2021 Aetna California Four Tier Open Small Group ACA Plan

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2020 Aetna Pharmacy Drug Guide Aetna Small Group ACA Formulary - California

Visit www.aetna.com/formulary for the most up-to-date information. For a summary of your coverage or benefits plan log in to your secure member site. Or call the toll-free number on your member ID card.

The formulary is updated the first week of each month. The formulary is subject to change. Previous versions are no longer in effect.

The Medical plan names to which this document applies to in the state of California are listed below:

Plan Name Aetna Value Network HMO AWH Sharp OA Managed Choice® POS Aetna Value Network HMO HDHP AWH Sharp OA Managed Choice® POS HDHP AHF OA Managed Choice® POS AWH Southern California HMO AHF Savings Plus OA Managed Choice® POS HMO AWH MemorialCare OA Elect Choice® EPO HMO Basic AWH MemorialCare OA Managed Choice® POS HMO Basic HDHP AWH MemorialCare OA Managed Choice® POS HDHP HMO Deductible AWH PrimeCare HMO HMO Deductible HDHP AWH PrimeCare OA Elect Choice® EPO HMO HDHP AWH PrimeCare OA Managed Choice® POS OA Managed Choice POS AWH PrimeCare OA Managed Choice® POS HDHP OA Managed Choice POS HDHP AWH Providence OA Elect Choice® EPO Open Choice PPO AWH Providence OA Managed Choice® POS Open Choice PPO HDHP AWH Providence OA Managed Choice® POS HDHP Savings Plus OA Managed Choice® POS AWH Sharp OA Elect Choice® EPO Savings Plus OA Managed Choice® POS HDHP Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna HealthAssurance Pennsylvania Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In Utah and Wyoming by Aetna Health of Utah Inc. and Aetna Life Insurance Company. In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. 2021 Small Group ACA CA

Table of Contents

INFORMATIONAL SECTION...... 4 ALTERNATIVE MEDICINES...... 17 ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION...... 17 ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS...... 32 ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER...... 54 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES...... 67 CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS...... 67 CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS...... 90 ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES...... 130 GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS...... 175 GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS...189 HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS...... 194 IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM.....202 MEDICAL DEVICES...... 213 NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS...... 240 OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS...... 251 OTHER...... 259 PHARMACEUTICAL ADJUVANTS...... 259 RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS...... 259 TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS...... 276

TOC-3 Definitions

Brand name drug means a drug that is marketed under Generic drug means a drug that is the same as its brand a proprietary, trademark-protected name. A brand name name drug equivalent in dosage, strength, effect, how it drug is listed in this formulary in all CAPITAL letters. is taken, quality, safety, and intended use. A generic drug is listed in this formulary in italicized lowercase letters. Coinsurance means a percentage of the cost of a covered health care benefit that you pay after you have Medically Necessary means health care benefits paid the deductible, if a deductible applies to the health needed to diagnose, treat, or prevent a medical condition care benefit. or its symptoms and that meet accepted standards of medicine. Health insurance usually does not cover health Copayment means a fixed dollar amount that you care benefits that are not medically necessary. pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the Non-formulary drug means a prescription drug that is health care benefit. not listed on this formulary.

Deductible means the amount you pay for covered Out-of-pocket costs means your expenses for health health care benefits that are subject to the deductible care benefits that aren’t reimbursed by your health before your health insurer begins to pay. If your health insurance. Out-of-pocket costs include deductibles, insurance policy has a deductible, it may have either one copayments, and coinsurance for covered health care deductible or separate deductibles for medical benefits benefits, plus all costs for health care benefits that are and prescription drug benefits. After you pay your not covered. deductible, you usually pay only a copayment or Prescribing provider means a health care provider who coinsurance for covered health care benefits. Your can write a prescription for a drug to diagnose, treat, or insurance company pays the rest. prevent a medical condition. Drug Tier means a group of prescription drugs that Prescription means an oral, written, or electronic order correspond to a specified cost sharing tier in your from a prescribing provider authorizing a prescription health insurance policy. The drug tier in which a drug to be provided to a specific individual. prescription drug is placed determines your portion of the cost for the drug. Prescription drug means a drug that by law requires a prescription. Enrollee is a person enrolled in a health plan who is entitled to receive services from the plan. Prior Authorization means a decision by your health insurer that a health care benefit is medically necessary Exception request means a request for coverage of for you. If a prescription drug is subject to prior a non-formulary drug. If you, your designee, or your authorization in this formulary, your prescribing provider prescribing health care provider submits a request for must request approval from your health insurer to cover coverage of a non-formulary drug, your insurer must the drug before you fill your prescription. Your health cover the non-formulary drug when it is medically insurer must grant a prior authorization request when necessary for you to take the drug. it is medically necessary for you to take the drug. Exigent circumstances means when you are suffering Step therapy means a specific sequence in which from a medical condition that may seriously jeopardize prescription drugs for a particular medical condition your life, health, or ability to regain maximum function, or must be tried. If a drug is subject to step therapy in this when you are undergoing a current course of treatment formulary, you may have to try one or more other drugs using a non-formulary drug. before your health insurance policy will cover that drug Formulary or prescription drug list means the list of for your medical condition. If your prescribing provider drugs that is covered by your health insurance policy submits a request for an exception to the step therapy under the prescription drug benefit of the policy. requirement, your health insurer must grant the request when it is medically necessary for you to take the drug.

Subscriber means the person who is responsible for payment to a plan or whose employment or other status, except for family dependency, is the basis for eligibility for membership in the plan.

1 How to use this guide

Your guide includes a list of commonly used drugs covered on your pharmacy plan. The amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the prescription’s price after you meet your deductible, if applicable. Preferred generic drugs cost less. Preferred brand drugs will have a higher cost.

Refer to the Summary of Benefits for differences and information about the prescription drugs covered under your Outpatient prescription drugs and medical benefit in your plan.

A prescription drug may be located by looking up Your plan includes the therapeutic category and class to which the drug • Brand and generic drugs that are hand-picked for their belongs or the brand or generic name of the drug quality and effectiveness in the alphabetical index; and • A specialty pharmacy fills specialty drug prescriptions If a generic equivalent for a brand name drug is not (ones that are injected, infused or taken by mouth) — available on the market or is not covered, the drug will and provides services that include personal support, not be separately listed by its generic name. helpful resources and training, and free secure • A drug is listed alphabetically by its brand and generic home delivery names in the therapeutic category and class to which • A home delivery pharmacy that delivers maintenance it belongs; drugs to your home or wherever you choose (for drugs • The generic name for a brand name drug is included that are taken regularly to treat conditions like diabetes after the brand name in parentheses and all lowercase or asthma) italicized letters. (For example: COREG (carvedilol)) • If a generic equivalent for a brand name drug is both What you can expect to pay available and covered, the generic drug will be listed With your pharmacy plan, the amount you pay depends separately from the brand name drug in all lowercase on the drug your doctor prescribes. It’s either a flat fee or italicized letters; and (For example: carvedilol) a percentage of the drug’s/medicine price. If a • If a generic drug is marketed under a proprietary, pharmacy’s retail price for a prescription drug is less than trademark-protected brand name, the brand name your total cost share amount, you will not be required to will be listed after the generic name in parentheses pay more than the retail drug price. and regular typeface with the first letter of each word capitalized. (For example: desogestrel-ethinyl Each drug is grouped as a generic, a brand or a specialty estradiol (Azurette)). drug. The preferred drugs within these groups will generally save you money compared to a non-preferred • Inclusion of a prescription drug on the formulary drug. Typically, generic drugs are less expensive does not guarantee that your provider will prescribe than brands. the drug for a particular medical condition. • Therapeutic categories and classes are based on Specialty prescription drugs typically include higher-cost the Medispan therapeutic classification system. drugs that require special handling, special storage or monitoring. These types of drugs may include, but are not limited to, drugs that are injected, infused, inhaled or taken by mouth.

2 You’re covered for all types of medicine — some more Specialty Pharmacy Network expensive, and some less. An in-network specialty pharmacy can fill your • Generic – G (tier 1): the lowest cost share prescriptions for specialty drugs. These are the • Preferred brand – PB (tier 2): a slightly higher types of drugs that may be injected, infused or taken cost share by mouth. They often need special storage and handling. And they need to be delivered quickly. A nurse or • Non-preferred brand – NPB (tier 3): a higher pharmacist may monitor your treatment, if needed. cost share With this type of pharmacy, you can get this medicine • Specialty – SP (tier 4): lower cost share for sent right to our mailbox. specialty drugs • Copay Exception – CE: Available to some members How to get started with a specialty pharmacy at no cost with a prescription from your provider Ordering your prescriptions through our specialty when obtained at an in-network pharmacy. Certain pharmacy is easy. And we typically offer a 30-day limitations may apply. medicine supply. Your pharmacy plan may not have all the coverage levels • To transfer your prescription, just call us toll-free listed above so check your plan documents to see how at 1-866-353-1892. much you will pay, for example your copayments and , your doctor can send it to maximum dollar amounts. • For a new prescription us in one of four ways: For your exact coverage and cost, and 1. Electronically: Through e-prescribe to learn more about your plan 2. Fax: 1-800-323-2445

Visit the website that’s on your member ID card. 3. Phone: 1-800-237-2767 Then log in to your account, where you can: If you mail in your own prescription, please send it • Find out the coverage and estimate of cost for with a completed Patient Profile Form. To find this specific drugs form, just visit the website that’s on your member ID • View your deductibles and plan limits card, to search for the “Patient Profile Form”.

• Order medications

• Check your pharmacy order status

• Get a member ID card

• View your claims, Explanation of Benefits and more

Have more questions about your pharmacy benefits?

We’re here to help. There are several ways you can learn more about your benefits:

• Check your Plan Design and Benefits Summary in your enrollment kit. • Call the toll-free number on your member ID card. • Review our pharmacy frequently asked questions (FAQs) and answers. Just visit the website that’s on your member ID card to search for the “Pharmacy FAQ”.

3 CVS Caremark Mail Service Pharmacy™

You can have maintenance drugs sent right to your home or anywhere else you choose with CVS Caremark Mail Service Pharmacy. These are drugs that are taken regularly for chronic conditions like diabetes or asthma. Depending on your plan, you can get up to a 90-day supply of medicine for less cost. It’s fast and convenient, and standard shipping is always free.

Get started right away

You can submit your order using one of these options:

1. Online — Visit your secure member website and sign in to your account. There you can add or remove your prescriptions.

2. Phone — Call us toll-free, 24/7 at 1-888-792-3862. If you need the help of a telephone device for the hard of hearing, call 1-877-833-2779.

3. Mail — Get a new prescription from your doctor. Then mail it to us with a completed order form. You can find the form on your secure member website. The mailing address is on the form.

Your doctor can submit your order using one of these options:

1. Online — They can submit your prescriptions using the e-prescribe services on our provider website.

2. Fax — They can fax your prescription to 1-877-270-3317. Make sure they include your member ID number, date of birth and mailing address on the fax cover sheet. Only a doctor may fax a prescription.

4 Frequently asked questions

How can I save on prescriptions? What is step therapy?

Here are some tips to pay less out of pocket for your Some drugs require step therapy. This means that prescription drugs: you must try one or more prerequisite drug(s) before a step therapy drug is covered. • Ask your doctor to consider prescribing drugs that are on the Pharmacy Drug Guide (formulary). The prerequisite drugs have U.S. Food and Drug • Ask your doctor to consider prescribing generic Administration (FDA) approval and may cost less. drugs instead of brand-name drugs. They treat the same condition as the step therapy drug. • Our home delivery service may save you money. For If you don’t try the appropriate prerequisite drug(s) first, more information, visit the website on your member you may need to pay full cost for the step-therapy drug. ID card and log in to your account. What are quantity limits? What are generic drugs? Quantity limits help your doctor and pharmacist make Generic drugs are proven to be just as safe and effective sure that you use your drug correctly and safely. We use as brand-name drugs. They contain the same active medical guidelines and FDA-approved recommendations ingredients in the same amounts as the brand-name from drug makers to set these coverage limits. The drugs and work the same way. So they have the same quantity limit program includes: risks and benefits as brand-name drugs. However, they • Dose efficiency edits — Limits prescription coverage typically cost less. to one dose per day for drugs that have approval for When appropriate, your doctor may decide to prescribe once-daily dosing a generic drug or allow the pharmacist to substitute a • Maximum daily dose — If a prescription is lower than generic drug. the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy What is prior authorization? • Quantity limits over time — Limits prescription Prior authorization is one way that we can help you and coverage to a specific number of units over a specific your doctor find safe, appropriate drugs and keep costs amount of time down. Prior authorization means that you or your doctor need to get approval from the plan before certain drugs What if I need a drug that requires an exception will be covered. Generally, Prior authorization applies to to the prior authorization, step therapy or drugs that: quantity limits requirements? Or what if I need • Are often taken in the wrong way a drug that’s not covered under my plan? • Should only be used for certain conditions In certain cases, you or your prescriber can request a • Often cost more than other drugs that are proven medical exception to the prior authorization, step therapy to be just as effective or quantity limits requirement or for a drug that’s not covered on your plan. Coverage determinations will be Keep in mind that your doctor must contact us to request made within 72 hours of receiving non-urgent requests. approval of coverage for these drugs. You can ask for your request to be expedited. Expedited coverage decisions are made within 24 hours.

5 We’ll then contact you or your prescriber with our Can the formulary change during the year? decision. All medically necessary outpatient prescription The formulary can change throughout the year. drugs will be covered. If a medical exception is approved, Some reasons why they can change include: you only need to pay the copay after the deductible. This amount is based on your pharmacy plan design. • New drugs are approved.

Medical exceptions which are approved for non-urgent • Existing drugs are removed from the market. requests will cover the duration of the prescription, • Prescription drugs may become available over the including refills. Approved medical exceptions for exigent counter (without a prescription). Over-the-counter circumstances will provide coverage for the duration of drugs are not generally covered in a formulary. the exigency. • Brand-name drugs lose patent protection and If your request is denied you have the right to file an generic versions become available. When this happens, appeal using the process described in the notification the generic drug will be covered in place of the letter. brand-name drug. The brand-name drug is likely to become non-formulary or covered at a higher cost. If a determination is not made for a prior authorization or See the “what are generic drugs?” section above for step therapy exception request within 72 hours of more information. receiving a non-urgent request and 24 hours of receiving a request based on exigent circumstances, the request Pharmacy and Therapeutics (P&T) committee is deemed approved and we may not deny the request thereafter. The services of an independent National Pharmacy and Therapeutics Committee (“P&T Committee”) are utilized In accordance with state law, members who are covered to approve safe and clinically effective drug therapies. under small group health insurance policies and who The P&T Committee is an external advisory body of have previously received approval from us for coverage clinical professionals from across the United States. The of medications for the members’ medical conditions P&T Committee’s voting members include physicians, will continue to have those medications covered, for pharmacists, a pharmacoeconomist and a medical as long as the prescriber continues prescribing them, ethicist, all of whom have a broad background of clinical provided that the drug is appropriately prescribed and and academic expertise regarding prescription drugs. is considered safe and effective for treating the Voting members of the P&T Committee are not member’s medical condition. employees of CVS Caremark and must disclose any financial relationship or conflicts of interest with any How can your provider request a medical pharmaceutical manufacturers. exception?

The following options will provide detail to help request How do you find a pharmacy? a medical exception. You can find a pharmacy in two ways: • Submit their request through our secure provider • Online: By logging onto your secure member website website on www.availity.com. at Aetna.com. • Call the Aetna Pharmacy prior authorization unit: • By phone: Call the toll-free number on your ID card. Non-Specialty 1-800-294-5979 or During regular business hours, a representative can Specialty 1-866-814-5506. assist you. Our automated telephone assistant can • Fax the completed request form to: give you this information 24 hours a day. Non-Specialty 1-888-836-0730 or Specialty 1-866-249-6155. • Mail the completed request form to: Aetna Pharmacy Management 1300 East Campbell Road Richardson, TX 75081

6 Assistive Technology

Persons using assistive technology may not be able to fully access the following information. For assistance, please call 1-888-802-3862.

Smartphone or Tablet

To view documents from your smartphone or tablet, the free WinZip app is required. It may be available from your App Store.

Non-Discrimination

Aetna complies with applicable California and Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, ancestry, religion, sex, marital status, age, gender, gender identity, sexual orientation or disability.

Aetna provides free aids/services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.

If you believe we have failed to provide these services or otherwise discriminated based on race, color, national origin, ancestry, religion, sex, marital status, age, gender, gender identity, sexual orientation or disability, you can also file a grievance with the Civil Rights Coordinator by contacting:

Civil Rights Coordinator P.O. Box 24030, Fresno, CA 93779 1-800-648-7817, TTY: 711, Fax: 860-262-7705 [email protected].

You can also file a complaint with the California Department of Insurance at www.insurance.ca.gov, or at: Consumer Services Division, 300 Spring Street South Tower, Los Angeles CA 90013, or at 1-800-927-HELP (4357), TDD: 1-800-482-4TDD (4833).

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights if there is a concern of discrimination based on race, color, national origin, age, disability, or sex. You can file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).

7 8 9 10 Remember to visit the website on your member ID card. Then sign in to your account for the most up-to-date information.

Please note that if your prescription drug benefits plan changes, the information here may no longer apply. Medications on the Aetna Drug Guide, precertification, step-therapy and quantity limits lists are subject to change. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. The drugs on the Pharmacy Drug (formulary) Guide, Formulary Exclusions, Precertification, Quantity Limit and Step Therapy Lists are subject to change. The quantity limits and step therapy drug coverage review programs are not available in all service areas. For example, step therapy programs do not apply to fully insured members in Indiana. Step therapy does not apply to fully-insured members in New Jersey. However, these programs are available to self-funded plans. In accordance with state law, commercial fully insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added or removed from the Pharmacy Drug (formulary) Guide, Precertification, Quantity Limits or Step-Therapy Lists during the plan year will continue to have those medications covered at the same benefit level until their plan’s renewal date. In Texas, precertification approval is known as “pre-service utilization review.” It is not “verification” as defined by Texas law. In accordance with state law, certain fully insured commercial California members (except Federal Employee Health Benefit Plan members) who obtained approval from an Aetna plan for coverage of drugs that are later added to the Preauthorization or Step Therapy Lists or removed from the Pharmacy Drug Guide will continue to have those drugs covered, for as long as the treating in-network provider continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical condition. Aetna reserves the right to periodically request clinical information from your provider to assess your medical condition and the appropriateness of your ongoing treatment. Failure to provide clinical information could result in subsequent denial of coverage for this medication. In accordance with state law, fully insured Commercial Connecticut preferred provider organization (PPO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for drugs that are added to the Precertification or Step-Therapy Lists will continue to have those drugs covered for as long as the treating prescriber prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. In certain states, including Arkansas, Colorado, Connecticut, Delaware, Georgia, Illinois, Louisiana, Maryland, Minnesota, North Dakota, Pennsylvania and Texas, step therapy programs do not apply to fully insured members utilizing prescription drugs for the treatment of stage-four advanced, metastatic cancer. This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information is subject to change. CVS Caremark Mail Service Pharmacy is part of the CVS Health family of companies

Aetna.com

©2021 Aetna Inc. List of Abbreviations CE: Copay Exception: Available to some members at no cost with a prescription from your provider when obtained at an in-network pharmacy. Certain limitations may apply.

NF: Non-formulary, not covered unless exception request granted

Tier 1: Generics

Tier 2: Preferred Brands

Tier 3: Non-Preferred Brands

Tier 4: Specialty

#: Brand-name drug expected to become available generically in the near future. After the generic drug becomes available, the brand-name drug may be covered at a higher non-preferred copay and/or added to the non-formulary list. The brand-name drug may also be subject to precertification and/or step-therapy.

AL: Age Limit

IBC: Indication Based Coverage

LGC: Lowest Generic Copay Applies

N2: Drug tier when CE does not apply

NPL: (National Precertification List) – Prior authorization, also called preauthorization or precertification, is required for all plans. Your doctor must contact us to request approval for coverage.

OTC: OTC Covered

PA: Prior Authorization

QL: Quantity Limit

SP Pharmacy: You may pay higher out of pocket costs and may be required to get these products at an Aetna Specialty Pharmacy network provider, like Aetna Specialty Pharmacy. Specialty products are limited to a 30 day supply.

ST: Step Therapy

15 UPPERCASE: Brand name drugs

16 Coverage Requirements and Prescription Drug Name Drug Tier Limits ALTERNATIVE MEDICINES ALTERNATIVE MEDICINES QUINZYME ORAL TABLET DISPERSIBLE 90 MG NF (coenzyme q10) ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION COX-2 INHIBITORS CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, NF 50 MG (celecoxib) celecoxib oral capsule 100 mg, 200 mg, 50 mg Tier 1 ST; QL (2 capsules per 1 celecoxib oral capsule 400 mg Tier 1 day) GOUT - DRUGS TO TREAT GOUT allopurinol oral tablet 100 mg, 300 mg Tier 1 colchicine oral capsule 0.6 mg NF colchicine oral tablet 0.6 mg Tier 1 colchicine-probenecid oral tablet 0.5-500 mg Tier 1 COLCRYS ORAL TABLET 0.6 MG (colchicine) NF DUZALLO ORAL TABLET 200-200 MG, 200-300 MG NF (lesinurad-allopurinol) febuxostat oral tablet 40 mg, 80 mg Tier 1 ST GLOPERBA ORAL SOLUTION 0.6 MG/5ML (colchicine) NF MITIGARE ORAL CAPSULE 0.6 MG (colchicine) NF probenecid oral tablet 500 mg Tier 1 ULORIC ORAL TABLET 40 MG, 80 MG (febuxostat) NF ZURAMPIC ORAL TABLET 200 MG (lesinurad) NF ZYLOPRIM ORAL TABLET 100 MG, 300 MG (allopurinol) NF MISCELLANEOUS butalbital-apap-caffeine (Capacet Oral Capsule 50-325-40 Mg) Tier 1 duraxin oral capsule 300-200-20 mg Tier 3

17 Coverage Requirements and Prescription Drug Name Drug Tier Limits marten-tab oral tablet 50-325 mg Tier 1 RIDAURA ORAL CAPSULE 3 MG (auranofin) Tier 3 NON-OPIOID ANALGESICS ALLZITAL ORAL TABLET 25-325 MG (butalbital- NF acetaminophen) butalbital-apap-caffeine (Bac Oral Tablet 50-325-40 Mg) Tier 1 QL (48 tablets per 25 days) butalbital-acetaminophen (Bupap Oral Tablet 50-300 Mg) Tier 1 butalbital-acetaminophen oral capsule 50-300 mg NF butalbital-acetaminophen oral tablet 25-325 mg NF butalbital-acetaminophen oral tablet 50-300 mg, 50-325 mg Tier 1 butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 QL (48 capsules per 1 Tier 1 mg month) butalbital-apap-caffeine oral tablet 50-325-40 mg Tier 1 QL (48 tablets per 1 month) QL (48 capsules per 1 butalbital-asa-caffeine oral capsule 50-325-40 mg Tier 1 month) butalbital-aspirin-caffeine oral capsule 50-325-40 mg Tier 1 butalbital-aspirin-caffeine oral tablet 50-325-40 mg Tier 3 butalbital-apap-caffeine (Esgic Oral Capsule 50-325-40 Mg) Tier 1 ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap- NF caffeine) FIORICET ORAL CAPSULE 50-300-40 MG (butalbital- NF apap-caffeine) FIORINAL ORAL CAPSULE 50-325-40 MG (butalbital- NF aspirin-caffeine) TENCON ORAL TABLET 50-325 MG (butalbital- NF acetaminophen) butalbital-apap-caffeine (Vanatol Lq Oral Solution 50-325-40 Tier 1 QL (90 ML per 1 day) Mg/15Ml) butalbital-apap-caffeine (Vanatol S Oral Solution 50-325-40 Tier 1 QL (90 ML per 1 day) Mg/15Ml)

18 Coverage Requirements and Prescription Drug Name Drug Tier Limits VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML NF (butalbital-apap-caffeine) butalbital-apap-caffeine (Zebutal Oral Capsule 50-325-40 Mg) Tier 1 NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION ANAPROX DS ORAL TABLET 550 MG (naproxen sodium) NF CAMBIA ORAL PACKET 50 MG (diclofenac NF potassium(migraine)) DAYPRO ORAL TABLET 600 MG (oxaprozin) NF diclofenac oral capsule 35 mg NF diclofenac potassium oral tablet 50 mg Tier 1 diclofenac sodium er oral tablet extended release 24 hour 100 Tier 1 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 Tier 1 mg EC-NAPROSYN ORAL TABLET DELAYED RELEASE NF 375 MG, 500 MG (naproxen) etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, Tier 1 600 mg etodolac oral capsule 200 mg, 300 mg Tier 1 etodolac oral tablet 400 mg, 500 mg Tier 1 FELDENE ORAL CAPSULE 10 MG, 20 MG (piroxicam) NF fenoprofen calcium oral capsule 200 mg Tier 3 fenoprofen calcium oral capsule 400 mg Tier 1 fenoprofen calcium oral tablet 600 mg Tier 1 FENORTHO ORAL CAPSULE 200 MG, 400 MG NF (fenoprofen calcium) flurbiprofen oral tablet 100 mg, 50 mg Tier 1 ibuprofen (Ibu Oral Tablet 600 Mg) Tier 1 ibuprofen oral suspension 100 mg/5ml Tier 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1

19 Coverage Requirements and Prescription Drug Name Drug Tier Limits INDOCIN ORAL SUSPENSION 25 MG/5ML Tier 3 (indomethacin) INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) Tier 3 indomethacin er oral capsule extended release 75 mg Tier 1 indomethacin oral capsule 20 mg NF indomethacin oral capsule 25 mg, 50 mg Tier 1 QL (3 capsules per 1 day) ketoprofen er oral capsule extended release 24 hour 200 mg NF ketoprofen oral capsule 50 mg, 75 mg Tier 1 ketorolac tromethamine nasal solution 15.75 mg/spray NF ketorolac tromethamine oral tablet 10 mg Tier 1 QL (20 tablets per 5 days) LODINE ORAL TABLET 400 MG (etodolac) NF meclofenamate sodium oral capsule 100 mg, 50 mg Tier 1 mefenamic acid oral capsule 250 mg Tier 1 meloxicam oral capsule 10 mg Tier 1 meloxicam oral capsule 5 mg NF meloxicam oral tablet 15 mg, 7.5 mg Tier 1 MOBIC ORAL TABLET 15 MG, 7.5 MG (meloxicam) NF nabumetone oral tablet 500 mg, 750 mg Tier 1 NALFON ORAL CAPSULE 400 MG (fenoprofen calcium) NF NAPRELAN ORAL TABLET EXTENDED RELEASE 24 NF HOUR 375 MG, 500 MG, 750 MG (naproxen sodium) NAPROSYN ORAL SUSPENSION 125 MG/5ML NF (naproxen) NAPROSYN ORAL TABLET 500 MG (naproxen) NF naproxen dr oral tablet delayed release 375 mg, 500 mg Tier 1 naproxen oral suspension 125 mg/5ml NF naproxen oral tablet 250 mg, 375 mg, 500 mg Tier 1 naproxen sodium er oral tablet extended release 24 hour 375 mg, NF 500 mg, 750 mg naproxen sodium oral tablet 275 mg, 550 mg Tier 1

20 Coverage Requirements and Prescription Drug Name Drug Tier Limits oxaprozin oral tablet 600 mg Tier 1 piroxicam oral capsule 10 mg, 20 mg Tier 1 PONSTEL ORAL CAPSULE 250 MG (mefenamic acid) NF QMIIZ ODT ORAL TABLET DISPERSIBLE 15 MG, 7.5 NF MG (meloxicam) RELAFEN DS ORAL TABLET 1000 MG (nabumetone) NF nabumetone (Relafen Oral Tablet 500 Mg, 750 Mg) NF SPRIX NASAL SOLUTION 15.75 MG/SPRAY (ketorolac NF tromethamine) sulindac oral tablet 150 mg, 200 mg Tier 1 TIVORBEX ORAL CAPSULE 20 MG, 40 MG NF (indomethacin) tolmetin sodium oral capsule 400 mg Tier 1 tolmetin sodium oral tablet 200 mg, 600 mg Tier 1 VIVLODEX ORAL CAPSULE 10 MG, 5 MG (meloxicam) NF # ZIPSOR ORAL CAPSULE 25 MG (diclofenac potassium) NF # ZORVOLEX ORAL CAPSULE 18 MG, 35 MG (diclofenac) NF NSAIDS, COMBINATIONS ARTHROTEC ORAL TABLET DELAYED RELEASE 50- NF 0.2 MG, 75-0.2 MG (diclofenac-misoprostol) diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75- Tier 1 0.2 mg DUEXIS ORAL TABLET 800-26.6 MG (ibuprofen- NF # famotidine) naproxen-esomeprazole oral tablet delayed release 375-20 mg, NF 500-20 mg VIMOVO ORAL TABLET DELAYED RELEASE 375-20 NF MG, 500-20 MG (naproxen-esomeprazole) OPIOID AGONIST/ANTAGONIST BUNAVAIL BUCCAL FILM 2.1-0.3 MG (buprenorphine Tier 3 ST; QL (6 films per 1 day) hcl-naloxone hcl)

21 Coverage Requirements and Prescription Drug Name Drug Tier Limits BUNAVAIL BUCCAL FILM 4.2-0.7 MG (buprenorphine Tier 3 ST; QL (3 films per 1 day) hcl-naloxone hcl) BUNAVAIL BUCCAL FILM 6.3-1 MG (buprenorphine hcl- Tier 3 ST; QL (2 films per 1 day) naloxone hcl) buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 2-0.5 Tier 1 QL (3 films per 1 day) mg, 4-1 mg, 8-2 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2- Tier 1 QL (3 tablets per 1 day) 0.5 mg, 8-2 mg pentazocine-naloxone hcl oral tablet 50-0.5 mg Tier 1 PA; QL (4 tablets per 1 day) SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4- Tier 3 QL (3 films per 1 day) 1 MG, 8-2 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7- 0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 Tier 2 MG, 8.6-2.1 MG (buprenorphine hcl-naloxone hcl) OPIOID ANALGESICS - DRUGS TO TREAT PAIN ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 100 MCG, 200 MCG, 300 MCG, 400 MCG, 600 MCG, 800 MCG NF # (fentanyl citrate) PA; QL (13 tablets per 1 acetaminophen-codeine #2 oral tablet 300-15 mg Tier 1 day) PA; QL (12 tablets per 1 acetaminophen-codeine #3 oral tablet 300-30 mg Tier 1 day) PA; QL (10 tablets per 1 acetaminophen-codeine #4 oral tablet 300-60 mg Tier 1 day) acetaminophen-codeine oral solution 120-12 mg/5ml Tier 1 PA; QL (90 ml per 1 day) PA; QL (13 tablets per 1 acetaminophen-codeine oral tablet 300-15 mg Tier 1 day) PA; QL (10 tablets per 1 acetaminophen-codeine oral tablet 300-60 mg Tier 1 day) ACTIQ BUCCAL LOZENGE ON A HANDLE 1200 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG NF (fentanyl citrate)

22 Coverage Requirements and Prescription Drug Name Drug Tier Limits APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG, NF 8.16-325 MG (benzhydrocodone-acetaminophen) PA; QL (10 capsules per 1 apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg Tier 1 day) apap-caff-dihydrocodeine oral tablet 325-30-16 mg NF ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT 15 MG, 30 MG, 60 MG (morphine NF sulfate) butalbital-asa-caff-codeine (Ascomp-Codeine Oral Capsule 50- PA; QL (6 capsules per 1 Tier 1 325-40-30 Mg) day) benzhydrocodone-acetaminophen oral tablet 4.08-325 mg, 6.12- PA; QL (168 tablets per 1 Tier 3 325 mg, 8.16-325 mg month) butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325- PA; QL (6 capsules per 1 Tier 1 40-30 mg day) PA; QL (48 tablets per 1 butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg Tier 1 month) PA; QL (2 bottles per 30 butorphanol tartrate nasal solution 10 mg/ml Tier 1 days) PA; QL (6 tablets per day codeine sulfate oral tablet 15 mg, 60 mg Tier 3 for 7 days only per 90 days) PA; QL (6 tablets per day codeine sulfate oral tablet 30 mg Tier 1 for 7 days only per 90 days) CONZIP ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 100 MG, 200 MG, 300 MG (tramadol hcl) DEMEROL ORAL TABLET 100 MG, 50 MG (meperidine NF hcl) DILAUDID ORAL LIQUID 1 MG/ML (hydromorphone hcl) NF DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG NF (hydromorphone hcl) DOLOPHINE ORAL TABLET 10 MG, 5 MG (methadone NF hcl) DURAGESIC-100 TRANSDERMAL PATCH 72 HOUR NF 100 MCG/HR (fentanyl) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

23 Coverage Requirements and Prescription Drug Name Drug Tier Limits DURAGESIC-12 TRANSDERMAL PATCH 72 HOUR 12 NF MCG/HR (fentanyl) DURAGESIC-25 TRANSDERMAL PATCH 72 HOUR 25 NF MCG/HR (fentanyl) DURAGESIC-50 TRANSDERMAL PATCH 72 HOUR 50 NF MCG/HR (fentanyl) DURAGESIC-75 TRANSDERMAL PATCH 72 HOUR 75 NF MCG/HR (fentanyl) EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 PA; ST; QL (1 capsule per 1 Tier 2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG (morphine-naltrexone) day) EMBEDA ORAL CAPSULE EXTENDED RELEASE 20- PA; ST; QL (2 capsules per Tier 2 0.8 MG, 30-1.2 MG (morphine-naltrexone) 1 day) oxycodone-acetaminophen (Endocet Oral Tablet 10-325 Mg) Tier 1 PA; QL (6 tablets per 1 day) oxycodone-acetaminophen (Endocet Oral Tablet 2.5-325 Mg, PA; QL (12 tablets per 1 Tier 1 5-325 Mg) day) oxycodone-acetaminophen (Endocet Oral Tablet 7.5-325 Mg) Tier 1 PA; QL (8 tablets per 1 day) EXALGO ORAL TABLET ER 24 HOUR ABUSE- DETERRENT 12 MG, 16 MG, 32 MG, 8 MG NF (hydromorphone hcl) EXALGO ORAL TABLET EXTENDED RELEASE 24 NF HOUR 12 MG, 16 MG, 32 MG, 8 MG (hydromorphone hcl) fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, PA; QL (120 lozenges per 30 Tier 1 200 mcg, 400 mcg, 600 mcg, 800 mcg days) fentanyl citrate buccal tablet 200 mcg, 400 mcg, 600 mcg, 800 PA; QL (120 tablets per 30 Tier 1 mcg days) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 PA; ST; QL (10 patches per mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 Tier 1 30 days) mcg/hr FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 NF MCG, 600 MCG, 800 MCG (fentanyl citrate) FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG NF (butalbital-apap-caff-cod)

24 Coverage Requirements and Prescription Drug Name Drug Tier Limits FIORINAL/CODEINE #3 ORAL CAPSULE 50-325-40-30 NF MG (butalbital-asa-caff-codeine) HYCET ORAL SOLUTION 7.5-325 MG/15ML NF (hydrocodone-acetaminophen) hydrocodone bitartrate er oral capsule er 12 hour abuse- PA; QL (2 capsules per 1 Tier 1 deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg day) hydrocodone bitartrate er oral capsule extended release 12 hour PA; ST; QL (2 capsules per Tier 1 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg 1 day) hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent PA; ST; QL (1 tablet per 1 Tier 1 100 mg, 120 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg day) hydrocodone-acetaminophen oral solution 10-325 mg/15ml Tier 3 QL (90 ml per 1 day) hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5- PA; QL (180 MLS per 1 Tier 1 217 mg/10ml day) hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml Tier 3 PA; QL (90 ml per 1 day) hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, Tier 1 PA; QL (6 tablets per 1 day) 7.5-300 mg, 7.5-325 mg PA; QL (12 tablets per 1 hydrocodone-acetaminophen oral tablet 2.5-325 mg Tier 1 day) hydrocodone-acetaminophen oral tablet 5-300 mg, 5-325 mg Tier 1 PA; QL (8 tablets per 1 day) hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 Tier 1 PA; QL (5 tablets per 1 day) mg hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12 Tier 1 PA; QL (1 tablet per 1 day) mg, 16 mg, 32 mg, 8 mg hydromorphone hcl er oral tablet extended release 24 hour 12 PA; ST; QL (1 tablet per 1 Tier 1 mg, 16 mg, 32 mg, 8 mg day) hydromorphone hcl oral liquid 1 mg/ml NF PA; QL (11 tablets per 1 hydromorphone hcl oral tablet 2 mg Tier 1 day) hydromorphone hcl oral tablet 4 mg Tier 1 PA; QL (5 tablets per 1 day) hydromorphone hcl oral tablet 8 mg Tier 1 PA; QL (2 tablets per 1 day) PA; QL (4 suppositories per hydromorphone hcl rectal suppository 3 mg Tier 3 1 day)

25 Coverage Requirements and Prescription Drug Name Drug Tier Limits HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE- DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, NF # 60 MG, 80 MG (hydrocodone bitartrate) IBUDONE ORAL TABLET 10-200 MG (hydrocodone- NF ibuprofen) hydrocodone-ibuprofen (Ibudone Oral Tablet 5-200 Mg) Tier 1 PA; QL (5 tablets per 1 day) KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 NF MG (morphine sulfate) KADIAN ORAL CAPSULE EXTENDED RELEASE 24 PA; ST; QL (1 capsule per 1 Tier 3 HOUR 200 MG (morphine sulfate) day) KADIAN ORAL CAPSULE EXTENDED RELEASE 24 PA; ST; QL (2 capsules per Tier 3 HOUR 40 MG (morphine sulfate) 1 day) LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 NF MCG/ACT, 400 MCG/ACT (fentanyl citrate) levorphanol tartrate oral tablet 2 mg NF levorphanol tartrate oral tablet 3 mg Tier 1 PA; QL (2 tablets per 1 day) hydrocodone-acetaminophen (Lorcet Hd Oral Tablet 10-325 Tier 1 PA; QL (6 tablets per 1 day) Mg) hydrocodone-acetaminophen (Lorcet Oral Tablet 5-325 Mg) Tier 1 PA; QL (8 tablets per 1 day) hydrocodone-acetaminophen (Lorcet Plus Oral Tablet 7.5-325 Tier 1 PA; QL (6 tablets per 1 day) Mg) LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- NF acetaminophen) meperidine hcl oral solution 50 mg/5ml Tier 1 QL (90 ml per 1 month) PA; QL (18 tablets per 1 meperidine hcl oral tablet 100 mg, 50 mg Tier 1 month) methadone hcl (Methadone Hcl Intensol Oral Concentrate 10 Tier 1 PA; QL (3 MLS per 1 day) Mg/Ml) methadone hcl oral concentrate 10 mg/ml Tier 1 PA; ST; QL (1 ml per 1 day) PA; ST; QL (10 ml per 1 methadone hcl oral solution 10 mg/5ml Tier 1 day)

26 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; ST; QL (15 ml per 1 methadone hcl oral solution 5 mg/5ml Tier 1 day) PA; ST; QL (2 tablets per 1 methadone hcl oral tablet 10 mg Tier 1 day) PA; ST; QL (6 tablets per 1 methadone hcl oral tablet 5 mg Tier 1 day) methadone hcl oral tablet soluble 40 mg Tier 1 QL (9 tablets per 1 month) METHADOSE ORAL CONCENTRATE 10 MG/ML NF (methadone hcl) PA; QL (9 tablets per 1 methadone hcl (Methadose Oral Tablet Soluble 40 Mg) Tier 1 month) METHADOSE SUGAR-FREE ORAL CONCENTRATE 10 NF MG/ML (methadone hcl) MORPHABOND ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 100 MG, 15 MG, 30 MG, 60 MG NF (morphine sulfate) morphine sulfate (concentrate) oral solution 100 mg/5ml Tier 1 PA; QL (4.5 MLS per 1 day) morphine sulfate (concentrate) oral solution 20 mg/ml Tier 1 morphine sulfate er beads oral capsule extended release 24 hour PA; ST; QL (1 capsule per 1 Tier 1 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg day) morphine sulfate er oral capsule extended release 24 hour 10 mg, PA; ST; QL (2 capsules per Tier 1 20 mg, 30 mg, 40 mg 1 day) morphine sulfate er oral capsule extended release 24 hour 100 PA; QL (2 capsules per 1 Tier 1 mg day) morphine sulfate er oral capsule extended release 24 hour 50 mg, PA; ST; QL (1 capsule per 1 Tier 1 60 mg, 80 mg day) PA; ST; QL (2 tablets per 1 morphine sulfate er oral tablet extended release 100 mg, 200 mg Tier 1 day) morphine sulfate er oral tablet extended release 15 mg, 30 mg, PA; ST; QL (3 tablets per 1 Tier 1 60 mg day) morphine sulfate oral solution 10 mg/5ml Tier 1 PA; QL (30 mls per 1 day) PA; QL (22.5 MLS per 1 morphine sulfate oral solution 20 mg/5ml Tier 1 day) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

27 Coverage Requirements and Prescription Drug Name Drug Tier Limits morphine sulfate oral tablet 15 mg Tier 1 PA; QL (6 tablets per 1 day) morphine sulfate oral tablet 30 mg Tier 1 PA; QL (3 tablets per 1 day) PA; QL (6 suppositories per morphine sulfate rectal suppository 10 mg, 5 mg Tier 1 1 day) PA; QL (4 suppositories per morphine sulfate rectal suppository 20 mg Tier 1 1 day) PA; QL (3 suppositories per morphine sulfate rectal suppository 30 mg Tier 1 1 day) MS CONTIN ORAL TABLET EXTENDED RELEASE 100 NF MG, 15 MG, 200 MG, 30 MG, 60 MG (morphine sulfate) PA; QL (12 tablets per 1 nalocet oral tablet 2.5-300 mg Tier 1 day) NORCO ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 NF MG (hydrocodone-acetaminophen) NUCYNTA ER ORAL TABLET EXTENDED RELEASE PA; ST; QL (2 tablets per 1 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG Tier 3 day) (tapentadol hcl) NUCYNTA ORAL TABLET 100 MG (tapentadol hcl) Tier 3 QL (2 tablets per 1 day) NUCYNTA ORAL TABLET 50 MG (tapentadol hcl) Tier 3 QL (4 tablets per 1 day) NUCYNTA ORAL TABLET 75 MG (tapentadol hcl) Tier 3 QL (3 tablets per 1 day) OPANA ER ORAL TABLET ER 12 HOUR ABUSE- PA; ST; QL (2 tablets per 1 DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 Tier 3 day) MG, 7.5 MG (oxymorphone hcl) OPANA ORAL TABLET 10 MG, 5 MG (oxymorphone hcl) NF OXAYDO ORAL TABLET 5 MG (oxycodone hcl) Tier 3 QL (6 tablets per 1 day) OXAYDO ORAL TABLET 7.5 MG (oxycodone hcl) Tier 3 PA; QL (6 tablets per 1 day) OXAYDO ORAL TABLET ABUSE-DETERRENT 5 MG Tier 3 QL (6 tablets per 1 day) (oxycodone hcl) OXAYDO ORAL TABLET ABUSE-DETERRENT 7.5 MG Tier 3 PA; QL (6 tablets per 1 day) (oxycodone hcl) oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, PA; ST; QL (2 tablets per 1 Tier 1 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg day)

28 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; QL (6 capsules per 1 oxycodone hcl oral capsule 5 mg Tier 1 day) oxycodone hcl oral concentrate 100 mg/5ml Tier 1 PA; QL (3 MLS per 1 day) oxycodone hcl oral solution 5 mg/5ml Tier 1 PA; QL (30 mls per 1 day) oxycodone hcl oral tablet 10 mg, 5 mg Tier 1 PA; QL (6 tablets per 1 day) oxycodone hcl oral tablet 15 mg Tier 1 PA; QL (4 tablets per 1 day) oxycodone hcl oral tablet 20 mg Tier 1 PA; QL (3 tablets per 1 day) oxycodone hcl oral tablet 30 mg Tier 1 PA; QL (2 tablets per 1 day) oxycodone-acetaminophen oral solution 10-300 mg/5ml, 5-325 NF mg/5ml oxycodone-acetaminophen oral tablet 10-300 mg, 2.5-300 mg, 5- NF 300 mg oxycodone-acetaminophen oral tablet 10-325 mg Tier 1 PA; QL (6 tablets per 1 day) PA; QL (12 tablets per 1 oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg Tier 1 day) oxycodone-acetaminophen oral tablet 7.5-325 mg Tier 1 PA; QL (8 tablets per 1 day) PA; QL (12 tablets per 1 oxycodone-aspirin oral tablet 4.8355-325 mg Tier 1 day) PA; QL (4 tablets per day oxycodone-ibuprofen oral tablet 5-400 mg Tier 1 for 7 days per 1 month) OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE- PA; ST; QL (2 tablets per 1 DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 Tier 3 day) MG, 80 MG (oxycodone hcl) oxymorphone hcl er oral tablet extended release 12 hour 10 mg, PA; ST; QL (2 tablets per 1 Tier 1 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg day) oxymorphone hcl oral tablet 10 mg Tier 1 QL (3 tablets per 1 day) oxymorphone hcl oral tablet 5 mg Tier 1 QL (6 tablets per 1 day) panlor oral tablet 325-30-16 mg NF PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5- NF 325 MG, 7.5-325 MG (oxycodone-acetaminophen) PRIMLEV ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 NF MG (oxycodone-acetaminophen) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

29 Coverage Requirements and Prescription Drug Name Drug Tier Limits PROLATE ORAL SOLUTION 10-300 MG/5ML NF (oxycodone-acetaminophen) PROLATE ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 NF MG (oxycodone-acetaminophen) QDOLO ORAL SOLUTION 5 MG/ML (tramadol hcl) NF ROXICODONE ORAL TABLET 15 MG, 30 MG, 5 MG NF (oxycodone hcl) SUBSYS SUBLINGUAL LIQUID 100 MCG, 1200 (600 X 2) MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600 NF MCG, 800 MCG (fentanyl) SYNALGOS-DC ORAL CAPSULE 356.4-30-16 MG NF (dihydrocodeine compound) tramadol hcl er (biphasic) oral tablet extended release 24 hour PA; ST; QL (1 tablet per 1 Tier 1 100 mg, 200 mg, 300 mg day) tramadol hcl er oral capsule extended release 24 hour 100 mg, NF 150 mg, 200 mg, 300 mg tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 PA; ST; QL (1 tablet per 1 Tier 1 mg, 300 mg day) tramadol hcl oral tablet 100 mg NF tramadol hcl oral tablet 50 mg Tier 1 PA; QL (6 tablets per 1 day) PA; QL (40 tablets per 1 tramadol-acetaminophen oral tablet 37.5-325 mg Tier 1 month) TREZIX ORAL CAPSULE 320.5-30-16 MG (apap-caff- NF dihydrocodeine) TYLENOL WITH CODEINE #3 ORAL TABLET 300-30 NF MG (acetaminophen-codeine) TYLENOL WITH CODEINE #4 ORAL TABLET 300-60 NF MG (acetaminophen-codeine) ULTRACET ORAL TABLET 37.5-325 MG (tramadol- PA; QL (40 tablets per 1 Tier 3 acetaminophen) month) ULTRAM ORAL TABLET 50 MG (tramadol hcl) NF VERDROCET ORAL TABLET 2.5-325 MG (hydrocodone- PA; QL (12 tablets per 1 Tier 3 acetaminophen) day) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

30 Coverage Requirements and Prescription Drug Name Drug Tier Limits hydrocodone-acetaminophen (Vicodin Es Oral Tablet 7.5-300 Tier 1 PA; QL (6 tablets per 1 day) Mg) hydrocodone-acetaminophen (Vicodin Hp Oral Tablet 10-300 Tier 1 PA; QL (6 tablets per 1 day) Mg) hydrocodone-acetaminophen (Vicodin Oral Tablet 5-300 Mg) Tier 1 PA; QL (8 tablets per 1 day) XODOL ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 NF MG (hydrocodone-acetaminophen) XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE- PA; ST; QL (2 tablets per 1 DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG Tier 2 day) (oxycodone) hydrocodone-ibuprofen (Xylon Oral Tablet 10-200 Mg) Tier 1 PA; QL (5 tablets per 1 day) ZAMICET ORAL SOLUTION 10-325 MG/15ML NF (hydrocodone-acetaminophen) ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE- DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 NF MG (hydrocodone bitartrate) ZOHYDRO ER ORAL CAPSULE EXTENDED RELEASE 12 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG NF (hydrocodone bitartrate) OPIOID PARTIAL AGONISTS BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG NF (buprenorphine hcl) buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg Tier 1 QL (3 tablets per 1 day) buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, PA; ST; QL (4 patches per Tier 1 20 mcg/hr, 5 mcg/hr, 7.5 mcg/hr 28 days) BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 NF MCG/HR (buprenorphine) SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.5ML, 300 MG/1.5ML Tier 4 (buprenorphine)

31 Coverage Requirements and Prescription Drug Name Drug Tier Limits SALICYLATES aspirin low dose oral tablet chewable 81 mg CE N2 (NF); AL aspirin oral tablet chewable 81 mg CE N2 (NF); AL aspirin oral tablet delayed release 81 mg CE N2 (NF); AL aspirin rectal suppository 120 mg, 200 mg CE N2 (NF); AL BAYER LOW DOSE ORAL TABLET CHEWABLE 81 MG CE N2 (NF); AL (aspirin) BAYER LOW DOSE ORAL TABLET DELAYED CE N2 (NF); AL RELEASE 81 MG (aspirin) childrens aspirin oral tablet chewable 81 mg CE N2 (NF); AL choline-mag trisalicylate oral liquid 500 mg/5ml Tier 1 diflunisal oral tablet 500 mg Tier 1 ECOTRIN LOW STRENGTH ORAL TABLET DELAYED CE N2 (NF); AL RELEASE 81 MG (aspirin) ST JOSEPH ASPIRIN ORAL TABLET DELAYED CE N2 (NF); AL RELEASE 81 MG (aspirin) VISCOSUPPLEMENTS sodium hyaluronate intra-articular solution prefilled syringe 20 NF mg/2ml ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML NF (amikacin sulfate liposome) BETHKIS INHALATION NEBULIZATION SOLUTION NF 300 MG/4ML (tobramycin) HUMATIN ORAL CAPSULE 250 MG (paromomycin NF sulfate) KITABIS PAK INHALATION NEBULIZATION NF SOLUTION 300 MG/5ML (tobramycin) MONUROL ORAL PACKET 3 GM (fosfomycin NF tromethamine)

32 Coverage Requirements and Prescription Drug Name Drug Tier Limits neomycin sulfate oral tablet 500 mg Tier 1 paromomycin sulfate oral capsule 250 mg Tier 1 sulfadiazine oral tablet 500 mg Tier 3 TINDAMAX ORAL TABLET 500 MG (tinidazole) NF tinidazole oral tablet 250 mg, 500 mg Tier 1 TOBI INHALATION NEBULIZATION SOLUTION 300 NF MG/5ML (tobramycin) TOBI PODHALER INHALATION CAPSULE 28 MG NF (tobramycin) SP Pharmacy; QL (224 ML tobramycin inhalation nebulization solution 300 mg/4ml Tier 4 per 1 month) PA; SP Pharmacy; QL (56 tobramycin inhalation nebulization solution 300 mg/5ml Tier 1 vials per 1 fill) ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ANCOBON ORAL CAPSULE 250 MG, 500 MG NF (flucytosine) bio-statin oral capsule 1000000 unit, 500000 unit Tier 2 bio-statin oral powder Tier 1 BREXAFEMME ORAL TABLET 150 MG (ibrexafungerp NF citrate) CRESEMBA ORAL CAPSULE 186 MG (isavuconazonium Tier 3 sulfate) DIFLUCAN ORAL SUSPENSION RECONSTITUTED 10 NF MG/ML, 40 MG/ML (fluconazole) DIFLUCAN ORAL TABLET 100 MG, 150 MG, 200 MG, NF 50 MG (fluconazole) fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml Tier 1 fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg Tier 1 flucytosine oral capsule 250 mg, 500 mg Tier 1 griseofulvin microsize oral suspension 125 mg/5ml Tier 1

33 Coverage Requirements and Prescription Drug Name Drug Tier Limits griseofulvin microsize oral tablet 500 mg Tier 1 griseofulvin ultramicrosize oral tablet 125 mg, 250 mg Tier 1 GRIS-PEG ORAL TABLET 125 MG, 250 MG (griseofulvin NF ultramicrosize) itraconazole oral capsule 100 mg Tier 1 PA itraconazole oral solution 10 mg/ml Tier 1 PA KERYDIN EXTERNAL SOLUTION 5 % (tavaborole) Tier 3 ketoconazole oral tablet 200 mg Tier 1 QL (2 tablets per 1 day) LAMISIL ORAL TABLET 250 MG (terbinafine hcl) NF NOXAFIL ORAL SUSPENSION 40 MG/ML (posaconazole) Tier 2 NOXAFIL ORAL TABLET DELAYED RELEASE 100 NF MG (posaconazole) nystatin oral tablet 500000 unit Tier 1 ONMEL ORAL TABLET 200 MG (itraconazole) NF posaconazole oral tablet delayed release 100 mg Tier 1 PA SPORANOX ORAL CAPSULE 100 MG (itraconazole) NF SPORANOX ORAL SOLUTION 10 MG/ML (itraconazole) NF SPORANOX PULSEPAK ORAL CAPSULE 100 MG NF (itraconazole) terbinafine hcl oral tablet 250 mg Tier 1 tolsura oral capsule 65 mg NF VFEND ORAL SUSPENSION RECONSTITUTED 40 NF MG/ML (voriconazole) VFEND ORAL TABLET 200 MG, 50 MG (voriconazole) NF voriconazole oral suspension reconstituted 40 mg/ml Tier 1 PA voriconazole oral tablet 200 mg, 50 mg Tier 1 PA ANTI-INFECTIVES - MISCELLANEOUS AEMCOLO ORAL TABLET DELAYED RELEASE 194 Tier 3 QL (12 tablets per 1 fill) MG (rifamycin sodium)

34 Coverage Requirements and Prescription Drug Name Drug Tier Limits QL (336 tablets per 365 albendazole oral tablet 200 mg Tier 1 days) ALINIA ORAL SUSPENSION RECONSTITUTED 100 Tier 3 #; QL (180 ml per 3 days) MG/5ML (nitazoxanide) ALINIA ORAL TABLET 500 MG (nitazoxanide) NF # atovaquone oral suspension 750 mg/5ml Tier 1 BACTRIM DS ORAL TABLET 800-160 MG NF (sulfamethoxazole-trimethoprim) BACTRIM ORAL TABLET 400-80 MG (sulfamethoxazole- NF trimethoprim) benznidazole oral tablet 100 mg, 12.5 mg Tier 3 BILTRICIDE ORAL TABLET 600 MG (praziquantel) Tier 3 CAYSTON INHALATION SOLUTION PA; #; SP Pharmacy; QL Tier 4 RECONSTITUTED 75 MG (aztreonam lysine) (84 vials per 28 days) CLEOCIN ORAL CAPSULE 150 MG, 300 MG, 75 MG NF (clindamycin hcl) CLEOCIN ORAL SOLUTION RECONSTITUTED 75 NF MG/5ML (clindamycin palmitate hcl) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg Tier 1 clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml Tier 1 dapsone oral tablet 100 mg, 25 mg Tier 1 DARAPRIM ORAL TABLET 25 MG (pyrimethamine) Tier 3 PA EMVERM ORAL TABLET CHEWABLE 100 MG Tier 1 QL (6 tablets per 3 days) (mebendazole) FIRVANQ ORAL SOLUTION RECONSTITUTED 25 Tier 3 MG/ML, 50 MG/ML (vancomycin hcl) FLAGYL ORAL CAPSULE 375 MG (metronidazole) NF FLAGYL ORAL TABLET 250 MG, 500 MG (metronidazole) NF FURADANTIN ORAL SUSPENSION 25 MG/5ML NF (nitrofurantoin) HIPREX ORAL TABLET 1 GM (methenamine hippurate) NF

35 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; #; QL (3 capsules per 1 IMPAVIDO ORAL CAPSULE 50 MG (miltefosine) Tier 3 day) ivermectin oral tablet 3 mg Tier 1 KETEK ORAL TABLET 300 MG (telithromycin) Tier 3 LAMPIT ORAL TABLET 120 MG, 30 MG (nifurtimox) Tier 3 linezolid oral suspension reconstituted 100 mg/5ml Tier 1 linezolid oral tablet 600 mg Tier 1 MACROBID ORAL CAPSULE 100 MG (nitrofurantoin NF monohyd macro) MACRODANTIN ORAL CAPSULE 100 MG, 25 MG, 50 NF MG (nitrofurantoin macrocrystal) methenamine hippurate oral tablet 1 gm Tier 1 methenamine mandelate oral tablet 0.5 gm, 1 gm Tier 1 METRONIDAZOLE BENZO+SYRSPEND ORAL SUSPENSION RECONSTITUTED 50 MG/ML NF (metronidazole benzoate) metronidazole oral capsule 375 mg Tier 1 metronidazole oral tablet 250 mg, 500 mg Tier 1 NEBUPENT INHALATION SOLUTION Tier 3 RECONSTITUTED 300 MG (pentamidine isethionate) nitazoxanide oral tablet 500 mg Tier 1 QL (6 tablets per 3 days) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg Tier 1 PA; AL nitrofurantoin monohyd macro oral capsule 100 mg Tier 1 PA; AL nitrofurantoin oral suspension 25 mg/5ml NF pentamidine isethionate inhalation solution reconstituted 300 mg Tier 1 praziquantel oral tablet 600 mg Tier 1 QL (24 tablets per 365 days) PRIMSOL ORAL SOLUTION 50 MG/5ML (trimethoprim Tier 2 hcl) pyrimethamine oral tablet 25 mg Tier 1 SIVEXTRO ORAL TABLET 200 MG (tedizolid phosphate) Tier 3 ST; QL (6 tablets per 1 fill) SOLOSEC ORAL PACKET 2 GM (secnidazole) NF 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

36 Coverage Requirements and Prescription Drug Name Drug Tier Limits sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml Tier 1 sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 Tier 1 mg sulfamethoxazole-trimethoprim (Sulfatrim Pediatric Oral Tier 1 Suspension 200-40 Mg/5Ml) trimethoprim oral tablet 100 mg Tier 1 trimpex oral solution 50 mg/5ml Tier 3 VANCOCIN HCL ORAL CAPSULE 125 MG, 250 MG NF (vancomycin hcl) vancomycin hcl oral capsule 125 mg, 250 mg Tier 1 QL (80 capsules per 10 days) XENLETA ORAL TABLET 600 MG (lefamulin acetate) NF XIFAXAN ORAL TABLET 200 MG (rifaximin) Tier 2 QL (9 tablets per 25 days) XIFAXAN ORAL TABLET 550 MG (rifaximin) Tier 2 PA ZYVOX ORAL SUSPENSION RECONSTITUTED 100 NF MG/5ML (linezolid) ZYVOX ORAL TABLET 600 MG (linezolid) NF ANTIMALARIALS - DRUGS TO TREAT MALARIA ARAKODA ORAL TABLET 100 MG (tafenoquine Tier 3 succinate) atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg Tier 1 chloroquine phosphate oral tablet 250 mg, 500 mg Tier 1 COARTEM ORAL TABLET 20-120 MG (artemether- Tier 3 lumefantrine) KRINTAFEL ORAL TABLET 150 MG (tafenoquine Tier 3 succinate) MALARONE ORAL TABLET 250-100 MG, 62.5-25 MG NF (atovaquone-proguanil hcl) mefloquine hcl oral tablet 250 mg Tier 1 primaquine phosphate oral tablet 26.3 (15 base) mg, 26.3 mg Tier 3 QUALAQUIN ORAL CAPSULE 324 MG (quinine sulfate) NF quinine sulfate oral capsule 324 mg Tier 1

37 Coverage Requirements and Prescription Drug Name Drug Tier Limits ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate oral solution 20 mg/ml Tier 1 QL (4 bottles per 30 days) abacavir sulfate oral tablet 300 mg Tier 1 QL (2 tablets per 1 day) APTIVUS ORAL CAPSULE 250 MG (tipranavir) Tier 2 #; QL (4 capsules per 1 day) APTIVUS ORAL SOLUTION 100 MG/ML (tipranavir) Tier 2 #; QL (4 bottles per 30 days) atazanavir sulfate oral capsule 150 mg, 300 mg Tier 1 QL (1 capsule per 1 day) atazanavir sulfate oral capsule 200 mg Tier 1 QL (2 capsules per 1 day) #; QL (15 capsules per 1 CRIXIVAN ORAL CAPSULE 200 MG (indinavir sulfate) Tier 2 day) CRIXIVAN ORAL CAPSULE 400 MG (indinavir sulfate) Tier 2 #; QL (6 capsules per 1 day) didanosine oral capsule delayed release 125 mg, 200 mg, 250 Tier 1 QL (1 capsule per 1 day) mg, 400 mg EDURANT ORAL TABLET 25 MG (rilpivirine hcl) Tier 2 QL (2 tablets per 1 day) efavirenz oral capsule 200 mg, 50 mg Tier 1 QL (3 capsules per 1 day) efavirenz oral tablet 600 mg Tier 1 QL (1 tablet per 1 day) emtricitabine oral capsule 200 mg Tier 1 QL (1 capsule per 1 day) EMTRIVA ORAL CAPSULE 200 MG (emtricitabine) NF EMTRIVA ORAL SOLUTION 10 MG/ML (emtricitabine) Tier 2 #; QL (4 bottles per 30 days) EPIVIR ORAL SOLUTION 10 MG/ML (lamivudine) NF EPIVIR ORAL TABLET 150 MG, 300 MG (lamivudine) NF etravirine oral tablet 100 mg Tier 1 QL (4 tablets per 1 day) etravirine oral tablet 200 mg Tier 1 QL (2 tablets per 1 day) fosamprenavir calcium oral tablet 700 mg Tier 1 QL (4 tablets per 1 day) FUZEON SUBCUTANEOUS SOLUTION #; SP Pharmacy; QL (2 vials Tier 4 RECONSTITUTED 90 MG (enfuvirtide) per 1 day) INTELENCE ORAL TABLET 100 MG, 25 MG (etravirine) Tier 2 #; QL (4 tablets per 1 day) INTELENCE ORAL TABLET 200 MG (etravirine) Tier 2 #; QL (2 tablets per 1 day) INVIRASE ORAL CAPSULE 200 MG (saquinavir mesylate) Tier 3 QL (10 capsules per 1 day) INVIRASE ORAL TABLET 500 MG (saquinavir mesylate) Tier 2 QL (4 tablets per 1 day)

38 Coverage Requirements and Prescription Drug Name Drug Tier Limits ISENTRESS HD ORAL TABLET 600 MG (raltegravir Tier 2 QL (2 tablets per 1 day) potassium) ISENTRESS ORAL PACKET 100 MG (raltegravir Tier 2 QL (2 packets per 1 day) potassium) ISENTRESS ORAL TABLET 400 MG (raltegravir Tier 2 QL (2 tablets per 1 day) potassium) ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 Tier 2 QL (6 tablets per 1 day) MG (raltegravir potassium) lamivudine oral solution 10 mg/ml Tier 1 QL (4 bottles per 30 days) lamivudine oral tablet 150 mg Tier 1 QL (2 tablets per 1 day) lamivudine oral tablet 300 mg Tier 1 QL (1 tablet per 1 day) LEXIVA ORAL SUSPENSION 50 MG/ML (fosamprenavir Tier 2 #; QL (8 bottles per 30 days) calcium) LEXIVA ORAL TABLET 700 MG (fosamprenavir calcium) NF nevirapine er oral tablet extended release 24 hour 100 mg Tier 1 QL (3 tablets per 1 day) nevirapine er oral tablet extended release 24 hour 400 mg Tier 1 QL (1 tablet per 1 day) nevirapine oral suspension 50 mg/5ml Tier 1 QL (5 bottles per 30 days) nevirapine oral tablet 200 mg Tier 1 QL (2 tablets per 1 day) #; QL (12 capsules per 1 NORVIR ORAL CAPSULE 100 MG (ritonavir) Tier 2 day) NORVIR ORAL PACKET 100 MG (ritonavir) Tier 2 QL (12 packets per 1 day) NORVIR ORAL SOLUTION 80 MG/ML (ritonavir) Tier 2 #; QL (2 bottles per 30 days) NORVIR ORAL TABLET 100 MG (ritonavir) NF PIFELTRO ORAL TABLET 100 MG (doravirine) Tier 3 QL (2 tablets per 1 day) PREZISTA ORAL SUSPENSION 100 MG/ML (darunavir Tier 2 QL (2 bottles per 30 days) ethanolate) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG Tier 2 #; QL (2 tablets per 1 day) (darunavir ethanolate) PREZISTA ORAL TABLET 800 MG (darunavir ethanolate) Tier 2 #; QL (1 tablet per 1 day) RESCRIPTOR ORAL TABLET 100 MG (delavirdine Tier 3 QL (30 tablets per 1 day) mesylate)

39 Coverage Requirements and Prescription Drug Name Drug Tier Limits RESCRIPTOR ORAL TABLET 200 MG (delavirdine Tier 3 QL (15 tablets per 1 day) mesylate) RETROVIR ORAL CAPSULE 100 MG (zidovudine) NF RETROVIR ORAL SYRUP 50 MG/5ML (zidovudine) NF REYATAZ ORAL CAPSULE 100 MG (atazanavir sulfate) NF REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG NF # (atazanavir sulfate) REYATAZ ORAL PACKET 50 MG (atazanavir sulfate) Tier 2 #; QL (6 packets per 1 day) ritonavir oral tablet 100 mg Tier 1 QL (12 tablets per 1 day) RUKOBIA ORAL TABLET EXTENDED RELEASE 12 NF HOUR 600 MG (fostemsavir tromethamine) SELZENTRY ORAL SOLUTION 20 MG/ML (maraviroc) Tier 2 QL (8 bottles per 1 month) SELZENTRY ORAL TABLET 150 MG, 75 MG (maraviroc) Tier 2 #; QL (2 tablets per 1 day) SELZENTRY ORAL TABLET 25 MG (maraviroc) Tier 2 #; QL (8 tablets per 1 day) SELZENTRY ORAL TABLET 300 MG (maraviroc) Tier 2 #; QL (4 tablets per 1 day) stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg Tier 1 QL (2 capsules per 1 day) stavudine oral solution reconstituted 1 mg/ml Tier 1 QL (12 bottles per 30 days) SUSTIVA ORAL CAPSULE 200 MG, 50 MG (efavirenz) NF # SUSTIVA ORAL TABLET 600 MG (efavirenz) NF # tenofovir disoproxil fumarate oral tablet 300 mg Tier 1 QL (1 tablet per 1 day) TIVICAY ORAL TABLET 10 MG (dolutegravir sodium) Tier 2 QL (8 tablets per 1 day) TIVICAY ORAL TABLET 25 MG, 50 MG (dolutegravir Tier 2 QL (2 tablets per 1 day) sodium) TIVICAY PD ORAL TABLET SOLUBLE 5 MG Tier 2 QL (12 tablets per 1 day) (dolutegravir sodium) TYBOST ORAL TABLET 150 MG (cobicistat) Tier 2 QL (1 tablet per 1 day) VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 Tier 2 MG (didanosine) VIDEX EC ORAL CAPSULE DELAYED RELEASE 200 NF MG, 250 MG, 400 MG (didanosine)

40 Coverage Requirements and Prescription Drug Name Drug Tier Limits VIDEX ORAL SOLUTION RECONSTITUTED 2 GM Tier 2 QL (12 bottles per 30 days) (didanosine) VIDEX ORAL SOLUTION RECONSTITUTED 4 GM Tier 2 QL (6 bottles per 30 days) (didanosine) VIRACEPT ORAL TABLET 250 MG (nelfinavir mesylate) Tier 2 QL (10 tablets per 1 day) VIRACEPT ORAL TABLET 625 MG (nelfinavir mesylate) Tier 2 QL (4 tablets per 1 day) VIRAMUNE ORAL SUSPENSION 50 MG/5ML NF (nevirapine) VIRAMUNE ORAL TABLET 200 MG (nevirapine) NF VIRAMUNE XR ORAL TABLET EXTENDED RELEASE NF 24 HOUR 100 MG, 400 MG (nevirapine) VIREAD ORAL POWDER 40 MG/GM (tenofovir disoproxil Tier 2 #; QL (4 bottles per 30 days) fumarate) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG Tier 2 #; QL (1 tablet per 1 day) (tenofovir disoproxil fumarate) VIREAD ORAL TABLET 300 MG (tenofovir disoproxil NF # fumarate) ZERIT ORAL CAPSULE 15 MG, 20 MG, 30 MG, 40 MG NF (stavudine) ZERIT ORAL SOLUTION RECONSTITUTED 1 MG/ML NF (stavudine) ZIAGEN ORAL SOLUTION 20 MG/ML (abacavir sulfate) NF ZIAGEN ORAL TABLET 300 MG (abacavir sulfate) NF zidovudine oral capsule 100 mg Tier 1 QL (6 capsules per 1 day) zidovudine oral syrup 50 mg/5ml Tier 1 QL (8 bottles per 30 days) zidovudine oral tablet 300 mg Tier 1 QL (2 tablets per 1 day) ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine oral tablet 600-300 mg Tier 1 QL (1 tablet per 1 day) abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg Tier 1 QL (2 tablets per 1 day) ATRIPLA ORAL TABLET 600-200-300 MG (efavirenz- Tier 2 QL (1 tablet per 1 day) emtricitab-tenofovir) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

41 Coverage Requirements and Prescription Drug Name Drug Tier Limits BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- Tier 2 QL (1 tablet per 1 day) emtricitab-tenofov) CIMDUO ORAL TABLET 300-300 MG (lamivudine- Tier 2 QL (1 tablet per 1 Day) tenofovir) COMBIVIR ORAL TABLET 150-300 MG (lamivudine- NF zidovudine) COMPLERA ORAL TABLET 200-25-300 MG (emtricitab- Tier 3 QL (1 tablet per 1 day) rilpivir-tenofovir) DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin- Tier 2 QL (1 tablet per 1 day) lamivudin-tenofov df) DESCOVY ORAL TABLET 200-25 MG (emtricitabine- Tier 2 QL (1 tablet per 1 day) tenofovir af) DOVATO ORAL TABLET 50-300 MG (dolutegravir- Tier 2 QL (1 tablet per 1 day) lamivudine) efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg Tier 1 QL (1 tablet per 1 day) efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg, 600- Tier 1 QL (1 tablet per 1 day) 300-300 mg emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, Tier 1 QL (1 TABLET per 1 Day) 167-250 mg emtricitabine-tenofovir df oral tablet 200-300 mg Tier 1 QL (1 tablet per 1 day) EPZICOM ORAL TABLET 600-300 MG (abacavir sulfate- NF lamivudine) EVOTAZ ORAL TABLET 300-150 MG (atazanavir- Tier 2 QL (1 tablet per 1 day) cobicistat) GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg- Tier 2 QL (1 tablet per 1 day) cobic-emtricit-tenofaf) JULUCA ORAL TABLET 50-25 MG (dolutegravir- Tier 3 ST; QL (1 tablet per 1 day) rilpivirine) KALETRA ORAL SOLUTION 400-100 MG/5ML NF (lopinavir-ritonavir) KALETRA ORAL TABLET 100-25 MG (lopinavir-ritonavir) Tier 2 #; QL (8 tablets per 1 day) KALETRA ORAL TABLET 200-50 MG (lopinavir-ritonavir) Tier 2 #; QL (4 tablets per 1 day)

42 Coverage Requirements and Prescription Drug Name Drug Tier Limits lamivudine-zidovudine oral tablet 150-300 mg Tier 1 QL (2 tablets per 1 day) lopinavir-ritonavir oral solution 400-100 mg/5ml Tier 1 QL (3 bottles per 30 days) lopinavir-ritonavir oral tablet 100-25 mg Tier 1 QL (8 tablets per 1 day) lopinavir-ritonavir oral tablet 200-50 mg Tier 1 QL (4 tablets per 1 day) ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab- Tier 2 QL (1 tablet per 1 day) rilpivir-tenofov af) PREZCOBIX ORAL TABLET 800-150 MG (darunavir- Tier 2 QL (1 tablet per 1 day) cobicistat) STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg- Tier 3 QL (1 tablet per 1 day) cobic-emtricit-tenofdf) SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz- NF lamivudine-tenofovir) SYMFI ORAL TABLET 600-300-300 MG (efavirenz- NF lamivudine-tenofovir) SYMTUZA ORAL TABLET 800-150-200-10 MG (darun- Tier 3 QL (1 tablet per 1 day) cobic-emtricit-tenofaf) TEMIXYS ORAL TABLET 300-300 MG (lamivudine- Tier 2 QL (1 tablet per 1 day) tenofovir) TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir- Tier 2 QL (1 tablet per 1 day) dolutegravir-lamivud) TRIZIVIR ORAL TABLET 300-150-300 MG (abacavir- NF lamivudine-zidovudine) TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, NF # 167-250 MG (emtricitabine-tenofovir df) TRUVADA ORAL TABLET 200-300 MG (emtricitabine- NF tenofovir df) ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS cycloserine oral capsule 250 mg Tier 1 ethambutol hcl oral tablet 100 mg, 400 mg Tier 1 isoniazid oral syrup 50 mg/5ml Tier 1 isoniazid oral tablet 100 mg, 300 mg Tier 1

43 Coverage Requirements and Prescription Drug Name Drug Tier Limits MYAMBUTOL ORAL TABLET 100 MG, 400 MG NF (ethambutol hcl) MYCOBUTIN ORAL CAPSULE 150 MG (rifabutin) NF PASER ORAL PACKET 4 GM (aminosalicylic acid) Tier 3 pretomanid oral tablet 200 mg Tier 3 PA; QL (1 tablet per 1 day) PRIFTIN ORAL TABLET 150 MG (rifapentine) Tier 2 pyrazinamide oral tablet 500 mg Tier 1 rifabutin oral capsule 150 mg Tier 1 RIFADIN ORAL CAPSULE 150 MG, 300 MG (rifampin) NF RIFAMATE ORAL CAPSULE 150-300 MG (isoniazid- Tier 2 rifampin) rifampin oral capsule 150 mg, 300 mg Tier 1 RIFAMPIN+SYRSPEND SF PH4 ORAL SUSPENSION 25 NF MG/ML (rifampin) RIFATER ORAL TABLET 50-120-300 MG (isoniazid- Tier 2 rifamp-pyrazinamide) SIRTURO ORAL TABLET 100 MG, 20 MG (bedaquiline Tier 4 PA; SP Pharmacy fumarate) TRECATOR ORAL TABLET 250 MG (ethionamide) Tier 2 ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir oral capsule 200 mg Tier 1 acyclovir oral suspension 200 mg/5ml Tier 1 acyclovir oral tablet 400 mg, 800 mg Tier 1 adefovir dipivoxil oral tablet 10 mg Tier 4 BARACLUDE ORAL SOLUTION 0.05 MG/ML (entecavir) Tier 3 BARACLUDE ORAL TABLET 0.5 MG, 1 MG (entecavir) NF diclofenac sodium external gel 3 % NF entecavir oral tablet 0.5 mg, 1 mg Tier 4 EPIVIR HBV ORAL SOLUTION 5 MG/ML (lamivudine) Tier 2 #; SP Pharmacy EPIVIR HBV ORAL TABLET 100 MG (lamivudine) NF

44 Coverage Requirements and Prescription Drug Name Drug Tier Limits famciclovir oral tablet 125 mg, 250 mg, 500 mg Tier 1 favipiravir oral tablet 200 mg Tier 3 FLUMADINE ORAL TABLET 100 MG (rimantadine hcl) NF HEPSERA ORAL TABLET 10 MG (adefovir dipivoxil) NF lamivudine oral tablet 100 mg Tier 1 QL (20 capsules per 365 oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg Tier 1 days) oseltamivir phosphate oral suspension reconstituted 6 mg/ml Tier 1 QL (480 MLS per 365 Days) PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) NF RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER Tier 2 QL (2 inhalers per 90 days) (zanamivir) ribavirin inhalation solution reconstituted 6 gm Tier 1 rimantadine hcl oral tablet 100 mg Tier 1 SITAVIG BUCCAL TABLET 50 MG (acyclovir) NF SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, Tier 4 PA; SP Pharmacy 50 MG/0.5ML (palivizumab) TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG NF (oseltamivir phosphate) TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 NF # MG/ML (oseltamivir phosphate) valacyclovir hcl oral tablet 1 gm, 500 mg Tier 1 VALCYTE ORAL TABLET 450 MG (valganciclovir hcl) NF PA; QL (1000 milliliters per valganciclovir hcl oral solution reconstituted 50 mg/ml Tier 1 30 days) PA; QL (120 tablets per 30 valganciclovir hcl oral tablet 450 mg Tier 1 days) VALTREX ORAL TABLET 1 GM, 500 MG (valacyclovir NF hcl) VEMLIDY ORAL TABLET 25 MG (tenofovir alafenamide Tier 3 PA; QL (1 tablet per 1 day) fumarate)

45 Coverage Requirements and Prescription Drug Name Drug Tier Limits XERESE EXTERNAL CREAM 5-1 % (acyclovir- NF hydrocortisone) XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY NF PACK 1 X 40 MG (baloxavir marboxil) XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY Tier 3 QL (4 tablets per 365 days) PACK 2 X 20 MG (baloxavir marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY NF PACK 1 X 80 MG (baloxavir marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY Tier 3 QL (4 tablets per 365 days) PACK 2 X 40 MG (baloxavir marboxil) ZOVIRAX ORAL CAPSULE 200 MG (acyclovir) NF ZOVIRAX ORAL SUSPENSION 200 MG/5ML (acyclovir) NF ZOVIRAX ORAL TABLET 400 MG, 800 MG (acyclovir) NF CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS CEDAX ORAL CAPSULE 400 MG (ceftibuten) NF CEDAX ORAL SUSPENSION RECONSTITUTED 180 NF MG/5ML (ceftibuten) cefaclor er oral tablet extended release 12 hour 500 mg Tier 3 cefaclor oral capsule 250 mg, 500 mg Tier 1 cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, Tier 1 375 mg/5ml cefadroxil oral capsule 500 mg Tier 1 cefadroxil oral suspension reconstituted 250 mg/5ml, 500 Tier 1 mg/5ml cefadroxil oral tablet 1 gm Tier 1 cefdinir oral capsule 300 mg Tier 1 cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml Tier 1 cefditoren pivoxil oral tablet 200 mg, 400 mg Tier 1 cefixime oral capsule 400 mg Tier 1 cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml Tier 1

46 Coverage Requirements and Prescription Drug Name Drug Tier Limits cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, Tier 1 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg Tier 1 cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml Tier 1 cefprozil oral tablet 250 mg, 500 mg Tier 1 ceftibuten oral capsule 400 mg Tier 1 ceftibuten oral suspension reconstituted 180 mg/5ml Tier 1 CEFTIN ORAL SUSPENSION RECONSTITUTED 125 NF MG/5ML, 250 MG/5ML (cefuroxime axetil) cefuroxime axetil oral tablet 250 mg, 500 mg Tier 1 cephalexin oral capsule 250 mg, 500 mg, 750 mg Tier 1 cephalexin oral suspension reconstituted 125 mg/5ml, 250 Tier 1 mg/5ml cephalexin oral tablet 250 mg, 500 mg Tier 1 DAXBIA ORAL CAPSULE 333 MG (cephalexin) NF KEFLEX ORAL CAPSULE 250 MG, 500 MG, 750 MG NF (cephalexin) SPECTRACEF ORAL TABLET 400 MG (cefditoren pivoxil) NF SUPRAX ORAL CAPSULE 400 MG (cefixime) Tier 3 SUPRAX ORAL SUSPENSION RECONSTITUTED 100 NF MG/5ML, 200 MG/5ML (cefixime) SUPRAX ORAL SUSPENSION RECONSTITUTED 500 Tier 2 MG/5ML (cefixime) SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG Tier 2 # (cefixime) ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin oral packet 1 gm Tier 1 azithromycin oral suspension reconstituted 100 mg/5ml, 200 Tier 1 mg/5ml azithromycin oral tablet 250 mg, 500 mg, 600 mg Tier 1

47 Coverage Requirements and Prescription Drug Name Drug Tier Limits BIAXIN ORAL TABLET 250 MG, 500 MG (clarithromycin) NF clarithromycin er oral tablet extended release 24 hour 500 mg Tier 1 clarithromycin oral suspension reconstituted 125 mg/5ml, 250 Tier 1 mg/5ml clarithromycin oral tablet 250 mg, 500 mg Tier 1 DIFICID ORAL SUSPENSION RECONSTITUTED 40 Tier 2 PA MG/ML (fidaxomicin) DIFICID ORAL TABLET 200 MG (fidaxomicin) Tier 2 PA E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML (erythromycin Tier 3 ethylsuccinate) ERYPED 200 ORAL SUSPENSION RECONSTITUTED Tier 3 200 MG/5ML (erythromycin ethylsuccinate) ERYPED 400 ORAL SUSPENSION RECONSTITUTED Tier 3 400 MG/5ML (erythromycin ethylsuccinate) erythromycin base (Ery-Tab Oral Tablet Delayed Release 250 Tier 1 Mg, 333 Mg, 500 Mg) ERYTHROCIN STEARATE ORAL TABLET 250 MG NF (erythromycin stearate) erythromycin base oral capsule delayed release particles 250 mg Tier 1 erythromycin base oral tablet 250 mg, 500 mg Tier 1 erythromycin ethylsuccinate oral suspension reconstituted 200 Tier 1 mg/5ml, 400 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg Tier 1 erythromycin stearate oral tablet 250 mg Tier 1 PCE ORAL TABLET DELAYED RELEASE 333 MG, 500 Tier 3 MG (erythromycin base coated) ZITHROMAX ORAL PACKET 1 GM (azithromycin) NF ZITHROMAX ORAL SUSPENSION RECONSTITUTED NF 100 MG/5ML, 200 MG/5ML (azithromycin) ZITHROMAX ORAL TABLET 250 MG, 500 MG, 600 MG NF (azithromycin)

48 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZITHROMAX TRI-PAK ORAL TABLET 500 MG NF (azithromycin) ZITHROMAX Z-PAK ORAL TABLET 250 MG NF (azithromycin) ZMAX ORAL SUSPENSION RECONSTITUTED 2 GM Tier 3 (azithromycin) FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS AVELOX ORAL TABLET 400 MG (moxifloxacin hcl) NF BAXDELA ORAL TABLET 450 MG (delafloxacin Tier 3 meglumine) CIPRO ORAL SUSPENSION RECONSTITUTED 250 NF MG/5ML (5%) (ciprofloxacin) CIPRO ORAL SUSPENSION RECONSTITUTED 500 Tier 3 MG/5ML (10%) (ciprofloxacin) CIPRO ORAL TABLET 250 MG, 500 MG (ciprofloxacin hcl) NF CIPRO XR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1000 MG, 500 MG (ciprofloxacin-ciproflox hcl) ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg Tier 1 ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), Tier 1 500 mg/5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 Tier 1 hour 1000 mg, 500 mg FACTIVE ORAL TABLET 320 MG (gemifloxacin mesylate) Tier 3 # LEVAQUIN ORAL TABLET 250 MG, 500 MG, 750 MG NF (levofloxacin) levofloxacin oral solution 25 mg/ml Tier 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg Tier 1 moxifloxacin hcl oral tablet 400 mg Tier 1 ofloxacin oral tablet 300 mg, 400 mg Tier 1 HEPATITIS C COPEGUS ORAL TABLET 200 MG (ribavirin) NF 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

49 Coverage Requirements and Prescription Drug Name Drug Tier Limits DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG PA; ST; SP Pharmacy; QL Tier 4 (daclatasvir dihydrochloride) (1 tablet per 1 day) EPCLUSA ORAL TABLET 200-50 MG (sofosbuvir- PA; NPL; QL (1 tablet per 1 Tier 2 velpatasvir) day) EPCLUSA ORAL TABLET 400-100 MG (sofosbuvir- PA; NPL; QL (28 tablets per Tier 2 velpatasvir) 28 days) HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG PA; NPL; QL (28 packets Tier 2 (ledipasvir-sofosbuvir) per 28 days) HARVONI ORAL TABLET 45-200 MG, 90-400 MG PA; NPL; QL (28 tablets per Tier 2 (ledipasvir-sofosbuvir) 28 days) ledipasvir-sofosbuvir oral tablet 90-400 mg NF MAVYRET ORAL TABLET 100-40 MG (glecaprevir- NF pibrentasvir) MODERIBA 1200 DOSE PACK ORAL TABLET 600 MG Tier 3 (ribavirin) MODERIBA 800 DOSE PACK ORAL TABLET 400 MG Tier 3 (ribavirin) ribavirin (Moderiba Oral Tablet 200 Mg) Tier 1 PA; ST; SP Pharmacy; QL OLYSIO ORAL CAPSULE 150 MG (simeprevir sodium) Tier 4 (1 capsule per 1 day) PEGASYS PROCLICK SUBCUTANEOUS SOLUTION Tier 2 PA; SP Pharmacy 135 MCG/0.5ML, 180 MCG/0.5ML (peginterferon alfa-2a) PEGASYS SUBCUTANEOUS SOLUTION 180 Tier 4 PA; SP Pharmacy MCG/0.5ML, 180 MCG/ML (peginterferon alfa-2a) PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML Tier 4 (peginterferon alfa-2b) REBETOL ORAL CAPSULE 200 MG (ribavirin) NF REBETOL ORAL SOLUTION 40 MG/ML (ribavirin) Tier 2 ribavirin (Ribasphere Oral Capsule 200 Mg) Tier 1 ribavirin (Ribasphere Oral Tablet 200 Mg) Tier 1 RIBASPHERE ORAL TABLET 400 MG (ribavirin) Tier 1 RIBASPHERE ORAL TABLET 600 MG (ribavirin) Tier 3

50 Coverage Requirements and Prescription Drug Name Drug Tier Limits RIBASPHERE RIBAPAK ORAL TABLET 400 MG, 600 Tier 1 MG (ribavirin) ribavirin oral capsule 200 mg Tier 1 PA ribavirin oral tablet 200 mg Tier 1 PA sofosbuvir-velpatasvir oral tablet 400-100 mg NF PA; ST; NPL; SP Pharmacy; SOVALDI ORAL PACKET 150 MG, 200 MG (sofosbuvir) Tier 4 QL (1 packet per 1 day) PA; ST; NPL; SP Pharmacy; SOVALDI ORAL TABLET 200 MG (sofosbuvir) Tier 4 QL (1 tablet per 1 day) PA; ST; SP Pharmacy; QL SOVALDI ORAL TABLET 400 MG (sofosbuvir) Tier 4 (1 tablet per 1 day) TECHNIVIE ORAL TABLET 12.5-75-50 MG (ombitasvir- PA; ST; SP Pharmacy; QL Tier 4 paritaprev-ritonav) (2 tablets per 1 day) VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5- PA; ST; SP Pharmacy; QL Tier 4 75-50 &250 MG (ombitas-paritapre-ritona-dasab) (1 Pak per 28 days) VIEKIRA XR ORAL TABLET EXTENDED RELEASE 24 PA; ST; SP Pharmacy; QL HOUR 200-8.33-50- 33.33 MG (ombitas-paritapre-ritona- Tier 4 (3 tablets per 1 day) dasab) VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv- PA; SP Pharmacy; QL (1 Tier 2 velpatasv-voxilaprev) tablet per 1 Day) ZEPATIER ORAL TABLET 50-100 MG (elbasvir- PA; ST; SP Pharmacy; QL Tier 4 grazoprevir) (1 tablet per 1 day) PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin oral capsule 250 mg, 500 mg Tier 1 amoxicillin oral suspension reconstituted 125 mg/5ml, 200 Tier 1 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg Tier 1 amoxicillin oral tablet chewable 125 mg, 250 mg Tier 1 amoxicillin-pot clavulanate er oral tablet extended release 12 Tier 1 hour 1000-62.5 mg

51 Coverage Requirements and Prescription Drug Name Drug Tier Limits amoxicillin-pot clavulanate oral suspension reconstituted 200- 28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 Tier 1 mg/5ml amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, Tier 1 875-125 mg amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, Tier 1 400-57 mg ampicillin oral capsule 500 mg Tier 1 AUGMENTIN ES-600 ORAL SUSPENSION RECONSTITUTED 600-42.9 MG/5ML (amoxicillin-pot NF clavulanate) AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML, 250-62.5 MG/5ML (amoxicillin-pot NF clavulanate) AUGMENTIN ORAL TABLET 500-125 MG, 875-125 MG NF (amoxicillin-pot clavulanate) AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 12 HOUR 1000-62.5 MG (amoxicillin-pot NF clavulanate) dicloxacillin sodium oral capsule 250 mg, 500 mg Tier 1 MOXATAG ORAL TABLET EXTENDED RELEASE 24 NF HOUR 775 MG (amoxicillin) penicillin v potassium oral solution reconstituted 125 mg/5ml, Tier 1 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg Tier 1 TETRACYCLINES - DRUGS TO TREAT INFECTIONS ACTICLATE ORAL TABLET 150 MG, 75 MG (doxycycline NF hyclate) ADOXA ORAL CAPSULE 150 MG (doxycycline NF monohydrate) avidoxy oral tablet 100 mg Tier 1 minocycline hcl (Coremino Oral Tablet Extended Release 24 NF Hour 135 Mg, 45 Mg, 90 Mg) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

52 Coverage Requirements and Prescription Drug Name Drug Tier Limits demeclocycline hcl oral tablet 150 mg, 300 mg Tier 1 DORYX MPC ORAL TABLET DELAYED RELEASE 120 NF # MG (doxycycline hyclate) DORYX ORAL TABLET DELAYED RELEASE 200 MG, NF 50 MG (doxycycline hyclate) doxycycline hyclate oral capsule 100 mg, 50 mg Tier 1 doxycycline hyclate oral tablet 100 mg, 20 mg, 50 mg Tier 1 doxycycline hyclate oral tablet 150 mg, 75 mg NF doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, Tier 1 75 mg doxycycline hyclate oral tablet delayed release 200 mg, 50 mg, NF 80 mg doxycycline monohydrate oral capsule 100 mg, 50 mg Tier 1 doxycycline monohydrate oral capsule 150 mg, 75 mg NF doxycycline monohydrate oral suspension reconstituted 25 Tier 1 mg/5ml doxycycline monohydrate oral tablet 100 mg NF doxycycline monohydrate oral tablet 150 mg, 50 mg, 75 mg Tier 1 MINOCIN ORAL CAPSULE 100 MG, 50 MG (minocycline NF hcl) minocycline hcl er oral capsule extended release 24 hour 135 mg, NF 45 mg, 90 mg minocycline hcl er oral tablet extended release 24 hour 105 mg, NF 115 mg, 135 mg, 45 mg, 55 mg, 65 mg, 80 mg, 90 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg Tier 1 minocycline hcl oral tablet 100 mg, 50 mg, 75 mg Tier 1 MINOLIRA ORAL TABLET EXTENDED RELEASE 24 NF HOUR 105 MG, 135 MG (minocycline hcl) doxycycline monohydrate (Mondoxyne Nl Oral Capsule 100 Tier 1 Mg, 50 Mg) doxycycline monohydrate (Mondoxyne Nl Oral Capsule 75 NF Mg) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

53 Coverage Requirements and Prescription Drug Name Drug Tier Limits MONODOX ORAL CAPSULE 100 MG, 75 MG NF (doxycycline monohydrate) doxycycline hyclate (Morgidox Oral Capsule 100 Mg, 50 Mg) Tier 1 NUZYRA ORAL TABLET 150 MG (omadacycline tosylate) NF SEYSARA ORAL TABLET 100 MG, 150 MG, 60 MG NF (sarecycline hcl) SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG NF (minocycline hcl) doxycycline hyclate (Targadox Oral Tablet 50 Mg) NF tetracycline hcl oral capsule 250 mg, 500 mg Tier 1 VIBRAMYCIN ORAL CAPSULE 100 MG (doxycycline NF hyclate) VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED NF 25 MG/5ML (doxycycline monohydrate) VIBRAMYCIN ORAL SYRUP 50 MG/5ML (doxycycline Tier 3 calcium) XIMINO ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 135 MG, 45 MG, 90 MG (minocycline hcl) ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS - CHEMOTHERAPY DRUGS ALKERAN ORAL TABLET 2 MG (melphalan) CE SP Pharmacy; N2 (NF) cyclophosphamide injection solution reconstituted 1 gm, 2 gm, Tier 4 500 mg cyclophosphamide oral capsule 25 mg, 50 mg CE N2 (Tier 1) EMCYT ORAL CAPSULE 140 MG (estramustine phosphate CE N2 (Tier 4) sodium) GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG CE N2 (Tier 4) (lomustine) GLEOSTINE ORAL CAPSULE 5 MG (lomustine) Tier 2 PA HEXALEN ORAL CAPSULE 50 MG (altretamine) Tier 4 SP Pharmacy

54 Coverage Requirements and Prescription Drug Name Drug Tier Limits LEUKERAN ORAL TABLET 2 MG (chlorambucil) CE N2 (Tier 2) melphalan oral tablet 2 mg CE N2 (Tier 1) MYLERAN ORAL TABLET 2 MG (busulfan) CE SP Pharmacy; N2 (Tier 3) TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, CE N2 (NF) 20 MG, 250 MG, 5 MG (temozolomide) temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 PA; SP Pharmacy; N2 (Tier CE mg, 5 mg 4) ANTIMETABOLITES - CHEMOTHERAPY DRUGS PA; SP Pharmacy; N2 (Tier capecitabine oral tablet 150 mg CE 4); QL (4 tablets per 1 day) PA; SP Pharmacy; N2 (Tier capecitabine oral tablet 500 mg CE 4); QL (10 tablets per 1 day) floxuridine injection solution reconstituted 0.5 gm Tier 1 mercaptopurine oral tablet 50 mg CE N2 (Tier 1) methotrexate oral tablet 2.5 mg CE N2 (Tier 1) methotrexate sodium (pf) injection solution 200 mg/8ml NF methotrexate sodium injection solution reconstituted 1 gm Tier 1 methotrexate sodium oral tablet 2.5 mg CE N2 (Tier 1) ONUREG ORAL TABLET 200 MG, 300 MG (azacitidine) NF PURIXAN ORAL SUSPENSION 2000 MG/100ML PA; ST; #; SP Pharmacy; CE (mercaptopurine) N2 (Tier 4) TABLOID ORAL TABLET 40 MG (thioguanine) CE N2 (Tier 2) TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG CE N2 (Tier 3) (methotrexate sodium) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) CE PA; N2 (Tier 3) XELODA ORAL TABLET 150 MG, 500 MG (capecitabine) CE N2 (NF) BIOLOGIC RESPONSE MODIFIERS DAURISMO ORAL TABLET 100 MG, 25 MG (glasdegib CE N2 (NF) maleate) PA; SP Pharmacy; N2 (Tier ERIVEDGE ORAL CAPSULE 150 MG (vismodegib) CE 4); QL (1 capsule per 1 day)

55 Coverage Requirements and Prescription Drug Name Drug Tier Limits FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG PA; N2 (Tier 4); QL (6 CE (panobinostat lactate) capsules per 21 days) PA; SP Pharmacy; N2 (Tier IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG CE 4); QL (21 capsules per 28 (palbociclib) days) PA; SP Pharmacy; N2 (Tier IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG CE 4); QL (21 tablets per 28 (palbociclib) days) KISQALI (200 MG DOSE) ORAL TABLET THERAPY PA; SP Pharmacy; QL (21 Tier 4 PACK 200 MG (ribociclib succinate) tablets per 28 days) KISQALI (400 MG DOSE) ORAL TABLET THERAPY PA; SP Pharmacy; QL (42 Tier 4 PACK 200 MG (ribociclib succinate) tablets per 28 days) KISQALI (600 MG DOSE) ORAL TABLET THERAPY PA; SP Pharmacy; QL (63 Tier 4 PACK 200 MG (ribociclib succinate) tablets per 28 days) KISQALI 200 DOSE ORAL TABLET 200 MG (ribociclib CE N2 (NF) succinate) KISQALI 400 DOSE ORAL TABLET 200 MG (ribociclib CE N2 (NF) succinate) KISQALI 600 DOSE ORAL TABLET 200 MG (ribociclib CE N2 (NF) succinate) KISQALI FEMARA (400 MG DOSE) ORAL TABLET CE N2 (NF) THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole) KISQALI FEMARA (600 MG DOSE) ORAL TABLET CE N2 (NF) THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole) KISQALI FEMARA(200 MG DOSE) ORAL TABLET CE N2 (NF) THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole) LYNPARZA ORAL TABLET 100 MG, 150 MG (olaparib) CE PA; N2 (Tier 4) RUBRACA ORAL TABLET 200 MG, 300 MG (rucaparib PA; SP Pharmacy; N2 (Tier CE camsylate) 4); QL (4 tablets per 1 day) PA; SP Pharmacy; N2 (Tier RUBRACA ORAL TABLET 250 MG (rucaparib camsylate) CE 4); QL (4 tablets per 1 Day) PA; N2 (Tier 4); QL (8 RYDAPT ORAL CAPSULE 25 MG (midostaurin) CE capsules per 1 day)

56 Coverage Requirements and Prescription Drug Name Drug Tier Limits TALZENNA ORAL CAPSULE 0.25 MG, 1 MG (talazoparib CE N2 (NF) tosylate) VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 CE N2 (NF) MG (abemaciclib) PA; N2 (Tier 4); QL (3 ZEJULA ORAL CAPSULE 100 MG (niraparib tosylate) CE capsules per 1 Day) PA; SP Pharmacy; N2 (Tier ZOLINZA ORAL CAPSULE 100 MG (vorinostat) CE 4); QL (4 capsules per 1 day) HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate oral tablet 250 mg CE SP Pharmacy; N2 (NF) PA; SP Pharmacy; N2 (Tier abiraterone acetate oral tablet 500 mg CE 4); QL (2 tablets per 1 day) anastrozole oral tablet 1 mg CE N2 (Tier 1) ARIMIDEX ORAL TABLET 1 MG (anastrozole) CE N2 (NF) AROMASIN ORAL TABLET 25 MG (exemestane) CE N2 (NF) bicalutamide oral tablet 50 mg CE N2 (Tier 1) CASODEX ORAL TABLET 50 MG (bicalutamide) CE N2 (NF) DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 Tier 3 MG/ML (medroxyprogesterone acetate) ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide Tier 4 PA; SP Pharmacy acetate (3 month)) ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide Tier 4 PA; SP Pharmacy acetate (4 month)) ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide Tier 4 PA; SP Pharmacy acetate (6 month)) ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide Tier 4 PA; SP Pharmacy acetate) ERLEADA ORAL TABLET 60 MG (apalutamide) CE PA; N2 (Tier 4) exemestane oral tablet 25 mg CE N2 (Tier 1) FARESTON ORAL TABLET 60 MG (toremifene citrate) CE N2 (NF) FEMARA ORAL TABLET 2.5 MG (letrozole) CE N2 (NF)

57 Coverage Requirements and Prescription Drug Name Drug Tier Limits FENSOLVI SUBCUTANEOUS KIT 45 MG (leuprolide NF acetate (6 month)) FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG/VIAL (degarelix Tier 4 PA acetate) FIRMAGON SUBCUTANEOUS SOLUTION Tier 4 PA; SP Pharmacy RECONSTITUTED 120 MG, 80 MG (degarelix acetate) flutamide oral capsule 125 mg CE N2 (Tier 1) fulvestrant intramuscular solution 250 mg/5ml Tier 4 PA letrozole oral tablet 2.5 mg CE N2 (Tier 1) leuprolide acetate injection kit 1 mg/0.2ml Tier 1 PA LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT Tier 4 PA; #; SP Pharmacy 3.75 MG, 7.5 MG (leuprolide acetate) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT Tier 4 PA; #; SP Pharmacy 11.25 MG, 22.5 MG (leuprolide acetate (3 month)) LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT Tier 4 PA; #; SP Pharmacy 30 MG (leuprolide acetate (4 month)) LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT Tier 4 PA; #; SP Pharmacy 45 MG (leuprolide acetate (6 month)) LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR Tier 4 PA; #; SP Pharmacy KIT 11.25 MG, 15 MG, 7.5 MG (leuprolide acetate) LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 11.25 MG (PED), 30 MG (PED) (leuprolide acetate (3 Tier 4 PA; #; SP Pharmacy month)) LYSODREN ORAL TABLET 500 MG (mitotane) CE N2 (Tier 2) megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 CE N2 (Tier 1) mg/5ml megestrol acetate oral tablet 20 mg, 40 mg CE N2 (Tier 1) NILANDRON ORAL TABLET 150 MG (nilutamide) CE N2 (NF) nilutamide oral tablet 150 mg CE N2 (Tier 1) NUBEQA ORAL TABLET 300 MG (darolutamide) CE PA; N2 (Tier 4) ORGOVYX ORAL TABLET 120 MG (relugolix) CE N2 (NF)

58 Coverage Requirements and Prescription Drug Name Drug Tier Limits SOLTAMOX ORAL SOLUTION 10 MG/5ML (tamoxifen CE #; N2 (NF) citrate) tamoxifen citrate oral tablet 10 mg, 20 mg CE N2 (Tier 1); AL toremifene citrate oral tablet 60 mg CE N2 (Tier 1) TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, Tier 4 PA; #; SP Pharmacy 3.75 MG (triptorelin pamoate) PA; SP Pharmacy; N2 (Tier XTANDI ORAL CAPSULE 40 MG (enzalutamide) CE 4); QL (4 capsules per 1 day) PA; SP Pharmacy; N2 (Tier XTANDI ORAL TABLET 40 MG (enzalutamide) CE 4); QL (4 tablets per 1 day) PA; SP Pharmacy; N2 (Tier XTANDI ORAL TABLET 80 MG (enzalutamide) CE 4); QL (2 tablets per 1 day) #; N2 (Tier 4); QL (4 tablets YONSA ORAL TABLET 125 MG (abiraterone acetate) CE per 1 day) ZYTIGA ORAL TABLET 250 MG, 500 MG (abiraterone CE N2 (NF) acetate) KINASE INHIBITORS AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 5 PA; #; N2 (Tier 4); QL (2 CE MG (everolimus) tablets per 1 day) AFINITOR DISPERZ ORAL TABLET SOLUBLE 3 MG PA; #; N2 (Tier 4); QL (3 CE (everolimus) tablets per 1 day) PA; #; SP Pharmacy; N2 AFINITOR ORAL TABLET 10 MG (everolimus) CE (Tier 4); QL (1 tablet per 1 day) AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG CE SP Pharmacy; N2 (NF) (everolimus) ALECENSA ORAL CAPSULE 150 MG (alectinib hcl) CE PA; N2 (Tier 4) ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG CE N2 (NF) (brigatinib) ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 CE N2 (NF) MG (brigatinib)

59 Coverage Requirements and Prescription Drug Name Drug Tier Limits BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG NF (erdafitinib) PA; SP Pharmacy; N2 (Tier BOSULIF ORAL TABLET 100 MG (bosutinib) CE 4); QL (3 tablets per 1 day) PA; SP Pharmacy; N2 (Tier BOSULIF ORAL TABLET 400 MG, 500 MG (bosutinib) CE 4); QL (1 tablet per 1 day) BRUKINSA ORAL CAPSULE 80 MG (zanubrutinib) CE N2 (NF) CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA; SP Pharmacy; N2 (Tier CE (cabozantinib s-malate) 4); QL (1 tablet per 1 day) CALQUENCE ORAL CAPSULE 100 MG (acalabrutinib) CE PA; N2 (Tier 4) PA; #; SP Pharmacy; N2 CAPRELSA ORAL TABLET 100 MG (vandetanib) CE (Tier 4); QL (2 tablets per 1 day) PA; #; SP Pharmacy; N2 CAPRELSA ORAL TABLET 300 MG (vandetanib) CE (Tier 4); QL (1 tablet per 1 day) COMETRIQ (100 MG DAILY DOSE) ORAL KIT 80 & 20 PA; SP Pharmacy; N2 (Tier CE MG (cabozantinib s-malate) 4); QL (2 capsules per 1 day) COMETRIQ (140 MG DAILY DOSE) ORAL KIT 3 X 20 PA; SP Pharmacy; N2 (Tier CE MG & 80 MG (cabozantinib s-malate) 4); QL (4 capsules per 1 day) COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG PA; SP Pharmacy; N2 (Tier CE (cabozantinib s-malate) 4); QL (3 capsules per 1 day) COPIKTRA ORAL CAPSULE 15 MG, 25 MG (duvelisib) CE N2 (NF) COTELLIC ORAL TABLET 20 MG (cobimetinib fumarate) CE N2 (NF) PA; N2 (Tier 4); QL (1 erlotinib hcl oral tablet 100 mg, 150 mg CE tablet per 1 day) PA; N2 (Tier 4); QL (2 erlotinib hcl oral tablet 25 mg CE tablets per 1 day) PA; SP Pharmacy; N2 (Tier everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg CE 4); QL (1 tablet per 1 day) FOTIVDA ORAL CAPSULE 0.89 MG, 1.34 MG (tivozanib CE N2 (NF) hcl)

60 Coverage Requirements and Prescription Drug Name Drug Tier Limits GLEEVEC ORAL TABLET 100 MG, 400 MG (imatinib CE N2 (NF) mesylate) PA; SP Pharmacy; N2 (Tier ICLUSIG ORAL TABLET 10 MG, 30 MG (ponatinib hcl) CE 4); QL (1 TABLET per 1 Day) PA; SP Pharmacy; N2 (Tier ICLUSIG ORAL TABLET 15 MG (ponatinib hcl) CE 4); QL (2 tablets per 1 day) PA; SP Pharmacy; N2 (Tier ICLUSIG ORAL TABLET 45 MG (ponatinib hcl) CE 4); QL (1 tablet per 1 day) IDHIFA ORAL TABLET 100 MG, 50 MG (enasidenib PA; N2 (Tier 4); QL (1 CE mesylate) tablet per 1 day) PA; SP Pharmacy; N2 (Tier imatinib mesylate oral tablet 100 mg CE 1); QL (3 tablets per 1 day) PA; SP Pharmacy; N2 (Tier imatinib mesylate oral tablet 400 mg CE 1); QL (2 tablets per 1 day) PA; N2 (Tier 4); QL (3 IMBRUVICA ORAL CAPSULE 140 MG (ibrutinib) CE capsules per 1 day) IMBRUVICA ORAL CAPSULE 70 MG (ibrutinib) CE PA; N2 (Tier 4) IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, CE PA; N2 (Tier 4) 560 MG (ibrutinib) PA; SP Pharmacy; N2 (Tier INLYTA ORAL TABLET 1 MG (axitinib) CE 4); QL (8 tablets per 1 day) PA; SP Pharmacy; N2 (Tier INLYTA ORAL TABLET 5 MG (axitinib) CE 4); QL (4 tablets per 1 day) SP Pharmacy; N2 (Tier 4); INREBIC ORAL CAPSULE 100 MG (fedratinib hcl) CE QL (4 capsules per 1 day) IRESSA ORAL TABLET 250 MG (gefitinib) CE #; N2 (NF) JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 PA; SP Pharmacy; N2 (Tier CE MG (ruxolitinib phosphate) 4); QL (2 tablets per 1 day) PA; SP Pharmacy; N2 (Tier KOSELUGO ORAL CAPSULE 10 MG (selumetinib sulfate) CE 4); QL (8 capsules per 1 day) PA; SP Pharmacy; N2 (Tier KOSELUGO ORAL CAPSULE 25 MG (selumetinib sulfate) CE 4); QL (4 capsules per 1 day) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

61 Coverage Requirements and Prescription Drug Name Drug Tier Limits LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE N2 (Tier 4); QL (1 capsule CE THERAPY PACK 10 MG (lenvatinib mesylate) per 1 day) LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE CE N2 (Tier 4) THERAPY PACK 3 X 4 MG (lenvatinib mesylate) LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE N2 (Tier 4); QL (2 capsules CE THERAPY PACK 10 & 4 MG (lenvatinib mesylate) per 1 day) LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE N2 (Tier 4); QL (3 capsules CE THERAPY PACK 10 MG & 2 X 4 MG (lenvatinib mesylate) per 1 day) LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE N2 (Tier 4); QL (2 capsules CE THERAPY PACK 2 X 10 MG (lenvatinib mesylate) per 1 day) LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE N2 (Tier 4); QL (3 capsules CE THERAPY PACK 2 X 10 MG & 4 MG (lenvatinib mesylate) per 1 day) LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE CE N2 (Tier 4) THERAPY PACK 4 MG (lenvatinib mesylate) LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE N2 (Tier 4); QL (2 capsules CE THERAPY PACK 2 X 4 MG (lenvatinib mesylate) per 1 day) LORBRENA ORAL TABLET 100 MG, 25 MG (lorlatinib) CE PA; N2 (Tier 4) LUMAKRAS ORAL TABLET 120 MG (sotorasib) CE N2 (NF) MEKINIST ORAL TABLET 0.5 MG (trametinib dimethyl PA; SP Pharmacy; N2 (Tier CE sulfoxide) 4); QL (3 tablets per 1 day) MEKINIST ORAL TABLET 2 MG (trametinib dimethyl PA; SP Pharmacy; N2 (Tier CE sulfoxide) 4); QL (1 tablet per 1 day) NERLYNX ORAL TABLET 40 MG (neratinib maleate) CE N2 (NF) PA; SP Pharmacy; N2 (Tier NEXAVAR ORAL TABLET 200 MG (sorafenib tosylate) CE 4); QL (4 tablets per 1 day) PIQRAY (200 MG DAILY DOSE) ORAL TABLET N2 (NF); QL (1 tablet per 1 CE THERAPY PACK 200 MG (alpelisib) day) PIQRAY (250 MG DAILY DOSE) ORAL TABLET N2 (NF); QL (2 tablets per 1 CE THERAPY PACK 200 & 50 MG (alpelisib) day) PIQRAY (300 MG DAILY DOSE) ORAL TABLET N2 (NF); QL (2 tablets per 1 CE THERAPY PACK 2 X 150 MG (alpelisib) day) RETEVMO ORAL CAPSULE 40 MG, 80 MG (selpercatinib) CE N2 (NF)

62 Coverage Requirements and Prescription Drug Name Drug Tier Limits ROZLYTREK ORAL CAPSULE 100 MG, 200 MG NF (entrectinib) SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 PA; SP Pharmacy; N2 (Tier CE MG, 80 MG (dasatinib) 4); QL (1 tablet per 1 day) PA; SP Pharmacy; N2 (Tier SPRYCEL ORAL TABLET 20 MG (dasatinib) CE 4); QL (3 tablets per 1 day) PA; SP Pharmacy; N2 (Tier STIVARGA ORAL TABLET 40 MG (regorafenib) CE 4); QL (3 tablets per 1 day) PA; #; SP Pharmacy; N2 SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 CE (Tier 4); QL (1 capsule per 1 MG (sunitinib malate) day) TAFINLAR ORAL CAPSULE 50 MG, 75 MG (dabrafenib PA; SP Pharmacy; N2 (Tier CE mesylate) 4); QL (4 capsules per 1 day) TAGRISSO ORAL TABLET 40 MG, 80 MG (osimertinib CE N2 (NF) mesylate) TARCEVA ORAL TABLET 100 MG, 150 MG (erlotinib hcl) CE SP Pharmacy; N2 (NF) SP Pharmacy; N2 (NF); QL TARCEVA ORAL TABLET 25 MG (erlotinib hcl) CE (2 tablets per 1 day) PA; ST; SP Pharmacy; N2 TASIGNA ORAL CAPSULE 150 MG, 200 MG (nilotinib CE (Tier 4); QL (4 capsules per hcl) 1 day) PA; ST; SP Pharmacy; N2 TASIGNA ORAL CAPSULE 50 MG (nilotinib hcl) CE (Tier 4); QL (4 capsules per 1 Day) TEPMETKO ORAL TABLET 225 MG (tepotinib hcl) CE N2 (NF) TRUSELTIQ (100MG DAILY DOSE) ORAL CAPSULE CE N2 (NF) THERAPY PACK 100 MG (infigratinib phosphate) TRUSELTIQ (125MG DAILY DOSE) ORAL CAPSULE CE N2 (NF) THERAPY PACK 100 & 25 MG (infigratinib phosphate) TRUSELTIQ (50MG DAILY DOSE) ORAL CAPSULE CE N2 (NF) THERAPY PACK 25 MG (infigratinib phosphate) TRUSELTIQ (75MG DAILY DOSE) ORAL CAPSULE CE N2 (NF) THERAPY PACK 25 MG (infigratinib phosphate)

63 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; SP Pharmacy; N2 (Tier TUKYSA ORAL TABLET 150 MG, 50 MG (tucatinib) CE 4); QL (4 tablets per 1 day) TURALIO ORAL CAPSULE 200 MG (pexidartinib hcl) NF PA; #; SP Pharmacy; N2 TYKERB ORAL TABLET 250 MG (lapatinib ditosylate) CE (NF); QL (6 tablets per 1 day) UKONIQ ORAL TABLET 200 MG (umbralisib tosylate) CE N2 (NF) VITRAKVI ORAL CAPSULE 100 MG, 25 MG (larotrectinib CE PA; N2 (Tier 4) sulfate) VITRAKVI ORAL SOLUTION 20 MG/ML (larotrectinib CE PA; N2 (Tier 4) sulfate) VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG CE N2 (NF) (dacomitinib) PA; SP Pharmacy; N2 (Tier VOTRIENT ORAL TABLET 200 MG (pazopanib hcl) CE 4); QL (4 tablets per 1 day) PA; SP Pharmacy; N2 (Tier XALKORI ORAL CAPSULE 200 MG, 250 MG (crizotinib) CE 4); QL (4 CAPSULES per 1 day) XOSPATA ORAL TABLET 40 MG (gilteritinib fumarate) CE N2 (NF) PA; SP Pharmacy; N2 (Tier ZELBORAF ORAL TABLET 240 MG (vemurafenib) CE 4); QL (8 tablets per 1 day) PA; SP Pharmacy; N2 (Tier ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) CE 4); QL (2 tablets per 1 day) PA; SP Pharmacy; N2 (Tier ZYKADIA ORAL TABLET 150 MG (ceritinib) CE 4); QL (3 tablets per 1 day) MISCELLANEOUS ALFERON N INJECTION SOLUTION 5000000 UNIT/ML Tier 4 (interferon alfa-n3) AYVAKIT ORAL TABLET 100 MG, 200 MG, 25 MG, 300 SP Pharmacy; N2 (NF); QL CE MG, 50 MG (avapritinib) (1 tablet per 1 day) PA; SP Pharmacy; N2 (Tier bexarotene oral capsule 75 mg CE 1) BRAFTOVI ORAL CAPSULE 50 MG, 75 MG (encorafenib) CE N2 (NF) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

64 Coverage Requirements and Prescription Drug Name Drug Tier Limits COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & PA; SP Pharmacy; N2 (Tier CE 1 X 20 MG (cabozantinib s-malate) 4); QL (2 capsules per 1 day) COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & PA; SP Pharmacy; N2 (Tier CE 3 X 20 MG (cabozantinib s-malate) 4); QL (4 capsules per 1 day) DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG Tier 2 (hydroxyurea) GAVRETO ORAL CAPSULE 100 MG (pralsetinib) CE N2 (NF) GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG PA; SP Pharmacy; N2 (Tier CE (afatinib dimaleate) 4); QL (1 tablet per 1 day) HYDREA ORAL CAPSULE 500 MG (hydroxyurea) CE N2 (NF) hydroxyurea oral capsule 500 mg CE N2 (Tier 1) INQOVI ORAL TABLET 35-100 MG (decitabine- NF cedazuridine) PA; SP Pharmacy; N2 (Tier LONSURF ORAL TABLET 15-6.14 MG (trifluridine- CE 4); QL (100 tablets per 28 tipiracil) days) PA; SP Pharmacy; N2 (Tier LONSURF ORAL TABLET 20-8.19 MG (trifluridine- CE 4); QL (80 tablets per 28 tipiracil) days) LYNPARZA ORAL CAPSULE 50 MG (olaparib) NF MATULANE ORAL CAPSULE 50 MG (procarbazine hcl) CE SP Pharmacy; N2 (Tier 4) MEKTOVI ORAL TABLET 15 MG (binimetinib) CE N2 (NF) PA; SP Pharmacy; N2 (Tier ODOMZO ORAL CAPSULE 200 MG (sonidegib phosphate) CE 4); QL (1 capsule per 1 day) ONCASPAR INJECTION SOLUTION 750 UNIT/ML Tier 4 PA (pegaspargase) PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 9 MG CE N2 (NF) (pemigatinib) QINLOCK ORAL TABLET 50 MG (ripretinib) CE N2 (NF) SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, PA; SP Pharmacy; QL (4 Tier 4 600 MCG (peginterferon alfa-2b) injections per 1 month)

65 Coverage Requirements and Prescription Drug Name Drug Tier Limits TABRECTA ORAL TABLET 150 MG, 200 MG (capmatinib CE N2 (NF) hcl) TARGRETIN ORAL CAPSULE 75 MG (bexarotene) CE N2 (NF) SP Pharmacy; N2 (NF); QL TAZVERIK ORAL TABLET 200 MG (tazemetostat hbr) CE (8 tablets per 1 day) TIBSOVO ORAL TABLET 250 MG (ivosidenib) CE N2 (NF) TICE BCG INTRAVESICAL SUSPENSION Tier 2 RECONSTITUTED 50 MG (bcg live) tretinoin oral capsule 10 mg CE SP Pharmacy; N2 (Tier 1) SP Pharmacy; QL (20 VISTOGARD ORAL PACKET 10 GM (uridine triacetate) Tier 4 packets per 1 prescription) XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET PA; SP Pharmacy; N2 (NF); CE THERAPY PACK 20 MG (selinexor) QL (16 tablets per 28 days) XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET CE N2 (NF) THERAPY PACK 50 MG (selinexor) XPOVIO (40 MG ONCE WEEKLY) ORAL TABLET CE N2 (NF) THERAPY PACK 20 MG, 40 MG (selinexor) XPOVIO (40 MG TWICE WEEKLY) ORAL TABLET CE N2 (NF) THERAPY PACK 20 MG, 40 MG (selinexor) XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET PA; SP Pharmacy; N2 (NF); CE THERAPY PACK 20 MG (selinexor) QL (16 tablets per 28 days) XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET CE N2 (NF) THERAPY PACK 60 MG (selinexor) XPOVIO (60 MG TWICE WEEKLY) ORAL TABLET CE N2 (NF) THERAPY PACK 20 MG (selinexor) XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET PA; SP Pharmacy; N2 (NF); CE THERAPY PACK 20 MG (selinexor) QL (16 tablets per 28 days) XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET CE N2 (NF) THERAPY PACK 40 MG (selinexor) XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET PA; SP Pharmacy; N2 (NF); CE THERAPY PACK 20 MG (selinexor) QL (16 tablets per 28 days) PA; SP Pharmacy; N2 (Tier ZYKADIA ORAL CAPSULE 150 MG (ceritinib) CE 4); QL (3 capsules per 1 day) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

66 Coverage Requirements and Prescription Drug Name Drug Tier Limits PROTEASOME INHIBITORS NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG CE N2 (NF) (ixazomib citrate) PROTECTIVE AGENTS leucovorin calcium injection solution reconstituted 500 mg Tier 1 leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg CE N2 (Tier 1) MESNEX ORAL TABLET 400 MG (mesna) CE N2 (Tier 4) TOPOISOMERASE INHIBITORS etoposide oral capsule 50 mg CE SP Pharmacy; N2 (Tier 1) HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG (topotecan PA; SP Pharmacy; N2 (Tier CE hcl) 4) ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC, BCL-2 INHIBITORS PA; N2 (Tier 4); QL (4 VENCLEXTA ORAL TABLET 10 MG, 50 MG (venetoclax) CE tablets per 1 day) VENCLEXTA ORAL TABLET 100 MG (venetoclax) CE PA; N2 (Tier 4) VENCLEXTA STARTING PACK ORAL TABLET PA; N2 (Tier 4); QL (1 pack CE THERAPY PACK 10 & 50 & 100 MG (venetoclax) per 1 month) CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, NF 20-25 MG (quinapril-hydrochlorothiazide) amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, Tier 1 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 Tier 1 mg, 20-25 mg, 5-6.25 mg captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, Tier 1 50-15 mg, 50-25 mg enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg Tier 1

67 Coverage Requirements and Prescription Drug Name Drug Tier Limits fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg Tier 1 lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 Tier 1 mg, 20-25 mg LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 NF MG, 20-25 MG (benazepril-hydrochlorothiazide) LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 NF MG, 5-20 MG (amlodipine besy-benazepril hcl) moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, Tier 1 7.5-12.5 mg PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 Tier 3 # MG (perindopril arg-amlodipine) quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 Tier 1 mg, 20-25 mg TARKA ORAL TABLET EXTENDED RELEASE 1-240 MG, 2-180 MG, 2-240 MG, 4-240 MG (trandolapril-verapamil NF hcl) trandolapril-verapamil hcl er oral tablet extended release 1-240 Tier 1 mg, 2-180 mg, 2-240 mg, 4-240 mg VASERETIC ORAL TABLET 10-25 MG (enalapril- NF hydrochlorothiazide) ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, NF 20-25 MG (lisinopril-hydrochlorothiazide) ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG NF (quinapril hcl) ACEON ORAL TABLET 4 MG, 8 MG (perindopril NF erbumine) ALTACE ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 NF MG (ramipril) benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1 captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg Tier 1 enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg Tier 1 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

68 Coverage Requirements and Prescription Drug Name Drug Tier Limits EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) Tier 3 #; QL (5 ml per 1 day) fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg Tier 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg Tier 1 LOTENSIN ORAL TABLET 20 MG, 40 MG (benazepril hcl) NF MAVIK ORAL TABLET 4 MG (trandolapril) NF moexipril hcl oral tablet 15 mg, 7.5 mg Tier 1 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg Tier 1 PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG NF (lisinopril) QBRELIS ORAL SOLUTION 1 MG/ML (lisinopril) NF quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1 ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg Tier 1 trandolapril oral tablet 1 mg, 2 mg, 4 mg Tier 1 VASOTEC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG NF (enalapril maleate) ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, NF 40 MG, 5 MG (lisinopril) ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone oral tablet 25 mg, 50 mg Tier 1 INSPRA ORAL TABLET 25 MG, 50 MG (eplerenone) NF ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG NF (doxazosin mesylate) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg Tier 1 MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG NF (prazosin hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg Tier 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg Tier 1

69 Coverage Requirements and Prescription Drug Name Drug Tier Limits ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, Tier 1 5-160 mg, 5-320 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, Tier 1 5-40 mg amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 Tier 1 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 NF MG, 32-25 MG (candesartan cilexetil-hctz) AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG NF (irbesartan-hydrochlorothiazide) AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5- NF 40 MG (amlodipine-olmesartan) BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, NF 40-25 MG (olmesartan medoxomil-hctz) BYVALSON ORAL TABLET 5-80 MG (nebivolol-valsartan) NF candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, Tier 1 32-25 mg CLORPRES ORAL TABLET 0.1-15 MG, 0.2-15 MG, 0.3-15 Tier 3 MG (clonidine-chlorthalidone) DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG (valsartan- NF hydrochlorothiazide) EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG Tier 3 ST; QL (1 tablet per 1 day) (azilsartan-chlorthalidone) EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160- 25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG NF (amlodipine-valsartan-hctz) EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 NF MG, 5-320 MG (amlodipine besylate-valsartan)

70 Coverage Requirements and Prescription Drug Name Drug Tier Limits HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50- NF 12.5 MG (losartan potassium-hctz) irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- Tier 1 12.5 mg losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50- Tier 1 12.5 mg MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 NF MG, 80-25 MG (telmisartan-hctz) olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, Tier 1 40-25 mg olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- Tier 1 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 Tier 1 mg, 80-5 mg telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg Tier 1 TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG (olmesartan- NF amlodipine-hctz) TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 NF MG, 80-5 MG (telmisartan-amlodipine) valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 Tier 1 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG NF (candesartan cilexetil) AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG NF (irbesartan) BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG NF (olmesartan medoxomil) candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg Tier 1 COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG NF (losartan potassium) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

71 Coverage Requirements and Prescription Drug Name Drug Tier Limits DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 NF MG (valsartan) eprosartan mesylate oral tablet 600 mg Tier 1 irbesartan oral tablet 150 mg, 300 mg, 75 mg Tier 1 losartan potassium oral tablet 100 mg, 25 mg, 50 mg Tier 1 MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG NF (telmisartan) olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg Tier 1 telmisartan oral tablet 20 mg, 40 mg, 80 mg Tier 1 valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg Tier 1 ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg Tier 1 disopyramide phosphate oral capsule 100 mg, 150 mg Tier 1 dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg Tier 1 PA flecainide acetate oral tablet 100 mg, 150 mg, 50 mg Tier 1 mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg Tier 1 MULTAQ ORAL TABLET 400 MG (dronedarone hcl) Tier 3 PA NORPACE CR ORAL CAPSULE EXTENDED RELEASE Tier 2 12 HOUR 100 MG, 150 MG (disopyramide phosphate) NORPACE ORAL CAPSULE 100 MG, 150 MG NF (disopyramide phosphate) amiodarone hcl (Pacerone Oral Tablet 100 Mg, 200 Mg, 400 Tier 1 Mg) propafenone hcl er oral capsule extended release 12 hour 225 Tier 1 mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg Tier 1 quinidine gluconate er oral tablet extended release 324 mg Tier 1 quinidine sulfate oral tablet 200 mg, 300 mg Tier 1 RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE NF 12 HOUR 225 MG, 325 MG, 425 MG (propafenone hcl)

72 Coverage Requirements and Prescription Drug Name Drug Tier Limits sotalol hcl (Sorine Oral Tablet 120 Mg, 160 Mg, 240 Mg, 80 Tier 1 Mg) sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg Tier 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg Tier 1 TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 NF MCG (dofetilide) ANTILIPEMICS, ACL INHIBITORS/COMBINATIONS NEXLETOL ORAL TABLET 180 MG (bempedoic acid) NF NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- NF ezetimibe) ANTILIPEMICS, BILE ACID RESINS cholestyramine light oral packet 4 gm Tier 1 cholestyramine light oral powder 4 gm/dose Tier 1 cholestyramine oral packet 4 gm Tier 1 cholestyramine oral powder 4 gm/dose Tier 1 colesevelam hcl oral packet 3.75 gm Tier 1 colesevelam hcl oral tablet 625 mg Tier 1 COLESTID FLAVORED ORAL GRANULES 5 GM NF (colestipol hcl) COLESTID FLAVORED ORAL PACKET 5 GM (colestipol NF hcl) COLESTID ORAL GRANULES 5 GM (colestipol hcl) NF COLESTID ORAL PACKET 5 GM (colestipol hcl) NF COLESTID ORAL TABLET 1 GM (colestipol hcl) NF colestipol hcl oral granules 5 gm Tier 1 colestipol hcl oral packet 5 gm Tier 1 colestipol hcl oral tablet 1 gm Tier 1 cholestyramine light (Prevalite Oral Packet 4 Gm) Tier 1 cholestyramine light (Prevalite Oral Powder 4 Gm/Dose) Tier 1

73 Coverage Requirements and Prescription Drug Name Drug Tier Limits QUESTRAN LIGHT ORAL POWDER 4 GM/DOSE NF (cholestyramine light) QUESTRAN ORAL PACKET 4 GM (cholestyramine) NF QUESTRAN ORAL POWDER 4 GM/DOSE NF (cholestyramine) WELCHOL ORAL PACKET 3.75 GM (colesevelam hcl) NF WELCHOL ORAL TABLET 625 MG (colesevelam hcl) NF ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITOR ezetimibe oral tablet 10 mg Tier 1 ZETIA ORAL TABLET 10 MG (ezetimibe) NF ANTILIPEMICS, FIBRATES ANTARA ORAL CAPSULE 30 MG, 90 MG (fenofibrate NF # micronized) fenofibrate micronized oral capsule 130 mg NF fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg Tier 1 QL (1 capsule per 1 day) fenofibrate micronized oral capsule 43 mg Tier 1 fenofibrate oral capsule 134 mg, 150 mg, 200 mg, 67 mg Tier 1 fenofibrate oral capsule 50 mg NF fenofibrate oral tablet 120 mg, 40 mg NF fenofibrate oral tablet 145 mg, 48 mg, 54 mg Tier 1 fenofibrate oral tablet 160 mg Tier 3 fenofibric acid oral capsule delayed release 135 mg, 45 mg Tier 1 fenofibric acid oral tablet 105 mg, 35 mg Tier 1 FENOGLIDE ORAL TABLET 120 MG, 40 MG NF (fenofibrate) FIBRICOR ORAL TABLET 105 MG, 35 MG (fenofibric NF acid) gemfibrozil oral tablet 600 mg Tier 1 LIPOFEN ORAL CAPSULE 150 MG, 50 MG (fenofibrate) NF

74 Coverage Requirements and Prescription Drug Name Drug Tier Limits LOFIBRA ORAL CAPSULE 134 MG, 67 MG (fenofibrate NF micronized) LOFIBRA ORAL TABLET 54 MG (fenofibrate) NF LOPID ORAL TABLET 600 MG (gemfibrozil) NF TRICOR ORAL TABLET 145 MG, 48 MG (fenofibrate) NF TRIGLIDE ORAL TABLET 160 MG (fenofibrate) NF TRILIPIX ORAL CAPSULE DELAYED RELEASE 135 NF MG, 45 MG (choline fenofibrate) ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS ALTOPREV ORAL TABLET EXTENDED RELEASE 24 ST; #; QL (2 tablets per 1 Tier 3 HOUR 20 MG, 40 MG, 60 MG (lovastatin) day) atorvastatin calcium oral tablet 10 mg, 20 mg CE N2 (NF); AL atorvastatin calcium oral tablet 40 mg, 80 mg NF CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG NF (rosuvastatin calcium) EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10 NF MG, 20 MG, 40 MG, 5 MG (rosuvastatin calcium) flolipid oral suspension 20 mg/5ml, 40 mg/5ml NF fluvastatin sodium er oral tablet extended release 24 hour 80 mg Tier 1 fluvastatin sodium oral capsule 20 mg, 40 mg Tier 1 LESCOL ORAL CAPSULE 20 MG (fluvastatin sodium) NF LESCOL XL ORAL TABLET EXTENDED RELEASE 24 NF HOUR 80 MG (fluvastatin sodium) LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG NF (atorvastatin calcium) LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG (pitavastatin Tier 3 ST; QL (1 tablet per 1 day) calcium) lovastatin oral tablet 10 mg, 20 mg, 40 mg Tier 1 MEVACOR ORAL TABLET 40 MG (lovastatin) NF PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG NF (pravastatin sodium)

75 Coverage Requirements and Prescription Drug Name Drug Tier Limits pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg Tier 1 rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1 simvastatin oral suspension 20 mg/5ml NF simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg CE N2 (Tier 1); AL simvastatin oral tablet 80 mg Tier 1 ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG, 80 NF MG (simvastatin) ZYPITAMAG ORAL TABLET 1 MG, 2 MG, 4 MG NF (pitavastatin magnesium) ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, Tier 1 10-80 mg ROSZET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, NF 10-5 MG (ezetimibe-rosuvastatin) VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 NF MG, 10-80 MG (ezetimibe-simvastatin) ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL icosapent ethyl oral capsule 1 gm Tier 1 JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 PA; ST; SP Pharmacy; QL Tier 4 MG, 5 MG, 60 MG (lomitapide mesylate) (1 capsule per 1 day) KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 200 MG/ML (mipomersen sodium) LOVAZA ORAL CAPSULE 1 GM (omega-3-acid ethyl NF esters) niacin (antihyperlipidemic) oral tablet 500 mg Tier 1 niacin er (antihyperlipidemic) oral tablet extended release 1000 Tier 1 mg, 500 mg, 750 mg NIACOR ORAL TABLET 500 MG (niacin NF (antihyperlipidemic))

76 Coverage Requirements and Prescription Drug Name Drug Tier Limits NIASPAN ORAL TABLET EXTENDED RELEASE 1000 NF MG, 500 MG, 750 MG (niacin (antihyperlipidemic)) ANTILIPEMICS, OMEGA-3 FATTY ACIDS omega-3-acid ethyl esters oral capsule 1 gm Tier 1 VASCEPA ORAL CAPSULE 0.5 GM (icosapent ethyl) Tier 2 # VASCEPA ORAL CAPSULE 1 GM (icosapent ethyl) Tier 2 ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT SUBCUTANEOUS SOLUTION AUTO- Tier 4 INJECTOR 150 MG/ML, 75 MG/ML (alirocumab) PRALUENT SUBCUTANEOUS SOLUTION PEN- NF INJECTOR 150 MG/ML, 75 MG/ML (alirocumab) PRALUENT SUBCUTANEOUS SOLUTION PREFILLED Tier 4 SYRINGE 150 MG/ML, 75 MG/ML (alirocumab) REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS NF PA SOLUTION CARTRIDGE 420 MG/3.5ML (evolocumab) REPATHA SUBCUTANEOUS SOLUTION PREFILLED NF PA SYRINGE 140 MG/ML (evolocumab) REPATHA SURECLICK SUBCUTANEOUS SOLUTION NF PA AUTO-INJECTOR 140 MG/ML (evolocumab) BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg Tier 1 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 Tier 1 mg, 5-6.25 mg CORZIDE ORAL TABLET 40-5 MG, 80-5 MG (nadolol- NF bendroflumethiazide) LOPRESSOR HCT ORAL TABLET 50-25 MG (metoprolol- NF hydrochlorothiazide) metoprolol-hctz er oral tablet extended release 24 hour 100-12.5 NF mg, 25-12.5 mg, 50-12.5 mg

77 Coverage Requirements and Prescription Drug Name Drug Tier Limits metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 Tier 1 mg, 50-25 mg nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg Tier 1 propranolol-hctz oral tablet 40-25 mg, 80-25 mg Tier 1 TENORETIC 100 ORAL TABLET 100-25 MG (atenolol- NF chlorthalidone) TENORETIC 50 ORAL TABLET 50-25 MG (atenolol- NF chlorthalidone) ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 NF MG (bisoprolol-hydrochlorothiazide) BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl oral capsule 200 mg, 400 mg Tier 1 atenolol oral tablet 100 mg, 25 mg, 50 mg Tier 1 ATENOLOL+SYRSPEND SF PH4 ORAL SUSPENSION 1 NF MG/ML (atenolol) BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG NF (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG NF (sotalol hcl) betaxolol hcl oral tablet 10 mg, 20 mg Tier 1 bisoprolol fumarate oral tablet 10 mg, 5 mg Tier 1 BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG Tier 3 # (nebivolol hcl) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg Tier 1 carvedilol phosphate er oral capsule extended release 24 hour 10 Tier 1 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 NF # HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 NF MG (carvedilol)

78 Coverage Requirements and Prescription Drug Name Drug Tier Limits CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG NF (nadolol) HEMANGEOL ORAL SOLUTION 4.28 MG/ML Tier 3 PA (propranolol hcl) INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol NF hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG (propranolol hcl sr NF # beads) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG Tier 3 (metoprolol succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg Tier 1 LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol NF tartrate) metoprolol succinate er oral tablet extended release 24 hour 100 Tier 1 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, Tier 1 75 mg nadolol oral tablet 20 mg, 40 mg, 80 mg Tier 1 pindolol oral tablet 10 mg, 5 mg Tier 1 propranolol hcl er oral capsule extended release 24 hour 120 mg, Tier 1 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml Tier 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg Tier 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) NF TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG NF (atenolol) timolol maleate oral tablet 10 mg, 20 mg, 5 mg Tier 1

79 Coverage Requirements and Prescription Drug Name Drug Tier Limits TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG (metoprolol NF succinate) CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 Tier 1 mg, 5-40 mg, 5-80 mg CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG NF (amlodipine-atorvastatin) CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS ADALAT CC ORAL TABLET EXTENDED RELEASE 24 NF HOUR 30 MG, 60 MG, 90 MG (nifedipine) nifedipine (Afeditab Cr Oral Tablet Extended Release 24 Hour Tier 1 QL (1 tablet per 1 day) 30 Mg) nifedipine (Afeditab Cr Oral Tablet Extended Release 24 Hour Tier 1 QL (2 tablets per 1 day) 60 Mg) AMLODIPINE BES+SYRSPEND SF ORAL NF SUSPENSION 1 MG/ML (amlodipine besylate) amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 CALAN ORAL TABLET 120 MG, 80 MG (verapamil hcl) NF CALAN SR ORAL TABLET EXTENDED RELEASE 120 NF MG, 180 MG, 240 MG (verapamil hcl) CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 360 MG NF (diltiazem hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE Tier 3 24 HOUR 120 MG (diltiazem hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG NF (diltiazem hcl coated beads)

80 Coverage Requirements and Prescription Drug Name Drug Tier Limits CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG NF (diltiazem hcl) diltiazem hcl coated beads (Cartia Xt Oral Capsule Extended Tier 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg) CONJUPRI ORAL TABLET 2.5 MG, 5 MG (levamlodipine NF maleate) CONSENSI ORAL TABLET 10-200 MG, 2.5-200 MG, 5-200 NF MG (amlodipine besylate-celecoxib) diltiazem cd oral capsule extended release 24 hour 120 mg, 180 Tier 1 QL (1 capsule per 1 day) mg, 300 mg diltiazem cd oral capsule extended release 24 hour 240 mg Tier 1 QL (2 capsules per 1 day) diltiazem hcl er beads oral capsule extended release 24 hour 120 Tier 1 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 Tier 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 Tier 1 QL (1 tablet per 1 day) hour 180 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 Tier 1 QL (2 tablets per 1 day) hour 240 mg diltiazem hcl er coated beads oral tablet extended release 24 Tier 1 hour 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, Tier 1 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 mg, Tier 1 180 mg diltiazem hcl er oral capsule extended release 24 hour 240 mg Tier 1 QL (2 capsules per 1 day) diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg Tier 1 dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, Tier 1 240 mg felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, Tier 1 5 mg isradipine oral capsule 2.5 mg, 5 mg Tier 1

81 Coverage Requirements and Prescription Drug Name Drug Tier Limits KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine NF benzoate) diltiazem hcl coated beads (Matzim La Oral Tablet Extended Tier 1 Release 24 Hour 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) nicardipine hcl oral capsule 20 mg, 30 mg NF nifedipine (Nifediac Cc Oral Tablet Extended Release 24 Hour Tier 1 QL (1 tablet per 1 day) 30 Mg) nifedipine (Nifedical Xl Oral Tablet Extended Release 24 Hour Tier 1 QL (2 tabs per 1 day) 60 Mg) nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, Tier 1 90 mg nifedipine er osmotic release oral tablet extended release 24 hour Tier 1 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg Tier 1 nimodipine oral capsule 30 mg Tier 1 nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, Tier 1 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG NF (amlodipine besylate) NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) Tier 3 NYMALIZE ORAL SOLUTION 60 MG/20ML (nimodipine) NF # PROCARDIA ORAL CAPSULE 10 MG (nifedipine) NF PROCARDIA XL ORAL TABLET EXTENDED NF RELEASE 24 HOUR 30 MG, 60 MG, 90 MG (nifedipine) SULAR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 17 MG, 34 MG, 8.5 MG (nisoldipine) diltiazem hcl er beads (Taztia Xt Oral Capsule Extended Tier 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg) diltiazem hcl er beads (Tiadylt Er Oral Capsule Extended Tier 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg)

82 Coverage Requirements and Prescription Drug Name Drug Tier Limits TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 NF MG (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, Tier 1 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 mg, Tier 1 240 mg verapamil hcl oral tablet 120 mg, 40 mg, 80 mg Tier 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digoxin (Digitek Oral Tablet 125 Mcg, 250 Mcg) Tier 1 digoxin (Digox Oral Tablet 125 Mcg, 250 Mcg) Tier 1 digoxin oral solution 0.05 mg/ml Tier 1 digoxin oral tablet 125 mcg, 250 mcg Tier 1 LANOXIN ORAL TABLET 125 MCG, 187.5 MCG, 250 NF MCG (digoxin) LANOXIN ORAL TABLET 62.5 MCG (digoxin) Tier 2 DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREAT HEART CONDITIONS aliskiren fumarate oral tablet 150 mg, 300 mg Tier 1 TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 Tier 3 ST; QL (1 tablet per 1 day) MG, 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) TEKTURNA ORAL TABLET 150 MG, 300 MG (aliskiren NF fumarate) DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide er oral capsule extended release 12 hour 500 mg Tier 1 acetazolamide oral tablet 125 mg, 250 mg Tier 1

83 Coverage Requirements and Prescription Drug Name Drug Tier Limits ALDACTAZIDE ORAL TABLET 25-25 MG NF (spironolactone-hctz) ALDACTAZIDE ORAL TABLET 50-50 MG Tier 2 (spironolactone-hctz) ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG NF (spironolactone) amiloride hcl oral tablet 5 mg Tier 1 amiloride-hydrochlorothiazide oral tablet 5-50 mg Tier 1 bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 BUMEX ORAL TABLET 0.5 MG, 1 MG, 2 MG NF (bumetanide) CAROSPIR ORAL SUSPENSION 25 MG/5ML NF (spironolactone) chlorothiazide oral tablet 250 mg, 500 mg Tier 1 chlorthalidone oral tablet 25 mg, 50 mg Tier 1 DEMADEX ORAL TABLET 10 MG, 20 MG (torsemide) NF DIAMOX SEQUELS ORAL CAPSULE EXTENDED NF RELEASE 12 HOUR 500 MG (acetazolamide) DIURIL ORAL SUSPENSION 250 MG/5ML Tier 3 (chlorothiazide) DYAZIDE ORAL CAPSULE 37.5-25 MG (triamterene-hctz) NF DYRENIUM ORAL CAPSULE 100 MG, 50 MG Tier 3 (triamterene) EDECRIN ORAL TABLET 25 MG (ethacrynic acid) NF ethacrynic acid oral tablet 25 mg Tier 1 furosemide oral solution 10 mg/ml, 8 mg/ml Tier 1 furosemide oral tablet 20 mg, 40 mg, 80 mg Tier 1 hydrochlorothiazide oral capsule 12.5 mg Tier 1 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg Tier 1 indapamide oral tablet 1.25 mg, 2.5 mg Tier 1 KEVEYIS ORAL TABLET 50 MG (dichlorphenamide) NF

84 Coverage Requirements and Prescription Drug Name Drug Tier Limits LASIX ORAL TABLET 20 MG, 40 MG, 80 MG (furosemide) NF MAXZIDE ORAL TABLET 75-50 MG (triamterene-hctz) NF MAXZIDE-25 ORAL TABLET 37.5-25 MG (triamterene- NF hctz) methazolamide oral tablet 25 mg, 50 mg Tier 1 methyclothiazide oral tablet 5 mg Tier 1 metolazone oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 MICROZIDE ORAL CAPSULE 12.5 MG NF (hydrochlorothiazide) NEPTAZANE ORAL TABLET 25 MG, 50 MG NF (methazolamide) spironolactone oral tablet 100 mg, 25 mg, 50 mg Tier 1 spironolactone-hctz oral tablet 25-25 mg Tier 1 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg Tier 1 triamterene oral capsule 100 mg, 50 mg Tier 1 triamterene-hctz oral capsule 37.5-25 mg, 50-25 mg Tier 1 triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg Tier 1 HEART FAILURE VERQUVO ORAL TABLET 10 MG, 2.5 MG, 5 MG NF (vericiguat) MISCELLANEOUS BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- Tier 3 # hydralazine) CATAPRES ORAL TABLET 0.1 MG, 0.2 MG, 0.3 MG NF (clonidine hcl) CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY NF 0.1 MG/24HR (clonidine) CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY NF 0.2 MG/24HR (clonidine) CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY NF 0.3 MG/24HR (clonidine)

85 Coverage Requirements and Prescription Drug Name Drug Tier Limits clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg Tier 1 clonidine hcl transdermal patch weekly 0.1 mg/24hr, 0.2 Tier 1 mg/24hr, 0.3 mg/24hr CORLANOR ORAL SOLUTION 5 MG/5ML (ivabradine Tier 2 hcl) CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine Tier 2 hcl) DEMSER ORAL CAPSULE 250 MG (metyrosine) Tier 4 ST DIBENZYLINE ORAL CAPSULE 10 MG NF (phenoxybenzamine hcl) droxidopa oral capsule 100 mg, 200 mg, 300 mg NF ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 Tier 2 MG (sacubitril-valsartan) guanfacine hcl oral tablet 1 mg, 2 mg Tier 1 hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg Tier 1 methyldopa oral tablet 250 mg, 500 mg Tier 1 methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 Tier 1 mg metyrosine oral capsule 250 mg Tier 1 midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 minoxidil oral tablet 10 mg, 2.5 mg Tier 1 NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG NF # (droxidopa) PA; SP Pharmacy; QL (12 phenoxybenzamine hcl oral capsule 10 mg Tier 4 capsules per 1 day) RANEXA ORAL TABLET EXTENDED RELEASE 12 NF HOUR 1000 MG (ranolazine) ranolazine er oral tablet extended release 12 hour 1000 mg, 500 Tier 1 ST mg reserpine oral tablet 0.1 mg, 0.25 mg Tier 1 VECAMYL ORAL TABLET 2.5 MG (mecamylamine hcl) NF

86 Coverage Requirements and Prescription Drug Name Drug Tier Limits VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) NF VYNDAQEL ORAL CAPSULE 20 MG (tafamidis NF meglumine (cardiac)) NITRATES - DRUGS TO TREAT HEART CONDITIONS DILATRATE-SR ORAL CAPSULE EXTENDED Tier 3 RELEASE 40 MG (isosorbide dinitrate) GONITRO SUBLINGUAL PACKET 400 MCG NF (nitroglycerin) ISORDIL TITRADOSE ORAL TABLET 40 MG (isosorbide Tier 3 dinitrate) ISORDIL TITRADOSE ORAL TABLET 5 MG (isosorbide NF dinitrate) isosorbide dinitrate er oral tablet extended release 40 mg Tier 1 isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg Tier 1 isosorbide dinitrate oral tablet 40 mg NF isosorbide mononitrate er oral tablet extended release 24 hour Tier 1 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg Tier 1 nitroglycerin (Minitran Transdermal Patch 24 Hour 0.1 Tier 1 Mg/Hr, 0.2 Mg/Hr, 0.4 Mg/Hr, 0.6 Mg/Hr) NITRO-BID TRANSDERMAL OINTMENT 2 % Tier 3 (nitroglycerin) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR NF (nitroglycerin) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 Tier 2 MG/HR, 0.8 MG/HR (nitroglycerin) nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg Tier 1 nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, Tier 1 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual aerosol solution 400 mcg/spray Tier 1 nitroglycerin translingual solution 0.4 mg/spray Tier 1

87 Coverage Requirements and Prescription Drug Name Drug Tier Limits NITROLINGUAL TRANSLINGUAL SOLUTION 0.4 NF MG/SPRAY (nitroglycerin) NITROMIST TRANSLINGUAL AEROSOL SOLUTION NF 400 MCG/SPRAY (nitroglycerin) NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 NF MG, 0.4 MG, 0.6 MG (nitroglycerin) RANEXA ORAL TABLET EXTENDED RELEASE 12 NF HOUR 500 MG (ranolazine) PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION PA; ST; QL (2 tablets per 1 ADCIRCA ORAL TABLET 20 MG (tadalafil (pah)) Tier 4 day) ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, PA; SP Pharmacy; QL (3 Tier 4 2.5 MG (riociguat) tablets per 1 day) PA; NPL; SP Pharmacy; QL tadalafil (pah) (Alyq Oral Tablet 20 Mg) Tier 4 (2 tablets per 1 day) PA; NPL; SP Pharmacy; QL ambrisentan oral tablet 10 mg, 5 mg Tier 4 (1 tablet per 1 day) PA; NPL; SP Pharmacy; QL bosentan oral tablet 125 mg, 62.5 mg Tier 4 (2 tablets per 1 day) epoprostenol sodium intravenous solution reconstituted 0.5 mg, NF PA; NPL; SP Pharmacy 1.5 mg FLOLAN INTRAVENOUS SOLUTION NF RECONSTITUTED 0.5 MG, 1.5 MG (epoprostenol sodium) LETAIRIS ORAL TABLET 10 MG, 5 MG (ambrisentan) Tier 4 PA; SP Pharmacy PA; SP Pharmacy; QL (2 OPSUMIT ORAL TABLET 10 MG (macitentan) Tier 4 tablets per 1 day) ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG (treprostinil Tier 4 PA; SP Pharmacy diolamine) REMODULIN INJECTION SOLUTION 1 MG/ML, 10 Tier 4 PA; #; SP Pharmacy MG/ML, 2.5 MG/ML, 5 MG/ML (treprostinil sodium)

88 Coverage Requirements and Prescription Drug Name Drug Tier Limits REMODULIN INJECTION SOLUTION 100 MG/20ML, 20 Tier 4 MG/20ML, 200 MG/20ML, 50 MG/20ML (treprostinil) REVATIO ORAL SUSPENSION RECONSTITUTED 10 NF MG/ML (sildenafil citrate) REVATIO ORAL TABLET 20 MG (sildenafil citrate) NF sildenafil citrate oral tablet 20 mg Tier 4 PA; QL (3 tablets per 1 day) PA; SP Pharmacy; QL (2 tadalafil (pah) oral tablet 20 mg Tier 4 tablets per 1 day) TRACLEER ORAL TABLET 125 MG, 62.5 MG (bosentan) NF TRACLEER ORAL TABLET SOLUBLE 32 MG (bosentan) Tier 4 QL (4 tablets per 1 day) treprostinil injection solution 100 mg/20ml, 20 mg/20ml, 200 Tier 1 PA; NPL; SP Pharmacy mg/20ml, 50 mg/20ml TYVASO INHALATION SOLUTION 0.6 MG/ML NF (treprostinil) TYVASO REFILL INHALATION SOLUTION 0.6 NF MG/ML (treprostinil) TYVASO STARTER INHALATION SOLUTION 0.6 Tier 4 MG/ML (treprostinil) UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 400 MCG, 600 MCG, 800 MCG Tier 4 (selexipag) UPTRAVI ORAL TABLET 200 MCG (selexipag) Tier 4 QL (5 tablets per 1 day) UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 Tier 4 QL (1 pack per 1 month) MCG (selexipag) VELETRI INTRAVENOUS SOLUTION NF RECONSTITUTED 0.5 MG, 1.5 MG (epoprostenol sodium) VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 PA; SP Pharmacy; QL (9 Tier 4 MCG/ML (iloprost) ampules per 1 day)

89 Coverage Requirements and Prescription Drug Name Drug Tier Limits CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, Tier 1 QL (2 tablets per 1 day) 2 mg, 3 mg ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 Tier 2 QL (10 ml per 1 day) MG/ML (alprazolam) alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg Tier 1 QL (5 tablets per 1 day) alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg Tier 1 QL (5 tablets per 1 day) alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, Tier 1 QL (2 tablets per 1 day) 2 mg, 3 mg ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG NF (lorazepam) chlordiazepoxide hcl oral capsule 10 mg, 25 mg NF chlordiazepoxide hcl oral capsule 5 mg Tier 1 QL (12 capsules per 1 day) lorazepam (Lorazepam Intensol Oral Concentrate 2 Mg/Ml) NF lorazepam oral concentrate 2 mg/ml Tier 1 QL (5 ml per 1 day) lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 QL (5 tablets per 1 day) meprobamate oral tablet 200 mg, 400 mg Tier 1 oxazepam oral capsule 10 mg, 15 mg, 30 mg Tier 1 QL (4 capsules per 1 day) XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG NF (alprazolam) XANAX XR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 0.5 MG, 1 MG, 2 MG, 3 MG (alprazolam) ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 Tier 3 PA; # MG (eslicarbazepine acetate) BANZEL ORAL SUSPENSION 40 MG/ML (rufinamide) Tier 3 BANZEL ORAL TABLET 200 MG, 400 MG (rufinamide) Tier 3 #; QL (8 tablets per 1 day) BRIVIACT ORAL SOLUTION 10 MG/ML (brivaracetam) Tier 3 PA

90 Coverage Requirements and Prescription Drug Name Drug Tier Limits BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 Tier 3 PA MG, 75 MG (brivaracetam) carbamazepine er oral capsule extended release 12 hour 100 mg, Tier 1 300 mg carbamazepine er oral capsule extended release 12 hour 200 mg NF carbamazepine er oral tablet extended release 12 hour 100 mg, Tier 1 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml Tier 1 carbamazepine oral tablet 200 mg Tier 1 carbamazepine oral tablet chewable 100 mg Tier 1 CARBATROL ORAL CAPSULE EXTENDED RELEASE NF 12 HOUR 100 MG, 200 MG, 300 MG (carbamazepine) CELONTIN ORAL CAPSULE 300 MG (methsuximide) Tier 3 clobazam oral suspension 2.5 mg/ml Tier 1 PA clobazam oral tablet 10 mg, 20 mg Tier 1 PA clonazepam oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 Tier 1 mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg Tier 1 QL (6 tablets per 1 day) DEPAKENE ORAL CAPSULE 250 MG (valproic acid) NF DEPAKENE ORAL SOLUTION 250 MG/5ML (valproate NF sodium) DEPAKOTE ER ORAL TABLET EXTENDED RELEASE NF 24 HOUR 250 MG, 500 MG (divalproex sodium) DEPAKOTE ORAL TABLET DELAYED RELEASE 125 NF MG, 250 MG, 500 MG (divalproex sodium) DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED NF RELEASE SPRINKLE 125 MG (divalproex sodium) SP Pharmacy; QL (12 DIACOMIT ORAL CAPSULE 250 MG (stiripentol) Tier 4 capsules per 1 day) SP Pharmacy; QL (6 DIACOMIT ORAL CAPSULE 500 MG (stiripentol) Tier 4 capsules per 1 day) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

91 Coverage Requirements and Prescription Drug Name Drug Tier Limits SP Pharmacy; QL (12 DIACOMIT ORAL PACKET 250 MG (stiripentol) Tier 4 packets per 1 day) SP Pharmacy; QL (6 packets DIACOMIT ORAL PACKET 500 MG (stiripentol) Tier 4 per 1 day) DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG NF (diazepam) DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) NF diazepam (Diazepam Intensol Oral Concentrate 5 Mg/Ml) Tier 1 QL (8 ml per 1 day) diazepam oral concentrate 5 mg/ml Tier 1 diazepam oral solution 1 mg/ml Tier 1 diazepam oral solution 5 mg/5ml Tier 1 QL (40 ml per 1 day) diazepam oral tablet 10 mg, 2 mg, 5 mg Tier 1 QL (4 tablets per 1 day) diazepam rectal gel 10 mg, 2.5 mg, 20 mg Tier 1 QL (1 pack per 1 fill) DILANTIN INFATABS ORAL TABLET CHEWABLE 50 NF MG (phenytoin) DILANTIN ORAL CAPSULE 100 MG (phenytoin sodium NF extended) DILANTIN ORAL CAPSULE 30 MG (phenytoin sodium Tier 3 extended) DILANTIN ORAL SUSPENSION 125 MG/5ML (phenytoin) NF divalproex sodium er oral tablet extended release 24 hour 250 Tier 1 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 125 mg Tier 1 divalproex sodium oral tablet delayed release 125 mg, 250 mg, Tier 1 500 mg ELEPSIA XR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1000 MG, 1500 MG (levetiracetam) PA; SP Pharmacy; QL (800 EPIDIOLEX ORAL SOLUTION 100 MG/ML (cannabidiol) Tier 4 ML per 1 month) carbamazepine (Epitol Oral Tablet 200 Mg) Tier 1 ethosuximide oral capsule 250 mg Tier 1

92 Coverage Requirements and Prescription Drug Name Drug Tier Limits ethosuximide oral solution 250 mg/5ml Tier 1 felbamate oral suspension 600 mg/5ml Tier 1 felbamate oral tablet 400 mg, 600 mg Tier 1 FELBATOL ORAL SUSPENSION 600 MG/5ML NF (felbamate) FELBATOL ORAL TABLET 400 MG, 600 MG (felbamate) NF FINTEPLA ORAL SOLUTION 2.2 MG/ML (fenfluramine PA; SP Pharmacy; QL (12 Tier 4 hcl) ML per 1 day) FYCOMPA ORAL SUSPENSION 0.5 MG/ML (perampanel) Tier 2 FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, Tier 2 6 MG, 8 MG (perampanel) gabapentin oral capsule 100 mg, 300 mg, 400 mg Tier 1 gabapentin oral solution 250 mg/5ml, 300 mg/6ml Tier 1 gabapentin oral tablet 600 mg, 800 mg Tier 1 GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG NF (tiagabine hcl) KEPPRA ORAL SOLUTION 100 MG/ML (levetiracetam) NF KEPPRA ORAL TABLET 1000 MG, 250 MG, 500 MG, 750 NF MG (levetiracetam) KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 500 MG, 750 MG (levetiracetam) KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG NF (clonazepam) LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, NF 25 & 50 & 100 MG, 42 X 50 MG & 14X100 MG (lamotrigine) LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 NF MG, 200 MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, NF 25 MG (lamotrigine) LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG NF (lamotrigine)

93 Coverage Requirements and Prescription Drug Name Drug Tier Limits LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 Tier 3 & 50 & 100 MG, 50 & 100 & 200 MG (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 NF MG (lamotrigine) lamotrigine er oral tablet extended release 24 hour 100 mg, 200 Tier 1 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral kit 21 x 25 mg & 7 x 50 mg, 25 & 50 & 100 mg, Tier 1 42 x 50 mg & 14x100 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg Tier 1 lamotrigine oral tablet chewable 25 mg, 5 mg Tier 1 lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 Tier 1 mg lamotrigine starter kit-blue oral kit 35 x 25 mg Tier 1 lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg Tier 1 lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg Tier 1 levetiracetam er oral tablet extended release 24 hour 500 mg, Tier 1 750 mg levetiracetam oral solution 100 mg/ml Tier 1 levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg Tier 1 LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 NF MG, 25 MG, 300 MG, 50 MG, 75 MG (pregabalin) LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) NF MYSOLINE ORAL TABLET 250 MG, 50 MG (primidone) NF NAYZILAM NASAL SOLUTION 5 MG/0.1ML (midazolam NF (anticonvulsant)) NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 NF MG (gabapentin) NEURONTIN ORAL SOLUTION 250 MG/5ML NF (gabapentin) NEURONTIN ORAL TABLET 600 MG, 800 MG NF (gabapentin)

94 Coverage Requirements and Prescription Drug Name Drug Tier Limits ONFI ORAL SUSPENSION 2.5 MG/ML (clobazam) NF ONFI ORAL TABLET 10 MG, 20 MG (clobazam) NF oxcarbazepine oral suspension 300 mg/5ml Tier 1 oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg Tier 1 OXTELLAR XR ORAL TABLET EXTENDED RELEASE Tier 3 ST; QL (2 tablets per 1 day) 24 HOUR 150 MG, 300 MG (oxcarbazepine) OXTELLAR XR ORAL TABLET EXTENDED RELEASE Tier 3 ST; QL (4 tablets per 1 day) 24 HOUR 600 MG (oxcarbazepine) PEGANONE ORAL TABLET 250 MG (ethotoin) Tier 3 phenobarbital oral elixir 20 mg/5ml Tier 1 phenobarbital oral solution 20 mg/5ml Tier 1 phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 Tier 1 mg, 60 mg, 64.8 mg, 97.2 mg PHENYTEK ORAL CAPSULE 200 MG, 300 MG (phenytoin NF sodium extended) phenytoin (Phenytoin Infatabs Oral Tablet Chewable 50 Mg) Tier 1 phenytoin oral suspension 125 mg/5ml Tier 1 phenytoin oral tablet chewable 50 mg Tier 1 phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 Tier 1 mg POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG Tier 3 QL (3 tablets per 1 Day) (ezogabine) POTIGA ORAL TABLET 50 MG (ezogabine) Tier 3 QL (6 tablets per 1 Day) pregabalin er oral tablet extended release 24 hour 165 mg, 330 NF mg, 82.5 mg pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 Tier 1 ST mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml Tier 1 ST primidone oral tablet 250 mg, 50 mg Tier 1 QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE NF 100 MG, 150 MG, 200 MG, 25 MG, 50 MG (topiramate)

95 Coverage Requirements and Prescription Drug Name Drug Tier Limits levetiracetam (Roweepra Oral Tablet 500 Mg) Tier 1 rufinamide oral suspension 40 mg/ml Tier 1 rufinamide oral tablet 200 mg, 400 mg Tier 1 QL (8 tablets per 1 day) SABRIL ORAL PACKET 500 MG (vigabatrin) NF PA; SP Pharmacy; QL (6 SABRIL ORAL TABLET 500 MG (vigabatrin) Tier 4 tablets per 1 day) SECONAL ORAL CAPSULE 100 MG (secobarbital sodium) Tier 3 SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG NF (levetiracetam) SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG NF (clobazam) TEGRETOL ORAL SUSPENSION 100 MG/5ML NF (carbamazepine) TEGRETOL ORAL TABLET 200 MG (carbamazepine) NF TEGRETOL-XR ORAL TABLET EXTENDED RELEASE NF 12 HOUR 100 MG, 200 MG, 400 MG (carbamazepine) tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg Tier 1 TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 NF MG (topiramate) TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 15 NF MG, 25 MG (topiramate) topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, NF 200 mg, 25 mg, 50 mg topiramate oral capsule sprinkle 15 mg, 25 mg Tier 1 topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg Tier 1 TRANXENE-T ORAL TABLET 7.5 MG (clorazepate NF dipotassium) TRILEPTAL ORAL SUSPENSION 300 MG/5ML NF (oxcarbazepine) TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG NF (oxcarbazepine)

96 Coverage Requirements and Prescription Drug Name Drug Tier Limits TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG NF # (topiramate) VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG (diazepam) NF valproate sodium intravenous solution 100 mg/ml, 500 mg/5ml Tier 1 valproate sodium oral solution 250 mg/5ml Tier 1 valproic acid oral capsule 250 mg Tier 1 valproic acid oral solution 250 mg/5ml Tier 1 VALTOCO 10 MG DOSE NASAL LIQUID 10 MG/0.1ML NF (diazepam) VALTOCO 15 MG DOSE NASAL LIQUID THERAPY NF PACK 7.5 MG/0.1ML (diazepam) VALTOCO 20 MG DOSE NASAL LIQUID THERAPY NF PACK 10 MG/0.1ML (diazepam) VALTOCO 5 MG DOSE NASAL LIQUID 5 MG/0.1ML NF (diazepam) PA; SP Pharmacy; QL (6 vigabatrin oral packet 500 mg Tier 4 packets per 1 Day) PA; SP Pharmacy; QL (6 vigabatrin oral tablet 500 mg Tier 4 tablets per 1 day) PA; SP Pharmacy; QL (6 vigabatrin (Vigadrone Oral Packet 500 Mg) Tier 4 packets per 1 day) VIMPAT ORAL SOLUTION 10 MG/ML (lacosamide) Tier 3 # VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 Tier 3 # MG (lacosamide) XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 100 & 150 MG, 50 & 200 MG NF (cenobamate) XCOPRI (350 MG DAILY DOSE) ORAL TABLET NF THERAPY PACK 150 & 200 MG (cenobamate) XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 NF MG (cenobamate)

97 Coverage Requirements and Prescription Drug Name Drug Tier Limits XCOPRI ORAL TABLET THERAPY PACK 14 X 12.5 MG & 14 X 25 MG, 14 X 150 MG & 14 X200 MG, 14 X 50 MG & NF 14 X100 MG (cenobamate) ZARONTIN ORAL CAPSULE 250 MG (ethosuximide) NF ZARONTIN ORAL SOLUTION 250 MG/5ML NF (ethosuximide) ZONEGRAN ORAL CAPSULE 100 MG, 25 MG NF (zonisamide) zonisamide oral capsule 100 mg, 25 mg, 50 mg Tier 1 ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS ARICEPT ORAL TABLET 10 MG, 23 MG, 5 MG (donepezil NF hcl) donepezil hcl oral tablet 10 mg, 23 mg, 5 mg Tier 1 donepezil hcl oral tablet dispersible 10 mg, 5 mg Tier 1 ergoloid mesylates oral tablet 1 mg Tier 1 EXELON TRANSDERMAL PATCH 24 HOUR 13.3 NF MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR (rivastigmine) galantamine hydrobromide er oral capsule extended release 24 Tier 1 hour 16 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml Tier 1 galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg Tier 1 memantine hcl er oral capsule extended release 24 hour 14 mg, Tier 1 21 mg, 28 mg, 7 mg memantine hcl oral solution 2 mg/ml Tier 1 memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 mg Tier 1 NAMENDA ORAL TABLET 10 MG, 5 MG (memantine hcl) NF NAMENDA TITRATION PAK ORAL TABLET 28 X 5 NF MG & 21 X 10 MG (memantine hcl) NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG NF (memantine hcl)

98 Coverage Requirements and Prescription Drug Name Drug Tier Limits NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 MG Tier 2 # (memantine hcl) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY Tier 2 PA PACK 7 & 14 & 21 &28 -10 MG (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG Tier 2 PA (memantine hcl-donepezil hcl) RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 16 MG, 24 MG, 8 MG (galantamine NF hydrobromide) RAZADYNE ORAL TABLET 12 MG, 4 MG, 8 MG NF (galantamine hydrobromide) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg Tier 1 rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 Tier 1 mg/24hr, 9.5 mg/24hr ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION amitriptyline hcl oral tablet 10 mg Tier 1 QL (5 tablets per 1 day) amitriptyline hcl oral tablet 100 mg, 150 mg, 75 mg Tier 1 PA; AL amitriptyline hcl oral tablet 25 mg Tier 1 QL (2 tablets per 1 day) amitriptyline hcl oral tablet 50 mg Tier 1 QL (1 tablet per 1 day) amoxapine oral tablet 100 mg, 25 mg, 50 mg Tier 1 QL (3 tablets per 1 day) amoxapine oral tablet 150 mg Tier 1 QL (2 tablets per 1 day) ANAFRANIL ORAL CAPSULE 25 MG, 50 MG, 75 MG NF (clomipramine hcl) APLENZIN ORAL TABLET EXTENDED RELEASE 24 NF HOUR 174 MG, 348 MG, 522 MG (bupropion hbr) BRISDELLE ORAL CAPSULE 7.5 MG (paroxetine NF mesylate) bupropion hcl er (sr) oral tablet extended release 12 hour 100 Tier 1 mg, 150 mg, 200 mg

99 Coverage Requirements and Prescription Drug Name Drug Tier Limits bupropion hcl er (xl) oral tablet extended release 24 hour 150 Tier 1 mg, 300 mg bupropion hcl er (xl) oral tablet extended release 24 hour 450 NF mg bupropion hcl oral tablet 100 mg, 75 mg Tier 1 CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG NF (citalopram hydrobromide) citalopram hydrobromide oral solution 10 mg/5ml Tier 1 citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg Tier 1 CYMBALTA ORAL CAPSULE DELAYED RELEASE NF PARTICLES 20 MG, 30 MG, 60 MG (duloxetine hcl) desipramine hcl oral tablet 10 mg, 25 mg, 50 mg Tier 1 QL (3 tablets per 1 day) desipramine hcl oral tablet 100 mg, 150 mg Tier 1 QL (1 tablet per 1 day) desipramine hcl oral tablet 75 mg Tier 1 QL (2 tablets per 1 day) desvenlafaxine er oral tablet extended release 24 hour 100 mg, NF 50 mg desvenlafaxine succinate er oral tablet extended release 24 hour Tier 1 ST; QL (1 tablet per 1 day) 100 mg, 25 mg, 50 mg doxepin hcl oral capsule 10 mg, 25 mg, 50 mg Tier 1 QL (3 capsules per 1 day) doxepin hcl oral capsule 100 mg, 150 mg Tier 1 QL (1 capsule per 1 day) doxepin hcl oral capsule 75 mg Tier 1 QL (2 capsules per 1 day) doxepin hcl oral concentrate 10 mg/ml Tier 1 QL (15 ml per 1 day) DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE SPRINKLE 20 MG, 30 MG, 40 MG, 60 MG NF (duloxetine hcl) duloxetine hcl oral capsule delayed release particles 20 mg, 30 Tier 1 mg, 40 mg, 60 mg EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 150 MG, 37.5 MG, 75 MG (venlafaxine hcl) ELAVIL ORAL TABLET 25 MG (amitriptyline hcl) NF EMSAM TRANSDERMAL PATCH 24 HOUR 12 Tier 3 PA; # MG/24HR, 6 MG/24HR, 9 MG/24HR (selegiline) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

100 Coverage Requirements and Prescription Drug Name Drug Tier Limits escitalopram oxalate oral solution 5 mg/5ml Tier 1 escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg Tier 1 FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG (levomilnacipran Tier 3 ST; QL (1 capsule per 1 day) hcl) FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR Tier 3 ST; QL (1 capsule per 1 day) THERAPY PACK 20 & 40 MG (levomilnacipran hcl) fluoxetine hcl (pmdd) oral capsule 10 mg, 20 mg Tier 1 fluoxetine hcl (pmdd) oral tablet 10 mg, 20 mg Tier 1 fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg Tier 1 fluoxetine hcl oral capsule delayed release 90 mg Tier 1 fluoxetine hcl oral solution 20 mg/5ml Tier 1 fluoxetine hcl oral tablet 10 mg, 20 mg Tier 1 fluoxetine hcl oral tablet 60 mg Tier 3 QL (1 tablet per 1 day) FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 NF HOUR 450 MG (bupropion hcl) imipramine hcl oral tablet 10 mg, 25 mg Tier 1 QL (4 tablets per 1 day) imipramine hcl oral tablet 50 mg Tier 1 QL (2 tablets per 1 day) imipramine pamoate oral capsule 100 mg, 75 mg Tier 1 QL (1 capsule per 1 day) imipramine pamoate oral capsule 125 mg, 150 mg Tier 1 PA KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 NF HOUR 100 MG, 50 MG (desvenlafaxine) LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG NF (escitalopram oxalate) maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg Tier 1 MARPLAN ORAL TABLET 10 MG (isocarboxazid) Tier 3 mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg Tier 1 mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg Tier 1 NARDIL ORAL TABLET 15 MG (phenelzine sulfate) NF nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 Tier 1 mg 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

101 Coverage Requirements and Prescription Drug Name Drug Tier Limits NORPRAMIN ORAL TABLET 10 MG, 25 MG NF (desipramine hcl) nortriptyline hcl oral capsule 10 mg Tier 1 QL (5 capsules per 1 day) nortriptyline hcl oral capsule 25 mg Tier 1 QL (2 capsules per 1 day) nortriptyline hcl oral capsule 50 mg Tier 1 QL (1 capsule per 1 day) nortriptyline hcl oral capsule 75 mg Tier 1 nortriptyline hcl oral solution 10 mg/5ml Tier 1 QL (750 ml per 1 month) PAMELOR ORAL CAPSULE 10 MG, 25 MG, 50 MG, 75 NF MG (nortriptyline hcl) PARNATE ORAL TABLET 10 MG (tranylcypromine NF sulfate) paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, Tier 1 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg Tier 1 paroxetine mesylate oral capsule 7.5 mg NF PAXIL CR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 12.5 MG, 25 MG, 37.5 MG (paroxetine hcl) PAXIL ORAL SUSPENSION 10 MG/5ML (paroxetine hcl) NF PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG NF (paroxetine hcl) PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG NF (paroxetine mesylate) phenelzine sulfate oral tablet 15 mg Tier 1 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 NF HOUR 100 MG, 25 MG, 50 MG (desvenlafaxine succinate) protriptyline hcl oral tablet 10 mg Tier 1 QL (2 tablets per 1 day) protriptyline hcl oral tablet 5 mg Tier 1 QL (3 tablets per 1 day) PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG NF (fluoxetine hcl) REMERON ORAL TABLET 15 MG, 30 MG, 45 MG NF (mirtazapine)

102 Coverage Requirements and Prescription Drug Name Drug Tier Limits REMERON SOLTAB ORAL TABLET DISPERSIBLE 15 NF MG, 30 MG, 45 MG (mirtazapine) SARAFEM ORAL TABLET 10 MG, 20 MG (fluoxetine hcl NF (pmdd)) sertraline hcl oral concentrate 20 mg/ml Tier 1 sertraline hcl oral tablet 100 mg, 25 mg, 50 mg Tier 1 SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG NF (trimipramine maleate) TOFRANIL ORAL TABLET 10 MG, 25 MG, 50 MG NF (imipramine hcl) tranylcypromine sulfate oral tablet 10 mg Tier 1 trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg Tier 1 trimipramine maleate oral capsule 100 mg Tier 1 QL (1 capsule per 1 day) trimipramine maleate oral capsule 25 mg, 50 mg Tier 1 QL (2 capsules per 1 day) TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG Tier 3 ST (vortioxetine hbr) venlafaxine hcl er oral capsule extended release 24 hour 150 mg, Tier 1 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 150 mg, Tier 1 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 225 mg Tier 1 QL (1 tablet per 1 day) venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 Tier 1 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG Tier 3 ST; # (vilazodone hcl) VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG Tier 3 ST; # (vilazodone hcl) WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG (bupropion NF hcl) WELLBUTRIN XL ORAL TABLET EXTENDED NF RELEASE 24 HOUR 150 MG, 300 MG (bupropion hcl)

103 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZOLOFT ORAL CONCENTRATE 20 MG/ML (sertraline NF hcl) ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG NF (sertraline hcl) ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl oral capsule 100 mg Tier 1 amantadine hcl oral syrup 50 mg/5ml Tier 1 amantadine hcl oral tablet 100 mg Tier 1 APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE PA; SP Pharmacy; QL (20 Tier 4 30 MG/3ML (apomorphine hcl) cartridges per 30 days) AZILECT ORAL TABLET 0.5 MG, 1 MG (rasagiline NF mesylate) benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 bromocriptine mesylate oral capsule 5 mg Tier 1 bromocriptine mesylate oral tablet 2.5 mg Tier 1 carbidopa oral tablet 25 mg Tier 1 carbidopa-levodopa er oral tablet extended release 25-100 mg, Tier 1 50-200 mg carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 Tier 1 mg carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 Tier 1 mg, 25-250 mg carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150- Tier 1 200 mg, 50-200-200 mg COMTAN ORAL TABLET 200 MG (entacapone) NF DUOPA ENTERAL SUSPENSION 4.63-20 MG/ML NF (carbidopa-levodopa) ELDEPRYL ORAL CAPSULE 5 MG (selegiline hcl) NF entacapone oral tablet 200 mg Tier 1

104 Coverage Requirements and Prescription Drug Name Drug Tier Limits GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 137 MG, 68.5 MG (amantadine hcl) INBRIJA INHALATION CAPSULE 42 MG (levodopa) NF KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, NF 25 MG, 30 MG (apomorphine hcl) LODOSYN ORAL TABLET 25 MG (carbidopa) NF MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 0.375 MG, 0.75 MG, 1.5 MG, 2.25 MG, 3 MG, 3.75 NF MG, 4.5 MG (pramipexole dihydrochloride) MIRAPEX ORAL TABLET 0.125 MG, 0.25 MG, 0.5 MG, NF 0.75 MG, 1 MG, 1.5 MG (pramipexole dihydrochloride) NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 Tier 2 # MG/24HR, 8 MG/24HR (rotigotine) NOURIANZ ORAL TABLET 20 MG, 40 MG (istradefylline) NF ONGENTYS ORAL CAPSULE 25 MG, 50 MG (opicapone) NF OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY NF PACK 129 & 193 MG (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE NF 24 HOUR 129 MG, 193 MG, 258 MG (amantadine hcl) PARLODEL ORAL CAPSULE 5 MG (bromocriptine NF mesylate) PARLODEL ORAL TABLET 2.5 MG (bromocriptine NF mesylate) pramipexole dihydrochloride er oral tablet extended release 24 Tier 1 hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 Tier 1 mg, 0.75 mg, 1 mg, 1.5 mg rasagiline mesylate oral tablet 0.5 mg, 1 mg Tier 1 REQUIP ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, NF 3 MG, 4 MG, 5 MG (ropinirole hcl) REQUIP XL ORAL TABLET EXTENDED RELEASE 24 NF HOUR 12 MG, 2 MG, 4 MG, 6 MG, 8 MG (ropinirole hcl) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

105 Coverage Requirements and Prescription Drug Name Drug Tier Limits ropinirole hcl er oral tablet extended release 24 hour 12 mg Tier 1 QL (2 tablets per 1 day) ropinirole hcl er oral tablet extended release 24 hour 2 mg, 4 mg, Tier 1 QL (1 tablet per 1 day) 6 mg, 8 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 Tier 1 mg, 5 mg RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG NF # (carbidopa-levodopa) selegiline hcl oral capsule 5 mg Tier 1 selegiline hcl oral tablet 5 mg Tier 1 SINEMET CR ORAL TABLET EXTENDED RELEASE NF 25-100 MG, 50-200 MG (carbidopa-levodopa) SINEMET ORAL TABLET 10-100 MG, 25-100 MG, 25-250 NF MG (carbidopa-levodopa) STALEVO 100 ORAL TABLET 25-100-200 MG (carbidopa- NF levodopa-entacapone) STALEVO 125 ORAL TABLET 31.25-125-200 MG NF (carbidopa-levodopa-entacapone) STALEVO 150 ORAL TABLET 37.5-150-200 MG NF (carbidopa-levodopa-entacapone) STALEVO 200 ORAL TABLET 50-200-200 MG (carbidopa- NF levodopa-entacapone) STALEVO 50 ORAL TABLET 12.5-50-200 MG (carbidopa- NF levodopa-entacapone) TASMAR ORAL TABLET 100 MG (tolcapone) NF tolcapone oral tablet 100 mg Tier 1 trihexyphenidyl hcl oral elixir 0.4 mg/ml Tier 1 trihexyphenidyl hcl oral tablet 2 mg, 5 mg Tier 1 XADAGO ORAL TABLET 100 MG, 50 MG (safinamide NF mesylate) ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG Tier 3 ST; QL (2 tablets per 1 day) (selegiline hcl)

106 Coverage Requirements and Prescription Drug Name Drug Tier Limits ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES ABILIFY MAINTENA INTRAMUSCULAR PREFILLED Tier 3 SYRINGE 300 MG, 400 MG (aripiprazole) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG Tier 3 (aripiprazole) ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, NF 30 MG, 5 MG (aripiprazole) aripiprazole oral solution 1 mg/ml Tier 1 aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg Tier 1 aripiprazole oral tablet dispersible 10 mg, 15 mg Tier 1 ARISTADA INITIO INTRAMUSCULAR PREFILLED Tier 2 SYRINGE 675 MG/2.4ML (aripiprazole lauroxil) ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 Tier 3 MG/3.2ML (aripiprazole lauroxil) asenapine maleate sublingual tablet sublingual 10 mg, 2.5 mg, 5 Tier 1 mg CAPLYTA ORAL CAPSULE 42 MG (lumateperone tosylate) NF chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml Tier 1 chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, Tier 1 50 mg clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg Tier 1 clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 200 Tier 1 mg, 25 mg CLOZARIL ORAL TABLET 100 MG, 25 MG (clozapine) NF EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG (carbamazepine Tier 3 (antipsychotic)) FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 Tier 3 QL (2 tablets per 1 day) MG, 6 MG, 8 MG (iloperidone)

107 Coverage Requirements and Prescription Drug Name Drug Tier Limits FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & Tier 3 6 MG (iloperidone) FAZACLO ORAL TABLET DISPERSIBLE 100 MG, 12.5 NF MG, 150 MG, 200 MG, 25 MG (clozapine) fluphenazine decanoate injection solution 25 mg/ml Tier 1 fluphenazine hcl injection solution 2.5 mg/ml Tier 1 fluphenazine hcl oral concentrate 5 mg/ml Tier 1 fluphenazine hcl oral elixir 2.5 mg/5ml Tier 1 fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg Tier 1 GEODON INTRAMUSCULAR SOLUTION NF RECONSTITUTED 20 MG (ziprasidone mesylate) GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 NF MG (ziprasidone hcl) HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/ML (haloperidol Tier 3 decanoate) HALDOL INJECTION SOLUTION 5 MG/ML (haloperidol Tier 3 lactate) haloperidol decanoate intramuscular solution 100 mg/ml, 50 Tier 1 mg/ml haloperidol lactate oral concentrate 2 mg/ml Tier 1 haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg Tier 1 INVEGA ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1.5 MG, 3 MG, 6 MG, 9 MG (paliperidone) INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML, Tier 3 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML (paliperidone palmitate) INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML, 410 NF MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML (paliperidone palmitate)

108 Coverage Requirements and Prescription Drug Name Drug Tier Limits LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 Tier 3 # MG, 80 MG (lurasidone hcl) LITHOBID ORAL TABLET EXTENDED RELEASE 300 NF MG (lithium carbonate) loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg Tier 1 NUPLAZID ORAL CAPSULE 34 MG (pimavanserin NF tartrate) NUPLAZID ORAL TABLET 10 MG, 17 MG (pimavanserin NF tartrate) olanzapine intramuscular solution reconstituted 10 mg Tier 1 olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 Tier 1 mg olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg Tier 1 paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 Tier 1 mg, 6 mg, 9 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg Tier 1 PERSERIS SUBCUTANEOUS PREFILLED SYRINGE NF 120 MG, 90 MG (risperidone) prochlorperazine edisylate injection solution 10 mg/2ml, 50 Tier 1 mg/10ml quetiapine fumarate er oral tablet extended release 24 hour 150 Tier 1 mg, 200 mg, 300 mg, 400 mg, 50 mg quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, Tier 1 400 mg, 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 Tier 3 MG, 3 MG, 4 MG (brexpiprazole) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 Tier 3 # MG, 50 MG (risperidone microspheres) RISPERDAL M-TAB ORAL TABLET DISPERSIBLE 0.5 NF MG, 1 MG, 3 MG, 4 MG (risperidone) RISPERDAL ORAL SOLUTION 1 MG/ML (risperidone) NF

109 Coverage Requirements and Prescription Drug Name Drug Tier Limits RISPERDAL ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 NF MG, 3 MG, 4 MG (risperidone) risperidone (Risperidone M-Tab Oral Tablet Dispersible 0.5 Tier 1 QL (2 tablets per 1 day) Mg, 1 Mg, 2 Mg) risperidone (Risperidone M-Tab Oral Tablet Dispersible 3 Mg) Tier 1 QL (3 tablets per 1 day) risperidone (Risperidone M-Tab Oral Tablet Dispersible 4 Mg) Tier 1 QL (4 tablets per 1 day) risperidone oral solution 1 mg/ml Tier 1 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg Tier 1 risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 Tier 1 mg, 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 NF # MG, 2.5 MG, 5 MG (asenapine maleate) SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 NF MG/24HR, 5.7 MG/24HR, 7.6 MG/24HR (asenapine) SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, NF 300 MG, 400 MG, 50 MG (quetiapine fumarate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG NF (quetiapine fumarate) thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg Tier 1 thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg Tier 1 trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg Tier 1 VERSACLOZ ORAL SUSPENSION 50 MG/ML (clozapine) NF VRAYLAR ORAL CAPSULE 1.5 MG (cariprazine hcl) Tier 3 QL (4 capsules per 1 day) VRAYLAR ORAL CAPSULE 3 MG (cariprazine hcl) Tier 3 QL (2 capsules per 1 day) VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG (cariprazine Tier 3 QL (1 capsule per 1 day) hcl) VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 Tier 3 MG (cariprazine hcl) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg Tier 1 ziprasidone mesylate intramuscular solution reconstituted 20 mg Tier 1

110 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZYPREXA INTRAMUSCULAR SOLUTION Tier 3 RECONSTITUTED 10 MG (olanzapine) ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 NF MG, 5 MG, 7.5 MG (olanzapine) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG, 300 MG, 405 Tier 3 MG (olanzapine pamoate) ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 10 MG, NF 15 MG, 20 MG, 5 MG (olanzapine) ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT ADHD ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG (amphetamine- NF dextroamphetamine) ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 NF MG, 5 MG (amphetamine-dextroamphetamine) ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 35 MG, 45 MG, 55 MG, 70 NF MG, 85 MG (methylphenidate hcl) ADZENYS ER ORAL SUSPENSION EXTENDED NF RELEASE 1.25 MG/ML (amphetamine) ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 12.5 MG, 15.7 MG, 18.8 MG, 3.1 NF MG, 6.3 MG, 9.4 MG (amphetamine) amphetamine er oral suspension extended release 1.25 mg/ml Tier 1 QL (15 ml per 1 day) amphetamine sulfate oral tablet 10 mg, 5 mg Tier 1 PA; QL (4 tablets per 1 day) amphetamine-dextroamphet er oral capsule extended release 24 Tier 1 QL (3 capsules per 1 day) hour 10 mg, 5 mg amphetamine-dextroamphet er oral capsule extended release 24 Tier 1 QL (1 capsule per 1 day) hour 15 mg, 20 mg, 25 mg, 30 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 5 Tier 1 QL (3 tablets per 1 day) mg, 7.5 mg

111 Coverage Requirements and Prescription Drug Name Drug Tier Limits amphetamine-dextroamphetamine oral tablet 15 mg, 20 mg Tier 1 QL (2 tablets per 1 day) amphetamine-dextroamphetamine oral tablet 30 mg Tier 1 QL (1 tablet per 1 day) APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, NF 60 MG (methylphenidate hcl) atomoxetine hcl oral capsule 10 mg, 18 mg, 40 mg Tier 1 QL (2 capsules per 1 day) atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg Tier 1 QL (1 capsule per 1 day) atomoxetine hcl oral capsule 25 mg Tier 1 QL (4 capsules per 1 day) AZSTARYS ORAL CAPSULE 26.1-5.2 MG, 39.2-7.8 MG, NF 52.3-10.4 MG (serdexmethylphen-dexmethylphen) clonidine hcl er oral tablet extended release 12 hour 0.1 mg Tier 1 QL (4 tablets per 1 day) CONCERTA ORAL TABLET EXTENDED RELEASE 18 NF MG, 27 MG (methylphenidate hcl) CONCERTA ORAL TABLET EXTENDED RELEASE 36 Tier 3 QL (2 tablets per 1 day) MG (methylphenidate hcl) CONCERTA ORAL TABLET EXTENDED RELEASE 54 Tier 3 QL (1 capsule per 1 day) MG (methylphenidate hcl) COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 17.3 MG, 25.9 MG, 8.6 MG NF (methylphenidate) DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 ST; #; QL (1 patch per 1 Tier 3 MG/9HR, 20 MG/9HR, 30 MG/9HR (methylphenidate) day) DESOXYN ORAL TABLET 5 MG (methamphetamine hcl) NF DEXEDRINE ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 10 MG, 15 MG, 5 MG (dextroamphetamine sulfate) dexmethylphenidate hcl er oral capsule extended release 24 hour NF 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 10 mg Tier 1 QL (2 tablets per 1 day) dexmethylphenidate hcl oral tablet 2.5 mg, 5 mg Tier 1 QL (4 tablets per 1 day) dextroamphetamine sulfate er oral capsule extended release 24 Tier 1 QL (4 capsules per 1 day) hour 10 mg, 5 mg

112 Coverage Requirements and Prescription Drug Name Drug Tier Limits dextroamphetamine sulfate er oral capsule extended release 24 Tier 1 QL (2 capsules per 1 day) hour 15 mg dextroamphetamine sulfate oral solution 5 mg/5ml Tier 1 QL (40 milliliters per 1 day) dextroamphetamine sulfate oral tablet 10 mg, 5 mg Tier 1 QL (4 tablets per 1 day) DYANAVEL XR ORAL SUSPENSION EXTENDED NF RELEASE 2.5 MG/ML (amphetamine) EVEKEO ODT ORAL TABLET DISPERSIBLE 10 MG, 15 NF MG, 20 MG, 5 MG (amphetamine sulfate) EVEKEO ORAL TABLET 10 MG, 5 MG (amphetamine NF sulfate) FOCALIN ORAL TABLET 10 MG (dexmethylphenidate hcl) Tier 3 QL (2 tablets per 1 day) FOCALIN ORAL TABLET 2.5 MG, 5 MG NF (dexmethylphenidate hcl) FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 5 MG NF (dexmethylphenidate hcl) FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 30 MG, 35 MG, 40 MG Tier 3 QL (1 capsule per 1 day) (dexmethylphenidate hcl) guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 Tier 1 QL (1 tablet per 1 day) mg, 3 mg, 4 mg INTUNIV ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1 MG, 2 MG, 3 MG, 4 MG (guanfacine hcl) JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 20 MG, 40 MG, 60 MG, 80 MG NF (methylphenidate hcl) KAPVAY ORAL TABLET EXTENDED RELEASE 12 NF HOUR 0.1 MG (clonidine hcl) methylphenidate hcl (Metadate Er Oral Tablet Extended Tier 1 QL (3 tablets per 1 day) Release 20 Mg) methamphetamine hcl oral tablet 5 mg Tier 1 QL (5 tablets per 1 day) METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML NF (methylphenidate hcl) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

113 Coverage Requirements and Prescription Drug Name Drug Tier Limits methylphenidate hcl er (cd) oral capsule extended release 10 Tier 1 QL (2 capsules per 1 day) mg, 20 mg, 30 mg methylphenidate hcl er (cd) oral capsule extended release 40 Tier 1 QL (1 capsule per 1 day) mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 Tier 1 QL (2 capsules per 1 day) hour 10 mg, 20 mg methylphenidate hcl er (la) oral capsule extended release 24 Tier 1 QL (1 capsule per 1 day) hour 30 mg, 40 mg, 60 mg methylphenidate hcl er (xr) oral capsule extended release 24 Tier 1 QL (2 capsules per 1 day) hour 10 mg, 15 mg, 20 mg, 30 mg methylphenidate hcl er (xr) oral capsule extended release 24 Tier 1 QL (1 capsule per 1 day) hour 40 mg, 50 mg, 60 mg methylphenidate hcl er oral tablet extended release 10 mg Tier 1 QL (3 tablet per 1 day) methylphenidate hcl er oral tablet extended release 18 mg, 27 Tier 1 QL (2 tablets per 1 day) mg, 36 mg methylphenidate hcl er oral tablet extended release 20 mg Tier 1 QL (3 tablets per 1 day) methylphenidate hcl er oral tablet extended release 24 hour 18 Tier 1 QL (2 tablets per 1 day) mg, 27 mg, 36 mg methylphenidate hcl er oral tablet extended release 24 hour 54 Tier 1 QL (1 capsule per 1 day) mg methylphenidate hcl er oral tablet extended release 54 mg Tier 1 QL (1 capsule per 1 day) methylphenidate hcl er oral tablet extended release 72 mg Tier 3 QL (1 tablet per 1 Day) methylphenidate hcl oral solution 10 mg/5ml Tier 1 QL (30 milliliters per 1 day) methylphenidate hcl oral solution 5 mg/5ml Tier 1 QL (60 milliliters per 1 day) methylphenidate hcl oral tablet 10 mg, 5 mg Tier 1 QL (6 tablets per 1 day) methylphenidate hcl oral tablet 20 mg Tier 1 QL (3 tablets per 1 day) methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 mg Tier 1 QL (6 tablets per 1 day) MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG, 50 MG (amphetamine- NF # dextroamphetamine) dextroamphetamine sulfate (Procentra Oral Solution 5 NF Mg/5Ml)

114 Coverage Requirements and Prescription Drug Name Drug Tier Limits QELBREE ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 100 MG, 150 MG, 200 MG (viloxazine hcl) QUILLICHEW ER ORAL TABLET CHEWABLE Tier 3 QL (2 tablets per 1 day) EXTENDED RELEASE 20 MG (methylphenidate hcl) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 30 MG, 40 MG (methylphenidate NF hcl) QUILLIVANT XR ORAL SUSPENSION PA; ST; #; QL (1 bottle per Tier 3 RECONSTITUTED 25 MG/5ML (methylphenidate hcl) 1 fill) QUILLIVANT XR ORAL SUSPENSION Tier 3 QL (20 ML per 1 day) RECONSTITUTED ER 25 MG/5ML (methylphenidate hcl) RELEXXII ORAL TABLET EXTENDED RELEASE 72 Tier 3 QL (1 tablet per 1 Day) MG (methylphenidate hcl) RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 30 MG, 40 MG, 60 MG NF (methylphenidate hcl) RITALIN ORAL TABLET 10 MG, 5 MG (methylphenidate NF hcl) RITALIN ORAL TABLET 20 MG (methylphenidate hcl) Tier 3 QL (3 tablets per 1 day) STALEVO 75 ORAL TABLET 18.75-75-200 MG (carbidopa- NF levodopa-entacapone) STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, NF 25 MG, 40 MG, 80 MG (atomoxetine hcl) STRATTERA ORAL CAPSULE 60 MG (atomoxetine hcl) Tier 3 QL (1 capsule per 1 day) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG ST; QL (2 capsules per 1 Tier 3 (lisdexamfetamine dimesylate) day) VYVANSE ORAL CAPSULE 40 MG, 50 MG, 60 MG, 70 Tier 3 ST; QL (1 capsule per 1 day) MG (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, Tier 3 ST; QL (2 tablets per 1 day) 30 MG (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 40 MG, 50 MG, Tier 3 ST; QL (1 capsule per 1 day) 60 MG (lisdexamfetamine dimesylate) dextroamphetamine sulfate (Zenzedi Oral Tablet 10 Mg, 5 Mg) Tier 1 QL (4 tablets per 1 day) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

115 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 NF MG, 7.5 MG (dextroamphetamine sulfate) HYPNOTICS - DRUGS TO TREAT INSOMNIA AMBIEN CR ORAL TABLET EXTENDED RELEASE NF 12.5 MG, 6.25 MG (zolpidem tartrate) AMBIEN ORAL TABLET 10 MG, 5 MG (zolpidem tartrate) NF BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 Tier 3 PA; QL (1 tablet per 1 day) MG (suvorexant) BUTISOL SODIUM ORAL TABLET 30 MG (butabarbital Tier 3 sodium) cvs ultra sleep oral tablet 25 mg Tier 1 DAYVIGO ORAL TABLET 10 MG, 5 MG (lemborexant) NF DORAL ORAL TABLET 15 MG (quazepam) NF doxepin hcl oral tablet 3 mg, 6 mg Tier 1 QL (1 tablet per 1 day) EDLUAR SUBLINGUAL TABLET SUBLINGUAL 10 NF MG, 5 MG (zolpidem tartrate) eql sleep aid oral tablet 25 mg Tier 1 estazolam oral tablet 1 mg, 2 mg Tier 1 eszopiclone oral tablet 1 mg, 2 mg, 3 mg Tier 1 QL (15 tablets per 1 month) flurazepam hcl oral capsule 15 mg, 30 mg Tier 1 HALCION ORAL TABLET 0.25 MG (triazolam) NF HETLIOZ LQ ORAL SUSPENSION 4 MG/ML NF (tasimelteon) PA; SP Pharmacy; QL (1 HETLIOZ ORAL CAPSULE 20 MG (tasimelteon) Tier 4 capsule per 1 day) hm sleep aid oral tablet 25 mg Tier 1 INTERMEZZO SUBLINGUAL TABLET SUBLINGUAL NF 1.75 MG, 3.5 MG (zolpidem tartrate) kls sleep aid oral tablet 25 mg Tier 1 LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG NF (eszopiclone)

116 Coverage Requirements and Prescription Drug Name Drug Tier Limits midazolam hcl oral syrup 2 mg/ml Tier 1 MIDAZOLAM+SYRSPEND SF PH4 ORAL NF SUSPENSION 1 MG/ML (midazolam) quazepam oral tablet 15 mg Tier 1 ra sleep aid oral tablet 25 mg Tier 1 ramelteon oral tablet 8 mg Tier 1 QL (15 tablets per 1 month) RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG, 7.5 NF MG (temazepam) ROZEREM ORAL TABLET 8 MG (ramelteon) NF SILENOR ORAL TABLET 3 MG, 6 MG (doxepin hcl) Tier 3 ST; QL (1 tablet per 1 day) sleep-aid oral tablet 25 mg Tier 1 sm sleep aid oral tablet 25 mg Tier 1 SONATA ORAL CAPSULE 10 MG, 5 MG (zaleplon) NF QL (15 capsules per 1 temazepam oral capsule 15 mg, 30 mg Tier 1 month) temazepam oral capsule 22.5 mg, 7.5 mg Tier 1 QL (1 capsule per 1 day) triazolam oral tablet 0.125 mg, 0.25 mg Tier 1 QL (10 tablets per 30 days) wal-som oral tablet 25 mg Tier 1 zaleplon oral capsule 10 mg, 5 mg Tier 1 QL (1 capsule per 1 day) zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 PA; QL (15 tablets per 1 Tier 1 mg month) zolpidem tartrate oral tablet 10 mg, 5 mg Tier 1 QL (2 tablets per 1 day) zolpidem tartrate sublingual tablet sublingual 1.75 mg, 3.5 mg NF ZOLPIMIST ORAL SOLUTION 5 MG/ACT (zolpidem NF # tartrate) MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES AIMOVIG (140 MG DOSE) SUBCUTANEOUS SOLUTION AUTO-INJECTOR 70 MG/ML (erenumab- Tier 2 aooe) AIMOVIG SUBCUTANEOUS SOLUTION AUTO- Tier 2 INJECTOR 140 MG/ML, 70 MG/ML (erenumab-aooe)

117 Coverage Requirements and Prescription Drug Name Drug Tier Limits AJOVY SUBCUTANEOUS SOLUTION AUTO- Tier 2 INJECTOR 225 MG/1.5ML (fremanezumab-vfrm) AJOVY SUBCUTANEOUS SOLUTION PREFILLED Tier 2 SYRINGE 225 MG/1.5ML (fremanezumab-vfrm) almotriptan malate oral tablet 12.5 mg, 6.25 mg Tier 1 QL (12 tablets per 30 days) AMERGE ORAL TABLET 1 MG, 2.5 MG (naratriptan hcl) NF AXERT ORAL TABLET 12.5 MG, 6.25 MG (almotriptan NF malate) D.H.E. 45 INJECTION SOLUTION 1 MG/ML NF (dihydroergotamine mesylate) dihydroergotamine mesylate injection solution 1 mg/ml Tier 1 dihydroergotamine mesylate nasal solution 4 mg/ml Tier 1 ST; QL (8 vials per 1 fill) eletriptan hydrobromide oral tablet 20 mg, 40 mg Tier 1 QL (12 tablets per 30 days) EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML Tier 2 ST (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION AUTO- Tier 2 INJECTOR 120 MG/ML (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION PREFILLED Tier 2 SYRINGE 120 MG/ML (galcanezumab-gnlm) ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 Tier 3 MG (ergotamine tartrate) ergotamine-caffeine oral tablet 1-100 mg Tier 1 FROVA ORAL TABLET 2.5 MG (frovatriptan succinate) NF frovatriptan succinate oral tablet 2.5 mg Tier 1 QL (18 tablets per 30 days) IMITREX NASAL SOLUTION 20 MG/ACT, 5 MG/ACT NF (sumatriptan) IMITREX ORAL TABLET 100 MG, 25 MG, 50 MG NF (sumatriptan succinate) IMITREX STATDOSE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE 4 MG/0.5ML, 6 MG/0.5ML NF (sumatriptan succinate)

118 Coverage Requirements and Prescription Drug Name Drug Tier Limits IMITREX STATDOSE SYSTEM SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 MG/0.5ML, 6 MG/0.5ML NF (sumatriptan succinate) IMITREX SUBCUTANEOUS SOLUTION 6 MG/0.5ML NF (sumatriptan succinate) MAXALT ORAL TABLET 10 MG, 5 MG (rizatriptan NF benzoate) MAXALT-MLT ORAL TABLET DISPERSIBLE 10 MG, 5 NF MG (rizatriptan benzoate) MIGERGOT RECTAL SUPPOSITORY 2-100 MG NF (ergotamine-caffeine) MIGRANAL NASAL SOLUTION 4 MG/ML NF (dihydroergotamine mesylate) naratriptan hcl oral tablet 1 mg, 2.5 mg Tier 1 QL (9 tablets per 30 days) NURTEC ORAL TABLET DISPERSIBLE 75 MG ST; QL (16 tablets per 30 Tier 2 (rimegepant sulfate) days) ONZETRA XSAIL NASAL EXHALER POWDER 11 NF MG/NOSEPC (sumatriptan succinate) RELPAX ORAL TABLET 20 MG, 40 MG (eletriptan NF hydrobromide) REYVOW ORAL TABLET 100 MG, 50 MG (lasmiditan NF succinate) rizatriptan benzoate oral tablet 10 mg, 5 mg Tier 1 QL (12 tablets per 30 days) rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg Tier 1 QL (9 tablets per 30 days) sumatriptan nasal solution 20 mg/act, 5 mg/act Tier 1 QL (6 sprays per 30 days) sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg Tier 1 QL (9 tablets per 30 days) sumatriptan succinate refill subcutaneous solution cartridge 4 QL (10 cart/30 days per 48 Tier 1 mg/0.5ml, 6 mg/0.5ml max in 365 dayss) QL (10 vials/30 days per 48 sumatriptan succinate subcutaneous solution 6 mg/0.5ml Tier 1 max in 365 dayss) sumatriptan succinate subcutaneous solution auto-injector 4 QL (10 cart/30 days per 48 Tier 1 mg/0.5ml, 6 mg/0.5ml max in 365 dayss)

119 Coverage Requirements and Prescription Drug Name Drug Tier Limits sumatriptan-naproxen sodium oral tablet 85-500 mg Tier 1 ST SUMAVEL DOSEPRO SUBCUTANEOUS SOLUTION JET-INJECTOR 4 MG/0.5ML, 6 MG/0.5ML (sumatriptan NF succinate) TOSYMRA NASAL SOLUTION 10 MG/ACT (sumatriptan) NF TREXIMET ORAL TABLET 10-60 MG (sumatriptan- NF # naproxen sodium) TREXIMET ORAL TABLET 85-500 MG (sumatriptan- NF naproxen sodium) UBRELVY ORAL TABLET 100 MG, 50 MG (ubrogepant) NF ZEMBRACE SYMTOUCH SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 MG/0.5ML (sumatriptan NF succinate) QL (12 SPRAYS per 1 zolmitriptan nasal solution 2.5 mg, 5 mg Tier 1 month) zolmitriptan oral tablet 2.5 mg, 5 mg Tier 1 QL (12 tablets per 30 days) zolmitriptan oral tablet dispersible 2.5 mg, 5 mg Tier 1 QL (12 tablets per 30 days) ZOMIG NASAL SOLUTION 2.5 MG, 5 MG (zolmitriptan) NF ZOMIG ORAL TABLET 2.5 MG, 5 MG (zolmitriptan) NF ZOMIG ZMT ORAL TABLET DISPERSIBLE 2.5 MG, 5 NF MG (zolmitriptan) MISCELLANEOUS AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG NF (deutetrabenazine) PA; ST; QL (2 tablets per 1 BELVIQ ORAL TABLET 10 MG (lorcaserin hcl) Tier 3 day) buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg Tier 1 caffeine citrate oral solution 20 mg/ml, 60 mg/3ml NF clomipramine hcl oral capsule 25 mg, 50 mg Tier 1 QL (5 capsules per 1 day) clomipramine hcl oral capsule 75 mg Tier 1 QL (3 capsules per 1 day) EVRYSDI ORAL SOLUTION RECONSTITUTED 0.75 PA; NPL; SP Pharmacy; QL Tier 4 MG/ML (risdiplam) (200 ML per 1 month) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

120 Coverage Requirements and Prescription Drug Name Drug Tier Limits EXSERVAN ORAL FILM 50 MG (riluzole) NF FIRDAPSE ORAL TABLET 10 MG (amifampridine PA; SP Pharmacy; QL (8 Tier 4 phosphate) tablets per 1 day) fluvoxamine maleate er oral capsule extended release 24 hour Tier 1 100 mg, 150 mg fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg Tier 1 guanidine hcl oral tablet 125 mg Tier 3 IMCIVREE SUBCUTANEOUS SOLUTION 10 MG/ML NF (setmelanotide acetate) INGREZZA ORAL CAPSULE 40 MG, 80 MG (valbenazine PA; QL (1 capsule per 1 Tier 4 tosylate) day) PA; SP Pharmacy; QL (1 INGREZZA ORAL CAPSULE 60 MG (valbenazine tosylate) Tier 4 capsule per 1 day) INGREZZA ORAL CAPSULE THERAPY PACK 40 & 80 NF MG (valbenazine tosylate) lithium carbonate er oral tablet extended release 300 mg, 450 Tier 1 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg Tier 1 lithium carbonate oral tablet 300 mg Tier 1 lithium oral solution 8 meq/5ml Tier 3 MESTINON ORAL SYRUP 60 MG/5ML (pyridostigmine Tier 3 bromide) MESTINON ORAL TABLET 60 MG (pyridostigmine NF bromide) MESTINON ORAL TABLET EXTENDED RELEASE 180 NF MG (pyridostigmine bromide) NUEDEXTA ORAL CAPSULE 20-10 MG Tier 3 PA (dextromethorphan-quinidine) ORAP ORAL TABLET 1 MG, 2 MG (pimozide) NF phendimetrazine tartrate er oral capsule extended release 24 NF hour 105 mg phendimetrazine tartrate oral tablet 35 mg Tier 1 QL (6 tablets per 1 day)

121 Coverage Requirements and Prescription Drug Name Drug Tier Limits phentermine hcl oral capsule 15 mg Tier 1 QL (2 capsules per 1 day) phentermine hcl oral capsule 30 mg, 37.5 mg Tier 1 QL (1 capsule per 1 day) pimozide oral tablet 1 mg, 2 mg Tier 1 pyridostigmine bromide er oral tablet extended release 180 mg Tier 1 pyridostigmine bromide oral solution 60 mg/5ml Tier 1 pyridostigmine bromide oral tablet 30 mg, 60 mg Tier 1 RILUTEK ORAL TABLET 50 MG (riluzole) NF riluzole oral tablet 50 mg Tier 1 RUZURGI ORAL TABLET 10 MG (amifampridine) NF SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 Tier 3 ST MG (milnacipran hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG Tier 3 ST (milnacipran hcl) PA; SP Pharmacy; QL (8 tetrabenazine oral tablet 12.5 mg Tier 4 tablets per 1 day) PA; SP Pharmacy; QL (4 tetrabenazine oral tablet 25 mg Tier 4 tablets per 1 day) TIGLUTIK ORAL SUSPENSION 50 MG/10ML (riluzole) NF TRIKAFTA ORAL TABLET THERAPY PACK 50-25-37.5 PA; SP Pharmacy; QL (8 Tier 4 & 75 MG (elexacaftor-tezacaftor-ivacaft) tablets per 1 day) XENAZINE ORAL TABLET 12.5 MG, 25 MG NF (tetrabenazine) MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSIS AMPYRA ORAL TABLET EXTENDED RELEASE 12 NF HOUR 10 MG (dalfampridine) AUBAGIO ORAL TABLET 14 MG, 7 MG (teriflunomide) Tier 2 PA; QL (1 tablet per 1 day) AVONEX INTRAMUSCULAR KIT 30 MCG (interferon Tier 4 PA; QL (1 kit per 30 days) beta-1a) AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR Tier 4 PA; QL (4 pens per 28 days) KIT 30 MCG/0.5ML (interferon beta-1a)

122 Coverage Requirements and Prescription Drug Name Drug Tier Limits AVONEX PREFILLED INTRAMUSCULAR PREFILLED PA; QL (4 syringes per 28 Tier 4 SYRINGE KIT 30 MCG/0.5ML (interferon beta-1a) days) BAFIERTAM ORAL CAPSULE DELAYED RELEASE 95 NF MG (monomethyl fumarate) BETASERON SUBCUTANEOUS KIT 0.3 MG (interferon Tier 2 PA; QL (1 kit per 1 month) beta-1b) COPAXONE SUBCUTANEOUS SOLUTION PA; NPL; SP Pharmacy; QL Tier 2 PREFILLED SYRINGE 20 MG/ML (glatiramer acetate) (1 syringe per 1 day) COPAXONE SUBCUTANEOUS SOLUTION PA; NPL; SP Pharmacy; QL Tier 2 PREFILLED SYRINGE 40 MG/ML (glatiramer acetate) (12 syringes per 28 days) PA; SP Pharmacy; QL (2 dalfampridine er oral tablet extended release 12 hour 10 mg Tier 4 tablets per 1 day) PA; NPL; SP Pharmacy; QL dimethyl fumarate oral capsule delayed release 120 mg, 240 mg Tier 4 (2 capsules per 1 day) EXTAVIA SUBCUTANEOUS KIT 0.3 MG (interferon beta- Tier 4 PA; QL (1 kit per 1 month) 1b) PA; #; QL (1 capsule per 1 GILENYA ORAL CAPSULE 0.25 MG (fingolimod hcl) Tier 2 Day) PA; #; QL (1 capsule per 1 GILENYA ORAL CAPSULE 0.5 MG (fingolimod hcl) Tier 2 day) glatiramer acetate subcutaneous solution prefilled syringe 20 PA; NPL; SP Pharmacy; QL Tier 1 mg/ml (1 syringe per 1 day) glatiramer acetate subcutaneous solution prefilled syringe 40 PA; NPL; SP Pharmacy; QL Tier 1 mg/ml (12 syringes per 28 days) glatiramer acetate (Glatopa Subcutaneous Solution Prefilled PA; NPL; SP Pharmacy; QL Tier 1 Syringe 20 Mg/Ml) (1 syringe per 1 day) glatiramer acetate (Glatopa Subcutaneous Solution Prefilled PA; NPL; SP Pharmacy; QL Tier 1 Syringe 40 Mg/Ml) (12 syringes per 28 days) MAVENCLAD (10 TABS) ORAL TABLET THERAPY NF PACK 10 MG (cladribine) MAVENCLAD (4 TABS) ORAL TABLET THERAPY NF PACK 10 MG (cladribine)

123 Coverage Requirements and Prescription Drug Name Drug Tier Limits MAVENCLAD (5 TABS) ORAL TABLET THERAPY NF PACK 10 MG (cladribine) MAVENCLAD (6 TABS) ORAL TABLET THERAPY NF PACK 10 MG (cladribine) MAVENCLAD (7 TABS) ORAL TABLET THERAPY NF PACK 10 MG (cladribine) MAVENCLAD (8 TABS) ORAL TABLET THERAPY NF PACK 10 MG (cladribine) MAVENCLAD (9 TABS) ORAL TABLET THERAPY NF PACK 10 MG (cladribine) MAYZENT ORAL TABLET 0.25 MG, 2 MG (siponimod NF fumarate) MAYZENT STARTER PACK ORAL TABLET THERAPY NF PACK 0.25 MG (siponimod fumarate) PLEGRIDY INTRAMUSCULAR SOLUTION PA; ST; NPL; SP Pharmacy; PREFILLED SYRINGE 125 MCG/0.5ML (peginterferon Tier 4 QL (2 SYRINGES per 1 beta-1a) month) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML Tier 4 PA; QL (1 kit per 365 days) (peginterferon beta-1a) PLEGRIDY STARTER PACK SUBCUTANEOUS PA; QL (2 syringes per 28 SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML Tier 4 days) (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS SOLUTION PEN- PA; QL (2 syringes per 28 Tier 4 INJECTOR 125 MCG/0.5ML (peginterferon beta-1a) days) PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED PA; QL (2 syringes per 28 Tier 4 SYRINGE 125 MCG/0.5ML (peginterferon beta-1a) days) PONVORY ORAL TABLET 20 MG (ponesimod) NF PONVORY STARTER PACK ORAL TABLET THERAPY NF PACK 2-3-4-5-6-7-8-9 & 10 MG (ponesimod) REBIF REBIDOSE SUBCUTANEOUS SOLUTION PA; QL (12 syringes per 28 AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML Tier 2 days) (interferon beta-1a)

124 Coverage Requirements and Prescription Drug Name Drug Tier Limits REBIF REBIDOSE TITRATION PACK PA; QL (12 injections per 1 SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 Tier 2 month) & 6X22 MCG (interferon beta-1a) REBIF SUBCUTANEOUS SOLUTION PREFILLED PA; QL (12 syringes per 28 SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML (interferon beta- Tier 2 days) 1a) REBIF TITRATION PACK SUBCUTANEOUS PA; QL (12 injections per 1 SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG Tier 2 month) (interferon beta-1a) TECFIDERA ORAL 120 & 240 MG (dimethyl fumarate) NF # TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 NF MG, 240 MG (dimethyl fumarate) VUMERITY (STARTER) ORAL CAPSULE DELAYED PA; NPL; SP Pharmacy; QL Tier 4 RELEASE 231 MG (diroximel fumarate) (1 pack per 1 month) VUMERITY ORAL CAPSULE DELAYED RELEASE 231 PA; NPL; SP Pharmacy; QL Tier 4 MG (diroximel fumarate) (4 capsules per 1 day) ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK 4 X 0.23MG & 3 X 0.46MG (ozanimod NF hcl) ZEPOSIA ORAL CAPSULE 0.92 MG (ozanimod hcl) NF ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY NF PACK 0.23MG & 0.46MG & 0.92MG (ozanimod hcl) MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS AMRIX ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 15 MG, 30 MG (cyclobenzaprine hcl) baclofen oral tablet 10 mg, 20 mg, 5 mg Tier 1 carisoprodol oral tablet 250 mg NF carisoprodol oral tablet 350 mg Tier 1 PA; AL carisoprodol-aspirin oral tablet 200-325 mg Tier 1 carisoprodol-aspirin-codeine oral tablet 200-325-16 mg Tier 1 PA chlorzoxazone oral tablet 250 mg, 375 mg, 500 mg, 750 mg NF

125 Coverage Requirements and Prescription Drug Name Drug Tier Limits cyclobenzaprine hcl er oral capsule extended release 24 hour 15 Tier 1 mg, 30 mg cyclobenzaprine hcl oral tablet 10 mg NF cyclobenzaprine hcl oral tablet 5 mg Tier 1 PA; AL cyclobenzaprine hcl oral tablet 7.5 mg Tier 1 DANTRIUM ORAL CAPSULE 25 MG, 50 MG (dantrolene NF sodium) dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg Tier 1 FEXMID ORAL TABLET 7.5 MG (cyclobenzaprine hcl) NF chlorzoxazone (Lorzone Oral Tablet 375 Mg, 750 Mg) NF metaxalone (Metaxall Oral Tablet 800 Mg) Tier 1 metaxalone oral tablet 400 mg, 800 mg Tier 1 PA; AL methocarbamol oral tablet 500 mg, 750 mg NF norgesic forte oral tablet 50-770-60 mg NF orphenadrine citrate er oral tablet extended release 12 hour 100 Tier 1 PA; AL mg orphenadrine-asa-caffeine oral tablet 50-770-60 mg NF orphenadrine-aspirin-caffeine (Orphengesic Forte Oral Tablet NF 50-770-60 Mg) OZOBAX ORAL SOLUTION 5 MG/5ML (baclofen) NF PARAFON FORTE DSC ORAL TABLET 500 MG NF (chlorzoxazone) ROBAXIN ORAL TABLET 500 MG (methocarbamol) NF ROBAXIN-750 ORAL TABLET 750 MG (methocarbamol) NF SKELAXIN ORAL TABLET 800 MG (metaxalone) NF SOMA ORAL TABLET 250 MG, 350 MG (carisoprodol) NF tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg NF tizanidine hcl oral tablet 2 mg, 4 mg Tier 1 carisoprodol (Vanadom Oral Tablet 350 Mg) NF

126 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZANAFLEX ORAL CAPSULE 2 MG, 4 MG, 6 MG NF (tizanidine hcl) ZANAFLEX ORAL TABLET 4 MG (tizanidine hcl) NF NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS armodafinil oral tablet 150 mg, 200 mg, 250 mg Tier 1 PA; QL (1 tablet per 1 day) armodafinil oral tablet 50 mg Tier 1 PA; QL (2 tablets per 1 day) modafinil oral tablet 100 mg, 200 mg Tier 1 PA; QL (2 tablets per 1 day) NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 NF MG (armodafinil) PROVIGIL ORAL TABLET 100 MG, 200 MG (modafinil) NF SUNOSI ORAL TABLET 150 MG, 75 MG (solriamfetol hcl) NF WAKIX ORAL TABLET 17.8 MG, 4.45 MG (pitolisant hcl) NF PA; SP Pharmacy; QL (540 XYREM ORAL SOLUTION 500 MG/ML (sodium oxybate) Tier 4 ml per 1 month) XYWAV ORAL SOLUTION 500 MG/ML (ca, mg, k, and na NF oxybates) POLYNEUROPATHY TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED PA; NPL; SP Pharmacy; QL Tier 4 SYRINGE 284 MG/1.5ML (inotersen sodium) (4 injections per 1 month) POSTHERPETIC NEURALGIA (PHN) GRALISE ORAL TABLET 300 MG (gabapentin (once- Tier 3 ST; QL (1 tablet per 1 day) daily)) GRALISE ORAL TABLET 600 MG (gabapentin (once- Tier 3 ST; QL (3 tablets per 1 day) daily)) GRALISE STARTER ORAL 300 & 600 MG (gabapentin Tier 3 ST; QL (1 pack per 1 fill) (once-daily)) HORIZANT ORAL TABLET EXTENDED RELEASE 300 Tier 3 ST; QL (1 tablet per 1 day) MG (gabapentin enacarbil) HORIZANT ORAL TABLET EXTENDED RELEASE 600 Tier 3 ST; QL (1 tablet per 2 days) MG (gabapentin enacarbil)

127 Coverage Requirements and Prescription Drug Name Drug Tier Limits LYRICA CR ORAL TABLET EXTENDED RELEASE 24 PA; ST; #; QL (3 tablets per Tier 3 HOUR 165 MG, 82.5 MG (pregabalin) 1 Day) LYRICA CR ORAL TABLET EXTENDED RELEASE 24 PA; ST; #; QL (2 tablets per Tier 3 HOUR 330 MG (pregabalin) 1 Day) PSYCHOTHERAPEUTIC-MISC acamprosate calcium oral tablet delayed release 333 mg Tier 1 PA ADDYI ORAL TABLET 100 MG (flibanserin) Tier 3 PA; QL (1 tablet per 1 day) ANTABUSE ORAL TABLET 250 MG, 500 MG (disulfiram) NF bupropion hcl er (smoking det) oral tablet extended release 12 N2 (Tier 1); QL (180 day CE hour 150 mg supply per 365 days) CHANTIX CONTINUING MONTH PAK ORAL TABLET #; N2 (Tier 3); QL (180 day CE 1 MG (varenicline tartrate) supply per 365 days) CHANTIX ORAL TABLET 0.5 MG, 1 MG (varenicline #; N2 (Tier 3); QL (180 day CE tartrate) supply per 365 days) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 #; N2 (Tier 3); QL (180 day CE MG X 11 & 1 MG X 42 (varenicline tartrate) supply per 365 days) chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg Tier 1 disulfiram oral tablet 250 mg, 500 mg Tier 1 EVZIO INJECTION SOLUTION AUTO-INJECTOR 0.4 Tier 3 MG/0.4ML (naloxone hcl) EVZIO INJECTION SOLUTION AUTO-INJECTOR 2 Tier 3 # MG/0.4ML (naloxone hcl) N2 (NF); QL (180 day goodsense nicotine mouth/throat gum 4 mg CE supply per 365 days) KLOXXADO NASAL LIQUID 8 MG/0.1ML (naloxone hcl) NF QL (16 tablets/day for 14 LUCEMYRA ORAL TABLET 0.18 MG (lofexidine hcl) Tier 3 days per 90 days) naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml Tier 1 naloxone hcl injection solution auto-injector 2 mg/0.4ml NF naloxone hcl injection solution cartridge 0.4 mg/ml Tier 1 naloxone hcl injection solution prefilled syringe 2 mg/2ml Tier 1

128 Coverage Requirements and Prescription Drug Name Drug Tier Limits naltrexone hcl oral tablet 50 mg Tier 1 NARCAN NASAL LIQUID 4 MG/0.1ML (naloxone hcl) Tier 2 QL (4 sprays per 180 days) N2 (NF); QL (180 day nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE supply per 365 days) N2 (NF); QL (180 day nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE supply per 365 days) N2 (NF); QL (180 day nicotine transdermal kit 21-14-7 mg/24hr Tier 3 supply per 365 days) nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 N2 (NF); QL (180 day CE mg/24hr supply per 365 days) N2 (Tier 3); QL (180 day NICOTROL INHALATION INHALER 10 MG (nicotine) CE supply per 365 days) N2 (Tier 3); QL (180 day NICOTROL NS NASAL SOLUTION 10 MG/ML (nicotine) CE supply per 365 days) olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-25 Tier 1 QL (1 capsule per 1 day) mg, 6-50 mg olanzapine-fluoxetine hcl oral capsule 3-25 mg Tier 1 perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 Tier 1 mg, 4-25 mg, 4-50 mg SYMBYAX ORAL CAPSULE 12-25 MG, 12-50 MG, 3-25 NF MG, 6-25 MG, 6-50 MG (olanzapine-fluoxetine hcl) THRIVE MOUTH/THROAT GUM 2 MG (nicotine N2 (NF); QL (180 day CE polacrilex) supply per 365 days) VIVITROL INTRAMUSCULAR SUSPENSION Tier 4 PA; QL (1 vial per 1 month) RECONSTITUTED 380 MG (naltrexone) VYLEESI SUBCUTANEOUS SOLUTION AUTO- NF INJECTOR 1.75 MG/0.3ML (bremelanotide acetate) ZYBAN ORAL TABLET EXTENDED RELEASE 12 NF HOUR 150 MG (bupropion hcl (smoking deter))

129 Coverage Requirements and Prescription Drug Name Drug Tier Limits ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS - DRUGS TO REGULATE MALE HORMONES ANADROL-50 ORAL TABLET 50 MG (oxymetholone) Tier 3 PA ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 NF MG/24HR, 4 MG/24HR (testosterone) ANDROGEL PUMP TRANSDERMAL GEL 20.25 NF MG/ACT (1.62%) (testosterone) ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM (1.62%), 50 NF MG/5GM (1%) (testosterone) ANDROID ORAL CAPSULE 10 MG (methyltestosterone) NF ANDROXY ORAL TABLET 10 MG (fluoxymesterone) Tier 3 DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML, 200 MG/ML (testosterone NF cypionate) FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%) NF (testosterone) INTRAROSA VAGINAL INSERT 6.5 MG (prasterone) Tier 3 JATENZO ORAL CAPSULE 158 MG, 198 MG, 237 MG NF (testosterone undecanoate) methitest oral tablet 10 mg Tier 3 methyltestosterone oral capsule 10 mg Tier 1 PA NATESTO NASAL GEL 5.5 MG/ACT (testosterone) NF OXANDRIN ORAL TABLET 10 MG, 2.5 MG NF (oxandrolone) oxandrolone oral tablet 10 mg, 2.5 mg Tier 1 PA TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) NF (testosterone) testosterone cypionate intramuscular solution 100 mg/ml, 200 Tier 1 PA mg/ml

130 Coverage Requirements and Prescription Drug Name Drug Tier Limits testosterone enanthate intramuscular solution 200 mg/ml Tier 1 PA testosterone transdermal gel 10 mg/act (2%), 25 mg/2.5gm Tier 1 PA (1%) PA; QL (10 grams per 1 testosterone transdermal gel 12.5 mg/act (1%) Tier 1 day) testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 20.25 Tier 1 QL (5 grams per 1 day) mg/act (1.62%), 40.5 mg/2.5gm (1.62%) testosterone transdermal gel 50 mg/5gm (1%) Tier 1 PA; QL (10 grams per 1 fill) PA; QL (6 milliliters per 1 testosterone transdermal solution 30 mg/act Tier 1 Day) TESTRED ORAL CAPSULE 10 MG (methyltestosterone) NF VOGELXO PUMP TRANSDERMAL GEL 12.5 MG/ACT NF (1%) (testosterone) VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) NF (testosterone) XYOSTED SUBCUTANEOUS SOLUTION AUTO- INJECTOR 100 MG/0.5ML, 50 MG/0.5ML, 75 MG/0.5ML NF (testosterone enanthate) ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose oral tablet 100 mg, 25 mg, 50 mg Tier 1 GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG NF (miglitol) miglitol oral tablet 100 mg, 25 mg, 50 mg Tier 1 PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG NF (acarbose) ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- Tier 3 ST INJECTOR 2700 MCG/2.7ML (pramlintide acetate) SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- Tier 3 ST INJECTOR 1500 MCG/1.5ML (pramlintide acetate)

131 Coverage Requirements and Prescription Drug Name Drug Tier Limits ANTIDIABETICS, BIGUANIDE FORTAMET ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1000 MG, 500 MG (metformin hcl) GLUCOPHAGE ORAL TABLET 1000 MG, 500 MG, 850 NF MG (metformin hcl) GLUCOPHAGE XR ORAL TABLET EXTENDED NF RELEASE 24 HOUR 500 MG, 750 MG (metformin hcl) GLUMETZA ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1000 MG, 500 MG (metformin hcl) metformin hcl er (mod) oral tablet extended release 24 hour NF 1000 mg, 500 mg metformin hcl er (osm) oral tablet extended release 24 hour Tier 1 ST; QL (2 tablets per 1 day) 1000 mg metformin hcl er (osm) oral tablet extended release 24 hour 500 Tier 1 ST; QL (3 tablets per 1 day) mg metformin hcl er oral tablet extended release 24 hour 500 mg, Tier 1 750 mg metformin hcl oral solution 500 mg/5ml Tier 1 metformin hcl oral tablet 1000 mg, 500 mg, 850 mg Tier 1 RIOMET ER ORAL SUSPENSION RECONSTITUTED NF ER 500 MG/5ML (metformin hcl) RIOMET ORAL SOLUTION 500 MG/5ML (metformin hcl) NF ANTIDIABETICS, BIGUANIDE/ MEGLITINIDE COMBINATIONS repaglinide-metformin hcl oral tablet 1-500 mg, 2-500 mg Tier 1 QL (2 tablets per 1 day) ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5- Tier 1 500 mg GLUCOVANCE ORAL TABLET 2.5-500 MG, 5-500 MG NF (glyburide-metformin)

132 Coverage Requirements and Prescription Drug Name Drug Tier Limits glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 Tier 1 mg ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg Tier 1 ST JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG Tier 2 ST (sitagliptin phosphate) NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG NF (alogliptin benzoate) ONGLYZA ORAL TABLET 2.5 MG, 5 MG (saxagliptin hcl) Tier 3 ST; QL (1 tablet per 1 day) TRADJENTA ORAL TABLET 5 MG (linagliptin) Tier 3 ST; QL (1 tablet per 1 day) ANTIDIABETICS, DOPAMINE RECEPTOR AGONISTS CYCLOSET ORAL TABLET 0.8 MG (bromocriptine Tier 3 mesylate) ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS alogliptin-metformin hcl oral tablet 12.5-1000 mg, 12.5-500 mg Tier 1 ST; QL (2 tablets per 1 day) alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5- Tier 1 QL (1 tablet per 1 day) 45 mg, 25-15 mg, 25-30 mg, 25-45 mg JANUMET ORAL TABLET 50-1000 MG, 50-500 MG Tier 2 ST (sitagliptin-metformin hcl) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG Tier 2 ST (sitagliptin-metformin hcl) JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, Tier 3 ST; QL (2 tablets per 1 day) 2.5-850 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG (linagliptin- Tier 3 ST metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG NF (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED Tier 3 ST; QL (2 tablets per 1 day) RELEASE 24 HOUR 2.5-1000 MG (saxagliptin-metformin)

133 Coverage Requirements and Prescription Drug Name Drug Tier Limits KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG, 5-500 MG (saxagliptin- Tier 3 ST; QL (1 tablet per 1 day) metformin) OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG (alogliptin- NF pioglitazone) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG, NF 5-2.5-1000 MG (empagliflozin-linaglip-metform) ANTIDIABETICS, INCRETIN MIMETIC AGENTS ADLYXIN STARTER PACK SUBCUTANEOUS PEN- NF INJECTOR KIT 10 & 20 MCG/0.2ML (lixisenatide) ADLYXIN SUBCUTANEOUS SOLUTION PEN- NF INJECTOR 20 MCG/0.2ML (lixisenatide) BYDUREON BCISE SUBCUTANEOUS AUTO- PA; ST; QL (4 pens per 1 Tier 3 INJECTOR 2 MG/0.85ML (exenatide) month) BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 MG PA; ST; QL (4 pens per 1 Tier 3 (exenatide) month) BYDUREON SUBCUTANEOUS SUSPENSION PA; ST; QL (4 pens per 1 Tier 3 RECONSTITUTED ER 2 MG (exenatide) month) BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PA; ST; #; QL (1 pen per 1 Tier 3 PEN-INJECTOR 10 MCG/0.04ML (exenatide) fill) BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PA; ST; #; QL (1 pen per 1 Tier 3 PEN-INJECTOR 5 MCG/0.02ML (exenatide) fill) OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS Tier 2 ST SOLUTION PEN-INJECTOR 2 MG/1.5ML (semaglutide) OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION Tier 2 ST PEN-INJECTOR 2 MG/1.5ML, 4 MG/3ML (semaglutide) RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG NF (semaglutide) TRULICITY SUBCUTANEOUS SOLUTION PEN- INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 MG/0.5ML, Tier 2 ST 4.5 MG/0.5ML (dulaglutide)

134 Coverage Requirements and Prescription Drug Name Drug Tier Limits VICTOZA SUBCUTANEOUS SOLUTION PEN- Tier 3 ST INJECTOR 18 MG/3ML (liraglutide) ANTIDIABETICS, INCRETIN MIMETIC COMBINATION AGENTS SOLIQUA SUBCUTANEOUS SOLUTION PEN- INJECTOR 100-33 UNT-MCG/ML (insulin glargine- Tier 3 ST lixisenatide) XULTOPHY SUBCUTANEOUS SOLUTION PEN- INJECTOR 100-3.6 UNIT-MG/ML (insulin degludec- Tier 3 ST liraglutide) ANTIDIABETICS, INSULIN ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 100 UNIT/ML (insulin lispro) ADMELOG SUBCUTANEOUS SOLUTION 100 NF UNIT/ML (insulin lispro) AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT, 90 X 8 Tier 3 ST UNIT & 90X12 UNIT (insulin regular human) AFREZZA INHALATION POWDER 30 X 4 UNIT & 60X8 UNIT, 60 X 4 UNIT & 30X8 UNIT, 60 X 8 UNIT & 30X12 NF UNIT (insulin regular human) APIDRA INJECTION SOLUTION 100 UNIT/ML (insulin Tier 3 ST glulisine) APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION Tier 3 ST PEN-INJECTOR 100 UNIT/ML (insulin glulisine) BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION Tier 2 PEN-INJECTOR 100 UNIT/ML (insulin glargine) FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin aspart Tier 2 (w/niacinamide)) FIASP PENFILL SUBCUTANEOUS SOLUTION Tier 2 CARTRIDGE 100 UNIT/ML (insulin aspart (w/niacinamide)) FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML Tier 2 (insulin aspart (w/niacinamide)) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

135 Coverage Requirements and Prescription Drug Name Drug Tier Limits HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS Tier 3 ST SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin lispro) HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin Tier 3 ST lispro) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML Tier 3 ST (insulin lispro prot & lispro) HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION Tier 3 ST (50-50) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML Tier 3 ST (insulin lispro prot & lispro) HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION Tier 3 ST (75-25) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG SUBCUTANEOUS SOLUTION 100 Tier 3 ST UNIT/ML (insulin lispro) HUMALOG SUBCUTANEOUS SOLUTION Tier 3 ST CARTRIDGE 100 UNIT/ML (insulin lispro) HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML Tier 3 (insulin nph isophane & regular) HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70- Tier 3 30) 100 UNIT/ML (insulin nph isophane & regular) HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph Tier 3 human (isophane)) HUMULIN N SUBCUTANEOUS SUSPENSION 100 Tier 3 UNIT/ML (insulin nph human (isophane)) HUMULIN R INJECTION SOLUTION 100 UNIT/ML Tier 3 (insulin regular human) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML (insulin Tier 2 regular human) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

136 Coverage Requirements and Prescription Drug Name Drug Tier Limits HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML (insulin regular Tier 2 human) insulin asp prot & asp flexpen subcutaneous suspension pen- NF injector (70-30) 100 unit/ml insulin aspart flexpen subcutaneous solution pen-injector 100 NF unit/ml insulin aspart penfill subcutaneous solution cartridge 100 unit/ml NF insulin aspart prot & aspart subcutaneous suspension (70-30) NF 100 unit/ml insulin aspart subcutaneous solution 100 unit/ml NF insulin lispro (1 unit dial) subcutaneous solution pen-injector Tier 3 100 unit/ml insulin lispro junior kwikpen subcutaneous solution pen-injector Tier 3 ST 100 unit/ml insulin lispro prot & lispro subcutaneous suspension pen-injector Tier 3 ST (75-25) 100 unit/ml insulin lispro subcutaneous solution 100 unit/ml Tier 3 ST insulin lispro subcutaneous solution pen-injector 100 unit/ml Tier 1 LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 100 UNIT/ML (insulin glargine) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML NF (insulin glargine) LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION Tier 2 PEN-INJECTOR 100 UNIT/ML (insulin detemir) LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML Tier 2 (insulin detemir) LYUMJEV INJECTION SOLUTION 100 UNIT/ML (insulin NF lispro-aabc) LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin NF lispro-aabc)

137 Coverage Requirements and Prescription Drug Name Drug Tier Limits NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML Tier 2 (insulin nph isophane & regular) NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML Tier 2 (insulin nph isophane & regular) NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML (insulin nph isophane & Tier 2 regular) NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) Tier 2 100 UNIT/ML (insulin nph isophane & regular) NOVOLIN N FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph NF human (isophane)) NOVOLIN N FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph Tier 2 human (isophane)) NOVOLIN N RELION SUBCUTANEOUS SUSPENSION Tier 2 100 UNIT/ML (insulin nph human (isophane)) NOVOLIN N SUBCUTANEOUS SUSPENSION 100 Tier 2 UNIT/ML (insulin nph human (isophane)) NOVOLIN R FLEXPEN INJECTION SOLUTION PEN- Tier 2 INJECTOR 100 UNIT/ML (insulin regular human) NOVOLIN R FLEXPEN RELION INJECTION SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin regular NF human) NOVOLIN R INJECTION SOLUTION 100 UNIT/ML Tier 2 (insulin regular human) NOVOLIN R RELION INJECTION SOLUTION 100 Tier 2 UNIT/ML (insulin regular human) NOVOLOG 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML NF (insulin aspart prot & aspart)

138 Coverage Requirements and Prescription Drug Name Drug Tier Limits NOVOLOG FLEXPEN RELION SUBCUTANEOUS NF SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin aspart) NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION Tier 2 PEN-INJECTOR 100 UNIT/ML (insulin aspart) NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML Tier 2 (insulin aspart prot & aspart) NOVOLOG MIX 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML (insulin aspart prot & NF aspart) NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION Tier 2 (70-30) 100 UNIT/ML (insulin aspart prot & aspart) NOVOLOG PENFILL SUBCUTANEOUS SOLUTION Tier 2 CARTRIDGE 100 UNIT/ML (insulin aspart) NOVOLOG RELION SUBCUTANEOUS SOLUTION 100 NF UNIT/ML (insulin aspart) NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML Tier 2 (insulin aspart) SEMGLEE SUBCUTANEOUS SOLUTION 100 UNIT/ML NF (insulin glargine) SEMGLEE SUBCUTANEOUS SOLUTION PEN- NF INJECTOR 100 UNIT/ML (insulin glargine) TANZEUM SUBCUTANEOUS PEN-INJECTOR 30 MG, PA; ST; QL (4 pens per 1 Tier 3 50 MG (albiglutide) month) TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML (insulin NF glargine) TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 300 UNIT/ML (insulin glargine) TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin Tier 3 degludec) TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML Tier 3 (insulin degludec) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

139 Coverage Requirements and Prescription Drug Name Drug Tier Limits ANTIDIABETICS, INSULIN SENSITIZER ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG NF (pioglitazone hcl) AVANDIA ORAL TABLET 2 MG, 4 MG (rosiglitazone Tier 3 QL (1 tablet per 1 day) maleate) pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg Tier 1 ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG NF (pioglitazone hcl-metformin hcl) ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 15-1000 MG (pioglitazone hcl- Tier 3 ST; QL (2 tablets per 1 day) metformin hcl) ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 30-1000 MG (pioglitazone hcl- Tier 3 ST; QL (1 tablet per 1 day) metformin hcl) pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg Tier 1 ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBINATION pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg Tier 1 ANTIDIABETICS, MEGLITINIDE nateglinide oral tablet 120 mg, 60 mg Tier 1 PRANDIN ORAL TABLET 1 MG, 2 MG (repaglinide) NF repaglinide oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 STARLIX ORAL TABLET 120 MG, 60 MG (nateglinide) NF ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 (SGLT2) INHIB QTERN ORAL TABLET 10-5 MG (dapagliflozin-saxagliptin) NF QTERN ORAL TABLET 5-5 MG (dapagliflozin-saxagliptin) Tier 2 ST; QL (1 tablet per 1 day) STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG NF (ertugliflozin-sitagliptin)

140 Coverage Requirements and Prescription Drug Name Drug Tier Limits ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, Tier 3 ST 5-1000 MG, 5-500 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 Tier 3 ST MG (empagliflozin-metformin hcl) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 MG, Tier 2 ST 5-500 MG (dapagliflozin-metformin hcl) ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGTL2) COMBO INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, Tier 3 QL (2 tablets per 1 day) 50-1000 MG, 50-500 MG (canagliflozin-metformin hcl) INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 Tier 3 QL (2 tablets per 1 day) MG, 50-500 MG (canagliflozin-metformin hcl) SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 NF MG, 7.5-1000 MG, 7.5-500 MG (ertugliflozin-metformin hcl) ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB(SGLT2)/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG Tier 3 ST (empagliflozin-linagliptin) ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER2 (SGLT2) INHIB FARXIGA ORAL TABLET 10 MG, 5 MG (dapagliflozin Tier 2 ST propanediol) INVOKANA ORAL TABLET 100 MG, 300 MG Tier 3 QL (1 tablet per 1 day) (canagliflozin) JARDIANCE ORAL TABLET 10 MG, 25 MG Tier 3 ST (empagliflozin) STEGLATRO ORAL TABLET 15 MG, 5 MG (ertugliflozin NF l-pyroglutamicac)

141 Coverage Requirements and Prescription Drug Name Drug Tier Limits ANTIDIABETICS, SULFONYLUREA AMARYL ORAL TABLET 1 MG, 2 MG, 4 MG NF (glimepiride) chlorpropamide oral tablet 100 mg, 250 mg Tier 1 glimepiride oral tablet 1 mg, 2 mg, 4 mg Tier 1 glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 Tier 1 mg glipizide oral tablet 10 mg, 5 mg Tier 1 glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 Tier 1 mg GLUCOTROL ORAL TABLET 10 MG, 5 MG (glipizide) NF GLUCOTROL XL ORAL TABLET EXTENDED NF RELEASE 24 HOUR 10 MG, 2.5 MG, 5 MG (glipizide) glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg Tier 1 glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg Tier 1 GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG NF (glyburide micronized) tolazamide oral tablet 250 mg, 500 mg Tier 1 tolbutamide oral tablet 500 mg Tier 1 ANTIDIABETICS, SULFONYLUREA/ THIAZOLIDINEDIONE COMBINATIONS DUETACT ORAL TABLET 30-2 MG, 30-4 MG NF (pioglitazone hcl-glimepiride) BISPHOSPHONATES - DRUGS TO TREAT BONE LOSS ACTONEL ORAL TABLET 150 MG, 30 MG, 35 MG, 5 NF MG (risedronate sodium) alendronate sodium oral solution 70 mg/75ml Tier 1 alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg Tier 1 alendronate sodium oral tablet 40 mg Tier 1 QL (1 tablet per 1 day) ATELVIA ORAL TABLET DELAYED RELEASE 35 MG NF (risedronate sodium)

142 Coverage Requirements and Prescription Drug Name Drug Tier Limits BINOSTO ORAL TABLET EFFERVESCENT 70 MG NF (alendronate sodium) BONIVA ORAL TABLET 150 MG (ibandronate sodium) NF etidronate disodium oral tablet 200 mg, 400 mg Tier 1 FOSAMAX ORAL TABLET 70 MG (alendronate sodium) NF FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, Tier 3 ST 70-5600 MG-UNIT (alendronate-cholecalciferol) ibandronate sodium oral tablet 150 mg Tier 1 risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg Tier 1 risedronate sodium oral tablet delayed release 35 mg Tier 1 CALCIUM RECEPTOR AGONISTS calcitriol oral capsule 0.25 mcg, 0.5 mcg Tier 1 calcitriol oral solution 1 mcg/ml Tier 1 cinacalcet hcl oral tablet 30 mg, 60 mg Tier 4 PA; QL (2 tablets per 1 day) cinacalcet hcl oral tablet 90 mg Tier 4 PA; QL (4 tablets per 1 day) doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg Tier 1 paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg Tier 1 RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30 PA; ST; QL (1 capsule per 1 Tier 3 MCG (calcifediol) day) ROCALTROL ORAL CAPSULE 0.25 MCG, 0.5 MCG NF (calcitriol) ROCALTROL ORAL SOLUTION 1 MCG/ML (calcitriol) NF SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG Tier 3 PA; QL (2 tablets per 1 day) (cinacalcet hcl) STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45ML, 28 MG/0.7ML, 40 MG/ML, 80 MG/0.8ML NF (asfotase alfa) ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG (paricalcitol) NF CARNITINE DEFICIENCY AGENTS CARNITOR ORAL SOLUTION 1 GM/10ML (levocarnitine) NF CARNITOR ORAL TABLET 330 MG (levocarnitine) NF 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

143 Coverage Requirements and Prescription Drug Name Drug Tier Limits CARNITOR SF ORAL SOLUTION 1 GM/10ML NF (levocarnitine) levocarnitine oral solution 1 gm/10ml Tier 1 levocarnitine oral tablet 330 mg Tier 1 CHELATING AGENTS CHEMET ORAL CAPSULE 100 MG (succimer) Tier 3 CUPRIMINE ORAL CAPSULE 250 MG (penicillamine) NF deferasirox granules oral packet 180 mg, 360 mg, 90 mg NF deferasirox oral tablet 180 mg, 360 mg, 90 mg NF deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg Tier 4 PA; SP Pharmacy deferiprone oral tablet 500 mg Tier 4 PA; SP Pharmacy DEPEN TITRATABS ORAL TABLET 250 MG Tier 3 PA (penicillamine) d-penamine oral tablet 125 mg Tier 4 PA; SP Pharmacy EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, Tier 4 PA; SP Pharmacy 500 MG (deferasirox) FERRIPROX ORAL SOLUTION 100 MG/ML (deferiprone) NF FERRIPROX ORAL TABLET 1000 MG (deferiprone) Tier 4 PA; #; SP Pharmacy FERRIPROX ORAL TABLET 500 MG (deferiprone) NF FERRIPROX TWICE-A-DAY ORAL TABLET 1000 MG Tier 4 PA; #; SP Pharmacy (deferiprone) JADENU ORAL TABLET 180 MG, 360 MG, 90 MG NF (deferasirox) JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, NF 90 MG (deferasirox) sodium polystyrene sulfonate (Kionex Oral Powder) Tier 1 sodium polystyrene sulfonate (Kionex Oral Suspension 15 Tier 1 Gm/60Ml) LOKELMA ORAL PACKET 10 GM, 5 GM (sodium NF zirconium cyclosilicate) penicillamine oral capsule 250 mg Tier 4 PA; SP Pharmacy

144 Coverage Requirements and Prescription Drug Name Drug Tier Limits penicillamine oral tablet 250 mg Tier 1 PA sodium polystyrene sulfonate oral powder Tier 1 sodium polystyrene sulfonate oral suspension 15 gm/60ml Tier 1 sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 Tier 1 gm/200ml SPS ORAL SUSPENSION 15 GM/60ML (sodium polystyrene Tier 1 sulfonate) SYPRINE ORAL CAPSULE 250 MG (trientine hcl) NF trientine hcl oral capsule 250 mg Tier 4 PA; SP Pharmacy VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM PA; ST; QL (1 packet per 1 Tier 3 (patiromer sorbitex calcium) day) CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL levonorgestrel-ethinyl estrad (Afirmelle Oral Tablet 0.1-20 Mg- CE N2 (Tier 1) Mcg) AFTERA ORAL TABLET 1.5 MG (levonorgestrel) CE N2 (NF) levonorgestrel-ethinyl estrad (Altavera Oral Tablet 0.15-30 Mg- CE N2 (Tier 1) Mcg) alyacen 1/35 oral tablet 1-35 mg-mcg CE N2 (Tier 1) alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg CE N2 (Tier 1) levonorgest-eth estrad 91-day (Amethia Lo Oral Tablet 0.1- CE N2 (Tier 1) 0.02 & 0.01 Mg) levonorgest-eth estrad 91-day (Amethia Oral Tablet 0.15-0.03 CE N2 (Tier 1) &0.01 Mg) ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR N2 (Tier 3); QL (1 ring per CE (segesterone-ethinyl estradiol) 365 days) desogestrel-ethinyl estradiol (Apri Oral Tablet 0.15-30 Mg- CE N2 (Tier 1) Mcg) norethin-eth estrad triphasic (Aranelle Oral Tablet 0.5/1/0.5-35 CE N2 (Tier 1) Mg-Mcg) levonorgest-eth estrad 91-day (Ashlyna Oral Tablet 0.15-0.03 CE N2 (Tier 1) &0.01 Mg)

145 Coverage Requirements and Prescription Drug Name Drug Tier Limits levonorgestrel-ethinyl estrad (Aubra Eq Oral Tablet 0.1-20 Mg- CE N2 (Tier 1) Mcg) levonorgestrel-ethinyl estrad (Aubra Oral Tablet 0.1-20 Mg- CE N2 (Tier 1) Mcg) norethindrone acet-ethinyl est (Aurovela 1.5/30 Oral Tablet 1.5- CE N2 (NF) 30 Mg-Mcg) norethindrone acet-ethinyl est (Aurovela 1/20 Oral Tablet 1-20 CE N2 (Tier 1) Mg-Mcg) norethin ace-eth estrad-fe (Aurovela 24 Fe Oral Tablet 1-20 CE N2 (NF) Mg-Mcg(24)) norethin ace-eth estrad-fe (Aurovela Fe 1/20 Oral Tablet 1-20 CE N2 (NF) Mg-Mcg) levonorgestrel-ethinyl estrad (Aviane Oral Tablet 0.1-20 Mg- CE N2 (Tier 1) Mcg) levonorgestrel-ethinyl estrad (Ayuna Oral Tablet 0.15-30 Mg- CE N2 (Tier 1) Mcg) desogestrel-ethinyl estradiol (Azurette Oral Tablet 0.15- CE N2 (Tier 1) 0.02/0.01 Mg (21/5)) BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) CE #; N2 (Tier 3) (levonorgest-eth estrad-fe bisg) norethindrone-eth estradiol (Balziva Oral Tablet 0.4-35 Mg- CE N2 (Tier 1) Mcg) desogestrel-ethinyl estradiol (Bekyree Oral Tablet 0.15- CE N2 (Tier 1) 0.02/0.01 Mg (21/5)) BEYAZ ORAL TABLET 3-0.02-0.451 MG (drospiren-eth Tier 3 estrad-levomefol) norethin ace-eth estrad-fe (Blisovi 24 Fe Oral Tablet 1-20 Mg- CE N2 (Tier 1) Mcg(24)) norethin ace-eth estrad-fe (Blisovi Fe 1.5/30 Oral Tablet 1.5-30 CE N2 (Tier 1) Mg-Mcg) norethin ace-eth estrad-fe (Blisovi Fe 1/20 Oral Tablet 1-20 CE N2 (Tier 1) Mg-Mcg) briellyn oral tablet 0.4-35 mg-mcg CE N2 (Tier 1) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

146 Coverage Requirements and Prescription Drug Name Drug Tier Limits norethindrone (Camila Oral Tablet 0.35 Mg) CE N2 (Tier 1) levonorgest-eth estrad 91-day (Camrese Lo Oral Tablet 0.1- CE N2 (Tier 1) 0.02 & 0.01 Mg) levonorgest-eth estrad 91-day (Camrese Oral Tablet 0.15-0.03 CE N2 (Tier 1) &0.01 Mg) desogestrel-ethinyl estradiol (Caziant Oral Tablet CE N2 (Tier 1) 0.1/0.125/0.15 -0.025 Mg) desogestrel-ethinyl estradiol (Cesia Oral Tablet 0.1/0.125/0.15 - CE N2 (Tier 1) 0.025 Mg) levonorgestrel-ethinyl estrad (Chateal Eq Oral Tablet 0.15-30 CE N2 (Tier 1) Mg-Mcg) levonorgestrel-ethinyl estrad (Chateal Oral Tablet 0.15-30 Mg- CE N2 (Tier 1) Mcg) norgestrel-ethinyl estradiol (Cryselle-28 Oral Tablet 0.3-30 Mg- CE N2 (Tier 1) Mcg) norethindrone-eth estradiol (Cyclafem 1/35 Oral Tablet 1-35 CE N2 (Tier 1) Mg-Mcg) norethin-eth estrad triphasic (Cyclafem 7/7/7 Oral Tablet CE N2 (Tier 1) 0.5/0.75/1-35 Mg-Mcg) desogestrel-ethinyl estradiol (Cyred Oral Tablet 0.15-30 Mg- CE N2 (Tier 1) Mcg) norethindrone-eth estradiol (Dasetta 1/35 Oral Tablet 1-35 Mg- CE N2 (Tier 1) Mcg) norethin-eth estrad triphasic (Dasetta 7/7/7 Oral Tablet CE N2 (Tier 1) 0.5/0.75/1-35 Mg-Mcg) levonorgest-eth estrad 91-day (Daysee Oral Tablet 0.15-0.03 CE N2 (Tier 1) &0.01 Mg) norethindrone (Deblitane Oral Tablet 0.35 Mg) CE N2 (Tier 1) levonorgestrel-ethinyl estrad (Delyla Oral Tablet 0.1-20 Mg- CE N2 (Tier 1) Mcg) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS #; N2 (Tier 3); QL (1 SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML CE syringe per 90 days) (medroxyprogesterone acetate) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

147 Coverage Requirements and Prescription Drug Name Drug Tier Limits desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg CE N2 (Tier 1) (21/5), 0.15-30 mg-mcg drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3- CE N2 (Tier 1) 0.03-0.451 mg drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg CE N2 (Tier 1) ECONTRA EZ ORAL TABLET 1.5 MG (levonorgestrel) CE N2 (NF) norgestrel-ethinyl estradiol (Elinest Oral Tablet 0.3-30 Mg- CE N2 (Tier 1) Mcg) ELLA ORAL TABLET 30 MG (ulipristal acetate) CE #; N2 (Tier 3) etonogestrel-ethinyl estradiol (Eluryng Vaginal Ring 0.12-0.015 CE N2 (Tier 1) Mg/24Hr) desogestrel-ethinyl estradiol (Emoquette Oral Tablet 0.15-30 CE N2 (Tier 1) Mg-Mcg) levonorg-eth estrad triphasic (Enpresse-28 Oral Tablet 50- CE N2 (Tier 1) 30/75-40/ 125-30 Mcg) desogestrel-ethinyl estradiol (Enskyce Oral Tablet 0.15-30 Mg- CE N2 (Tier 1) Mcg) norethindrone (Errin Oral Tablet 0.35 Mg) CE N2 (Tier 1) norgestimate-eth estradiol (Estarylla Oral Tablet 0.25-35 Mg- CE N2 (Tier 1) Mcg) ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg CE N2 (Tier 1) FALESSA ORAL KIT 20-1-0.1 MCG-MG (levonorgestrel-eth CE N2 (Tier 3) estrad & fa) levonorgestrel-ethinyl estrad (Falmina Oral Tablet 0.1-20 Mg- CE N2 (Tier 1) Mcg) levonorgest-eth estrad 91-day (Fayosim Oral Tablet 42-21-21-7 CE N2 (Tier 1) Days) norgestimate-eth estradiol (Femynor Oral Tablet 0.25-35 Mg- CE N2 (Tier 1) Mcg) norethin ace-eth estrad-fe (Gemmily Oral Capsule 1-20 Mg- CE N2 (Tier 1) Mcg(24)) drospirenone-ethinyl estradiol (Gianvi Oral Tablet 3-0.02 Mg) CE N2 (Tier 1)

148 Coverage Requirements and Prescription Drug Name Drug Tier Limits norethindrone-eth estradiol (Gildagia Oral Tablet 0.4-35 Mg- CE N2 (Tier 1) Mcg) norethin ace-eth estrad-fe (Gildess Fe 1.5/30 Oral Tablet 1.5-30 CE N2 (Tier 1) Mg-Mcg) norethin ace-eth estrad-fe (Gildess Fe 1/20 Oral Tablet 1-20 CE N2 (Tier 1) Mg-Mcg) norethin ace-eth estrad-fe (Hailey 24 Fe Oral Tablet 1-20 Mg- CE N2 (Tier 1) Mcg(24)) norethindrone (Heather Oral Tablet 0.35 Mg) CE N2 (Tier 1) levonorgest-eth estrad 91-day (Introvale Oral Tablet 0.15-0.03 CE N2 (Tier 1) Mg) desogestrel-ethinyl estradiol (Isibloom Oral Tablet 0.15-30 Mg- CE N2 (Tier 1) Mcg) drospirenone-ethinyl estradiol (Jasmiel Oral Tablet 3-0.02 Mg) CE N2 (Tier 1) norethindrone (Jencycla Oral Tablet 0.35 Mg) CE N2 (Tier 1) levonorgest-eth estrad 91-day (Jolessa Oral Tablet 0.15-0.03 CE N2 (Tier 1) Mg) norethindrone (Jolivette Oral Tablet 0.35 Mg) CE N2 (Tier 1) desogestrel-ethinyl estradiol (Juleber Oral Tablet 0.15-30 Mg- CE N2 (Tier 1) Mcg) norethindrone acet-ethinyl est (Junel 1.5/30 Oral Tablet 1.5-30 CE N2 (Tier 1) Mg-Mcg) norethindrone acet-ethinyl est (Junel 1/20 Oral Tablet 1-20 Mg- CE N2 (Tier 1) Mcg) norethin ace-eth estrad-fe (Junel Fe 1.5/30 Oral Tablet 1.5-30 CE N2 (Tier 1) Mg-Mcg) norethin ace-eth estrad-fe (Junel Fe 1/20 Oral Tablet 1-20 Mg- CE N2 (Tier 1) Mcg) norethin ace-eth estrad-fe (Junel Fe 24 Oral Tablet 1-20 Mg- CE N2 (Tier 1) Mcg(24)) norethin-eth estradiol-fe (Kaitlib Fe Oral Tablet Chewable 0.8- CE N2 (Tier 1) 25 Mg-Mcg)

149 Coverage Requirements and Prescription Drug Name Drug Tier Limits desogestrel-ethinyl estradiol (Kariva Oral Tablet 0.15-0.02/0.01 CE N2 (Tier 1) Mg (21/5)) ethynodiol diac-eth estradiol (Kelnor 1/35 Oral Tablet 1-35 CE N2 (Tier 1) Mg-Mcg) desogestrel-ethinyl estradiol (Kimidess Oral Tablet 0.15- CE N2 (Tier 1) 0.02/0.01 Mg (21/5)) levonorgestrel-ethinyl estrad (Kurvelo Oral Tablet 0.15-30 Mg- CE N2 (Tier 1) Mcg) KYLEENA INTRAUTERINE INTRAUTERINE DEVICE CE N2 (Tier 3) 19.5 MG (levonorgestrel) norethindrone acet-ethinyl est (Larin 1.5/30 Oral Tablet 1.5-30 CE N2 (Tier 1) Mg-Mcg) norethindrone acet-ethinyl est (Larin 1/20 Oral Tablet 1-20 Mg- CE N2 (Tier 1) Mcg) norethin ace-eth estrad-fe (Larin 24 Fe Oral Tablet 1-20 Mg- CE N2 (Tier 1) Mcg(24)) norethin ace-eth estrad-fe (Larin Fe 1.5/30 Oral Tablet 1.5-30 CE N2 (Tier 1) Mg-Mcg) norethin ace-eth estrad-fe (Larin Fe 1/20 Oral Tablet 1-20 Mg- CE N2 (Tier 1) Mcg) levonorgestrel-ethinyl estrad (Larissia Oral Tablet 0.1-20 Mg- CE N2 (Tier 1) Mcg) norethin-eth estradiol-fe (Layolis Fe Oral Tablet Chewable 0.8- CE N2 (Tier 1) 25 Mg-Mcg) norethin-eth estrad triphasic (Leena Oral Tablet 0.5/1/0.5-35 CE N2 (Tier 1) Mg-Mcg) levonorgestrel-ethinyl estrad (Lessina Oral Tablet 0.1-20 Mg- CE N2 (Tier 1) Mcg) levonorg-eth estrad triphasic (Levonest Oral Tablet 50-30/75- CE N2 (Tier 1) 40/ 125-30 Mcg) levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, CE N2 (Tier 1) 0.15-0.03 &0.01 mg, 0.15-0.03 mg levonorgestrel oral tablet 1.5 mg CE N2 (NF) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

150 Coverage Requirements and Prescription Drug Name Drug Tier Limits levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 CE N2 (Tier 1) mg-mcg, 90-20 mcg levonorg-eth estrad triphasic oral tablet CE N2 (Tier 1) levonorgestrel-ethinyl estrad (Levora 0.15/30 (28) Oral Tablet CE N2 (Tier 1) 0.15-30 Mg-Mcg) LILETTA (52 MG) INTRAUTERINE INTRAUTERINE CE N2 (Tier 3) DEVICE 19.5 MCG/DAY (levonorgestrel) LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 CE N2 (Tier 3) MCG (norethin-eth estrad-fe biphas) norethindrone acet-ethinyl est (Loestrin 1.5/30 (21) Oral Tablet Tier 3 1.5-30 Mg-Mcg) norethindrone acet-ethinyl est (Loestrin 1/20 (21) Oral Tablet 1- Tier 3 20 Mg-Mcg) norethin ace-eth estrad-fe (Lomedia 24 Fe Oral Tablet 1-20 CE N2 (Tier 1) Mg-Mcg(24)) drospirenone-ethinyl estradiol (Loryna Oral Tablet 3-0.02 Mg) CE N2 (Tier 1) norgestrel-ethinyl estradiol (Low-Ogestrel Oral Tablet 0.3-30 CE N2 (Tier 1) Mg-Mcg) drospirenone-ethinyl estradiol (Lo-Zumandimine Oral Tablet CE N2 (Tier 1) 3-0.02 Mg) levonorgestrel-ethinyl estrad (Lutera Oral Tablet 0.1-20 Mg- CE N2 (Tier 1) Mcg) norethindrone (Lyza Oral Tablet 0.35 Mg) CE N2 (Tier 1) marlissa oral tablet 0.15-30 mg-mcg CE N2 (Tier 1) medroxyprogesterone acetate intramuscular suspension 150 CE N2 (Tier 1) mg/ml medroxyprogesterone acetate intramuscular suspension prefilled N2 (Tier 1); QL (1 injection CE syringe 150 mg/ml per 90 days) norethin ace-eth estrad-fe (Mibelas 24 Fe Oral Tablet CE N2 (Tier 1) Chewable 1-20 Mg-Mcg(24)) norethindrone acet-ethinyl est (Microgestin 1.5/30 Oral Tablet CE N2 (Tier 1) 1.5-30 Mg-Mcg)

151 Coverage Requirements and Prescription Drug Name Drug Tier Limits norethindrone acet-ethinyl est (Microgestin 1/20 Oral Tablet 1- CE N2 (Tier 1) 20 Mg-Mcg) norethin ace-eth estrad-fe (Microgestin Fe 1.5/30 Oral Tablet CE N2 (Tier 1) 1.5-30 Mg-Mcg) norethin ace-eth estrad-fe (Microgestin Fe 1/20 Oral Tablet 1- CE N2 (Tier 1) 20 Mg-Mcg) MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 Tier 3 MG-MCG(24) (norethin ace-eth estrad-fe) MIRENA (52 MG) INTRAUTERINE INTRAUTERINE CE #; N2 (Tier 3) DEVICE 20 MCG/24HR (levonorgestrel) norgestimate-eth estradiol (Mono-Linyah Oral Tablet 0.25-35 CE N2 (Tier 1) Mg-Mcg) norgestimate-eth estradiol (Mononessa Oral Tablet 0.25-35 CE N2 (Tier 1) Mg-Mcg) MY WAY ORAL TABLET 1.5 MG (levonorgestrel) CE N2 (NF) levonorg-eth estrad triphasic (Myzilra Oral Tablet 50-30/75-40/ CE N2 (Tier 1) 125-30 Mcg) NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol CE N2 (Tier 3) valerate-dienogest) norethindrone-eth estradiol (Necon 0.5/35 (28) Oral Tablet 0.5- CE N2 (Tier 1) 35 Mg-Mcg) norethindrone-eth estradiol (Necon 1/35 (28) Oral Tablet 1-35 CE N2 (Tier 1) Mg-Mcg) NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG CE N2 (Tier 1) (norethindrone-mestranol) norethin-eth estrad triphasic (Necon 7/7/7 Oral Tablet CE N2 (Tier 1) 0.5/0.75/1-35 Mg-Mcg) NEXPLANON SUBCUTANEOUS IMPLANT 68 MG CE N2 (Tier 3) (etonogestrel) NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG CE N2 (NF) (levonorgestrel) NEXTSTELLIS ORAL TABLET 3-14.2 MG (drospirenone- NF estetrol) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

152 Coverage Requirements and Prescription Drug Name Drug Tier Limits drospirenone-ethinyl estradiol (Nikki Oral Tablet 3-0.02 Mg) CE N2 (Tier 1) norethindrone (Nora-Be Oral Tablet 0.35 Mg) CE N2 (Tier 1) norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) CE N2 (Tier 1) norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1-20 mg- CE N2 (Tier 1) mcg(24) norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- CE N2 (Tier 1) mcg(24) norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg CE N2 (Tier 1) norethindrone oral tablet 0.35 mg CE N2 (Tier 1) norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, CE N2 (Tier 1) 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg CE N2 (Tier 1) norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-25 CE N2 (Tier 1) mcg, 0.18/0.215/0.25 mg-35 mcg norethindrone (Norlyroc Oral Tablet 0.35 Mg) CE N2 (Tier 1) norethindrone-eth estradiol (Nortrel 0.5/35 (28) Oral Tablet CE N2 (Tier 1) 0.5-35 Mg-Mcg) norethindrone-eth estradiol (Nortrel 1/35 (21) Oral Tablet 1-35 CE N2 (Tier 1) Mg-Mcg) norethindrone-eth estradiol (Nortrel 1/35 (28) Oral Tablet 1-35 CE N2 (Tier 1) Mg-Mcg) norethin-eth estrad triphasic (Nortrel 7/7/7 Oral Tablet CE N2 (Tier 1) 0.5/0.75/1-35 Mg-Mcg) NUVARING VAGINAL RING 0.12-0.015 MG/24HR Tier 3 (etonogestrel-ethinyl estradiol) drospirenone-ethinyl estradiol (Ocella Oral Tablet 3-0.03 Mg) CE N2 (Tier 1) OGESTREL ORAL TABLET 0.5-50 MG-MCG (norgestrel- CE N2 (Tier 1) ethinyl estradiol) OPCICON ONE-STEP ORAL TABLET 1.5 MG CE N2 (NF) (levonorgestrel) OPTION 2 ORAL TABLET 1.5 MG (levonorgestrel) CE N2 (NF)

153 Coverage Requirements and Prescription Drug Name Drug Tier Limits levonorgestrel-ethinyl estrad (Orsythia Oral Tablet 0.1-20 Mg- CE N2 (Tier 1) Mcg) ORTHO TRI-CYCLEN LO ORAL TABLET 0.18/0.215/0.25 Tier 3 MG-25 MCG (norgestim-eth estrad triphasic) ORTHO-NOVUM 7/7/7 (28) ORAL TABLET 0.5/0.75/1-35 Tier 3 MG-MCG (norethin-eth estrad triphasic) PARAGARD INTRAUTERINE COPPER CE N2 (Tier 3) INTRAUTERINE INTRAUTERINE DEVICE (copper) norethindrone-eth estradiol (Philith Oral Tablet 0.4-35 Mg- CE N2 (Tier 1) Mcg) desogestrel-ethinyl estradiol (Pimtrea Oral Tablet 0.15- CE N2 (Tier 1) 0.02/0.01 Mg (21/5)) norethindrone-eth estradiol (Pirmella 1/35 Oral Tablet 1-35 CE N2 (Tier 1) Mg-Mcg) norethin-eth estrad triphasic (Pirmella 7/7/7 Oral Tablet CE N2 (Tier 1) 0.5/0.75/1-35 Mg-Mcg) levonorgestrel-ethinyl estrad (Portia-28 Oral Tablet 0.15-30 CE N2 (Tier 1) Mg-Mcg) norgestimate-eth estradiol (Previfem Oral Tablet 0.25-35 Mg- CE N2 (Tier 1) Mcg) QUARTETTE ORAL TABLET 42-21-21-7 DAYS Tier 3 (levonorgest-eth estrad 91-day) levonorgest-eth estrad 91-day (Quasense Oral Tablet 0.15-0.03 CE N2 (Tier 1) Mg) drospiren-eth estrad-levomefol (Rajani Oral Tablet 3-0.02-0.451 CE N2 (Tier 1) Mg) REACT ORAL TABLET 1.5 MG (levonorgestrel) CE N2 (NF) desogestrel-ethinyl estradiol (Reclipsen Oral Tablet 0.15-30 CE N2 (Tier 1) Mg-Mcg) levonorgest-eth estrad 91-day (Rivelsa Oral Tablet 42-21-21-7 CE N2 (Tier 1) Days) SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth CE N2 (Tier 3) estrad-levomefol) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

154 Coverage Requirements and Prescription Drug Name Drug Tier Limits levonorgest-eth estrad 91-day (Setlakin Oral Tablet 0.15-0.03 CE N2 (Tier 1) Mg) norethindrone (Sharobel Oral Tablet 0.35 Mg) CE N2 (Tier 1) desogestrel-ethinyl estradiol (Simliya Oral Tablet 0.15- CE N2 (Tier 1) 0.02/0.01 Mg (21/5)) levonorgest-eth estrad 91-day (Simpesse Oral Tablet 0.15-0.03 CE N2 (Tier 1) &0.01 Mg) SKYLA INTRAUTERINE INTRAUTERINE DEVICE CE N2 (Tier 3) 13.5 MG (levonorgestrel) SLYND ORAL TABLET 4 MG (drospirenone) CE N2 (Tier 3) desogestrel-ethinyl estradiol (Solia Oral Tablet 0.15-30 Mg- CE N2 (Tier 1) Mcg) norgestimate-eth estradiol (Sprintec 28 Oral Tablet 0.25-35 CE N2 (Tier 1) Mg-Mcg) levonorgestrel-ethinyl estrad (Sronyx Oral Tablet 0.1-20 Mg- CE N2 (Tier 1) Mcg) drospirenone-ethinyl estradiol (Syeda Oral Tablet 3-0.03 Mg) CE N2 (Tier 1) TAKE ACTION ORAL TABLET 1.5 MG (levonorgestrel) CE N2 (NF) norethin ace-eth estrad-fe (Tarina 24 Fe Oral Tablet 1-20 Mg- CE N2 (Tier 1) Mcg(24)) norethin ace-eth estrad-fe (Tarina Fe 1/20 Oral Tablet 1-20 CE N2 (Tier 1) Mg-Mcg) TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24) NF # (norethin ace-eth estrad-fe) norethindron-ethinyl estrad-fe (Tilia Fe Oral Tablet 1-20/1- CE N2 (Tier 1) 30/1-35 Mg-Mcg) norgestim-eth estrad triphasic (Tri Femynor Oral Tablet CE N2 (Tier 1) 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Estarylla Oral Tablet CE N2 (Tier 1) 0.18/0.215/0.25 Mg-35 Mcg) norethindron-ethinyl estrad-fe (Tri-Legest Fe Oral Tablet 1- CE N2 (Tier 1) 20/1-30/1-35 Mg-Mcg)

155 Coverage Requirements and Prescription Drug Name Drug Tier Limits norgestim-eth estrad triphasic (Tri-Linyah Oral Tablet CE N2 (Tier 1) 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Estarylla Oral Tablet CE N2 (Tier 1) 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Marzia Oral Tablet CE N2 (Tier 1) 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Sprintec Oral Tablet CE N2 (Tier 1) 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Mili Oral Tablet CE N2 (Tier 1) 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Trinessa (28) Oral Tablet CE N2 (Tier 1) 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Trinessa Lo Oral Tablet CE N2 (Tier 1) 0.18/0.215/0.25 Mg-25 Mcg) TRI-NORINYL (28) ORAL TABLET 0.5/1/0.5-35 MG- Tier 3 MCG (norethin-eth estrad triphasic) norgestim-eth estrad triphasic (Tri-Previfem Oral Tablet CE N2 (Tier 1) 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Sprintec Oral Tablet CE N2 (Tier 1) 0.18/0.215/0.25 Mg-35 Mcg) levonorg-eth estrad triphasic (Trivora (28) Oral Tablet 50- CE N2 (Tier 1) 30/75-40/ 125-30 Mcg) norgestim-eth estrad triphasic (Tri-Vylibra Lo Oral Tablet CE N2 (Tier 1) 0.18/0.215/0.25 Mg-25 Mcg) norethindrone (Tulana Oral Tablet 0.35 Mg) CE N2 (Tier 1) TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 NF MCG/24HR (levonorgestrel-eth estradiol) drospiren-eth estrad-levomefol (Tydemy Oral Tablet 3-0.03- CE N2 (Tier 1) 0.451 Mg) desogestrel-ethinyl estradiol (Velivet Oral Tablet 0.1/0.125/0.15 CE N2 (Tier 1) -0.025 Mg) drospirenone-ethinyl estradiol (Vestura Oral Tablet 3-0.02 Mg) CE N2 (Tier 1)

156 Coverage Requirements and Prescription Drug Name Drug Tier Limits levonorgestrel-ethinyl estrad (Vienva Oral Tablet 0.1-20 Mg- CE N2 (Tier 1) Mcg) viorele oral tablet 0.15-0.02/0.01 mg (21/5) CE N2 (Tier 1) norethindrone-eth estradiol (Vyfemla Oral Tablet 0.4-35 Mg- CE N2 (Tier 1) Mcg) norethindrone-eth estradiol (Wera Oral Tablet 0.5-35 Mg-Mcg) CE N2 (Tier 1) norethin-eth estradiol-fe (Wymzya Fe Oral Tablet Chewable CE N2 (Tier 1) 0.4-35 Mg-Mcg) norelgestromin-eth estradiol (Xulane Transdermal Patch CE N2 (Tier 1) Weekly 150-35 Mcg/24Hr) drospirenone-ethinyl estradiol (Zarah Oral Tablet 3-0.03 Mg) CE N2 (Tier 1) norethindrone-eth estradiol (Zenchent Oral Tablet 0.4-35 Mg- CE N2 (Tier 1) Mcg) ethynodiol diac-eth estradiol (Zovia 1/35E (28) Oral Tablet 1- CE N2 (Tier 1) 35 Mg-Mcg) ethynodiol diac-eth estradiol (Zovia 1/50E (28) Oral Tablet 1- CE N2 (Tier 1) 50 Mg-Mcg) drospirenone-ethinyl estradiol (Zumandimine Oral Tablet 3- CE N2 (Tier 1) 0.03 Mg) DIABETIC SUPPLIES anti-stick insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml Tier 1 BD INSULIN SYRINGE ULTRAFINE 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML (insulin Tier 2 syringe-needle u-100) ENDOMETRIOSIS danazol oral capsule 100 mg, 200 mg, 50 mg Tier 1 ORILISSA ORAL TABLET 150 MG, 200 MG (elagolix Tier 2 sodium) SYNAREL NASAL SOLUTION 2 MG/ML (nafarelin Tier 4 PA; SP Pharmacy acetate) TRIPTODUR INTRAMUSCULAR SUSPENSION Tier 4 PA; SP Pharmacy RECONSTITUTED ER 22.5 MG (triptorelin pamoate)

157 Coverage Requirements and Prescription Drug Name Drug Tier Limits ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES ADAGEN INTRAMUSCULAR SOLUTION 250 Tier 4 PA; SP Pharmacy UNIT/ML (pegademase bovine) BUPHENYL ORAL POWDER 3 GM/TSP (sodium NF phenylbutyrate) BUPHENYL ORAL TABLET 500 MG (sodium NF phenylbutyrate) CARBAGLU ORAL TABLET 200 MG (carglumic acid) Tier 4 PA; #; SP Pharmacy PA; SP Pharmacy; QL (2 CERDELGA ORAL CAPSULE 84 MG (eliglustat tartrate) Tier 4 capsules per 1 day) CYSTADANE ORAL POWDER (betaine) Tier 4 PA; SP Pharmacy CYSTAGON ORAL CAPSULE 150 MG, 50 MG Tier 4 PA; SP Pharmacy (cysteamine bitartrate) KUVAN ORAL PACKET 100 MG, 500 MG (sapropterin NF dihydrochloride) KUVAN ORAL TABLET 100 MG (sapropterin NF dihydrochloride) KUVAN ORAL TABLET SOLUBLE 100 MG (sapropterin NF dihydrochloride) PA; ST; SP Pharmacy; QL miglustat oral capsule 100 mg Tier 4 (3 capsules per 1 Day) MYALEPT SUBCUTANEOUS SOLUTION PA; SP Pharmacy; QL (1 Tier 4 RECONSTITUTED 11.3 MG (metreleptin) vial per 1 day) nitisinone oral capsule 10 mg, 2 mg, 5 mg Tier 4 PA; SP Pharmacy NITYR ORAL TABLET 10 MG, 2 MG, 5 MG (nitisinone) NF ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG Tier 4 PA; SP Pharmacy (nitisinone) ORFADIN ORAL SUSPENSION 4 MG/ML (nitisinone) Tier 4 PA; SP Pharmacy PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED PA; SP Pharmacy; QL (1 Tier 4 SYRINGE 10 MG/0.5ML, 2.5 MG/0.5ML (pegvaliase-pqpz) syringe per 1 day)

158 Coverage Requirements and Prescription Drug Name Drug Tier Limits PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED PA; SP Pharmacy; QL (3 Tier 4 SYRINGE 20 MG/ML (pegvaliase-pqpz) SYRINGES per 1 day) RAVICTI ORAL LIQUID 1.1 GM/ML (glycerol PA; ST; SP Pharmacy; QL Tier 4 phenylbutyrate) (20 bottles per 30 days) sapropterin dihydrochloride oral packet 100 mg Tier 4 PA sapropterin dihydrochloride oral packet 500 mg Tier 4 PA; SP Pharmacy sapropterin dihydrochloride oral tablet 100 mg Tier 4 PA sapropterin dihydrochloride oral tablet soluble 100 mg Tier 4 PA; SP Pharmacy PA; SP Pharmacy; QL (20 sodium phenylbutyrate oral powder 3 gm/tsp Tier 4 grams per 1 day) PA; SP Pharmacy; QL (40 sodium phenylbutyrate oral tablet 500 mg Tier 1 tablets per 1 day) PA; ST; SP Pharmacy; QL ZAVESCA ORAL CAPSULE 100 MG (miglustat) Tier 4 (3 capsules per 1 day) ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES ACTIVELLA ORAL TABLET 0.5-0.1 MG, 1-0.5 MG NF (estradiol-norethindrone acet) ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 NF MG/24HR (estradiol) estradiol-norethindrone acet (Amabelz Oral Tablet 0.5-0.1 Mg) Tier 1 QL (1 tablet per 1 day) estradiol-norethindrone acet (Amabelz Oral Tablet 1-0.5 Mg) Tier 1 ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG Tier 3 (drospirenone-estradiol) BIEST/PROGESTERONE TRANSDERMAL CREAM NF (estradiol-estriol-progesterone) BIJUVA ORAL CAPSULE 1-100 MG (estradiol- NF progesterone) CLIMARA PRO TRANSDERMAL PATCH WEEKLY Tier 2 # 0.045-0.015 MG/DAY (estradiol-levonorgestrel)

159 Coverage Requirements and Prescription Drug Name Drug Tier Limits CLIMARA TRANSDERMAL PATCH WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.06 NF MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR (estradiol) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY Tier 3 QL (8 patches per 1 month) (estradiol-norethindrone acet) DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML, 20 NF MG/ML, 40 MG/ML (estradiol valerate) DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML Tier 3 (estradiol cypionate) DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 Tier 3 PA; AL MG/1.25GM (estradiol) DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- Tier 2 bazedoxifene) ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM Tier 3 PA; AL (0.06%) (estradiol) ESTRACE ORAL TABLET 0.5 MG, 1 MG, 2 MG (estradiol) NF ESTRACE VAGINAL CREAM 0.1 MG/GM (estradiol) NF estradiol oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 PA; AL estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 Tier 1 PA; AL mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 Tier 1 PA; AL mg/24hr estradiol vaginal cream 0.1 mg/gm Tier 1 estradiol vaginal tablet 10 mcg Tier 1 estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml Tier 1 estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg Tier 1 ESTRING VAGINAL RING 2 MG (estradiol) Tier 3 ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM Tier 3 PA; AL (0.06%) (estradiol)

160 Coverage Requirements and Prescription Drug Name Drug Tier Limits estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg Tier 1 EVAMIST TRANSDERMAL SOLUTION 1.53 Tier 3 PA; #; AL MG/SPRAY (estradiol) FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 Tier 3 #; QL (1 ring per 90 days) MG/24HR (estradiol acetate) norethindrone-eth estradiol (Fyavolv Oral Tablet 0.5-2.5 Mg- Tier 1 Mcg, 1-5 Mg-Mcg) IMVEXXY MAINTENANCE PACK VAGINAL INSERT NF 10 MCG (estradiol) IMVEXXY STARTER PACK VAGINAL INSERT 10 NF MCG (estradiol) IMVEXXY VAGINAL INSERT 10 MCG, 4 MCG NF (estradiol) jevantique lo oral tablet 0.5-2.5 mg-mcg Tier 1 norethindrone-eth estradiol (Jinteli Oral Tablet 1-5 Mg-Mcg) Tier 1 estradiol-norethindrone acet (Lopreeza Oral Tablet 0.5-0.1 Mg) Tier 1 QL (1 tablet per 1 day) estradiol-norethindrone acet (Lopreeza Oral Tablet 1-0.5 Mg) Tier 1 MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG Tier 3 PA; AL (esterified estrogens) MENOSTAR TRANSDERMAL PATCH WEEKLY 14 #; QL (4 patches per 28 Tier 3 MCG/24HR (estradiol) days) estradiol-norethindrone acet (Mimvey Lo Oral Tablet 0.5-0.1 Tier 1 QL (1 tablet per 1 day) Mg) estradiol-norethindrone acet (Mimvey Oral Tablet 1-0.5 Mg) Tier 1 MINIVELLE TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 NF MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR (estradiol) norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg- Tier 1 mcg ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 NF & 300 MG (elagolix-estradiol-norethind)

161 Coverage Requirements and Prescription Drug Name Drug Tier Limits PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol- Tier 3 QL (1 tablet per 1 day) norgestimate) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, Tier 3 PA; AL 0.9 MG, 1.25 MG (estrogens conjugated) PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens, Tier 3 conjugated) PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog- Tier 3 medroxyprogest ace) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, Tier 3 0.625-2.5 MG, 0.625-5 MG (conj estrog-medroxyprogest ace) VAGIFEM VAGINAL TABLET 10 MCG (estradiol) NF VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 NF MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR (estradiol) estradiol (Yuvafem Vaginal Tablet 10 Mcg) Tier 1 FERTILITY REGULATORS chorionic gonadotropin intramuscular solution reconstituted Tier 4 PA; SP Pharmacy 10000 unit GONAL-F INJECTION SOLUTION RECONSTITUTED Tier 4 PA; SP Pharmacy 1050 UNIT, 450 UNIT (follitropin alfa) GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION 300 UNIT/0.5ML, 450 UNT/0.75ML, 900 Tier 4 PA; SP Pharmacy UNIT/1.5ML (follitropin alfa) GONAL-F RFF SUBCUTANEOUS SOLUTION Tier 4 PA; SP Pharmacy RECONSTITUTED 75 UNIT (follitropin alfa) NOVAREL INTRAMUSCULAR SOLUTION NF SP Pharmacy RECONSTITUTED 10000 UNIT (chorionic gonadotropin) PREGNYL INTRAMUSCULAR SOLUTION NF SP Pharmacy RECONSTITUTED 10000 UNIT (chorionic gonadotropin) GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE ALKINDI SPRINKLE ORAL CAPSULE SPRINKLE 0.5 NF MG, 1 MG, 2 MG, 5 MG (hydrocortisone) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

162 Coverage Requirements and Prescription Drug Name Drug Tier Limits budesonide er oral tablet extended release 24 hour 9 mg Tier 1 QL (1 tablet per 1 day) CORTEF ORAL TABLET 10 MG, 20 MG, 5 MG NF (hydrocortisone) cortisone acetate oral tablet 25 mg Tier 1 prednisone (Deltasone Oral Tablet 20 Mg) Tier 1 DEXAMETHASONE INTENSOL ORAL Tier 2 CONCENTRATE 1 MG/ML (dexamethasone) dexamethasone oral elixir 0.5 mg/5ml Tier 1 dexamethasone oral solution 0.5 mg/5ml Tier 1 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, Tier 1 4 mg, 6 mg dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg Tier 1 (35), 1.5 mg (51) dexamethasone (Dexpak 10 Day Oral Tablet Therapy Pack 1.5 NF Mg (35)) dexamethasone (Dexpak 13 Day Oral Tablet Therapy Pack 1.5 NF Mg (51)) dexamethasone (Dexpak 6 Day Oral Tablet Therapy Pack 1.5 NF Mg (21)) DXEVO 11-DAY ORAL TABLET THERAPY PACK 1.5 NF MG (dexamethasone) EMFLAZA ORAL SUSPENSION 22.75 MG/ML NF (deflazacort) EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG NF (deflazacort) fludrocortisone acetate oral tablet 0.1 mg Tier 1 HEMADY ORAL TABLET 20 MG (dexamethasone) NF dexamethasone (Hidex 6-Day Oral Tablet Therapy Pack 1.5 Tier 1 Mg (21)) hydrocortisone oral tablet 10 mg, 20 mg, 5 mg Tier 1 LOCORT 11-DAY ORAL TABLET THERAPY PACK 1.5 NF MG (41) (dexamethasone)

163 Coverage Requirements and Prescription Drug Name Drug Tier Limits LOCORT 7-DAY ORAL TABLET THERAPY PACK 1.5 NF MG (27) (dexamethasone) MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG NF (methylprednisolone) MEDROL ORAL TABLET 2 MG (methylprednisolone) Tier 2 MEDROL ORAL TABLET THERAPY PACK 4 MG NF (methylprednisolone) methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg Tier 1 methylprednisolone oral tablet therapy pack 4 mg Tier 1 MILLIPRED DP 12-DAY ORAL TABLET THERAPY Tier 3 PACK 5 MG (48) (prednisolone) MILLIPRED DP ORAL TABLET THERAPY PACK 5 MG Tier 3 (21), 5 MG (48) (prednisolone) MILLIPRED ORAL SOLUTION 10 MG/5ML (prednisolone NF sodium phosphate) MILLIPRED ORAL TABLET 5 MG (prednisolone) Tier 2 ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, NF 15 MG, 30 MG (prednisolone sodium phosphate) PEDIAPRED ORAL SOLUTION 6.7 (5 BASE) MG/5ML NF (prednisolone sodium phosphate) prednisolone oral solution 15 mg/5ml Tier 1 prednisolone oral syrup 15 mg/5ml Tier 1 prednisolone sodium phosphate oral solution 10 mg/5ml, 15 Tier 1 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 Tier 1 mg, 30 mg PREDNISONE INTENSOL ORAL CONCENTRATE 5 Tier 2 MG/ML (prednisone) prednisone oral solution 5 mg/5ml Tier 1 prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg Tier 1 prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 Tier 1 mg (21), 5 mg (48)

164 Coverage Requirements and Prescription Drug Name Drug Tier Limits TAPERDEX 12-DAY ORAL TABLET THERAPY PACK NF 1.5 MG (49) (dexamethasone) dexamethasone (Taperdex 6-Day Oral Tablet Therapy Pack NF 1.5 Mg (21)) TAPERDEX 7-DAY ORAL TABLET THERAPY PACK NF 1.5 MG (27) (dexamethasone) VERIPRED 20 ORAL SOLUTION 20 MG/5ML NF (prednisolone sodium phosphate) zcort 7-day oral tablet therapy pack 1.5 mg (25) NF ZODEX 12-DAY ORAL TABLET THERAPY PACK 1.5 NF MG (49) (dexamethasone) ZONACORT 11 DAY ORAL TABLET THERAPY PACK NF 1.5 MG (41) (dexamethasone) ZONACORT 7 DAY ORAL TABLET THERAPY PACK NF 1.5 MG (27) (dexamethasone) GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGAR BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE NF (glucagon) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE NF (glucagon) BD GLUCOSE ORAL TABLET CHEWABLE 5 GM Tier 3 (dextrose (diabetic use)) DEX4 GLUCOSE GO-POUCH ORAL GEL 15 GM/33GM Tier 3 (dextrose (diabetic use)) DEX4 GLUCOSE ORAL LIQUID 15 GM/59ML (dextrose Tier 3 (diabetic use)) DEX4 GLUCOSE ORAL TABLET CHEWABLE 4-6 GM- Tier 3 MG (glucose-vitamin c) DEX4 QUICK DISSOLVE GLUCOSE ORAL TABLET Tier 3 CHEWABLE 4 GM (dextrose (diabetic use)) diazoxide oral suspension 50 mg/ml Tier 1

165 Coverage Requirements and Prescription Drug Name Drug Tier Limits GLUCAGEN HYPOKIT INJECTION SOLUTION Tier 2 RECONSTITUTED 1 MG (glucagon hcl (rdna)) glucagon emergency injection kit 1 mg Tier 3 glucagon emergency injection solution reconstituted 1 mg/ml Tier 3 GLUCO BURST ORAL GEL 40 % (dextrose (diabetic use)) Tier 1 glucose oral gel 40 % Tier 1 glucose oral liquid 15 gm/59ml Tier 1 glucose oral tablet chewable 4 gm, 4-6 gm-mg Tier 3 GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 NF MG/0.2ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 NF MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) INSTA-GLUCOSE ORAL GEL 77.4 % (dextrose (diabetic Tier 3 use)) leader quick dissolve glucose oral tablet chewable 4 gm Tier 3 PROGLYCEM ORAL SUSPENSION 50 MG/ML Tier 3 (diazoxide) RELION GLUCOSE DRINK ORAL LIQUID 15 Tier 1 GM/59ML (dextrose (diabetic use)) RELION GLUCOSE ORAL GEL 15 GM/38GM (dextrose Tier 1 (diabetic use)) value plus glucose oral gel 40 % Tier 1 ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO- NF INJECTOR 0.6 MG/0.6ML (dasiglucagon hcl) ZEGALOGUE SUBCUTANEOUS SOLUTION NF PREFILLED SYRINGE 0.6 MG/0.6ML (dasiglucagon hcl)

166 Coverage Requirements and Prescription Drug Name Drug Tier Limits HUMAN GROWTH HORMONES - DRUGS TO REGULATE PITUITARY HORMONES GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED 0.2 MG, 0.4 MG, 0.6 MG, NF 0.8 MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG (somatropin) GENOTROPIN SUBCUTANEOUS SOLUTION NF RECONSTITUTED 12 MG, 5 MG (somatropin) HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, 5 MG, 6 MG Tier 4 PA; SP Pharmacy (somatropin) NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 NF MG/1.5ML (somatropin) NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MG/1.5ML, 15 NF MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML (somatropin) NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS NF SOLUTION 10 MG/2ML (somatropin) NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS NF SOLUTION PEN-INJECTOR 10 MG/2ML (somatropin) NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS NF SOLUTION 20 MG/2ML (somatropin) NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS NF SOLUTION PEN-INJECTOR 20 MG/2ML (somatropin) NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS NF SOLUTION 5 MG/2ML (somatropin) NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS NF SOLUTION PEN-INJECTOR 5 MG/2ML (somatropin) OMNITROPE SUBCUTANEOUS SOLUTION 10 NF MG/1.5ML, 5 MG/1.5ML (somatropin) OMNITROPE SUBCUTANEOUS SOLUTION NF CARTRIDGE 10 MG/1.5ML, 5 MG/1.5ML (somatropin)

167 Coverage Requirements and Prescription Drug Name Drug Tier Limits OMNITROPE SUBCUTANEOUS SOLUTION NF RECONSTITUTED 5.8 MG (somatropin) SAIZEN CLICK.EASY INJECTION SOLUTION NF RECONSTITUTED 8.8 MG (somatropin (non-refrigerated)) SAIZEN INJECTION SOLUTION RECONSTITUTED 5 NF MG, 8.8 MG (somatropin (non-refrigerated)) SAIZENPREP INJECTION SOLUTION NF RECONSTITUTED 8.8 MG (somatropin (non-refrigerated)) SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG (somatropin (non- Tier 4 PA; ST; SP Pharmacy refrigerated)) ZOMACTON (FOR ZOMA-JET 10) SUBCUTANEOUS NF SOLUTION RECONSTITUTED 10 MG (somatropin) ZOMACTON SUBCUTANEOUS SOLUTION NF RECONSTITUTED 10 MG, 5 MG (somatropin) ZORBTIVE SUBCUTANEOUS SOLUTION Tier 4 PA; ST; SP Pharmacy RECONSTITUTED 8.8 MG (somatropin (non-refrigerated)) HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS HECTOROL ORAL CAPSULE 0.5 MCG, 1 MCG, 2.5 NF MCG (doxercalciferol) MISCELLANEOUS ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) NF BYNFEZIA PEN SUBCUTANEOUS SOLUTION PEN- NF INJECTOR 2500 MCG/ML (2.8 ML) (octreotide acetate) cabergoline oral tablet 0.5 mg Tier 1 calcitonin (salmon) nasal solution 200 unit/act Tier 1 CERVIDIL VAGINAL INSERT 10 MG (dinoprostone) NF EVENITY SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 105 MG/1.17ML (romosozumab-aqqg) EVISTA ORAL TABLET 60 MG (raloxifene hcl) NF

168 Coverage Requirements and Prescription Drug Name Drug Tier Limits FORTEO SUBCUTANEOUS SOLUTION 600 Tier 4 PA; ST; #; SP Pharmacy MCG/2.4ML (teriparatide (recombinant)) FORTEO SUBCUTANEOUS SOLUTION PEN- Tier 4 # INJECTOR 600 MCG/2.4ML (teriparatide (recombinant)) FORTEO SUBCUTANEOUS SOLUTION PEN- Tier 4 INJECTOR 620 MCG/2.48ML (teriparatide (recombinant)) PA; SP Pharmacy; QL (14 GALAFOLD ORAL CAPSULE 123 MG (migalastat hcl) Tier 4 capsules per 28 days) INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML Tier 4 PA; SP Pharmacy (mecasermin) ISTURISA ORAL TABLET 1 MG, 10 MG, 5 MG NF (osilodrostat phosphate) JYNARQUE ORAL TABLET THERAPY PACK 15 MG, 30 & 15 MG, 45 & 15 MG, 60 & 30 MG, 90 & 30 MG Tier 4 PA; SP Pharmacy (tolvaptan) PA; #; SP Pharmacy; QL (4 KORLYM ORAL TABLET 300 MG (mifepristone) Tier 4 tablets per 1 day) methylergonovine maleate (Methergine Oral Tablet 0.2 Mg) Tier 1 QL (28 tablets per 7 days) MIACALCIN NASAL SOLUTION 200 UNIT/ACT NF (calcitonin (salmon)) MYCAPSSA ORAL CAPSULE DELAYED RELEASE 20 NF MG (octreotide acetate) NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, NF 25 MCG, 50 MCG, 75 MCG (parathyroid hormone (recomb)) octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml, 500 PA; SP Pharmacy; QL (90 Tier 4 mcg/ml ml per 30 days) PA; SP Pharmacy; QL (45 octreotide acetate injection solution 1000 mcg/ml Tier 4 ml per 30 days) PA; SP Pharmacy; QL (225 octreotide acetate injection solution 200 mcg/ml Tier 4 ml per 30 days) OSPHENA ORAL TABLET 60 MG (ospemifene) Tier 2 PREPIDIL VAGINAL GEL 0.5 MG/3GM (dinoprostone) Tier 3

169 Coverage Requirements and Prescription Drug Name Drug Tier Limits PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML Tier 4 PA; ST; SP Pharmacy (denosumab) PROLIA SUBCUTANEOUS SOLUTION PREFILLED Tier 4 SYRINGE 60 MG/ML (denosumab) PROSTIN E2 VAGINAL SUPPOSITORY 20 MG Tier 3 (dinoprostone) raloxifene hcl oral tablet 60 mg CE N2 (Tier 1) SAMSCA ORAL TABLET 15 MG (tolvaptan) NF PA; SP Pharmacy; QL (2 SAMSCA ORAL TABLET 30 MG (tolvaptan) Tier 4 tablets per 1 day) SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, 1000 MCG/ML, 200 MCG/ML, 50 MCG/ML, 500 MCG/ML NF (octreotide acetate) SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT NF # 10 MG, 20 MG, 30 MG (octreotide acetate) SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 20 MG, 30 MG, 40 MG, 60 NF MG (pasireotide pamoate) SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, PA; SP Pharmacy; QL (2 Tier 4 0.6 MG/ML, 0.9 MG/ML (pasireotide diaspartate) ampules per 1 day) SOMATULINE DEPOT SUBCUTANEOUS SOLUTION PA; #; SP Pharmacy; QL (1 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML (lanreotide Tier 4 injection per 28 days) acetate) SOMAVERT SUBCUTANEOUS SOLUTION PA; #; SP Pharmacy; QL (1 RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG Tier 4 vial per 1 day) (pegvisomant) teriparatide (recombinant) subcutaneous solution pen-injector NF 620 mcg/2.48ml tolvaptan oral tablet 15 mg Tier 4 PA; SP Pharmacy PA; SP Pharmacy; QL (2 tolvaptan oral tablet 30 mg Tier 4 tablets per 1 day) TYMLOS SUBCUTANEOUS SOLUTION PEN- PA; SP Pharmacy; QL (1 Tier 4 INJECTOR 3120 MCG/1.56ML (abaloparatide) injection per 1 month)

170 Coverage Requirements and Prescription Drug Name Drug Tier Limits XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML Tier 4 PA; ST; SP Pharmacy (denosumab) PA; SP Pharmacy; QL (4 XURIDEN ORAL PACKET 2 GM (uridine triacetate) Tier 4 packets per 1 day) ZOKINVY ORAL CAPSULE 50 MG, 75 MG (lonafarnib) NF PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS AURYXIA ORAL TABLET 1 GM 210 MG(FE) (ferric NF citrate) calcium acetate (phos binder) oral capsule 667 mg Tier 1 calcium acetate (phos binder) oral tablet 667 mg Tier 1 calcium acetate oral capsule 667 mg Tier 1 CALPHRON ORAL TABLET 667 MG (calcium acetate Tier 1 (phos binder)) FOSRENOL ORAL PACKET 1000 MG, 750 MG Tier 3 (lanthanum carbonate) FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 NF MG, 750 MG (lanthanum carbonate) GEMTESA ORAL TABLET 75 MG (vibegron) NF lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 Tier 1 mg MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 Tier 2 ST; QL (1 tablet per 1 day) HOUR 50 MG (mirabegron) PHOSLO ORAL CAPSULE 667 MG (calcium acetate (phos NF binder)) PHOSLYRA ORAL SOLUTION 667 MG/5ML (calcium Tier 2 acetate (phos binder)) RENAGEL ORAL TABLET 400 MG (sevelamer hcl) Tier 3 # RENAGEL ORAL TABLET 800 MG (sevelamer hcl) NF RENVELA ORAL PACKET 0.8 GM, 2.4 GM (sevelamer NF carbonate) RENVELA ORAL TABLET 800 MG (sevelamer carbonate) NF

171 Coverage Requirements and Prescription Drug Name Drug Tier Limits sevelamer carbonate oral packet 0.8 gm, 2.4 gm Tier 1 sevelamer carbonate oral tablet 800 mg Tier 1 sevelamer hcl oral tablet 400 mg, 800 mg Tier 1 VELPHORO ORAL TABLET CHEWABLE 500 MG Tier 3 # (sucroferric oxyhydroxide) PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES AYGESTIN ORAL TABLET 5 MG (norethindrone acetate) NF CRINONE VAGINAL GEL 4 %, 8 % (progesterone) Tier 2 PA; SP Pharmacy; QL (5 hydroxyprogesterone caproate intramuscular oil 250 mg/ml Tier 4 vials per 1 year) LUPANETA PACK COMBINATION KIT 11.25 & 5 MG, Tier 4 PA; SP Pharmacy 3.75 & 5 MG (leuprolide & norethindrone) MAKENA INTRAMUSCULAR OIL 250 MG/ML NF (hydroxyprogesterone caproate) MAKENA SUBCUTANEOUS SOLUTION AUTO- PA; ST; QL (21 syringes per Tier 4 INJECTOR 275 MG/1.1ML (hydroxyprogesterone caproate) 365 days) medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 MEGACE ES ORAL SUSPENSION 625 MG/5ML CE N2 (NF) (megestrol acetate) norethindrone acetate oral tablet 5 mg Tier 1 progesterone intramuscular oil 50 mg/ml NF progesterone micronized oral capsule 100 mg, 200 mg Tier 1 progesterone oral capsule 100 mg, 200 mg NF PROMETRIUM ORAL CAPSULE 100 MG, 200 MG NF (progesterone) PROVERA ORAL TABLET 10 MG, 2.5 MG, 5 MG NF (medroxyprogesterone acetate) THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, Tier 3 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG (thyroid) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

172 Coverage Requirements and Prescription Drug Name Drug Tier Limits CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG NF (liothyronine sodium) levothyroxine sodium (Euthyrox Oral Tablet 88 Mcg) Tier 1 levothyroxine sodium (Levo-T Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 Mcg, 300 Tier 1 Mcg, 50 Mcg, 75 Mcg, 88 Mcg) levothyroxine sodium oral capsule 100 mcg, 112 mcg, 125 mcg, 13 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, NF 75 mcg, 88 mcg levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, Tier 1 75 mcg, 88 mcg levothyroxine sodium (Levoxyl Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 Mcg, 50 Tier 1 Mcg, 75 Mcg, 88 Mcg) liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg Tier 1 methimazole oral tablet 10 mg, 5 mg Tier 1 NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 Tier 3 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG (thyroid) np thyroid oral tablet 15 mg, 30 mg, 60 mg, 90 mg Tier 1 propylthiouracil oral tablet 50 mg Tier 1 SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, Tier 2 300 MCG, 50 MCG, 75 MCG, 88 MCG (levothyroxine sodium) TAPAZOLE ORAL TABLET 10 MG, 5 MG (methimazole) NF THYQUIDITY ORAL SOLUTION 100 MCG/5ML NF (levothyroxine sodium) THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG) Tier 3 (liotrix (t3-t4))

173 Coverage Requirements and Prescription Drug Name Drug Tier Limits THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG) Tier 3 (liotrix (t3-t4)) THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG (MCG) Tier 3 (liotrix (t3-t4)) THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG) Tier 3 (liotrix (t3-t4)) THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG) Tier 3 (liotrix (t3-t4)) TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, Tier 3 25 MCG, 50 MCG, 75 MCG, 88 MCG (levothyroxine sodium) TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 50 Tier 3 # MCG/ML, 75 MCG/ML, 88 MCG/ML (levothyroxine sodium) TIROSINT-SOL ORAL SOLUTION 37.5 MCG/ML, 44 NF MCG/ML, 62.5 MCG/ML (levothyroxine sodium) levothyroxine sodium (Unithroid Direct Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 Mcg, 300 Tier 1 Mcg, 50 Mcg, 75 Mcg, 88 Mcg) levothyroxine sodium (Unithroid Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 Tier 1 Mcg, 300 Mcg, 50 Mcg, 75 Mcg, 88 Mcg) WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, Tier 3 65 MG, 97.5 MG (thyroid) WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG Tier 3 (thyroid) VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES DDAVP NASAL SOLUTION 0.01 % (desmopressin acetate NF spray)

174 Coverage Requirements and Prescription Drug Name Drug Tier Limits DDAVP ORAL TABLET 0.1 MG, 0.2 MG (desmopressin NF acetate) DDAVP RHINAL TUBE NASAL SOLUTION 0.01 % NF (desmopressin ace refrigerated) desmopressin ace rhinal tube nasal solution 0.01 % NF desmopressin ace spray refrig nasal solution 0.01 % Tier 1 desmopressin acetate oral tablet 0.1 mg, 0.2 mg Tier 1 desmopressin acetate spray nasal solution 0.01 % Tier 1 NOCDURNA SUBLINGUAL TABLET SUBLINGUAL Tier 3 PA; QL (1 tablet per 1 Day) 27.7 MCG, 55.3 MCG (desmopressin acetate) NOCTIVA NASAL EMULSION 0.83 MCG/0.1ML, 1.66 PA; QL (1 bottle per 30 Tier 3 MCG/0.1ML (desmopressin acetate) days); AL STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin Tier 3 PA; SP Pharmacy acetate) GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTICHOLINERGICS belladonna alkaloids-opium rectal suppository 16.2-60 mg Tier 3 belladonna-opium rectal suppository 16.2-30 mg Tier 1 BENTYL ORAL CAPSULE 10 MG (dicyclomine hcl) NF chlordiazepoxide-clidinium oral capsule 5-2.5 mg NF CUVPOSA ORAL SOLUTION 1 MG/5ML (glycopyrrolate) Tier 2 # dicyclomine hcl oral capsule 10 mg Tier 1 dicyclomine hcl oral solution 10 mg/5ml Tier 1 dicyclomine hcl oral tablet 20 mg Tier 1 ed-spaz oral tablet dispersible 0.125 mg Tier 1 glycopyrrolate oral tablet 1 mg, 2 mg Tier 1 glycopyrrolate oral tablet 1.5 mg NF hyoscyamine sulfate er oral tablet extended release 12 hour NF 0.375 mg hyoscyamine sulfate oral tablet 0.125 mg Tier 1 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

175 Coverage Requirements and Prescription Drug Name Drug Tier Limits hyoscyamine sulfate oral tablet dispersible 0.125 mg Tier 1 hyoscyamine sulfate sublingual tablet sublingual 0.125 mg Tier 1 LIBRAX ORAL CAPSULE 5-2.5 MG (chlordiazepoxide- NF clidinium) methscopolamine bromide oral tablet 2.5 mg, 5 mg Tier 1 PA; AL hyoscyamine sulfate (Nulev Oral Tablet Dispersible 0.125 Mg) Tier 1 oscimin oral tablet 0.125 mg Tier 1 oscimin oral tablet dispersible 0.125 mg Tier 1 oscimin sr oral tablet extended release 12 hour 0.375 mg NF oscimin sublingual tablet sublingual 0.125 mg Tier 1 PAMINE FORTE ORAL TABLET 5 MG (methscopolamine NF bromide) PAMINE ORAL TABLET 2.5 MG (methscopolamine NF bromide) propantheline bromide oral tablet 15 mg Tier 1 ROBINUL ORAL TABLET 1 MG (glycopyrrolate) NF ROBINUL-FORTE ORAL TABLET 2 MG (glycopyrrolate) NF hyoscyamine sulfate (Symax-Sl Sublingual Tablet Sublingual Tier 1 0.125 Mg) hyoscyamine sulfate (Symax-Sr Oral Tablet Extended Release NF 12 Hour 0.375 Mg) ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- Tier 3 QL (2 capsules per 1 month) palonosetron) ANZEMET ORAL TABLET 100 MG, 50 MG (dolasetron Tier 3 QL (6 tablets per 1 month) mesylate) aprepitant oral capsule 125 mg Tier 1 QL (5 capsules per 30 days) aprepitant oral capsule 40 mg, 80 mg Tier 1 QL (3 capsules per 1 fill) aprepitant oral capsule 80 & 125 mg Tier 1 QL (9 tablets per 30 days)

176 Coverage Requirements and Prescription Drug Name Drug Tier Limits BONJESTA ORAL TABLET EXTENDED RELEASE 20- NF # 20 MG (doxylamine-pyridoxine) CESAMET ORAL CAPSULE 1 MG (nabilone) Tier 3 QL (2 capsules per 1 day) prochlorperazine (Compro Rectal Suppository 25 Mg) Tier 1 DICLEGIS ORAL TABLET DELAYED RELEASE 10-10 NF MG (doxylamine-pyridoxine) doxylamine-pyridoxine oral tablet delayed release 10-10 mg NF DRAMAMINE LESS DROWSY ORAL TABLET 25 MG Tier 1 OTC (meclizine hcl) QL (4 CAPSULES per 1 dronabinol oral capsule 10 mg, 2.5 mg, 5 mg Tier 1 day) EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG NF (aprepitant) EMEND ORAL SUSPENSION RECONSTITUTED 125 Tier 2 # MG/5ML (aprepitant) EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG NF (aprepitant) GIMOTI NASAL SOLUTION 15 MG/ACT (metoclopramide NF hcl) granisetron hcl oral tablet 1 mg Tier 1 QL (12 tablets per 21 days) MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG NF (dronabinol) meclizine hcl oral tablet 12.5 mg, 25 mg Tier 1 OTC meclizine hcl oral tablet 50 mg NF metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml Tier 1 metoclopramide hcl oral tablet 10 mg, 5 mg Tier 1 metoclopramide hcl oral tablet dispersible 10 mg Tier 3 metoclopramide hcl oral tablet dispersible 5 mg Tier 1 ondansetron hcl oral solution 4 mg/5ml Tier 1 QL (200 ml per 21 days) ondansetron hcl oral tablet 24 mg Tier 1 QL (2 tablets per 21 days) ondansetron hcl oral tablet 4 mg, 8 mg Tier 1 QL (18 tablets per 21 days)

177 Coverage Requirements and Prescription Drug Name Drug Tier Limits ondansetron oral tablet dispersible 4 mg, 8 mg Tier 1 QL (18 tablets per 21 days) promethazine hcl (Phenadoz Rectal Suppository 12.5 Mg, 25 Tier 1 Mg) promethazine hcl (Phenergan Rectal Suppository 12.5 Mg, 25 Tier 1 Mg, 50 Mg) prochlorperazine maleate oral tablet 10 mg, 5 mg Tier 1 prochlorperazine rectal suppository 25 mg Tier 1 promethazine hcl oral solution 6.25 mg/5ml Tier 1 PA; AL promethazine hcl oral syrup 6.25 mg/5ml Tier 1 PA; AL promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg Tier 1 PA; AL promethazine hcl rectal suppository 12.5 mg, 25 mg, 50 mg Tier 1 promethazine hcl (Promethegan Rectal Suppository 12.5 Mg, Tier 1 25 Mg) PROMETHEGAN RECTAL SUPPOSITORY 50 MG Tier 1 (promethazine hcl) REGLAN ORAL TABLET 10 MG, 5 MG (metoclopramide NF hcl) SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR Tier 2 QL (2 patches per 21 days) (granisetron) scopolamine transdermal patch 72 hour 1 mg/3days Tier 1 SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) NF # TIGAN ORAL CAPSULE 300 MG (trimethobenzamide hcl) NF TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH NF 72 HOUR 1 MG/3DAYS (scopolamine base) trimethobenzamide hcl oral capsule 300 mg Tier 1 VARUBI (180 MG DOSE) ORAL TABLET THERAPY Tier 2 PACK 2 X 90 MG (rolapitant hcl) VARUBI ORAL TABLET 90 MG (rolapitant hcl) NF ZOFRAN ODT ORAL TABLET DISPERSIBLE 4 MG, 8 NF MG (ondansetron) ZOFRAN ORAL SOLUTION 4 MG/5ML (ondansetron hcl) NF

178 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZOFRAN ORAL TABLET 4 MG, 8 MG (ondansetron hcl) NF ZUPLENZ ORAL FILM 4 MG, 8 MG (ondansetron) NF H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID cimetidine hcl oral solution 300 mg/5ml Tier 1 cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg Tier 1 OTC eq famotidine max st oral tablet 20 mg Tier 1 famotidine oral suspension reconstituted 40 mg/5ml Tier 1 famotidine oral tablet 20 mg Tier 1 OTC famotidine oral tablet 40 mg Tier 1 nizatidine oral capsule 150 mg, 300 mg Tier 1 nizatidine oral solution 15 mg/ml Tier 1 PEPCID ORAL SUSPENSION RECONSTITUTED 40 NF MG/5ML (famotidine) PEPCID ORAL TABLET 40 MG (famotidine) NF ranitidine hcl oral capsule 150 mg, 300 mg Tier 1 OTC ranitidine hcl oral syrup 15 mg/ml, 150 mg/10ml, 75 mg/5ml Tier 1 OTC ranitidine hcl oral tablet 150 mg, 300 mg Tier 1 OTC ZANTAC ORAL TABLET 300 MG (ranitidine hcl) NF INFLAMMATORY BOWEL DISEASE - BOWEL, INTESTINE, AND STOMACH CONDITION DRUGS APRISO ORAL CAPSULE EXTENDED RELEASE 24 Tier 2 QL (4 capsules per 1 day) HOUR 0.375 GM (mesalamine) ASACOL HD ORAL TABLET DELAYED RELEASE 800 NF MG (mesalamine) AZULFIDINE EN-TABS ORAL TABLET DELAYED NF RELEASE 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) NF balsalazide disodium oral capsule 750 mg Tier 1 budesonide oral capsule delayed release particles 3 mg Tier 1

179 Coverage Requirements and Prescription Drug Name Drug Tier Limits ST; QL (1 suppository per 1 CANASA RECTAL SUPPOSITORY 1000 MG (mesalamine) Tier 3 day) COLAZAL ORAL CAPSULE 750 MG (balsalazide disodium) NF hydrocortisone (Colocort Rectal Enema 100 Mg/60Ml) Tier 1 CORTENEMA RECTAL ENEMA 100 MG/60ML NF (hydrocortisone) CORTIFOAM EXTERNAL FOAM 10 % (hydrocortisone Tier 3 acetate) CORTIFOAM RECTAL FOAM 10 % (hydrocortisone Tier 3 QL (30 grams per 30 days) acetate) DELZICOL ORAL CAPSULE DELAYED RELEASE 400 NF MG (mesalamine) DIPENTUM ORAL CAPSULE 250 MG (olsalazine sodium) Tier 3 PA ENTOCORT EC ORAL CAPSULE DELAYED RELEASE NF PARTICLES 3 MG (budesonide) ST; #; QL (6 tablets per 1 GIAZO ORAL TABLET 1.1 GM (balsalazide disodium) Tier 3 day) hydrocortisone rectal enema 100 mg/60ml Tier 1 LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM NF (mesalamine) mesalamine er oral capsule extended release 24 hour 0.375 gm Tier 1 mesalamine oral capsule delayed release 400 mg Tier 1 mesalamine oral tablet delayed release 1.2 gm, 800 mg Tier 1 mesalamine rectal enema 4 gm Tier 1 mesalamine rectal suppository 1000 mg Tier 1 mesalamine-cleanser rectal kit 4 gm Tier 1 ORTIKOS ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 6 MG, 9 MG (budesonide) PENTASA ORAL CAPSULE EXTENDED RELEASE 250 ST; QL (16 capsules per 1 Tier 3 MG (mesalamine) day) PENTASA ORAL CAPSULE EXTENDED RELEASE 500 ST; QL (8 capsules per 1 Tier 3 MG (mesalamine) day) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

180 Coverage Requirements and Prescription Drug Name Drug Tier Limits SFROWASA RECTAL ENEMA 4 GM/60ML (mesalamine) NF sulfasalazine oral tablet 500 mg Tier 1 sulfasalazine oral tablet delayed release 500 mg Tier 1 sulfasalazine (Sulfazine Oral Tablet 500 Mg) Tier 1 QL (8 tabs per 1 day) UCERIS ORAL TABLET EXTENDED RELEASE 24 NF HOUR 9 MG (budesonide) UCERIS RECTAL FOAM 2 MG/ACT (budesonide) NF # IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA ORAL CAPSULE 24 MCG, 8 MCG NF # (lubiprostone) LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG Tier 2 (linaclotide) lubiprostone oral capsule 24 mcg, 8 mcg Tier 1 TRULANCE ORAL TABLET 3 MG (plecanatide) NF ZELNORM ORAL TABLET 6 MG (tegaserod maleate) NF IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl oral tablet 0.5 mg, 1 mg Tier 1 PA LOTRONEX ORAL TABLET 0.5 MG, 1 MG (alosetron hcl) NF VIBERZI ORAL TABLET 100 MG, 75 MG (eluxadoline) NF LAXATIVES - DRUGS FOR CONSTIPATION bisacodyl powder Tier 3 N2 (NF); AL bisacodyl rectal suppository 10 mg CE N2 (NF); AL citrate of magnesia oral solution , 1.745 gm/30ml CE N2 (NF); AL CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM - CE N2 (Tier 3); AL GM/160ML (sod picosulfate-mag ox-cit acd) COLYTE WITH FLAVOR PACKS ORAL SOLUTION Tier 3 RECONSTITUTED 240 GM (peg 3350-kcl-nabcb-nacl-nasulf) constulose oral solution 10 gm/15ml Tier 1 DULCOLAX BOWEL PREP KIT COMBINATION KIT CE N2 (NF); AL (bisacodyl) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

181 Coverage Requirements and Prescription Drug Name Drug Tier Limits enulose oral solution 10 gm/15ml Tier 1 FLEET LAXATIVE ORAL TABLET DELAYED CE N2 (NF); AL RELEASE 5 MG (bisacodyl) GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 Tier 1 GM (peg 3350-kcl-nabcb-nacl-nasulf) peg 3350-kcl-nabcb-nacl-nasulf (Gavilyte-G Oral Solution Tier 1 Reconstituted 236 Gm) bisacodyl-peg-kcl-nabicar-nacl (Gavilyte-H Oral Kit 5-210 Mg- CE N2 (Tier 1); AL Gm) peg 3350-kcl-na bicarb-nacl (Gavilyte-N With Flavor Pack Tier 1 Oral Solution Reconstituted 420 Gm) generlac oral solution 10 gm/15ml Tier 1 GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 Tier 2 GM (peg 3350-kcl-nabcb-nacl-nasulf) GOLYTELY ORAL SOLUTION RECONSTITUTED 236 Tier 3 GM (peg 3350-kcl-nabcb-nacl-nasulf) KRISTALOSE ORAL PACKET 10 GM, 20 GM (lactulose) Tier 3 QL (60 packets per 30 days) lactulose encephalopathy oral solution 10 gm/15ml Tier 1 lactulose oral packet 10 gm Tier 3 QL (2 packets per 1 day) lactulose oral solution 10 gm/15ml, 20 gm/30ml Tier 1 MOVIPREP ORAL SOLUTION RECONSTITUTED 100 NF GM (peg-kcl-nacl-nasulf-na asc-c) NULYTELY WITH FLAVOR PACKS ORAL SOLUTION Tier 3 RECONSTITUTED 420 GM (peg 3350-kcl-na bicarb-nacl) OSMOPREP ORAL TABLET 1.102-0.398 GM (sod phos CE PA; #; N2 (Tier 3); AL mono-sod phos dibasic) peg 3350 oral powder 17 gm/scoop Tier 1 peg 3350/electrolytes oral solution reconstituted 240 gm Tier 1 peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm Tier 1 peg-3350/electrolytes oral solution reconstituted 236 gm Tier 1 peg-3350/electrolytes/ascorbat oral solution reconstituted 100 Tier 1 gm 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

182 Coverage Requirements and Prescription Drug Name Drug Tier Limits peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 100 gm CE N2 (NF); AL PEG-PREP ORAL KIT 5-210 MG-GM (bisacodyl-peg-kcl- CE N2 (Tier 1); AL nabicar-nacl) PLENVU ORAL SOLUTION RECONSTITUTED 140 GM CE N2 (Tier 3); AL (peg-kcl-nacl-nasulf-na asc-c) polyethylene glycol 3350 oral powder 17 gm/scoop Tier 1 POLY-PREP COMBINATION KIT (bisacodyl-peg 3350-lido- Tier 3 hc) PREPOPIK ORAL PACKET 10-3.5-12 MG-GM-GM (sod CE #; N2 (Tier 3); AL picosulfate-mag ox-cit acd) saline laxative oral solution 0.9-2.4 gm/5ml CE N2 (NF); AL SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13- CE #; N2 (Tier 3); AL 1.6 GM/177ML (na sulfate-k sulfate-mg sulf) SUTAB ORAL TABLET 1479-225-188 MG (sodium sulfate- CE N2 (Tier 3); AL mag sulfate-kcl) peg 3350-kcl-na bicarb-nacl (Trilyte Oral Solution Tier 1 Reconstituted 420 Gm) MISCELLANEOUS ACTIGALL ORAL CAPSULE 300 MG (ursodiol) NF bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg Tier 1 CARAFATE ORAL SUSPENSION 1 GM/10ML (sucralfate) Tier 3 CARAFATE ORAL TABLET 1 GM (sucralfate) NF CHENODAL ORAL TABLET 250 MG (chenodiol) Tier 4 PA; SP Pharmacy CHOLBAM ORAL CAPSULE 250 MG, 50 MG (cholic acid) NF # cromolyn sodium oral concentrate 100 mg/5ml Tier 1 CYTOTEC ORAL TABLET 100 MCG, 200 MCG NF (misoprostol) diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml Tier 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg Tier 1 flavoxate hcl oral tablet 100 mg Tier 1

183 Coverage Requirements and Prescription Drug Name Drug Tier Limits GASTROCROM ORAL CONCENTRATE 100 MG/5ML NF (cromolyn sodium) GATTEX SUBCUTANEOUS KIT 5 MG (teduglutide PA; SP Pharmacy; QL (1 Tier 4 (rdna)) box per 30 fillss) HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) NF LOMOTIL ORAL TABLET 2.5-0.025 MG (diphenoxylate- NF atropine) loperamide hcl oral capsule 2 mg Tier 1 misoprostol oral tablet 100 mcg, 200 mcg Tier 1 MOTEGRITY ORAL TABLET 1 MG, 2 MG (prucalopride NF succinate) MOTOFEN ORAL TABLET 1-0.025 MG (difenoxin- Tier 3 atropine) MOVANTIK ORAL TABLET 12.5 MG, 25 MG (naloxegol Tier 2 oxalate) MYTESI ORAL TABLET DELAYED RELEASE 125 MG PA; ST; QL (2 tablets per 1 Tier 3 (crofelemer) day) OCALIVA ORAL TABLET 10 MG, 5 MG (obeticholic acid) NF opium oral tincture 10 mg/ml (1%) Tier 1 paregoric oral tincture 2 mg/5ml Tier 1 PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- Tier 3 # metronid-tetracyc) RELISTOR ORAL TABLET 150 MG (methylnaltrexone NF bromide) RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML PA; QL (0.6 milliliters per 1 Tier 3 (methylnaltrexone bromide) day) RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML PA; QL (0.4 milliliters per 1 Tier 3 (methylnaltrexone bromide) day) RELTONE ORAL CAPSULE 200 MG, 400 MG (ursodiol) NF sucralfate oral suspension 1 gm/10ml Tier 1 sucralfate oral tablet 1 gm Tier 1 SYMPROIC ORAL TABLET 0.2 MG (naldemedine tosylate) NF 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

184 Coverage Requirements and Prescription Drug Name Drug Tier Limits URECHOLINE ORAL TABLET 10 MG, 25 MG, 5 MG, 50 NF MG (bethanechol chloride) URSO 250 ORAL TABLET 250 MG (ursodiol) NF URSO FORTE ORAL TABLET 500 MG (ursodiol) NF ursodiol oral capsule 300 mg Tier 1 ursodiol oral tablet 250 mg, 500 mg Tier 1 XERMELO ORAL TABLET 250 MG (telotristat etiprate) NF PANCREATIC ENZYMES CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, 3000- Tier 2 PA 9500 UNIT, 36000-114000 UNIT, 6000-19000 UNIT (pancrelipase (lip-prot-amyl)) PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000- Tier 3 ST 54700 UNIT, 4200-14200 UNIT (pancrelipase (lip-prot-amyl)) pancreaze oral capsule delayed release particles 2600-6200 unit Tier 3 PA; ST PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 2600-8800 UNIT, 37000-97300 UNIT NF (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000-57500 UNIT, 24000-86250 UNIT, 4000- Tier 3 PA; ST 14375 UNIT, 8000-28750 UNIT (pancrelipase (lip-prot-amyl)) PA; QL (354 ml per 1 SUCRAID ORAL SOLUTION 8500 UNIT/ML (sacrosidase) Tier 3 month) VIOKACE ORAL TABLET 10440-39150 UNIT, 20880- Tier 2 PA 78300 UNIT (pancrelipase (lip-prot-amyl)) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000-51000 UNIT, 20000-68000 Tier 2 UNIT, 25000 UNIT, 3000-10000 UNIT, 40000-136000 UNIT, 5000 UNIT (pancrelipase (lip-prot-amyl))

185 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000- 63000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 40000- Tier 2 PA 126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot- amyl)) PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACID PA; QL (1 capsule per day acid reducer oral capsule delayed release 20.6 (20 base) mg Tier 1 and 90 capsules per 365 days) ACIPHEX ORAL TABLET DELAYED RELEASE 20 MG NF (rabeprazole sodium) ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 NF MG (rabeprazole sodium) ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 5 NF # MG (rabeprazole sodium) DEXILANT ORAL CAPSULE DELAYED RELEASE 30 ST; #; QL (1 capsule per 1 Tier 3 MG, 60 MG (dexlansoprazole) day) esomeprazole magnesium oral capsule delayed release 20 mg Tier 1 esomeprazole magnesium oral capsule delayed release 40 mg Tier 1 QL (1 capsule per 1 day) PA; QL (1 packet per day, esomeprazole magnesium oral packet 10 mg, 20 mg, 40 mg Tier 1 90 day supply per 365 days) esomeprazole strontium oral capsule delayed release 24.65 mg NF esomeprazole strontium oral capsule delayed release 49.3 mg Tier 3 PA; QL (1 capsule per 1 lansoprazole oral capsule delayed release 15 mg, 30 mg Tier 1 day) lansoprazole oral tablet dispersible 15 mg, 30 mg Tier 1 QL (1 tablet per 1 Day) NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE PA; OTC; QL (1 capsule per Tier 1 20 MG (esomeprazole magnesium) 1 day) NEXIUM ORAL PACKET 10 MG, 20 MG, 40 MG PA; ST; QL (1 packet per 1 Tier 3 (esomeprazole magnesium) day) NEXIUM ORAL PACKET 2.5 MG, 5 MG (esomeprazole PA; ST; #; QL (1 packet per Tier 3 magnesium) 1 day) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

186 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; OTC; QL (1 capsule per omeprazole magnesium oral capsule delayed release 20.6 (20 Tier 1 day, 90 day supply per 365 base) mg days) PA; OTC; QL (1 capsule per omeprazole oral capsule delayed release 10 mg, 40 mg Tier 1 day, 90 day supply per 365 days) QL (90 capsules per 365 omeprazole oral capsule delayed release 20 mg Tier 1 days) PA; OTC; QL (1 tablet per omeprazole oral tablet delayed release 20 mg Tier 1 day, 90 day supply per 365 days) omeprazole-sodium bicarbonate oral capsule 20-1100 mg, 40- PA; QL (1 capsule per 1 Tier 1 1100 mg day) omeprazole-sodium bicarbonate oral packet 20-1680 mg, 40- NF 1680 mg QL (1 packet per day, 90 pantoprazole sodium oral packet 40 mg Tier 1 day supply per 365 days) pantoprazole sodium oral tablet delayed release 20 mg, 40 mg NF PREVACID 24HR ORAL CAPSULE DELAYED PA; OTC; QL (2 capsules Tier 1 RELEASE 15 MG (lansoprazole) per 1 day) PREVACID ORAL CAPSULE DELAYED RELEASE 30 NF MG (lansoprazole) PREVACID SOLUTAB ORAL TABLET DISPERSIBLE 15 NF MG, 30 MG (lansoprazole) PRILOSEC ORAL CAPSULE DELAYED RELEASE 10 NF MG, 40 MG (omeprazole) PRILOSEC ORAL PACKET 10 MG, 2.5 MG (omeprazole NF # magnesium) PRILOSEC OTC ORAL TABLET DELAYED RELEASE Tier 1 OTC 20 MG (omeprazole magnesium) PROTONIX ORAL PACKET 40 MG (pantoprazole sodium) NF PROTONIX ORAL TABLET DELAYED RELEASE 20 NF MG, 40 MG (pantoprazole sodium)

187 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; QL (1 capsule per day, rabeprazole sodium oral capsule sprinkle 10 mg Tier 3 90 day supply per 365 days) PA; QL (1 tablet per day, 90 rabeprazole sodium oral tablet delayed release 20 mg Tier 1 day supply per 365 days) ZEGERID ORAL CAPSULE 40-1100 MG (omeprazole- NF sodium bicarbonate) ZEGERID ORAL PACKET 20-1680 MG, 40-1680 MG NF (omeprazole-sodium bicarbonate) ZEGERID OTC ORAL CAPSULE 20-1100 MG PA; OTC; QL (1 capsule per Tier 1 (omeprazole-sodium bicarbonate) 1 day) RECTAL,CORTICOSTEROIDS ANALPRAM-HC EXTERNAL LOTION 2.5-1 % NF (hydrocortisone ace-pramoxine) ANALPRAM-HC RECTAL LOTION 2.5-1 % NF (hydrocortisone ace-pramoxine) ANUSOL-HC EXTERNAL CREAM 2.5 % (hydrocortisone) NF ANUSOL-HC RECTAL CREAM 2.5 % (hydrocortisone) NF hydrocortisone (perianal) external cream 1 %, 2.5 % Tier 1 hydrocortisone rectal cream 1 %, 2.5 % Tier 1 PROCTOCORT EXTERNAL CREAM 1 % (hydrocortisone) NF PROCTOCORT RECTAL CREAM 1 % (hydrocortisone) NF PROCTOFOAM HC EXTERNAL FOAM 1-1 % Tier 3 (hydrocortisone ace-pramoxine) PROCTOFOAM HC RECTAL FOAM 1-1 % (hydrocortisone Tier 3 QL (20 grams per 30 days) ace-pramoxine) hydrocortisone (Procto-Med Hc External Cream 2.5 %) Tier 1 hydrocortisone (Procto-Med Hc Rectal Cream 2.5 %) Tier 1 hydrocortisone (Procto-Pak External Cream 1 %) Tier 1 hydrocortisone (Procto-Pak Rectal Cream 1 %) Tier 1 hydrocortisone (Proctosol Hc External Cream 2.5 %) Tier 1 hydrocortisone (Proctosol Hc Rectal Cream 2.5 %) Tier 1

188 Coverage Requirements and Prescription Drug Name Drug Tier Limits hydrocortisone (Proctozone-Hc External Cream 2.5 %) Tier 1 hydrocortisone (Proctozone-Hc Rectal Cream 2.5 %) Tier 1 RECTIV RECTAL OINTMENT 0.4 % (nitroglycerin) Tier 3 ULCER THERAPY COMBINATIONS OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill- NF clarithro-omeprazole) PREVPAC ORAL (amoxicill-clarithro-lansopraz) NF TALICIA ORAL CAPSULE DELAYED RELEASE 250- Tier 3 12.5-10 MG (amoxicill-rifabutin-omeprazole) GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE alfuzosin hcl er oral tablet extended release 24 hour 10 mg Tier 1 AVODART ORAL CAPSULE 0.5 MG (dutasteride) NF CARDURA XL ORAL TABLET EXTENDED RELEASE Tier 3 ST 24 HOUR 4 MG, 8 MG (doxazosin mesylate) dutasteride oral capsule 0.5 mg Tier 1 dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg Tier 1 finasteride oral tablet 5 mg Tier 1 FLOMAX ORAL CAPSULE 0.4 MG (tamsulosin hcl) NF JALYN ORAL CAPSULE 0.5-0.4 MG (dutasteride- NF tamsulosin hcl) PROSCAR ORAL TABLET 5 MG (finasteride) NF RAPAFLO ORAL CAPSULE 4 MG, 8 MG (silodosin) Tier 3 silodosin oral capsule 4 mg, 8 mg Tier 1 tamsulosin hcl oral capsule 0.4 mg Tier 1 UROXATRAL ORAL TABLET EXTENDED RELEASE NF 24 HOUR 10 MG (alfuzosin hcl)

189 Coverage Requirements and Prescription Drug Name Drug Tier Limits CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL ENCARE VAGINAL SUPPOSITORY 100 MG (nonoxynol- CE N2 (NF) 9) OPTIONS CONCEPTROL VAGINAL GEL 4 % CE N2 (NF) (nonoxynol-9) OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL CE N2 (NF) 3 % (nonoxynol-9) PHEXXI VAGINAL GEL 1.8-1-0.4 % (lactic ac-citric ac-pot NF bitart) SHUR-SEAL CONTRACEPTIVE VAGINAL GEL 2 % CE N2 (NF) (nonoxynol-9) TODAY SPONGE VAGINAL 1000 MG (nonoxynol-9) CE N2 (NF) VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 28 CE N2 (NF) % (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM CE N2 (NF) 12.5 % (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL GEL 4 % CE N2 (NF) (nonoxynol-9) ERECTILE DYSFUNCTION tadalafil oral tablet 2.5 mg, 5 mg Tier 1 PA; QL (1 tablet per 1 day) MISCELLANEOUS acetic acid irrigation solution 0.25 % Tier 1 sodium chloride (gu irrigant) (Argyle Sterile Saline Irrigation Tier 1 Solution 0.9 %) azo tabs oral tablet 95 mg Tier 1 azo-standard oral tablet 95 mg Tier 1 sodium chloride (gu irrigant) (Curity Sterile Saline Irrigation Tier 1 Solution 0.9 %) ELMIRON ORAL CAPSULE 100 MG (pentosan polysulfate Tier 3 sodium)

190 Coverage Requirements and Prescription Drug Name Drug Tier Limits FEM PH VAGINAL GEL 0.9-0.025 % (acetic acid- Tier 3 oxyquinoline) gnp urinary pain relief oral tablet 95 mg Tier 1 K-PHOS NO 2 ORAL TABLET 305-700 MG (pot & sod ac Tier 3 phosphates) LITHOSTAT ORAL TABLET 250 MG (acetohydroxamic Tier 3 acid) neomycin-polymyxin b gu irrigation solution 40-200000 Tier 1 ORACIT ORAL SOLUTION 490-640 MG/5ML (sod citrate- Tier 3 citric acid) potassium citrate er oral tablet extended release 10 meq (1080 Tier 1 mg), 15 meq (1620 mg), 5 meq (540 mg) potassium citrate-citric acid oral packet 3300-1002 mg Tier 1 potassium citrate-citric acid oral solution 1100-334 mg/5ml Tier 1 PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 NF MG, 75 MG (cysteamine bitartrate) PROCYSBI ORAL PACKET 300 MG, 75 MG (cysteamine NF bitartrate) qc azo oral tablet 95 mg Tier 1 qc urinary pain relief oral tablet 95 mg Tier 1 ra urinary pain relief oral tablet 95 mg Tier 1 RELAGARD VAGINAL GEL 0.9-0.025 % (acetic acid- Tier 3 oxyquinoline) RENACIDIN IRRIGATION SOLUTION (citric ac- Tier 3 gluconolact-mg carb) sod citrate-citric acid oral solution 500-334 mg/5ml Tier 1 sodium chloride irrigation solution 0.9 % Tier 1 sorbitol-mannitol irrigation solution 2.7-0.54 gm/100ml Tier 3 potassium citrate-citric acid (Taron-Crystals Oral Packet 3300- Tier 1 1002 Mg) THIOLA EC ORAL TABLET DELAYED RELEASE 100 Tier 4 PA; SP Pharmacy MG, 300 MG (tiopronin) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

191 Coverage Requirements and Prescription Drug Name Drug Tier Limits THIOLA ORAL TABLET 100 MG (tiopronin) Tier 4 PA; SP Pharmacy tiopronin oral tablet 100 mg NF tricitrates oral solution 550-500-334 mg/5ml Tier 1 UROCIT-K 10 ORAL TABLET EXTENDED RELEASE 10 NF MEQ (1080 MG) (potassium citrate) UROCIT-K 15 ORAL TABLET EXTENDED RELEASE 15 NF MEQ (1620 MG) (potassium citrate) UROCIT-K 5 ORAL TABLET EXTENDED RELEASE 5 NF MEQ (540 MG) (potassium citrate) virtrate-2 oral solution 500-334 mg/5ml Tier 1 virtrate-3 oral solution 550-500-334 mg/5ml Tier 1 virtrate-k oral solution 1100-334 mg/5ml Tier 1 PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES ENDOMETRIN VAGINAL INSERT 100 MG Tier 3 PA; # (progesterone) URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE darifenacin hydrobromide er oral tablet extended release 24 Tier 1 hour 15 mg, 7.5 mg DETROL LA ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 2 MG, 4 MG (tolterodine tartrate) DETROL ORAL TABLET 1 MG, 2 MG (tolterodine NF tartrate) DITROPAN XL ORAL TABLET EXTENDED RELEASE NF 24 HOUR 10 MG, 15 MG, 5 MG (oxybutynin chloride) ENABLEX ORAL TABLET EXTENDED RELEASE 24 NF HOUR 15 MG, 7.5 MG (darifenacin hydrobromide) GELNIQUE PUMP TRANSDERMAL GEL 10 % Tier 3 ST; # (oxybutynin chloride) GELNIQUE TRANSDERMAL GEL 10 % (oxybutynin Tier 3 ST; # chloride)

192 Coverage Requirements and Prescription Drug Name Drug Tier Limits MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 Tier 2 ST; QL (1 tablet per 1 day) HOUR 25 MG (mirabegron) oxybutynin chloride er oral tablet extended release 24 hour 10 Tier 1 mg, 15 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml Tier 1 oxybutynin chloride oral tablet 5 mg Tier 1 OXYTROL FOR WOMEN TRANSDERMAL PATCH #; OTC; QL (1 box per 1 Tier 1 TWICE WEEKLY 3.9 MG/24HR (oxybutynin) fill) solifenacin succinate oral tablet 10 mg, 5 mg Tier 1 tolterodine tartrate er oral capsule extended release 24 hour 2 Tier 1 mg, 4 mg tolterodine tartrate oral tablet 1 mg, 2 mg Tier 1 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 Tier 3 ST; # HOUR 4 MG, 8 MG (fesoterodine fumarate) trospium chloride er oral capsule extended release 24 hour 60 Tier 1 mg trospium chloride oral tablet 20 mg Tier 1 VESICARE LS ORAL SUSPENSION 5 MG/5ML NF (solifenacin succinate) VESICARE ORAL TABLET 10 MG, 5 MG (solifenacin NF succinate) VAGINAL ANTI-INFECTIVES - DRUGS TO TREAT VAGINAL INFECTIONS AVC VAGINAL VAGINAL CREAM 15 % (sulfanilamide) Tier 3 CLEOCIN VAGINAL CREAM 2 % (clindamycin phosphate) NF CLEOCIN VAGINAL SUPPOSITORY 100 MG Tier 2 (clindamycin phosphate) clindamycin phosphate vaginal cream 2 % Tier 1 CLINDESSE VAGINAL CREAM 2 % (clindamycin NF phosphate (1 dose)) GYNAZOLE-1 VAGINAL CREAM 2 % (butoconazole Tier 3 nitrate (1 dose))

193 Coverage Requirements and Prescription Drug Name Drug Tier Limits METROGEL-VAGINAL VAGINAL GEL 0.75 % NF (metronidazole) metronidazole vaginal gel 0.75 % Tier 1 miconazole 3 vaginal suppository 200 mg Tier 1 NUVESSA VAGINAL GEL 1.3 % (metronidazole) NF TERAZOL 7 VAGINAL CREAM 0.4 % (terconazole) NF terconazole vaginal cream 0.4 %, 0.8 % Tier 1 terconazole vaginal suppository 80 mg Tier 1 metronidazole (Vandazole Vaginal Gel 0.75 %) Tier 1 HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS - BLOOD THINNERS ANTICOAGULANT COMPOUND IN VITRO Tier 3 SOLUTION (anticoag cit phos dex soln) ARIXTRA SUBCUTANEOUS SOLUTION 10 MG/0.8ML, 2.5 MG/0.5ML, 5 MG/0.4ML, 7.5 MG/0.6ML (fondaparinux NF sodium) BEVYXXA ORAL CAPSULE 40 MG, 80 MG (betrixaban NF maleate) COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 NF MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG (warfarin sodium) ELIQUIS DVT/PE STARTER PACK ORAL TABLET 5 Tier 2 QL (1 pack per 365 Days) MG (apixaban) ELIQUIS DVT/PE STARTER PACK ORAL TABLET Tier 2 QL (1 pack per 365 days) THERAPY PACK 5 MG (apixaban) ELIQUIS ORAL TABLET 2.5 MG, 5 MG (apixaban) Tier 2 enoxaparin sodium injection solution 300 mg/3ml Tier 1 enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, Tier 1 80 mg/0.8ml fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 Tier 1 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml

194 Coverage Requirements and Prescription Drug Name Drug Tier Limits FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 Tier 3 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML (dalteparin sodium) heparin sodium (porcine) injection solution 1000 unit/ml, 10000 Tier 1 unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml Tier 1 heparin sodium (porcine) pf injection solution 5000 unit/ml NF IPRIVASK SUBCUTANEOUS SOLUTION NF RECONSTITUTED 15 MG (desirudin) warfarin sodium (Jantoven Oral Tablet 1 Mg, 10 Mg, 2 Mg, 2.5 Tier 1 Mg, 3 Mg, 4 Mg, 5 Mg, 6 Mg, 7.5 Mg) LOVENOX INJECTION SOLUTION 300 MG/3ML NF (enoxaparin sodium) LOVENOX SUBCUTANEOUS SOLUTION 100 MG/ML, 120 MG/0.8ML, 150 MG/ML, 30 MG/0.3ML, 40 MG/0.4ML, NF 60 MG/0.6ML, 80 MG/0.8ML (enoxaparin sodium) PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG Tier 3 # (dabigatran etexilate mesylate) SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG NF (edoxaban tosylate) TRICITRASOL IN VITRO CONCENTRATE 46.7 % Tier 3 (anticoagulant sodium citrate) warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 Tier 1 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 Tier 2 MG (rivaroxaban) XARELTO STARTER PACK ORAL TABLET THERAPY Tier 2 PACK 15 & 20 MG (rivaroxaban) ANTI-VON WILLEBRAND FACTOR AGENTS PA; NPL; SP Pharmacy; QL CABLIVI INJECTION KIT 11 MG (caplacizumab-yhdp) Tier 4 (1 vial per day, 2 courses (58 day supply) per 1 lifetime)

195 Coverage Requirements and Prescription Drug Name Drug Tier Limits BLEEDING DISORDERS AGENTS SEVENFACT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 5 MG (coagulation factor viia- NF jncw) HEMATOPOIETIC GROWTH FACTORS ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, Tier 4 PA; SP Pharmacy 40 MCG/ML, 60 MCG/ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 Tier 4 PA; SP Pharmacy MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML (darbepoetin alfa) DOPTELET ORAL TABLET 20 MG (avatrombopag PA; SP Pharmacy; QL (3 Tier 4 maleate) /day for 5 days per 30 days) EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 Tier 4 PA; SP Pharmacy UNIT/ML (epoetin alfa) FULPHILA SUBCUTANEOUS SOLUTION PREFILLED Tier 4 PA; SP Pharmacy SYRINGE 6 MG/0.6ML (pegfilgrastim-jmdb) GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, NF 480 MCG/1.6ML (tbo-filgrastim) GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (tbo- NF filgrastim) MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 150 MCG/0.3ML, 200 Tier 4 PA; SP Pharmacy MCG/0.3ML, 30 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML (methoxy peg-epoetin beta) PA; SP Pharmacy; QL (1 MULPLETA ORAL TABLET 3 MG (lusutrombopag) Tier 4 /day for 7 days per 30 days) NEULASTA ONPRO SUBCUTANEOUS PREFILLED PA; SP Pharmacy; QL (2 Tier 4 SYRINGE KIT 6 MG/0.6ML (pegfilgrastim) injections per 1 month)

196 Coverage Requirements and Prescription Drug Name Drug Tier Limits NEULASTA SUBCUTANEOUS SOLUTION PREFILLED PA; SP Pharmacy; QL (2 Tier 4 SYRINGE 6 MG/0.6ML (pegfilgrastim) injections per 1 month) NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 Tier 4 PA; ST; SP Pharmacy MCG/1.6ML (filgrastim) NEUPOGEN INJECTION SOLUTION PREFILLED Tier 4 PA; ST; SP Pharmacy SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim) NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 Tier 4 PA; NPL; SP Pharmacy MCG/1.6ML (filgrastim-aafi) NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim- Tier 4 PA; SP Pharmacy aafi) NPLATE SUBCUTANEOUS SOLUTION NF RECONSTITUTED 125 MCG (romiplostim) NPLATE SUBCUTANEOUS SOLUTION Tier 4 PA; SP Pharmacy RECONSTITUTED 250 MCG, 500 MCG (romiplostim) NYVEPRIA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 6 MG/0.6ML (pegfilgrastim-apgf) PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 Tier 4 PA; SP Pharmacy UNIT/ML, 40000 UNIT/ML (epoetin alfa) PROMACTA ORAL PACKET 12.5 MG (eltrombopag PA; SP Pharmacy; QL (4 Tier 4 olamine) packets per 1 day) PROMACTA ORAL PACKET 25 MG (eltrombopag PA; SP Pharmacy; QL (180 Tier 4 olamine) packets per 30 days) PROMACTA ORAL TABLET 12.5 MG (eltrombopag PA; SP Pharmacy; QL (4 Tier 4 olamine) tablets per 1 day) PA; SP Pharmacy; QL (1 PROMACTA ORAL TABLET 25 MG (eltrombopag olamine) Tier 4 tablet per 1 day) PROMACTA ORAL TABLET 50 MG, 75 MG (eltrombopag PA; SP Pharmacy; QL (2 Tier 4 olamine) tablets per 1 day) RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 Tier 4 PA; SP Pharmacy UNIT/ML (epoetin alfa-epbx)

197 Coverage Requirements and Prescription Drug Name Drug Tier Limits UDENYCA SUBCUTANEOUS SOLUTION PREFILLED PA; NPL; SP Pharmacy; QL Tier 4 SYRINGE 6 MG/0.6ML (pegfilgrastim-cbqv) (2 injections per 1 month) ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim- Tier 4 PA; SP Pharmacy sndz) ZIEXTENZO SUBCUTANEOUS SOLUTION NF PREFILLED SYRINGE 6 MG/0.6ML (pegfilgrastim-bmez) HEMOPHILIA A AGENTS ESPEROCT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, NF 3000 UNIT, 500 UNIT (antihemoph fact rcmb gpeg-exei) MISCELLANEOUS AGRYLIN ORAL CAPSULE 0.5 MG (anagrelide hcl) NF ALAWAY OPHTHALMIC SOLUTION 0.025 % (ketotifen Tier 1 OTC fumarate) ALCAINE OPHTHALMIC SOLUTION 0.5 % (proparacaine NF hcl) phenylephrine hcl (Altafrin Ophthalmic Solution 10 %, 2.5 %) Tier 1 AMICAR ORAL SOLUTION 0.25 GM/ML (aminocaproic NF acid) AMICAR ORAL TABLET 1000 MG (aminocaproic acid) Tier 2 AMICAR ORAL TABLET 500 MG (aminocaproic acid) NF aminocaproic acid oral solution 0.25 gm/ml NF aminocaproic acid oral tablet 1000 mg, 500 mg Tier 1 anagrelide hcl oral capsule 0.5 mg, 1 mg Tier 1 atropine sulfate ophthalmic solution 1 % NF BEOVU INTRAVITREAL SOLUTION 6 MG/0.05ML NF (brolucizumab-dbll) CEQUA OPHTHALMIC SOLUTION 0.09 % (cyclosporine) NF cilostazol oral tablet 100 mg, 50 mg Tier 1 CLARITIN EYE OPHTHALMIC SOLUTION 0.025 % Tier 1 OTC (ketotifen fumarate) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

198 Coverage Requirements and Prescription Drug Name Drug Tier Limits CORVITE 150 ORAL TABLET (iron combinations) NF corvite fe oral tablet NF CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 1 %, 2 % NF (cyclopentolate hcl) CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % Tier 3 (cyclopentolate-phenylephrine) cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 % Tier 1 CYSTADROPS OPHTHALMIC SOLUTION 0.37 % NF (cysteamine hcl) CYSTARAN OPHTHALMIC SOLUTION 0.44 % PA; #; SP Pharmacy; QL (4 Tier 4 (cysteamine hcl) bottles per 1 month) DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 162.5 MG (aspirin) ELESTAT OPHTHALMIC SOLUTION 0.05 % (epinastine NF hcl) EMADINE OPHTHALMIC SOLUTION 0.05 % (emedastine Tier 3 difumarate) ENDARI ORAL PACKET 5 GM (glutamine (sickle cell)) NF EVITHROM EXTERNAL SOLUTION 800-1200 UNIT/ML NF (thrombin (human)) FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML NF (icatibant acetate) FLURA-SAFE OPHTHALMIC SOLUTION 0.35-0.4 % NF (fluorexon-benoxinate) FOLVITE-FE ORAL TABLET 90-120-0.012-1 MG (iron-vit NF c-vit b12-folic acid) GELFILM OPHTHALMIC FILM (gelatin adsorbable) NF HAEGARDA SUBCUTANEOUS SOLUTION PA; ST; QL (20 vials per 1 RECONSTITUTED 2000 UNIT, 3000 UNIT (c1 esterase Tier 4 month) inhibitor (human)) HEMOCYTE-F ORAL ELIXIR (iron combinations) NF

199 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; NPL; SP Pharmacy; QL icatibant acetate subcutaneous solution 30 mg/3ml Tier 4 (15 syringes per 1 month) KALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML NF (ecallantide) ketotifen fumarate ophthalmic solution 0.025 % Tier 1 LACRISERT OPHTHALMIC INSERT 5 MG (artificial tear Tier 3 insert) LYSTEDA ORAL TABLET 650 MG (tranexamic acid) NF MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML Tier 4 PA; SP Pharmacy (plerixafor) MYDRIACYL OPHTHALMIC SOLUTION 1 % NF (tropicamide) NIFEREX ORAL TABLET (iron combinations) NF NUFERA ORAL TABLET (iron combinations) NF ORLADEYO ORAL CAPSULE 110 MG, 150 MG NF (berotralstat hcl) OXBRYTA ORAL TABLET 500 MG (voxelotor) NF PA; SP Pharmacy; QL (2 ml OXERVATE OPHTHALMIC SOLUTION 0.002 % Tier 4 per 1 day and 112 ml per (cenegermin-bkbj) lifetime) PAREMYD OPHTHALMIC SOLUTION 1-0.25 % Tier 3 (hydroxyamphetamine-tropicamide) PATADAY OPHTHALMIC SOLUTION 0.2 % (olopatadine NF hcl) PATANOL OPHTHALMIC SOLUTION 0.1 % (olopatadine NF hcl) pentoxifylline er oral tablet extended release 400 mg Tier 1 phenylephrine hcl ophthalmic solution 10 %, 2.5 % Tier 1 proparacaine hcl ophthalmic solution 0.5 % Tier 1 RADIOGARDASE ORAL CAPSULE 0.5 GM (prussian blue NF insoluble)

200 Coverage Requirements and Prescription Drug Name Drug Tier Limits RESTASIS MULTIDOSE OPHTHALMIC EMULSION Tier 3 # 0.05 % (cyclosporine) RESTASIS MULTIDOSE OPHTHALMIC EMULSION PA; QL (1 bottle per 28 Tier 3 0.05 % (cyclosporine) days) RESTASIS OPHTHALMIC EMULSION 0.05 % PA; #; QL (2 single use vials Tier 3 (cyclosporine) per 1 day) RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 2100 UNIT (c1 esterase inhibitor Tier 4 SP Pharmacy (recomb)) SIKLOS ORAL TABLET 100 MG, 1000 MG (hydroxyurea) Tier 3 PA TAKHZYRO SUBCUTANEOUS SOLUTION 300 NF MG/2ML (lanadelumab-flyo) TAVALISSE ORAL TABLET 100 MG, 150 MG NF (fostamatinib disodium) tranexamic acid oral tablet 650 mg Tier 1 tropicamide ophthalmic solution 0.5 %, 1 % Tier 1 UPNEEQ OPHTHALMIC SOLUTION 0.1 % NF (oxymetazoline hcl) ZADITOR OPHTHALMIC SOLUTION 0.025 % (ketotifen Tier 1 OTC fumarate) PLATELET AGGREGATION INHIBITORS - BLOOD THINNERS AGGRENOX ORAL CAPSULE EXTENDED RELEASE NF 12 HOUR 25-200 MG (aspirin-dipyridamole) aspirin-dipyridamole er oral capsule extended release 12 hour Tier 1 25-200 mg aspirin-omeprazole oral tablet delayed release 325-40 mg, 81-40 NF mg BRILINTA ORAL TABLET 60 MG, 90 MG (ticagrelor) Tier 2 clopidogrel bisulfate oral tablet 300 mg, 75 mg Tier 1 dipyridamole oral tablet 25 mg, 50 mg, 75 mg Tier 1 PA; AL EFFIENT ORAL TABLET 10 MG, 5 MG (prasugrel hcl) NF

201 Coverage Requirements and Prescription Drug Name Drug Tier Limits PLAVIX ORAL TABLET 300 MG, 75 MG (clopidogrel NF bisulfate) prasugrel hcl oral tablet 10 mg, 5 mg Tier 1 ticlopidine hcl oral tablet 250 mg Tier 1 YOSPRALA ORAL TABLET DELAYED RELEASE 325- Tier 3 40 MG, 81-40 MG (aspirin-omeprazole) ZONTIVITY ORAL TABLET 2.08 MG (vorapaxar sulfate) Tier 3 IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM ALLERGENIC EXTRACTS GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 Tier 3 PA; ST BAU (timothy grass pollen allergen) ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 Tier 3 SQ-HDM (dust mite mixed allergen ext) ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 Tier 3 IR (grass mix pollens allergen ext) PALFORZIA (12 MG DAILY DOSE) ORAL 2 X 1 MG & NF 10 MG (peanut powder-dnfp) PALFORZIA (120 MG DAILY DOSE) ORAL 20 MG & 100 NF MG (peanut powder-dnfp) PALFORZIA (160 MG DAILY DOSE) ORAL 3 X 20 MG & NF 100 MG (peanut powder-dnfp) PALFORZIA (20 MG DAILY DOSE) ORAL 20 MG NF (peanut powder-dnfp) PALFORZIA (200 MG DAILY DOSE) ORAL 2 X 100 MG NF (peanut powder-dnfp) PALFORZIA (240 MG DAILY DOSE) ORAL 2 X 20 MG & NF 2 X 100 MG (peanut powder-dnfp) PALFORZIA (3 MG DAILY DOSE) ORAL 3 X 1 MG NF (peanut powder-dnfp) PALFORZIA (300 MG MAINTENANCE) ORAL PACKET NF 300 MG (peanut powder-dnfp)

202 Coverage Requirements and Prescription Drug Name Drug Tier Limits PALFORZIA (300 MG TITRATION) ORAL PACKET 300 NF MG (peanut powder-dnfp) PALFORZIA (40 MG DAILY DOSE) ORAL 2 X 20 MG NF (peanut powder-dnfp) PALFORZIA (6 MG DAILY DOSE) ORAL 6 X 1 MG NF (peanut powder-dnfp) PALFORZIA (80 MG DAILY DOSE) ORAL 4 X 20 MG NF (peanut powder-dnfp) PALFORZIA INITIAL ESCALATION ORAL 0.5 & 1 & 1.5 NF & 3 & 6 MG (peanut powder-dnfp) RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 Tier 3 AMB A 1-U (short ragweed pollen ext) BIOLOGIC DISEASE-MODIFYING AGENTS ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION PA; ST; NPL; SP Pharmacy; Tier 4 AUTO-INJECTOR 162 MG/0.9ML (tocilizumab) QL (4 pens per 1 month) ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; QL (1 syringe per 1 Tier 4 SYRINGE 162 MG/0.9ML (tocilizumab) month) AVSOLA INTRAVENOUS SOLUTION NF RECONSTITUTED 100 MG (infliximab-axxq) CIMZIA PREFILLED SUBCUTANEOUS KIT 2 X 200 NF MG/ML (certolizumab pegol) CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 NF MG/ML (certolizumab pegol) CIMZIA SUBCUTANEOUS KIT 2 X 200 MG (certolizumab NF pegol) PA; IBC (Preferred agent ENBREL MINI SUBCUTANEOUS SOLUTION for all conditions except Tier 4 CARTRIDGE 50 MG/ML (etanercept) Psoriasis); SP Pharmacy; QL (4 syringes per 28 days) PA; IBC (Preferred agent for all conditions except ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML Tier 4 Psoriasis); NPL; SP (etanercept) Pharmacy; QL (4 vials per 28 days) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

203 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; IBC (Preferred agent ENBREL SUBCUTANEOUS SOLUTION PREFILLED for all conditions except Tier 4 SYRINGE 25 MG/0.5ML, 50 MG/ML (etanercept) Psoriasis); SP Pharmacy; QL (4 syringes per 28 days) PA; IBC (Preferred agent ENBREL SUBCUTANEOUS SOLUTION for all conditions except Tier 4 RECONSTITUTED 25 MG (etanercept) Psoriasis); SP Pharmacy; QL (4 vials per 28 days) PA; IBC (Preferred agent ENBREL SURECLICK SUBCUTANEOUS SOLUTION for all conditions except Tier 4 AUTO-INJECTOR 50 MG/ML (etanercept) Psoriasis); SP Pharmacy; QL (4 injections per 28 days) HUMIRA PEDIATRIC CROHNS START PA; ST; SP Pharmacy; QL SUBCUTANEOUS PREFILLED SYRINGE KIT 40 Tier 4 (6 injections per 28 days) MG/0.8ML (adalimumab) HUMIRA PEDIATRIC CROHNS START PA; SP Pharmacy; QL (3 SUBCUTANEOUS PREFILLED SYRINGE KIT 80 Tier 4 syringes per 1 month) MG/0.8ML (adalimumab) HUMIRA PEDIATRIC CROHNS START PA; SP Pharmacy; QL (2 SUBCUTANEOUS PREFILLED SYRINGE KIT 80 Tier 4 syringes per 1 month) MG/0.8ML & 40MG/0.4ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT PA; SP Pharmacy; QL (6 Tier 4 40 MG/0.4ML (adalimumab) syringes per 1 month) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT PA; ST; SP Pharmacy; QL Tier 4 40 MG/0.8ML (adalimumab) (6 injections per 28 days) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT Tier 4 PA; QL (1 kit per 28 days) 80 MG/0.8ML (adalimumab) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PA; SP Pharmacy; QL (6 Tier 4 PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) injections per 28 days) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PA; SP Pharmacy; QL (1 kit Tier 4 PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) per 1 month) HUMIRA PEN-PS/UV/ADOL HS START PA; SP Pharmacy; QL (6 SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML Tier 4 injections per 28 days) (adalimumab)

204 Coverage Requirements and Prescription Drug Name Drug Tier Limits HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & Tier 4 PA; QL (1 kit per 1 month) 40MG/0.4ML (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE PA; SP Pharmacy; QL (2 Tier 4 KIT 10 MG/0.1ML, 20 MG/0.2ML (adalimumab) syringes per 1 month) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE PA; SP Pharmacy; QL (2 Tier 4 KIT 10 MG/0.2ML, 20 MG/0.4ML (adalimumab) injections per 28 days) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE PA; SP Pharmacy; QL (6 Tier 4 KIT 40 MG/0.4ML (adalimumab) syringes per 1 month) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE PA; SP Pharmacy; QL (6 Tier 4 KIT 40 MG/0.8ML (adalimumab) injections per 28 days) ILARIS SUBCUTANEOUS SOLUTION 150 MG/ML Tier 4 PA; SP Pharmacy (canakinumab) IBC (Preferred agent for KEVZARA SUBCUTANEOUS SOLUTION AUTO- Rheumatoid Arthritis (after Tier 4 INJECTOR 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) failure of 2 other preferred agents)) IBC (Preferred agent for Rheumatoid Arthritis (after KEVZARA SUBCUTANEOUS SOLUTION PREFILLED Tier 4 failure of 2 other preferred SYRINGE 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) agents)); QL (2 injections per 1 month) KINERET SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 100 MG/0.67ML (anakinra) OLUMIANT ORAL TABLET 1 MG, 2 MG (baricitinib) NF ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION NF AUTO-INJECTOR 125 MG/ML (abatacept) ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML NF (abatacept) PA; IBC (Preferred agent RINVOQ ORAL TABLET EXTENDED RELEASE 24 for Rheumatoid Arthritis); Tier 4 HOUR 15 MG (upadacitinib) SP Pharmacy; QL (1 tablet per 1 day)

205 Coverage Requirements and Prescription Drug Name Drug Tier Limits SIMPONI SUBCUTANEOUS SOLUTION AUTO- Tier 4 PA; ST; QL (1 pen per 1 fill) INJECTOR 100 MG/ML, 50 MG/0.5ML (golimumab) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED Tier 4 PA; ST; QL (1 pen per 1 fill) SYRINGE 100 MG/ML, 50 MG/0.5ML (golimumab) SKYRIZI (150 MG DOSE) SUBCUTANEOUS IBC (Preferred agent for PREFILLED SYRINGE KIT 75 MG/0.83ML (risankizumab- Tier 4 Psoriasis) rzaa) SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO- PA; SP Pharmacy; QL (1 Tier 4 INJECTOR 150 MG/ML (risankizumab-rzaa) syringe per 84 days) SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED PA; SP Pharmacy; QL (1 Tier 4 SYRINGE 150 MG/ML (risankizumab-rzaa) syringe per 84 days) PA; ST; IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease and Ulcerative STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML Tier 4 Colitis after failure of (ustekinumab) Humira. Not covered for Psoriatic Arthritis.); SP Pharmacy; QL (2 vials per 90 days) PA; IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease STELARA SUBCUTANEOUS SOLUTION PREFILLED and Ulcerative Colitis after Tier 4 SYRINGE 45 MG/0.5ML (ustekinumab) failure of Humira. Not covered for Psoriatic Arthritis.); SP Pharmacy; QL (2 syringes per 90 days) PA; IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease STELARA SUBCUTANEOUS SOLUTION PREFILLED and Ulcerative Colitis after Tier 4 SYRINGE 90 MG/ML (ustekinumab) failure of Humira. Not covered for Psoriatic Arthritis.); SP Pharmacy; QL (2 syringes per 60 days) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

206 Coverage Requirements and Prescription Drug Name Drug Tier Limits IBC (Preferred agent for TALTZ SUBCUTANEOUS SOLUTION AUTO- Psoriasis. Not covered for Tier 4 INJECTOR 80 MG/ML (ixekizumab) Psoriatic Arthritis or Ankylosing Spondylitis) IBC (Preferred agent for TALTZ SUBCUTANEOUS SOLUTION PREFILLED Psoriasis. Not covered for Tier 4 SYRINGE 80 MG/ML (ixekizumab) Psoriatic Arthritis or Ankylosing Spondylitis) PA; ST; IBC (Preferred agent for Psoriasis. Not TREMFYA SUBCUTANEOUS SOLUTION PEN- covered for Psoriatic Tier 4 INJECTOR 100 MG/ML (guselkumab) Arthritis); NPL; SP Pharmacy; QL (1 syringe per 8 weeks) PA; ST; IBC (Preferred agent for Psoriasis. Not TREMFYA SUBCUTANEOUS SOLUTION PREFILLED covered for Psoriatic Tier 4 SYRINGE 100 MG/ML (guselkumab) Arthritis); NPL; SP Pharmacy; QL (1 syringe per 8 weeks) PA; IBC (Preferred agent for Rheumatoid Arthritis. Preferred agent for Ulcerative Colitis (after XELJANZ ORAL SOLUTION 1 MG/ML (tofacitinib citrate) Tier 4 failure of Humira). Not covered for Psoriatic Arthritis.); NPL; SP Pharmacy; QL (10 ML per 1 day)

207 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; IBC (Preferred agent for Rheumatoid Arthritis. Preferred agent for Ulcerative Colitis (after XELJANZ ORAL TABLET 10 MG (tofacitinib citrate) Tier 4 failure of Humira). Not covered for Psoriatic Arthritis.); SP Pharmacy; QL (2 tablets per 1 day) PA; IBC (Preferred agent for Rheumatoid Arthritis. Preferred agent for Ulcerative Colitis (after XELJANZ ORAL TABLET 5 MG (tofacitinib citrate) Tier 4 failure of Humira). Not covered for Psoriatic Arthritis.); QL (2 tablets per 1 day) PA; IBC (Preferred agent for Rheumatoid Arthritis. Preferred agent for XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 Ulcerative Colitis (after Tier 4 HOUR 11 MG (tofacitinib citrate) failure of Humira). Not covered for Psoriatic Arthritis.); QL (1 tablet per 1 day) PA; IBC (Preferred agent for Rheumatoid Arthritis. Preferred agent for Ulcerative Colitis (after XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 Tier 4 failure of Humira). Not HOUR 22 MG (tofacitinib citrate) covered for Psoriatic Arthritis.); NPL; SP Pharmacy; QL (1 tablet per 1 day)

208 Coverage Requirements and Prescription Drug Name Drug Tier Limits DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS ARAVA ORAL TABLET 10 MG, 20 MG (leflunomide) NF hydroxychloroquine sulfate oral tablet 200 mg Tier 1 leflunomide oral tablet 10 mg, 20 mg Tier 1 PA; IBC (Preferred agent for Psoriasis and Psoriatic OTEZLA ORAL TABLET 30 MG (apremilast) Tier 4 Arthritis); SP Pharmacy; QL (2 tablets per 1 day) PA; IBC (Preferred agent OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 for Psoriasis and Psoriatic Tier 4 MG (apremilast) Arthritis); SP Pharmacy; QL (1 pack per 1 year) OTREXUP SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, NF 17.5 MG/0.4ML, 20 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML (methotrexate (anti-rheumatic)) PLAQUENIL ORAL TABLET 200 MG (hydroxychloroquine NF sulfate) RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 NF MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML (methotrexate (anti-rheumatic)) REDITREX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.4ML, 12.5 MG/0.5ML, 15 MG/0.6ML, NF 17.5 MG/0.7ML, 20 MG/0.8ML, 22.5 MG/0.9ML, 25 MG/ML, 7.5 MG/0.3ML (methotrexate (anti-rheumatic)) IMMUNOGLOBULIN ASCENIV INTRAVENOUS SOLUTION 5 GM/50ML NF (immune globulin (human)-slra)

209 Coverage Requirements and Prescription Drug Name Drug Tier Limits CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM (immune globulin NF (human)) CUTAQUIG SUBCUTANEOUS SOLUTION 1 GM/6ML, 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, 4 GM/24ML, 8 NF GM/48ML (immune globulin (human)-hipp) CUVITRU SUBCUTANEOUS SOLUTION 1 GM/5ML, 2 GM/10ML, 4 GM/20ML, 8 GM/40ML (immune globulin Tier 4 PA; ST (human)) CUVITRU SUBCUTANEOUS SOLUTION 10 GM/50ML NF (immune globulin (human)) GAMASTAN INTRAMUSCULAR INJECTABLE (immune NF globulin (human)) GAMASTAN S/D INTRAMUSCULAR INJECTABLE NF (immune globulin (human)) GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, NF 5 GM/50ML (immune globulin (human)) GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM (immune NF globulin (human)) GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML NF (immune globulin (human)) GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, Tier 4 PA; SP Pharmacy 5 GM/50ML (immune globulin (human)) HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin Tier 4 PA; SP Pharmacy (human)) HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 1 GM/5ML, 2 GM/10ML, 4 GM/20ML (immune NF globulin (human))

210 Coverage Requirements and Prescription Drug Name Drug Tier Limits HYPERRAB INJECTION SOLUTION 900 UNIT/3ML NF (rabies immune globulin) HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML Tier 4 PA; SP Pharmacy (immune globulin-hyaluronidase) OCTAGAM INTRAVENOUS SOLUTION 30 GM/300ML Tier 4 PA; NPL (immune globulin (human)) PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, NF 5 GM/50ML (immune globulin (human)-ifas) XEMBIFY SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin NF (human)-klhw) IMMUNOMODULATORS ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 Tier 4 PA UNIT/0.5ML (interferon gamma-1b) ARCALYST SUBCUTANEOUS SOLUTION PA; SP Pharmacy; QL (8 Tier 4 RECONSTITUTED 220 MG (rilonacept) vials per 28 days) INTRON A INJECTION SOLUTION 10000000 UNIT/ML, Tier 4 PA; SP Pharmacy 6000000 UNIT/ML (interferon alfa-2b) INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon Tier 4 PA; SP Pharmacy alfa-2b) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PA; #; N2 (Tier 4); QL (21 CE (pomalidomide) capsules per 28 days) PA; #; SP Pharmacy; N2 REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 5 CE (Tier 4); QL (1 capsule per 1 MG (lenalidomide) day) PA; #; SP Pharmacy; N2 REVLIMID ORAL CAPSULE 20 MG, 25 MG CE (Tier 4); QL (21 capsules per (lenalidomide) 1 month) THALOMID ORAL CAPSULE 100 MG, 50 MG PA; #; SP Pharmacy; QL (1 Tier 4 (thalidomide) capsule per 1 day)

211 Coverage Requirements and Prescription Drug Name Drug Tier Limits THALOMID ORAL CAPSULE 150 MG, 200 MG PA; #; SP Pharmacy; QL (2 Tier 4 (thalidomide) capsules per 1 day) IMMUNOSUPPRESSANTS ASTAGRAF XL ORAL CAPSULE EXTENDED Tier 3 # RELEASE 24 HOUR 0.5 MG, 1 MG, 5 MG (tacrolimus) AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) Tier 3 azathioprine oral tablet 50 mg Tier 1 PA; ST; NPL; SP Pharmacy; BENLYSTA SUBCUTANEOUS SOLUTION AUTO- Tier 4 QL (4 injections per 1 INJECTOR 200 MG/ML (belimumab) month) PA; ST; NPL; SP Pharmacy; BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED Tier 4 QL (4 inhections per 1 SYRINGE 200 MG/ML (belimumab) month) CELLCEPT ORAL CAPSULE 250 MG (mycophenolate NF mofetil) CELLCEPT ORAL TABLET 500 MG (mycophenolate NF mofetil) cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg Tier 1 cyclosporine modified oral solution 100 mg/ml Tier 1 SP Pharmacy cyclosporine oral capsule 100 mg, 25 mg Tier 1 ENSPRYNG SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 120 MG/ML (satralizumab-mwge) ENVARSUS XR ORAL TABLET EXTENDED RELEASE NF 24 HOUR 0.75 MG, 1 MG, 4 MG (tacrolimus) everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg Tier 1 cyclosporine modified (Gengraf Oral Capsule 100 Mg, 25 Mg, Tier 1 SP Pharmacy 50 Mg) cyclosporine modified (Gengraf Oral Solution 100 Mg/Ml) Tier 1 SP Pharmacy IMURAN ORAL TABLET 50 MG (azathioprine) NF LUPKYNIS ORAL CAPSULE 7.9 MG (voclosporin) NF mycophenolate mofetil oral capsule 250 mg Tier 1 mycophenolate mofetil oral suspension reconstituted 200 mg/ml Tier 1 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

212 Coverage Requirements and Prescription Drug Name Drug Tier Limits mycophenolate mofetil oral tablet 500 mg Tier 1 mycophenolate sodium oral tablet delayed release 180 mg, 360 Tier 1 SP Pharmacy mg MYFORTIC ORAL TABLET DELAYED RELEASE 180 NF MG, 360 MG (mycophenolate sodium) NEORAL ORAL CAPSULE 100 MG, 25 MG (cyclosporine NF modified) NEORAL ORAL SOLUTION 100 MG/ML (cyclosporine NF modified) PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG NF (tacrolimus) PROGRAF ORAL PACKET 0.2 MG, 1 MG (tacrolimus) Tier 3 RAPAMUNE ORAL SOLUTION 1 MG/ML (sirolimus) Tier 4 SP Pharmacy SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG NF (cyclosporine) SANDIMMUNE ORAL SOLUTION 100 MG/ML Tier 3 (cyclosporine) sirolimus oral solution 1 mg/ml Tier 1 sirolimus oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg Tier 1 ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG Tier 4 (everolimus) ZORTRESS ORAL TABLET 1 MG (everolimus) Tier 2 MISCELLANEOUS equapax/ibuprofen/minrex oral therapy pack 800 mg NF ILARIS (150MG DELIVERED) SUBCUTANEOUS Tier 4 PA; SP Pharmacy SOLUTION RECONSTITUTED 180 MG (canakinumab) MEDICAL DEVICES CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL FC FEMALE CONDOM (condoms - female) CE N2 (NF)

213 Coverage Requirements and Prescription Drug Name Drug Tier Limits FC2 FEMALE CONDOM (condoms - female) CE N2 (NF) FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM CE N2 (Tier 3) (cervical caps) WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM N2 (Tier 3); QL (1 CE 2 % (diaphragm wide seal) diaphragm per 1 year) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM N2 (Tier 3); QL (1 CE 2 % (diaphragm wide seal) diaphragm per 1 year) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM N2 (Tier 3); QL (1 CE 2 % (diaphragm wide seal) diaphragm per 1 year) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM N2 (Tier 3); QL (1 CE 2 % (diaphragm wide seal) diaphragm per 1 year) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM N2 (Tier 3); QL (1 CE 2 % (diaphragm wide seal) diaphragm per 1 year) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM N2 (Tier 3); QL (1 CE 2 % (diaphragm wide seal) diaphragm per 1 year) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM N2 (Tier 3); QL (1 CE 2 % (diaphragm wide seal) diaphragm per 1 year) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM N2 (Tier 3); QL (1 CE 2 % (diaphragm wide seal) diaphragm per 1 year) DIABETIC SUPPLIES 1st tier unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , Tier 2 31g x 8 mm , 32g x 4 mm 1st tier unifine pentips plus 31g x 8 mm Tier 2 1st tier unilet comfortouch Tier 3 ACCU-CHEK AVIVA PLUS IN VITRO STRIP (glucose Tier 2 QL (300 strips per 30 days) blood) ACCU-CHEK COMPACT PLUS IN VITRO STRIP (glucose Tier 2 QL (300 strips per 30 days) blood) ACCU-CHEK FASTCLIX LANCETS (lancets) Tier 2 ACCU-CHEK GUIDE IN VITRO STRIP (glucose blood) Tier 2 QL (300 strips per 30 days) ACCU-CHEK MULTICLIX LANCETS (lancets) Tier 2 ACCU-CHEK SAFE-T PRO LANCETS (lancets) Tier 3

214 Coverage Requirements and Prescription Drug Name Drug Tier Limits ACCU-CHEK SMARTVIEW IN VITRO STRIP (glucose Tier 2 QL (300 strips per 30 days) blood) ACCU-CHEK SOFT TOUCH LANCETS (lancets) Tier 2 ACCU-CHEK SOFTCLIX LANCET DEV KIT (lancets Tier 2 misc.) ACCU-CHEK SOFTCLIX LANCETS (lancets) Tier 2 ACCUTREND GLUCOSE CONTROL IN VITRO NF SOLUTION (blood glucose calibration) ACCUTREND GLUCOSE IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) acti-lance 28g Tier 2 acti-lance lite lancets 28g Tier 2 acti-lance special lancets 17g Tier 2 acti-lance universal 23g Tier 2 adjustable lancing device Tier 3 ADVANCE INTUITION TEST IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) ADVOCATE INSULIN PEN NEEDLES 31G X 5 MM , Tier 3 31G X 8 MM (insulin pen needle) ADVOCATE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, Tier 3 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ADVOCATE LANCETS (lancets) Tier 3 ADVOCATE RAPID-SAFE LANCING (lancet devices) Tier 2 ADVOCATE REDI-CODE IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) ADVOCATE REDI-CODE+ TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) ADVOCATE SAFETY LANCETS (lancets) Tier 2

215 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; QL (300 strips per 30 ADVOCATE TEST IN VITRO STRIP (glucose blood) Tier 3 days) AGAMATRIX AMP TEST IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) AGAMATRIX JAZZ TEST IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) AGAMATRIX KEYNOTE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) AGAMATRIX PRESTO TEST IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) AGAMATRIX ULTRA-THIN LANCETS (lancets) Tier 2 alcohol swabs pad Tier 3 alternate site lancing device Tier 3 PA; QL (300 strips per 30 ASSURE 3 TEST IN VITRO STRIP (glucose blood) Tier 3 days) PA; QL (300 strips per 30 ASSURE 4 TEST IN VITRO STRIP (glucose blood) Tier 3 days) assure comfort lancets 28g Tier 2 assure comfort lancets 30g Tier 3 ASSURE HAEMOLANCE PLUS HIGH (lancets) Tier 2 ASSURE HAEMOLANCE PLUS LOW (lancets) Tier 2 ASSURE HAEMOLANCE PLUS MICRO (lancets) Tier 2 ASSURE HAEMOLANCE PLUS NORMAL (lancets) Tier 2 ASSURE HAEMOLANCE PLUS PED (lancets) Tier 2 ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, Tier 2 29G X 1/2" 1 ML (insulin syringe-needle u-100) ASSURE LANCE LANCETS (lancets) Tier 3 ASSURE LANCETS (lancets) Tier 2 PA; QL (300 strips per 30 ASSURE PLATINUM IN VITRO STRIP (glucose blood) Tier 3 days)

216 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; QL (300 strips per 30 ASSURE PRO TEST IN VITRO STRIP (glucose blood) Tier 3 days) aurora lancet super thin 30g Tier 2 aurora lancet thin 23g Tier 2 aurora pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm Tier 3 aurora unifine pentips 31g x 5 mm Tier 2 aurora unifine pentips 32g x 4 mm Tier 3 PA; QL (300 strips per 30 BAYER BREEZE 2 TEST IN VITRO DISK (glucose blood) Tier 3 days) BAYER CONTOUR NEXT TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) BAYER CONTOUR TEST IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) BAYER MICROLET LANCETS (lancets) Tier 2 BD AUTOSHIELD 29G X 5MM , 29G X 8MM (insulin pen Tier 2 needle) BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.5 ML Tier 2 (insulin syringe-needle u-100) BD INSULIN SYR ULTRAFINE II 31G X 5/16" 1 ML Tier 2 (insulin syringe-needle u-100) BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27G X 1/2" 1 ML, 29G X 1/2" 1 ML (insulin Tier 2 syringe-needle u-100) BD INSULIN SYRINGE 30G X 1/2" 0.5 ML (insulin syringe- Tier 2 needle u-100) BD INSULIN SYRINGE HALF-UNIT 31G X 5/16" 0.3 ML Tier 2 (insulin syringe-needle u-100) BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML (insulin syringe-needle Tier 2 u-100) BD INSULIN SYRINGE U/F 30G X 1/2" 1 ML, 31G X Tier 2 5/16" 0.3 ML (insulin syringe-needle u-100)

217 Coverage Requirements and Prescription Drug Name Drug Tier Limits BD INSULIN SYRINGE U-100 1 ML (insulin syringes Tier 2 (disposable)) BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, Tier 2 30G X 1/2" 0.5 ML, 31G X 5/16" 0.5 ML (insulin syringe- needle u-100) BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 1 ML Tier 2 (insulin syringe-needle u-100) BD LANCET ULTRAFINE 30G (lancets) Tier 2 BD LANCET ULTRAFINE 33G (lancets) Tier 2 BD MICROTAINER LANCETS (lancets) Tier 2 BD PEN NEEDLE MINI U/F 31G X 5 MM (insulin pen Tier 2 needle) BD PEN NEEDLE NANO U/F 32G X 4 MM (insulin pen Tier 2 needle) BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM (insulin Tier 2 pen needle) BD PEN NEEDLE SHORT U/F 31G X 8 MM (insulin pen Tier 2 needle) BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 Tier 2 ML, 31G X 5/16" 0.3 ML (insulin syringe-needle u-100) BD SAFETY-LOK INSULIN SYRINGE 29G X 1/2" 1 ML Tier 2 (insulin syringe-needle u-100) BD VEO INSULIN SYR U/F 1/2UNIT 31G X 15/64" 0.3 ML Tier 2 (insulin syringe-needle u-100) BD VEO INSULIN SYRINGE U/F 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML (insulin syringe- Tier 2 needle u-100) blood glucose test in vitro strip NF bullseye mini safety lancets Tier 2 CAREFINE PEN NEEDLES 31G X 6 MM (insulin pen Tier 2 needle) CAREONE LANCET SUPER THIN 30G (lancets) Tier 2 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

218 Coverage Requirements and Prescription Drug Name Drug Tier Limits careone lancet thin 23g Tier 2 careone lancet ultra thin 28g Tier 2 careone unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , Tier 3 31g x 8 mm , 32g x 4 mm CARESENS N GLUCOSE TEST IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) CHEK-STIX CONTROL IN VITRO STRIP (acetone (urine) Tier 3 test) CHEMSTRIP 10 MD IN VITRO STRIP (multiple urine tests) Tier 3 CHEMSTRIP 10/SG IN VITRO STRIP (multiple urine tests) Tier 3 CHEMSTRIP 2 GP IN VITRO STRIP (multiple urine tests) Tier 3 CHEMSTRIP 5 OB IN VITRO STRIP (multiple urine tests) Tier 3 CHEMSTRIP 7 IN VITRO STRIP (multiple urine tests) Tier 3 CHEMSTRIP 9 IN VITRO STRIP (multiple urine tests) Tier 3 CHEMSTRIP K IN VITRO STRIP (acetone (urine) test) Tier 3 CHEMSTRIP UGK IN VITRO STRIP (urine glucose-ketones Tier 3 test) CLEVER CHEK AUTO-CODE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) CLEVER CHEK AUTO-CODE VOICE IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) CLEVER CHEK LANCETS (lancets) Tier 3 PA; QL (300 strips per 30 CLEVER CHEK TEST IN VITRO STRIP (glucose blood) Tier 3 days) CLEVER CHOICE AUTO-CODE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) CLEVER CHOICE MICRO TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) clickfine pen needles 31g x 6 mm Tier 3 clickfine pen needles 31g x 8 mm Tier 2 COMBISTIX IN VITRO STRIP (multiple urine tests) Tier 3

219 Coverage Requirements and Prescription Drug Name Drug Tier Limits comfort assured lancets 28g Tier 2 comfort assured lancets 33g Tier 2 COMFORT EZ INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, Tier 3 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML (insulin syringe-needle u-100) COMFORT EZ INSULIN SYRINGE 31G X 5/16" 0.5 ML, Tier 2 31G X 5/16" 1 ML (insulin syringe-needle u-100) COMFORT EZ PEN NEEDLES 31G X 5 MM , 31G X 6 Tier 2 MM (insulin pen needle) COMFORT EZ PEN NEEDLES 31G X 8 MM (insulin pen Tier 3 needle) comfort lancets Tier 2 DEXCOM G4 PLAT PED RCV/SHARE DEVICE Tier 2 (continuous blood gluc receiver) DEXCOM G4 PLAT PED RECEIVER DEVICE (continuous Tier 2 blood gluc receiver) DEXCOM G4 PLATINUM RCV/SHARE DEVICE Tier 2 (continuous blood gluc receiver) DEXCOM G4 PLATINUM RECEIVER DEVICE Tier 2 (continuous blood gluc receiver) DEXCOM G4 PLATINUM TRANSMITTER (continuous Tier 2 blood gluc transmit) DEXCOM G4 SENSOR (continuous blood gluc sensor) Tier 2 DEXCOM G5 MOB/G4 PLAT SENSOR (continuous blood Tier 2 gluc sensor) DEXCOM G5 MOBILE RECEIVER DEVICE (continuous Tier 2 blood gluc receiver) DEXCOM G5 MOBILE TRANSMITTER (continuous blood Tier 2 gluc transmit)

220 Coverage Requirements and Prescription Drug Name Drug Tier Limits DEXCOM G5 RECEIVER KIT DEVICE (continuous blood Tier 2 gluc receiver) DEXCOM G6 RECEIVER DEVICE (continuous blood gluc Tier 2 receiver) DEXCOM G6 SENSOR (continuous blood gluc sensor) Tier 2 DEXCOM G6 TRANSMITTER (continuous blood gluc Tier 2 transmit) DROPLET LANCETS ULTRA THIN 30G (lancets) Tier 2 easy comfort insulin syringe 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml Tier 3 easy comfort lancets Tier 3 PA; QL (300 strips per 30 easy plus ii glucose test in vitro strip Tier 3 days) PA; QL (300 strips per 30 EASY STEP TEST IN VITRO STRIP (glucose blood) Tier 3 days) PA; QL (300 strips per 30 easy talk blood glucose test in vitro strip Tier 3 days) EASY TOUCH INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 1 ML (insulin syringe- Tier 3 needle u-100) EASY TOUCH INSULIN SYRINGE 27G X 1/2" 0.5 ML, Tier 2 27G X 1/2" 1 ML (insulin syringe-needle u-100) EASY TOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X Tier 3 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) EASY TOUCH LANCETS 21G (lancets) Tier 2 EASY TOUCH LANCETS 23G (lancets) Tier 2 EASY TOUCH LANCETS 26G (lancets) Tier 2 EASY TOUCH LANCETS 28G (lancets) Tier 2 EASY TOUCH LANCETS 28G/TWIST (lancets) Tier 3

221 Coverage Requirements and Prescription Drug Name Drug Tier Limits EASY TOUCH LANCETS 30G (lancets) Tier 2 EASY TOUCH LANCETS 30G/TWIST (lancets) Tier 3 EASY TOUCH LANCETS 32G (lancets) Tier 2 EASY TOUCH LANCETS 32G/TWIST (lancets) Tier 3 EASY TOUCH LANCETS 33G/TWIST (lancets) Tier 2 EASY TOUCH PEN NEEDLES 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 5 MM , 32G X 6 Tier 2 MM (insulin pen needle) EASY TOUCH SAFETY LANCETS 21G (lancets) Tier 3 EASY TOUCH SAFETY LANCETS 23G (lancets) Tier 3 EASY TOUCH SAFETY LANCETS 26G (lancets) Tier 3 EASY TOUCH SAFETY LANCETS 28G (lancets) Tier 3 PA; QL (300 strips per 30 EASY TOUCH TEST IN VITRO STRIP (glucose blood) Tier 3 days) PA; QL (300 strips per 30 easy trak blood glucose test in vitro strip Tier 3 days) EASY TWIST & CAP LANCETS (lancets) Tier 3 PA; QL (300 strips per 30 EASYGLUCO IN VITRO STRIP (glucose blood) Tier 3 days) PA; QL (300 strips per 30 EASYMAX 15 TEST IN VITRO STRIP (glucose blood) Tier 3 days) PA; QL (300 strips per 30 EASYMAX TEST IN VITRO STRIP (glucose blood) Tier 3 days) PA; QL (300 strips per 30 easyplus blood glucose test in vitro strip Tier 3 days) PA; QL (300 strips per 30 EASYPRO PLUS IN VITRO STRIP (glucose blood) Tier 3 days) PA; QL (300 strips per 30 ELEMENT TEST IN VITRO STRIP (glucose blood) Tier 3 days) elite-thin insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 29g Tier 3 x 5/16" 1 ml elite-thin insulin syringe 29g x 5/16" 0.5 ml Tier 2 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

222 Coverage Requirements and Prescription Drug Name Drug Tier Limits EMBRACE BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) eq blood glucose test in vitro strip NF EVENCARE + BLOOD GLUCOSE TEST IN VITRO PA; QL (300 strips per 30 Tier 3 STRIP (glucose blood) days) EVENCARE BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) PA; QL (300 strips per 30 EVENCARE G2 TEST IN VITRO STRIP (glucose blood) Tier 3 days) PA; QL (300 strips per 30 EVENCARE G3 TEST IN VITRO STRIP (glucose blood) Tier 3 days) EVOLUTION AUTOCODE IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 30G X 5/16" 0.3 Tier 2 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) EXEL COMFORT POINT INSULIN SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML (insulin syringe- Tier 3 needle u-100) E-Z JECT LANCET MICRO-THIN 33G (lancets) Tier 2 E-Z JECT LANCET SUPER THIN 30G (lancets) Tier 2 E-Z JECT LANCETS (lancets) Tier 3 E-Z JECT LANCETS 21G (lancets) Tier 3 E-Z JECT LANCETS THIN 26G (lancets) Tier 2 EZ SMART BLOOD GLUCOSE LANCETS (lancets) Tier 2 EZ SMART BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) EZ SMART PLUS GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) FIFTY50 GLUCOSE TEST 2.0 IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) FIFTY50 PEN NEEDLES 31G X 5 MM (insulin pen needle) Tier 2

223 Coverage Requirements and Prescription Drug Name Drug Tier Limits FIFTY50 SAFETY SEAL LANCETS (lancets) Tier 2 FIFTY50 SUPERIOR COMFORT SYR 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe- Tier 3 needle u-100) FINE 30 (lancets) Tier 2 FINGERSTIX LANCETS (lancets) Tier 2 FORA D15G BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) FORA D20 BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) FORA G20 BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) FORA G30/PREM V10 GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) PA; QL (300 strips per 30 FORA GD20 TEST IN VITRO STRIP (glucose blood) Tier 3 days) FORA LANCETS (lancets) Tier 3 FORA V10 BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) FORA V12 BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) FORA V20 BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) FORA V30A BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) PA; QL (300 strips per 30 FORACARE GD40 TEST IN VITRO STRIP (glucose blood) Tier 3 days) FORACARE PREMIUM V10 TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) FREESTYLE INSULINX TEST IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) FREESTYLE LANCETS (lancets) Tier 3

224 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; QL (300 strips per 30 FREESTYLE LITE TEST IN VITRO STRIP (glucose blood) Tier 3 days) FREESTYLE PRECISION INS SYR 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML Tier 3 (insulin syringe-needle u-100) FREESTYLE PRECISION NEO TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) PA; QL (300 strips per 30 FREESTYLE TEST IN VITRO STRIP (glucose blood) Tier 3 days) FREESTYLE UNISTICK II LANCETS (lancets) Tier 3 PA; QL (300 strips per 30 ge100 blood glucose test in vitro strip Tier 3 days) global ease inject pen needles 29g x 12mm , 31g x 5 mm , 31g x Tier 3 8 mm global inject ease insulin syr 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, Tier 3 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml global inject ease lancets 28g Tier 2 global inject ease lancets 30g Tier 2 GLUCAGEN DIAGNOSTIC INJECTION SOLUTION Tier 3 QL (1 kit per 1 fill) RECONSTITUTED 1 MG (glucagon hcl rdna (diagnostic)) GLUCOCARD 01 SENSOR PLUS IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) GLUCOCARD EXPRESSION TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) GLUCOCARD VITAL TEST IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) GLUCOCARD X-SENSOR IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) GLUCOCOM LANCETS 28G (lancets) Tier 2 GLUCOCOM LANCETS 30G (lancets) Tier 2 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

225 Coverage Requirements and Prescription Drug Name Drug Tier Limits GLUCOCOM LANCETS 33G (lancets) Tier 2 PA; QL (300 strips per 30 GLUCOCOM TEST IN VITRO STRIP (glucose blood) Tier 3 days) GLUCOPRO INSULIN SYRINGE 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, Tier 3 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) GOJJI BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) GUARDIAN CONNECT TRANSMITTER (continuous NF blood gluc transmit) GUARDIAN LINK 3 TRANSMITTER (continuous blood NF gluc transmit) GUARDIAN SENSOR (3) (continuous blood gluc sensor) NF HAEMOLANCE (lancets) Tier 2 HAEMOLANCE LOW FLOW LANCETS (lancets) Tier 2 HAEMOLANCE PLUS (lancets) Tier 2 HAEMOLANCE PLUS HIGH FLOW (lancets) Tier 2 HAEMOLANCE PLUS LOW FLOW (lancets) Tier 2 HAEMOLANCE PLUS MAX FLOW (lancets) Tier 2 HAEMOLANCE PLUS PEDIATRIC FLOW (lancets) Tier 2 healthwise mini pen needles 31g x 6 mm Tier 3 healthwise pen needles 29g x 12mm Tier 3 healthwise short pen needles 31g x 8 mm Tier 3 healthwise unifine pentips 32g x 4 mm Tier 3 healthy accents unifine pentip 29g x 12mm , 31g x 5 mm , 31g x Tier 3 6 mm , 31g x 8 mm healthy accents unilet lancets Tier 2 HEMA-COMBISTIX IN VITRO STRIP (multiple urine tests) Tier 3

226 Coverage Requirements and Prescription Drug Name Drug Tier Limits HM ULTICARE INSULIN SYRINGE 31G X 5/16" 0.3 ML Tier 2 (insulin syringe-needle u-100) INFINITY BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) PA; QL (300 strips per 30 INFINITY VOICE IN VITRO STRIP (glucose blood) Tier 3 days) insulin syringe 27g x 1/2" 0.5 ml, 27g x 1/2" 1 ml, 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1" 0.3 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, Tier 3 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml insulin syringe/needle 27g x 1/2" 0.5 ml, 28g x 1/2" 0.5 ml, 28g x Tier 3 1/2" 1 ml insulin syringe-needle u-100 31g x 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, Tier 3 31g x 1/4" 1 ml insupen pen needles 32g x 4 mm Tier 2 INSUPEN SENSITIVE 32G X 6 MM , 32G X 8 MM (insulin Tier 2 pen needle) INSUPEN ULTRAFIN 30G X 8 MM , 31G X 6 MM , 31G Tier 2 X 8 MM (insulin pen needle) KETOCARE IN VITRO STRIP (acetone (urine) test) Tier 3 KETO-DIASTIX IN VITRO STRIP (urine glucose-ketones Tier 3 test) ketone test in vitro strip Tier 3 KETOSTIX IN VITRO STRIP (acetone (urine) test) Tier 3 kinney lancets Tier 2 kinney thin lancets Tier 2 kinray insulin syringe 29g x 1/2" 0.5 ml, 31g x 5/16" 0.3 ml, 31g Tier 3 x 5/16" 0.5 ml, 31g x 5/16" 1 ml kroger blood glucose test in vitro strip NF LABSTIX IN VITRO STRIP (multiple urine tests) Tier 3 lancet device Tier 3

227 Coverage Requirements and Prescription Drug Name Drug Tier Limits lancet transporter case Tier 3 lancets Tier 3 lancets 28g Tier 1 lancets 30g Tier 3 lancets thin Tier 3 LANCETS ULTRA FINE (lancets) Tier 2 LANCETS ULTRA THIN (lancets) Tier 2 lancets ultra thin 30g Tier 2 lancing device Tier 3 leader insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 Tier 3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml LEADER UNIFINE PENTIPS 31G X 5 MM , 32G X 4 MM Tier 3 (insulin pen needle) LIBERTY NEXT GENERATION TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) PA; QL (300 strips per 30 liberty test in vitro strip Tier 3 days) lite touch lancets Tier 3 LITE TOUCH PEN NEEDLES 31G X 5 MM (insulin pen Tier 3 needle) LITETOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, Tier 3 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) LITETOUCH PEN NEEDLES 29G X 12.7MM , 31G X 8 Tier 2 MM (insulin pen needle) live better lancet super thin Tier 3 live better lancet ultra thin Tier 2 longs insulin syringe 31g x 5/16" 0.5 ml Tier 3

228 Coverage Requirements and Prescription Drug Name Drug Tier Limits longs lancets standard Tier 2 longs lancets thin Tier 2 longs lancets ultra thin Tier 2 MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML Tier 2 (insulin syringe-needle u-100) MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, Tier 3 29G X 1/2" 1 ML (insulin syringe-needle u-100) MAXI-COMFORT INSULIN SYRINGE 28G X 1/2" 0.5 Tier 3 ML, 28G X 1/2" 1 ML (insulin syringe-needle u-100) MEDISENSE THIN LANCETS (lancets) Tier 2 MEDLANCE EXTRA 21G (lancets) Tier 2 MEDLANCE LITE 25G (lancets) Tier 2 MEDLANCE PLUS EXTRA 21G (lancets) Tier 2 MEDLANCE PLUS LANCETS (lancets) Tier 2 MEDLANCE PLUS LITE 25G (lancets) Tier 2 MEDLANCE PLUS SUPERLITE 30G (lancets) Tier 3 MEDLANCE PLUS UNIVERSAL 21G (lancets) Tier 2 MEDLANCE UNIVERSAL 21G (lancets) Tier 2 PA; QL (300 strips per 30 MICRODOT TEST IN VITRO STRIP (glucose blood) Tier 3 days) MICROLET LANCETS (lancets) Tier 2 MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML, 27G X Tier 2 1/2" 1 ML (insulin syringe-needle u-100) MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X Tier 3 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) MONOJECT INSULIN SYRINGE U-100 1 ML (insulin Tier 2 syringes (disposable)) MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" Tier 2 0.5 ML, 28G X 1/2" 1 ML (insulin syringe-needle u-100) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

229 Coverage Requirements and Prescription Drug Name Drug Tier Limits MONOJECT ULTRA COMFORT SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" Tier 3 0.3 ML, 30G X 5/16" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML (insulin syringe-needle u-100) MONOLET LANCETS (lancets) Tier 2 ms insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x Tier 3 5/16" 1 ml multi-lancet device Tier 3 MULTISTIX 10 SG IN VITRO STRIP (multiple urine tests) Tier 3 MULTISTIX 5 IN VITRO STRIP (multiple urine tests) Tier 3 MULTISTIX 7 IN VITRO STRIP (multiple urine tests) Tier 3 MULTISTIX 8 IN VITRO STRIP (multiple urine tests) Tier 3 MULTISTIX 9 IN VITRO STRIP (multiple urine tests) Tier 3 MULTISTIX 9 SG IN VITRO STRIP (multiple urine tests) Tier 3 MULTISTIX IN VITRO STRIP (multiple urine tests) Tier 3 MYGLUCOHEALTH LANCETS 30G (lancets) Tier 2 MYGLUCOHEALTH TEST IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) PA; QL (300 strips per 30 NEUTEK 2TEK TEST IN VITRO STRIP (glucose blood) Tier 3 days) NOVA MAX GLUCOSE TEST IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) NOVA SAFETY LANCETS 23G (lancets) Tier 2 NOVA SAFETY LANCETS 28G (lancets) Tier 2 NOVA SUREFLEX LANCETS (lancets) Tier 3 NOVOFINE 32G X 6 MM (insulin pen needle) Tier 2 NOVOFINE AUTOCOVER 30G X 8 MM (insulin pen Tier 2 needle) NOVOTWIST 32G X 5 MM (insulin pen needle) Tier 2 OMNIPOD 10 PACK (insulin disposable pump) Tier 2 OMNIPOD DASH 5 PACK PODS (insulin disposable pump) Tier 2

230 Coverage Requirements and Prescription Drug Name Drug Tier Limits OMNIPOD DASH SYSTEM KIT (insulin disposable pump) Tier 2 OMNIPOD STARTER KIT (insulin disposable pump) Tier 2 ON CALL LANCETS (lancets) Tier 2 ON CALL PLUS BLOOD GLUCOSE IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) ON CALL PLUS LANCETS (lancets) Tier 2 ON CALL VIVID BLOOD GLUCOSE IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) ONETOUCH CLUB LANCETS FINE PT (lancets) Tier 2 ONETOUCH DELICA LANCETS 30G (lancets) Tier 2 ONETOUCH DELICA LANCETS 33G (lancets) Tier 2 ONETOUCH DELICA LANCETS FINE (lancets) Tier 3 ONETOUCH DELICA LANCING DEV (lancet devices) Tier 2 ONETOUCH FINEPOINT LANCETS (lancets) Tier 3 ONETOUCH LANCETS (lancets) Tier 3 ONETOUCH SURESOFT LANCING DEV (lancets misc.) Tier 2 ONETOUCH ULTRA BLUE IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) PA; QL (300 strips per 30 ONETOUCH ULTRA IN VITRO STRIP (glucose blood) Tier 3 days) ONETOUCH ULTRASOFT LANCETS (lancets) Tier 2 PA; QL (300 strips per 30 ONETOUCH VERIO IN VITRO STRIP (glucose blood) Tier 3 days) pen needles 1/2" 29g x 12mm Tier 3 pen needles 29g x 12mm , 30g x 5 mm , 30g x 8 mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 32g x 5 mm , 32g Tier 3 x 6 mm pen needles 3/16" 31g x 5 mm Tier 3 pen needles 5/16" 30g x 8 mm , 31g x 8 mm Tier 3 PHARMACIST CHOICE AUTOCODE IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days)

231 Coverage Requirements and Prescription Drug Name Drug Tier Limits PHARMACIST CHOICE LANCETS (lancets) Tier 3 PA; QL (300 strips per 30 POCKETCHEM EZ TEST IN VITRO STRIP (glucose blood) Tier 3 days) POGO AUTOMATIC TEST CARTRIDGES IN VITRO NF DIAGNOSTIC TEST (glucose blood) PA; QL (300 strips per 30 PRECISION PCX IN VITRO STRIP (glucose blood) Tier 3 days) PRECISION PCX PLUS TEST IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) PRECISION POINT OF CARE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) PA; QL (300 strips per 30 PRECISION QID TEST IN VITRO STRIP (glucose blood) Tier 3 days) PRECISION SOF-TACT TEST IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) PRECISION SUREDOSE PLUS SYR 29G X 1/2" 0.3 ML, Tier 3 29G X 1/2" 1 ML (insulin syringe-needle u-100) PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML Tier 3 (insulin syringe-needle u-100) PRECISION SURE-DOSE SYRINGE 30G X 3/8" 0.5 ML Tier 2 (insulin syringe-needle u-100) PRECISION THIN LANCETS (lancets) Tier 2 PRECISION ULTRA LANCET (lancets) Tier 2 PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) preferred plus insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x Tier 3 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml preferred plus lancets colored Tier 2 preferred plus lancets thin Tier 3 preferred plus unifine pentips 29g x 12mm , 31g x 5 mm , 31g x Tier 3 6 mm , 31g x 8 mm , 32g x 4 mm 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

232 Coverage Requirements and Prescription Drug Name Drug Tier Limits PRODIGY INSULIN SYRINGE 28G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML (insulin syringe-needle u- Tier 3 100) PRODIGY LANCETS 28G (lancets) Tier 2 PRODIGY NO CODING BLOOD GLUC IN VITRO PA; QL (300 strips per 30 Tier 3 STRIP (glucose blood) days) PRODIGY TWIST TOP LANCETS 28G (lancets) Tier 3 reality insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml Tier 3 REFUAH PLUS BLOOD GLUCOSE TEST IN VITRO PA; QL (300 strips per 30 Tier 3 STRIP (glucose blood) days) RELION BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) RELI-ON INSULIN SYRINGE 29G 0.3 ML, 29G 0.5 ML, 30G 0.3 ML, 30G 0.5 ML, 30G 1 ML (insulin syringe-needle u- Tier 2 100) RELION INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G Tier 3 X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u- 100) RELI-ON INSULIN SYRINGE 29G X 1/2" 1 ML (insulin Tier 3 syringe-needle u-100) RELION KETONE IN VITRO STRIP (acetone (urine) test) Tier 3 RELION LANCETS STANDARD 21G (lancets) Tier 2 RELION LANCETS THIN 26G (lancets) Tier 2 RELION LANCETS ULTRA-THIN 30G (lancets) Tier 3 RELION MINI PEN NEEDLES 31G X 6 MM (insulin pen Tier 3 needle) RELION PEN NEEDLES 29G X 12MM , 31G X 8 MM , Tier 2 32G X 4 MM (insulin pen needle) RELION SHORT PEN NEEDLES 31G X 8 MM (insulin pen Tier 3 needle) RELION ULTRA THIN LANCETS 30G (lancets) Tier 3 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

233 Coverage Requirements and Prescription Drug Name Drug Tier Limits RELION ULTRA THIN PLUS LANCETS (lancets) Tier 3 REVEAL BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) RIGHTEST GL300 LANCETS (lancets) Tier 2 RIGHTEST GS100 BLOOD GLUCOSE IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) RIGHTEST GS300 BLOOD GLUCOSE IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) RIGHTEST GS550 BLOOD GLUCOSE IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) SAFESNAP INSULIN SYRINGE 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X Tier 3 5/16" 0.5 ML (insulin syringe-needle u-100) safety lancet 21g/pressure act Tier 3 safety lancet 28g/pressure act Tier 3 SAFETY LANCETS (lancets) Tier 2 SAFETY LANCETS 21G (lancets) Tier 3 safety lancets 28g Tier 3 SAFETY LET LANCETS (lancets) Tier 2 SAFETY SEAL LANCETS (lancets) Tier 3 SAFETY-GLIDE SYRINGE 29G X 1/2" 0.3 ML (insulin Tier 2 syringe-needle u-100) SHOPKO UNIFINE PENTIPS 29G X 12MM , 31G X 5 MM Tier 3 , 31G X 8 MM , 32G X 4 MM (insulin pen needle) SHOPKO UNILET LANCETS 28G (lancets) Tier 3 SHOPKO UNILET LANCETS 30G (lancets) Tier 3 SINGLE-LET (lancets) Tier 2 SMART SENSE COLOR LANCETS 33G (lancets) Tier 2 SMART SENSE STANDARD LANCETS (lancets) Tier 2 SMART SENSE SUPER THIN LANCETS (lancets) Tier 2 SMART SENSE THIN LANCETS 26G (lancets) Tier 2

234 Coverage Requirements and Prescription Drug Name Drug Tier Limits SMARTEST BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) SMARTEST LANCETS 28G (lancets) Tier 2 SOLUS V2 LANCETS 28G (lancets) Tier 2 PA; QL (300 strips per 30 SOLUS V2 TEST IN VITRO STRIP (glucose blood) Tier 3 days) SOLUS V2 TWIST LANCETS 30G (lancets) Tier 2 STERILANCE PA (lancets misc.) Tier 2 STERILANCE TL (lancets) Tier 3 super thin lancets Tier 3 sure comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, Tier 3 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml sure comfort lancets 28g Tier 3 sure comfort lancets 30g Tier 3 sure comfort pen needles 29g x 12.7mm , 31g x 5 mm , 31g x 8 Tier 2 mm PA; QL (300 strips per 30 SURE EDGE TEST IN VITRO STRIP (glucose blood) Tier 3 days) SURECHEK BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) SURE-FINE PEN NEEDLES 29G X 12.7MM , 31G X 5 Tier 2 MM , 31G X 8 MM (insulin pen needle) SURE-JECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X Tier 3 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) SURE-LANCE FLAT LANCETS (lancets) Tier 2 SURE-LANCE THIN LANCETS 28G (lancets) Tier 3 SURE-LANCE ULTRA THIN LANCETS (lancets) Tier 3

235 Coverage Requirements and Prescription Drug Name Drug Tier Limits SURE-TEST EASYPLUS MINI TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) SURE-TOUCH LANCETS UNIVERSAL (lancets) Tier 2 TECHLITE AST LANCETS (lancets) Tier 2 TECHLITE LANCETS (lancets) Tier 2 TECHLITE LANCETS 30G (lancets) Tier 2 TELCARE BLOOD GLUCOSE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) THINLETS LANCET (lancets) Tier 2 topcare clickfine pen needles 31g x 6 mm , 31g x 8 mm Tier 2 topcare ultra comfort ins syr 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g Tier 3 x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml TRUEPLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G Tier 2 X 1/2" 1 ML (insulin syringe-needle u-100) TRUEPLUS INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, Tier 3 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) TRUEPLUS LANCETS 28G (lancets) Tier 2 TRUEPLUS LANCETS 30G (lancets) Tier 2 TRUEPLUS LANCETS 33G (lancets) Tier 3 TRUEPLUS SAFETY LANCETS 28G (lancets) Tier 2 PA; QL (300 strips per 30 TRUETEST TEST IN VITRO STRIP (glucose blood) Tier 3 days) PA; QL (300 strips per 30 TRUETRACK TEST IN VITRO STRIP (glucose blood) Tier 3 days) ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, Tier 3 29G X 1/2" 1 ML (insulin syringe-needle u-100)

236 Coverage Requirements and Prescription Drug Name Drug Tier Limits ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X Tier 3 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ULTICARE MICRO PEN NEEDLES 32G X 4 MM (insulin Tier 2 pen needle) ULTICARE MINI PEN NEEDLES 31G X 6 MM (insulin Tier 2 pen needle) ULTICARE PEN NEEDLES 29G X 12.7MM (insulin pen Tier 2 needle) ULTICARE PEN NEEDLES 29G X 12MM (insulin pen Tier 3 needle) ULTICARE SHORT PEN NEEDLES 31G X 8 MM (insulin Tier 2 pen needle) ULTILET CLASSIC LANCETS (lancets) Tier 3 ULTILET LANCETS (lancets) Tier 2 ULTILET SAFETY LANCETS 23G (lancets) Tier 2 PA; QL (300 strips per 30 ULTIMA TEST IN VITRO STRIP (glucose blood) Tier 3 days) ultra comfort insulin syringe 30g x 5/16" 0.3 ml Tier 3 ultra-comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x Tier 3 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml ULTRALANCE (lancets misc.) Tier 2 ULTRA-THIN II AUTO LANCET (lancets) Tier 3 ULTRA-THIN II INS SYR SHORT 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 Tier 3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe- needle u-100)

237 Coverage Requirements and Prescription Drug Name Drug Tier Limits ULTRA-THIN II INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML (insulin syringe-needle Tier 3 u-100) ULTRA-THIN II LANCETS (lancets) Tier 3 ULTRA-THIN II MINI PEN NEEDLE 31G X 5 MM Tier 3 (insulin pen needle) ULTRA-THIN II PEN NEEDLE SHORT 31G X 8 MM Tier 3 (insulin pen needle) ULTRA-THIN II PEN NEEDLES 29G X 12.7MM (insulin Tier 2 pen needle) PA; QL (300 strips per 30 ULTRATRAK PRO TEST IN VITRO STRIP (glucose blood) Tier 3 days) ULTRATRAK ULTIMATE TEST IN VITRO STRIP PA; QL (300 strips per 30 Tier 3 (glucose blood) days) UNIFINE PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 6 Tier 3 MM , 31G X 8 MM , 32G X 4 MM (insulin pen needle) UNILET COMFORTOUCH LANCET (lancets) Tier 2 UNILET EXCELITE (lancets) Tier 2 UNILET EXCELITE II (lancets) Tier 2 UNILET G.P. LANCET (lancets) Tier 2 UNILET G.P. SUPERLITE LANCET (lancets) Tier 3 UNILET GP 28 ULTRA THIN (lancets) Tier 2 UNILET LANCET (lancets) Tier 3 UNILET SUPERLITE LANCET (lancets) Tier 2 UNISTIK 3 COMFORT (lancets misc.) Tier 2 UNISTIK 3 EXTRA (lancets misc.) Tier 3 UNISTIK 3 NORMAL (lancets misc.) Tier 2 UNISTIK CZT COMFORT (lancets misc.) Tier 2 UNISTIK CZT NORMAL (lancets misc.) Tier 2 UNIVERSAL 1 LANCETS THIN 26G (lancets) Tier 2 UNIVERSAL 1 LANCETS ULTRA THIN (lancets) Tier 2

238 Coverage Requirements and Prescription Drug Name Drug Tier Limits URISTIX 4 IN VITRO STRIP (multiple urine tests) Tier 3 URISTIX IN VITRO STRIP (multiple urine tests) Tier 3 value health insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml Tier 3 value plus lancet standard 21g Tier 2 value plus lancets super thin Tier 3 value plus lancets thin 26g Tier 3 valumark lancet super thin 30g Tier 2 valumark lancet ultra thin 28g Tier 2 valumark pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm Tier 3 VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML, Tier 3 30G X 1/2" 0.5 ML (insulin syringe-needle u-100) V-GO 20 KIT (insulin disposable pump) Tier 2 V-GO 30 KIT (insulin disposable pump) Tier 2 V-GO 40 KIT (insulin disposable pump) Tier 2 VICTORY AGM-4000 TEST IN VITRO STRIP (glucose PA; QL (300 strips per 30 Tier 3 blood) days) VIDA MIA UNIFINE PENTIPS 29G X 12MM , 31G X 6 Tier 3 MM , 31G X 8 MM (insulin pen needle) VIDA MIA UNILET LANCETS 28G (lancets) Tier 3 VIDA MIA UNILET LANCETS 30G (lancets) Tier 3 VOCAL POINT BLOOD GLUCOSE TEST IN VITRO PA; QL (300 strips per 30 Tier 3 STRIP (glucose blood) days) PA; QL (300 strips per 30 WAVESENSE PRESTO IN VITRO STRIP (glucose blood) Tier 3 days) MISCELLANEOUS AEROCHAMBER PLUS FLO-VU (spacer/aero-holding Tier 2 chambers) FLEXICHAMBER ADULT MASK/SMALL (spacer/aero- Tier 2 hold chamber mask) OPTICHAMBER FACE MASK-LARGE (spacer/aero- Tier 2 holding chambers)

239 Coverage Requirements and Prescription Drug Name Drug Tier Limits PEDIATRIC PANDA MASK (spacer/aero-hold chamber Tier 2 mask) NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES av-phos 250 neutral oral tablet 155-852-130 mg Tier 1 EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 Tier 3 MEQ (potassium bicarb-citric acid) potassium bicarbonate (Effer-K Oral Tablet Effervescent 25 Tier 1 Meq) effervescent pot chloride oral tablet effervescent 25 meq Tier 1 GALZIN ORAL CAPSULE 25 MG, 50 MG (zinc acetate Tier 3 (oral)) iodine strong oral solution 5 % NF k-effervescent oral tablet effervescent 25 meq Tier 1 potassium chloride (Klor-Con 10 Oral Tablet Extended Tier 1 Release 10 Meq) potassium chloride crys er (Klor-Con M10 Oral Tablet Tier 1 Extended Release 10 Meq) potassium chloride crys er (Klor-Con M15 Oral Tablet Tier 1 Extended Release 15 Meq) potassium chloride crys er (Klor-Con M20 Oral Tablet Tier 1 Extended Release 20 Meq) potassium chloride (Klor-Con Oral Tablet Extended Release 8 Tier 1 Meq) potassium chloride (Klor-Con Sprinkle Oral Capsule Extended Tier 1 Release 10 Meq, 8 Meq) potassium bicarbonate (Klor-Con/Ef Oral Tablet Effervescent Tier 1 25 Meq) K-PHOS ORAL TABLET 500 MG (potassium phosphate Tier 3 monobasic)

240 Coverage Requirements and Prescription Drug Name Drug Tier Limits K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG (k NF phos mono-sod phos di & mono) potassium bicarbonate (K-Prime Oral Tablet Effervescent 25 Tier 1 Meq) K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, NF 20 MEQ, 8 MEQ (potassium chloride) k-vescent oral tablet effervescent 25 meq Tier 1 MAGNEBIND 400 ORAL TABLET 400-200-1 MG NF (magnesium-calcium-folic acid) MICRO-K ORAL CAPSULE EXTENDED RELEASE 10 NF MEQ, 8 MEQ (potassium chloride) k phos mono-sod phos di & mono (Phospha 250 Neutral Oral Tier 1 Tablet 155-852-130 Mg) pot bicarb-pot chloride oral tablet effervescent 25 meq Tier 1 potassium bicarbonate oral tablet effervescent 25 meq Tier 1 potassium chloride crys er oral tablet extended release 10 meq, Tier 1 20 meq potassium chloride er oral capsule extended release 10 meq, 8 Tier 1 meq potassium chloride er oral tablet extended release 10 meq, 20 Tier 1 meq, 8 meq potassium chloride oral packet 20 meq Tier 1 potassium chloride oral solution 20 meq/15ml (10%), 40 Tier 1 meq/15ml (20%) virt-phos 250 neutral oral tablet 155-852-130 mg Tier 1 VITAMINS - VITAMINS AND SUPPLEMENTS ACCRUFER ORAL CAPSULE 30 MG (ferric maltol) NF azeschew prenatal/postnatal oral tablet chewable 13-1 mg NF azesco oral tablet 13-1 mg NF b-6 oral tablet 50 mg Tier 1 BAL-CARE DHA ORAL 27-1 & 430 MG (prenat-fepoly- Tier 3 fered-fa-omega 3) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

241 Coverage Requirements and Prescription Drug Name Drug Tier Limits bp folinatal plus b oral tablet 1 mg Tier 1 bp multinatal plus oral tablet chewable 40-1 mg Tier 1 CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6- NF b12-boron-mg) calcium pnv oral capsule 28-1-250 mg Tier 3 calcium-folic acid plus d oral wafer 1342-1 mg NF CARDIOVID PLUS ORAL CAPSULE (dha-epa-vit b6-b12- NF folic acid) CITRANATAL 90 DHA ORAL 90-1 & 300 MG (prenat w/o Tier 3 a-fecbgl-dss-fa-dha) CITRANATAL ASSURE ORAL 35-1 & 300 MG (prenat w/o Tier 3 a-fecbgl-dss-fa-dha) CITRANATAL B-CALM ORAL 20-1 MG & 2 X 25 MG Tier 3 (prenat w/o a fecbnfeglu-fa &b6) CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 NF & 300 MG (prenat w/o a-fecbgl-fa-dha) CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG Tier 3 (prenat-fecb-fefum-fa-dha w/o a) CITRANATAL RX ORAL TABLET 27-1 MG (prenat w/o a- Tier 3 fecb-fegl-dss-fa) complete natal dha oral 29-1-200 & 250 mg Tier 3 completenate oral tablet chewable 29-1 mg Tier 3 CO-NATAL FA ORAL TABLET (prenatal vit-fe fumarate- Tier 3 fa) CONCEPT DHA ORAL CAPSULE 53.5-38-1 MG (prenat- Tier 3 fefum-fepo-fa-omega 3) CONCEPT OB ORAL CAPSULE 130-92.4-1 MG (prenat w/o Tier 3 a vit-fefum-fepo-fa) cyanocobalamin injection solution 1000 mcg/ml Tier 1 DIALYVITE 3000 ORAL TABLET 3 MG (b complex-c- NF biotin-e-min-fa)

242 Coverage Requirements and Prescription Drug Name Drug Tier Limits DIALYVITE 5000 ORAL TABLET 5 MG (b complex-c- NF biotin-e-min-fa) DIALYVITE SUPREME D ORAL TABLET 3 MG (multiple NF vitamins-minerals-fa) DIALYVITE/ZINC ORAL TABLET (b complex-c-zn-folic NF acid) DUET DHA BALANCED ORAL 25-1 & 267 MG (prenat- Tier 3 fepoly-fered-fa-omega 3) ELITE-OB ORAL TABLET 50-1.25 MG (prenatal vit-iron Tier 1 carbonyl-fa) ergocal oral capsule 62.5 mcg (2500 ut) Tier 3 FLORIVA ORAL LIQUID 0.25-400 MG-UNIT/ML (sodium Tier 3 fluoride-vitamin d) FLUORABON ORAL SOLUTION 0.55 (0.25 F) MG/0.6ML CE N2 (Tier 3); AL (sodium fluoride) FLUOR-A-DAY ORAL TABLET CHEWABLE 0.25 (F)- 236.79 MG, 0.5 (F)-236.79 MG, 1 (F)-236.79 MG (sodium Tier 3 fluoride-xylitol) fluoritab oral solution 0.275 (0.125 f) mg/drop CE N2 (Tier 1); AL fluoritab oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg CE N2 (Tier 1); AL fluoritab oral tablet chewable 2.2 (1 f) mg Tier 1 FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) CE N2 (Tier 3); AL MG/DROP (sodium fluoride) folate oral tablet 400 mcg CE N2 (NF) FOLBEE PLUS CZ ORAL TABLET 5 MG (b-complex-c- Tier 1 biotin-minerals-fa) folcal dha oral capsule 27-1.25-300 mg Tier 3 FOLCAPS OMEGA 3 ORAL CAPSULE 27-1 MG (prenatal- Tier 3 fecbn-feaspgl-fa-omeg) folic acid oral capsule 0.8 mg CE N2 (NF) folic acid oral tablet 1 mg Tier 1 folic acid oral tablet 400 mcg, 800 mcg CE N2 (NF)

243 Coverage Requirements and Prescription Drug Name Drug Tier Limits FOLIVANE-OB ORAL CAPSULE 130-92.4-1 MG (prenat Tier 3 w/o a vit-fefum-fepo-fa) GENICIN VITA-Q ORAL TABLET 1 MG (multiple vitamins NF with fa) hemenatal ob + dha oral 28-6-1 & 203 mg Tier 3 hemenatal ob oral tablet 28-6-1 mg Tier 3 hm biotin oral tablet dispersible 10000 mcg NF INATAL ADVANCE ORAL TABLET 90-1 MG (prenatal Tier 1 vit-dss-fe cbn-fa) INATAL GT ORAL TABLET (prenatal vit-dss-fe cbn-fa) Tier 1 INATAL ULTRA ORAL TABLET (prenatal vit-dss-fe cbn- Tier 1 fa) infanate balance oral capsule 29-1-265 mg Tier 3 jenliva prenatal/postnatal oral capsule 1 mg NF KIDS PROTEIN ORGANIC SHAKE ORAL LIQUID NF (nutritional supplements) levocarnitine (dietary) oral solution 1 gm/10ml Tier 3 levocarnitine l-tartrate oral tablet 330 mg Tier 3 levocarnitine-b5-taurine oral liquid 1000-10-150 mg/15ml NF levomefolate dha oral capsule 27-1.13-0.4 mg Tier 3 LOZI-FLUR MOUTH/THROAT LOZENGE 2.2 (1 F) MG Tier 3 (sodium fluoride) sodium fluoride (Ludent Oral Tablet Chewable 0.55 (0.25 F) CE N2 (Tier 1); AL Mg, 1.1 (0.5 F) Mg) sodium fluoride (Ludent Oral Tablet Chewable 2.2 (1 F) Mg) Tier 1 MEPHYTON ORAL TABLET 5 MG (phytonadione) Tier 3 QL (25 tablets per 30 days) multi-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml Tier 1 multi-vitamin/fluoride oral solution 0.25 mg/ml Tier 1 multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml Tier 1 multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg Tier 1

244 Coverage Requirements and Prescription Drug Name Drug Tier Limits multivitamins/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 Tier 1 mg pediatric multivitamins-fl (Mvc-Fluoride Oral Tablet Chewable Tier 1 0.25 Mg, 0.5 Mg, 1 Mg) M-VIT ORAL TABLET (prenatal vit-fe fumarate-fa) Tier 1 MYNATAL ADVANCE ORAL TABLET (prenatal vit-dss-fe Tier 1 cbn-fa) MYNATAL ORAL TABLET 90-1 MG (prenatal vit-dss-fe Tier 1 cbn-fa) mynatal plus oral tablet Tier 3 mynatal-z oral tablet Tier 3 sodium fluoride (Nafrinse Oral Tablet Chewable 2.2 (1 F) Mg) Tier 1 NASCOBAL NASAL SOLUTION 500 MCG/0.1ML NF # (cyanocobalamin) NATACHEW ORAL TABLET CHEWABLE 28-1 MG Tier 3 (prenatal vit-fe fum-fe bisg-fa) NATALVIT ORAL TABLET (prenatal vit-fe fumarate-fa) Tier 3 NATELLE ONE ORAL CAPSULE 28-1-250 MG (prenat w/o Tier 3 a-fe fum-fa-omega 3) NEEVO DHA ORAL CAPSULE 27-1.13 MG (prenat w/oa- Tier 3 fefum-methf-omegas) neonatal + dha oral 29-1 & 200 mg NF neonatal 19 oral tablet 1 mg NF neonatal fe oral tablet 90-1 mg NF NEPHPLEX RX ORAL TABLET (b complex-c-zn-folic acid) NF NESTABS DHA ORAL 32-1 MG (prenat-w/oa-fe bisgly-fa- Tier 3 omega) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o Tier 3 vit a) NEWGEN ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o Tier 3 vit a)

245 Coverage Requirements and Prescription Drug Name Drug Tier Limits NEXA PLUS ORAL CAPSULE 29-1.25-350 MG (prenat- Tier 3 fefum-doc-fa-dha w/o a) OB COMPLETE ADVANCED ORAL CAPSULE 27-1-385 Tier 3 MG (prenat w/o a-fe-methf-fa-omega) OB COMPLETE GOLD ORAL CAPSULE 27.5-1-200 MG Tier 3 (prenat w/o a-fecbn-meth-fa-dha) OB COMPLETE ONE ORAL CAPSULE 50-1-476 MG Tier 3 (prenat-fecbn-feaspgl-fa-fish) OB COMPLETE ORAL TABLET 50-1.25 MG (prenatal vit- Tier 3 iron carbonyl-fa) OB COMPLETE PREMIER ORAL TABLET 30-20-1 MG Tier 3 (prenatal-fe cbn-fe asp gly-fa) OB COMPLETE/DHA ORAL CAPSULE 30-10-1-200 MG Tier 3 (prenat-fecbn-feaspgl-fa-omega) O-CAL FA ORAL TABLET 27-1 MG (prenatal vit-fe Tier 3 fumarate-fa) O-CAL PRENATAL ORAL TABLET (prenatal vit-fe Tier 3 fumarate-fa) OCUVEL ORAL CAPSULE 0.5 MG (multiple vitamins- NF minerals-fa) ORGANIC NUTRITION SHAKE ORAL LIQUID NF (nutritional supplements) phytonadione oral tablet 5 mg Tier 1 pnv folic acid + iron oral tablet 27-1 mg Tier 3 pnv prenatal plus multivitamin oral tablet 27-1 mg Tier 3 pnv-dha oral capsule 27-0.6-0.4-300 mg Tier 1 pnv-dha+docusate oral capsule 27-1.25-300 mg Tier 3 pnv-omega oral capsule 28-0.6-0.4-340 mg Tier 3 pnv-select oral tablet 27-0.6-0.4 mg Tier 1 pnv-total oral capsule 35-5-1.2 mg Tier 3 pnv-vp-u oral capsule 106.5-1 mg Tier 3

246 Coverage Requirements and Prescription Drug Name Drug Tier Limits POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML Tier 3 (pediatric multivitamins-fl) POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, Tier 3 0.5 MG, 1 MG (pediatric multivitamins-fl) PR NATAL 400 ORAL 29-1-200 & 400 MG (prenat-febis- Tier 1 fepro-fa-ca-omega) PR NATAL 430 EC ORAL 29-1-200 & 430 MG (DR) Tier 1 (prenat-febis-fepro-fa-ca-omega) PR NATAL 430 ORAL 29-1-200 & 430 MG (prenat-febis- Tier 1 fepro-fa-ca-omega) PREFERA OB ORAL TABLET 34-1 MG (prenatal vit- Tier 3 fepoly-fehempo-fa) PREFERAOB ONE ORAL CAPSULE 22-6-1-200 MG Tier 3 (prenat fepoly-fehempo-fa-dha) pregen dha oral capsule 28-1-35 mg NF pregenna oral tablet 20-1 mg NF prenaissance balance oral capsule 30-1-260 mg Tier 3 prenaissance harmony dha oral 27-1 & 380 mg Tier 3 prenaissance next oral tablet 1.2 mg Tier 3 prenaissance next-b oral tablet 1.22 mg Tier 3 prenaissance oral capsule 29-1.25-325 mg Tier 3 prenaissance plus oral capsule 28-1-250 mg Tier 3 prenara oral capsule 15-1 mg NF PRENATA ORAL TABLET CHEWABLE 29-1 MG Tier 3 (prenatal w/o a vit-fe fum-fa) PRENATABS RX ORAL TABLET 29-1 MG (prenatal vit- Tier 1 iron carbonyl-fa) prenatal 19 oral tablet Tier 3 prenatal 19 oral tablet chewable Tier 1 prenatal low iron oral tablet 27-1 mg Tier 1 prenatal plus iron oral tablet 29-1 mg Tier 3

247 Coverage Requirements and Prescription Drug Name Drug Tier Limits PRENATAL-U ORAL CAPSULE 106.5-1 MG (prenatal w/o Tier 3 a vit-fe fum-fa) PRENATE DHA ORAL CAPSULE 28-0.6-0.4-300 MG Tier 3 (prenat w/o a-fe-methfol-fa-dha) PRENATE ELITE ORAL TABLET 26-0.6-0.4 MG (prenatal Tier 3 vit w/fe-methylfol-fa) PRENATE ESSENTIAL ORAL CAPSULE 29-0.6-0.4-340 Tier 3 MG (pren-fe-meth-fa-omeg w/o a) PRENATE MINI ORAL CAPSULE 29-0.6-0.4-350 MG Tier 3 (prenat w/o a-fecbn-meth-fa-dha) PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG Tier 3 (prenat mv-min-methylfolate-fa) prenatvite complete oral tablet 1 mg NF prenatvite plus oral tablet 1 mg NF prenatvite rx oral tablet 0.8 mg NF pretab oral tablet 29-1 mg Tier 3 PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe- Tier 3 meth-fa-omeg w/o a) pyridoxine hcl oral tablet 25 mg, 50 mg Tier 1 QUFLORA FE PEDIATRIC ORAL LIQUID 0.25-9.5 Tier 3 MG/ML (ped multivitamins-fl-iron) relnate dha oral capsule 28-1-200 mg Tier 3 SELECT-OB ORAL TABLET CHEWABLE 29-1 MG Tier 3 (prenatal vit-fe psac cmplx-fa) se-natal 19 oral tablet 29-1 mg Tier 3 se-natal 19 oral tablet chewable 29-1 mg Tier 3 sodium fluoride oral solution 1.1 (0.5 f) mg/ml CE N2 (Tier 1); AL sodium fluoride oral tablet 1.1 (0.5 f) mg CE N2 (Tier 1); AL sodium fluoride oral tablet 2.2 (1 f) mg Tier 1 sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 CE N2 (Tier 1); AL f) mg

248 Coverage Requirements and Prescription Drug Name Drug Tier Limits sodium fluoride oral tablet chewable 2.2 (1 f) mg Tier 1 TARON-BC ORAL 20-1 MG & 2 X 25 MG (prenatal w/o vit Tier 3 a-fecbn-fa-b6) TARON-C DHA ORAL CAPSULE 53.5-38-1 MG (prenat- Tier 3 fefum-fepo-fa-omega 3) TARON-PREX ORAL CAPSULE 30-1.2-265 MG (prenat- Tier 3 fefum-dss-fa-dha w/o a) tl-care dha oral capsule 27-1-500 mg Tier 3 tl-select oral capsule 29-1.25-325 mg Tier 3 TRICARE ORAL TABLET (prenatal vit-fe fumarate-fa) Tier 3 TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1- Tier 3 500 MG (prenatal-fefum-fa-dss-fish oil) trinatal rx 1 oral tablet 60-1 mg Tier 3 TRINATE ORAL TABLET (prenatal vit-fe fumarate-fa) Tier 1 trinaz oral tablet 12-1 mg NF tristart dha oral capsule 31-0.6-0.4-200 mg Tier 3 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o NF a-fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat Tier 3 w/o a-fecbn-meth-fa-dha) tri-tabs dha oral 32-1 mg Tier 3 TRIVEEN-DUO DHA ORAL 29-1-200 & 400 MG (prenat- Tier 3 febis-fepro-fa-ca-omega) TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 Tier 3 MG/ML (ped vit a-c-d-methylfolate-fl) tri-vi-floro oral suspension 0.25 mg/ml, 0.5 mg/ml Tier 3 ultimatecare one oral capsule 27-1 mg Tier 1 VEMAVITE-PRX 2 ORAL CAPSULE 27-1.25-300 MG Tier 3 (prenat-fefum-dss-fa-dha w/o a) vena-bal dha oral 27-1 & 430 mg Tier 3

249 Coverage Requirements and Prescription Drug Name Drug Tier Limits VINATE II ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg- Tier 3 fa) VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe Tier 3 fumarate-fa) virt nate oral tablet 28-1 mg Tier 3 virt-advance oral tablet 90-1 mg Tier 3 virt-pn dha oral capsule 27-0.6-0.4-300 mg Tier 3 virt-pn oral tablet 27-0.6-0.4 mg Tier 3 virt-pn plus oral capsule 28-0.6-0.4-340 mg Tier 3 virtprex oral capsule 26-1.2-300 mg Tier 3 virt-select oral capsule 29-1.25-325 mg Tier 3 virt-vite forte oral tablet 2.5-25-2 mg Tier 1 virt-vite gt oral tablet 90-1 mg Tier 3 VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG NF (prenat-fe poly-methfol-fa-dha) iron-vitamins (Vitafol Oral Tablet) NF VITAFOL STRIPS ORAL FILM 1 MG (prenatal-b6-b12-d3- NF folic acid) VITAFOL-OB ORAL TABLET (prenatal vit-fe fumarate-fa) Tier 3 VITAFOL-ONE ORAL CAPSULE 29-1-200 MG (prenatal Tier 3 vit-fepoly-fa-dha) VITAL HP 1.0 CAL ORAL LIQUID (nutritional NF supplements) VITAL-D RX ORAL TABLET 1 MG (b complex-c-biotin-d- NF zinc-fa) VITAMEDMD ONE RX/QUATREFOLIC ORAL CAPSULE 30-0.6-0.4-200 MG (prenat w/o a-fe-methfol-fa- Tier 3 dha) vitamin b-6 oral tablet 25 mg, 50 mg Tier 1 vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) Tier 1 vitamin d3 oral capsule 1.25 mg (50000 ut) Tier 1

250 Coverage Requirements and Prescription Drug Name Drug Tier Limits VITAPEARL ORAL CAPSULE EXTENDED RELEASE Tier 3 30-1.4-200 MG (prenat-fefum-fered-fa-dha w/oa) VIVA DHA ORAL CAPSULE 28-1-200 MG (prenatal vit-fe Tier 3 fum-fa-omega) vol-nate oral tablet 28-1 mg Tier 3 vol-plus oral tablet 27-1 mg Tier 3 vol-tab rx oral tablet 29-1 mg Tier 3 vp-ch-pnv oral capsule 30-1-260 mg Tier 3 vp-ggr-b6 prenatal oral tablet 1.2 mg Tier 3 vp-heme ob + dha oral 28-6-1 & 203 mg Tier 3 vp-heme ob oral tablet 28-6-1 mg Tier 3 vp-heme one oral capsule 22-6-1-200 mg Tier 3 vp-pnv-dha oral capsule 28-1-215.8 mg Tier 3 westab max oral tablet 2.5-25-2 mg Tier 1 ZATEAN-PN DHA ORAL CAPSULE 27-0.6-0.4-300 MG Tier 3 (prenat w/o a-fe-methfol-fa-dha) ZATEAN-PN PLUS ORAL CAPSULE 28-0.6-0.4-340 MG Tier 3 (prenat w/o a-fe-methf-fa-omega) OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ANTIALLERGICS - DRUGS TO TREAT ALLERGIES ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil Tier 3 sodium) ALOMIDE OPHTHALMIC SOLUTION 0.1 % (lodoxamide Tier 3 tromethamine) azelastine hcl ophthalmic solution 0.05 % Tier 1 bepotastine besilate ophthalmic solution 1.5 % Tier 1 BEPREVE OPHTHALMIC SOLUTION 1.5 % (bepotastine Tier 3 # besilate) cromolyn sodium ophthalmic solution 4 % Tier 1 epinastine hcl ophthalmic solution 0.05 % Tier 1

251 Coverage Requirements and Prescription Drug Name Drug Tier Limits LASTACAFT OPHTHALMIC SOLUTION 0.25 % Tier 2 (alcaftadine) olopatadine hcl ophthalmic solution 0.1 %, 0.2 % Tier 1 PAZEO OPHTHALMIC SOLUTION 0.7 % (olopatadine hcl) Tier 2 ZERVIATE OPHTHALMIC SOLUTION 0.24 % (cetirizine NF hcl) ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % Tier 3 (brimonidine tartrate) apraclonidine hcl ophthalmic solution 0.5 % Tier 1 AZOPT OPHTHALMIC SUSPENSION 1 % (brinzolamide) Tier 3 BETAGAN OPHTHALMIC SOLUTION 0.5 % (levobunolol NF hcl) betaxolol hcl ophthalmic solution 0.5 % Tier 1 BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 % Tier 3 (timolol hemihydrate) BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % Tier 2 (betaxolol hcl) bimatoprost ophthalmic solution 0.03 % Tier 1 brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % Tier 1 brinzolamide ophthalmic suspension 1 % Tier 1 carteolol hcl ophthalmic solution 1 % Tier 1 COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % Tier 2 # (brimonidine tartrate-timolol) COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML NF (dorzolamide hcl-timolol mal) COSOPT PF OPHTHALMIC SOLUTION 22.3-6.8 MG/ML Tier 3 ST (dorzolamide hcl-timolol mal) dorzolamide hcl ophthalmic solution 2 % Tier 3 dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml Tier 1

252 Coverage Requirements and Prescription Drug Name Drug Tier Limits dorzolamide hcl-timolol mal pf ophthalmic solution 22.3-6.8 Tier 1 mg/ml IOPIDINE OPHTHALMIC SOLUTION 0.5 % NF (apraclonidine hcl) IOPIDINE OPHTHALMIC SOLUTION 1 % (apraclonidine Tier 3 hcl) ISOPTO CARPINE OPHTHALMIC SOLUTION 1 %, 2 %, NF 4 % (pilocarpine hcl) ISTALOL OPHTHALMIC SOLUTION 0.5 % (timolol NF # maleate) latanoprost ophthalmic solution 0.005 % Tier 1 levobunolol hcl ophthalmic solution 0.5 % Tier 1 LUMIGAN OPHTHALMIC SOLUTION 0.01 % Tier 2 ST (bimatoprost) metipranolol ophthalmic solution 0.3 % Tier 1 PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION Tier 3 RECONSTITUTED 0.125 % (echothiophate iodide) pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % Tier 1 RESCULA OPHTHALMIC SOLUTION 0.15 % Tier 3 ST; # (unoprostone isopropyl) SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % Tier 2 (brinzolamide-brimonidine) timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % Tier 1 timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % Tier 1 (daily) timolol maleate pf ophthalmic solution 0.5 % NF TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 Tier 3 %, 0.5 % (timolol maleate) TIMOPTIC OPHTHALMIC SOLUTION 0.25 %, 0.5 % NF (timolol maleate) TIMOPTIC-XE OPHTHALMIC GEL FORMING NF SOLUTION 0.25 %, 0.5 % (timolol maleate)

253 Coverage Requirements and Prescription Drug Name Drug Tier Limits TRAVATAN Z OPHTHALMIC SOLUTION 0.004 % Tier 2 (travoprost) travoprost (bak free) ophthalmic solution 0.004 % Tier 1 TRUSOPT OPHTHALMIC SOLUTION 2 % (dorzolamide NF hcl) VEXOL OPHTHALMIC SUSPENSION 1 % (rimexolone) Tier 3 VYZULTA OPHTHALMIC SOLUTION 0.024 % NF (latanoprostene bunod) XALATAN OPHTHALMIC SOLUTION 0.005 % NF (latanoprost) XELPROS OPHTHALMIC EMULSION 0.005 % Tier 3 PA; ST (latanoprost) ZIOPTAN OPHTHALMIC SOLUTION 0.0015 % Tier 3 ST; # (tafluprost) ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % Tier 1 BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % Tier 2 (sulfacetamide-prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 Tier 2 % (sulfacetamide-prednisolone) double pm ophthalmic solution reconstituted 1-0.5 % NF MAXITROL OPHTHALMIC OINTMENT 3.5-10000-0.1 NF (neomycin-polymyxin-dexameth) MAXITROL OPHTHALMIC SUSPENSION 3.5-10000-0.1 NF (neomycin-polymyxin-dexameth) neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000- Tier 1 0.1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- Tier 1 10000-0.1 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 Tier 1

254 Coverage Requirements and Prescription Drug Name Drug Tier Limits bacitracin-polymyx-neo-hc (Neo-Polycin Hc Ophthalmic Tier 1 Ointment 1 %) PRED-G OPHTHALMIC SUSPENSION 0.3-1 % Tier 3 (gentamicin-prednisolone acet) PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % Tier 3 (gentamicin-prednisolone acet) sulfacetamide-prednisolone ophthalmic solution 10-0.23 % Tier 1 TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % Tier 2 (tobramycin-dexamethasone) TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % NF (tobramycin-dexamethasone) TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % Tier 2 (tobramycin-dexamethasone) tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % Tier 1 ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % Tier 3 (loteprednol-tobramycin) ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS AZASITE OPHTHALMIC SOLUTION 1 % (azithromycin) Tier 2 # BACIGUENT OPHTHALMIC OINTMENT 500 UNIT/GM NF (bacitracin) bacitracin ophthalmic ointment 500 unit/gm Tier 1 bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm Tier 1 BESIVANCE OPHTHALMIC SUSPENSION 0.6 % Tier 3 (besifloxacin hcl) BETADINE OPHTHALMIC PREP OPHTHALMIC Tier 3 SOLUTION 5 % (povidone-iodine) BLEPH-10 OPHTHALMIC SOLUTION 10 % (sulfacetamide NF sodium) CILOXAN OPHTHALMIC OINTMENT 0.3 % Tier 3 (ciprofloxacin hcl) CILOXAN OPHTHALMIC SOLUTION 0.3 % NF (ciprofloxacin hcl)

255 Coverage Requirements and Prescription Drug Name Drug Tier Limits ciprofloxacin hcl ophthalmic solution 0.3 % Tier 1 erythromycin ophthalmic ointment 5 mg/gm Tier 1 gatifloxacin ophthalmic solution 0.5 % Tier 1 GENTAK OPHTHALMIC OINTMENT 0.3 % (gentamicin Tier 1 sulfate) gentamicin sulfate ophthalmic solution 0.3 % Tier 1 levofloxacin ophthalmic solution 0.5 % Tier 1 MOXEZA OPHTHALMIC SOLUTION 0.5 % (moxifloxacin Tier 3 hcl) moxifloxacin hcl (2x day) ophthalmic solution 0.5 % Tier 1 moxifloxacin hcl ophthalmic solution 0.5 % Tier 1 NATACYN OPHTHALMIC SUSPENSION 5 % Tier 2 (natamycin) neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400- Tier 1 10000 neomycin-polymyxin-gramicidin ophthalmic solution 1.75- Tier 1 10000-.025 neomycin-bacitracin zn-polymyx (Neo-Polycin Ophthalmic Tier 1 Ointment 3.5-400-10000) NEOSPORIN OPHTHALMIC SOLUTION 1.75-10000-.025 NF (neomycin-polymyxin-gramicidin) OCUFLOX OPHTHALMIC SOLUTION 0.3 % (ofloxacin) NF ofloxacin ophthalmic solution 0.3 % Tier 1 bacitracin-polymyxin b (Polycin Ophthalmic Ointment 500- Tier 1 10000 Unit/Gm) polymyxin b-trimethoprim ophthalmic solution 10000-0.1 Tier 1 unit/ml-% POLYTRIM OPHTHALMIC SOLUTION 10000-0.1 NF UNIT/ML-% (polymyxin b-trimethoprim) sulfacetamide sodium ophthalmic ointment 10 % Tier 1 sulfacetamide sodium ophthalmic solution 10 % Tier 1

256 Coverage Requirements and Prescription Drug Name Drug Tier Limits tobramycin ophthalmic solution 0.3 % Tier 1 TOBREX OPHTHALMIC OINTMENT 0.3 % (tobramycin) Tier 3 TOBREX OPHTHALMIC SOLUTION 0.3 % (tobramycin) NF trifluridine ophthalmic solution 1 % Tier 1 VIGAMOX OPHTHALMIC SOLUTION 0.5 % NF (moxifloxacin hcl) VIROPTIC OPHTHALMIC SOLUTION 1 % (trifluridine) NF ZIRGAN OPHTHALMIC GEL 0.15 % (ganciclovir) Tier 3 # ZYMAXID OPHTHALMIC SOLUTION 0.5 % NF (gatifloxacin) ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ACULAR LS OPHTHALMIC SOLUTION 0.4 % (ketorolac NF tromethamine) ACULAR OPHTHALMIC SOLUTION 0.5 % (ketorolac NF tromethamine) ACUVAIL OPHTHALMIC SOLUTION 0.45 % (ketorolac Tier 2 tromethamine) ALREX OPHTHALMIC SUSPENSION 0.2 % (loteprednol Tier 3 etabonate) bromfenac sodium (once-daily) ophthalmic solution 0.09 % Tier 1 BROMSITE OPHTHALMIC SOLUTION 0.075 % NF (bromfenac sodium) dexamethasone sodium phosphate ophthalmic solution 0.1 % Tier 1 diclofenac sodium ophthalmic solution 0.1 % Tier 1 DUREZOL OPHTHALMIC EMULSION 0.05 % Tier 3 # (difluprednate) EYSUVIS OPHTHALMIC SUSPENSION 0.25 % NF (loteprednol etabonate) FLAREX OPHTHALMIC SUSPENSION 0.1 % Tier 3 (fluorometholone acetate) fluorometholone ophthalmic suspension 0.1 % Tier 1 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

257 Coverage Requirements and Prescription Drug Name Drug Tier Limits flurbiprofen sodium ophthalmic solution 0.03 % Tier 1 FML FORTE OPHTHALMIC SUSPENSION 0.25 % Tier 2 (fluorometholone) FML OPHTHALMIC OINTMENT 0.1 % (fluorometholone) Tier 2 ILEVRO OPHTHALMIC SUSPENSION 0.3 % (nepafenac) Tier 2 INVELTYS OPHTHALMIC SUSPENSION 1 % (loteprednol Tier 3 etabonate) ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % Tier 1 LOTEMAX OPHTHALMIC GEL 0.5 % (loteprednol Tier 3 # etabonate) LOTEMAX OPHTHALMIC OINTMENT 0.5 % (loteprednol Tier 3 etabonate) LOTEMAX OPHTHALMIC SUSPENSION 0.5 % NF (loteprednol etabonate) LOTEMAX SM OPHTHALMIC GEL 0.38 % (loteprednol Tier 3 # etabonate) loteprednol etabonate ophthalmic gel 0.5 % NF loteprednol etabonate ophthalmic suspension 0.5 % Tier 1 MAXIDEX OPHTHALMIC SUSPENSION 0.1 % Tier 2 (dexamethasone) NEVANAC OPHTHALMIC SUSPENSION 0.1 % Tier 2 (nepafenac) PRED MILD OPHTHALMIC SUSPENSION 0.12 % Tier 2 (prednisolone acetate) prednisolone acetate ophthalmic suspension 1 % Tier 1 prednisolone sodium phosphate ophthalmic solution 1 % Tier 3 PROLENSA OPHTHALMIC SOLUTION 0.07 % NF (bromfenac sodium) DRY EYE DISEASE XIIDRA OPHTHALMIC SOLUTION 5 % (lifitegrast) Tier 3

258 Coverage Requirements and Prescription Drug Name Drug Tier Limits MISCELLANEOUS naphazoline hcl ophthalmic solution 0.1 % Tier 1 RHOPRESSA OPHTHALMIC SOLUTION 0.02 % Tier 3 ST (netarsudil dimesylate) ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % Tier 3 ST (netarsudil-latanoprost) OTHER IRRIGATION SOLUTIONS irrigation solns physiological (Physiolyte Irrigation Solution) Tier 1 irrigation solns physiological (Physiosol Irrigation Irrigation Tier 1 Solution) ringers irrigation irrigation solution Tier 1 ringers irrigation (Tis-U-Sol Irrigation Solution) Tier 1 PHARMACEUTICAL ADJUVANTS ORAL VEHICLES mouth wash-gp oral liquid NF mouthwash-af oral liquid NF mouthwash-om oral liquid NF RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ANAPHYLAXIS TREATMENT AGENTS ADYPHREN AMP II INJECTION KIT 1 MG/ML NF (epinephrine) ADYPHREN AMP INJECTION KIT 1 MG/ML NF (epinephrine) ADYPHREN II INJECTION KIT 1 MG/ML (epinephrine) NF ADYPHREN INJECTION KIT 1 MG/ML (epinephrine) NF AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 NF MG/0.1ML, 0.15 MG/0.15ML, 0.3 MG/0.3ML (epinephrine) epinephrine injection solution auto-injector 0.15 mg/0.15ml Tier 1 QL (1 pack per 1 fill)

259 Coverage Requirements and Prescription Drug Name Drug Tier Limits epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 Tier 1 QL (8 pens per 1 month) mg/0.3ml EPISNAP INJECTION KIT 1 MG/ML (epinephrine) NF SYMJEPI INJECTION SOLUTION PREFILLED Tier 3 QL (4 syringes per 30 days) SYRINGE 0.15 MG/0.3ML, 0.3 MG/0.3ML (epinephrine) ANTIALLERGICS - DRUGS TO TREAT ALLERGIES acetylcysteine inhalation solution 10 % Tier 1 PATANASE NASAL SOLUTION 0.6 % (olopatadine hcl) NF ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPD AIRDUO RESPICLICK 113/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT NF (fluticasone-salmeterol) AIRDUO RESPICLICK 232/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 232-14 MCG/ACT NF (fluticasone-salmeterol) AIRDUO RESPICLICK 55/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 55-14 MCG/ACT NF (fluticasone-salmeterol) ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- Tier 3 QL (1 kit per 1 fill) vilanterol) BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 Tier 2 MCG/ACT (glycopyrrolate-formoterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160- NF 9-4.8 MCG/ACT (budeson-glycopyrrol-formoterol) COMBIVENT RESPIMAT INHALATION AEROSOL Tier 3 QL (3 inhalers per 1 month) SOLUTION 20-100 MCG/ACT (ipratropium-albuterol) DULERA INHALATION AEROSOL 100-5 MCG/ACT, Tier 2 #; QL (1 inhaler per 1 fill) 200-5 MCG/ACT (mometasone furo-formoterol fum) DULERA INHALATION AEROSOL 50-5 MCG/ACT #; QL (1 inhaler per 1 Tier 2 (mometasone furo-formoterol fum) month)

260 Coverage Requirements and Prescription Drug Name Drug Tier Limits fluticasone-salmeterol inhalation aerosol powder breath Tier 1 QL (1 inhaler per 30 days) activated 113-14 mcg/act, 232-14 mcg/act, 55-14 mcg/act ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml Tier 1 QL (6 boxes per 30 days) STIOLTO RESPIMAT INHALATION AEROSOL ST; QL (1 inhaler per 1 SOLUTION 2.5-2.5 MCG/ACT (tiotropium bromide- Tier 3 month) olodaterol) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH Tier 2 (fluticasone-umeclidin-vilant) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 200-62.5-25 MCG/INH Tier 2 QL (1 pack per 1 month) (fluticasone-umeclidin-vilant) UTIBRON NEOHALER INHALATION CAPSULE 27.5- NF 15.6 MCG (indacaterol-glycopyrrolate) ANTICHOLINERGICS - DRUGS TO TREAT COPD ATROVENT HFA INHALATION AEROSOL SOLUTION Tier 3 QL (2 inhalers per 1 month) 17 MCG/ACT (ipratropium bromide hfa) INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH (umeclidinium Tier 2 QL (1 blister per 1 day) bromide) ipratropium bromide inhalation solution 0.02 % Tier 1 QL (5 boxes per 25 days) ipratropium bromide nasal solution 0.03 %, 0.06 % Tier 1 LONHALA MAGNAIR REFILL KIT INHALATION NF SOLUTION 25 MCG/ML (glycopyrrolate) LONHALA MAGNAIR STARTER KIT INHALATION NF SOLUTION 25 MCG/ML (glycopyrrolate) SEEBRI NEOHALER INHALATION CAPSULE 15.6 NF MCG (glycopyrrolate) SPIRIVA HANDIHALER INHALATION CAPSULE 18 Tier 2 QL (1 capsule per 1 day) MCG (tiotropium bromide monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT (tiotropium Tier 2 QL (1 inhaler per 30 days) bromide monohydrate)

261 Coverage Requirements and Prescription Drug Name Drug Tier Limits TUDORZA PRESSAIR INHALATION AEROSOL PA; ST; QL (1 inhaler per 1 POWDER BREATH ACTIVATED 400 MCG/ACT Tier 3 month) (aclidinium bromide) YUPELRI INHALATION SOLUTION 175 MCG/3ML NF (revefenacin) ANTIHISTAMINE COMBINATIONS azelastine-fluticasone nasal suspension 137-50 mcg/act Tier 1 QL (1 package per 1 month) DYMISTA NASAL SUSPENSION 137-50 MCG/ACT Tier 2 (azelastine-fluticasone) ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES ALAVERT ORAL TABLET 10 MG (loratadine) Tier 1 OTC ALAVERT ORAL TABLET DISPERSIBLE 10 MG Tier 1 OTC (loratadine) ALLEGRA ALLERGY CHILDRENS ORAL Tier 1 OTC SUSPENSION 30 MG/5ML (fexofenadine hcl) ALLEGRA ALLERGY CHILDRENS ORAL TABLET Tier 1 OTC DISPERSIBLE 30 MG (fexofenadine hcl) ALLEGRA ALLERGY ORAL TABLET 180 MG, 60 MG Tier 1 OTC (fexofenadine hcl) azelastine hcl nasal solution 0.1 % Tier 1 azelastine hcl nasal solution 0.15 %, 137 mcg/spray Tier 1 QL (60 ml per 30 days) brompheniramine tannate oral tablet chewable 12 mg Tier 1 carbinoxamine maleate oral solution 4 mg/5ml Tier 1 carbinoxamine maleate oral tablet 4 mg Tier 1 carbinoxamine maleate oral tablet 6 mg NF cetirizine hcl oral syrup 1 mg/ml Tier 1 OTC cetirizine hcl oral tablet 10 mg, 5 mg Tier 1 OTC cetirizine hcl oral tablet chewable 10 mg, 5 mg Tier 1 OTC CLARINEX ORAL SYRUP 0.5 MG/ML (desloratadine) NF CLARINEX ORAL TABLET 5 MG (desloratadine) NF

262 Coverage Requirements and Prescription Drug Name Drug Tier Limits CLARITIN CHILDRENS ORAL TABLET CHEWABLE 5 Tier 1 OTC MG (loratadine) CLARITIN ORAL SYRUP 5 MG/5ML (loratadine) Tier 1 OTC CLARITIN ORAL TABLET 10 MG (loratadine) Tier 1 OTC CLARITIN ORAL TABLET CHEWABLE 5 MG Tier 1 OTC (loratadine) CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 Tier 1 OTC MG, 5 MG (loratadine) clemastine fumarate oral syrup 0.67 mg/5ml NF clemastine fumarate oral tablet 2.68 mg Tier 1 PA; OTC; AL cyproheptadine hcl oral syrup 2 mg/5ml Tier 1 cyproheptadine hcl oral tablet 4 mg Tier 1 desloratadine oral tablet 5 mg Tier 1 desloratadine oral tablet dispersible 2.5 mg, 5 mg Tier 1 diphenhydramine hcl oral elixir 12.5 mg/5ml Tier 1 PA; AL fexofenadine hcl childrens oral suspension 30 mg/5ml Tier 1 OTC fexofenadine hcl oral tablet 180 mg, 60 mg Tier 1 OTC hydroxyzine hcl oral syrup 10 mg/5ml Tier 1 PA; AL hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg Tier 1 PA; AL hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg Tier 1 PA; AL KARBINAL ER ORAL SUSPENSION EXTENDED NF RELEASE 4 MG/5ML (carbinoxamine maleate) levocetirizine dihydrochloride oral solution 2.5 mg/5ml Tier 1 levocetirizine dihydrochloride oral tablet 5 mg Tier 1 loratadine allergy relief oral tablet dispersible 10 mg Tier 1 OTC loratadine childrens oral syrup 5 mg/5ml Tier 1 OTC loratadine oral tablet 10 mg Tier 1 OTC loratadine oral tablet chewable 5 mg Tier 1 OTC MUCINEX ALLERGY ORAL TABLET 180 MG Tier 1 OTC (fexofenadine hcl)

263 Coverage Requirements and Prescription Drug Name Drug Tier Limits olopatadine hcl nasal solution 0.6 % Tier 1 QL (1 container per 30 days) RYCLORA ORAL SOLUTION 2 MG/5ML NF (dexchlorpheniramine maleate) RYCLORA ORAL SYRUP 2 MG/5ML NF (dexchlorpheniramine maleate) RYVENT ORAL TABLET 6 MG (carbinoxamine maleate) NF VISTARIL ORAL CAPSULE 25 MG, 50 MG (hydroxyzine NF pamoate) XYZAL ALLERGY 24HR CHILDRENS ORAL Tier 1 OTC SOLUTION 2.5 MG/5ML (levocetirizine dihydrochloride) XYZAL ALLERGY 24HR ORAL TABLET 5 MG Tier 1 OTC (levocetirizine dihydrochloride) ZYRTEC ALLERGY ORAL CAPSULE 10 MG (cetirizine Tier 1 OTC hcl) ZYRTEC ALLERGY ORAL TABLET 10 MG (cetirizine Tier 1 OTC hcl) ZYRTEC CHILDRENS ALLERGY ORAL SYRUP 1 Tier 1 OTC MG/ML (cetirizine hcl) BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 Tier 1 mg albuterol sulfate hfa inhalation aerosol solution 108 (90 base) Tier 1 QL (2 inhalers per 30 days) mcg/act albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) Tier 1 QL (5 boxes per 1 month) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml albuterol sulfate inhalation nebulization solution (5 mg/ml) Tier 3 0.5% albuterol sulfate inhalation nebulization solution 2.5 mg/0.5ml Tier 1 QL (2 ml per 1 day) albuterol sulfate oral syrup 2 mg/5ml Tier 1 albuterol sulfate oral tablet 2 mg, 4 mg Tier 1

264 Coverage Requirements and Prescription Drug Name Drug Tier Limits ARCAPTA NEOHALER INHALATION CAPSULE 75 NF MCG (indacaterol maleate) arformoterol tartrate inhalation nebulization solution 15 NF mcg/2ml BROVANA INHALATION NEBULIZATION SOLUTION PA; ST; #; QL (60 vials per Tier 3 15 MCG/2ML (arformoterol tartrate) 1 fill) formoterol fumarate inhalation nebulization solution 20 mcg/2ml Tier 1 QL (30 vials per 1 month) levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, Tier 1 QL (10 ml per 1 day) 0.63 mg/3ml, 1.25 mg/3ml levalbuterol hcl inhalation nebulization solution 1.25 mg/0.5ml Tier 1 QL (45 ml per 1 month) levalbuterol tartrate inhalation aerosol 45 mcg/act Tier 1 QL (2 inhalers per 1 month) metaproterenol sulfate oral syrup 10 mg/5ml Tier 1 metaproterenol sulfate oral tablet 10 mg, 20 mg Tier 1 PERFOROMIST INHALATION NEBULIZATION Tier 3 #; QL (30 vials per 1 month) SOLUTION 20 MCG/2ML (formoterol fumarate) PROAIR DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) NF MCG/ACT, 108 MCG/ACT (albuterol sulfate) PROAIR HFA INHALATION AEROSOL SOLUTION 108 NF (90 BASE) MCG/ACT (albuterol sulfate) PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) NF MCG/ACT (albuterol sulfate) PROVENTIL HFA INHALATION AEROSOL SOLUTION NF 108 (90 BASE) MCG/ACT (albuterol sulfate) SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE NF (salmeterol xinafoate) STRIVERDI RESPIMAT INHALATION AEROSOL Tier 2 QL (1 inhaler per 30 days) SOLUTION 2.5 MCG/ACT (olodaterol hcl) terbutaline sulfate oral tablet 2.5 mg, 5 mg Tier 1 VENTOLIN HFA INHALATION AEROSOL SOLUTION Tier 2 108 (90 BASE) MCG/ACT (albuterol sulfate) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

265 Coverage Requirements and Prescription Drug Name Drug Tier Limits VOSPIRE ER ORAL TABLET EXTENDED RELEASE 12 NF HOUR 4 MG, 8 MG (albuterol sulfate) XOPENEX CONCENTRATE INHALATION NEBULIZATION SOLUTION 1.25 MG/0.5ML (levalbuterol NF hcl) XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT NF (levalbuterol tartrate) XOPENEX INHALATION NEBULIZATION SOLUTION 0.31 MG/3ML, 0.63 MG/3ML, 1.25 MG/3ML (levalbuterol NF hcl) BIOLOGIC RESPONSE MODIFIERS FASENRA PEN SUBCUTANEOUS SOLUTION AUTO- PA; NPL; SP Pharmacy; QL Tier 4 INJECTOR 30 MG/ML (benralizumab) (1 pen per 56 days) NUCALA SUBCUTANEOUS SOLUTION AUTO- Tier 4 INJECTOR 100 MG/ML (mepolizumab) NUCALA SUBCUTANEOUS SOLUTION PREFILLED Tier 4 SYRINGE 100 MG/ML (mepolizumab) XOLAIR SUBCUTANEOUS SOLUTION PREFILLED PA; SP Pharmacy; QL (8 Tier 4 SYRINGE 150 MG/ML (omalizumab) syringes per 28 days) XOLAIR SUBCUTANEOUS SOLUTION PREFILLED PA; SP Pharmacy; QL (2 Tier 4 SYRINGE 75 MG/0.5ML (omalizumab) injections per 1 month) XOLAIR SUBCUTANEOUS SOLUTION PA; SP Pharmacy; QL (8 Tier 4 RECONSTITUTED 150 MG (omalizumab) vials per 28 days) COLD/COUGH ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HOUR 5-120 MG (loratadine- Tier 1 OTC pseudoephedrine) ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HOUR 60-120 MG Tier 1 OTC (fexofenadine-pseudoephedrine) ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 24 HOUR 180-240 MG Tier 1 OTC (fexofenadine-pseudoephedrine)

266 Coverage Requirements and Prescription Drug Name Drug Tier Limits benzonatate oral capsule 100 mg, 200 mg Tier 1 benzonatate oral capsule 150 mg NF CARBAPHEN 12 ORAL LIQUID 10-4-27.5 MG/5ML NF (phenyleph-chlorphen-carbetapen) CARBAPHEN 12 PED ORAL SUSPENSION 2.5-1.25-7.5 NF MG/ML (phenyleph-chlorphen-carbetapen) cetirizine-pseudoephedrine er oral tablet extended release 12 Tier 1 OTC hour 5-120 mg CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR 2.5-120 MG (desloratadine- NF pseudoephedrine) CLARITIN-D 12 HOUR ORAL TABLET EXTENDED Tier 1 OTC RELEASE 12 HOUR 5-120 MG (loratadine-pseudoephedrine) CLARITIN-D 24 HOUR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-240 MG (loratadine- Tier 1 OTC pseudoephedrine) CODAR AR ORAL LIQUID 2-8 MG/5ML NF (chlorpheniramine-codeine) DECON-A ORAL ELIXIR 2-5 MG/5ML (brompheniramine- NF phenylephrine) fexofenadine-pseudoephed er oral tablet extended release 12 Tier 1 OTC hour 60-120 mg fexofenadine-pseudoephed er oral tablet extended release 24 Tier 1 OTC hour 180-240 mg HYCOFENIX ORAL SOLUTION 30-2.5-200 MG/5ML NF (pseudoeph-hydrocodone-gg) hydrocod polst-cpm polst er oral suspension extended release 10- PA; QL (10 ML per day for Tier 1 8 mg/5ml 7 days per 30 days) PA; QL (60 ml per 1 day hydrocodone-guaifenesin oral solution 2.5-200 mg/5ml Tier 1 over 5 days in a 30 day period) PA; QL (30 ML per day for hydrocodone-homatropine oral syrup 5-1.5 mg/5ml Tier 1 7 days per 30 days)

267 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; QL (6 tablets per day hydrocodone-homatropine oral tablet 5-1.5 mg Tier 1 for 7 days per 30 days) PA; QL (30 ML per day for hydromet oral syrup 5-1.5 mg/5ml Tier 1 7 days per 30 days) HYPERSAL INHALATION NEBULIZATION NF SOLUTION 7 % (sodium chloride) loratadine-d 12hr oral tablet extended release 12 hour 5-120 mg Tier 1 OTC loratadine-d 24hr oral tablet extended release 24 hour 10-240 Tier 1 OTC mg sodium chloride (Nebusal Inhalation Nebulization Solution 3 Tier 1 OTC %) NEBUSAL INHALATION NEBULIZATION SOLUTION NF 6 % (sodium chloride) NEOTUSS PLUS ORAL LIQUID 7.5-4-30 MG/5ML NF (phenylephrine-chlorphen-dm) NORTUSS-DE ORAL LIQUID 2.5-5-50 MG/ML NF (phenylephrine-dm-gg) nortuss-ex oral liquid 20-200 mg/5ml NF promethazine vc oral syrup 6.25-5 mg/5ml NF PA; QL (30 ML per day for promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml Tier 1 7 days per 30 days) promethazine-dm oral syrup 6.25-15 mg/5ml Tier 1 promethazine-phenylephrine oral syrup 6.25-5 mg/5ml Tier 1 pseudoeph-chlorphen-hydrocod oral solution 60-4-5 mg/5ml Tier 1 sodium chloride (Pulmosal Inhalation Nebulization Solution 7 Tier 1 %) RELHIST ORAL TABLET CHEWABLE 6-15 MG NF (bromphen tann-phenyleph tann) SEMPREX-D ORAL CAPSULE 8-60 MG (acrivastine- Tier 3 pseudoephedrine) SSKI ORAL SOLUTION 1 GM/ML (potassium iodide Tier 3 (expectorant))

268 Coverage Requirements and Prescription Drug Name Drug Tier Limits TESSALON PERLES ORAL CAPSULE 100 MG NF (benzonatate) tgq 15dm/5peh/2cpm oral syrup 15-5-2 mg/5ml NF tgq 30pse/150gfn/15dm oral syrup 30-150-15 mg/5ml NF tgq 30pse/3brm/15dm oral syrup 30-3-15 mg/5ml NF TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 PA; QL (2 capsules per day Tier 3 HOUR 10-8 MG, 5-4 MG (hydrocod polst-chlorphen polst) for 7 days per 30 days) PA; QL (6 tablets per day hydrocodone-homatropine (Tussigon Oral Tablet 5-1.5 Mg) Tier 1 for 7 days per 30 days) TUSSIONEX PENNKINETIC ER ORAL SUSPENSION EXTENDED RELEASE 10-8 MG/5ML (hydrocod polst- NF chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE PA; QL (2 tablets per day Tier 3 12 HOUR 54.3-8 MG (chlorpheniramine-codeine) for 7 days per 30 days) TUZISTRA XR ORAL SUSPENSION EXTENDED PA; QL (20 ML per day for Tier 3 RELEASE 14.7-2.8 MG/5ML (codeine polst-chlorphen polst) 7 days per 30 days) ZONATUSS ORAL CAPSULE 150 MG (benzonatate) NF ZUTRIPRO ORAL SOLUTION 60-4-5 MG/5ML NF (pseudoeph-chlorphen-hydrocod) ZYRTEC-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HOUR 5-120 MG (cetirizine- Tier 1 OTC pseudoephedrine) LEUKOTRIENE MODIFIERS zileuton er oral tablet extended release 12 hour 600 mg Tier 1 ZYFLO ORAL TABLET 600 MG (zileuton) Tier 3 QL (4 tablets per 1 day) LEUKOTRIENE RECEPTOR ANTAGONISTS - DRUGS TO TREAT ASTHMA AND ALLERGIES ACCOLATE ORAL TABLET 10 MG, 20 MG (zafirlukast) NF montelukast sodium oral packet 4 mg Tier 1 montelukast sodium oral tablet 10 mg Tier 1 montelukast sodium oral tablet chewable 4 mg, 5 mg Tier 1 SINGULAIR ORAL PACKET 4 MG (montelukast sodium) NF 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

269 Coverage Requirements and Prescription Drug Name Drug Tier Limits SINGULAIR ORAL TABLET 10 MG (montelukast sodium) NF SINGULAIR ORAL TABLET CHEWABLE 4 MG, 5 MG NF (montelukast sodium) zafirlukast oral tablet 10 mg, 20 mg Tier 1 ZYFLO CR ORAL TABLET EXTENDED RELEASE 12 NF HOUR 600 MG (zileuton) MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIES cromolyn sodium inhalation nebulization solution 20 mg/2ml Tier 1 QL (2 boxes per 1 month) MISCELLANEOUS acetylcysteine inhalation solution 20 % Tier 1 ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl Tier 3 (nasal)) ALZAIR ALLERGY NASAL SPRAY NASAL POWDER NF (hypromellose) BRONCHITOL INHALATION CAPSULE 40 MG NF (mannitol (cystic fibrosis)) DALIRESP ORAL TABLET 250 MCG, 500 MCG Tier 3 PA; # (roflumilast) dyphylline-guaifenesin (Difil-G Forte Oral Liquid 100-100 NF Mg/5Ml) PA; QL (9 capsules per 1 ESBRIET ORAL CAPSULE 267 MG (pirfenidone) Tier 4 day) ESBRIET ORAL TABLET 267 MG (pirfenidone) Tier 4 PA; QL (9 tablets per 1 day) ESBRIET ORAL TABLET 801 MG (pirfenidone) Tier 4 PA; QL (3 tablets per 1 day) HYPERSAL INHALATION NEBULIZATION NF SOLUTION 3.5 % (sodium chloride) KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG PA; SP Pharmacy; QL (2 Tier 4 (ivacaftor) packets per 1 day) PA; SP Pharmacy; QL (2 KALYDECO ORAL TABLET 150 MG (ivacaftor) Tier 4 tablets per 1 day)

270 Coverage Requirements and Prescription Drug Name Drug Tier Limits ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG PA; SP Pharmacy; QL (2 Tier 4 (lumacaftor-ivacaftor) packets per 1 day) ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG PA; SP Pharmacy; QL (4 Tier 4 (lumacaftor-ivacaftor) tablets per 1 day) sodium chloride inhalation nebulization solution 0.9 %, 10 %, 7 Tier 1 % sodium chloride inhalation nebulization solution 3 % Tier 1 OTC SYMDEKO ORAL TABLET THERAPY PACK 100-150 & PA; SP Pharmacy; QL (2 Tier 4 150 MG (tezacaftor-ivacaftor) tablets per 1 Day) SYMDEKO ORAL TABLET THERAPY PACK 50-75 & 75 PA; SP Pharmacy; QL (2 Tier 4 MG (tezacaftor-ivacaftor) tablets per 1 day) TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 PA; SP Pharmacy; QL (1 Tier 4 & 150 MG (elexacaftor-tezacaftor-ivacaft) pack per 28 days) NASAL STEROIDS - DRUGS TO TREAT ALLERGIES BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY Tier 3 ST (beclomethasone diprop monohyd) FLONASE ALLERGY RELIEF NASAL SUSPENSION 50 Tier 1 OTC MCG/ACT (fluticasone propionate) flunisolide nasal solution 25 mcg/act (0.025%) Tier 1 QL (75 ml per 30 days) OTC; QL (1 16 gram bottle fluticasone propionate nasal suspension 50 mcg/act Tier 1 per 30 days) mometasone furoate nasal suspension 50 mcg/act Tier 1 QL (34 grams per 30 days) NASACORT ALLERGY 24HR NASAL AEROSOL 55 OTC; QL (17 grams per 30 Tier 1 MCG/ACT (triamcinolone acetonide) days) NASONEX NASAL SUSPENSION 50 MCG/ACT NF (mometasone furoate) OMNARIS NASAL SUSPENSION 50 MCG/ACT ST; #; QL (1 inhaler per 30 Tier 3 (ciclesonide) days) QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 Tier 3 ST MCG/ACT (beclomethasone diprop (nasal)) QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT Tier 3 ST (beclomethasone diprop (nasal))

271 Coverage Requirements and Prescription Drug Name Drug Tier Limits RHINOCORT ALLERGY NASAL SUSPENSION 32 Tier 1 OTC MCG/ACT (budesonide) OTC; QL (1 bottle per 1 triamcinolone acetonide nasal aerosol 55 mcg/act Tier 1 day) XHANCE NASAL EXHALER SUSPENSION 93 NF MCG/ACT (fluticasone propionate) ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT Tier 3 ST (ciclesonide) PULMONARY FIBROSIS AGENTS OFEV ORAL CAPSULE 100 MG, 150 MG (nintedanib NF esylate) SEVERE ASTHMA AGENTS DUPIXENT SOLUTION PEN-INJECTOR 200 MG/1.14ML SUBCUTANEOUS 200 MG/1.14ML NF (dupilumab) DUPIXENT SOLUTION PREFILLED SYRINGE 200 PA; SP Pharmacy; QL (2 MG/1.14ML SUBCUTANEOUS 200 MG/1.14ML Tier 4 syringes per 4 weeks) (dupilumab) DUPIXENT SOLUTION PREFILLED SYRINGE 300 PA; SP Pharmacy; QL (2 Tier 4 MG/2ML SUBCUTANEOUS 300 MG/2ML (dupilumab) syringes per 4 weeks) STEROID INHALANTS - DRUGS TO TREAT ASTHMA AEROSPAN INHALATION AEROSOL SOLUTION 80 NF MCG/ACT (flunisolide hfa) ALVESCO INHALATION AEROSOL SOLUTION 160 ST; QL (2 inhalers per 1 Tier 3 MCG/ACT (ciclesonide) month) ALVESCO INHALATION AEROSOL SOLUTION 80 ST; QL (1 inhaler per 1 Tier 3 MCG/ACT (ciclesonide) month) ARMONAIR DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113 MCG/ACT, 232 NF MCG/ACT, 55 MCG/ACT (fluticasone propionate (inhal)) ARMONAIR RESPICLICK 113 INHALATION AEROSOL POWDER BREATH ACTIVATED 113 NF MCG/ACT (fluticasone propionate (inhal))

272 Coverage Requirements and Prescription Drug Name Drug Tier Limits ARMONAIR RESPICLICK 232 INHALATION AEROSOL POWDER BREATH ACTIVATED 232 NF MCG/ACT (fluticasone propionate (inhal)) ARMONAIR RESPICLICK 55 INHALATION AEROSOL POWDER BREATH ACTIVATED 55 MCG/ACT NF (fluticasone propionate (inhal)) ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 Tier 2 MCG/ACT, 50 MCG/ACT (fluticasone furoate) ASMANEX (120 METERED DOSES) INHALATION ST; #; QL (1 inhaler per 1 AEROSOL POWDER BREATH ACTIVATED 220 Tier 3 month) MCG/INH (mometasone furoate) ASMANEX (14 METERED DOSES) INHALATION ST; #; QL (1 inhaler per 1 AEROSOL POWDER BREATH ACTIVATED 220 Tier 3 month) MCG/INH (mometasone furoate) ASMANEX (30 METERED DOSES) INHALATION ST; #; QL (1 inhaler per 1 AEROSOL POWDER BREATH ACTIVATED 110 Tier 3 month) MCG/INH, 220 MCG/INH (mometasone furoate) ASMANEX (60 METERED DOSES) INHALATION ST; #; QL (1 inhaler per 1 AEROSOL POWDER BREATH ACTIVATED 220 Tier 3 month) MCG/INH (mometasone furoate) ASMANEX (7 METERED DOSES) INHALATION ST; #; QL (1 inhaler per 1 AEROSOL POWDER BREATH ACTIVATED 110 Tier 3 month) MCG/INH (mometasone furoate) ASMANEX HFA INHALATION AEROSOL 100 ST; QL (1 inhaler per 1 Tier 3 MCG/ACT, 200 MCG/ACT (mometasone furoate) month) ASMANEX HFA INHALATION AEROSOL 50 NF MCG/ACT (mometasone furoate) budesonide inhalation suspension 0.25 mg/2ml Tier 1 QL (4 vials per 1 day) budesonide inhalation suspension 0.5 mg/2ml Tier 1 QL (4 mls per 1 day) budesonide inhalation suspension 1 mg/2ml Tier 1 QL (1 vial per 1 day) FLOVENT DISKUS INHALATION AEROSOL POWDER ST; #; QL (2 blisters per 1 BREATH ACTIVATED 100 MCG/BLIST, 250 Tier 3 day) MCG/BLIST, 50 MCG/BLIST (fluticasone propionate (inhal)) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

273 Coverage Requirements and Prescription Drug Name Drug Tier Limits FLOVENT HFA INHALATION AEROSOL 110 ST; #; QL (1 inhaler per 1 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT (fluticasone Tier 3 month) propionate hfa) PULMICORT FLEXHALER INHALATION AEROSOL PA; ST; QL (1 inhaler per 1 POWDER BREATH ACTIVATED 180 MCG/ACT, 90 Tier 3 month) MCG/ACT (budesonide) PULMICORT INHALATION SUSPENSION 0.25 NF MG/2ML, 0.5 MG/2ML, 1 MG/2ML (budesonide) PULMOZYME INHALATION SOLUTION 1 MG/ML PA; SP Pharmacy; QL (60 Tier 4 (dornase alfa) units per 1 fill) QVAR INHALATION AEROSOL SOLUTION 40 Tier 2 QL (1 inhaler per 1 month) MCG/ACT, 80 MCG/ACT (beclomethasone dipropionate) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT (beclomethasone Tier 2 QL (1 inhaler per 1 month) diprop hfa) STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPD ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE (fluticasone- NF salmeterol) ADVAIR DISKUS INHALATION AEROSOL POWDER ST; QL (1 diskus per 1 BREATH ACTIVATED 250-50 MCG/DOSE (fluticasone- Tier 3 month) salmeterol) ADVAIR DISKUS INHALATION AEROSOL POWDER ST; QL (2 inhalers per 1 BREATH ACTIVATED 500-50 MCG/DOSE (fluticasone- Tier 3 month) salmeterol) ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT Tier 2 QL (1 inhaler per 1 month) (fluticasone-salmeterol) AIRDUO DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232- NF 14 MCG/ACT, 55-14 MCG/ACT (fluticasone-salmeterol)

274 Coverage Requirements and Prescription Drug Name Drug Tier Limits BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 Tier 3 ST; QL (2 blisters per 1 day) MCG/INH (fluticasone furoate-vilanterol) budesonide-formoterol fumarate inhalation aerosol 160-4.5 Tier 1 QL (1 inhaler per 1 month) mcg/act, 80-4.5 mcg/act DUAKLIR PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400-12 MCG/ACT NF (aclidinium br-formoterol fum) fluticasone-salmeterol inhalation aerosol powder breath Tier 1 QL (2 inhalations per 1 day) activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT (budesonide-formoterol NF fumarate) fluticasone-salmeterol (Wixela Inhub Inhalation Aerosol Powder Breath Activated 100-50 Mcg/Dose, 250-50 Tier 1 QL (2 inhalations per 1 day) Mcg/Dose, 500-50 Mcg/Dose) XANTHINES - DRUGS TO TREAT COPD ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML Tier 3 (theophylline) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 Tier 3 HOUR 100 MG, 200 MG, 300 MG, 400 MG (theophylline) THEOCHRON ORAL TABLET EXTENDED RELEASE Tier 1 12 HOUR 100 MG, 200 MG (theophylline) theophylline (Theochron Oral Tablet Extended Release 12 Tier 1 Hour 300 Mg) theophylline er oral tablet extended release 12 hour 100 mg, 200 Tier 1 mg, 300 mg, 450 mg theophylline er oral tablet extended release 24 hour 400 mg, 600 Tier 1 mg theophylline oral solution 80 mg/15ml Tier 1

275 Coverage Requirements and Prescription Drug Name Drug Tier Limits TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE ABSORICA LD ORAL CAPSULE 16 MG, 24 MG, 32 MG, NF 8 MG (isotretinoin micronized) ABSORICA ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 NF MG (isotretinoin) ABSORICA ORAL CAPSULE 25 MG, 35 MG (isotretinoin) NF # ACANYA EXTERNAL GEL 1.2-2.5 % (clindamycin phos- NF benzoyl perox) ACZONE EXTERNAL GEL 7.5 % (dapsone) Tier 3 QL (60 grams per 30 days) adapalene external cream 0.1 % Tier 1 PA; AL adapalene external gel 0.1 %, 0.3 % Tier 1 PA; AL adapalene external lotion 0.1 % Tier 1 ST adapalene external solution 0.1 % Tier 3 QL (2 ml per 1 day) adapalene-benzoyl peroxide external gel 0.1-2.5 % Tier 1 AKLIEF EXTERNAL CREAM 0.005 % (trifarotene) NF AKTIPAK EXTERNAL PACKET 5-3 % (benzoyl peroxide- Tier 3 QL (2 packets per 1 day) erythromycin) ALTRENO EXTERNAL LOTION 0.05 % (tretinoin) NF # isotretinoin (Amnesteem Oral Capsule 10 Mg, 20 Mg, 40 Mg) Tier 1 PA; ST AMZEEQ EXTERNAL FOAM 4 % (minocycline hcl NF micronized) ARAZLO EXTERNAL LOTION 0.045 % (tazarotene) NF ATRALIN EXTERNAL GEL 0.05 % (tretinoin) NF AVAR LS CLEANSER EXTERNAL LIQUID 10-2 % NF (sulfacetamide sodium-sulfur) AVAR-E LS EXTERNAL CREAM 10-2 % (sulfacetamide NF sodium-sulfur) tretinoin (Avita External Cream 0.025 %) Tier 1 PA tretinoin (Avita External Gel 0.025 %) Tier 1 PA

276 Coverage Requirements and Prescription Drug Name Drug Tier Limits AZELEX EXTERNAL CREAM 20 % (azelaic acid) Tier 3 BENZAC AC WASH EXTERNAL LIQUID 5 % (benzoyl NF peroxide) BENZACLIN EXTERNAL GEL 1-5 % (clindamycin phos- NF benzoyl perox) BENZACLIN WITH PUMP EXTERNAL GEL 1-5 % NF (clindamycin phos-benzoyl perox) BENZAMYCIN EXTERNAL GEL 5-3 % (benzoyl peroxide- NF erythromycin) BENZIQ EXTERNAL GEL 5.25 % (benzoyl peroxide) Tier 2 BENZIQ LS EXTERNAL GEL 2.75 % (benzoyl peroxide) Tier 2 benzoyl peroxide-erythromycin external gel 5-3 % Tier 1 bp wash external liquid 2.5 % Tier 1 isotretinoin (Claravis Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 Tier 1 PA; ST Mg) CLEOCIN-T EXTERNAL GEL 1 % (clindamycin phosphate) NF CLEOCIN-T EXTERNAL LOTION 1 % (clindamycin NF phosphate) CLEOCIN-T EXTERNAL SOLUTION 1 % (clindamycin NF phosphate) CLEOCIN-T EXTERNAL SWAB 1 % (clindamycin NF phosphate) clindamycin phosphate (Clindacin Etz External Swab 1 %) Tier 1 clindamycin phosphate (Clindacin-P External Swab 1 %) Tier 1 CLINDAGEL EXTERNAL GEL 1 % (clindamycin NF phosphate) clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, Tier 1 1.2-5 % clindamycin phosphate external foam 1 % Tier 1 clindamycin phosphate external gel 1 % NF clindamycin phosphate external lotion 1 % Tier 1 QL (60 ml per 1 month)

277 Coverage Requirements and Prescription Drug Name Drug Tier Limits clindamycin phosphate external solution 1 % Tier 1 QL (2 ml per 1 day) clindamycin phosphate external swab 1 % Tier 1 clindamycin-tretinoin external gel 1.2-0.025 % Tier 1 dapsone external gel 5 % Tier 1 QL (60 grams per 30 Days) dapsone external gel 7.5 % Tier 1 QL (60 GM per 30 days) DIFFERIN EXTERNAL CREAM 0.1 % (adapalene) NF DIFFERIN EXTERNAL GEL 0.3 % (adapalene) NF DIFFERIN EXTERNAL LOTION 0.1 % (adapalene) NF DUAC EXTERNAL GEL 1.2-5 % (clindamycin-benzoyl per NF (refr)) EPIDUO EXTERNAL GEL 0.1-2.5 % (adapalene-benzoyl NF peroxide) EPIDUO FORTE EXTERNAL GEL 0.3-2.5 % (adapalene- Tier 3 # benzoyl peroxide) ery external pad 2 % Tier 1 erythromycin external gel 2 % Tier 1 QL (60 grams per 1 month) erythromycin external pad 2 % Tier 1 erythromycin external solution 2 % Tier 1 QL (60 ml per 1 month) EVOCLIN EXTERNAL FOAM 1 % (clindamycin phosphate) NF FABIOR EXTERNAL FOAM 0.1 % (tazarotene) NF isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg Tier 1 PA isotretinoin oral capsule 25 mg, 35 mg NF KLARON EXTERNAL LOTION 10 % (sulfacetamide NF sodium (acne)) isotretinoin (Myorisan Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 Tier 1 PA; ST Mg) clindamycin-benzoyl per (refr) (Neuac External Gel 1.2-5 %) Tier 1 ONEXTON EXTERNAL GEL 1.2-3.75 % (clindamycin phos- NF # benzoyl perox) PLEXION CLEANSER EXTERNAL LIQUID 9.8-4.8 % NF (sulfacetamide sodium-sulfur) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

278 Coverage Requirements and Prescription Drug Name Drug Tier Limits PLEXION CLEANSING CLOTH EXTERNAL PAD 9.8- NF 4.8 % (sulfacetamide sodium-sulfur) PLEXION EXTERNAL CREAM 9.8-4.8 % (sulfacetamide NF sodium-sulfur) PLEXION EXTERNAL LOTION 9.8-4.8 % (sulfacetamide NF sodium-sulfur) PLIXDA EXTERNAL PAD 0.1 % (adapalene) NF RETIN-A EXTERNAL CREAM 0.025 %, 0.05 %, 0.1 % NF (tretinoin) RETIN-A EXTERNAL GEL 0.01 %, 0.025 % (tretinoin) NF RETIN-A MICRO EXTERNAL GEL 0.04 %, 0.1 % NF (tretinoin microsphere) RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.06 NF %, 0.08 %, 0.1 % (tretinoin microsphere) sss 10-5 external foam 10-5 % NF sulfacetamide sodium (acne) external lotion 10 % Tier 1 sulfacetamide sodium external suspension 10 % Tier 1 sulfacetamide-sulfur in urea external emulsion 10-5 % Tier 3 SUMAXIN EXTERNAL PAD 10-4 % (sulfacetamide sodium- NF sulfur) SUMAXIN TS EXTERNAL SUSPENSION 8-4 % NF (sulfacetamide sodium-sulfur) tazarotene external foam 0.1 % NF tretinoin external cream 0.025 %, 0.05 %, 0.1 % Tier 1 PA tretinoin external gel 0.01 %, 0.025 %, 0.05 % Tier 1 PA tretinoin microsphere external gel 0.04 %, 0.1 % Tier 1 PA; AL tretinoin microsphere pump external gel 0.04 %, 0.1 % Tier 1 PA; AL TRETIN-X EXTERNAL CREAM 0.075 % (tretinoin) NF WINLEVI EXTERNAL CREAM 1 % (clascoterone) NF isotretinoin (Zenatane Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 Tier 1 PA; ST Mg)

279 Coverage Requirements and Prescription Drug Name Drug Tier Limits DERMATOLOGY, ACTINIC KERATOSIS CARAC EXTERNAL CREAM 0.5 % (fluorouracil) NF EFUDEX EXTERNAL CREAM 5 % (fluorouracil) NF FLUOROPLEX EXTERNAL CREAM 1 % (fluorouracil) Tier 3 fluorouracil external cream 0.5 %, 5 % Tier 1 fluorouracil external solution 2 %, 5 % Tier 1 imiquimod external cream 5 % Tier 1 imiquimod pump external cream 3.75 % Tier 1 QL (1 pump per 1 month) KLISYRI EXTERNAL OINTMENT 1 % (tirbanibulin) NF PICATO EXTERNAL GEL 0.015 %, 0.05 % (ingenol Tier 3 mebutate) TOLAK EXTERNAL CREAM 4 % (fluorouracil) Tier 2 # ZYCLARA EXTERNAL CREAM 3.75 % (imiquimod) NF ZYCLARA PUMP EXTERNAL CREAM 2.5 % (imiquimod) NF DERMATOLOGY, ANTIBIOTICS ALTABAX EXTERNAL OINTMENT 1 % (retapamulin) Tier 3 BACTROBAN EXTERNAL CREAM 2 % (mupirocin NF calcium) BACTROBAN NASAL NASAL OINTMENT 2 % Tier 3 (mupirocin calcium) CENTANY EXTERNAL OINTMENT 2 % (mupirocin) NF CORTISPORIN EXTERNAL CREAM 3.5-10000-0.5 Tier 3 (neomycin-polymyxin-hc) CORTISPORIN EXTERNAL OINTMENT 1 % (bacit-poly- Tier 3 neo hc) gentamicin sulfate external cream 0.1 % Tier 1 gentamicin sulfate external ointment 0.1 % Tier 1 mupirocin calcium external cream 2 % Tier 1 QL (60 grams per 30 days) mupirocin external ointment 2 % Tier 1 QL (60 grams per 30 days)

280 Coverage Requirements and Prescription Drug Name Drug Tier Limits NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 % Tier 3 (neomycin-fluocinolone) silver sulfadiazine external cream 1 % Tier 1 silver sulfadiazine (Ssd External Cream 1 %) Tier 1 SULFAMYLON EXTERNAL CREAM 85 MG/GM Tier 3 (mafenide acetate) XEPI EXTERNAL CREAM 1 % (ozenoxacin) NF DERMATOLOGY, ANTIFUNGALS ciclopirox olamine (Ciclodan External Cream 0.77 %) Tier 1 ciclopirox (Ciclodan External Solution 8 %) Tier 1 PA ciclopirox external gel 0.77 % Tier 1 QL (120 grams per 1 month) ciclopirox external shampoo 1 % Tier 1 QL (120 grams per 1 month) ciclopirox external solution 8 % Tier 1 ciclopirox olamine external cream 0.77 % Tier 1 QL (120 grams per 1 month) ciclopirox olamine external suspension 0.77 % Tier 1 QL (120 grams per 1 month) clotrimazole external cream 1 % Tier 1 QL (120 grams per 1 month) clotrimazole external solution 1 % Tier 1 QL (120 ml per 1 month) clotrimazole-betamethasone external cream 1-0.05 % Tier 1 QL (45 grams per 1 month) clotrimazole-betamethasone external lotion 1-0.05 % Tier 1 QL (2 ml per 1 day) econazole nitrate external cream 1 % Tier 1 QL (85 grams per 30 days) ECOZA EXTERNAL FOAM 1 % (econazole nitrate) NF ERTACZO EXTERNAL CREAM 2 % (sertaconazole nitrate) Tier 3 QL (60 grams per 30 days) EXELDERM EXTERNAL CREAM 1 % (sulconazole Tier 3 QL (60 grams per 30 days) nitrate) EXELDERM EXTERNAL SOLUTION 1 % (sulconazole Tier 3 ST; QL (60 mls per 30 days) nitrate) EXTINA EXTERNAL FOAM 2 % (ketoconazole) Tier 3 QL (50 grams per 30 days) HALOTIN EXTERNAL CREAM 1 % (haloprogin) NF PA; #; QL (4 ml per 1 JUBLIA EXTERNAL SOLUTION 10 % (efinaconazole) Tier 3 month)

281 Coverage Requirements and Prescription Drug Name Drug Tier Limits ketoconazole external cream 2 % Tier 1 QL (2 grams per 1 day) ketoconazole external foam 2 % Tier 1 QL (50 grams per 30 days) LOPROX EXTERNAL CREAM 0.77 % (ciclopirox olamine) NF LOPROX EXTERNAL SHAMPOO 1 % (ciclopirox) NF LOPROX EXTERNAL SUSPENSION 0.77 % (ciclopirox NF olamine) LOTRISONE EXTERNAL CREAM 1-0.05 % (clotrimazole- NF betamethasone) luliconazole external cream 1 % Tier 1 LUZU EXTERNAL CREAM 1 % (luliconazole) NF MENTAX EXTERNAL CREAM 1 % (butenafine hcl) Tier 3 QL (60 grams per 1 month) miconazole-zinc oxide-petrolat external ointment 0.25-15-81.35 NF % naftifine hcl external cream 1 % Tier 1 QL (60 grams per 1 month) naftifine hcl external cream 2 % Tier 1 QL (2 grams per 1 day) NAFTIN EXTERNAL CREAM 2 % (naftifine hcl) NF NAFTIN EXTERNAL GEL 1 % (naftifine hcl) Tier 3 ST; QL (2 grams per 1 day) ST; #; QL (2 grams per 1 NAFTIN EXTERNAL GEL 2 % (naftifine hcl) Tier 3 day) nystatin (Nyamyc External Powder 100000 Unit/Gm) Tier 1 QL (120 grams per 1 month) nystatin (Nyata External Powder 100000 Unit/Gm) Tier 1 QL (120 grams per 1 month) nystatin external cream 100000 unit/gm Tier 1 QL (120 grams per 1 month) nystatin external ointment 100000 unit/gm Tier 1 QL (120 grams per 1 month) nystatin external powder 100000 unit/gm Tier 1 QL (120 grams per 1 month) nystatin-triamcinolone external cream 100000-0.1 unit/gm-% Tier 1 QL (60 grams per 1 month) nystatin-triamcinolone external ointment 100000-0.1 unit/gm-% Tier 1 QL (2 grams per 1 day) nystatin (Nystop External Powder 100000 Unit/Gm) Tier 1 QL (120 grams per 1 month) oxiconazole nitrate external cream 1 % NF OXISTAT EXTERNAL CREAM 1 % (oxiconazole nitrate) NF OXISTAT EXTERNAL LOTION 1 % (oxiconazole nitrate) Tier 3 QL (60 mls per 30 days)

282 Coverage Requirements and Prescription Drug Name Drug Tier Limits PENLAC EXTERNAL SOLUTION 8 % (ciclopirox) NF sulconazole nitrate external cream 1 % Tier 1 QL (60 GM per 1 month) sulconazole nitrate external solution 1 % Tier 1 QL (60 ML per 1 month) XOLEGEL EXTERNAL GEL 2 % (ketoconazole) Tier 3 QL (50 grams per 30 days) DERMATOLOGY, ANTIPRURITIC ST; QL (45 grams per 1 doxepin hcl external cream 5 % Tier 1 month) PRUDOXIN EXTERNAL CREAM 5 % (doxepin hcl NF (antipruritic)) ZONALON EXTERNAL CREAM 5 % (doxepin hcl NF (antipruritic)) DERMATOLOGY, ANTIPSORIATICS acitretin oral capsule 10 mg, 17.5 mg, 25 mg Tier 1 ST; QL (120 grams per 1 calcipotriene external cream 0.005 % Tier 1 month) calcipotriene external foam 0.005 % NF calcipotriene external ointment 0.005 % Tier 1 ST calcipotriene external solution 0.005 % Tier 1 calcipotriene (Calcitrene External Ointment 0.005 %) Tier 1 ST calcitriol external ointment 3 mcg/gm Tier 1 PA; IBC (Preferred agent for Ankylosing Spondylitis COSENTYX (300 MG DOSE) SUBCUTANEOUS and Psoriatic Arthritis. Not SOLUTION PREFILLED SYRINGE 150 MG/ML Tier 4 covered for Psoriasis); NPL; (secukinumab) SP Pharmacy; QL (2 injections per 1 month) PA; IBC (Preferred agent for Ankylosing Spondylitis COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS and Psoriatic Arthritis. Not Tier 4 SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) covered for Psoriasis); NPL; SP Pharmacy; QL (2 injections per 1 month)

283 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; IBC (Preferred agent for Ankylosing Spondylitis COSENTYX SENSOREADY PEN SUBCUTANEOUS and Psoriatic Arthritis. Not Tier 4 SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) covered for Psoriasis); NPL; SP Pharmacy; QL (1 package per 28 days) PA; IBC (Preferred agent for Ankylosing Spondylitis COSENTYX SUBCUTANEOUS SOLUTION PREFILLED and Psoriatic Arthritis. Not Tier 4 SYRINGE 150 MG/ML (secukinumab) covered for Psoriasis); NPL; SP Pharmacy; QL (1 package per 28 days) PA; IBC (Preferred agent for Ankylosing Spondylitis COSENTYX SUBCUTANEOUS SOLUTION PREFILLED and Psoriatic Arthritis. Not Tier 4 SYRINGE 75 MG/0.5ML (secukinumab) covered for Psoriasis.); SP Pharmacy; QL (1 box per 1 month) DOVONEX EXTERNAL CREAM 0.005 % (calcipotriene) NF DRITHO-CREME HP EXTERNAL CREAM 1 % Tier 3 (anthralin) ILUMYA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 100 MG/ML (tildrakizumab-asmn) methoxsalen oral capsule 10 mg Tier 1 methoxsalen rapid oral capsule 10 mg Tier 1 OXSORALEN ULTRA ORAL CAPSULE 10 MG NF (methoxsalen rapid) SILIQ SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 210 MG/1.5ML (brodalumab) SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG NF (acitretin) SORILUX EXTERNAL FOAM 0.005 % (calcipotriene) NF tazarotene external cream 0.1 % Tier 1 TAZORAC EXTERNAL CREAM 0.05 % (tazarotene) Tier 2 PA; # 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

284 Coverage Requirements and Prescription Drug Name Drug Tier Limits TAZORAC EXTERNAL CREAM 0.1 % (tazarotene) NF TAZORAC EXTERNAL GEL 0.05 %, 0.1 % (tazarotene) Tier 2 PA; # VECTICAL EXTERNAL OINTMENT 3 MCG/GM NF (calcitriol) WYNZORA EXTERNAL CREAM 0.005-0.064 % NF (calcipotriene-betameth diprop) DERMATOLOGY, ANTISEBORRHEICS ketoconazole external shampoo 2 % Tier 1 NIZORAL EXTERNAL SHAMPOO 2 % (ketoconazole) NF selenium sulfide external lotion 2.5 % Tier 1 DERMATOLOGY, ATOPIC DERMATITIS DUPIXENT SUBCUTANEOUS SOLUTION PEN- NF INJECTOR 200 MG/1.14ML (dupilumab) DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED PA; SP Pharmacy; QL (2 Tier 4 SYRINGE 200 MG/1.14ML, 300 MG/2ML (dupilumab) syringes per 4 weeks) DERMATOLOGY, CORTICOSTEROIDS ALA SCALP EXTERNAL LOTION 2 % (hydrocortisone) NF ala-cort external cream 1 % Tier 1 QL (120 grams per 1 month) ala-cort external cream 2.5 % NF alclometasone dipropionate external cream 0.05 % Tier 1 QL (120 grams per 1 month) alclometasone dipropionate external ointment 0.05 % Tier 1 QL (120 grams per 1 month) amcinonide external cream 0.1 % Tier 1 QL (120 grams per 1 month) amcinonide external lotion 0.1 % Tier 1 QL (120 ml per 1 month) amcinonide external ointment 0.1 % Tier 3 APEXICON E EXTERNAL CREAM 0.05 % (diflorasone Tier 3 diacet emoll base) betamethasone dipropionate aug external cream 0.05 % Tier 1 QL (120 grams per 1 month) betamethasone dipropionate aug external gel 0.05 % Tier 1 QL (120 grams per 1 month) betamethasone dipropionate aug external lotion 0.05 % Tier 1 QL (120 grams per 30 days) betamethasone dipropionate aug external ointment 0.05 % Tier 1 QL (100 grams per 30 days)

285 Coverage Requirements and Prescription Drug Name Drug Tier Limits betamethasone dipropionate external cream 0.05 % Tier 1 QL (120 grams per 1 month) betamethasone dipropionate external lotion 0.05 % Tier 1 QL (120 ml per 1 month) betamethasone dipropionate external ointment 0.05 % Tier 1 QL (120 grams per 1 month) betamethasone valerate external cream 0.1 % Tier 1 QL (120 grams per 1 month) betamethasone valerate external foam 0.12 % Tier 1 QL (120 grams per 1 month) betamethasone valerate external lotion 0.1 % Tier 1 QL (120 ml per 1 month) betamethasone valerate external ointment 0.1 % Tier 1 QL (120 grams per 1 month) BRYHALI EXTERNAL LOTION 0.01 % (halobetasol NF propionate) calcipotriene-betameth diprop external ointment 0.005-0.064 % NF calcipotriene-betameth diprop external suspension 0.005-0.064 NF % CAPEX EXTERNAL SHAMPOO 0.01 % (fluocinolone Tier 3 QL (120 mls per 30 days) acetonide) ST; QL (120 grams per 30 clobetasol propionate e external cream 0.05 % Tier 1 days) clobetasol propionate emulsion external foam 0.05 % Tier 1 QL (100 grams per 30 days) clobetasol propionate external cream 0.05 % Tier 1 QL (120 grams per 30 days) clobetasol propionate external foam 0.05 % Tier 1 QL (100 grams per 30 days) clobetasol propionate external gel 0.05 % Tier 1 QL (120 grams per 30 days) clobetasol propionate external liquid 0.05 % Tier 1 QL (100 grams per 30 days) clobetasol propionate external lotion 0.05 % Tier 1 QL (120 ml per 1 month) clobetasol propionate external ointment 0.05 % Tier 1 QL (120 grams per 30 days) clobetasol propionate external shampoo 0.05 % Tier 1 QL (236 mls per 30 days) clobetasol propionate external solution 0.05 % Tier 1 QL (120 ml per 1 month) CLOBEX EXTERNAL LOTION 0.05 % (clobetasol NF propionate) CLOBEX EXTERNAL SHAMPOO 0.05 % (clobetasol NF propionate) CLOBEX SPRAY EXTERNAL LIQUID 0.05 % (clobetasol NF propionate) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

286 Coverage Requirements and Prescription Drug Name Drug Tier Limits clocortolone pivalate external cream 0.1 % Tier 1 QL (120 grams per 1 month) clocortolone pivalate pump external cream 0.1 % Tier 1 QL (120 grams per 1 month) clobetasol propionate (Clodan External Shampoo 0.05 %) Tier 1 QL (236 mls per 30 days) CLODERM EXTERNAL CREAM 0.1 % (clocortolone NF pivalate) CLODERM PUMP EXTERNAL CREAM 0.1 % NF (clocortolone pivalate) CORDRAN EXTERNAL CREAM 0.05 % (flurandrenolide) NF CORDRAN EXTERNAL LOTION 0.05 % (flurandrenolide) NF CORDRAN EXTERNAL OINTMENT 0.05 % NF (flurandrenolide) CORDRAN EXTERNAL TAPE 4 MCG/SQCM Tier 3 #; QL (1 roll per 1 fill) (flurandrenolide) clobetasol propionate (Cormax Scalp Application External ST; QL (100 grams per 30 Tier 1 Solution 0.05 %) days) CUTIVATE EXTERNAL CREAM 0.05 % (fluticasone NF propionate) CUTIVATE EXTERNAL LOTION 0.05 % (fluticasone NF propionate) DERMA-SMOOTHE/FS BODY EXTERNAL OIL 0.01 % NF (fluocinolone acetonide) DERMA-SMOOTHE/FS SCALP EXTERNAL OIL 0.01 % NF (fluocinolone acetonide) DERMATOP EXTERNAL CREAM 0.1 % (prednicarbate) NF DERMATOP EXTERNAL OINTMENT 0.1 % NF (prednicarbate) DESONATE EXTERNAL GEL 0.05 % (desonide) NF desonide external cream 0.05 % Tier 1 QL (120 grams per 1 month) desonide external gel 0.05 % NF desonide external lotion 0.05 % Tier 1 QL (120 ml per 1 month) desonide external ointment 0.05 % Tier 1 QL (120 grams per 1 month)

287 Coverage Requirements and Prescription Drug Name Drug Tier Limits DESOWEN EXTERNAL CREAM 0.05 % (desonide) NF DESOWEN EXTERNAL LOTION 0.05 % (desonide) NF desoximetasone external cream 0.05 %, 0.25 % Tier 1 QL (120 grams per 1 month) desoximetasone external gel 0.05 % Tier 1 QL (120 grams per 1 month) desoximetasone external liquid 0.25 % NF desoximetasone external ointment 0.05 % NF desoximetasone external ointment 0.25 % Tier 1 QL (120 grams per 1 month) diflorasone diacetate external cream 0.05 % Tier 1 QL (120 grams per 1 month) diflorasone diacetate external ointment 0.05 % Tier 1 QL (120 grams per 1 month) DIPROLENE AF EXTERNAL CREAM 0.05 % NF (betamethasone dipropionate aug) DIPROLENE EXTERNAL LOTION 0.05 % (betamethasone NF dipropionate aug) DIPROLENE EXTERNAL OINTMENT 0.05 % NF (betamethasone dipropionate aug) DUOBRII EXTERNAL LOTION 0.01-0.045 % (halobetasol QL (1 100 gram tube per 1 Tier 3 prop-tazarotene) month) ELOCON EXTERNAL CREAM 0.1 % (mometasone furoate) NF ELOCON EXTERNAL OINTMENT 0.1 % (mometasone NF furoate) ENSTILAR EXTERNAL FOAM 0.005-0.064 % NF (calcipotriene-betameth diprop) fluocinolone acetonide body external oil 0.01 % Tier 1 QL (120 ml per 1 month) fluocinolone acetonide external cream 0.01 %, 0.025 % Tier 1 QL (120 grams per 1 month) fluocinolone acetonide external ointment 0.025 % Tier 1 QL (120 grams per 1 month) fluocinolone acetonide external solution 0.01 % Tier 1 QL (120 ml per 1 month) fluocinolone acetonide scalp external oil 0.01 % Tier 1 QL (120 ml per 1 month) fluocinonide emulsified base external cream 0.05 % Tier 1 QL (4 grams per 1 day) fluocinonide external cream 0.05 % Tier 1 QL (120 grams per 30 days) ST; QL (120 grams per 30 fluocinonide external cream 0.1 % Tier 1 days) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

288 Coverage Requirements and Prescription Drug Name Drug Tier Limits fluocinonide external gel 0.05 % Tier 1 QL (120 grams per 30 days) fluocinonide external ointment 0.05 % Tier 1 QL (120 grams per 30 days) fluocinonide external solution 0.05 % Tier 1 QL (120 mls per 30 days) flurandrenolide external cream 0.05 % Tier 1 flurandrenolide external lotion 0.05 % Tier 1 flurandrenolide external ointment 0.05 % NF fluticasone propionate external cream 0.05 % Tier 1 QL (120 grams per 1 month) fluticasone propionate external lotion 0.05 % Tier 1 QL (120 ml per 1 month) fluticasone propionate external ointment 0.005 % Tier 1 QL (120 grams per 1 month) halcinonide external cream 0.1 % NF halobetasol propionate external cream 0.05 % Tier 1 QL (120 grams per 1 month) halobetasol propionate external foam 0.05 % NF halobetasol propionate external ointment 0.05 % Tier 1 QL (120 grams per 1 month) HALOG EXTERNAL CREAM 0.1 % (halcinonide) Tier 3 HALOG EXTERNAL OINTMENT 0.1 % (halcinonide) Tier 3 HALOG EXTERNAL SOLUTION 0.1 % (halcinonide) NF hydrocortisone butyr lipo base external cream 0.1 % Tier 1 hydrocortisone butyrate external cream 0.1 % Tier 1 QL (120 grams per 1 month) hydrocortisone butyrate external lotion 0.1 % NF hydrocortisone butyrate external ointment 0.1 % Tier 1 QL (120 grams per 1 month) hydrocortisone butyrate external solution 0.1 % Tier 1 QL (120 ml per 1 month) hydrocortisone external cream 1 %, 2.5 % Tier 1 QL (120 grams per 1 month) hydrocortisone external lotion 2.5 % Tier 1 QL (120 ml per 1 month) hydrocortisone external ointment 2.5 % Tier 1 QL (120 grams per 1 month) hydrocortisone valerate external cream 0.2 % Tier 1 QL (120 grams per 1 month) hydrocortisone valerate external ointment 0.2 % Tier 1 QL (120 grams per 1 month) IMPEKLO EXTERNAL LOTION 0.15 MG/ACT (0.05%) NF (clobetasol propionate)

289 Coverage Requirements and Prescription Drug Name Drug Tier Limits IMPOYZ EXTERNAL CREAM 0.025 % (clobetasol NF # propionate) KENALOG EXTERNAL AEROSOL SOLUTION 0.147 NF MG/GM (triamcinolone acetonide) LEXETTE EXTERNAL FOAM 0.05 % (halobetasol NF propionate) LOCOID EXTERNAL CREAM 0.1 % (hydrocortisone NF butyrate) LOCOID EXTERNAL LOTION 0.1 % (hydrocortisone NF butyrate) LOCOID EXTERNAL OINTMENT 0.1 % (hydrocortisone NF butyrate) LOCOID EXTERNAL SOLUTION 0.1 % (hydrocortisone NF butyrate) LOCOID LIPOCREAM EXTERNAL CREAM 0.1 % NF (hydrocortisone butyr lipo base) LUXIQ EXTERNAL FOAM 0.12 % (betamethasone valerate) NF MICORT-HC EXTERNAL CREAM 2.5 % (hydrocortisone NF acetate) mometasone furoate external cream 0.1 % Tier 1 QL (120 grams per 1 month) mometasone furoate external ointment 0.1 % Tier 1 QL (120 grams per 1 month) mometasone furoate external solution 0.1 % Tier 1 QL (120 ml per 1 month) OLUX EXTERNAL FOAM 0.05 % (clobetasol propionate) NF OLUX-E EXTERNAL FOAM 0.05 % (clobetasol propionate NF emulsion) PANDEL EXTERNAL CREAM 0.1 % (hydrocortisone NF probutate) prednicarbate external cream 0.1 % Tier 1 QL (120 grams per 1 month) prednicarbate external ointment 0.1 % Tier 1 QL (120 grams per 1 month) psorcon external cream 0.05 % NF SERNIVO EXTERNAL EMULSION 0.05 % (betamethasone NF dipropionate)

290 Coverage Requirements and Prescription Drug Name Drug Tier Limits SYNALAR EXTERNAL CREAM 0.025 % (fluocinolone NF acetonide) SYNALAR EXTERNAL OINTMENT 0.025 % (fluocinolone NF acetonide) SYNALAR EXTERNAL SOLUTION 0.01 % (fluocinolone NF acetonide) TACLONEX EXTERNAL OINTMENT 0.005-0.064 % NF (calcipotriene-betameth diprop) TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % ST; QL (60 grams per 30 Tier 3 (calcipotriene-betameth diprop) days) TEMOVATE EXTERNAL CREAM 0.05 % (clobetasol NF propionate) TEMOVATE EXTERNAL GEL 0.05 % (clobetasol NF propionate) TEMOVATE EXTERNAL OINTMENT 0.05 % (clobetasol NF propionate) TEMOVATE EXTERNAL SOLUTION 0.05 % (clobetasol NF propionate) TEXACORT EXTERNAL SOLUTION 2.5 % Tier 3 (hydrocortisone) TOPICORT EXTERNAL CREAM 0.05 %, 0.25 % NF (desoximetasone) TOPICORT EXTERNAL GEL 0.05 % (desoximetasone) NF TOPICORT EXTERNAL OINTMENT 0.05 %, 0.25 % NF (desoximetasone) TOPICORT SPRAY EXTERNAL LIQUID 0.25 % NF (desoximetasone) triamcinolone acetonide external aerosol solution 0.147 mg/gm NF triamcinolone acetonide external cream 0.025 %, 0.5 % Tier 1 QL (120 grams per 1 month) triamcinolone acetonide external cream 0.1 % Tier 1 QL (60 grams per 1 month) triamcinolone acetonide external lotion 0.025 %, 0.1 % Tier 1 QL (120 ml per 1 month) triamcinolone acetonide external ointment 0.025 %, 0.5 % Tier 1 QL (120 grams per 1 month)

291 Coverage Requirements and Prescription Drug Name Drug Tier Limits triamcinolone acetonide external ointment 0.1 % Tier 1 QL (60 grams per 1 month) triamcinolone acetonide (Triderm External Cream 0.1 %) Tier 1 QL (60 grams per 1 month) triamcinolone acetonide (Triderm External Cream 0.5 %) Tier 1 TRIDESILON EXTERNAL CREAM 0.05 % (desonide) NF ULTRAVATE EXTERNAL CREAM 0.05 % (halobetasol NF propionate) ULTRAVATE EXTERNAL LOTION 0.05 % (halobetasol NF # propionate) ULTRAVATE EXTERNAL OINTMENT 0.05 % NF (halobetasol propionate) VANOS EXTERNAL CREAM 0.1 % (fluocinonide) NF VERDESO EXTERNAL FOAM 0.05 % (desonide) Tier 3 QL (100 grams per 30 days) WESTCORT EXTERNAL OINTMENT 0.2 % NF (hydrocortisone valerate) DERMATOLOGY, LOCAL ANESTHETICS asperflex max st external patch 4 % Tier 1 QL (1 patch per 1 day) cvs pain relief external patch 4 % Tier 1 QL (1 patch per 1 day) DOLOTRANZ EXTERNAL KIT 2.5-2.5 & 4 % (lidocaine- NF prilocaine) EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) Tier 3 eq lidocaine pain relieving external patch 4 % Tier 1 QL (1 patch per 1 day) gnp lidocaine pain relief external patch 4 % Tier 1 QL (1 patch per 1 day) hm lidocaine patch external patch 4 % Tier 1 QL (1 patch per 1 day) PA; QL (50 grams per 30 lidocaine external ointment 5 % Tier 1 days) lidocaine external patch 4 % Tier 1 QL (1 patch per 1 day) lidocaine external patch 5 % Tier 1 PA lidocaine hcl external solution 4 % Tier 1 lidocaine hcl urethral/mucosal external gel 2 % Tier 1 QL (2 ml per 1 day) lidocaine hcl urethral/mucosal external prefilled syringe 2 % Tier 1 QL (2 ml per 1 day)

292 Coverage Requirements and Prescription Drug Name Drug Tier Limits lidocaine pain relief external patch 4 % Tier 1 QL (1 patch per 1 day) PA; QL (50 grams per 30 lidocaine pak external ointment 5 % Tier 1 days) PA; QL (30 grams per 30 lidocaine-prilocaine external cream 2.5-2.5 % Tier 1 days) lidocaine-tetracaine external cream 7-7 % NF LIDODERM EXTERNAL PATCH 5 % (lidocaine) NF pain relief maximum strength external patch 4 % Tier 1 QL (1 patch per 1 day) pain relieving lidocaine external patch 4 % Tier 1 QL (1 patch per 1 day) PRAMOSONE EXTERNAL CREAM 1-1 % (pramoxine-hc) NF PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 % Tier 3 (pramoxine-hc) premium lidocaine external ointment 5 % Tier 1 PA; QL (50 grams per 1 fill) qc lidocaine pain relief external patch 4 % Tier 1 QL (1 patch per 1 day) ra lidocaine pain relieving external patch 4 % Tier 1 QL (1 patch per 1 day) ra pain relieving external patch 4 % Tier 1 QL (1 patch per 1 day) SYNERA EXTERNAL PATCH 70-70 MG (lidocaine- Tier 3 QL (10 patches per 30 days) tetracaine) theracare pain relief external patch 4 % Tier 1 QL (1 patch per 1 day) XYLOCAINE EXTERNAL SOLUTION 4 % (lidocaine hcl) NF DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ABREVA EXTERNAL CREAM 10 % (docosanol) Tier 1 OTC acyclovir external cream 5 % NF acyclovir external ointment 5 % NF ALDARA EXTERNAL CREAM 5 % (imiquimod) NF AMELUZ EXTERNAL GEL 10 % (aminolevulinic acid hcl) Tier 3 # ammonium lactate external cream 12 % Tier 1 ammonium lactate external lotion 12 % Tier 1 OTC

293 Coverage Requirements and Prescription Drug Name Drug Tier Limits BUCALSEP EXTERNAL SOLUTION (antiseptic products, NF misc.) chlorhexidine gluconate solution 20 % NF CONDYLOX EXTERNAL GEL 0.5 % (podofilox) Tier 3 DENAVIR EXTERNAL CREAM 1 % (penciclovir) Tier 3 # PA; QL (2 patches per 1 diclofenac epolamine external patch 1.3 % Tier 1 day) diclofenac epolamine transdermal patch 1.3 % Tier 1 QL (2 patches per 1 day) diclofenac sodium external gel 1 % Tier 1 QL (300 GM per 1 month) diclofenac sodium external solution 1.5 % NF diclofenac sodium transdermal gel 1 % Tier 1 QL (300 grams per 1 month) diclofenac sodium transdermal gel 3 % NF diclofenac sodium transdermal solution 1.5 % NF docosanol external cream 10 % Tier 1 OTC ELIDEL EXTERNAL CREAM 1 % (pimecrolimus) NF EUCRISA EXTERNAL OINTMENT 2 % (crisaborole) Tier 3 ST FLECTOR EXTERNAL PATCH 1.3 % (diclofenac NF epolamine) FLECTOR TRANSDERMAL PATCH 1.3 % (diclofenac NF epolamine) hyalucil-4 transdermal cream 2-4 % NF hydrogen peroxide solution 30 % NF diclofenac sodium (Klofensaid Ii External Solution 1.5 %) NF diclofenac sodium (Klofensaid Ii Transdermal Solution 1.5 %) NF lactic acid external lotion 10 % Tier 1 LEVULAN KERASTICK EXTERNAL SOLUTION Tier 3 QL (1 stick per 30 days) RECONSTITUTED 20 % (aminolevulinic acid hcl) LICART EXTERNAL PATCH 24 HOUR 1.3 % (diclofenac NF epolamine) LICART TRANSDERMAL PATCH 24 HOUR 1.3 % NF (diclofenac epolamine) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

294 Coverage Requirements and Prescription Drug Name Drug Tier Limits lugols external solution NF lugols strong iodine external solution 5-10 % NF NUVAIL EXTERNAL SOLUTION (dermatological Tier 3 products, misc.) PANRETIN EXTERNAL GEL 0.1 % (alitretinoin) Tier 3 PENNSAID EXTERNAL SOLUTION 2 % (diclofenac NF sodium) PENNSAID TRANSDERMAL SOLUTION 2 % (diclofenac NF sodium) pimecrolimus external cream 1 % Tier 1 PA; ST podofilox external solution 0.5 % Tier 1 PROTOPIC EXTERNAL OINTMENT 0.03 %, 0.1 % NF (tacrolimus) QBREXZA EXTERNAL PAD 2.4 % (glycopyrronium PA; ST; QL (1 pad per 1 Tier 3 tosylate) Day) SANTYL EXTERNAL OINTMENT 250 UNIT/GM Tier 3 QL (60 grams per 30 days) (collagenase) SILVADENE EXTERNAL CREAM 1 % (silver sulfadiazine) NF SOLARAZE EXTERNAL GEL 3 % (diclofenac sodium) NF SOLARAZE TRANSDERMAL GEL 3 % (diclofenac NF sodium) SULFAMYLON EXTERNAL PACKET 5 % (mafenide Tier 3 acetate) tacrolimus external ointment 0.03 %, 0.1 % Tier 1 TARGRETIN EXTERNAL GEL 1 % (bexarotene) Tier 4 PA; SP Pharmacy VALCHLOR EXTERNAL GEL 0.016 % (mechlorethamine NF # hcl (topical)) VEREGEN EXTERNAL OINTMENT 15 % (sinecatechins) Tier 3 VOLTAREN TRANSDERMAL GEL 1 % (diclofenac Tier 1 QL (300 grams per 1 month) sodium) XERAC AC EXTERNAL SOLUTION 6.25 % (aluminum Tier 2 chloride in alcohol) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

295 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZOVIRAX EXTERNAL CREAM 5 % (acyclovir) NF ZOVIRAX EXTERNAL OINTMENT 5 % (acyclovir) NF ZYCLARA PUMP EXTERNAL CREAM 3.75 % NF (imiquimod) DERMATOLOGY, ROSACEA azelaic acid external gel 15 % Tier 1 FINACEA EXTERNAL FOAM 15 % (azelaic acid) Tier 2 FINACEA EXTERNAL GEL 15 % (azelaic acid) NF ivermectin external cream 1 % Tier 1 METROCREAM EXTERNAL CREAM 0.75 % NF (metronidazole) METROGEL EXTERNAL GEL 1 % (metronidazole) NF METROLOTION EXTERNAL LOTION 0.75 % NF (metronidazole) metronidazole external cream 0.75 % Tier 1 metronidazole external gel 0.75 %, 1 % Tier 1 metronidazole external lotion 0.75 % Tier 1 MIRVASO EXTERNAL GEL 0.33 % (brimonidine tartrate) Tier 3 PA NORITATE EXTERNAL CREAM 1 % (metronidazole) NF ORACEA ORAL CAPSULE DELAYED RELEASE 40 MG NF (doxycycline) RHOFADE EXTERNAL CREAM 1 % (oxymetazoline hcl) NF metronidazole (Rosadan External Cream 0.75 %) Tier 1 metronidazole (Rosadan External Gel 0.75 %) Tier 1 SOOLANTRA EXTERNAL CREAM 1 % (ivermectin) NF ZILXI EXTERNAL FOAM 1.5 % (minocycline hcl NF micronized) DERMATOLOGY, SCABICIDES AND PEDICULIDES CROTAN EXTERNAL LOTION 10 % (crotamiton) Tier 1 cvs lice treatment external liquid 1 % Tier 1

296 Coverage Requirements and Prescription Drug Name Drug Tier Limits cvs permethrin external lotion 1 % Tier 1 ELIMITE EXTERNAL CREAM 5 % (permethrin) NF EURAX EXTERNAL CREAM 10 % (crotamiton) Tier 3 EURAX EXTERNAL LOTION 10 % (crotamiton) Tier 3 ivermectin external lotion 0.5 % Tier 1 ST lindane external shampoo 1 % Tier 1 malathion external lotion 0.5 % Tier 1 NATROBA EXTERNAL SUSPENSION 0.9 % (spinosad) NF OVIDE EXTERNAL LOTION 0.5 % (malathion) NF permethrin external cream 5 % Tier 1 ra lice treatment external lotion 1 % Tier 1 SKLICE EXTERNAL LOTION 0.5 % (ivermectin) NF # sm lice treatment external lotion 1 % Tier 1 spinosad external suspension 0.9 % Tier 1 ULESFIA EXTERNAL LOTION 5 % (benzyl alcohol) Tier 3 #; QL (3 bottles per 1 fill) DERMATOLOGY, WOUND CARE AGENTS LIDOTREX (ALOE VERA) EXTERNAL GEL 2 % NF (lidocaine-collagen-aloe vera) LIDOTREX EXTERNAL GEL 2 % (lidocaine) NF REGRANEX EXTERNAL GEL 0.01 % (becaplermin) Tier 3 PA MOUTH/THROAT/DENTAL AGENTS cevimeline hcl oral capsule 30 mg Tier 1 chlorhexidine gluconate mouth/throat solution 0.12 % Tier 1 clotrimazole mouth/throat lozenge 10 mg Tier 1 clotrimazole mouth/throat troche 10 mg Tier 1 DEBACTEROL MOUTH/THROAT SOLUTION 30-50 % Tier 3 (sulfuric acid-sulf phenolics) EVOXAC ORAL CAPSULE 30 MG (cevimeline hcl) NF FLUORIDEX SENSITIVITY RELIEF DENTAL GEL 1.1- Tier 3 5 % (sod fluoride-potassium nitrate) 2021 Small Group ACA CA The formulary is updated the first week of each month. 09/01/2021 CE=Copay Exception | Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non-Preferred Brands | Tier 4=Specialty | NF=Non-Formulary | PA=Prior Authorization | ST=Step Therapy | QL=Quantity Limits | AL=Age Limits | LGC=Lowest Generic Copay | NPL=National Precertification | #=Generic coming to market | SP=Specialty Network; 30 day supply | N2=Drug tier when CE does not apply |Select OTC=You may have coverage for products noted with a doctor’s prescription

297 Coverage Requirements and Prescription Drug Name Drug Tier Limits lidocaine hcl mouth/throat solution 4 % Tier 1 lidocaine viscous mouth/throat solution 2 % Tier 1 sodium fluoride (Neutragard Advanced Dental Gel 1.1 %) CE N2 (NF); AL neutral sodium fluoride mouth/throat solution 0.2 % CE N2 (NF); AL nystatin mouth/throat suspension 100000 unit/ml Tier 1 triamcinolone acetonide (Oralone Mouth/Throat Paste 0.1 %) Tier 1 ORAVIG BUCCAL TABLET 50 MG (miconazole) Tier 3 QL (14 tablets per 1 fill) chlorhexidine gluconate (Paroex Mouth/Throat Solution 0.12 Tier 1 %) PERIDEX MOUTH/THROAT SOLUTION 0.12 % NF (chlorhexidine gluconate) chlorhexidine gluconate (Periogard Mouth/Throat Solution Tier 1 0.12 %) pilocarpine hcl oral tablet 5 mg, 7.5 mg Tier 1 SALAGEN ORAL TABLET 5 MG, 7.5 MG (pilocarpine hcl) NF sf dental gel 1.1 % CE N2 (NF); AL triamcinolone acetonide mouth/throat paste 0.1 % Tier 1 OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR hydrocortisone-acetic acid (Acetasol Hc Otic Solution 2-1 %) Tier 1 acetic acid otic solution 2 % Tier 1 CETRAXAL OTIC SOLUTION 0.2 % (ciprofloxacin hcl) NF CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- Tier 3 # hydrocortisone) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- NF dexamethasone) ciprofloxacin hcl otic solution 0.2 % Tier 1 ciprofloxacin-dexamethasone otic suspension 0.3-0.1 % Tier 1 ciprofloxacin-fluocinolone pf otic solution 0.3-0.025 % NF COLY-MYCIN S OTIC SUSPENSION 3.3-3-10-0.5 MG/ML Tier 3 (neomycin-colist-hc-thonzonium)

298 Coverage Requirements and Prescription Drug Name Drug Tier Limits DERMOTIC OTIC OIL 0.01 % (fluocinolone acetonide) NF FLOXIN OTIC OTIC SOLUTION 0.3 % (ofloxacin) NF fluocinolone acetonide otic oil 0.01 % Tier 1 hydrocortisone-acetic acid otic solution 1-2 % Tier 1 neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 Tier 1 neomycin-polymyxin-hc otic suspension 3.5-10000-1 Tier 1 ofloxacin otic solution 0.3 % Tier 1 OTIPRIO INTRATYMPANIC SUSPENSION 6 % NF (ciprofloxacin) OTOVEL OTIC SOLUTION 0.3-0.025 % (ciprofloxacin- Tier 3 fluocinolone) PRAMOTIC OTIC LIQUID 1-0.1 % (pramoxine- NF chloroxylenol)

299 Index 1st tier unifine pentips...... 214 acetazolamide...... 83 ADVAIR HFA...... 274 1st tier unifine pentips plus...... 214 acetazolamide er...... 83 ADVANCE INTUITION 1st tier unilet comfortouch...... 214 acetic acid...... 190, 298 TEST...... 215 abacavir sulfate...... 38 acetylcysteine...... 260, 270 ADVOCATE INSULIN PEN abacavir sulfate-lamivudine...... 41 acid reducer...... 186 NEEDLES...... 215 abacavir-lamivudine-zidovudine 41 ACIPHEX...... 186 ADVOCATE INSULIN ABILIFY...... 107 ACIPHEX SPRINKLE...... 186 SYRINGE...... 215 ABILIFY MAINTENA...... 107 acitretin...... 283 ADVOCATE LANCETS...... 215 abiraterone acetate...... 57 ACTEMRA...... 203 ADVOCATE RAPID-SAFE ABREVA...... 293 ACTEMRA ACTPEN...... 203 LANCING...... 215 ABSORICA...... 276 ACTHAR...... 168 ADVOCATE REDI-CODE..215 ABSORICA LD...... 276 ACTICLATE...... 52 ADVOCATE REDI-CODE+ ABSTRAL...... 22 ACTIGALL...... 183 TEST...... 215 acamprosate calcium...... 128 acti-lance 28g...... 215 ADVOCATE SAFETY ACANYA...... 276 acti-lance lite lancets 28g...... 215 LANCETS...... 215 acarbose...... 131 acti-lance special lancets 17g.. 215 ADVOCATE TEST...... 216 ACCOLATE...... 269 acti-lance universal 23g...... 215 ADYPHREN...... 259 ACCRUFER...... 241 ACTIMMUNE...... 211 ADYPHREN AMP...... 259 ACCU-CHEK AVIVA PLUS ACTIQ...... 22 ADYPHREN AMP II...... 259 ...... 214 ACTIVELLA...... 159 ADYPHREN II...... 259 ACCU-CHEK COMPACT ACTONEL...... 142 ADZENYS ER...... 111 PLUS...... 214 ACTOPLUS MET...... 140 ADZENYS XR-ODT...... 111 ACCU-CHEK FASTCLIX ACTOPLUS MET XR...... 140 AEMCOLO...... 34 LANCETS...... 214 ACTOS...... 140 AEROCHAMBER PLUS ACCU-CHEK GUIDE...... 214 ACULAR...... 257 FLO-VU...... 239 ACCU-CHEK MULTICLIX ACULAR LS...... 257 AEROSPAN...... 272 LANCETS...... 214 ACUVAIL...... 257 Afeditab Cr...... 80 ACCU-CHEK SAFE-T PRO acyclovir...... 44, 293 AFINITOR...... 59 LANCETS...... 214 ACZONE...... 276 AFINITOR DISPERZ...... 59 ACCU-CHEK ADAGEN...... 158 Afirmelle...... 145 SMARTVIEW...... 215 ADALAT CC...... 80 AFREZZA...... 135 ACCU-CHEK SOFT adapalene...... 276 AFTERA...... 145 TOUCH LANCETS...... 215 adapalene-benzoyl peroxide.... 276 AGAMATRIX AMP TEST..216 ACCU-CHEK SOFTCLIX ADCIRCA...... 88 AGAMATRIX JAZZ TEST.216 LANCET DEV...... 215 ADDERALL...... 111 AGAMATRIX KEYNOTE ACCU-CHEK SOFTCLIX ADDERALL XR...... 111 TEST...... 216 LANCETS...... 215 ADDYI...... 128 AGAMATRIX PRESTO ACCUPRIL...... 68 adefovir dipivoxil...... 44 TEST...... 216 ACCURETIC...... 67 ADEMPAS...... 88 AGAMATRIX ULTRA- ACCUTREND GLUCOSE..215 ADHANSIA XR...... 111 THIN LANCETS...... 216 ACCUTREND GLUCOSE adjustable lancing device...... 215 AGGRENOX...... 201 CONTROL...... 215 ADLYXIN...... 134 AGRYLIN...... 198 acebutolol hcl...... 78 ADLYXIN STARTER AIMOVIG...... 117 ACEON...... 68 PACK...... 134 AIMOVIG (140 MG DOSE).117 acetaminophen-codeine...... 22 ADMELOG...... 135 AIRDUO DIGIHALER...... 274 acetaminophen-codeine #2...... 22 ADMELOG SOLOSTAR.....135 AIRDUO RESPICLICK acetaminophen-codeine #3...... 22 ADOXA...... 52 113/14...... 260 acetaminophen-codeine #4...... 22 ADRENALIN...... 270 AIRDUO RESPICLICK Acetasol Hc...... 298 ADVAIR DISKUS...... 274 232/14...... 260 300 AIRDUO RESPICLICK ALREX...... 257 amphetamine- 55/14...... 260 ALTABAX...... 280 dextroamphetamine...... 111, 112 AJOVY...... 118 ALTACE...... 68 ampicillin...... 52 AKLIEF...... 276 Altafrin...... 198 AMPYRA...... 122 AKTIPAK...... 276 Altavera...... 145 AMRIX...... 125 AKYNZEO...... 176 alternate site lancing device.... 216 AMZEEQ...... 276 ALA SCALP...... 285 ALTOPREV...... 75 ANADROL-50...... 130 ala-cort...... 285 ALTRENO...... 276 ANAFRANIL...... 99 ALAVERT...... 262 ALUNBRIG...... 59 anagrelide hcl...... 198 ALAVERT ALVESCO...... 272 ANALPRAM-HC...... 188 ALLERGY/SINUS...... 266 alyacen 1/35...... 145 ANAPROX DS...... 19 ALAWAY...... 198 alyacen 7/7/7...... 145 anastrozole...... 57 albendazole...... 35 Alyq...... 88 ANCOBON...... 33 albuterol sulfate...... 264 ALZAIR ALLERGY ANDRODERM...... 130 albuterol sulfate er...... 264 NASAL SPRAY...... 270 ANDROGEL...... 130 albuterol sulfate hfa...... 264 Amabelz...... 159 ANDROGEL PUMP...... 130 ALCAINE...... 198 amantadine hcl...... 104 ANDROID...... 130 alclometasone dipropionate.....285 AMARYL...... 142 ANDROXY...... 130 alcohol swabs...... 216 AMBIEN...... 116 ANGELIQ...... 159 ALDACTAZIDE...... 84 AMBIEN CR...... 116 ANNOVERA...... 145 ALDACTONE...... 84 ambrisentan...... 88 ANORO ELLIPTA...... 260 ALDARA...... 293 amcinonide...... 285 ANTABUSE...... 128 ALECENSA...... 59 AMELUZ...... 293 ANTARA...... 74 alendronate sodium...... 142 AMERGE...... 118 ANTICOAGULANT ALFERON N...... 64 Amethia...... 145 COMPOUND...... 194 alfuzosin hcl er...... 189 Amethia Lo...... 145 anti-stick insulin syringe...... 157 ALINIA...... 35 AMICAR...... 198 ANUSOL-HC...... 188 aliskiren fumarate...... 83 amiloride hcl...... 84 ANZEMET...... 176 ALKERAN...... 54 amiloride-hydrochlorothiazide.. 84 APADAZ...... 23 ALKINDI SPRINKLE...... 162 aminocaproic acid...... 198 apap-caff-dihydrocodeine...... 23 ALLEGRA ALLERGY...... 262 amiodarone hcl...... 72 APEXICON E...... 285 ALLEGRA ALLERGY AMITIZA...... 181 APIDRA...... 135 CHILDRENS...... 262 amitriptyline hcl...... 99 APIDRA SOLOSTAR...... 135 ALLEGRA-D ALLERGY & AMLODIPINE APLENZIN...... 99 CONGESTION...... 266 BES+SYRSPEND SF...... 80 APOKYN...... 104 allopurinol...... 17 amlodipine besy-benazepril hcl..67 apraclonidine hcl...... 252 ALLZITAL...... 18 amlodipine besylate...... 80 aprepitant...... 176 almotriptan malate...... 118 amlodipine besylate-valsartan...70 Apri...... 145 ALOCRIL...... 251 amlodipine-atorvastatin...... 80 APRISO...... 179 alogliptin benzoate...... 133 amlodipine-olmesartan...... 70 APTENSIO XR...... 112 alogliptin-metformin hcl...... 133 amlodipine-valsartan-hctz...... 70 APTIOM...... 90 alogliptin-pioglitazone...... 133 ammonium lactate...... 293 APTIVUS...... 38 ALOMIDE...... 251 Amnesteem...... 276 ARAKODA...... 37 ALORA...... 159 amoxapine...... 99 Aranelle...... 145 alosetron hcl...... 181 amoxicillin...... 51 ARANESP (ALBUMIN ALPHAGAN P...... 252 amoxicillin-pot clavulanate...... 52 FREE)...... 196 alprazolam...... 90 amoxicillin-pot clavulanate er...51 ARAVA...... 209 alprazolam er...... 90 amphetamine er...... 111 ARAZLO...... 276 ALPRAZOLAM INTENSOL 90 amphetamine sulfate...... 111 ARCALYST...... 211 alprazolam xr...... 90 amphetamine-dextroamphet er111 ARCAPTA NEOHALER.....265 301 arformoterol tartrate...... 265 ASSURE HAEMOLANCE AVALIDE...... 70 Argyle Sterile Saline...... 190 PLUS LOW...... 216 AVANDIA...... 140 ARICEPT...... 98 ASSURE HAEMOLANCE AVAPRO...... 71 ARIKAYCE...... 32 PLUS MICRO...... 216 AVAR LS CLEANSER...... 276 ARIMIDEX...... 57 ASSURE HAEMOLANCE AVAR-E LS...... 276 aripiprazole...... 107 PLUS NORMAL...... 216 AVC VAGINAL...... 193 ARISTADA...... 107 ASSURE HAEMOLANCE AVELOX...... 49 ARISTADA INITIO...... 107 PLUS PED...... 216 Aviane...... 146 ARIXTRA...... 194 ASSURE ID INSULIN avidoxy...... 52 armodafinil...... 127 SAFETY SYR...... 216 Avita...... 276 ARMONAIR DIGIHALER.272 ASSURE LANCE AVODART...... 189 ARMONAIR RESPICLICK LANCETS...... 216 AVONEX...... 122 113...... 272 ASSURE LANCETS...... 216 AVONEX PEN...... 122 ARMONAIR RESPICLICK ASSURE PLATINUM...... 216 AVONEX PREFILLED...... 123 232...... 273 ASSURE PRO TEST...... 217 av-phos 250 neutral...... 240 ARMONAIR RESPICLICK ASTAGRAF XL...... 212 AVSOLA...... 203 55...... 273 ATACAND...... 71 AXERT...... 118 ARMOUR THYROID...... 172 ATACAND HCT...... 70 AYGESTIN...... 172 ARNUITY ELLIPTA...... 273 atazanavir sulfate...... 38 Ayuna...... 146 AROMASIN...... 57 ATELVIA...... 142 AYVAKIT...... 64 ARTHROTEC...... 21 atenolol...... 78 AZASAN...... 212 ARYMO ER...... 23 ATENOLOL+SYRSPEND AZASITE...... 255 ASACOL HD...... 179 SF PH4...... 78 azathioprine...... 212 ASCENIV...... 209 atenolol-chlorthalidone...... 77 azelaic acid...... 296 Ascomp-Codeine...... 23 ATIVAN...... 90 azelastine hcl...... 251, 262 asenapine maleate...... 107 atomoxetine hcl...... 112 azelastine-fluticasone...... 262 Ashlyna...... 145 atorvastatin calcium...... 75 AZELEX...... 277 ASMANEX (120 METERED atovaquone...... 35 azeschew prenatal/postnatal....241 DOSES)...... 273 atovaquone-proguanil hcl...... 37 azesco...... 241 ASMANEX (14 METERED ATRALIN...... 276 AZILECT...... 104 DOSES)...... 273 ATRIPLA...... 41 azithromycin...... 47 ASMANEX (30 METERED atropine sulfate...... 198 azo tabs...... 190 DOSES)...... 273 ATROVENT HFA...... 261 AZOPT...... 252 ASMANEX (60 METERED AUBAGIO...... 122 AZOR...... 70 DOSES)...... 273 Aubra...... 146 azo-standard...... 190 ASMANEX (7 METERED Aubra Eq...... 146 AZSTARYS...... 112 DOSES)...... 273 AUGMENTIN...... 52 AZULFIDINE...... 179 ASMANEX HFA...... 273 AUGMENTIN ES-600...... 52 AZULFIDINE EN-TABS.... 179 asperflex max st...... 292 AUGMENTIN XR...... 52 Azurette...... 146 aspirin...... 32 aurora lancet super thin 30g....217 b-6...... 241 aspirin low dose...... 32 aurora lancet thin 23g...... 217 Bac...... 18 aspirin-dipyridamole er...... 201 aurora pen needles...... 217 BACIGUENT...... 255 aspirin-omeprazole...... 201 aurora unifine pentips...... 217 bacitracin...... 255 ASSURE 3 TEST...... 216 Aurovela 1.5/30...... 146 bacitracin-polymyxin b...... 255 ASSURE 4 TEST...... 216 Aurovela 1/20...... 146 bacitra-neomycin-polymyxin- assure comfort lancets 28g...... 216 Aurovela 24 Fe...... 146 hc...... 254 assure comfort lancets 30g...... 216 Aurovela Fe 1/20...... 146 baclofen...... 125 ASSURE HAEMOLANCE AURYXIA...... 171 BACTRIM...... 35 PLUS HIGH...... 216 AUSTEDO...... 120 BACTRIM DS...... 35 AUVI-Q...... 259 BACTROBAN...... 280 302 BACTROBAN NASAL...... 280 BD SAFETY-LOK BETOPTIC-S...... 252 BAFIERTAM...... 123 INSULIN SYRINGE...... 218 BEVESPI AEROSPHERE....260 BAL-CARE DHA...... 241 BD VEO INSULIN SYR U/F BEVYXXA...... 194 BALCOLTRA...... 146 1/2UNIT...... 218 bexarotene...... 64 balsalazide disodium...... 179 BD VEO INSULIN BEYAZ...... 146 BALVERSA...... 60 SYRINGE U/F...... 218 BIAXIN...... 48 Balziva...... 146 BECONASE AQ...... 271 bicalutamide...... 57 BANZEL...... 90 Bekyree...... 146 BIDIL...... 85 BAQSIMI ONE PACK...... 165 BELBUCA...... 31 BIEST/PROGESTERONE...159 BAQSIMI TWO PACK...... 165 belladonna alkaloids-opium.....175 BIJUVA...... 159 BARACLUDE...... 44 belladonna-opium...... 175 BIKTARVY...... 42 BASAGLAR KWIKPEN..... 135 BELSOMRA...... 116 BILTRICIDE...... 35 BAXDELA...... 49 BELVIQ...... 120 bimatoprost...... 252 BAYER BREEZE 2 TEST....217 benazepril hcl...... 68 BINOSTO...... 143 BAYER CONTOUR NEXT benazepril-hydrochlorothiazide.67 bio-statin...... 33 TEST...... 217 BENICAR...... 71 bisacodyl...... 181 BAYER CONTOUR TEST..217 BENICAR HCT...... 70 bisoprolol fumarate...... 78 BAYER LOW DOSE...... 32 BENLYSTA...... 212 bisoprolol-hydrochlorothiazide..77 BAYER MICROLET BENTYL...... 175 BLEPH-10...... 255 LANCETS...... 217 BENZAC AC WASH...... 277 BLEPHAMIDE...... 254 BD AUTOSHIELD...... 217 BENZACLIN...... 277 BLEPHAMIDE S.O.P...... 254 BD GLUCOSE...... 165 BENZACLIN WITH PUMP 277 Blisovi 24 Fe...... 146 BD INSULIN SYR BENZAMYCIN...... 277 Blisovi Fe 1.5/30...... 146 ULTRAFINE II...... 217 benzhydrocodone- Blisovi Fe 1/20...... 146 BD INSULIN SYRINGE acetaminophen...... 23 blood glucose test...... 218 ...... 217, 218 BENZIQ...... 277 BONIVA...... 143 BD INSULIN SYRINGE BENZIQ LS...... 277 BONJESTA...... 177 HALF-UNIT...... 217 benznidazole...... 35 bosentan...... 88 BD INSULIN SYRINGE benzonatate...... 267 BOSULIF...... 60 MICROFINE...... 217 benzoyl peroxide-erythromycin bp folinatal plus b...... 242 BD INSULIN SYRINGE ...... 277 bp multinatal plus...... 242 U/F...... 217 benztropine mesylate...... 104 bp wash...... 277 BD INSULIN SYRINGE BEOVU...... 198 BRAFTOVI...... 64 ULTRAFINE...... 157, 218 bepotastine besilate...... 251 BREO ELLIPTA...... 275 BD LANCET ULTRAFINE BEPREVE...... 251 BREXAFEMME...... 33 30G...... 218 BESIVANCE...... 255 BREZTRI AEROSPHERE.. 260 BD LANCET ULTRAFINE BETADINE OPHTHALMIC briellyn...... 146 33G...... 218 PREP...... 255 BRILINTA...... 201 BD MICROTAINER BETAGAN...... 252 brimonidine tartrate...... 252 LANCETS...... 218 betamethasone dipropionate....286 brinzolamide...... 252 BD PEN NEEDLE MINI betamethasone dipropionate BRISDELLE...... 99 U/F...... 218 aug...... 285 BRIVIACT...... 90, 91 BD PEN NEEDLE NANO betamethasone valerate...... 286 bromfenac sodium (once-daily) U/F...... 218 BETAPACE...... 78 ...... 257 BD PEN NEEDLE BETAPACE AF...... 78 bromocriptine mesylate...... 104 ORIGINAL U/F...... 218 BETASERON...... 123 brompheniramine tannate...... 262 BD PEN NEEDLE SHORT betaxolol hcl...... 78, 252 BROMSITE...... 257 U/F...... 218 bethanechol chloride...... 183 BRONCHITOL...... 270 BD SAFETYGLIDE BETHKIS...... 32 BROVANA...... 265 INSULIN SYRINGE...... 218 BETIMOL...... 252 BRUKINSA...... 60 303 BRYHALI...... 286 calcium acetate...... 171 carisoprodol...... 125 BUCALSEP...... 294 calcium acetate (phos binder).171 carisoprodol-aspirin...... 125 budesonide...... 179, 273 calcium pnv...... 242 carisoprodol-aspirin-codeine... 125 budesonide er...... 163 calcium-folic acid plus d...... 242 CARNITOR...... 143 budesonide-formoterol CALPHRON...... 171 CARNITOR SF...... 144 fumarate...... 275 CALQUENCE...... 60 CAROSPIR...... 84 bullseye mini safety lancets.....218 CAMBIA...... 19 carteolol hcl...... 252 bumetanide...... 84 Camila...... 147 Cartia Xt...... 81 BUMEX...... 84 Camrese...... 147 carvedilol...... 78 BUNAVAIL...... 21, 22 Camrese Lo...... 147 carvedilol phosphate er...... 78 Bupap...... 18 CANASA...... 180 CASODEX...... 57 BUPHENYL...... 158 candesartan cilexetil...... 71 CATAPRES...... 85 buprenorphine...... 31 candesartan cilexetil-hctz...... 70 CATAPRES-TTS-1...... 85 buprenorphine hcl...... 31 Capacet...... 17 CATAPRES-TTS-2...... 85 buprenorphine hcl-naloxone hcl.22 capecitabine...... 55 CATAPRES-TTS-3...... 85 bupropion hcl...... 100 CAPEX...... 286 CAYSTON...... 35 bupropion hcl er (smoking det) CAPLYTA...... 107 Caziant...... 147 ...... 128 CAPRELSA...... 60 CEDAX...... 46 bupropion hcl er (sr)...... 99 captopril...... 68 cefaclor...... 46 bupropion hcl er (xl)...... 100 captopril-hydrochlorothiazide...67 cefaclor er...... 46 buspirone hcl...... 120 CARAC...... 280 cefadroxil...... 46 butalbital-acetaminophen...... 18 CARAFATE...... 183 cefdinir...... 46 butalbital-apap-caff-cod...... 23 CARBAGLU...... 158 cefditoren pivoxil...... 46 butalbital-apap-caffeine...... 18 carbamazepine...... 91 cefixime...... 46 butalbital-asa-caff-codeine...... 23 carbamazepine er...... 91 cefpodoxime proxetil...... 47 butalbital-asa-caffeine...... 18 CARBAPHEN 12...... 267 cefprozil...... 47 butalbital-aspirin-caffeine...... 18 CARBAPHEN 12 PED...... 267 ceftibuten...... 47 BUTISOL SODIUM...... 116 CARBATROL...... 91 CEFTIN...... 47 butorphanol tartrate...... 23 carbidopa...... 104 cefuroxime axetil...... 47 BUTRANS...... 31 carbidopa-levodopa...... 104 CELEBREX...... 17 BYDUREON...... 134 carbidopa-levodopa er...... 104 celecoxib...... 17 BYDUREON BCISE...... 134 carbidopa-levodopa-entacapone CELEXA...... 100 BYETTA 10 MCG PEN...... 134 ...... 104 CELLCEPT...... 212 BYETTA 5 MCG PEN...... 134 carbinoxamine maleate...... 262 CELONTIN...... 91 BYNFEZIA PEN...... 168 CARDIOVID PLUS...... 242 CENTANY...... 280 BYSTOLIC...... 78 CARDIZEM...... 81 cephalexin...... 47 BYVALSON...... 70 CARDIZEM CD...... 80 CEQUA...... 198 cabergoline...... 168 CARDIZEM LA...... 80 CERDELGA...... 158 CABLIVI...... 195 CARDURA...... 69 CERVIDIL...... 168 CABOMETYX...... 60 CARDURA XL...... 189 CESAMET...... 177 CADUET...... 80 CAREFINE PEN NEEDLES Cesia...... 147 caffeine citrate...... 120 ...... 218 cetirizine hcl...... 262 CALAN...... 80 CAREONE LANCET cetirizine-pseudoephedrine er.. 267 CALAN SR...... 80 SUPER THIN 30G...... 218 CETRAXAL...... 298 CALCIFOL...... 242 careone lancet thin 23g...... 219 cevimeline hcl...... 297 calcipotriene...... 283 careone lancet ultra thin 28g...219 CHANTIX...... 128 calcipotriene-betameth diprop.286 careone unifine pentips...... 219 CHANTIX CONTINUING calcitonin (salmon)...... 168 CARESENS N GLUCOSE MONTH PAK...... 128 Calcitrene...... 283 TEST...... 219 CHANTIX STARTING calcitriol...... 143, 283 CARIMUNE NF...... 210 MONTH PAK...... 128 304 Chateal...... 147 citalopram hydrobromide...... 100 clobetasol propionate emulsion286 Chateal Eq...... 147 CITRANATAL 90 DHA...... 242 CLOBEX...... 286 CHEK-STIX CONTROL..... 219 CITRANATAL ASSURE.... 242 CLOBEX SPRAY...... 286 CHEMET...... 144 CITRANATAL B-CALM.... 242 clocortolone pivalate...... 287 CHEMSTRIP 10 MD...... 219 CITRANATAL ESSENCE.. 242 clocortolone pivalate pump..... 287 CHEMSTRIP 10/SG...... 219 CITRANATAL MEDLEY...242 Clodan...... 287 CHEMSTRIP 2 GP...... 219 CITRANATAL RX...... 242 CLODERM...... 287 CHEMSTRIP 5 OB...... 219 citrate of magnesia...... 181 CLODERM PUMP...... 287 CHEMSTRIP 7...... 219 Claravis...... 277 clomipramine hcl...... 120 CHEMSTRIP 9...... 219 CLARINEX...... 262 clonazepam...... 91 CHEMSTRIP K...... 219 CLARINEX-D 12 HOUR.... 267 clonidine hcl...... 86 CHEMSTRIP UGK...... 219 clarithromycin...... 48 clonidine hcl er...... 112 CHENODAL...... 183 clarithromycin er...... 48 clopidogrel bisulfate...... 201 childrens aspirin...... 32 CLARITIN...... 263 clorazepate dipotassium...... 91 chlordiazepoxide hcl...... 90 CLARITIN CHILDRENS... 263 CLORPRES...... 70 chlordiazepoxide-amitriptyline128 CLARITIN EYE...... 198 clotrimazole...... 281, 297 chlordiazepoxide-clidinium..... 175 CLARITIN REDITABS...... 263 clotrimazole-betamethasone....281 chlorhexidine gluconate...294, 297 CLARITIN-D 12 HOUR...... 267 clozapine...... 107 chloroquine phosphate...... 37 CLARITIN-D 24 HOUR...... 267 CLOZARIL...... 107 chlorothiazide...... 84 clemastine fumarate...... 263 COARTEM...... 37 chlorpromazine hcl...... 107 CLENPIQ...... 181 CODAR AR...... 267 chlorpropamide...... 142 CLEOCIN...... 35, 193 codeine sulfate...... 23 chlorthalidone...... 84 CLEOCIN-T...... 277 COLAZAL...... 180 chlorzoxazone...... 125 CLEVER CHEK AUTO- colchicine...... 17 CHOLBAM...... 183 CODE TEST...... 219 colchicine-probenecid...... 17 cholestyramine...... 73 CLEVER CHEK AUTO- COLCRYS...... 17 cholestyramine light...... 73 CODE VOICE...... 219 colesevelam hcl...... 73 choline-mag trisalicylate...... 32 CLEVER CHEK LANCETS 219 COLESTID...... 73 chorionic gonadotropin...... 162 CLEVER CHEK TEST...... 219 COLESTID FLAVORED...... 73 Ciclodan...... 281 CLEVER CHOICE AUTO- colestipol hcl...... 73 ciclopirox...... 281 CODE TEST...... 219 Colocort...... 180 ciclopirox olamine...... 281 CLEVER CHOICE MICRO COLY-MYCIN S...... 298 cilostazol...... 198 TEST...... 219 COLYTE WITH FLAVOR CILOXAN...... 255 clickfine pen needles...... 219 PACKS...... 181 CIMDUO...... 42 CLIMARA...... 160 COMBIGAN...... 252 cimetidine...... 179 CLIMARA PRO...... 159 COMBIPATCH...... 160 cimetidine hcl...... 179 Clindacin Etz...... 277 COMBISTIX...... 219 CIMZIA...... 203 Clindacin-P...... 277 COMBIVENT RESPIMAT..260 CIMZIA PREFILLED...... 203 CLINDAGEL...... 277 COMBIVIR...... 42 CIMZIA STARTER KIT..... 203 clindamycin hcl...... 35 COMETRIQ (100 MG cinacalcet hcl...... 143 clindamycin palmitate hcl...... 35 DAILY DOSE)...... 60, 65 CIPRO...... 49 clindamycin phos-benzoyl COMETRIQ (140 MG CIPRO HC...... 298 perox...... 277 DAILY DOSE)...... 60, 65 CIPRO XR...... 49 clindamycin phosphate COMETRIQ (60 MG DAILY CIPRODEX...... 298 ...... 193, 277, 278 DOSE)...... 60 ciprofloxacin...... 49 clindamycin-tretinoin...... 278 comfort assured lancets 28g.... 220 ciprofloxacin hcl...... 49, 256, 298 CLINDESSE...... 193 comfort assured lancets 33g.... 220 ciprofloxacin-ciproflox hcl er....49 clobazam...... 91 COMFORT EZ INSULIN ciprofloxacin-dexamethasone..298 clobetasol propionate...... 286 SYRINGE...... 220 ciprofloxacin-fluocinolone pf.. 298 clobetasol propionate e...... 286 305 COMFORT EZ PEN CRESTOR...... 75 DAURISMO...... 55 NEEDLES...... 220 CRINONE...... 172 DAXBIA...... 47 comfort lancets...... 220 CRIXIVAN...... 38 DAYPRO...... 19 COMPLERA...... 42 cromolyn sodium..... 183, 251, 270 Daysee...... 147 complete natal dha...... 242 CROTAN...... 296 DAYTRANA...... 112 completenate...... 242 Cryselle-28...... 147 DAYVIGO...... 116 Compro...... 177 CUPRIMINE...... 144 DDAVP...... 174, 175 COMTAN...... 104 Curity Sterile Saline...... 190 DDAVP RHINAL TUBE.....175 CO-NATAL FA...... 242 CUTAQUIG...... 210 DEBACTEROL...... 297 CONCEPT DHA...... 242 CUTIVATE...... 287 Deblitane...... 147 CONCEPT OB...... 242 CUVITRU...... 210 DECON-A...... 267 CONCERTA...... 112 CUVPOSA...... 175 deferasirox...... 144 CONDYLOX...... 294 cvs lice treatment...... 296 deferasirox granules...... 144 CONJUPRI...... 81 cvs pain relief...... 292 deferiprone...... 144 CONSENSI...... 81 cvs permethrin...... 297 DELESTROGEN...... 160 constulose...... 181 cvs ultra sleep...... 116 DELSTRIGO...... 42 CONZIP...... 23 cyanocobalamin...... 242 Deltasone...... 163 COPAXONE...... 123 Cyclafem 1/35...... 147 Delyla...... 147 COPEGUS...... 49 Cyclafem 7/7/7...... 147 DELZICOL...... 180 COPIKTRA...... 60 cyclobenzaprine hcl...... 126 DEMADEX...... 84 CORDRAN...... 287 cyclobenzaprine hcl er...... 126 demeclocycline hcl...... 53 COREG...... 78 CYCLOGYL...... 199 DEMEROL...... 23 COREG CR...... 78 CYCLOMYDRIL...... 199 DEMSER...... 86 Coremino...... 52 cyclopentolate hcl...... 199 DENAVIR...... 294 CORGARD...... 79 cyclophosphamide...... 54 DEPAKENE...... 91 CORLANOR...... 86 cycloserine...... 43 DEPAKOTE...... 91 Cormax Scalp Application.... 287 CYCLOSET...... 133 DEPAKOTE ER...... 91 CORTEF...... 163 cyclosporine...... 212 DEPAKOTE SPRINKLES.... 91 CORTENEMA...... 180 cyclosporine modified...... 212 DEPEN TITRATABS...... 144 CORTIFOAM...... 180 CYMBALTA...... 100 DEPO-ESTRADIOL...... 160 cortisone acetate...... 163 cyproheptadine hcl...... 263 DEPO-PROVERA...... 57 CORTISPORIN...... 280 Cyred...... 147 DEPO-SUBQ PROVERA CORVITE 150...... 199 CYSTADANE...... 158 104...... 147 corvite fe...... 199 CYSTADROPS...... 199 DEPO-TESTOSTERONE.... 130 CORZIDE...... 77 CYSTAGON...... 158 DERMA-SMOOTHE/FS COSENTYX...... 284 CYSTARAN...... 199 BODY...... 287 COSENTYX (300 MG CYTOMEL...... 173 DERMA-SMOOTHE/FS DOSE)...... 283 CYTOTEC...... 183 SCALP...... 287 COSENTYX D.H.E. 45...... 118 DERMATOP...... 287 SENSOREADY (300 MG)... 283 DAKLINZA...... 50 DERMOTIC...... 299 COSENTYX dalfampridine er...... 123 DESCOVY...... 42 SENSOREADY PEN...... 284 DALIRESP...... 270 desipramine hcl...... 100 COSOPT...... 252 danazol...... 157 desloratadine...... 263 COSOPT PF...... 252 DANTRIUM...... 126 desmopressin ace rhinal tube...175 COTELLIC...... 60 dantrolene sodium...... 126 desmopressin ace spray refrig. 175 COTEMPLA XR-ODT...... 112 dapsone...... 35, 278 desmopressin acetate...... 175 COUMADIN...... 194 DARAPRIM...... 35 desmopressin acetate spray..... 175 COZAAR...... 71 darifenacin hydrobromide er... 192 desogestrel-ethinyl estradiol....148 CREON...... 185 Dasetta 1/35...... 147 DESONATE...... 287 CRESEMBA...... 33 Dasetta 7/7/7...... 147 desonide...... 287 306 DESOWEN...... 288 dextroamphetamine sulfate er DIPROLENE...... 288 desoximetasone...... 288 ...... 112, 113 DIPROLENE AF...... 288 DESOXYN...... 112 DIACOMIT...... 91, 92 dipyridamole...... 201 desvenlafaxine er...... 100 DIALYVITE 3000...... 242 disopyramide phosphate...... 72 desvenlafaxine succinate er..... 100 DIALYVITE 5000...... 243 disulfiram...... 128 DETROL...... 192 DIALYVITE SUPREME D. 243 DITROPAN XL...... 192 DETROL LA...... 192 DIALYVITE/ZINC...... 243 DIURIL...... 84 DEX4 GLUCOSE...... 165 DIAMOX SEQUELS...... 84 divalproex sodium...... 92 DEX4 GLUCOSE GO- DIASTAT ACUDIAL...... 92 divalproex sodium er...... 92 POUCH...... 165 DIASTAT PEDIATRIC...... 92 DIVIGEL...... 160 DEX4 QUICK DISSOLVE diazepam...... 92 docosanol...... 294 GLUCOSE...... 165 Diazepam Intensol...... 92 dofetilide...... 72 dexamethasone...... 163 diazoxide...... 165 DOLOPHINE...... 23 DEXAMETHASONE DIBENZYLINE...... 86 DOLOTRANZ...... 292 INTENSOL...... 163 DICLEGIS...... 177 donepezil hcl...... 98 dexamethasone sodium diclofenac...... 19 DOPTELET...... 196 phosphate...... 257 diclofenac epolamine...... 294 DORAL...... 116 DEXCOM G4 PLAT PED diclofenac potassium...... 19 DORYX...... 53 RCV/SHARE...... 220 diclofenac sodium.19, 44, 257, 294 DORYX MPC...... 53 DEXCOM G4 PLAT PED diclofenac sodium er...... 19 dorzolamide hcl...... 252 RECEIVER...... 220 diclofenac-misoprostol...... 21 dorzolamide hcl-timolol mal....252 DEXCOM G4 PLATINUM dicloxacillin sodium...... 52 dorzolamide hcl-timolol mal pf253 RCV/SHARE...... 220 dicyclomine hcl...... 175 double pm...... 254 DEXCOM G4 PLATINUM didanosine...... 38 DOVATO...... 42 RECEIVER...... 220 DIFFERIN...... 278 DOVONEX...... 284 DEXCOM G4 PLATINUM DIFICID...... 48 doxazosin mesylate...... 69 TRANSMITTER...... 220 Difil-G Forte...... 270 doxepin hcl...... 100, 116, 283 DEXCOM G4 SENSOR...... 220 diflorasone diacetate...... 288 doxercalciferol...... 143 DEXCOM G5 MOB/G4 DIFLUCAN...... 33 doxycycline hyclate...... 53 PLAT SENSOR...... 220 diflunisal...... 32 doxycycline monohydrate...... 53 DEXCOM G5 MOBILE Digitek...... 83 doxylamine-pyridoxine...... 177 RECEIVER...... 220 Digox...... 83 d-penamine...... 144 DEXCOM G5 MOBILE digoxin...... 83 DRAMAMINE LESS TRANSMITTER...... 220 dihydroergotamine mesylate... 118 DROWSY...... 177 DEXCOM G5 RECEIVER DILANTIN...... 92 DRITHO-CREME HP...... 284 KIT...... 221 DILANTIN INFATABS...... 92 DRIZALMA SPRINKLE.... 100 DEXCOM G6 RECEIVER.. 221 DILATRATE-SR...... 87 dronabinol...... 177 DEXCOM G6 SENSOR...... 221 DILAUDID...... 23 DROPLET LANCETS DEXCOM G6 diltiazem cd...... 81 ULTRA THIN 30G...... 221 TRANSMITTER...... 221 diltiazem hcl...... 81 drospiren-eth estrad-levomefol 148 DEXEDRINE...... 112 diltiazem hcl er...... 81 drospirenone-ethinyl estradiol. 148 DEXILANT...... 186 diltiazem hcl er beads...... 81 DROXIA...... 65 dexmethylphenidate hcl...... 112 diltiazem hcl er coated beads.... 81 droxidopa...... 86 dexmethylphenidate hcl er...... 112 dilt-xr...... 81 DUAC...... 278 Dexpak 10 Day...... 163 dimethyl fumarate...... 123 DUAKLIR PRESSAIR...... 275 Dexpak 13 Day...... 163 DIOVAN...... 72 DUAVEE...... 160 Dexpak 6 Day...... 163 DIOVAN HCT...... 70 DUET DHA BALANCED...243 dextroamphetamine sulfate.....113 DIPENTUM...... 180 DUETACT...... 142 diphenhydramine hcl...... 263 DUEXIS...... 21 diphenoxylate-atropine...... 183 307 DULCOLAX BOWEL PREP EASY TOUCH LANCETS ELIDEL...... 294 KIT...... 181 32G/TWIST...... 222 ELIGARD...... 57 DULERA...... 260 EASY TOUCH LANCETS ELIMITE...... 297 duloxetine hcl...... 100 33G/TWIST...... 222 Elinest...... 148 DUOBRII...... 288 EASY TOUCH PEN ELIQUIS...... 194 DUOPA...... 104 NEEDLES...... 222 ELIQUIS DVT/PE DUPIXENT...... 272, 285 EASY TOUCH SAFETY STARTER PACK...... 194 DURAGESIC-100...... 23 LANCETS 21G...... 222 ELITE-OB...... 243 DURAGESIC-12...... 24 EASY TOUCH SAFETY elite-thin insulin syringe...... 222 DURAGESIC-25...... 24 LANCETS 23G...... 222 ELIXOPHYLLIN...... 275 DURAGESIC-50...... 24 EASY TOUCH SAFETY ELLA...... 148 DURAGESIC-75...... 24 LANCETS 26G...... 222 ELMIRON...... 190 duraxin...... 17 EASY TOUCH SAFETY ELOCON...... 288 DUREZOL...... 257 LANCETS 28G...... 222 Eluryng...... 148 DURLAZA...... 199 EASY TOUCH TEST...... 222 EMADINE...... 199 dutasteride...... 189 easy trak blood glucose test.... 222 EMBEDA...... 24 dutasteride-tamsulosin hcl...... 189 EASY TWIST & CAP EMBRACE BLOOD DUZALLO...... 17 LANCETS...... 222 GLUCOSE TEST...... 223 DXEVO 11-DAY...... 163 EASYGLUCO...... 222 EMCYT...... 54 DYANAVEL XR...... 113 EASYMAX 15 TEST...... 222 EMEND...... 177 DYAZIDE...... 84 EASYMAX TEST...... 222 EMEND TRI-PACK...... 177 DYMISTA...... 262 easyplus blood glucose test...... 222 EMFLAZA...... 163 DYRENIUM...... 84 EASYPRO PLUS...... 222 EMGALITY...... 118 E.E.S. GRANULES...... 48 EC-NAPROSYN...... 19 EMGALITY (300 MG easy comfort insulin syringe....221 econazole nitrate...... 281 DOSE)...... 118 easy comfort lancets...... 221 ECONTRA EZ...... 148 Emoquette...... 148 easy plus ii glucose test...... 221 ECOTRIN LOW EMSAM...... 100 EASY STEP TEST...... 221 STRENGTH...... 32 emtricitabine...... 38 easy talk blood glucose test.....221 ECOZA...... 281 emtricitabine-tenofovir df...... 42 EASY TOUCH INSULIN EDARBYCLOR...... 70 EMTRIVA...... 38 SAFETY SYR...... 221 EDECRIN...... 84 EMVERM...... 35 EASY TOUCH INSULIN EDLUAR...... 116 ENABLEX...... 192 SYRINGE...... 221 ed-spaz...... 175 enalapril maleate...... 68 EASY TOUCH LANCETS EDURANT...... 38 enalapril-hydrochlorothiazide... 67 21G...... 221 efavirenz...... 38 ENBREL...... 203, 204 EASY TOUCH LANCETS efavirenz-emtricitab-tenofovir...42 ENBREL MINI...... 203 23G...... 221 efavirenz-lamivudine-tenofovir..42 ENBREL SURECLICK...... 204 EASY TOUCH LANCETS EFFER-K...... 240 ENCARE...... 190 26G...... 221 Effer-K...... 240 ENDARI...... 199 EASY TOUCH LANCETS effervescent pot chloride...... 240 Endocet...... 24 28G...... 221 EFFEXOR XR...... 100 ENDOMETRIN...... 192 EASY TOUCH LANCETS EFFIENT...... 201 enoxaparin sodium...... 194 28G/TWIST...... 221 EFUDEX...... 280 Enpresse-28...... 148 EASY TOUCH LANCETS ELAVIL...... 100 Enskyce...... 148 30G...... 222 ELDEPRYL...... 104 ENSPRYNG...... 212 EASY TOUCH LANCETS ELEMENT TEST...... 222 ENSTILAR...... 288 30G/TWIST...... 222 ELEPSIA XR...... 92 entacapone...... 104 EASY TOUCH LANCETS ELESTAT...... 199 entecavir...... 44 32G...... 222 ELESTRIN...... 160 ENTOCORT EC...... 180 eletriptan hydrobromide...... 118 ENTRESTO...... 86 308 enulose...... 182 Estarylla...... 148 EXSERVAN...... 121 ENVARSUS XR...... 212 estazolam...... 116 EXTAVIA...... 123 EPANED...... 69 ESTRACE...... 160 EXTINA...... 281 EPCLUSA...... 50 estradiol...... 160 EYSUVIS...... 257 EPIDIOLEX...... 92 estradiol valerate...... 160 E-Z JECT LANCET EPIDUO...... 278 estradiol-norethindrone acet... 160 MICRO-THIN 33G...... 223 EPIDUO FORTE...... 278 ESTRING...... 160 E-Z JECT LANCET SUPER EPIFOAM...... 292 ESTROGEL...... 160 THIN 30G...... 223 epinastine hcl...... 251 estropipate...... 161 E-Z JECT LANCETS...... 223 epinephrine...... 259, 260 eszopiclone...... 116 E-Z JECT LANCETS 21G....223 EPISNAP...... 260 ethacrynic acid...... 84 E-Z JECT LANCETS THIN Epitol...... 92 ethambutol hcl...... 43 26G...... 223 EPIVIR...... 38 ethosuximide...... 92, 93 EZ SMART BLOOD EPIVIR HBV...... 44 ethynodiol diac-eth estradiol... 148 GLUCOSE LANCETS...... 223 eplerenone...... 69 etidronate disodium...... 143 EZ SMART BLOOD EPOGEN...... 196 etodolac...... 19 GLUCOSE TEST...... 223 epoprostenol sodium...... 88 etodolac er...... 19 EZ SMART PLUS eprosartan mesylate...... 72 etoposide...... 67 GLUCOSE TEST...... 223 EPZICOM...... 42 etravirine...... 38 EZALLOR SPRINKLE...... 75 eq blood glucose test...... 223 EUCRISA...... 294 ezetimibe...... 74 eq famotidine max st...... 179 EURAX...... 297 ezetimibe-simvastatin...... 76 eq lidocaine pain relieving...... 292 Euthyrox...... 173 FABIOR...... 278 eql sleep aid...... 116 EVAMIST...... 161 FACTIVE...... 49 equapax/ibuprofen/minrex...... 213 EVEKEO...... 113 FALESSA...... 148 EQUETRO...... 107 EVEKEO ODT...... 113 Falmina...... 148 ergocal...... 243 EVENCARE + BLOOD famciclovir...... 45 ergoloid mesylates...... 98 GLUCOSE TEST...... 223 famotidine...... 179 ERGOMAR...... 118 EVENCARE BLOOD FANAPT...... 107 ergotamine-caffeine...... 118 GLUCOSE TEST...... 223 FANAPT TITRATION ERIVEDGE...... 55 EVENCARE G2 TEST...... 223 PACK...... 108 ERLEADA...... 57 EVENCARE G3 TEST...... 223 FARESTON...... 57 erlotinib hcl...... 60 EVENITY...... 168 FARXIGA...... 141 Errin...... 148 everolimus...... 60, 212 FARYDAK...... 56 ERTACZO...... 281 EVISTA...... 168 FASENRA PEN...... 266 ery...... 278 EVITHROM...... 199 favipiravir...... 45 ERYPED 200...... 48 EVOCLIN...... 278 Fayosim...... 148 ERYPED 400...... 48 EVOLUTION AUTOCODE 223 FAZACLO...... 108 Ery-Tab...... 48 EVOTAZ...... 42 FC FEMALE CONDOM..... 213 ERYTHROCIN STEARATE 48 EVOXAC...... 297 FC2 FEMALE CONDOM... 214 erythromycin...... 256, 278 EVRYSDI...... 120 febuxostat...... 17 erythromycin base...... 48 EVZIO...... 128 felbamate...... 93 erythromycin ethylsuccinate..... 48 EXALGO...... 24 FELBATOL...... 93 erythromycin stearate...... 48 EXEL COMFORT POINT FELDENE...... 19 ESBRIET...... 270 INSULIN SYR...... 223 felodipine er...... 81 escitalopram oxalate...... 101 EXELDERM...... 281 FEM PH...... 191 Esgic...... 18 EXELON...... 98 FEMARA...... 57 ESGIC...... 18 exemestane...... 57 FEMCAP...... 214 esomeprazole magnesium...... 186 EXFORGE...... 70 FEMRING...... 161 esomeprazole strontium...... 186 EXFORGE HCT...... 70 Femynor...... 148 ESPEROCT...... 198 EXJADE...... 144 fenofibrate...... 74 309 fenofibrate micronized...... 74 FLEXICHAMBER ADULT FOCALIN XR...... 113 fenofibric acid...... 74 MASK/SMALL...... 239 folate...... 243 FENOGLIDE...... 74 FLOLAN...... 88 FOLBEE PLUS CZ...... 243 fenoprofen calcium...... 19 flolipid...... 75 folcal dha...... 243 FENORTHO...... 19 FLOMAX...... 189 FOLCAPS OMEGA 3...... 243 FENSOLVI...... 58 FLONASE ALLERGY folic acid...... 243 fentanyl...... 24 RELIEF...... 271 FOLIVANE-OB...... 244 fentanyl citrate...... 24 FLORIVA...... 243 FOLVITE-FE...... 199 FENTORA...... 24 FLOVENT DISKUS...... 273 fondaparinux sodium...... 194 FERRIPROX...... 144 FLOVENT HFA...... 274 FORA D15G BLOOD FERRIPROX TWICE-A- FLOXIN OTIC...... 299 GLUCOSE TEST...... 224 DAY...... 144 floxuridine...... 55 FORA D20 BLOOD FETZIMA...... 101 fluconazole...... 33 GLUCOSE TEST...... 224 FETZIMA TITRATION...... 101 flucytosine...... 33 FORA G20 BLOOD FEXMID...... 126 fludrocortisone acetate...... 163 GLUCOSE TEST...... 224 fexofenadine hcl...... 263 FLUMADINE...... 45 FORA G30/PREM V10 fexofenadine hcl childrens...... 263 flunisolide...... 271 GLUCOSE TEST...... 224 fexofenadine-pseudoephed er.. 267 fluocinolone acetonide..... 288, 299 FORA GD20 TEST...... 224 FIASP...... 135 fluocinolone acetonide body.... 288 FORA LANCETS...... 224 FIASP FLEXTOUCH...... 135 fluocinolone acetonide scalp....288 FORA V10 BLOOD FIASP PENFILL...... 135 fluocinonide...... 288, 289 GLUCOSE TEST...... 224 FIBRICOR...... 74 fluocinonide emulsified base....288 FORA V12 BLOOD FIFTY50 GLUCOSE TEST FLUORABON...... 243 GLUCOSE TEST...... 224 2.0...... 223 FLUOR-A-DAY...... 243 FORA V20 BLOOD FIFTY50 PEN NEEDLES... 223 FLUORIDEX GLUCOSE TEST...... 224 FIFTY50 SAFETY SEAL SENSITIVITY RELIEF...... 297 FORA V30A BLOOD LANCETS...... 224 fluoritab...... 243 GLUCOSE TEST...... 224 FIFTY50 SUPERIOR fluorometholone...... 257 FORACARE GD40 TEST....224 COMFORT SYR...... 224 FLUOROPLEX...... 280 FORACARE PREMIUM FINACEA...... 296 fluorouracil...... 280 V10 TEST...... 224 finasteride...... 189 fluoxetine hcl...... 101 FORFIVO XL...... 101 FINE 30...... 224 fluoxetine hcl (pmdd)...... 101 formoterol fumarate...... 265 FINGERSTIX LANCETS... 224 fluphenazine decanoate...... 108 FORTAMET...... 132 FINTEPLA...... 93 fluphenazine hcl...... 108 FORTEO...... 169 FIORICET...... 18 FLURA-DROPS...... 243 FORTESTA...... 130 FIORICET/CODEINE...... 24 flurandrenolide...... 289 FOSAMAX...... 143 FIORINAL...... 18 FLURA-SAFE...... 199 FOSAMAX PLUS D...... 143 FIORINAL/CODEINE #3.....25 flurazepam hcl...... 116 fosamprenavir calcium...... 38 FIRAZYR...... 199 flurbiprofen...... 19 fosinopril sodium...... 69 FIRDAPSE...... 121 flurbiprofen sodium...... 258 fosinopril sodium-hctz...... 68 FIRMAGON...... 58 flutamide...... 58 FOSRENOL...... 171 FIRMAGON (240 MG fluticasone propionate..... 271, 289 FOTIVDA...... 60 DOSE)...... 58 fluticasone-salmeterol..... 261, 275 FRAGMIN...... 195 FIRVANQ...... 35 fluvastatin sodium...... 75 FREESTYLE INSULINX FLAGYL...... 35 fluvastatin sodium er...... 75 TEST...... 224 FLAREX...... 257 fluvoxamine maleate...... 121 FREESTYLE LANCETS..... 224 flavoxate hcl...... 183 fluvoxamine maleate er...... 121 FREESTYLE LITE TEST....225 flecainide acetate...... 72 FML...... 258 FREESTYLE PRECISION FLECTOR...... 294 FML FORTE...... 258 INS SYR...... 225 FLEET LAXATIVE...... 182 FOCALIN...... 113 310 FREESTYLE PRECISION GENVOYA...... 42 GLUCOVANCE...... 132 NEO TEST...... 225 GEODON...... 108 GLUMETZA...... 132 FREESTYLE TEST...... 225 Gianvi...... 148 glyburide...... 142 FREESTYLE UNISTICK II GIAZO...... 180 glyburide micronized...... 142 LANCETS...... 225 Gildagia...... 149 glyburide-metformin...... 133 FROVA...... 118 Gildess Fe 1.5/30...... 149 glycopyrrolate...... 175 frovatriptan succinate...... 118 Gildess Fe 1/20...... 149 GLYNASE...... 142 FULPHILA...... 196 GILENYA...... 123 GLYSET...... 131 fulvestrant...... 58 GILOTRIF...... 65 GLYXAMBI...... 141 FURADANTIN...... 35 GIMOTI...... 177 gnp lidocaine pain relief...... 292 furosemide...... 84 glatiramer acetate...... 123 gnp urinary pain relief...... 191 FUZEON...... 38 Glatopa...... 123 GOCOVRI...... 105 Fyavolv...... 161 GLEEVEC...... 61 GOJJI BLOOD GLUCOSE FYCOMPA...... 93 GLEOSTINE...... 54 TEST...... 226 gabapentin...... 93 glimepiride...... 142 GOLYTELY...... 182 GABITRIL...... 93 glipizide...... 142 GONAL-F...... 162 GALAFOLD...... 169 glipizide er...... 142 GONAL-F RFF...... 162 galantamine hydrobromide...... 98 glipizide xl...... 142 GONAL-F RFF REDIJECT 162 galantamine hydrobromide er... 98 glipizide-metformin hcl...... 132 GONITRO...... 87 GALZIN...... 240 global ease inject pen needles.. 225 goodsense nicotine...... 128 GAMASTAN...... 210 global inject ease insulin syr....225 GRALISE...... 127 GAMASTAN S/D...... 210 global inject ease lancets 28g.. 225 GRALISE STARTER...... 127 GAMMAGARD...... 210 global inject ease lancets 30g.. 225 granisetron hcl...... 177 GAMMAGARD S/D LESS GLOPERBA...... 17 GRANIX...... 196 IGA...... 210 GLUCAGEN GRASTEK...... 202 GAMMAKED...... 210 DIAGNOSTIC...... 225 griseofulvin microsize...... 33, 34 GAMUNEX-C...... 210 GLUCAGEN HYPOKIT..... 166 griseofulvin ultramicrosize...... 34 GASTROCROM...... 184 glucagon emergency...... 166 GRIS-PEG...... 34 gatifloxacin...... 256 GLUCO BURST...... 166 guanfacine hcl...... 86 GATTEX...... 184 GLUCOCARD 01 SENSOR guanfacine hcl er...... 113 GAVILYTE-C...... 182 PLUS...... 225 guanidine hcl...... 121 Gavilyte-G...... 182 GLUCOCARD GUARDIAN CONNECT Gavilyte-H...... 182 EXPRESSION TEST...... 225 TRANSMITTER...... 226 Gavilyte-N With Flavor Pack182 GLUCOCARD VITAL GUARDIAN LINK 3 GAVRETO...... 65 TEST...... 225 TRANSMITTER...... 226 ge100 blood glucose test...... 225 GLUCOCARD X-SENSOR.225 GUARDIAN SENSOR (3)...226 GELFILM...... 199 GLUCOCOM LANCETS GVOKE HYPOPEN 1- GELNIQUE...... 192 28G...... 225 PACK...... 166 GELNIQUE PUMP...... 192 GLUCOCOM LANCETS GVOKE HYPOPEN 2- gemfibrozil...... 74 30G...... 225 PACK...... 166 Gemmily...... 148 GLUCOCOM LANCETS GVOKE PFS...... 166 GEMTESA...... 171 33G...... 226 GYNAZOLE-1...... 193 generlac...... 182 GLUCOCOM TEST...... 226 HAEGARDA...... 199 Gengraf...... 212 GLUCOPHAGE...... 132 HAEMOLANCE...... 226 GENICIN VITA-Q...... 244 GLUCOPHAGE XR...... 132 HAEMOLANCE LOW GENOTROPIN...... 167 GLUCOPRO INSULIN FLOW LANCETS...... 226 GENOTROPIN SYRINGE...... 226 HAEMOLANCE PLUS...... 226 MINIQUICK...... 167 glucose...... 166 HAEMOLANCE PLUS GENTAK...... 256 GLUCOTROL...... 142 HIGH FLOW...... 226 gentamicin sulfate...... 256, 280 GLUCOTROL XL...... 142 311 HAEMOLANCE PLUS HUMALOG JUNIOR hydrocortisone-acetic acid...... 299 LOW FLOW...... 226 KWIKPEN...... 136 hydrogen peroxide...... 294 HAEMOLANCE PLUS HUMALOG KWIKPEN...... 136 hydromet...... 268 MAX FLOW...... 226 HUMALOG MIX 50/50...... 136 hydromorphone hcl...... 25 HAEMOLANCE PLUS HUMALOG MIX 50/50 hydromorphone hcl er...... 25 PEDIATRIC FLOW...... 226 KWIKPEN...... 136 hydroxychloroquine sulfate.....209 Hailey 24 Fe...... 149 HUMALOG MIX 75/25...... 136 hydroxyprogesterone caproate 172 halcinonide...... 289 HUMALOG MIX 75/25 hydroxyurea...... 65 HALCION...... 116 KWIKPEN...... 136 hydroxyzine hcl...... 263 HALDOL...... 108 HUMATIN...... 32 hydroxyzine pamoate...... 263 HALDOL DECANOATE.... 108 HUMATROPE...... 167 hyoscyamine sulfate...... 175, 176 halobetasol propionate...... 289 HUMIRA...... 205 hyoscyamine sulfate er...... 175 HALOG...... 289 HUMIRA PEDIATRIC HYPERRAB...... 211 haloperidol...... 108 CROHNS START...... 204 HYPERSAL...... 268, 270 haloperidol decanoate...... 108 HUMIRA PEN...... 204 HYQVIA...... 211 haloperidol lactate...... 108 HUMIRA PEN-CD/UC/HS HYSINGLA ER...... 26 HALOTIN...... 281 STARTER...... 204 HYZAAR...... 71 HARVONI...... 50 HUMIRA PEN- ibandronate sodium...... 143 healthwise mini pen needles.....226 PS/UV/ADOL HS START....204 IBRANCE...... 56 healthwise pen needles...... 226 HUMIRA PEN- Ibu...... 19 healthwise short pen needles....226 PSOR/UVEIT STARTER.... 205 IBUDONE...... 26 healthwise unifine pentips...... 226 HUMULIN 70/30...... 136 Ibudone...... 26 healthy accents unifine pentip. 226 HUMULIN 70/30 ibuprofen...... 19 healthy accents unilet lancets.. 226 KWIKPEN...... 136 icatibant acetate...... 200 Heather...... 149 HUMULIN N...... 136 ICLUSIG...... 61 HECTOROL...... 168 HUMULIN N KWIKPEN...136 icosapent ethyl...... 76 HELIDAC THERAPY...... 184 HUMULIN R...... 136 IDHIFA...... 61 HEMA-COMBISTIX...... 226 HUMULIN R U-500 ILARIS...... 205 HEMADY...... 163 (CONCENTRATED)...... 136 ILARIS (150MG HEMANGEOL...... 79 HUMULIN R U-500 DELIVERED)...... 213 hemenatal ob...... 244 KWIKPEN...... 137 ILEVRO...... 258 hemenatal ob + dha...... 244 hyalucil-4...... 294 ILUMYA...... 284 HEMOCYTE-F...... 199 HYCAMTIN...... 67 imatinib mesylate...... 61 heparin sodium (porcine)...... 195 HYCET...... 25 IMBRUVICA...... 61 heparin sodium (porcine) pf... 195 HYCOFENIX...... 267 IMCIVREE...... 121 HEPSERA...... 45 hydralazine hcl...... 86 imipramine hcl...... 101 HETLIOZ...... 116 HYDREA...... 65 imipramine pamoate...... 101 HETLIOZ LQ...... 116 hydrochlorothiazide...... 84 imiquimod...... 280 HEXALEN...... 54 hydrocod polst-cpm polst er.... 267 imiquimod pump...... 280 Hidex 6-Day...... 163 hydrocodone bitartrate er...... 25 IMITREX...... 118, 119 HIPREX...... 35 hydrocodone-acetaminophen.....25 IMITREX STATDOSE HIZENTRA...... 210 hydrocodone-guaifenesin...... 267 REFILL...... 118 hm biotin...... 244 hydrocodone-homatropine IMITREX STATDOSE hm lidocaine patch...... 292 ...... 267, 268 SYSTEM...... 119 hm sleep aid...... 116 hydrocodone-ibuprofen...... 25 IMPAVIDO...... 36 HM ULTICARE INSULIN hydrocortisone. 163, 180, 188, 289 IMPEKLO...... 289 SYRINGE...... 227 hydrocortisone (perianal)...... 188 IMPOYZ...... 290 HORIZANT...... 127 hydrocortisone butyr lipo base 289 IMURAN...... 212 HUMALOG...... 136 hydrocortisone butyrate...... 289 IMVEXXY...... 161 hydrocortisone valerate...... 289 312 IMVEXXY INVEGA TRINZA...... 108 JUBLIA...... 281 MAINTENANCE PACK.....161 INVELTYS...... 258 Juleber...... 149 IMVEXXY STARTER INVIRASE...... 38 JULUCA...... 42 PACK...... 161 INVOKAMET...... 141 Junel 1.5/30...... 149 INATAL ADVANCE...... 244 INVOKAMET XR...... 141 Junel 1/20...... 149 INATAL GT...... 244 INVOKANA...... 141 Junel Fe 1.5/30...... 149 INATAL ULTRA...... 244 iodine strong...... 240 Junel Fe 1/20...... 149 INBRIJA...... 105 IOPIDINE...... 253 Junel Fe 24...... 149 INCRELEX...... 169 ipratropium bromide...... 261 JUXTAPID...... 76 INCRUSE ELLIPTA...... 261 ipratropium-albuterol...... 261 JYNARQUE...... 169 indapamide...... 84 IPRIVASK...... 195 KADIAN...... 26 INDERAL LA...... 79 irbesartan...... 72 Kaitlib Fe...... 149 INDERAL XL...... 79 irbesartan-hydrochlorothiazide. 71 KALBITOR...... 200 INDOCIN...... 20 IRESSA...... 61 KALETRA...... 42 indomethacin...... 20 ISENTRESS...... 39 KALYDECO...... 270 indomethacin er...... 20 ISENTRESS HD...... 39 KAPSPARGO SPRINKLE....79 infanate balance...... 244 Isibloom...... 149 KAPVAY...... 113 INFINITY BLOOD isoniazid...... 43 KARBINAL ER...... 263 GLUCOSE TEST...... 227 ISOPTO CARPINE...... 253 Kariva...... 150 INFINITY VOICE...... 227 ISORDIL TITRADOSE...... 87 KATERZIA...... 82 INGREZZA...... 121 isosorbide dinitrate...... 87 KAZANO...... 133 INLYTA...... 61 isosorbide dinitrate er...... 87 k-effervescent...... 240 INNOPRAN XL...... 79 isosorbide mononitrate...... 87 KEFLEX...... 47 INQOVI...... 65 isosorbide mononitrate er...... 87 Kelnor 1/35...... 150 INREBIC...... 61 isotretinoin...... 278 KENALOG...... 290 INSPRA...... 69 isradipine...... 81 KEPPRA...... 93 INSTA-GLUCOSE...... 166 ISTALOL...... 253 KEPPRA XR...... 93 insulin asp prot & asp flexpen. 137 ISTURISA...... 169 KERYDIN...... 34 insulin aspart...... 137 itraconazole...... 34 KETEK...... 36 insulin aspart flexpen...... 137 ivermectin...... 36, 296, 297 KETOCARE...... 227 insulin aspart penfill...... 137 JADENU...... 144 ketoconazole...... 34, 282, 285 insulin aspart prot & aspart.....137 JADENU SPRINKLE...... 144 KETO-DIASTIX...... 227 insulin lispro...... 137 JAKAFI...... 61 ketone test...... 227 insulin lispro (1 unit dial)...... 137 JALYN...... 189 ketoprofen...... 20 insulin lispro junior kwikpen... 137 Jantoven...... 195 ketoprofen er...... 20 insulin lispro prot & lispro...... 137 JANUMET...... 133 ketorolac tromethamine.... 20, 258 insulin syringe...... 227 JANUMET XR...... 133 KETOSTIX...... 227 insulin syringe/needle...... 227 JANUVIA...... 133 ketotifen fumarate...... 200 insulin syringe-needle u-100.... 227 JARDIANCE...... 141 KEVEYIS...... 84 insupen pen needles...... 227 Jasmiel...... 149 KEVZARA...... 205 INSUPEN SENSITIVE...... 227 JATENZO...... 130 KHEDEZLA...... 101 INSUPEN ULTRAFIN...... 227 Jencycla...... 149 KIDS PROTEIN ORGANIC INTELENCE...... 38 jenliva prenatal/postnatal...... 244 SHAKE...... 244 INTERMEZZO...... 116 JENTADUETO...... 133 Kimidess...... 150 INTRAROSA...... 130 JENTADUETO XR...... 133 KINERET...... 205 INTRON A...... 211 jevantique lo...... 161 kinney lancets...... 227 Introvale...... 149 Jinteli...... 161 kinney thin lancets...... 227 INTUNIV...... 113 Jolessa...... 149 kinray insulin syringe...... 227 INVEGA...... 108 Jolivette...... 149 Kionex...... 144 INVEGA SUSTENNA...... 108 JORNAY PM...... 113 KISQALI (200 MG DOSE).... 56 313 KISQALI (400 MG DOSE).... 56 LAMICTAL XR...... 94 LENVIMA (18 MG DAILY KISQALI (600 MG DOSE).... 56 LAMISIL...... 34 DOSE)...... 62 KISQALI 200 DOSE...... 56 lamivudine...... 39, 45 LENVIMA (20 MG DAILY KISQALI 400 DOSE...... 56 lamivudine-zidovudine...... 43 DOSE)...... 62 KISQALI 600 DOSE...... 56 lamotrigine...... 94 LENVIMA (24 MG DAILY KISQALI FEMARA (400 lamotrigine er...... 94 DOSE)...... 62 MG DOSE)...... 56 lamotrigine starter kit-blue...... 94 LENVIMA (4 MG DAILY KISQALI FEMARA (600 lamotrigine starter kit-green.....94 DOSE)...... 62 MG DOSE)...... 56 lamotrigine starter kit-orange...94 LENVIMA (8 MG DAILY KISQALI FEMARA(200 LAMPIT...... 36 DOSE)...... 62 MG DOSE)...... 56 lancet device...... 227 LESCOL...... 75 KITABIS PAK...... 32 lancet transporter case...... 228 LESCOL XL...... 75 KLARON...... 278 lancets...... 228 Lessina...... 150 KLISYRI...... 280 lancets 28g...... 228 LETAIRIS...... 88 Klofensaid Ii...... 294 lancets 30g...... 228 letrozole...... 58 KLONOPIN...... 93 lancets thin...... 228 leucovorin calcium...... 67 Klor-Con...... 240 LANCETS ULTRA FINE....228 LEUKERAN...... 55 Klor-Con 10...... 240 LANCETS ULTRA THIN...228 leuprolide acetate...... 58 Klor-Con M10...... 240 lancets ultra thin 30g...... 228 levalbuterol hcl...... 265 Klor-Con M15...... 240 lancing device...... 228 levalbuterol tartrate...... 265 Klor-Con M20...... 240 LANOXIN...... 83 LEVAQUIN...... 49 Klor-Con Sprinkle...... 240 lansoprazole...... 186 LEVEMIR...... 137 Klor-Con/Ef...... 240 lanthanum carbonate...... 171 LEVEMIR FLEXTOUCH... 137 KLOXXADO...... 128 LANTUS...... 137 levetiracetam...... 94 kls sleep aid...... 116 LANTUS SOLOSTAR...... 137 levetiracetam er...... 94 KOMBIGLYZE XR...... 133, 134 Larin 1.5/30...... 150 levobunolol hcl...... 253 KORLYM...... 169 Larin 1/20...... 150 levocarnitine...... 144 KOSELUGO...... 61 Larin 24 Fe...... 150 levocarnitine (dietary)...... 244 K-PHOS...... 240 Larin Fe 1.5/30...... 150 levocarnitine l-tartrate...... 244 K-PHOS NO 2...... 191 Larin Fe 1/20...... 150 levocarnitine-b5-taurine...... 244 K-PHOS-NEUTRAL...... 241 Larissia...... 150 levocetirizine dihydrochloride..263 K-Prime...... 241 LASIX...... 85 levofloxacin...... 49, 256 KRINTAFEL...... 37 LASTACAFT...... 252 levomefolate dha...... 244 KRISTALOSE...... 182 latanoprost...... 253 Levonest...... 150 kroger blood glucose test...... 227 LATUDA...... 109 levonorgest-eth estrad 91-day. 150 K-TAB...... 241 Layolis Fe...... 150 levonorgestrel...... 150 Kurvelo...... 150 LAZANDA...... 26 levonorgestrel-ethinyl estrad... 151 KUVAN...... 158 leader insulin syringe...... 228 levonorg-eth estrad triphasic...151 k-vescent...... 241 leader quick dissolve glucose... 166 Levora 0.15/30 (28)...... 151 KYLEENA...... 150 LEADER UNIFINE levorphanol tartrate...... 26 KYNAMRO...... 76 PENTIPS...... 228 Levo-T...... 173 KYNMOBI...... 105 ledipasvir-sofosbuvir...... 50 levothyroxine sodium...... 173 labetalol hcl...... 79 Leena...... 150 Levoxyl...... 173 LABSTIX...... 227 leflunomide...... 209 LEVULAN KERASTICK....294 LACRISERT...... 200 LENVIMA (10 MG DAILY LEXAPRO...... 101 lactic acid...... 294 DOSE)...... 62 LEXETTE...... 290 lactulose...... 182 LENVIMA (12 MG DAILY LEXIVA...... 39 lactulose encephalopathy...... 182 DOSE)...... 62 LIALDA...... 180 LAMICTAL...... 93 LENVIMA (14 MG DAILY LIBERTY NEXT LAMICTAL ODT...... 93 DOSE)...... 62 GENERATION TEST...... 228 314 liberty test...... 228 LOMOTIL...... 184 Ludent...... 244 LIBRAX...... 176 longs insulin syringe...... 228 lugols...... 295 LICART...... 294 longs lancets standard...... 229 lugols strong iodine...... 295 lidocaine...... 292 longs lancets thin...... 229 luliconazole...... 282 lidocaine hcl...... 292, 298 longs lancets ultra thin...... 229 LUMAKRAS...... 62 lidocaine hcl urethral/mucosal.292 LONHALA MAGNAIR LUMIGAN...... 253 lidocaine pain relief...... 293 REFILL KIT...... 261 LUNESTA...... 116 lidocaine pak...... 293 LONHALA MAGNAIR LUPANETA PACK...... 172 lidocaine viscous...... 298 STARTER KIT...... 261 LUPKYNIS...... 212 lidocaine-prilocaine...... 293 LONSURF...... 65 LUPRON DEPOT (1- lidocaine-tetracaine...... 293 loperamide hcl...... 184 MONTH)...... 58 LIDODERM...... 293 LOPID...... 75 LUPRON DEPOT (3- LIDOTREX...... 297 lopinavir-ritonavir...... 43 MONTH)...... 58 LIDOTREX (ALOE VERA) 297 Lopreeza...... 161 LUPRON DEPOT (4- LILETTA (52 MG)...... 151 LOPRESSOR...... 79 MONTH)...... 58 lindane...... 297 LOPRESSOR HCT...... 77 LUPRON DEPOT (6- linezolid...... 36 LOPROX...... 282 MONTH)...... 58 LINZESS...... 181 loratadine...... 263 LUPRON DEPOT-PED (1- liothyronine sodium...... 173 loratadine allergy relief...... 263 MONTH)...... 58 LIPITOR...... 75 loratadine childrens...... 263 LUPRON DEPOT-PED (3- LIPOFEN...... 74 loratadine-d 12hr...... 268 MONTH)...... 58 lisinopril...... 69 loratadine-d 24hr...... 268 Lutera...... 151 lisinopril-hydrochlorothiazide... 68 lorazepam...... 90 LUXIQ...... 290 lite touch lancets...... 228 Lorazepam Intensol...... 90 LUZU...... 282 LITE TOUCH PEN LORBRENA...... 62 LYNPARZA...... 56, 65 NEEDLES...... 228 Lorcet...... 26 LYRICA...... 94 LITETOUCH INSULIN Lorcet Hd...... 26 LYRICA CR...... 128 SYRINGE...... 228 Lorcet Plus...... 26 LYSODREN...... 58 LITETOUCH PEN LORTAB...... 26 LYSTEDA...... 200 NEEDLES...... 228 Loryna...... 151 LYUMJEV...... 137 lithium...... 121 Lorzone...... 126 LYUMJEV KWIKPEN...... 137 lithium carbonate...... 121 losartan potassium...... 72 Lyza...... 151 lithium carbonate er...... 121 losartan potassium-hctz...... 71 MACROBID...... 36 LITHOBID...... 109 LOTEMAX...... 258 MACRODANTIN...... 36 LITHOSTAT...... 191 LOTEMAX SM...... 258 MAGELLAN INSULIN LIVALO...... 75 LOTENSIN...... 69 SAFETY SYR...... 229 live better lancet super thin..... 228 LOTENSIN HCT...... 68 MAGNEBIND 400...... 241 live better lancet ultra thin...... 228 loteprednol etabonate...... 258 MAKENA...... 172 LO LOESTRIN FE...... 151 LOTREL...... 68 MALARONE...... 37 LOCOID...... 290 LOTRISONE...... 282 malathion...... 297 LOCOID LIPOCREAM...... 290 LOTRONEX...... 181 maprotiline hcl...... 101 LOCORT 11-DAY...... 163 lovastatin...... 75 MARINOL...... 177 LOCORT 7-DAY...... 164 LOVAZA...... 76 marlissa...... 151 LODINE...... 20 LOVENOX...... 195 MARPLAN...... 101 LODOSYN...... 105 Low-Ogestrel...... 151 marten-tab...... 18 Loestrin 1.5/30 (21)...... 151 loxapine succinate...... 109 MATULANE...... 65 Loestrin 1/20 (21)...... 151 LOZI-FLUR...... 244 Matzim La...... 82 LOFIBRA...... 75 Lo-Zumandimine...... 151 MAVENCLAD (10 TABS)...123 LOKELMA...... 144 lubiprostone...... 181 MAVENCLAD (4 TABS).....123 Lomedia 24 Fe...... 151 LUCEMYRA...... 128 MAVENCLAD (5 TABS).....124 315 MAVENCLAD (6 TABS).....124 MENTAX...... 282 metipranolol...... 253 MAVENCLAD (7 TABS).....124 meperidine hcl...... 26 metoclopramide hcl...... 177 MAVENCLAD (8 TABS).....124 MEPHYTON...... 244 metolazone...... 85 MAVENCLAD (9 TABS).....124 meprobamate...... 90 metoprolol succinate er...... 79 MAVIK...... 69 mercaptopurine...... 55 metoprolol tartrate...... 79 MAVYRET...... 50 mesalamine...... 180 metoprolol-hctz er...... 77 MAXALT...... 119 mesalamine er...... 180 metoprolol-hydrochlorothiazide 78 MAXALT-MLT...... 119 mesalamine-cleanser...... 180 METROCREAM...... 296 MAXI-COMFORT MESNEX...... 67 METROGEL...... 296 INSULIN SYRINGE...... 229 MESTINON...... 121 METROGEL-VAGINAL.....194 MAXIDEX...... 258 Metadate Er...... 113 METROLOTION...... 296 MAXITROL...... 254 metaproterenol sulfate...... 265 metronidazole...... 36, 194, 296 MAXZIDE...... 85 Metaxall...... 126 METRONIDAZOLE MAXZIDE-25...... 85 metaxalone...... 126 BENZO+SYRSPEND...... 36 MAYZENT...... 124 metformin hcl...... 132 metyrosine...... 86 MAYZENT STARTER metformin hcl er...... 132 MEVACOR...... 75 PACK...... 124 metformin hcl er (mod)...... 132 mexiletine hcl...... 72 meclizine hcl...... 177 metformin hcl er (osm)...... 132 MIACALCIN...... 169 meclofenamate sodium...... 20 methadone hcl...... 26, 27 Mibelas 24 Fe...... 151 MEDISENSE THIN Methadone Hcl Intensol...... 26 MICARDIS...... 72 LANCETS...... 229 METHADOSE...... 27 MICARDIS HCT...... 71 MEDLANCE EXTRA 21G..229 Methadose...... 27 miconazole 3...... 194 MEDLANCE LITE 25G...... 229 METHADOSE SUGAR- miconazole-zinc oxide-petrolat282 MEDLANCE PLUS EXTRA FREE...... 27 MICORT-HC...... 290 21G...... 229 methamphetamine hcl...... 113 MICRODOT TEST...... 229 MEDLANCE PLUS methazolamide...... 85 Microgestin 1.5/30...... 151 LANCETS...... 229 methenamine hippurate...... 36 Microgestin 1/20...... 152 MEDLANCE PLUS LITE methenamine mandelate...... 36 Microgestin Fe 1.5/30...... 152 25G...... 229 Methergine...... 169 Microgestin Fe 1/20...... 152 MEDLANCE PLUS methimazole...... 173 MICRO-K...... 241 SUPERLITE 30G...... 229 methitest...... 130 MICROLET LANCETS...... 229 MEDLANCE PLUS methocarbamol...... 126 MICROZIDE...... 85 UNIVERSAL 21G...... 229 methotrexate...... 55 midazolam hcl...... 117 MEDLANCE UNIVERSAL methotrexate sodium...... 55 MIDAZOLAM+SYRSPEN 21G...... 229 methotrexate sodium (pf)...... 55 D SF PH4...... 117 MEDROL...... 164 methoxsalen...... 284 midodrine hcl...... 86 medroxyprogesterone acetate methoxsalen rapid...... 284 MIGERGOT...... 119 ...... 151, 172 methscopolamine bromide...... 176 miglitol...... 131 mefenamic acid...... 20 methyclothiazide...... 85 miglustat...... 158 mefloquine hcl...... 37 methyldopa...... 86 MIGRANAL...... 119 MEGACE ES...... 172 methyldopa- MILLIPRED...... 164 megestrol acetate...... 58 hydrochlorothiazide...... 86 MILLIPRED DP...... 164 MEKINIST...... 62 METHYLIN...... 113 MILLIPRED DP 12-DAY....164 MEKTOVI...... 65 methylphenidate hcl...... 114 Mimvey...... 161 meloxicam...... 20 methylphenidate hcl er...... 114 Mimvey Lo...... 161 melphalan...... 55 methylphenidate hcl er (cd)....114 MINASTRIN 24 FE...... 152 memantine hcl...... 98 methylphenidate hcl er (la).... 114 MINIPRESS...... 69 memantine hcl er...... 98 methylphenidate hcl er (xr)....114 Minitran...... 87 MENEST...... 161 methylprednisolone...... 164 MINIVELLE...... 161 MENOSTAR...... 161 methyltestosterone...... 130 MINOCIN...... 53 316 minocycline hcl...... 53 MOZOBIL...... 200 naftifine hcl...... 282 minocycline hcl er...... 53 MS CONTIN...... 28 NAFTIN...... 282 MINOLIRA...... 53 ms insulin syringe...... 230 NALFON...... 20 minoxidil...... 86 MUCINEX ALLERGY...... 263 nalocet...... 28 MIRAPEX...... 105 MULPLETA...... 196 naloxone hcl...... 128 MIRAPEX ER...... 105 MULTAQ...... 72 naltrexone hcl...... 129 MIRCERA...... 196 multi-lancet device...... 230 NAMENDA...... 98 MIRENA (52 MG)...... 152 MULTISTIX...... 230 NAMENDA TITRATION mirtazapine...... 101 MULTISTIX 10 SG...... 230 PAK...... 98 MIRVASO...... 296 MULTISTIX 5...... 230 NAMENDA XR...... 98 misoprostol...... 184 MULTISTIX 7...... 230 NAMENDA XR MITIGARE...... 17 MULTISTIX 8...... 230 TITRATION PACK...... 99 MOBIC...... 20 MULTISTIX 9...... 230 NAMZARIC...... 99 modafinil...... 127 MULTISTIX 9 SG...... 230 naphazoline hcl...... 259 Moderiba...... 50 multi-vit/fluoride...... 244 NAPRELAN...... 20 MODERIBA 1200 DOSE multivitamin/fluoride...... 244 NAPROSYN...... 20 PACK...... 50 multi-vitamin/fluoride...... 244 naproxen...... 20 MODERIBA 800 DOSE multivitamins/fluoride...... 245 naproxen dr...... 20 PACK...... 50 mupirocin...... 280 naproxen sodium...... 20 moexipril hcl...... 69 mupirocin calcium...... 280 naproxen sodium er...... 20 moexipril-hydrochlorothiazide.. 68 Mvc-Fluoride...... 245 naproxen-esomeprazole...... 21 mometasone furoate...... 271, 290 M-VIT...... 245 naratriptan hcl...... 119 Mondoxyne Nl...... 53 MY WAY...... 152 NARCAN...... 129 MONODOX...... 54 MYALEPT...... 158 NARDIL...... 101 MONOJECT INSULIN MYAMBUTOL...... 44 NASACORT ALLERGY SYRINGE...... 229 MYCAPSSA...... 169 24HR...... 271 MONOJECT ULTRA MYCOBUTIN...... 44 NASCOBAL...... 245 COMFORT SYRINGE.229, 230 mycophenolate mofetil.... 212, 213 NASONEX...... 271 MONOLET LANCETS...... 230 mycophenolate sodium...... 213 NATACHEW...... 245 Mono-Linyah...... 152 MYDAYIS...... 114 NATACYN...... 256 Mononessa...... 152 MYDRIACYL...... 200 NATALVIT...... 245 montelukast sodium...... 269 MYFORTIC...... 213 NATAZIA...... 152 MONUROL...... 32 MYGLUCOHEALTH nateglinide...... 140 Morgidox...... 54 LANCETS 30G...... 230 NATELLE ONE...... 245 MORPHABOND ER...... 27 MYGLUCOHEALTH TEST NATESTO...... 130 morphine sulfate...... 27, 28 ...... 230 NATPARA...... 169 morphine sulfate (concentrate).27 MYLERAN...... 55 NATROBA...... 297 morphine sulfate er...... 27 MYNATAL...... 245 NATURE-THROID...... 173 morphine sulfate er beads...... 27 MYNATAL ADVANCE...... 245 NAYZILAM...... 94 MOTEGRITY...... 184 mynatal plus...... 245 NEBUPENT...... 36 MOTOFEN...... 184 mynatal-z...... 245 Nebusal...... 268 mouth wash-gp...... 259 Myorisan...... 278 NEBUSAL...... 268 mouthwash-af...... 259 MYRBETRIQ...... 171, 193 Necon 0.5/35 (28)...... 152 mouthwash-om...... 259 MYSOLINE...... 94 Necon 1/35 (28)...... 152 MOVANTIK...... 184 MYTESI...... 184 NECON 1/50 (28)...... 152 MOVIPREP...... 182 Myzilra...... 152 Necon 7/7/7...... 152 MOXATAG...... 52 nabumetone...... 20 NEEVO DHA...... 245 MOXEZA...... 256 nadolol...... 79 nefazodone hcl...... 101 moxifloxacin hcl...... 49, 256 nadolol-bendroflumethiazide.....78 neomycin sulfate...... 33 moxifloxacin hcl (2x day)...... 256 Nafrinse...... 245 317 neomycin-bacitracin zn- nicardipine hcl...... 82 NORPRAMIN...... 102 polymyx...... 256 nicotine...... 129 NORTHERA...... 86 neomycin-polymyxin b gu...... 191 nicotine polacrilex...... 129 Nortrel 0.5/35 (28)...... 153 neomycin-polymyxin-dexameth NICOTROL...... 129 Nortrel 1/35 (21)...... 153 ...... 254 NICOTROL NS...... 129 Nortrel 1/35 (28)...... 153 neomycin-polymyxin- Nifediac Cc...... 82 Nortrel 7/7/7...... 153 gramicidin...... 256 Nifedical Xl...... 82 nortriptyline hcl...... 102 neomycin-polymyxin-hc.. 254, 299 nifedipine...... 82 NORTUSS-DE...... 268 neonatal + dha...... 245 nifedipine er...... 82 nortuss-ex...... 268 neonatal 19...... 245 nifedipine er osmotic release..... 82 NORVASC...... 82 neonatal fe...... 245 NIFEREX...... 200 NORVIR...... 39 Neo-Polycin...... 256 Nikki...... 153 NOURIANZ...... 105 Neo-Polycin Hc...... 255 NILANDRON...... 58 NOVA MAX GLUCOSE NEORAL...... 213 nilutamide...... 58 TEST...... 230 NEOSPORIN...... 256 nimodipine...... 82 NOVA SAFETY LANCETS NEO-SYNALAR...... 281 NINLARO...... 67 23G...... 230 NEOTUSS PLUS...... 268 nisoldipine er...... 82 NOVA SAFETY LANCETS NEPHPLEX RX...... 245 nitazoxanide...... 36 28G...... 230 NEPTAZANE...... 85 nitisinone...... 158 NOVA SUREFLEX NERLYNX...... 62 NITRO-BID...... 87 LANCETS...... 230 NESINA...... 133 NITRO-DUR...... 87 NOVAREL...... 162 NESTABS...... 245 nitrofurantoin...... 36 NOVOFINE...... 230 NESTABS DHA...... 245 nitrofurantoin macrocrystal...... 36 NOVOFINE AUTOCOVER 230 Neuac...... 278 nitrofurantoin monohyd macro. 36 NOVOLIN 70/30...... 138 NEULASTA...... 197 nitroglycerin...... 87 NOVOLIN 70/30 FLEXPEN 138 NEULASTA ONPRO...... 196 NITROLINGUAL...... 88 NOVOLIN 70/30 FLEXPEN NEUPOGEN...... 197 NITROMIST...... 88 RELION...... 138 NEUPRO...... 105 NITROSTAT...... 88 NOVOLIN 70/30 RELION...138 NEURONTIN...... 94 NITYR...... 158 NOVOLIN N...... 138 NEUTEK 2TEK TEST...... 230 NIVESTYM...... 197 NOVOLIN N FLEXPEN..... 138 Neutragard Advanced...... 298 nizatidine...... 179 NOVOLIN N FLEXPEN neutral sodium fluoride...... 298 NIZORAL...... 285 RELION...... 138 NEVANAC...... 258 NOCDURNA...... 175 NOVOLIN N RELION...... 138 nevirapine...... 39 NOCTIVA...... 175 NOVOLIN R...... 138 nevirapine er...... 39 Nora-Be...... 153 NOVOLIN R FLEXPEN..... 138 NEWGEN...... 245 NORCO...... 28 NOVOLIN R FLEXPEN NEXA PLUS...... 246 NORDITROPIN FLEXPRO167 RELION...... 138 NEXAVAR...... 62 norethin ace-eth estrad-fe...... 153 NOVOLIN R RELION...... 138 NEXIUM...... 186 norethindrone...... 153 NOVOLOG...... 139 NEXIUM 24HR...... 186 norethindrone acetate...... 172 NOVOLOG 70/30 FLEXPEN NEXLETOL...... 73 norethindrone acet-ethinyl est. 153 RELION...... 138 NEXLIZET...... 73 norethindrone-eth estradiol..... 161 NOVOLOG FLEXPEN...... 139 NEXPLANON...... 152 norethin-eth estradiol-fe...... 153 NOVOLOG FLEXPEN NEXT CHOICE ONE DOSE norgesic forte...... 126 RELION...... 139 ...... 152 norgestimate-eth estradiol...... 153 NOVOLOG MIX 70/30...... 139 NEXTSTELLIS...... 152 norgestim-eth estrad triphasic.153 NOVOLOG MIX 70/30 niacin (antihyperlipidemic)...... 76 NORITATE...... 296 FLEXPEN...... 139 niacin er (antihyperlipidemic).. 76 Norlyroc...... 153 NOVOLOG MIX 70/30 NIACOR...... 76 NORPACE...... 72 RELION...... 139 NIASPAN...... 77 NORPACE CR...... 72 NOVOLOG PENFILL...... 139 318 NOVOLOG RELION...... 139 ODOMZO...... 65 ONETOUCH SURESOFT NOVOTWIST...... 230 OFEV...... 272 LANCING DEV...... 231 NOXAFIL...... 34 ofloxacin...... 49, 256, 299 ONETOUCH ULTRA...... 231 np thyroid...... 173 OGESTREL...... 153 ONETOUCH ULTRA NPLATE...... 197 olanzapine...... 109 BLUE...... 231 NUBEQA...... 58 olanzapine-fluoxetine hcl...... 129 ONETOUCH ULTRASOFT NUCALA...... 266 olmesartan medoxomil...... 72 LANCETS...... 231 NUCYNTA...... 28 olmesartan medoxomil-hctz...... 71 ONETOUCH VERIO...... 231 NUCYNTA ER...... 28 olmesartan-amlodipine-hctz...... 71 ONEXTON...... 278 NUEDEXTA...... 121 olopatadine hcl...... 252, 264 ONFI...... 95 NUFERA...... 200 OLUMIANT...... 205 ONGENTYS...... 105 Nulev...... 176 OLUX...... 290 ONGLYZA...... 133 NULYTELY WITH OLUX-E...... 290 ONMEL...... 34 FLAVOR PACKS...... 182 OLYSIO...... 50 ONUREG...... 55 NUPLAZID...... 109 OMECLAMOX-PAK...... 189 ONZETRA XSAIL...... 119 NURTEC...... 119 omega-3-acid ethyl esters...... 77 OPANA...... 28 NUTROPIN AQ NUSPIN 10 omeprazole...... 187 OPANA ER...... 28 ...... 167 omeprazole magnesium...... 187 OPCICON ONE-STEP...... 153 NUTROPIN AQ NUSPIN 20 omeprazole-sodium opium...... 184 ...... 167 bicarbonate...... 187 OPSUMIT...... 88 NUTROPIN AQ NUSPIN 5 167 OMNARIS...... 271 OPTICHAMBER FACE NUVAIL...... 295 OMNIPOD 10 PACK...... 230 MASK-LARGE...... 239 NUVARING...... 153 OMNIPOD DASH 5 PACK OPTION 2...... 153 NUVESSA...... 194 PODS...... 230 OPTIONS CONCEPTROL.. 190 NUVIGIL...... 127 OMNIPOD DASH SYSTEM OPTIONS GYNOL II NUZYRA...... 54 ...... 231 CONTRACEPTIVE...... 190 Nyamyc...... 282 OMNIPOD STARTER...... 231 ORACEA...... 296 Nyata...... 282 OMNITROPE...... 167, 168 ORACIT...... 191 NYMALIZE...... 82 ON CALL LANCETS...... 231 ORALAIR...... 202 nystatin...... 34, 282, 298 ON CALL PLUS BLOOD Oralone...... 298 nystatin-triamcinolone...... 282 GLUCOSE...... 231 ORAP...... 121 Nystop...... 282 ON CALL PLUS LANCETS231 ORAPRED ODT...... 164 NYVEPRIA...... 197 ON CALL VIVID BLOOD ORAVIG...... 298 OB COMPLETE...... 246 GLUCOSE...... 231 ORENCIA...... 205 OB COMPLETE ONCASPAR...... 65 ORENCIA CLICKJECT...... 205 ADVANCED...... 246 ondansetron...... 178 ORENITRAM...... 88 OB COMPLETE GOLD...... 246 ondansetron hcl...... 177 ORFADIN...... 158 OB COMPLETE ONE...... 246 ONETOUCH CLUB ORGANIC NUTRITION OB COMPLETE PREMIER 246 LANCETS FINE PT...... 231 SHAKE...... 246 OB COMPLETE/DHA...... 246 ONETOUCH DELICA ORGOVYX...... 58 O-CAL FA...... 246 LANCETS 30G...... 231 ORIAHNN...... 161 O-CAL PRENATAL...... 246 ONETOUCH DELICA ORILISSA...... 157 OCALIVA...... 184 LANCETS 33G...... 231 ORKAMBI...... 271 Ocella...... 153 ONETOUCH DELICA ORLADEYO...... 200 OCTAGAM...... 211 LANCETS FINE...... 231 orphenadrine citrate er...... 126 octreotide acetate...... 169 ONETOUCH DELICA orphenadrine-asa-caffeine...... 126 OCUFLOX...... 256 LANCING DEV...... 231 Orphengesic Forte...... 126 OCUVEL...... 246 ONETOUCH FINEPOINT Orsythia...... 154 ODACTRA...... 202 LANCETS...... 231 ORTHO TRI-CYCLEN LO. 154 ODEFSEY...... 43 ONETOUCH LANCETS..... 231 ORTHO-NOVUM 7/7/7 (28) 154 319 ORTIKOS...... 180 PALFORZIA (20 MG PAXIL CR...... 102 oscimin...... 176 DAILY DOSE)...... 202 PAZEO...... 252 oscimin sr...... 176 PALFORZIA (200 MG PCE...... 48 oseltamivir phosphate...... 45 DAILY DOSE)...... 202 PEDIAPRED...... 164 OSENI...... 134 PALFORZIA (240 MG PEDIATRIC PANDA OSMOLEX ER...... 105 DAILY DOSE)...... 202 MASK...... 240 OSMOPREP...... 182 PALFORZIA (3 MG DAILY peg 3350...... 182 OSPHENA...... 169 DOSE)...... 202 peg 3350/electrolytes...... 182 OTEZLA...... 209 PALFORZIA (300 MG peg 3350-kcl-na bicarb-nacl.... 182 OTIPRIO...... 299 MAINTENANCE)...... 202 peg-3350/electrolytes...... 182 OTOVEL...... 299 PALFORZIA (300 MG peg-3350/electrolytes/ascorbat 182 OTREXUP...... 209 TITRATION)...... 203 PEGANONE...... 95 OVIDE...... 297 PALFORZIA (40 MG PEGASYS...... 50 OXANDRIN...... 130 DAILY DOSE)...... 203 PEGASYS PROCLICK...... 50 oxandrolone...... 130 PALFORZIA (6 MG DAILY PEGINTRON...... 50 oxaprozin...... 21 DOSE)...... 203 peg-kcl-nacl-nasulf-na asc-c....183 OXAYDO...... 28 PALFORZIA (80 MG PEG-PREP...... 183 oxazepam...... 90 DAILY DOSE)...... 203 PEMAZYRE...... 65 OXBRYTA...... 200 PALFORZIA INITIAL pen needles...... 231 oxcarbazepine...... 95 ESCALATION...... 203 pen needles 1/2"...... 231 OXERVATE...... 200 paliperidone er...... 109 pen needles 3/16"...... 231 oxiconazole nitrate...... 282 PALYNZIQ...... 158, 159 pen needles 5/16"...... 231 OXISTAT...... 282 PAMELOR...... 102 penicillamine...... 144, 145 OXSORALEN ULTRA...... 284 PAMINE...... 176 penicillin v potassium...... 52 OXTELLAR XR...... 95 PAMINE FORTE...... 176 PENLAC...... 283 oxybutynin chloride...... 193 PANCREAZE...... 185 PENNSAID...... 295 oxybutynin chloride er...... 193 pancreaze...... 185 pentamidine isethionate...... 36 oxycodone hcl...... 29 PANDEL...... 290 PENTASA...... 180 oxycodone hcl er...... 28 panlor...... 29 pentazocine-naloxone hcl...... 22 oxycodone-acetaminophen...... 29 PANRETIN...... 295 pentoxifylline er...... 200 oxycodone-aspirin...... 29 pantoprazole sodium...... 187 PEPCID...... 179 oxycodone-ibuprofen...... 29 PANZYGA...... 211 PERCOCET...... 29 OXYCONTIN...... 29 PARAFON FORTE DSC.....126 PERFOROMIST...... 265 oxymorphone hcl...... 29 PARAGARD PERIDEX...... 298 oxymorphone hcl er...... 29 INTRAUTERINE COPPER 154 perindopril erbumine...... 69 OXYTROL FOR WOMEN..193 paregoric...... 184 Periogard...... 298 OZEMPIC (0.25 OR 0.5 PAREMYD...... 200 permethrin...... 297 MG/DOSE)...... 134 paricalcitol...... 143 perphenazine...... 109 OZEMPIC (1 MG/DOSE).... 134 PARLODEL...... 105 perphenazine-amitriptyline..... 129 OZOBAX...... 126 PARNATE...... 102 PERSERIS...... 109 Pacerone...... 72 Paroex...... 298 PERTZYE...... 185 pain relief maximum strength. 293 paromomycin sulfate...... 33 PEXEVA...... 102 pain relieving lidocaine...... 293 paroxetine hcl...... 102 PHARMACIST CHOICE PALFORZIA (12 MG paroxetine hcl er...... 102 AUTOCODE...... 231 DAILY DOSE)...... 202 paroxetine mesylate...... 102 PHARMACIST CHOICE PALFORZIA (120 MG PASER...... 44 LANCETS...... 232 DAILY DOSE)...... 202 PATADAY...... 200 Phenadoz...... 178 PALFORZIA (160 MG PATANASE...... 260 phendimetrazine tartrate...... 121 DAILY DOSE)...... 202 PATANOL...... 200 phendimetrazine tartrate er.....121 PAXIL...... 102 phenelzine sulfate...... 102 320 Phenergan...... 178 pnv-dha...... 246 PRECISION POINT OF phenobarbital...... 95 pnv-dha+docusate...... 246 CARE TEST...... 232 phenoxybenzamine hcl...... 86 pnv-omega...... 246 PRECISION QID TEST...... 232 phentermine hcl...... 122 pnv-select...... 246 PRECISION SOF-TACT phenylephrine hcl...... 200 pnv-total...... 246 TEST...... 232 PHENYTEK...... 95 pnv-vp-u...... 246 PRECISION SUREDOSE phenytoin...... 95 POCKETCHEM EZ TEST...232 PLUS SYR...... 232 Phenytoin Infatabs...... 95 podofilox...... 295 PRECISION SURE-DOSE phenytoin sodium extended...... 95 POGO AUTOMATIC TEST SYRINGE...... 232 PHEXXI...... 190 CARTRIDGES...... 232 PRECISION THIN Philith...... 154 Polycin...... 256 LANCETS...... 232 PHOSLO...... 171 polyethylene glycol 3350...... 183 PRECISION ULTRA PHOSLYRA...... 171 polymyxin b-trimethoprim...... 256 LANCET...... 232 Phospha 250 Neutral...... 241 POLY-PREP...... 183 PRECISION XTRA BLOOD PHOSPHOLINE IODIDE....253 POLYTRIM...... 256 GLUCOSE...... 232 Physiolyte...... 259 POLY-VI-FLOR...... 247 PRECOSE...... 131 Physiosol Irrigation...... 259 POMALYST...... 211 PRED MILD...... 258 phytonadione...... 246 PONSTEL...... 21 PRED-G...... 255 PICATO...... 280 PONVORY...... 124 PRED-G S.O.P...... 255 PIFELTRO...... 39 PONVORY STARTER prednicarbate...... 290 pilocarpine hcl...... 253, 298 PACK...... 124 prednisolone...... 164 pimecrolimus...... 295 Portia-28...... 154 prednisolone acetate...... 258 pimozide...... 122 posaconazole...... 34 prednisolone sodium phosphate Pimtrea...... 154 pot bicarb-pot chloride...... 241 ...... 164, 258 pindolol...... 79 potassium bicarbonate...... 241 prednisone...... 164 pioglitazone hcl...... 140 potassium chloride...... 241 PREDNISONE INTENSOL 164 pioglitazone hcl-glimepiride.... 140 potassium chloride crys er...... 241 PREFERA OB...... 247 pioglitazone hcl-metformin hcl 140 potassium chloride er...... 241 PREFERAOB ONE...... 247 PIQRAY (200 MG DAILY potassium citrate er...... 191 preferred plus insulin syringe...232 DOSE)...... 62 potassium citrate-citric acid....191 preferred plus lancets colored..232 PIQRAY (250 MG DAILY POTIGA...... 95 preferred plus lancets thin...... 232 DOSE)...... 62 PR NATAL 400...... 247 preferred plus unifine pentips.. 232 PIQRAY (300 MG DAILY PR NATAL 430...... 247 PREFEST...... 162 DOSE)...... 62 PR NATAL 430 EC...... 247 pregabalin...... 95 Pirmella 1/35...... 154 PRADAXA...... 195 pregabalin er...... 95 Pirmella 7/7/7...... 154 PRALUENT...... 77 pregen dha...... 247 piroxicam...... 21 pramipexole dihydrochloride...105 pregenna...... 247 PLAQUENIL...... 209 pramipexole dihydrochloride er PREGNYL...... 162 PLAVIX...... 202 ...... 105 PREMARIN...... 162 PLEGRIDY...... 124 PRAMOSONE...... 293 premium lidocaine...... 293 PLEGRIDY STARTER PRAMOTIC...... 299 PREMPHASE...... 162 PACK...... 124 PRANDIN...... 140 PREMPRO...... 162 PLENVU...... 183 prasugrel hcl...... 202 prenaissance...... 247 PLEXION...... 279 PRAVACHOL...... 75 prenaissance balance...... 247 PLEXION CLEANSER...... 278 pravastatin sodium...... 76 prenaissance harmony dha...... 247 PLEXION CLEANSING praziquantel...... 36 prenaissance next...... 247 CLOTH...... 279 prazosin hcl...... 69 prenaissance next-b...... 247 PLIXDA...... 279 PRECISION PCX...... 232 prenaissance plus...... 247 pnv folic acid + iron...... 246 PRECISION PCX PLUS prenara...... 247 pnv prenatal plus multivitamin 246 TEST...... 232 PRENATA...... 247 321 PRENATABS RX...... 247 Procto-Med Hc...... 188 PULMICORT prenatal 19...... 247 Procto-Pak...... 188 FLEXHALER...... 274 prenatal low iron...... 247 Proctosol Hc...... 188 Pulmosal...... 268 prenatal plus iron...... 247 Proctozone-Hc...... 189 PULMOZYME...... 274 PRENATAL-U...... 248 PROCYSBI...... 191 PURIXAN...... 55 PRENATE...... 248 PRODIGY INSULIN PYLERA...... 184 PRENATE DHA...... 248 SYRINGE...... 233 pyrazinamide...... 44 PRENATE ELITE...... 248 PRODIGY LANCETS 28G..233 pyridostigmine bromide...... 122 PRENATE ESSENTIAL...... 248 PRODIGY NO CODING pyridostigmine bromide er...... 122 PRENATE MINI...... 248 BLOOD GLUC...... 233 pyridoxine hcl...... 248 prenatvite complete...... 248 PRODIGY TWIST TOP pyrimethamine...... 36 prenatvite plus...... 248 LANCETS 28G...... 233 QBRELIS...... 69 prenatvite rx...... 248 progesterone...... 172 QBREXZA...... 295 PREPIDIL...... 169 progesterone micronized...... 172 qc azo...... 191 PREPOPIK...... 183 PROGLYCEM...... 166 qc lidocaine pain relief...... 293 PRESTALIA...... 68 PROGRAF...... 213 qc urinary pain relief...... 191 pretab...... 248 PROLATE...... 30 QDOLO...... 30 pretomanid...... 44 PROLENSA...... 258 QELBREE...... 115 PREVACID...... 187 PROLIA...... 170 QINLOCK...... 65 PREVACID 24HR...... 187 PROMACTA...... 197 QMIIZ ODT...... 21 PREVACID SOLUTAB...... 187 promethazine hcl...... 178 QNASL...... 271 Prevalite...... 73 promethazine vc...... 268 QNASL CHILDRENS...... 271 Previfem...... 154 promethazine vc/codeine...... 268 QTERN...... 140 PREVPAC...... 189 promethazine-dm...... 268 QUALAQUIN...... 37 PREVYMIS...... 45 promethazine-phenylephrine... 268 QUARTETTE...... 154 PREZCOBIX...... 43 Promethegan...... 178 Quasense...... 154 PREZISTA...... 39 PROMETHEGAN...... 178 quazepam...... 117 PRIFTIN...... 44 PROMETRIUM...... 172 QUDEXY XR...... 95 PRILOSEC...... 187 propafenone hcl...... 72 QUESTRAN...... 74 PRILOSEC OTC...... 187 propafenone hcl er...... 72 QUESTRAN LIGHT...... 74 PRIMACARE...... 248 propantheline bromide...... 176 quetiapine fumarate...... 109 primaquine phosphate...... 37 proparacaine hcl...... 200 quetiapine fumarate er...... 109 primidone...... 95 propranolol hcl...... 79 QUFLORA FE PEDIATRIC PRIMLEV...... 29 propranolol hcl er...... 79 ...... 248 PRIMSOL...... 36 propranolol-hctz...... 78 QUILLICHEW ER...... 115 PRINIVIL...... 69 propylthiouracil...... 173 QUILLIVANT XR...... 115 PRISTIQ...... 102 PROSCAR...... 189 quinapril hcl...... 69 PROAIR DIGIHALER...... 265 PROSTIN E2...... 170 quinapril-hydrochlorothiazide...68 PROAIR HFA...... 265 PROTONIX...... 187 quinidine gluconate er...... 72 PROAIR RESPICLICK...... 265 PROTOPIC...... 295 quinidine sulfate...... 72 probenecid...... 17 protriptyline hcl...... 102 quinine sulfate...... 37 PROCARDIA...... 82 PROVENTIL HFA...... 265 QUINZYME...... 17 PROCARDIA XL...... 82 PROVERA...... 172 QVAR...... 274 Procentra...... 114 PROVIGIL...... 127 QVAR REDIHALER...... 274 prochlorperazine...... 178 PROZAC...... 102 ra lice treatment...... 297 prochlorperazine edisylate...... 109 PRUDOXIN...... 283 ra lidocaine pain relieving...... 293 prochlorperazine maleate...... 178 pseudoeph-chlorphen-hydrocod268 ra pain relieving...... 293 PROCRIT...... 197 psorcon...... 290 ra sleep aid...... 117 PROCTOCORT...... 188 PULMICORT...... 274 ra urinary pain relief...... 191 PROCTOFOAM HC...... 188 rabeprazole sodium...... 188 322 RADIOGARDASE...... 200 RELION LANCETS THIN RHINOCORT ALLERGY.. 272 RAGWITEK...... 203 26G...... 233 RHOFADE...... 296 Rajani...... 154 RELION LANCETS RHOPRESSA...... 259 raloxifene hcl...... 170 ULTRA-THIN 30G...... 233 Ribasphere...... 50 ramelteon...... 117 RELION MINI PEN RIBASPHERE...... 50 ramipril...... 69 NEEDLES...... 233 RIBASPHERE RIBAPAK.....51 RANEXA...... 86, 88 RELION PEN NEEDLES....233 ribavirin...... 45, 51 ranitidine hcl...... 179 RELION SHORT PEN RIDAURA...... 18 ranolazine er...... 86 NEEDLES...... 233 rifabutin...... 44 RAPAFLO...... 189 RELION ULTRA THIN RIFADIN...... 44 RAPAMUNE...... 213 LANCETS 30G...... 233 RIFAMATE...... 44 rasagiline mesylate...... 105 RELION ULTRA THIN rifampin...... 44 RASUVO...... 209 PLUS LANCETS...... 234 RIFAMPIN+SYRSPEND RAVICTI...... 159 RELISTOR...... 184 SF PH4...... 44 RAYALDEE...... 143 relnate dha...... 248 RIFATER...... 44 RAZADYNE...... 99 RELPAX...... 119 RIGHTEST GL300 RAZADYNE ER...... 99 RELTONE...... 184 LANCETS...... 234 REACT...... 154 REMERON...... 102 RIGHTEST GS100 BLOOD reality insulin syringe...... 233 REMERON SOLTAB...... 103 GLUCOSE...... 234 REBETOL...... 50 REMODULIN...... 88, 89 RIGHTEST GS300 BLOOD REBIF...... 125 RENACIDIN...... 191 GLUCOSE...... 234 REBIF REBIDOSE...... 124 RENAGEL...... 171 RIGHTEST GS550 BLOOD REBIF REBIDOSE RENVELA...... 171 GLUCOSE...... 234 TITRATION PACK...... 125 repaglinide...... 140 RILUTEK...... 122 REBIF TITRATION PACK 125 repaglinide-metformin hcl...... 132 riluzole...... 122 Reclipsen...... 154 REPATHA...... 77 rimantadine hcl...... 45 RECTIV...... 189 REPATHA PUSHTRONEX ringers irrigation...... 259 REDITREX...... 209 SYSTEM...... 77 RINVOQ...... 205 REFUAH PLUS BLOOD REPATHA SURECLICK...... 77 RIOMET...... 132 GLUCOSE TEST...... 233 REQUIP...... 105 RIOMET ER...... 132 REGLAN...... 178 REQUIP XL...... 105 risedronate sodium...... 143 REGRANEX...... 297 RESCRIPTOR...... 39, 40 RISPERDAL...... 109, 110 Relafen...... 21 RESCULA...... 253 RISPERDAL CONSTA...... 109 RELAFEN DS...... 21 reserpine...... 86 RISPERDAL M-TAB...... 109 RELAGARD...... 191 RESTASIS...... 201 risperidone...... 110 RELENZA DISKHALER...... 45 RESTASIS MULTIDOSE....201 Risperidone M-Tab...... 110 RELEXXII...... 115 RESTORIL...... 117 RITALIN...... 115 RELHIST...... 268 RETACRIT...... 197 RITALIN LA...... 115 RELION BLOOD RETEVMO...... 62 ritonavir...... 40 GLUCOSE TEST...... 233 RETIN-A...... 279 rivastigmine...... 99 RELION GLUCOSE...... 166 RETIN-A MICRO...... 279 rivastigmine tartrate...... 99 RELION GLUCOSE RETIN-A MICRO PUMP....279 Rivelsa...... 154 DRINK...... 166 RETROVIR...... 40 rizatriptan benzoate...... 119 RELION INSULIN REVATIO...... 89 ROBAXIN...... 126 SYRINGE...... 233 REVEAL BLOOD ROBAXIN-750...... 126 RELI-ON INSULIN GLUCOSE TEST...... 234 ROBINUL...... 176 SYRINGE...... 233 REVLIMID...... 211 ROBINUL-FORTE...... 176 RELION KETONE...... 233 REXULTI...... 109 ROCALTROL...... 143 RELION LANCETS REYATAZ...... 40 ROCKLATAN...... 259 STANDARD 21G...... 233 REYVOW...... 119 ropinirole hcl...... 106 323 ropinirole hcl er...... 106 SAVELLA TITRATION simvastatin...... 76 Rosadan...... 296 PACK...... 122 SINEMET...... 106 rosuvastatin calcium...... 76 scopolamine...... 178 SINEMET CR...... 106 ROSZET...... 76 SECONAL...... 96 SINGLE-LET...... 234 Roweepra...... 96 SECUADO...... 110 SINGULAIR...... 269, 270 ROXICODONE...... 30 SEEBRI NEOHALER...... 261 sirolimus...... 213 ROZEREM...... 117 SEGLUROMET...... 141 SIRTURO...... 44 ROZLYTREK...... 63 SELECT-OB...... 248 SITAVIG...... 45 RUBRACA...... 56 selegiline hcl...... 106 SIVEXTRO...... 36 RUCONEST...... 201 selenium sulfide...... 285 SKELAXIN...... 126 rufinamide...... 96 SELZENTRY...... 40 SKLICE...... 297 RUKOBIA...... 40 SEMGLEE...... 139 SKYLA...... 155 RUZURGI...... 122 SEMPREX-D...... 268 SKYRIZI...... 206 RYBELSUS...... 134 se-natal 19...... 248 SKYRIZI (150 MG DOSE).. 206 RYCLORA...... 264 SENSIPAR...... 143 SKYRIZI PEN...... 206 RYDAPT...... 56 SEREVENT DISKUS...... 265 sleep-aid...... 117 RYTARY...... 106 SERNIVO...... 290 SLYND...... 155 RYTHMOL SR...... 72 SEROQUEL...... 110 sm lice treatment...... 297 RYVENT...... 264 SEROQUEL XR...... 110 sm sleep aid...... 117 SABRIL...... 96 SEROSTIM...... 168 SMART SENSE COLOR SAFESNAP INSULIN sertraline hcl...... 103 LANCETS 33G...... 234 SYRINGE...... 234 Setlakin...... 155 SMART SENSE safety lancet 21g/pressure act. 234 sevelamer carbonate...... 172 STANDARD LANCETS..... 234 safety lancet 28g/pressure act. 234 sevelamer hcl...... 172 SMART SENSE SUPER SAFETY LANCETS...... 234 SEVENFACT...... 196 THIN LANCETS...... 234 SAFETY LANCETS 21G.....234 SEYSARA...... 54 SMART SENSE THIN safety lancets 28g...... 234 sf...... 298 LANCETS 26G...... 234 SAFETY LET LANCETS.... 234 SFROWASA...... 181 SMARTEST BLOOD SAFETY SEAL LANCETS..234 Sharobel...... 155 GLUCOSE TEST...... 235 SAFETY-GLIDE SYRINGE SHOPKO UNIFINE SMARTEST LANCETS 28G ...... 234 PENTIPS...... 234 ...... 235 SAFYRAL...... 154 SHOPKO UNILET sod citrate-citric acid...... 191 SAIZEN...... 168 LANCETS 28G...... 234 sodium chloride...... 191, 271 SAIZEN CLICK.EASY...... 168 SHOPKO UNILET sodium fluoride...... 248, 249 SAIZENPREP...... 168 LANCETS 30G...... 234 sodium hyaluronate...... 32 SALAGEN...... 298 SHUR-SEAL sodium phenylbutyrate...... 159 saline laxative...... 183 CONTRACEPTIVE...... 190 sodium polystyrene sulfonate.. 145 SAMSCA...... 170 SIGNIFOR...... 170 sofosbuvir-velpatasvir...... 51 SANCUSO...... 178 SIGNIFOR LAR...... 170 SOLARAZE...... 295 SANDIMMUNE...... 213 SIKLOS...... 201 Solia...... 155 SANDOSTATIN...... 170 sildenafil citrate...... 89 solifenacin succinate...... 193 SANDOSTATIN LAR SILENOR...... 117 SOLIQUA...... 135 DEPOT...... 170 SILIQ...... 284 SOLODYN...... 54 SANTYL...... 295 silodosin...... 189 SOLOSEC...... 36 SAPHRIS...... 110 SILVADENE...... 295 SOLTAMOX...... 59 sapropterin dihydrochloride.... 159 silver sulfadiazine...... 281 SOLUS V2 LANCETS 28G.. 235 SARAFEM...... 103 SIMBRINZA...... 253 SOLUS V2 TEST...... 235 SAVAYSA...... 195 Simliya...... 155 SOLUS V2 TWIST SAVELLA...... 122 Simpesse...... 155 LANCETS 30G...... 235 SIMPONI...... 206 SOMA...... 126 324 SOMATULINE DEPOT...... 170 SUBLOCADE...... 31 SURE-TOUCH LANCETS SOMAVERT...... 170 SUBOXONE...... 22 UNIVERSAL...... 236 SONATA...... 117 SUBSYS...... 30 SURMONTIL...... 103 SOOLANTRA...... 296 SUCRAID...... 185 SUSTIVA...... 40 sorbitol-mannitol...... 191 sucralfate...... 184 SUTAB...... 183 SORIATANE...... 284 SULAR...... 82 SUTENT...... 63 SORILUX...... 284 sulconazole nitrate...... 283 Syeda...... 155 Sorine...... 73 sulfacetamide sodium...... 256, 279 SYLATRON...... 65 sotalol hcl...... 73 sulfacetamide sodium (acne).. 279 Symax-Sl...... 176 sotalol hcl (af)...... 73 sulfacetamide-prednisolone..... 255 Symax-Sr...... 176 SOTYLIZE...... 79 sulfacetamide-sulfur in urea.... 279 SYMBICORT...... 275 SOVALDI...... 51 sulfadiazine...... 33 SYMBYAX...... 129 SPECTRACEF...... 47 sulfamethoxazole-trimethoprim 37 SYMDEKO...... 271 spinosad...... 297 SULFAMYLON...... 281, 295 SYMFI...... 43 SPIRIVA HANDIHALER...261 sulfasalazine...... 181 SYMFI LO...... 43 SPIRIVA RESPIMAT...... 261 Sulfatrim Pediatric...... 37 SYMJEPI...... 260 spironolactone...... 85 Sulfazine...... 181 SYMLINPEN 120...... 131 spironolactone-hctz...... 85 sulindac...... 21 SYMLINPEN 60...... 131 SPORANOX...... 34 sumatriptan...... 119 SYMPAZAN...... 96 SPORANOX PULSEPAK..... 34 sumatriptan succinate...... 119 SYMPROIC...... 184 Sprintec 28...... 155 sumatriptan succinate refill.....119 SYMTUZA...... 43 SPRITAM...... 96 sumatriptan-naproxen sodium.120 SYNAGIS...... 45 SPRIX...... 21 SUMAVEL DOSEPRO...... 120 SYNALAR...... 291 SPRYCEL...... 63 SUMAXIN...... 279 SYNALGOS-DC...... 30 SPS...... 145 SUMAXIN TS...... 279 SYNAREL...... 157 Sronyx...... 155 SUNOSI...... 127 SYNDROS...... 178 Ssd...... 281 super thin lancets...... 235 SYNERA...... 293 SSKI...... 268 SUPRAX...... 47 SYNJARDY...... 141 sss 10-5...... 279 SUPREP BOWEL PREP KIT SYNJARDY XR...... 141 ST JOSEPH ASPIRIN...... 32 ...... 183 SYNTHROID...... 173 STALEVO 100...... 106 sure comfort insulin syringe.... 235 SYPRINE...... 145 STALEVO 125...... 106 sure comfort lancets 28g...... 235 TABLOID...... 55 STALEVO 150...... 106 sure comfort lancets 30g...... 235 TABRECTA...... 66 STALEVO 200...... 106 sure comfort pen needles...... 235 TACLONEX...... 291 STALEVO 50...... 106 SURE EDGE TEST...... 235 tacrolimus...... 213, 295 STALEVO 75...... 115 SURECHEK BLOOD tadalafil...... 190 STARLIX...... 140 GLUCOSE TEST...... 235 tadalafil (pah)...... 89 stavudine...... 40 SURE-FINE PEN TAFINLAR...... 63 STEGLATRO...... 141 NEEDLES...... 235 TAGRISSO...... 63 STEGLUJAN...... 140 SURE-JECT INSULIN TAKE ACTION...... 155 STELARA...... 206 SYRINGE...... 235 TAKHZYRO...... 201 STERILANCE PA...... 235 SURE-LANCE FLAT TALICIA...... 189 STERILANCE TL...... 235 LANCETS...... 235 TALTZ...... 207 STIMATE...... 175 SURE-LANCE THIN TALZENNA...... 57 STIOLTO RESPIMAT...... 261 LANCETS 28G...... 235 TAMIFLU...... 45 STIVARGA...... 63 SURE-LANCE ULTRA tamoxifen citrate...... 59 STRATTERA...... 115 THIN LANCETS...... 235 tamsulosin hcl...... 189 STRENSIQ...... 143 SURE-TEST EASYPLUS TANZEUM...... 139 STRIBILD...... 43 MINI TEST...... 236 TAPAZOLE...... 173 STRIVERDI RESPIMAT.... 265 TAPERDEX 12-DAY...... 165 325 Taperdex 6-Day...... 165 terconazole...... 194 tiopronin...... 192 TAPERDEX 7-DAY...... 165 teriparatide (recombinant).....170 TIROSINT...... 174 TARCEVA...... 63 TESSALON PERLES...... 269 TIROSINT-SOL...... 174 Targadox...... 54 TESTIM...... 130 Tis-U-Sol...... 259 TARGRETIN...... 66, 295 testosterone...... 131 TIVICAY...... 40 Tarina 24 Fe...... 155 testosterone cypionate...... 130 TIVICAY PD...... 40 Tarina Fe 1/20...... 155 testosterone enanthate...... 131 TIVORBEX...... 21 TARKA...... 68 TESTRED...... 131 tizanidine hcl...... 126 TARON-BC...... 249 tetrabenazine...... 122 tl-care dha...... 249 TARON-C DHA...... 249 tetracycline hcl...... 54 tl-select...... 249 Taron-Crystals...... 191 TEXACORT...... 291 TOBI...... 33 TARON-PREX...... 249 tgq 15dm/5peh/2cpm...... 269 TOBI PODHALER...... 33 TASIGNA...... 63 tgq 30pse/150gfn/15dm...... 269 TOBRADEX...... 255 TASMAR...... 106 tgq 30pse/3brm/15dm...... 269 TOBRADEX ST...... 255 TAVALISSE...... 201 THALOMID...... 211, 212 tobramycin...... 33, 257 TAYTULLA...... 155 THEO-24...... 275 tobramycin-dexamethasone.... 255 tazarotene...... 279, 284 THEOCHRON...... 275 TOBREX...... 257 TAZORAC...... 284, 285 Theochron...... 275 TODAY SPONGE...... 190 Taztia Xt...... 82 theophylline...... 275 TOFRANIL...... 103 TAZVERIK...... 66 theophylline er...... 275 TOLAK...... 280 TECFIDERA...... 125 theracare pain relief...... 293 tolazamide...... 142 TECHLITE AST LANCETS 236 THINLETS LANCET...... 236 tolbutamide...... 142 TECHLITE LANCETS...... 236 THIOLA...... 192 tolcapone...... 106 TECHLITE LANCETS 30G 236 THIOLA EC...... 191 tolmetin sodium...... 21 TECHNIVIE...... 51 thioridazine hcl...... 110 tolsura...... 34 TEGRETOL...... 96 thiothixene...... 110 tolterodine tartrate...... 193 TEGRETOL-XR...... 96 THRIVE...... 129 tolterodine tartrate er...... 193 TEGSEDI...... 127 THYQUIDITY...... 173 tolvaptan...... 170 TEKTURNA...... 83 THYROLAR-1...... 173 TOPAMAX...... 96 TEKTURNA HCT...... 83 THYROLAR-1/2...... 174 TOPAMAX SPRINKLE...... 96 TELCARE BLOOD THYROLAR-1/4...... 174 topcare clickfine pen needles... 236 GLUCOSE TEST...... 236 THYROLAR-2...... 174 topcare ultra comfort ins syr...236 telmisartan...... 72 THYROLAR-3...... 174 TOPICORT...... 291 telmisartan-amlodipine...... 71 Tiadylt Er...... 82 TOPICORT SPRAY...... 291 telmisartan-hctz...... 71 tiagabine hcl...... 96 topiramate...... 96 temazepam...... 117 TIAZAC...... 83 topiramate er...... 96 TEMIXYS...... 43 TIBSOVO...... 66 TOPROL XL...... 80 TEMODAR...... 55 TICE BCG...... 66 toremifene citrate...... 59 TEMOVATE...... 291 ticlopidine hcl...... 202 torsemide...... 85 temozolomide...... 55 TIGAN...... 178 TOSYMRA...... 120 TENCON...... 18 TIGLUTIK...... 122 TOUJEO MAX SOLOSTAR139 tenofovir disoproxil fumarate....40 TIKOSYN...... 73 TOUJEO SOLOSTAR...... 139 TENORETIC 100...... 78 Tilia Fe...... 155 TOVIAZ...... 193 TENORETIC 50...... 78 timolol maleate...... 79, 253 TRACLEER...... 89 TENORMIN...... 79 timolol maleate pf...... 253 TRADJENTA...... 133 TEPMETKO...... 63 TIMOPTIC...... 253 tramadol hcl...... 30 TERAZOL 7...... 194 TIMOPTIC OCUDOSE...... 253 tramadol hcl er...... 30 terazosin hcl...... 69 TIMOPTIC-XE...... 253 tramadol hcl er (biphasic)...... 30 terbinafine hcl...... 34 TINDAMAX...... 33 tramadol-acetaminophen...... 30 terbutaline sulfate...... 265 tinidazole...... 33 trandolapril...... 69 326 trandolapril-verapamil hcl er.... 68 Tri-Lo-Estarylla...... 156 TRUSELTIQ (50MG DAILY tranexamic acid...... 201 Tri-Lo-Marzia...... 156 DOSE)...... 63 TRANSDERM-SCOP (1.5 Tri-Lo-Sprintec...... 156 TRUSELTIQ (75MG DAILY MG)...... 178 Trilyte...... 183 DOSE)...... 63 TRANXENE-T...... 96 trimethobenzamide hcl...... 178 TRUSOPT...... 254 tranylcypromine sulfate...... 103 trimethoprim...... 37 TRUVADA...... 43 TRAVATAN Z...... 254 Tri-Mili...... 156 TUDORZA PRESSAIR...... 262 travoprost (bak free)...... 254 trimipramine maleate...... 103 TUKYSA...... 64 trazodone hcl...... 103 trimpex...... 37 Tulana...... 156 TRECATOR...... 44 trinatal rx 1...... 249 TURALIO...... 64 TRELEGY ELLIPTA...... 261 TRINATE...... 249 TUSSICAPS...... 269 TRELSTAR MIXJECT...... 59 trinaz...... 249 Tussigon...... 269 TREMFYA...... 207 Trinessa (28)...... 156 TUSSIONEX treprostinil...... 89 Trinessa Lo...... 156 PENNKINETIC ER...... 269 TRESIBA...... 139 TRI-NORINYL (28)...... 156 TUXARIN ER...... 269 TRESIBA FLEXTOUCH.....139 TRINTELLIX...... 103 TUZISTRA XR...... 269 tretinoin...... 66, 279 Tri-Previfem...... 156 TWIRLA...... 156 tretinoin microsphere...... 279 TRIPTODUR...... 157 TWYNSTA...... 71 tretinoin microsphere pump.....279 Tri-Sprintec...... 156 TYBOST...... 40 TRETIN-X...... 279 tristart dha...... 249 Tydemy...... 156 TREXALL...... 55 TRISTART FREE...... 249 TYKERB...... 64 TREXIMET...... 120 TRISTART ONE...... 249 TYLENOL WITH TREZIX...... 30 tri-tabs dha...... 249 CODEINE #3...... 30 Tri Femynor...... 155 TRIUMEQ...... 43 TYLENOL WITH triamcinolone acetonide TRIVEEN-DUO DHA...... 249 CODEINE #4...... 30 ...... 272, 291, 292, 298 TRI-VI-FLOR...... 249 TYMLOS...... 170 triamterene...... 85 tri-vi-floro...... 249 TYVASO...... 89 triamterene-hctz...... 85 Trivora (28)...... 156 TYVASO REFILL...... 89 triazolam...... 117 Tri-Vylibra Lo...... 156 TYVASO STARTER...... 89 TRIBENZOR...... 71 TRIZIVIR...... 43 UBRELVY...... 120 TRICARE...... 249 TROKENDI XR...... 97 UCERIS...... 181 TRICARE PRENATAL tropicamide...... 201 UDENYCA...... 198 DHA ONE...... 249 trospium chloride...... 193 UKONIQ...... 64 TRICITRASOL...... 195 trospium chloride er...... 193 ULESFIA...... 297 tricitrates...... 192 TRUEPLUS INSULIN ULORIC...... 17 TRICOR...... 75 SYRINGE...... 236 ULTICARE INSULIN Triderm...... 292 TRUEPLUS LANCETS 28G236 SAFETY SYR...... 236 TRIDESILON...... 292 TRUEPLUS LANCETS 30G236 ULTICARE INSULIN trientine hcl...... 145 TRUEPLUS LANCETS 33G236 SYRINGE...... 237 Tri-Estarylla...... 155 TRUEPLUS SAFETY ULTICARE MICRO PEN trifluoperazine hcl...... 110 LANCETS 28G...... 236 NEEDLES...... 237 trifluridine...... 257 TRUETEST TEST...... 236 ULTICARE MINI PEN TRIGLIDE...... 75 TRUETRACK TEST...... 236 NEEDLES...... 237 trihexyphenidyl hcl...... 106 TRULANCE...... 181 ULTICARE PEN NEEDLES TRIJARDY XR...... 134 TRULICITY...... 134 ...... 237 TRIKAFTA...... 122, 271 TRUSELTIQ (100MG ULTICARE SHORT PEN Tri-Legest Fe...... 155 DAILY DOSE)...... 63 NEEDLES...... 237 TRILEPTAL...... 96 TRUSELTIQ (125MG ULTILET CLASSIC Tri-Linyah...... 156 DAILY DOSE)...... 63 LANCETS...... 237 TRILIPIX...... 75 ULTILET LANCETS...... 237 327 ULTILET SAFETY UNIVERSAL 1 LANCETS VASERETIC...... 68 LANCETS 23G...... 237 ULTRA THIN...... 238 VASOTEC...... 69 ULTIMA TEST...... 237 UPNEEQ...... 201 VCF VAGINAL ultimatecare one...... 249 UPTRAVI...... 89 CONTRACEPTIVE...... 190 ultra comfort insulin syringe... 237 URECHOLINE...... 185 VECAMYL...... 86 ULTRACET...... 30 URISTIX...... 239 VECTICAL...... 285 ultra-comfort insulin syringe...237 URISTIX 4...... 239 VELETRI...... 89 ULTRALANCE...... 237 UROCIT-K 10...... 192 Velivet...... 156 ULTRAM...... 30 UROCIT-K 15...... 192 VELPHORO...... 172 ULTRA-THIN II AUTO UROCIT-K 5...... 192 VELTASSA...... 145 LANCET...... 237 UROXATRAL...... 189 VEMAVITE-PRX 2...... 249 ULTRA-THIN II INS SYR URSO 250...... 185 VEMLIDY...... 45 SHORT...... 237 URSO FORTE...... 185 vena-bal dha...... 249 ULTRA-THIN II INSULIN ursodiol...... 185 VENCLEXTA...... 67 SYRINGE...... 238 UTIBRON NEOHALER..... 261 VENCLEXTA STARTING ULTRA-THIN II LANCETS VAGIFEM...... 162 PACK...... 67 ...... 238 valacyclovir hcl...... 45 venlafaxine hcl...... 103 ULTRA-THIN II MINI PEN VALCHLOR...... 295 venlafaxine hcl er...... 103 NEEDLE...... 238 VALCYTE...... 45 VENTAVIS...... 89 ULTRA-THIN II PEN valganciclovir hcl...... 45 VENTOLIN HFA...... 265 NEEDLE SHORT...... 238 VALIUM...... 97 verapamil hcl...... 83 ULTRA-THIN II PEN valproate sodium...... 97 verapamil hcl er...... 83 NEEDLES...... 238 valproic acid...... 97 VERDESO...... 292 ULTRATRAK PRO TEST.. 238 valsartan...... 72 VERDROCET...... 30 ULTRATRAK ULTIMATE valsartan-hydrochlorothiazide...71 VEREGEN...... 295 TEST...... 238 VALTOCO 10 MG DOSE...... 97 VERELAN...... 83 ULTRAVATE...... 292 VALTOCO 15 MG DOSE...... 97 VERELAN PM...... 83 UNIFINE PENTIPS...... 238 VALTOCO 20 MG DOSE...... 97 VERIPRED 20...... 165 UNILET COMFORTOUCH VALTOCO 5 MG DOSE...... 97 VERQUVO...... 85 LANCET...... 238 VALTREX...... 45 VERSACLOZ...... 110 UNILET EXCELITE...... 238 value health insulin syringe..... 239 VERZENIO...... 57 UNILET EXCELITE II...... 238 value plus glucose...... 166 VESICARE...... 193 UNILET G.P. LANCET...... 238 value plus lancet standard 21g.239 VESICARE LS...... 193 UNILET G.P. SUPERLITE value plus lancets super thin.... 239 Vestura...... 156 LANCET...... 238 value plus lancets thin 26g...... 239 VEXOL...... 254 UNILET GP 28 ULTRA valumark lancet super thin 30g239 VFEND...... 34 THIN...... 238 valumark lancet ultra thin 28g 239 V-GO 20...... 239 UNILET LANCET...... 238 valumark pen needles...... 239 V-GO 30...... 239 UNILET SUPERLITE Vanadom...... 126 V-GO 40...... 239 LANCET...... 238 Vanatol Lq...... 18 VIBERZI...... 181 UNISTIK 3 COMFORT...... 238 Vanatol S...... 18 VIBRAMYCIN...... 54 UNISTIK 3 EXTRA...... 238 VANCOCIN HCL...... 37 Vicodin...... 31 UNISTIK 3 NORMAL...... 238 vancomycin hcl...... 37 Vicodin Es...... 31 UNISTIK CZT COMFORT.238 Vandazole...... 194 Vicodin Hp...... 31 UNISTIK CZT NORMAL...238 VANISHPOINT INSULIN VICTORY AGM-4000 TEST239 Unithroid...... 174 SYRINGE...... 239 VICTOZA...... 135 Unithroid Direct...... 174 VANOS...... 292 VIDA MIA UNIFINE UNIVERSAL 1 LANCETS VARUBI...... 178 PENTIPS...... 239 THIN 26G...... 238 VARUBI (180 MG DOSE)... 178 VIDA MIA UNILET VASCEPA...... 77 LANCETS 28G...... 239 328 VIDA MIA UNILET vitamin d3...... 250 WIDE-SEAL DIAPHRAGM LANCETS 30G...... 239 VITAPEARL...... 251 65...... 214 VIDEX...... 41 VITRAKVI...... 64 WIDE-SEAL DIAPHRAGM VIDEX EC...... 40 VIVA DHA...... 251 70...... 214 VIEKIRA PAK...... 51 VIVELLE-DOT...... 162 WIDE-SEAL DIAPHRAGM VIEKIRA XR...... 51 VIVITROL...... 129 75...... 214 Vienva...... 157 VIVLODEX...... 21 WIDE-SEAL DIAPHRAGM vigabatrin...... 97 VIZIMPRO...... 64 80...... 214 Vigadrone...... 97 VOCAL POINT BLOOD WIDE-SEAL DIAPHRAGM VIGAMOX...... 257 GLUCOSE TEST...... 239 85...... 214 VIIBRYD...... 103 VOGELXO...... 131 WIDE-SEAL DIAPHRAGM VIIBRYD STARTER PACK VOGELXO PUMP...... 131 90...... 214 ...... 103 vol-nate...... 251 WIDE-SEAL DIAPHRAGM VIMOVO...... 21 vol-plus...... 251 95...... 214 VIMPAT...... 97 vol-tab rx...... 251 WINLEVI...... 279 VINATE II...... 250 VOLTAREN...... 295 Wixela Inhub...... 275 VINATE ONE...... 250 voriconazole...... 34 WP THYROID...... 174 VIOKACE...... 185 VOSEVI...... 51 Wymzya Fe...... 157 viorele...... 157 VOSPIRE ER...... 266 WYNZORA...... 285 VIRACEPT...... 41 VOTRIENT...... 64 XADAGO...... 106 VIRAMUNE...... 41 vp-ch-pnv...... 251 XALATAN...... 254 VIRAMUNE XR...... 41 vp-ggr-b6 prenatal...... 251 XALKORI...... 64 VIREAD...... 41 vp-heme ob...... 251 XANAX...... 90 VIROPTIC...... 257 vp-heme ob + dha...... 251 XANAX XR...... 90 virt nate...... 250 vp-heme one...... 251 XARELTO...... 195 virt-advance...... 250 vp-pnv-dha...... 251 XARELTO STARTER virt-phos 250 neutral...... 241 VRAYLAR...... 110 PACK...... 195 virt-pn...... 250 VTOL LQ...... 19 XATMEP...... 55 virt-pn dha...... 250 VUMERITY...... 125 XCOPRI...... 97, 98 virt-pn plus...... 250 VUMERITY (STARTER)....125 XCOPRI (250 MG DAILY virtprex...... 250 Vyfemla...... 157 DOSE)...... 97 virtrate-2...... 192 VYLEESI...... 129 XCOPRI (350 MG DAILY virtrate-3...... 192 VYNDAMAX...... 87 DOSE)...... 97 virtrate-k...... 192 VYNDAQEL...... 87 XELJANZ...... 207, 208 virt-select...... 250 VYTORIN...... 76 XELJANZ XR...... 208 virt-vite forte...... 250 VYVANSE...... 115 XELODA...... 55 virt-vite gt...... 250 VYZULTA...... 254 XELPROS...... 254 VISTARIL...... 264 WAKIX...... 127 XEMBIFY...... 211 VISTOGARD...... 66 wal-som...... 117 XENAZINE...... 122 Vitafol...... 250 warfarin sodium...... 195 XENLETA...... 37 VITAFOL FE+...... 250 WAVESENSE PRESTO...... 239 XEPI...... 281 VITAFOL STRIPS...... 250 WELCHOL...... 74 XERAC AC...... 295 VITAFOL-OB...... 250 WELLBUTRIN SR...... 103 XERESE...... 46 VITAFOL-ONE...... 250 WELLBUTRIN XL...... 103 XERMELO...... 185 VITAL HP 1.0 CAL...... 250 Wera...... 157 XGEVA...... 171 VITAL-D RX...... 250 westab max...... 251 XHANCE...... 272 VITAMEDMD ONE WESTCORT...... 292 XIFAXAN...... 37 RX/QUATREFOLIC...... 250 WESTHROID...... 174 XIGDUO XR...... 141 vitamin b-6...... 250 WIDE-SEAL DIAPHRAGM XIIDRA...... 258 vitamin d (ergocalciferol)...... 250 60...... 214 XIMINO...... 54 329 XODOL...... 31 ZATEAN-PN DHA...... 251 ZOKINVY...... 171 XOFLUZA (40 MG DOSE)... 46 ZATEAN-PN PLUS...... 251 ZOLINZA...... 57 XOFLUZA (80 MG DOSE)... 46 ZAVESCA...... 159 zolmitriptan...... 120 XOLAIR...... 266 zcort 7-day...... 165 ZOLOFT...... 104 XOLEGEL...... 283 Zebutal...... 19 zolpidem tartrate...... 117 XOPENEX...... 266 ZEGALOGUE...... 166 zolpidem tartrate er...... 117 XOPENEX ZEGERID...... 188 ZOLPIMIST...... 117 CONCENTRATE...... 266 ZEGERID OTC...... 188 ZOMACTON...... 168 XOPENEX HFA...... 266 ZEJULA...... 57 ZOMACTON (FOR ZOMA- XOSPATA...... 64 ZELAPAR...... 106 JET 10)...... 168 XPOVIO (100 MG ONCE ZELBORAF...... 64 ZOMIG...... 120 WEEKLY)...... 66 ZELNORM...... 181 ZOMIG ZMT...... 120 XPOVIO (40 MG ONCE ZEMBRACE SYMTOUCH. 120 ZONACORT 11 DAY...... 165 WEEKLY)...... 66 ZEMPLAR...... 143 ZONACORT 7 DAY...... 165 XPOVIO (40 MG TWICE Zenatane...... 279 ZONALON...... 283 WEEKLY)...... 66 Zenchent...... 157 ZONATUSS...... 269 XPOVIO (60 MG ONCE ZENPEP...... 185, 186 ZONEGRAN...... 98 WEEKLY)...... 66 Zenzedi...... 115 zonisamide...... 98 XPOVIO (60 MG TWICE ZENZEDI...... 116 ZONTIVITY...... 202 WEEKLY)...... 66 ZEPATIER...... 51 ZORBTIVE...... 168 XPOVIO (80 MG ONCE ZEPOSIA...... 125 ZORTRESS...... 213 WEEKLY)...... 66 ZEPOSIA 7-DAY STARTER ZORVOLEX...... 21 XPOVIO (80 MG TWICE PACK...... 125 Zovia 1/35E (28)...... 157 WEEKLY)...... 66 ZEPOSIA STARTER KIT... 125 Zovia 1/50E (28)...... 157 XTAMPZA ER...... 31 ZERIT...... 41 ZOVIRAX...... 46, 296 XTANDI...... 59 ZERVIATE...... 252 ZUBSOLV...... 22 Xulane...... 157 ZESTORETIC...... 68 Zumandimine...... 157 XULTOPHY...... 135 ZESTRIL...... 69 ZUPLENZ...... 179 XURIDEN...... 171 ZETIA...... 74 ZURAMPIC...... 17 XYLOCAINE...... 293 ZETONNA...... 272 ZUTRIPRO...... 269 Xylon...... 31 ZIAC...... 78 ZYBAN...... 129 XYOSTED...... 131 ZIAGEN...... 41 ZYCLARA...... 280 XYREM...... 127 zidovudine...... 41 ZYCLARA PUMP...... 280, 296 XYWAV...... 127 ZIEXTENZO...... 198 ZYDELIG...... 64 XYZAL ALLERGY 24HR...264 zileuton er...... 269 ZYFLO...... 269 XYZAL ALLERGY 24HR ZILXI...... 296 ZYFLO CR...... 270 CHILDRENS...... 264 ZIOPTAN...... 254 ZYKADIA...... 64, 66 YONSA...... 59 ziprasidone hcl...... 110 ZYLET...... 255 YOSPRALA...... 202 ziprasidone mesylate...... 110 ZYLOPRIM...... 17 YUPELRI...... 262 ZIPSOR...... 21 ZYMAXID...... 257 Yuvafem...... 162 ZIRGAN...... 257 ZYPITAMAG...... 76 ZADITOR...... 201 ZITHROMAX...... 48 ZYPREXA...... 111 zafirlukast...... 270 ZITHROMAX TRI-PAK...... 49 ZYPREXA RELPREVV...... 111 zaleplon...... 117 ZITHROMAX Z-PAK...... 49 ZYPREXA ZYDIS...... 111 ZAMICET...... 31 ZMAX...... 49 ZYRTEC ALLERGY...... 264 ZANAFLEX...... 127 ZOCOR...... 76 ZYRTEC CHILDRENS ZANTAC...... 179 ZODEX 12-DAY...... 165 ALLERGY...... 264 Zarah...... 157 ZOFRAN...... 178, 179 ZYRTEC-D ALLERGY & ZARONTIN...... 98 ZOFRAN ODT...... 178 CONGESTION...... 269 ZARXIO...... 198 ZOHYDRO ER...... 31 ZYTIGA...... 59 330 ZYVOX...... 37

331