg SUSPENSION 3 PA; QL EXTENDED RELEASE atomoxetine hcl oral capsule 1 or 1b* PA; QL 100 mg, 60 mg, 80 mg ADZENYS XR-ODT ORAL TABLET 3 ST; QL QELBREE ORAL EXTENDED RELEASE CAPSULE EXTENDED 3 ST; DO DISPERSIBLE RELEASE 24 HOUR 100 amphetamine er oral MG 1 or 1b* QL suspension extended release QELBREE ORAL CAPSULE EXTENDED amphetamine sulfate oral 3 ST; QL 1 or 1b* QL RELEASE 24 HOUR 150 tablet 10 mg MG, 200 MG amphetamine sulfate oral 1 or 1b* DO STRATTERA ORAL tablet 5 mg CAPSULE 10 MG, 18 MG, 3 PA; DO DESOXYN ORAL 3 ST; QL 25 MG, 40 MG TABLET STRATTERA ORAL CAPSULE 100 MG, 60 3 PA; QL MG, 80 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 3 Drug Name Tier Notes Drug Name Tier Notes DEXEDRINE ORAL caffeine citrate intravenous 1 or 1b* CAPSULE EXTENDED solution 3 ST; QL RELEASE 24 HOUR 10 caffeine citrate oral solution 1 or 1b* MG, 15 MG DOPRAM DEXEDRINE ORAL INTRAVENOUS 3 CAPSULE EXTENDED 3 ST; DO SOLUTION RELEASE 24 HOUR 5 MG *ANOREXIANT dextroamphetamine sulfate er COMBINATIONS*** oral capsule extended release 1 or 1b* PA; QL 24 hour 10 mg, 15 mg QSYMIA ORAL CAPSULE EXTENDED 3 PA dextroamphetamine sulfate er RELEASE 24 HOUR oral capsule extended release 1 or 1b* PA; DO 24 hour 5 mg *ANOREXIANTS NON- AMPHETAMINE*** dextroamphetamine sulfate 1 or 1b* PA; QL ADIPEX-P ORAL oral solution 3 PA CAPSULE dextroamphetamine sulfate ADIPEX-P ORAL oral tablet 10 mg, 15 mg, 20 1 or 1b* PA; QL 3 PA mg, 30 mg TABLET dextroamphetamine sulfate benzphetamine hcl oral tablet 1 or 1b* PA; DO 1 or 1b* oral tablet 5 mg 25 mg benzphetamine hcl oral tablet DYANAVEL XR ORAL 1 or 1b* PA SUSPENSION 3 ST; QL 50 mg EXTENDED RELEASE diethylpropion hcl er oral EVEKEO ODT ORAL tablet extended release 24 1 or 1b* PA 3 ST; QL TABLET DISPERSIBLE hour EVEKEO ORAL TABLET diethylpropion hcl oral tablet 1 or 1b* PA 3 PA; QL 10 MG LOMAIRA ORAL 3 PA EVEKEO ORAL TABLET TABLET 3 PA; DO 5 MG phendimetrazine tartrate er methamphetamine hcl oral oral capsule extended release 1 or 1b* PA 3 ST; QL tablet 24 hour phendimetrazine tartrate oral procentra oral solution 1 or 1b* PA; QL 1 or 1b* PA tablet VYVANSE ORAL CAPSULE 10 MG, 20 MG, 2 PA; DO phentermine hcl oral capsule 1 or 1b* PA 30 MG phentermine hcl oral tablet 1 or 1b* PA VYVANSE ORAL *ANTI-OBESITY - GLP-1 CAPSULE 40 MG, 50 MG, 2 PA; QL RECEPTOR 60 MG, 70 MG AGONISTS*** VYVANSE ORAL SAXENDA TABLET CHEWABLE 10 2 PA; DO SUBCUTANEOUS 3 PA MG, 20 MG, 30 MG SOLUTION PEN- VYVANSE ORAL INJECTOR TABLET CHEWABLE 40 2 PA; QL WEGOVY MG, 50 MG, 60 MG SUBCUTANEOUS 3 PA zenzedi oral tablet 10 mg, 15 SOLUTION AUTO- 1 or 1b* PA; QL mg, 20 mg, 30 mg, 7.5 mg INJECTOR zenzedi oral tablet 2.5 mg, 5 *ANTI-OBESITY AGENT 1 or 1b* PA; DO mg COMBINATIONS** *ANALEPTICS*** CONTRAVE ORAL TABLET EXTENDED 3 PA CAFCIT INTRAVENOUS 3 RELEASE 12 HOUR SOLUTION * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 4 Drug Name Tier Notes Drug Name Tier Notes *DOPAMINE AND COTEMPLA XR-ODT NOREPINEPHRINE ORAL TABLET 3 ST; QL REUPTAKE INHIBITORS EXTENDED RELEASE (DNRIS)*** DISPERSIBLE SUNOSI ORAL TABLET DAYTRANA 3 PA; QL 150 MG TRANSDERMAL PATCH 3 ST; DO SUNOSI ORAL TABLET 10 MG/9HR, 15 MG/9HR 3 PA; DO 75 MG DAYTRANA *HISTAMINE H3- TRANSDERMAL PATCH 3 ST; QL RECEPTOR 20 MG/9HR, 30 MG/9HR ANTAGONIST/INVERSE dexmethylphenidate hcl er AGONISTS*** oral capsule extended release 1 or 1b* PA; DO WAKIX ORAL TABLET 24 hour 10 mg, 15 mg, 20 4 PA; LD; SP; QL 17.8 MG mg, 5 mg WAKIX ORAL TABLET dexmethylphenidate hcl er 4 PA; DO; LD; SP oral capsule extended release 4.45 MG 1 or 1b* PA; QL 24 hour 25 mg, 30 mg, 35 *LIPASE mg, 40 mg INHIBITORS*** dexmethylphenidate hcl oral XENICAL ORAL 1 or 1b* PA; QL 3 PA tablet 10 mg CAPSULE dexmethylphenidate hcl oral 1 or 1b* PA; DO *MELANOCORTIN 4 tablet 2.5 mg, 5 mg (MC4) RECEPTOR FOCALIN ORAL AGONISTS*** 3 PA; QL TABLET 10 MG IMCIVREE FOCALIN ORAL SUBCUTANEOUS 4 PA; LD; QL 3 PA; DO SOLUTION TABLET 2.5 MG, 5 MG *STIMULANT FOCALIN XR ORAL CAPSULE EXTENDED COMBINATIONS*** 3 PA; DO RELEASE 24 HOUR 10 AZSTARYS ORAL 3 ST; QL MG, 15 MG, 20 MG, 5 MG CAPSULE FOCALIN XR ORAL *STIMULANTS - CAPSULE EXTENDED MISC.*** RELEASE 24 HOUR 25 3 PA; QL ADHANSIA XR ORAL MG, 30 MG, 35 MG, 40 CAPSULE EXTENDED 3 ST; QL MG RELEASE 24 HOUR JORNAY PM ORAL CAPSULE EXTENDED APTENSIO XR ORAL 3 ST; QL CAPSULE EXTENDED RELEASE 24 HOUR 100 RELEASE 24 HOUR 10 3 ST; DO MG, 60 MG, 80 MG MG, 15 MG, 20 MG, 30 JORNAY PM ORAL MG CAPSULE EXTENDED 3 ST; DO APTENSIO XR ORAL RELEASE 24 HOUR 20 CAPSULE EXTENDED MG, 40 MG 3 ST; QL RELEASE 24 HOUR 40 METHYLIN ORAL 3 ST; QL MG, 50 MG, 60 MG SOLUTION armodafinil oral tablet 1 or 1b* PA; QL methylphenidate hcl er (cd) CONCERTA ORAL oral capsule extended release 1 or 1b* PA; DO TABLET EXTENDED 3 ST; DO 10 mg, 20 mg, 30 mg RELEASE 18 MG, 27 MG methylphenidate hcl er (cd) CONCERTA ORAL oral capsule extended release 1 or 1b* PA; QL TABLET EXTENDED 3 ST; QL 40 mg, 50 mg, 60 mg RELEASE 36 MG, 54 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 5 Drug Name Tier Notes Drug Name Tier Notes methylphenidate hcl er (la) QUILLICHEW ER ORAL oral capsule extended release 1 or 1b* PA; DO TABLET CHEWABLE 3 ST; QL 24 hour 10 mg, 20 mg EXTENDED RELEASE 30 methylphenidate hcl er (la) MG, 40 MG oral capsule extended release QUILLIVANT XR ORAL 1 or 1b* PA; QL 24 hour 30 mg, 40 mg, 60 SUSPENSION 3 ST; QL mg RECONSTITUTED ER methylphenidate hcl er (xr) RELEXXII ORAL oral capsule extended release TABLET EXTENDED 3 ST; QL 1 or 1b* PA; DO 24 hour 10 mg, 15 mg, 20 RELEASE mg, 30 mg RITALIN LA ORAL methylphenidate hcl er (xr) CAPSULE EXTENDED 3 PA; DO oral capsule extended release RELEASE 24 HOUR 10 1 or 1b* PA; QL 24 hour 40 mg, 50 mg, 60 MG, 20 MG mg RITALIN LA ORAL methylphenidate hcl er oral CAPSULE EXTENDED 3 PA; QL tablet extended release 10 1 or 1b* PA; DO RELEASE 24 HOUR 30 mg, 18 mg, 27 mg MG, 40 MG methylphenidate hcl er oral RITALIN ORAL TABLET 3 PA; DO tablet extended release 20 1 or 1b* PA; QL 10 MG, 5 MG mg, 36 mg, 54 mg RITALIN ORAL TABLET 3 PA; QL methylphenidate hcl er oral 20 MG tablet extended release 24 1 or 1b* PA; DO *ALLERGENIC hour EXTRACTS/BIOLOGICA METHYLPHENIDATE LS MISC* HCL ER ORAL TABLET 3 ST; QL *ALLERGENIC EXTENDED RELEASE 72 EXTRACTS*** MG ACACIA methylphenidate hcl oral 1 or 1b* PA; QL SUBCUTANEOUS 3 solution SOLUTION methylphenidate hcl oral 1 or 1b* PA; DO ACREMONIUM tablet 10 mg, 5 mg SUBCUTANEOUS 3 methylphenidate hcl oral SOLUTION 1 or 1b* PA; QL tablet 20 mg ALDER methylphenidate hcl oral SUBCUTANEOUS 3 1 or 1b* PA; QL tablet chewable 10 mg SOLUTION methylphenidate hcl oral ALTERNARIA 1 or 1b* ST; DO tablet chewable 2.5 mg SUBCUTANEOUS 3 methylphenidate hcl oral SOLUTION 1 or 1b* PA; DO tablet chewable 5 mg AMERICAN BEECH modafinil oral tablet 100 mg 1 or 1b* PA; DO SUBCUTANEOUS 3 SOLUTION modafinil oral tablet 200 mg 1 or 1b* PA; QL AMERICAN NUVIGIL ORAL TABLET 3 PA; QL COCKROACH 3 PROVIGIL ORAL SUBCUTANEOUS 3 PA; DO TABLET 100 MG SOLUTION PROVIGIL ORAL AMERICAN ELM 3 PA; QL TABLET 200 MG SUBCUTANEOUS 3 SOLUTION QUILLICHEW ER ORAL TABLET CHEWABLE ARIZONA CYPRESS 3 ST; DO EXTENDED RELEASE 20 SUBCUTANEOUS 3 MG SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 6 Drug Name Tier Notes Drug Name Tier Notes ASPERGILLUS CAT HAIR EXTRACT FUMIGATUS 3 SUBCUTANEOUS 3 INJECTION SOLUTION SOLUTION AUREOBASIDIUM CATTLE EPITHELIUM PULLULANS INJECTION 3 SUBCUTANEOUS 3 SOLUTION SOLUTION AUREOBASIDIUM CEDAR ELM SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION AUSTRALIAN PINE CLADOSPORIUM SUBCUTANEOUS 3 CLADOSPORIOIDES 3 SOLUTION INJECTION SOLUTION BAHIA SUBCUTANEOUS CLADOSPORIUM 3 SOLUTION CLADOSPORIOIDES 3 BALD CYPRESS INTRADERMAL SUBCUTANEOUS 3 SOLUTION SOLUTION CLADOSPORIUM CLADOSPORIOIDES BAYBERRY (WAX 3 MYRTLE) SUBCUTANEOUS 3 SUBCUTANEOUS SOLUTION SOLUTION CLADOSPORIUM BERMUDA GRASS SPHAEROSPERMUM 3 3 INJECTION SOLUTION SUBCUTANEOUS SOLUTION BERMUDA GRASS SUBCUTANEOUS 3 COCKLEBUR SOLUTION SUBCUTANEOUS 3 SOLUTION BLACK WILLOW SUBCUTANEOUS 3 CORN POLLEN SOLUTION SUBCUTANEOUS 3 SOLUTION BOTRYTIS INJECTION 3 SOLUTION CURVULARIA SUBCUTANEOUS 3 BOTRYTIS SOLUTION SUBCUTANEOUS 3 SOLUTION DANDELION SUBCUTANEOUS 3 BROME SOLUTION SUBCUTANEOUS 3 SOLUTION DOG EPITHELIUM SUBCUTANEOUS 3 CALIFORNIA PEPPER SOLUTION TREE SUBCUTANEOUS 3 SOLUTION DOG FENNEL SUBCUTANEOUS 3 CANDIDA ALBICANS SOLUTION EXTRACT INJECTION 3 SOLUTION DRECHSLERA SUBCUTANEOUS 3 CANDIDA ALBICANS SOLUTION EXTRACT SUBCUTANEOUS 3 EASTERN COTTONWOOD SOLUTION 10000 3 PNU/ML SUBCUTANEOUS SOLUTION CAT HAIR EXTRACT 3 EPICOCCUM NIGRUM INJECTION SOLUTION 3 INJECTION SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 7 Drug Name Tier Notes Drug Name Tier Notes EPICOCCUM MEADOW FESCUE SUBCUTANEOUS 3 GRASS POLLEN 3 SOLUTION SUBCUTANEOUS FIRE ANT SOLUTION SUBCUTANEOUS 3 MELALEUCA SOLUTION SUBCUTANEOUS 3 FUSARIUM SOLUTION SUBCUTANEOUS 3 MESQUITE SOLUTION SUBCUTANEOUS 3 GERMAN COCKROACH SOLUTION SUBCUTANEOUS 3 MITE (D. FARINAE) 3 SOLUTION INJECTION SOLUTION GOLDENROD MITE (D. FARINAE) SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION GRASS POLLEN(K-O-R- MITE (D. T-SWT VERN) 3 PTERONYSSINUS) 3 INJECTION SOLUTION INJECTION SOLUTION GRASTEK SUBLINGUAL MITE (D. 3 PA; QL TABLET SUBLINGUAL PTERONYSSINUS) 3 HACKBERRY SUBCUTANEOUS SUBCUTANEOUS 3 SOLUTION SOLUTION MIXED RAGWEED HONEY BEE VENOM SUBCUTANEOUS 3 PROTEIN INJECTION SOLUTION 3 SOLUTION MIXED VESPID VENOM RECONSTITUTED PROTEIN INJECTION 3 HONEY BEE VENOM SOLUTION SUBCUTANEOUS RECONSTITUTED 3 SOLUTION MIXED VESPID VENOM RECONSTITUTED PROTEIN HORSE EPITHELIUM SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION RECONSTITUTED JOHNSON GRASS MOUNTAIN CEDAR SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION JUNE GRASS POLLEN MOUSE EPITHELIUM STANDARDIZED SUBCUTANEOUS 3 3 SUBCUTANEOUS SOLUTION SOLUTION MUCOR INJECTION 3 KAPOK SOLUTION SUBCUTANEOUS 3 MUCOR INTRADERMAL 3 SOLUTION SOLUTION KOCHIA MUCOR SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION LENSCALE MUGWORT SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 8 Drug Name Tier Notes Drug Name Tier Notes OLIVE TREE QUEEN PALM SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION ORCHARD GRASS RABBIT EPITHELIUM POLLEN SUBCUTANEOUS 3 3 SUBCUTANEOUS SOLUTION SOLUTION RAGWITEK PALFORZIA (12 MG SUBLINGUAL TABLET 3 PA; QL 4 PA; LD; SP; QL DAILY DOSE) ORAL SUBLINGUAL PALFORZIA (120 MG RED MAPLE 4 PA; LD; SP; QL DAILY DOSE) ORAL SUBCUTANEOUS 3 PALFORZIA (160 MG SOLUTION 4 PA; LD; SP; QL DAILY DOSE) ORAL RED MULBERRY PALFORZIA (20 MG SUBCUTANEOUS 3 4 PA; LD; SP; QL DAILY DOSE) ORAL SOLUTION PALFORZIA (200 MG RED TOP GRASS 4 PA; LD; SP; QL POLLEN DAILY DOSE) ORAL 3 SUBCUTANEOUS PALFORZIA (240 MG 4 PA; LD; SP; QL SOLUTION DAILY DOSE) ORAL RHIZOPUS PALFORZIA (3 MG 4 PA; LD; SP; QL SUBCUTANEOUS 3 DAILY DOSE) ORAL SOLUTION PALFORZIA (300 MG ROUGH MARSH ELDER MAINTENANCE) ORAL 4 PA; LD; SP; QL SUBCUTANEOUS 3 PACKET SOLUTION PALFORZIA (300 MG RUSSIAN THISTLE TITRATION) ORAL 4 PA; LD; SP; QL SUBCUTANEOUS 3 PACKET SOLUTION PALFORZIA (40 MG 4 PA; LD; SP; QL SACCHAROMYCES DAILY DOSE) ORAL CEREVISIAE 3 PALFORZIA (6 MG INJECTION SOLUTION 4 PA; LD; SP; QL DAILY DOSE) ORAL SACCHAROMYCES PALFORZIA (80 MG CEREVISIAE 4 PA; LD; SP; QL 3 DAILY DOSE) ORAL SUBCUTANEOUS SOLUTION PALFORZIA INITIAL 4 PA; LD; SP; QL ESCALATION ORAL SHAGBARK HICKORY SUBCUTANEOUS 3 PENICILLIUM SOLUTION NOTATUM INJECTION 3 SOLUTION SHEEP SORREL SUBCUTANEOUS 3 PENICILLIUM SOLUTION NOTATUM 3 SUBCUTANEOUS SHORT RAGWEED POLLEN EXT SOLUTION 3 SUBCUTANEOUS PERENNIAL RYE GRASS SOLUTION POLLEN INJECTION 3 SOLUTION SPINY PIGWEED SUBCUTANEOUS 3 PHOMA EXIGUA SOLUTION SUBCUTANEOUS 3 SOLUTION STEMPHYLIUM SUBCUTANEOUS 3 PRIVET SOLUTION SUBCUTANEOUS 3 SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 9 Drug Name Tier Notes Drug Name Tier Notes SWEET GUM WHITE BIRCH SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION SWEET VERNAL GRASS WHITE FACED HORNET POLLEN VENOM 3 SUBCUTANEOUS SUBCUTANEOUS 3 SOLUTION SOLUTION TALL RAGWEED RECONSTITUTED SUBCUTANEOUS 3 WHITE MULBERRY SOLUTION SUBCUTANEOUS 3 TIMOTHY GRASS SOLUTION POLLEN ALLERGEN 3 WHITE OAK INJECTION SOLUTION SUBCUTANEOUS 3 TIMOTHY GRASS SOLUTION POLLEN ALLERGEN WHITE PINE 3 SUBCUTANEOUS SUBCUTANEOUS 3 SOLUTION SOLUTION TRICHOPHYTON WHITE-FACED HORNET MENTAGROPHYTES VENOM INJECTION 3 3 SUBCUTANEOUS SOLUTION SOLUTION RECONSTITUTED TRICHOPHYTON YELLOW DOCK SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION VENOMIL HONEY BEE YELLOW HORNET 3 VENOM INJECTION KIT VENOM PROTEIN VENOMIL MIXED INJECTION SOLUTION 3 VESPID VENOM RECONSTITUTED 550 3 INJECTION SOLUTION MCG RECONSTITUTED YELLOW HORNET VENOMIL WASP VENOM PROTEIN 3 VENOM INJECTION KIT SUBCUTANEOUS 3 SOLUTION VENOMIL WHITE RECONSTITUTED FACED HORNET 3 INJECTION KIT YELLOW JACKET VENOM PROTEIN VENOMIL YELLOW INJECTION SOLUTION 3 HORNET VENOM 3 RECONSTITUTED 1300 INJECTION KIT MCG, 550 MCG VENOMIL YELLOW YELLOW JACKET JACKET VENOM 3 VENOM PROTEIN INJECTION KIT SUBCUTANEOUS 3 WASP VENOM PROTEIN SOLUTION INJECTION SOLUTION RECONSTITUTED 3 RECONSTITUTED 1300 *MIXED ALLERGENIC MCG, 550 MCG EXTRACTS*** WASP VENOM PROTEIN DUST MITE MIXED SUBCUTANEOUS 3 ALLERGEN EXT 3 SOLUTION INJECTION SOLUTION RECONSTITUTED DUST MITE MIXED WESTERN JUNIPER ALLERGEN EXT 3 SUBCUTANEOUS 3 SUBCUTANEOUS SOLUTION SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 10 Drug Name Tier Notes Drug Name Tier Notes MIXED ASPERGILLUS TOBI INHALATION SUBCUTANEOUS 3 NEBULIZATION 4 LD; SP; QL SOLUTION SOLUTION MIXED FEATHERS TOBI PODHALER 4 LD; SP; QL SUBCUTANEOUS 3 INHALATION CAPSULE SOLUTION tobramycin inhalation 4 SP; QL ODACTRA nebulization solution SUBLINGUAL TABLET 3 PA; QL tobramycin sulfate injection 1 or 1b* QL SUBLINGUAL solution ORALAIR SUBLINGUAL tobramycin sulfate injection 3 PA; LD; QL 1 or 1b* QL TABLET SUBLINGUAL solution reconstituted SORREL/DOCK MIX ZEMDRI INTRAVENOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION *ANALGESICS - ANTI- *AMEBICIDES* INFLAMMATORY* *AMEBICIDES*** *ANTIRHEUMATIC - SOLOSEC ORAL JANUS KINASE (JAK) 3 ST; QL PACKET INHIBITORS*** *AMINOGLYCOSIDES* OLUMIANT ORAL 4 PA; LD; QL *AMINOGLYCOSIDES** TABLET 1 MG * OLUMIANT ORAL 4 PA; LD; SP; QL amikacin sulfate injection TABLET 2 MG solution 1 gm/4ml, 500 1 or 1b* RINVOQ ORAL TABLET mg/2ml EXTENDED RELEASE 24 4 PA; LD; SP; QL ARIKAYCE HOUR INHALATION 4 PA; LD; QL XELJANZ ORAL 4 PA; SP; QL SUSPENSION SOLUTION BETHKIS INHALATION XELJANZ ORAL 4 PA; SP; QL NEBULIZATION 4 LD; SP; QL TABLET SOLUTION XELJANZ XR ORAL gentamicin in saline TABLET EXTENDED 4 PA; SP; QL intravenous solution 0.8-0.9 RELEASE 24 HOUR 11 mg/ml-%, 1-0.9 mg/ml-%, 1 or 1b* MG 1.2-0.9 mg/ml-%, 1.6-0.9 XELJANZ XR ORAL mg/ml-%, 2-0.9 mg/ml-% TABLET EXTENDED 4 PA; QL gentamicin sulfate injection RELEASE 24 HOUR 22 1 or 1b* solution MG HUMATIN ORAL *ANTIRHEUMATIC 3 CAPSULE ANTIMETABOLITES*** KITABIS PAK OTREXUP INHALATION SUBCUTANEOUS 4 LD; SP; QL NEBULIZATION SOLUTION AUTO- SOLUTION INJECTOR 10 MG/0.4ML, neomycin sulfate oral tablet 1 or 1a* 12.5 MG/0.4ML, 15 4 PA; SP; QL MG/0.4ML, 17.5 paromomycin sulfate oral 1 or 1b* MG/0.4ML, 20 MG/0.4ML, capsule 22.5 MG/0.4ML, 25 streptomycin sulfate MG/0.4ML intramuscular solution 1 or 1b* reconstituted

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 11 Drug Name Tier Notes Drug Name Tier Notes RASUVO SIMPONI SUBCUTANEOUS SUBCUTANEOUS 4 PA; SP; QL SOLUTION AUTO- SOLUTION AUTO- INJECTOR 10 MG/0.2ML, INJECTOR 12.5 MG/0.25ML, 15 SIMPONI MG/0.3ML, 17.5 4 PA; SP; QL SUBCUTANEOUS 4 PA; SP; QL MG/0.35ML, 20 SOLUTION PREFILLED MG/0.4ML, 22.5 SYRINGE MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, *CYCLOOXYGENASE 2 7.5 MG/0.15ML (COX-2) INHIBITORS*** CELEBREX ORAL REDITREX 3 ST; QL SUBCUTANEOUS CAPSULE 4 PA; LD; QL SOLUTION PREFILLED celecoxib oral capsule 1 or 1b* ST; QL SYRINGE *GOLD COMPOUNDS*** *ANTI-TNF-ALPHA - RIDAURA ORAL MONOCLONAL 2 ANTIBODIES*** CAPSULE *INTERLEUKIN-1 HUMIRA PEDIATRIC BLOCKERS*** CROHNS START SUBCUTANEOUS ARCALYST PREFILLED SYRINGE 4 PA; SP; QL SUBCUTANEOUS 4 PA; LD; SP; QL KIT 80 MG/0.8ML, 80 SOLUTION MG/0.8ML & RECONSTITUTED 40MG/0.4ML *INTERLEUKIN-1 HUMIRA PEN RECEPTOR SUBCUTANEOUS PEN- 4 PA; SP; QL ANTAGONIST (IL- INJECTOR KIT 1RA)*** HUMIRA PEN-CD/UC/HS KINERET STARTER SUBCUTANEOUS 4 PA; SP; QL 4 PA; LD; QL SUBCUTANEOUS PEN- SOLUTION PREFILLED INJECTOR KIT SYRINGE HUMIRA PEN- *INTERLEUKIN-1BETA PEDIATRIC UC START BLOCKERS*** 4 PA; SP; QL SUBCUTANEOUS PEN- ILARIS INJECTOR KIT SUBCUTANEOUS 4 PA; LD; SP; QL HUMIRA PEN- SOLUTION PS/UV/ADOL HS START *INTERLEUKIN-6 SUBCUTANEOUS PEN- 4 PA; SP; QL RECEPTOR INJECTOR KIT 40 INHIBITORS*** MG/0.8ML ACTEMRA ACTPEN HUMIRA PEN- SUBCUTANEOUS PSOR/UVEIT STARTER 4 PA; LD; SP; QL 4 PA; SP; QL SOLUTION AUTO- SUBCUTANEOUS PEN- INJECTOR INJECTOR KIT ACTEMRA HUMIRA INTRAVENOUS 4 PA; LD; SP SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL KIT 10 MG/0.1ML, 20 ACTEMRA SUBCUTANEOUS MG/0.2ML, 40 MG/0.4ML, 4 PA; LD; SP; QL 40 MG/0.8ML SOLUTION PREFILLED SYRINGE SIMPONI ARIA INTRAVENOUS 4 PA; SP SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 12 Drug Name Tier Notes Drug Name Tier Notes KEVZARA etodolac oral capsule 1 or 1b* QL SUBCUTANEOUS 4 PA; LD; SP; QL etodolac oral tablet 1 or 1b* QL SOLUTION AUTO- FELDENE ORAL INJECTOR 3 QL CAPSULE KEVZARA SUBCUTANEOUS FENOPROFEN 4 PA; LD; SP; QL SOLUTION PREFILLED CALCIUM ORAL 3 QL SYRINGE CAPSULE 200 MG fenoprofen calcium oral *NONSTEROIDAL ANTI- 3 ST; QL INFLAMMATORY capsule 400 mg AGENT fenoprofen calcium oral 3 ST; QL COMBINATIONS*** tablet ARTHROTEC ORAL flurbiprofen oral tablet 1 or 1b* QL TABLET DELAYED 3 ST; QL RELEASE ibu oral tablet 1 or 1a* QL diclofenac-misoprostol oral ibuprofen lysine intravenous 1 or 1b* ST; QL 1 or 1b* tablet delayed release solution DUEXIS ORAL TABLET 3 ST; QL ibuprofen oral suspension 1 or 1a* QL ibuprofen-famotidine oral ibuprofen oral tablet 400 mg, 3 ST; QL 1 or 1a* QL tablet 600 mg, 800 mg naproxen-esomeprazole oral INDOCIN ORAL 3 ST; QL 3 ST; QL tablet delayed release SUSPENSION VIMOVO ORAL TABLET INDOCIN RECTAL 3 ST; QL 3 ST; QL DELAYED RELEASE SUPPOSITORY indomethacin er oral capsule *NONSTEROIDAL ANTI- 1 or 1b* QL INFLAMMATORY extended release AGENTS (NSAIDS)*** indomethacin oral capsule 20 3 ST; QL ANJESO INTRAVENOUS mg 3 INJECTABLE indomethacin oral capsule 25 1 or 1b* QL CALDOLOR mg, 50 mg INTRAVENOUS indomethacin sodium 3 SOLUTION 800 intravenous solution 1 or 1b* MG/200ML, 800 MG/8ML reconstituted cataflam oral tablet 1 or 1b* ketoprofen er oral capsule 1 or 1b* QL DAYPRO ORAL TABLET 3 QL extended release 24 hour DICLOFENAC ORAL ketoprofen oral capsule 25 3 ST; QL 3 ST; QL CAPSULE mg diclofenac potassium oral ketoprofen oral capsule 50 1 or 1b* 1 or 1b* tablet mg ketoprofen oral capsule 75 diclofenac sodium er oral 1 or 1b* QL tablet extended release 24 1 or 1b* QL mg hour ketorolac tromethamine diclofenac sodium oral tablet injection solution 15 mg/ml, 1 or 1b* QL 1 or 1b* QL delayed release 30 mg/ml EC-NAPROSYN ORAL ketorolac tromethamine TABLET DELAYED 3 ST intramuscular solution 60 1 or 1b* QL RELEASE mg/2ml ec-naproxen oral tablet KETOROLAC 1 or 1b* delayed release TROMETHAMINE 3 ST; QL NASAL SOLUTION etodolac er oral tablet 1 or 1b* QL extended release 24 hour * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 13 Drug Name Tier Notes Drug Name Tier Notes ketorolac tromethamine oral *PHOSPHODIESTERASE 1 or 1a* QL tablet 4 (PDE4) INHIBITORS*** LODINE ORAL TABLET 3 QL OTEZLA ORAL TABLET 4 PA; SP; QL meclofenamate sodium oral OTEZLA ORAL TABLET 1 or 1b* QL 4 PA; SP; QL capsule THERAPY PACK mefenamic acid oral capsule 1 or 1b* QL *PYRIMIDINE meloxicam oral capsule 3 ST; QL SYNTHESIS INHIBITORS*** meloxicam oral tablet 1 or 1b* QL ARAVA ORAL TABLET 3 MOBIC ORAL TABLET 3 ST; QL leflunomide oral tablet 1 or 1b* nabumetone oral tablet 1 or 1b* QL *SELECTIVE NALFON ORAL 3 ST; QL COSTIMULATION CAPSULE 400 MG MODULATORS*** NALFON ORAL TABLET 3 ST; QL ORENCIA CLICKJECT SUBCUTANEOUS NAPRELAN ORAL 4 PA; SP; QL TABLET EXTENDED SOLUTION AUTO- 3 ST; QL RELEASE 24 HOUR 375 INJECTOR MG, 500 MG, 750 MG ORENCIA NAPROSYN ORAL INTRAVENOUS 3 4 PA; SP; QL SUSPENSION SOLUTION RECONSTITUTED NAPROSYN ORAL 3 ST TABLET 500 MG ORENCIA SUBCUTANEOUS 4 PA; SP; QL naproxen oral suspension 3 ST SOLUTION PREFILLED naproxen oral tablet 1 or 1b* SYRINGE naproxen oral tablet delayed *SOLUBLE TUMOR 1 or 1b* release NECROSIS FACTOR naproxen sodium er oral RECEPTOR AGENTS*** tablet extended release 24 3 ST; QL ENBREL MINI hour SUBCUTANEOUS 4 PA; SP; QL naproxen sodium oral tablet SOLUTION CARTRIDGE 1 or 1b* QL 275 mg, 550 mg ENBREL NEOPROFEN SUBCUTANEOUS 4 PA; SP; QL INTRAVENOUS 3 SOLUTION 25 MG/0.5ML SOLUTION ENBREL SUBCUTANEOUS oxaprozin oral tablet 1 or 1b* QL 4 PA; SP; QL SOLUTION PREFILLED piroxicam oral capsule 1 or 1b* QL SYRINGE RELAFEN DS ORAL 3 ST; QL ENBREL TABLET SUBCUTANEOUS 4 PA; SP; QL relafen oral tablet 1 or 1b* QL SOLUTION RECONSTITUTED SPRIX NASAL 3 ST; QL SOLUTION ENBREL SURECLICK SUBCUTANEOUS sulindac oral tablet 1 or 1b* QL 4 PA; SP; QL SOLUTION AUTO- TIVORBEX ORAL 3 ST; QL INJECTOR CAPSULE 20 MG VIVLODEX ORAL 3 ST; QL CAPSULE ZIPSOR ORAL CAPSULE 3 ST; QL ZORVOLEX ORAL 3 ST; QL CAPSULE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 14 Drug Name Tier Notes Drug Name Tier Notes *ANALGESICS - *SALICYLATES*** NONNARCOTIC* adult aspirin regimen oral 1 or 1a* OTC; $0 *ANALGESICS tablet delayed release OTHER*** aspirin 81 oral tablet 1 or 1a* OTC; $0 acetaminophen intravenous chewable 1 or 1b* solution aspirin adult low dose oral 1 or 1a* OTC; $0 clonidine hcl (analgesia) tablet delayed release 1 or 1b* epidural solution aspirin adult low strength 1 or 1a* OTC; $0 DURACLON EPIDURAL oral tablet delayed release 3 SOLUTION 100 MCG/ML aspirin childrens oral tablet 1 or 1a* OTC; $0 OFIRMEV chewable INTRAVENOUS 3 aspirin ec adult low strength 1 or 1a* OTC; $0 SOLUTION oral tablet delayed release *ANALGESICS- aspirin ec low dose oral 1 or 1a* OTC; $0 SEDATIVES*** tablet delayed release ALLZITAL ORAL aspirin ec low strength oral 3 QL 1 or 1a* OTC; $0 TABLET tablet delayed release bac oral tablet 1 or 1b* QL aspirin ec oral tablet delayed 1 or 1a* OTC; $0 bupap oral tablet 50-300 mg 3 QL release butalbital-acetaminophen aspirin low dose oral tablet 1 or 1b* QL 1 or 1a* OTC; $0 oral capsule chewable butalbital-acetaminophen aspirin low dose oral tablet 1 or 1a* OTC; $0 oral tablet 25-325 mg, 50- 1 or 1b* QL delayed release 325 mg aspirin low strength oral 1 or 1a* OTC; $0 butalbital-acetaminophen tablet chewable 3 QL oral tablet 50-300 mg aspirin oral tablet 325 mg 1 or 1a* OTC; $0 butalbital-apap-caffeine oral 1 or 1b* QL aspirin oral tablet chewable 1 or 1a* OTC; $0 capsule aspirin oral tablet delayed butalbital-apap-caffeine oral 1 or 1a* OTC; $0 1 or 1b* QL release 325 mg, 81 mg tablet 50-325-40 mg bayer advanced aspirin reg st butalbital-aspirin-caffeine 1 or 1a* OTC; $0 1 or 1b* QL oral tablet oral capsule bayer aspirin ec low dose 1 or 1a* OTC; $0 esgic oral capsule 1 or 1b* QL oral tablet delayed release ESGIC ORAL TABLET 3 QL bayer aspirin oral tablet 1 or 1a* OTC; $0 FIORICET ORAL bayer aspirin oral tablet 3 QL 1 or 1a* OTC; $0 CAPSULE delayed release tencon oral tablet 50-325 mg 1 or 1b* QL bayer low dose oral tablet 1 or 1a* OTC; $0 vtol lq oral solution 3 QL chewable zebutal oral capsule 50-325- bayer low dose oral tablet 1 or 1b* QL 1 or 1a* OTC; $0 40 mg delayed release *SALICYLATE childrens aspirin oral tablet 1 or 1a* OTC; $0 COMBINATIONS*** chewable sm aspirin tri-buffered oral cvs aspirin adult low dose 1 or 1b* OTC; $0 1 or 1a* OTC; $0 tablet oral tablet chewable tri-buffered aspirin oral tablet cvs aspirin adult low strength 1 or 1b* OTC; $0 1 or 1a* OTC; $0 325 mg oral tablet delayed release cvs aspirin ec oral tablet 1 or 1a* OTC; $0 delayed release

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 15 Drug Name Tier Notes Drug Name Tier Notes cvs aspirin low dose oral hm aspirin oral tablet delayed 1 or 1a* OTC; $0 1 or 1a* OTC; $0 tablet delayed release release cvs aspirin low strength oral kls aspirin low dose oral 1 or 1a* OTC; $0 1 or 1a* OTC; $0 tablet delayed release tablet delayed release cvs aspirin oral tablet 325 mg 1 or 1a* OTC; $0 kp aspirin oral tablet delayed 1 or 1a* OTC; $0 diflunisal oral tablet 1 or 1b* release ecotrin low strength oral meijer aspirin ec oral tablet 1 or 1a* OTC; $0 1 or 1a* OTC; $0 tablet delayed release delayed release eq aspirin adult low dose oral px aspirin oral tablet 1 or 1a* OTC; $0 1 or 1a* OTC; $0 tablet delayed release px aspirin oral tablet 1 or 1a* OTC; $0 eq aspirin low dose oral chewable 1 or 1a* OTC; $0 tablet chewable px enteric aspirin oral tablet 1 or 1a* OTC; $0 eq aspirin oral tablet 1 or 1a* OTC; $0 delayed release eql aspirin ec oral tablet qc aspirin low dose oral 1 or 1a* OTC; $0 1 or 1a* OTC; $0 delayed release 325 mg tablet chewable eql aspirin low dose oral qc aspirin low dose oral 1 or 1a* OTC; $0 1 or 1a* OTC; $0 tablet chewable tablet delayed release eql aspirin low dose oral qc aspirin oral tablet 1 or 1a* OTC; $0 1 or 1a* OTC; $0 tablet delayed release qc aspirin oral tablet delayed 1 or 1a* OTC; $0 gnp adult aspirin low release 1 or 1a* OTC; $0 strength oral tablet chewable qc childrens aspirin oral 1 or 1a* OTC; $0 gnp aspirin low dose oral tablet chewable 1 or 1a* OTC; $0 tablet delayed release qc enteric aspirin oral tablet 1 or 1a* OTC; $0 gnp aspirin oral tablet 325 delayed release 1 or 1a* OTC; $0 mg ra aspirin adult low dose oral 1 or 1a* OTC; $0 gnp aspirin oral tablet tablet chewable 1 or 1a* OTC; $0 delayed release ra aspirin adult low strength 1 or 1a* OTC; $0 goodsense aspirin adult low oral tablet chewable 1 or 1a* OTC; $0 st oral tablet chewable ra aspirin childrens oral 1 or 1a* OTC; $0 goodsense aspirin adults oral tablet chewable 1 or 1a* OTC; $0 tablet ra aspirin ec adult low st oral 1 or 1a* OTC; $0 goodsense aspirin low dose tablet delayed release 1 or 1a* OTC; $0 oral tablet delayed release ra aspirin ec oral tablet 1 or 1a* OTC; $0 goodsense aspirin oral tablet 1 or 1a* OTC; $0 delayed release goodsense aspirin oral tablet ra aspirin oral tablet 325 mg 1 or 1a* OTC; $0 1 or 1a* OTC; $0 chewable ra pain relief aspirin oral 1 or 1a* OTC; $0 goodsense aspirin oral tablet tablet 1 or 1a* OTC; $0 delayed release sb aspirin ec oral tablet 1 or 1a* OTC; $0 h-e-b aspirin oral tablet delayed release 1 or 1a* OTC; $0 delayed release sb aspirin oral tablet 1 or 1a* OTC; $0 hm adult aspirin oral tablet 1 or 1a* OTC; $0 sb childrens aspirin oral 1 or 1a* OTC; $0 hm aspirin ec low dose oral tablet chewable 1 or 1a* OTC; $0 tablet delayed release sb low dose asa ec oral tablet 1 or 1a* OTC; $0 hm aspirin ec oral tablet delayed release 1 or 1a* OTC; $0 delayed release sm aspirin adult low strength 1 or 1a* OTC; $0 hm aspirin oral tablet 1 or 1a* OTC; $0 oral tablet chewable hm aspirin oral tablet sm aspirin adult low strength 1 or 1a* OTC; $0 1 or 1a* OTC; $0 chewable oral tablet delayed release

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 16 Drug Name Tier Notes Drug Name Tier Notes sm aspirin ec low strength trezix oral capsule 320.5-30- 1 or 1a* OTC; $0 1 or 1b* QL oral tablet delayed release 16 mg sm aspirin ec oral tablet *FENTANYL 1 or 1a* OTC; $0 delayed release COMBINATIONS*** sm aspirin low dose oral FENTANYL CIT- 1 or 1a* OTC; $0 tablet chewable ROPIVACAINE-NACL 3 sm aspirin oral tablet 1 or 1a* OTC; $0 EPIDURAL SOLUTION 0.4-0.2-0.9 MG/200ML-% sm childrens aspirin oral 1 or 1a* OTC; $0 tablet chewable FENTANYL- BUPIVACAINE-NACL st joseph aspirin oral tablet 1 or 1a* OTC; $0 EPIDURAL SOLUTION 3 delayed release 0.8-0.1667-0.9 MG/200ML- st joseph low dose oral tablet % 1 or 1a* OTC; $0 chewable *HYDROCODONE st joseph low dose oral tablet COMBINATIONS*** 1 or 1a* OTC; $0 delayed release hydrocodone-acetaminophen *SELECTIVE N-TYPE oral solution 10-325 NEURONAL CALCIUM mg/15ml, 2.5-108 mg/5ml, 5- 1 or 1b* QL CHANNEL 217 mg/10ml, 7.5-325 BLOCKERS*** mg/15ml PRIALT INTRATHECAL hydrocodone-acetaminophen 4 PA; LD oral tablet 10-300 mg, 10- SOLUTION 1 or 1b* QL 325 mg, 5-300 mg, 5-325 *ANALGESICS - mg, 7.5-300 mg, 7.5-325 mg OPIOID* hydrocodone-ibuprofen oral *CODEINE tablet 10-200 mg, 5-200 mg, 1 or 1b* QL COMBINATIONS*** 7.5-200 mg acetaminophen-codeine #2 LORTAB ORAL ELIXIR 1 or 1a* QL 3 QL oral tablet 10-300 MG/15ML acetaminophen-codeine #3 1 or 1a* QL *OPIOID AGONISTS*** oral tablet ACTIQ BUCCAL acetaminophen-codeine #4 1 or 1a* QL LOZENGE ON A 3 PA; QL oral tablet HANDLE acetaminophen-codeine oral 1 or 1a* QL ALFENTANIL HCL solution INTRAVENOUS 3 acetaminophen-codeine oral SOLUTION 1 or 1a* QL tablet CODEINE SULFATE ascomp-codeine oral capsule 1 or 1b* QL ORAL TABLET 15 MG, 3 QL butalbital-apap-caff-cod oral 60 MG 1 or 1b* QL capsule codeine sulfate oral tablet 30 1 or 1b* QL butalbital-asa-caff-codeine mg 1 or 1b* QL oral capsule CONZIP ORAL FIORICET/CODEINE CAPSULE EXTENDED 3 PA; QL ORAL CAPSULE 50-300- 3 QL RELEASE 24 HOUR 40-30 MG DEMEROL INJECTION SOLUTION 100 MG/2ML, *DIHYDROCODEINE 3 QL COMBINATIONS*** 100 MG/ML, 25 MG/ML, 50 MG/ML, 75 MG/ML apap-caff-dihydrocodeine 1 or 1b* QL oral capsule DILAUDID INJECTION SOLUTION 0.2 MG/ML, 1 3 QL apap-caff-dihydrocodeine 1 or 1b* QL MG/ML, 2 MG/ML oral tablet 325-30-16 mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 17 Drug Name Tier Notes Drug Name Tier Notes DILAUDID ORAL HYDROCODONE 3 QL LIQUID BITARTRATE ER ORAL 3 PA; QL DILAUDID ORAL CAPSULE EXTENDED 3 QL TABLET RELEASE 12 HOUR DSUVIA SUBLINGUAL hydrocodone bitartrate er 3 TABLET SUBLINGUAL oral tablet er 24 hour abuse- 1 or 1b* PA; QL deterrent duramorph injection solution 1 or 1b* QL hydromorphone hcl er oral FENTANYL CITRATE tablet extended release 24 1 or 1b* PA; QL (PF) INJECTION hour SOLUTION 100 3 hydromorphone hcl injection MCG/2ML, 250 1 or 1b* QL MCG/5ML, 50 MCG/ML solution 4 mg/ml hydromorphone hcl oral fentanyl citrate (pf) injection 1 or 1b* QL solution 1000 mcg/20ml, liquid 1 or 1b* 2500 mcg/50ml, 500 hydromorphone hcl oral 1 or 1b* QL mcg/10ml tablet fentanyl citrate (pf) injection HYDROMORPHONE 1 or 1b* solution cartridge HCL PF INJECTION fentanyl citrate buccal SOLUTION 1 MG/ML, 10 3 QL 1 or 1b* PA; QL lozenge on a handle MG/ML, 2 MG/ML, 4 MG/ML fentanyl citrate buccal tablet 1 or 1b* PA; QL hydromorphone hcl pf FENTANYL CITRATE injection solution 50 mg/5ml, 1 or 1b* QL INTRAVENOUS 500 mg/50ml SOLUTION 1500 3 MCG/30ML, 2500 HYDROMORPHONE MCG/50ML HCL-NACL INTRAVENOUS FENTANYL CITRATE SOLUTION PREFILLED 3 INTRAVENOUS SYRINGE 15-0.9 SOLUTION PREFILLED MG/30ML-%, 5-0.9 SYRINGE 100 MG/25ML-% MCG/10ML, 1000 3 MCG/20ML, 1250 HYSINGLA ER ORAL MCG/25ML, 20 TABLET ER 24 HOUR 3 PA; QL MCG/2ML, 50 MCG/5ML, ABUSE-DETERRENT 500 MCG/50ML INFUMORPH 200 3 QL FENTANYL CITRATE PF INJECTION SOLUTION INJECTION SOLUTION 3 INFUMORPH 500 3 QL PREFILLED SYRINGE INJECTION SOLUTION FENTANYL CITRATE- LAZANDA NASAL NACL INTRAVENOUS SOLUTION 100 3 PA; QL SOLUTION PREFILLED MCG/ACT, 400 3 SYRINGE 100-0.9 MCG/ACT MCG/10ML-%, 500-0.9 levorphanol tartrate oral 1 or 1b* PA; QL MCG/50ML-% tablet fentanyl transdermal patch 1 or 1b* PA; QL meperidine hcl injection 72 hour solution 100 mg/ml, 25 1 or 1b* QL FENTORA BUCCAL mg/ml, 50 mg/ml TABLET 100 MCG, 200 3 PA; QL meperidine hcl oral solution 1 or 1b* QL MCG, 400 MCG, 600 meperidine hcl oral tablet 50 MCG, 800 MCG 1 or 1b* QL mg METHADONE HCL 3 PA; QL INJECTION SOLUTION * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 18 Drug Name Tier Notes Drug Name Tier Notes methadone hcl intensol oral MS CONTIN ORAL 1 or 1b* PA; QL concentrate TABLET EXTENDED 3 PA; QL methadone hcl oral RELEASE 1 or 1b* PA; QL concentrate NUCYNTA ER ORAL methadone hcl oral solution 1 or 1b* PA; QL TABLET EXTENDED 3 PA; QL RELEASE 12 HOUR methadone hcl oral tablet 1 or 1b* PA; QL NUCYNTA ORAL methadone hcl oral tablet 3 QL 1 or 1b* PA; QL TABLET soluble OLINVYK METHADOSE ORAL INTRAVENOUS 3 CONCENTRATE 10 3 PA; QL SOLUTION MG/ML OXAYDO ORAL TABLET 3 QL methadose oral tablet soluble 1 or 1b* PA; QL oxycodone hcl er oral tablet 3 PA; QL METHADOSE SUGAR- er 12 hour abuse-deterrent FREE ORAL 3 PA; QL CONCENTRATE oxycodone hcl oral capsule 1 or 1b* QL oxycodone hcl oral mitigo injection solution 1 or 1b* QL 1 or 1b* QL concentrate 100 mg/5ml morphine sulfate (concentrate) oral solution 1 or 1b* QL oxycodone hcl oral solution 1 or 1b* QL 100 mg/5ml, 20 mg/ml oxycodone hcl oral tablet 1 or 1b* QL morphine sulfate (pf) OXYCONTIN ORAL injection solution 0.5 mg/ml, 1 or 1b* QL TABLET ER 12 HOUR 3 PA; QL 1 mg/ml ABUSE-DETERRENT MORPHINE SULFATE oxymorphone hcl er oral (PF) INJECTION tablet extended release 12 1 or 1b* PA; QL SOLUTION 10 MG/ML, 2 3 QL hour MG/ML, 4 MG/ML, 5 oxymorphone hcl oral tablet 1 or 1b* QL MG/ML, 8 MG/ML QDOLO ORAL 3 QL MORPHINE SULFATE SOLUTION (PF) INTRAVENOUS remifentanil hcl intravenous SOLUTION 10 MG/ML, 2 3 QL 1 or 1b* MG/ML, 4 MG/ML, 8 solution reconstituted MG/ML ROXICODONE ORAL 3 QL morphine sulfate er beads TABLET oral capsule extended release 1 or 1b* PA; QL SUBSYS SUBLINGUAL 3 PA; QL 24 hour LIQUID morphine sulfate er oral SUFENTANIL CITRATE capsule extended release 24 1 or 1b* PA; QL INTRAVENOUS 3 hour SOLUTION morphine sulfate er oral 1 or 1b* PA; QL tramadol hcl er (biphasic) tablet extended release oral tablet extended release 1 or 1b* PA; QL MORPHINE SULFATE 24 hour 100 mg, 200 mg, 300 INJECTION SOLUTION 2 3 QL mg MG/ML, 4 MG/ML tramadol hcl er oral capsule morphine sulfate oral extended release 24 hour 100 1 or 1b* PA; QL 1 or 1b* QL solution mg, 200 mg, 300 mg tramadol hcl er oral tablet morphine sulfate oral tablet 1 or 1b* QL 1 or 1b* PA; QL extended release 24 hour MORPHINE SULFATE- NACL INTRAVENOUS tramadol hcl oral tablet 1 or 1b* QL SOLUTION PREFILLED 3 ULTIVA INTRAVENOUS SYRINGE 1-0.9 MG/ML- SOLUTION 3 % RECONSTITUTED * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 19 Drug Name Tier Notes Drug Name Tier Notes ULTRAM ORAL TABLET 3 QL buprenorphine hcl-naloxone XTAMPZA ER ORAL hcl sublingual tablet 1 or 1b* QL CAPSULE ER 12 HOUR 3 PA; QL sublingual ABUSE-DETERRENT buprenorphine transdermal 1 or 1b* PA; QL *OPIOID patch weekly COMBINATIONS*** butorphanol tartrate injection 1 or 1b* QL APADAZ ORAL TABLET 3 QL solution butorphanol tartrate nasal BENZHYDROCODONE- 1 or 1b* QL ACETAMINOPHEN 3 QL solution ORAL TABLET BUTRANS endocet oral tablet 10-325 TRANSDERMAL PATCH 3 PA; QL mg, 2.5-325 mg, 5-325 mg, 1 or 1b* QL WEEKLY 7.5-325 mg nalbuphine hcl injection 1 or 1b* QL NALOCET ORAL solution 3 QL TABLET pentazocine-naloxone hcl 1 or 1b* QL OXYCODONE- oral tablet ACETAMINOPHEN SUBLOCADE 3 QL ORAL SOLUTION 10-300 SUBCUTANEOUS 4 LD; QL MG/5ML SOLUTION PREFILLED OXYCODONE- SYRINGE ACETAMINOPHEN SUBOXONE 3 QL ORAL TABLET 10-300 3 QL SUBLINGUAL FILM MG, 2.5-300 MG, 5-300 ZUBSOLV SUBLINGUAL 3 QL MG TABLET SUBLINGUAL oxycodone-acetaminophen *TRAMADOL oral tablet 10-325 mg, 2.5- 1 or 1b* QL COMBINATIONS*** 325 mg, 5-325 mg, 7.5-325 tramadol-acetaminophen oral mg 1 or 1b* QL tablet PERCOCET ORAL TABLET 10-325 MG, 2.5- ULTRACET ORAL 3 QL 3 QL 325 MG, 5-325 MG, 7.5-325 TABLET MG *ANDROGENS- PROLATE ORAL ANABOLIC* 3 QL SOLUTION *ANABOLIC PROLATE ORAL STEROIDS*** 3 QL TABLET oxandrolone oral tablet 1 or 1b* PA *OPIOID PARTIAL *ANDROGENS*** AGONISTS*** ANDRODERM BELBUCA BUCCAL 3 PA; QL TRANSDERMAL PATCH 3 PA; QL FILM 24 HOUR BUNAVAIL BUCCAL 3 QL ANDROGEL PUMP FILM 4.2-0.7 MG TRANSDERMAL GEL 3 PA; QL BUPRENEX INJECTION 20.25 MG/ACT (1.62%) 3 QL SOLUTION ANDROGEL 3 PA; QL buprenorphine hcl injection TRANSDERMAL GEL 1 or 1b* QL solution 0.3 mg/ml AVEED buprenorphine hcl sublingual INTRAMUSCULAR 3 PA; LD; SP 1 or 1b* QL tablet sublingual SOLUTION buprenorphine hcl-naloxone danazol oral capsule 1 or 1b* 1 or 1b* QL hcl sublingual film

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 20 Drug Name Tier Notes Drug Name Tier Notes DEPO-TESTOSTERONE *NITRATE INTRAMUSCULAR 3 PA VASODILATING SOLUTION AGENTS*** FORTESTA RECTIV RECTAL 3 PA; QL 3 QL TRANSDERMAL GEL OINTMENT JATENZO ORAL *RECTAL 3 PA; QL CAPSULE ANESTHETIC/STEROIDS METHITEST ORAL *** 3 TABLET ANALPRAM-HC 3 methyltestosterone oral EXTERNAL CREAM 3 capsule ANALPRAM-HC 3 NATESTO NASAL GEL 3 PA; QL EXTERNAL LOTION TESTIM hydrocortisone ace- 3 PA; QL TRANSDERMAL GEL pramoxine external cream 1- 1 or 1b* 1 % TESTOPEL IMPLANT 3 PA PROCTOFOAM HC PELLET 3 EXTERNAL FOAM testosterone cypionate intramuscular solution 100 1 or 1b* PA *RECTAL LOCAL mg/ml, 200 mg/ml ANESTHETICS*** testosterone enanthate LIDOCAINE 1 or 1b* PA intramuscular solution (ANORECTAL) RECTAL 3 SUPPOSITORY testosterone transdermal gel 1.62 %, 10 mg/act (2%), 12.5 *RECTAL STEROIDS*** mg/act (1%), 20.25 ANUSOL-HC EXTERNAL 3 mg/1.25gm (1.62%), 20.25 CREAM 1 or 1b* PA; QL mg/act (1.62%), 25 hydrocortisone (perianal) 1 or 1b* mg/2.5gm (1%), 40.5 external cream mg/2.5gm (1.62%), 50 PROCTOCORT mg/5gm (1%) 3 EXTERNAL CREAM testosterone transdermal 1 or 1b* PA; QL procto-med hc external solution 1 or 1b* cream VOGELXO PUMP 3 PA; QL TRANSDERMAL GEL procto-pak external cream 1 or 1b* VOGELXO proctozone-hc external cream 1 or 1b* TRANSDERMAL GEL 50 3 PA; QL *ANTACIDS* MG/5GM (1%) *ANTACIDS - XYOSTED BICARBONATE*** SUBCUTANEOUS 3 PA SODIUM BICARBONATE SOLUTION AUTO- 3 INJECTOR ORAL POWDER *ANORECTAL AND *ANTHELMINTICS* RELATED PRODUCTS* *ANTHELMINTICS*** *INTRARECTAL albendazole oral tablet 1 or 1b* PA; QL STEROIDS*** ALBENZA ORAL 3 PA; QL CORTENEMA RECTAL TABLET 3 ENEMA BENZNIDAZOLE ORAL 3 CORTIFOAM TABLET 3 QL EXTERNAL FOAM BILTRICIDE ORAL 3 hydrocortisone rectal enema 1 or 1b* TABLET UCERIS RECTAL FOAM 3 QL EMVERM ORAL 3 TABLET CHEWABLE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 21 Drug Name Tier Notes Drug Name Tier Notes ivermectin oral tablet 1 or 1b* PA; QL NITROLINGUAL praziquantel oral tablet 1 or 1b* TRANSLINGUAL 3 SOLUTION STROMECTOL ORAL 3 PA; QL TABLET NITROMIST TRANSLINGUAL 3 *ANTIANGINAL AEROSOL SOLUTION AGENTS* NITROSTAT *ANTIANGINALS- SUBLINGUAL TABLET 3 OTHER*** SUBLINGUAL RANEXA ORAL TABLET *ANTIANXIETY EXTENDED RELEASE 12 3 AGENTS* HOUR *ANTIANXIETY ranolazine er oral tablet 1 or 1b* AGENTS - MISC.*** extended release 12 hour buspirone hcl oral tablet 1 or 1b* *NITRATES*** droperidol injection solution 1 or 1b* GONITRO SUBLINGUAL 3 hydroxyzine hcl PACKET 1 or 1b* intramuscular solution ISORDIL TITRADOSE 3 ORAL TABLET hydroxyzine hcl oral syrup 1 or 1b* isosorbide dinitrate oral hydroxyzine hcl oral tablet 1 or 1b* 1 or 1b* tablet hydroxyzine pamoate oral 1 or 1a* isosorbide mononitrate er capsule oral tablet extended release 1 or 1b* meprobamate oral tablet 3 24 hour VISTARIL ORAL 3 isosorbide mononitrate oral CAPSULE 1 or 1b* tablet **** minitran transdermal patch alprazolam er oral tablet 1 or 1b* 1 or 1b* QL 24 hour extended release 24 hour NITRO-BID ALPRAZOLAM TRANSDERMAL 3 INTENSOL ORAL 3 QL OINTMENT CONCENTRATE NITRO-DUR alprazolam oral tablet 1 or 1b* QL TRANSDERMAL PATCH alprazolam oral tablet 24 HOUR 0.1 MG/HR, 0.2 3 1 or 1b* QL MG/HR, 0.4 MG/HR, 0.6 dispersible MG/HR alprazolam xr oral tablet 1 or 1b* QL NITRO-DUR extended release 24 hour TRANSDERMAL PATCH ATIVAN INJECTION 2 3 24 HOUR 0.3 MG/HR, 0.8 SOLUTION MG/HR ATIVAN ORAL TABLET 3 QL nitroglycerin in d5w 1 or 1b* chlordiazepoxide hcl oral intravenous solution 1 or 1b* QL capsule NITROGLYCERIN clorazepate dipotassium oral INTRAVENOUS 3 1 or 1b* QL SOLUTION tablet nitroglycerin sublingual diazepam injection solution 1 or 1a* 1 or 1b* tablet sublingual diazepam intensol oral 1 or 1a* QL nitroglycerin transdermal concentrate 1 or 1b* patch 24 hour DIAZEPAM nitroglycerin translingual INTRAMUSCULAR 1 or 1b* 3 solution SOLUTION AUTO- INJECTOR * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 22 Drug Name Tier Notes Drug Name Tier Notes diazepam oral concentrate 1 or 1a* QL LIDOCAINE HCL diazepam oral solution 5 (CARDIAC) 1 or 1a* mg/5ml INTRAVENOUS 3 SOLUTION PREFILLED diazepam oral tablet 1 or 1a* QL SYRINGE 100 MG/5ML lorazepam injection solution 1 or 1b* lidocaine hcl (cardiac) lorazepam intensol oral intravenous solution prefilled 1 or 1b* 1 or 1b* QL concentrate syringe 50 mg/5ml lorazepam oral concentrate 2 LIDOCAINE HCL 1 or 1b* QL (CARDIAC) PF mg/ml 3 INTRAVENOUS lorazepam oral tablet 1 or 1b* QL SOLUTION oxazepam oral capsule 1 or 1b* QL lidocaine hcl (cardiac) pf TRANXENE-T ORAL intravenous solution prefilled 1 or 1b* 3 QL TABLET 7.5 MG syringe VALIUM ORAL TABLET 3 QL lidocaine in d5w intravenous XANAX ORAL TABLET 3 QL solution 4-5 mg/ml-%, 8-5 1 or 1b* mg/ml-% XANAX XR ORAL TABLET EXTENDED 3 QL mexiletine hcl oral capsule 1 or 1b* RELEASE 24 HOUR *ANTIARRHYTHMICS *ANTIARRHYTHMICS* TYPE I-C*** *ANTIARRHYTHMICS - flecainide acetate oral tablet 1 or 1b* QL MISC.*** propafenone hcl er oral adenosine intravenous capsule extended release 12 1 or 1b* solution 12 mg/4ml, 6 1 or 1b* hour mg/2ml propafenone hcl oral tablet 1 or 1b* *ANTIARRHYTHMICS RYTHMOL SR ORAL TYPE I-A*** CAPSULE EXTENDED 3 disopyramide phosphate oral RELEASE 12 HOUR 1 or 1b* capsule *ANTIARRHYTHMICS NORPACE CR ORAL TYPE III*** CAPSULE EXTENDED 2 AMIODARONE HCL IN RELEASE 12 HOUR DEXTROSE NORPACE ORAL INTRAVENOUS 3 3 CAPSULE SOLUTION 450-5 MG/250ML-%, 900-5 procainamide hcl injection 1 or 1b* MG/500ML-% solution amiodarone hcl intravenous quinidine gluconate er oral 1 or 1b* 1 or 1b* solution tablet extended release amiodarone hcl oral tablet 1 or 1b* quinidine sulfate oral tablet 1 or 1a* 100 mg, 400 mg *ANTIARRHYTHMICS amiodarone hcl oral tablet 1 or 1b* QL TYPE I-B*** 200 mg LIDOCAINE HCL BRETYLIUM TOSYLATE 3 (CARDIAC) INJECTION SOLUTION INTRAVENOUS 3 SOLUTION PREFILLED CORVERT SYRINGE 100 MG/10ML INTRAVENOUS 3 SOLUTION dofetilide oral capsule 1 or 1b* ibutilide fumarate 1 or 1b* intravenous solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 23 Drug Name Tier Notes Drug Name Tier Notes MULTAQ ORAL BREO ELLIPTA 3 QL TABLET INHALATION AEROSOL 2 QL NEXTERONE POWDER BREATH INTRAVENOUS 3 ACTIVATED SOLUTION BREZTRI AEROSPHERE 3 QL pacerone oral tablet 100 mg, INHALATION AEROSOL 1 or 1b* 400 mg budesonide-formoterol 1 or 1b* QL pacerone oral tablet 200 mg 1 or 1b* QL fumarate inhalation aerosol TIKOSYN ORAL COMBIVENT RESPIMAT 3 CAPSULE INHALATION AEROSOL 2 QL SOLUTION *ANTIASTHMATIC AND BRONCHODILATOR DUAKLIR PRESSAIR INHALATION AEROSOL AGENTS* 3 ST; QL POWDER BREATH *5-LIPOXYGENASE ACTIVATED INHIBITORS*** DULERA INHALATION zileuton er oral tablet 3 ST; QL 3 PA; QL AEROSOL extended release 12 hour fluticasone-salmeterol ZYFLO ORAL TABLET 3 PA; QL inhalation aerosol powder 1 or 1b* QL *ADRENERGIC breath activated COMBINATIONS*** ipratropium-albuterol 1 or 1b* ADVAIR DISKUS inhalation solution INHALATION AEROSOL 3 QL STIOLTO RESPIMAT POWDER BREATH INHALATION AEROSOL 2 QL ACTIVATED SOLUTION 2.5-2.5 ADVAIR HFA MCG/ACT 2 QL INHALATION AEROSOL SYMBICORT 2 QL AIRDUO DIGIHALER INHALATION AEROSOL INHALATION AEROSOL 3 ST; QL TRELEGY ELLIPTA POWDER BREATH INHALATION AEROSOL 2 QL ACTIVATED POWDER BREATH AIRDUO RESPICLICK ACTIVATED 113/14 INHALATION 3 QL wixela inhub inhalation AEROSOL POWDER aerosol powder breath 1 or 1b* QL BREATH ACTIVATED activated AIRDUO RESPICLICK *ANTI-IGE 232/14 INHALATION 3 QL MONOCLONAL AEROSOL POWDER ANTIBODIES*** BREATH ACTIVATED XOLAIR AIRDUO RESPICLICK SUBCUTANEOUS 55/14 INHALATION 4 PA; LD; SP 3 QL SOLUTION PREFILLED AEROSOL POWDER SYRINGE BREATH ACTIVATED XOLAIR ANORO ELLIPTA SUBCUTANEOUS INHALATION AEROSOL 4 PA; LD; SP 2 QL SOLUTION POWDER BREATH RECONSTITUTED ACTIVATED *ANTI- BEVESPI AEROSPHERE 3 ST; QL INFLAMMATORY INHALATION AEROSOL AGENTS*** cromolyn sodium inhalation 1 or 1b* nebulization solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 24 Drug Name Tier Notes Drug Name Tier Notes *BETA SEREVENT DISKUS ADRENERGICS*** INHALATION AEROSOL 2 QL albuterol sulfate hfa POWDER BREATH inhalation aerosol solution 1 or 1b* QL ACTIVATED 108 (90 base) mcg/act STRIVERDI RESPIMAT albuterol sulfate inhalation INHALATION AEROSOL 3 QL 1 or 1b* QL nebulization solution SOLUTION terbutaline sulfate injection albuterol sulfate oral syrup 1 or 1b* 1 or 1b* solution albuterol sulfate oral tablet 1 or 1b* terbutaline sulfate oral tablet 1 or 1b* arformoterol tartrate inhalation nebulization 1 or 1b* QL VENTOLIN HFA solution INHALATION AEROSOL 2 ST; QL SOLUTION BROVANA INHALATION NEBULIZATION 3 QL XOPENEX SOLUTION CONCENTRATE INHALATION 3 QL formoterol fumarate NEBULIZATION inhalation nebulization 1 or 1b* QL SOLUTION solution XOPENEX HFA isoproterenol hcl injection 3 QL 1 or 1b* INHALATION AEROSOL solution XOPENEX INHALATION ISOPROTERENOL- NEBULIZATION 3 QL SODIUM CHLORIDE 3 SOLUTION INTRAVENOUS SOLUTION *BRONCHODILATORS - ANTICHOLINERGICS*** ISUPREL INJECTION 3 SOLUTION ATROVENT HFA INHALATION AEROSOL 2 QL levalbuterol hcl inhalation SOLUTION nebulization solution 0.31 1 or 1b* QL mg/3ml, 0.63 mg/3ml, 1.25 INCRUSE ELLIPTA INHALATION AEROSOL mg/0.5ml, 1.25 mg/3ml 3 ST; QL POWDER BREATH levalbuterol tartrate 1 or 1b* QL ACTIVATED inhalation aerosol ipratropium bromide 1 or 1b* QL PERFOROMIST inhalation solution INHALATION 3 QL NEBULIZATION LONHALA MAGNAIR REFILL KIT SOLUTION 3 ST; QL INHALATION PROAIR DIGIHALER SOLUTION INHALATION AEROSOL POWDER BREATH 3 ST; QL LONHALA MAGNAIR STARTER KIT ACTIVATED 108 (90 3 ST; QL BASE) MCG/ACT INHALATION SOLUTION PROAIR HFA SPIRIVA HANDIHALER INHALATION AEROSOL 2 ST; QL 2 QL SOLUTION INHALATION CAPSULE PROAIR RESPICLICK SPIRIVA RESPIMAT INHALATION AEROSOL INHALATION AEROSOL 2 QL 2 QL POWDER BREATH SOLUTION 1.25 ACTIVATED MCG/ACT, 2.5 MCG/ACT PROVENTIL HFA INHALATION AEROSOL 3 ST; QL SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 25 Drug Name Tier Notes Drug Name Tier Notes TUDORZA PRESSAIR SINGULAIR ORAL 3 QL INHALATION AEROSOL TABLET CHEWABLE POWDER BREATH 3 ST; QL zafirlukast oral tablet 1 or 1b* QL ACTIVATED 400 MCG/ACT *SELECTIVE PHOSPHODIESTERASE YUPELRI INHALATION 3 ST; QL 4 (PDE4) INHIBITORS*** SOLUTION DALIRESP ORAL 3 PA; QL *INTERLEUKIN-5 TABLET ANTAGONISTS (IGG1 KAPPA)*** *STEROID INHALANTS*** FASENRA PEN SUBCUTANEOUS ALVESCO INHALATION 4 PA; LD; QL 3 ST; QL SOLUTION AUTO- AEROSOL SOLUTION INJECTOR ARMONAIR DIGIHALER INHALATION AEROSOL FASENRA 3 ST; QL SUBCUTANEOUS POWDER BREATH 4 PA; LD; SP; QL SOLUTION PREFILLED ACTIVATED SYRINGE ARNUITY ELLIPTA INHALATION AEROSOL NUCALA 2 QL SUBCUTANEOUS POWDER BREATH 4 PA; LD; SP; QL SOLUTION AUTO- ACTIVATED INJECTOR ASMANEX (120 NUCALA METERED DOSES) SUBCUTANEOUS INHALATION AEROSOL 3 ST; QL 4 PA; LD; SP; QL SOLUTION PREFILLED POWDER BREATH SYRINGE ACTIVATED NUCALA ASMANEX (14 SUBCUTANEOUS METERED DOSES) 4 PA; LD; SP; QL SOLUTION INHALATION AEROSOL 3 ST; QL RECONSTITUTED POWDER BREATH ACTIVATED *INTERLEUKIN-5 ANTAGONISTS (IGG4 ASMANEX (30 KAPPA)*** METERED DOSES) INHALATION AEROSOL 3 ST; QL CINQAIR POWDER BREATH INTRAVENOUS 4 PA; LD; SP ACTIVATED SOLUTION ASMANEX (60 *LEUKOTRIENE METERED DOSES) RECEPTOR INHALATION AEROSOL 3 ST; QL ANTAGONISTS*** POWDER BREATH ACCOLATE ORAL ACTIVATED 3 QL TABLET ASMANEX (7 METERED montelukast sodium oral DOSES) INHALATION 1 or 1b* QL 3 ST; QL packet AEROSOL POWDER montelukast sodium oral BREATH ACTIVATED 1 or 1b* QL tablet ASMANEX HFA 3 ST; QL montelukast sodium oral INHALATION AEROSOL 1 or 1b* QL tablet chewable budesonide inhalation 1 or 1b* QL SINGULAIR ORAL suspension 3 QL PACKET FLOVENT DISKUS SINGULAIR ORAL INHALATION AEROSOL 3 QL 2 QL TABLET POWDER BREATH ACTIVATED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 26 Drug Name Tier Notes Drug Name Tier Notes FLOVENT HFA SAVAYSA ORAL 2 QL 3 QL INHALATION AEROSOL TABLET PULMICORT XARELTO ORAL 2 QL FLEXHALER TABLET INHALATION AEROSOL 3 ST; QL XARELTO STARTER POWDER BREATH PACK ORAL TABLET 2 QL ACTIVATED THERAPY PACK PULMICORT *HEPARINS AND INHALATION 3 QL HEPARINOID-LIKE SUSPENSION AGENTS*** QVAR REDIHALER heparin (porcine) in nacl INHALATION AEROSOL 2 QL intravenous solution 1000- 1 or 1b* BREATH ACTIVATED 0.9 ut/500ml-%, 2000-0.9 *XANTHINES*** unit/l-% aminophylline intravenous HEPARIN (PORCINE) IN 1 or 1b* solution NACL INTRAVENOUS ELIXOPHYLLIN ORAL SOLUTION 12500-0.45 2 QL 3 ELIXIR UT/250ML-%, 25000-0.45 UT/250ML-%, 25000-0.45 THEO-24 ORAL UT/500ML-% CAPSULE EXTENDED 2 QL RELEASE 24 HOUR HEPARIN (PORCINE) IN NACL INTRAVENOUS theophylline er oral tablet SOLUTION 2500-0.9 extended release 12 hour 300 1 or 1b* QL UT/500ML-%, 30000-0.9 mg, 450 mg UNIT/L-%, 4000-0.9 3 theophylline er oral tablet UNIT/L-%, 500-0.9 1 or 1b* QL extended release 24 hour UT/500ML-%, 5000-0.9 UNIT/L-%, 5000-0.9 theophylline oral solution 1 or 1b* QL UT/500ML-% *ANTICOAGULANTS* HEPARIN (PORCINE) IN *ANTICOAGULANTS - NACL INTRAVENOUS MISC.*** SOLUTION PREFILLED 3 SODIUM CITRATE SYRINGE 20-0.9 LOCK FLUSH UNT/20ML-%, 50-0.9 3 INTRAVENOUS UNT/50ML-% SOLUTION heparin lock flush SODIUM CITRATE intravenous solution 1 1 or 1b* LOCK FLUSH unit/ml, 10 unit/ml INTRAVENOUS 3 HEPARIN SOD SOLUTION PREFILLED (PORCINE) IN D5W SYRINGE INTRAVENOUS 3 *COUMARIN SOLUTION 100 ANTICOAGULANTS*** UNIT/ML, 25000-5 UT/500ML-% jantoven oral tablet 1 or 1a* heparin sod (porcine) in d5w warfarin sodium oral tablet 1 or 1a* intravenous solution 40-5 1 or 1b* *DIRECT FACTOR XA unit/ml-% INHIBITORS*** heparin sodium (porcine) injection solution 1000 ELIQUIS DVT/PE 1 or 1b* STARTER PACK ORAL unit/ml, 10000 unit/ml, 2 QL TABLET THERAPY 20000 unit/ml, 5000 unit/ml PACK ELIQUIS ORAL TABLET 2 QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 27 Drug Name Tier Notes Drug Name Tier Notes HEPARIN SODIUM BIVALIRUDIN RTU (PORCINE) INJECTION INTRAVENOUS 3 3 SOLUTION PREFILLED SOLUTION SYRINGE BIVALIRUDIN-SODIUM heparin sodium (porcine) pf CHLORIDE injection solution 5000 1 or 1b* INTRAVENOUS 3 unit/0.5ml SOLUTION 500-0.9 HEPARIN SODIUM MG/100ML-% (PORCINE) PF *THROMBIN 3 INJECTION SOLUTION INHIBITORS - 5000 UNIT/ML SELECTIVE DIRECT & heparin sodium lock flush REVERSIBLE*** intravenous solution 100 1 or 1b* ARGATROBAN IN unit/ml SODIUM CHLORIDE *LOW MOLECULAR INTRAVENOUS 3 WEIGHT HEPARINS*** SOLUTION 50-0.9 MG/50ML-% enoxaparin sodium injection 4 QL solution ARGATROBAN INTRAVENOUS enoxaparin sodium 3 4 QL SOLUTION 250 subcutaneous solution MG/2.5ML, 50 MG/50ML FRAGMIN PRADAXA ORAL 3 QL SUBCUTANEOUS CAPSULE SOLUTION 10000 UNIT/ML, 12500 *ANTICONVULSANTS* UNIT/0.5ML, 15000 *AMPA GLUTAMATE UNIT/0.6ML, 18000 4 QL RECEPTOR UNT/0.72ML, 2500 ANTAGONISTS*** UNIT/0.2ML, 5000 FYCOMPA ORAL 3 QL UNIT/0.2ML, 7500 SUSPENSION UNIT/0.3ML, 95000 FYCOMPA ORAL UNIT/3.8ML 3 QL TABLET LOVENOX INJECTION 4 QL SOLUTION *ANTICONVULSANTS - BENZODIAZEPINES*** LOVENOX SUBCUTANEOUS 4 QL clobazam oral suspension 1 or 1b* QL SOLUTION clobazam oral tablet 1 or 1b* QL *SYNTHETIC clonazepam oral tablet 1 or 1b* QL HEPARINOID-LIKE clonazepam oral tablet AGENTS*** 1 or 1b* QL dispersible ARIXTRA DIASTAT ACUDIAL SUBCUTANEOUS 4 QL 3 QL SOLUTION RECTAL GEL fondaparinux sodium DIASTAT PEDIATRIC 4 QL 3 QL subcutaneous solution RECTAL GEL *THROMBIN diazepam rectal gel 1 or 1b* QL INHIBITORS - HIRUDIN KLONOPIN ORAL 3 QL TYPE*** TABLET ANGIOMAX NAYZILAM NASAL 3 PA; QL INTRAVENOUS SOLUTION 3 SOLUTION ONFI ORAL 3 QL RECONSTITUTED SUSPENSION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 28 Drug Name Tier Notes Drug Name Tier Notes ONFI ORAL TABLET 10 ELEPSIA XR ORAL 3 QL MG, 20 MG TABLET EXTENDED 3 QL SYMPAZAN ORAL FILM 3 QL RELEASE 24 HOUR VALTOCO 10 MG DOSE EPIDIOLEX ORAL 3 PA; QL 4 PA; LD; SP NASAL LIQUID SOLUTION VALTOCO 15 MG DOSE epitol oral tablet 1 or 1b* QL NASAL LIQUID 3 PA; QL FINTEPLA ORAL 4 PA; LD; QL THERAPY PACK SOLUTION VALTOCO 20 MG DOSE gabapentin oral capsule 1 or 1b* QL NASAL LIQUID 3 PA; QL gabapentin oral solution 1 or 1b* QL THERAPY PACK gabapentin oral tablet 1 or 1b* QL VALTOCO 5 MG DOSE 3 PA; QL KEPPRA INTRAVENOUS NASAL LIQUID 3 SOLUTION *ANTICONVULSANTS - KEPPRA ORAL MISC.*** 3 SOLUTION APTIOM ORAL TABLET 3 DO 200 MG, 400 MG KEPPRA ORAL TABLET 3 QL APTIOM ORAL TABLET KEPPRA XR ORAL 3 QL 600 MG, 800 MG TABLET EXTENDED 3 QL RELEASE 24 HOUR BANZEL ORAL 3 QL LAMICTAL ODT ORAL SUSPENSION 3 QL KIT BANZEL ORAL TABLET 3 QL LAMICTAL ODT ORAL 3 QL BRIVIACT TABLET DISPERSIBLE INTRAVENOUS 3 LAMICTAL ORAL SOLUTION 3 QL TABLET BRIVIACT ORAL 3 QL SOLUTION LAMICTAL ORAL TABLET CHEWABLE 25 3 QL BRIVIACT ORAL 3 MG, 5 MG TABLET 10 MG LAMICTAL STARTER 3 QL BRIVIACT ORAL ORAL KIT TABLET 100 MG, 25 MG, 3 QL LAMICTAL XR ORAL 50 MG, 75 MG 3 QL KIT er oral capsule extended release 12 1 or 1b* QL LAMICTAL XR ORAL hour TABLET EXTENDED 3 QL RELEASE 24 HOUR carbamazepine er oral tablet 1 or 1b* QL lamotrigine er oral tablet extended release 12 hour 1 or 1b* QL extended release 24 hour carbamazepine oral 1 or 1b* QL lamotrigine oral kit 25 & 50 suspension 1 or 1b* QL & 100 mg carbamazepine oral tablet 1 or 1b* QL lamotrigine oral tablet 1 or 1b* QL carbamazepine oral tablet 1 or 1b* QL lamotrigine oral tablet chewable 1 or 1b* QL chewable CARBATROL ORAL lamotrigine oral tablet CAPSULE EXTENDED 3 QL 1 or 1b* QL RELEASE 12 HOUR dispersible DIACOMIT ORAL lamotrigine starter kit-blue 4 PA; LD; QL 1 or 1b* QL CAPSULE oral kit DIACOMIT ORAL lamotrigine starter kit-green 4 PA; LD; QL 1 or 1b* QL PACKET oral kit

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 29 Drug Name Tier Notes Drug Name Tier Notes lamotrigine starter kit-orange subvenite starter kit-orange 1 or 1b* QL 1 or 1b* QL oral kit oral kit levetiracetam er oral tablet TEGRETOL ORAL 1 or 1b* QL 3 QL extended release 24 hour SUSPENSION LEVETIRACETAM IN TEGRETOL ORAL 3 QL NACL INTRAVENOUS 3 TABLET SOLUTION TEGRETOL-XR ORAL levetiracetam intravenous TABLET EXTENDED 3 QL 1 or 1b* solution RELEASE 12 HOUR levetiracetam oral solution 1 or 1b* TOPAMAX ORAL 3 QL levetiracetam oral tablet 1 or 1b* QL TABLET LYRICA ORAL TOPAMAX SPRINKLE 3 QL CAPSULE ORAL CAPSULE 3 QL SPRINKLE LYRICA ORAL 3 QL topiramate er oral capsule er SOLUTION 1 or 1b* QL 24 hour sprinkle MYSOLINE ORAL 3 topiramate oral capsule TABLET 1 or 1b* QL sprinkle NEURONTIN ORAL 3 QL CAPSULE topiramate oral tablet 1 or 1b* QL NEURONTIN ORAL TRILEPTAL ORAL 3 QL 3 QL SOLUTION SUSPENSION NEURONTIN ORAL TRILEPTAL ORAL 3 QL 3 QL TABLET TABLET oral TROKENDI XR ORAL 1 or 1b* QL suspension CAPSULE EXTENDED 2 QL RELEASE 24 HOUR oxcarbazepine oral tablet 1 or 1b* QL VIMPAT INTRAVENOUS 3 OXTELLAR XR ORAL SOLUTION TABLET EXTENDED 3 QL VIMPAT ORAL RELEASE 24 HOUR 3 QL SOLUTION pregabalin oral capsule 1 or 1b* QL VIMPAT ORAL TABLET 3 QL pregabalin oral solution 1 or 1b* QL ZONEGRAN ORAL 3 QL primidone oral tablet 1 or 1b* CAPSULE QUDEXY XR ORAL zonisamide oral capsule 1 or 1b* QL CAPSULE ER 24 HOUR 3 ST; QL SPRINKLE *CARBAMATES*** roweepra oral tablet 500 mg 1 or 1b* QL felbamate oral suspension 1 or 1b* rufinamide oral suspension 1 or 1b* QL felbamate oral tablet 1 or 1b* FELBATOL ORAL rufinamide oral tablet 1 or 1b* QL 3 SUSPENSION SPRITAM ORAL TABLET FELBATOL ORAL 3 QL 3 DISINTEGRATING TABLET SOLUBLE XCOPRI (250 MG DAILY DOSE) ORAL TABLET subvenite oral tablet 1 or 1b* QL 3 QL THERAPY PACK 100 & subvenite starter kit-blue oral 1 or 1b* QL 150 MG kit XCOPRI (350 MG DAILY subvenite starter kit-green 1 or 1b* QL DOSE) ORAL TABLET 3 QL oral kit THERAPY PACK XCOPRI ORAL TABLET 3 QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 30 Drug Name Tier Notes Drug Name Tier Notes XCOPRI ORAL TABLET *VALPROIC ACID*** 3 QL THERAPY PACK DEPAKOTE ER ORAL *GABA TABLET EXTENDED 3 QL MODULATORS*** RELEASE 24 HOUR GABITRIL ORAL DEPAKOTE ORAL 3 TABLET TABLET DELAYED 3 QL SABRIL ORAL PACKET 3 LD; SP; QL RELEASE SABRIL ORAL TABLET 3 LD; SP; QL DEPAKOTE SPRINKLES ORAL CAPSULE 3 QL tiagabine hcl oral tablet 1 or 1b* DELAYED RELEASE vigabatrin oral packet 1 or 1b* LD; SP; QL SPRINKLE vigabatrin oral tablet 1 or 1b* LD; SP; QL divalproex sodium er oral tablet extended release 24 1 or 1b* QL vigadrone oral packet 1 or 1b* LD; QL hour *HYDANTOINS*** divalproex sodium oral CEREBYX INJECTION capsule delayed release 1 or 1b* QL 3 SOLUTION sprinkle DILANTIN INFATABS divalproex sodium oral tablet 1 or 1b* QL ORAL TABLET 3 delayed release CHEWABLE valproate sodium intravenous 1 or 1b* DILANTIN ORAL solution 3 CAPSULE 100 MG valproic acid oral capsule 1 or 1b* QL DILANTIN ORAL 2 valproic acid oral solution 1 or 1b* CAPSULE 30 MG *ANTIDEPRESSANTS* DILANTIN ORAL 3 SUSPENSION *ALPHA-2 RECEPTOR ANTAGONISTS fosphenytoin sodium 1 or 1b* ()*** injection solution oral tablet 1 or 1b* PHENYTEK ORAL 3 mirtazapine oral tablet CAPSULE 1 or 1b* dispersible phenytoin infatabs oral tablet 1 or 1b* REMERON ORAL chewable 3 TABLET 15 MG, 30 MG phenytoin oral suspension 1 or 1b* REMERON SOLTAB phenytoin oral tablet 1 or 1b* ORAL TABLET 3 chewable DISPERSIBLE phenytoin sodium extended 1 or 1b* *ANTIDEPRESSANTS - oral capsule MISC.*** phenytoin sodium injection 1 or 1b* APLENZIN ORAL solution TABLET EXTENDED 3 ST; DO *SUCCINIMIDES*** RELEASE 24 HOUR 174 CELONTIN ORAL MG 3 CAPSULE APLENZIN ORAL TABLET EXTENDED ethosuximide oral capsule 1 or 1b* 3 ST; QL RELEASE 24 HOUR 348 ethosuximide oral solution 1 or 1b* MG, 522 MG ZARONTIN ORAL 3 bupropion hcl er (sr) oral CAPSULE tablet extended release 12 1 or 1b* DO ZARONTIN ORAL hour 100 mg 3 SOLUTION bupropion hcl er (sr) oral tablet extended release 12 1 or 1b* QL hour 150 mg, 200 mg * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 31 Drug Name Tier Notes Drug Name Tier Notes bupropion hcl er (xl) oral *N-METHYL-D- tablet extended release 24 1 or 1b* DO ASPARTIC ACID hour 150 mg (NMDA) RECEPTOR bupropion hcl er (xl) oral ANTAGONISTS*** tablet extended release 24 1 or 1b* QL SPRAVATO (56 MG hour 300 mg, 450 mg DOSE) NASAL 4 PA; LD; QL bupropion hcl oral tablet 100 SOLUTION THERAPY 1 or 1b* QL mg PACK bupropion hcl oral tablet 75 SPRAVATO (84 MG 1 or 1b* DO DOSE) NASAL mg 4 PA; LD; QL SOLUTION THERAPY FORFIVO XL ORAL PACK TABLET EXTENDED 3 ST; QL RELEASE 24 HOUR *SELECTIVE SEROTONIN REUPTAKE WELLBUTRIN SR ORAL INHIBITORS (SSRIS)*** TABLET EXTENDED 3 ST; DO CELEXA ORAL TABLET RELEASE 12 HOUR 100 3 ST; DO MG 10 MG, 20 MG CELEXA ORAL TABLET WELLBUTRIN SR ORAL 3 ST; QL TABLET EXTENDED 40 MG 3 ST; QL RELEASE 12 HOUR 150 citalopram hydrobromide 1 or 1b* QL MG, 200 MG oral solution WELLBUTRIN XL ORAL citalopram hydrobromide 1 or 1b* DO TABLET EXTENDED oral tablet 10 mg, 20 mg 3 ST; DO RELEASE 24 HOUR 150 citalopram hydrobromide 1 or 1b* QL MG oral tablet 40 mg WELLBUTRIN XL ORAL escitalopram oxalate oral TABLET EXTENDED 1 or 1b* QL 3 ST; QL solution RELEASE 24 HOUR 300 escitalopram oxalate oral MG 1 or 1b* DO tablet 10 mg, 5 mg *GABA RECEPTOR escitalopram oxalate oral MODULATOR - 1 or 1b* QL NEUROACTIVE tablet 20 mg STEROID*** fluoxetine hcl oral capsule 10 1 or 1b* DO ZULRESSO mg INTRAVENOUS 4 PA; SP fluoxetine hcl oral capsule 20 1 or 1b* QL SOLUTION mg, 40 mg *MONOAMINE fluoxetine hcl oral capsule 1 or 1b* QL OXIDASE INHIBITORS delayed release (MAOIS)*** fluoxetine hcl oral solution 1 or 1b* QL EMSAM fluoxetine hcl oral tablet 10 TRANSDERMAL PATCH 3 1 or 1b* DO 24 HOUR mg MARPLAN ORAL fluoxetine hcl oral tablet 20 3 QL 1 or 1b* QL TABLET mg FLUOXETINE HCL NARDIL ORAL TABLET 3 3 QL ORAL TABLET 60 MG PARNATE ORAL 3 TABLET fluvoxamine maleate er oral capsule extended release 24 1 or 1b* QL phenelzine sulfate oral tablet 1 or 1b* hour tranylcypromine sulfate oral fluvoxamine maleate oral 1 or 1b* 1 or 1b* QL tablet tablet 100 mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 32 Drug Name Tier Notes Drug Name Tier Notes fluvoxamine maleate oral *SEROTONIN 1 or 1b* DO tablet 25 mg, 50 mg MODULATORS*** LEXAPRO ORAL nefazodone hcl oral tablet 1 or 1b* 3 ST; DO TABLET 10 MG, 5 MG trazodone hcl oral tablet 1 or 1a* LEXAPRO ORAL TRINTELLIX ORAL 3 ST; QL 3 DO TABLET 20 MG TABLET 10 MG, 5 MG paroxetine hcl er oral tablet TRINTELLIX ORAL 3 QL extended release 24 hour 1 or 1b* DO TABLET 20 MG 12.5 mg VIIBRYD ORAL TABLET 3 ST; DO paroxetine hcl er oral tablet 10 MG, 20 MG extended release 24 hour 25 1 or 1b* QL VIIBRYD ORAL TABLET mg, 37.5 mg 3 ST; QL 40 MG paroxetine hcl oral tablet 10 1 or 1b* DO VIIBRYD STARTER mg, 20 mg 3 ST; QL PACK ORAL KIT paroxetine hcl oral tablet 30 1 or 1b* QL mg, 40 mg *SEROTONIN- NOREPINEPHRINE PAXIL CR ORAL REUPTAKE INHIBITORS TABLET EXTENDED 3 ST; DO (SNRIS)*** RELEASE 24 HOUR 12.5 MG CYMBALTA ORAL CAPSULE DELAYED 3 PA; QL PAXIL CR ORAL RELEASE PARTICLES 20 TABLET EXTENDED 3 ST; QL MG, 60 MG RELEASE 24 HOUR 25 MG, 37.5 MG CYMBALTA ORAL CAPSULE DELAYED PAXIL ORAL 3 PA; DO 3 ST; QL RELEASE PARTICLES 30 SUSPENSION MG PAXIL ORAL TABLET 10 3 ST; DO DESVENLAFAXINE ER MG, 20 MG ORAL TABLET 3 ST; QL PAXIL ORAL TABLET 30 EXTENDED RELEASE 24 3 ST; QL MG, 40 MG HOUR 100 MG PEXEVA ORAL TABLET DESVENLAFAXINE ER 3 ST; DO 10 MG, 20 MG ORAL TABLET 3 ST PEXEVA ORAL TABLET EXTENDED RELEASE 24 3 ST; QL 30 MG, 40 MG HOUR 50 MG PROZAC ORAL desvenlafaxine succinate er 3 ST; DO CAPSULE 10 MG oral tablet extended release 1 or 1b* QL 24 hour 100 mg PROZAC ORAL 3 ST; QL CAPSULE 20 MG, 40 MG desvenlafaxine succinate er oral tablet extended release 1 or 1b* DO sertraline hcl oral concentrate 1 or 1b* QL 24 hour 25 mg, 50 mg sertraline hcl oral tablet 100 1 or 1b* QL DRIZALMA SPRINKLE mg ORAL CAPSULE 3 PA; QL sertraline hcl oral tablet 25 DELAYED RELEASE 1 or 1b* DO mg, 50 mg SPRINKLE 20 MG, 60 MG ZOLOFT ORAL DRIZALMA SPRINKLE 3 ST; QL ORAL CAPSULE CONCENTRATE 3 PA; DO DELAYED RELEASE ZOLOFT ORAL TABLET 3 ST; QL SPRINKLE 30 MG, 40 MG 100 MG duloxetine hcl oral capsule ZOLOFT ORAL TABLET 3 ST; DO delayed release particles 20 1 or 1b* QL 25 MG, 50 MG mg, 40 mg, 60 mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 33 Drug Name Tier Notes Drug Name Tier Notes duloxetine hcl oral capsule hcl oral tablet 1 or 1b* delayed release particles 30 1 or 1b* DO imipramine pamoate oral 1 or 1b* mg capsule EFFEXOR XR ORAL NORPRAMIN ORAL CAPSULE EXTENDED 3 3 ST; QL TABLET 10 MG, 25 MG RELEASE 24 HOUR 150 MG hcl oral capsule 1 or 1b* EFFEXOR XR ORAL nortriptyline hcl oral solution 1 or 1b* CAPSULE EXTENDED PAMELOR ORAL 3 ST; DO 3 RELEASE 24 HOUR 37.5 CAPSULE MG, 75 MG hcl oral tablet 1 or 1b* FETZIMA ORAL maleate oral CAPSULE EXTENDED 3 ST; QL 1 or 1b* RELEASE 24 HOUR capsule *ANTIDIABETICS* FETZIMA TITRATION ORAL CAPSULE ER 24 3 ST; QL *ALPHA-GLUCOSIDASE HOUR THERAPY PACK INHIBITORS*** PRISTIQ ORAL TABLET acarbose oral tablet 1 or 1b* QL EXTENDED RELEASE 24 3 ST; QL miglitol oral tablet 1 or 1b* QL HOUR 100 MG PRECOSE ORAL 3 QL PRISTIQ ORAL TABLET TABLET EXTENDED RELEASE 24 3 ST; DO HOUR 25 MG, 50 MG *ANTIDIABETIC - AMYLIN ANALOGS*** venlafaxine hcl er oral capsule extended release 24 1 or 1b* QL SYMLINPEN 120 SUBCUTANEOUS hour 150 mg 2 QL SOLUTION PEN- venlafaxine hcl er oral INJECTOR capsule extended release 24 1 or 1b* DO hour 37.5 mg, 75 mg SYMLINPEN 60 SUBCUTANEOUS 2 QL venlafaxine hcl er oral tablet SOLUTION PEN- extended release 24 hour 150 1 or 1b* QL INJECTOR mg, 225 mg *BIGUANIDES*** venlafaxine hcl er oral tablet extended release 24 hour 1 or 1b* DO GLUMETZA ORAL 37.5 mg, 75 mg TABLET EXTENDED 3 ST RELEASE 24 HOUR venlafaxine hcl oral tablet 1 or 1b* QL metformin hcl er (mod) oral * tablet extended release 24 3 ST AGENTS*** hour hcl oral tablet 1 or 1a* metformin hcl er (osm) oral oral tablet 100 tablet extended release 24 3 ST 1 or 1b* QL mg, 150 mg hour 1000 mg, 500 mg amoxapine oral tablet 25 mg, metformin hcl er oral tablet 1 or 1b* DO 1 or 1b* 50 mg extended release 24 hour ANAFRANIL ORAL metformin hcl oral solution 3 PA; QL 3 CAPSULE metformin hcl oral tablet 1 or 1b* hcl oral RIOMET ORAL 1 or 1b* 3 PA; QL capsule SOLUTION hcl oral tablet 1 or 1b* *DIABETIC OTHER*** hcl oral capsule 1 or 1b* BAQSIMI ONE PACK 3 QL doxepin hcl oral concentrate 1 or 1b* NASAL POWDER

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 34 Drug Name Tier Notes Drug Name Tier Notes BAQSIMI TWO PACK *DIPEPTIDYL 3 QL NASAL POWDER PEPTIDASE-4 diazoxide oral suspension 1 or 1b* INHIBITOR-BIGUANIDE COMBINATIONS*** GLUCAGEN HYPOKIT alogliptin-metformin hcl oral INJECTION SOLUTION 2 QL 1 or 1b* ST; QL RECONSTITUTED tablet JANUMET ORAL GLUCAGON 2 ST; QL EMERGENCY 1 or 1b* QL TABLET INJECTION KIT JANUMET XR ORAL GLUCAGON TABLET EXTENDED 2 ST; QL EMERGENCY RELEASE 24 HOUR 3 INJECTION SOLUTION JENTADUETO ORAL 3 ST; QL RECONSTITUTED TABLET GVOKE HYPOPEN 1- JENTADUETO XR ORAL PACK SUBCUTANEOUS TABLET EXTENDED 3 ST; QL 3 QL SOLUTION AUTO- RELEASE 24 HOUR INJECTOR KAZANO ORAL TABLET 3 ST; QL GVOKE HYPOPEN 2- KOMBIGLYZE XR ORAL PACK SUBCUTANEOUS 3 QL TABLET EXTENDED 3 ST; QL SOLUTION AUTO- RELEASE 24 HOUR INJECTOR *DOPAMINE RECEPTOR GVOKE PFS AGONISTS - ERGOT SUBCUTANEOUS 3 QL DERIVATIVES*** SOLUTION PREFILLED CYCLOSET ORAL SYRINGE 3 TABLET PROGLYCEM ORAL 3 SUSPENSION *DPP-4 INHIBITOR- THIAZOLIDINEDIONE ZEGALOGUE COMBINATIONS*** SUBCUTANEOUS 3 QL alogliptin-pioglitazone oral SOLUTION AUTO- 1 or 1b* ST; QL INJECTOR tablet ZEGALOGUE OSENI ORAL TABLET 3 ST; QL SUBCUTANEOUS 3 QL *HUMAN INSULIN*** SOLUTION PREFILLED SYRINGE ADMELOG SOLOSTAR SUBCUTANEOUS 3 ST; QL *DIPEPTIDYL SOLUTION PEN- PEPTIDASE-4 (DPP-4) INJECTOR INHIBITORS*** ADMELOG alogliptin benzoate oral 1 or 1b* ST; QL SUBCUTANEOUS 3 ST; QL tablet SOLUTION JANUVIA ORAL 2 ST; QL AFREZZA INHALATION TABLET POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 NESINA ORAL TABLET 3 ST; QL 3 PA; QL UNIT, 90 X 4 UNIT & ONGLYZA ORAL 3 ST; QL 90X8 UNIT, 90 X 8 UNIT TABLET & 90X12 UNIT TRADJENTA ORAL APIDRA INJECTION 3 ST; DO 3 ST; QL TABLET SOLUTION APIDRA SOLOSTAR SUBCUTANEOUS 3 ST; QL SOLUTION PEN- INJECTOR

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 35 Drug Name Tier Notes Drug Name Tier Notes BASAGLAR KWIKPEN HUMULIN N KWIKPEN SUBCUTANEOUS SUBCUTANEOUS 3 ST; QL 2 OTC; QL SOLUTION PEN- SUSPENSION PEN- INJECTOR INJECTOR FIASP FLEXTOUCH HUMULIN N SUBCUTANEOUS SUBCUTANEOUS 2 OTC; QL 3 ST; QL SOLUTION PEN- SUSPENSION INJECTOR HUMULIN R INJECTION 2 OTC; QL FIASP PENFILL SOLUTION SUBCUTANEOUS 3 ST; QL HUMULIN R U-500 SOLUTION CARTRIDGE (CONCENTRATED) 2 PA; QL FIASP SUBCUTANEOUS SUBCUTANEOUS 3 ST; QL SOLUTION SOLUTION HUMALOG JUNIOR HUMULIN R U-500 KWIKPEN KWIKPEN SUBCUTANEOUS 2 QL SUBCUTANEOUS 2 PA; QL SOLUTION PEN- SOLUTION PEN- INJECTOR INJECTOR HUMALOG KWIKPEN INSULIN ASP PROT & SUBCUTANEOUS ASP FLEXPEN SOLUTION PEN- 2 QL SUBCUTANEOUS 3 ST; QL INJECTOR 100 UNIT/ML, SUSPENSION PEN- 200 UNIT/ML INJECTOR HUMALOG MIX 50/50 INSULIN ASPART KWIKPEN FLEXPEN SUBCUTANEOUS 2 QL SUBCUTANEOUS 3 ST; QL SUSPENSION PEN- SOLUTION PEN- INJECTOR INJECTOR HUMALOG MIX 50/50 INSULIN ASPART SUBCUTANEOUS 2 QL PENFILL 3 ST; QL SUSPENSION SUBCUTANEOUS HUMALOG MIX 75/25 SOLUTION CARTRIDGE KWIKPEN INSULIN ASPART PROT SUBCUTANEOUS 2 QL & ASPART 3 ST; QL SUSPENSION PEN- SUBCUTANEOUS INJECTOR SUSPENSION HUMALOG MIX 75/25 INSULIN ASPART SUBCUTANEOUS 2 QL SUBCUTANEOUS 3 ST; QL SUSPENSION SOLUTION HUMALOG INSULIN LISPRO (1 SUBCUTANEOUS 2 QL UNIT DIAL) SOLUTION SUBCUTANEOUS 2 QL HUMALOG SOLUTION PEN- SUBCUTANEOUS 2 QL INJECTOR SOLUTION CARTRIDGE INSULIN LISPRO HUMULIN 70/30 JUNIOR KWIKPEN KWIKPEN SUBCUTANEOUS 2 QL SUBCUTANEOUS 2 OTC; QL SOLUTION PEN- SUSPENSION PEN- INJECTOR INJECTOR INSULIN LISPRO PROT HUMULIN 70/30 & LISPRO SUBCUTANEOUS 2 OTC; QL SUBCUTANEOUS 2 QL SUSPENSION SUSPENSION PEN- INJECTOR * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 36 Drug Name Tier Notes Drug Name Tier Notes INSULIN LISPRO NOVOLIN N RELION SUBCUTANEOUS 2 QL SUBCUTANEOUS 3 ST; OTC; QL SOLUTION SUSPENSION LANTUS SOLOSTAR NOVOLIN N SUBCUTANEOUS SUBCUTANEOUS 3 ST; OTC; QL 2 QL SOLUTION PEN- SUSPENSION INJECTOR NOVOLIN R FLEXPEN LANTUS INJECTION SOLUTION 3 ST; OTC; QL SUBCUTANEOUS 2 QL PEN-INJECTOR SOLUTION NOVOLIN R FLEXPEN LEVEMIR FLEXTOUCH RELION INJECTION 3 ST; OTC; QL SUBCUTANEOUS SOLUTION PEN- 2 QL SOLUTION PEN- INJECTOR INJECTOR NOVOLIN R INJECTION 3 ST; OTC; QL LEVEMIR SOLUTION SUBCUTANEOUS 2 QL NOVOLIN R RELION 3 ST; OTC; QL SOLUTION INJECTION SOLUTION LYUMJEV INJECTION 3 ST; QL NOVOLOG 70/30 SOLUTION FLEXPEN RELION LYUMJEV KWIKPEN SUBCUTANEOUS 3 ST; QL SUBCUTANEOUS SUSPENSION PEN- 3 ST; QL SOLUTION PEN- INJECTOR INJECTOR NOVOLOG FLEXPEN MYXREDLIN RELION INTRAVENOUS 3 SUBCUTANEOUS 3 ST; QL SOLUTION SOLUTION PEN- NOVOLIN 70/30 INJECTOR FLEXPEN RELION NOVOLOG FLEXPEN SUBCUTANEOUS 3 ST; OTC; QL SUBCUTANEOUS 3 ST; QL SUSPENSION PEN- SOLUTION PEN- INJECTOR INJECTOR NOVOLIN 70/30 NOVOLOG MIX 70/30 FLEXPEN FLEXPEN SUBCUTANEOUS 3 ST; OTC; QL SUBCUTANEOUS 3 ST; QL SUSPENSION PEN- SUSPENSION PEN- INJECTOR INJECTOR NOVOLIN 70/30 RELION NOVOLOG MIX 70/30 SUBCUTANEOUS 3 ST; OTC; QL RELION 3 ST; QL SUSPENSION SUBCUTANEOUS NOVOLIN 70/30 SUSPENSION SUBCUTANEOUS 3 ST; OTC; QL NOVOLOG MIX 70/30 SUSPENSION SUBCUTANEOUS 3 ST; QL NOVOLIN N FLEXPEN SUSPENSION RELION NOVOLOG PENFILL SUBCUTANEOUS 3 ST; OTC; QL SUBCUTANEOUS 3 ST; QL SUSPENSION PEN- SOLUTION CARTRIDGE INJECTOR NOVOLOG RELION NOVOLIN N FLEXPEN SUBCUTANEOUS 3 ST; QL SUBCUTANEOUS SOLUTION 3 ST; OTC; QL SUSPENSION PEN- NOVOLOG INJECTOR SUBCUTANEOUS 3 ST; QL SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 37 Drug Name Tier Notes Drug Name Tier Notes SEMGLEE OZEMPIC (1 MG/DOSE) SUBCUTANEOUS 3 QL SUBCUTANEOUS 2 ST; QL SOLUTION SOLUTION PEN- SEMGLEE INJECTOR SUBCUTANEOUS RYBELSUS ORAL 3 QL 2 ST; QL SOLUTION PEN- TABLET INJECTOR TRULICITY TOUJEO MAX SUBCUTANEOUS 2 ST; QL SOLOSTAR SOLUTION PEN- SUBCUTANEOUS 2 QL INJECTOR SOLUTION PEN- VICTOZA INJECTOR SUBCUTANEOUS 2 ST; QL TOUJEO SOLOSTAR SOLUTION PEN- SUBCUTANEOUS INJECTOR 2 QL SOLUTION PEN- *INSULIN-INCRETIN INJECTOR MIMETIC TRESIBA FLEXTOUCH COMBINATIONS*** SUBCUTANEOUS 2 QL SOLIQUA SOLUTION PEN- SUBCUTANEOUS 3 ST; QL INJECTOR SOLUTION PEN- TRESIBA INJECTOR SUBCUTANEOUS 2 QL XULTOPHY SOLUTION SUBCUTANEOUS 3 ST; QL *INCRETIN MIMETIC SOLUTION PEN- AGENTS (GLP-1 INJECTOR RECEPTOR *MEGLITINIDE AGONISTS)*** ANALOGUES*** ADLYXIN STARTER nateglinide oral tablet 1 or 1b* QL PACK SUBCUTANEOUS 3 ST; QL PEN-INJECTOR KIT repaglinide oral tablet 1 or 1b* QL ADLYXIN *PROGESTERONE SUBCUTANEOUS RECEPTOR 3 ST; QL SOLUTION PEN- ANTAGONISTS*** INJECTOR KORLYM ORAL 4 PA; LD BYDUREON BCISE TABLET SUBCUTANEOUS AUTO- 3 ST; QL *SGLT2 INHIBITOR - INJECTOR DPP-4 INHIBITOR - BYETTA 10 MCG PEN BIGUANIDE COMB*** SUBCUTANEOUS 3 ST; QL TRIJARDY XR ORAL SOLUTION PEN- TABLET EXTENDED 3 ST; QL INJECTOR RELEASE 24 HOUR BYETTA 5 MCG PEN *SGLT2 INHIBITOR - SUBCUTANEOUS 3 ST; QL DPP-4 INHIBITOR SOLUTION PEN- COMBINATIONS*** INJECTOR GLYXAMBI ORAL 3 ST; QL OZEMPIC (0.25 OR 0.5 TABLET MG/DOSE) SUBCUTANEOUS 2 ST; QL QTERN ORAL TABLET 3 ST; QL SOLUTION PEN- STEGLUJAN ORAL 3 ST; QL INJECTOR TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 38 Drug Name Tier Notes Drug Name Tier Notes *SODIUM-GLUCOSE glyburide micronized oral 1 or 1b* ST CO-TRANSPORTER 2 tablet (SGLT2) INHIBITORS*** glyburide oral tablet 1 or 1b* ST FARXIGA ORAL GLYNASE ORAL 2 ST; QL 3 ST TABLET TABLET INVOKANA ORAL 3 ST; QL tolbutamide oral tablet 1 or 1b* ST TABLET *SULFONYLUREA- JARDIANCE ORAL 2 ST; QL THIAZOLIDINEDIONE TABLET COMBINATIONS*** STEGLATRO ORAL DUETACT ORAL 3 ST; QL 3 ST; QL TABLET TABLET *SODIUM-GLUCOSE pioglitazone hcl-glimepiride 1 or 1b* ST; QL CO-TRANSPORTER 2 oral tablet INHIBITOR-BIGUANIDE COMB*** *THIAZOLIDINEDIONE- BIGUANIDE INVOKAMET ORAL 3 ST; QL COMBINATIONS*** TABLET ACTOPLUS MET ORAL 3 ST; QL INVOKAMET XR ORAL TABLET TABLET EXTENDED 3 ST; QL pioglitazone hcl-metformin RELEASE 24 HOUR 1 or 1b* ST; QL hcl oral tablet SEGLUROMET ORAL 3 ST; QL TABLET *THIAZOLIDINEDIONES *** SYNJARDY ORAL 2 ST; QL TABLET ACTOS ORAL TABLET 3 ST; QL SYNJARDY XR ORAL pioglitazone hcl oral tablet 1 or 1b* ST; QL TABLET EXTENDED 2 ST; QL *ANTIDIARRHEAL/PRO RELEASE 24 HOUR BIOTIC AGENTS* XIGDUO XR ORAL *ANTIDIARRHEAL - TABLET EXTENDED 2 ST; QL CHLORIDE CHANNEL RELEASE 24 HOUR ANTAGONISTS*** *SULFONYLUREA- MYTESI ORAL TABLET 3 PA; LD; QL BIGUANIDE DELAYED RELEASE COMBINATIONS*** *ANTIDIARRHEAL/PRO glipizide-metformin hcl oral 1 or 1b* ST BIOTIC tablet COMBINATIONS*** glyburide-metformin oral RESTORA RX ORAL 1 or 1b* ST 3 tablet CAPSULE *SULFONYLUREAS*** *ANTIPERISTALTIC AMARYL ORAL AGENTS*** 3 ST TABLET diphenoxylate-atropine oral 1 or 1b* glimepiride oral tablet 1 or 1b* ST liquid glipizide er oral tablet diphenoxylate-atropine oral 1 or 1a* ST 1 or 1b* extended release 24 hour tablet 2.5-0.025 mg LOMOTIL ORAL glipizide oral tablet 1 or 1a* ST 3 TABLET glipizide xl oral tablet 1 or 1a* ST extended release 24 hour loperamide hcl oral capsule 1 or 1b* MOTOFEN ORAL GLUCOTROL XL ORAL 3 TABLET EXTENDED 3 ST TABLET RELEASE 24 HOUR

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 39 Drug Name Tier Notes Drug Name Tier Notes *ANTIDOTES AND ANDEXXA SPECIFIC INTRAVENOUS ANTAGONISTS* SOLUTION 3 *ANTIDOTE RECONSTITUTED 200 COMBINATIONS*** MG DUODOTE BAL IN OIL INTRAMUSCULAR INTRAMUSCULAR 3 3 SOLUTION AUTO- SOLUTION INJECTOR BRIDION NITHIODOTE INTRAVENOUS 3 INTRAVENOUS KIT SOLUTION 3 300MG/10ML&12.5 CALCIUM DISODIUM GM/50ML VERSENATE 3 *ANTIDOTES - INJECTION SOLUTION 1 CHELATING GM/5ML AGENTS*** CYANOKIT CHEMET ORAL INTRAVENOUS 3 3 CAPSULE SOLUTION RECONSTITUTED 5 GM deferasirox granules oral 4 PA; SP packet deferoxamine mesylate injection solution 4 SP deferasirox oral packet 4 PA; SP reconstituted deferasirox oral tablet 4 PA; SP DESFERAL INJECTION deferasirox oral tablet SOLUTION 4 PA; SP 4 SP soluble RECONSTITUTED 500 MG deferiprone oral tablet 4 PA DIGIFAB EXJADE ORAL TABLET INTRAVENOUS 4 PA; LD; SP 3 SOLUBLE SOLUTION FERRIPROX ORAL RECONSTITUTED 4 PA; LD SOLUTION fomepizole intravenous 1 or 1b* FERRIPROX TWICE-A- solution 1.5 gm/1.5ml 4 PA; LD DAY ORAL TABLET PRAXBIND JADENU ORAL TABLET 4 PA; LD; SP INTRAVENOUS 3 JADENU SPRINKLE SOLUTION 4 PA; LD; SP ORAL PACKET PROTOPAM CHLORIDE INTRAVENOUS PENTETATE CALCIUM 3 TRISODIUM SOLUTION 3 COMBINATION RECONSTITUTED SOLUTION PROVAYBLUE PENTETATE ZINC INTRAVENOUS 3 TRISODIUM SOLUTION 3 COMBINATION RADIOGARDASE ORAL 3 SOLUTION CAPSULE *ANTIDOTES AND SODIUM NITRITE SPECIFIC INTRAVENOUS 3 ANTAGONISTS*** SOLUTION ACETADOTE VISTOGARD ORAL 3 PA; LD; QL INTRAVENOUS 3 PACKET SOLUTION acetylcysteine intravenous 1 or 1b* solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 40 Drug Name Tier Notes Drug Name Tier Notes * ZOFRAN ORAL TABLET 3 QL ANTAGONISTS*** 4 MG flumazenil intravenous ZUPLENZ ORAL FILM 3 QL 1 or 1b* solution *ANTIEMETIC *OPIOID COMBINATIONS*** ANTAGONISTS*** AKYNZEO KLOXXADO NASAL INTRAVENOUS 3 PA; QL 3 ST; QL LIQUID SOLUTION naloxone hcl injection AKYNZEO solution 0.4 mg/ml, 4 1 or 1b* QL INTRAVENOUS 3 PA; QL mg/10ml SOLUTION naloxone hcl injection RECONSTITUTED 1 or 1b* QL solution cartridge AKYNZEO ORAL 3 QL naloxone hcl injection CAPSULE 1 or 1b* QL solution prefilled syringe BONJESTA ORAL naltrexone hcl oral tablet 1 or 1b* TABLET EXTENDED 3 PA; QL RELEASE NARCAN NASAL LIQUID 2 QL DICLEGIS ORAL VIVITROL TABLET DELAYED 3 PA; QL INTRAMUSCULAR 4 LD; SP; QL RELEASE SUSPENSION doxylamine-pyridoxine oral RECONSTITUTED 1 or 1b* PA; QL tablet delayed release *ANTIEMETICS* *ANTIEMETICS - *5-HT3 RECEPTOR ANTICHOLINERGIC*** ANTAGONISTS*** ANTIVERT ORAL ALOXI INTRAVENOUS 3 3 PA TABLET 50 MG SOLUTION 0.25 MG/5ML DIMENHYDRINATE granisetron hcl intravenous 3 1 or 1b* INJECTION SOLUTION solution 1 mg/ml, 4 mg/4ml meclizine hcl oral tablet 12.5 1 or 1a* granisetron hcl oral tablet 1 or 1b* QL mg, 25 mg ondansetron hcl injection scopolamine transdermal 1 or 1b* solution 4 mg/2ml, 40 1 or 1b* patch 72 hour mg/20ml TIGAN ondansetron hcl oral solution 1 or 1b* QL INTRAMUSCULAR 3 ondansetron hcl oral tablet 1 or 1b* QL SOLUTION ondansetron oral tablet TRANSDERM-SCOP (1.5 1 or 1b* QL dispersible MG) TRANSDERMAL 3 PATCH 72 HOUR PALONOSETRON HCL trimethobenzamide hcl oral INTRAVENOUS 3 PA 1 or 1b* SOLUTION 0.25 MG/2ML capsule palonosetron hcl intravenous *ANTIEMETICS - 1 or 1b* PA solution 0.25 mg/5ml ANTIDOPAMINERGIC** * palonosetron hcl intravenous 1 or 1b* PA solution prefilled syringe BARHEMSYS INTRAVENOUS 3 SANCUSO 3 QL SOLUTION TRANSDERMAL PATCH *ANTIEMETICS - SUSTOL MISCELLANEOUS*** SUBCUTANEOUS 3 PREFILLED SYRINGE dronabinol oral capsule 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 41 Drug Name Tier Notes Drug Name Tier Notes MARINOL ORAL MYCAMINE 3 CAPSULE INTRAVENOUS 3 SYNDROS ORAL SOLUTION 3 SOLUTION RECONSTITUTED *SUBSTANCE *ANTIFUNGAL - P/NEUROKININ 1 (NK1) GLUCAN SYNTHESIS RECEPTOR INHIBITORS ANTAGONISTS*** (TRITERPENOIDS)*** BREXAFEMME ORAL aprepitant oral 1 or 1b* QL 3 TABLET aprepitant oral capsule 1 or 1b* QL *ANTIFUNGALS*** CINVANTI INTRAVENOUS 3 PA; QL ABELCET EMULSION INTRAVENOUS 3 SUSPENSION EMEND INTRAVENOUS SOLUTION AMBISOME 3 PA; QL INTRAVENOUS RECONSTITUTED 150 3 MG SUSPENSION RECONSTITUTED EMEND ORAL CAPSULE 3 QL amphotericin b intravenous 80 MG 1 or 1b* solution reconstituted EMEND ORAL ANCOBON ORAL SUSPENSION 3 QL 3 PA RECONSTITUTED CAPSULE EMEND TRI-PACK flucytosine oral capsule 1 or 1b* PA 3 QL ORAL CAPSULE griseofulvin microsize oral 1 or 1b* fosaprepitant dimeglumine suspension intravenous solution 1 or 1b* PA; QL griseofulvin microsize oral 1 or 1b* reconstituted tablet VARUBI (180 MG DOSE) griseofulvin ultramicrosize 1 or 1b* ORAL TABLET 3 QL oral tablet THERAPY PACK nystatin oral tablet 1 or 1b* *ANTIFUNGALS* terbinafine hcl oral tablet 1 or 1b* QL *ANTIFUNGAL - *IMIDAZOLES*** GLUCAN SYNTHESIS INHIBITORS ketoconazole oral tablet 1 or 1b* QL (ECHINOCANDINS)*** *TRIAZOLES*** CANCIDAS CRESEMBA INTRAVENOUS INTRAVENOUS 3 3 PA; QL SOLUTION SOLUTION RECONSTITUTED RECONSTITUTED CASPOFUNGIN CRESEMBA ORAL 3 PA; QL ACETATE CAPSULE INTRAVENOUS 3 SOLUTION DIFLUCAN ORAL RECONSTITUTED SUSPENSION 3 QL RECONSTITUTED ERAXIS INTRAVENOUS DIFLUCAN ORAL SOLUTION 3 3 QL RECONSTITUTED TABLET micafungin sodium fluconazole in sodium chloride intravenous solution intravenous solution 1 or 1b* 1 or 1b* reconstituted 200-0.9 mg/100ml-%, 400- 0.9 mg/200ml-%

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 42 Drug Name Tier Notes Drug Name Tier Notes fluconazole oral suspension CARBINOXAMINE 1 or 1b* QL reconstituted MALEATE ORAL 3 QL fluconazole oral tablet 1 or 1b* QL TABLET 6 MG itraconazole oral capsule 1 or 1b* PA; QL CLEMASTINE FUMARATE ORAL 3 QL itraconazole oral solution 1 or 1b* PA; QL SYRUP NOXAFIL clemastine fumarate oral 1 or 1b* INTRAVENOUS 3 tablet 2.68 mg SOLUTION diphen oral elixir 1 or 1a* QL NOXAFIL ORAL 3 PA; QL SUSPENSION di-phen oral elixir 1 or 1a* QL diphenhydramine hcl NOXAFIL ORAL 1 or 1b* TABLET DELAYED 3 PA; QL injection solution RELEASE diphenhydramine hcl oral 1 or 1a* QL posaconazole oral tablet elixir 1 or 1b* PA; QL delayed release KARBINAL ER ORAL SPORANOX ORAL SUSPENSION 3 QL 3 PA; QL CAPSULE EXTENDED RELEASE SPORANOX ORAL RYVENT ORAL TABLET 1 or 1b* QL 3 PA; QL SOLUTION *ANTIHISTAMINES - SPORANOX PULSEPAK NON-SEDATING*** 3 PA; QL ORAL CAPSULE cetirizine hcl oral solution 1 or 1b* TOLSURA ORAL CLARINEX ORAL 3 PA; QL 3 ST; QL CAPSULE TABLET VFEND IV oral tablet 1 or 1b* QL INTRAVENOUS desloratadine oral tablet 3 1 or 1b* QL SOLUTION dispersible RECONSTITUTED levocetirizine 1 or 1b* QL VFEND ORAL dihydrochloride oral solution SUSPENSION 3 PA; QL levocetirizine RECONSTITUTED 1 or 1b* QL dihydrochloride oral tablet VFEND ORAL TABLET 3 PA; QL QUZYTTIR voriconazole intravenous 1 or 1b* INTRAVENOUS 3 solution reconstituted SOLUTION voriconazole oral suspension 1 or 1b* PA; QL *ANTIHISTAMINES - reconstituted *** voriconazole oral tablet 1 or 1b* PA; QL PHENERGAN 3 *ANTIHISTAMINES* INJECTION SOLUTION *ANTIHISTAMINES - hcl injection 1 or 1a* ALKYLAMINES*** solution dexchlorpheniramine maleate promethazine hcl oral 3 1 or 1a* oral solution solution ryclora oral solution 1 or 1b* promethazine hcl oral syrup 1 or 1a* *ANTIHISTAMINES - promethazine hcl oral tablet 1 or 1a* ETHANOLAMINES*** 12.5 mg, 50 mg carbinoxamine maleate oral promethazine hcl oral tablet 1 or 1b* 1 or 1a* QL solution 25 mg carbinoxamine maleate oral promethazine hcl rectal 1 or 1b* 1 or 1b* tablet 4 mg suppository 12.5 mg, 25 mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 43 Drug Name Tier Notes Drug Name Tier Notes promethegan rectal COLESTID FLAVORED 1 or 1b* 3 QL suppository ORAL GRANULES *ANTIHISTAMINES - COLESTID FLAVORED 3 QL PIPERIDINES*** ORAL PACKET hcl oral COLESTID ORAL 1 or 1b* 3 QL syrup GRANULES cyproheptadine hcl oral COLESTID ORAL 1 or 1b* 3 QL tablet PACKET *ANTIHYPERLIPIDEMI COLESTID ORAL 3 QL CS* TABLET *ACL INHIB- colestipol hcl oral granules 1 or 1b* QL INTESTINAL colestipol hcl oral packet 1 or 1b* QL CHOLESTEROL ABSORPTION INHIB colestipol hcl oral tablet 1 or 1b* QL COMB*** prevalite oral packet 1 or 1b* QL NEXLIZET ORAL 3 PA; QL prevalite oral powder 1 or 1b* QL TABLET QUESTRAN LIGHT 3 QL *ADENOSINE ORAL POWDER TRIPHOSPHATE- QUESTRAN ORAL CITRATE LYASE (ACL) 3 QL INHIBITORS*** PACKET NEXLETOL ORAL QUESTRAN ORAL 3 PA; QL 3 QL TABLET POWDER WELCHOL ORAL *ANGIOPOIETIN-LIKE 3 QL PROTEIN 3 (ANGPTL3) PACKET INHIBITORS*** WELCHOL ORAL 3 QL EVKEEZA TABLET INTRAVENOUS 4 PA; LD *FIBRIC ACID SOLUTION DERIVATIVES*** *ANTIHYPERLIPIDEMI ANTARA ORAL 3 ST; QL CS - MISC.*** CAPSULE 30 MG, 90 MG icosapent ethyl oral capsule 1 or 1b* PA; QL fenofibrate micronized oral 1 or 1b* QL LOVAZA ORAL capsule 3 PA; QL CAPSULE fenofibrate oral capsule 1 or 1b* QL omega-3-acid ethyl esters fenofibrate oral tablet 120 1 or 1b* PA; QL 3 ST; QL oral capsule mg, 40 mg VASCEPA ORAL fenofibrate oral tablet 145 2 PA; QL 1 or 1b* QL CAPSULE mg, 160 mg, 48 mg, 54 mg *BILE ACID fenofibric acid oral capsule 1 or 1b* QL SEQUESTRANTS*** delayed release cholestyramine light oral fenofibric acid oral tablet 1 or 1b* QL 1 or 1b* QL packet FENOGLIDE ORAL 3 ST; QL cholestyramine light oral TABLET 1 or 1b* QL powder FIBRICOR ORAL 3 ST; QL cholestyramine oral packet 1 or 1b* QL TABLET cholestyramine oral powder 1 or 1b* QL gemfibrozil oral tablet 1 or 1b* QL colesevelam hcl oral packet 3 QL LIPOFEN ORAL 3 ST; QL colesevelam hcl oral tablet 1 or 1b* QL CAPSULE LOPID ORAL TABLET 3 ST; QL TRICOR ORAL TABLET 3 ST; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 44 Drug Name Tier Notes Drug Name Tier Notes TRILIPIX ORAL lovastatin oral tablet 40 mg 1 or 1b* $0; QL CAPSULE DELAYED 3 ST; QL pravastatin sodium oral tablet 1 or 1b* DO; $0 RELEASE 10 mg, 20 mg, 40 mg *HMG COA REDUCTASE pravastatin sodium oral tablet 1 or 1b* $0; QL INHIBITORS*** 80 mg ALTOPREV ORAL rosuvastatin calcium oral TABLET EXTENDED 1 or 1b* DO; $0 3 ST; DO tablet 10 mg, 5 mg RELEASE 24 HOUR 20 rosuvastatin calcium oral MG, 40 MG 1 or 1b* DO tablet 20 mg ALTOPREV ORAL TABLET EXTENDED rosuvastatin calcium oral 3 ST; QL 1 or 1b* QL RELEASE 24 HOUR 60 tablet 40 mg MG simvastatin oral tablet 10 mg, 1 or 1b* DO; $0 atorvastatin calcium oral 20 mg, 40 mg, 5 mg 1 or 1b* DO; $0 tablet 10 mg, 20 mg simvastatin oral tablet 80 mg 1 or 1b* PA; QL atorvastatin calcium oral ZOCOR ORAL TABLET 1 or 1b* DO 3 ST; DO tablet 40 mg 10 MG, 20 MG, 40 MG atorvastatin calcium oral ZOCOR ORAL TABLET 1 or 1b* QL 3 PA; QL tablet 80 mg 80 MG CRESTOR ORAL ZYPITAMAG ORAL 3 ST; DO TABLET 10 MG, 20 MG, 5 3 ST; DO TABLET 2 MG MG ZYPITAMAG ORAL CRESTOR ORAL 3 ST; QL 3 ST; QL TABLET 4 MG TABLET 40 MG *INTEST CHOLEST EZALLOR SPRINKLE ABSORP INHIB-HMG ORAL CAPSULE 3 ST; DO COA REDUCTASE INHIB SPRINKLE 10 MG, 20 COMB*** MG, 5 MG ezetimibe-simvastatin oral 1 or 1b* ST; QL EZALLOR SPRINKLE tablet ORAL CAPSULE 3 ST; QL SPRINKLE 40 MG ROSZET ORAL TABLET 3 ST; QL FLOLIPID ORAL VYTORIN ORAL 3 ST; QL 3 ST; QL SUSPENSION TABLET *INTESTINAL fluvastatin sodium er oral CHOLESTEROL tablet extended release 24 3 ST; $0; QL ABSORPTION hour INHIBITORS*** fluvastatin sodium oral 1 or 1b* DO; $0 capsule ezetimibe oral tablet 1 or 1b* ST; QL LESCOL XL ORAL ZETIA ORAL TABLET 3 ST; QL TABLET EXTENDED 3 ST; QL *MICROSOMAL RELEASE 24 HOUR TRIGLYCERIDE TRANSFER PROTEIN LIPITOR ORAL TABLET 3 ST; DO INHIBITORS*** 10 MG, 20 MG, 40 MG LIPITOR ORAL TABLET JUXTAPID ORAL 3 ST; QL 80 MG CAPSULE 10 MG, 20 MG, 3 PA; DO; LD 30 MG, 5 MG LIVALO ORAL TABLET 3 ST; DO *NICOTINIC ACID 1 MG, 2 MG DERIVATIVES*** LIVALO ORAL TABLET 3 ST; QL niacin (antihyperlipidemic) 4 MG 1 or 1b* ST; QL oral tablet lovastatin oral tablet 10 mg, 1 or 1b* DO; $0 20 mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 45 Drug Name Tier Notes Drug Name Tier Notes niacin er *ACE INHIBITORS & (antihyperlipidemic) oral 1 or 1b* ST; QL THIAZIDE/THIAZIDE- tablet extended release LIKE*** niacor oral tablet 1 or 1b* ST; QL ACCURETIC ORAL 3 QL NIASPAN ORAL TABLET TABLET 3 ST; QL EXTENDED RELEASE benazepril- *PCSK9 INHIBITORS*** hydrochlorothiazide oral 1 or 1b* DO tablet 10-12.5 mg PRALUENT SUBCUTANEOUS benazepril- 3 PA; QL SOLUTION AUTO- hydrochlorothiazide oral 1 or 1b* QL INJECTOR tablet 20-12.5 mg, 20-25 mg REPATHA BENAZEPRIL- PUSHTRONEX SYSTEM HYDROCHLOROTHIAZI 3 PA; QL 1 or 1b* DO SUBCUTANEOUS DE ORAL TABLET 5-6.25 SOLUTION CARTRIDGE MG enalapril-hydrochlorothiazide REPATHA 1 or 1b* QL SUBCUTANEOUS oral tablet 3 PA; QL SOLUTION PREFILLED fosinopril sodium-hctz oral 1 or 1b* QL SYRINGE tablet REPATHA SURECLICK lisinopril- SUBCUTANEOUS hydrochlorothiazide oral 1 or 1b* DO 3 PA; QL SOLUTION AUTO- tablet 10-12.5 mg INJECTOR lisinopril- *ANTIHYPERTENSIVES hydrochlorothiazide oral 1 or 1b* QL * tablet 20-12.5 mg, 20-25 mg *ACE INHIBITOR & LOTENSIN HCT ORAL 3 DO CALCIUM CHANNEL TABLET 10-12.5 MG BLOCKER LOTENSIN HCT ORAL COMBINATIONS*** TABLET 20-12.5 MG, 20- 3 QL amlodipine besy-benazepril 25 MG hcl oral capsule 10-20 mg, 1 or 1b* QL quinapril- 10-40 mg, 5-40 mg hydrochlorothiazide oral 1 or 1b* QL amlodipine besy-benazepril tablet hcl oral capsule 2.5-10 mg, 1 or 1b* DO VASERETIC ORAL 3 QL 5-10 mg, 5-20 mg TABLET LOTREL ORAL ZESTORETIC ORAL 3 DO CAPSULE 10-20 MG, 10- 3 QL TABLET 10-12.5 MG 40 MG ZESTORETIC ORAL LOTREL ORAL TABLET 20-12.5 MG, 20- 3 QL CAPSULE 5-10 MG, 5-20 3 DO 25 MG MG *ACE INHIBITORS*** PRESTALIA ORAL 3 QL ACCUPRIL ORAL TABLET 14-10 MG 3 QL TABLET PRESTALIA ORAL ALTACE ORAL TABLET 3.5-2.5 MG, 7-5 3 DO 3 QL MG CAPSULE trandolapril-verapamil hcl er benazepril hcl oral tablet 1 or 1a* QL 1 or 1b* QL oral tablet extended release captopril oral tablet 1 or 1b* QL enalapril maleate oral 1 or 1b* QL solution enalapril maleate oral tablet 1 or 1b* QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 46 Drug Name Tier Notes Drug Name Tier Notes enalaprilat intravenous amlodipine besylate- 1 or 1b* injectable valsartan oral tablet 5-160 1 or 1b* DO EPANED ORAL mg 3 QL SOLUTION amlodipine-olmesartan oral fosinopril sodium oral tablet 1 or 1b* QL tablet 10-20 mg, 10-40 mg, 1 or 1b* QL 5-40 mg lisinopril oral tablet 10 mg, 1 or 1a* DO amlodipine-olmesartan oral 2.5 mg, 20 mg, 5 mg 1 or 1b* DO tablet 5-20 mg lisinopril oral tablet 30 mg, 1 or 1a* QL 40 mg AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-40 3 QL LOTENSIN ORAL MG TABLET 10 MG, 20 MG, 3 QL AZOR ORAL TABLET 5- 40 MG 3 DO 20 MG moexipril hcl oral tablet 1 or 1b* QL EXFORGE ORAL perindopril erbumine oral 1 or 1b* QL TABLET 10-160 MG, 10- 3 QL tablet 320 MG, 5-320 MG PRINIVIL ORAL EXFORGE ORAL 3 DO 3 DO TABLET 20 MG TABLET 5-160 MG QBRELIS ORAL 3 QL telmisartan-amlodipine oral SOLUTION tablet 40-10 mg, 80-10 mg, 1 or 1b* QL quinapril hcl oral tablet 1 or 1b* QL 80-5 mg telmisartan-amlodipine oral ramipril oral capsule 1 or 1b* QL 1 or 1b* DO tablet 40-5 mg trandolapril oral tablet 1 or 1b* QL TWYNSTA ORAL VASOTEC ORAL 3 QL TABLET 40-10 MG, 80-10 3 QL TABLET MG, 80-5 MG ZESTRIL ORAL TABLET TWYNSTA ORAL 3 DO 10 MG, 2.5 MG, 20 MG, 5 3 DO TABLET 40-5 MG MG *ANGIOTENSIN II ZESTRIL ORAL TABLET 3 QL RECEPTOR ANTAG & 30 MG, 40 MG THIAZIDE/THIAZIDE- *AGENTS FOR LIKE*** PHEOCHROMOCYTOM ATACAND HCT ORAL A*** 3 QL TABLET DEMSER ORAL 3 PA; QL AVALIDE ORAL CAPSULE TABLET 150-12.5 MG, 3 QL DIBENZYLINE ORAL 300-12.5 MG 3 PA; QL CAPSULE BENICAR HCT ORAL 3 DO metyrosine oral capsule 1 or 1b* PA; QL TABLET 20-12.5 MG phenoxybenzamine hcl oral BENICAR HCT ORAL 1 or 1b* PA; QL capsule TABLET 40-12.5 MG, 40- 3 QL phentolamine mesylate 25 MG injection solution 1 or 1b* candesartan cilexetil-hctz 1 or 1b* QL reconstituted oral tablet *ANGIOTENSIN II DIOVAN HCT ORAL RECEPTOR ANTAG & TABLET 160-12.5 MG, 80- 3 DO CA CHANNEL 12.5 MG BLOCKER COMB*** DIOVAN HCT ORAL amlodipine besylate- TABLET 160-25 MG, 320- 3 QL valsartan oral tablet 10-160 1 or 1b* QL 12.5 MG, 320-25 MG mg, 10-320 mg, 5-320 mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 47 Drug Name Tier Notes Drug Name Tier Notes EDARBYCLOR ORAL COZAAR ORAL TABLET 3 QL 3 QL TABLET DIOVAN ORAL TABLET 3 QL HYZAAR ORAL TABLET EDARBI ORAL TABLET 3 QL 3 DO 100-12.5 MG, 100-25 MG 40 MG HYZAAR ORAL TABLET EDARBI ORAL TABLET 3 DO 3 QL 50-12.5 MG 80 MG irbesartan- irbesartan oral tablet 150 mg, 1 or 1b* DO hydrochlorothiazide oral 1 or 1b* QL 75 mg tablet irbesartan oral tablet 300 mg 1 or 1b* QL losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 1 or 1b* QL losartan potassium oral tablet 1 or 1b* QL mg MICARDIS ORAL 3 DO losartan potassium-hctz oral TABLET 20 MG, 40 MG 1 or 1b* DO tablet 50-12.5 mg MICARDIS ORAL 3 QL MICARDIS HCT ORAL TABLET 80 MG 3 DO TABLET 40-12.5 MG olmesartan medoxomil oral 1 or 1b* DO MICARDIS HCT ORAL tablet 20 mg TABLET 80-12.5 MG, 80- 3 QL olmesartan medoxomil oral 1 or 1b* QL 25 MG tablet 40 mg, 5 mg olmesartan medoxomil-hctz telmisartan oral tablet 20 mg, 1 or 1b* DO 1 or 1b* DO oral tablet 20-12.5 mg 40 mg olmesartan medoxomil-hctz telmisartan oral tablet 80 mg 1 or 1b* QL oral tablet 40-12.5 mg, 40-25 1 or 1b* QL mg valsartan oral tablet 1 or 1b* QL *ANGIOTENSIN II telmisartan-hctz oral tablet 1 or 1b* DO RECEPTOR ANT-CA 40-12.5 mg CHANNEL BLOCKER- telmisartan-hctz oral tablet 1 or 1b* QL THIAZIDES*** 80-12.5 mg, 80-25 mg amlodipine-valsartan-hctz valsartan- oral tablet 10-160-12.5 mg, hydrochlorothiazide oral 1 or 1b* QL 1 or 1b* DO 10-160-25 mg, 10-320-25 tablet 160-12.5 mg, 80-12.5 mg, 5-160-25 mg mg amlodipine-valsartan-hctz 1 or 1b* DO valsartan- oral tablet 5-160-12.5 mg hydrochlorothiazide oral 1 or 1b* QL tablet 160-25 mg, 320-12.5 EXFORGE HCT ORAL TABLET 10-160-12.5 MG, mg, 320-25 mg 3 QL 10-160-25 MG, 10-320-25 *ANGIOTENSIN II MG, 5-160-25 MG RECEPTOR EXFORGE HCT ORAL ANTAGONISTS*** 3 DO TABLET 5-160-12.5 MG ATACAND ORAL 3 QL olmesartan-amlodipine-hctz TABLET 1 or 1b* DO oral tablet 20-5-12.5 mg AVAPRO ORAL TABLET 3 DO 150 MG, 75 MG olmesartan-amlodipine-hctz oral tablet 40-10-12.5 mg, AVAPRO ORAL TABLET 1 or 1b* QL 3 QL 40-10-25 mg, 40-5-12.5 mg, 300 MG 40-5-25 mg BENICAR ORAL TRIBENZOR ORAL 3 DO 3 DO TABLET 20 MG TABLET 20-5-12.5 MG BENICAR ORAL 3 QL TRIBENZOR ORAL TABLET 40 MG, 5 MG TABLET 40-10-12.5 MG, 3 QL candesartan cilexetil oral 40-10-25 MG, 40-5-12.5 1 or 1b* QL tablet MG, 40-5-25 MG * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 48 Drug Name Tier Notes Drug Name Tier Notes *ANTIADRENERGICS - TENORETIC 100 ORAL 3 QL CENTRALLY TABLET ACTING*** TENORETIC 50 ORAL 3 QL CATAPRES-TTS-1 TABLET TRANSDERMAL PATCH 3 ZIAC ORAL TABLET 3 QL WEEKLY *DIRECT RENIN CATAPRES-TTS-2 INHIBITORS & TRANSDERMAL PATCH 3 THIAZIDE/THIAZIDE- WEEKLY LIKE COMB*** CATAPRES-TTS-3 TEKTURNA HCT ORAL 3 DO TRANSDERMAL PATCH 3 TABLET 150-12.5 MG WEEKLY TEKTURNA HCT ORAL clonidine hcl oral tablet 1 or 1a* QL TABLET 150-25 MG, 300- 3 QL clonidine transdermal patch 12.5 MG, 300-25 MG 1 or 1b* weekly *DIRECT RENIN guanfacine hcl oral tablet 1 or 1b* INHIBITORS*** METHYLDOPA ORAL aliskiren fumarate oral tablet 1 or 1b* DO 1 or 1b* DO TABLET 250 MG 150 mg METHYLDOPA ORAL aliskiren fumarate oral tablet 1 or 1b* QL 1 or 1b* QL TABLET 500 MG 300 mg *ANTIADRENERGICS - TEKTURNA ORAL 3 DO PERIPHERALLY TABLET 150 MG ACTING*** TEKTURNA ORAL 3 QL CARDURA ORAL TABLET 300 MG 3 QL TABLET *DOPAMINE D1 doxazosin mesylate oral RECEPTOR 1 or 1b* QL tablet AGONISTS*** MINIPRESS ORAL CORLOPAM 3 CAPSULE INTRAVENOUS 3 prazosin hcl oral capsule 1 or 1b* SOLUTION terazosin hcl oral capsule 1 or 1b* QL *SELECTIVE ALDOSTERONE *ANTIHYPERTENSIVES RECEPTOR - MISC.*** ANTAGONISTS VECAMYL ORAL (SARAS)*** 3 TABLET eplerenone oral tablet 1 or 1b* *BETA BLOCKER & INSPRA ORAL TABLET 3 DIURETIC COMBINATIONS*** *VASODILATORS*** atenolol-chlorthalidone oral hydralazine hcl injection 1 or 1b* QL 1 or 1b* tablet solution bisoprolol- hydralazine hcl oral tablet 1 or 1b* hydrochlorothiazide oral 1 or 1b* QL minoxidil oral tablet 1 or 1b* tablet NIPRIDE RTU DUTOPROL ORAL INTRAVENOUS TABLET EXTENDED 3 QL SOLUTION 20-0.9 3 RELEASE 24 HOUR MG/100ML-%, 50-0.9 metoprolol- MG/100ML-% hydrochlorothiazide oral 1 or 1b* QL nitroprusside sodium 1 or 1b* tablet intravenous solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 49 Drug Name Tier Notes Drug Name Tier Notes sodium nitroprusside BACTRIM ORAL 1 or 1b* 3 intravenous solution TABLET *ANTI-INFECTIVE sulfamethoxazole- AGENTS - MISC.* trimethoprim intravenous 1 or 1b* *ANTI-INFECTIVE solution AGENTS - MISC.*** sulfamethoxazole- AEMCOLO ORAL trimethoprim oral suspension 1 or 1a* TABLET DELAYED 3 PA; QL 200-40 mg/5ml RELEASE sulfamethoxazole- 1 or 1a* bacitracin intramuscular trimethoprim oral tablet 1 or 1b* solution reconstituted sulfatrim pediatric oral 1 or 1a* FLAGYL ORAL suspension 3 CAPSULE *ANTIPROTOZOAL IMPAVIDO ORAL AGENTS*** 3 PA; QL CAPSULE ALINIA ORAL metronidazole in nacl SUSPENSION 3 intravenous solution 5-0.79 RECONSTITUTED 1 or 1b* mg/ml-%, 500-0.79 ALINIA ORAL TABLET 3 mg/100ml-% atovaquone oral suspension 1 or 1b* METRONIDAZOLE IN LAMPIT ORAL TABLET 3 NACL INTRAVENOUS 3 MEPRON ORAL SOLUTION 500-0.74 3 MG/100ML-% SUSPENSION metronidazole oral capsule 1 or 1a* nitazoxanide oral tablet 1 or 1b* metronidazole oral tablet 1 or 1a* *CARBAPENEM COMBINATIONS*** NEBUPENT INHALATION imipenem-cilastatin 3 SOLUTION intravenous solution 1 or 1b* RECONSTITUTED reconstituted PENTAM INJECTION PRIMAXIN IV SOLUTION 4 INTRAVENOUS RECONSTITUTED SOLUTION 3 RECONSTITUTED 500- pentamidine isethionate 500 MG inhalation solution 1 or 1b* reconstituted RECARBRIO INTRAVENOUS 3 pentamidine isethionate SOLUTION injection solution 4 RECONSTITUTED reconstituted VABOMERE PRIMSOL ORAL INTRAVENOUS 3 3 SOLUTION SOLUTION tinidazole oral tablet 1 or 1b* QL RECONSTITUTED trimethoprim oral tablet 1 or 1a* *CARBAPENEMS*** XIFAXAN ORAL ertapenem sodium injection 3 PA; QL 1 or 1b* TABLET solution reconstituted *ANTI-INFECTIVE INVANZ INJECTION MISC. - SOLUTION 3 COMBINATIONS*** RECONSTITUTED BACTRIM DS ORAL meropenem intravenous 3 1 or 1b* TABLET solution reconstituted

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 50 Drug Name Tier Notes Drug Name Tier Notes MEROPENEM-SODIUM VANCOMYCIN HCL IN CHLORIDE DEXTROSE INTRAVENOUS INTRAVENOUS 3 SOLUTION SOLUTION 1-5 3 QL RECONSTITUTED 1 GM/200ML-%, 500-5 GM/50ML, 500 MG/50ML MG/100ML-%, 750-5 *CHLORAMPHENICALS MG/150ML-% *** VANCOMYCIN HCL IN chloramphenicol sod NACL INTRAVENOUS SOLUTION 1.5-0.9 succinate intravenous 1 or 1b* 3 QL solution reconstituted GM/250ML-%, 1.5-0.9 GM/500ML-%, 1.75-0.9 *CYCLIC GM/250ML-% LIPOPEPTIDES*** VANCOMYCIN HCL IN CUBICIN NACL INTRAVENOUS INTRAVENOUS SOLUTION 1-0.9 3 3 QL SOLUTION GM/200ML-%, 500-0.9 RECONSTITUTED MG/100ML-%, 750-0.9 CUBICIN RF MG/150ML-% INTRAVENOUS 3 VANCOMYCIN HCL SOLUTION INTRAVENOUS RECONSTITUTED SOLUTION 1000 DAPTOMYCIN MG/200ML, 1250 MG/250ML, 1500 INTRAVENOUS 3 QL SOLUTION 3 MG/300ML, 1750 RECONSTITUTED 350 MG/350ML, 2000 MG MG/400ML, 500 MG/100ML, 750 daptomycin intravenous MG/150ML solution reconstituted 500 1 or 1b* mg vancomycin hcl intravenous solution reconstituted 1 gm, *GLYCOPEPTIDES*** 1 or 1b* QL 10 gm, 100 gm, 1000 mg, 5 DALVANCE gm, 500 mg, 750 mg INTRAVENOUS 3 VANCOMYCIN HCL SOLUTION INTRAVENOUS RECONSTITUTED SOLUTION 3 QL FIRVANQ ORAL RECONSTITUTED 1.25 SOLUTION 3 PA; QL GM, 1.5 GM, 250 MG RECONSTITUTED vancomycin hcl oral capsule 1 or 1b* PA; QL KIMYRSA VANCOMYCIN HCL INTRAVENOUS 3 ORAL SOLUTION 3 PA; QL SOLUTION RECONSTITUTED RECONSTITUTED VIBATIV ORBACTIV INTRAVENOUS INTRAVENOUS 3 SOLUTION 3 SOLUTION RECONSTITUTED 750 RECONSTITUTED MG VANCOCIN HCL ORAL 3 PA; QL *LEPROSTATICS*** CAPSULE 125 MG dapsone oral tablet 1 or 1b* VANCOCIN ORAL 3 PA; QL CAPSULE *LINCOSAMIDES*** CLEOCIN ORAL 3 QL CAPSULE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 51 Drug Name Tier Notes Drug Name Tier Notes CLEOCIN ORAL ZYVOX ORAL TABLET 3 PA; QL SOLUTION 3 *PLEUROMUTILINS*** RECONSTITUTED XENLETA CLEOCIN PHOSPHATE 3 QL INTRAVENOUS 3 INJECTION SOLUTION SOLUTION clindamycin hcl oral capsule 1 or 1b* QL XENLETA ORAL 3 PA; QL clindamycin palmitate hcl TABLET 1 or 1b* oral solution reconstituted *POLYMYXINS*** clindamycin phosphate in 1 or 1b* colistimethate sodium (cba) d5w intravenous solution injection solution 1 or 1b* CLINDAMYCIN reconstituted PHOSPHATE IN NACL 3 COLY-MYCIN M INTRAVENOUS INJECTION SOLUTION 3 SOLUTION RECONSTITUTED clindamycin phosphate polymyxin b sulfate injection 1 or 1b* QL 1 or 1b* injection solution solution reconstituted LINCOCIN INJECTION 3 *STREPTOGRAMIN SOLUTION COMBINATIONS*** lincomycin hcl injection 1 or 1b* SYNERCID solution INTRAVENOUS 3 *MONOBACTAMS*** SOLUTION AZACTAM INJECTION RECONSTITUTED SOLUTION 3 *URINARY ANTI- RECONSTITUTED INFECTIVES*** aztreonam injection solution fosfomycin tromethamine 1 or 1b* 1 or 1b* QL reconstituted oral packet CAYSTON INHALATION HIPREX ORAL TABLET 3 SOLUTION 4 LD; SP; QL MACROBID ORAL 3 QL RECONSTITUTED CAPSULE *OXAZOLIDINONES*** MACRODANTIN ORAL 3 QL linezolid in sodium chloride CAPSULE 1 or 1b* intravenous solution methenamine hippurate oral 1 or 1b* linezolid intravenous solution tablet 1 or 1b* 600 mg/300ml MONUROL ORAL 3 QL linezolid oral suspension PACKET 1 or 1b* PA; QL reconstituted nitrofurantoin macrocrystal 1 or 1b* QL linezolid oral tablet 1 or 1b* PA; QL oral capsule SIVEXTRO nitrofurantoin monohyd 1 or 1b* QL INTRAVENOUS macro oral capsule 3 SOLUTION nitrofurantoin oral 1 or 1b* QL RECONSTITUTED suspension SIVEXTRO ORAL 3 PA; QL *ANTIMALARIALS* TABLET *ANTIMALARIAL ZYVOX INTRAVENOUS COMBINATIONS*** SOLUTION 200 3 atovaquone-proguanil hcl MG/100ML, 600 1 or 1b* MG/300ML oral tablet COARTEM ORAL ZYVOX ORAL 3 SUSPENSION 3 PA; QL TABLET RECONSTITUTED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 52 Drug Name Tier Notes Drug Name Tier Notes MALARONE ORAL pyridostigmine bromide er 3 1 or 1b* TABLET oral tablet extended release *ANTIMALARIALS*** pyridostigmine bromide oral 1 or 1b* ARAKODA ORAL solution 3 QL TABLET pyridostigmine bromide oral 1 or 1b* ARTESUNATE tablet INTRAVENOUS REGONOL 3 SOLUTION INTRAVENOUS 3 RECONSTITUTED SOLUTION chloroquine phosphate oral RUZURGI ORAL 1 or 1a* 4 PA; LD; QL tablet TABLET DARAPRIM ORAL *ANTIMYCOBACTERIA 3 PA; QL TABLET L AGENTS* hydroxychloroquine sulfate *ANTIMYCOBACTERIA 1 or 1b* QL oral tablet 200 mg L AGENTS*** KRINTAFEL ORAL CAPASTAT SULFATE 3 QL TABLET INJECTION SOLUTION 3 mefloquine hcl oral tablet 1 or 1b* QL RECONSTITUTED PLAQUENIL ORAL cycloserine oral capsule 1 or 1b* 3 QL TABLET ethambutol hcl oral tablet 1 or 1b* PRIMAQUINE isoniazid injection solution 1 or 1a* PHOSPHATE ORAL 3 isoniazid oral syrup 1 or 1a* TABLET 26.3 (15 BASE) MG isoniazid oral tablet 1 or 1a* MYAMBUTOL ORAL pyrimethamine oral tablet 1 or 1b* PA; QL 3 TABLET 400 MG QUALAQUIN ORAL 3 PA; QL MYCOBUTIN ORAL CAPSULE 3 CAPSULE quinine sulfate oral capsule 1 or 1b* PA; QL PASER ORAL PACKET 3 *ANTIMYASTHENIC/CH PRETOMANID ORAL OLINERGIC AGENTS* 3 TABLET *ANTIMYASTHENIC/CH OLINERGIC AGENTS*** PRIFTIN ORAL TABLET 2 BLOXIVERZ pyrazinamide oral tablet 1 or 1b* INTRAVENOUS 3 rifabutin oral capsule 1 or 1b* SOLUTION RIFADIN FIRDAPSE ORAL INTRAVENOUS 4 PA; LD; QL 3 TABLET SOLUTION MESTINON ORAL RECONSTITUTED 3 SOLUTION rifampin intravenous solution 1 or 1b* MESTINON ORAL reconstituted 3 TABLET rifampin oral capsule 1 or 1b* MESTINON ORAL SIRTURO ORAL 3 TABLET EXTENDED 3 TABLET RELEASE TRECATOR ORAL 3 NEOSTIGMINE TABLET METHYLSULFATE INTRAVENOUS 3 SOLUTION 10 MG/10ML, 5 MG/10ML

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 53 Drug Name Tier Notes Drug Name Tier Notes *ANTINEOPLASTICS *ANTIADRENALS*** AND ADJUNCTIVE LYSODREN ORAL 2 QL THERAPIES* TABLET *ALKYLATING *ANTIANDROGENS*** AGENTS*** bicalutamide oral tablet 1 or 1b* BELRAPZO CASODEX ORAL INTRAVENOUS 3 PA; SP 3 SOLUTION TABLET ERLEADA ORAL BENDEKA 2 PA; LD; SP; QL INTRAVENOUS 3 PA; LD; SP TABLET SOLUTION flutamide oral capsule 1 or 1b* busulfan intravenous solution 1 or 1b* SP NILANDRON ORAL 3 QL BUSULFEX TABLET INTRAVENOUS 3 SP nilutamide oral tablet 1 or 1b* QL SOLUTION NUBEQA ORAL TABLET 3 PA; LD; SP; QL carboplatin intravenous 1 or 1b* SP XTANDI ORAL solution 2 PA; LD; SP; QL CAPSULE cisplatin intravenous solution 100 mg/100ml, 200 1 or 1b* SP XTANDI ORAL TABLET 2 PA; LD; SP; QL mg/200ml, 50 mg/50ml *ANTIESTROGENS*** CISPLATIN FARESTON ORAL 3 QL INTRAVENOUS TABLET 3 SP SOLUTION SOLTAMOX ORAL 2 $0 RECONSTITUTED SOLUTION MYLERAN ORAL 2 tamoxifen citrate oral tablet 1 or 1b* $0 TABLET toremifene citrate oral tablet 1 or 1b* QL oxaliplatin intravenous 1 or 1b* SP solution *ANTIMETABOLITES*** oxaliplatin intravenous ALIMTA INTRAVENOUS 1 or 1b* SP solution reconstituted SOLUTION 3 PA; SP RECONSTITUTED paraplatin intravenous 1 or 1b* SP solution ARRANON INTRAVENOUS 3 SP TEPADINA INJECTION SOLUTION SOLUTION 3 SP azacitidine injection RECONSTITUTED 1 or 1b* PA; SP suspension reconstituted thiotepa injection solution 1 or 1b* SP reconstituted capecitabine oral tablet 1 or 1b* PA; SP cladribine intravenous TREANDA 1 or 1b* SP INTRAVENOUS solution 10 mg/10ml 3 PA; SP SOLUTION clofarabine intravenous 1 or 1b* SP RECONSTITUTED solution ZEPZELCA CLOLAR INTRAVENOUS 3 PA; LD; SP INTRAVENOUS 3 SP SOLUTION SOLUTION RECONSTITUTED cytarabine (pf) injection 1 or 1b* SP *ANDROGEN solution BIOSYNTHESIS cytarabine injection solution 1 or 1b* SP INHIBITORS*** DACOGEN abiraterone acetate oral tablet 1 or 1b* PA; SP; QL INTRAVENOUS 3 SP YONSA ORAL TABLET 3 PA; LD; SP; QL SOLUTION ZYTIGA ORAL TABLET 3 PA; LD; SP; QL RECONSTITUTED * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 54 Drug Name Tier Notes Drug Name Tier Notes decitabine intravenous *ANTINEOPLASTIC - 1 or 1b* SP solution reconstituted ALK INHIBITORS*** floxuridine injection solution ALECENSA ORAL 1 or 1b* SP 3 PA; LD; SP; QL reconstituted CAPSULE fludarabine phosphate ALUNBRIG ORAL 1 or 1b* SP 3 PA; SP; QL intravenous solution TABLET fludarabine phosphate ALUNBRIG ORAL intravenous solution 1 or 1b* SP TABLET THERAPY 3 PA; SP; QL reconstituted PACK fluorouracil intravenous LORBRENA ORAL 1 or 1b* SP 3 PA; LD; SP; QL solution TABLET FOLOTYN XALKORI ORAL 2 PA; LD; SP; QL INTRAVENOUS 3 SP CAPSULE SOLUTION ZYKADIA ORAL 3 PA; LD; SP; QL GEMCITABINE HCL TABLET INTRAVENOUS 3 SP *ANTINEOPLASTIC - SOLUTION ANTI-BCMA ANTIBODY- gemcitabine hcl intravenous DRUG COMPLEX*** 1 or 1b* SP solution reconstituted BLENREP INFUGEM INTRAVENOUS 3 PA; LD; SP INTRAVENOUS 3 SP SOLUTION SOLUTION RECONSTITUTED mercaptopurine oral tablet 1 or 1b* *ANTINEOPLASTIC - methotrexate oral tablet 1 or 1b* ANTI-CCR4 ANTIBODIES*** methotrexate sodium (pf) injection solution 1 gm/40ml, 1 or 1b* POTELIGEO 250 mg/10ml, 50 mg/2ml INTRAVENOUS 3 LD; SP SOLUTION methotrexate sodium injection solution 250 1 or 1b* *ANTINEOPLASTIC - mg/10ml, 50 mg/2ml ANTI-CD19 ANTIBODIES*** methotrexate sodium injection solution 1 or 1b* MONJUVI INTRAVENOUS reconstituted 3 PA; LD SOLUTION methotrexate sodium oral 1 or 1b* RECONSTITUTED tablet *ANTINEOPLASTIC - ONUREG ORAL TABLET 3 PA; LD; SP; QL ANTI-CD19 ANTIBODY- PURIXAN ORAL DRUG COMPLEX*** 3 PA; LD SUSPENSION ZYNLONTA TABLOID ORAL INTRAVENOUS 2 3 PA; LD TABLET SOLUTION RECONSTITUTED TREXALL ORAL 2 TABLET *ANTINEOPLASTIC - ANTI-CD20 VIDAZA INJECTION ANTIBODIES*** SUSPENSION 3 PA; SP RECONSTITUTED ARZERRA INTRAVENOUS 3 PA; LD; SP XATMEP ORAL 3 PA; SP CONCENTRATE SOLUTION GAZYVA XELODA ORAL TABLET 3 PA; SP INTRAVENOUS 3 PA; LD; SP SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 55 Drug Name Tier Notes Drug Name Tier Notes RIABNI INTRAVENOUS *ANTINEOPLASTIC - 3 PA; SP SOLUTION ANTI-CD79B RITUXAN ANTIBODY-DRUG INTRAVENOUS 3 PA; LD; SP COMPLEX*** SOLUTION POLIVY INTRAVENOUS RUXIENCE SOLUTION 3 PA; SP INTRAVENOUS 3 PA; SP RECONSTITUTED SOLUTION *ANTINEOPLASTIC - TRUXIMA ANTI-CTLA-4 INTRAVENOUS 3 PA; SP ANTIBODIES*** SOLUTION YERVOY *ANTINEOPLASTIC - INTRAVENOUS 3 PA; SP ANTI-CD22 SOLUTION ANTIBODIES*** *ANTINEOPLASTIC - LUMOXITI ANTI-GD2 INTRAVENOUS ANTIBODIES*** 3 PA; LD; SP SOLUTION DANYELZA RECONSTITUTED INTRAVENOUS 3 PA; LD *ANTINEOPLASTIC - SOLUTION ANTI-CD22 ANTIBODY- UNITUXIN DRUG COMPLEX*** INTRAVENOUS 3 LD BESPONSA SOLUTION INTRAVENOUS *ANTINEOPLASTIC - 3 PA; LD; SP SOLUTION ANTI-HER2 AGENTS*** RECONSTITUTED HERCEPTIN *ANTINEOPLASTIC - INTRAVENOUS ANTI-CD30 ANTIBODY- SOLUTION 3 SP DRUG COMPLEX*** RECONSTITUTED 150 ADCETRIS MG INTRAVENOUS HERZUMA 3 PA; LD; SP SOLUTION INTRAVENOUS 3 SP RECONSTITUTED SOLUTION *ANTINEOPLASTIC - RECONSTITUTED ANTI-CD33 ANTIBODY- KANJINTI DRUG COMPLEX*** INTRAVENOUS 3 SP MYLOTARG SOLUTION INTRAVENOUS RECONSTITUTED SOLUTION 3 PA; LD; SP MARGENZA RECONSTITUTED 4.5 INTRAVENOUS 3 PA; LD; SP MG SOLUTION *ANTINEOPLASTIC - OGIVRI INTRAVENOUS ANTI-CD38 SOLUTION 3 SP ANTIBODIES*** RECONSTITUTED DARZALEX ONTRUZANT INTRAVENOUS 3 PA; LD; SP INTRAVENOUS 3 SP SOLUTION SOLUTION SARCLISA RECONSTITUTED INTRAVENOUS 3 PA; LD; SP PERJETA SOLUTION INTRAVENOUS 3 PA; LD; SP SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 56 Drug Name Tier Notes Drug Name Tier Notes TRAZIMERA *ANTINEOPLASTIC - INTRAVENOUS AUTOLOGOUS 3 SP SOLUTION CELLULAR RECONSTITUTED IMMUNOTHERAPY*** TUKYSA ORAL TABLET 3 PA; LD; QL PROVENGE *ANTINEOPLASTIC - INTRAVENOUS 4 PA ANTI-NECTIN-4 SUSPENSION ANTIBODY-DRUG *ANTINEOPLASTIC - COMPLEX*** BCL-2 INHIBITORS*** PADCEV INTRAVENOUS VENCLEXTA ORAL 3 PA; LD; QL SOLUTION 3 PA; LD; SP TABLET RECONSTITUTED VENCLEXTA STARTING *ANTINEOPLASTIC - PACK ORAL TABLET 3 PA; LD; QL ANTI-PD-1 THERAPY PACK ANTIBODIES*** *ANTINEOPLASTIC - JEMPERLI BCR-ABL KINASE INTRAVENOUS 3 PA; LD; SP INHIBITORS*** SOLUTION BOSULIF ORAL TABLET 2 PA; SP; QL KEYTRUDA GLEEVEC ORAL 3 PA; SP; QL INTRAVENOUS 3 PA; LD; SP TABLET SOLUTION ICLUSIG ORAL TABLET 2 PA; LD; QL LIBTAYO INTRAVENOUS 3 PA; LD imatinib mesylate oral tablet 1 or 1b* PA; SP; QL SOLUTION SPRYCEL ORAL 2 PA; SP; QL OPDIVO INTRAVENOUS TABLET SOLUTION 100 TASIGNA ORAL 3 PA; LD; SP 2 PA; SP; QL MG/10ML, 240 MG/24ML, CAPSULE 40 MG/4ML *ANTINEOPLASTIC - *ANTINEOPLASTIC - BISPECIFIC T-CELL ANTI-PD-L1 ENGAGERS*** ANTIBODIES*** BLINCYTO BAVENCIO INTRAVENOUS 3 PA; LD; SP INTRAVENOUS 3 PA; LD SOLUTION SOLUTION RECONSTITUTED IMFINZI INTRAVENOUS 3 PA; LD; SP *ANTINEOPLASTIC - SOLUTION BRAF KINASE TECENTRIQ INHIBITORS*** INTRAVENOUS 3 PA; LD; SP BRAFTOVI ORAL 3 PA; LD; SP; QL SOLUTION CAPSULE 75 MG *ANTINEOPLASTIC - TAFINLAR ORAL 3 PA; LD; SP; QL ANTI-SLAMF7 CAPSULE ANTIBODIES*** ZELBORAF ORAL 2 PA; LD; SP; QL EMPLICITI TABLET INTRAVENOUS 3 PA; LD; SP *ANTINEOPLASTIC - SOLUTION BTK INHIBITORS*** RECONSTITUTED BRUKINSA ORAL 3 PA; LD; QL CAPSULE CALQUENCE ORAL 3 PA; LD; QL CAPSULE IMBRUVICA ORAL 3 PA; LD; QL CAPSULE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 57 Drug Name Tier Notes Drug Name Tier Notes IMBRUVICA ORAL *ANTINEOPLASTIC - 3 PA; LD; QL TABLET HEDGEHOG PATHWAY *ANTINEOPLASTIC - INHIBITORS*** EGFR INHIBITORS*** DAURISMO ORAL 3 PA; LD; SP; QL ERBITUX TABLET INTRAVENOUS 3 PA; SP ERIVEDGE ORAL 2 PA; LD; SP; QL SOLUTION CAPSULE erlotinib hcl oral tablet 1 or 1b* PA; SP; QL ODOMZO ORAL 3 PA; LD; SP; QL GILOTRIF ORAL CAPSULE 3 PA; LD; QL TABLET *ANTINEOPLASTIC - IRESSA ORAL TABLET 2 PA; LD; SP; QL HIF-2-ALPHA INHIBITORS*** PORTRAZZA WELIREG ORAL INTRAVENOUS 3 LD; SP 3 LD SOLUTION TABLET TAGRISSO ORAL *ANTINEOPLASTIC - 3 PA; LD; SP; QL TABLET HISTONE DEACETYLASE TARCEVA ORAL 3 PA; LD; SP; QL INHIBITORS*** TABLET BELEODAQ VECTIBIX INTRAVENOUS INTRAVENOUS 3 PA; LD; SP 3 PA; SP SOLUTION SOLUTION 100 MG/5ML, RECONSTITUTED 400 MG/20ML FARYDAK ORAL VIZIMPRO ORAL 3 PA; LD; SP; QL 3 PA; LD; SP; QL CAPSULE TABLET ISTODAX (OVERFILL) *ANTINEOPLASTIC - INTRAVENOUS 3 PA; LD; SP FGFR KINASE SOLUTION INHIBITORS*** RECONSTITUTED BALVERSA ORAL 3 PA; LD; QL ROMIDEPSIN TABLET INTRAVENOUS 3 PA; LD; SP PEMAZYRE ORAL SOLUTION 3 PA; LD; QL TABLET ZOLINZA ORAL 2 PA; SP; QL TRUSELTIQ (100MG CAPSULE DAILY DOSE) ORAL 3 PA; LD; QL *ANTINEOPLASTIC - CAPSULE THERAPY HORMONAL AND PACK RELATED AGENT TRUSELTIQ (125MG COMBINATIONS*** DAILY DOSE) ORAL 3 PA; LD; QL LEUPROLIDE CAPSULE THERAPY ACETATE- PACK BUPIVACAINE 3 TRUSELTIQ (50MG INTRAMUSCULAR DAILY DOSE) ORAL SOLUTION 3 PA; LD; QL CAPSULE THERAPY *ANTINEOPLASTIC - PACK IMMUNOMODULATORS TRUSELTIQ (75MG *** DAILY DOSE) ORAL POMALYST ORAL 3 PA; LD; QL 3 PA; LD; SP; QL CAPSULE THERAPY CAPSULE PACK *ANTINEOPLASTIC - KRAS INHIBITORS*** LUMAKRAS ORAL 3 PA; LD; SP; QL TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 58 Drug Name Tier Notes Drug Name Tier Notes *ANTINEOPLASTIC - COMETRIQ (60 MG 3 PA; LD; SP; QL MEK INHIBITORS*** DAILY DOSE) ORAL KIT COTELLIC ORAL FOTIVDA ORAL 3 PA; LD; SP; QL 3 PA; LD; QL TABLET CAPSULE KOSELUGO ORAL lapatinib ditosylate oral 3 PA; LD; QL 1 or 1b* PA; SP; QL CAPSULE tablet MEKINIST ORAL NERLYNX ORAL 3 PA; LD; SP; QL 3 PA; LD; SP; QL TABLET TABLET MEKTOVI ORAL NEXAVAR ORAL 3 PA; LD; SP; QL 2 PA; LD; SP; QL TABLET TABLET *ANTINEOPLASTIC - QINLOCK ORAL 3 PA; LD; QL MET INHIBITORS*** TABLET TABRECTA ORAL RYDAPT ORAL 3 PA; LD; SP; QL 3 PA; SP; QL TABLET CAPSULE *ANTINEOPLASTIC - STIVARGA ORAL 2 PA; LD; SP; QL METHYLTRANSFERASE TABLET INHIBITORS*** sunitinib malate oral capsule 1 or 1b* PA; SP; QL TAZVERIK ORAL SUTENT ORAL 3 PA; LD; QL 2 PA; SP; QL TABLET CAPSULE *ANTINEOPLASTIC - TEPMETKO ORAL 3 PA; LD; QL MTOR KINASE TABLET INHIBITORS*** TURALIO ORAL 3 PA; LD; QL AFINITOR DISPERZ CAPSULE ORAL TABLET 3 PA; SP SOLUBLE TYKERB ORAL TABLET 3 PA; LD; SP; QL AFINITOR ORAL UKONIQ ORAL TABLET 3 PA; LD; QL 2 PA; SP TABLET 10 MG VOTRIENT ORAL 2 PA; LD; SP; QL AFINITOR ORAL TABLET TABLET 2.5 MG, 5 MG, 3 PA; SP XOSPATA ORAL 3 PA; LD; QL 7.5 MG TABLET everolimus oral tablet 2.5 1 or 1b* PA; SP *ANTINEOPLASTIC - mg, 5 mg, 7.5 mg MULTIPLE RECEPTOR temsirolimus intravenous ANTIBODIES*** 1 or 1b* PA; SP solution RYBREVANT TORISEL INTRAVENOUS 3 PA; LD; SP INTRAVENOUS 3 PA; SP SOLUTION SOLUTION *ANTINEOPLASTIC - *ANTINEOPLASTIC - PDGFR-ALPHA MULTIKINASE INHIBITORS*** INHIBITORS*** AYVAKIT ORAL 3 PA; LD; QL CABOMETYX ORAL TABLET 3 PA; LD; SP; QL TABLET *ANTINEOPLASTIC - CAPRELSA ORAL PROTEASOME 2 PA; LD; QL TABLET INHIBITORS*** COMETRIQ (100 MG BORTEZOMIB INTRAVENOUS DAILY DOSE) ORAL KIT 3 PA; LD; SP; QL 3 PA 80 & 20 MG SOLUTION RECONSTITUTED COMETRIQ (140 MG DAILY DOSE) ORAL KIT 3 PA; LD; SP; QL 3 X 20 MG & 80 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 59 Drug Name Tier Notes Drug Name Tier Notes KYPROLIS XPOVIO (80 MG TWICE INTRAVENOUS WEEKLY) ORAL 3 PA; LD; SP 3 PA; LD; QL SOLUTION TABLET THERAPY RECONSTITUTED PACK NINLARO ORAL *ANTINEOPLASTIC 3 PA; LD; SP; QL CAPSULE ANTIBIOTICS*** VELCADE INJECTION adriamycin intravenous 1 or 1b* SP SOLUTION 3 PA; SP solution RECONSTITUTED adriamycin intravenous *ANTINEOPLASTIC - solution reconstituted 10 mg, 1 or 1b* SP RET INHIBITORS*** 50 mg GAVRETO ORAL bleomycin sulfate injection 3 PA; LD; SP; QL 1 or 1b* SP CAPSULE solution reconstituted RETEVMO ORAL COSMEGEN 3 PA; LD; SP; QL CAPSULE INTRAVENOUS 3 SP *ANTINEOPLASTIC - SOLUTION TROPOMYOSIN RECONSTITUTED RECEPTOR KINASE dactinomycin intravenous 1 or 1b* SP INHIBITORS*** solution reconstituted ROZLYTREK ORAL DAUNORUBICIN HCL 3 PA; SP; QL CAPSULE INTRAVENOUS 3 SP VITRAKVI ORAL SOLUTION 3 PA; LD; SP; QL CAPSULE DOXIL INTRAVENOUS 3 PA; SP VITRAKVI ORAL INJECTABLE 3 PA; LD; SP; QL SOLUTION doxorubicin hcl intravenous 1 or 1b* SP *ANTINEOPLASTIC - solution XPO1 INHIBITORS*** doxorubicin hcl intravenous 1 or 1b* SP XPOVIO (100 MG ONCE solution reconstituted 10 mg WEEKLY) ORAL doxorubicin hcl liposomal 3 PA; LD; QL 1 or 1b* PA; SP TABLET THERAPY intravenous injectable PACK 50 MG ELLENCE XPOVIO (40 MG ONCE INTRAVENOUS 3 PA; SP WEEKLY) ORAL SOLUTION 3 PA; LD; QL TABLET THERAPY epirubicin hcl intravenous PACK 40 MG solution 200 mg/100ml, 50 1 or 1b* PA; SP XPOVIO (40 MG TWICE mg/25ml WEEKLY) ORAL 3 PA; LD; QL IDAMYCIN PFS TABLET THERAPY INTRAVENOUS 3 SP PACK 40 MG SOLUTION XPOVIO (60 MG ONCE idarubicin hcl intravenous WEEKLY) ORAL 1 or 1b* SP 3 PA; LD; QL solution TABLET THERAPY JELMYTO SOLUTION PACK 60 MG 3 PA; LD RECONSTITUTED XPOVIO (60 MG TWICE WEEKLY) ORAL mitomycin intravenous 3 PA; LD; QL 1 or 1b* SP TABLET THERAPY solution reconstituted PACK MITOMYCIN INTRAVESICAL XPOVIO (80 MG ONCE 3 WEEKLY) ORAL SOLUTION PREFILLED 3 PA; LD; QL TABLET THERAPY SYRINGE PACK 40 MG mitoxantrone hcl intravenous 1 or 1b* SP concentrate

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 60 Drug Name Tier Notes Drug Name Tier Notes mutamycin intravenous RITUXAN HYCELA 1 or 1b* SP solution reconstituted SUBCUTANEOUS 3 LD; SP valrubicin intravesical SOLUTION 1 or 1b* SP solution VYXEOS INTRAVENOUS SUSPENSION VALSTAR 3 LD; SP INTRAVESICAL 3 SP RECONSTITUTED 44-100 SOLUTION MG *ANTINEOPLASTIC - *ANTINEOPLASTIC ANTIBODY FOR ENZYMES*** RADIOPHARMACEUTIC ASPARLAS AL THERAPY*** INTRAVENOUS 3 PA; LD; SP ZEVALIN Y-90 SOLUTION 3 PA INTRAVENOUS KIT ERWINASE INJECTION *ANTINEOPLASTIC SOLUTION 3 PA; SP ANTIBODY-DRUG RECONSTITUTED COMPLEXES*** ONCASPAR INJECTION 3 PA; SP ENHERTU SOLUTION INTRAVENOUS RYLAZE 3 PA; LD; SP SOLUTION INTRAMUSCULAR 3 PA; LD RECONSTITUTED SOLUTION KADCYLA *ANTINEOPLASTIC INTRAVENOUS RADIOPHARMACEUTIC 3 PA; SP SOLUTION ALS*** RECONSTITUTED AZEDRA DOSIMETRIC *ANTINEOPLASTIC INTRAVENOUS 4 PA; LD COMBINATIONS*** SOLUTION DARZALEX FASPRO AZEDRA THERAPEUTIC SUBCUTANEOUS 3 PA; LD; SP INTRAVENOUS 4 PA; LD SOLUTION SOLUTION HERCEPTIN HYLECTA LUTATHERA SUBCUTANEOUS 3 SP INTRAVENOUS 3 PA; LD SOLUTION SOLUTION INQOVI ORAL TABLET 3 PA; LD; SP; QL QUADRAMET KISQALI FEMARA (400 INTRAVENOUS 3 MG DOSE) ORAL SOLUTION 2 PA; SP; QL TABLET THERAPY STRONTIUM CHLORIDE PACK SR-89 INTRAVENOUS 3 KISQALI FEMARA (600 SOLUTION MG DOSE) ORAL XOFIGO INTRAVENOUS 2 PA; SP; QL 3 PA TABLET THERAPY SOLUTION 30 MCCI/ML PACK *ANTINEOPLASTICS - KISQALI FEMARA(200 INTERLEUKINS*** MG DOSE) ORAL 2 PA; SP; QL ELZONRIS TABLET THERAPY INTRAVENOUS 3 PA; LD PACK SOLUTION LONSURF ORAL 3 PA; LD; SP PROLEUKIN TABLET INTRAVENOUS 3 PA; SP PHESGO SOLUTION SUBCUTANEOUS 3 PA; LD; SP RECONSTITUTED SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 61 Drug Name Tier Notes Drug Name Tier Notes *ANTINEOPLASTICS - exemestane oral tablet 1 or 1b* $0; QL PHOTOACTIVATED FEMARA ORAL TABLET 3 QL AGENTS*** letrozole oral tablet 1 or 1b* $0; QL PHOTOFRIN INTRAVENOUS *CARBOXYPEPTIDASE 3 SOLUTION ENZYME AGENTS*** RECONSTITUTED VORAXAZE UVADEX INJECTION INTRAVENOUS 3 3 LD SOLUTION SOLUTION RECONSTITUTED *ANTINEOPLASTICS MISC.*** *CARDIAC PROTECTIVE ACTIMMUNE AGENTS*** SUBCUTANEOUS 4 PA; LD; SP dexrazoxane hcl intravenous SOLUTION 1 or 1b* SP solution reconstituted ALFERON N INJECTION 4 SP SOLUTION TOTECT INTRAVENOUS SOLUTION 3 SP arsenic trioxide intravenous 1 or 1b* SP RECONSTITUTED solution *CHEMOTHERAPY dacarbazine intravenous 1 or 1b* SP ADJUNCTS - solution reconstituted HYPERURICEMIA HYDREA ORAL AGENTS*** 3 CAPSULE ELITEK INTRAVENOUS hydroxyurea oral capsule 1 or 1b* SOLUTION 3 PA; SP INTRON A INJECTION RECONSTITUTED 4 LD; SP SOLUTION *CHEMOTHERAPY INTRON A INJECTION ADJUNCTS - SOLUTION 4 LD; SP KERATINOCYTE RECONSTITUTED GROWTH FACTORS*** MATULANE ORAL KEPIVANCE 2 LD INTRAVENOUS CAPSULE 4 SOLUTION NIPENT INTRAVENOUS RECONSTITUTED SOLUTION 3 SP RECONSTITUTED *CYCLIN-DEPENDENT KINASES (CDK) SYNRIBO INHIBITORS*** SUBCUTANEOUS 3 PA; LD IBRANCE ORAL SOLUTION 2 PA; LD; SP; QL RECONSTITUTED CAPSULE IBRANCE ORAL TICE BCG 2 PA; LD; SP; QL INTRAVESICAL TABLET 4 SP SUSPENSION KISQALI (200 MG DOSE) RECONSTITUTED ORAL TABLET 2 PA; SP; QL TRISENOX THERAPY PACK INTRAVENOUS 3 SP KISQALI (400 MG DOSE) SOLUTION 12 MG/6ML ORAL TABLET 2 PA; SP; QL *AROMATASE THERAPY PACK INHIBITORS*** KISQALI (600 MG DOSE) anastrozole oral tablet 1 or 1b* $0; QL ORAL TABLET 2 PA; SP; QL THERAPY PACK ARIMIDEX ORAL 3 QL VERZENIO ORAL TABLET 3 PA; LD; SP; QL TABLET AROMASIN ORAL 3 QL TABLET * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 62 Drug Name Tier Notes Drug Name Tier Notes *ESTROGEN RECEPTOR temozolomide oral capsule 1 or 1b* PA; SP; QL ANTAGONIST*** *ISOCITRATE FASLODEX DEHYDROGENASE-1 INTRAMUSCULAR 3 PA; SP (IDH1) INHIBITORS*** SOLUTION 250 MG/5ML TIBSOVO ORAL 3 PA; LD; QL fulvestrant intramuscular TABLET 1 or 1b* PA; SP solution *ISOCITRATE *ESTROGENS- DEHYDROGENASE-2 ANTINEOPLASTIC*** (IDH2) INHIBITORS*** EMCYT ORAL CAPSULE 2 PA IDHIFA ORAL TABLET 3 PA; LD; SP; QL *FOLIC ACID *JANUS ASSOCIATED ANTAGONISTS RESCUE KINASE (JAK) AGENTS*** INHIBITORS*** KHAPZORY INREBIC ORAL 3 PA; LD; SP; QL INTRAVENOUS CAPSULE 3 PA; LD; SP SOLUTION JAKAFI ORAL TABLET 2 PA; LD; SP; QL RECONSTITUTED *LHRH ANALOGS*** leucovorin calcium injection 1 or 1b* ELIGARD solution 3 PA; SP; QL SUBCUTANEOUS KIT leucovorin calcium injection 1 or 1b* leuprolide acetate injection solution reconstituted 1 or 1b* PA; SP kit leucovorin calcium oral 1 or 1b* tablet LUPRON DEPOT (1- MONTH) 4 PA; SP; QL levoleucovorin calcium INTRAMUSCULAR KIT intravenous solution 1 or 1b* PA 3.75 MG reconstituted 50 mg LUPRON DEPOT (1- levoleucovorin calcium pf MONTH) 1 or 1b* 3 PA; SP; QL intravenous solution INTRAMUSCULAR KIT *GONADOTROPIN 7.5 MG RELEASING HORMONE LUPRON DEPOT (3- (GNRH) MONTH) 4 PA; SP; QL ANTAGONISTS*** INTRAMUSCULAR KIT FIRMAGON (240 MG 11.25 MG DOSE) SUBCUTANEOUS 3 PA; SP; QL LUPRON DEPOT (3- SOLUTION MONTH) 3 PA; SP; QL RECONSTITUTED INTRAMUSCULAR KIT FIRMAGON 22.5 MG SUBCUTANEOUS 3 PA; SP; QL LUPRON DEPOT (4- SOLUTION MONTH) 3 PA; SP; QL RECONSTITUTED 80 MG INTRAMUSCULAR KIT ORGOVYX ORAL 3 PA; LD; QL LUPRON DEPOT (6- TABLET MONTH) 3 PA; SP; QL *IMIDAZOTETRAZINES INTRAMUSCULAR KIT *** TRELSTAR MIXJECT TEMODAR INTRAMUSCULAR 3 PA; SP; QL INTRAVENOUS SUSPENSION 2 PA; SP SOLUTION RECONSTITUTED RECONSTITUTED VANTAS 3 PA; SP; QL TEMODAR ORAL SUBCUTANEOUS KIT CAPSULE 100 MG, 140 3 PA; SP; QL MG, 180 MG, 250 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 63 Drug Name Tier Notes Drug Name Tier Notes ZOLADEX vinorelbine tartrate 1 or 1b* SP SUBCUTANEOUS 3 PA; SP; QL intravenous solution IMPLANT *MYELOPROTECTIVE *MITOTIC AGENTS*** INHIBITORS*** COSELA INTRAVENOUS ABRAXANE SOLUTION 3 PA; LD INTRAVENOUS RECONSTITUTED 3 PA; SP SUSPENSION *NITROGEN RECONSTITUTED MUSTARDS*** DOCETAXEL ALKERAN INTRAVENOUS INTRAVENOUS 3 SP CONCENTRATE 160 3 PA; SP SOLUTION MG/8ML, 20 MG/ML, 80 RECONSTITUTED MG/4ML ALKERAN ORAL 3 SP DOCETAXEL TABLET INTRAVENOUS cyclophosphamide injection SOLUTION 160 3 PA; SP 1 or 1b* SP MG/16ML, 20 MG/2ML, solution reconstituted 80 MG/8ML CYCLOPHOSPHAMIDE ETOPOPHOS INTRAVENOUS 3 SP INTRAVENOUS SOLUTION 3 SP SOLUTION cyclophosphamide oral 1 or 1b* SP RECONSTITUTED capsule etoposide intravenous CYCLOPHOSPHAMIDE 3 solution 1 gm/50ml, 100 1 or 1b* SP ORAL TABLET mg/5ml, 500 mg/25ml EVOMELA etoposide oral capsule 1 or 1b* SP INTRAVENOUS 3 LD; SP HALAVEN SOLUTION INTRAVENOUS 3 PA; SP RECONSTITUTED SOLUTION IFEX INTRAVENOUS IXEMPRA KIT SOLUTION 3 SP INTRAVENOUS RECONSTITUTED 3 PA; SP SOLUTION ifosfamide intravenous 1 or 1b* SP RECONSTITUTED solution JEVTANA ifosfamide intravenous 1 or 1b* SP INTRAVENOUS 3 PA; SP solution reconstituted 1 gm SOLUTION IFOSFAMIDE MARQIBO INTRAVENOUS 3 SP INTRAVENOUS 3 LD SOLUTION SUSPENSION RECONSTITUTED 3 GM NAVELBINE LEUKERAN ORAL 2 INTRAVENOUS 3 SP TABLET SOLUTION melphalan hcl intravenous paclitaxel intravenous 1 or 1b* SP 1 or 1b* SP solution reconstituted concentrate melphalan oral tablet 1 or 1b* SP toposar intravenous solution 1 gm/50ml, 100 mg/5ml, 500 1 or 1b* SP PEPAXTO INTRAVENOUS mg/25ml 3 PA; LD SOLUTION vinblastine sulfate 1 or 1b* SP RECONSTITUTED intravenous solution vincristine sulfate 1 or 1b* SP intravenous solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 64 Drug Name Tier Notes Drug Name Tier Notes *NITROSOUREAS*** *PROGESTINS- BICNU INTRAVENOUS ANTINEOPLASTIC*** SOLUTION 3 SP hydroxyprogesterone RECONSTITUTED caproate intramuscular 1 or 1b* PA carmustine intravenous solution 1 or 1b* SP solution reconstituted megestrol acetate oral GLEOSTINE ORAL suspension 40 mg/ml, 400 1 or 1b* CAPSULE 10 MG, 100 3 PA mg/10ml MG, 40 MG megestrol acetate oral tablet 1 or 1b* GLIADEL WAFER *RETINOIDS*** 3 IMPLANT WAFER tretinoin oral capsule 1 or 1b* ZANOSAR *SELECTIVE RETINOID INTRAVENOUS 3 SP X RECEPTOR SOLUTION AGONISTS*** RECONSTITUTED bexarotene oral capsule 1 or 1b* PA; SP; QL *ONCOLYTIC VIRAL TARGRETIN ORAL AGENTS - HSV1*** 3 PA; SP; QL CAPSULE IMLYGIC INTRALESIONAL 3 LD *TETRAHYDROISOQUI SUSPENSION NOLINES*** *PHOSPHATIDYLINOSI YONDELIS INTRAVENOUS TOL 3-KINASE (PI3K) 3 LD; SP INHIBITORS*** SOLUTION RECONSTITUTED ALIQOPA INTRAVENOUS *TOPOISOMERASE I 3 PA; LD SOLUTION INHIBITORS - RECONSTITUTED ANTIBODY-DRUG COMPLEX*** COPIKTRA ORAL 3 PA; LD; QL CAPSULE TRODELVY INTRAVENOUS 3 PA; LD PIQRAY (200 MG DAILY SOLUTION DOSE) ORAL TABLET 3 PA; SP; QL RECONSTITUTED THERAPY PACK *TOPOISOMERASE I PIQRAY (250 MG DAILY INHIBITORS*** DOSE) ORAL TABLET 3 PA; SP; QL THERAPY PACK CAMPTOSAR INTRAVENOUS 3 SP PIQRAY (300 MG DAILY SOLUTION DOSE) ORAL TABLET 3 PA; SP; QL THERAPY PACK HYCAMTIN INTRAVENOUS ZYDELIG ORAL 3 SP 3 PA; LD; SP; QL SOLUTION TABLET RECONSTITUTED *POLY (ADP-RIBOSE) HYCAMTIN ORAL 2 PA; SP POLYMERASE (PARP) CAPSULE INHIBITORS*** irinotecan hcl intravenous LYNPARZA ORAL 1 or 1b* SP 3 PA; LD; SP; QL solution TABLET ONIVYDE RUBRACA ORAL 3 PA; LD; SP; QL INTRAVENOUS 3 LD TABLET INJECTABLE TALZENNA ORAL 3 PA; LD; SP; QL TOPOTECAN HCL CAPSULE INTRAVENOUS 3 SP ZEJULA ORAL SOLUTION 3 PA; LD; QL CAPSULE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 65 Drug Name Tier Notes Drug Name Tier Notes topotecan hcl intravenous ZALTRAP 1 or 1b* SP solution reconstituted INTRAVENOUS 3 PA; LD; SP *URINARY TRACT SOLUTION PROTECTIVE ZIRABEV AGENTS*** INTRAVENOUS 3 PA; SP ETHYOL SOLUTION INTRAVENOUS *ANTIPARKINSON AND 3 PA; SP SOLUTION RELATED THERAPY RECONSTITUTED AGENTS* mesna intravenous solution 1 or 1b* PA *ADENOSINE MESNEX RECEPTOR INTRAVENOUS 3 PA ANTAGONIST*** SOLUTION NOURIANZ ORAL 4 PA; SP; QL MESNEX ORAL TABLET 2 PA TABLET *VASCULAR *ANTIPARKINSON ENDOTHELIAL ANTICHOLINERGICS*** GROWTH FACTOR benztropine mesylate 1 or 1a* (VEGF) INHIBITORS*** injection solution AVASTIN benztropine mesylate oral 1 or 1a* INTRAVENOUS 3 PA; SP tablet SOLUTION COGENTIN INJECTION 3 CYRAMZA SOLUTION INTRAVENOUS 3 PA; LD; SP trihexyphenidyl hcl oral 1 or 1a* SOLUTION solution INLYTA ORAL TABLET 2 PA; LD; SP; QL trihexyphenidyl hcl oral 1 or 1a* LENVIMA (10 MG DAILY tablet DOSE) ORAL CAPSULE 3 PA; LD; SP; QL *ANTIPARKINSON THERAPY PACK DOPAMINERGICS*** LENVIMA (12 MG DAILY amantadine hcl oral capsule 1 or 1b* QL DOSE) ORAL CAPSULE 3 PA; LD; SP; QL THERAPY PACK amantadine hcl oral syrup 1 or 1b* QL LENVIMA (14 MG DAILY amantadine hcl oral tablet 1 or 1b* QL DOSE) ORAL CAPSULE 3 PA; LD; SP; QL bromocriptine mesylate oral 1 or 1b* THERAPY PACK capsule LENVIMA (18 MG DAILY bromocriptine mesylate oral 1 or 1b* DOSE) ORAL CAPSULE 3 PA; LD; SP; QL tablet THERAPY PACK GOCOVRI ORAL LENVIMA (20 MG DAILY CAPSULE EXTENDED 3 PA; QL DOSE) ORAL CAPSULE 3 PA; LD; SP; QL RELEASE 24 HOUR 137 THERAPY PACK MG LENVIMA (24 MG DAILY GOCOVRI ORAL DOSE) ORAL CAPSULE 3 PA; LD; SP; QL CAPSULE EXTENDED 3 PA; DO THERAPY PACK RELEASE 24 HOUR 68.5 LENVIMA (4 MG DAILY MG DOSE) ORAL CAPSULE 3 PA; LD; SP; QL INBRIJA INHALATION 4 PA; LD; QL THERAPY PACK CAPSULE LENVIMA (8 MG DAILY OSMOLEX ER ORAL DOSE) ORAL CAPSULE 3 PA; LD; SP; QL TABLET ER 24 HOUR 3 PA; QL THERAPY PACK THERAPY PACK MVASI INTRAVENOUS 3 PA; SP SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 66 Drug Name Tier Notes Drug Name Tier Notes OSMOLEX ER ORAL RYTARY ORAL TABLET EXTENDED CAPSULE EXTENDED 3 3 PA; DO RELEASE 24 HOUR 129 RELEASE MG SINEMET ORAL OSMOLEX ER ORAL TABLET 10-100 MG, 25- 3 TABLET EXTENDED 100 MG 3 PA; QL RELEASE 24 HOUR 193 STALEVO 100 ORAL 3 MG, 258 MG TABLET PARLODEL ORAL STALEVO 125 ORAL 3 3 CAPSULE TABLET PARLODEL ORAL STALEVO 150 ORAL 3 3 TABLET TABLET *ANTIPARKINSON STALEVO 200 ORAL 3 MONOAMINE OXIDASE TABLET INHIBITORS*** STALEVO 50 ORAL AZILECT ORAL 3 3 TABLET TABLET STALEVO 75 ORAL rasagiline mesylate oral 3 1 or 1b* TABLET tablet *NONERGOLINE selegiline hcl oral capsule 1 or 1b* DOPAMINE RECEPTOR selegiline hcl oral tablet 1 or 1b* AGONISTS*** XADAGO ORAL TABLET 3 PA; QL APOKYN ZELAPAR ORAL SUBCUTANEOUS 4 PA; LD; SP; QL 3 PA; QL TABLET DISPERSIBLE SOLUTION CARTRIDGE KYNMOBI SUBLINGUAL *CENTRAL/PERIPHERA 3 PA; LD; QL L COMT INHIBITORS*** FILM TASMAR ORAL TABLET MIRAPEX ER ORAL 3 PA; QL 100 MG TABLET EXTENDED 3 QL RELEASE 24 HOUR tolcapone oral tablet 1 or 1b* PA; QL NEUPRO *DECARBOXYLASE TRANSDERMAL PATCH 3 QL INHIBITORS*** 24 HOUR carbidopa oral tablet 1 or 1b* pramipexole dihydrochloride LODOSYN ORAL er oral tablet extended 1 or 1b* QL 3 TABLET release 24 hour pramipexole dihydrochloride *LEVODOPA 1 or 1b* QL COMBINATIONS*** oral tablet ropinirole hcl er oral tablet carbidopa-levodopa er oral 1 or 1b* tablet extended release 25- 1 or 1b* extended release 24 hour 100 mg, 50-200 mg ropinirole hcl oral tablet 1 or 1b* carbidopa-levodopa oral 1 or 1b* *PERIPHERAL COMT tablet INHIBITORS*** CARBIDOPA- COMTAN ORAL 3 QL LEVODOPA ORAL 1 or 1b* TABLET TABLET DISPERSIBLE entacapone oral tablet 1 or 1b* QL carbidopa-levodopa- 1 or 1b* ONGENTYS ORAL entacapone oral tablet 3 PA; QL CAPSULE DUOPA ENTERAL 3 PA; LD; SP SUSPENSION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 67 Drug Name Tier Notes Drug Name Tier Notes *ANTIPSYCHOTICS/ANT *BENZISOXAZOLES*** IMANIC AGENTS* FANAPT ORAL TABLET 3 ST; DO *ANTIMANIC 1 MG, 2 MG, 4 MG, 6 MG AGENTS*** FANAPT ORAL TABLET 3 ST; QL lithium carbonate er oral 10 MG, 12 MG, 8 MG 1 or 1a* tablet extended release FANAPT TITRATION 3 ST; QL lithium carbonate oral PACK ORAL TABLET 1 or 1a* capsule INVEGA ORAL TABLET lithium carbonate oral tablet 1 or 1a* EXTENDED RELEASE 24 3 ST; DO LITHOBID ORAL HOUR 1.5 MG, 3 MG TABLET EXTENDED 3 INVEGA ORAL TABLET RELEASE EXTENDED RELEASE 24 3 ST; QL *ANTIPSYCHOTICS - HOUR 6 MG, 9 MG MISC.*** INVEGA SUSTENNA CAPLYTA ORAL INTRAMUSCULAR 3 ST; QL 3 QL CAPSULE SUSPENSION PREFILLED SYRINGE EQUETRO ORAL CAPSULE EXTENDED 3 PA; QL INVEGA TRINZA INTRAMUSCULAR RELEASE 12 HOUR 3 QL SUSPENSION GEODON PREFILLED SYRINGE INTRAMUSCULAR 3 SOLUTION paliperidone er oral tablet RECONSTITUTED extended release 24 hour 1.5 1 or 1b* DO mg, 3 mg GEODON ORAL 3 ST; DO CAPSULE 20 MG, 40 MG paliperidone er oral tablet extended release 24 hour 6 1 or 1b* QL GEODON ORAL 3 ST; QL mg, 9 mg CAPSULE 60 MG, 80 MG PERSERIS LATUDA ORAL TABLET 3 QL SUBCUTANEOUS 3 QL 120 MG, 80 MG PREFILLED SYRINGE LATUDA ORAL TABLET 3 DO RISPERDAL CONSTA 20 MG, 40 MG, 60 MG INTRAMUSCULAR 2 QL NUPLAZID ORAL SUSPENSION 4 PA; LD; SP; QL CAPSULE RECONSTITUTED ER NUPLAZID ORAL RISPERDAL ORAL 4 PA; LD; SP; QL 3 ST; QL TABLET 10 MG SOLUTION VRAYLAR ORAL RISPERDAL ORAL 3 ST; DO CAPSULE 1.5 MG, 3 MG TABLET 0.5 MG, 1 MG, 2 3 ST; DO MG VRAYLAR ORAL 3 ST; QL RISPERDAL ORAL CAPSULE 4.5 MG, 6 MG 3 ST; QL TABLET 3 MG, 4 MG VRAYLAR ORAL CAPSULE THERAPY 3 ST; QL risperidone oral solution 1 or 1b* ST; QL PACK risperidone oral tablet 0.25 1 or 1b* DO ziprasidone hcl oral capsule mg, 0.5 mg, 1 mg, 2 mg 1 or 1b* DO 20 mg, 40 mg risperidone oral tablet 3 mg, 1 or 1b* QL ziprasidone hcl oral capsule 4 mg 1 or 1b* QL 60 mg, 80 mg risperidone oral tablet 1 or 1b* PA; DO ziprasidone mesylate dispersible 0.25 mg intramuscular solution 1 or 1b* risperidone oral tablet reconstituted dispersible 0.5 mg, 1 mg, 2 1 or 1b* DO mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 68 Drug Name Tier Notes Drug Name Tier Notes risperidone oral tablet *DIBENZOTHIAZEPINE 1 or 1b* QL dispersible 3 mg, 4 mg S*** *BUTYROPHENONES*** fumarate er oral HALDOL DECANOATE tablet extended release 24 1 or 1b* DO INTRAMUSCULAR 3 QL hour 150 mg, 200 mg SOLUTION quetiapine fumarate er oral haloperidol decanoate tablet extended release 24 1 or 1b* QL intramuscular solution 100 1 or 1b* QL hour 300 mg, 400 mg, 50 mg mg/ml, 50 mg/ml quetiapine fumarate oral 1 or 1b* DO haloperidol lactate injection tablet 100 mg, 25 mg, 50 mg 1 or 1b* solution 5 mg/ml quetiapine fumarate oral haloperidol lactate oral tablet 200 mg, 300 mg, 400 1 or 1b* QL 1 or 1b* concentrate mg haloperidol oral tablet 1 or 1b* SEROQUEL ORAL TABLET 100 MG, 25 MG, 3 ST; DO *DIBENZODIAZEPINES* 50 MG ** SEROQUEL ORAL oral tablet 100 mg, 1 or 1b* QL TABLET 200 MG, 300 3 ST; QL 200 mg MG, 400 MG clozapine oral tablet 25 mg, 1 or 1b* DO SEROQUEL XR ORAL 50 mg TABLET EXTENDED 3 ST; DO clozapine oral tablet RELEASE 24 HOUR 150 dispersible 100 mg, 150 mg, 1 or 1b* QL MG, 200 MG 200 mg SEROQUEL XR ORAL clozapine oral tablet TABLET EXTENDED 1 or 1b* DO 3 ST; QL dispersible 12.5 mg, 25 mg RELEASE 24 HOUR 300 MG, 400 MG, 50 MG CLOZARIL ORAL 3 QL TABLET 100 MG, 200 MG *DIBENZOXAZEPINES** * CLOZARIL ORAL 3 DO TABLET 25 MG, 50 MG ADASUVE INHALATION AEROSOL POWDER 3 VERSACLOZ ORAL 3 QL BREATH ACTIVATED SUSPENSION succinate oral *DIBENZO-OXEPINO 1 or 1b* capsule PYRROLES*** *DIHYDROINDOLONES* maleate sublingual 1 or 1b* QL ** tablet sublingual 10 mg molindone hcl oral tablet 1 or 1b* asenapine maleate sublingual tablet sublingual 2.5 mg, 5 1 or 1b* DO *PHENOTHIAZINES*** mg hcl injection 1 or 1b* SAPHRIS SUBLINGUAL solution TABLET SUBLINGUAL 3 ST; QL CHLORPROMAZINE 10 MG HCL ORAL 3 SAPHRIS SUBLINGUAL CONCENTRATE TABLET SUBLINGUAL 3 ST; DO chlorpromazine hcl oral 1 or 1b* 2.5 MG, 5 MG tablet SECUADO compro rectal suppository 1 or 1b* TRANSDERMAL PATCH 3 ST; QL decanoate 24 HOUR 1 or 1b* injection solution fluphenazine hcl injection 1 or 1b* solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 69 Drug Name Tier Notes Drug Name Tier Notes fluphenazine hcl oral aripiprazole oral tablet 10 1 or 1b* 1 or 1b* DO concentrate mg, 15 mg, 2 mg, 5 mg fluphenazine hcl oral elixir 1 or 1b* aripiprazole oral tablet 20 1 or 1b* QL fluphenazine hcl oral tablet 1 or 1b* mg, 30 mg aripiprazole oral tablet oral tablet 1 or 1b* 1 or 1b* QL dispersible edisylate injection solution 10 mg/2ml, 1 or 1b* ARISTADA INITIO 50 mg/10ml INTRAMUSCULAR 3 QL PREFILLED SYRINGE prochlorperazine maleate 1 or 1a* oral tablet ARISTADA INTRAMUSCULAR prochlorperazine rectal 3 PA 1 or 1b* PREFILLED SYRINGE suppository 1064 MG/3.9ML hcl oral tablet 1 or 1b* ARISTADA hcl oral tablet 1 or 1b* INTRAMUSCULAR PREFILLED SYRINGE *QUINOLINONE 3 441 MG/1.6ML, 662 DERIVATIVES*** MG/2.4ML, 882 ABILIFY MAINTENA MG/3.2ML INTRAMUSCULAR 3 REXULTI ORAL PREFILLED SYRINGE TABLET 0.25 MG, 0.5 3 ST; DO ABILIFY MAINTENA MG, 1 MG, 2 MG INTRAMUSCULAR REXULTI ORAL 3 QL 3 ST; QL SUSPENSION TABLET 3 MG, 4 MG RECONSTITUTED ER *THIENBENZODIAZEPI ABILIFY MYCITE NES*** MAINTENANCE KIT 3 ST; DO intramuscular ORAL TABLET 10 MG, 1 or 1b* PA 15 MG, 2 MG, 5 MG solution reconstituted olanzapine oral tablet 10 mg, ABILIFY MYCITE 1 or 1b* DO MAINTENANCE KIT 2.5 mg, 5 mg, 7.5 mg 3 ST; QL ORAL TABLET 20 MG, olanzapine oral tablet 15 mg, 1 or 1b* QL 30 MG 20 mg ABILIFY MYCITE ORAL olanzapine oral tablet 1 or 1b* DO TABLET 10 MG, 15 MG, 2 3 ST; DO dispersible 10 mg, 5 mg MG, 5 MG olanzapine oral tablet ABILIFY MYCITE ORAL 1 or 1b* QL 3 ST; QL dispersible 15 mg, 20 mg TABLET 20 MG, 30 MG ZYPREXA ABILIFY MYCITE INTRAMUSCULAR STARTER KIT ORAL 3 PA 3 ST; DO SOLUTION TABLET 10 MG, 15 MG, 2 RECONSTITUTED MG, 5 MG ZYPREXA ORAL ABILIFY MYCITE TABLET 10 MG, 2.5 MG, 3 ST; DO STARTER KIT ORAL 3 ST; QL 5 MG, 7.5 MG TABLET 20 MG, 30 MG ZYPREXA ORAL 3 ST; QL ABILIFY ORAL TABLET TABLET 15 MG, 20 MG 10 MG, 15 MG, 2 MG, 5 3 ST; DO MG ZYPREXA RELPREVV INTRAMUSCULAR ABILIFY ORAL TABLET 3 3 ST; QL SUSPENSION 20 MG, 30 MG RECONSTITUTED aripiprazole oral solution 1 or 1b* QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 70 Drug Name Tier Notes Drug Name Tier Notes ZYPREXA ZYDIS ORAL COMPLERA ORAL 3 PA; QL TABLET DISPERSIBLE 3 ST; DO TABLET 10 MG, 5 MG DELSTRIGO ORAL 3 QL ZYPREXA ZYDIS ORAL TABLET TABLET DISPERSIBLE 3 ST; QL DESCOVY ORAL 3 $0; QL 15 MG, 20 MG TABLET **** DOVATO ORAL TABLET 2 QL thiothixene oral capsule 1 or 1b* PA efavirenz-emtricitab- 1 or 1b* QL *ANTISEPTICS & tenofovir oral tablet DISINFECTANTS* efavirenz-lamivudine- 1 or 1b* QL *ANTISEPTICS & tenofovir oral tablet DISINFECTANTS*** emtricitabine-tenofovir df FORMALDEHYDE oral tablet 100-150 mg, 133- 1 or 1b* QL EXTERNAL SOLUTION 3 200 mg, 167-250 mg 37 % emtricitabine-tenofovir df 1 or 1b* $0; QL GLUTARALDEHYDE oral tablet 200-300 mg 2 EXTERNAL SOLUTION EPZICOM ORAL 3 QL *CHLORINE TABLET ANTISEPTICS*** EVOTAZ ORAL TABLET 3 QL BENZALKONIUM GENVOYA ORAL 2 QL CHLORIDE EXTERNAL 3 TABLET SOLUTION , 50 % JULUCA ORAL TABLET 3 PA; QL *IODINE KALETRA ORAL ANTISEPTICS*** 3 QL SOLUTION IODINE TINCTURE KALETRA ORAL EXTERNAL TINCTURE 2 3 2 QL % TABLET IODOFLEX EXTERNAL lamivudine-zidovudine oral 3 1 or 1b* QL PAD tablet IODOSORB EXTERNAL lopinavir-ritonavir oral 3 1 or 1b* QL GEL solution *ANTIVIRALS* lopinavir-ritonavir oral tablet 1 or 1b* QL ODEFSEY ORAL *ANTIRETROVIRAL 3 PA; QL COMBINATIONS*** TABLET abacavir sulfate-lamivudine PREZCOBIX ORAL 1 or 1b* QL 3 QL oral tablet TABLET abacavir-lamivudine- STRIBILD ORAL 1 or 1b* QL 2 QL zidovudine oral tablet TABLET ATRIPLA ORAL SYMFI LO ORAL 3 QL 3 QL TABLET TABLET BIKTARVY ORAL SYMFI ORAL TABLET 3 QL 2 QL TABLET SYMTUZA ORAL 3 QL CABENUVA TABLET INTRAMUSCULAR TEMIXYS ORAL 3 PA; LD; QL 3 QL SUSPENSION TABLET EXTENDED RELEASE TRIUMEQ ORAL 2 QL CIMDUO ORAL TABLET 3 QL TABLET COMBIVIR ORAL TRIZIVIR ORAL 3 QL 3 QL TABLET TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 71 Drug Name Tier Notes Drug Name Tier Notes TRUVADA ORAL atazanavir sulfate oral 1 or 1b* QL TABLET 100-150 MG, 2 ST; QL capsule 133-200 MG, 167-250 MG CRIXIVAN ORAL 2 QL TRUVADA ORAL CAPSULE 400 MG 3 ST; QL TABLET 200-300 MG fosamprenavir calcium oral 1 or 1b* QL *ANTIRETROVIRALS - tablet CCR5 ANTAGONISTS INVIRASE ORAL 2 QL (ENTRY INHIBITOR)*** TABLET SELZENTRY ORAL LEXIVA ORAL 3 QL 2 QL SOLUTION SUSPENSION SELZENTRY ORAL 2 QL LEXIVA ORAL TABLET 3 QL TABLET NORVIR ORAL PACKET 3 QL *ANTIRETROVIRALS - NORVIR ORAL CD4-DIRECTED POST- 2 QL ATTACHMENT SOLUTION INHIBITOR*** NORVIR ORAL TABLET 3 QL TROGARZO PREZISTA ORAL 2 QL INTRAVENOUS 3 PA; LD; QL SUSPENSION SOLUTION PREZISTA ORAL *ANTIRETROVIRALS - TABLET 150 MG, 600 2 QL FUSION INHIBITORS*** MG, 75 MG, 800 MG FUZEON REYATAZ ORAL SUBCUTANEOUS 2 PA; QL CAPSULE 150 MG, 200 3 QL SOLUTION MG, 300 MG RECONSTITUTED REYATAZ ORAL 2 QL *ANTIRETROVIRALS - PACKET GP120-DIRECTED ATTACHMENT ritonavir oral tablet 1 or 1b* QL INHIBITOR*** VIRACEPT ORAL 2 QL RUKOBIA ORAL TABLET TABLET EXTENDED 3 PA; LD; QL *ANTIRETROVIRALS - RELEASE 12 HOUR RTI-NON-NUCLEOSIDE *ANTIRETROVIRALS - ANALOGUES*** INTEGRASE EDURANT ORAL 2 PA; QL INHIBITORS*** TABLET ISENTRESS HD ORAL efavirenz oral capsule 1 or 1b* QL 3 QL TABLET efavirenz oral tablet 1 or 1b* QL ISENTRESS ORAL 3 QL etravirine oral tablet 1 or 1b* PA; QL PACKET INTELENCE ORAL ISENTRESS ORAL 2 PA; QL 2 QL TABLET TABLET nevirapine er oral tablet ISENTRESS ORAL 1 or 1b* QL 2 QL extended release 24 hour TABLET CHEWABLE nevirapine oral suspension 1 or 1b* QL TIVICAY ORAL TABLET 3 LD; QL nevirapine oral tablet 1 or 1b* QL TIVICAY PD ORAL 3 LD; QL PIFELTRO ORAL TABLET SOLUBLE 3 QL TABLET *ANTIRETROVIRALS - SUSTIVA ORAL PROTEASE 3 QL INHIBITORS*** CAPSULE APTIVUS ORAL SUSTIVA ORAL TABLET 3 QL 2 PA; QL CAPSULE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 72 Drug Name Tier Notes Drug Name Tier Notes VIRAMUNE ORAL *ANTIRETROVIRALS - 3 QL SUSPENSION RTI-NUCLEOTIDE VIRAMUNE XR ORAL ANALOGUES*** TABLET EXTENDED tenofovir disoproxil fumarate 3 QL 1 or 1b* $0; QL RELEASE 24 HOUR 400 oral tablet MG VIREAD ORAL POWDER 2 QL *ANTIRETROVIRALS - VIREAD ORAL TABLET 2 QL RTI-NUCLEOSIDE 150 MG, 200 MG, 250 MG ANALOGUES- VIREAD ORAL TABLET PURINES*** 3 QL 300 MG abacavir sulfate oral solution 1 or 1b* QL *ANTIRETROVIRALS abacavir sulfate oral tablet 1 or 1b* QL ADJUVANTS*** ZIAGEN ORAL 3 QL TYBOST ORAL TABLET 3 QL SOLUTION *CMV AGENTS*** ZIAGEN ORAL TABLET 3 QL cidofovir intravenous 1 or 1b* *ANTIRETROVIRALS - solution RTI-NUCLEOSIDE foscarnet sodium intravenous ANALOGUES- 1 or 1b* PYRIMIDINES*** solution 6000 mg/250ml emtricitabine oral capsule 1 or 1b* $0; QL FOSCAVIR INTRAVENOUS EMTRIVA ORAL 3 3 QL SOLUTION 6000 CAPSULE MG/250ML EMTRIVA ORAL 2 QL GANCICLOVIR SOLUTION INTRAVENOUS 4 SP EPIVIR ORAL SOLUTION 3 QL SOLUTION GANCICLOVIR SODIUM EPIVIR ORAL TABLET 3 QL INTRAVENOUS 4 SP lamivudine oral solution 1 or 1b* QL SOLUTION lamivudine oral tablet 150 ganciclovir sodium 1 or 1b* QL mg, 300 mg intravenous solution 4 SP reconstituted *ANTIRETROVIRALS - RTI-NUCLEOSIDE PREVYMIS ANALOGUES- INTRAVENOUS 4 PA; SP; QL THYMIDINES*** SOLUTION PREVYMIS ORAL RETROVIR 4 PA; SP; QL INTRAVENOUS 2 TABLET SOLUTION VALCYTE ORAL RETROVIR ORAL SOLUTION 3 3 QL CAPSULE RECONSTITUTED RETROVIR ORAL VALCYTE ORAL 3 QL 3 SYRUP TABLET valganciclovir hcl oral stavudine oral capsule 1 or 1b* QL 1 or 1b* solution reconstituted zidovudine oral capsule 1 or 1b* QL valganciclovir hcl oral tablet 1 or 1b* zidovudine oral syrup 1 or 1b* QL *HEPATITIS B zidovudine oral tablet 1 or 1b* QL AGENTS*** adefovir dipivoxil oral tablet 4 SP; QL BARACLUDE ORAL 4 QL SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 73 Drug Name Tier Notes Drug Name Tier Notes BARACLUDE ORAL SOVALDI ORAL 4 QL 4 PA; SP; QL TABLET TABLET 400 MG entecavir oral tablet 4 QL *HERPES AGENTS - EPIVIR HBV ORAL PURINE 4 QL SOLUTION ANALOGUES*** EPIVIR HBV ORAL acyclovir oral capsule 1 or 1b* 4 QL TABLET acyclovir oral suspension 1 or 1b* HEPSERA ORAL acyclovir oral tablet 1 or 1b* 4 SP; QL TABLET acyclovir sodium intravenous 1 or 1b* lamivudine oral tablet 100 solution 1 or 1b* QL mg SITAVIG BUCCAL 3 PA; QL VEMLIDY ORAL TABLET 4 SP; QL TABLET valacyclovir hcl oral tablet 1 or 1b* QL *HEPATITIS C AGENT - VALTREX ORAL 3 QL COMBINATIONS*** TABLET EPCLUSA ORAL ZOVIRAX ORAL 4 PA; SP; QL 3 TABLET SUSPENSION HARVONI ORAL 4 PA; QL *HERPES AGENTS - PACKET THYMIDINE HARVONI ORAL ANALOGUES*** 4 PA; QL TABLET 45-200 MG famciclovir oral tablet 1 or 1b* QL HARVONI ORAL 4 PA; SP; QL *INFLUENZA TABLET 90-400 MG AGENTS*** LEDIPASVIR- rimantadine hcl oral tablet 1 or 1b* SOFOSBUVIR ORAL 4 PA; SP; QL TABLET *NEURAMINIDASE INHIBITORS*** MAVYRET ORAL 4 PA; SP; QL oseltamivir phosphate oral TABLET 1 or 1b* QL capsule SOFOSBUVIR- oseltamivir phosphate oral VELPATASVIR ORAL 4 PA; SP; QL 1 or 1b* QL TABLET suspension reconstituted VIEKIRA PAK ORAL RAPIVAB TABLET THERAPY 4 PA; SP; QL INTRAVENOUS 3 PACK SOLUTION VOSEVI ORAL TABLET 4 PA; SP; QL RELENZA DISKHALER INHALATION AEROSOL ZEPATIER ORAL 2 QL 4 PA; SP; QL POWDER BREATH TABLET ACTIVATED *HEPATITIS C TAMIFLU ORAL 3 QL AGENTS*** CAPSULE PEGASYS TAMIFLU ORAL SUBCUTANEOUS 4 SP; QL SUSPENSION 3 QL SOLUTION RECONSTITUTED 6 ribavirin oral capsule 4 SP MG/ML ribavirin oral tablet 200 mg 4 SP *PA ENDONUCLEASE SOVALDI ORAL INHIBITORS*** 4 PA; QL PACKET XOFLUZA (40 MG DOSE) SOVALDI ORAL ORAL TABLET 3 QL 4 PA; QL TABLET 200 MG THERAPY PACK

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 74 Drug Name Tier Notes Drug Name Tier Notes XOFLUZA (80 MG DOSE) BREVIBLOC PREMIXED ORAL TABLET 3 QL DS INTRAVENOUS 3 THERAPY PACK SOLUTION *RSV AGENTS - BREVIBLOC PREMIXED NUCLEOSIDE INTRAVENOUS 3 ANALOGUES*** SOLUTION ribavirin inhalation solution BYSTOLIC ORAL 1 or 1b* 2 QL reconstituted TABLET VIRAZOLE esmolol hcl intravenous 1 or 1b* INHALATION solution 100 mg/10ml 3 SOLUTION ESMOLOL HCL RECONSTITUTED INTRAVENOUS *BETA BLOCKERS* SOLUTION 2000 3 *ALPHA-BETA MG/100ML, 2500 BLOCKERS*** MG/250ML oral tablet 1 or 1b* QL ESMOLOL HCL INTRAVENOUS 3 carvedilol phosphate er oral SOLUTION PREFILLED capsule extended release 24 1 or 1b* QL SYRINGE hour esmolol hcl-sodium chloride 1 or 1b* COREG CR ORAL intravenous solution CAPSULE EXTENDED 3 QL RELEASE 24 HOUR KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 3 QL COREG ORAL TABLET 3 QL HOUR SPRINKLE labetalol hcl oral tablet 1 or 1b* QL LOPRESSOR ORAL 3 QL LABETALOL HCL- TABLET DEXTROSE metoprolol succinate er oral INTRAVENOUS 3 tablet extended release 24 1 or 1b* SOLUTION 200-5 hour MG/200ML-% metoprolol tartrate LABETALOL HCL- intravenous solution 5 1 or 1a* SODIUM CHLORIDE mg/5ml INTRAVENOUS SOLUTION 100-0.72 3 metoprolol tartrate oral tablet 1 or 1a* QL MG/100ML-%, 200-0.72 TENORMIN ORAL 3 QL MG/200ML-%, 300-0.72 TABLET MG/300ML-% TOPROL XL ORAL *BETA BLOCKERS TABLET EXTENDED 3 CARDIO-SELECTIVE*** RELEASE 24 HOUR acebutolol hcl oral capsule 1 or 1b* QL *BETA BLOCKERS NON- atenolol oral tablet 1 or 1a* QL SELECTIVE*** BETAPACE AF ORAL betaxolol hcl oral tablet 1 or 1b* QL 3 TABLET bisoprolol fumarate oral 1 or 1b* QL tablet BETAPACE ORAL TABLET 120 MG, 160 3 QL BREVIBLOC IN NACL MG, 80 MG INTRAVENOUS 3 CORGARD ORAL SOLUTION 3 QL TABLET BREVIBLOC HEMANGEOL ORAL INTRAVENOUS 3 3 SOLUTION 100 MG/10ML SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 75 Drug Name Tier Notes Drug Name Tier Notes INDERAL LA ORAL CARDIZEM CD ORAL CAPSULE EXTENDED 3 QL CAPSULE EXTENDED 3 DO RELEASE 24 HOUR RELEASE 24 HOUR 120 INDERAL XL ORAL MG, 180 MG CAPSULE EXTENDED 3 QL CARDIZEM CD ORAL RELEASE 24 HOUR CAPSULE EXTENDED 3 QL INNOPRAN XL ORAL RELEASE 24 HOUR 240 CAPSULE EXTENDED 3 QL MG, 300 MG, 360 MG RELEASE 24 HOUR CARDIZEM LA ORAL nadolol oral tablet 20 mg, 40 TABLET EXTENDED 1 or 1b* QL 3 DO mg, 80 mg RELEASE 24 HOUR 120 MG, 180 MG pindolol oral tablet 1 or 1b* QL CARDIZEM LA ORAL propranolol hcl er oral TABLET EXTENDED capsule extended release 24 1 or 1b* QL RELEASE 24 HOUR 240 3 QL hour MG, 300 MG, 360 MG, 420 propranolol hcl intravenous MG 1 or 1b* solution CARDIZEM ORAL 3 QL propranolol hcl oral solution 1 or 1b* QL TABLET 120 MG CARDIZEM ORAL propranolol hcl oral tablet 1 or 1b* QL 3 DO TABLET 30 MG, 60 MG sorine oral tablet 1 or 1b* QL cartia xt oral capsule sotalol hcl (af) oral tablet 1 or 1b* extended release 24 hour 120 1 or 1b* DO SOTALOL HCL mg, 180 mg INTRAVENOUS 3 cartia xt oral capsule SOLUTION extended release 24 hour 240 1 or 1b* QL sotalol hcl oral tablet 1 or 1b* QL mg, 300 mg SOTYLIZE ORAL CLEVIPREX 3 SOLUTION INTRAVENOUS 3 timolol maleate oral tablet 1 or 1b* QL EMULSION 25 MG/50ML, 50 MG/100ML *CALCIUM CHANNEL CONJUPRI ORAL BLOCKERS* 3 ST; DO TABLET 2.5 MG *CALCIUM CHANNEL CONJUPRI ORAL BLOCKER-NSAID 3 ST; QL COMBINATIONS*** TABLET 5 MG CONSENSI ORAL diltiazem hcl er beads oral 3 ST; QL TABLET capsule extended release 24 1 or 1b* DO hour 120 mg, 180 mg *CALCIUM CHANNEL BLOCKERS*** diltiazem hcl er beads oral capsule extended release 24 amlodipine besylate oral 1 or 1b* QL 1 or 1b* QL hour 240 mg, 300 mg, 360 tablet 10 mg mg, 420 mg amlodipine besylate oral 1 or 1b* DO diltiazem hcl er coated beads tablet 2.5 mg, 5 mg oral capsule extended release 1 or 1b* DO CALAN SR ORAL 24 hour 120 mg, 180 mg TABLET EXTENDED 3 QL diltiazem hcl er coated beads RELEASE oral capsule extended release 1 or 1b* QL CARDENE IV 24 hour 240 mg, 300 mg, 360 INTRAVENOUS mg SOLUTION 20-0.86 3 diltiazem hcl er coated beads MG/200ML-%, 20-4.8 oral tablet extended release 1 or 1b* DO MG/200ML-%, 40-0.83 24 hour 180 mg MG/200ML-% * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 76 Drug Name Tier Notes Drug Name Tier Notes diltiazem hcl er coated beads NICARDIPINE HCL IN oral tablet extended release NACL INTRAVENOUS 1 or 1b* QL 24 hour 240 mg, 300 mg, 360 SOLUTION 20-0.9 3 mg, 420 mg MG/200ML-%, 40-0.9 diltiazem hcl er oral capsule MG/200ML-% 1 or 1b* QL extended release 12 hour NICARDIPINE HCL IN diltiazem hcl er oral capsule NACL INTRAVENOUS extended release 24 hour 120 1 or 1b* DO SOLUTION PREFILLED 3 mg, 180 mg SYRINGE 1-0.9 MG/10ML-% diltiazem hcl er oral capsule nicardipine hcl intravenous extended release 24 hour 240 1 or 1b* QL 1 or 1b* mg solution diltiazem hcl intravenous nicardipine hcl oral capsule 1 or 1b* QL 1 or 1b* solution nifedipine er oral tablet DILTIAZEM HCL extended release 24 hour 30 1 or 1b* DO INTRAVENOUS mg 3 SOLUTION nifedipine er oral tablet RECONSTITUTED extended release 24 hour 60 1 or 1b* QL diltiazem hcl oral tablet 120 mg, 90 mg 1 or 1b* QL mg, 90 mg nifedipine er osmotic release diltiazem hcl oral tablet 30 oral tablet extended release 1 or 1b* DO 1 or 1b* DO mg, 60 mg 24 hour 30 mg DILTIAZEM HCL- nifedipine er osmotic release DEXTROSE oral tablet extended release 1 or 1b* QL INTRAVENOUS 3 24 hour 60 mg, 90 mg SOLUTION 125-5 nifedipine oral capsule 1 or 1b* QL MG/125ML-% nimodipine oral capsule 1 or 1b* QL DILTIAZEM HCL- nisoldipine er oral tablet SODIUM CHLORIDE extended release 24 hour 17 1 or 1b* DO INTRAVENOUS 3 mg, 20 mg, 8.5 mg SOLUTION 125-0.7 MG/125ML-% nisoldipine er oral tablet extended release 24 hour 1 or 1b* QL dilt-xr oral capsule extended 25.5 mg, 30 mg, 34 mg, 40 release 24 hour 120 mg, 180 1 or 1b* DO mg mg NORVASC ORAL dilt-xr oral capsule extended 3 QL 1 or 1b* QL TABLET 10 MG release 24 hour 240 mg NORVASC ORAL 3 DO felodipine er oral tablet TABLET 2.5 MG, 5 MG extended release 24 hour 10 1 or 1b* QL NYMALIZE ORAL mg 3 QL SOLUTION 6 MG/ML felodipine er oral tablet extended release 24 hour 2.5 1 or 1b* DO PROCARDIA XL ORAL TABLET EXTENDED mg, 5 mg 3 DO RELEASE 24 HOUR 30 isradipine oral capsule 1 or 1b* QL MG KATERZIA ORAL 3 QL PROCARDIA XL ORAL SUSPENSION TABLET EXTENDED 3 QL matzim la oral tablet RELEASE 24 HOUR 60 extended release 24 hour 180 1 or 1b* DO MG, 90 MG mg SULAR ORAL TABLET matzim la oral tablet EXTENDED RELEASE 24 3 DO extended release 24 hour 240 1 or 1b* QL HOUR 17 MG, 8.5 MG mg, 300 mg, 360 mg, 420 mg * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 77 Drug Name Tier Notes Drug Name Tier Notes SULAR ORAL TABLET *CARDIOTONICS* EXTENDED RELEASE 24 3 QL *CARDIAC HOUR 34 MG GLYCOSIDES*** taztia xt oral capsule digitek oral tablet 1 or 1b* extended release 24 hour 120 1 or 1b* DO mg, 180 mg digox oral tablet 1 or 1b* taztia xt oral capsule digoxin injection solution 1 or 1b* extended release 24 hour 240 1 or 1b* QL digoxin oral solution 1 or 1b* mg, 300 mg, 360 mg digoxin oral tablet 1 or 1b* tiadylt er oral capsule LANOXIN INJECTION extended release 24 hour 120 1 or 1b* DO 3 mg, 180 mg SOLUTION 0.25 MG/ML tiadylt er oral capsule LANOXIN ORAL extended release 24 hour 240 1 or 1b* QL TABLET 125 MCG, 250 3 mg, 300 mg, 360 mg, 420 mg MCG LANOXIN ORAL TIAZAC ORAL 2 CAPSULE EXTENDED TABLET 62.5 MCG 3 DO RELEASE 24 HOUR 120 LANOXIN PEDIATRIC 2 MG, 180 MG INJECTION SOLUTION TIAZAC ORAL *INOTROPES*** CAPSULE EXTENDED dobutamine hcl intravenous 1 or 1b* RELEASE 24 HOUR 240 3 QL solution 250 mg/20ml MG, 300 MG, 360 MG, 420 MG DOBUTAMINE IN D5W INTRAVENOUS 3 verapamil hcl er oral capsule SOLUTION extended release 24 hour 100 1 or 1b* DO dopamine hcl intravenous mg, 120 mg, 180 mg 1 or 1b* solution 40 mg/ml verapamil hcl er oral capsule extended release 24 hour 200 1 or 1b* QL DOPAMINE IN D5W mg, 240 mg, 300 mg, 360 mg INTRAVENOUS 3 SOLUTION verapamil hcl er oral tablet milrinone lactate in dextrose extended release 120 mg, 1 or 1b* QL 1 or 1b* 180 mg, 240 mg intravenous solution verapamil hcl intravenous milrinone lactate intravenous 1 or 1b* solution solution 10 mg/10ml, 20 1 or 1b* mg/20ml, 50 mg/50ml verapamil hcl oral tablet 1 or 1b* QL *CARDIOVASCULAR VERELAN ORAL AGENTS - MISC.* CAPSULE EXTENDED 3 DO RELEASE 24 HOUR 120 *CALCIUM CHANNEL MG, 180 MG BLOCKER & HMG COA REDUCTASE INHIBIT VERELAN ORAL COMB*** CAPSULE EXTENDED 3 QL RELEASE 24 HOUR 240 amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, MG, 360 MG 1 or 1b* QL 10-40 mg, 10-80 mg, 5-80 VERELAN PM ORAL mg CAPSULE EXTENDED 3 DO RELEASE 24 HOUR 100 amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, MG 1 or 1b* DO 2.5-40 mg, 5-10 mg, 5-20 VERELAN PM ORAL mg, 5-40 mg CAPSULE EXTENDED 3 QL RELEASE 24 HOUR 200 MG, 300 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 78 Drug Name Tier Notes Drug Name Tier Notes CADUET ORAL TABLET TYVASO INHALATION 4 PA; LD; SP; QL 10-10 MG, 10-20 MG, 10- SOLUTION 3 QL 40 MG, 10-80 MG, 5-80 TYVASO REFILL MG INHALATION 4 PA; LD; SP; QL CADUET ORAL TABLET SOLUTION 5-10 MG, 5-20 MG, 5-40 3 DO TYVASO STARTER MG INHALATION 4 PA; LD; SP; QL *NEPRILYSIN INHIB SOLUTION (ARNI)-ANGIOTENSIN II VELETRI RECEPT ANTAG INTRAVENOUS 4 PA; LD; SP COMB*** SOLUTION ENTRESTO ORAL RECONSTITUTED 3 QL TABLET VENTAVIS *NITRATE & INHALATION 4 PA; LD; SP; QL VASODILATOR SOLUTION COMBINATIONS*** *PULM HYPERTEN- BIDIL ORAL TABLET 2 SOLUBLE GUANYLATE *PROSTAGLANDIN - CYCLASE STIMULATOR IMPOTENCE (SGC)*** AGENTS*** ADEMPAS ORAL 4 PA; LD; SP; QL CAVERJECT IMPULSE TABLET INTRACAVERNOSAL 3 PA *PULMONARY KIT HYPERTENSION - CAVERJECT ENDOTHELIN INTRACAVERNOSAL RECEPTOR SOLUTION 3 PA ANTAGONISTS*** RECONSTITUTED 40 ambrisentan oral tablet 4 PA; LD; SP; QL MCG bosentan oral tablet 4 PA; LD; SP; QL EDEX LETAIRIS ORAL 4 PA; LD; SP; QL INTRACAVERNOSAL 3 PA TABLET KIT OPSUMIT ORAL 4 PA; LD; SP; QL MUSE URETHRAL TABLET PELLET 1000 MCG, 250 3 PA TRACLEER ORAL MCG, 500 MCG 4 PA; LD; SP; QL TABLET *PROSTAGLANDIN TRACLEER ORAL VASODILATORS*** 4 PA; LD; SP; QL TABLET SOLUBLE epoprostenol sodium intravenous solution 4 PA; LD; SP *PULMONARY reconstituted HYPERTENSION - PHOSPHODIESTERASE FLOLAN INTRAVENOUS INHIBITORS*** SOLUTION 4 PA; LD; SP ADCIRCA ORAL RECONSTITUTED 4 PA; SP; QL TABLET ORENITRAM ORAL TABLET EXTENDED 4 PA; LD; SP alyq oral tablet 4 PA; SP; QL RELEASE REVATIO REMODULIN INTRAVENOUS 4 PA; SP; QL INJECTION SOLUTION SOLUTION 100 MG/20ML, 20 4 PA; LD; SP REVATIO ORAL MG/20ML, 200 MG/20ML, SUSPENSION 4 PA; SP; QL 50 MG/20ML RECONSTITUTED treprostinil injection solution 4 PA; SP REVATIO ORAL 4 PA; SP; QL TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 79 Drug Name Tier Notes Drug Name Tier Notes sildenafil citrate intravenous *TRANSTHYRETIN 4 PA; SP; QL solution STABILIZERS*** sildenafil citrate oral VYNDAMAX ORAL 4 PA; SP; QL 4 PA; SP; QL suspension reconstituted CAPSULE sildenafil citrate oral tablet VYNDAQEL ORAL 4 PA; SP; QL 4 PA; SP; QL 20 mg CAPSULE tadalafil (pah) oral tablet 4 PA; SP; QL *VASOACTIVE *PULMONARY SOLUBLE GUANYLATE HYPERTENSION - CYCLASE STIMULATOR PROSTACYCLIN (SGC)*** RECEPTOR VERQUVO ORAL 3 PA; QL AGONIST*** TABLET UPTRAVI *CEPHALOSPORINS* INTRAVENOUS 4 PA; LD; QL *CEPHALOSPORIN SOLUTION COMBINATIONS*** RECONSTITUTED AVYCAZ UPTRAVI ORAL INTRAVENOUS 4 PA; LD; SP; QL 3 TABLET SOLUTION UPTRAVI ORAL RECONSTITUTED TABLET THERAPY 4 PA; LD; SP; QL ZERBAXA PACK INTRAVENOUS 3 *SELECTIVE CGMP SOLUTION PHOSPHODIESTERASE RECONSTITUTED TYPE 5 INHIBITORS*** *CEPHALOSPORINS - CIALIS ORAL TABLET 1ST GENERATION*** 3 PA 10 MG, 20 MG cefadroxil oral capsule 1 or 1b* CIALIS ORAL TABLET cefadroxil oral suspension 3 PA; QL 1 or 1b* 2.5 MG, 5 MG reconstituted sildenafil citrate oral tablet 1 or 1b* PA cefadroxil oral tablet 1 or 1b* 100 mg, 25 mg, 50 mg CEFAZOLIN IN SODIUM STENDRA ORAL 3 PA CHLORIDE TABLET INTRAVENOUS 3 tadalafil oral tablet 10 mg, 20 SOLUTION 2-0.9 1 or 1b* PA mg GM/100ML-% tadalafil oral tablet 2.5 mg, 5 cefazolin sodium injection 1 or 1b* PA; QL mg solution reconstituted 1 gm, 1 or 1b* vardenafil hcl oral tablet 3 PA 10 gm, 500 mg vardenafil hcl oral tablet CEFAZOLIN SODIUM 1 or 1b* PA INJECTION SOLUTION dispersible 3 RECONSTITUTED 100 VIAGRA ORAL TABLET 3 PA GM, 300 GM *SEPTAL AGENTS - CEFAZOLIN SODIUM ABLATION** INTRAVENOUS 3 ABLYSINOL INTRA- SOLUTION PREFILLED 3 ARTERIAL SOLUTION SYRINGE 1 GM/10ML cefazolin sodium intravenous *SINUS NODE 1 or 1b* INHIBITORS** solution reconstituted CORLANOR ORAL 3 PA; QL SOLUTION CORLANOR ORAL 2 PA; QL TABLET * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 80 Drug Name Tier Notes Drug Name Tier Notes CEFAZOLIN SODIUM- CEFOXITIN SODIUM- DEXTROSE DEXTROSE INTRAVENOUS INTRAVENOUS 3 SOLUTION 1-4 SOLUTION 3 GM/50ML-%, 2-4 RECONSTITUTED 1-4 GM/100ML-% GM-%(50ML), 2-2.2 GM- CEFAZOLIN SODIUM- %(50ML) DEXTROSE cefprozil oral suspension 1 or 1b* INTRAVENOUS 3 reconstituted SOLUTION 2-5 cefprozil oral tablet 1 or 1b* GM/100ML-% cefuroxime axetil oral tablet 1 or 1b* CEFAZOLIN SODIUM- DEXTROSE cefuroxime sodium injection INTRAVENOUS solution reconstituted 750 1 or 1b* SOLUTION 3 mg RECONSTITUTED 1-4 cefuroxime sodium GM-%(50ML), 2-3 GM- intravenous solution 1 or 1b* %(50ML) reconstituted 1.5 gm cephalexin oral capsule 1 or 1a* *CEPHALOSPORINS - cephalexin oral suspension 3RD GENERATION*** 1 or 1a* reconstituted cefdinir oral capsule 1 or 1b* QL cephalexin oral tablet 1 or 1a* cefdinir oral suspension 1 or 1b* QL KEFLEX ORAL reconstituted 3 CAPSULE 750 MG cefixime oral capsule 1 or 1b* QL *CEPHALOSPORINS - cefixime oral suspension 1 or 1b* QL 2ND GENERATION*** reconstituted CEFACLOR ER ORAL cefotaxime sodium injection TABLET EXTENDED 3 solution reconstituted 1 gm, 1 or 1b* RELEASE 12 HOUR 2 gm cefaclor oral capsule 1 or 1b* cefpodoxime proxetil oral 1 or 1b* cefaclor oral suspension suspension reconstituted 1 or 1b* reconstituted cefpodoxime proxetil oral 1 or 1b* CEFOTAN INJECTION tablet SOLUTION 3 CEFTAZIDIME AND RECONSTITUTED DEXTROSE cefotetan disodium injection INTRAVENOUS solution reconstituted 1 gm, 1 or 1b* SOLUTION 3 2 gm RECONSTITUTED 1-5 GM-%(50ML), 2-5 GM- CEFOTETAN %(50ML) DISODIUM-DEXTROSE INTRAVENOUS ceftazidime injection solution SOLUTION 3 reconstituted 1 gm, 2 gm, 6 1 or 1b* RECONSTITUTED 1-3.58 gm GM-%(50ML), 2-2.08 GM- ceftriaxone sodium in 1 or 1b* QL %(50ML) dextrose intravenous solution cefoxitin sodium injection 1 or 1b* ceftriaxone sodium injection solution reconstituted solution reconstituted 1 gm, 1 or 1b* QL cefoxitin sodium intravenous 2 gm, 250 mg, 500 mg 1 or 1b* solution reconstituted CEFTRIAXONE SODIUM INJECTION SOLUTION 3 QL RECONSTITUTED 100 GM

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 81 Drug Name Tier Notes Drug Name Tier Notes ceftriaxone sodium *CEPHALOSPORINS - intravenous solution 1 or 1b* QL 5TH GENERATION*** reconstituted TEFLARO CEFTRIAXONE INTRAVENOUS 3 SODIUM-DEXTROSE SOLUTION INTRAVENOUS RECONSTITUTED SOLUTION 3 QL *CEPHALOSPORINS - RECONSTITUTED 1-3.74 SIDEROPHORES*** GM-%(50ML), 2-2.22 GM- %(50ML) FETROJA INTRAVENOUS 3 FORTAZ INJECTION SOLUTION SOLUTION 3 RECONSTITUTED RECONSTITUTED 1 GM, 500 MG *CONTRACEPTIVES* FORTAZ INTRAVENOUS *BIPHASIC SOLUTION 3 CONTRACEPTIVES - RECONSTITUTED 2 GM ORAL*** SUPRAX ORAL azurette oral tablet 1 or 1b* $0 3 QL CAPSULE desogestrel-ethinyl estradiol SUPRAX ORAL oral tablet 0.15-0.02/0.01 mg 1 or 1b* $0 SUSPENSION 3 QL (21/5) RECONSTITUTED kariva oral tablet 1 or 1b* $0 SUPRAX ORAL TABLET LO LOESTRIN FE ORAL 3 QL 2 CHEWABLE TABLET tazicef injection solution MIRCETTE ORAL 1 or 1b* 3 reconstituted TABLET TAZICEF pimtrea oral tablet 1 or 1b* $0 INTRAVENOUS 3 SOLUTION simliya oral tablet 1 or 1b* $0 tazicef intravenous solution viorele oral tablet 1 or 1b* $0 1 or 1b* reconstituted volnea oral tablet 1 or 1b* $0 *CEPHALOSPORINS - *COMBINATION 4TH GENERATION*** CONTRACEPTIVES - ORAL*** cefepime hcl injection 1 or 1b* solution reconstituted afirmelle oral tablet 1 or 1a* $0 CEFEPIME HCL altavera oral tablet 1 or 1a* $0 INTRAVENOUS 3 alyacen 1/35 oral tablet 1 or 1a* $0 SOLUTION apri oral tablet 1 or 1a* $0 CEFEPIME HCL INTRAVENOUS aubra eq oral tablet 1 or 1a* $0 3 SOLUTION aubra oral tablet 1 or 1a* $0 RECONSTITUTED aurovela 1.5/30 oral tablet 1 or 1a* $0 CEFEPIME-DEXTROSE aurovela 1/20 oral tablet 1 or 1a* $0 INTRAVENOUS SOLUTION aurovela 24 fe oral tablet 1 or 1a* $0 3 RECONSTITUTED 1-5 aurovela fe 1.5/30 oral tablet 1 or 1a* $0 GM-%(50ML), 2-5 GM- %(50ML) aurovela fe 1/20 oral tablet 1 or 1a* $0 aviane oral tablet 1 or 1a* $0 ayuna oral tablet 1 or 1a* $0 BALCOLTRA ORAL 3 TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 82 Drug Name Tier Notes Drug Name Tier Notes balziva oral tablet 1 or 1a* $0 junel fe 1/20 oral tablet 1 or 1a* $0 BEYAZ ORAL TABLET 3 junel fe 24 oral tablet 1 or 1a* $0 blisovi 24 fe oral tablet 1 or 1a* $0 kaitlib fe oral tablet chewable 1 or 1b* $0 blisovi fe 1.5/30 oral tablet 1 or 1a* $0 kalliga oral tablet 1 or 1a* $0 blisovi fe 1/20 oral tablet 1 or 1a* $0 kelnor 1/35 oral tablet 1 or 1a* $0 briellyn oral tablet 1 or 1a* $0 kelnor 1/50 oral tablet 1 or 1a* $0 charlotte 24 fe oral tablet kurvelo oral tablet 1 or 1a* $0 1 or 1a* $0 chewable larin 1.5/30 oral tablet 1 or 1a* $0 chateal eq oral tablet 1 or 1a* $0 larin 1/20 oral tablet 1 or 1a* $0 chateal oral tablet 1 or 1a* $0 larin 24 fe oral tablet 1 or 1a* $0 cryselle-28 oral tablet 1 or 1a* $0 larin fe 1.5/30 oral tablet 1 or 1a* $0 cyclafem 1/35 oral tablet 1 or 1a* $0 larin fe 1/20 oral tablet 1 or 1a* $0 cyred eq oral tablet 1 or 1a* $0 larissia oral tablet 1 or 1a* $0 cyred oral tablet 1 or 1a* $0 layolis fe oral tablet 1 or 1b* $0 dasetta 1/35 oral tablet 1 or 1a* $0 chewable delyla oral tablet 1 or 1a* $0 lessina oral tablet 1 or 1a* $0 desogestrel-ethinyl estradiol levonorgestrel-ethinyl estrad 1 or 1a* $0 oral tablet 0.15-30 mg-mcg oral tablet 0.1-20 mg-mcg, 1 or 1a* $0 drospiren-eth estrad- 0.15-30 mg-mcg 1 or 1b* $0 levomefol oral tablet levora 0.15/30 (28) oral 1 or 1a* $0 drospirenone-ethinyl tablet 1 or 1b* $0 estradiol oral tablet lillow oral tablet 1 or 1a* $0 elinest oral tablet 1 or 1a* $0 loestrin 1.5/30 (21) oral 1 or 1a* $0 emoquette oral tablet 1 or 1a* $0 tablet enskyce oral tablet 0.15-30 loestrin 1/20 (21) oral tablet 1 or 1a* $0 1 or 1a* $0 mg-mcg loestrin fe 1.5/30 oral tablet 1 or 1a* $0 estarylla oral tablet 1 or 1a* $0 loestrin fe 1/20 oral tablet 1 or 1a* $0 ethynodiol diac-eth estradiol loryna oral tablet 1 or 1b* $0 1 or 1a* $0 oral tablet low-ogestrel oral tablet 1 or 1a* $0 falmina oral tablet 1 or 1a* $0 lo-zumandimine oral tablet 1 or 1b* $0 femynor oral tablet 1 or 1a* $0 lutera oral tablet 1 or 1a* $0 gemmily oral capsule 1 or 1b* $0 marlissa oral tablet 1 or 1a* $0 GENERESS FE ORAL 3 merzee oral capsule 1 or 1b* $0 TABLET CHEWABLE mibelas 24 fe oral tablet 1 or 1a* $0 hailey 1.5/30 oral tablet 1 or 1a* $0 chewable hailey 24 fe oral tablet 1 or 1a* $0 microgestin 1.5/30 oral tablet 1 or 1a* $0 hailey fe 1.5/30 oral tablet 1 or 1a* $0 microgestin 1/20 oral tablet 1 or 1a* $0 hailey fe 1/20 oral tablet 1 or 1a* $0 microgestin 24 fe oral tablet 1 or 1a* $0 isibloom oral tablet 1 or 1a* $0 microgestin fe 1.5/30 oral 1 or 1a* $0 jasmiel oral tablet 1 or 1b* $0 tablet juleber oral tablet 1 or 1a* $0 microgestin fe 1/20 oral 1 or 1a* $0 junel 1.5/30 oral tablet 1 or 1a* $0 tablet junel 1/20 oral tablet 1 or 1a* $0 mili oral tablet 1 or 1a* $0 MINASTRIN 24 FE ORAL junel fe 1.5/30 oral tablet 1 or 1a* $0 3 TABLET CHEWABLE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 83 Drug Name Tier Notes Drug Name Tier Notes mono-linyah oral tablet 1 or 1a* $0 vyfemla oral tablet 1 or 1a* $0 necon 0.5/35 (28) oral tablet 1 or 1a* $0 vylibra oral tablet 1 or 1a* $0 NEXTSTELLIS ORAL wera oral tablet 1 or 1a* $0 3 TABLET wymzya fe oral tablet 1 or 1b* $0 nikki oral tablet 1 or 1b* $0 chewable norethin ace-eth estrad-fe YASMIN 28 ORAL 1 or 1b* $0 3 oral capsule TABLET norethin ace-eth estrad-fe YAZ ORAL TABLET 3 oral tablet 1-20 mg-mcg, 1.5- 1 or 1a* $0 zarah oral tablet 1 or 1b* $0 30 mg-mcg zovia 1/35 (28) oral tablet 1 or 1a* $0 norethin ace-eth estrad-fe 1 or 1a* $0 oral tablet chewable zovia 1/35e (28) oral tablet 1 or 1a* $0 norethindrone acet-ethinyl zumandimine oral tablet 1 or 1b* $0 1 or 1a* $0 est oral tablet *COMBINATION norethin-eth estradiol-fe oral CONTRACEPTIVES - 1 or 1b* $0 tablet chewable TRANSDERMAL*** norgestimate-eth estradiol TWIRLA 1 or 1a* $0 oral tablet 0.25-35 mg-mcg TRANSDERMAL PATCH 3 WEEKLY nortrel 0.5/35 (28) oral tablet 1 or 1a* $0 xulane transdermal patch 1 or 1b* $0 nortrel 1/35 (21) oral tablet 1 or 1a* $0 weekly nortrel 1/35 (28) oral tablet 1 or 1a* $0 zafemy transdermal patch 1 or 1b* $0 nymyo oral tablet 1 or 1a* $0 weekly ocella oral tablet 1 or 1b* $0 *COMBINATION orsythia oral tablet 1 or 1a* $0 CONTRACEPTIVES - VAGINAL*** philith oral tablet 1 or 1a* $0 ANNOVERA VAGINAL 3 pirmella 1/35 oral tablet 1 or 1a* $0 RING portia-28 oral tablet 1 or 1a* $0 eluryng vaginal ring 1 or 1b* $0 previfem oral tablet 1 or 1a* $0 etonogestrel-ethinyl estradiol 1 or 1b* $0 reclipsen oral tablet 1 or 1a* $0 vaginal ring SAFYRAL ORAL NUVARING VAGINAL 3 3 TABLET RING sprintec 28 oral tablet 1 or 1a* $0 *CONTINUOUS CONTRACEPTIVES - sronyx oral tablet 1 or 1a* $0 ORAL*** syeda oral tablet 1 or 1b* $0 amethyst oral tablet 1 or 1b* $0 tarina 24 fe oral tablet 1 or 1a* $0 dolishale oral tablet 1 or 1b* $0 tarina fe 1/20 eq oral tablet 1 or 1a* $0 levonorgestrel-ethinyl estrad 1 or 1b* $0 tarina fe 1/20 oral tablet 1 or 1a* $0 oral tablet 90-20 mcg taysofy oral capsule 1 or 1b* $0 *COPPER TAYTULLA ORAL CONTRACEPTIVES - 3 CAPSULE IUD*** TYBLUME ORAL PARAGARD 3 TABLET CHEWABLE INTRAUTERINE COPPER 3 tydemy oral tablet 1 or 1b* $0 INTRAUTERINE vestura oral tablet 1 or 1b* $0 INTRAUTERINE DEVICE vienva oral tablet 1 or 1a* $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 84 Drug Name Tier Notes Drug Name Tier Notes *EMERGENCY *FOUR PHASE CONTRACEPTIVES*** CONTRACEPTIVES - aftera oral tablet 1 or 1b* OTC; $0 ORAL*** NATAZIA ORAL afterpill oral tablet 1 or 1b* OTC; $0 3 TABLET econtra ez oral tablet 1 or 1b* OTC; $0 *PROGESTIN econtra one-step oral tablet 1 or 1b* OTC; $0 CONTRACEPTIVES - ELLA ORAL TABLET 3 $0 IMPLANTS*** levonorgestrel oral tablet 1.5 NEXPLANON 1 or 1b* OTC; $0 mg SUBCUTANEOUS 4 LD; SP IMPLANT my choice oral tablet 1 or 1b* OTC; $0 *PROGESTIN my way oral tablet 1 or 1b* OTC; $0 CONTRACEPTIVES - new day oral tablet 1 or 1b* OTC; $0 INJECTABLE*** opcicon one-step oral tablet 1 or 1b* OTC; $0 DEPO-PROVERA option 2 oral tablet 1 or 1b* OTC; $0 INTRAMUSCULAR 3 SUSPENSION 150 MG/ML preventeza oral tablet 1 or 1b* OTC; $0 DEPO-PROVERA react oral tablet 1 or 1b* OTC; $0 INTRAMUSCULAR 3 take action oral tablet 1 or 1b* OTC; $0 SUSPENSION PREFILLED SYRINGE *EXTENDED-CYCLE CONTRACEPTIVES - DEPO-SUBQ PROVERA 104 SUBCUTANEOUS ORAL*** 3 $0 SUSPENSION amethia oral tablet 1 or 1b* $0 PREFILLED SYRINGE ashlyna oral tablet 1 or 1b* $0 medroxyprogesterone acetate 1 or 1b* $0 camrese lo oral tablet 1 or 1b* $0 intramuscular suspension camrese oral tablet 1 or 1b* $0 medroxyprogesterone acetate daysee oral tablet 1 or 1b* $0 intramuscular suspension 1 or 1b* $0 prefilled syringe fayosim oral tablet 1 or 1b* $0 *PROGESTIN iclevia oral tablet 1 or 1b* $0 CONTRACEPTIVES - introvale oral tablet 1 or 1b* $0 IUD*** jaimiess oral tablet 1 or 1b* $0 KYLEENA INTRAUTERINE jolessa oral tablet 1 or 1b* $0 4 LD; SP INTRAUTERINE levonorgest-eth est & eth est 1 or 1b* $0 DEVICE oral tablet LILETTA (52 MG) levonorgest-eth estrad 91-day INTRAUTERINE 1 or 1b* $0 3 LD; SP oral tablet INTRAUTERINE lojaimiess oral tablet 1 or 1b* $0 DEVICE 19.5 MCG/DAY LOSEASONIQUE ORAL MIRENA (52 MG) 3 INTRAUTERINE TABLET 3 LD; SP INTRAUTERINE QUARTETTE ORAL 3 DEVICE TABLET SKYLA INTRAUTERINE rivelsa oral tablet 1 or 1b* $0 INTRAUTERINE 3 LD; SP SEASONIQUE ORAL DEVICE 3 TABLET *PROGESTIN setlakin oral tablet 1 or 1b* $0 CONTRACEPTIVES - ORAL*** simpesse oral tablet 1 or 1b* $0 camila oral tablet 1 or 1b* $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 85 Drug Name Tier Notes Drug Name Tier Notes deblitane oral tablet 1 or 1b* $0 tri-mili oral tablet 1 or 1b* $0 errin oral tablet 1 or 1b* $0 tri-nymyo oral tablet 1 or 1b* $0 heather oral tablet 1 or 1b* $0 tri-previfem oral tablet 1 or 1b* $0 incassia oral tablet 1 or 1b* $0 tri-sprintec oral tablet 1 or 1b* $0 jencycla oral tablet 1 or 1b* $0 trivora (28) oral tablet 1 or 1a* $0 lyleq oral tablet 1 or 1b* $0 tri-vylibra lo oral tablet 1 or 1b* $0 lyza oral tablet 1 or 1b* $0 tri-vylibra oral tablet 1 or 1b* $0 nora-be oral tablet 1 or 1b* $0 velivet oral tablet 1 or 1a* $0 norethindrone oral tablet 1 or 1b* $0 *CORTICOSTEROIDS* norlyda oral tablet 1 or 1b* $0 *GLUCOCORTICOSTER norlyroc oral tablet 1 or 1b* $0 OIDS*** sharobel oral tablet 1 or 1b* $0 ALKINDI SPRINKLE ORAL CAPSULE 3 PA SLYND ORAL TABLET 3 SPRINKLE tulana oral tablet 1 or 1b* $0 budesonide er oral tablet 1 or 1b* QL *TRIPHASIC extended release 24 hour CONTRACEPTIVES - budesonide oral capsule 1 or 1b* QL ORAL*** delayed release particles alyacen 7/7/7 oral tablet 1 or 1a* $0 CORTEF ORAL TABLET 3 aranelle oral tablet 1 or 1a* $0 decadron oral tablet 1 or 1a* caziant oral tablet 1 or 1a* $0 DEPO-MEDROL cyclafem 7/7/7 oral tablet 1 or 1a* $0 INJECTION 3 SUSPENSION dasetta 7/7/7 oral tablet 1 or 1a* $0 DEXABLISS ORAL enpresse-28 oral tablet 1 or 1a* $0 TABLET THERAPY 3 ESTROSTEP FE ORAL PACK 3 TABLET DEXAMETHASONE leena oral tablet 1 or 1a* $0 INTENSOL ORAL 2 levonest oral tablet 1 or 1a* $0 CONCENTRATE levonorg-eth estrad triphasic dexamethasone oral elixir 1 or 1a* oral tablet 50-30/75-40/ 125- 1 or 1a* $0 dexamethasone oral solution 1 or 1a* 30 mcg dexamethasone oral tablet 1 or 1a* norgestim-eth estrad triphasic dexamethasone oral tablet 1 or 1b* $0 1 or 1b* oral tablet therapy pack nortrel 7/7/7 oral tablet 1 or 1a* $0 DEXAMETHASONE SOD nylia 7/7/7 oral tablet 1 or 1a* $0 PHOS-NACL pirmella 7/7/7 oral tablet 1 or 1a* $0 INTRAVENOUS 3 SOLUTION 6-0.9 tilia fe oral tablet 1 or 1b* $0 MG/25ML-% tri femynor oral tablet 1 or 1b* $0 dexamethasone sod tri-estarylla oral tablet 1 or 1b* $0 phosphate pf injection 1 or 1b* solution tri-legest fe oral tablet 1 or 1b* $0 DEXAMETHASONE SOD tri-linyah oral tablet 1 or 1b* $0 PHOSPHATE PF 3 tri-lo-estarylla oral tablet 1 or 1b* $0 INJECTION SOLUTION tri-lo-marzia oral tablet 1 or 1b* $0 PREFILLED SYRINGE tri-lo-mili oral tablet 1 or 1b* $0 tri-lo-sprintec oral tablet 1 or 1b* $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 86 Drug Name Tier Notes Drug Name Tier Notes DEXAMETHASONE ORTIKOS ORAL SODIUM PHOSPHATE CAPSULE EXTENDED 3 QL 3 INJECTION SOLUTION RELEASE 24 HOUR 10 MG/ML, 4 MG/ML PEDIAPRED ORAL 3 dexamethasone sodium SOLUTION phosphate injection solution 1 or 1b* prednisolone oral solution 1 or 1a* 100 mg/10ml, 120 mg/30ml, 20 mg/5ml prednisolone sodium phosphate oral solution 10 DXEVO 11-DAY ORAL mg/5ml, 15 mg/5ml, 20 1 or 1a* TABLET THERAPY 3 mg/5ml, 25 mg/5ml, 6.7 (5 PACK base) mg/5ml EMFLAZA ORAL 4 PA; LD prednisolone sodium SUSPENSION phosphate oral tablet 1 or 1a* QL EMFLAZA ORAL dispersible 10 mg, 30 mg 4 PA; LD TABLET prednisolone sodium ENTOCORT EC ORAL phosphate oral tablet 1 or 1a* DO CAPSULE DELAYED 3 QL dispersible 15 mg RELEASE PARTICLES PREDNISONE HEMADY ORAL INTENSOL ORAL 3 3 PA; QL TABLET CONCENTRATE hydrocortisone oral tablet 1 or 1b* prednisone oral solution 1 or 1a* KENALOG INJECTION prednisone oral tablet 1 or 1a* 3 SUSPENSION prednisone oral tablet 1 or 1a* KENALOG-80 therapy pack INJECTION 3 RAYOS ORAL TABLET 3 ST SUSPENSION DELAYED RELEASE MEDROL ORAL SOLU-CORTEF TABLET 16 MG, 32 MG, 4 3 INJECTION SOLUTION 3 MG, 8 MG RECONSTITUTED MEDROL ORAL 2 SOLU-MEDROL TABLET 2 MG INJECTION SOLUTION 3 MEDROL ORAL RECONSTITUTED TABLET THERAPY 3 taperdex 12-day oral tablet 1 or 1b* PACK therapy pack methylprednisolone oral taperdex 6-day oral tablet 1 or 1a* 1 or 1b* tablet therapy pack methylprednisolone oral taperdex 7-day oral tablet 1 or 1a* 1 or 1b* tablet therapy pack therapy pack 1.5 mg (27) methylprednisolone sodium UCERIS ORAL TABLET succ injection solution 1 or 1b* EXTENDED RELEASE 24 3 QL reconstituted 1000 mg, 125 HOUR mg, 40 mg, 500 mg ZCORT 7-DAY ORAL MILLIPRED ORAL 3 TABLET THERAPY 3 TABLET PACK ORAPRED ODT ORAL ZILRETTA INTRA- TABLET DISPERSIBLE 3 QL ARTICULAR 4 PA; QL 10 MG, 30 MG SUSPENSION ORAPRED ODT ORAL RECONSTITUTED ER TABLET DISPERSIBLE 3 DO 15 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 87 Drug Name Tier Notes Drug Name Tier Notes *MINERALOCORTICOI *ANTITUSSIVE- DS*** EXPECTORANTS- fludrocortisone acetate oral DECONGESTANT*** 1 or 1b* tablet CODITUSSIN DAC ORAL 3 OTC *STEROID LIQUID COMBINATIONS*** TUSNEL C ORAL SYRUP 2 PA; OTC BSP 0820 INJECTION VIRTUSSIN DAC ORAL 3 2 OTC KIT SOLUTION CELESTONE SOLUSPAN *DECONGESTANT & INJECTION 3 *** SUSPENSION CLARINEX-D 12 HOUR *COUGH/COLD/ALLER ORAL TABLET 3 ST; QL GY* EXTENDED RELEASE 12 *ANTITUSSIVE - HOUR NONNARCOTIC*** promethazine vc oral syrup 1 or 1b* QL benzonatate oral capsule 1 or 1b* promethazine-phenylephrine 1 or 1b* QL TESSALON PERLES oral syrup 3 ORAL CAPSULE *DECONGESTANT W/ *ANTITUSSIVE - EXPECTORANT*** OPIOID*** GILPHEX TR ORAL 3 HYCODAN ORAL SYRUP 3 QL TABLET hydrocodone-homatropine *IODINE 1 or 1a* QL oral syrup EXPECTORANTS*** hydrocodone-homatropine SSKI ORAL SOLUTION 3 1 or 1a* PA oral tablet *MISC. RESPIRATORY hydromet oral syrup 1 or 1a* QL INHALANTS*** *ANTITUSSIVE- HYPERSAL INHALATION EXPECTORANT*** 3 NEBULIZATION CODITUSSIN AC ORAL 3 OTC SOLUTION LIQUID sodium chloride inhalation g tussin ac oral solution 1 or 1a* OTC nebulization solution 0.9 %, 1 or 1b* guaiatussin ac oral syrup 1 or 1a* OTC 10 %, 3 %, 7 % guaifenesin ac oral syrup 1 or 1a* OTC *MUCOLYTICS*** guaifenesin-codeine oral acetylcysteine inhalation 1 or 1a* OTC 1 or 1b* solution solution MAR-COF CG *NON-NARC EXPECTORANT ORAL 2 OTC ANTITUSSIVE- LIQUID ANTIHISTAMINE*** maxi-tuss ac oral solution 1 or 1a* OTC promethazine-dm oral syrup 1 or 1a* QL M-CLEAR WC ORAL *NON-NARC 2 OTC SOLUTION ANTITUSSIVE- DECONGESTANT- NINJACOF-XG ORAL 3 OTC ANTIHISTAMINE*** LIQUID pseudoeph-bromphen-dm 1 or 1b* trymine cg oral liquid 1 or 1a* OTC oral syrup 30-2-10 mg/5ml virtussin a/c oral solution 1 or 1a* OTC virtussin ac w/alc oral liquid 1 or 1a* OTC

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 88 Drug Name Tier Notes Drug Name Tier Notes *OPIOID ANTITUSSIVE- clindacin-p external swab 1 or 1b* QL ANTIHISTAMINE*** CLINDAGEL EXTERNAL 3 ST; QL hydrocod polst-cpm polst er GEL oral suspension extended 1 or 1b* QL clindamycin phosphate 1 or 1b* QL release external foam promethazine-codeine oral clindamycin phosphate 1 or 1a* QL 1 or 1b* QL solution external gel promethazine-codeine oral clindamycin phosphate 1 or 1a* QL 1 or 1b* QL syrup external lotion TUSSICAPS ORAL clindamycin phosphate CAPSULE EXTENDED 1 or 1b* QL 2 external solution RELEASE 12 HOUR 10-8 clindamycin phosphate MG 1 or 1b* QL external swab TUXARIN ER ORAL TABLET EXTENDED 3 dapsone external gel 5 % 1 or 1b* ST; QL RELEASE 12 HOUR dapsone external gel 7.5 % 3 ST; QL TUZISTRA XR ORAL ery external pad 1 or 1b* QL SUSPENSION 3 ERYGEL EXTERNAL EXTENDED RELEASE 3 QL GEL *OPIOID ANTITUSSIVE- DECONGESTANT- erythromycin external gel 1 or 1b* QL ANTIHISTAMINE*** erythromycin external 1 or 1b* CAPCOF ORAL SYRUP 3 OTC solution HISTEX-AC ORAL EVOCLIN EXTERNAL 3 OTC 3 ST; QL SYRUP FOAM MAR-COF BP ORAL KLARON EXTERNAL 3 OTC 3 LIQUID LOTION MAXI-TUSS CD ORAL sulfacetamide sodium (acne) 2 OTC 1 or 1b* LIQUID external lotion *ACNE M-END PE ORAL 3 OTC COMBINATIONS*** LIQUID POLY-TUSSIN AC ORAL ACANYA EXTERNAL 2 OTC 3 ST; QL LIQUID 10-4-10 MG/5ML GEL promethazine vc/codeine oral adapalene-benzoyl peroxide 1 or 1b* QL 1 or 1b* PA; QL syrup external gel promethazine-phenyleph- BENZACLIN EXTERNAL 1 or 1b* QL 3 ST; QL codeine oral syrup GEL PRO-RED AC ORAL BENZACLIN WITH 3 PA; OTC 3 ST; QL SYRUP 5-1-9 MG/5ML PUMP EXTERNAL GEL BENZAMYCIN RYDEX ORAL LIQUID 2 OTC 3 ST; QL EXTERNAL GEL *DERMATOLOGICALS* benzoyl peroxide- 1 or 1b* QL *ACNE ANTIBIOTICS*** erythromycin external gel ACZONE EXTERNAL 3 ST; QL clindamycin phos-benzoyl GEL perox external gel 1-5 %, 1 or 1b* QL AMZEEQ EXTERNAL 1.2-2.5 %, 1.2-5 % 3 ST; QL FOAM clindamycin-tretinoin 3 ST CLEOCIN-T EXTERNAL external gel 3 ST; QL LOTION EPIDUO EXTERNAL 3 ST; QL clindacin etz external swab 1 or 1b* QL GEL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 89 Drug Name Tier Notes Drug Name Tier Notes EPIDUO FORTE isotretinoin oral capsule 2 PA 3 ST; QL EXTERNAL GEL myorisan oral capsule 2 PA neuac external gel 1 or 1b* QL RETIN-A EXTERNAL 3 PA; QL ONEXTON EXTERNAL CREAM 0.025 % 2 QL GEL RETIN-A EXTERNAL 3 ST; QL sulfacetamide sod-sulfur CREAM 0.05 %, 0.1 % 1 or 1b* PA wash external liquid RETIN-A EXTERNAL 3 ST; QL TAROXIA EXTERNAL GEL 0.01 % 3 GEL RETIN-A EXTERNAL 3 PA; QL VELTIN EXTERNAL GEL 0.025 % 3 ST GEL RETIN-A MICRO 3 ST; QL ZIANA EXTERNAL GEL 3 ST EXTERNAL GEL *ACNE PRODUCTS*** RETIN-A MICRO PUMP 3 ST; QL ABSORICA LD ORAL EXTERNAL GEL 3 PA CAPSULE TAZAROTENE 3 ST; QL ABSORICA ORAL EXTERNAL FOAM 3 PA CAPSULE tretinoin external cream 1 or 1b* PA; QL accutane oral capsule 20 mg, tretinoin external gel 1 or 1b* PA; QL 2 PA 30 mg, 40 mg tretinoin microsphere 1 or 1b* PA; QL adapalene external cream 1 or 1b* PA; QL external gel adapalene external gel 1 or 1b* PA; QL tretinoin microsphere pump 1 or 1b* PA; QL adapalene external pad 1 or 1b* PA external gel ADAPALENE WINLEVI EXTERNAL 3 ST 3 ST; QL EXTERNAL SOLUTION CREAM AKLIEF EXTERNAL zenatane oral capsule 2 PA 3 ST; QL CREAM *AGENTS FOR ALTRENO EXTERNAL EXTERNAL GENITAL 3 PA; QL LOTION AND PERIANAL WARTS*** amnesteem oral capsule 2 PA VEREGEN EXTERNAL ARAZLO EXTERNAL 3 3 ST; QL OINTMENT LOTION *AGENTS FOR FACIAL ATRALIN EXTERNAL 3 ST; QL WRINKLES - GEL RETINOIDS*** avita external cream 1 or 1b* ST; QL refissa external cream 1 or 1b* PA; QL avita external gel 1 or 1b* ST; QL RENOVA EXTERNAL 3 PA; QL AZELEX EXTERNAL CREAM 3 PA; QL CREAM RENOVA PUMP 3 PA; QL bp wash external liquid 2.5 EXTERNAL CREAM 1 or 1b* %, 7 % tretinoin (emollient) external 1 or 1b* PA; QL claravis oral capsule 2 PA cream DIFFERIN EXTERNAL *ANTIBIOTIC STEROID 3 PA; QL CREAM COMBINATIONS - TOPICAL*** DIFFERIN EXTERNAL 3 PA; QL NEO-SYNALAR GEL 0.3 % 3 EXTERNAL CREAM DIFFERIN EXTERNAL 3 ST; QL LOTION FABIOR EXTERNAL 3 ST; QL FOAM * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 90 Drug Name Tier Notes Drug Name Tier Notes *ANTIBIOTICS - naftifine hcl external cream 1 or 1b* ST; QL TOPICAL*** naftifine hcl external gel 1 or 1b* ST; QL ALTABAX EXTERNAL NAFTIN EXTERNAL 2 QL 3 ST; QL OINTMENT GEL CENTANY EXTERNAL 3 ST; QL nyamyc external powder 1 or 1b* QL OINTMENT nystatin external cream 1 or 1b* QL gentamicin sulfate external 1 or 1b* QL cream nystatin external ointment 1 or 1b* QL gentamicin sulfate external nystatin external powder 1 or 1b* QL 1 or 1b* QL ointment nystop external powder 1 or 1b* QL mupirocin calcium external 3 ST; QL *ANTI- cream INFLAMMATORY mupirocin external ointment 1 or 1b* QL AGENTS - TOPICAL*** XEPI EXTERNAL diclofenac epolamine 3 QL 3 ST; QL CREAM external patch diclofenac sodium external *ANTIFUNGALS - 1 or 1b* QL TOPICAL gel 1 % COMBINATIONS*** FLECTOR EXTERNAL 3 ST; QL clotrimazole-betamethasone PATCH 1 or 1b* QL external cream LICART EXTERNAL 3 ST; QL clotrimazole-betamethasone PATCH 24 HOUR 1 or 1b* QL external lotion PENNSAID EXTERNAL 3 ST; QL corti-sav external cream 1 or 1b* SOLUTION miconazole-zinc oxide- *ANTINEOPLASTIC 1 or 1b* QL petrolat external ointment ALKYLATING AGENTS - TOPICAL*** nystatin-triamcinolone 1 or 1b* QL VALCHLOR EXTERNAL external cream 3 PA; LD; QL GEL nystatin-triamcinolone 1 or 1b* QL external ointment *ANTINEOPLASTIC ANTIMETABOLITES - VUSION EXTERNAL 3 QL TOPICAL*** OINTMENT CARAC EXTERNAL 3 ST; QL *ANTIFUNGALS - CREAM TOPICAL*** EFUDEX EXTERNAL 3 ST; QL ciclopirox external gel 1 or 1b* QL CREAM ciclopirox external shampoo 1 or 1b* QL FLUOROPLEX 3 ST; QL ciclopirox external solution 1 or 1b* QL EXTERNAL CREAM ciclopirox olamine external fluorouracil external cream 1 or 1b* QL 1 or 1b* ST; QL cream 0.5 % ciclopirox olamine external fluorouracil external cream 5 1 or 1b* QL 1 or 1b* QL suspension % LOPROX EXTERNAL fluorouracil external solution 1 or 1b* QL 3 ST; QL CREAM *ANTINEOPLASTIC LOPROX EXTERNAL RETINOIDS - 3 QL SHAMPOO TOPICAL*** LOPROX EXTERNAL PANRETIN EXTERNAL 3 ST; QL 3 SP SUSPENSION GEL MENTAX EXTERNAL 3 ST; QL CREAM

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 91 Drug Name Tier Notes Drug Name Tier Notes *ANTIPRURITICS - STELARA TOPICAL*** SUBCUTANEOUS 4 PA; SP; QL doxepin hcl external cream 1 or 1b* PA; QL SOLUTION 45 MG/0.5ML PRUDOXIN EXTERNAL STELARA 3 PA; QL SUBCUTANEOUS CREAM 4 PA; SP; QL SOLUTION PREFILLED ZONALON EXTERNAL 3 PA; QL SYRINGE CREAM TALTZ SUBCUTANEOUS *ANTIPSORIATICS - SOLUTION AUTO- 4 PA; LD; SP; QL SYSTEMIC*** INJECTOR acitretin oral capsule 1 or 1b* TALTZ SUBCUTANEOUS COSENTYX (300 MG SOLUTION PREFILLED 4 PA; LD; SP; QL DOSE) SUBCUTANEOUS SYRINGE 4 PA; LD; SP; QL SOLUTION PREFILLED TREMFYA SYRINGE SUBCUTANEOUS 4 PA; SP; QL COSENTYX SOLUTION PEN- SENSOREADY (300 MG) INJECTOR SUBCUTANEOUS 4 PA; LD; SP; QL TREMFYA SOLUTION AUTO- SUBCUTANEOUS 4 PA; SP; QL INJECTOR SOLUTION PREFILLED COSENTYX SYRINGE SENSOREADY PEN *ANTIPSORIATICS*** SUBCUTANEOUS 4 PA; LD; SP; QL SOLUTION AUTO- calcipotriene external cream 1 or 1b* QL INJECTOR 150 MG/ML calcipotriene external foam 1 or 1b* QL COSENTYX calcipotriene external 1 or 1b* QL SUBCUTANEOUS ointment 4 PA; LD; SP; QL SOLUTION PREFILLED calcipotriene external 1 or 1b* QL SYRINGE solution ILUMYA calcitrene external ointment 1 or 1b* QL SUBCUTANEOUS 4 PA; LD; SP; QL SOLUTION PREFILLED calcitriol external ointment 1 or 1b* QL SYRINGE DOVONEX EXTERNAL 3 QL methoxsalen rapid oral CREAM 1 or 1b* SP capsule SORILUX EXTERNAL 3 QL SILIQ SUBCUTANEOUS FOAM SOLUTION PREFILLED 4 PA; SP; QL tazarotene external cream 1 or 1b* QL SYRINGE TAZORAC EXTERNAL 2 QL SKYRIZI (150 MG DOSE) CREAM 0.05 % SUBCUTANEOUS 4 PA; SP; QL TAZORAC EXTERNAL PREFILLED SYRINGE 3 ST; QL KIT CREAM 0.1 % TAZORAC EXTERNAL SKYRIZI PEN 2 QL SUBCUTANEOUS GEL 4 PA; SP; QL SOLUTION AUTO- VECTICAL EXTERNAL 3 QL INJECTOR OINTMENT SKYRIZI *ANTISEBORRHEIC SUBCUTANEOUS COMBINATIONS*** 4 PA; SP; QL SOLUTION PREFILLED PROMISEB EXTERNAL 3 SYRINGE CREAM SORIATANE ORAL 3 CAPSULE 10 MG, 25 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 92 Drug Name Tier Notes Drug Name Tier Notes SODIUM ala-cort external cream 1 or 1a* QL SULFACETAMIDE- alclometasone dipropionate 3 1 or 1b* QL BAKUCHIOL external cream EXTERNAL LIQUID alclometasone dipropionate 1 or 1b* QL *ANTISEBORRHEIC external ointment PRODUCTS*** amcinonide external cream 3 ST; QL selenium sulfide external 1 or 1a* QL lotion amcinonide external lotion 3 ST; QL AMCINONIDE *ANTIVIRAL TOPICAL 3 ST; QL COMBINATIONS*** EXTERNAL OINTMENT XERESE EXTERNAL APEXICON E 3 PA; QL 3 ST; QL CREAM EXTERNAL CREAM *ANTIVIRALS - beser external lotion 1 or 1b* QL TOPICAL*** betamethasone dipropionate 1 or 1b* QL acyclovir external cream 1 or 1b* PA; QL aug external cream betamethasone dipropionate acyclovir external ointment 1 or 1b* QL 1 or 1b* QL aug external gel DENAVIR EXTERNAL 3 PA; QL betamethasone dipropionate CREAM 1 or 1b* QL aug external lotion ZOVIRAX EXTERNAL 3 PA; QL betamethasone dipropionate CREAM 1 or 1b* QL aug external ointment ZOVIRAX EXTERNAL 3 QL betamethasone dipropionate OINTMENT 1 or 1b* QL external cream *ATOPIC DERMATITIS - betamethasone dipropionate MONOCLONAL 1 or 1b* QL ANTIBODIES*** external lotion betamethasone dipropionate DUPIXENT 1 or 1b* QL SUBCUTANEOUS external ointment 4 PA; SP; QL SOLUTION PEN- betamethasone valerate 1 or 1b* QL INJECTOR external cream DUPIXENT betamethasone valerate SUBCUTANEOUS 3 ST; QL 4 PA; SP; QL external foam SOLUTION PREFILLED betamethasone valerate SYRINGE 1 or 1b* ST; QL external lotion *BURN PRODUCTS*** betamethasone valerate mafenide acetate external 1 or 1b* QL 1 or 1b* external ointment packet BRYHALI EXTERNAL SILVADENE EXTERNAL 3 ST; QL 3 LOTION CREAM CAPEX EXTERNAL silver sulfadiazine external 3 ST; QL 1 or 1a* SHAMPOO cream clobetasol prop emollient 1 or 1b* QL ssd external cream 1 or 1a* base external cream SULFAMYLON clobetasol propionate e 3 1 or 1b* QL EXTERNAL CREAM external cream SULFAMYLON clobetasol propionate 3 1 or 1b* QL EXTERNAL PACKET emulsion external foam *CORTICOSTEROIDS - clobetasol propionate 1 or 1b* QL TOPICAL*** external cream ALA SCALP EXTERNAL clobetasol propionate 3 ST; QL 1 or 1b* QL LOTION external foam

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 93 Drug Name Tier Notes Drug Name Tier Notes clobetasol propionate desoximetasone external 1 or 1b* QL 3 ST; QL external gel ointment clobetasol propionate desrx external gel 1 or 1b* QL 1 or 1b* QL external liquid diflorasone diacetate external 3 ST; QL clobetasol propionate cream 1 or 1b* QL external lotion diflorasone diacetate external 3 ST; QL clobetasol propionate ointment 1 or 1b* QL external ointment DIPROLENE AF 3 ST; QL clobetasol propionate EXTERNAL CREAM 1 or 1b* QL external shampoo DIPROLENE EXTERNAL 3 ST; QL clobetasol propionate OINTMENT 1 or 1b* QL external solution fluocinolone acetonide body 1 or 1b* ST; QL CLOBEX EXTERNAL external oil 3 ST; QL LOTION fluocinolone acetonide 1 or 1b* QL CLOBEX EXTERNAL external cream 3 ST; QL SHAMPOO fluocinolone acetonide 1 or 1b* QL CLOBEX SPRAY external ointment 3 ST; QL EXTERNAL LIQUID fluocinolone acetonide 1 or 1b* QL clocortolone pivalate external external solution 3 ST; QL cream fluocinolone acetonide scalp 1 or 1b* QL clodan external shampoo 1 or 1b* QL external oil CLODERM EXTERNAL fluocinonide emulsified base 3 ST; QL 1 or 1b* QL CREAM external cream CORDRAN EXTERNAL fluocinonide external cream 1 or 1b* QL 3 ST; QL CREAM fluocinonide external gel 1 or 1b* QL CORDRAN EXTERNAL fluocinonide external 3 ST; QL 1 or 1b* QL LOTION ointment CORDRAN EXTERNAL fluocinonide external 3 ST; QL 1 or 1b* QL OINTMENT solution CORDRAN EXTERNAL flurandrenolide external 3 ST; QL 3 ST; QL TAPE cream CUTIVATE EXTERNAL flurandrenolide external 3 ST; QL 3 ST; QL LOTION lotion DERMA-SMOOTHE/FS flurandrenolide external 3 ST; QL 3 ST; QL BODY EXTERNAL OIL ointment DESONATE EXTERNAL fluticasone propionate 3 ST; QL 1 or 1b* QL GEL external cream desonide external cream 1 or 1b* QL fluticasone propionate 1 or 1b* QL desonide external gel 1 or 1b* QL external lotion desonide external lotion 1 or 1b* QL fluticasone propionate 1 or 1b* QL desonide external ointment 1 or 1b* QL external ointment DESOWEN EXTERNAL halcinonide external cream 3 ST; QL 3 ST; QL CREAM halobetasol propionate 1 or 1b* QL desoximetasone external external cream 3 ST; QL cream HALOBETASOL desoximetasone external gel 3 ST; QL PROPIONATE 3 ST; QL EXTERNAL FOAM desoximetasone external 3 ST; QL halobetasol propionate liquid 1 or 1b* QL external ointment * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 94 Drug Name Tier Notes Drug Name Tier Notes HALOG EXTERNAL OLUX-E EXTERNAL 3 ST; QL 3 ST; QL CREAM FOAM HALOG EXTERNAL PANDEL EXTERNAL 3 ST; QL 3 ST; QL OINTMENT CREAM HALOG EXTERNAL prednicarbate external 3 ST; QL 1 or 1b* QL SOLUTION ointment hydrocortisone butyr lipo PSORCON EXTERNAL 3 ST; QL 3 ST; QL base external cream CREAM hydrocortisone butyrate SERNIVO EXTERNAL 3 ST; QL 3 ST; QL external cream EMULSION hydrocortisone butyrate SYNALAR EXTERNAL 3 ST; QL 3 ST; QL external lotion CREAM hydrocortisone butyrate SYNALAR EXTERNAL 3 ST; QL 3 ST; QL external ointment OINTMENT hydrocortisone butyrate SYNALAR EXTERNAL 3 ST; QL 3 ST; QL external solution SOLUTION hydrocortisone external TEMOVATE EXTERNAL 1 or 1a* QL 3 ST; QL cream 1 %, 2.5 % CREAM hydrocortisone external TEMOVATE EXTERNAL 1 or 1a* QL 3 ST; QL lotion 2.5 % OINTMENT hydrocortisone external TEXACORT EXTERNAL 1 or 1a* QL 3 ST; QL ointment 1 %, 2.5 % SOLUTION hydrocortisone valerate TOPICORT EXTERNAL 3 ST; QL 3 ST; QL external cream CREAM hydrocortisone valerate TOPICORT EXTERNAL 3 ST; QL 3 ST; QL external ointment GEL IMPEKLO EXTERNAL TOPICORT EXTERNAL 3 ST; QL 3 ST; QL LOTION OINTMENT IMPOYZ EXTERNAL TOPICORT SPRAY 3 ST; QL 3 ST; QL CREAM EXTERNAL LIQUID KENALOG EXTERNAL tovet external foam 1 or 1b* QL 3 ST; QL AEROSOL SOLUTION triamcinolone acetonide 3 ST; QL LEXETTE EXTERNAL external aerosol solution 3 ST; QL FOAM triamcinolone acetonide 1 or 1a* QL LOCOID EXTERNAL external cream 3 ST; QL LOTION triamcinolone acetonide 1 or 1a* QL LOCOID LIPOCREAM external lotion 3 ST; QL EXTERNAL CREAM triamcinolone acetonide LUXIQ EXTERNAL external ointment 0.025 %, 1 or 1a* QL 3 ST; QL FOAM 0.1 %, 0.5 % mometasone furoate external triamcinolone acetonide 1 or 1b* QL 3 ST; QL cream external ointment 0.05 % mometasone furoate external triamcinolone in absorbase 1 or 1b* QL 3 ST; QL ointment external ointment mometasone furoate external triderm external cream 1 or 1a* QL 1 or 1b* QL solution TRIDESILON 3 ST; QL nolix external lotion 3 ST; QL EXTERNAL CREAM OLUX EXTERNAL tritocin external ointment 3 QL 3 ST; QL FOAM

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 95 Drug Name Tier Notes Drug Name Tier Notes ULTRAVATE ERTACZO EXTERNAL 3 ST; QL 3 ST; QL EXTERNAL LOTION CREAM VANOS EXTERNAL EXELDERM EXTERNAL 3 ST; QL 3 ST; QL CREAM CREAM VERDESO EXTERNAL EXELDERM EXTERNAL 3 ST; QL 3 ST; QL FOAM SOLUTION *DEPIGMENTING EXTINA EXTERNAL 3 QL AGENTS*** FOAM blanche external cream 1 or 1b* JUBLIA EXTERNAL 3 QL *DEPIGMENTING SOLUTION COMBINATIONS*** ketoconazole external cream 1 or 1b* QL TRI-LUMA EXTERNAL ketoconazole external foam 3 QL 3 CREAM ketoconazole external 1 or 1b* QL *EMOLLIENT shampoo 2 % COMBINATIONS*** luliconazole external cream 1 or 1b* ST; QL LACTIC ACID E LUZU EXTERNAL 3 3 ST; QL EXTERNAL CREAM CREAM *EMOLLIENT/KERATO oxiconazole nitrate external 3 ST; QL LYTIC AGENTS*** cream CEROVEL EXTERNAL OXISTAT EXTERNAL 3 3 ST; QL LOTION CREAM *EMOLLIENTS*** OXISTAT EXTERNAL 3 ST; QL ammonium lactate external LOTION 1 or 1b* QL cream sulconazole nitrate external 1 or 1b* ST; QL ammonium lactate external cream 1 or 1b* lotion sulconazole nitrate external 1 or 1b* ST; QL LACTIC ACID solution 3 EXTERNAL LOTION XOLEGEL EXTERNAL 3 QL *ENZYMES - GEL TOPICAL*** *IMMUNOMODULATOR SANTYL EXTERNAL S 3 QL OINTMENT IMIDAZOQUINOLINAMI *GLABELLAR LINES NES - TOPICAL*** (FROWN LINES) ALDARA EXTERNAL 3 ST; QL AGENTS*** CREAM BOTOX COSMETIC imiquimod external cream 1 or 1b* ST; QL INTRAMUSCULAR 3.75 % 4 PA SOLUTION imiquimod external cream 5 1 or 1b* QL RECONSTITUTED % *IMIDAZOLE-RELATED imiquimod pump external 1 or 1b* ST; QL ANTIFUNGALS - cream TOPICAL*** ZYCLARA EXTERNAL 3 ST; QL clotrimazole external cream 1 or 1b* QL CREAM clotrimazole external ZYCLARA PUMP 1 or 1b* QL 3 ST; QL solution EXTERNAL CREAM econazole nitrate external 1 or 1b* QL *KERATOLYTIC/ANTIM cream ITOTIC AGENTS*** ECOZA EXTERNAL ACNESIC EXTERNAL 3 ST; QL 3 FOAM GEL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 96 Drug Name Tier Notes Drug Name Tier Notes CONDYLOX EXTERNAL *MISC. TOPICAL*** 3 GEL BORIC ACID EXTERNAL 3 podofilox external solution 1 or 1b* GRANULES *LOCAL ANESTHETICS QBREXZA EXTERNAL 3 PA; QL - TOPICAL*** PAD glydo external prefilled *ORNITHINE 1 or 1b* syringe DECARBOXYLASE lidocaine external ointment 5 (ODC) INHIBITORS - 1 or 1b* QL % TOPICAL*** VANIQA EXTERNAL lidocaine external patch 5 % 1 or 1b* PA; QL 3 CREAM lidocaine hcl external 1 or 1b* QL solution *OXABOROLE- RELATED lidocaine hcl 1 or 1b* ANTIFUNGALS - urethral/mucosal external gel TOPICAL*** lidocaine hcl KERYDIN EXTERNAL 3 ST; QL urethral/mucosal external 1 or 1b* SOLUTION prefilled syringe tavaborole external solution 1 or 1b* ST; QL LIDODERM EXTERNAL 3 PA; QL PATCH *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - QUTENZA (4 PATCH) 3 LD TOPICAL*** EXTERNAL KIT EUCRISA EXTERNAL ZTLIDO EXTERNAL 3 ST; QL 3 PA; QL OINTMENT PATCH *PHOTODYNAMIC *MACROLIDE THERAPY AGENTS - IMMUNOSUPPRESSANT TOPICAL*** S - TOPICAL*** AMELUZ EXTERNAL ELIDEL EXTERNAL 3 3 ST; QL GEL CREAM LEVULAN KERASTICK pimecrolimus external cream 1 or 1b* ST; QL EXTERNAL SOLUTION 3 PROTOPIC EXTERNAL RECONSTITUTED 3 ST; QL OINTMENT *PROSTAGLANDINS - tacrolimus external ointment 1 or 1b* ST; QL TOPICAL*** *MELANOCORTIN bimatoprost external solution 1 or 1b* RECEPTOR AGONISTS LATISSE EXTERNAL 3 (UV PROTECTIVE)*** SOLUTION SCENESSE *ROSACEA AGENTS*** SUBCUTANEOUS 3 PA; LD; QL IMPLANT azelaic acid external gel 1 or 1b* QL doxycycline oral capsule *MICROTUBULE 3 ST; QL INHIBITORS - delayed release TOPICAL*** FINACEA EXTERNAL 2 QL KLISYRI EXTERNAL FOAM 3 ST; QL OINTMENT FINACEA EXTERNAL 3 QL *MISC. GEL DERMATOLOGICAL ivermectin external cream 1 or 1b* QL PRODUCTS*** METROCREAM 3 ST; QL ILIDERM EXTERNAL EXTERNAL CREAM 3 EMULSION METROGEL EXTERNAL 3 ST; QL GEL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 97 Drug Name Tier Notes Drug Name Tier Notes METROLOTION PRAMOSONE 3 ST; QL 2 EXTERNAL LOTION EXTERNAL LOTION metronidazole external cream 1 or 1b* QL *TAR PRODUCTS*** metronidazole external gel 1 or 1b* QL coal tar external solution 1 or 1b* metronidazole external lotion 1 or 1b* QL *TISSUE MIRVASO EXTERNAL REPLACEMENTS*** 3 QL GEL AFFINITY EXTERNAL 3 NORITATE EXTERNAL SHEET 3 ST; QL CREAM AMNIOFIX INJECTION ORACEA ORAL SUSPENSION 3 CAPSULE DELAYED 3 ST; QL RECONSTITUTED RELEASE AMNIOTEXT 3 RHOFADE EXTERNAL EXTERNAL SHEET 3 QL CREAM AMPHENOL-40 INJECTION rosadan external cream 1 or 1b* QL 3 SUSPENSION rosadan external gel 1 or 1b* QL RECONSTITUTED SOOLANTRA APLIGRAF EXTERNAL 3 QL 3 EXTERNAL CREAM DISK ZILXI EXTERNAL BIOVANCE EXTERNAL 3 ST; QL 3 FOAM SHEET *SCABICIDES & EPICORD EXTERNAL 3 PEDICULICIDES*** SHEET crotan external lotion 1 or 1b* QL EPIFIX EXTERNAL DISK 3 ivermectin external lotion 1 or 1b* QL EPIFIX EXTERNAL 3 lindane external shampoo 1 or 1b* QL SHEET malathion external lotion 1 or 1b* QL EPIFIX MICRONIZED INJECTION NATROBA EXTERNAL 3 QL SUSPENSION 3 SUSPENSION RECONSTITUTED 100 OVIDE EXTERNAL MG, 160 MG, 40 MG 3 QL LOTION KARDIAMEMBRANE 3 permethrin external cream 1 or 1b* QL EXTERNAL SHEET spinosad external suspension 1 or 1b* QL NEOX 100 EXTERNAL 3 SULFURATED LIME SHEET 3 EXTERNAL SOLUTION NEOX CORD 1K 3 *SEBORRHEIC EXTERNAL SHEET KERATOSIS NOVACHOR EXTERNAL 3 PRODUCTS** SHEET ESKATA EXTERNAL NUSHIELD EXTERNAL 3 3 SOLUTION DISK *STEROID-LOCAL NUSHIELD EXTERNAL ANESTHETIC SHEET 2 CM X 4 CM , 4 COMBINATIONS*** CM X 3 CM , 4 CM X 4 3 EPIFOAM EXTERNAL CM , 4 CM X 6 CM , 6 CM 3 FOAM X 6 CM PRAMOSONE PALINGEN FLOW EXTERNAL CREAM 1-1 2 INJECTION 3 % INJECTABLE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 98 Drug Name Tier Notes Drug Name Tier Notes PALINGEN *TOPICAL SELECTIVE HYDROMEMBRANE 3 RETINOID X RECEPTOR EXTERNAL SHEET AGONISTS*** PALINGEN INOVOFLO TARGRETIN EXTERNAL 2 PA; SP INJECTION 3 GEL INJECTABLE *TOPICAL STEROID PALINGEN MEMBRANE COMBINATIONS*** 3 EXTERNAL SHEET calcipotriene-betameth 2 ST; QL PALINGEN XPLUS diprop external ointment HYDROMEMBRANE 3 calcipotriene-betameth 2 ST; QL EXTERNAL SHEET diprop external suspension PALINGEN XPLUS DUOBRII EXTERNAL 3 PA; QL MEMBRANE EXTERNAL 3 LOTION SHEET ENSTILAR EXTERNAL STRAVIX EXTERNAL 3 QL 3 FOAM SHEET TACLONEX EXTERNAL TRUSKIN EXTERNAL 3 ST; QL 3 OINTMENT SHEET TACLONEX EXTERNAL 3 ST; QL *TOPICAL ANESTHETIC SUSPENSION COMBINATIONS*** WYNZORA EXTERNAL CETACAINE EXTERNAL 3 ST; QL 3 CREAM GEL *TYPE II 5-ALPHA FLEXIN EXTERNAL 3 REDUCTASE PATCH INHIBITORS*** lidocaine-prilocaine external 1 or 1b* QL finasteride oral tablet 1 mg 1 or 1b* kit PROPECIA ORAL 3 LIDOCAINE- TABLET TETRACAINE 3 PA; QL EXTERNAL CREAM 7-7 *WOUND CARE - % GROWTH FACTOR AGENTS*** PLIAGLIS EXTERNAL 3 PA; QL REGRANEX EXTERNAL CREAM 3 GEL PLIAGLIS EXTERNAL 3 PA; QL KIT *WOUND DRESSINGS*** PRILO PATCH II KENDALL HYDROGEL 3 EXTERNAL KIT WOUND DRESS 3 EXTERNAL REAL HEAL-I 3 TEGADERM AG MESH EXTERNAL KIT 2 EXTERNAL PAD 2"X2" SYNERA EXTERNAL 3 PA; QL PATCH WOUNDGELHA MATRIX EXTERNAL 3 VENIPUNCTURE PX1 GEL PHLEBOTOMY 3 EXTERNAL KIT *DIAGNOSTIC PRODUCTS* *TOPICAL ANESTHETIC GASES*** *DIAGNOSTIC TESTS*** CRYODOSE TA ACCU-CHEK AVIVA 3 2 ST; OTC; QL EXTERNAL AEROSOL PLUS IN VITRO STRIP ACCU-CHEK COMPACT 2 ST; OTC; QL PLUS IN VITRO STRIP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 99 Drug Name Tier Notes Drug Name Tier Notes ACCU-CHEK GUIDE IN CARESENS N GLUCOSE 2 ST; OTC; QL 3 OTC VITRO STRIP TEST IN VITRO STRIP ACCU-CHEK CARETOUCH TEST IN 3 OTC SMARTVIEW IN VITRO 2 ST; OTC; QL VITRO STRIP STRIP CLEVER CHEK AUTO- ACCUTREND GLUCOSE CODE TEST IN VITRO 3 OTC 2 ST; OTC; QL IN VITRO STRIP STRIP ADVANCE INTUITION CLEVER CHEK AUTO- 3 OTC TEST IN VITRO STRIP CODE VOICE IN VITRO 3 OTC ADVANCE MICRO- STRIP DRAW TEST IN VITRO 3 OTC CLEVER CHEK TEST IN 3 OTC STRIP VITRO STRIP ADVOCATE REDI-CODE CLEVER CHOICE 3 OTC IN VITRO STRIP AUTO-CODE TEST IN 3 OTC ADVOCATE REDI- VITRO STRIP CODE+ TEST IN VITRO 3 OTC CLEVER CHOICE STRIP MICRO TEST IN VITRO 3 OTC ADVOCATE TEST IN STRIP 3 OTC VITRO STRIP CLEVER CHOICE NO AGAMATRIX AMP TEST CODING IN VITRO 3 OTC 3 OTC IN VITRO STRIP STRIP AGAMATRIX JAZZ CLEVER CHOICE TALK 3 OTC TEST IN VITRO STRIP SYSTEM IN VITRO 3 OTC STRIP AGAMATRIX KEYNOTE 3 OTC CONTOUR NEXT TEST TEST IN VITRO STRIP 3 OTC IN VITRO STRIP AGAMATRIX PRESTO 3 OTC CONTOUR TEST IN TEST IN VITRO STRIP 3 OTC VITRO STRIP ASSURE 3 TEST IN 3 OTC VITRO STRIP COOL BLOOD GLUCOSE TEST STRIPS 3 OTC ASSURE 4 TEST IN 3 OTC IN VITRO STRIP VITRO STRIP CVS ADVANCED ASSURE II CHECK IN 3 OTC GLUCOSE TEST IN 3 OTC VITRO STRIP VITRO STRIP ASSURE II IN VITRO 3 OTC CVS GLUCOSE METER STRIP TEST STRIPS IN VITRO 3 OTC ASSURE PLATINUM IN STRIP 3 OTC VITRO STRIP D-CARE BLOOD ASSURE PRISM MULTI GLUCOSE IN VITRO 3 3 OTC TEST IN VITRO STRIP STRIP ASSURE PRO TEST IN DIATHRIVE BLOOD 3 OTC VITRO STRIP GLUCOSE TEST IN 3 OTC VITRO STRIP BIOSCANNER GLUCOSE 3 OTC DIATHRIVE GLUCOSE TEST IN VITRO STRIP 3 OTC TEST IN VITRO STRIP BLOOD GLUCOSE TEST 3 OTC DIATHRIVE+ GLUCOSE IN VITRO STRIP 3 OTC TEST IN VITRO STRIP BLULINK GLUCOSE 3 OTC DIATRUE PLUS TEST IN TEST IN VITRO STRIP 3 OTC VITRO STRIP CAREONE BLOOD DUO-CARE TEST IN GLUCOSE TEST IN 3 OTC 3 OTC VITRO STRIP VITRO STRIP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 100 Drug Name Tier Notes Drug Name Tier Notes EASY PLUS II GLUCOSE EXACTECH R-S-G TEST 3 OTC 3 OTC TEST IN VITRO STRIP IN VITRO STRIP EASY STEP TEST IN EXACTECH TEST IN 3 OTC 3 OTC VITRO STRIP VITRO STRIP EASY TALK BLOOD FIFTY50 GLUCOSE GLUCOSE TEST IN 3 OTC TEST 2.0 IN VITRO 3 OTC VITRO STRIP STRIP EASY TOUCH FORA 6 CONNECT IN 3 OTC HEALTHPRO GLUCOSE 3 OTC VITRO STRIP IN VITRO STRIP FORA BLOOD GLUCOSE 3 OTC EASY TOUCH TEST IN TEST IN VITRO STRIP 3 OTC VITRO STRIP FORA D15G BLOOD EASY TRAK BLOOD GLUCOSE TEST IN 3 OTC GLUCOSE TEST IN 3 OTC VITRO STRIP VITRO STRIP FORA D20 BLOOD EASY TRAK II GLUCOSE TEST IN 3 OTC GLUCOSE TEST IN 3 OTC VITRO STRIP VITRO STRIP FORA D40/G31 BLOOD EASYGLUCO IN VITRO GLUCOSE IN VITRO 3 OTC 3 OTC STRIP STRIP EASYMAX 15 TEST IN FORA G20 BLOOD 3 OTC VITRO STRIP GLUCOSE TEST IN 3 OTC EASYMAX TEST IN VITRO STRIP 3 OTC VITRO STRIP FORA G30/PREM V10 EASYPRO BLOOD GLUCOSE TEST IN 3 OTC GLUCOSE TEST IN 3 OTC VITRO STRIP VITRO STRIP FORA GD20 TEST IN 3 OTC EASYPRO PLUS IN VITRO STRIP 3 OTC VITRO STRIP FORA GD50 BLOOD ELEMENT COMPACT GLUCOSE TEST IN 3 OTC 3 OTC TEST IN VITRO STRIP VITRO STRIP ELEMENT TEST IN FORA GTEL BLOOD 3 OTC VITRO STRIP GLUCOSE TEST IN 3 OTC VITRO STRIP EMBRACE BLOOD FORA TN'G ADVANCE GLUCOSE TEST IN 3 OTC 3 OTC VITRO STRIP PRO IN VITRO STRIP FORA TN'G/TN'G VOICE EMBRACE EVO BLOOD 3 OTC GLUCOSE TEST IN 3 OTC IN VITRO STRIP VITRO STRIP FORA V10 BLOOD EMBRACE PRO GLUCOSE TEST IN 3 OTC GLUCOSE TEST IN 3 OTC VITRO STRIP VITRO STRIP FORA V12 BLOOD EMBRACE TALK GLUCOSE TEST IN 3 OTC GLUCOSE TEST IN 3 OTC VITRO STRIP VITRO STRIP FORA V20 BLOOD EQ BLOOD GLUCOSE GLUCOSE TEST IN 3 OTC 3 OTC TEST IN VITRO STRIP VITRO STRIP EVOLUTION FORA V30A BLOOD AUTOCODE IN VITRO 3 OTC GLUCOSE TEST IN 3 OTC STRIP VITRO STRIP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 101 Drug Name Tier Notes Drug Name Tier Notes FORACARE GD40 TEST GNP EASY TOUCH 3 OTC IN VITRO STRIP GLUCOSE TEST IN 3 OTC FORACARE PREMIUM VITRO STRIP V10 TEST IN VITRO 3 OTC GNP TRUE METRIX STRIP GLUCOSE STRIPS IN 3 ST; OTC; QL FORACARE TEST N GO VITRO STRIP 3 OTC TEST IN VITRO STRIP GOJJI BLOOD FORTISCARE G1 TEST GLUCOSE TEST IN 3 OTC 3 OTC STRIP IN VITRO STRIP VITRO STRIP FORTISCARE TEST IN GOJJI BLOOD TEST 3 OTC VITRO STRIP STRIP/LANCETS IN 3 OTC VITRO STRIP FREESTYLE INSULINX 3 OTC TEST IN VITRO STRIP GOODSENSE BLOOD GLUCOSE IN VITRO 3 OTC FREESTYLE LITE TEST 3 OTC STRIP IN VITRO STRIP HW EMBRACE PRO FREESTYLE PRECISION GLUCOSE TEST IN 3 OTC NEO TEST IN VITRO 3 OTC VITRO STRIP STRIP HW EMBRACE TALK FREESTYLE TEST IN 3 OTC GLUCOSE TEST IN 3 OTC VITRO STRIP VITRO STRIP GE100 BLOOD IGLUCOSE TEST STRIPS 3 OTC GLUCOSE TEST IN 3 OTC IN VITRO STRIP VITRO STRIP IN TOUCH BLOOD GENULTIMATE TEST IN 3 OTC GLUCOSE TEST IN 3 OTC VITRO STRIP VITRO STRIP GHT TEST IN VITRO 3 OTC INFINITY BLOOD STRIP GLUCOSE TEST IN 3 OTC GLUCO PERFECT 3 VITRO STRIP 3 OTC TEST IN VITRO STRIP INFINITY VOICE IN 3 OTC GLUCOCARD 01 VITRO STRIP SENSOR PLUS IN VITRO 3 OTC KROGER BLOOD STRIP GLUCOSE TEST IN 3 OTC GLUCOCARD VITRO STRIP EXPRESSION TEST IN 3 OTC KROGER HEALTHPRO VITRO STRIP GLUCOSE TEST IN 3 OTC GLUCOCARD SHINE VITRO STRIP 3 OTC TEST IN VITRO STRIP KROGER PREMIUM GLUCOCARD VITAL GLUCOSE TEST IN 3 OTC 3 OTC TEST IN VITRO STRIP VITRO STRIP GLUCOCARD X-SENSOR KROGER TEST IN 3 OTC 3 OTC IN VITRO STRIP VITRO STRIP GLUCOCOM TEST IN LIBERTY NEXT 3 OTC VITRO STRIP GENERATION TEST IN 3 OTC VITRO STRIP GLUCONAVII BLOOD LIBERTY TEST IN GLUCOSE TEST IN 3 OTC 3 OTC VITRO STRIP VITRO STRIP GLUCOSE METER TEST MEIJER BLOOD 3 OTC IN VITRO STRIP GLUCOSE TEST IN 3 OTC VITRO STRIP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 102 Drug Name Tier Notes Drug Name Tier Notes MEIJER ESSENTIAL PRECISION QID TEST IN 3 OTC GLUCOSE TEST IN 3 OTC VITRO STRIP VITRO STRIP PRECISION SOF-TACT 3 OTC MEIJER PREMIUM TEST IN VITRO STRIP GLUCOSE TEST IN 3 OTC PRECISION XTRA VITRO STRIP BLOOD GLUCOSE IN 3 OTC MEIJER TRUETEST VITRO STRIP 3 OTC TEST IN VITRO STRIP PREMIUM BLOOD MEIJER TRUETRACK GLUCOSE TEST IN 3 OTC 3 OTC TEST IN VITRO STRIP VITRO STRIP MICRODOT TEST IN PRO VOICE V8/V9 3 OTC VITRO STRIP GLUCOSE IN VITRO 3 OTC MM EASY TOUCH STRIP GLUCOSE IN VITRO 3 OTC PRODIGY NO CODING STRIP BLOOD GLUC IN VITRO 3 OTC MYGLUCOHEALTH STRIP 3 OTC TEST IN VITRO STRIP PTS PANELS GLUCOSE 3 OTC NEUTEK 2TEK TEST IN TEST IN VITRO STRIP 3 OTC VITRO STRIP QUICKTEK TEST IN 3 OTC NOVA MAX GLUCOSE VITRO STRIP 3 OTC TEST IN VITRO STRIP QUINTET AC BLOOD ONE DROP TEST IN GLUCOSE TEST IN 3 OTC 3 OTC VITRO STRIP VITRO STRIP ONETOUCH ULTRA IN QUINTET BLOOD 2 OTC VITRO STRIP GLUCOSE TEST IN 3 OTC VITRO STRIP ONETOUCH VERIO IN 2 ST; OTC; QL VITRO STRIP REFUAH PLUS BLOOD GLUCOSE TEST IN 3 OTC OPTIUM TEST IN VITRO 3 OTC VITRO STRIP STRIP RELION BLOOD OPTIUMEZ TEST IN 3 OTC GLUCOSE TEST IN 3 OTC VITRO STRIP VITRO STRIP PHARMACIST CHOICE RELION AUTOCODE IN VITRO 3 OTC CONFIRM/MICRO TEST 3 OTC STRIP IN VITRO STRIP PHARMACIST CHOICE RELION PREMIER TEST 3 OTC NO CODING IN VITRO 3 OTC IN VITRO STRIP STRIP RELION PRIME TEST IN POCKETCHEM EZ TEST 3 OTC 3 OTC VITRO STRIP IN VITRO STRIP RELION TRUE METRIX POGO AUTOMATIC TEST STRIPS IN VITRO 3 OTC TEST CARTRIDGES IN 3 OTC STRIP VITRO DIAGNOSTIC RELION ULTIMA TEST TEST 3 OTC IN VITRO STRIP PRECISION PCX IN 3 OTC VITRO STRIP REXALL BLOOD GLUCOSE TEST IN 3 OTC PRECISION PCX PLUS 3 OTC VITRO STRIP TEST IN VITRO STRIP RIGHTEST GS100 PRECISION POINT OF BLOOD GLUCOSE IN 3 OTC CARE TEST IN VITRO 3 OTC VITRO STRIP STRIP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 103 Drug Name Tier Notes Drug Name Tier Notes RIGHTEST GS300 PANCREAZE ORAL BLOOD GLUCOSE IN 3 OTC CAPSULE DELAYED VITRO STRIP RELEASE PARTICLES 10500-35500 UNIT, 16800- RIGHTEST GS550 3 ST; QL BLOOD GLUCOSE IN 3 OTC 56800 UNIT, 21000-54700 VITRO STRIP UNIT, 2600-8800 UNIT, 37000-97300 UNIT, 4200- RIGHTEST GT333 14200 UNIT BLOOD GLUCOSE IN 3 ST; OTC; QL VITRO STRIP PERTZYE ORAL CAPSULE DELAYED 3 ST; QL SMART SENSE RELEASE PARTICLES PREMIUM TEST IN 3 OTC SUCRAID ORAL VITRO STRIP 4 PA; LD; QL SOLUTION SMART SENSE VALUE 3 OTC VIOKACE ORAL TEST IN VITRO STRIP 3 QL TABLET SMARTEST BLOOD GLUCOSE TEST IN 3 OTC ZENPEP ORAL VITRO STRIP CAPSULE DELAYED RELEASE PARTICLES SOLUS V2 TEST IN 3 OTC 10000-32000 UNIT, 15000- VITRO STRIP 47000 UNIT, 20000-63000 2 QL SUPREME TEST IN UNIT, 25000-79000 UNIT, 3 OTC VITRO STRIP 3000-10000 UNIT, 40000- 126000 UNIT, 5000-24000 SURE-TEST EASYPLUS UNIT MINI TEST IN VITRO 3 OTC STRIP *DIURETICS* TGT BLOOD GLUCOSE *CARBONIC 3 OTC TEST IN VITRO STRIP ANHYDRASE INHIBITORS*** TRUE FOCUS BLOOD acetazolamide er oral capsule GLUCOSE STRIP IN 3 OTC 1 or 1b* VITRO STRIP extended release 12 hour TRUE METRIX BLOOD acetazolamide oral tablet 1 or 1b* GLUCOSE TEST IN 3 OTC acetazolamide sodium VITRO STRIP injection solution 1 or 1b* TRUETEST TEST IN reconstituted 3 OTC VITRO STRIP KEVEYIS ORAL 4 PA; LD; QL TRUETRACK TEST IN TABLET 3 OTC VITRO STRIP methazolamide oral tablet 1 or 1b* UNISTRIP1 GENERIC IN 3 OTC *DIURETIC VITRO STRIP COMBINATIONS*** VERASENS BLOOD ALDACTAZIDE ORAL 3 DO GLUCOSE TEST IN 3 OTC TABLET 25-25 MG VITRO STRIP ALDACTAZIDE ORAL VIVAGUARD INO TEST 3 QL 3 OTC TABLET 50-50 MG STRIPS IN VITRO STRIP amiloride- *DIGESTIVE AIDS* hydrochlorothiazide oral 1 or 1b* *DIGESTIVE tablet ENZYMES*** MAXZIDE ORAL 3 CREON ORAL CAPSULE TABLET DELAYED RELEASE 2 QL MAXZIDE-25 ORAL 3 PARTICLES TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 104 Drug Name Tier Notes Drug Name Tier Notes spironolactone-hctz oral spironolactone oral tablet 1 or 1b* DO 1 or 1a* QL tablet 100 mg triamterene-hctz oral capsule spironolactone oral tablet 25 1 or 1a* 1 or 1a* DO 37.5-25 mg mg, 50 mg triamterene-hctz oral tablet 1 or 1a* triamterene oral capsule 1 or 1b* *LOOP DIURETICS*** *THIAZIDES AND bumetanide injection solution 1 or 1b* THIAZIDE-LIKE DIURETICS*** bumetanide oral tablet 1 or 1b* chlorothiazide sodium BUMEX ORAL TABLET 3 intravenous solution 1 or 1b* 0.5 MG reconstituted EDECRIN ORAL chlorthalidone oral tablet 25 3 1 or 1a* TABLET mg, 50 mg ethacrynate sodium DIURIL ORAL 3 intravenous solution 1 or 1b* SUSPENSION reconstituted hydrochlorothiazide oral 1 or 1a* ethacrynic acid oral tablet 1 or 1b* capsule FUROSEMIDE IN hydrochlorothiazide oral SODIUM CHLORIDE 1 or 1a* 3 tablet INTRAVENOUS SOLUTION indapamide oral tablet 1 or 1b* furosemide injection solution metolazone oral tablet 1 or 1b* 1 or 1a* 10 mg/ml SODIUM DIURIL furosemide oral solution 10 INTRAVENOUS 1 or 1a* 3 mg/ml, 8 mg/ml SOLUTION RECONSTITUTED furosemide oral tablet 1 or 1a* *ENDOCRINE AND LASIX ORAL TABLET 3 METABOLIC AGENTS - SODIUM EDECRIN MISC.* INTRAVENOUS 3 *ABORTIFACIENT - SOLUTION PROGESTERONE RECONSTITUTED RECEPTOR torsemide oral tablet 1 or 1b* ANTAGONISTS*** MIFEPREX ORAL *OSMOTIC 3 DIURETICS*** TABLET mannitol intravenous mifepristone oral tablet 1 or 1b* 1 or 1b* solution 20 %, 25 % *ADENOSINE osmitrol intravenous solution DEAMINASE SCID 1 or 1b* 10 %, 15 %, 20 % TREATMENT - AGENTS*** *POTASSIUM SPARING DIURETICS*** REVCOVI INTRAMUSCULAR 4 PA; LD ALDACTONE ORAL 3 QL SOLUTION TABLET 100 MG *BISPHOSPHONATES*** ALDACTONE ORAL 3 DO ACTONEL ORAL TABLET 25 MG, 50 MG 3 QL TABLET 150 MG, 35 MG amiloride hcl oral tablet 1 or 1b* alendronate sodium oral CAROSPIR ORAL 1 or 1b* QL 3 QL solution SUSPENSION alendronate sodium oral DYRENIUM ORAL 3 tablet 10 mg, 35 mg, 5 mg, 1 or 1b* QL CAPSULE 70 mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 105 Drug Name Tier Notes Drug Name Tier Notes ATELVIA ORAL calcitonin (salmon) nasal 1 or 1b* QL TABLET DELAYED 3 QL solution RELEASE MIACALCIN INJECTION 4 BINOSTO ORAL SOLUTION TABLET 3 QL *CARNITINE EFFERVESCENT REPLENISHER - BONIVA ORAL TABLET AGENTS*** 3 ST; QL 150 MG CARNITOR FOSAMAX ORAL INTRAVENOUS 3 3 QL TABLET 70 MG SOLUTION FOSAMAX PLUS D CARNITOR ORAL 2 QL 3 ORAL TABLET SOLUTION ibandronate sodium CARNITOR ORAL 3 intravenous solution 3 4 TABLET mg/3ml CARNITOR SF ORAL 3 ibandronate sodium oral SOLUTION 1 or 1b* QL tablet levocarnitine oral solution 1 or 1b* pamidronate disodium levocarnitine oral tablet 1 or 1b* intravenous solution 30 4 SP mg/10ml, 90 mg/10ml levocarnitine sf oral solution 1 or 1b* PAMIDRONATE *CORTICOTROPIN*** DISODIUM ACTHAR INJECTION 4 SP 4 PA; LD; SP INTRAVENOUS GEL SOLUTION 6 MG/ML *CORTISOL SYNTHESIS RECLAST INHIBITORS*** INTRAVENOUS 4 PA; SP; QL ISTURISA ORAL SOLUTION 4 PA; LD; QL TABLET risedronate sodium oral *DOPAMINE RECEPTOR tablet 150 mg, 30 mg, 35 mg, 1 or 1b* QL AGONISTS*** 5 mg risedronate sodium oral cabergoline oral tablet 1 or 1b* QL 1 or 1b* QL tablet delayed release *FABRY DISEASE - AGENTS*** zoledronic acid intravenous 1 or 1b* PA; SP concentrate FABRAZYME INTRAVENOUS ZOLEDRONIC ACID 4 PA; LD; SP INTRAVENOUS 4 PA; SP SOLUTION SOLUTION 4 MG/100ML RECONSTITUTED zoledronic acid intravenous GALAFOLD ORAL 4 PA; SP; QL 4 PA; LD; QL solution 5 mg/100ml CAPSULE *CALCIMIMETIC *GAA DEFICIENCY AGENTS*** TREATMENT - AGENTS*** cinacalcet hcl oral tablet 4 PA; QL LUMIZYME PARSABIV INTRAVENOUS 4 PA; LD; SP INTRAVENOUS 4 PA SOLUTION SOLUTION RECONSTITUTED SENSIPAR ORAL 4 PA; QL NEXVIAZYME TABLET INTRAVENOUS 4 SP *CALCITONINS*** SOLUTION RECONSTITUTED calcitonin (salmon) injection 4 solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 106 Drug Name Tier Notes Drug Name Tier Notes *GNRH/LHRH NUTROPIN AQ NUSPIN 5 ANTAGONISTS*** SUBCUTANEOUS 4 PA; SP; QL CETROTIDE SOLUTION PEN- SUBCUTANEOUS KIT 4 PA; SP INJECTOR 0.25 MG OMNITROPE GANIRELIX ACETATE SUBCUTANEOUS 4 PA; SP; QL SUBCUTANEOUS SOLUTION CARTRIDGE 4 PA; SP SOLUTION PREFILLED OMNITROPE SYRINGE SUBCUTANEOUS 4 PA; SP; QL ORILISSA ORAL SOLUTION 3 PA; QL TABLET RECONSTITUTED *GROWTH HORMONE SAIZEN INJECTION RECEPTOR SOLUTION 4 PA; SP; QL ANTAGONISTS*** RECONSTITUTED SOMAVERT SAIZENPREP SUBCUTANEOUS INJECTION SOLUTION 4 PA; SP; QL 4 PA; LD; SP; QL SOLUTION RECONSTITUTED RECONSTITUTED SEROSTIM *GROWTH HORMONE SUBCUTANEOUS RELEASING SOLUTION 4 PA; LD; QL HORMONES (GHRH)*** RECONSTITUTED 4 MG, 5 MG, 6 MG EGRIFTA SV SUBCUTANEOUS ZOMACTON (FOR 4 PA; LD; QL SOLUTION ZOMA-JET 10) RECONSTITUTED SUBCUTANEOUS 4 PA; SP; QL SOLUTION *GROWTH RECONSTITUTED HORMONES*** ZOMACTON GENOTROPIN SUBCUTANEOUS 4 PA; SP; QL MINIQUICK SOLUTION SUBCUTANEOUS 4 PA; SP; QL RECONSTITUTED SOLUTION RECONSTITUTED ZORBTIVE SUBCUTANEOUS 4 PA; SP; QL GENOTROPIN SOLUTION SUBCUTANEOUS 4 PA; SP; QL RECONSTITUTED SOLUTION RECONSTITUTED *HEREDITARY OROTIC ACIDURIA TREATMENT HUMATROPE - AGENTS** INJECTION SOLUTION 4 PA; SP; QL XURIDEN ORAL RECONSTITUTED 12 3 PA; LD; QL MG, 24 MG, 6 MG PACKET NORDITROPIN *HEREDITARY FLEXPRO TYROSINEMIA TYPE 1 SUBCUTANEOUS 4 PA; SP; QL (HT-1) TREATMENT - SOLUTION PEN- AGENTS*** INJECTOR nitisinone oral capsule 4 PA; SP NUTROPIN AQ NUSPIN NITYR ORAL TABLET 4 PA; LD 10 SUBCUTANEOUS ORFADIN ORAL 4 PA; SP; QL 4 PA; LD SOLUTION PEN- CAPSULE INJECTOR ORFADIN ORAL 4 PA; LD NUTROPIN AQ NUSPIN SUSPENSION 20 SUBCUTANEOUS 4 PA; SP; QL SOLUTION PEN- INJECTOR

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 107 Drug Name Tier Notes Drug Name Tier Notes *HOMOCYSTINURIA *INSULIN-LIKE TREATMENT - GROWTH FACTOR-1 AGENTS*** RECEPTOR CYSTADANE ORAL INHIBITORS(IGF-1R)*** 3 LD POWDER TEPEZZA INTRAVENOUS *HYPERAMMONEMIA 4 PA; QL TREATMENT - SOLUTION AGENTS*** RECONSTITUTED CARBAGLU ORAL *INSULIN-LIKE 4 PA; LD TABLET GROWTH FACTORS (SOMATOMEDINS)*** *HYPERPARATHYROID TREATMENT - VITAMIN INCRELEX D ANALOGS*** SUBCUTANEOUS 4 PA; LD; SP SOLUTION calcitriol intravenous 1 or 1b* PA solution 1 mcg/ml *LEPTIN ANALOGUES*** calcitriol oral capsule 1 or 1b* PA MYALEPT calcitriol oral solution 1 or 1b* PA SUBCUTANEOUS 4 PA; LD doxercalciferol intravenous SOLUTION 1 or 1b* PA solution RECONSTITUTED doxercalciferol oral capsule 1 or 1b* PA *LHRH/GNRH AGONIST ANALOG HECTOROL COMBINATIONS*** INTRAVENOUS 3 PA LUPANETA PACK SOLUTION 4 MCG/2ML 4 PA; SP; QL COMBINATION KIT paricalcitol intravenous 1 or 1b* PA solution *LHRH/GNRH AGONIST ANALOG PITUITARY paricalcitol oral capsule 1 or 1b* PA SUPPRESSANTS*** RAYALDEE ORAL FENSOLVI (6 MONTH) 3 PA; LD; SP; QL CAPSULE EXTENDED 3 PA; QL SUBCUTANEOUS KIT RELEASE LUPRON DEPOT-PED (1- ROCALTROL ORAL 3 PA MONTH) 4 PA; SP; QL CAPSULE INTRAMUSCULAR KIT ROCALTROL ORAL 3 PA LUPRON DEPOT-PED (3- SOLUTION MONTH) 4 PA; SP; QL ZEMPLAR INTRAMUSCULAR KIT INTRAVENOUS 3 PA SUPPRELIN LA 4 PA; LD; SP; QL SOLUTION SUBCUTANEOUS KIT ZEMPLAR ORAL SYNAREL NASAL 3 PA 4 PA; SP; QL CAPSULE 1 MCG, 2 MCG SOLUTION *HYPOPHOSPHATASIA TRIPTODUR (HPP) AGENTS*** INTRAMUSCULAR 4 PA; LD; QL STRENSIQ SUSPENSION SUBCUTANEOUS 4 PA; LD RECONSTITUTED ER SOLUTION *LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS*** KANUMA INTRAVENOUS 3 PA; LD; SP SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 108 Drug Name Tier Notes Drug Name Tier Notes *MOLYBDENUM FOLLISTIM AQ COFACTOR SUBCUTANEOUS 4 ST; SP DEFICIENCY (MOCD) - SOLUTION AGENTS*** GONAL-F INJECTION NULIBRY SOLUTION 4 PA; SP INTRAVENOUS RECONSTITUTED 4 PA; LD SOLUTION GONAL-F RFF RECONSTITUTED REDIJECT 4 PA; SP *MUCOPOLYSACCHARI SUBCUTANEOUS DOSIS I (MPS I) - SOLUTION AGENTS*** GONAL-F RFF ALDURAZYME SUBCUTANEOUS 4 PA; SP INTRAVENOUS 4 PA; LD; SP SOLUTION SOLUTION RECONSTITUTED *MUCOPOLYSACCHARI MENOPUR DOSIS II (MPS II) - SUBCUTANEOUS 4 PA; SP AGENTS*** SOLUTION ELAPRASE RECONSTITUTED INTRAVENOUS 4 PA; LD; SP NOVAREL SOLUTION INTRAMUSCULAR 4 PA; SP *MUCOPOLYSACCHARI SOLUTION DOSIS IV (MPS IV) - RECONSTITUTED AGENTS*** OVIDREL VIMIZIM SUBCUTANEOUS 4 PA; SP INTRAVENOUS 4 PA; LD; SP INJECTABLE SOLUTION PREGNYL INTRAMUSCULAR *MUCOPOLYSACCHARI 4 PA; SP DOSIS VI (MPS VI) - SOLUTION AGENTS*** RECONSTITUTED NAGLAZYME *OVULATION INTRAVENOUS 4 PA; LD; SP STIMULANTS- SOLUTION SYNTHETIC*** *MUCOPOLYSACCHARI clomiphene citrate oral tablet 1 or 1b* PA DOSIS VII (MPS VII) - *PARATHYROID AGENTS*** HORMONE AND MEPSEVII DERIVATIVES*** INTRAVENOUS 4 PA; LD FORTEO SOLUTION SUBCUTANEOUS *NON-STEROIDAL SOLUTION PEN- 4 PA; SP; QL MINERALOCORTICOID INJECTOR 620 RECEPTOR MCG/2.48ML ANTAGONISTS*** NATPARA KERENDIA ORAL SUBCUTANEOUS 3 PA; LD; SP; QL 3 PA; QL TABLET CARTRIDGE *OVULATION TERIPARATIDE STIMULANTS- (RECOMBINANT) GONADOTROPINS*** SUBCUTANEOUS 4 PA; SP; QL SOLUTION PEN- CHORIONIC INJECTOR GONADOTROPIN INTRAMUSCULAR 4 PA; SP TYMLOS SUBCUTANEOUS SOLUTION 4 PA; SP; QL RECONSTITUTED SOLUTION PEN- INJECTOR

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 109 Drug Name Tier Notes Drug Name Tier Notes *PHENYLKETONURIA SAMSCA ORAL TABLET 3 PA; LD; SP; QL TREATMENT - tolvaptan oral tablet 1 or 1b* PA; QL AGENTS*** *SOMATOSTATIC KUVAN ORAL PACKET 4 PA; LD; SP AGENTS*** KUVAN ORAL TABLET 4 PA; LD; SP MYCAPSSA ORAL PALYNZIQ CAPSULE DELAYED 4 PA; LD; QL SUBCUTANEOUS RELEASE SOLUTION PREFILLED 4 PA; LD; SP octreotide acetate injection SYRINGE 10 MG/0.5ML, solution 100 mcg/ml, 1000 4 PA; SP 2.5 MG/0.5ML mcg/ml, 200 mcg/ml, 50 PALYNZIQ mcg/ml, 500 mcg/ml SUBCUTANEOUS 4 PA; LD; SP; QL SANDOSTATIN SOLUTION PREFILLED INJECTION SOLUTION 4 PA; SP SYRINGE 20 MG/ML 100 MCG/ML, 50 sapropterin dihydrochloride MCG/ML, 500 MCG/ML 4 PA; SP oral packet SANDOSTATIN LAR sapropterin dihydrochloride DEPOT 4 PA; SP; QL 4 PA; SP oral tablet INTRAMUSCULAR KIT *RANK LIGAND SIGNIFOR LAR (RANKL) INTRAMUSCULAR 4 PA; LD; QL INHIBITORS*** SUSPENSION PROLIA RECONSTITUTED ER SUBCUTANEOUS SIGNIFOR 3 PA; SP; QL SOLUTION PREFILLED SUBCUTANEOUS 4 PA; LD; QL SYRINGE SOLUTION XGEVA SOMATULINE DEPOT SUBCUTANEOUS 3 PA; SP; QL SUBCUTANEOUS 4 PA; LD; SP; QL SOLUTION SOLUTION *SCLEROSTIN *UREA CYCLE INHIBITORS*** DISORDER - AGENTS*** EVENITY AMMONUL SUBCUTANEOUS INTRAVENOUS 3 4 PA; SP; QL SOLUTION PREFILLED SOLUTION SYRINGE BUPHENYL ORAL 3 PA; LD; QL *SELECTIVE POWDER 3 GM/TSP ESTROGEN RECEPTOR BUPHENYL ORAL 3 PA; LD; QL MODULATORS TABLET (SERMS)*** CITRULLINE EASY EVISTA ORAL TABLET 3 $0 ORAL TABLET 3 OSPHENA ORAL EXTENDED RELEASE 3 PA; QL TABLET RAVICTI ORAL LIQUID 3 PA; LD; SP; QL raloxifene hcl oral tablet 1 or 1b* $0 sod benz-sod phenylacet 1 or 1b* *SELECTIVE intravenous solution VASOPRESSIN V2- sodium phenylbutyrate oral 1 or 1b* PA; QL RECEPTOR powder 3 gm/tsp ANTAGONISTS*** sodium phenylbutyrate oral JYNARQUE ORAL 1 or 1b* PA; QL 4 PA; LD; QL tablet TABLET JYNARQUE ORAL TABLET THERAPY 4 PA; LD; QL PACK

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 110 Drug Name Tier Notes Drug Name Tier Notes *V1A/V2-ARGININE *ESTROGEN & VASOPRESSIN (AVP) PROGESTIN*** RECEPTOR ACTIVELLA ORAL 3 ANTAGONISTS*** TABLET 1-0.5 MG VAPRISOL amabelz oral tablet 1 or 1b* INTRAVENOUS 3 ANGELIQ ORAL SOLUTION 3 TABLET *VASOPRESSIN*** BIJUVA ORAL CAPSULE 2 QL DDAVP INJECTION 3 SOLUTION 4 MCG/ML CLIMARA PRO TRANSDERMAL PATCH 2 QL DDAVP ORAL TABLET 3 DO WEEKLY 0.1 MG COMBIPATCH DDAVP ORAL TABLET 3 QL TRANSDERMAL PATCH 2 QL 0.2 MG TWICE WEEKLY DDAVP PF INJECTION estradiol-norethindrone acet 3 1 or 1b* SOLUTION oral tablet desmopressin ace spray 1 or 1b* FEMHRT ORAL TABLET 3 refrig nasal solution fyavolv oral tablet 1 or 1b* desmopressin acetate 1 or 1b* injection solution jinteli oral tablet 1 or 1b* desmopressin acetate oral mimvey oral tablet 1 or 1b* 1 or 1b* DO tablet 0.1 mg norethindrone-eth estradiol 1 or 1b* desmopressin acetate oral oral tablet 1 or 1b* QL tablet 0.2 mg PREFEST ORAL 3 desmopressin acetate pf TABLET 1 or 1b* injection solution PREMPHASE ORAL 2 desmopressin acetate spray TABLET 1 or 1b* nasal solution PREMPRO ORAL 2 NOCDURNA TABLET SUBLINGUAL TABLET 4 PA; QL *ESTROGEN- SUBLINGUAL PROGESTIN-GNRH STIMATE NASAL ANTAGONIST*** 3 PA; QL SOLUTION MYFEMBREE ORAL 3 PA; QL VASOSTRICT TABLET INTRAVENOUS 3 ORIAHNN ORAL SOLUTION CAPSULE THERAPY 3 PA; QL *X-LINKED PACK HYPOPHOSPHATEMIA *ESTROGENS*** (XLH) TREATMENT - AGENTS*** ALORA TRANSDERMAL PATCH TWICE 3 QL CRYSVITA WEEKLY SUBCUTANEOUS 4 PA; LD; SP SOLUTION CLIMARA TRANSDERMAL PATCH 3 QL *ESTROGENS* WEEKLY *ESTROGEN & DELESTROGEN 3 ANDROGEN*** INTRAMUSCULAR OIL est estrogens-methyltest oral DEPO-ESTRADIOL 1 or 1b* 3 tablet 0.625-1.25 mg INTRAMUSCULAR OIL DIVIGEL 2 QL TRANSDERMAL GEL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 111 Drug Name Tier Notes Drug Name Tier Notes dotti transdermal patch twice *FLUOROQUINOLONES 1 or 1b* QL weekly * ELESTRIN *FLUOROQUINOLONES 3 QL TRANSDERMAL GEL *** ESTRACE ORAL BAXDELA 3 TABLET INTRAVENOUS 3 ESTRADIOL IMPLANT SOLUTION 3 PELLET 6 MG RECONSTITUTED BAXDELA ORAL estradiol oral tablet 1 or 1b* 3 PA; QL TABLET estradiol transdermal patch 1 or 1b* QL twice weekly CIPRO ORAL SUSPENSION 3 QL estradiol transdermal patch 1 or 1b* QL RECONSTITUTED weekly CIPRO ORAL TABLET 3 QL estradiol valerate 250 MG, 500 MG intramuscular oil 20 mg/ml, 1 or 1b* 40 mg/ml ciprofloxacin hcl oral tablet 1 or 1b* QL ESTROGEL ciprofloxacin in d5w 3 QL 1 or 1b* TRANSDERMAL GEL intravenous solution levofloxacin in d5w EVAMIST 1 or 1b* TRANSDERMAL 2 QL intravenous solution SOLUTION levofloxacin intravenous 1 or 1b* lyllana transdermal patch solution 1 or 1b* QL twice weekly levofloxacin oral solution 1 or 1b* QL MENEST ORAL TABLET levofloxacin oral tablet 1 or 1b* QL 0.3 MG, 0.625 MG, 1.25 2 moxifloxacin hcl in nacl 1 or 1b* MG intravenous solution MENOSTAR MOXIFLOXACIN HCL TRANSDERMAL PATCH 3 QL INTRAVENOUS 3 WEEKLY SOLUTION MINIVELLE moxifloxacin hcl oral tablet 1 or 1b* QL TRANSDERMAL PATCH 3 QL ofloxacin oral tablet 300 mg, TWICE WEEKLY 1 or 1b* QL 400 mg PREMARIN INJECTION SOLUTION 2 *GASTROINTESTINAL RECONSTITUTED AGENTS - MISC.* PREMARIN ORAL *5-HT4 RECEPTOR 2 QL TABLET AGONISTS*** MOTEGRITY ORAL VIVELLE-DOT 3 ST; QL TRANSDERMAL PATCH 3 QL TABLET TWICE WEEKLY *BILE ACID SYNTHESIS *ESTROGEN- DISORDER AGENTS*** SELECTIVE ESTROGEN CHOLBAM ORAL 3 PA; LD; QL RECEPTOR CAPSULE MODULATOR COMB*** *CIC AGENTS - DUAVEE ORAL TABLET 3 PA; QL GUANYLATE CYCLASE- C (GC-C) AGONISTS*** TRULANCE ORAL 3 ST; QL TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 112 Drug Name Tier Notes Drug Name Tier Notes *FARNESOID X metoclopramide hcl oral 1 or 1a* ST; QL RECEPTOR (FXR) tablet dispersible 5 mg AGONISTS*** REGLAN ORAL TABLET 3 QL OCALIVA ORAL 4 PA; LD; SP; QL *GLUCAGON-LIKE TABLET PEPTIDE-2 (GLP-2) *GALLSTONE ANALOGS*** SOLUBILIZING GATTEX 3 PA; LD; SP AGENTS*** SUBCUTANEOUS KIT CHENODAL ORAL 3 PA; LD; QL *IBS AGENT - 5-HT4 TABLET RECEPTOR PARTIAL RELTONE ORAL AGONISTS*** 3 CAPSULE ZELNORM ORAL 3 ST; QL URSO 250 ORAL TABLET 3 TABLET *IBS AGENT - URSO FORTE ORAL GUANYLATE CYCLASE- 3 TABLET C (GC-C) AGONISTS*** URSODIOL ORAL LINZESS ORAL 2 QL CAPSULE 200 MG, 400 3 CAPSULE MG *IBS AGENT - MU- ursodiol oral capsule 300 mg 1 or 1b* OPIOID RECEPTOR ursodiol oral tablet 1 or 1b* AGONISTS*** *GASTROINTESTINAL VIBERZI ORAL TABLET 3 PA; QL ANTIALLERGY *IBS AGENT - AGENTS*** SELECTIVE 5-HT3 cromolyn sodium oral RECEPTOR 1 or 1b* concentrate ANTAGONISTS*** GASTROCROM ORAL alosetron hcl oral tablet 1 or 1b* PA; QL 3 CONCENTRATE LOTRONEX ORAL 3 PA; QL *GASTROINTESTINAL TABLET CHLORIDE CHANNEL *ILEAL BILE ACID ACTIVATORS*** TRANSPORTER (IBAT) AMITIZA ORAL INHIBITORS*** 3 ST; QL CAPSULE BYLVAY (PELLETS) lubiprostone oral capsule 1 or 1b* QL ORAL CAPSULE 4 PA; LD; QL SPRINKLE *GASTROINTESTINAL BYLVAY ORAL STIMULANTS*** 4 PA; LD; QL CAPSULE DEXPANTHENOL 3 INJECTION SOLUTION *INFLAMMATORY BOWEL AGENTS*** GIMOTI NASAL 3 PA; QL SOLUTION APRISO ORAL CAPSULE EXTENDED RELEASE 24 3 ST; QL metoclopramide hcl injection 1 or 1a* HOUR solution ASACOL HD ORAL metoclopramide hcl oral TABLET DELAYED 3 ST; QL solution 10 mg/10ml, 5 1 or 1a* QL RELEASE mg/5ml AZULFIDINE EN-TABS metoclopramide hcl oral 1 or 1a* QL ORAL TABLET 3 QL tablet DELAYED RELEASE METOCLOPRAMIDE AZULFIDINE ORAL 3 QL HCL ORAL TABLET 3 ST; QL TABLET DISPERSIBLE 10 MG * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 113 Drug Name Tier Notes Drug Name Tier Notes balsalazide disodium oral lactulose encephalopathy oral 1 or 1b* QL 1 or 1b* capsule solution CANASA RECTAL *PERIPHERAL OPIOID 3 QL SUPPOSITORY RECEPTOR COLAZAL ORAL ANTAGONISTS*** 3 QL CAPSULE alvimopan oral capsule 1 or 1b* DELZICOL ORAL ENTEREG ORAL 3 CAPSULE DELAYED 3 ST; QL CAPSULE RELEASE MOVANTIK ORAL 2 QL DIPENTUM ORAL TABLET 3 ST; QL CAPSULE RELISTOR ORAL 3 ST; QL LIALDA ORAL TABLET TABLET 3 ST; QL DELAYED RELEASE RELISTOR mesalamine er oral capsule SUBCUTANEOUS 1 or 1b* QL 3 ST; QL extended release 24 hour SOLUTION 12 MG/0.6ML, mesalamine oral capsule 8 MG/0.4ML 1 or 1b* QL delayed release SYMPROIC ORAL 3 ST; QL mesalamine oral tablet TABLET 1 or 1b* QL delayed release *PHOSPHATE BINDER mesalamine rectal enema 1 or 1b* QL AGENTS*** mesalamine rectal AURYXIA ORAL 1 or 1b* QL 3 ST; QL suppository TABLET mesalamine-cleanser rectal calcium acetate (phos binder) 1 or 1b* QL 1 or 1b* QL kit oral capsule calcium acetate (phos binder) PENTASA ORAL 1 or 1b* QL CAPSULE EXTENDED 2 QL oral tablet RELEASE calcium acetate oral tablet 1 or 1b* QL ROWASA RECTAL KIT 3 QL 667 mg SFROWASA RECTAL FOSRENOL ORAL 3 QL 3 ST; QL ENEMA PACKET sulfasalazine oral tablet 1 or 1b* QL FOSRENOL ORAL TABLET CHEWABLE sulfasalazine oral tablet 3 ST; QL 1 or 1b* QL 1000 MG, 500 MG, 750 delayed release MG *INTEGRIN RECEPTOR lanthanum carbonate oral 1 or 1b* QL ANTAGONISTS*** tablet chewable ENTYVIO PHOSLYRA ORAL INTRAVENOUS 3 ST; QL 4 PA; SP; QL SOLUTION SOLUTION RENAGEL ORAL RECONSTITUTED 3 ST; QL TABLET 800 MG *INTERLEUKIN RENVELA ORAL ANTAGONISTS*** 3 ST; QL PACKET STELARA RENVELA ORAL INTRAVENOUS 4 PA; SP; QL 3 ST; QL SOLUTION TABLET sevelamer carbonate oral *INTESTINAL 1 or 1b* QL ACIDIFIERS*** packet sevelamer carbonate oral enulose oral solution 1 or 1b* 1 or 1b* QL tablet generlac oral solution 1 or 1b* sevelamer hcl oral tablet 1 or 1b* QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 114 Drug Name Tier Notes Drug Name Tier Notes VELPHORO ORAL etomidate intravenous 3 ST; QL 1 or 1b* TABLET CHEWABLE solution *TRYPTOPHAN fresenius propoven HYDROXYLASE intravenous emulsion 1000 1 or 1b* INHIBITORS*** mg/100ml, 200 mg/20ml, XERMELO ORAL 500 mg/50ml 4 PA; LD; QL TABLET KETALAR INJECTION 3 *TUMOR NECROSIS SOLUTION FACTOR ALPHA ketamine hcl injection BLOCKERS*** solution 10 mg/ml, 100 1 or 1b* AVSOLA INTRAVENOUS mg/ml, 50 mg/ml SOLUTION 4 PA; LD; SP KETAMINE HCL RECONSTITUTED INTRAVENOUS 3 CIMZIA PREFILLED SOLUTION PREFILLED 4 PA; SP; QL SUBCUTANEOUS KIT SYRINGE CIMZIA STARTER KIT KETAMINE HCL- 4 PA; SP; QL SUBCUTANEOUS KIT SODIUM CHLORIDE INTRAVENOUS 3 CIMZIA SOLUTION PREFILLED SUBCUTANEOUS KIT 2 4 PA; SP; QL SYRINGE X 200 MG propofol intravenous INFLECTRA emulsion 1000 mg/100ml, 1 or 1b* INTRAVENOUS 4 PA; SP 200 mg/20ml, 500 mg/50ml SOLUTION propofol-lipuro intravenous RECONSTITUTED 1 or 1b* emulsion REMICADE INTRAVENOUS *BARBITURATE 4 PA; SP SOLUTION ANESTHETICS*** RECONSTITUTED BREVITAL SODIUM INJECTION SOLUTION RENFLEXIS 3 INTRAVENOUS RECONSTITUTED 500 4 PA; LD; SP SOLUTION MG RECONSTITUTED METHOHEXITAL SODIUM INTRAVENOUS *GENERAL 3 ANESTHETICS* SOLUTION PREFILLED SYRINGE 100 MG/10ML *ANESTHETICS - MISC.*** *VOLATILE ANESTHETICS*** AMIDATE INTRAVENOUS 3 desflurane inhalation solution 1 or 1b* SOLUTION FORANE INHALATION 3 ANESTHESIA S/I-40A SOLUTION 3 INTRAVENOUS KIT isoflurane inhalation solution 1 or 1b* ANESTHESIA S/I-40H sevoflurane inhalation 3 1 or 1b* INTRAVENOUS KIT solution ANESTHESIA S/I-40S SUPRANE INHALATION 3 3 INTRAVENOUS KIT SOLUTION DIPRIVAN terrell inhalation solution 1 or 1b* INTRAVENOUS ULTANE INHALATION EMULSION 100 3 3 SOLUTION MG/10ML, 1000 MG/100ML, 200 MG/20ML, 500 MG/50ML

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 115 Drug Name Tier Notes Drug Name Tier Notes *GENITOURINARY *CYSTINOSIS AGENTS - AGENTS*** MISCELLANEOUS* CYSTAGON ORAL 4 LD; SP *5-ALPHA REDUCTASE CAPSULE INHIBITORS*** PROCYSBI ORAL AVODART ORAL CAPSULE DELAYED 4 ST; LD 3 QL CAPSULE RELEASE dutasteride oral capsule 1 or 1b* QL PROCYSBI ORAL 4 ST; LD finasteride oral tablet 5 mg 1 or 1b* QL PACKET PROSCAR ORAL *GENITOURINARY 3 QL TABLET IRRIGANTS*** *ALPHA 1- acetic acid irrigation solution 1 or 1b* ADRENOCEPTOR argyle sterile saline irrigation 1 or 1b* ANTAGONISTS*** solution alfuzosin hcl er oral tablet curity sterile saline irrigation 1 or 1b* QL 1 or 1b* extended release 24 hour solution CARDURA XL ORAL glycine irrigation solution 1 or 1b* TABLET EXTENDED 3 QL glycine urologic irrigation 1 or 1b* RELEASE 24 HOUR solution FLOMAX ORAL RENACIDIN 3 QL 3 CAPSULE IRRIGATION SOLUTION RAPAFLO ORAL sodium chloride irrigation 3 QL 1 or 1b* CAPSULE solution 0.9 % silodosin oral capsule 1 or 1b* QL SORBITOL IRRIGATION 3 tamsulosin hcl oral capsule 1 or 1b* QL SOLUTION 3 % UROXATRAL ORAL SORBITOL-MANNITOL 3 TABLET EXTENDED 3 QL IRRIGATION SOLUTION RELEASE 24 HOUR *INTERSTITIAL *ANTI-INFECTIVE CYSTITIS AGENTS*** GENITOURINARY ELMIRON ORAL 3 QL IRRIGANTS*** CAPSULE neomycin-polymyxin b gu 1 or 1b* RIMSO-50 irrigation solution INTRAVESICAL 3 *CITRATES*** SOLUTION pot & sod cit-cit ac oral *PHOSPHATES*** 1 or 1b* solution K-PHOS NO 2 ORAL 3 potassium citrate er oral TABLET 1 or 1b* tablet extended release *PROSTATIC UROCIT-K 10 ORAL HYPERTROPHY AGENT TABLET EXTENDED 3 COMBINATIONS*** RELEASE dutasteride-tamsulosin hcl 1 or 1b* QL UROCIT-K 15 ORAL oral capsule TABLET EXTENDED 3 JALYN ORAL CAPSULE 3 QL RELEASE *SMALL INTERFERING UROCIT-K 5 ORAL RIBONUCLEIC ACID TABLET EXTENDED 3 AGENTS (SIRNA)*** RELEASE OXLUMO SUBCUTANEOUS 4 PA; LD SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 116 Drug Name Tier Notes Drug Name Tier Notes *URINARY STONE *HEMATOLOGICAL AGENTS*** AGENTS - MISC.* LITHOSTAT ORAL *AMINOLEVULINATE 3 TABLET SYNTHASE 1-DIRECTED THIOLA EC ORAL SIRNA*** TABLET DELAYED 3 PA; LD; QL GIVLAARI RELEASE SUBCUTANEOUS 4 PA; LD THIOLA ORAL TABLET 3 PA; LD; QL SOLUTION tiopronin oral tablet 1 or 1b* PA; QL *ANTIHEMOPHILIC PRODUCTS - *VESICOURETERAL MONOCLONAL REFLUX (VUR) AGENT ANTIBODIES*** COMBINATIONS*** HEMLIBRA DEFLUX INJECTION 3 SUBCUTANEOUS 4 PA; SP PREFILLED SYRINGE SOLUTION *GOUT AGENTS* *ANTIHEMOPHILIC *GOUT AGENT PRODUCTS*** COMBINATIONS*** ADVATE INTRAVENOUS colchicine-probenecid oral SOLUTION 4 PA; SP 1 or 1b* tablet RECONSTITUTED *GOUT AGENTS*** ADYNOVATE INTRAVENOUS 4 PA; SP allopurinol oral tablet 1 or 1a* SOLUTION allopurinol sodium RECONSTITUTED intravenous solution 1 or 1b* AFSTYLA 4 PA; SP reconstituted INTRAVENOUS KIT ALOPRIM ALPHANATE INTRAVENOUS 3 INTRAVENOUS SOLUTION SOLUTION RECONSTITUTED RECONSTITUTED 1000 4 PA; SP colchicine oral capsule 3 ST; QL UNIT, 1500 UNIT, 2000 colchicine oral tablet 2 QL UNIT, 250 UNIT, 500 UNIT COLCRYS ORAL 3 ST; QL TABLET ALPHANINE SD INTRAVENOUS 4 PA; SP febuxostat oral tablet 1 or 1b* ST; QL SOLUTION GLOPERBA ORAL RECONSTITUTED 3 ST; QL SOLUTION ALPROLIX INTRAVENOUS KRYSTEXXA 4 PA; SP INTRAVENOUS 4 PA; LD; SP; QL SOLUTION SOLUTION RECONSTITUTED MITIGARE ORAL BENEFIX 3 ST; QL 4 PA; SP CAPSULE INTRAVENOUS KIT ULORIC ORAL TABLET 3 ST; QL COAGADEX INTRAVENOUS ZYLOPRIM ORAL 4 PA; LD; SP 3 SOLUTION TABLET RECONSTITUTED *URICOSURICS*** CORIFACT 4 PA; LD; SP probenecid oral tablet 1 or 1b* INTRAVENOUS KIT ELOCTATE INTRAVENOUS 4 PA; SP SOLUTION RECONSTITUTED * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 117 Drug Name Tier Notes Drug Name Tier Notes ESPEROCT MONONINE INTRAVENOUS INTRAVENOUS 4 PA; SP SOLUTION SOLUTION 4 PA; SP RECONSTITUTED RECONSTITUTED 1000 FEIBA INTRAVENOUS UNIT SOLUTION NOVOEIGHT RECONSTITUTED 1000 4 PA; SP INTRAVENOUS 4 PA; LD; SP UNIT, 2500 UNIT, 500 SOLUTION UNIT RECONSTITUTED FIBRYGA NOVOSEVEN RT INTRAVENOUS INTRAVENOUS 4 PA 4 PA; SP SOLUTION SOLUTION RECONSTITUTED RECONSTITUTED HEMOFIL M NUWIQ INTRAVENOUS 4 PA; SP INTRAVENOUS KIT SOLUTION 4 PA; SP NUWIQ INTRAVENOUS RECONSTITUTED 1000 SOLUTION 4 PA; SP UNIT, 1700 UNIT, 250 RECONSTITUTED UNIT, 500 UNIT OBIZUR INTRAVENOUS HUMATE-P SOLUTION 4 PA; LD; SP INTRAVENOUS RECONSTITUTED SOLUTION 4 PA; SP RECONSTITUTED 1000- PROFILNINE INTRAVENOUS 2400 UNIT, 250-600 UNIT, 4 PA; SP 500-1200 UNIT SOLUTION RECONSTITUTED IDELVION INTRAVENOUS REBINYN 4 PA; SP INTRAVENOUS SOLUTION 4 PA; SP RECONSTITUTED SOLUTION RECONSTITUTED IXINITY INTRAVENOUS SOLUTION 4 PA; SP RECOMBINATE INTRAVENOUS RECONSTITUTED 4 PA; SP SOLUTION JIVI INTRAVENOUS RECONSTITUTED SOLUTION 4 PA; SP RECONSTITUTED RIASTAP INTRAVENOUS KCENTRA 3 PA 3 SOLUTION INTRAVENOUS KIT RECONSTITUTED KOATE INTRAVENOUS RIXUBIS INTRAVENOUS SOLUTION 4 PA; SP SOLUTION 4 PA; SP RECONSTITUTED RECONSTITUTED KOATE-DVI SEVENFACT INTRAVENOUS INTRAVENOUS 4 PA; LD; SP SOLUTION 4 PA; SP SOLUTION RECONSTITUTED 1000 RECONSTITUTED UNIT, 500 UNIT TRETTEN KOGENATE FS INTRAVENOUS 4 PA; SP 4 PA; LD; SP INTRAVENOUS KIT SOLUTION KOVALTRY RECONSTITUTED INTRAVENOUS 4 PA; SP VONVENDI SOLUTION INTRAVENOUS 4 PA; LD; SP RECONSTITUTED SOLUTION RECONSTITUTED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 118 Drug Name Tier Notes Drug Name Tier Notes WILATE INTRAVENOUS *DIRECT-ACTING P2Y12 4 PA; SP KIT INHIBITORS*** XYNTHA BRILINTA ORAL 2 QL INTRAVENOUS KIT 1000 TABLET 4 PA; SP UNIT, 2000 UNIT, 250 KENGREAL UNIT, 500 UNIT INTRAVENOUS 3 XYNTHA SOLOFUSE SOLUTION 4 PA; SP INTRAVENOUS KIT RECONSTITUTED *ANTI-VON *GLYCOPROTEIN WILLEBRAND FACTOR IIB/IIIA RECEPTOR AGENTS*** INHIBITORS*** CABLIVI INJECTION AGGRASTAT 4 PA; LD KIT INTRAVENOUS 3 *BRADYKININ B2 CONCENTRATE RECEPTOR AGGRASTAT ANTAGONISTS*** INTRAVENOUS FIRAZYR SOLUTION 12.5-0.9 3 SUBCUTANEOUS 4 PA; LD; SP; QL MG/250ML-%, 5-0.9 SOLUTION MG/100ML-% icatibant acetate eptifibatide intravenous 4 PA; LD; SP; QL subcutaneous solution solution 20 mg/10ml, 200 1 or 1b* mg/100ml, 75 mg/100ml sajazir subcutaneous solution 4 PA; SP; QL *HEMATORHEOLOGIC *C1 INHIBITORS*** AGENTS*** BERINERT pentoxifylline er oral tablet 4 PA; LD; SP; QL 1 or 1b* INTRAVENOUS KIT extended release CINRYZE *HEMIN*** INTRAVENOUS 4 PA; LD; SP; QL SOLUTION PANHEMATIN RECONSTITUTED INTRAVENOUS SOLUTION 3 HAEGARDA RECONSTITUTED 350 SUBCUTANEOUS 4 PA; LD; SP; QL MG SOLUTION RECONSTITUTED *HUMAN PROTEIN C*** RUCONEST CEPROTIN INTRAVENOUS INTRAVENOUS 4 PA; LD; SP; QL 4 LD; SP SOLUTION SOLUTION RECONSTITUTED RECONSTITUTED *COMPLEMENT *PHOSPHODIESTERASE INHIBITORS*** III INHIBITORS*** EMPAVELI cilostazol oral tablet 1 or 1b* SUBCUTANEOUS 4 PA; LD; QL *PLASMA SOLUTION EXPANDERS*** SOLIRIS INTRAVENOUS HESPAN INTRAVENOUS 4 PA; LD; SP 3 SOLUTION 300 MG/30ML SOLUTION ULTOMIRIS hetastarch-nacl intravenous 1 or 1b* INTRAVENOUS solution 4 PA; LD; SP; QL SOLUTION 1100 HEXTEND MG/11ML, 300 MG/3ML INTRAVENOUS 3 SOLUTION lmd in d5w intravenous 1 or 1b* solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 119 Drug Name Tier Notes Drug Name Tier Notes lmd in nacl intravenous OCTAPLAS BLOOD 1 or 1b* solution GROUP AB 3 *PLASMA KALLIKREIN INTRAVENOUS INHIBITORS - SOLUTION MONOCLONAL OCTAPLAS BLOOD ANTIBODIES*** GROUP B 3 TAKHZYRO INTRAVENOUS SUBCUTANEOUS 4 PA; LD; SP; QL SOLUTION SOLUTION OCTAPLAS BLOOD GROUP O *PLASMA KALLIKREIN 3 INHIBITORS*** INTRAVENOUS SOLUTION KALBITOR SUBCUTANEOUS 4 PA; LD; SP; QL PLASBUMIN-25 SOLUTION INTRAVENOUS 3 SOLUTION ORLADEYO ORAL 4 PA; LD; QL CAPSULE PLASBUMIN-5 INTRAVENOUS 3 *PLASMA PROTEINS*** SOLUTION ALBUKED 25 PLASMANATE INTRAVENOUS 3 INTRAVENOUS 3 SOLUTION SOLUTION ALBUKED 5 THROMBATE III INTRAVENOUS 3 INTRAVENOUS 3 SOLUTION SOLUTION ALBUMIN HUMAN RECONSTITUTED INTRAVENOUS 3 *PLATELET SOLUTION AGGREGATION ALBUMINEX INHIBITOR INTRAVENOUS 3 COMBINATIONS*** SOLUTION aspirin-dipyridamole er oral ALBUMIN-ZLB capsule extended release 12 1 or 1b* QL INTRAVENOUS 3 hour SOLUTION ASPIRIN-OMEPRAZOLE ALBURX INTRAVENOUS ORAL TABLET 3 PA; QL 3 SOLUTION DELAYED RELEASE ALBUTEIN YOSPRALA ORAL INTRAVENOUS 3 TABLET DELAYED 3 PA; QL SOLUTION RELEASE FLEXBUMIN *PLATELET INTRAVENOUS 3 AGGREGATION SOLUTION INHIBITORS*** HUMAN ALBUMIN dipyridamole oral tablet 1 or 1b* GRIFOLS 3 DURLAZA ORAL INTRAVENOUS CAPSULE EXTENDED 3 PA; QL SOLUTION RELEASE 24 HOUR KEDBUMIN *PROTAMINE*** INTRAVENOUS 3 protamine sulfate intravenous SOLUTION 1 or 1b* solution OCTAPLAS BLOOD GROUP A 3 INTRAVENOUS SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 120 Drug Name Tier Notes Drug Name Tier Notes *PROTEASE- RETAVASE ACTIVATED INTRAVENOUS KIT 2 X 3 RECEPTOR-1 (PAR-1) 10 UNIT ANTAGONISTS*** TNKASE INTRAVENOUS 3 ZONTIVITY ORAL KIT 3 PA; QL TABLET *HEMATOPOIETIC *QUINAZOLINE AGENTS* AGENTS*** *AGENTS FOR AGRYLIN ORAL GAUCHER DISEASE*** 3 CAPSULE CERDELGA ORAL 4 PA; LD; SP anagrelide hcl oral capsule 1 or 1b* CAPSULE *SPLEEN TYROSINE CEREZYME KINASE (SYK) INTRAVENOUS INHIBITORS*** SOLUTION 4 PA; LD; SP TAVALISSE ORAL RECONSTITUTED 400 4 PA; LD; QL TABLET UNIT *THIENOPYRIDINE ELELYSO INTRAVENOUS DERIVATIVES*** 4 PA; LD; SP SOLUTION clopidogrel bisulfate oral 1 or 1b* RECONSTITUTED tablet 300 mg miglustat oral capsule 4 PA; SP clopidogrel bisulfate oral 1 or 1b* QL tablet 75 mg VPRIV INTRAVENOUS SOLUTION 4 PA; LD; SP EFFIENT ORAL TABLET 3 QL RECONSTITUTED 10 MG ZAVESCA ORAL EFFIENT ORAL TABLET 4 PA; LD 3 DO CAPSULE 5 MG *AMINO ACIDS*** PLAVIX ORAL TABLET 3 QL 75 MG ENDARI ORAL PACKET 4 PA; LD prasugrel hcl oral tablet 10 *COBALAMIN 1 or 1b* QL mg COMBINATIONS*** prasugrel hcl oral tablet 5 mg 1 or 1b* DO LIPO-B INTRAMUSCULAR 3 *THROMBOLYTIC SOLUTION AGENT - MISC*** NEURIN-SL DEFITELIO SUBLINGUAL TABLET 3 INTRAVENOUS 4 SUBLINGUAL SOLUTION *COBALAMINS*** *TISSUE PLASMINOGEN cyanocobalamin injection ACTIVATORS*** 1 or 1a* solution 1000 mcg/ml ACTIVASE INTRAVENOUS CYANOCOBALAMIN 3 SOLUTION INJECTION SOLUTION 3 RECONSTITUTED 2000 MCG/ML hydroxocobalamin acetate CATHFLO ACTIVASE 1 or 1b* INJECTION SOLUTION 3 intramuscular solution RECONSTITUTED METHYLCOBALAMIN RETAVASE HALF-KIT INJECTION SOLUTION 3 INTRAVENOUS KIT 1 X 3 RECONSTITUTED 10 UNIT NASCOBAL NASAL 3 SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 121 Drug Name Tier Notes Drug Name Tier Notes *CXCR4 RECEPTOR foltabs 800 oral tablet 1 or 1b* OTC; $0 ANTAGONIST*** millguard oral tablet 1 or 1b* OTC; $0 MOZOBIL *FOLIC SUBCUTANEOUS 4 PA; LD; SP ACID/FOLATES*** SOLUTION cvs folic acid oral tablet 800 1 or 1a* OTC; $0 *CYTOTOXIC mcg AGENTS*** fa-8 oral capsule 1 or 1b* OTC; $0 DROXIA ORAL 2 CAPSULE folate oral tablet 1 or 1a* OTC; $0 SIKLOS ORAL TABLET 3 PA; SP folic acid injection solution 1 or 1a* *ERYTHROID folic acid oral capsule 0.8 mg 1 or 1b* OTC; $0 MATURATION folic acid oral tablet 1 mg 1 or 1a* AGENTS*** folic acid oral tablet 400 1 or 1a* OTC; $0 REBLOZYL mcg, 800 mcg SUBCUTANEOUS 4 PA; SP SOLUTION gnp folic acid oral tablet 1 or 1a* OTC; $0 RECONSTITUTED hm folic acid oral tablet 1 or 1a* OTC; $0 *ERYTHROPOIESIS- kp folic acid oral tablet 800 1 or 1a* OTC; $0 STIMULATING AGENTS mcg (ESAS)*** px folic acid oral tablet 1 or 1a* OTC; $0 ARANESP (ALBUMIN qc folic acid oral tablet 1 or 1a* OTC; $0 FREE) INJECTION SOLUTION 100 MCG/ML, ra folic acid oral tablet 1 or 1a* OTC; $0 4 PA; SP; QL 200 MCG/ML, 25 sm folic acid oral tablet 1 or 1a* OTC; $0 MCG/ML, 40 MCG/ML, yl folic acid oral tablet 1 or 1a* OTC; $0 60 MCG/ML *GRANULOCYTE ARANESP (ALBUMIN COLONY- FREE) INJECTION 4 PA; SP; QL STIMULATING SOLUTION PREFILLED FACTORS (G-CSF)*** SYRINGE FULPHILA EPOGEN INJECTION SUBCUTANEOUS SOLUTION 10000 4 PA; SP; QL SOLUTION PREFILLED UNIT/ML, 2000 UNIT/ML, 4 PA; SP; QL SYRINGE 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML GRANIX SUBCUTANEOUS 4 PA; SP MIRCERA INJECTION SOLUTION SOLUTION PREFILLED 4 PA; LD; QL SYRINGE GRANIX SUBCUTANEOUS PROCRIT INJECTION 4 PA; SP 4 PA; SP; QL SOLUTION PREFILLED SOLUTION SYRINGE RETACRIT INJECTION NEULASTA ONPRO SOLUTION 10000 SUBCUTANEOUS UNIT/ML, 2000 UNIT/ML, 4 PA; SP; QL 4 PA; SP; QL PREFILLED SYRINGE 20000 UNIT/ML, 3000 KIT UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML NEULASTA SUBCUTANEOUS *FOLIC ACID/FOLATE 4 PA; SP; QL SOLUTION PREFILLED COMBINATIONS*** SYRINGE fa-vitamin b-6-vitamin b-12 1 or 1b* NEUPOGEN INJECTION oral tablet SOLUTION 300 MCG/ML, 4 PA; SP FOLGARD RX ORAL 3 480 MCG/1.6ML TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 122 Drug Name Tier Notes Drug Name Tier Notes NEUPOGEN INJECTION INJECTAFER SOLUTION PREFILLED 4 PA; SP INTRAVENOUS 4 PA; SP; QL SYRINGE SOLUTION NIVESTYM INJECTION MONOFERRIC 4 PA; SP SOLUTION INTRAVENOUS 3 PA; SP; QL NIVESTYM INJECTION SOLUTION SOLUTION PREFILLED 4 PA; SP na ferric gluc cplx in sucrose 4 SP SYRINGE intravenous solution NYVEPRIA TRIFERIC SUBCUTANEOUS HEMODIALYSIS 4 PA 4 PA; LD; SP; QL SOLUTION PREFILLED PACKET SYRINGE TRIFERIC UDENYCA HEMODIALYSIS 4 PA SUBCUTANEOUS SOLUTION 4 PA; SP; QL SOLUTION PREFILLED VENOFER SYRINGE INTRAVENOUS 4 PA; SP; QL ZARXIO INJECTION SOLUTION SOLUTION PREFILLED 4 PA; SP *SELECTIN SYRINGE BLOCKERS*** ZIEXTENZO ADAKVEO SUBCUTANEOUS 4 PA; LD; SP; QL INTRAVENOUS 4 PA; LD; SP SOLUTION PREFILLED SOLUTION SYRINGE *THROMBOPOIETIN *GRANULOCYTE/MACR (TPO) RECEPTOR OPHAGE COLONY- AGONISTS*** STIMULATING DOPTELET ORAL FACTOR(GM-CSF)*** 4 PA; LD; SP; QL TABLET 20 MG LEUKINE INJECTION MULPLETA ORAL SOLUTION 4 PA; SP 4 PA; SP; QL RECONSTITUTED TABLET *HEMOGLOBIN S (HBS) NPLATE POLYMERIZATION SUBCUTANEOUS INHIBITORS*** SOLUTION 4 PA RECONSTITUTED 125 OXBRYTA ORAL 4 PA; LD; SP; QL MCG TABLET NPLATE *IRON SUBCUTANEOUS COMBINATIONS*** SOLUTION 4 PA; SP foltrin oral capsule 1 or 1b* RECONSTITUTED 250 *IRON*** MCG, 500 MCG ACCRUFER ORAL PROMACTA ORAL 3 4 PA; DO; LD; SP CAPSULE PACKET 12.5 MG PROMACTA ORAL FERAHEME 4 PA; LD; SP; QL INTRAVENOUS 4 PA; SP; QL PACKET 25 MG SOLUTION PROMACTA ORAL 4 PA; DO; LD; SP FERRLECIT TABLET 12.5 MG, 25 MG INTRAVENOUS 4 PA; SP; QL PROMACTA ORAL 4 PA; LD; SP; QL SOLUTION TABLET 50 MG, 75 MG ferumoxytol intravenous 4 PA; SP; QL solution INFED INJECTION 4 PA; SP SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 123 Drug Name Tier Notes Drug Name Tier Notes *HEMOSTATICS* *HEMOSTATICS - *HEMOSTATIC TOPICAL*** COMBINATIONS - ACTIFOAM COLLAGEN 3 TOPICAL*** SPONGE EXTERNAL ARTISS EXTERNAL AVITENE EXTERNAL 3 3 SOLUTION PAD THROMBI-GEL 10 AVITENE FLOUR 3 3 EXTERNAL PAD EXTERNAL POWDER THROMBI-GEL 100 ENDO AVITENE 3 3 EXTERNAL PAD EXTERNAL THROMBI-GEL 40 GEL-FLOW NT 3 EXTERNAL PAD EXTERNAL PREFILLED 3 THROMBI-PAD SYRINGE 3 EXTERNAL PAD GELFOAM TISSEEL EXTERNAL COMPRESSED SIZE 100 3 3 KIT EXTERNAL TISSEEL EXTERNAL GELFOAM DENTAL 3 SOLUTION PACK SIZE 4 3 EXTERNAL *HEMOSTATICS - SYSTEMIC*** GELFOAM MOUTH/THROAT 3 AMICAR ORAL 3 QL POWDER SOLUTION GELFOAM SPONGE AMICAR ORAL TABLET 3 3 EXTERNAL 1000 MG GELFOAM SPONGE AMICAR ORAL TABLET 3 3 QL SIZE 100 EXTERNAL 500 MG GELFOAM SPONGE aminocaproic acid 3 1 or 1b* SIZE 200 EXTERNAL intravenous solution GELFOAM SPONGE aminocaproic acid oral 3 1 or 1b* QL SIZE 50 EXTERNAL solution INSTAT EXTERNAL PAD 3 aminocaproic acid oral tablet 1 or 1b* INTERCEED (TC7) 1000 mg 3 EXTERNAL PAD aminocaproic acid oral tablet 1 or 1b* QL INTERCEED EXTERNAL 500 mg 3 PAD CYKLOKAPRON INTRAVENOUS RECOTHROM 3 SOLUTION 1000 EXTERNAL SOLUTION 3 MG/10ML RECONSTITUTED LYSTEDA ORAL RECOTHROM SPRAY 3 QL KIT EXTERNAL TABLET 3 SOLUTION tranexamic acid intravenous 1 or 1b* RECONSTITUTED solution 1000 mg/10ml SURGICEL FIBRILLAR 3 tranexamic acid oral tablet 1 or 1b* QL EXTERNAL PAD TRANEXAMIC ACID- SURGICEL NU-KNIT 3 NACL INTRAVENOUS 3 EXTERNAL PAD SOLUTION SYRINGE AVITENE 3 EXTERNAL TACHOSIL EXTERNAL 3 PATCH

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 124 Drug Name Tier Notes Drug Name Tier Notes THROMBIN-JMI midazolam hcl injection EPISTAXIS EXTERNAL 3 solution 10 mg/10ml, 10 KIT mg/2ml, 2 mg/2ml, 25 1 or 1b* THROMBIN-JMI mg/5ml, 5 mg/5ml, 5 mg/ml, 3 EXTERNAL KIT 50 mg/10ml THROMBIN-JMI midazolam hcl oral syrup 1 or 1b* QL EXTERNAL SOLUTION 3 MIDAZOLAM HCL- RECONSTITUTED SODIUM CHLORIDE THROMBOGEN INTRAVENOUS 3 3 EXTERNAL KIT SOLUTION 100-0.8 MG/100ML-%, 50-0.8 THROMBOGEN MG/50ML-% EXTERNAL SOLUTION 3 RECONSTITUTED MIDAZOLAM HCL- SODIUM CHLORIDE ULTRAFOAM SPONGE 3 INTRAVENOUS 2X6.25X7CM EXTERNAL SOLUTION PREFILLED 3 ULTRAFOAM SPONGE SYRINGE 2-0.9 MG/2ML- 3 8X12.5X1CM EXTERNAL %, 5-0.9 MG/5ML-%, 55- 0.9 MG/55ML-% ULTRAFOAM SPONGE 3 8X12.5X3CM EXTERNAL MIDAZOLAM INTRAVENOUS ULTRAFOAM SPONGE 3 SOLUTION PREFILLED 3 8X25X1CM EXTERNAL SYRINGE 2 MG/2ML, 25 ULTRAFOAM SPONGE MG/25ML 3 8X6.25X1CM EXTERNAL MIDAZOLAM-SODIUM *HYPNOTICS/SEDATIVE CHLORIDE 3 S/SLEEP DISORDER INTRAVENOUS AGENTS* SOLUTION *BARBITURATE MIDAZOLAM-SODIUM HYPNOTICS*** CHLORIDE NEMBUTAL INJECTION INTRAVENOUS 3 SOLUTION PREFILLED SOLUTION 3 SYRINGE 30-0.9 pentobarbital sodium 1 or 1b* MG/30ML-%, 50-0.9 injection solution MG/50ML-%, 60-0.9 phenobarbital oral elixir 1 or 1b* QL MG/30ML-% phenobarbital oral tablet 1 or 1b* QL quazepam oral tablet 1 or 1b* QL phenobarbital sodium RESTORIL ORAL 1 or 1b* 3 QL injection solution CAPSULE *BENZODIAZEPINE temazepam oral capsule 1 or 1b* QL HYPNOTICS*** triazolam oral tablet 1 or 1b* QL BYFAVO INTRAVENOUS *HYPNOTICS - SOLUTION 4 TRICYCLIC AGENTS*** RECONSTITUTED doxepin hcl oral tablet 1 or 1b* ST; QL DORAL ORAL TABLET 3 ST; QL SILENOR ORAL 3 ST; QL estazolam oral tablet 1 or 1b* QL TABLET flurazepam hcl oral capsule 1 or 1b* QL *NON- HALCION ORAL BENZODIAZEPINE - 3 QL TABLET GABA-RECEPTOR MODULATORS*** midazolam hcl (pf) injection 1 or 1b* solution AMBIEN CR ORAL TABLET EXTENDED 3 ST; QL RELEASE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 125 Drug Name Tier Notes Drug Name Tier Notes AMBIEN ORAL TABLET 3 ST; QL PRECEDEX EDLUAR SUBLINGUAL INTRAVENOUS 3 ST; QL TABLET SUBLINGUAL SOLUTION 1000 MCG/250ML, 200 3 eszopiclone oral tablet 1 or 1b* QL MCG/2ML, 200 LUNESTA ORAL MCG/50ML, 400 3 ST; QL TABLET MCG/100ML, 80 MCG/20ML zaleplon oral capsule 1 or 1b* QL *SELECTIVE zolpidem tartrate er oral 1 or 1b* ST; QL MELATONIN tablet extended release RECEPTOR zolpidem tartrate oral tablet 1 or 1b* QL AGONISTS*** zolpidem tartrate sublingual HETLIOZ LQ ORAL 1 or 1b* ST; QL 4 PA; LD; QL tablet sublingual SUSPENSION ZOLPIMIST ORAL HETLIOZ ORAL 3 ST; QL 4 PA; LD; QL SOLUTION CAPSULE *OREXIN RECEPTOR ramelteon oral tablet 1 or 1b* ST; QL ANTAGONISTS*** ROZEREM ORAL 3 ST; QL BELSOMRA ORAL TABLET 3 ST; QL TABLET *LAXATIVES* DAYVIGO ORAL 3 ST; QL *BOWEL EVACUANT TABLET COMBINATIONS*** *SELECTIVE ALPHA2- CLENPIQ ORAL ADRENORECEPTOR 3 QL SOLUTION AGONIST gavilyte-c oral solution SEDATIVES*** 1 or 1a* $0; QL reconstituted dexmedetomidine hcl in nacl gavilyte-g oral solution intravenous solution 200 1 or 1a* $0; QL mcg/50ml, 200-0.9 1 or 1b* reconstituted mcg/50ml-%, 400 gavilyte-n with flavor pack 1 or 1a* $0; QL mcg/100ml, 80 mcg/20ml oral solution reconstituted DEXMEDETOMIDINE GOLYTELY ORAL HCL IN NACL SOLUTION 3 QL INTRAVENOUS 3 RECONSTITUTED 236 SOLUTION PREFILLED GM SYRINGE MOVIPREP ORAL DEXMEDETOMIDINE SOLUTION 3 QL HCL INTRAVENOUS RECONSTITUTED SOLUTION 1000 3 MCG/10ML, 400 NULYTELY LEMON- MCG/4ML LIME ORAL SOLUTION 3 QL RECONSTITUTED dexmedetomidine hcl peg 3350-kcl-na bicarb-nacl intravenous solution 200 1 or 1b* 1 or 1a* $0; QL mcg/2ml oral solution reconstituted peg-3350/electrolytes oral DEXMEDETOMIDINE 1 or 1a* $0; QL HCL-DEXTROSE solution reconstituted 3 INTRAVENOUS peg- SOLUTION 3350/electrolytes/ascorbat 1 or 1b* $0; QL oral solution reconstituted peg-kcl-nacl-nasulf-na asc-c 1 or 1b* $0; QL oral solution reconstituted peg-prep oral kit 1 or 1b* $0; QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 126 Drug Name Tier Notes Drug Name Tier Notes PLENVU ORAL *LUBRICANT SOLUTION 3 QL LAXATIVES*** RECONSTITUTED mineral oil heavy oral oil 1 or 1b* SUPREP BOWEL PREP 2 QL *SALINE LAXATIVE KIT ORAL SOLUTION MIXTURES*** SUTAB ORAL TABLET 3 QL OSMOPREP ORAL 3 QL *LAXATIVES - TABLET MISCELLANEOUS*** *SALINE LAXATIVES*** clearlax oral powder 1 or 1b* OTC; $0 citrate of magnesia oral 1 or 1a* OTC; $0 constulose oral solution 1 or 1b* solution cvs purelax oral packet 1 or 1b* OTC; $0 citroma oral solution 1 or 1a* OTC; $0 cvs purelax oral powder 1 or 1b* OTC; $0 cvs citrate of magnesia oral 1 or 1a* OTC; $0 eq clearlax oral powder 1 or 1b* OTC; $0 solution cvs magnesium citrate oral eql clearlax oral powder 1 or 1b* OTC; $0 1 or 1a* OTC; $0 solution gavilax oral powder 1 or 1b* OTC; $0 cvs milk of magnesia oral 1 or 1b* OTC; $0 gentlelax oral powder 1 or 1b* OTC; $0 suspension glycolax oral powder 1 or 1b* OTC; $0 dulcolax milk of magnesia 1 or 1b* OTC; $0 gnp clearlax oral packet 1 or 1b* OTC; $0 oral suspension gnp clearlax oral powder 1 or 1b* OTC; $0 dulcolax oral suspension 1 or 1b* OTC; $0 goodsense clearlax oral eq magnesium citrate oral 1 or 1b* OTC; $0 1 or 1a* OTC; $0 powder solution eql magnesium citrate oral healthylax oral packet 1 or 1b* OTC; $0 1 or 1a* OTC; $0 solution hm clearlax oral packet 1 or 1b* OTC; $0 eql milk of magnesia oral 1 or 1b* OTC; $0 hm clearlax oral powder 1 or 1b* OTC; $0 suspension kls laxaclear oral powder 1 or 1b* OTC; $0 gnp milk of magnesia oral 1 or 1b* OTC; $0 KRISTALOSE ORAL suspension 3 PACKET goodsense magnesium citrate 1 or 1a* OTC; $0 LACTULOSE ORAL oral solution 3 PACKET hm magnesium citrate oral 1 or 1a* OTC; $0 lactulose oral solution 1 or 1b* solution mm clearlax oral powder 1 or 1b* OTC; $0 hm milk of magnesia oral 1 or 1b* OTC; $0 peg 3350 oral packet 1 or 1b* OTC; $0 suspension magnesium citrate oral peg 3350 oral powder 1 or 1b* OTC; $0 1 or 1a* OTC; $0 solution 1.745 gm/30ml polyethylene glycol 3350 1 or 1b* $0 milk of magnesia concentrate oral packet 17 gm 1 or 1b* OTC; $0 oral suspension polyethylene glycol 3350 1 or 1b* $0 milk of magnesia oral oral powder 1 or 1b* OTC; $0 suspension qc natura-lax oral powder 1 or 1b* OTC; $0 phillips milk of magnesia 1 or 1b* OTC; $0 ra laxative oral powder 1 or 1b* OTC; $0 oral suspension 400 mg/5ml sb polyethylene glycol 3350 px milk of magnesia oral 1 or 1b* OTC; $0 1 or 1b* OTC; $0 oral powder suspension sm clearlax oral powder 1 or 1b* OTC; $0 qc magnesium citrate oral 1 or 1a* OTC; $0 smooth lax oral packet 1 or 1b* OTC; $0 solution qc milk of magnesia oral smooth lax oral powder 1 or 1b* OTC; $0 1 or 1b* OTC; $0 suspension

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 127 Drug Name Tier Notes Drug Name Tier Notes ra milk of magnesia oral hm laxative oral tablet 1 or 1b* OTC; $0 1 or 1a* OTC; $0 suspension delayed release sb magnesium citrate oral kp bisacodyl oral tablet 1 or 1a* OTC; $0 1 or 1a* OTC; $0 solution delayed release sb milk of magnesia oral laxative oral tablet delayed 1 or 1b* OTC; $0 1 or 1a* OTC; $0 suspension release sm magnesium citrate oral px laxative oral tablet 1 or 1a* OTC; $0 1 or 1a* OTC; $0 solution delayed release sm milk of magnesia oral qc gentle laxative oral tablet 1 or 1b* OTC; $0 1 or 1a* OTC; $0 suspension 1200 mg/15ml delayed release *STIMULANT ra laxative oral tablet delayed 1 or 1a* OTC; $0 LAXATIVES*** release alophen oral tablet delayed ra womens laxative oral 1 or 1a* OTC; $0 1 or 1a* OTC; $0 release tablet delayed release bisacodyl ec oral tablet sb bisacodyl laxative ec oral 1 or 1a* OTC; $0 1 or 1a* OTC; $0 delayed release tablet delayed release CASCARA SAGRADA sb gentle lax-women oral 3 1 or 1a* OTC; $0 ORAL FLUID EXTRACT tablet delayed release correctol oral tablet delayed sm gentle laxative oral tablet 1 or 1a* OTC; $0 1 or 1a* OTC; $0 release delayed release cvs bisacodyl oral tablet womans laxative oral tablet 1 or 1a* OTC; $0 1 or 1a* OTC; $0 delayed release delayed release cvs c-lax laxative oral tablet womens laxative oral tablet 1 or 1a* OTC; $0 1 or 1a* OTC; $0 delayed release delayed release cvs gentle laxative oral tablet *LOCAL ANESTHETICS- 1 or 1a* OTC; $0 delayed release PARENTERAL* cvs gentle laxative womens *LOCAL ANESTHETIC 1 or 1a* OTC; $0 oral tablet delayed release & eq gentle laxative oral tablet SYMPATHOMIMETIC** 1 or 1a* OTC; $0 delayed release * eql gentle laxative oral tablet articadent dental injection 1 or 1a* OTC; $0 delayed release solution cartridge 4 %- 3 1:100000 eql laxative oral tablet 1 or 1a* OTC; $0 delayed release bupivacaine-epinephrine (pf) injection solution 0.25% - 1 or 1b* ex-lax ultra oral tablet 1 or 1a* OTC; $0 1:200000, 0.5% -1:200000 delayed release bupivacaine-epinephrine feenamint oral tablet delayed 1 or 1a* OTC; $0 injection solution 0.25% - 1 or 1b* release 1:200000, 0.5% -1:200000 gentle laxative oral tablet 1 or 1a* OTC; $0 lidocaine-epinephrine delayed release injection solution 0.5 %- gnp gentle laxative oral tablet 1:200000, 1 %-1:100000, 1.5 1 or 1b* 1 or 1a* OTC; $0 delayed release %-1:200000, 2 %-1:100000, 2 %-1:200000, 2 %-1:50000 gnp womens gentle laxative 1 or 1a* OTC; $0 oral tablet delayed release MARCAINE/EPINEPHRI NE INJECTION 3 goodsense bisacodyl ec oral 1 or 1a* OTC; $0 SOLUTION tablet delayed release MARCAINE/EPINEPHRI goodsense womens laxative 1 or 1a* OTC; $0 NE PF INJECTION 3 oral tablet delayed release SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 128 Drug Name Tier Notes Drug Name Tier Notes ORABLOC INJECTION CARBOCAINE 3 SOLUTION CARTRIDGE INJECTION SOLUTION 1 3 sensorcaine/epinephrine % 1 or 1b* injection solution CARBOCAINE sensorcaine-mpf/epinephrine PRESERVATIVE-FREE 3 injection solution 0.25% - 1 or 1b* INJECTION SOLUTION 1:200000, 0.5% -1:200000 lidocaine hcl (pf) injection 1 or 1b* SENSORCAINE- solution MPF/EPINEPHRINE lidocaine hcl injection 3 1 or 1b* INJECTION SOLUTION solution 0.5 % 0.75-1:200000 % LIDOCAINE HCL XYLOCAINE/EPINEPHR INJECTION SOLUTION 3 INE INJECTION 3 PREFILLED SYRINGE SOLUTION 200 MG/10ML XYLOCAINE- lidocaine hcl intradermal jet- 1 or 1b* MPF/EPINEPHRINE 3 injector INJECTION SOLUTION LIDOCAINE IN 3 *LOCAL ANESTHETIC DEXTROSE SOLUTION COMBINATIONS*** MARCAINE INJECTION 3 LIDOCAINE HCL- SOLUTION TETRACAINE HCL 3 MARCAINE INJECTION SOLUTION PRESERVATIVE FREE 3 LIDOCAINE-SODIUM INJECTION SOLUTION BICARBONATE MARCAINE SPINAL INJECTION SOLUTION 3 INTRATHECAL 3 PREFILLED SYRINGE 1- SOLUTION 8.4 % MONOJECT BONE POINT OF CARE LM-2.5 3 MARROW BIOPSY 3 INJECTION KIT INJECTION KIT *LOCAL ANESTHETICS NAROPIN INJECTION 3 - AMIDES*** SOLUTION BUPIVACAINE polocaine injection solution 1 or 1b* FISIOPHARMA 3 polocaine-mpf injection INJECTION SOLUTION 1 or 1b* solution bupivacaine hcl (pf) injection 1 or 1b* solution ropivacaine hcl injection solution 10 mg/ml, 5 mg/ml, 1 or 1b* bupivacaine hcl injection 1 or 1b* 7.5 mg/ml solution 0.25 %, 0.5 % ROPIVACAINE HCL- BUPIVACAINE HCL- NACL EPIDURAL 3 NACL EPIDURAL 3 SOLUTION 0.15-0.9 %, SOLUTION 0.125-0.9 % 0.2-0.9 % BUPIVACAINE HCL- sensorcaine injection solution 1 or 1b* NACL EPIDURAL 3 sensorcaine-mpf injection SOLUTION PREFILLED 1 or 1b* SYRINGE 0.25-0.9 % solution bupivacaine in dextrose XARACOLL IMPLANT 1 or 1b* 3 intrathecal solution IMPLANT bupivacaine spinal XYLOCAINE 1 or 1b* 3 intrathecal solution INJECTION SOLUTION XYLOCAINE-MPF INJECTION SOLUTION 3 0.5 %, 1 %, 1.5 %, 2 % * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 129 Drug Name Tier Notes Drug Name Tier Notes ZINGO INTRADERMAL ERYPED 200 ORAL 3 JET-INJECTOR SUSPENSION 3 *LOCAL ANESTHETICS RECONSTITUTED - ESTERS*** ERYPED 400 ORAL chloroprocaine hcl (pf) SUSPENSION 3 1 or 1b* injection solution RECONSTITUTED ery-tab oral tablet delayed CLOROTEKAL 1 or 1b* INTRATHECAL 3 release SOLUTION ERYTHROCIN NESACAINE INJECTION LACTOBIONATE 3 INTRAVENOUS SOLUTION 3 SOLUTION NESACAINE-MPF 3 RECONSTITUTED 500 INJECTION SOLUTION MG *MACROLIDES* erythrocin stearate oral tablet 1 or 1b* *AZITHROMYCIN*** 250 mg azithromycin intravenous erythromycin base oral solution reconstituted 500 1 or 1b* capsule delayed release 1 or 1b* mg particles azithromycin oral packet 1 or 1b* QL erythromycin base oral tablet 1 or 1b* azithromycin oral suspension erythromycin base oral tablet 1 or 1b* QL 1 or 1b* reconstituted delayed release azithromycin oral tablet 250 erythromycin ethylsuccinate 1 or 1b* QL 1 or 1b* mg, 500 mg, 600 mg oral suspension reconstituted erythromycin ethylsuccinate ZITHROMAX 1 or 1b* INTRAVENOUS oral tablet 3 SOLUTION erythromycin oral tablet 1 or 1b* RECONSTITUTED delayed release ZITHROMAX ORAL 3 QL *FIDAXOMICIN*** PACKET DIFICID ORAL ZITHROMAX ORAL SUSPENSION 3 SUSPENSION 3 QL RECONSTITUTED RECONSTITUTED DIFICID ORAL TABLET 3 ZITHROMAX ORAL 3 QL TABLET 250 MG, 500 MG *MEDICAL DEVICES AND SUPPLIES* ZITHROMAX TRI-PAK 3 QL ORAL TABLET *CERVICAL CAPS*** ZITHROMAX Z-PAK FEMCAP VAGINAL 3 QL 2 $0 ORAL TABLET DEVICE *CLARITHROMYCIN*** *CONDOMS - FEMALE*** clarithromycin er oral tablet 1 or 1b* extended release 24 hour FC FEMALE CONDOM 2 OTC; $0 clarithromycin oral FC2 FEMALE CONDOM 2 OTC; $0 1 or 1b* QL suspension reconstituted *DENTAL clarithromycin oral tablet 1 or 1b* QL DESENSITIZING PRODUCTS*** *ERYTHROMYCINS*** REMESENSE DENTAL 3 e.e.s. 400 oral tablet 1 or 1b* *DENTIFRICES*** E.E.S. GRANULES ORAL MI PASTE DENTAL SUSPENSION 3 3 RECONSTITUTED PASTE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 130 Drug Name Tier Notes Drug Name Tier Notes MI PASTE PLUS ACTI-LANCE LITE 3 2 OTC; QL DENTAL PASTE LANCETS 28G *DIAPHRAGMS*** ACTI-LANCE SPECIAL 2 OTC; QL CAYA VAGINAL LANCETS 17G 2 $0 DIAPHRAGM ACTI-LANCE 2 OTC; QL OMNIFLEX UNIVERSAL 23G DIAPHRAGM VAGINAL 3 ADJUSTABLE LANCING 2 OTC DIAPHRAGM DEVICE WIDE-SEAL ADVANCED MOBILE 2 OTC; QL DIAPHRAGM 60 2 $0 LANCET VAGINAL DIAPHRAGM ADVOCATE LANCETS 2 OTC; QL WIDE-SEAL ADVOCATE LANCETS 2 OTC; QL DIAPHRAGM 65 2 $0 30G VAGINAL DIAPHRAGM ADVOCATE LANCING 2 OTC WIDE-SEAL DEVICE DIAPHRAGM 70 2 $0 ADVOCATE RAPID- VAGINAL DIAPHRAGM 2 OTC SAFE LANCING WIDE-SEAL ADVOCATE SAFETY DIAPHRAGM 75 2 $0 2 OTC; QL VAGINAL DIAPHRAGM LANCETS ADVOCATE SAFETY WIDE-SEAL 2 OTC; QL DIAPHRAGM 80 2 $0 LANCETS 26G VAGINAL DIAPHRAGM AGAMATRIX ULTRA- 2 OTC; QL WIDE-SEAL THIN LANCETS DIAPHRAGM 85 2 $0 AIMSCO TWIST 2 OTC; QL VAGINAL DIAPHRAGM LANCETS 32G WIDE-SEAL AIMSCO TWIST 2 OTC; QL DIAPHRAGM 90 2 $0 LANCETS 33G VAGINAL DIAPHRAGM AQUALANCE LANCETS 2 OTC; QL WIDE-SEAL 30G DIAPHRAGM 95 2 $0 ASSURE COMFORT VAGINAL DIAPHRAGM 2 OTC; QL LANCETS 28G *GLUCOSE ASSURE HAEMOLANCE MONITORING TEST 2 OTC; QL SUPPLIES*** PLUS HIGH 1ST TIER UNILET ASSURE HAEMOLANCE 2 OTC; QL 2 OTC; QL COMFORTOUCH PLUS LOW ACCU-CHEK FASTCLIX ASSURE HAEMOLANCE 2 OTC; QL 2 OTC; QL LANCET KIT PLUS MICRO ACCU-CHEK FASTCLIX ASSURE HAEMOLANCE 2 OTC; QL 2 OTC; QL LANCETS PLUS NORMAL ACCU-CHEK ASSURE HAEMOLANCE 2 OTC; QL 2 OTC; QL MULTICLIX LANCETS PLUS PED ACCU-CHEK SAFE-T ASSURE LANCE 2 OTC; QL 2 OTC; QL PRO LANCETS LANCETS ACCU-CHEK SOFTCLIX ASSURE LANCE 2 OTC; QL 2 OTC; QL LANCET DEV KIT LANCETS 21G ACCU-CHEK SOFTCLIX ASSURE LANCE PLUS 2 OTC; QL 2 OTC; QL LANCETS SAFETY 25G ASSURE LANCE PLUS ACTI-LANCE 28G 2 OTC; QL 2 OTC; QL SAFETY 30G

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 131 Drug Name Tier Notes Drug Name Tier Notes ASSURE LANCE SAFETY CLEVER CHEK 2 OTC; QL 2 OTC; QL LANCET 28G LANCETS AURORA LANCET CLEVER CHOICE 2 OTC; QL 2 OTC; QL SUPER THIN 30G LANCETS 21G AURORA LANCET THIN CLEVER CHOICE 2 OTC; QL 2 OTC; QL 23G LANCETS 23G AUTO-LANCET 2 OTC CLEVER CHOICE 2 OTC; QL AUTO-LANCET MINI 2 OTC LANCETS 28G AUTOLET II CLINISAFE COAGUCHEK LANCETS 2 OTC; QL 2 OTC; QL KIT COMFORT ASSURED 2 OTC; QL AUTOLET LANCING LANCETS 28G 2 OTC DEVICE COMFORT ASSURED 2 OTC; QL AUTOLET LITE LANCETS 33G 2 OTC; QL CLINISAFE KIT COMFORT LANCETS 2 OTC; QL AUTOLET LITE COMFORT TOUCH 2 OTC; QL 2 OTC; QL STARTER PACK KIT LANCETS 31G AUTOLET MINI 2 OTC COMFORT TOUCH 2 OTC; QL AUTOLET PLATFORMS 2 OTC; QL PLUS LANCETS 30G AUTOLET PLUS 2 OTC CVS LANCETS 21G 2 OTC; QL BD LANCET CVS LANCETS MICRO 2 OTC; QL 2 OTC; QL ULTRAFINE 30G THIN 33G BD LANCET CVS LANCETS 2 OTC; QL 2 OTC; QL ULTRAFINE 33G ORIGINAL BD MICROTAINER CVS LANCETS THIN 26G 2 OTC; QL 2 OTC; QL LANCETS CVS LANCETS ULTRA 2 OTC; QL CARDIOCOM LANCING THIN 30G 2 OTC DEVICE CVS LANCETS ULTRA- 2 OTC; QL CAREONE ADVANCED THIN 30G 2 OTC LANCING DEV CVS LANCING DEVICE 2 OTC CAREONE LANCET CVS ULTRA THIN 2 OTC; QL 2 OTC; QL SUPER THIN 30G LANCETS CAREONE LANCET DEXCOM G4 PLAT PED 2 OTC; QL 2 PA; QL THIN 23G RCV/SHARE DEVICE CARESENS LANCETS 2 OTC; QL DEXCOM G4 PLAT PED 2 PA; QL CARETOUCH RECEIVER DEVICE 2 OTC LANCING/EJECTOR DEXCOM G4 PLATINUM 2 PA; QL CARETOUCH SAFETY RCV/SHARE DEVICE 2 OTC; QL LANCETS DEXCOM G4 PLATINUM 2 PA; QL CARETOUCH SAFETY RECEIVER DEVICE 2 OTC; QL LANCETS 26G DEXCOM G4 PLATINUM 2 PA CARETOUCH TWIST TRANSMITTER 2 OTC; QL LANCETS 28G DEXCOM G4 SENSOR 2 PA CARETOUCH TWIST DEXCOM G5 MOB/G4 2 OTC; QL 2 PA; QL LANCETS 30G PLAT SENSOR CARETOUCH TWIST DEXCOM G5 MOBILE 2 OTC; QL 2 PA; QL LANCETS 33G RECEIVER DEVICE CLEANLET LANCETS DEXCOM G5 MOBILE 2 OTC; QL 2 PA; QL 28G TRANSMITTER

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 132 Drug Name Tier Notes Drug Name Tier Notes DEXCOM G5 RECEIVER EASY TOUCH LANCETS 2 PA; QL 2 OTC; QL KIT DEVICE 28G/TWIST DEXCOM G6 RECEIVER EASY TOUCH LANCETS 2 PA; QL 2 OTC; QL DEVICE 30G DEXCOM G6 SENSOR 2 PA; QL EASY TOUCH LANCETS 2 OTC; QL DEXCOM G6 30G/TWIST 2 PA; QL TRANSMITTER EASY TOUCH LANCETS 2 OTC; QL DIATHRIVE LANCET 32G 2 OTC; QL ULTRA THIN 30 EASY TOUCH LANCETS 2 OTC; QL DIATHRIVE LANCETS 2 OTC; QL 32G/TWIST DIATHRIVE LANCING EASY TOUCH LANCETS 2 OTC 2 OTC; QL DEVICE 33G/TWIST DROPLET GENTEEL EASY TOUCH LANCING 2 OTC 2 OTC LANCING DEVICE DEVICE DROPLET LANCETS EASY TOUCH SAFETY 2 OTC; QL 2 OTC; QL ULTRA THIN 30G LANCETS 21G DROPLET LANCING EASY TOUCH SAFETY 2 OTC 2 OTC; QL DEVICE LANCETS 23G DROPLET PERSONAL EASY TOUCH SAFETY 2 OTC; QL 2 OTC; QL LANCETS 30G LANCETS 26G DRUG MART LANCETS EASY TOUCH SAFETY 2 OTC; QL 2 OTC; QL THIN 26G LANCETS 28G DRUG MART LANCING EMBRACE LANCETS 2 OTC 2 OTC; QL DEVICE ULTRA THIN 30G DRUG MART ON-THE- EMBRACE LANCING 2 OTC; QL 2 OTC GO LANCET 30G DEVICE/EJECTOR DRUG MART UNILET EMBRACE PRESSURE 2 OTC; QL 2 OTC; QL LANCETS 28G ACTIVATED 21G DRUG MART UNILET EMBRACE PRESSURE 2 OTC; QL 2 OTC; QL LANCETS 30G ACTIVATED 28G DRUG MART UNILET ENLITE GLUCOSE 2 OTC; QL 3 PA LANCETS 33G SENSOR EASY COMFORT EQL COLOR LANCETS 2 OTC; QL 2 OTC; QL LANCETS 21G EASY COMFORT EQL COLOR LANCETS 2 OTC; QL 2 OTC; QL LANCETS TWIST TOP MICRO 33G EASY MINI EJECT EQL SUPER THIN 2 OTC 2 OTC; QL LANCING DEVICE LANCETS 30G EASY MINI LANCING EQL THIN LANCETS 2 OTC 2 OTC; QL DEVICE 26G EASY TOUCH LANCETS EVERSENSE 2 OTC; QL 3 PA 21G SENSOR/HOLDER EASY TOUCH LANCETS EVERSENSE SMART 2 OTC; QL 3 PA; QL 23G TRANSMITTER EASY TOUCH LANCETS E-Z JECT LANCET 2 OTC; QL 2 OTC; QL 26G MICRO-THIN 33G EASY TOUCH LANCETS E-Z JECT LANCET 2 OTC; QL 2 OTC; QL 28G SUPER THIN 30G E-Z JECT LANCETS 2 OTC; QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 133 Drug Name Tier Notes Drug Name Tier Notes E-Z JECT LANCETS 21G 2 OTC; QL GENTEEL CONTACT 2 OTC; QL E-Z JECT LANCETS TIPS (VIOLET) 2 OTC; QL THIN 26G GENTEEL CONTACT 2 OTC; QL EZ-LETS LANCETS 21G 2 OTC; QL TIPS (YELLOW) GENTEEL LANCING KIT EZ-LETS LANCETS 26G 2 OTC; QL 2 OTC; QL (BLUE) KIT EZ-LETS LANCETS 28G 2 OTC; QL GENTEEL NOZZLES 2 OTC; QL EZ-LETS LANCETS 30G 2 OTC; QL GENTEEL PLUS FIFTY50 SAFETY SEAL 2 OTC 2 OTC; QL LANCING (BLACK) LANCETS GENTEEL PLUS FIFTY50 UNILET 2 OTC 2 OTC; QL LANCING (PURPLE) LANCETS 33G GENTEEL PLUS 2 OTC FINE 30 2 OTC; QL LANCING (WHITE) FINGERSTIX LANCETS 2 OTC; QL GENTEEL PLUS 2 OTC FORA LANCETS 2 OTC; QL LANCING DEV(BLUE) FORA LANCING GENTEEL PLUS 2 OTC 2 OTC DEVICE LANCING DEV(PINK) FREDS PHARMACY GENTLE-LET GP 2 OTC 2 OTC; QL AUTOLET LANCING LANCETS FREDS PHARMACY GENTLE-LET LANCETS 2 OTC; QL 2 OTC; QL UNILET LANC 28G GENTLE-LET 2 OTC; QL FREDS PHARMACY PLATFORMS 2 OTC; QL UNILET LANC 30G GLOBAL INJECT EASE 2 OTC; QL FREESTYLE LANCETS 2 OTC; QL LANCETS 28G FREESTYLE LIBRE 14 GLOBAL INJECT EASE 2 PA; QL 2 OTC; QL DAY READER DEVICE LANCETS 30G FREESTYLE LIBRE 14 GLOBAL LANCING 2 PA; QL 2 OTC DAY SENSOR DEVICE FREESTYLE LIBRE 2 GLUCOCOM LANCETS 2 PA; QL 2 OTC; QL READER DEVICE 28G FREESTYLE LIBRE 2 GLUCOCOM LANCETS 2 PA; QL 2 OTC; QL SENSOR 30G FREESTYLE LIBRE GLUCOCOM LANCETS 2 PA; QL 2 OTC; QL READER DEVICE 33G FREESTYLE UNISTICK GNP LANCETS 21G 2 OTC; QL 2 OTC; QL II LANCETS GNP LANCETS MICRO 2 OTC; QL GENTEEL BUTTERFLY THIN 33G 2 OTC; QL TOUCH LANCET GNP LANCETS SUPER 2 OTC; QL GENTEEL CONTACT THIN 30G 2 OTC; QL TIPS (BLUE) GNP LANCETS THIN 2 OTC; QL GENTEEL CONTACT GNP LANCETS THIN 2 OTC; QL 2 OTC; QL TIPS (CLEAR) 26G GENTEEL CONTACT GNP STERILE LANCETS 2 OTC; QL 2 OTC; QL TIPS (GREEN) 28G GENTEEL CONTACT GNP STERILE LANCETS 2 OTC; QL 2 OTC; QL TIPS (ORANGE) 30G GENTEEL CONTACT GNP STERILE LANCETS 2 OTC; QL 2 OTC; QL TIPS (RAINBOW) 33G

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 134 Drug Name Tier Notes Drug Name Tier Notes GOJJI LANCING H-E-B INCONTROL 2 OTC 2 OTC; QL DEVICE/CLEAR CAP LANCETS 30G GOJJI STERILE H-E-B INCONTROL 2 OTC; QL 2 OTC; QL LANCETS LANCETS 33G GOODSENSE COLOR HYPOLANCE AST 2 OTC; QL 2 OTC; QL LANCETS 33G LANCING KIT GOODSENSE LANCETS HY-VEE LANCETS 2 OTC; QL 2 OTC; QL 26G UNIV HY-VEE THIN LANCETS 2 OTC; QL GOODSENSE LANCETS IN TOUCH LANCING 2 OTC; QL 2 OTC 30G DEVICE GOODSENSE LANCETS IN TOUCH STERILE 2 OTC; QL 2 OTC; QL 30G UNIV LANCETS 30G GOODSENSE LANCETS 2 OTC; QL KINNEY LANCETS 2 OTC; QL 33G KINNEY THIN LANCETS 2 OTC; QL GOODSENSE LANCETS 2 OTC; QL KROGER AUTOLET 33G UNIV 2 OTC LANCING DEVICE GOODSENSE LANCING 2 OTC KROGER HEALTHPRO DEVICE 2 OTC; QL LANCET 26G GUARDIAN CONNECT 3 PA; QL TRANSMITTER KROGER LANCETS 2 OTC; QL GUARDIAN LINK 3 KROGER LANCETS 21G 2 OTC; QL 3 PA TRANSMITTER KROGER LANCETS 2 OTC; QL GUARDIAN REAL-TIME MICRO THIN 33G 3 PA; QL REPLACE PED DEVICE KROGER LANCETS 2 OTC; QL GUARDIAN SENSOR (3) 3 PA; QL SUPER THIN KROGER LANCETS GUARDIAN SENSOR 3 3 PA; QL 2 OTC; QL THIN HAEMOLANCE 2 OTC; QL KROGER LANCETS HAEMOLANCE LOW 2 OTC; QL 2 OTC; QL THIN 26G FLOW LANCETS KROGER LANCETS 2 OTC; QL HAEMOLANCE PLUS 2 OTC; QL ULTRATHIN 30G HAEMOLANCE PLUS KROGER LANCING 2 OTC; QL 2 OTC HIGH FLOW DEVICE HAEMOLANCE PLUS 2 OTC; QL LANCET DEVICE 2 OTC LOW FLOW LANCET DEVICE WITH HAEMOLANCE PLUS 2 OTC 2 OTC; QL EJECTOR MAX FLOW LANCET HAEMOLANCE PLUS 2 OTC; QL 2 OTC; QL TRANSPORTER CASE PEDIATRIC FLOW LANCETS 2 OTC; QL HEALTH CARE 2 OTC LANCING DEVICE LANCETS 30G 2 OTC; QL HEALTHY ACCENTS LANCETS 33G 2 OTC; QL 2 OTC LANCING DEVICE LANCETS MICRO THIN 2 OTC; QL HEALTHY ACCENTS 33G 2 OTC; QL UNILET LANCETS LANCETS SUPER THIN 2 OTC; QL H-E-B INCONTROL ADV 28G 2 OTC LANCING LANCETS THIN 2 OTC; QL H-E-B INCONTROL 2 OTC; QL LANCETS ULTRA THIN 2 OTC; QL LANCETS 28G

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 135 Drug Name Tier Notes Drug Name Tier Notes LANCETS ULTRA THIN MEDLANCE PLUS 2 OTC; QL 2 OTC; QL 30G UNIVERSAL 21G LANCING DEVICE 2 OTC MEDLANCE 2 OTC; QL LANZO 2 OTC UNIVERSAL 21G LEADER ADVANCED MEIJER LANCETS 2 OTC; QL 2 OTC LANCING DEVICE MEIJER LANCETS THIN 2 OTC; QL LIBERTY MEDICAL MEIJER LANCETS 2 OTC; QL 2 OTC; QL LANCETS UNIVERSAL 21G LIBERTY MINI MEIJER LANCETS 2 OTC 2 OTC; QL LANCING DEVICE UNIVERSAL 30G LIFESCAN UNISTIK 2 2 OTC; QL MEIJER LANCETS 2 OTC; QL LIFESCAN UNISTIK II UNIVERSAL 33G 2 OTC; QL LANCETS MEIJER SUPER THIN 2 OTC; QL LITE TOUCH LANCETS 2 OTC; QL LANCETS LITE TOUCH LANCING MICROLET LANCETS 2 OTC; QL 2 OTC PEN MICROLET NEXT 2 OTC LITETOUCH LANCETS 2 OTC; QL LANCING DEVICE LIVE BETTER ADV MINI LANCING DEVICE 2 OTC 2 OTC LANCING DEVICE MINILINK REAL-TIME 3 PA LIVE BETTER LANCET TRANSMITTER 2 OTC; QL SUPER THIN MINIMED 630G 3 PA LIVE BETTER LANCET GUARDIAN PRESS 2 OTC; QL ULTRA THIN MINIMED GUARDIAN 3 PA LONGS LANCETS LINK 3 2 OTC; QL STANDARD MM LANCING DEVICE 2 OTC LONGS LANCETS THIN 2 OTC; QL MM TWIST LANCETS 2 OTC; QL LONGS LANCETS MONOLET LANCETS 2 OTC; QL 2 OTC; QL ULTRA THIN MONOLET OPD 2 OTC; QL MEDICHOICE SAFETY LANCETS 2 OTC; QL LANCET MONOLETTOR SAFETY 2 OTC; QL MEDICHOICE SAFETY LANCETS 2 OTC; QL LANCET EXTRA MPD SAFETY LANCET 2 OTC; QL MEDICHOICE SAFETY 21G 2 OTC; QL LANCET NORM MPD SAFETY LANCET 2 OTC; QL MEDISENSE THIN 23G 2 OTC; QL LANCETS MPD SAFETY LANCET 2 OTC; QL MEDLANCE EXTRA 21G 2 OTC; QL 28G MEDLANCE LITE 25G 2 OTC; QL MPD SAFETY LANCET 2 OTC; QL MEDLANCE PLUS 30G 2 OTC; QL EXTRA 21G MULTI-LANCET 2 OTC MEDLANCE PLUS DEVICE 2 OTC; QL LANCETS MULTI-LANCET 2 OTC; QL MEDLANCE PLUS LITE DEVICE 2 KIT 2 OTC; QL 25G MYGLUCOHEALTH 2 OTC; QL MEDLANCE PLUS LANCETS 30G 2 OTC; QL SPECIAL 0.8MM NOVA SAFETY 2 OTC; QL MEDLANCE PLUS LANCETS 23G 2 OTC; QL SUPERLITE 30G

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 136 Drug Name Tier Notes Drug Name Tier Notes NOVA SAFETY PREFERRED PLUS 2 OTC; QL 2 OTC; QL LANCETS 28G LANCETS THIN NOVA SUREFLEX PRO COMFORT 2 OTC; QL 2 OTC; QL LANCETS LANCETS 30G NOVA SUREFLEX PRO COMFORT 2 OTC 2 OTC; QL LANCING DEVICE LANCETS 31G ONETOUCH CLUB PRODIGY LANCETS 28G 2 OTC; QL 2 OTC; QL LANCETS FINE PT PRODIGY LANCING 2 OTC ONETOUCH DELICA DEVICE 2 OTC; QL LANCETS 30G PRODIGY SAFETY 2 OTC; QL ONETOUCH DELICA LANCETS 26G 2 OTC; QL LANCETS 33G PRODIGY TWIST TOP 2 OTC; QL ONETOUCH DELICA LANCETS 28G 2 OTC LANCING DEV PSS SELECT GP 2 OTC; QL ONETOUCH DELICA LANCETS 2 OTC; QL PLUS LANCET30G PSS SELECT 2 OTC; QL ONETOUCH DELICA PLATFORMS 2 OTC; QL PLUS LANCET33G PSS SELECT SAFETY 2 OTC; QL ONETOUCH DELICA LANCETS 2 OTC PLUS LANCING PURE COMFORT 2 OTC; QL ONETOUCH DELICA LANCETS 30G 2 OTC SAFETY LANCING PX ADVANCED 2 OTC ONETOUCH FINEPOINT LANCING DEVICE 2 OTC; QL LANCETS PX LANCET AUTO 2 OTC ONETOUCH SURESOFT INJECTOR 2 OTC; QL LANCING DEV PX LANCETS 2 OTC; QL ONETOUCH MICROTHIN 33G 2 OTC; QL ULTRASOFT LANCETS PX LANCETS ULTRA 2 OTC; QL PARADIGM REAL-TIME THIN 3 PA TRANSMITTER PX LANCETS ULTRA 2 OTC; QL PC LANCETS SUPER THIN 28G 2 OTC; QL THIN 30G QC ADVANCED 2 OTC PENLET II BLOOD LANCING DEVICE 2 OTC; QL SAMPLER KIT QC LANCETS SUPER 2 OTC; QL PENLET II THIN 30G 2 OTC; QL REPLACEMENT CAP QC LANCETS ULTRA 2 OTC; QL PERFECT LANCETS 28G 2 OTC; QL THIN PERFECT LANCETS 30G 2 OTC; QL QC UNILET LANCETS 2 OTC; QL PHARMACIST CHOICE 28G 2 OTC; QL LANCETS QC UNILET LANCETS 2 OTC; QL PHARMACY COUNTER MICRO THIN 2 OTC; QL LANCETS RA E-ZJECT LANCETS 2 OTC; QL PIP LANCETS 28G 2 OTC; QL 28G RA E-ZJECT LANCETS PIP LANCETS 30G 2 OTC; QL 2 OTC; QL THIN 26G PRECISION THINS GP 2 OTC; QL RA E-ZJECT LANCETS LANCETS 2 OTC; QL THIN 28G PREFERRED PLUS 2 OTC; QL RA E-ZJECT LANCETS LANCETS COLORED 2 OTC; QL ULTRA THIN

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 137 Drug Name Tier Notes Drug Name Tier Notes READYLANCE SAFETY SELECT-LITE LANCING 2 OTC; QL 2 OTC LANCETS DEVICE REALITY LANCETS 2 OTC; QL SHOPKO AUTOLET 2 OTC REALITY TRIGGER LANCING DEVICE 2 OTC; QL LANCETS SHOPKO ON-THE-GO 2 OTC; QL RELION LANCET LANCETS 30G 2 OTC DEVICES 30G SHOPKO UNILET 2 OTC; QL RELION LANCETS LANCETS 28G 2 OTC; QL MICRO-THIN 33G SHOPKO UNILET 2 OTC; QL RELION LANCETS THIN LANCETS 30G 2 OTC; QL 26G SIMPLE DIAGNOSTICS 2 OTC RELION LANCETS LANCING DEV 2 OTC; QL ULTRA-THIN 30G SINGLE-LET 2 OTC; QL RELION LANCING SM LANCETS 33G 2 OTC; QL 2 OTC DEVICE SM TRUEDRAW 2 OTC RELION LANCING LANCING DEVICE 2 OTC; QL DEVICE KIT SMART DIABETES 2 OTC RELION ULTRA THIN VANTAGE LANCING 2 OTC; QL LANCETS 30G SMART SENSE COLOR 2 OTC; QL RELION ULTRA THIN LANCETS 33G 2 OTC; QL PLUS LANCETS SMART SENSE 2 OTC; QL REXALL LANCETS STANDARD LANCETS 2 OTC; QL ULTRA THIN 30G SMART SENSE SUPER 2 OTC; QL RIGHTEST ALTERNATE THIN LANCETS 2 OTC; QL SITE ADAPT SMART SENSE THIN 2 OTC; QL RIGHTEST GD500 LANCETS 26G 2 OTC LANCING DEVICE SMARTEST LANCETS 2 OTC; QL RIGHTEST GL300 28G 2 OTC; QL LANCETS SOLUS V2 LANCETS 28G 2 OTC; QL SAFE-T-LANCE 2 OTC; QL SOLUS V2 LANCING 2 OTC SAFE-T-LANCE PLUS 2 OTC; QL DEVICE SAFETY LANCET SOLUS V2 TWIST 2 OTC; QL 2 OTC; QL 30G/PRESSURE ACT LANCETS 30G SAFETY LANCETS 2 OTC; QL STERILANCE PA 2 OTC; QL SAFETY LANCETS 21G 2 OTC; QL STERILANCE TL 2 OTC; QL SAFETY LANCETS 28G 2 OTC; QL SUPER THIN LANCETS 2 OTC; QL SAPS HEALTH TWIST SURE COMFORT 2 OTC; QL 2 OTC; QL TOP LANCETS LANCETS 18G SAPS TWIST TOP SURE COMFORT 2 OTC; QL 2 OTC; QL LANCETS LANCETS 21G SAPSCARE TWIST TOP SURE COMFORT 2 OTC; QL 2 OTC; QL LANCETS LANCETS 23G SB LANCETS THIN 2 OTC; QL SURE COMFORT 2 OTC; QL SB LANCETS ULTRA LANCETS 28G 2 OTC; QL THIN SURE COMFORT 2 OTC; QL SELECT-LITE LANCETS 30G 2 OTC; QL DEVICE/LANCETS KIT SURE COMFORT 2 OTC LANCING PEN

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 138 Drug Name Tier Notes Drug Name Tier Notes SURE-LANCE FLAT TRUEPLUS SAFETY 2 OTC; QL 2 OTC; QL LANCETS LANCETS 28G SURE-LANCE LANCETS ULTI-LANCE 2 OTC; QL 2 OTC 26G AUTOMATIC SURE-LANCE THIN ULTILET CLASSIC 2 OTC; QL 2 OTC; QL LANCETS 28G LANCETS SURE-LANCE ULTRA ULTILET LANCETS 2 OTC; QL 2 OTC; QL THIN LANCETS ULTILET SAFETY 2 OTC; QL SURELITE LANCETS 2 OTC; QL LANCETS SURE-PEN 2 OTC ULTILET SAFETY 2 OTC; QL SURE-TOUCH LANCETS LANCETS 23G 2 OTC; QL UNIVERSAL ULTRA THIN LANCETS 2 OTC; QL TECHLITE AST 31G 2 OTC; QL LANCETS ULTRA-CARE LANCETS 2 OTC; QL TECHLITE LANCETS 2 OTC; QL 30G TECHLITE LANCETS ULTRA-THIN II AUTO 2 OTC; QL 2 OTC; QL 30G LANCET TGT LANCET MICRO ULTRA-THIN II 2 OTC; QL 2 OTC; QL THIN 33G LANCETS TGT LANCET THIN 26G 2 OTC; QL UNILET COMFORTOUCH 2 OTC; QL TGT LANCET ULTRA 2 OTC; QL LANCET THIN 30G UNILET EXCELITE 2 OTC; QL TGT LANCING DEVICE 2 OTC UNILET EXCELITE II 2 OTC; QL THINLETS GP LANCETS 2 OTC; QL UNILET G.P. LANCET 2 OTC; QL TODAYS HEALTH 2 OTC UNILET G.P. SUPERLITE LANCING DEVICE 2 OTC; QL LANCET TODAYS HEALTH THIN 2 OTC; QL UNILET GP 28 ULTRA LANCETS 28G 2 OTC; QL THIN TODAYS HEALTH THIN 2 OTC; QL LANCETS 30G UNILET LANCET 2 OTC; QL TOPCARE LANCETS UNILET MICRO-THIN 2 OTC; QL 2 OTC; QL MICRO-THIN 33G 33G UNILET SUPERLITE TRAVEL LANCETS 2 OTC; QL 2 OTC; QL LANCET TRAVEL LANCETS 2 OTC; QL UNILET SUPER-THIN ADVANCED 28G 2 OTC; QL 30G TRUE COMFORT TWIST 2 OTC; QL UNILET ULTRA-THIN TOP LANCETS 2 OTC; QL 28G TRUEDRAW LANCING 2 OTC DEVICE UNISTIK 1 2 OTC; QL TRUEPLUS LANCETS UNISTIK 2 2 OTC; QL 2 OTC; QL 26G UNISTIK 2 COMFORT 2 OTC; QL TRUEPLUS LANCETS UNISTIK 2 EXTRA 2 OTC; QL 2 OTC; QL 28G UNISTIK 2 NEONATAL 2 OTC; QL TRUEPLUS LANCETS 2 OTC; QL UNISTIK 2 NORMAL 2 OTC; QL 30G UNISTIK 2 SUPER 2 OTC; QL TRUEPLUS LANCETS 2 OTC; QL 33G UNISTIK 3 2 OTC; QL UNISTIK 3 COMFORT 2 OTC; QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 139 Drug Name Tier Notes Drug Name Tier Notes UNISTIK 3 EXTRA 2 OTC; QL VIVAGUARD LANCING 2 OTC UNISTIK 3 GENTLE 2 OTC; QL DEVICE WALGREENS ADV UNISTIK 3 NEONATAL 2 OTC; QL 2 OTC; QL TRAVEL LANCETS UNISTIK 3 NORMAL 2 OTC; QL WALGREENS LANCETS 2 OTC; QL UNISTIK CZT 2 OTC; QL WALGREENS LANCETS COMFORT 2 OTC; QL MICRO THIN UNISTIK CZT NORMAL 2 OTC; QL WALGREENS LANCETS 2 OTC; QL UNISTIK NORMAL 2 OTC; QL SUPER THIN UNISTIK PRO SAFETY WALGREENS THIN 2 OTC; QL 2 OTC; QL LANCET LANCETS UNISTIK SAFETY WALGREENS ULTRA 2 OTC; QL 2 OTC; QL LANCETS 28G THIN LANCETS UNISTIK SAFETY ZEVRX TWIST TOP 2 OTC; QL 2 OTC; QL LANCETS 30G LANCETS 30G UNISTIK TOUCH 2 OTC; QL *INSULIN SAFETY LANC 21G ADMINISTRATION UNISTIK TOUCH SUPPLIES*** 2 OTC; QL SAFETY LANC 23G OMNIPOD 5 PACK 2 PA; QL UNISTIK TOUCH OMNIPOD DASH 5 PACK 2 OTC; QL 2 PA; QL SAFETY LANC 28G PODS UNISTIK TOUCH OMNIPOD STARTER 2 OTC; QL 2 PA; QL SAFETY LANC 30G KIT UNIVERSAL 1 LANCETS 2 OTC; QL V-GO 20 KIT 3 PA THIN 26G V-GO 30 KIT 3 PA UNIVERSAL 1 LANCETS 2 OTC; QL THIN 33G V-GO 40 KIT 3 PA UNIVERSAL 1 LANCETS *NEEDLES & 2 OTC; QL ULTRA THIN SYRINGES*** VALUE PLUS LANCET 1ST TIER UNIFINE 2 OTC; QL 3 ST; OTC; QL STANDARD 21G PENTIPS VALUE PLUS LANCETS 1ST TIER UNIFINE 2 OTC; QL 3 ST; OTC; QL SUPER THIN PENTIPS PLUS VALUE PLUS LANCETS ABOUTTIME PEN 2 OTC; QL 3 ST; OTC; QL THIN 26G NEEDLE VALUE PLUS LANCING ADVOCATE INSULIN 2 OTC 3 ST; OTC; QL DEVICE PEN NEEDLES VALUMARK LANCET ADVOCATE INSULIN 2 OTC; QL 3 ST; OTC; QL SUPER THIN 30G SYRINGE VALUMARK LANCET ASSURE ID SAFETY PEN 2 OTC; QL 3 OTC; QL ULTRA THIN 28G NEEDLES VIDA MIA AUTOLET AURORA PEN NEEDLES 3 ST; OTC; QL 2 OTC LANCING DEV AURORA UNIFINE 3 ST; OTC; QL VIDA MIA UNILET PENTIPS 2 OTC; QL LANCETS 28G BD AUTOSHIELD 29G X 2 ST; OTC; QL VIDA MIA UNILET 5MM , 29G X 8MM 2 OTC; QL LANCETS 30G BD AUTOSHIELD DUO 2 OTC; QL VIVAGUARD LANCETS 2 ST; OTC; QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 140 Drug Name Tier Notes Drug Name Tier Notes BD INSULIN SYR BD SAFETYGLIDE ULTRAFINE II 31G X INSULIN SYRINGE 29G 2 ST; OTC; QL 2 ST; OTC; QL 5/16" 0.3 ML, 31G X 5/16" X 1/2" 0.5 ML 0.5 ML BD SAFETYGLIDE BD INSULIN SYRINGE INSULIN SYRINGE 31G 2 QL 25G X 1" 1 ML, 25G X X 15/64" 0.3 ML 5/8" 1 ML, 26G X 1/2" 1 BD SAFETY-LOK ML, 27.5G X 5/8" 2 ML, 2 OTC; QL 2 OTC; QL INSULIN SYRINGE 27G X 1/2" 1 ML, 29G X BD VEO INSULIN SYR 1/2" 0.3 ML, 29G X 1/2" 2 ST; OTC; QL 0.5 ML, 29G X 1/2" 1 ML, U/F 1/2UNIT U-100 1 ML BD VEO INSULIN 2 OTC; QL BD INSULIN SYRINGE SYRINGE U/F 2 OTC; QL HALF-UNIT CAREFINE PEN 3 ST; OTC; QL BD INSULIN SYRINGE NEEDLES MICROFINE 27G X 5/8" 1 CAREONE INSULIN 2 OTC; QL 3 ST; OTC; QL ML, 28G X 1/2" 0.5 ML, SYRINGE 28G X 1/2" 1 ML CAREONE UNIFINE BD INSULIN SYRINGE 3 ST; OTC; QL 2 OTC; QL PENTIPS U/F CAREONE UNIFINE BD INSULIN SYRINGE 3 ST; OTC; QL 2 OTC; QL PENTIPS PLUS U/F 1/2UNIT CARETOUCH INSULIN BD INSULIN SYRINGE 2 QL SYRINGE 28G X 5/16" 1 U-500 ML, 30G X 5/16" 0.5 ML, 3 ST; OTC; QL BD INSULIN SYRINGE 30G X 5/16" 1 ML, 31G X ULTRAFINE 29G X 1/2" 5/16" 0.5 ML 0.3 ML, 29G X 1/2" 0.5 2 OTC; QL CARETOUCH INSULIN ML, 30G X 1/2" 0.3 ML, SYRINGE 29G X 5/16" 1 3 OTC; QL 30G X 1/2" 0.5 ML, 31G X ML 5/16" 0.5 ML CARETOUCH PEN BD INSULIN SYRINGE NEEDLES 31G X 5 MM , ULTRAFINE 29G X 1/2" 1 2 ST; OTC; QL 31G X 6 MM , 31G X 8 3 ST; OTC; QL ML MM , 32G X 4 MM , 32G X BD PEN NEEDLE MICRO 5 MM 2 OTC; QL U/F CEQUR SIMPLICITY 2U 3 PA BD PEN NEEDLE MINI DEVICE 2 OTC; QL U/F CEQUR SIMPLICITY 3 PA BD PEN NEEDLE NANO STARTER KIT 2 ST; OTC; QL 2ND GEN CLEVER CHOICE 3 ST; OTC; QL BD PEN NEEDLE NANO COMFORT EZ 2 QL U/F CLICKFINE PEN 3 ST; OTC; QL BD PEN NEEDLE NEEDLES 2 OTC; QL ORIGINAL U/F COMFORT ASSIST BD PEN NEEDLE SHORT INSULIN SYRINGE 31G 3 ST; OTC; QL 2 OTC; QL U/F X 5/16" 0.3 ML COMFORT EZ INSULIN BD SAFETYGLIDE 3 ST; OTC; QL INSULIN SYRINGE 29G SYRINGE X 1/2" 0.3 ML, 30G X COMFORT EZ MICRO 3 ST; OTC; QL 5/16" 0.5 ML, 31G X 2 OTC; QL PEN NEEDLES 15/64" 0.5 ML, 31G X COMFORT EZ PEN 15/64" 1 ML, 31G X 5/16" 3 ST; OTC; QL 0.3 ML NEEDLES

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 141 Drug Name Tier Notes Drug Name Tier Notes COMFORT EZ SHORT EASY TOUCH INSULIN 3 ST; OTC; QL 3 ST; OTC; QL PEN NEEDLES SAFETY SYR COMFORT TOUCH EASY TOUCH INSULIN 3 ST; OTC; QL 3 ST; OTC; QL INSULIN PEN NEED SYRINGE DIATHRIVE PEN EASY TOUCH PEN 3 ST; OTC; QL 3 ST; OTC; QL NEEDLE NEEDLES DROPLET INSULIN EASY TOUCH SAFETY 3 ST; OTC; QL SYRINGE 29G X 1/2" 0.3 PEN NEEDLES ML, 29G X 1/2" 0.5 ML, EASY TOUCH 29G X 1/2" 1 ML, 30G X SHEATHLOCK 1/2" 0.3 ML, 30G X 1/2" 3 OTC; QL SYRINGE 29G X 1/2" 1 3 ST; OTC; QL 0.5 ML, 30G X 15/64" 0.5 ML, 30G X 1/2" 1 ML, 30G ML, 30G X 5/16" 0.5 ML, X 5/16" 1 ML, 31G X 5/16" 31G X 15/64" 0.5 ML, 31G 1 ML X 5/16" 0.5 ML EQL INSULIN SYRINGE DROPLET INSULIN 29G X 1/2" 0.3 ML, 29G X SYRINGE 30G X 1/2" 1 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 15/64" 0.3 ML, ML, 30G X 5/16" 0.3 ML, 3 ST; OTC; QL 30G X 15/64" 1 ML, 30G X 30G X 5/16" 0.5 ML, 30G 5/16" 0.3 ML, 30G X 5/16" 3 ST; OTC; QL X 5/16" 1 ML, 31G X 5/16" 1 ML, 31G X 15/64" 0.3 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 15/64" 1 ML, ML, 31G X 5/16" 1 ML 31G X 5/16" 0.3 ML, 31G EXEL COMFORT POINT X 5/16" 1 ML 3 ST; OTC; QL INSULIN SYR DROPLET MICRON 3 OTC; QL EXEL COMFORT POINT DROPLET PEN 3 ST; OTC; QL 3 ST; OTC; QL PEN NEEDLE NEEDLES FIFTY50 PEN NEEDLES 3 ST; OTC; QL DROPSAFE SAFETY PEN 3 OTC; QL FIFTY50 SUPERIOR NEEDLES 3 ST; OTC; QL COMFORT SYR DRUG MART UNIFINE 3 ST; OTC; QL FREDS PHARMACY PENTIPS 3 ST; OTC; QL UNIFINE PENTIP+ DRUG MART UNIFINE 3 ST; OTC; QL FREDS PHARMACY PENTIPS PLUS 3 ST; OTC; QL UNIFINE PENTIPS EASY COMFORT FREESTYLE PRECISION INSULIN SYRINGE 30G 3 ST; OTC; QL X 1/2" 0.5 ML, 30G X 1/2" INS SYR 1 ML, 30G X 5/16" 0.5 ML, GLOBAL EASE INJECT 3 ST; OTC; QL 3 ST; OTC; QL 30G X 5/16" 1 ML, 31G X PEN NEEDLES 5/16" 0.5 ML, 31G X 5/16" 1 ML, 32G X 5/16" 0.5 ML, GLOBAL EASY GLIDE INSULIN SYR 31G X 32G X 5/16" 1 ML 3 OTC; QL 15/64" 0.3 ML, 31G X EASY COMFORT PEN 15/64" 0.5 ML NEEDLES 31G X 5 MM , 3 OTC; QL 31G X 8 MM GLOBAL EASY GLIDE INSULIN SYR 31G X 3 ST; OTC; QL EASY COMFORT PEN 15/64" 1 ML, 31G X 5/16" NEEDLES 31G X 6 MM , 0.3 ML 32G X 4 MM , 33G X 4 3 ST; OTC; QL GLOBAL EASY GLIDE MM , 33G X 5 MM , 33G X 3 ST; OTC; QL 6 MM PEN NEEDLES EASY GLIDE PEN GLOBAL INJECT EASE 3 ST; OTC; QL 3 ST; OTC; QL NEEDLES INSULIN SYR EASY TOUCH GLOBAL INSULIN 3 ST; OTC; QL 3 ST; OTC; QL FLIPLOCK INSULIN SY SYRINGES

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 142 Drug Name Tier Notes Drug Name Tier Notes GLUCOPRO INSULIN HEALTHWISE SHORT SYRINGE 30G X 1/2" 0.3 PEN NEEDLES 31G X 8 3 ST; OTC; QL ML, 30G X 5/16" 0.3 ML, MM 30G X 5/16" 0.5 ML, 30G 3 ST; OTC; QL HEALTHWISE UNIFINE 3 ST; OTC; QL X 5/16" 1 ML, 31G X 5/16" PENTIPS 0.3 ML, 31G X 5/16" 0.5 HEALTHY ACCENTS ML, 31G X 5/16" 1 ML 3 ST; OTC; QL UNIFINE PENTIP GLUCOPRO INSULIN H-E-B INCONTROL PEN SYRINGE 30G X 1/2" 0.5 3 OTC; QL 3 ST; OTC; QL ML, 30G X 1/2" 1 ML NEEDLES GNP CLICKFINE PEN H-E-B INCONTROL 3 ST; OTC; QL 3 ST; OTC; QL NEEDLES UNIFINE PENTIP HM ULTICARE INSULIN GNP INSULIN SYRINGE 3 ST; OTC; QL 28G X 1/2" 0.5 ML, 29G X SYRINGE 1/2" 0.3 ML, 29G X 1/2" HM ULTICARE MINI 3 ST; OTC; QL 0.5 ML, 29G X 1/2" 1 ML, PEN NEEDLES 30G X 5/16" 0.3 ML, 30G 3 ST; OTC; QL HM ULTICARE SHORT X 5/16" 0.5 ML, 30G X 3 ST; OTC; QL 5/16" 1 ML, 31G X 5/16" PEN NEEDLES 0.3 ML, 31G X 5/16" 0.5 INSULIN SYRINGE 27G ML, 31G X 5/16" 1 ML X 1/2" 0.5 ML, 27G X 1/2" GNP INSULIN SYRINGES 1 ML, 28G X 1/2" 0.5 ML, 3 ST; OTC; QL 28GX1/2" 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" GNP INSULIN SYRINGES 0.5 ML, 29G X 1/2" 1 ML, 3 ST; OTC; QL 29GX1/2" 29G X 1/2" 0.5 3 ST; OTC; QL 30G X 1/2" 1 ML, 30G X ML 5/16" 0.3 ML, 30G X 5/16" GNP INSULIN SYRINGES 0.5 ML, 30G X 5/16" 1 ML, 3 ST; OTC; QL 30GX5/16" 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X GNP INSULIN SYRINGES 3 ST; OTC; QL 5/16" 1 ML 31GX5/16" INSULIN GNP ULTICARE PEN 3 ST; OTC; QL 3 ST; OTC; QL SYRINGE/NEEDLE NEEDLES INSULIN SYRINGE- 3 ST; OTC; QL GNP ULTRA COM NEEDLE U-100 INSULIN SYRINGE 28G 3 ST; OTC; QL X 1/2" 1 ML INSUPEN PEN NEEDLES 3 ST; OTC; QL GOODSENSE INSUPEN SENSITIVE 3 ST; OTC; QL CLICKFINE PEN 3 ST; OTC; QL INSUPEN ULTRAFIN 30G NEEDLE X 8 MM , 31G X 6 MM , 3 ST; OTC; QL GOODSENSE PEN 31G X 8 MM 3 ST; OTC; QL NEEDLE PENFINE KINRAY INSULIN 3 ST; OTC; QL HEALTHWISE INSULIN SYRINGE 3 OTC; QL SYR/NEEDLE KMART VALU INSULIN 3 ST; OTC; QL HEALTHWISE MICRON SYRINGE 29G 3 OTC; QL PEN NEEDLES KMART VALU INSULIN 3 ST; OTC; QL HEALTHWISE MINI PEN SYRINGE 30G 3 ST; OTC; QL NEEDLES HEALTHWISE PEN 3 ST; OTC; QL NEEDLES HEALTHWISE SHORT PEN NEEDLES 31G X 5 3 OTC; QL MM

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 143 Drug Name Tier Notes Drug Name Tier Notes KROGER INSULIN MONOJECT INSULIN SYRINGE 29G X 1/2" 0.3 SYRINGE 25G X 5/8" 1 3 ST; OTC; QL ML, 29G X 1/2" 0.5 ML, ML, 31G X 5/16" 1 ML 29G X 1/2" 1 ML, 30G X MONOJECT INSULIN 5/16" 0.3 ML, 30G X 5/16" 3 ST; OTC; QL SYRINGE 27G X 1/2" 1 0.5 ML, 30G X 5/16" 1 ML, ML, 28G X 1/2" 0.5 ML, 31G X 5/16" 0.3 ML, 31G 28G X 1/2" 1 ML, 29G X X 5/16" 0.5 ML, 31G X 1/2" 0.3 ML, 29G X 1/2" 3 ST; QL 5/16" 1 ML 0.5 ML, 29G X 1/2" 1 ML, KROGER PEN NEEDLES 30G X 5/16" 0.3 ML, 30G 3 OTC; QL 29G X 12MM X 5/16" 0.5 ML, 30G X KROGER PEN NEEDLES 5/16" 1 ML, U-100 1 ML 31G X 5 MM , 31G X 6 MONOJECT ULTRA 3 ST; OTC; QL MM , 31G X 8 MM , 32G X COMFORT SYRINGE 4 MM , 33G X 4 MM 28G X 1/2" 0.5 ML, 28G X 3 ST; QL LEADER INSULIN 1/2" 1 ML, 30G X 5/16" 0.3 3 ST; OTC; QL SYRINGE ML, 30G X 5/16" 0.5 ML LEADER UNIFINE MONOJECT ULTRA 3 ST; OTC; QL PENTIPS COMFORT SYRINGE 29G X 1/2" 0.3 ML, 29G X LEADER UNIFINE 3 ST; OTC; QL 3 ST; OTC; QL 1/2" 0.5 ML, 29G X 1/2" 1 PENTIPS PLUS ML, 31G X 5/16" 0.3 ML, LITETOUCH INSULIN 31G X 5/16" 0.5 ML 3 ST; OTC; QL SYRINGE MS INSULIN SYRINGE LITETOUCH PEN 31G X 5/16" 0.3 ML, 31G 3 ST; OTC; QL 3 ST; OTC; QL NEEDLES X 5/16" 0.5 ML, 31G X 5/16" 1 ML LONGS INSULIN SYRINGE 31G X 5/16" 0.5 3 ST; OTC; QL NOVOFINE ML AUTOCOVER PEN 3 ST; OTC; QL NEEDLE MAGELLAN INSULIN 3 ST; QL NOVOFINE PEN SAFETY SYR 3 ST; OTC; QL NEEDLE MARATHON MEDICAL 3 ST; QL NOVOFINE PLUS PEN PENTIPS 3 ST; OTC; QL NEEDLE MAXICOMFORT II PEN 3 ST; OTC; QL NOVOTWIST PEN NEEDLE 3 ST; OTC; QL NEEDLE MAXI-COMFORT 3 ST; OTC; QL INSULIN SYRINGE PC UNIFINE PENTIPS 3 ST; OTC; QL MAXI-COMFORT PEN NEEDLES 3 ST; OTC; QL 3 ST; OTC; QL SAFETY PEN NEEDLE PEN NEEDLES 1/2" 3 ST; OTC; QL MAXICOMFORT SYR PEN NEEDLES 5/16" 31G 3 ST; OTC; QL 3 ST; OTC; QL 27G X 1/2" X 8 MM MEDIC INSULIN 3 ST; OTC; QL PENTIPS 29G X 12MM , SYRINGE 31G X 5 MM , 31G X 8 3 ST; QL MEDICINE SHOPPE PEN MM , 32G X 4 MM 3 ST; OTC; QL NEEDLES PENTIPS 31G X 6 MM 3 ST; OTC; QL MEIJER PEN NEEDLES 3 ST; OTC; QL PRECISION SUREDOSE MICRODOT PEN PLUS SYR 29G X 1/2" 0.3 3 OTC; QL 3 ST; OTC; QL NEEDLE ML MM INSULIN PRECISION SUREDOSE 3 ST; OTC; QL SYRINGE/NEEDLE PLUS SYR 29G X 1/2" 1 3 ST; OTC; QL ML MM PEN NEEDLES 3 ST; OTC; QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 144 Drug Name Tier Notes Drug Name Tier Notes PRECISION SURE-DOSE RELION MINI PEN 3 ST; OTC; QL SYRINGE 28G X 1/2" 0.5 3 OTC; QL NEEDLES ML, 28G X 1/2" 1 ML RELION PEN NEEDLES 3 ST; OTC; QL PRECISION SURE-DOSE RELION SHORT PEN SYRINGE 29G X 1/2" 0.5 3 ST; OTC; QL 3 ST; OTC; QL NEEDLES ML, 30G X 3/8" 0.5 ML, SAFETY INSULIN 30G X 5/16" 0.3 ML 3 ST; OTC; QL SYRINGES PREFERRED PLUS 3 ST; OTC; QL INSULIN SYRINGE SB INSULIN SYRINGE 3 ST; OTC; QL PREFERRED PLUS SECURESAFE INSULIN 3 ST; OTC; QL 3 ST; OTC; QL UNIFINE PENTIPS SYRINGE PREVENT SAFETY PEN SECURESAFE SAFETY 3 ST; OTC; QL 3 ST; OTC; QL NEEDLES PEN NEEDLES PRO COMFORT SHOPKO UNIFINE 3 ST; OTC; QL 3 ST; OTC; QL INSULIN SYRINGE PENTIPS SHOPKO UNIFINE PRO COMFORT PEN 3 ST; OTC; QL NEEDLES 31G X 8 MM , PENTIPS PLUS 3 ST; QL 32G X 4 MM , 32G X 5 SURE COMFORT 3 ST; OTC; QL MM INSULIN SYRINGE PRO COMFORT PEN SURE COMFORT PEN 3 ST; OTC; QL 3 ST; OTC; QL NEEDLES 32G X 6 MM NEEDLES PRODIGY INSULIN SURE-FINE PEN 3 ST; OTC; QL 3 ST; OTC; QL SYRINGE NEEDLES PURE COMFORT PEN SURE-JECT INSULIN 3 ST; OTC; QL 3 ST; OTC; QL NEEDLE SYRINGE PX EXTRA SHORT PEN 3 ST; OTC; QL TECHLITE INSULIN NEEDLES SYRINGE 29G X 1/2" 0.3 PX INSULIN SYRINGE ML, 29G X 1/2" 1 ML, 30G 3 ST; OTC; QL X 1/2" 1 ML, 30G X 5/16" 30G X 1/2" 0.5 ML 3 ST; OTC; QL 0.3 ML, 31G X 15/64" 0.3 PX MINI PEN NEEDLES 3 ST; OTC; QL ML, 31G X 15/64" 1 ML, PX PEN NEEDLE 3 ST; OTC; QL 31G X 5/16" 0.3 ML, 31G PX SHORTLENGTH PEN X 5/16" 1 ML 3 ST; OTC; QL NEEDLES TECHLITE INSULIN QC PEN NEEDLES 3 ST; OTC; QL SYRINGE 29G X 1/2" 0.5 ML, 30G X 1/2" 0.5 ML, 3 OTC; QL QC UNIFINE PENTIPS 3 ST; OTC; QL 30G X 5/16" 0.5 ML, 31G RA INSULIN SYRINGE 3 ST; OTC; QL X 15/64" 0.5 ML, 31G X 5/16" 0.5 ML RA PEN NEEDLES 3 ST; OTC; QL TECHLITE PEN 3 ST; OTC; QL REALITY INSULIN NEEDLES SYRINGE 28G X 1/2" 0.5 3 OTC; QL TODAYS HEALTH MINI ML, 28G X 1/2" 1 ML 3 ST; OTC; QL PEN NEEDLES REALITY INSULIN TODAYS HEALTH PEN SYRINGE 29G X 1/2" 0.5 3 ST; OTC; QL 3 ST; OTC; QL ML, 29G X 1/2" 1 ML NEEDLES TODAYS HEALTH RELION INSULIN 3 ST; OTC; QL SYRINGE 29G X 1/2" 0.5 SHORT PEN NEEDLE ML, 31G X 15/64" 0.3 ML, TOPCARE CLICKFINE 3 ST; OTC; QL 31G X 15/64" 0.5 ML, 31G 3 ST; OTC; QL PEN NEEDLES X 15/64" 1 ML, 31G X TOPCARE ULTRA 5/16" 0.3 ML, 31G X 5/16" 3 ST; OTC; QL 0.5 ML, 31G X 5/16" 1 ML COMFORT INS SYR

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 145 Drug Name Tier Notes Drug Name Tier Notes TRUE COMFORT ULTRACARE INSULIN 3 OTC; QL 3 OTC; QL INSULIN SYRINGE SYRINGE TRUE COMFORT PEN ULTRACARE PEN 3 ST; OTC; QL 3 ST; OTC; QL NEEDLES NEEDLES TRUE COMFORT PRO ULTRA-THIN II INS SYR 3 ST; OTC; QL 3 ST; OTC; QL INSULIN SYR SHORT TRUE COMFORT PRO ULTRA-THIN II INSULIN 3 ST; OTC; QL PEN NEEDLES SYRINGE 29G X 1/2" 0.5 3 ST; OTC; QL TRUEPLUS 5-BEVEL ML, 29G X 1/2" 1 ML PEN NEEDLES 29G X 3 OTC; QL ULTRA-THIN II MINI 3 ST; OTC; QL 12.7MM PEN NEEDLE TRUEPLUS 5-BEVEL ULTRA-THIN II PEN 3 ST; OTC; QL PEN NEEDLES 31G X 5 NEEDLE SHORT 3 ST; OTC; QL MM , 31G X 6 MM , 31G X ULTRA-THIN II PEN 3 ST; OTC; QL 8 MM , 32G X 4 MM NEEDLES TRUEPLUS INSULIN 3 ST; OTC; QL UNIFINE PEN NEEDLES 3 ST; OTC; QL SYRINGE UNIFINE PENTIPS 3 ST; OTC; QL TRUEPLUS PEN NEEDLES 31G X 6 MM , 3 OTC; QL UNIFINE PENTIPS PLUS 3 ST; OTC; QL 32G X 4 MM UNIFINE ULTICARE INSULIN SAFECONTROL PEN 3 ST; OTC; QL 3 ST; QL SAFETY SYR NEEDLE ULTICARE INSULIN VALUE HEALTH 3 ST; OTC; QL 3 ST; OTC; QL SYRINGE INSULIN SYRINGE ULTICARE MICRO PEN VALUMARK PEN 3 ST; OTC; QL 3 ST; OTC; QL NEEDLES NEEDLES ULTICARE MINI PEN VANISHPOINT INSULIN 3 ST; OTC; QL NEEDLES SYRINGE 29G X 1/2" 1 ML, 29G X 5/16" 1 ML, 3 ST; OTC; QL ULTICARE PEN 30G X 1/2" 0.5 ML, 30G X NEEDLES 29G X 12.7MM 3 ST; OTC; QL 5/16" 0.5 ML, 30G X 5/16" , 31G X 5 MM 1 ML ULTICARE SHORT PEN 3 ST; OTC; QL VANISHPOINT INSULIN NEEDLES SYRINGE 30G X 3/16" 0.5 3 OTC; QL ULTIGUARD SAFEPACK ML, 30G X 3/16" 1 ML 3 ST; OTC; QL PEN NEEDLE VIDA MIA UNIFINE 3 ST; OTC; QL ULTIGUARD SAFEPACK PENTIPS 3 ST; OTC; QL SYR/NEEDLE VP INSULIN SYRINGE 3 ST; OTC; QL ULTILET PEN NEEDLE 3 ST; OTC; QL WEGMANS UNIFINE 3 ST; OTC; QL ULTRA COMFORT PENTIPS PLUS INSULIN SYRINGE 30G 3 ST; OTC; QL ZEVRX INSULIN 3 ST; OTC; QL X 5/16" 0.3 ML SYRINGE ULTRA FLO INSULIN 3 ST; OTC; QL ZEVRX PEN NEEDLES 3 ST; OTC; QL PEN NEEDLES *MIGRAINE ULTRA FLO INSULIN 3 ST; OTC; QL PRODUCTS* SYR 1/2 UNIT *CALCITONIN GENE- ULTRA FLO INSULIN 3 ST; OTC; QL RELATED PEPTIDE SYRINGE RECEPTOR ANTAG ULTRA THIN PEN (CGRP)*** 3 ST; OTC; QL NEEDLES NURTEC ORAL TABLET 2 PA; QL DISPERSIBLE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 146 Drug Name Tier Notes Drug Name Tier Notes UBRELVY ORAL ERGOMAR 3 ST; QL TABLET SUBLINGUAL TABLET 3 *CGRP RECEPTOR SUBLINGUAL ANTAGONISTS - MIGRANAL NASAL 3 ST; QL MONOCOLONAL SOLUTION ANTIBODIES*** *SELECTIVE AIMOVIG SEROTONIN AGONIST- SUBCUTANEOUS NSAID 3 PA; QL SOLUTION AUTO- COMBINATIONS*** INJECTOR sumatriptan-naproxen 3 ST; QL AJOVY sodium oral tablet SUBCUTANEOUS TREXIMET ORAL 3 PA; QL 3 ST; QL SOLUTION AUTO- TABLET 85-500 MG INJECTOR *SELECTIVE AJOVY SEROTONIN AGONISTS SUBCUTANEOUS 3 PA; QL 5-HT(1)*** SOLUTION PREFILLED SYRINGE almotriptan malate oral tablet 1 or 1b* QL AMERGE ORAL EMGALITY (300 MG 3 ST; QL DOSE) SUBCUTANEOUS TABLET 3 PA; QL SOLUTION PREFILLED eletriptan hydrobromide oral 1 or 1b* QL SYRINGE tablet EMGALITY FROVA ORAL TABLET 3 ST; QL SUBCUTANEOUS 3 PA; QL frovatriptan succinate oral SOLUTION AUTO- 1 or 1b* ST; QL INJECTOR tablet IMITREX NASAL EMGALITY 3 ST; QL SUBCUTANEOUS SOLUTION 3 PA; QL SOLUTION PREFILLED IMITREX ORAL 3 ST; QL SYRINGE TABLET VYEPTI INTRAVENOUS IMITREX STATDOSE 4 PA; QL SOLUTION REFILL 3 ST; QL *ERGOT SUBCUTANEOUS COMBINATIONS*** SOLUTION CARTRIDGE CAFERGOT ORAL IMITREX STATDOSE 3 TABLET SYSTEM SUBCUTANEOUS 3 ST; QL ergotamine-caffeine oral 1 or 1b* SOLUTION AUTO- tablet INJECTOR migergot rectal suppository 1 or 1b* IMITREX *MIGRAINE PRODUCTS SUBCUTANEOUS 3 ST; QL - NSAIDS*** SOLUTION MAXALT ORAL TABLET CAMBIA ORAL PACKET 3 ST; QL 3 ST; QL 10 MG *MIGRAINE PRODUCTS*** MAXALT-MLT ORAL TABLET DISPERSIBLE 3 ST; QL D.H.E. 45 INJECTION 3 PA 10 MG SOLUTION naratriptan hcl oral tablet 1 or 1b* QL dihydroergotamine mesylate 1 or 1b* PA ONZETRA XSAIL NASAL injection solution 3 ST; QL EXHALER POWDER dihydroergotamine mesylate 3 ST; QL nasal solution RELPAX ORAL TABLET 3 ST; QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 147 Drug Name Tier Notes Drug Name Tier Notes rizatriptan benzoate oral *CALCIUM 1 or 1b* QL tablet COMBINATIONS*** rizatriptan benzoate oral CALCIUM 1 or 1b* QL tablet dispersible GLUCONATE-NACL INTRAVENOUS sumatriptan nasal solution 1 or 1b* QL 3 SOLUTION 1-0.675 sumatriptan succinate oral 1 or 1b* QL GM/50ML-%, 2-0.675 tablet GM/100ML-% sumatriptan succinate refill CALCIUM subcutaneous solution 1 or 1b* QL GLUCONATE-NACL cartridge INTRAVENOUS 3 sumatriptan succinate SOLUTION 1-0.9 subcutaneous solution 6 1 or 1b* QL GM/100ML-%, 2-0.9 mg/0.5ml GM/100ML-% sumatriptan succinate *CALCIUM*** subcutaneous solution auto- 1 or 1b* QL CALCIUM GLUCONATE injector 4 mg/0.5ml, 6 INTRAVENOUS 3 mg/0.5ml SOLUTION TOSYMRA NASAL 3 ST; QL *ELECTROLYTES & SOLUTION DEXTROSE*** ZEMBRACE DEXTROSE SYMTOUCH 5%/ELECTROLYTE #48 3 SUBCUTANEOUS 3 ST; QL INTRAVENOUS SOLUTION AUTO- SOLUTION INJECTOR dextrose in lactated ringers 1 or 1b* zolmitriptan nasal solution 1 or 1b* ST; QL intravenous solution zolmitriptan oral tablet 1 or 1b* QL DEXTROSE-NACL zolmitriptan oral tablet INTRAVENOUS 1 or 1b* QL 3 dispersible SOLUTION 10-0.2 %, 2.5- 0.45 % ZOMIG NASAL 3 ST; QL SOLUTION dextrose-nacl intravenous solution 10-0.45 %, 5-0.2 %, 1 or 1b* ZOMIG ORAL TABLET 3 ST; QL 5-0.33 %, 5-0.45 %, 5-0.9 % *SELECTIVE dextrose-sodium chloride SEROTONIN AGONISTS intravenous solution 2.5-0.45 1 or 1b* 5-HT(1F)*** %, 5-0.45 %, 5-0.9 % REYVOW ORAL 3 ST; QL DEXTROSE-SODIUM TABLET CHLORIDE *MINERALS & INTRAVENOUS 3 ELECTROLYTES* SOLUTION 5-0.225 %, 5- *BICARBONATES*** 0.3 % SODIUM ACETATE ELLIOTTS B INTRAVENOUS 3 INTRATHECAL 3 SOLUTION 2 MEQ/ML SOLUTION sodium bicarbonate IONOSOL-MB IN D5W 1 or 1b* intravenous solution 7.5 % INTRAVENOUS 3 SOLUTION THAM INTRAVENOUS 3 SOLUTION ISOLYTE-P IN D5W INTRAVENOUS 3 SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 148 Drug Name Tier Notes Drug Name Tier Notes kcl in dextrose-nacl POTASSIUM CHLORIDE intravenous solution 10-5- IN NACL INTRAVENOUS 0.45 meq/l-%-%, 20-5-0.2 SOLUTION 20-0.45 3 meq/l-%-%, 20-5-0.45 meq/l- 1 or 1b* MEQ/L-%, 40-0.9 MEQ/L- %-%, 20-5-0.9 meq/l-%-%, % 30-5-0.45 meq/l-%-%, 40-5- potassium chloride in nacl 0.45 meq/l-%-% intravenous solution 20-0.9 1 or 1b* KCL IN DEXTROSE- meq/l-% NACL INTRAVENOUS ringers intravenous solution 1 or 1b* SOLUTION 20-5-0.225 3 MEQ/L-%-%, 40-5-0.9 TPN ELECTROLYTES MEQ/L-%-% INTRAVENOUS 3 CONCENTRATE KCL-LACTATED RINGERS-D5W *FLUORIDE 3 INTRAVENOUS COMBINATIONS*** SOLUTION FLORIVA ORAL LIQUID 3 NORMOSOL-M IN D5W *FLUORIDE*** INTRAVENOUS 3 SOLUTION fluoritab oral solution 1 or 1a* $0 NORMOSOL-R IN D5W nafrinse drops oral solution 1 or 1a* $0 INTRAVENOUS 3 nafrinse oral tablet chewable 1 or 1a* $0 SOLUTION sodium fluoride oral solution 1 or 1b* OTC; $0 potassium chloride in 0.5 mg/ml dextrose intravenous solution 1 or 1b* sodium fluoride oral solution 1 or 1a* $0 20-5 meq/l-% 1.1 (0.5 f) mg/ml *ELECTROLYTES sodium fluoride oral tablet 1 or 1a* $0 PARENTERAL*** sodium fluoride oral tablet 1 or 1a* $0 ISOLYTE-S chewable INTRAVENOUS 3 SOLUTION *MAGNESIUM*** ISOLYTE-S PH 7.4 MAGNESIUM SULFATE IN D5W INTRAVENOUS INTRAVENOUS 3 3 SOLUTION SOLUTION 1-5 GM/100ML-% KCL (IN NACL 0.9%) INTRAVENOUS MAGNESIUM SULFATE 3 SOLUTION 40 INTRAVENOUS SOLUTION 2 GM/50ML, MEQ/500ML 3 20 GM/500ML, 4 lactated ringers intravenous 1 or 1b* GM/100ML, 4 GM/50ML, solution 40 GM/1000ML NORMOSOL-R *MANGANESE*** INTRAVENOUS 3 manganese chloride SOLUTION 1 or 1b* intravenous solution NORMOSOL-R PH 7.4 INTRAVENOUS 3 *PHOSPHATE*** SOLUTION K-PHOS ORAL TABLET 2 PLASMA-LYTE 148 K-PHOS-NEUTRAL 3 INTRAVENOUS 3 ORAL TABLET SOLUTION phosphorous oral tablet 1 or 1b* PLASMA-LYTE A phospho-trin 250 neutral oral INTRAVENOUS 3 1 or 1b* tablet SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 149 Drug Name Tier Notes Drug Name Tier Notes POTASSIUM potassium chloride PHOSPHATES intravenous solution 2 1 or 1b* INTRAVENOUS meq/ml 3 SOLUTION 15 potassium chloride oral 1 or 1b* MMOLE/5ML, 150 packet MMOLE/50ML potassium chloride oral potassium phosphates solution 10 %, 20 meq/15ml 1 or 1b* intravenous solution 45 1 or 1b* (10%), 40 meq/15ml (20%) mmole/15ml *SODIUM*** potassium phosphates(66 1 or 1b* monoject flush syringe meq k) intravenous solution 1 or 1b* QL intravenous solution POTASSIUM PHOSPHATES(71 MEQ monoject sodium chloride 3 1 or 1b* K) INTRAVENOUS flush intravenous solution SOLUTION normal saline flush 1 or 1b* sodium phosphates intravenous solution intravenous solution 15 1 or 1b* sodium chloride flush 1 or 1b* mmole/5ml intravenous solution virt-phos 250 neutral oral sodium chloride injection 1 or 1b* 1 or 1b* tablet solution 2.5 meq/ml *POTASSIUM*** sodium chloride intravenous klor-con 10 oral tablet solution 0.45 %, 0.9 %, 3 %, 1 or 1b* 1 or 1b* extended release 5 % klor-con m10 oral tablet *TRACE MINERAL 1 or 1a* extended release COMBINATIONS*** klor-con m15 oral tablet MULTRYS 1 or 1a* extended release INTRAVENOUS 3 SOLUTION klor-con m20 oral tablet 1 or 1a* THE LIQUILIFT TRACE extended release 3 INTRAVENOUS KIT klor-con oral packet 20 meq 1 or 1b* TRALEMENT klor-con oral tablet extended 1 or 1b* INTRAVENOUS 3 release SOLUTION K-TAB ORAL TABLET 3 *TRACE MINERALS*** EXTENDED RELEASE chromic chloride intravenous 1 or 1b* potassium acetate solution intravenous solution 2 1 or 1b* cupric chloride intravenous meq/ml 1 or 1b* solution potassium chloride crys er 1 or 1a* oral tablet extended release SELENIOUS ACID INTRAVENOUS 3 potassium chloride er oral 1 or 1b* SOLUTION capsule extended release *ZINC*** potassium chloride er oral 1 or 1b* GALZIN ORAL tablet extended release 3 CAPSULE POTASSIUM CHLORIDE INTRAVENOUS WILZIN ORAL CAPSULE 3 SOLUTION 10 zinc chloride intravenous MEQ/100ML, 10 1 or 1b* 3 solution MEQ/50ML, 20 zinc sulfate intravenous MEQ/100ML, 20 1 or 1b* MEQ/50ML, 40 solution 3 mg/ml, 5 mg/ml MEQ/100ML

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 150 Drug Name Tier Notes Drug Name Tier Notes *MISCELLANEOUS PRISMASOL BGK 0/2.5 THERAPEUTIC INTRAVENOUS 3 CLASSES* SOLUTION *ANTILEPROTICS*** PRISMASOL BGK 2/0 THALOMID ORAL INTRAVENOUS 3 2 PA; SP; QL CAPSULE SOLUTION *B-LYMPHOCYTE PRISMASOL BGK 2/3.5 STIMULATOR (BLYS)- INTRAVENOUS 3 SPECIFIC SOLUTION INHIBITORS*** PRISMASOL BGK 4/0/1.2 BENLYSTA INTRAVENOUS 3 INTRAVENOUS SOLUTION 4 PA; LD; SP SOLUTION PRISMASOL BGK 4/2.5 RECONSTITUTED INTRAVENOUS 3 BENLYSTA SOLUTION SUBCUTANEOUS PRISMASOL BK 0/0/1.2 4 PA; LD; SP; QL SOLUTION AUTO- INTRAVENOUS 3 INJECTOR SOLUTION BENLYSTA *CYCLOSPORINE SUBCUTANEOUS ANALOGS*** 4 PA; LD; SP; QL SOLUTION PREFILLED cyclosporine intravenous 1 or 1b* SP SYRINGE solution *CHELATING cyclosporine modified oral 1 or 1b* AGENTS*** capsule clovique oral capsule 1 or 1b* PA; SP; QL cyclosporine modified oral 1 or 1b* CUPRIMINE ORAL solution 3 PA; QL CAPSULE 250 MG cyclosporine oral capsule 1 or 1b* DEPEN TITRATABS gengraf oral capsule 100 mg, 3 PA; LD; QL 1 or 1b* ORAL TABLET 25 mg EDETATE DISODIUM gengraf oral solution 1 or 1b* INTRAVENOUS 3 LUPKYNIS ORAL SOLUTION 4 PA; LD; QL CAPSULE penicillamine oral capsule 1 or 1b* PA; QL NEORAL ORAL 3 penicillamine oral tablet 1 or 1b* PA; QL CAPSULE SYPRINE ORAL NEORAL ORAL 3 PA; LD; SP; QL 3 CAPSULE SOLUTION trientine hcl oral capsule 1 or 1b* PA; SP; QL SANDIMMUNE *CONTINUOUS RENAL INTRAVENOUS 3 SP REPLACEMENT SOLUTION THERAPY (CRRT) SANDIMMUNE ORAL 3 SOLUTIONS*** CAPSULE PHOXILLUM B22K4/0 SANDIMMUNE ORAL 3 INTRAVENOUS 3 SOLUTION SOLUTION *ENZYMES*** PHOXILLUM BK4/2.5 AMPHADASE INTRAVENOUS 3 3 SOLUTION INJECTION SOLUTION HYLENEX INJECTION PRISMASOL B22GK 4/0 3 INTRAVENOUS 3 SOLUTION SOLUTION VITRASE INJECTION 3 SOLUTION * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 151 Drug Name Tier Notes Drug Name Tier Notes XIAFLEX INJECTION mycophenolate mofetil oral 1 or 1b* SOLUTION 4 PA; LD suspension reconstituted RECONSTITUTED mycophenolate mofetil oral 1 or 1b* *FARNESYLTRANSFER tablet ASE INHIBITORS*** mycophenolate sodium oral 1 or 1b* ZOKINVY ORAL tablet delayed release 4 PA; LD; QL CAPSULE MYFORTIC ORAL *FECAL TABLET DELAYED 3 INCONTINENCE RELEASE BULKING AGENT - *INTERLEUKIN-6 (IL-6) COMBINATIONS*** ANTAGONISTS*** SOLESTA INJECTION 4 LD; SP SYLVANT GEL INTRAVENOUS 4 PA; LD; SP *IMMUNE GLOBULIN SOLUTION IMMUNOSUPPRESSANT RECONSTITUTED S*** *IRRIGATION ATGAM INTRAVENOUS SOLUTIONS*** 3 SP INJECTABLE argyle sterile water irrigation 1 or 1b* THYMOGLOBULIN solution INTRAVENOUS lactated ringers irrigation 3 SP 1 or 1b* SOLUTION solution RECONSTITUTED physiolyte irrigation solution 1 or 1b* *IMMUNOMODULATOR physiosol irrigation irrigation S FOR 1 or 1b* MYELODYSPLASTIC solution SYNDROMES*** ringers irrigation irrigation 1 or 1b* REVLIMID ORAL solution 2 PA; LD; SP; QL CAPSULE sterile water for irrigation 1 or 1b* *INOSINE irrigation solution MONOPHOSPHATE tis-u-sol irrigation solution 1 or 1b* DEHYDROGENASE water for irrigation, sterile INHIBITORS*** 1 or 1b* irrigation solution CELLCEPT *MACROLIDE INTRAVENOUS IMMUNOSUPPRESSANT INTRAVENOUS 3 SP S*** SOLUTION RECONSTITUTED ASTAGRAF XL ORAL CELLCEPT ORAL CAPSULE EXTENDED 3 3 CAPSULE RELEASE 24 HOUR CELLCEPT ORAL ENVARSUS XR ORAL SUSPENSION 3 TABLET EXTENDED 3 RECONSTITUTED RELEASE 24 HOUR CELLCEPT ORAL everolimus oral tablet 0.25 3 1 or 1b* TABLET mg, 0.5 mg, 0.75 mg mycophenolate mofetil hcl PROGRAF intravenous solution 1 or 1b* SP INTRAVENOUS 2 SP reconstituted SOLUTION PROGRAF ORAL mycophenolate mofetil 3 intravenous solution 1 or 1b* SP CAPSULE reconstituted PROGRAF ORAL 3 mycophenolate mofetil oral PACKET 1 or 1b* capsule * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 152 Drug Name Tier Notes Drug Name Tier Notes RAPAMUNE ORAL DELFLEX-SM/2.5% 3 SOLUTION DEXTROSE 3 RAPAMUNE ORAL INTRAPERITONEAL 3 TABLET SOLUTION sirolimus oral solution 1 or 1b* DIANEAL LOW CALCIUM/1.5% DEX 3 sirolimus oral tablet 1 or 1b* INTRAPERITONEAL tacrolimus oral capsule 1 or 1b* SOLUTION ZORTRESS ORAL DIANEAL LOW 3 CALCIUM/2.5% DEX TABLET 3 INTRAPERITONEAL *MISCELLANEOUS SOLUTION THERAPEUTIC CLASSES*** DIANEAL LOW CALCIUM/4.25% DEX NEXAVIR INJECTION 3 3 INTRAPERITONEAL SOLUTION SOLUTION *MONOCLONAL DIANEAL PD-2/1.5% ANTIBODIES*** DEXTROSE 3 ENSPRYNG INTRAPERITONEAL SUBCUTANEOUS SOLUTION 4 PA; LD; SP; QL SOLUTION PREFILLED DIANEAL PD-2/2.5% SYRINGE DEXTROSE 3 GAMIFANT INTRAPERITONEAL INTRAVENOUS 3 PA; LD; SP SOLUTION SOLUTION DIANEAL PD-2/4.25% SIMULECT DEXTROSE 3 INTRAVENOUS INTRAPERITONEAL 3 SOLUTION SOLUTION RECONSTITUTED EXTRANEAL UPLIZNA INTRAPERITONEAL 3 INTRAVENOUS 4 PA; LD; QL SOLUTION SOLUTION ULTRABAG/DIANEAL *PERITONEAL PD-2/1.5% DEX 3 DIALYSIS INTRAPERITONEAL SOLUTIONS*** SOLUTION DELFLEX-LC/1.5% ULTRABAG/DIANEAL DEXTROSE PD-2/2.5% DEX 3 3 INTRAPERITONEAL INTRAPERITONEAL SOLUTION 344 MOSM/L SOLUTION DELFLEX-LC/2.5% ULTRABAG/DIANEAL DEXTROSE PD-2/4.25%DEX 3 3 INTRAPERITONEAL INTRAPERITONEAL SOLUTION SOLUTION DELFLEX-LC/4.25% ULTRABAG/DIANEAL/1. DEXTROSE 5% DEXTROSE 3 3 INTRAPERITONEAL INTRAPERITONEAL SOLUTION SOLUTION DELFLEX-SM/1.5% ULTRABAG/DIANEAL/2. DEXTROSE 5% DEXTROSE 2 3 INTRAPERITONEAL INTRAPERITONEAL SOLUTION SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 153 Drug Name Tier Notes Drug Name Tier Notes ULTRABAG/DIANEAL/4. *SELECTIVE T-CELL 25% DEX COSTIMULATION 3 INTRAPERITONEAL BLOCKERS*** SOLUTION NULOJIX *POTASSIUM INTRAVENOUS 3 PA; SP REMOVING AGENTS*** SOLUTION LOKELMA ORAL RECONSTITUTED 3 PACKET *TYPE I INTERFERON sodium polystyrene sulfonate (IFN) RECEPTOR 1 or 1b* oral powder ANTAGONISTS*** sps oral suspension 1 or 1b* SAPHNELO INTRAVENOUS 4 LD VELTASSA ORAL 3 SOLUTION PACKET *MOUTH/THROAT/DEN *PROSTAGLANDINS*** TAL AGENTS* alprostadil injection solution 1 or 1b* *ANESTHETICS PROSTIN VR TOPICAL ORAL*** 3 INJECTION SOLUTION lidocaine hcl mouth/throat 1 or 1a* QL *PURINE ANALOGS*** solution lidocaine viscous hcl AZASAN ORAL TABLET 3 1 or 1a* QL mouth/throat solution azathioprine oral tablet 1 or 1b* *ANTI-INFECTIVES - AZATHIOPRINE THROAT*** SODIUM INJECTION 3 clotrimazole mouth/throat SOLUTION 1 or 1b* QL RECONSTITUTED troche nystatin mouth/throat IMURAN ORAL TABLET 3 1 or 1b* QL suspension *ROCK INHIBITORS*** ORAVIG BUCCAL REZUROCK ORAL 3 3 PA; LD; QL TABLET TABLET *ANTISEPTICS - *SCLEROSING MOUTH/THROAT*** AGENTS*** chlorhexidine gluconate 1 or 1a* QL ASCLERA mouth/throat solution INTRAVENOUS 3 SOLUTION PERIDEX MOUTH/THROAT 3 QL ETHAMOLIN SOLUTION INTRAVENOUS 3 periogard mouth/throat SOLUTION 1 or 1a* QL solution sodium tetradecyl sulfate 1 or 1b* intravenous solution *DENTAL PRODUCTS - COMBINATIONS*** SOTRADECOL fluoridex sensitivity relief INTRAVENOUS 3 1 or 1b* SOLUTION 1 % dental paste sotradecol intravenous NAFRINSE DAILY 1 or 1b* solution 3 % ACIDULATED MOUTH/THROAT 3 VARITHENA 3 LD SOLUTION INTRAVENOUS FOAM RECONSTITUTED PREVIDENT 5000 ENAMEL PROTECT 3 DENTAL PASTE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 154 Drug Name Tier Notes Drug Name Tier Notes PREVIDENT 5000 sodium fluoride 5000 ppm 1 or 1b* SENSITIVE DENTAL 3 dental paste PASTE sodium fluoride dental cream 1 or 1b* sodium fluoride 5000 enamel sodium fluoride dental gel 1 or 1b* 1 or 1b* dental paste 1.1 % sodium fluoride 5000 sodium fluoride mouth/throat 1 or 1b* 1 or 1a* sensitive dental paste solution *FLUORIDE DENTAL *SALIVA PRODUCTS*** STIMULANTS*** cavarest dental gel 1 or 1b* cevimeline hcl oral capsule 1 or 1b* clinpro 5000 dental paste 1 or 1b* EVOXAC ORAL 3 denta 5000 plus dental cream 1 or 1b* CAPSULE dentagel dental gel 1 or 1a* pilocarpine hcl oral tablet 1 or 1b* QL easygel dental gel 1 or 1b* SALAGEN ORAL 3 QL fluoridex daily renewal TABLET 1 or 1b* mouth/throat concentrate *STEROIDS - fluoridex dental paste 1 or 1b* MOUTH/THROAT/DENT AL*** fluoridex enhanced 1 or 1b* whitening dental paste oralone mouth/throat paste 1 or 1b* triamcinolone acetonide NAFRINSE 1 or 1b* DAILY/NEUTRAL mouth/throat paste MOUTH/THROAT 3 *MULTIVITAMINS* SOLUTION *B-COMPLEX RECONSTITUTED VITAMINS*** NAFRINSE WEEKLY b complex-b12 oral tablet 1 or 1b* OTC; $0 MOUTH/THROAT 3 SOLUTION B-COMPLEX RECONSTITUTED INJECTION 3 INJECTABLE PREVIDENT 5000 b-complex plus b-12 oral BOOSTER PLUS 3 1 or 1b* OTC; $0 DENTAL PASTE tablet PREVIDENT 5000 DRY b-complex/b-12 oral tablet 1 or 1b* OTC; $0 3 MOUTH DENTAL GEL ra b-complex oral tablet 1 or 1b* OTC; $0 PREVIDENT 5000 ra b-complex with b-12 oral 1 or 1b* OTC; $0 ORTHO DEFENSE 3 tablet DENTAL PASTE vitamin b complex oral tablet 1 or 1b* OTC; $0 PREVIDENT 5000 PLUS 3 DENTAL CREAM vitamin b-complex oral tablet 1 or 1b* OTC; $0 PREVIDENT DENTAL vitamin-b complex oral tablet 1 or 1b* OTC; $0 3 GEL *B-COMPLEX W/ C & CALCIUM*** PREVIDENT MOUTH/THROAT 3 gnp b-complex plus vitamin 1 or 1b* OTC; $0 SOLUTION c oral tablet sf 5000 plus dental cream 1 or 1b* qc b-complex/vitamin c oral 1 or 1b* OTC; $0 sf dental gel 1 or 1a* tablet *B-COMPLEX W/ C & sodium fluoride 5000 plus 1 or 1b* FOLIC ACID*** dental cream sodium fluoride 5000 ppm b complex-c-folic acid oral 1 or 1b* 1 or 1b* OTC; $0 dental cream tablet

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 155 Drug Name Tier Notes Drug Name Tier Notes b-complex balanced oral cvs super b complex/c oral 1 or 1b* OTC; $0 1 or 1b* OTC; $0 tablet tablet b-complex/vitamin c oral hm b complex/c oral tablet 1 or 1b* OTC; $0 1 or 1b* OTC; $0 tablet sm super b complex/c oral 1 or 1b* OTC; $0 b-complex-c (w/folic acid) tablet 1 or 1b* OTC; $0 oral tablet sm vitamin b 1 or 1b* OTC; $0 dialyvite 800 oral tablet 1 or 1b* OTC; $0 complex/vitamin c oral tablet eql super b complex/vitamin super b complex/vitamin c 1 or 1b* OTC; $0 1 or 1b* OTC; $0 c oral tablet oral tablet FULL SPECTRUM super b-complex + vitamin c 1 or 1b* OTC; $0 B/VITAMIN C ORAL 2 OTC; $0 oral tablet TABLET vitamin b + c complex oral 1 or 1b* OTC; $0 hm vitamin b tablet 1 or 1b* OTC; $0 complex/vitamin c oral tablet *B-COMPLEX W/ C- kp b complex-c oral tablet 1 or 1b* OTC; $0 BIOTIN-E & FOLIC nephro vitamins oral tablet 1 or 1b* OTC; $0 ACID*** NEPHRO-VITE ORAL B COMPLEX-C-BIOTIN- 2 OTC; $0 2 OTC; $0 TABLET E-FA ORAL TABLET px b complex/vitamin c oral *B-COMPLEX W/ FOLIC 1 or 1b* OTC; $0 tablet ACID*** renal multivitamin formula b complex (folic acid) oral 1 or 1b* OTC; $0 1 or 1b* OTC; $0 oral tablet tablet b complex formula 1 (w/ fa) renal vitamin oral tablet 1 or 1b* OTC; $0 1 or 1b* OTC; $0 oral tablet renal-vite oral tablet 1 or 1b* OTC; $0 b complex plus oral tablet 1 or 1b* OTC; $0 rena-vite oral tablet 1 or 1b* OTC; $0 b-complex (folic acid) oral sm b super vitamin complex 1 or 1b* OTC; $0 1 or 1b* OTC; $0 tablet oral tablet big 100 oral tablet 1 or 1b* OTC; $0 SM B- COMPLEX/VITAMIN C 2 OTC; $0 kobee oral tablet 1 or 1b* OTC; $0 ORAL TABLET sm balanced b-100 oral tablet 1 or 1b* OTC; $0 stress formula (folic acid) sm balanced b-50 oral tablet 1 or 1b* OTC; $0 1 or 1b* OTC; $0 oral tablet super b complex maxi oral 1 or 1b* OTC; $0 super b complex/fa/vit c oral tablet 1 or 1b* OTC; $0 tablet *B-COMPLEX W/BIOTIN super b-complex/vit c/fa oral & FOLIC ACID*** 1 or 1b* OTC; $0 tablet b complex 100 tr oral tablet 1 or 1b* OTC; $0 VITALINE BIOTIN extended release 2 OTC; $0 FORTE ORAL TABLET b complex-biotin-fa oral 1 or 1b* OTC; $0 WEST-VITE W/FOLIC tablet 2 OTC; $0 ACID ORAL TABLET b-100 b-complex oral tablet 1 or 1b* OTC; $0 *B-COMPLEX W/ C*** b-100 complex cr oral tablet 1 or 1b* OTC; $0 allbee/c oral tablet 1 or 1b* OTC; $0 extended release b complex-c oral tablet 1 or 1b* OTC; $0 b-100 tr oral tablet extended 1 or 1b* OTC; $0 b-complex-c oral tablet 1 or 1b* OTC; $0 release b-50 complex oral tablet better b complex oral tablet 1 or 1b* OTC; $0 1 or 1b* OTC; $0 extended release cvs b complex plus c oral 1 or 1b* OTC; $0 tablet balance b-50 oral tablet 1 or 1b* OTC; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 156 Drug Name Tier Notes Drug Name Tier Notes balanced b complex oral *BIOFLAVONOID 1 or 1b* OTC; $0 tablet PRODUCTS*** balanced b-100 oral tablet 1 or 1b* OTC; $0 ADRENAL C FORMULA 3 balanced b-100 oral tablet ORAL TABLET 1 or 1b* OTC; $0 extended release *MULTIPLE VITAMINS balanced b-50/fa oral tablet 1 or 1b* OTC; $0 & FLUORIDE-FOLIC ACID*** b-compleet-100 oral tablet 1 or 1b* OTC; $0 MULTIVITAMIN/FLUOR b-compleet-50 oral tablet 1 or 1b* OTC; $0 IDE ORAL TABLET 3 b-complex oral tablet 1 or 1b* OTC; $0 CHEWABLE 0.25-0.3 MG, 0.5-0.3 MG, 1-0.3 MG big 100 (biotin) oral tablet 1 or 1b* OTC; $0 *MULTIPLE VITAMINS complex b-100 oral tablet 1 or 1b* OTC; $0 W/ IRON*** extended release daily multiple vitamins/iron 1 or 1b* OTC; $0 complex b-50 prolonged oral tablet release oral tablet extended 1 or 1b* OTC; $0 daily vitamin formula+iron release 1 or 1b* OTC; $0 oral tablet endur-b oral tablet extended 1 or 1b* OTC; $0 daily vite multivitamin/iron release 1 or 1b* OTC; $0 oral tablet eql b complex 50 oral tablet 1 or 1b* OTC; $0 daily-vitamin/iron oral tablet 1 or 1b* OTC; $0 eql b-100 complex oral tablet 1 or 1b* OTC; $0 extended release hm one daily/iron oral tablet 1 or 1b* OTC; $0 gnp b-100 complex oral multi-day plus iron oral 1 or 1b* OTC; $0 1 or 1b* OTC; $0 tablet extended release tablet gnp b-50 complex oral tablet multiple vitamins/iron oral 1 or 1b* OTC; $0 1 or 1b* OTC; $0 extended release tablet hm vitamin b100 complex multivitamin plus iron adult 1 or 1b* OTC; $0 1 or 1b* OTC; $0 oral tablet oral tablet hm vitamin b50 complex oral multi-vitamin/iron oral tablet 1 or 1b* OTC; $0 1 or 1b* OTC; $0 tablet nat-rul daily-vite+iron oral 1 or 1b* OTC; $0 qc b50 prolonged release oral tablet 1 or 1b* OTC; $0 tablet extended release one daily multivitamin/iron 1 or 1b* OTC; $0 quin b strong b-25 oral tablet 1 or 1b* OTC; $0 oral tablet ra balanced b-100 cr oral one-daily multi-vitamin/iron 1 or 1b* OTC; $0 1 or 1b* OTC; $0 tablet extended release oral tablet ra balanced b-100 oral tablet 1 or 1b* OTC; $0 one-daily/iron oral tablet 1 or 1b* OTC; $0 qc daily multivitamins/iron ra balanced b-50 oral tablet 1 or 1b* OTC; $0 1 or 1b* OTC; $0 oral tablet ra balanced b-50 tr oral tablet 1 or 1b* OTC; $0 sm multiple vitamins/iron extended release 1 or 1b* OTC; $0 oral tablet sm b100 complex oral tablet 1 or 1b* OTC; $0 stress b complex/iron oral 1 or 1b* OTC; $0 sm b-complex oral tablet 1 or 1b* OTC; $0 tablet super b-100 oral tablet 1 or 1b* OTC; $0 stress formula/iron oral tablet 1 or 1b* OTC; $0 super b-50 oral tablet 1 or 1b* OTC; $0 tab-a-vite/iron oral tablet 1 or 1b* OTC; $0 super b-complex oral tablet 1 or 1b* OTC; $0 TAB-A-VITE/IRON/BETA super dec b-100 oral tablet 1 or 1b* OTC; $0 CAROTENE ORAL 2 OTC; $0 super quints b-50 oral tablet 1 or 1b* OTC; $0 TABLET yl balanced b-100 oral tablet 1 or 1b* OTC; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 157 Drug Name Tier Notes Drug Name Tier Notes *MULTIPLE VITAMINS M.V.I. ADULT W/ MINERALS & INTRAVENOUS 3 CALCIUM-FOLIC INJECTABLE ACID*** multi vitamin daily oral 1 or 1b* OTC; $0 FOLGARD OS ORAL tablet 3 TABLET MULTI VITAMIN ORAL 2 OTC; $0 *MULTIPLE VITAMINS TABLET W/ MINERALS & MULTI VITAMIN W/D-3 2 OTC; $0 FLUORIDE-IRON-FOLIC ORAL TABLET ACID*** multi-day oral tablet 1 or 1b* OTC; $0 QUFLORA FE ORAL 3 multiple vitamin-folic acid TABLET CHEWABLE 1 or 1b* OTC; $0 oral tablet *MULTIPLE VITAMINS multiple vitamins essential W/ MINERALS*** 1 or 1b* OTC; $0 oral tablet VENEXA ORAL TABLET 3 multiple vitamins oral tablet 1 or 1b* OTC; $0 VITRAMYN ORAL 3 TABLET multivitamin adult oral tablet 1 or 1b* OTC; $0 VITRANOL FE ORAL multi-vitamin daily oral 3 1 or 1b* OTC; $0 TABLET tablet ZYVANA ORAL multivitamin iron-free oral 3 1 or 1b* OTC; $0 CAPSULE tablet MULTIVITAMIN ORAL *MULTIVITAMINS*** 2 OTC; $0 TABLET anti-oxidant oral tablet 1 or 1b* OTC; $0 multi-vitamin oral tablet 1 or 1b* OTC; $0 daily multiple vitamins oral 1 or 1b* OTC; $0 NEOMULTIVITE ORAL tablet 2 OTC; $0 TABLET daily value multivitamin oral 1 or 1b* OTC; $0 OMNICAP ORAL tablet 2 OTC; $0 TABLET daily vitamin oral tablet 1 or 1b* OTC; $0 once daily oral tablet 1 or 1b* OTC; $0 daily vitamins oral tablet 1 or 1b* OTC; $0 one daily essential oral tablet 1 or 1b* OTC; $0 daily vite oral tablet 1 or 1b* OTC; $0 one daily multivitamin adult 1 or 1b* OTC; $0 daily vites oral tablet 1 or 1b* OTC; $0 oral tablet daily-vitamin oral tablet 1 or 1b* OTC; $0 one daily oral tablet 1 or 1b* OTC; $0 daily-vite multivitamin oral ONE-A-DAY ESSENTIAL 1 or 1b* OTC; $0 2 OTC; $0 tablet ORAL TABLET daily-vite oral tablet 1 or 1b* OTC; $0 ONE-A-DAY MENS 2 OTC; $0 ESTROFACTORS ORAL ORAL TABLET 2 OTC; $0 TABLET one-daily multi vitamins oral 1 or 1b* OTC; $0 gnp essential one daily oral tablet 1 or 1b* OTC; $0 tablet one-daily multi-vitamin oral 1 or 1b* OTC; $0 healthy hair/skin/nails oral tablet 1 or 1b* OTC; $0 tablet qc essentials oral tablet 1 or 1b* OTC; $0 HIGH POTENCY QUINTABS ORAL 2 OTC; $0 MULTIVITAMIN ORAL 2 OTC; $0 TABLET TABLET sm multiple vitamins 1 or 1b* OTC; $0 INFUVITE ADULT essential oral tablet INTRAVENOUS 3 INJECTABLE stress formula oral tablet 1 or 1b* OTC; $0 stresstabs energy oral tablet 1 or 1b* OTC; $0 tab-a-vite oral tablet 1 or 1b* OTC; $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 158 Drug Name Tier Notes Drug Name Tier Notes tab-a-vite/beta carotene oral TRI-VI-FLORO ORAL 1 or 1b* OTC; $0 3 tablet SUSPENSION THERA ORAL TABLET 2 OTC; $0 *PED VITAMINS ACD W/ thera-mill oral tablet 1 or 1b* OTC; $0 FLUORIDE*** adc/f (0.5mg/ml) oral thera-tabs oral tablet 1 or 1b* OTC; $0 1 or 1b* $0 solution THEREMS ORAL 2 OTC; $0 multivitamin select/fluoride TABLET 1 or 1b* OTC; $0 oral solution vit e-vit c-beta carotene oral 1 or 1b* OTC; $0 tablet tri-vite/fluoride oral solution 1 or 1b* $0 vitamins acd-fluoride oral vitalee oral tablet 1 or 1b* OTC; $0 1 or 1b* $0 solution *PED MULTI VITAMINS W/FL & FE*** *PEDIATRIC MULTIPLE VITAMINS & MINERALS multi-vitamin/fluoride/iron 1 or 1b* W/ FLUORIDE*** oral solution FLORIVA ORAL POLY-VI-FLOR/IRON 3 3 TABLET CHEWABLE ORAL SUSPENSION *PEDIATRIC MULTIPLE POLY-VI-FLOR/IRON VITAMINS*** ORAL TABLET 3 CHEWABLE INFUVITE PEDIATRIC INTRAVENOUS 3 QUFLORA FE SOLUTION PEDIATRIC ORAL 3 LIQUID M.V.I. PEDIATRIC INTRAVENOUS 3 *PED MV W/ SOLUTION FLUORIDE*** RECONSTITUTED FLORIVA PLUS ORAL 3 *PRENATAL MV & MIN SOLUTION W/FE-FA*** multivitamin/fluoride oral 1 or 1b* $0 ATABEX EC ORAL solution TABLET DELAYED 3 QL multi-vitamin/fluoride oral RELEASE 1 or 1b* $0 solution ATABEX OB ORAL 3 QL multivitamin/fluoride oral TABLET tablet chewable 0.25 mg, 0.5 1 or 1b* $0 AZESCO ORAL TABLET 3 ST; QL mg, 1 mg CITRANATAL B-CALM POLY-VI-FLOR ORAL 3 QL 3 ORAL SUSPENSION CITRANATAL BLOOM POLY-VI-FLOR ORAL 3 ST; QL 3 ORAL TABLET TABLET CHEWABLE CITRANATAL RX ORAL 3 ST; QL QUFLORA GUMMIES TABLET ORAL TABLET 2 CLASSIC PRENATAL CHEWABLE 2 OTC; $0 ORAL TABLET QUFLORA PEDIATRIC 3 C-NATE DHA ORAL ORAL SOLUTION 3 QL CAPSULE QUFLORA PEDIATRIC COMPLETENATE ORAL ORAL TABLET 3 2 QL CHEWABLE TABLET CHEWABLE CO-NATAL FA ORAL *PED VITAMINS ACD & 3 QL FA W/ FLUORIDE*** TABLET TRI-VI-FLOR ORAL CONCEPT DHA ORAL 3 3 QL SUSPENSION CAPSULE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 159 Drug Name Tier Notes Drug Name Tier Notes CONCEPT OB ORAL NEEVO DHA ORAL 3 QL 3 ST; QL CAPSULE CAPSULE 27-1.13 MG CVS PRENATAL ORAL NEONATAL COMPLETE 2 OTC; $0 3 ST; QL TABLET 27-0.8 MG ORAL TABLET DUET DHA 400 ORAL 3 ST; QL NEONATAL FE ORAL 3 ST; QL DUET DHA BALANCED TABLET 3 ST; QL ORAL 25-1 & 267 MG NEONATAL PLUS ORAL 3 ST; QL elite-ob oral tablet 1 or 1b* QL TABLET ENBRACE HR ORAL NEONATAL VITAMIN 3 ST; QL 2 OTC; $0 CAPSULE ORAL TABLET EQL PRENATAL NESTABS DHA ORAL 3 ST; QL FORMULA ORAL 2 OTC; $0 NESTABS ORAL 3 ST; QL TABLET TABLET FOLIVANE-OB ORAL NIVA-PLUS ORAL 2 QL 3 QL CAPSULE TABLET GNP PRENATAL ORAL OB COMPLETE ONE 2 OTC; $0 3 ST; QL TABLET ORAL CAPSULE HM ONE DAILY OB COMPLETE ORAL 2 OTC; $0 3 ST; QL PRENATAL ORAL TABLET HM PRENATAL ORAL OB COMPLETE PETITE 2 OTC; $0 3 ST; QL TABLET ORAL CAPSULE inatal gt oral tablet 1 or 1b* QL OB COMPLETE JENLIVA PREMIER ORAL 3 ST; QL PRENATAL/POSTNATAL 2 ST; QL TABLET ORAL CAPSULE OB COMPLETE/DHA 3 ST; QL KOSHER PRENATAL ORAL CAPSULE PLUS IRON ORAL 3 ST; QL OBSTETRIX DHA ORAL 3 QL TABLET OBSTETRIX EC ORAL 3 QL KP PRENATAL TABLET MULTIVITAMINS ORAL 2 OTC; $0 ONE VITE WOMENS 2 OTC; $0 TABLET ORAL TABLET KPN PRENATAL ORAL ONE VITE WOMENS 2 OTC; $0 3 QL TABLET PLUS ORAL TABLET M-NATAL PLUS ORAL ONE-A-DAY WOMENS 3 QL 2 OTC; $0 TABLET PRENATAL ORAL MULTI PRENATAL PERRY PRENATAL 2 OTC; $0 2 OTC; $0 ORAL TABLET ORAL CAPSULE MYNATAL ORAL PNV TABS 20-1 ORAL 3 ST; QL 3 ST; QL CAPSULE TABLET MYNATAL PLUS ORAL PNV TABS 29-1 ORAL 2 QL 2 ST; QL TABLET TABLET MYNATAL-Z ORAL PNV-OMEGA ORAL 2 QL 3 QL TABLET CAPSULE NATACHEW ORAL pnv-select oral tablet 1 or 1b* ST; QL TABLET CHEWABLE 28- 3 ST; QL PREGENNA ORAL 1 MG 3 ST; QL TABLET NATALVIT ORAL 3 QL TABLET PRENA1 PEARL ORAL CAPSULE EXTENDED 3 ST; QL RELEASE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 160 Drug Name Tier Notes Drug Name Tier Notes PRENARA ORAL PRENATVITE 3 ST; QL CAPSULE COMPLETE ORAL 3 ST; QL prenatabs rx oral tablet 1 or 1a* ST; QL TABLET PRENATAL (W/IRON & PRENATVITE PLUS 2 OTC; $0 3 ST; QL FA) ORAL TABLET ORAL TABLET PRENATAL 19 ORAL PRENATVITE RX ORAL 3 QL 3 ST; QL TABLET 29-1 MG TABLET prenatal 19 oral tablet PREPLUS ORAL 1 or 1a* QL 2 QL chewable TABLET PRENATAL 19 ORAL PRETAB ORAL TABLET 2 QL TABLET CHEWABLE 29- 3 QL PRIMACARE ORAL 3 ST; QL 1 MG CAPSULE PRENATAL COMPLETE PROVIDA OB ORAL 2 OTC; $0 3 QL ORAL TABLET CAPSULE PRE-NATAL FORMULA PX PRENATAL 2 OTC; $0 ORAL TABLET MULTIVITAMINS ORAL 2 OTC; $0 PRENATAL FORTE TABLET 2 OTC; $0 ORAL TABLET QC PRENATAL ORAL 2 OTC; $0 PRENATAL ONE DAILY TABLET 2 OTC; $0 ORAL TABLET RA PRENATAL PRENATAL ORAL FORMULA ORAL 2 OTC; $0 2 $0 TABLET 27-0.8 MG TABLET PRENATAL ORAL RA PRENATAL ORAL 2 QL 2 OTC; $0 TABLET 27-1 MG TABLET PRENATAL ORAL RELNATE DHA ORAL 2 OTC; $0 3 ST; QL TABLET 28-0.8 MG CAPSULE PRENATAL PLUS IRON SELECT-OB ORAL 2 ST; QL ORAL TABLET TABLET CHEWABLE 29- 3 ST; QL 0.6-0.4 MG PRENATAL VITAMIN AND MINERAL ORAL 2 OTC; $0 SELECT-OB ORAL TABLET TABLET CHEWABLE 29- 3 QL 1 MG PRENATAL VITAMIN 2 OTC; $0 SE-NATAL 19 ORAL ORAL TABLET 2 QL TABLET PRENATAL VITAMIN SE-NATAL 19 ORAL PLUS LOW IRON ORAL 2 QL 2 QL TABLET TABLET CHEWABLE SM ONE DAILY PRENATAL VITAMINS 2 OTC; $0 ORAL TABLET 28-0.8 2 OTC; $0 PRENATAL ORAL MG SM PRENATAL PRENATAL/IRON ORAL VITAMINS ORAL 2 OTC; $0 2 OTC; $0 TABLET TABLET PRENATAL-U ORAL TARON-C DHA ORAL 2 QL 3 QL CAPSULE CAPSULE PRENATE ELITE ORAL THRIVITE RX ORAL 3 ST; QL 2 ST; QL TABLET 20-0.6-0.4 MG TABLET PRENATRIX ORAL TRICARE ORAL 3 ST; QL 3 QL TABLET TABLET PRENATRYL ORAL TRICARE PRENATAL 3 ST; QL TABLET DHA ONE ORAL 3 QL CAPSULE 27-1-500 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 161 Drug Name Tier Notes Drug Name Tier Notes TRINATAL RX 1 ORAL CITRANATAL BLOOM 2 QL 3 ST; QL TABLET DHA ORAL trinate oral tablet 1 or 1a* QL CITRANATAL DHA 3 ST; QL TRINAZ ORAL TABLET 3 ST; QL ORAL VINATE DHA RF ORAL CITRANATAL ESSENCE 3 ST; QL 3 ST; QL CAPSULE ORAL THERAPY PACK VINATE II ORAL CITRANATAL 2 QL TABLET HARMONY ORAL 3 ST; QL CAPSULE 27-1-260 MG VINATE ONE ORAL 2 QL CITRANATAL MEDLEY TABLET 3 ST; QL ORAL CAPSULE VIRT-C DHA ORAL 3 QL ENFAMIL EXPECTA CAPSULE 2 OTC; $0 ORAL VIRT-NATE DHA ORAL 3 ST; QL NEONATAL + DHA CAPSULE 3 ST; QL ORAL VIRT-PN PLUS ORAL 3 ST; QL NESTABS ONE ORAL CAPSULE 3 ST; QL CAPSULE VITAFOL GUMMIES OBSTETRIX ONE ORAL ORAL TABLET 3 ST; QL 3 QL CHEWABLE CAPSULE VITAFOL-NANO ORAL pnv-dha oral capsule 1 or 1b* QL 3 ST; QL TABLET PNV-DHA+DOCUSATE 3 ST; QL VITAFOL-OB ORAL ORAL CAPSULE 3 ST; QL TABLET PREGEN DHA ORAL 3 ST; QL VITAPEARL ORAL CAPSULE CAPSULE EXTENDED 3 ST; QL PRENA 1 TRUE ORAL 3 QL RELEASE PRENAISSANCE ORAL 3 ST; QL VITATHELY WITH CAPSULE 3 ST; QL GINGER ORAL TABLET PRENAISSANCE PLUS 3 ST; QL VIVA DHA ORAL ORAL CAPSULE 3 ST; QL CAPSULE PRENATAL VP-PNV-DHA ORAL MULTIVITAMIN + DHA 2 OTC; $0 3 ST; QL CAPSULE ORAL WESTAB PLUS ORAL PRENATE DHA ORAL 3 ST; QL TABLET CAPSULE 18-0.6-0.4-300 3 ST; QL ZALVIT ORAL TABLET 3 ST; QL MG ZATEAN-PN PLUS ORAL PRENATE ENHANCE 3 ST; QL 3 ST; QL CAPSULE ORAL CAPSULE *PRENATAL MV & MIN PRENATE ESSENTIAL W/FE-FA-CA-OMEGA 3 ORAL CAPSULE 18-0.6- 3 ST; QL FISH OIL*** 0.4-300 MG COMPLETE NATAL PRENATE MINI ORAL 3 QL DHA ORAL CAPSULE 18-0.6-0.4-350 3 ST; QL MG *PRENATAL MV & MIN PRENATE PIXIE ORAL W/FE-FA-DHA*** 3 ST; QL CAPSULE CITRANATAL 90 DHA 3 ST; QL PRENATE RESTORE ORAL 90-1 & 300 MG 3 ST; QL ORAL CAPSULE CITRANATAL ASSURE 3 ST; QL ORAL 35-1 & 300 MG SELECT-OB+DHA ORAL 3 ST; QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 162 Drug Name Tier Notes Drug Name Tier Notes TARON-PREX ORAL *VITAMINS A & D*** 3 QL CAPSULE COD LIVER OIL ORAL 3 TRISTART DHA ORAL OIL 3 ST; QL CAPSULE *VITAMINS W/ TRISTART FREE ORAL LIPOTROPICS*** 3 ST; QL CAPSULE ACTIFLOVIT EAR 2 OTC; $0 TRISTART ONE ORAL HEALTH ORAL TABLET 3 ST; QL CAPSULE b complex (lipotropics) oral 1 or 1b* OTC; $0 VIRT-PN DHA ORAL tablet 3 QL CAPSULE b complex formula 1 1 or 1b* OTC; $0 VITAFOL FE+ ORAL (lipotrop) oral tablet 3 ST; QL CAPSULE b-100 complex oral tablet 1 or 1b* OTC; $0 VITAFOL ULTRA ORAL b-100 cr oral tablet extended 3 ST; QL 1 or 1b* OTC; $0 CAPSULE release VITAFOL-OB+DHA 3 ST; QL b-100 oral tablet 1 or 1b* OTC; $0 ORAL b-50 oral tablet 1 or 1b* OTC; $0 VITAFOL-ONE ORAL 3 ST; QL CAPSULE balance b-100 oral tablet 1 or 1b* OTC; $0 balanced b-100 complex cr VITAMEDMD ONE 1 or 1b* OTC; $0 RX/QUATREFOLIC 3 ST; QL oral tablet extended release ORAL CAPSULE balanced b-50 complex oral 1 or 1b* OTC; $0 VITATRUE ORAL 3 ST; QL tablet WESTGEL DHA ORAL complex b-100-inositol oral 3 ST; QL 1 or 1b* OTC; $0 CAPSULE tablet extended release ZATEAN-PN DHA ORAL cvs balanced b50 oral tablet 1 or 1b* OTC; $0 3 ST; QL CAPSULE cvs inner ear plus oral tablet 1 or 1b* OTC; $0 *PRENATAL MV & ear health formula oral tablet 1 or 1b* OTC; $0 MINERALS W/FA WITHOUT IRON*** ear health plus oral tablet 1 or 1b* OTC; $0 PRENATE ORAL inner ear plus oral tablet 1 or 1b* OTC; $0 3 ST; QL TABLET CHEWABLE lipo flavonoid plus oral tablet 1 or 1b* OTC; $0 *PRENATAL lipoflavovit oral tablet 1 or 1b* OTC; $0 VITAMINS*** LIPOTRIAD ORAL 2 OTC; $0 NEONATAL 19 ORAL TABLET 3 ST; QL TABLET mega multiple/chelated 1 or 1b* OTC; $0 PREMESISRX ORAL mineral oral tablet 2 ST; QL TABLET nat-rul b-50 oral tablet 1 or 1b* OTC; $0 PRENA1 ORAL TABLET 2 ST; QL px b-50 oral tablet 1 or 1b* OTC; $0 CHEWABLE risanoid plus oral tablet 1 or 1b* OTC; $0 PRENATE AM ORAL 3 ST; QL super stress b-complex cr TABLET 1 or 1b* OTC; $0 oral tablet extended release VITAFOL STRIPS ORAL 3 ST; QL ultra b-100 complex oral FILM 1 or 1b* OTC; $0 tablet VITAMEDMD REDICHEW RX ORAL 3 ST; QL TABLET CHEWABLE 1.4 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 163 Drug Name Tier Notes Drug Name Tier Notes *MUSCULOSKELETAL orphenadrine citrate er oral THERAPY AGENTS* tablet extended release 12 1 or 1b* QL *CENTRAL MUSCLE hour RELAXANTS*** orphenadrine citrate injection 1 or 1b* AMRIX ORAL CAPSULE solution EXTENDED RELEASE 24 3 ST; QL OZOBAX ORAL 3 QL HOUR SOLUTION baclofen intrathecal solution 4 ROBAXIN INJECTION BACLOFEN SOLUTION 1000 3 ST INTRATHECAL MG/10ML 4 SOLUTION PREFILLED SKELAXIN ORAL 3 ST; QL SYRINGE TABLET baclofen oral tablet 1 or 1b* QL SOMA ORAL TABLET 3 ST; QL carisoprodol oral tablet 1 or 1b* QL tizanidine hcl oral capsule 1 or 1b* QL CHLORZOXAZONE tizanidine hcl oral tablet 1 or 1b* QL 3 ST; QL ORAL TABLET 250 MG ZANAFLEX ORAL 3 ST; QL chlorzoxazone oral tablet 375 CAPSULE 1 or 1b* ST; QL mg, 750 mg ZANAFLEX ORAL 3 ST; QL chlorzoxazone oral tablet 500 TABLET 1 or 1b* QL mg *DIRECT MUSCLE hcl er oral RELAXANTS*** capsule extended release 24 3 ST; QL DANTRIUM hour INTRAVENOUS 3 cyclobenzaprine hcl oral SOLUTION 1 or 1b* QL tablet 10 mg, 5 mg RECONSTITUTED cyclobenzaprine hcl oral DANTRIUM ORAL 3 ST; QL 3 tablet 7.5 mg CAPSULE 25 MG, 50 MG fexmid oral tablet 1 or 1b* ST; QL dantrolene sodium GABLOFEN intravenous solution 1 or 1b* INTRATHECAL reconstituted SOLUTION 10000 dantrolene sodium oral 4 1 or 1b* MCG/20ML, 20000 capsule MCG/20ML, 40000 revonto intravenous solution 1 or 1b* MCG/20ML reconstituted GABLOFEN RYANODEX INTRATHECAL INTRAVENOUS 3 SOLUTION PREFILLED SUSPENSION SYRINGE 10000 4 RECONSTITUTED MCG/20ML, 20000 MCG/20ML, 40000 *MUSCLE RELAXANT MCG/20ML, 50 MCG/ML COMBINATIONS*** carisoprodol-aspirin-codeine LIORESAL 1 or 1b* QL INTRATHECAL 3 oral tablet SOLUTION CYCLOPAK lorzone oral tablet 1 or 1b* ST; QL COMBINATION 3 THERAPY PACK metaxalone oral tablet 1 or 1b* ST; QL orphenadrine-asa-caffeine methocarbamol injection 1 or 1b* ST 1 or 1b* oral tablet solution 1000 mg/10ml orphengesic forte oral tablet 1 or 1b* ST methocarbamol oral tablet 1 or 1b* QL 50-770-60 mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 164 Drug Name Tier Notes Drug Name Tier Notes *VISCOSUPPLEMENTS* DYMISTA NASAL 3 QL ** SUSPENSION DUROLANE INTRA- *NASAL ARTICULAR 4 PA ANESTHETICS*** PREFILLED SYRINGE GOPRELTO NASAL 3 EUFLEXXA INTRA- SOLUTION ARTICULAR SOLUTION 4 PA NUMBRINO NASAL 3 PREFILLED SYRINGE SOLUTION GEL-ONE INTRA- *NASAL ARTICULAR 4 PA; SP ANTICHOLINERGICS*** PREFILLED SYRINGE ipratropium bromide nasal 1 or 1b* QL GELSYN-3 INTRA- solution ARTICULAR SOLUTION 4 PA; SP PREFILLED SYRINGE *NASAL ANTIHISTAMINES*** HYALGAN INTRA- 4 PA ARTICULAR SOLUTION azelastine hcl nasal solution 1 or 1b* QL hcl nasal HYALGAN INTRA- 1 or 1b* QL ARTICULAR SOLUTION 4 PA solution PREFILLED SYRINGE PATANASE NASAL 3 QL HYMOVIS INTRA- SOLUTION ARTICULAR SOLUTION 4 PA; LD; SP *NASAL STEROIDS*** PREFILLED SYRINGE BECONASE AQ NASAL 3 ST; QL MONOVISC INTRA- SUSPENSION ARTICULAR SOLUTION 4 PA flunisolide nasal solution 25 PREFILLED SYRINGE 3 ST; QL mcg/act (0.025%) ORTHOVISC INTRA- fluticasone propionate nasal ARTICULAR SOLUTION 4 PA 1 or 1a* QL PREFILLED SYRINGE suspension mometasone furoate nasal SUPARTZ FX INTRA- 3 ST; QL ARTICULAR SOLUTION 4 PA suspension PREFILLED SYRINGE NASONEX NASAL 3 ST; QL SYNVISC INTRA- SUSPENSION ARTICULAR SOLUTION 4 PA OMNARIS NASAL 3 ST; QL PREFILLED SYRINGE SUSPENSION SYNVISC ONE INTRA- PROPEL MINI NASAL 3 ARTICULAR SOLUTION 4 PA IMPLANT PREFILLED SYRINGE PROPEL NASAL 3 TRILURON INTRA- IMPLANT ARTICULAR SOLUTION 4 PA; SP QNASL CHILDRENS PREFILLED SYRINGE NASAL AEROSOL 3 ST; QL VISCO-3 INTRA- SOLUTION ARTICULAR SOLUTION 4 PA; SP QNASL NASAL 3 ST; QL PREFILLED SYRINGE AEROSOL SOLUTION *NASAL AGENTS - XHANCE NASAL 3 PA; QL SYSTEMIC AND EXHALER SUSPENSION TOPICAL* ZETONNA NASAL 3 ST; QL *ANTIHISTAMINE- AEROSOL SOLUTION STEROID*** *NEUROMUSCULAR azelastine-fluticasone nasal 3 QL AGENTS* suspension *BENZATHIAZOLES*** EXSERVAN ORAL FILM 4 QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 165 Drug Name Tier Notes Drug Name Tier Notes RILUTEK ORAL *NONDEPOLARIZING 4 SP; QL TABLET MUSCLE riluzole oral tablet 4 SP; QL RELAXANTS*** TIGLUTIK ORAL atracurium besylate 4 SUSPENSION intravenous solution 100 1 or 1b* mg/10ml, 50 mg/5ml *DEPOLARIZING cisatracurium besylate (pf) MUSCLE 1 or 1b* RELAXANTS*** intravenous solution ANECTINE INJECTION cisatracurium besylate 3 SOLUTION intravenous solution 20 1 or 1b* mg/10ml QUELICIN INJECTION 3 SOLUTION NIMBEX INTRAVENOUS SOLUTION 10 MG/5ML, 3 SUCCINYLCHOLINE 20 MG/10ML, 200 CHLORIDE MG/20ML INTRAVENOUS 3 pancuronium bromide SOLUTION PREFILLED 1 or 1b* SYRINGE 140 MG/7ML intravenous solution 1 mg/ml rocuronium bromide *MUSCULAR 1 or 1b* DYSTROPHY intravenous solution AGENTS*** ROCURONIUM AMONDYS 45 BROMIDE INTRAVENOUS 4 PA; LD INTRAVENOUS 3 SOLUTION SOLUTION PREFILLED SYRINGE 100 MG/10ML EXONDYS 51 INTRAVENOUS 4 PA; LD VECURONIUM SOLUTION BROMIDE INTRAVENOUS 3 VILTEPSO SOLUTION PREFILLED INTRAVENOUS 4 PA; LD SYRINGE SOLUTION vecuronium bromide VYONDYS 53 intravenous solution 1 or 1b* INTRAVENOUS 4 PA; LD reconstituted SOLUTION *SPINAL MUSCULAR *NEUROMUSCULAR ATROPHY-SMN2 BLOCKING AGENT - SPLICING NEUROTOXINS*** MODIFIERS*** BOTOX INJECTION EVRYSDI ORAL SOLUTION 4 PA SOLUTION 4 PA; LD; QL RECONSTITUTED RECONSTITUTED DYSPORT *NUTRIENTS* INTRAMUSCULAR 4 PA; SP SOLUTION *AMINO ACID RECONSTITUTED MIXTURES*** MYOBLOC AMINOPROTECT INTRAMUSCULAR 4 PA; SP INTRAVENOUS 3 SOLUTION SOLUTION XEOMIN AMINOSYN II INTRAMUSCULAR INTRAVENOUS 3 4 PA; LD; SP SOLUTION SOLUTION 10 %, 15 % RECONSTITUTED AMINOSYN-PF INTRAVENOUS 3 SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 166 Drug Name Tier Notes Drug Name Tier Notes CLINIMIX E/DEXTROSE PROCALAMINE (2.75/5) INTRAVENOUS 3 INTRAVENOUS 3 SOLUTION SOLUTION CLINIMIX E/DEXTROSE PROSOL INTRAVENOUS 3 (4.25/10) INTRAVENOUS 3 SOLUTION SOLUTION TRAVASOL CLINIMIX E/DEXTROSE INTRAVENOUS 3 (4.25/5) INTRAVENOUS 3 SOLUTION SOLUTION TROPHAMINE CLINIMIX E/DEXTROSE INTRAVENOUS 3 (5/15) INTRAVENOUS 3 SOLUTION 10 % SOLUTION *AMINO ACIDS- CLINIMIX E/DEXTROSE SINGLE*** (5/20) INTRAVENOUS 3 ARGININE HCL 3 SOLUTION INJECTION SOLUTION CLINIMIX E/DEXTROSE ELCYS INTRAVENOUS 3 (8/10) INTRAVENOUS 3 SOLUTION SOLUTION GLUTATHIONE 3 CLINIMIX E/DEXTROSE INJECTION SOLUTION (8/14) INTRAVENOUS 3 SOLUTION GLUTATHIONE INTRAVENOUS 3 CLINIMIX/DEXTROSE SOLUTION (4.25/10) INTRAVENOUS 3 GLYCINE INJECTION SOLUTION 3 SOLUTION CLINIMIX/DEXTROSE LYSINE HCL (4.25/5) INTRAVENOUS 3 3 SOLUTION INJECTION SOLUTION TAURINE INJECTION CLINIMIX/DEXTROSE 3 (5/15) INTRAVENOUS 3 SOLUTION SOLUTION *CARBOHYDRATES*** CLINIMIX/DEXTROSE dextrose intravenous solution 1 or 1b* (5/20) INTRAVENOUS 3 10 %, 250 mg/ml, 5 %, 70 % SOLUTION DEXTROSE CLINIMIX/DEXTROSE INTRAVENOUS 3 (6/5) INTRAVENOUS 3 SOLUTION 20 %, 40 % SOLUTION *LIPIDS*** CLINIMIX/DEXTROSE (8/10) INTRAVENOUS 3 CLINOLIPID SOLUTION INTRAVENOUS 3 EMULSION CLINIMIX/DEXTROSE (8/14) INTRAVENOUS 3 DOJOLVI ORAL LIQUID 4 PA; LD; SP; QL SOLUTION INTRALIPID clinisol sf intravenous INTRAVENOUS 3 1 or 1b* solution EMULSION FREAMINE III NUTRILIPID INTRAVENOUS 3 INTRAVENOUS 3 SOLUTION 10 % EMULSION 20 % plenamine intravenous OMEGAVEN 1 or 1b* solution INTRAVENOUS 3 EMULSION PREMASOL INTRAVENOUS 3 SOLUTION 10 % * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 167 Drug Name Tier Notes Drug Name Tier Notes SMOFLIPID dorzolamide hcl-timolol mal 1 or 1b* QL INTRAVENOUS 3 pf ophthalmic solution EMULSION *BETA-BLOCKERS - *LIPOTROPIC OPHTHALMIC*** COMBINATIONS*** betaxolol hcl ophthalmic 1 or 1b* QL LIPO INTRAMUSCULAR solution 3 SOLUTION BETIMOL LIPO-C OPHTHALMIC 3 QL INTRAMUSCULAR 3 SOLUTION SOLUTION BETOPTIC-S *PROTEIN OPHTHALMIC 2 QL COMBINATIONS*** SUSPENSION TRI-AMINO INJECTION carteolol hcl ophthalmic 3 1 or 1a* SOLUTION solution *PROTEIN- ISTALOL OPHTHALMIC 3 QL CARBOHYDRATE-LIPID SOLUTION WITH ELECTROLYTE levobunolol hcl ophthalmic 1 or 1b* COMBINATIONS*** solution 0.5 % KABIVEN timolol maleate ocudose 1 or 1b* QL INTRAVENOUS 3 ophthalmic solution EMULSION timolol maleate ophthalmic 1 or 1b* QL PERIKABIVEN gel forming solution INTRAVENOUS 3 timolol maleate ophthalmic EMULSION 1 or 1b* QL solution *OPHTHALMIC timolol maleate pf AGENTS* 1 or 1b* QL ophthalmic solution *ALPHA ADRENERGIC AGONIST & CARBONIC TIMOPTIC OCUDOSE ANHYDRASE INHIB OPHTHALMIC 3 QL COMB*** SOLUTION SIMBRINZA TIMOPTIC OPHTHALMIC 2 QL OPHTHALMIC 3 QL SUSPENSION SOLUTION *ARTIFICIAL TEAR TIMOPTIC-XE INSERTS*** OPHTHALMIC GEL 3 QL FORMING SOLUTION LACRISERT 3 PA; QL OPHTHALMIC INSERT *CYCLOPLEGIC MYDRIATIC *BETA-BLOCKERS - COMBINATIONS*** OPHTHALMIC COMBINATIONS*** CYCLOMYDRIL OPHTHALMIC 3 COMBIGAN SOLUTION OPHTHALMIC 2 QL SOLUTION *CYCLOPLEGIC MYDRIATICS*** COSOPT OPHTHALMIC 3 QL altafrin ophthalmic solution SOLUTION 1 or 1b* 10 %, 2.5 % COSOPT PF atropine sulfate ophthalmic OPHTHALMIC 3 QL 1 or 1b* QL SOLUTION 2-0.5 % ointment dorzolamide hcl-timolol mal ATROPINE SULFATE 1 or 1b* QL ophthalmic solution OPHTHALMIC 3 SOLUTION 0.01 %

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 168 Drug Name Tier Notes Drug Name Tier Notes ATROPINE SULFATE *OPHTHALMIC OPHTHALMIC 3 QL ADRENERGIC SOLUTION 1 % AGENTS*** CYCLOGYL EPINEPHRINE HCL OPHTHALMIC 3 INTRAOCULAR 3 SOLUTION 0.5 %, 2 % SOLUTION PREFILLED CYCLOGYL SYRINGE OPHTHALMIC 3 QL *OPHTHALMIC SOLUTION 1 % ANTIALLERGIC*** cyclopentolate hcl ALOCRIL ophthalmic solution 0.5 %, 2 1 or 1b* OPHTHALMIC 3 ST; QL % SOLUTION cyclopentolate hcl ALOMIDE 1 or 1b* QL ophthalmic solution 1 % OPHTHALMIC 3 ST; QL ISOPTO ATROPINE SOLUTION OPHTHALMIC 3 QL azelastine hcl ophthalmic 1 or 1b* QL SOLUTION solution MYDRIACYL bepotastine besilate 3 ST; QL OPHTHALMIC 3 ophthalmic solution SOLUTION BEPREVE PHENYLEPHRINE HCL OPHTHALMIC 3 ST; QL INTRAOCULAR SOLUTION 3 SOLUTION PREFILLED cromolyn sodium ophthalmic 1 or 1a* QL SYRINGE solution phenylephrine hcl hcl ophthalmic 1 or 1b* QL ophthalmic solution 10 %, 1 or 1b* solution 2.5 % LASTACAFT tropicamide ophthalmic 1 or 1b* OPHTHALMIC 3 ST; QL solution SOLUTION *LYMPHOCYTE olopatadine hcl ophthalmic 3 ST; QL FUNCTION- solution ASSOCIATED ANTIGEN- 1 (LFA-1) ANTAG*** ZERVIATE OPHTHALMIC 3 ST; QL XIIDRA OPHTHALMIC 3 PA; QL SOLUTION SOLUTION *OPHTHALMIC *MIOTICS - DIRECT ANTIBIOTICS*** ACTING*** AZASITE OPHTHALMIC 3 ISOPTO CARPINE SOLUTION OPHTHALMIC 3 bacitracin ophthalmic SOLUTION 1 or 1b* QL ointment MIOCHOL-E INTRAOCULAR BESIVANCE 3 SOLUTION OPHTHALMIC 3 RECONSTITUTED SUSPENSION MIOSTAT CILOXAN INTRAOCULAR 3 OPHTHALMIC 3 QL SOLUTION OINTMENT pilocarpine hcl ophthalmic CILOXAN 1 or 1b* solution 1 %, 2 %, 4 % OPHTHALMIC 3 SOLUTION ciprofloxacin hcl ophthalmic 1 or 1a* solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 169 Drug Name Tier Notes Drug Name Tier Notes erythromycin ophthalmic *OPHTHALMIC ANTI- 1 or 1a* QL ointment INFECTIVE gatifloxacin ophthalmic COMBINATIONS*** 1 or 1b* solution ak-poly-bac ophthalmic 1 or 1a* gentak ophthalmic ointment 1 or 1a* QL ointment gentamicin sulfate bacitracin-polymyxin b 1 or 1a* QL ophthalmic solution ophthalmic ointment 500- 1 or 1a* 10000 unit/gm levofloxacin ophthalmic 1 or 1b* solution neomycin-bacitracin zn- polymyx ophthalmic 1 or 1b* MITOMYCIN ointment INTRAOCULAR 3 SOLUTION PREFILLED neomycin-polymyxin- SYRINGE gramicidin ophthalmic 1 or 1b* QL solution 1.75-10000-.025 MITOSOL 3 neo-polycin ophthalmic OPHTHALMIC KIT 1 or 1b* ointment MOXEZA OPHTHALMIC 3 QL SOLUTION polycin ophthalmic ointment 1 or 1a* moxifloxacin hcl (2x day) polymyxin b-trimethoprim 1 or 1b* QL 1 or 1a* QL ophthalmic solution ophthalmic solution MOXIFLOXACIN HCL POLYTRIM INTRAOCULAR 3 OPHTHALMIC 3 QL SOLUTION SOLUTION MOXIFLOXACIN HCL *OPHTHALMIC INTRAOCULAR ANTISEPTICS*** 3 SOLUTION PREFILLED BETADINE SYRINGE OPHTHALMIC PREP 3 moxifloxacin hcl ophthalmic OPHTHALMIC 1 or 1b* QL solution SOLUTION OCUFLOX *OPHTHALMIC OPHTHALMIC 3 QL ANTIVIRALS*** SOLUTION trifluridine ophthalmic 1 or 1b* QL ofloxacin ophthalmic solution 1 or 1a* QL solution ZIRGAN OPHTHALMIC 3 QL tobramycin ophthalmic GEL 1 or 1a* QL solution *OPHTHALMIC TOBREX OPHTHALMIC CARBONIC 3 QL OINTMENT ANHYDRASE INHIBITORS*** TOBREX OPHTHALMIC 3 QL AZOPT OPHTHALMIC SOLUTION 3 QL SUSPENSION VIGAMOX brinzolamide ophthalmic OPHTHALMIC 3 QL 1 or 1b* QL SOLUTION suspension dorzolamide hcl ophthalmic ZYMAXID 1 or 1b* QL OPHTHALMIC 3 solution SOLUTION TRUSOPT *OPHTHALMIC OPHTHALMIC 3 QL ANTIFUNGAL*** SOLUTION NATACYN OPHTHALMIC 3 SUSPENSION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 170 Drug Name Tier Notes Drug Name Tier Notes *OPHTHALMIC *OPHTHALMIC KINASE DIAGNOSTIC INHIBITORS - PRODUCTS*** COMBINATIONS*** ak-fluor intravenous solution ROCKLATAN 1 or 1b* 10 % OPHTHALMIC 3 QL AK-FLUOR SOLUTION INTRAVENOUS 3 *OPHTHALMIC LOCAL SOLUTION 25 % ANESTHETIC - altafluor benox ophthalmic COMBINATIONS*** 1 or 1b* solution LIDOCAINE- EPINEPHRINE FLUORESCEIN 3 SODIUM/BENOXINATE INTRAOCULAR 3 OPHTHALMIC SOLUTION SOLUTION LIDOCAINE- fluorescein-benoxinate PHENYLEPHRINE 1 or 1b* 3 ophthalmic solution INTRAOCULAR SOLUTION FLUORESCITE INTRAVENOUS 3 LIDOCAINE- SOLUTION PHENYLEPHRINE-BSS INTRAOCULAR 3 fluor-i-strips a.t. ophthalmic 1 or 1b* SOLUTION PREFILLED strip SYRINGE FLURA-SAFE *OPHTHALMIC LOCAL OPHTHALMIC 3 ANESTHETICS*** SOLUTION AKTEN OPHTHALMIC 3 PAREMYD GEL OPHTHALMIC 3 SOLUTION ALCAINE OPHTHALMIC 3 proparacaine-fluorescein 1 or 1b* SOLUTION ophthalmic solution proparacaine hcl ophthalmic 1 or 1b* *OPHTHALMIC solution IMMUNOMODULATORS tetracaine hcl ophthalmic *** 1 or 1b* solution CEQUA OPHTHALMIC 3 PA; QL SOLUTION *OPHTHALMIC NERVE GROWTH FACTORS*** RESTASIS MULTIDOSE OPHTHALMIC 3 PA; QL OXERVATE EMULSION 0.05 % OPHTHALMIC 4 PA; LD; QL SOLUTION RESTASIS OPHTHALMIC 3 PA; QL *OPHTHALMIC EMULSION NONSTEROIDAL ANTI- INFLAMMATORY *OPHTHALMIC AGENTS*** IRRIGATION SOLUTIONS*** ACULAR LS OPHTHALMIC 3 QL balanced salt intraocular 1 or 1b* SOLUTION solution ACULAR OPHTHALMIC BSS INTRAOCULAR 3 QL 3 SOLUTION SOLUTION ACUVAIL BSS PLUS OPHTHALMIC 3 QL INTRAOCULAR 3 SOLUTION SOLUTION bromfenac sodium (once- 1 or 1b* QL daily) ophthalmic solution * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 171 Drug Name Tier Notes Drug Name Tier Notes BROMSITE apraclonidine hcl ophthalmic 1 or 1b* OPHTHALMIC 3 QL solution SOLUTION brimonidine tartrate 1 or 1b* QL diclofenac sodium ophthalmic solution 1 or 1b* QL ophthalmic solution IOPIDINE flurbiprofen sodium OPHTHALMIC 3 1 or 1b* QL ophthalmic solution SOLUTION 1 % ILEVRO OPHTHALMIC *OPHTHALMIC 2 QL SUSPENSION STEROID ketorolac tromethamine COMBINATIONS*** 1 or 1b* QL ophthalmic solution bacitra-neomycin- NEVANAC polymyxin-hc ophthalmic 1 or 1b* OPHTHALMIC 3 QL ointment SUSPENSION BLEPHAMIDE PROLENSA OPHTHALMIC 3 QL OPHTHALMIC 3 QL SUSPENSION SOLUTION BLEPHAMIDE S.O.P. *OPHTHALMIC OPHTHALMIC 3 PHOTODYNAMIC OINTMENT THERAPY AGENTS*** DEXAMETHASONE- MOXIFLOXACIN VISUDYNE 3 INTRAVENOUS INTRAOCULAR 4 LD; SP SOLUTION SOLUTION RECONSTITUTED DEXAMETH- *OPHTHALMIC MOXIFLOX- PHOTOENHANCER KETOROLAC 3 COMBINATIONS*** INTRAOCULAR SOLUTION PHOTREXA VISCOUS OPHTHALMIC MAXITROL 3 SOLUTION PREFILLED OPHTHALMIC 3 SYRINGE OINTMENT PHOTREXA-PHOTREXA MAXITROL VISCOUS KIT OPHTHALMIC 3 OPHTHALMIC 3 SUSPENSION SOLUTION PREFILLED neomycin-polymyxin- SYRINGE dexameth ophthalmic 1 or 1a* *OPHTHALMIC RHO ointment KINASE INHIBITORS*** neomycin-polymyxin- RHOPRESSA dexameth ophthalmic 1 or 1a* OPHTHALMIC 3 QL suspension 3.5-10000-0.1 SOLUTION neomycin-polymyxin-hc *OPHTHALMIC ophthalmic suspension 3.5- 1 or 1b* SELECTIVE ALPHA 10000-1 ADRENERGIC neo-polycin hc ophthalmic 1 or 1b* AGONISTS*** ointment ALPHAGAN P PRED-G OPHTHALMIC 3 OPHTHALMIC 2 QL SUSPENSION SOLUTION 0.1 % PRED-G S.O.P. ALPHAGAN P OPHTHALMIC 3 OPHTHALMIC 3 QL OINTMENT SOLUTION 0.15 % sulfacetamide-prednisolone 1 or 1a* QL ophthalmic solution * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 172 Drug Name Tier Notes Drug Name Tier Notes TOBRADEX INVELTYS OPHTHALMIC 2 OPHTHALMIC 3 QL OINTMENT SUSPENSION TOBRADEX LOTEMAX 3 QL OPHTHALMIC 3 QL OPHTHALMIC GEL SUSPENSION LOTEMAX TOBRADEX ST OPHTHALMIC 3 QL OPHTHALMIC 3 QL OINTMENT SUSPENSION LOTEMAX tobramycin-dexamethasone OPHTHALMIC 3 QL 1 or 1b* QL ophthalmic suspension SUSPENSION TRIAMCINOLONE- LOTEMAX SM 3 QL MOXIFLOXACIN OPHTHALMIC GEL 3 INTRAOCULAR loteprednol etabonate 1 or 1b* QL SUSPENSION ophthalmic gel ZYLET OPHTHALMIC loteprednol etabonate 2 1 or 1b* QL SUSPENSION ophthalmic suspension *OPHTHALMIC MAXIDEX STEROIDS*** OPHTHALMIC 3 ALREX OPHTHALMIC SUSPENSION 3 SUSPENSION OZURDEX dexamethasone sodium INTRAVITREAL 3 PA; LD; SP phosphate ophthalmic 1 or 1b* IMPLANT solution PRED FORTE DEXTENZA OPHTHALMIC 3 QL 3 OPHTHALMIC INSERT SUSPENSION DEXYCU PRED MILD INTRAOCULAR 3 OPHTHALMIC 3 SUSPENSION SUSPENSION DUREZOL prednisolone acetate 1 or 1b* QL OPHTHALMIC 2 QL ophthalmic suspension EMULSION PREDNISOLONE EYSUVIS OPHTHALMIC SODIUM PHOSPHATE 3 PA; QL 3 QL SUSPENSION OPHTHALMIC FLAREX OPHTHALMIC SOLUTION 3 SUSPENSION RETISERT fluorometholone ophthalmic INTRAVITREAL 3 PA; LD; SP 1 or 1b* suspension IMPLANT FML FORTE TRIESENCE OPHTHALMIC 3 INTRAOCULAR 3 SUSPENSION SUSPENSION YUTIQ INTRAVITREAL FML LIQUIFILM 3 PA; LD OPHTHALMIC 3 IMPLANT SUSPENSION *OPHTHALMIC FML OPHTHALMIC SULFONAMIDES*** 3 OINTMENT BLEPH-10 ILUVIEN OPHTHALMIC 3 QL INTRAVITREAL 4 PA; LD; SP SOLUTION IMPLANT sulfacetamide sodium 1 or 1b* QL ophthalmic ointment

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 173 Drug Name Tier Notes Drug Name Tier Notes sulfacetamide sodium ocucoat viscoadherent 1 or 1b* QL 1 or 1b* ophthalmic solution intraocular solution *OPHTHALMIC PROVISC SURGICAL AIDS - INTRAOCULAR 4 COMBINATIONS*** SOLUTION DISCOVISC TISSUEBLUE INTRAOCULAR 3 INTRAOCULAR 3 SOLUTION SOLUTION PREFILLED DUOVISC SYRINGE INTRAOCULAR KIT 0.4- 3 VISIONBLUE 0.35 ML, 0.55-0.5 ML OPHTHALMIC 3 OMIDRIA SOLUTION INTRAOCULAR 3 *OPHTHALMICS - SOLUTION BLEPHAROPTOSIS VISCOAT AGENTS** INTRAOCULAR 3 UPNEEQ OPHTHALMIC 3 PA; QL SOLUTION SOLUTION *OPHTHALMIC *OPHTHALMICS - SURGICAL AIDS*** CYSTINOSIS AGENTS** AMVISC INTRAOCULAR CYSTADROPS 4 SOLUTION OPHTHALMIC 4 PA; LD; QL AMVISC PLUS SOLUTION INTRAOCULAR 4 CYSTARAN SOLUTION OPHTHALMIC 3 PA; LD; QL CELLUGEL SOLUTION INTRAOCULAR 3 *PROSTAGLANDINS - SOLUTION OPHTHALMIC*** HEALON DUET PRO bimatoprost ophthalmic 1 or 1b* INTRAOCULAR solution 4 SOLUTION PREFILLED DURYSTA SYRINGE INTRAOCULAR 4 PA; LD; SP; QL HEALON GV IMPLANT INTRAOCULAR 4 latanoprost ophthalmic 1 or 1b* QL SOLUTION solution HEALON GV PRO LUMIGAN INTRAOCULAR 4 OPHTHALMIC 2 QL SOLUTION SOLUTION 0.01 % HEALON TRAVATAN Z INTRAOCULAR 4 OPHTHALMIC 3 QL SOLUTION SOLUTION HEALON PRO travoprost (bak free) 1 or 1b* QL INTRAOCULAR 4 ophthalmic solution SOLUTION VYZULTA HEALON5 OPHTHALMIC 3 QL INTRAOCULAR 4 SOLUTION SOLUTION XALATAN HEALON5 PRO OPHTHALMIC 3 QL INTRAOCULAR 4 SOLUTION SOLUTION XELPROS MEMBRANEBLUE OPHTHALMIC 3 QL OPHTHALMIC 3 EMULSION SOLUTION * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 174 Drug Name Tier Notes Drug Name Tier Notes ZIOPTAN OPHTHALMIC ciprofloxacin-dexamethasone 3 QL 1 or 1b* QL SOLUTION otic suspension *VASCULAR ciprofloxacin-fluocinolone pf 1 or 1b* QL ENDOTHELIAL otic solution GROWTH FACTOR CORTISPORIN-TC OTIC 3 (VEGF) SUSPENSION ANTAGONISTS*** neomycin-polymyxin-hc otic BEOVU INTRAVITREAL 1 or 1b* 4 PA; LD; SP solution SOLUTION neomycin-polymyxin-hc otic 1 or 1b* BEVACIZUMAB suspension INTRAOCULAR 3 PA OTOVEL OTIC SOLUTION PREFILLED 3 QL SYRINGE SOLUTION EYLEA INTRAVITREAL *OTIC STEROIDS*** 4 PA; LD; SP SOLUTION DERMOTIC OTIC OIL 3 EYLEA INTRAVITREAL flac otic oil 1 or 1b* SOLUTION PREFILLED 4 PA; LD fluocinolone acetonide otic SYRINGE 1 or 1b* oil LUCENTIS hydrocortisone-acetic acid INTRAVITREAL 4 PA; LD; SP 1 or 1b* QL SOLUTION otic solution *OXYTOCICS* LUCENTIS INTRAVITREAL *ABORTIFACIENTS/CER 4 PA; LD; SP SOLUTION PREFILLED VICAL RIPENING - SYRINGE PROSTAGLANDINS*** *OTIC AGENTS* carboprost tromethamine 1 or 1b* *OTIC AGENTS - intramuscular solution MISCELLANEOUS*** CERVIDIL VAGINAL 3 acetic acid otic solution 1 or 1b* INSERT *OTIC ANALGESIC HEMABATE COMBINATIONS*** INTRAMUSCULAR 3 SOLUTION PRAMOTIC OTIC 3 PREPIDIL VAGINAL LIQUID 3 GEL *OTIC ANTI- INFECTIVES*** *OXYTOCICS*** CETRAXAL OTIC methergine oral tablet 1 or 1b* 3 QL SOLUTION methylergonovine maleate 1 or 1b* ciprofloxacin hcl otic injection solution 1 or 1b* QL solution methylergonovine maleate 1 or 1b* ofloxacin otic solution 1 or 1b* QL oral tablet OTIPRIO oxytocin injection solution 1 or 1b* INTRATYMPANIC 3 OXYTOCIN-LACTATED SUSPENSION RINGERS *OTIC STEROID-ANTI- INTRAVENOUS 3 INFECTIVE SOLUTION 20 UNIT/L, 30 COMBINATIONS*** UNIT/500ML CIPRO HC OTIC 3 QL SUSPENSION CIPRODEX OTIC 3 QL SUSPENSION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 175 Drug Name Tier Notes Drug Name Tier Notes OXYTOCIN-SODIUM CUTAQUIG CHLORIDE SUBCUTANEOUS 4 PA; LD; SP INTRAVENOUS SOLUTION 3 SOLUTION 15-0.9 CUVITRU UT/250ML-%, 20-0.9 SUBCUTANEOUS 4 PA; LD; SP UNIT/L-% SOLUTION PITOCIN INJECTION 3 CYTOGAM SOLUTION INTRAVENOUS 4 SP *PASSIVE IMMUNIZING INJECTABLE AND TREATMENT FLEBOGAMMA DIF AGENTS* INTRAVENOUS 4 PA; SP *ANTITOXINS- SOLUTION ANTIVENINS*** GAMASTAN ANASCORP INTRAMUSCULAR 4 PA; SP INTRAVENOUS INJECTABLE 3 SOLUTION GAMMAGARD 4 PA; SP RECONSTITUTED INJECTION SOLUTION ANAVIP INTRAVENOUS GAMMAGARD S/D LESS SOLUTION 3 IGA INTRAVENOUS 4 PA; SP RECONSTITUTED SOLUTION ANTIVENIN RECONSTITUTED LATRODECTUS 3 GAMMAKED MACTANS INJECTION INJECTION SOLUTION 1 KIT GM/10ML, 10 GM/100ML, 4 PA; SP ANTIVENIN MICRURUS 20 GM/200ML, 5 FULVIUS GM/50ML INTRAVENOUS 3 GAMMAPLEX SOLUTION INTRAVENOUS RECONSTITUTED SOLUTION 10 CROFAB INTRAVENOUS GM/100ML, 10 4 PA; LD; SP SOLUTION 3 GM/200ML, 20 RECONSTITUTED GM/200ML, 20 *ANTIVIRAL GM/400ML, 5 GM/100ML, MONOCLONAL 5 GM/50ML ANTIBODIES*** GAMUNEX-C 4 PA; SP SYNAGIS INJECTION SOLUTION INTRAMUSCULAR 4 PA; SP HEPAGAM B 4 SP SOLUTION INJECTION SOLUTION *BACTERIAL HIZENTRA MONOCLONAL SUBCUTANEOUS ANTIBODIES*** SOLUTION 1 GM/5ML, 10 4 PA; LD; SP ZINPLAVA GM/50ML, 2 GM/10ML, 4 INTRAVENOUS 3 PA GM/20ML SOLUTION HIZENTRA SUBCUTANEOUS *IMMUNE SERUMS*** 4 PA; LD; SP SOLUTION PREFILLED ASCENIV SYRINGE INTRAVENOUS 4 PA; SP SOLUTION HYPERHEP B INTRAMUSCULAR 4 SP BIVIGAM SOLUTION INTRAVENOUS 4 PA; LD; SP HYPERRAB INJECTION SOLUTION 5 GM/50ML 4 SP SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 176 Drug Name Tier Notes Drug Name Tier Notes HYPERRHO S/D XEMBIFY INTRAMUSCULAR SUBCUTANEOUS 4 PA; LD; SP 4 SP; QL SOLUTION PREFILLED SOLUTION SYRINGE *PASSIVE IMMUNIZING HYPERTET S/D AGENTS - INTRAMUSCULAR 3 COMBINATIONS*** INJECTABLE HYQVIA 4 PA; LD; SP IMOGAM RABIES-HT SUBCUTANEOUS KIT INJECTION SOLUTION 4 SP *PENICILLINS* 300 UNIT/2ML *AMINOPENICILLINS** KEDRAB INJECTION 4 SP * SOLUTION amoxicillin oral capsule 1 or 1a* MICRHOGAM ULTRA- amoxicillin oral suspension FILTERED PLUS 1 or 1a* QL INTRAMUSCULAR 4 SP; QL reconstituted SOLUTION PREFILLED amoxicillin oral tablet 1 or 1a* SYRINGE amoxicillin oral tablet 1 or 1a* NABI-HB chewable 125 mg, 250 mg INTRAMUSCULAR 4 SP ampicillin oral capsule 500 SOLUTION 1 or 1a* mg OCTAGAM INTRAVENOUS ampicillin sodium injection solution reconstituted 1 gm, SOLUTION 1 GM/20ML, 1 or 1b* 10 GM/100ML, 10 125 mg, 2 gm, 250 mg, 500 GM/200ML, 2 GM/20ML, 4 PA; SP mg 2.5 GM/50ML, 20 ampicillin sodium GM/200ML, 25 intravenous solution 1 or 1b* GM/500ML, 5 GM/100ML, reconstituted 5 GM/50ML *NATURAL OCTAGAM PENICILLINS*** INTRAVENOUS 4 PA BICILLIN L-A SOLUTION 30 GM/300ML INTRAMUSCULAR 3 PANZYGA SUSPENSION INTRAVENOUS 4 PA; SP PENICILLIN G POT IN SOLUTION DEXTROSE 3 PRIVIGEN INTRAVENOUS INTRAVENOUS 4 PA; SP SOLUTION SOLUTION penicillin g potassium RHOGAM ULTRA- injection solution 1 or 1b* FILTERED PLUS reconstituted INTRAMUSCULAR 4 SP; QL PENICILLIN G SOLUTION PREFILLED PROCAINE 3 SYRINGE INTRAMUSCULAR RHOPHYLAC SUSPENSION INJECTION SOLUTION 4 SP; QL penicillin g sodium injection 1 or 1b* PREFILLED SYRINGE solution reconstituted VARIZIG penicillin v potassium oral 1 or 1b* INTRAMUSCULAR 3 solution reconstituted SOLUTION penicillin v potassium oral WINRHO SDF 1 or 1b* 4 SP; QL tablet INJECTION SOLUTION pfizerpen injection solution 1 or 1b* reconstituted

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 177 Drug Name Tier Notes Drug Name Tier Notes *PENICILLIN NAFCILLIN SODIUM IN COMBINATIONS*** DEXTROSE 3 amoxicillin-pot clavulanate INTRAVENOUS er oral tablet extended 1 or 1b* QL SOLUTION release 12 hour nafcillin sodium injection amoxicillin-pot clavulanate solution reconstituted 1 gm, 1 or 1b* 1 or 1b* oral suspension reconstituted 2 gm amoxicillin-pot clavulanate nafcillin sodium intravenous 1 or 1b* 1 or 1b* oral tablet solution reconstituted amoxicillin-pot clavulanate OXACILLIN SODIUM IN 1 or 1b* DEXTROSE oral tablet chewable 3 INTRAVENOUS ampicillin-sulbactam sodium SOLUTION injection solution 1 or 1b* reconstituted 1.5 (1-0.5) gm, oxacillin sodium injection 3 (2-1) gm solution reconstituted 1 gm, 1 or 1b* 2 gm ampicillin-sulbactam sodium oxacillin sodium intravenous intravenous solution 1 or 1b* 1 or 1b* reconstituted solution reconstituted AUGMENTIN ES-600 *PROGESTINS* ORAL SUSPENSION 3 *PROGESTINS*** RECONSTITUTED AYGESTIN ORAL 3 AUGMENTIN ORAL TABLET SUSPENSION hydroxyprogesterone 3 4 PA; SP; QL RECONSTITUTED 250- caproate intramuscular oil 62.5 MG/5ML MAKENA AUGMENTIN ORAL 4 PA; LD; SP; QL 3 INTRAMUSCULAR OIL TABLET 500-125 MG MAKENA BICILLIN C-R 900/300 SUBCUTANEOUS 4 PA; LD; SP; QL INTRAMUSCULAR 3 SOLUTION AUTO- SUSPENSION INJECTOR BICILLIN C-R medroxyprogesterone acetate 1 or 1a* QL INTRAMUSCULAR 3 oral tablet SUSPENSION megestrol acetate oral 1 or 1b* piperacillin sod-tazobactam suspension 625 mg/5ml so intravenous solution 1 or 1b* norethindrone acetate oral reconstituted 1 or 1b* tablet UNASYN INJECTION SOLUTION progesterone intramuscular 3 1 or 1b* RECONSTITUTED 1.5 (1- oil 0.5) GM, 3 (2-1) GM progesterone oral capsule 1 or 1b* QL UNASYN INTRAVENOUS PROMETRIUM ORAL SOLUTION 3 QL 3 CAPSULE RECONSTITUTED 15 (10- PROVERA ORAL 5) GM 3 QL TABLET ZOSYN INTRAVENOUS 3 *PSYCHOTHERAPEUTI SOLUTION C AND NEUROLOGICAL *PENICILLINASE- AGENTS - MISC.* RESISTANT PENICILLINS*** *AGENTS FOR OPIOID WITHDRAWAL*** dicloxacillin sodium oral 1 or 1b* LUCEMYRA ORAL capsule 3 QL TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 178 Drug Name Tier Notes Drug Name Tier Notes *ALCOHOL galantamine hydrobromide er DETERRENTS*** oral capsule extended release 1 or 1b* QL acamprosate calcium oral 24 hour 16 mg, 24 mg 1 or 1b* QL tablet delayed release galantamine hydrobromide er disulfiram oral tablet 1 or 1b* oral capsule extended release 1 or 1b* DO 24 hour 8 mg *ANTI-CATAPLECTIC galantamine hydrobromide AGENTS*** 1 or 1b* oral solution XYREM ORAL 3 PA; LD; QL galantamine hydrobromide SOLUTION 1 or 1b* QL oral tablet 12 mg, 8 mg *ANTI-CATAPLECTIC galantamine hydrobromide COMBINATIONS*** 1 or 1b* DO oral tablet 4 mg XYWAV ORAL 4 PA; LD; QL SOLUTION RAZADYNE ER ORAL CAPSULE EXTENDED 3 QL *ANTIDEMENTIA RELEASE 24 HOUR 16 AGENT MG, 24 MG COMBINATIONS*** RAZADYNE ER ORAL NAMZARIC ORAL CAPSULE EXTENDED 3 DO CAPSULE ER 24 HOUR 2 RELEASE 24 HOUR 8 MG THERAPY PACK rivastigmine tartrate oral 1 or 1b* DO NAMZARIC ORAL capsule 1.5 mg, 3 mg CAPSULE EXTENDED 2 QL rivastigmine tartrate oral RELEASE 24 HOUR 1 or 1b* QL capsule 4.5 mg, 6 mg *ANTISENSE rivastigmine transdermal OLIGONUCLEOTIDE 1 or 1b* QL (ASO) INHIBITOR patch 24 hour AGENTS*** *FIBROMYALGIA TEGSEDI AGENT - SNRIS*** SUBCUTANEOUS SAVELLA ORAL 4 PA; LD; QL 2 QL SOLUTION PREFILLED TABLET SYRINGE SAVELLA TITRATION 2 QL *BENZODIAZEPINES & PACK ORAL TRICYCLIC AGENTS*** *MELANOCORTIN chlordiazepoxide- RECEPTOR 1 or 1b* amitriptyline oral tablet AGONISTS*** *CHOLINOMIMETICS - VYLEESI ACHE INHIBITORS*** SUBCUTANEOUS 3 PA; QL ARICEPT ORAL SOLUTION AUTO- 3 QL TABLET 10 MG, 23 MG INJECTOR ARICEPT ORAL *MOVEMENT 3 DO TABLET 5 MG DISORDER DRUG THERAPY*** donepezil hcl oral tablet 10 1 or 1b* QL AUSTEDO ORAL mg, 23 mg 4 PA; SP; QL TABLET donepezil hcl oral tablet 5 1 or 1b* DO INGREZZA ORAL mg 4 PA; DO; LD CAPSULE 40 MG donepezil hcl oral tablet 1 or 1b* QL INGREZZA ORAL dispersible 4 PA; LD; QL CAPSULE 60 MG, 80 MG EXELON TRANSDERMAL PATCH 3 ST; QL INGREZZA ORAL 24 HOUR CAPSULE THERAPY 4 PA; LD; QL PACK tetrabenazine oral tablet 1 or 1b* PA; SP; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 179 Drug Name Tier Notes Drug Name Tier Notes XENAZINE ORAL PLEGRIDY STARTER 4 PA; LD; SP; QL TABLET PACK SUBCUTANEOUS 4 PA; LD; SP; QL *MS AGENTS - SOLUTION PEN- PYRIMIDINE INJECTOR SYNTHESIS PLEGRIDY STARTER INHIBITORS*** PACK SUBCUTANEOUS 4 PA; LD; SP; QL AUBAGIO ORAL SOLUTION PREFILLED 4 PA; LD; SP; QL TABLET SYRINGE *MULTIPLE SCLEROSIS PLEGRIDY SUBCUTANEOUS AGENTS - 4 PA; LD; SP; QL ANTIMETABOLITES*** SOLUTION PEN- INJECTOR MAVENCLAD (10 TABS) ORAL TABLET 4 PA; LD; SP; QL PLEGRIDY SUBCUTANEOUS THERAPY PACK 4 PA; LD; SP; QL SOLUTION PREFILLED MAVENCLAD (4 TABS) SYRINGE ORAL TABLET 4 PA; LD; SP; QL THERAPY PACK REBIF REBIDOSE SUBCUTANEOUS 4 PA; SP; QL MAVENCLAD (5 TABS) SOLUTION AUTO- ORAL TABLET 4 PA; LD; SP; QL INJECTOR THERAPY PACK REBIF REBIDOSE MAVENCLAD (6 TABS) TITRATION PACK ORAL TABLET 4 PA; LD; SP; QL SUBCUTANEOUS 4 PA; SP; QL THERAPY PACK SOLUTION AUTO- MAVENCLAD (7 TABS) INJECTOR ORAL TABLET 4 PA; LD; SP; QL REBIF SUBCUTANEOUS THERAPY PACK SOLUTION PREFILLED 4 PA; SP; QL MAVENCLAD (8 TABS) SYRINGE ORAL TABLET 4 PA; LD; SP; QL REBIF TITRATION THERAPY PACK PACK SUBCUTANEOUS 4 PA; SP; QL MAVENCLAD (9 TABS) SOLUTION PREFILLED ORAL TABLET 4 PA; LD; SP; QL SYRINGE THERAPY PACK *MULTIPLE SCLEROSIS *MULTIPLE SCLEROSIS AGENTS - AGENTS - MONOCLONAL INTERFERONS*** ANTIBODIES*** AVONEX PEN KESIMPTA SUBCUTANEOUS INTRAMUSCULAR 4 PA; SP; QL 4 PA; LD; SP; QL AUTO-INJECTOR KIT SOLUTION AUTO- INJECTOR AVONEX PREFILLED INTRAMUSCULAR LEMTRADA 4 PA; SP; QL PREFILLED SYRINGE INTRAVENOUS 4 PA; LD; SP; QL KIT SOLUTION BETASERON OCREVUS 4 PA; SP; QL SUBCUTANEOUS KIT INTRAVENOUS 4 PA; LD; SP; QL SOLUTION EXTAVIA 4 PA; SP; QL SUBCUTANEOUS KIT TYSABRI INTRAVENOUS 4 PA; LD; SP; QL PLEGRIDY CONCENTRATE INTRAMUSCULAR 4 PA; LD; SP; QL SOLUTION PREFILLED SYRINGE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 180 Drug Name Tier Notes Drug Name Tier Notes *MULTIPLE SCLEROSIS memantine hcl oral tablet 5 1 or 1b* DO AGENTS - NRF2 mg PATHWAY NAMENDA TITRATION 3 QL ACTIVATORS*** PAK ORAL TABLET BAFIERTAM ORAL NAMENDA XR ORAL CAPSULE DELAYED 4 PA; LD; SP; QL CAPSULE EXTENDED 3 DO RELEASE RELEASE 24 HOUR 14 dimethyl fumarate oral MG, 7 MG 4 PA; SP; QL capsule delayed release NAMENDA XR ORAL dimethyl fumarate starter CAPSULE EXTENDED 4 PA; SP; QL 3 QL pack oral RELEASE 24 HOUR 21 TECFIDERA ORAL 4 PA; LD; SP; QL MG, 28 MG TECFIDERA ORAL *PHENOTHIAZINES & CAPSULE DELAYED 4 PA; LD; SP; QL TRICYCLIC AGENTS*** RELEASE perphenazine-amitriptyline 1 or 1b* VUMERITY ORAL oral tablet CAPSULE DELAYED 4 PA; LD; SP; QL *POSTHERPETIC RELEASE NEURALGIA *MULTIPLE SCLEROSIS (PHN)/NEUROPATHIC AGENTS - POTASSIUM PAIN AGENTS*** CHANNEL GRALISE ORAL 2 PA; DO BLOCKERS*** TABLET 300 MG AMPYRA ORAL TABLET GRALISE ORAL 2 PA; QL EXTENDED RELEASE 12 4 PA; LD; SP; QL TABLET 600 MG HOUR LYRICA CR ORAL dalfampridine er oral tablet TABLET EXTENDED 4 PA; SP; QL 3 PA; DO extended release 12 hour RELEASE 24 HOUR 165 *MULTIPLE SCLEROSIS MG, 82.5 MG AGENTS*** LYRICA CR ORAL TABLET EXTENDED COPAXONE 3 PA; QL SUBCUTANEOUS RELEASE 24 HOUR 330 4 PA; SP; QL SOLUTION PREFILLED MG SYRINGE pregabalin er oral tablet glatiramer acetate extended release 24 hour 165 1 or 1b* PA; DO subcutaneous solution 4 PA; SP; QL mg, 82.5 mg prefilled syringe pregabalin er oral tablet glatopa subcutaneous extended release 24 hour 330 1 or 1b* PA; QL 4 PA; SP; QL solution prefilled syringe mg *N-METHYL-D- *PREMENSTRUAL ASPARTATE (NMDA) DYSPHORIC DISORDER RECEPTOR (PMDD) AGENTS - ANTAGONISTS*** SSRIS*** fluoxetine hcl (pmdd) oral memantine hcl er oral 1 or 1b* DO capsule extended release 24 1 or 1b* DO tablet 10 mg hour 14 mg, 7 mg fluoxetine hcl (pmdd) oral 1 or 1b* QL memantine hcl er oral tablet 20 mg capsule extended release 24 1 or 1b* QL *PSEUDOBULBAR hour 21 mg, 28 mg AFFECT AGENT memantine hcl oral solution 1 or 1b* QL COMBINATIONS*** memantine hcl oral tablet 10 NUEDEXTA ORAL 1 or 1b* QL 3 PA; QL mg, 28 x 5 mg & 21 x 10 mg CAPSULE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 181 Drug Name Tier Notes Drug Name Tier Notes *PSYCHOTHERAPEUTI eql nicotine polacrilex 1 or 1b* OTC; $0 C AND NEUROLOGICAL mouth/throat lozenge AGENTS - MISC.*** gnp nicotine mini 1 or 1b* OTC; $0 ergoloid mesylates oral tablet 1 or 1b* QL mouth/throat lozenge pimozide oral tablet 1 or 1b* gnp nicotine mouth/throat 1 or 1b* OTC; $0 *RESTLESS LEG gum SYNDROME (RLS) gnp nicotine polacrilex 1 or 1b* OTC; $0 AGENTS*** mouth/throat gum HORIZANT ORAL gnp nicotine polacrilex 1 or 1b* OTC; $0 TABLET EXTENDED 3 PA; QL mouth/throat lozenge RELEASE gnp nicotine transdermal 1 or 1b* OTC; $0 *SEROTONIN 1A patch 24 hour RECEPT goodsense nicotine 1 or 1b* OTC; $0 AGONIST/SEROTONIN mouth/throat gum 2A RECEPT ANTAG*** goodsense nicotine 1 or 1b* OTC; $0 ADDYI ORAL TABLET 3 PA; QL mouth/throat lozenge *SMALL INTERFERING habitrol transdermal patch 24 1 or 1b* OTC; $0 RIBONUCLEIC ACID hour (SIRNA) AGENTS*** hm nicotine polacrilex 1 or 1b* OTC; $0 ONPATTRO mouth/throat gum INTRAVENOUS 4 PA; QL hm nicotine polacrilex SOLUTION 1 or 1b* OTC; $0 mouth/throat lozenge *SMOKING hm nicotine transdermal DETERRENTS*** 1 or 1b* OTC; $0 patch 24 hour APO-VARENICLINE 3 PA; $0; QL ORAL TABLET kls quit2 mouth/throat gum 1 or 1b* OTC; $0 kls quit2 mouth/throat bupropion hcl er (smoking 1 or 1b* OTC; $0 det) oral tablet extended 1 or 1b* PA; $0; QL lozenge release 12 hour kls quit4 mouth/throat gum 1 or 1b* OTC; $0 cvs nicotine mouth/throat kls quit4 mouth/throat 1 or 1b* OTC; $0 1 or 1b* OTC; $0 gum lozenge cvs nicotine mouth/throat 1 or 1b* OTC; $0 NICODERM CQ lozenge TRANSDERMAL PATCH 2 OTC; $0 cvs nicotine polacrilex 24 HOUR 1 or 1b* OTC; $0 mouth/throat gum NICORETTE MINI cvs nicotine polacrilex MOUTH/THROAT 2 OTC; $0 1 or 1b* OTC; $0 mouth/throat lozenge LOZENGE cvs nicotine transdermal NICORETTE 1 or 1b* OTC; $0 2 OTC; $0 patch 24 hour MOUTH/THROAT GUM eq nicotine mouth/throat NICORETTE 1 or 1b* OTC; $0 lozenge MOUTH/THROAT 2 OTC; $0 LOZENGE eq nicotine polacrilex 1 or 1b* OTC; $0 mouth/throat gum NICORETTE STARTER KIT MOUTH/THROAT 2 OTC; $0 eq nicotine polacrilex 1 or 1b* OTC; $0 GUM mouth/throat lozenge nicotine mini mouth/throat eq nicotine step 3 1 or 1b* OTC; $0 1 or 1b* OTC; $0 lozenge transdermal patch 24 hour nicotine polacrilex mini 1 or 1b* OTC; $0 eq nicotine transdermal patch mouth/throat lozenge 24 hour 14 mg/24hr, 21 1 or 1b* OTC; $0 mg/24hr

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 182 Drug Name Tier Notes Drug Name Tier Notes nicotine polacrilex *SPHINGOSINE 1- 1 or 1b* OTC; $0 mouth/throat gum PHOSPHATE (S1P) nicotine polacrilex RECEPTOR 1 or 1b* OTC; $0 mouth/throat lozenge MODULATORS*** nicotine step 1 transdermal GILENYA ORAL 1 or 1b* OTC; $0 4 PA; SP; QL patch 24 hour CAPSULE 0.5 MG nicotine step 2 transdermal MAYZENT ORAL 1 or 1b* OTC; $0 4 PA; LD; SP; QL patch 24 hour TABLET nicotine step 3 transdermal MAYZENT STARTER 1 or 1b* OTC; $0 PACK ORAL TABLET patch 24 hour 4 PA; LD; SP; QL THERAPY PACK 12 X NICOTINE 2 OTC; $0 0.25 MG TRANSDERMAL KIT PONVORY ORAL nicotine transdermal patch 24 4 PA; LD; SP; QL 1 or 1b* OTC; $0 TABLET hour PONVORY STARTER NICOTROL 3 PA; $0 PACK ORAL TABLET 4 PA; LD; SP; QL INHALATION INHALER THERAPY PACK NICOTROL NS NASAL 3 PA; $0 ZEPOSIA 7-DAY SOLUTION STARTER PACK ORAL 4 PA; LD; SP; QL px stop smoking aid CAPSULE THERAPY 1 or 1b* OTC; $0 mouth/throat gum PACK px stop smoking aid ZEPOSIA ORAL 1 or 1b* OTC; $0 4 PA; LD; SP; QL mouth/throat lozenge CAPSULE qc nicotine transdermal ZEPOSIA STARTER KIT system transdermal patch 24 1 or 1b* OTC; $0 ORAL CAPSULE 4 PA; LD; SP; QL hour THERAPY PACK ra mini nicotine mouth/throat *THIENBENZODIAZEPI 1 or 1b* OTC; $0 lozenge NES & SSRIS*** ra nicotine gum mouth/throat olanzapine-fluoxetine hcl 1 or 1b* OTC; $0 gum 2 mg, 4 mg oral capsule 12-25 mg, 12-50 1 or 1b* QL mg, 6-50 mg ra nicotine mouth/throat gum 1 or 1b* OTC; $0 olanzapine-fluoxetine hcl ra nicotine polacrilex 1 or 1b* OTC; $0 oral capsule 3-25 mg, 6-25 1 or 1b* DO mouth/throat lozenge mg ra nicotine transdermal patch SYMBYAX ORAL 24 hour 14 mg/24hr, 21 1 or 1b* OTC; $0 CAPSULE 3-25 MG, 6-25 3 DO mg/24hr MG sm nicotine mouth/throat 1 or 1b* OTC; $0 *VASOMOTOR gum SYMPTOM AGENTS - sm nicotine mouth/throat SSRIS*** 1 or 1b* OTC; $0 lozenge BRISDELLE ORAL 3 sm nicotine polacrilex CAPSULE 1 or 1b* OTC; $0 mouth/throat gum paroxetine mesylate oral 1 or 1b* sm nicotine polacrilex capsule 1 or 1b* OTC; $0 mouth/throat lozenge sm nicotine transdermal 1 or 1b* OTC; $0 patch 24 hour thrive mouth/throat gum 2 1 or 1b* OTC; $0 mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 183 Drug Name Tier Notes Drug Name Tier Notes *RESPIRATORY *HYDROLYTIC AGENTS - MISC.* ENZYMES*** *ALPHA-PROTEINASE PULMOZYME INHIBITOR (HUMAN)*** INHALATION 4 SP; QL ARALAST NP SOLUTION INTRAVENOUS *PLEURAL SOLUTION 4 PA; LD; SP SCLEROSING RECONSTITUTED 1000 AGENTS*** MG, 500 MG SCLEROSOL GLASSIA INTRAPLEURAL 3 INTRAVENOUS 4 PA; LD; SP INTRAPLEURAL SOLUTION AEROSOL POWDER PROLASTIN-C STERILE TALC INTRAVENOUS 4 PA; LD POWDER SOLUTION INTRAPLEURAL 3 PROLASTIN-C SUSPENSION INTRAVENOUS RECONSTITUTED SOLUTION 4 PA; LD STERITALC RECONSTITUTED 1000 INTRAPLEURAL 3 MG POWDER ZEMAIRA *PULMONARY INTRAVENOUS FIBROSIS AGENTS - 4 PA; LD; SP SOLUTION KINASE INHIBITORS*** RECONSTITUTED OFEV ORAL CAPSULE 4 PA; LD; SP; QL *CFTR *PULMONARY POTENTIATORS*** FIBROSIS AGENTS*** KALYDECO ORAL ESBRIET ORAL 4 PA; LD; QL 4 PA; LD; SP; QL PACKET CAPSULE KALYDECO ORAL 4 PA; LD; QL ESBRIET ORAL TABLET 4 PA; LD; SP; QL TABLET *RESPIRATORY *CYSTIC FIBROSIS AGENTS - MISC.*** AGENT - COMBINATIONS*** CUROSURF INTRATRACHEAL ORKAMBI ORAL 3 4 PA; LD; QL SUSPENSION 120 PACKET MG/1.5ML, 240 MG/3ML ORKAMBI ORAL 4 PA; LD; QL INFASURF TABLET INTRATRACHEAL 3 SYMDEKO ORAL SUSPENSION TABLET THERAPY 4 PA; LD; QL SURVANTA PACK INTRATRACHEAL 3 TRIKAFTA ORAL SUSPENSION TABLET THERAPY 4 PA; LD; QL *SULFONAMIDES* PACK *SULFONAMIDES*** *CYSTIC FIBROSIS SULFADIAZINE ORAL AGENTS - 3 MISCELLANEOUS*** TABLET BRONCHITOL 4 PA; LD; SP; QL INHALATION CAPSULE BRONCHITOL TOLERANCE TEST 4 PA; LD; SP; QL INHALATION CAPSULE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 184 Drug Name Tier Notes Drug Name Tier Notes *TETRACYCLINES* doxycycline hyclate oral 3 ST; QL *AMINOMETHYLCYCLI tablet delayed release NES*** doxycycline monohydrate NUZYRA oral capsule 100 mg, 50 mg, 1 or 1b* QL INTRAVENOUS 75 mg 3 LD SOLUTION doxycycline monohydrate 3 ST RECONSTITUTED oral capsule 150 mg NUZYRA ORAL TABLET doxycycline monohydrate 3 PA; LD; QL 1 or 1b* QL 150 MG oral suspension reconstituted *FLUOROCYCLINES*** doxycycline monohydrate XERAVA oral tablet 100 mg, 50 mg, 75 1 or 1b* QL INTRAVENOUS mg 3 SOLUTION doxycycline monohydrate 1 or 1b* RECONSTITUTED oral tablet 150 mg *GLYCYLCYCLINES*** MINOCIN INTRAVENOUS TIGECYCLINE 3 INTRAVENOUS SOLUTION 3 SOLUTION RECONSTITUTED RECONSTITUTED minocycline hcl er oral TYGACIL capsule extended release 24 3 ST INTRAVENOUS hour 3 SOLUTION minocycline hcl er oral tablet 3 ST RECONSTITUTED extended release 24 hour *TETRACYCLINES*** minocycline hcl oral capsule 1 or 1b* ACTICLATE ORAL minocycline hcl oral tablet 1 or 1b* 3 ST; QL TABLET MINOLIRA ORAL coremino oral tablet TABLET EXTENDED 3 ST 1 or 1b* ST extended release 24 hour RELEASE 24 HOUR demeclocycline hcl oral mondoxyne nl oral capsule 1 or 1b* 1 or 1b* QL tablet 100 mg, 75 mg DORYX MPC ORAL morgidox oral capsule 100 1 or 1b* QL TABLET DELAYED 3 ST; QL mg RELEASE SEYSARA ORAL 3 ST; QL DORYX ORAL TABLET TABLET DELAYED RELEASE 200 3 ST; QL SOLODYN ORAL MG, 50 MG, 80 MG TABLET EXTENDED doxy 100 intravenous RELEASE 24 HOUR 105 3 ST 1 or 1b* QL solution reconstituted MG, 115 MG, 55 MG, 65 doxycycline hyclate MG, 80 MG intravenous solution 1 or 1b* QL tetracycline hcl oral capsule 1 or 1b* reconstituted VIBRAMYCIN ORAL 3 ST; QL doxycycline hyclate oral CAPSULE 1 or 1b* QL capsule 100 mg VIBRAMYCIN ORAL doxycycline hyclate oral SUSPENSION 3 ST; QL 1 or 1b* capsule 50 mg RECONSTITUTED doxycycline hyclate oral VIBRAMYCIN ORAL 1 or 1b* QL 3 ST tablet 100 mg, 20 mg, 50 mg SYRUP doxycycline hyclate oral XIMINO ORAL 3 ST; QL tablet 150 mg, 75 mg CAPSULE EXTENDED 3 ST RELEASE 24 HOUR

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 185 Drug Name Tier Notes Drug Name Tier Notes *THYROID AGENTS* TRIOSTAT *ANTITHYROID INTRAVENOUS 3 AGENTS - SOLUTION RADIOPHARMACEUTIC unithroid oral tablet 1 or 1a* ALS*** WESTHROID ORAL SODIUM IODIDE I-131 TABLET 130 MG, 195 3 3 ORAL SOLUTION MG, 32.5 MG, 65 MG, 97.5 *ANTITHYROID MG AGENTS*** WP THYROID ORAL 3 methimazole oral tablet 1 or 1a* TABLET propylthiouracil oral tablet 1 or 1b* *TOXOIDS* TAPAZOLE ORAL *TOXOID 3 TABLET COMBINATIONS*** *THYROID ADACEL INTRAMUSCULAR HORMONES*** 3 $0 SUSPENSION 5-2-15.5 LF- ARMOUR THYROID 3 MCG/0.5 ORAL TABLET BOOSTRIX CYTOMEL ORAL INTRAMUSCULAR 3 3 $0 TABLET SUSPENSION 5-2.5-18.5 euthyrox oral tablet 1 or 1b* LF-MCG/0.5 levo-t oral tablet 1 or 1b* DAPTACEL INTRAMUSCULAR 3 $0 LEVOTHYROXINE SUSPENSION 23-15-5 SODIUM INTRAVENOUS 3 SOLUTION DIPHTHERIA-TETANUS TOXOIDS DT 3 $0 LEVOTHYROXINE INTRAMUSCULAR SODIUM INTRAVENOUS 3 SUSPENSION SOLUTION RECONSTITUTED INFANRIX INTRAMUSCULAR 3 $0 levothyroxine sodium oral 1 or 1b* SUSPENSION capsule KINRIX levothyroxine sodium oral 1 or 1a* INTRAMUSCULAR 3 $0 tablet SUSPENSION levoxyl oral tablet 1 or 1a* PEDIARIX liothyronine sodium INTRAMUSCULAR 3 $0 1 or 1b* intravenous solution SUSPENSION liothyronine sodium oral PENTACEL 1 or 1b* tablet INTRAMUSCULAR 3 $0 NATURE-THROID ORAL SUSPENSION 3 TABLET RECONSTITUTED np thyroid oral tablet 1 or 1a* QUADRACEL INTRAMUSCULAR 3 $0 SYNTHROID ORAL 3 SUSPENSION TABLET TDVAX THYQUIDITY ORAL 3 INTRAMUSCULAR 3 $0 SOLUTION SUSPENSION TIROSINT ORAL 3 TENIVAC CAPSULE INTRAMUSCULAR 3 $0 TIROSINT-SOL ORAL INJECTABLE 3 SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 186 Drug Name Tier Notes Drug Name Tier Notes TETANUS-DIPHTHERIA hyoscyamine sulfate er oral TOXOIDS TD tablet extended release 12 1 or 1b* 3 $0 INTRAMUSCULAR hour SUSPENSION hyoscyamine sulfate sl 1 or 1b* VAXELIS sublingual tablet sublingual INTRAMUSCULAR 3 hyoscyamine sulfate 1 or 1b* SUSPENSION sublingual tablet sublingual VAXELIS *H-2 ANTAGONISTS*** INTRAMUSCULAR 3 SUSPENSION cimetidine hcl oral solution 1 or 1b* PREFILLED SYRINGE cimetidine oral tablet 1 or 1b* QL *ULCER famotidine intravenous DRUGS/ANTISPASMODI solution 20 mg/2ml, 200 1 or 1b* CS/ANTICHOLINERGIC mg/20ml, 40 mg/4ml S* famotidine oral suspension 1 or 1b* QL *ANTICHOLINERGIC reconstituted COMBINATIONS*** famotidine oral tablet 20 mg, chlordiazepoxide-clidinium 1 or 1b* QL 1 or 1b* 40 mg oral capsule famotidine premixed LIBRAX ORAL 1 or 1b* 3 intravenous solution CAPSULE nizatidine oral capsule 1 or 1b* QL phenohytro oral elixir 1 or 1b* nizatidine oral solution 1 or 1b* QL phenohytro oral tablet 1 or 1b* PEPCID ORAL TABLET 3 QL *ANTISPASMODICS*** *MISC. ANTI-ULCER*** BENTYL CARAFATE ORAL INTRAMUSCULAR 3 3 SOLUTION SUSPENSION dicyclomine hcl CARAFATE ORAL 1 or 1b* 3 intramuscular solution TABLET dicyclomine hcl oral capsule 1 or 1a* sucralfate oral suspension 1 or 1b* dicyclomine hcl oral solution 1 or 1a* sucralfate oral tablet 1 or 1b* *PROTON PUMP dicyclomine hcl oral tablet 1 or 1a* INHIBITOR-ANTACID *BELLADONNA COMBINATIONS*** ALKALOIDS*** omeprazole-sodium 3 ST; QL ATROPEN bicarbonate oral packet INTRAMUSCULAR 3 ZEGERID ORAL SOLUTION AUTO- 3 ST; QL INJECTOR CAPSULE ZEGERID ORAL atropine sulfate injection 3 ST; QL solution prefilled syringe 1 or 1b* PACKET 0.25 mg/5ml *PROTON PUMP INHIBITORS*** ATROPINE SULFATE INTRAVENOUS 3 ACIPHEX ORAL SOLUTION TABLET DELAYED 3 ST; QL ATROPINE SULFATE RELEASE INTRAVENOUS ACIPHEX SPRINKLE SOLUTION PREFILLED 3 ORAL CAPSULE 3 ST; QL SYRINGE 0.8 MG/2ML, 1 SPRINKLE MG/2.5ML DEXILANT ORAL CAPSULE DELAYED 2 ST; QL RELEASE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 187 Drug Name Tier Notes Drug Name Tier Notes esomeprazole magnesium RABEPRAZOLE 3 ST; QL oral capsule delayed release SODIUM ORAL 3 ST; QL esomeprazole magnesium CAPSULE SPRINKLE 3 ST; QL oral packet rabeprazole sodium oral 3 ST; QL esomeprazole sodium tablet delayed release intravenous solution 1 or 1b* *QUATERNARY reconstituted 40 mg ANTICHOLINERGICS*** ESOMEPRAZOLE CUVPOSA ORAL 3 STRONTIUM ORAL SOLUTION 3 ST; QL CAPSULE DELAYED glycopyrrolate injection 1 or 1b* RELEASE 49.3 MG solution lansoprazole oral capsule glycopyrrolate oral tablet 1 3 ST; QL 1 or 1b* delayed release mg, 2 mg lansoprazole oral tablet 3 ST; QL GLYCOPYRROLATE PF delayed release dispersible INJECTION SOLUTION 3 NEXIUM I.V. PREFILLED SYRINGE INTRAVENOUS GLYRX-PF INJECTION 3 3 SOLUTION SOLUTION RECONSTITUTED 40 MG GLYRX-PF INJECTION NEXIUM ORAL SOLUTION PREFILLED 3 CAPSULE DELAYED 3 ST; QL SYRINGE RELEASE methscopolamine bromide 1 or 1b* NEXIUM ORAL PACKET 3 ST; QL oral tablet omeprazole oral capsule 1 or 1b* *ULCER ANTI- delayed release INFECTIVE W/ pantoprazole sodium BISMUTH intravenous solution 1 or 1b* COMBINATIONS*** reconstituted HELIDAC THERAPY 3 ST; QL pantoprazole sodium oral ORAL 3 ST; QL packet PYLERA ORAL 3 ST; QL pantoprazole sodium oral CAPSULE 1 or 1b* tablet delayed release *ULCER ANTI- PREVACID ORAL INFECTIVE W/ PROTON CAPSULE DELAYED 3 ST; QL PUMP INHIBITORS*** RELEASE 30 MG amoxicill-clarithro-lansopraz 1 or 1b* ST; QL PREVACID SOLUTAB oral ORAL TABLET OMECLAMOX-PAK 3 ST; QL 3 ST; QL DELAYED RELEASE ORAL DISPERSIBLE TALICIA ORAL PRILOSEC ORAL 3 ST; QL CAPSULE DELAYED 3 ST; QL PACKET RELEASE PROTONIX *ULCER DRUGS - INTRAVENOUS 3 PROSTAGLANDINS*** SOLUTION CYTOTEC ORAL RECONSTITUTED 3 TABLET PROTONIX ORAL 3 ST; QL PACKET misoprostol oral tablet 1 or 1a* PROTONIX ORAL TABLET DELAYED 3 ST; QL RELEASE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 188 Drug Name Tier Notes Drug Name Tier Notes *URINARY *URINARY ANTISPASMODICS* ANTISPASMODICS - *URINARY BETA-3 ADRENERGIC ANTISPASMODIC - AGONISTS*** ANTIMUSCARINIC GEMTESA ORAL 3 ST; QL (ANTICHOLINERGIC)** TABLET * MYRBETRIQ ORAL darifenacin hydrobromide er SUSPENSION 3 QL oral tablet extended release 1 or 1b* QL RECONSTITUTED ER 24 hour MYRBETRIQ ORAL DETROL LA ORAL TABLET EXTENDED 3 QL CAPSULE EXTENDED 3 ST; QL RELEASE 24 HOUR RELEASE 24 HOUR *URINARY DETROL ORAL TABLET 3 ST; QL ANTISPASMODICS - DITROPAN XL ORAL CHOLINERGIC TABLET EXTENDED AGONISTS*** 3 ST; QL RELEASE 24 HOUR 10 bethanechol chloride oral 1 or 1b* MG, 5 MG tablet GELNIQUE *URINARY TRANSDERMAL GEL 10 3 ST; QL ANTISPASMODICS - % DIRECT MUSCLE oxybutynin chloride er oral RELAXANTS*** tablet extended release 24 1 or 1b* QL flavoxate hcl oral tablet 1 or 1b* hour *VACCINES* oxybutynin chloride oral 1 or 1b* QL *BACTERIAL syrup VACCINES*** oxybutynin chloride oral 1 or 1b* QL ACTHIB tablet INTRAMUSCULAR 3 $0 OXYTROL SOLUTION TRANSDERMAL PATCH 3 ST; QL RECONSTITUTED TWICE WEEKLY BCG VACCINE solifenacin succinate oral INJECTION 3 $0 1 or 1b* QL tablet INJECTABLE tolterodine tartrate er oral BEXSERO capsule extended release 24 1 or 1b* QL INTRAMUSCULAR 3 $0 hour SUSPENSION tolterodine tartrate oral tablet 1 or 1b* QL PREFILLED SYRINGE TOVIAZ ORAL TABLET BIOTHRAX EXTENDED RELEASE 24 3 QL INTRAMUSCULAR 3 HOUR SUSPENSION trospium chloride er oral HIBERIX INJECTION capsule extended release 24 1 or 1b* QL SOLUTION 3 $0 hour RECONSTITUTED trospium chloride oral tablet 1 or 1b* QL MENACTRA INTRAMUSCULAR 3 $0 VESICARE LS ORAL 3 PA; QL INJECTABLE SUSPENSION MENQUADFI VESICARE ORAL 3 ST; QL INTRAMUSCULAR 3 $0 TABLET INJECTABLE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 189 Drug Name Tier Notes Drug Name Tier Notes MENVEO ENGERIX-B INJECTION INTRAMUSCULAR SUSPENSION 10 3 $0 3 $0 SOLUTION MCG/0.5ML, 20 MCG/ML RECONSTITUTED FLUAD PEDVAX HIB QUADRIVALENT 2 $0; QL INTRAMUSCULAR 3 $0 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE PNEUMOVAX 23 FLUARIX INJECTION 2 $0 QUADRIVALENT INJECTABLE INTRAMUSCULAR 2 $0; QL PREVNAR 13 SUSPENSION INTRAMUSCULAR 2 $0 PREFILLED SYRINGE SUSPENSION FLUBLOK PREVNAR 20 QUADRIVALENT INTRAMUSCULAR INTRAMUSCULAR 2 $0; QL 2 SUSPENSION SOLUTION PREFILLED PREFILLED SYRINGE SYRINGE TRUMENBA FLUCELVAX INTRAMUSCULAR QUADRIVALENT 3 $0 2 $0; QL SUSPENSION INTRAMUSCULAR PREFILLED SYRINGE SUSPENSION TYPHIM VI FLUCELVAX INTRAMUSCULAR QUADRIVALENT 3 SOLUTION 25 INTRAMUSCULAR 2 $0; QL MCG/0.5ML SUSPENSION PREFILLED SYRINGE VAXCHORA ORAL SUSPENSION 3 FLULAVAL RECONSTITUTED QUADRIVALENT INTRAMUSCULAR 2 $0; QL *VIRAL VACCINE SUSPENSION COMBINATIONS*** PREFILLED SYRINGE M-M-R II INJECTION FLUMIST SOLUTION 3 $0 QUADRIVALENT NASAL 2 $0; QL RECONSTITUTED SUSPENSION PROQUAD FLUZONE HIGH-DOSE SUBCUTANEOUS 3 $0 QUADRIVALENT SUSPENSION INTRAMUSCULAR 2 $0; QL RECONSTITUTED SUSPENSION TWINRIX PREFILLED SYRINGE INTRAMUSCULAR 3 $0 FLUZONE SUSPENSION QUADRIVALENT 2 $0; QL PREFILLED SYRINGE INTRAMUSCULAR *VIRAL VACCINES*** SUSPENSION , 0.5 ML AFLURIA FLUZONE QUADRIVALENT QUADRIVALENT 2 $0; QL INTRAMUSCULAR INTRAMUSCULAR 2 $0; QL SUSPENSION SUSPENSION PREFILLED SYRINGE AFLURIA 0.5 ML QUADRIVALENT INTRAMUSCULAR 2 $0; QL GARDASIL 9 SUSPENSION INTRAMUSCULAR 2 $0 PREFILLED SYRINGE SUSPENSION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 190 Drug Name Tier Notes Drug Name Tier Notes GARDASIL 9 *VAGINAL AND INTRAMUSCULAR RELATED PRODUCTS* 2 $0 SUSPENSION *IMIDAZOLE-RELATED PREFILLED SYRINGE ANTIFUNGALS*** HAVRIX GYNAZOLE-1 VAGINAL INTRAMUSCULAR 3 3 $0 CREAM SUSPENSION 1440 EL miconazole 3 vaginal U/ML, 720 EL U/0.5ML 1 or 1b* suppository HEPLISAV-B INTRAMUSCULAR terconazole vaginal cream 1 or 1b* QL 3 $0 SOLUTION PREFILLED terconazole vaginal 1 or 1b* QL SYRINGE suppository IMOVAX RABIES *MISCELLANEOUS INTRAMUSCULAR 3 VAGINAL INJECTABLE PRODUCTS*** IPOL INJECTION INTRAROSA VAGINAL 3 $0 3 ST; QL INJECTABLE INSERT IXIARO *SPERMICIDES*** INTRAMUSCULAR 3 ENCARE VAGINAL SUSPENSION 2 OTC; $0 SUPPOSITORY RABAVERT INTRAMUSCULAR OPTIONS GYNOL II 3 SUSPENSION CONTRACEPTIVE 2 OTC; $0 RECONSTITUTED VAGINAL GEL RECOMBIVAX HB SHUR-SEAL INJECTION CONTRACEPTIVE 2 OTC; $0 SUSPENSION 10 3 $0 VAGINAL GEL MCG/ML, 40 MCG/ML, 5 TODAY SPONGE 2 OTC; $0 MCG/0.5ML VAGINAL ROTARIX ORAL VCF VAGINAL SUSPENSION 3 $0 CONTRACEPTIVE 2 OTC; $0 RECONSTITUTED VAGINAL FILM ROTATEQ ORAL VCF VAGINAL 3 $0 SOLUTION CONTRACEPTIVE 2 OTC; $0 SHINGRIX VAGINAL FOAM INTRAMUSCULAR VCF VAGINAL SUSPENSION 3 $0 CONTRACEPTIVE 2 OTC; $0 RECONSTITUTED 50 VAGINAL GEL MCG/0.5ML *VAGINAL ANTI- STAMARIL INJECTION INFECTIVES*** SUSPENSION 3 CLEOCIN VAGINAL 3 RECONSTITUTED CREAM VAQTA CLEOCIN VAGINAL INTRAMUSCULAR 2 3 $0 SUPPOSITORY SUSPENSION 25 clindamycin phosphate UNIT/0.5ML, 50 UNIT/ML 1 or 1b* vaginal cream VARIVAX CLINDESSE VAGINAL SUBCUTANEOUS 3 $0 3 INJECTABLE CREAM YF-VAX metronidazole vaginal gel 1 or 1b* SUBCUTANEOUS 3 NUVESSA VAGINAL 3 INJECTABLE GEL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 191 Drug Name Tier Notes Drug Name Tier Notes vandazole vaginal gel 1 or 1b* EPIPEN JR 2-PAK *VAGINAL INJECTION SOLUTION 3 ST; QL CONTRACEPTIVE PH AUTO-INJECTOR MODULATOR - SYMJEPI INJECTION COMBINATIONS*** SOLUTION PREFILLED 2 QL PHEXXI VAGINAL GEL 3 SYRINGE *VAGINAL *NEUROGENIC ESTROGENS*** ORTHOSTATIC HYPOTENSION (NOH) - ESTRACE VAGINAL 3 AGENTS*** CREAM droxidopa oral capsule 1 or 1b* PA; LD; SP; QL estradiol vaginal cream 1 or 1b* NORTHERA ORAL 3 PA; LD; SP; QL estradiol vaginal tablet 1 or 1b* QL CAPSULE ESTRING VAGINAL 3 QL *VASOPRESSORS*** RING AKOVAZ FEMRING VAGINAL 3 QL INTRAVENOUS 3 RING SOLUTION IMVEXXY BIORPHEN MAINTENANCE PACK 3 QL INTRAVENOUS 3 VAGINAL INSERT SOLUTION IMVEXXY STARTER 3 QL EMERPHED PACK VAGINAL INSERT INTRAVENOUS 3 PREMARIN VAGINAL SOLUTION 2 QL CREAM EPHEDRINE SULFATE VAGIFEM VAGINAL (PRESSORS) INJECTION 3 QL 3 TABLET 10 MCG SOLUTION PREFILLED SYRINGE 50 MG/10ML yuvafem vaginal tablet 1 or 1b* QL EPHEDRINE SULFATE *VAGINAL INTRAVENOUS 3 PROGESTINS*** SOLUTION CRINONE VAGINAL 4 SP EPHEDRINE SULFATE- GEL 4 % NACL INTRAVENOUS CRINONE VAGINAL SOLUTION PREFILLED 4 PA; SP; QL 3 GEL 8 % SYRINGE 10-0.9 MG/ML- ENDOMETRIN %, 100-0.9 MG/10ML-%, 3 PA VAGINAL INSERT 50-0.9 MG/10ML-% *VASOPRESSORS* EPINEPHRINE HCL- NACL INTRAVENOUS 3 *ANAPHYLAXIS SOLUTION 8-0.9 THERAPY AGENTS*** MG/250ML-% ADRENALIN INJECTION 3 EPINEPHRINE SOLUTION INJECTION SOLUTION 3 AUVI-Q INJECTION PREFILLED SYRINGE SOLUTION AUTO- 3 ST; QL 0.2 MG/0.2ML INJECTOR EPINEPHRINE epinephrine (anaphylaxis) INTRAVENOUS 3 1 or 1b* injection solution SOLUTION epinephrine injection EPINEPHRINE 1 or 1b* QL INTRAVENOUS solution auto-injector 3 SOLUTION PREFILLED EPIPEN 2-PAK SYRINGE 1 MG/10ML INJECTION SOLUTION 3 ST; QL AUTO-INJECTOR

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 192 Drug Name Tier Notes Drug Name Tier Notes EPINEPHRINE PF PHENYLEPHRINE HCL- 3 INJECTION SOLUTION NACL INTRAVENOUS EPINEPHRINE- SOLUTION PREFILLED DEXTROSE SYRINGE 0.4-0.9 3 INTRAVENOUS MG/10ML-%, 0.8-0.9 3 SOLUTION MG/10ML-%, 100-0.9 MCG/10ML-%, 20-0.9 EPINEPHRINE-NACL MG/50ML-%, 5-0.9 INTRAVENOUS 3 MG/50ML-% SOLUTION VAZCULEP GIAPREZA INTRAVENOUS 3 INTRAVENOUS 3 SOLUTION SOLUTION *VITAMINS* LEVOPHED INTRAVENOUS 3 *VITAMIN A*** SOLUTION AQUASOL A INTRAMUSCULAR midodrine hcl oral tablet 1 or 1b* 3 SOLUTION 50000 NOREPINEPHRINE UNIT/ML (BASE)-DEXTROSE INTRAVENOUS 3 *VITAMIN B-1*** SOLUTION 4-5 thiamine hcl injection 1 or 1b* MG/250ML-% solution norepinephrine bitartrate *VITAMIN B-6*** 1 or 1b* intravenous solution pyridoxine hcl injection 1 or 1b* NOREPINEPHRINE- solution DEXTROSE *VITAMIN C*** INTRAVENOUS 3 ASCOR INTRAVENOUS SOLUTION 4-5 3 MG/250ML-%, 8-5 SOLUTION MG/250ML-% *VITAMIN D*** NOREPINEPHRINE- DRISDOL ORAL 3 SODIUM CHLORIDE CAPSULE INTRAVENOUS 3 SOLUTION 8-0.9 ergocalciferol oral capsule 1 or 1a* MG/500ML-% vitamin d (ergocalciferol) PHENYLEPHRINE HCL oral capsule 1.25 mg (50000 1 or 1a* INTRAVENOUS 3 ut) SOLUTION 10 MG/ML *VITAMIN K*** PHENYLEPHRINE HCL- MEPHYTON ORAL 3 NACL INTRAVENOUS TABLET SOLUTION 10-0.9 phytonadione injection MG/250ML-%, 100-0.9 solution 1 mg/0.5ml, 10 1 or 1b* MG/250ML-%, 20-0.9 3 mg/ml MG/250ML-%, 25-0.9 MG/250ML-%, 40-0.9 phytonadione oral tablet 1 or 1b* MG/250ML-%, 50-0.9 vitamin k1 injection solution 1 or 1b* MG/250ML-%, 80-0.9 1 mg/0.5ml, 10 mg/ml MG/250ML-%

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 193 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 10/01/2021 194 Most plans include our convenient home delivery program at no extra cost to you. Find out more at anthem.com or call 833-236-6196.

For information about your pharmacy benefit, log in at anthem.com.

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

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Rev. 8/19