Traditional Open Drug List

Drug list — Three Tier Drug Plan

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

Here are a few things to remember about the list:

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

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

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

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

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

05373MUMENABS Traditional Open Drug List

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

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

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

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

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

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

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

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

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

o Tier 3 drugs have the highest cost share. They often include non-preferred brand and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA or specialty drugs that are used to treat serious, long-term health conditions and that may need special handling.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Brand name drugs are in UPPER CASE, bold type.

Generic drugs are in lower case, plain type.

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

CTT1 = Tier 1 copay for members in a Connecticut plan, by state mandate.

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

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

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

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

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

ST = step therapy. You may need to use another recommended drug first before a prescribed drug is covered.

Traditional Open Drug List Three-Tier

Table of Contents *5-HT4 RECEPTOR AGONISTS***...... 5 *ADENOSINE DEAMINASE SCID TREATMENT - AGENTS***...... 5 *ADENOSINE RECEPTOR ANTAGONIST***...... 5 *ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORS***...... 5 *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...... 5 *AGENTS FOR NARCOTIC WITHDRAWAL***...... 7 *AGENTS FOR OPIOID WITHDRAWAL***...... 7 *AMEBICIDES*...... 7 *AMINO ACIDS***...... 7 *AMINOGLYCOSIDES*...... 7 *AMINOLEVULINATE SYNTHASE 1-DIRECTED SIRNA***...... 8 *AMINOMETHYLCYCLINES***...... 8 *ANALGESIC COMBINATIONS - TOPICAL***...... 8 *ANALGESICS - ANTI-INFLAMMATORY*...... 8 *ANALGESICS - NONNARCOTIC*...... 11 *ANALGESICS - OPIOID*...... 12 *ANDROGENS-ANABOLIC*...... 17 *ANORECTAL AGENTS*...... 17 *ANTACIDS*...... 18 *ANTHELMINTICS*...... 18 *ANTIANGINAL AGENTS*...... 18 *ANTIANXIETY AGENTS*...... 18 *ANTIARRHYTHMICS*...... 19 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS*...... 20 *ANTICOAGULANTS - MISC.***...... 23 *ANTICOAGULANTS*...... 23 *ANTICONVULSANTS*...... 24 *ANTIDEMENTIA AGENT COMBINATIONS***...... 27 *ANTIDEPRESSANTS*...... 27 *ANTIDIABETICS*...... 30 *ANTIDIARRHEAL/PROBIOTIC AGENTS*...... 34 *ANTIDIARRHEALS*...... 34 *ANTIDOTE COMBINATIONS***...... 35 *ANTIDOTES AND SPECIFIC ANTAGONISTS*...... 35 *ANTIDOTES*...... 36 *ANTIEMETICS*...... 37 *ANTIFUNGALS*...... 38 *ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES***...... 39 *ANTIHISTAMINES*...... 39 *ANTIHYPERLIPIDEMICS MISC. COMBINATIONS***...... 40 *ANTIHYPERLIPIDEMICS*...... 40 *ANTIHYPERTENSIVES*...... 42 *ANTI-INFECTIVE AGENTS - MISC.*...... 45 *ANTIMALARIALS*...... 48 *ANTIMYASTHENIC AGENTS*...... 48 *ANTIMYASTHENIC/CHOLINERGIC AGENTS*...... 49 *ANTIMYCOBACTERIAL AGENTS*...... 49 *ANTINEOPLASTIC - BCL-2 INHIBITORS***...... 49 *ANTINEOPLASTIC - BISPECIFIC T-CELL ENGAGERS***...... 49 *ANTINEOPLASTIC - FGFR KINASE INHIBITORS***...... 50 *ANTINEOPLASTIC - HORMONAL AND RELATED AGENT COMBINATIONS***...... 50 *ANTINEOPLASTIC - METHYLTRANSFERASE INHIBITORS***...... 50 *ANTINEOPLASTIC - TROPOMYOSIN RECEPTOR KINASE INHIBITORS***...... 50 *ANTINEOPLASTIC - XPO1 INHIBITORS***...... 50 *ANTINEOPLASTIC OR PREMALIGNANT LESION AGENT - COMB***...... 50 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...... 50 *ANTI-OBESITY - GLP-1 RECEPTOR AGONISTS***...... 60 *ANTI-OBESITY AGENT COMBINATIONS**...... 60 1 *ANTIPARKINSON AGENTS*...... 60 *ANTIPSYCHOTICS/ANTIMANIC AGENTS*...... 61 *ANTIRETROVIRALS - CD4-DIRECTED POST-ATTACHMENT INHIBITOR***...... 63 *ANTIRETROVIRALS ADJUVANTS***...... 63 *ANTISENSE OLIGONUCLEOTIDE (ASO) INHIBITOR AGENTS***...... 63 *ANTISEPTICS & DISINFECTANTS*...... 64 *ANTIVIRALS*...... 64 *ANTI-VON WILLEBRAND FACTOR AGENTS***...... 67 *ASSORTED CLASSES*...... 67 *ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES***...... 71 *BACTERIAL MONOCLONAL ANTIBODIES***...... 71 *BETA BLOCKERS*...... 71 *BILE ACID SYNTHESIS DISORDER AGENTS***...... 72 *BIOLOGICALS MISC*...... 72 *CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG***...... 76 *CALCITONIN GENE-RELATED PEPTIDE RECEPTOR ANTAG (CGRP)***...... 77 *CALCIUM CHANNEL BLOCKER-NSAID COMBINATIONS***...... 77 *CALCIUM CHANNEL BLOCKERS*...... 77 *CARDIOTONICS*...... 79 *CARDIOVASCULAR AGENTS - MISC.*...... 79 *CEPHALOSPORIN COMBINATIONS***...... 80 *CEPHALOSPORINS - SIDEROPHORES***...... 81 *CEPHALOSPORINS*...... 81 *CGRP RECEPTOR ANTAGONISTS - MONOCOLONAL ANTIBODIES***...... 82 *CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS***...... 83 *CONTRACEPTIVES*...... 83 *CORTICOSTEROIDS*...... 86 *COUGH/COLD/ALLERGY*...... 88 *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS***...... 90 *CYSTIC FIBROSIS AGENT - COMBINATIONS***...... 90 *DERMATOLOGICALS*...... 90 *DIAGNOSTIC PRODUCTS*...... 106 *DIGESTIVE AIDS*...... 111 *DIRECT-ACTING P2Y12 INHIBITORS***...... 112 *DIURETICS*...... 112 *DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)***...... 113 *ENDOCRINE AND METABOLIC AGENTS - MISC.*...... 113 *ERYTHROID MATURATION AGENTS***...... 117 *ESTROGEN COMBINATIONS***...... 117 *ESTROGEN-ANDROGEN-PROGESTIN***...... 118 *ESTROGENS*...... 118 *ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB***...... 119 *FARNESOID X RECEPTOR (FXR) AGONISTS***...... 119 *FENTANYL COMBINATIONS***...... 119 *FLUOROCYCLINES***...... 119 *FLUOROQUINOLONES*...... 119 *GABA RECEPTOR MODULATOR - NEUROACTIVE STEROID***...... 119 *GASTROINTESTINAL AGENTS - MISC.*...... 120 *GENERAL ANESTHETICS*...... 121 *GENITOURINARY AGENTS - MISCELLANEOUS*...... 122 *GLYCOPEPTIDES***...... 123 *GOUT AGENTS*...... 124 *HEMATOLOGICAL AGENTS - MISC.*...... 124 *HEMATOPOIETIC AGENTS*...... 128 *HEMOGLOBIN S (HBS) POLYMERIZATION INHIBITORS***...... 131 *HEMOSTATICS*...... 131 *HEPATITIS C AGENT - COMBINATIONS***...... 132 *HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS**...... 133 *HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS***...... 133 *HYPNOTICS*...... 133 *HYPOPHOSPHATASIA (HPP) AGENTS***...... 134 *IBS AGENT - 5-HT4 RECEPTOR PARTIAL AGONISTS***...... 134 *IBS AGENT - MU-OPIOID RECEPTOR AGONISTS***...... 134 2 *IMPOTENCE AGENT COMBINATIONS***...... 134 *IMPOTENCE AGENTS - OTHER***...... 135 *IN VITRO/LOCK ANTICOAGULANTS***...... 135 *INSULIN-INCRETIN MIMETIC COMBINATIONS***...... 135 *INSULIN-LIKE GROWTH FACTOR-1 RECEPTOR INHIBITORS(IGF-1R)***...... 135 *INTEGRIN RECEPTOR ANTAGONISTS***...... 135 *INTERLEUKIN ANTAGONISTS***...... 135 *INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)***...... 135 *INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)***...... 136 *INTERLEUKIN-6 (IL-6) ANTAGONISTS***...... 136 *ISOCITRATE DEHYDROGENASE-1 (IDH1) INHIBITORS***...... 136 *ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS***...... 136 *LAXATIVES*...... 136 *LEPTIN ANALOGUES***...... 136 *LHRH/GNRH AGONIST ANALOG COMBINATIONS***...... 137 *LOCAL ANESTHETICS-PARENTERAL*...... 137 *LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG***...... 138 *LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS***...... 138 *MACROLIDES*...... 138 *MEDICAL DEVICES*...... 139 *MELANOCORTIN RECEPTOR AGONISTS (UV PROTECTIVE)***...... 156 *MELANOCORTIN RECEPTOR AGONISTS***...... 156 *MIGRAINE PRODUCTS*...... 156 *MINERALS & ELECTROLYTES*...... 157 *MISC. ANTIVIRALS***...... 160 *MISCELLANEOUS THERAPEUTIC CLASSES*...... 161 *MIXED ALLERGENIC EXTRACTS***...... 161 *MONOBACTAMS***...... 161 *MOUTH/THROAT/DENTAL AGENTS*...... 161 *MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS***...... 162 *MUCOPOLYSACCHARIDOSIS VII (MPS VII) - AGENTS***...... 163 *MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES***...... 163 *MULTIPLE VITAMINS & FLUORIDE-FOLIC ACID***...... 163 *MULTIPLE VITAMINS W/ MINERALS & FLUORIDE-IRON-FOLIC ACID***...... 163 *MULTIPLE VITAMINS WITH FOLIC ACID***...... 163 *MULTIVITAMINS*...... 163 *MUSCULAR DYSTROPHY AGENTS***...... 169 *MUSCULOSKELETAL THERAPY AGENTS*...... 169 *NASAL AGENTS - SYSTEMIC AND TOPICAL*...... 170 *NASAL ANESTHETICS***...... 171 *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***...... 171 *NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS***...... 171 *NEUROMUSCULAR AGENTS*...... 171 *N-METHYL-D-ASPARTIC ACID (NMDA) RECEPTOR ANTAGONISTS***...... 172 *NSAID-DIETARY MANAGEMENT COMBINATIONS***...... 172 *NSAID-VITAMINS AND/OR MINERALS COMBINATIONS***...... 172 *NUTRIENTS*...... 172 *ONCOLYTIC VIRAL AGENTS - HSV1***...... 173 *OPHTHALMIC AGENTS*...... 174 *OPHTHALMIC KINASE INHIBITORS - COMBINATIONS***...... 180 *OPHTHALMIC NERVE GROWTH FACTORS***...... 180 *OPHTHALMIC PHOTOENHANCER COMBINATIONS***...... 180 *OPHTHALMIC RHO KINASE INHIBITORS***...... 180 *OPIOID ANTAGONIST COMBINATIONS***...... 180 *OREXIN RECEPTOR ANTAGONISTS***...... 180 *OTIC AGENTS*...... 180 *OXABOROLE-RELATED ANTIFUNGALS - TOPICAL***...... 181 *OXYTOCICS*...... 181 *PA ENDONUCLEASE INHIBITORS***...... 181 *PASSIVE IMMUNIZING AGENTS - COMBINATIONS***...... 181 *PASSIVE IMMUNIZING AGENTS*...... 181 *PCSK9 INHIBITORS***...... 183 *PEDIATRIC MULTIPLE VITAMINS & MINERALS W/ FLUORIDE***...... 183 3 *PENICILLINS*...... 183 *PERITONEAL DIALYSIS SOLUTIONS***...... 184 *PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS***...... 185 *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL***...... 185 *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS***...... 185 *PLASMA KALLIKREIN INHIBITORS - MONOCLONAL ANTIBODIES***...... 185 *PLEUROMUTILINS***...... 185 *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS**...... 186 *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS***...... 186 *POSTHERPETIC NEURALGIA (PHN) COMBINATION AGENTS***...... 186 *POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS***...... 186 *POSTHERPETIC NEURALGIA(PHN)/NEUROPATHIC PAIN COMB AGENTS***...... 186 *POTASSIUM REMOVING AGENTS***...... 186 *PRENATAL MV & MINERALS W/FA WITHOUT IRON***...... 186 *PROGESTINS*...... 186 *PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS***...... 187 *PROTEIN-CARBOHYDRATE-LIPID WITH ELECTROLYTE COMBINATIONS***...... 187 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*...... 187 *PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS***...... 190 *PULMONARY FIBROSIS AGENTS***...... 190 *PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST***...... 190 *RESPIRATORY AGENTS - MISC.*...... 190 *SCLEROSTIN INHIBITORS***...... 191 *SEBORRHEIC KERATOSIS PRODUCTS**...... 191 *SELECTIN BLOCKERS***...... 191 *SELECTIVE SEROTONIN AGONISTS 5-HT(1F)***...... 191 *SEPTAL AGENTS - ABLATION**...... 191 *SEROTONIN 1A RECEPT AGONIST/SEROTONIN 2A RECEPT ANTAG***...... 191 *SEROTONIN MODULATORS***...... 191 *SGLT2 INHIBITOR - DPP-4 INHIBITOR - BIGUANIDE COMB***...... 191 *SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS***...... 192 *SINUS NODE INHIBITORS**...... 192 *SMALL INTERFERING RIBONUCLEIC ACID (SIRNA) AGENTS***...... 192 *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***...... 192 *SPLEEN TYROSINE KINASE (SYK) INHIBITORS***...... 192 *STEROIDS - MOUTH/THROAT/DENTAL***...... 192 *SULFONAMIDES*...... 192 *TETRACYCLINES*...... 192 *TETRAHYDROISOQUINOLINES***...... 193 *THYROID AGENTS*...... 193 *TOXOIDS*...... 194 *TRANSTHYRETIN STABILIZERS***...... 194 *TRYPTOPHAN HYDROXYLASE INHIBITORS***...... 194 *ULCER DRUGS*...... 194 *URINARY ANTI-INFECTIVES*...... 196 *URINARY ANTISPASMODICS*...... 196 *VACCINES*...... 198 *VAGINAL PRODUCTS*...... 200 *VASOPRESSORS*...... 200 *VESICOURETERAL REFLUX (VUR) AGENT COMBINATIONS***...... 201 *VITAMINS*...... 201 *X-LINKED HYPOPHOSPHATEMIA (XLH) TREATMENT - AGENTS***...... 202

4 Three-Tier Drug Name Tier Notes INTUNIV ORAL TABLET CURRENT AS OF 5/1/2020 EXTENDED RELEASE 24 3 PA; QL HOUR Drug Name Tier Notes KAPVAY ORAL TABLET EXTENDED RELEASE 12 3 PA; QL *5-HT4 RECEPTOR HOUR AGONISTS*** *ADHD AGENT - *5-HT4 RECEPTOR SELECTIVE AGONISTS*** NOREPINEPHRINE MOTEGRITY ORAL REUPTAKE 3 ST; QL TABLET INHIBITOR*** *ADENOSINE atomoxetine hcl oral capsule 1 or 1b* PA; QL DEAMINASE SCID STRATTERA ORAL 3 PA; QL TREATMENT - CAPSULE AGENTS*** *AMPHETAMINE *ADENOSINE MIXTURES*** DEAMINASE SCID ADDERALL ORAL TREATMENT - 3 PA; QL AGENTS*** TABLET REVCOVI ADDERALL XR ORAL INTRAMUSCULAR 3 PA; QL; LD CAPSULE EXTENDED 1 or 1b* PA; QL SOLUTION RELEASE 24 HOUR *ADENOSINE amphetamine-dextroamphet RECEPTOR er oral capsule extended 1 or 1b* PA; QL ANTAGONIST*** release 24 hour *ADENOSINE amphetamine- RECEPTOR dextroamphetamine oral 1 or 1b* PA; QL ANTAGONIST*** tablet NOURIANZ ORAL MYDAYIS ORAL 3 PA; QL; LD; SP TABLET CAPSULE EXTENDED 3 PA; QL RELEASE 24 HOUR *ADENOSINE TRIPHOSPHATE- *AMPHETAMINES*** CITRATE LYASE (ACL) ADZENYS ER ORAL INHIBITORS*** SUSPENSION 3 PA; QL *ADENOSINE EXTENDED RELEASE TRIPHOSPHATE- ADZENYS XR-ODT CITRATE LYASE (ACL) ORAL TABLET 3 PA; QL INHIBITORS*** EXTENDED RELEASE NEXLETOL ORAL DISPERSIBLE 3 PA; QL TABLET amphetamine er oral 1 or 1b* *ADHD/ANTI- suspension extended release NARCOLEPSY/ANTI- amphetamine sulfate oral 1 or 1b* OBESITY/ANOREXIANT tablet S* DESOXYN ORAL 3 PA; QL *ADHD AGENT - TABLET SELECTIVE ALPHA ADRENERGIC DEXEDRINE ORAL AGONISTS*** CAPSULE EXTENDED 3 PA; QL RELEASE 24 HOUR clonidine hcl er oral tablet 1 or 1b* PA; QL extended release 12 hour dextroamphetamine sulfate er oral capsule extended release 1 or 1b* PA; QL guanfacine hcl er oral tablet 1 or 1b* PA; QL 24 hour extended release 24 hour

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 5 Drug Name Tier Notes Drug Name Tier Notes dextroamphetamine sulfate phendimetrazine tartrate er 1 or 1b* PA; QL oral solution oral capsule extended release 1 or 1b* PA; QL dextroamphetamine sulfate 24 hour 1 or 1b* PA; QL oral tablet phendimetrazine tartrate oral 1 or 1b* PA; QL DYANAVEL XR ORAL tablet SUSPENSION 3 PA; QL phentermine hcl oral capsule 1 or 1b* PA; QL EXTENDED RELEASE phentermine hcl oral tablet 1 or 1b* PA; QL EVEKEO ODT ORAL 3 PA; QL *LIPASE TABLET DISPERSIBLE INHIBITORS*** EVEKEO ORAL TABLET 3 PA; QL XENICAL ORAL 3 PA; QL methamphetamine hcl oral CAPSULE 1 or 1b* PA; QL tablet *STIMULANTS - procentra oral solution 1 or 1b* PA; QL MISC.*** VYVANSE ORAL ADHANSIA XR ORAL 2 PA; QL CAPSULE CAPSULE EXTENDED 3 PA; QL VYVANSE ORAL RELEASE 24 HOUR 2 PA; QL TABLET CHEWABLE APTENSIO XR ORAL zenzedi oral tablet 1 or 1b* PA; QL CAPSULE EXTENDED 3 PA; QL RELEASE 24 HOUR *ANALEPTICS*** armodafinil oral tablet 1 or 1b* PA; QL CAFCIT INTRAVENOUS 3 SOLUTION CONCERTA ORAL TABLET EXTENDED 3 PA; QL caffeine citrate intravenous 1 or 1b* RELEASE solution COTEMPLA XR-ODT caffeine citrate oral solution 1 or 1b* ORAL TABLET 3 PA; QL DOPRAM EXTENDED RELEASE INTRAVENOUS 3 DISPERSIBLE SOLUTION DAYTRANA 3 PA; QL *ANOREXIANT TRANSDERMAL PATCH COMBINATIONS*** dexmethylphenidate hcl er QSYMIA ORAL oral capsule extended release 1 or 1b* PA; QL CAPSULE EXTENDED 3 PA; QL 24 hour RELEASE 24 HOUR dexmethylphenidate hcl oral 1 or 1b* PA; QL *ANOREXIANTS NON- tablet AMPHETAMINE*** FOCALIN ORAL 3 PA; QL ADIPEX-P ORAL TABLET 3 PA; QL CAPSULE FOCALIN XR ORAL ADIPEX-P ORAL CAPSULE EXTENDED 3 PA; QL 3 PA; QL TABLET RELEASE 24 HOUR benzphetamine hcl oral tablet JORNAY PM ORAL 1 or 1b* 25 mg CAPSULE EXTENDED 3 PA; QL RELEASE 24 HOUR benzphetamine hcl oral tablet 1 or 1b* PA; QL metadate er oral tablet 50 mg 1 or 1b* PA; QL extended release 20 mg diethylpropion hcl er oral METHYLIN ORAL tablet extended release 24 1 or 1b* PA; QL 3 PA; QL hour SOLUTION methylphenidate hcl er (cd) diethylpropion hcl oral tablet 1 or 1b* PA; QL 1 or 1b* PA; QL oral capsule extended release LOMAIRA ORAL 3 PA; QL TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 6 Drug Name Tier Notes Drug Name Tier Notes methylphenidate hcl er (la) *AGENTS FOR OPIOID oral capsule extended release 1 or 1b* PA; QL WITHDRAWAL*** 24 hour *AGENTS FOR OPIOID methylphenidate hcl er oral WITHDRAWAL*** tablet extended release 10 LUCEMYRA ORAL 1 or 1b* PA; QL 3 mg, 18 mg, 20 mg, 27 mg, 36 TABLET mg, 54 mg *AMEBICIDES* methylphenidate hcl er oral tablet extended release 24 1 or 1b* PA; QL *AMEBICIDES*** hour SOLOSEC ORAL 3 ST; QL METHYLPHENIDATE PACKET HCL ER ORAL TABLET 3 PA; QL *AMINO ACIDS*** EXTENDED RELEASE 72 *AMINO ACIDS*** MG methylphenidate hcl oral ENDARI ORAL PACKET 3 PA; QL; LD 1 or 1b* PA; QL solution *AMINOGLYCOSIDES* methylphenidate hcl oral *AMINOGLYCOSIDES** 1 or 1b* PA; QL tablet * methylphenidate hcl oral amikacin sulfate injection 1 or 1b* PA; QL tablet chewable solution 1 gm/4ml, 500 1 or 1b* modafinil oral tablet 100 mg 1 or 1b* PA; DO; QL mg/2ml modafinil oral tablet 200 mg 1 or 1b* PA; QL ARIKAYCE INHALATION 3 PA; QL; LD NUVIGIL ORAL TABLET 3 PA; QL SUSPENSION PROVIGIL ORAL 3 PA; DO; QL BETHKIS INHALATION TABLET 100 MG NEBULIZATION 3 LD; SP PROVIGIL ORAL SOLUTION 3 PA; QL TABLET 200 MG gentamicin in saline QUILLICHEW ER ORAL intravenous solution 0.8-0.9 TABLET CHEWABLE 3 PA; QL mg/ml-%, 1-0.9 mg/ml-%, 1 or 1b* EXTENDED RELEASE 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9 mg/ml-% QUILLIVANT XR ORAL gentamicin sulfate injection SUSPENSION 3 1 or 1b* RECONSTITUTED ER solution RELEXXII ORAL KITABIS PAK INHALATION TABLET EXTENDED 3 PA; QL 3 LD; SP RELEASE NEBULIZATION SOLUTION RITALIN LA ORAL CAPSULE EXTENDED neomycin sulfate oral tablet 1 or 1a* RELEASE 24 HOUR 10 3 PA; QL paromomycin sulfate oral 1 or 1b* MG, 20 MG, 30 MG, 40 capsule MG streptomycin sulfate RITALIN ORAL TABLET 3 PA; QL intramuscular solution 1 or 1b* *AGENTS FOR reconstituted NARCOTIC TOBI INHALATION WITHDRAWAL*** NEBULIZATION 3 LD; SP *AGENTS FOR SOLUTION NARCOTIC TOBI PODHALER 3 LD; SP WITHDRAWAL*** INHALATION CAPSULE LUCEMYRA ORAL tobramycin inhalation 3 1 or 1b* SP TABLET nebulization solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 7 Drug Name Tier Notes Drug Name Tier Notes tobramycin sulfate injection XELJANZ XR ORAL 1 or 1b* solution TABLET EXTENDED 3 PA; QL; SP tobramycin sulfate injection RELEASE 24 HOUR 11 1 or 1b* solution reconstituted MG ZEMDRI INTRAVENOUS XELJANZ XR ORAL 3 TABLET EXTENDED SOLUTION 3 PA; QL RELEASE 24 HOUR 22 *AMINOLEVULINATE MG SYNTHASE 1-DIRECTED SIRNA*** *ANTIRHEUMATIC ANTIMETABOLITES*** *AMINOLEVULINATE SYNTHASE 1-DIRECTED OTREXUP SIRNA*** SUBCUTANEOUS SOLUTION AUTO- GIVLAARI INJECTOR 10 MG/0.4ML, SUBCUTANEOUS 3 PA; QL; LD 12.5 MG/0.4ML, 15 3 PA; QL; SP SOLUTION MG/0.4ML, 17.5 *AMINOMETHYLCYCLI MG/0.4ML, 20 MG/0.4ML, NES*** 22.5 MG/0.4ML, 25 MG/0.4ML *AMINOMETHYLCYCLI NES*** RASUVO SUBCUTANEOUS NUZYRA SOLUTION AUTO- INTRAVENOUS 3 LD INJECTOR 10 MG/0.2ML, SOLUTION 12.5 MG/0.25ML, 15 RECONSTITUTED MG/0.3ML, 17.5 3 PA; QL; SP NUZYRA ORAL TABLET MG/0.35ML, 20 3 PA; QL; LD 150 MG MG/0.4ML, 22.5 *ANALGESIC MG/0.45ML, 25 COMBINATIONS - MG/0.5ML, 30 MG/0.6ML, TOPICAL*** 7.5 MG/0.15ML *ANALGESIC *ANTI-TNF-ALPHA - COMBINATIONS - MONOCLONAL TOPICAL*** ANTIBODIES*** A.A.G.C. KIT IN HUMIRA PEDIATRIC TERODERM EXTERNAL 2 CROHNS START CREAM SUBCUTANEOUS PREFILLED SYRINGE 3 PA; QL; SP ACTIVE-PREP KIT IV 2 KIT 80 MG/0.8ML, 80 EXTERNAL CREAM MG/0.8ML & *ANALGESICS - ANTI- 40MG/0.4ML INFLAMMATORY* HUMIRA PEN *ANTIRHEUMATIC - SUBCUTANEOUS PEN- 3 PA; QL; SP JANUS KINASE (JAK) INJECTOR KIT INHIBITORS*** HUMIRA PEN-CD/UC/HS OLUMIANT ORAL STARTER 3 PA; QL; LD 3 PA; QL; SP TABLET 1 MG SUBCUTANEOUS PEN- INJECTOR KIT OLUMIANT ORAL 3 PA; QL; LD; SP TABLET 2 MG HUMIRA PEN- PS/UV/ADOL HS START RINVOQ ORAL TABLET 3 PA; QL; SP SUBCUTANEOUS PEN- EXTENDED RELEASE 24 3 PA; QL; SP INJECTOR KIT HOUR HUMIRA XELJANZ ORAL 3 PA; QL; SP SUBCUTANEOUS TABLET 3 PA; QL; SP PREFILLED SYRINGE KIT * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 8 Drug Name Tier Notes Drug Name Tier Notes SIMPONI ARIA *GOLD COMPOUNDS*** INTRAVENOUS 3 PA; QL; SP RIDAURA ORAL 2 SOLUTION CAPSULE SIMPONI *INTERLEUKIN-1 SUBCUTANEOUS 3 PA; QL; SP BLOCKERS*** SOLUTION AUTO- INJECTOR ARCALYST SUBCUTANEOUS 3 PA; QL; LD; SP SIMPONI SOLUTION SUBCUTANEOUS 3 PA; QL; SP RECONSTITUTED SOLUTION PREFILLED SYRINGE *INTERLEUKIN-1 RECEPTOR *ANTI-TNF-ALPHA - ANTAGONIST (IL- MONOCLONOAL 1RA)*** ANTIBODIES*** KINERET HUMIRA PEDIATRIC SUBCUTANEOUS 3 PA; QL; LD CROHNS START SOLUTION PREFILLED SUBCUTANEOUS SYRINGE PREFILLED SYRINGE 3 PA; QL; SP KIT 80 MG/0.8ML, 80 *INTERLEUKIN-1BETA MG/0.8ML & BLOCKERS*** 40MG/0.4ML ILARIS HUMIRA PEN SUBCUTANEOUS 3 PA; QL; LD; SP SUBCUTANEOUS PEN- 3 PA; QL; SP SOLUTION INJECTOR KIT *INTERLEUKIN-6 HUMIRA PEN-CD/UC/HS RECEPTOR STARTER INHIBITORS*** 3 PA; QL; SP SUBCUTANEOUS PEN- ACTEMRA ACTPEN INJECTOR KIT SUBCUTANEOUS 3 PA; QL; LD; SP HUMIRA PEN- SOLUTION AUTO- PS/UV/ADOL HS START INJECTOR 3 PA; QL; SP SUBCUTANEOUS PEN- ACTEMRA INJECTOR KIT INTRAVENOUS 3 PA; QL; LD; SP HUMIRA SOLUTION SUBCUTANEOUS 3 PA; QL; SP ACTEMRA PREFILLED SYRINGE SUBCUTANEOUS 3 PA; QL; LD; SP KIT SOLUTION PREFILLED SIMPONI ARIA SYRINGE INTRAVENOUS 3 PA; QL; SP KEVZARA SOLUTION SUBCUTANEOUS 3 PA; QL; LD; SP SIMPONI SOLUTION AUTO- SUBCUTANEOUS INJECTOR 3 PA; QL; SP SOLUTION AUTO- KEVZARA INJECTOR SUBCUTANEOUS 3 PA; QL; LD; SP SIMPONI SOLUTION PREFILLED SUBCUTANEOUS SYRINGE 3 PA; QL; SP SOLUTION PREFILLED *NONSTEROIDAL ANTI- SYRINGE INFLAMMATORY *CYCLOOXYGENASE 2 AGENT (COX-2) INHIBITORS*** COMBINATIONS*** CELEBREX ORAL ACTIVE INJECTION 3 ST; QL 3 CAPSULE KET-L INJECTION KIT celecoxib oral capsule 1 or 1b* ST; QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 9 Drug Name Tier Notes Drug Name Tier Notes ACTIVE INJECTION etodolac er oral tablet 1 or 1b* KETMARC-L 3 extended release 24 hour INJECTION KIT etodolac oral capsule 1 or 1b* ARTHROTEC ORAL etodolac oral tablet 1 or 1b* TABLET DELAYED 3 ST; QL FELDENE ORAL RELEASE 3 CAPSULE DERMACINRX ANALGESIC FENOPROFEN 3 COMBOPAK CALCIUM ORAL 3 ST; QL COMBINATION KIT CAPSULE 200 MG diclofenac-misoprostol oral fenoprofen calcium oral 1 or 1b* ST; QL 1 or 1b* ST; QL tablet delayed release capsule 400 mg fenoprofen calcium oral DUEXIS ORAL TABLET 3 ST; QL 1 or 1b* tablet naproxen-esomeprazole oral 3 ST; QL; CTT1 tablet delayed release flurbiprofen oral tablet 1 or 1b* PREVIDOLRX ibu oral tablet 1 or 1a* ANALGESIC ibuprofen lysine intravenous 3 1 or 1b* COMBINATION solution THERAPY PACK ibuprofen oral suspension 1 or 1a* READYSHARP ANESTH ibuprofen oral tablet 400 mg, + KETOROLAC 3 1 or 1a* INJECTION KIT 600 mg, 800 mg VIMOVO ORAL TABLET INDOCIN ORAL 3 ST; QL 3 ST; QL DELAYED RELEASE SUSPENSION INDOCIN RECTAL *NONSTEROIDAL ANTI- 3 ST; QL INFLAMMATORY SUPPOSITORY AGENTS (NSAIDS)*** indomethacin er oral capsule 1 or 1b* ANJESO INTRAVENOUS extended release 3 INJECTABLE indomethacin oral capsule 20 3 CTT1 CALDOLOR mg INTRAVENOUS indomethacin oral capsule 25 3 1 or 1b* SOLUTION 800 mg, 50 mg MG/200ML, 800 MG/8ML indomethacin sodium DAYPRO ORAL TABLET 3 intravenous solution 1 or 1b* DFS DR/MS/MENTH/CAP reconstituted PAK COMBINATION 3 ketoprofen er oral capsule 1 or 1b* KIT extended release 24 hour diclofenac potassium oral ketoprofen oral capsule 1 or 1b* 1 or 1b* tablet ketorolac tromethamine diclofenac sodium er oral injection solution 15 mg/ml, 1 or 1b* QL tablet extended release 24 1 or 1b* 30 mg/ml hour ketorolac tromethamine oral 1 or 1a* QL diclofenac sodium oral tablet tablet 1 or 1b* delayed release LODINE ORAL TABLET 3 EC-NAPROSYN ORAL meclofenamate sodium oral 1 or 1b* TABLET DELAYED 3 capsule RELEASE 375 MG mefenamic acid oral capsule 1 or 1b* EC-NAPROXEN ORAL TABLET DELAYED 3 meloxicam oral tablet 1 or 1b* RELEASE MOBIC ORAL TABLET 3 nabumetone oral tablet 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 10 Drug Name Tier Notes Drug Name Tier Notes NALFON ORAL leflunomide oral tablet 1 or 1b* 3 ST; QL CAPSULE 400 MG *SELECTIVE NALFON ORAL TABLET 3 ST; QL COSTIMULATION NAPRELAN ORAL MODULATORS*** TABLET EXTENDED ORENCIA CLICKJECT 3 ST; QL RELEASE 24 HOUR 375 SUBCUTANEOUS 3 PA; QL; SP MG, 500 MG, 750 MG SOLUTION AUTO- NAPROSYN ORAL INJECTOR 3 SUSPENSION ORENCIA naproxen dr oral tablet INTRAVENOUS 1 or 1b* 3 PA; QL; SP delayed release SOLUTION RECONSTITUTED naproxen oral suspension 1 or 1b* ORENCIA naproxen oral tablet 1 or 1b* SUBCUTANEOUS 3 PA; QL; SP naproxen sodium er oral SOLUTION PREFILLED tablet extended release 24 1 or 1b* ST; QL SYRINGE hour *SOLUBLE TUMOR naproxen sodium oral tablet NECROSIS FACTOR 1 or 1b* 275 mg, 550 mg RECEPTOR AGENTS*** NEOPROFEN ENBREL MINI INTRAVENOUS 3 SUBCUTANEOUS 3 PA; QL; SP SOLUTION SOLUTION CARTRIDGE oxaprozin oral tablet 1 or 1b* ENBREL SUBCUTANEOUS 3 PA; QL; SP piroxicam oral capsule 1 or 1b* SOLUTION PREFILLED QMIIZ ODT ORAL SYRINGE 3 ST; QL TABLET DISPERSIBLE ENBREL RELAFEN DS ORAL SUBCUTANEOUS 3 ST; QL 3 PA; QL; SP TABLET SOLUTION SPRIX NASAL RECONSTITUTED 3 ST; QL SOLUTION ENBREL SURECLICK SUBCUTANEOUS sulindac oral tablet 1 or 1b* 3 PA; QL; SP SOLUTION AUTO- TIVORBEX ORAL 3 INJECTOR CAPSULE 20 MG *ANALGESICS - tolmetin sodium oral capsule 1 or 1b* NONNARCOTIC* tolmetin sodium oral tablet 1 or 1b* *ANALGESIC 600 mg COMBINATIONS*** VIVLODEX ORAL 3 ST; QL duraxin oral capsule 1 or 1b* CAPSULE *ANALGESICS ZIPSOR ORAL CAPSULE 3 ST; QL OTHER*** ZORVOLEX ORAL clonidine hcl (analgesia) 3 ST; QL 1 or 1b* CAPSULE epidural solution *NSAID-NUTRITIONAL DURACLON EPIDURAL 3 SUPPLEMENT SOLUTION 100 MCG/ML COMBINATIONS*** OFIRMEV PRASTERA ORAL KIT 3 INTRAVENOUS 3 *PYRIMIDINE SOLUTION SYNTHESIS INHIBITORS*** ARAVA ORAL TABLET 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 11 Drug Name Tier Notes Drug Name Tier Notes *ANALGESICS- acetaminophen-codeine #4 1 or 1a* QL SEDATIVES*** oral tablet ALLZITAL ORAL acetaminophen-codeine oral 3 1 or 1a* QL TABLET solution bupap oral tablet 50-300 mg 1 or 1b* acetaminophen-codeine oral 1 or 1a* QL BUTALBITAL- tablet ACETAMINOPHEN 3 ascomp-codeine oral capsule 1 or 1b* QL ORAL CAPSULE butalbital-apap-caff-cod oral 1 or 1b* QL butalbital-acetaminophen capsule 1 or 1b* oral tablet butalbital-asa-caff-codeine 1 or 1b* QL butalbital-apap-caffeine oral oral capsule 1 or 1b* capsule FIORICET/CODEINE butalbital-apap-caffeine oral ORAL CAPSULE 50-300- 3 QL 1 or 1b* tablet 50-325-40 mg 40-30 MG butalbital-aspirin-caffeine FIORINAL/CODEINE #3 1 or 1b* 3 QL oral capsule ORAL CAPSULE BUTALBITAL-ASPIRIN- TYLENOL WITH CAFFEINE ORAL 3 CODEINE #3 ORAL 3 QL TABLET TABLET esgic oral capsule 1 or 1b* *DIHYDROCODEINE ESGIC ORAL TABLET 3 COMBINATIONS*** FIORICET ORAL apap-caff-dihydrocodeine 3 1 or 1b* QL CAPSULE oral capsule FIORINAL ORAL apap-caff-dihydrocodeine 3 1 or 1b* QL CAPSULE oral tablet 325-30-16 mg tencon oral tablet 50-325 mg 1 or 1b* dvorah oral tablet 1 or 1b* QL trezix oral capsule 320.5-30- vanatol lq oral solution 3 CTT1 1 or 1b* QL 16 mg vanatol s oral solution 3 CTT1 *HYDROCODONE vtol lq oral solution 3 CTT1 COMBINATIONS*** zebutal oral capsule 50-325- 1 or 1b* HYDROCODONE- 40 mg ACETAMINOPHEN 3 QL *SALICYLATES*** ORAL SOLUTION 10-325 MG/15ML diflunisal oral tablet 1 or 1b* hydrocodone-acetaminophen *SELECTIVE N-TYPE oral solution 2.5-108 NEURONAL CALCIUM 1 or 1b* QL mg/5ml, 5-217 mg/10ml, 7.5- CHANNEL 325 mg/15ml BLOCKERS*** hydrocodone-acetaminophen PRIALT INTRATHECAL oral tablet 10-300 mg, 10- 3 PA; QL; LD 1 or 1b* QL SOLUTION 325 mg, 5-300 mg, 5-325 *ANALGESICS - mg, 7.5-300 mg, 7.5-325 mg OPIOID* hydrocodone-ibuprofen oral *CODEINE tablet 10-200 mg, 5-200 mg, 1 or 1b* QL COMBINATIONS*** 7.5-200 mg acetaminophen-codeine #2 lorcet hd oral tablet 1 or 1b* QL 1 or 1a* QL oral tablet lorcet oral tablet 1 or 1b* QL acetaminophen-codeine #3 lorcet plus oral tablet 7.5-325 1 or 1a* QL 1 or 1b* QL oral tablet mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 12 Drug Name Tier Notes Drug Name Tier Notes LORTAB ORAL ELIXIR DURAGESIC-25 3 QL 10-300 MG/15ML TRANSDERMAL PATCH 3 PA; QL NORCO ORAL TABLET 3 QL 72 HOUR vicodin hp oral tablet 10-300 DURAGESIC-50 1 or 1b* QL mg TRANSDERMAL PATCH 3 PA; QL 72 HOUR *OPIOID AGONISTS*** DURAGESIC-75 ABSTRAL SUBLINGUAL TRANSDERMAL PATCH 3 PA; QL TABLET SUBLINGUAL 3 PA; QL 72 HOUR 400 MCG, 600 MCG, 800 MCG duramorph injection solution 1 or 1b* QL ACTIQ BUCCAL FENTANYL CITRATE LOZENGE ON A 3 PA; QL (PF) INJECTION HANDLE SOLUTION 100 3 MCG/2ML, 250 ALFENTANIL HCL MCG/5ML, 50 MCG/ML INTRAVENOUS 3 SOLUTION fentanyl citrate (pf) injection solution 1000 mcg/20ml, 1 or 1b* ARYMO ER ORAL 2500 mcg/50ml, 500 TABLET EXTENDED 3 PA; QL mcg/10ml RELEASE ABUSE- fentanyl citrate (pf) injection DETERRENT 1 or 1b* solution cartridge CODEINE SULFATE 3 QL fentanyl citrate buccal ORAL TABLET 1 or 1b* PA; QL lozenge on a handle CONZIP ORAL CAPSULE EXTENDED 3 PA; QL fentanyl citrate buccal tablet 1 or 1b* PA; QL RELEASE 24 HOUR FENTANYL CITRATE DEMEROL INJECTION INJECTION SOLUTION 3 SOLUTION 100 MG/2ML, 1500 MCG/30ML 3 QL 100 MG/ML, 25 MG/ML, FENTANYL CITRATE 50 MG/ML, 75 MG/ML INTRAVENOUS 3 DEMEROL INJECTION SOLUTION 5000 SOLUTION 25 MG/0.5ML, 3 MCG/100ML 75 MG/1.5ML FENTANYL CITRATE INTRAVENOUS DILAUDID INJECTION 3 SOLUTION 1 MG/ML, 2 3 QL SOLUTION PREFILLED MG/ML SYRINGE DILAUDID ORAL FENTANYL CITRATE- 3 QL LIQUID NACL INTRAVENOUS SOLUTION 1-0.9 DILAUDID ORAL 3 3 QL MG/100ML-%, 1.25-0.9 TABLET MG/250ML-%, 2.5-0.9 DOLOPHINE ORAL MG/250ML-% 3 PA; QL TABLET FENTANYL CITRATE- DSUVIA SUBLINGUAL NACL INTRAVENOUS 3 TABLET SUBLINGUAL SOLUTION PREFILLED SYRINGE 10-0.9 DURAGESIC-100 MCG/2ML-%, 10-0.9 3 TRANSDERMAL PATCH 3 PA; QL MCG/ML-%, 5-0.9 72 HOUR MCG/ML-%, 500-0.9 DURAGESIC-12 MCG/50ML-%, 550-0.9 TRANSDERMAL PATCH 3 PA; QL MCG/55ML-% 72 HOUR fentanyl transdermal patch 1 or 1b* PA; QL 72 hour

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 13 Drug Name Tier Notes Drug Name Tier Notes FENTORA BUCCAL HYDROMORPHONE TABLET 100 MCG, 200 HCL-NACL 3 PA; QL MCG, 400 MCG, 600 INTRAVENOUS MCG, 800 MCG SOLUTION PREFILLED hydrocodone bitartrate er SYRINGE 0.2-0.9 oral capsule er 12 hour 3 PA; QL; CTT1 MG/0.2ML-%, 0.5-0.9 abuse-deterrent MG/0.5ML-%, 1-0.9 MG/5ML-%, 1-0.9 3 hydromorphone hcl er oral MG/ML-%, 10-0.9 tablet er 24 hour abuse- 1 or 1b* PA; QL MG/50ML-%, 2-0.9 deterrent MG/ML-%, 30-0.9 HYDROMORPHONE MG/30ML-%, 50-0.9 HCL INJECTION 3 MG/50ML-%, 55-0.9 SOLUTION 0.2 MG/ML MG/55ML-%, 6-0.9 MG/30ML-% hydromorphone hcl injection 1 or 1b* QL solution 2 mg/ml, 4 mg/ml HYSINGLA ER ORAL TABLET ER 24 HOUR 3 PA; QL hydromorphone hcl oral 1 or 1b* QL ABUSE-DETERRENT liquid INFUMORPH 200 hydromorphone hcl oral 3 1 or 1b* QL INJECTION SOLUTION tablet INFUMORPH 500 3 HYDROMORPHONE INJECTION SOLUTION HCL PF INJECTION SOLUTION 1 MG/ML, 10 3 QL KADIAN ORAL MG/ML, 2 MG/ML, 4 CAPSULE EXTENDED RELEASE 24 HOUR 10 MG/ML 3 PA; QL MG, 100 MG, 20 MG, 200 hydromorphone hcl pf MG, 30 MG, 40 MG, 50 injection solution 50 mg/5ml, 1 or 1b* QL MG, 60 MG, 80 MG 500 mg/50ml LAZANDA NASAL 3 PA; QL HYDROMORPHONE SOLUTION HCL RECTAL 3 QL levorphanol tartrate oral SUPPOSITORY 1 or 1b* PA; QL tablet HYDROMORPHONE HCL-NACL INJECTION meperidine hcl injection 3 SOLUTION 20-0.9 solution 100 mg/ml, 25 1 or 1b* QL MG/100ML-% mg/ml, 50 mg/ml HYDROMORPHONE meperidine hcl oral solution 1 or 1b* QL HCL-NACL meperidine hcl oral tablet 1 or 1b* QL INTRAVENOUS METHADONE HCL SOLUTION 10-0.9 3 PA; QL MG/50ML-%, 20-0.9 INJECTION SOLUTION 3 MG/100ML-%, 25-0.9 methadone hcl intensol oral 1 or 1b* PA; QL MG/50ML-%, 30-0.9 concentrate MG/30ML-%, 50-0.9 methadone hcl oral 1 or 1b* PA; QL MG/50ML-%, 6-0.9 concentrate MG/30ML-% methadone hcl oral solution 1 or 1b* PA; QL methadone hcl oral tablet 1 or 1b* PA; QL methadone hcl oral tablet 1 or 1b* PA; QL soluble METHADOSE ORAL CONCENTRATE 10 3 PA; QL MG/ML methadose oral tablet soluble 1 or 1b* PA; QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 14 Drug Name Tier Notes Drug Name Tier Notes METHADOSE SUGAR- MORPHINE SULFATE- FREE ORAL 3 PA; QL NACL INTRAVENOUS CONCENTRATE SOLUTION 100-0.9 3 mitigo injection solution 1 or 1b* QL MG/100ML-%, 50-0.9 MG/50ML-%, 500-0.9 MORPHABOND ER MG/100ML-% ORAL TABLET ER 12 3 PA; QL HOUR ABUSE- MORPHINE SULFATE- DETERRENT NACL INTRAVENOUS SOLUTION PREFILLED 3 QL morphine sulfate SYRINGE 150-0.9 (concentrate) oral solution 1 or 1b* QL MG/30ML-%, 50-0.9 100 mg/5ml, 20 mg/ml MG/50ML-% morphine sulfate (pf) MORPHINE SULFATE- injection solution 0.5 mg/ml, 1 or 1b* QL NACL INTRAVENOUS 1 mg/ml SOLUTION PREFILLED MORPHINE SULFATE SYRINGE 2-0.9 MG/ML- 3 (PF) INJECTION %, 30-0.9 MG/30ML-%, 4- SOLUTION 10 MG/ML, 2 3 QL 0.9 MG/ML-%, 55-0.9 MG/ML, 4 MG/ML, 5 MG/55ML-% MG/ML, 8 MG/ML MS CONTIN ORAL MORPHINE SULFATE TABLET EXTENDED 3 PA; QL (PF) INTRAVENOUS RELEASE SOLUTION 10 MG/ML, 2 3 QL NUCYNTA ER ORAL MG/ML, 4 MG/ML, 8 TABLET EXTENDED 3 PA; QL MG/ML RELEASE 12 HOUR morphine sulfate er beads NUCYNTA ORAL 3 QL oral capsule extended release 1 or 1b* PA; QL TABLET 24 hour OPANA ORAL TABLET 3 QL morphine sulfate er oral 10 MG capsule extended release 24 1 or 1b* PA; QL OXAYDO ORAL TABLET hour 3 QL ABUSE-DETERRENT morphine sulfate er oral 1 or 1b* PA; QL oxycodone hcl er oral tablet tablet extended release 3 PA; QL; CTT1 er 12 hour abuse-deterrent MORPHINE SULFATE INTRAMUSCULAR 3 QL oxycodone hcl oral capsule 1 or 1b* QL DEVICE oxycodone hcl oral 1 or 1b* QL MORPHINE SULFATE concentrate 100 mg/5ml INTRAVENOUS 3 QL oxycodone hcl oral solution 1 or 1b* QL SOLUTION 0.5 MG/ML oxycodone hcl oral tablet 1 or 1b* QL morphine sulfate intravenous 1 or 1b* QL OXYCONTIN ORAL solution 25 mg/ml TABLET ER 12 HOUR 3 PA; QL morphine sulfate intravenous ABUSE-DETERRENT 1 or 1b* solution 50 mg/ml oxymorphone hcl er oral morphine sulfate oral tablet extended release 12 1 or 1b* PA; QL 1 or 1b* QL solution hour morphine sulfate oral tablet 1 or 1b* QL oxymorphone hcl oral tablet 1 or 1b* QL morphine sulfate rectal remifentanil hcl intravenous 1 or 1b* QL 1 or 1b* suppository solution reconstituted ROXICODONE ORAL 3 QL TABLET SUBSYS SUBLINGUAL 3 PA; QL LIQUID

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 15 Drug Name Tier Notes Drug Name Tier Notes SUFENTANIL CITRATE PROLATE ORAL 3 QL INTRAVENOUS 3 TABLET SOLUTION *OPIOID PARTIAL SYNAPRYN FUSEPAQ AGONISTS*** ORAL SUSPENSION 3 BELBUCA BUCCAL 3 PA; QL RECONSTITUTED FILM tramadol hcl er (biphasic) BUNAVAIL BUCCAL oral tablet extended release 3 QL 1 or 1b* PA; QL FILM 24 hour 100 mg, 200 mg, 300 BUPRENEX INJECTION mg 3 QL SOLUTION tramadol hcl er oral capsule 1 or 1b* PA; QL buprenorphine hcl injection extended release 24 hour 1 or 1b* QL solution 0.3 mg/ml tramadol hcl er oral tablet 1 or 1b* PA; QL buprenorphine hcl sublingual extended release 24 hour 1 or 1b* QL tablet sublingual tramadol hcl oral tablet 1 or 1b* QL buprenorphine hcl-naloxone 1 or 1b* QL ULTIVA INTRAVENOUS hcl sublingual film SOLUTION 3 RECONSTITUTED buprenorphine hcl-naloxone hcl sublingual tablet 1 or 1b* QL ULTRAM ORAL TABLET 3 QL sublingual XTAMPZA ER ORAL buprenorphine transdermal 1 or 1b* PA; QL CAPSULE ER 12 HOUR 3 PA; QL patch weekly ABUSE-DETERRENT butorphanol tartrate injection 1 or 1b* QL ZOHYDRO ER ORAL solution CAPSULE ER 12 HOUR 3 PA; QL butorphanol tartrate nasal ABUSE-DETERRENT 1 or 1b* QL solution *OPIOID COMBINATIONS*** BUTRANS TRANSDERMAL PATCH 3 PA; QL APADAZ ORAL TABLET 3 QL WEEKLY BENZHYDROCODONE- nalbuphine hcl injection 1 or 1b* ACETAMINOPHEN 3 QL solution ORAL TABLET pentazocine-naloxone hcl 1 or 1b* QL endocet oral tablet 10-325 oral tablet mg, 2.5-325 mg, 5-325 mg, 1 or 1b* QL 7.5-325 mg PROBUPHINE IMPLANT KIT SUBCUTANEOUS 3 PA; QL; LD nalocet oral tablet 3 QL; CTT1 IMPLANT oxycodone-acetaminophen SUBLOCADE oral tablet 10-325 mg, 2.5- SUBCUTANEOUS 1 or 1b* QL 3 LD 325 mg, 5-325 mg, 7.5-325 SOLUTION PREFILLED mg SYRINGE oxycodone-acetaminophen SUBOXONE 3 QL; CTT1 3 QL oral tablet 2.5-300 mg SUBLINGUAL FILM oxycodone-aspirin oral tablet ZUBSOLV SUBLINGUAL 1 or 1b* QL 3 QL 4.8355-325 mg TABLET SUBLINGUAL oxycodone-ibuprofen oral 1 or 1a* QL *TRAMADOL tablet COMBINATIONS*** PERCOCET ORAL tramadol-acetaminophen oral TABLET 10-325 MG, 2.5- 1 or 1b* QL 3 QL tablet 325 MG, 5-325 MG, 7.5-325 ULTRACET ORAL MG 3 QL TABLET PRIMLEV ORAL 3 QL TABLET * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 16 Drug Name Tier Notes Drug Name Tier Notes *ANDROGENS- TESTOSTERONE ANABOLIC* IMPLANT PELLET 100 3 *ANABOLIC MG, 25 MG, 50 MG STEROIDS*** testosterone transdermal gel ANADROL-50 ORAL 1.62 %, 10 mg/act (2%), 12.5 3 TABLET mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 1 or 1b* PA; QL oxandrolone oral tablet 1 or 1b* PA; QL mg/act (1.62%), 25 *ANDROGENS*** mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 ANDRODERM mg/5gm (1%) TRANSDERMAL PATCH 3 PA; QL testosterone transdermal 24 HOUR 1 or 1b* PA; QL solution ANDROGEL PUMP VOGELXO PUMP TRANSDERMAL GEL 3 PA; QL 3 PA; QL 20.25 MG/ACT (1.62%) TRANSDERMAL GEL ANDROGEL VOGELXO 3 PA; QL TRANSDERMAL GEL TRANSDERMAL GEL 50 3 PA; QL MG/5GM (1%) AVEED INTRAMUSCULAR 3 PA; QL; LD; SP XYOSTED SUBCUTANEOUS SOLUTION 3 PA; QL SOLUTION AUTO- danazol oral capsule 1 or 1b* INJECTOR DEPO-TESTOSTERONE *ANORECTAL AGENTS* INTRAMUSCULAR 3 PA; QL SOLUTION *INTRARECTAL STEROIDS*** EC-RX TESTOSTERONE 3 TRANSDERMAL CREAM colocort rectal enema 1 or 1b* FORTESTA CORTENEMA RECTAL 3 PA; QL 3 TRANSDERMAL GEL ENEMA JATENZO ORAL CORTIFOAM 3 PA; QL 3 CAPSULE EXTERNAL FOAM METHITEST ORAL hydrocortisone rectal enema 1 or 1b* 3 TABLET UCERIS RECTAL FOAM 3 methyltestosterone oral 1 or 1b* *NITRATE capsule VASODILATING NATESTO NASAL GEL 3 PA; QL AGENTS*** RECTIV RECTAL STRIANT BUCCAL 3 PA; QL 3 OINTMENT TESTIM 3 PA; QL TRANSDERMAL GEL *RECTAL ANESTHETIC/STEROIDS TESTOPEL IMPLANT 3 PA; QL; LD *** PELLET ANALPRAM-HC 3 TESTOSTERONE EXTERNAL CREAM COMPOUNDING KIT 3 ANALPRAM-HC TRANSDERMAL CREAM 3 EXTERNAL LOTION testosterone cypionate intramuscular solution 100 1 or 1b* PA; QL hydrocortisone ace- mg/ml, 200 mg/ml pramoxine external cream 1- 1 or 1b* 1 % testosterone enanthate 1 or 1b* PA; QL PROCTOFOAM HC intramuscular solution 3 EXTERNAL FOAM

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 17 Drug Name Tier Notes Drug Name Tier Notes *RECTAL STEROIDS*** ISORDIL TITRADOSE 3 ANUSOL-HC EXTERNAL ORAL TABLET 3 CREAM isosorbide dinitrate oral 1 or 1b* hydrocortisone (perianal) tablet 1 or 1b* external cream isosorbide mononitrate er PROCTOCORT oral tablet extended release 1 or 1b* 3 EXTERNAL CREAM 24 hour procto-med hc external isosorbide mononitrate oral 1 or 1b* 1 or 1b* cream tablet minitran transdermal patch procto-pak external cream 1 or 1b* 1 or 1b* 24 hour proctosol hc external cream 1 or 1b* NITRO-BID proctozone-hc external cream 1 or 1b* TRANSDERMAL 3 *ANTACIDS* OINTMENT *ANTACIDS - NITRO-DUR BICARBONATE*** TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 3 SODIUM BICARBONATE 3 MG/HR, 0.4 MG/HR, 0.6 ORAL POWDER MG/HR *ANTHELMINTICS* NITRO-DUR *ANTHELMINTICS*** TRANSDERMAL PATCH 2 albendazole oral tablet 1 or 1b* PA; QL 24 HOUR 0.3 MG/HR, 0.8 MG/HR ALBENZA ORAL 3 PA; QL nitroglycerin in d5w TABLET 1 or 1b* intravenous solution BENZNIDAZOLE ORAL 3 TABLET NITROGLYCERIN INTRAVENOUS 3 BILTRICIDE ORAL 3 SOLUTION TABLET nitroglycerin sublingual EMVERM ORAL 1 or 1b* 3 tablet sublingual TABLET CHEWABLE nitroglycerin transdermal 1 or 1b* ivermectin oral tablet 1 or 1b* patch 24 hour praziquantel oral tablet 1 or 1b* nitroglycerin translingual 1 or 1b* STROMECTOL ORAL solution 3 TABLET NITROLINGUAL *ANTIANGINAL TRANSLINGUAL 3 AGENTS* SOLUTION *ANTIANGINALS- NITROMIST OTHER*** TRANSLINGUAL 3 AEROSOL SOLUTION RANEXA ORAL TABLET EXTENDED RELEASE 12 3 NITROSTAT HOUR SUBLINGUAL TABLET 3 SUBLINGUAL ranolazine er oral tablet 1 or 1b* nitro-time oral capsule extended release 12 hour 1 or 1b* extended release *NITRATES*** *ANTIANXIETY DILATRATE-SR ORAL AGENTS* CAPSULE EXTENDED 2 RELEASE *ANTIANXIETY AGENTS - MISC.*** GONITRO SUBLINGUAL 3 PACKET buspirone hcl oral tablet 1 or 1b* droperidol injection solution 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 18 Drug Name Tier Notes Drug Name Tier Notes hydroxyzine hcl XANAX XR ORAL 1 or 1b* intramuscular solution TABLET EXTENDED 3 hydroxyzine hcl oral syrup 1 or 1b* RELEASE 24 HOUR hydroxyzine hcl oral tablet 1 or 1b* *ANTIARRHYTHMICS* hydroxyzine pamoate oral *ANTIARRHYTHMICS - 1 or 1a* capsule MISC.*** meprobamate oral tablet 1 or 1b* ADENOCARD INTRAVENOUS 3 VISTARIL ORAL 3 SOLUTION 6 MG/2ML CAPSULE adenosine intravenous *BENZODIAZEPINES*** solution 12 mg/4ml, 6 1 or 1b* alprazolam er oral tablet mg/2ml 1 or 1b* extended release 24 hour *ANTIARRHYTHMICS ALPRAZOLAM TYPE I-A*** INTENSOL ORAL 3 disopyramide phosphate oral 1 or 1b* CONCENTRATE capsule alprazolam oral tablet 1 or 1b* NORPACE CR ORAL alprazolam oral tablet CAPSULE EXTENDED 2 1 or 1b* dispersible RELEASE 12 HOUR alprazolam xr oral tablet NORPACE ORAL 1 or 1b* 3 extended release 24 hour CAPSULE ATIVAN INJECTION procainamide hcl injection 3 1 or 1b* SOLUTION solution quinidine gluconate er oral ATIVAN ORAL TABLET 3 1 or 1b* tablet extended release chlordiazepoxide hcl oral 1 or 1b* capsule quinidine sulfate oral tablet 1 or 1a* clorazepate dipotassium oral *ANTIARRHYTHMICS 1 or 1b* tablet TYPE I-B*** diazepam intensol oral lidocaine hcl (cardiac) 1 or 1a* concentrate intravenous solution prefilled 1 or 1b* syringe DIAZEPAM INTRAMUSCULAR LIDOCAINE HCL 3 (CARDIAC) PF SOLUTION AUTO- 3 INJECTOR INTRAVENOUS SOLUTION diazepam oral concentrate 1 or 1a* lidocaine hcl (cardiac) pf diazepam oral solution 5 1 or 1a* intravenous solution prefilled 1 or 1b* mg/5ml syringe diazepam oral tablet 1 or 1a* LIDOCAINE IN D5W lorazepam injection solution 1 or 1b* INTRAVENOUS 3 lorazepam intensol oral SOLUTION 2-5 MG/ML- 1 or 1b* concentrate %, 3-5 MG/ML-% lorazepam oral concentrate 2 lidocaine in d5w intravenous 1 or 1b* mg/ml solution 4-5 mg/ml-%, 8-5 1 or 1b* mg/ml-% lorazepam oral tablet 1 or 1b* mexiletine hcl oral capsule 1 or 1b* oxazepam oral capsule 1 or 1b* *ANTIARRHYTHMICS TRANXENE-T ORAL 3 TYPE I-C*** TABLET 7.5 MG flecainide acetate oral tablet 1 or 1b* VALIUM ORAL TABLET 3 XANAX ORAL TABLET 3 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 19 Drug Name Tier Notes Drug Name Tier Notes propafenone hcl er oral AIRDUO RESPICLICK capsule extended release 12 1 or 1b* 232/14 INHALATION 3 hour AEROSOL POWDER propafenone hcl oral tablet 1 or 1b* BREATH ACTIVATED RYTHMOL SR ORAL AIRDUO RESPICLICK 55/14 INHALATION CAPSULE EXTENDED 3 3 RELEASE 12 HOUR AEROSOL POWDER BREATH ACTIVATED *ANTIARRHYTHMICS TYPE III*** ANORO ELLIPTA INHALATION AEROSOL amiodarone hcl intravenous 2 1 or 1b* POWDER BREATH solution ACTIVATED amiodarone hcl oral tablet 1 or 1b* BEVESPI AEROSPHERE 3 ST; QL BRETYLIUM TOSYLATE INHALATION AEROSOL 3 INJECTION SOLUTION BREO ELLIPTA INHALATION AEROSOL CORVERT 2 INTRAVENOUS 3 POWDER BREATH SOLUTION ACTIVATED budesonide-formoterol dofetilide oral capsule 1 or 1b* 1 or 1b* fumarate inhalation aerosol ibutilide fumarate 1 or 1b* intravenous solution COMBIVENT RESPIMAT INHALATION AEROSOL 2 MULTAQ ORAL 3 SOLUTION TABLET DUAKLIR PRESSAIR NEXTERONE INHALATION AEROSOL 3 ST; QL INTRAVENOUS 3 POWDER BREATH SOLUTION ACTIVATED pacerone oral tablet 100 mg, DULERA INHALATION 1 or 1b* 2 200 mg, 400 mg AEROSOL TIKOSYN ORAL 3 fluticasone-salmeterol CAPSULE inhalation aerosol powder *ANTIASTHMATIC AND breath activated 100-50 1 or 1b* BRONCHODILATOR mcg/dose, 250-50 mcg/dose, AGENTS* 500-50 mcg/dose *5-LIPOXYGENASE fluticasone-salmeterol INHIBITORS*** inhalation aerosol powder zileuton er oral tablet breath activated 113-14 3 CTT1 1 or 1b* PA; QL extended release 12 hour mcg/act, 232-14 mcg/act, 55- 14 mcg/act ZYFLO ORAL TABLET 3 PA; QL ipratropium-albuterol 1 or 1b* *ADRENERGIC inhalation solution COMBINATIONS*** STIOLTO RESPIMAT ADVAIR DISKUS INHALATION AEROSOL INHALATION AEROSOL 2 3 SOLUTION 2.5-2.5 POWDER BREATH MCG/ACT ACTIVATED SYMBICORT ADVAIR HFA 2 2 INHALATION AEROSOL INHALATION AEROSOL TRELEGY ELLIPTA AIRDUO RESPICLICK INHALATION AEROSOL 113/14 INHALATION 3 PA; QL 3 POWDER BREATH AEROSOL POWDER ACTIVATED BREATH ACTIVATED UTIBRON NEOHALER 3 ST; QL INHALATION CAPSULE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 20 Drug Name Tier Notes Drug Name Tier Notes wixela inhub inhalation PROAIR DIGIHALER aerosol powder breath 1 or 1b* INHALATION AEROSOL 3 activated POWDER BREATH *ANTI-IGE ACTIVATED MONOCLONAL PROAIR HFA ANTIBODIES*** INHALATION AEROSOL 2 XOLAIR SOLUTION SUBCUTANEOUS PROAIR RESPICLICK 3 PA; QL; LD; SP SOLUTION PREFILLED INHALATION AEROSOL 2 SYRINGE POWDER BREATH XOLAIR ACTIVATED SUBCUTANEOUS PROVENTIL HFA 3 PA; QL; LD; SP SOLUTION INHALATION AEROSOL 3 RECONSTITUTED SOLUTION *ANTI- SEREVENT DISKUS INFLAMMATORY INHALATION AEROSOL 2 AGENTS*** POWDER BREATH cromolyn sodium inhalation ACTIVATED 1 or 1b* nebulization solution STRIVERDI RESPIMAT *BETA INHALATION AEROSOL 3 ADRENERGICS*** SOLUTION albuterol sulfate er oral tablet terbutaline sulfate injection 1 or 1b* 1 or 1b* extended release 12 hour solution albuterol sulfate hfa terbutaline sulfate oral tablet 1 or 1b* inhalation aerosol solution 1 or 1b* VENTOLIN HFA 108 (90 base) mcg/act INHALATION AEROSOL 2 albuterol sulfate inhalation SOLUTION 1 or 1b* nebulization solution XOPENEX albuterol sulfate oral syrup 1 or 1b* CONCENTRATE INHALATION 3 albuterol sulfate oral tablet 1 or 1b* NEBULIZATION ARCAPTA NEOHALER SOLUTION 3 INHALATION CAPSULE XOPENEX HFA 3 BROVANA INHALATION INHALATION AEROSOL NEBULIZATION 3 XOPENEX INHALATION SOLUTION NEBULIZATION 3 isoproterenol hcl injection SOLUTION 1 or 1b* solution *BRONCHODILATORS - ISUPREL INJECTION ANTICHOLINERGICS*** 3 SOLUTION ATROVENT HFA levalbuterol hcl inhalation INHALATION AEROSOL 2 nebulization solution 0.31 SOLUTION 1 or 1b* mg/3ml, 0.63 mg/3ml, 1.25 INCRUSE ELLIPTA mg/0.5ml, 1.25 mg/3ml INHALATION AEROSOL 3 levalbuterol tartrate POWDER BREATH 3 CTT1 inhalation aerosol ACTIVATED metaproterenol sulfate oral ipratropium bromide 1 or 1a* 1 or 1b* syrup inhalation solution PERFOROMIST LONHALA MAGNAIR INHALATION REFILL KIT 2 3 NEBULIZATION INHALATION SOLUTION SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 21 Drug Name Tier Notes Drug Name Tier Notes LONHALA MAGNAIR ASMANEX (120 STARTER KIT METERED DOSES) 3 INHALATION INHALATION AEROSOL 3 ST; QL SOLUTION POWDER BREATH SEEBRI NEOHALER ACTIVATED 3 INHALATION CAPSULE ASMANEX (14 SPIRIVA HANDIHALER METERED DOSES) 2 INHALATION CAPSULE INHALATION AEROSOL 3 ST; QL POWDER BREATH SPIRIVA RESPIMAT ACTIVATED INHALATION AEROSOL 2 SOLUTION 1.25 ASMANEX (30 MCG/ACT, 2.5 MCG/ACT METERED DOSES) INHALATION AEROSOL 3 ST; QL TUDORZA PRESSAIR POWDER BREATH INHALATION AEROSOL ACTIVATED POWDER BREATH 3 ACTIVATED 400 ASMANEX (60 MCG/ACT METERED DOSES) INHALATION AEROSOL 3 ST; QL YUPELRI INHALATION 3 POWDER BREATH SOLUTION ACTIVATED *LEUKOTRIENE ASMANEX (7 METERED RECEPTOR DOSES) INHALATION 3 ST; QL ANTAGONISTS*** AEROSOL POWDER ACCOLATE ORAL BREATH ACTIVATED 3 TABLET ASMANEX HFA 3 ST; QL montelukast sodium oral INHALATION AEROSOL 1 or 1b* packet budesonide inhalation 1 or 1b* montelukast sodium oral suspension 1 or 1b* tablet FLOVENT DISKUS montelukast sodium oral INHALATION AEROSOL 1 or 1b* 2 tablet chewable POWDER BREATH ACTIVATED SINGULAIR ORAL 3 FLOVENT HFA PACKET 2 INHALATION AEROSOL SINGULAIR ORAL 3 TABLET PULMICORT FLEXHALER SINGULAIR ORAL 3 INHALATION AEROSOL 3 ST; QL TABLET CHEWABLE POWDER BREATH zafirlukast oral tablet 1 or 1b* ACTIVATED *SELECTIVE PULMICORT PHOSPHODIESTERASE INHALATION 3 4 (PDE4) INHIBITORS*** SUSPENSION DALIRESP ORAL QVAR REDIHALER 3 PA; QL TABLET INHALATION AEROSOL 2 *STEROID BREATH ACTIVATED INHALANTS*** *XANTHINE- ALVESCO INHALATION EXPECTORANTS*** 3 ST; QL AEROSOL SOLUTION difil-g forte oral liquid 1 or 1b* ARNUITY ELLIPTA *XANTHINES*** INHALATION AEROSOL aminophylline intravenous 2 1 or 1b* POWDER BREATH solution ACTIVATED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 22 Drug Name Tier Notes Drug Name Tier Notes ELIXOPHYLLIN ORAL *HEPARINS AND 2 ELIXIR HEPARINOID-LIKE THEO-24 ORAL AGENTS*** CAPSULE EXTENDED 2 HEPARIN (PORCINE) IN RELEASE 24 HOUR NACL INTRAVENOUS theophylline er oral tablet SOLUTION 1000-0.9 extended release 12 hour 300 1 or 1b* UT/500ML-%, 12500-0.45 mg, 450 mg UT/250ML-%, 2500-0.9 UT/500ML-%, 25000-0.45 theophylline er oral tablet 3 1 or 1b* UT/250ML-%, 25000-0.45 extended release 24 hour UT/500ML-%, 30000-0.9 THEOPHYLLINE IN UNIT/L-%, 500-0.9 D5W INTRAVENOUS UT/500ML-%, 5000-0.9 3 SOLUTION 0.8-5 MG/ML- UNIT/L-%, 5000-0.9 % UT/500ML-% theophylline oral solution 1 or 1b* heparin (porcine) in nacl intravenous solution 2000- 1 or 1b* *ANTICOAGULANTS - 0.9 unit/l-% MISC.*** heparin lock flush *ANTICOAGULANTS - intravenous solution 1 1 or 1b* MISC.*** unit/ml, 10 unit/ml DEFITELIO HEPARIN SOD INTRAVENOUS 3 (PORCINE) IN D5W SOLUTION INTRAVENOUS 3 SODIUM CITRATE SOLUTION 100 LOCK FLUSH UNIT/ML, 25000-5 INTRAVENOUS 3 UT/500ML-% SOLUTION PREFILLED heparin sod (porcine) in d5w SYRINGE intravenous solution 40-5 1 or 1b* *ANTICOAGULANTS* unit/ml-% *COUMARIN heparin sodium (porcine) ANTICOAGULANTS*** injection solution 1000 1 or 1b* COUMADIN ORAL unit/ml, 10000 unit/ml, 2 TABLET 20000 unit/ml, 5000 unit/ml jantoven oral tablet 1 or 1a* HEPARIN SODIUM (PORCINE) INJECTION 3 warfarin sodium oral tablet 1 or 1a* SOLUTION PREFILLED *DIRECT FACTOR XA SYRINGE INHIBITORS*** heparin sodium (porcine) pf BEVYXXA ORAL injection solution 5000 1 or 1b* 3 CAPSULE unit/0.5ml ELIQUIS DVT/PE HEPARIN SODIUM (PORCINE) PF STARTER PACK ORAL 2 3 TABLET INJECTION SOLUTION 5000 UNIT/ML ELIQUIS ORAL TABLET 2 heparin sodium lock flush SAVAYSA ORAL 3 intravenous solution 100 1 or 1b* TABLET unit/ml XARELTO ORAL 2 HEPMED TABLET 3 COMBINATION KIT XARELTO STARTER PACK ORAL TABLET 2 THERAPY PACK

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 23 Drug Name Tier Notes Drug Name Tier Notes *IN VITRO bivalirudin trifluoroacetate ANTICOAGULANTS*** intravenous solution 1 or 1b* ACD FORMULA A IN reconstituted 3 VITRO SOLUTION BIVALIRUDIN-SODIUM ACD-A NOCLOT-50 IN CHLORIDE 3 3 VITRO SOLUTION INTRAVENOUS SOLUTION ANTICOAGULANT CIT DEXT SOLN A IN VITRO 3 *THROMBIN SOLUTION INHIBITORS - SELECTIVE DIRECT & ANTICOAGULANT REVERSIBLE*** SODIUM CITRATE IN 3 VITRO SOLUTION ARGATROBAN IN SODIUM CHLORIDE TRICITRASOL IN VITRO INTRAVENOUS 3 3 CONCENTRATE SOLUTION 125-0.9 *LOW MOLECULAR MG/125ML-%, 50-0.9 WEIGHT HEPARINS*** MG/50ML-% enoxaparin sodium injection ARGATROBAN 1 or 1b* INTRAVENOUS solution 3 SOLUTION 250 enoxaparin sodium 1 or 1b* MG/2.5ML, 50 MG/50ML subcutaneous solution PRADAXA ORAL 3 FRAGMIN CAPSULE SUBCUTANEOUS SOLUTION 10000 *ANTICONVULSANTS* UNIT/ML, 12500 *AMPA GLUTAMATE UNIT/0.5ML, 15000 RECEPTOR UNIT/0.6ML, 18000 3 ANTAGONISTS*** UNT/0.72ML, 2500 FYCOMPA ORAL UNIT/0.2ML, 5000 3 UNIT/0.2ML, 7500 SUSPENSION UNIT/0.3ML, 95000 FYCOMPA ORAL 3 UNIT/3.8ML TABLET LOVENOX INJECTION *ANTICONVULSANTS - 3 SOLUTION BENZODIAZEPINES*** LOVENOX clobazam oral suspension 1 or 1b* SUBCUTANEOUS 3 clobazam oral tablet 1 or 1b* SOLUTION clonazepam oral tablet 1 or 1b* *SYNTHETIC clonazepam oral tablet HEPARINOID-LIKE 1 or 1b* AGENTS*** dispersible DIASTAT ACUDIAL ARIXTRA 2 SUBCUTANEOUS 3 RECTAL GEL SOLUTION DIASTAT PEDIATRIC 2 fondaparinux sodium RECTAL GEL 1 or 1b* subcutaneous solution diazepam rectal gel 1 or 1b* *THROMBIN KLONOPIN ORAL 3 INHIBITORS - HIRUDIN TABLET TYPE*** NAYZILAM NASAL 3 PA; QL ANGIOMAX SOLUTION INTRAVENOUS 3 ONFI ORAL SOLUTION 3 RECONSTITUTED SUSPENSION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 24 Drug Name Tier Notes Drug Name Tier Notes ONFI ORAL TABLET 10 gabapentin oral solution 1 or 1b* 3 MG, 20 MG gabapentin oral tablet 1 or 1b* SYMPAZAN ORAL FILM 3 KEPPRA INTRAVENOUS 2 VALTOCO 10 MG DOSE SOLUTION 3 PA; QL NASAL LIQUID KEPPRA ORAL 2 VALTOCO 15 MG DOSE SOLUTION NASAL LIQUID 3 PA; QL KEPPRA ORAL TABLET 2 THERAPY PACK KEPPRA XR ORAL VALTOCO 20 MG DOSE TABLET EXTENDED 2 NASAL LIQUID 3 PA; QL RELEASE 24 HOUR THERAPY PACK LAMICTAL ODT ORAL VALTOCO 5 MG DOSE 2 3 PA; QL KIT NASAL LIQUID LAMICTAL ODT ORAL 2 *ANTICONVULSANTS - TABLET DISPERSIBLE MISC.*** LAMICTAL ORAL 2 APTIOM ORAL TABLET 3 TABLET BANZEL ORAL 3 LAMICTAL ORAL SUSPENSION TABLET CHEWABLE 25 2 BANZEL ORAL TABLET 3 MG, 5 MG BRIVIACT LAMICTAL STARTER 3 INTRAVENOUS 3 ORAL KIT SOLUTION LAMICTAL XR ORAL 3 BRIVIACT ORAL KIT 3 SOLUTION LAMICTAL XR ORAL BRIVIACT ORAL TABLET EXTENDED 3 3 TABLET RELEASE 24 HOUR carbamazepine er oral lamotrigine er oral tablet 1 or 1b* capsule extended release 12 1 or 1b* extended release 24 hour hour lamotrigine oral tablet 1 or 1b* carbamazepine er oral tablet lamotrigine oral tablet 1 or 1b* 1 or 1b* extended release 12 hour chewable carbamazepine oral lamotrigine oral tablet 1 or 1b* 1 or 1b* suspension dispersible carbamazepine oral tablet 1 or 1b* lamotrigine starter kit-blue 1 or 1b* carbamazepine oral tablet oral kit 1 or 1b* chewable lamotrigine starter kit-green 1 or 1b* CARBATROL ORAL oral kit CAPSULE EXTENDED 2 lamotrigine starter kit-orange 1 or 1b* RELEASE 12 HOUR oral kit DIACOMIT ORAL levetiracetam er oral tablet 3 PA; QL; LD 1 or 1b* CAPSULE extended release 24 hour DIACOMIT ORAL 3 PA; QL; LD LEVETIRACETAM IN PACKET NACL INTRAVENOUS 3 EPIDIOLEX ORAL SOLUTION 3 PA; QL; LD; SP SOLUTION levetiracetam intravenous 1 or 1b* epitol oral tablet 1 or 1b* solution FANATREX FUSEPAQ levetiracetam oral solution 1 or 1b* 3 ORAL SUSPENSION levetiracetam oral tablet 1 or 1b* gabapentin oral capsule 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 25 Drug Name Tier Notes Drug Name Tier Notes LYRICA ORAL TOPAMAX SPRINKLE 3 CAPSULE ORAL CAPSULE 2 LYRICA ORAL SPRINKLE 3 SOLUTION topiramate er oral capsule er 1 or 1b* ST; QL MYSOLINE ORAL 24 hour sprinkle 3 TABLET topiramate oral capsule 1 or 1b* NEURONTIN ORAL sprinkle 3 CAPSULE topiramate oral tablet 1 or 1b* NEURONTIN ORAL TRILEPTAL ORAL 3 2 SOLUTION SUSPENSION NEURONTIN ORAL TRILEPTAL ORAL 3 3 TABLET TABLET oxcarbazepine oral TROKENDI XR ORAL 1 or 1b* suspension CAPSULE EXTENDED 2 oxcarbazepine oral tablet 1 or 1b* RELEASE 24 HOUR VIMPAT INTRAVENOUS OXTELLAR XR ORAL 3 TABLET EXTENDED 3 SOLUTION RELEASE 24 HOUR VIMPAT ORAL 3 pregabalin oral capsule 1 or 1b* SOLUTION pregabalin oral solution 1 or 1b* VIMPAT ORAL TABLET 3 ZONEGRAN ORAL primidone oral tablet 1 or 1b* 3 CAPSULE QUDEXY XR ORAL CAPSULE ER 24 HOUR 3 ST; QL zonisamide oral capsule 1 or 1b* SPRINKLE *CARBAMATES*** roweepra oral tablet 1 or 1b* felbamate oral suspension 1 or 1b* roweepra xr oral tablet felbamate oral tablet 1 or 1b* 1 or 1b* extended release 24 hour FELBATOL ORAL 2 SPRITAM ORAL SUSPENSION TABLET FELBATOL ORAL 3 2 DISINTEGRATING TABLET SOLUBLE *GABA subvenite oral tablet 1 or 1b* MODULATORS*** subvenite starter kit-blue oral GABITRIL ORAL 1 or 1b* 2 kit TABLET subvenite starter kit-green 1 or 1b* SABRIL ORAL PACKET 3 LD; SP oral kit SABRIL ORAL TABLET 3 LD; SP subvenite starter kit-orange 1 or 1b* oral kit tiagabine hcl oral tablet 1 or 1b* TEGRETOL ORAL vigabatrin oral packet 1 or 1b* LD; SP 2 SUSPENSION vigabatrin oral tablet 1 or 1b* LD; SP TEGRETOL ORAL 2 vigadrone oral packet 1 or 1b* LD TABLET *HYDANTOINS*** TEGRETOL-XR ORAL CEREBYX INJECTION TABLET EXTENDED 2 3 SOLUTION RELEASE 12 HOUR TOPAMAX ORAL DILANTIN INFATABS 2 TABLET ORAL TABLET 2 CHEWABLE DILANTIN ORAL 2 CAPSULE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 26 Drug Name Tier Notes Drug Name Tier Notes DILANTIN ORAL valproic acid oral solution 1 or 1b* 2 SUSPENSION *ANTIDEMENTIA fosphenytoin sodium AGENT 1 or 1b* injection solution COMBINATIONS*** PEGANONE ORAL *ANTIDEMENTIA 3 TABLET AGENT PHENYTEK ORAL COMBINATIONS*** 2 CAPSULE NAMZARIC ORAL phenytoin infatabs oral tablet CAPSULE ER 24 HOUR 2 1 or 1b* chewable THERAPY PACK phenytoin oral suspension NAMZARIC ORAL 1 or 1b* 125 mg/5ml CAPSULE EXTENDED 2 RELEASE 24 HOUR phenytoin oral tablet 1 or 1b* chewable *ANTIDEPRESSANTS* phenytoin sodium extended *ALPHA-2 RECEPTOR 1 or 1b* oral capsule ANTAGONISTS (TETRACYCLICS)*** phenytoin sodium injection 1 or 1b* solution mirtazapine oral tablet 1 or 1b* mirtazapine oral tablet *SUCCINIMIDES*** 1 or 1b* dispersible CELONTIN ORAL 3 REMERON ORAL CAPSULE 3 TABLET 15 MG, 30 MG ethosuximide oral capsule 1 or 1b* REMERON SOLTAB ethosuximide oral solution 1 or 1b* ORAL TABLET 3 ZARONTIN ORAL DISPERSIBLE 2 CAPSULE *ANTIDEPRESSANTS - ZARONTIN ORAL MISC.*** 2 SOLUTION APLENZIN ORAL TABLET EXTENDED *VALPROIC ACID*** 3 ST; DO; QL RELEASE 24 HOUR 174 DEPAKOTE ER ORAL MG TABLET EXTENDED 2 RELEASE 24 HOUR APLENZIN ORAL TABLET EXTENDED 3 ST; QL DEPAKOTE ORAL RELEASE 24 HOUR 348 TABLET DELAYED 2 MG, 522 MG RELEASE bupropion hcl er (sr) oral DEPAKOTE SPRINKLES tablet extended release 12 1 or 1b* DO ORAL CAPSULE 2 hour 100 mg DELAYED RELEASE SPRINKLE bupropion hcl er (sr) oral tablet extended release 12 1 or 1b* divalproex sodium er oral hour 150 mg, 200 mg tablet extended release 24 1 or 1b* hour bupropion hcl er (xl) oral tablet extended release 24 1 or 1b* DO divalproex sodium oral hour 150 mg capsule delayed release 1 or 1b* sprinkle bupropion hcl er (xl) oral tablet extended release 24 1 or 1b* divalproex sodium oral tablet 1 or 1b* hour 300 mg delayed release bupropion hcl er (xl) oral valproate sodium intravenous 1 or 1b* tablet extended release 24 1 or 1b* ST; QL solution hour 450 mg valproic acid oral capsule 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 27 Drug Name Tier Notes Drug Name Tier Notes bupropion hcl oral tablet 100 tranylcypromine sulfate oral 1 or 1b* 1 or 1b* mg tablet bupropion hcl oral tablet 75 *SELECTIVE 1 or 1b* DO mg SEROTONIN REUPTAKE FORFIVO XL ORAL INHIBITORS (SSRIS)*** TABLET EXTENDED 3 ST; QL CELEXA ORAL TABLET 3 ST; DO; QL RELEASE 24 HOUR 10 MG, 20 MG maprotiline hcl oral tablet 1 or 1b* CELEXA ORAL TABLET 3 ST; QL WELLBUTRIN SR ORAL 40 MG TABLET EXTENDED citalopram hydrobromide 3 ST; DO; QL 1 or 1b* RELEASE 12 HOUR 100 oral solution MG citalopram hydrobromide 1 or 1b* DO WELLBUTRIN SR ORAL oral tablet 10 mg, 20 mg TABLET EXTENDED citalopram hydrobromide 3 ST; QL 1 or 1b* RELEASE 12 HOUR 150 oral tablet 40 mg MG, 200 MG escitalopram oxalate oral 1 or 1b* WELLBUTRIN XL ORAL solution TABLET EXTENDED 3 DO escitalopram oxalate oral RELEASE 24 HOUR 150 1 or 1b* DO MG tablet 10 mg, 5 mg escitalopram oxalate oral WELLBUTRIN XL ORAL 1 or 1b* TABLET EXTENDED tablet 20 mg 3 RELEASE 24 HOUR 300 fluoxetine hcl oral capsule 10 1 or 1b* DO MG mg *MODIFIED fluoxetine hcl oral capsule 20 1 or 1b* CYCLICS*** mg, 40 mg nefazodone hcl oral tablet 1 or 1b* fluoxetine hcl oral capsule 1 or 1b* trazodone hcl oral tablet 1 or 1a* delayed release TRINTELLIX ORAL fluoxetine hcl oral solution 1 or 1b* 3 ST; DO; QL TABLET 10 MG, 5 MG fluoxetine hcl oral tablet 10 1 or 1b* DO TRINTELLIX ORAL mg 3 ST; QL TABLET 20 MG fluoxetine hcl oral tablet 20 1 or 1b* VIIBRYD ORAL TABLET mg 3 ST; DO; QL 10 MG, 20 MG FLUOXETINE HCL 3 VIIBRYD ORAL TABLET ORAL TABLET 60 MG 3 ST; QL 40 MG fluvoxamine maleate er oral VIIBRYD STARTER capsule extended release 24 1 or 1b* 3 ST; QL PACK ORAL KIT hour fluvoxamine maleate oral *MONOAMINE 1 or 1b* OXIDASE INHIBITORS tablet 100 mg (MAOIS)*** fluvoxamine maleate oral 1 or 1b* DO EMSAM tablet 25 mg, 50 mg TRANSDERMAL PATCH 3 LEXAPRO ORAL 3 ST; DO; QL 24 HOUR TABLET 10 MG, 5 MG MARPLAN ORAL LEXAPRO ORAL 3 3 ST; QL TABLET TABLET 20 MG NARDIL ORAL TABLET 3 paroxetine hcl er oral tablet PARNATE ORAL extended release 24 hour 1 or 1b* DO 3 TABLET 12.5 mg phenelzine sulfate oral tablet 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 28 Drug Name Tier Notes Drug Name Tier Notes paroxetine hcl er oral tablet CYMBALTA ORAL extended release 24 hour 25 1 or 1b* CAPSULE DELAYED 3 PA; DO; QL mg, 37.5 mg RELEASE PARTICLES 30 paroxetine hcl oral tablet 10 MG 1 or 1b* DO mg, 20 mg DESVENLAFAXINE ER paroxetine hcl oral tablet 30 ORAL TABLET 1 or 1b* 3 ST; QL mg, 40 mg EXTENDED RELEASE 24 HOUR 100 MG PAXIL CR ORAL TABLET EXTENDED DESVENLAFAXINE ER 3 ST; DO; QL ORAL TABLET RELEASE 24 HOUR 12.5 3 ST; DO; QL MG EXTENDED RELEASE 24 HOUR 50 MG PAXIL CR ORAL TABLET EXTENDED desvenlafaxine succinate er 3 ST; QL RELEASE 24 HOUR 25 oral tablet extended release 1 or 1b* MG, 37.5 MG 24 hour 100 mg PAXIL ORAL desvenlafaxine succinate er 3 ST; QL SUSPENSION oral tablet extended release 1 or 1b* DO 24 hour 25 mg, 50 mg PAXIL ORAL TABLET 10 3 ST; DO; QL MG, 20 MG DRIZALMA SPRINKLE ORAL CAPSULE PAXIL ORAL TABLET 30 3 PA; QL 3 ST; QL DELAYED RELEASE MG, 40 MG SPRINKLE 20 MG, 60 MG PEXEVA ORAL TABLET 3 ST; DO; QL DRIZALMA SPRINKLE 10 MG, 20 MG ORAL CAPSULE 3 PA; DO; QL PEXEVA ORAL TABLET DELAYED RELEASE 3 ST; QL 30 MG, 40 MG SPRINKLE 30 MG, 40 MG PROZAC ORAL duloxetine hcl oral capsule 3 ST; DO; QL CAPSULE 10 MG delayed release particles 20 1 or 1b* mg, 40 mg, 60 mg PROZAC ORAL 3 ST; QL CAPSULE 20 MG, 40 MG duloxetine hcl oral capsule delayed release particles 30 1 or 1b* DO sertraline hcl oral concentrate 1 or 1b* mg sertraline hcl oral tablet 100 1 or 1b* EFFEXOR XR ORAL mg CAPSULE EXTENDED 3 ST; QL sertraline hcl oral tablet 25 RELEASE 24 HOUR 150 1 or 1b* DO mg, 50 mg MG ZOLOFT ORAL EFFEXOR XR ORAL 3 ST; QL CONCENTRATE CAPSULE EXTENDED 3 ST; DO; QL ZOLOFT ORAL TABLET RELEASE 24 HOUR 37.5 3 ST; QL 100 MG MG, 75 MG ZOLOFT ORAL TABLET FETZIMA ORAL 3 ST; DO; QL 25 MG, 50 MG CAPSULE EXTENDED 3 ST; QL RELEASE 24 HOUR *SEROTONIN- NOREPINEPHRINE FETZIMA TITRATION REUPTAKE INHIBITORS ORAL CAPSULE ER 24 3 ST; QL (SNRIS)*** HOUR THERAPY PACK CYMBALTA ORAL PRISTIQ ORAL TABLET CAPSULE DELAYED EXTENDED RELEASE 24 3 ST; QL 3 PA; QL RELEASE PARTICLES 20 HOUR 100 MG MG, 60 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 3 ST; DO; QL HOUR 25 MG, 50 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 29 Drug Name Tier Notes Drug Name Tier Notes venlafaxine hcl er oral *ANTIDIABETIC - capsule extended release 24 1 or 1b* AMYLIN ANALOGS*** hour 150 mg SYMLINPEN 120 venlafaxine hcl er oral SUBCUTANEOUS 2 capsule extended release 24 1 or 1b* DO SOLUTION PEN- hour 37.5 mg, 75 mg INJECTOR venlafaxine hcl er oral tablet SYMLINPEN 60 extended release 24 hour 150 1 or 1b* SUBCUTANEOUS 2 mg, 225 mg SOLUTION PEN- venlafaxine hcl er oral tablet INJECTOR extended release 24 hour 1 or 1b* DO *BIGUANIDES*** 37.5 mg, 75 mg FORTAMET ORAL venlafaxine hcl oral tablet 1 or 1b* TABLET EXTENDED 3 ST; QL *TRICYCLIC RELEASE 24 HOUR AGENTS*** GLUMETZA ORAL amitriptyline hcl oral tablet 1 or 1a* TABLET EXTENDED 3 ST; QL RELEASE 24 HOUR amoxapine oral tablet 1 or 1b* metformin hcl er (mod) oral ST; QL; generic ANAFRANIL ORAL tablet extended release 24 3 3 Glumetza; CTT1 CAPSULE hour clomipramine hcl oral metformin hcl er (osm) oral 1 or 1b* ST; QL; generic capsule tablet extended release 24 3 Fortamet; CTT1 desipramine hcl oral tablet 1 or 1b* hour 1000 mg, 500 mg metformin hcl er oral tablet generic doxepin hcl oral capsule 1 or 1b* 1 or 1b* extended release 24 hour Glucophage XR doxepin hcl oral concentrate 1 or 1b* METFORMIN HCL 3 PA; QL imipramine hcl oral tablet 1 or 1b* ORAL SOLUTION imipramine pamoate oral 1 or 1b* metformin hcl oral tablet 1 or 1b* capsule RIOMET ER ORAL NORPRAMIN ORAL 3 SUSPENSION 3 PA; QL TABLET 10 MG, 25 MG RECONSTITUTED ER nortriptyline hcl oral capsule 1 or 1b* RIOMET ORAL 3 PA; QL nortriptyline hcl oral solution 1 or 1b* SOLUTION PAMELOR ORAL *DIABETIC OTHER*** 3 CAPSULE BAQSIMI ONE PACK 3 protriptyline hcl oral tablet 1 or 1b* NASAL POWDER trimipramine maleate oral BAQSIMI TWO PACK 1 or 1b* 3 capsule NASAL POWDER *ANTIDIABETICS* diazoxide oral suspension 1 or 1b* *ALPHA-GLUCOSIDASE GLUCAGEN HYPOKIT INHIBITORS*** INJECTION SOLUTION 2 acarbose oral tablet 1 or 1b* RECONSTITUTED GLYSET ORAL TABLET 3 GLUCAGON EMERGENCY 2 miglitol oral tablet 1 or 1b* INJECTION KIT PRECOSE ORAL 3 GLUCAGON TABLET EMERGENCY 3 INJECTION SOLUTION RECONSTITUTED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 30 Drug Name Tier Notes Drug Name Tier Notes GVOKE PFS *HUMAN INSULIN*** SUBCUTANEOUS 3 ADMELOG SOLOSTAR SOLUTION PREFILLED SUBCUTANEOUS 3 ST; QL SYRINGE SOLUTION PEN- PROGLYCEM ORAL INJECTOR 3 SUSPENSION ADMELOG *DIPEPTIDYL SUBCUTANEOUS 3 ST; QL PEPTIDASE-4 (DPP-4) SOLUTION INHIBITORS*** AFREZZA INHALATION alogliptin benzoate oral POWDER 12 UNIT, 4 & 8 3 ST; QL; CTT1 tablet & 12 UNIT, 4 UNIT, 8 3 PA; QL JANUVIA ORAL UNIT, 90 X 4 UNIT & 2 ST; QL TABLET 90X8 UNIT, 90 X 8 UNIT & 90X12 UNIT NESINA ORAL TABLET 3 ST; QL APIDRA INJECTION ONGLYZA ORAL 3 ST; QL 3 ST; QL SOLUTION TABLET APIDRA SOLOSTAR TRADJENTA ORAL SUBCUTANEOUS 2 ST; DO; QL 3 ST; QL TABLET SOLUTION PEN- *DIPEPTIDYL INJECTOR PEPTIDASE-4 BASAGLAR KWIKPEN INHIBITOR-BIGUANIDE SUBCUTANEOUS 3 ST; QL COMBINATIONS*** SOLUTION PEN- alogliptin-metformin hcl oral INJECTOR 3 ST; QL; CTT1 tablet FIASP FLEXTOUCH JANUMET ORAL SUBCUTANEOUS 2 ST; QL 3 ST; QL TABLET SOLUTION PEN- INJECTOR JANUMET XR ORAL TABLET EXTENDED 2 ST; QL FIASP PENFILL RELEASE 24 HOUR SUBCUTANEOUS 3 ST; QL SOLUTION CARTRIDGE JENTADUETO ORAL 2 ST; QL FIASP SUBCUTANEOUS TABLET 3 ST; QL SOLUTION JENTADUETO XR ORAL TABLET EXTENDED 2 ST; QL HUMALOG JUNIOR RELEASE 24 HOUR KWIKPEN SUBCUTANEOUS 2 KAZANO ORAL TABLET 3 ST; QL SOLUTION PEN- KOMBIGLYZE XR ORAL INJECTOR TABLET EXTENDED 3 ST; QL HUMALOG KWIKPEN RELEASE 24 HOUR SUBCUTANEOUS *DOPAMINE RECEPTOR SOLUTION PEN- 2 AGONISTS - ERGOT INJECTOR 100 UNIT/ML, DERIVATIVES*** 200 UNIT/ML CYCLOSET ORAL HUMALOG MIX 50/50 3 TABLET KWIKPEN *DPP-4 INHIBITOR- SUBCUTANEOUS 2 THIAZOLIDINEDIONE SUSPENSION PEN- COMBINATIONS*** INJECTOR alogliptin-pioglitazone oral HUMALOG MIX 50/50 3 ST; QL; CTT1 tablet SUBCUTANEOUS 2 SUSPENSION OSENI ORAL TABLET 3 ST; QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 31 Drug Name Tier Notes Drug Name Tier Notes HUMALOG MIX 75/25 INSULIN ASPART KWIKPEN PENFILL 3 ST; QL SUBCUTANEOUS 2 SUBCUTANEOUS SUSPENSION PEN- SOLUTION CARTRIDGE INJECTOR INSULIN ASPART PROT HUMALOG MIX 75/25 & ASPART 3 ST; QL SUBCUTANEOUS 2 SUBCUTANEOUS SUSPENSION SUSPENSION HUMALOG INSULIN ASPART SUBCUTANEOUS 2 SUBCUTANEOUS 3 ST; QL SOLUTION SOLUTION HUMALOG INSULIN LISPRO (1 SUBCUTANEOUS 2 UNIT DIAL) SOLUTION CARTRIDGE SUBCUTANEOUS 2 HUMULIN 70/30 SOLUTION PEN- KWIKPEN INJECTOR SUBCUTANEOUS 2 INSULIN LISPRO SUSPENSION PEN- SUBCUTANEOUS 2 INJECTOR SOLUTION HUMULIN 70/30 LANTUS SOLOSTAR SUBCUTANEOUS 2 SUBCUTANEOUS 2 SUSPENSION SOLUTION PEN- HUMULIN N KWIKPEN INJECTOR SUBCUTANEOUS LANTUS 2 SUSPENSION PEN- SUBCUTANEOUS 2 INJECTOR SOLUTION HUMULIN N LEVEMIR FLEXTOUCH SUBCUTANEOUS 2 SUBCUTANEOUS 2 SUSPENSION SOLUTION PEN- HUMULIN R INJECTION INJECTOR 2 SOLUTION LEVEMIR HUMULIN R U-500 SUBCUTANEOUS 2 (CONCENTRATED) SOLUTION 2 PA; QL SUBCUTANEOUS MYXREDLIN SOLUTION INTRAVENOUS 3 HUMULIN R U-500 SOLUTION KWIKPEN NOVOLIN 70/30 SUBCUTANEOUS 2 PA; QL FLEXPEN RELION SOLUTION PEN- SUBCUTANEOUS 3 ST; QL INJECTOR SUSPENSION PEN- INSULIN ASP PROT & INJECTOR ASP FLEXPEN NOVOLIN 70/30 SUBCUTANEOUS 3 FLEXPEN SUSPENSION PEN- SUBCUTANEOUS 3 ST; QL INJECTOR SUSPENSION PEN- INSULIN ASPART INJECTOR FLEXPEN NOVOLIN 70/30 RELION SUBCUTANEOUS 3 ST; QL SUBCUTANEOUS 3 ST; QL SOLUTION PEN- SUSPENSION INJECTOR NOVOLIN 70/30 SUBCUTANEOUS 3 ST; QL SUSPENSION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 32 Drug Name Tier Notes Drug Name Tier Notes NOVOLIN N FLEXPEN TRESIBA FLEXTOUCH RELION SUBCUTANEOUS 3 ST; QL SUBCUTANEOUS 3 ST; QL SOLUTION PEN- SUSPENSION PEN- INJECTOR INJECTOR TRESIBA NOVOLIN N FLEXPEN SUBCUTANEOUS 3 ST; QL SUBCUTANEOUS SOLUTION 3 ST; QL SUSPENSION PEN- *INCRETIN MIMETIC INJECTOR AGENTS (GLP-1 NOVOLIN N RELION RECEPTOR SUBCUTANEOUS 3 ST; QL AGONISTS)*** SUSPENSION ADLYXIN STARTER NOVOLIN N PACK SUBCUTANEOUS 3 ST; QL SUBCUTANEOUS 3 ST; QL PEN-INJECTOR KIT SUSPENSION ADLYXIN NOVOLIN R FLEXPEN SUBCUTANEOUS 3 ST; QL INJECTION SOLUTION 3 ST; QL SOLUTION PEN- PEN-INJECTOR INJECTOR NOVOLIN R FLEXPEN BYDUREON BCISE RELION INJECTION SUBCUTANEOUS AUTO- 2 ST; QL 3 ST; QL SOLUTION PEN- INJECTOR INJECTOR BYDUREON NOVOLIN R INJECTION SUBCUTANEOUS PEN- 2 ST; QL 3 ST; QL SOLUTION INJECTOR NOVOLIN R RELION BYETTA 10 MCG PEN 3 ST; QL INJECTION SOLUTION SUBCUTANEOUS 2 ST; QL NOVOLOG FLEXPEN SOLUTION PEN- SUBCUTANEOUS INJECTOR 3 ST; QL SOLUTION PEN- BYETTA 5 MCG PEN INJECTOR SUBCUTANEOUS 2 ST; QL NOVOLOG MIX 70/30 SOLUTION PEN- FLEXPEN INJECTOR SUBCUTANEOUS 3 ST; QL OZEMPIC (0.25 OR 0.5 SUSPENSION PEN- MG/DOSE) INJECTOR SUBCUTANEOUS 2 ST; QL NOVOLOG MIX 70/30 SOLUTION PEN- SUBCUTANEOUS 3 ST; QL INJECTOR SUSPENSION OZEMPIC (1 MG/DOSE) SUBCUTANEOUS NOVOLOG PENFILL 2 ST; QL SUBCUTANEOUS 3 ST; QL SOLUTION PEN- SOLUTION CARTRIDGE INJECTOR RYBELSUS ORAL NOVOLOG 3 ST; QL SUBCUTANEOUS 3 ST; QL TABLET SOLUTION TRULICITY SUBCUTANEOUS TOUJEO MAX 2 ST; QL SOLOSTAR SOLUTION PEN- SUBCUTANEOUS 2 INJECTOR SOLUTION PEN- VICTOZA INJECTOR SUBCUTANEOUS 2 ST; QL TOUJEO SOLOSTAR SOLUTION PEN- SUBCUTANEOUS INJECTOR 2 SOLUTION PEN- INJECTOR

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 33 Drug Name Tier Notes Drug Name Tier Notes *MEGLITINIDE *SULFONYLUREA- ANALOGUES*** THIAZOLIDINEDIONE nateglinide oral tablet 1 or 1b* COMBINATIONS*** DUETACT ORAL repaglinide oral tablet 1 or 1b* 3 ST; QL TABLET STARLIX ORAL TABLET 3 pioglitazone hcl-glimepiride 1 or 1b* ST; QL *PROGESTERONE oral tablet RECEPTOR ANTAGONISTS*** *THIAZOLIDINEDIONE- BIGUANIDE KORLYM ORAL 3 PA; QL; LD COMBINATIONS*** TABLET ACTOPLUS MET ORAL 3 ST; QL *SODIUM-GLUCOSE TABLET CO-TRANSPORTER 2 pioglitazone hcl-metformin (SGLT2) INHIBITORS*** 1 or 1b* ST; QL hcl oral tablet FARXIGA ORAL 2 ST; QL TABLET *THIAZOLIDINEDIONES *** INVOKANA ORAL 3 ST; QL TABLET ACTOS ORAL TABLET 3 ST; QL JARDIANCE ORAL AVANDIA ORAL 2 ST; QL 3 ST; QL TABLET TABLET 2 MG, 4 MG STEGLATRO ORAL pioglitazone hcl oral tablet 1 or 1b* ST; QL 3 ST; QL TABLET *ANTIDIARRHEAL/PRO *SULFONYLUREA- BIOTIC AGENTS* BIGUANIDE *ANTIDIARRHEAL/PRO COMBINATIONS*** BIOTIC AGENTS - glipizide-metformin hcl oral MISC.*** 1 or 1b* ST; QL tablet PRODIGEN ORAL 2 glyburide-metformin oral CAPSULE 1 or 1b* ST; QL tablet PROVAD ORAL 2 *SULFONYLUREAS*** CAPSULE AMARYL ORAL VISBIOME ORAL 3 ST; QL 2 TABLET PACKET VSL#3 DS ORAL glimepiride oral tablet 1 or 1b* ST; QL 2 PACKET glipizide er oral tablet 1 or 1a* ST; QL extended release 24 hour *ANTIDIARRHEAL/PRO BIOTIC glipizide oral tablet 1 or 1a* ST; QL COMBINATIONS*** glipizide xl oral tablet RESTORA RX ORAL 1 or 1a* ST; QL 3 extended release 24 hour CAPSULE GLUCOTROL ORAL 3 ST; QL *ANTIDIARRHEALS* TABLET *ANTIDIARRHEAL - GLUCOTROL XL ORAL CHLORIDE CHANNEL TABLET EXTENDED 3 ST; QL ANTAGONISTS*** RELEASE 24 HOUR MYTESI ORAL TABLET glyburide micronized oral 3 PA; QL 1 or 1b* ST; QL DELAYED RELEASE tablet *ANTIDIARRHEAL glyburide oral tablet 1 or 1b* ST; QL AGENTS - MISC.*** GLYNASE ORAL PRODIGEN ORAL 3 ST; QL 2 TABLET CAPSULE tolbutamide oral tablet 1 or 1b* ST; QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 34 Drug Name Tier Notes Drug Name Tier Notes PROVAD ORAL BRIDION 2 CAPSULE INTRAVENOUS 3 VISBIOME ORAL SOLUTION 2 PACKET CALCIUM DISODIUM VSL#3 DS ORAL VERSENATE 2 3 PACKET INJECTION SOLUTION 1 GM/5ML *ANTIDIARRHEAL COMBINATIONS*** CYANOKIT INTRAVENOUS RESTORA RX ORAL 3 3 SOLUTION CAPSULE RECONSTITUTED 5 GM *ANTIPERISTALTIC deferoxamine mesylate AGENTS*** injection solution 1 or 1b* SP diphenoxylate-atropine oral reconstituted 1 or 1b* liquid DESFERAL INJECTION diphenoxylate-atropine oral SOLUTION 1 or 1b* 3 SP tablet RECONSTITUTED 500 MG LOMOTIL ORAL 3 TABLET DIGIFAB INTRAVENOUS 3 loperamide hcl oral capsule 1 or 1b* SOLUTION MOTOFEN ORAL RECONSTITUTED 3 TABLET fomepizole intravenous 1 or 1b* *ANTIDOTE solution 1.5 gm/1.5ml COMBINATIONS*** methylene blue injection 1 or 1b* *ANTIDOTE solution COMBINATIONS*** PRALIDOXIME DUODOTE CHLORIDE INTRAMUSCULAR INTRAMUSCULAR 3 3 SOLUTION AUTO- SOLUTION AUTO- INJECTOR INJECTOR NITHIODOTE PRAXBIND INTRAVENOUS KIT INTRAVENOUS 3 3 300MG/10ML&12.5 SOLUTION GM/50ML PROTOPAM CHLORIDE *ANTIDOTES AND INTRAVENOUS 3 SPECIFIC SOLUTION ANTAGONISTS* RECONSTITUTED *ANTIDOTES AND PROVAYBLUE SPECIFIC INTRAVENOUS 3 ANTAGONISTS*** SOLUTION ACETADOTE RADIOGARDASE ORAL 3 INTRAVENOUS 3 CAPSULE SOLUTION SODIUM NITRITE acetylcysteine intravenous INTRAVENOUS 3 1 or 1b* solution SOLUTION ANDEXXA sodium thiosulfate 1 or 1b* INTRAVENOUS intravenous solution 25 % 3 SOLUTION VISTOGARD ORAL 3 PA; QL; LD RECONSTITUTED PACKET BAL IN OIL INTRAMUSCULAR 3 SOLUTION * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 35 Drug Name Tier Notes Drug Name Tier Notes *ANTIDOTES* BRIDION *ANTIDOTE INTRAVENOUS 3 COMBINATIONS AND SOLUTION KITS*** CALCIUM DISODIUM VERSENATE DUODOTE 3 INTRAMUSCULAR INJECTION SOLUTION 1 3 SOLUTION AUTO- GM/5ML INJECTOR CYANOKIT INTRAVENOUS NITHIODOTE 3 INTRAVENOUS KIT SOLUTION 3 300MG/10ML&12.5 RECONSTITUTED 5 GM GM/50ML deferoxamine mesylate *ANTIDOTES - injection solution 1 or 1b* SP CHELATING reconstituted AGENTS*** DESFERAL INJECTION CHEMET ORAL SOLUTION 3 3 SP CAPSULE RECONSTITUTED 500 MG deferasirox oral tablet 360 1 or 1b* PA; QL; SP mg, 90 mg DIGIFAB INTRAVENOUS deferasirox oral tablet 3 1 or 1b* PA; QL; SP SOLUTION soluble RECONSTITUTED EXJADE ORAL TABLET fomepizole intravenous 3 PA; QL; LD; SP 1 or 1b* SOLUBLE solution 1.5 gm/1.5ml FERRIPROX ORAL methylene blue injection 3 PA; QL; LD 1 or 1b* SOLUTION solution FERRIPROX ORAL 3 PA; QL; LD PRALIDOXIME TABLET CHLORIDE JADENU ORAL TABLET 3 PA; QL; LD; SP INTRAMUSCULAR 3 SOLUTION AUTO- JADENU SPRINKLE 3 PA; QL; LD; SP INJECTOR ORAL PACKET PRAXBIND PENTETATE CALCIUM INTRAVENOUS 3 TRISODIUM 3 SOLUTION COMBINATION SOLUTION PROTOPAM CHLORIDE INTRAVENOUS 3 PENTETATE ZINC SOLUTION TRISODIUM 3 RECONSTITUTED COMBINATION SOLUTION PROVAYBLUE INTRAVENOUS 3 *ANTIDOTES*** SOLUTION ACETADOTE RADIOGARDASE ORAL 3 INTRAVENOUS 3 CAPSULE SOLUTION SODIUM NITRITE acetylcysteine intravenous 1 or 1b* INTRAVENOUS 3 solution SOLUTION ANDEXXA sodium thiosulfate INTRAVENOUS 1 or 1b* 3 intravenous solution 25 % SOLUTION VISTOGARD ORAL RECONSTITUTED 3 PA; QL; LD PACKET BAL IN OIL INTRAMUSCULAR 3 SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 36 Drug Name Tier Notes Drug Name Tier Notes *BENZODIAZEPINE SUSTOL ANTAGONISTS*** SUBCUTANEOUS 3 flumazenil intravenous PREFILLED SYRINGE 1 or 1b* solution ZOFRAN ORAL TABLET 3 QL *OPIOID ZUPLENZ ORAL FILM 3 QL ANTAGONISTS*** *ANTIEMETIC EVZIO INJECTION COMBINATIONS*** SOLUTION AUTO- 3 ST; QL AKYNZEO INJECTOR 2 MG/0.4ML INTRAVENOUS 3 PA; QL naloxone hcl injection SOLUTION solution 0.4 mg/ml, 4 1 or 1b* RECONSTITUTED mg/10ml AKYNZEO ORAL 3 naloxone hcl injection CAPSULE 3 ST; QL; CTT1 solution auto-injector BONJESTA ORAL naloxone hcl injection TABLET EXTENDED 3 PA; QL 1 or 1b* solution cartridge RELEASE naloxone hcl injection DICLEGIS ORAL 1 or 1b* solution prefilled syringe TABLET DELAYED 3 PA; QL naltrexone hcl oral tablet 1 or 1b* RELEASE doxylamine-pyridoxine oral NARCAN NASAL LIQUID 2 1 or 1b* PA; QL tablet delayed release VIVITROL INTRAMUSCULAR *ANTIEMETICS - 3 SP SUSPENSION ANTICHOLINERGIC*** RECONSTITUTED DIMENHYDRINATE 3 *ANTIEMETICS* INJECTION SOLUTION *5-HT3 RECEPTOR meclizine hcl oral tablet 1 or 1a* ANTAGONISTS*** scopolamine transdermal 1 or 1b* ALOXI INTRAVENOUS patch 72 hour 3 PA; QL SOLUTION 0.25 MG/5ML TIGAN ANZEMET ORAL INTRAMUSCULAR 3 3 QL TABLET SOLUTION granisetron hcl intravenous TIGAN ORAL CAPSULE 3 1 or 1b* solution 1 mg/ml, 4 mg/4ml TRANSDERM SCOP (1.5 granisetron hcl oral tablet 1 or 1b* QL MG) TRANSDERMAL 3 PATCH 72 HOUR ondansetron hcl injection 1 or 1b* solution 40 mg/20ml TRANSDERM-SCOP (1.5 MG) TRANSDERMAL 3 ondansetron hcl oral solution 1 or 1b* QL PATCH 72 HOUR ondansetron hcl oral tablet 1 or 1b* QL trimethobenzamide hcl oral 1 or 1b* ondansetron oral tablet capsule 1 or 1b* QL dispersible *ANTIEMETICS - PALONOSETRON HCL MISCELLANEOUS*** INTRAVENOUS 3 PA; QL dronabinol oral capsule 1 or 1b* SOLUTION 0.25 MG/2ML SYNDROS ORAL palonosetron hcl intravenous 3 1 or 1b* PA; QL SOLUTION solution 0.25 mg/5ml *SUBSTANCE palonosetron hcl intravenous 1 or 1b* PA; QL P/NEUROKININ 1 (NK1) solution prefilled syringe RECEPTOR SANCUSO ANTAGONISTS*** 3 QL TRANSDERMAL PATCH aprepitant oral capsule 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 37 Drug Name Tier Notes Drug Name Tier Notes CINVANTI ANCOBON ORAL 3 PA; QL INTRAVENOUS 3 PA; QL CAPSULE EMULSION BIO-STATIN ORAL 3 EMEND INTRAVENOUS CAPSULE SOLUTION 3 PA; QL bio-statin oral powder 1 or 1b* RECONSTITUTED 150 MG flucytosine oral capsule 1 or 1b* PA; QL EMEND ORAL CAPSULE griseofulvin microsize oral 3 1 or 1b* 40 MG, 80 MG suspension griseofulvin microsize oral EMEND ORAL 1 or 1b* SUSPENSION 3 tablet RECONSTITUTED griseofulvin ultramicrosize 1 or 1b* EMEND TRI-PACK oral tablet 3 ORAL CAPSULE nystatin oral tablet 1 or 1b* fosaprepitant dimeglumine terbinafine hcl oral tablet 1 or 1b* intravenous solution 1 or 1b* PA; QL *IMIDAZOLES*** reconstituted VARUBI (180 MG DOSE) ketoconazole oral tablet 1 or 1b* ORAL TABLET 3 *TRIAZOLES*** THERAPY PACK CRESEMBA *ANTIFUNGALS* INTRAVENOUS 3 PA; QL *ANTIFUNGAL - SOLUTION GLUCAN SYNTHESIS RECONSTITUTED INHIBITORS CRESEMBA ORAL 3 PA; QL (ECHINOCANDINS)*** CAPSULE CANCIDAS DIFLUCAN ORAL INTRAVENOUS SUSPENSION 3 3 SOLUTION RECONSTITUTED RECONSTITUTED DIFLUCAN ORAL 3 CASPOFUNGIN TABLET ACETATE fluconazole in sodium INTRAVENOUS 3 chloride intravenous solution 1 or 1b* SOLUTION 200-0.9 mg/100ml-%, 400- RECONSTITUTED 0.9 mg/200ml-% ERAXIS INTRAVENOUS fluconazole oral suspension 1 or 1b* SOLUTION 3 reconstituted RECONSTITUTED fluconazole oral tablet 1 or 1b* MYCAMINE INTRAVENOUS itraconazole oral capsule 1 or 1b* PA; QL 3 SOLUTION itraconazole oral solution 1 or 1b* PA; QL RECONSTITUTED NOXAFIL *ANTIFUNGALS*** INTRAVENOUS 3 ABELCET SOLUTION INTRAVENOUS 3 NOXAFIL ORAL 3 PA; QL SUSPENSION SUSPENSION AMBISOME NOXAFIL ORAL INTRAVENOUS 3 TABLET DELAYED 3 PA; QL SUSPENSION RELEASE RECONSTITUTED posaconazole oral tablet amphotericin b intravenous 1 or 1b* PA; QL 1 or 1b* delayed release solution reconstituted SPORANOX ORAL 3 PA; QL CAPSULE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 38 Drug Name Tier Notes Drug Name Tier Notes SPORANOX ORAL CARBINOXAMINE 3 PA; QL SOLUTION MALEATE ORAL 3 SPORANOX PULSEPAK TABLET 6 MG 3 PA; QL ORAL CAPSULE clemastine fumarate oral 1 or 1b* TOLSURA ORAL tablet 2.68 mg 3 PA; QL CAPSULE DICOPANOL FUSEPAQ VFEND IV ORAL SUSPENSION 3 INTRAVENOUS RECONSTITUTED 3 SOLUTION DICOPANOL RAPIDPAQ RECONSTITUTED ORAL SUSPENSION 3 VFEND ORAL RECONSTITUTED SUSPENSION 3 PA; QL diphen oral elixir 1 or 1a* RECONSTITUTED diphenhydramine hcl 1 or 1b* VFEND ORAL TABLET 3 PA; QL injection solution voriconazole intravenous diphenhydramine hcl oral 1 or 1b* 1 or 1a* solution reconstituted elixir voriconazole oral suspension KARBINAL ER ORAL 1 or 1b* PA; QL reconstituted SUSPENSION 3 voriconazole oral tablet 1 or 1b* PA; QL EXTENDED RELEASE *ANTIHEMOPHILIC RYVENT ORAL TABLET 1 or 1b* PRODUCTS - *ANTIHISTAMINES - MONOCLONAL NON-SEDATING*** ANTIBODIES*** cetirizine hcl oral solution 1 or 1b* *ANTIHEMOPHILIC CLARINEX ORAL 3 ST; QL PRODUCTS - TABLET MONOCLONAL ANTIBODIES*** desloratadine oral tablet 1 or 1b* desloratadine oral tablet HEMLIBRA 1 or 1b* SUBCUTANEOUS 3 PA; QL; SP dispersible SOLUTION levocetirizine 1 or 1b* *ANTIHISTAMINES* dihydrochloride oral solution levocetirizine *ANTIHISTAMINES - 1 or 1b* ALKYLAMINES*** dihydrochloride oral tablet BROMPHENIRAMINE QUZYTTIR MALEATE INTRAVENOUS 3 3 INTRAMUSCULAR SOLUTION SOLUTION *ANTIHISTAMINES - brompheniramine tannate PHENOTHIAZINES*** 1 or 1b* oral tablet chewable phenadoz rectal suppository 1 or 1b* dexchlorpheniramine maleate PHENERGAN 1 or 1b* 3 oral solution INJECTION SOLUTION ryclora oral solution 1 or 1b* promethazine hcl injection 1 or 1a* *ANTIHISTAMINES - solution ETHANOLAMINES*** promethazine hcl oral 1 or 1a* carbinoxamine maleate oral solution 1 or 1b* solution promethazine hcl oral syrup 1 or 1a* carbinoxamine maleate oral 1 or 1b* promethazine hcl oral tablet 1 or 1a* tablet 4 mg promethazine hcl rectal 1 or 1b* suppository 12.5 mg, 25 mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 39 Drug Name Tier Notes Drug Name Tier Notes promethegan rectal COLESTID ORAL 1 or 1b* 3 suppository PACKET *ANTIHISTAMINES - COLESTID ORAL 3 PIPERIDINES*** TABLET cyproheptadine hcl oral colestipol hcl oral granules 1 or 1b* 1 or 1b* syrup colestipol hcl oral packet 1 or 1b* cyproheptadine hcl oral 1 or 1b* colestipol hcl oral tablet 1 or 1b* tablet prevalite oral packet 1 or 1b* *ANTIHYPERLIPIDEMI CS MISC. prevalite oral powder 1 or 1b* COMBINATIONS*** QUESTRAN LIGHT 3 *ANTIHYPERLIPIDEMI ORAL POWDER CS MISC. QUESTRAN ORAL 3 COMBINATIONS*** PACKET OMEGA-3 RX QUESTRAN ORAL 3 COMPLETE ORAL 3 POWDER THERAPY PACK WELCHOL ORAL 3 OMEGA-3/D-3 PACKET WELLNESS PACK ORAL 3 WELCHOL ORAL KIT 3 TABLET SURE RESULT O3D3 3 *FIBRIC ACID SYSTEM ORAL KIT DERIVATIVES*** *ANTIHYPERLIPIDEMI ANTARA ORAL CS* 3 ST; QL CAPSULE 30 MG, 90 MG *ANTIHYPERLIPIDEMI fenofibrate micronized oral CS - MISC.*** 1 or 1b* capsule LOVAZA ORAL 3 PA; QL CAPSULE fenofibrate oral capsule 1 or 1b* omega-3-acid ethyl esters fenofibrate oral tablet 1 or 1b* 1 or 1b* PA; QL oral capsule fenofibric acid oral capsule 1 or 1b* VASCEPA ORAL delayed release 2 PA; QL CAPSULE FENOFIBRIC ACID 3 *BILE ACID ORAL TABLET 105 MG SEQUESTRANTS*** FENOGLIDE ORAL 3 ST; QL cholestyramine light oral TABLET 1 or 1b* packet FIBRICOR ORAL 3 ST; QL cholestyramine light oral TABLET 1 or 1b* powder gemfibrozil oral tablet 1 or 1b* cholestyramine oral packet 1 or 1b* LIPOFEN ORAL 3 ST; QL cholestyramine oral powder 1 or 1b* CAPSULE colesevelam hcl oral packet 1 or 1b* LOPID ORAL TABLET 3 ST; QL colesevelam hcl oral tablet 1 or 1b* TRICOR ORAL TABLET 3 ST; QL COLESTID FLAVORED TRIGLIDE ORAL 3 3 ST; QL ORAL GRANULES TABLET 160 MG TRILIPIX ORAL COLESTID FLAVORED 3 ORAL PACKET CAPSULE DELAYED 3 ST; QL RELEASE COLESTID ORAL 3 GRANULES

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 40 Drug Name Tier Notes Drug Name Tier Notes *HMG COA REDUCTASE LIVALO ORAL TABLET 3 ST; QL INHIBITOR 4 MG COMBINATIONS*** lovastatin oral tablet 10 mg, 1 or 1b* DO; $0 EQUAPAX/ATORVASTA 20 mg TIN/COQ10 ORAL 3 lovastatin oral tablet 40 mg 1 or 1b* $0 THERAPY PACK PRAVACHOL ORAL 3 ST; DO; QL *HMG COA REDUCTASE TABLET 20 MG, 40 MG INHIBITORS*** pravastatin sodium oral tablet 1 or 1b* DO; $0 ALTOPREV ORAL 10 mg, 20 mg, 40 mg TABLET EXTENDED 3 ST; DO; QL pravastatin sodium oral tablet RELEASE 24 HOUR 20 1 or 1b* $0 MG, 40 MG 80 mg rosuvastatin calcium oral ALTOPREV ORAL 1 or 1b* DO; $0 TABLET EXTENDED tablet 10 mg, 5 mg 3 ST; QL RELEASE 24 HOUR 60 rosuvastatin calcium oral 1 or 1b* DO MG tablet 20 mg atorvastatin calcium oral rosuvastatin calcium oral 1 or 1b* DO; $0 1 or 1b* tablet 10 mg, 20 mg tablet 40 mg atorvastatin calcium oral SIMVASTATIN ORAL 1 or 1b* DO 3 ST; QL tablet 40 mg SUSPENSION atorvastatin calcium oral simvastatin oral tablet 10 mg, 1 or 1b* 1 or 1b* DO; $0 tablet 80 mg 20 mg, 40 mg, 5 mg CRESTOR ORAL simvastatin oral tablet 80 mg 1 or 1b* PA; QL TABLET 10 MG, 20 MG, 5 3 ST; DO; QL ZOCOR ORAL TABLET MG 3 ST; DO; QL 10 MG, 20 MG, 40 MG CRESTOR ORAL 3 ST; QL ZOCOR ORAL TABLET TABLET 40 MG 3 ST; QL 80 MG EZALLOR SPRINKLE ORAL CAPSULE ZYPITAMAG ORAL 3 ST; DO; QL 3 ST; DO; QL SPRINKLE 10 MG, 20 TABLET 1 MG, 2 MG MG, 5 MG ZYPITAMAG ORAL 3 ST; QL EZALLOR SPRINKLE TABLET 4 MG ORAL CAPSULE 3 ST; QL *INTEST CHOLEST SPRINKLE 40 MG ABSORP INHIB-HMG COA REDUCTASE INHIB FLOLIPID ORAL 3 ST; QL COMB*** SUSPENSION ezetimibe-simvastatin oral fluvastatin sodium er oral 1 or 1b* ST; QL tablet extended release 24 1 or 1b* $0 tablet hour VYTORIN ORAL 3 ST; QL fluvastatin sodium oral TABLET 1 or 1b* DO; $0 capsule *INTESTINAL CHOLESTEROL LESCOL XL ORAL ABSORPTION TABLET EXTENDED 3 ST; QL INHIBITORS*** RELEASE 24 HOUR LIPITOR ORAL TABLET ezetimibe oral tablet 1 or 1b* ST; QL 3 ST; DO; QL 10 MG, 20 MG, 40 MG ZETIA ORAL TABLET 3 ST; QL LIPITOR ORAL TABLET 3 ST; QL 80 MG LIVALO ORAL TABLET 3 ST; DO; QL 1 MG, 2 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 41 Drug Name Tier Notes Drug Name Tier Notes *MICROSOMAL benazepril- TRIGLYCERIDE hydrochlorothiazide oral 1 or 1b* TRANSFER PROTEIN tablet INHIBITORS*** captopril- JUXTAPID ORAL hydrochlorothiazide oral 1 or 1b* CAPSULE 10 MG, 20 MG, 3 PA; DO; QL; LD tablet 30 MG, 5 MG enalapril-hydrochlorothiazide 1 or 1b* JUXTAPID ORAL oral tablet 3 PA; QL; LD CAPSULE 40 MG, 60 MG fosinopril sodium-hctz oral 1 or 1b* *NICOTINIC ACID tablet DERIVATIVES*** lisinopril- niacin (antihyperlipidemic) hydrochlorothiazide oral 1 or 1b* 1 or 1b* oral tablet tablet niacin er LOTENSIN HCT ORAL (antihyperlipidemic) oral 1 or 1b* ST; QL TABLET 10-12.5 MG, 20- 3 tablet extended release 12.5 MG, 20-25 MG niacor oral tablet 1 or 1b* ST; QL quinapril- NIASPAN ORAL TABLET hydrochlorothiazide oral 1 or 1b* 3 ST; QL EXTENDED RELEASE tablet VASERETIC ORAL *ANTIHYPERTENSIVES 3 * TABLET ZESTORETIC ORAL *ACE INHIBITOR & 3 CALCIUM CHANNEL TABLET BLOCKER *ACE INHIBITORS*** COMBINATIONS*** ACCUPRIL ORAL 3 amlodipine besy-benazepril TABLET 1 or 1b* hcl oral capsule ALTACE ORAL 3 LOTREL ORAL CAPSULE CAPSULE 10-20 MG, 10- 3 benazepril hcl oral tablet 1 or 1a* 40 MG, 5-10 MG, 5-20 MG captopril oral tablet 1 or 1b* PRESTALIA ORAL 3 TABLET 14-10 MG enalapril maleate oral tablet 1 or 1b* enalaprilat intravenous PRESTALIA ORAL 1 or 1b* TABLET 3.5-2.5 MG, 7-5 3 DO injectable MG EPANED ORAL 3 TARKA ORAL TABLET SOLUTION EXTENDED RELEASE 2- 3 fosinopril sodium oral tablet 1 or 1b* 180 MG, 2-240 MG, 4-240 MG lisinopril oral tablet 1 or 1a* trandolapril-verapamil hcl er LOTENSIN ORAL oral tablet extended release 1 or 1b* DO TABLET 10 MG, 20 MG, 3 1-240 mg 40 MG trandolapril-verapamil hcl er moexipril hcl oral tablet 1 or 1b* oral tablet extended release perindopril erbumine oral 1 or 1b* 1 or 1b* 2-180 mg, 2-240 mg, 4-240 tablet mg PRINIVIL ORAL 3 *ACE INHIBITORS & TABLET 10 MG, 20 MG THIAZIDE/THIAZIDE- QBRELIS ORAL 3 LIKE*** SOLUTION ACCURETIC ORAL 3 quinapril hcl oral tablet 1 or 1b* TABLET ramipril oral capsule 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 42 Drug Name Tier Notes Drug Name Tier Notes trandolapril oral tablet 1 or 1b* telmisartan-amlodipine oral 1 or 1b* DO VASOTEC ORAL tablet 40-5 mg 3 TABLET TWYNSTA ORAL ZESTRIL ORAL TABLET 3 TABLET 40-10 MG, 80-10 3 MG, 80-5 MG *ADRENOLYTICS- TWYNSTA ORAL CENTRAL & 3 DO THIAZIDE/THIAZIDE- TABLET 40-5 MG LIKE COMB*** *ANGIOTENSIN II methyldopa- RECEPTOR ANTAG & hydrochlorothiazide oral 1 or 1b* THIAZIDE/THIAZIDE- tablet LIKE*** ATACAND HCT ORAL *AGENTS FOR 3 PHEOCHROMOCYTOM TABLET A*** AVALIDE ORAL DEMSER ORAL TABLET 150-12.5 MG, 3 3 PA; QL CAPSULE 300-12.5 MG DIBENZYLINE ORAL BENICAR HCT ORAL 3 PA; QL 3 DO CAPSULE TABLET 20-12.5 MG phenoxybenzamine hcl oral BENICAR HCT ORAL 1 or 1b* PA; QL capsule TABLET 40-12.5 MG, 40- 3 25 MG phentolamine mesylate candesartan cilexetil-hctz injection solution 1 or 1b* 1 or 1b* reconstituted oral tablet *ANGIOTENSIN II DIOVAN HCT ORAL RECEPTOR ANTAG & TABLET 160-12.5 MG, 80- 3 DO CA CHANNEL 12.5 MG BLOCKER COMB*** DIOVAN HCT ORAL amlodipine besylate- TABLET 160-25 MG, 320- 3 valsartan oral tablet 10-160 1 or 1b* 12.5 MG, 320-25 MG mg, 10-320 mg, 5-320 mg EDARBYCLOR ORAL 3 amlodipine besylate- TABLET valsartan oral tablet 5-160 1 or 1b* DO HYZAAR ORAL TABLET 3 mg 100-12.5 MG, 100-25 MG amlodipine-olmesartan oral HYZAAR ORAL TABLET 3 DO tablet 10-20 mg, 10-40 mg, 1 or 1b* 50-12.5 MG 5-40 mg irbesartan- amlodipine-olmesartan oral hydrochlorothiazide oral 1 or 1b* 1 or 1b* DO tablet 5-20 mg tablet AZOR ORAL TABLET losartan potassium-hctz oral 10-20 MG, 10-40 MG, 5-40 3 tablet 100-12.5 mg, 100-25 1 or 1b* MG mg AZOR ORAL TABLET 5- losartan potassium-hctz oral 3 DO 1 or 1b* DO 20 MG tablet 50-12.5 mg EXFORGE ORAL MICARDIS HCT ORAL 3 DO TABLET 10-160 MG, 10- 3 TABLET 40-12.5 MG 320 MG, 5-320 MG MICARDIS HCT ORAL EXFORGE ORAL TABLET 80-12.5 MG, 80- 3 3 DO TABLET 5-160 MG 25 MG telmisartan-amlodipine oral olmesartan medoxomil-hctz 1 or 1b* DO tablet 40-10 mg, 80-10 mg, 1 or 1b* oral tablet 20-12.5 mg 80-5 mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 43 Drug Name Tier Notes Drug Name Tier Notes olmesartan medoxomil-hctz telmisartan oral tablet 20 mg, 1 or 1b* DO oral tablet 40-12.5 mg, 40-25 1 or 1b* 40 mg mg telmisartan oral tablet 80 mg 1 or 1b* telmisartan-hctz oral tablet 1 or 1b* DO valsartan oral tablet 1 or 1b* 40-12.5 mg *ANGIOTENSIN II telmisartan-hctz oral tablet 1 or 1b* RECEPTOR ANT-CA 80-12.5 mg, 80-25 mg CHANNEL BLOCKER- valsartan- THIAZIDES*** hydrochlorothiazide oral 1 or 1b* DO amlodipine-valsartan-hctz tablet 160-12.5 mg, 80-12.5 oral tablet 10-160-12.5 mg, 1 or 1b* mg 10-160-25 mg, 10-320-25 valsartan- mg, 5-160-25 mg hydrochlorothiazide oral amlodipine-valsartan-hctz 1 or 1b* 1 or 1b* DO tablet 160-25 mg, 320-12.5 oral tablet 5-160-12.5 mg mg, 320-25 mg EXFORGE HCT ORAL *ANGIOTENSIN II TABLET 10-160-12.5 MG, 3 RECEPTOR 10-160-25 MG, 10-320-25 ANTAGONISTS*** MG, 5-160-25 MG ATACAND ORAL EXFORGE HCT ORAL 3 3 DO TABLET TABLET 5-160-12.5 MG AVAPRO ORAL TABLET olmesartan-amlodipine-hctz 3 DO 1 or 1b* DO 150 MG, 75 MG oral tablet 20-5-12.5 mg AVAPRO ORAL TABLET 3 olmesartan-amlodipine-hctz 300 MG oral tablet 40-10-12.5 mg, 1 or 1b* BENICAR ORAL 40-10-25 mg, 40-5-12.5 mg, 3 DO TABLET 20 MG 40-5-25 mg BENICAR ORAL TRIBENZOR ORAL 3 3 DO TABLET 40 MG, 5 MG TABLET 20-5-12.5 MG candesartan cilexetil oral TRIBENZOR ORAL 1 or 1b* tablet TABLET 40-10-12.5 MG, 3 COZAAR ORAL TABLET 3 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG DIOVAN ORAL TABLET 3 *ANTIADRENERGICS - EDARBI ORAL TABLET 3 DO CENTRALLY 40 MG ACTING*** EDARBI ORAL TABLET CATAPRES ORAL 3 3 80 MG TABLET irbesartan oral tablet 150 mg, 1 or 1b* DO CATAPRES-TTS-1 75 mg TRANSDERMAL PATCH 3 irbesartan oral tablet 300 mg 1 or 1b* WEEKLY losartan potassium oral tablet 1 or 1b* CATAPRES-TTS-2 TRANSDERMAL PATCH 3 MICARDIS ORAL 3 DO WEEKLY TABLET 20 MG, 40 MG CATAPRES-TTS-3 MICARDIS ORAL 3 TRANSDERMAL PATCH 3 TABLET 80 MG WEEKLY olmesartan medoxomil oral 1 or 1b* DO clonidine hcl oral tablet 1 or 1a* tablet 20 mg clonidine transdermal patch olmesartan medoxomil oral 1 or 1b* 1 or 1b* weekly tablet 40 mg, 5 mg guanfacine hcl oral tablet 1 or 1b* methyldopa oral tablet 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 44 Drug Name Tier Notes Drug Name Tier Notes *ANTIADRENERGICS - aliskiren fumarate oral tablet 1 or 1b* PERIPHERALLY 300 mg ACTING*** TEKTURNA ORAL 3 DO CARDURA ORAL TABLET 150 MG 3 TABLET TEKTURNA ORAL 3 doxazosin mesylate oral TABLET 300 MG 1 or 1b* tablet *DOPAMINE D1 MINIPRESS ORAL RECEPTOR 3 CAPSULE AGONISTS*** prazosin hcl oral capsule 1 or 1b* CORLOPAM terazosin hcl oral capsule 1 or 1b* INTRAVENOUS 3 SOLUTION *ANTIHYPERTENSIVES - MISC.*** *SELECTIVE ALDOSTERONE VECAMYL ORAL 3 RECEPTOR TABLET ANTAGONISTS *BETA BLOCKER & (SARAS)*** DIURETIC eplerenone oral tablet 1 or 1b* COMBINATIONS*** INSPRA ORAL TABLET 3 atenolol-chlorthalidone oral 1 or 1b* tablet *VASODILATORS*** hydralazine hcl injection bisoprolol- 1 or 1b* hydrochlorothiazide oral 1 or 1b* solution tablet hydralazine hcl oral tablet 1 or 1b* DUTOPROL ORAL minoxidil oral tablet 1 or 1b* TABLET EXTENDED 3 NIPRIDE RTU RELEASE 24 HOUR INTRAVENOUS LOPRESSOR HCT ORAL SOLUTION 20-0.9 3 3 TABLET 50-25 MG MG/100ML-%, 50-0.9 metoprolol- MG/100ML-% hydrochlorothiazide oral 1 or 1b* NITROPRESS tablet INTRAVENOUS 3 propranolol-hctz oral tablet 1 or 1b* SOLUTION TENORETIC 100 ORAL nitroprusside sodium 3 1 or 1b* TABLET intravenous solution TENORETIC 50 ORAL *ANTI-INFECTIVE 3 TABLET AGENTS - MISC.* ZIAC ORAL TABLET 3 *ANTI-INFECTIVE AGENTS - MISC.*** *DIRECT RENIN INHIBITORS & AEMCOLO ORAL THIAZIDE/THIAZIDE- TABLET DELAYED 3 PA; QL LIKE COMB*** RELEASE TEKTURNA HCT ORAL baciim intramuscular 3 DO 1 or 1b* TABLET 150-12.5 MG solution reconstituted bacitracin intramuscular TEKTURNA HCT ORAL 1 or 1b* TABLET 150-25 MG, 300- 3 solution reconstituted 12.5 MG, 300-25 MG FIRST- *DIRECT RENIN METRONIDAZOLE INHIBITORS*** ORAL SUSPENSION 3 RECONSTITUTED 50 aliskiren fumarate oral tablet 1 or 1b* DO MG/ML 150 mg * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 45 Drug Name Tier Notes Drug Name Tier Notes FLAGYL ORAL sulfamethoxazole- 3 1 or 1a* CAPSULE trimethoprim oral tablet FLAGYL ORAL TABLET 3 sulfatrim pediatric oral 1 or 1a* IMPAVIDO ORAL suspension 3 PA; QL CAPSULE *ANTIPROTOZOAL METRONIDAZOLE AGENTS*** BENZO+SYRSPEND ALINIA ORAL 3 ORAL SUSPENSION SUSPENSION 3 RECONSTITUTED RECONSTITUTED metronidazole in nacl ALINIA ORAL TABLET 3 intravenous solution 5-0.79 1 or 1b* atovaquone oral suspension 1 or 1b* mg/ml-%, 500-0.79 MEPRON ORAL mg/100ml-% 3 SUSPENSION METRONIDAZOLE IN NACL INTRAVENOUS *CARBAPENEM 3 SOLUTION 500-0.74 COMBINATIONS*** MG/100ML-% imipenem-cilastatin metronidazole oral capsule 1 or 1a* intravenous solution 1 or 1b* reconstituted metronidazole oral tablet 1 or 1a* PRIMAXIN IV NEBUPENT INTRAVENOUS INHALATION 3 SOLUTION 3 SOLUTION RECONSTITUTED 500- RECONSTITUTED 500 MG PENTAM INJECTION RECARBRIO SOLUTION 3 INTRAVENOUS 3 RECONSTITUTED SOLUTION pentamidine isethionate RECONSTITUTED inhalation solution 1 or 1b* VABOMERE reconstituted INTRAVENOUS 3 pentamidine isethionate SOLUTION injection solution 1 or 1b* RECONSTITUTED reconstituted *CARBAPENEMS*** PRIMSOL ORAL ertapenem sodium injection 3 1 or 1b* SOLUTION solution reconstituted tinidazole oral tablet 1 or 1b* INVANZ INJECTION trimethoprim oral tablet 1 or 1a* SOLUTION 3 XIFAXAN ORAL RECONSTITUTED 3 PA; QL TABLET meropenem intravenous 1 or 1b* *ANTI-INFECTIVE solution reconstituted MISC. - MEROPENEM-SODIUM COMBINATIONS*** CHLORIDE BACTRIM DS ORAL INTRAVENOUS 3 3 TABLET SOLUTION RECONSTITUTED 1 BACTRIM ORAL 3 GM/50ML, 500 MG/50ML TABLET MERREM sulfamethoxazole- INTRAVENOUS 3 trimethoprim intravenous 1 or 1b* SOLUTION solution RECONSTITUTED sulfamethoxazole- trimethoprim oral suspension 1 or 1a* 200-40 mg/5ml * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 46 Drug Name Tier Notes Drug Name Tier Notes *CHLORAMPHENICALS CLINDAMYCIN *** PHOSPHATE IN NACL 3 chloramphenicol sod INTRAVENOUS succinate intravenous 1 or 1b* SOLUTION solution reconstituted clindamycin phosphate 1 or 1b* *CYCLIC injection solution LIPOPEPTIDES*** LINCOCIN INJECTION 3 CUBICIN SOLUTION INTRAVENOUS lincomycin hcl injection 3 1 or 1b* SOLUTION solution RECONSTITUTED *OXAZOLIDINONES*** CUBICIN RF linezolid in sodium chloride INTRAVENOUS 1 or 1b* 3 intravenous solution SOLUTION linezolid intravenous solution RECONSTITUTED 1 or 1b* 600 mg/300ml DAPTOMYCIN linezolid oral suspension INTRAVENOUS 1 or 1b* PA; QL SOLUTION 3 reconstituted RECONSTITUTED 350 linezolid oral tablet 1 or 1b* PA; QL MG SIVEXTRO daptomycin intravenous INTRAVENOUS 3 solution reconstituted 500 1 or 1b* SOLUTION mg RECONSTITUTED *GLYCYLCYCLINES*** SIVEXTRO ORAL 3 PA; QL TIGECYCLINE TABLET INTRAVENOUS 3 ZYVOX INTRAVENOUS SOLUTION SOLUTION 200 3 RECONSTITUTED MG/100ML, 600 TYGACIL MG/300ML INTRAVENOUS 3 ZYVOX ORAL SOLUTION SUSPENSION 3 PA; QL RECONSTITUTED RECONSTITUTED *LEPROSTATICS*** ZYVOX ORAL TABLET 3 PA; QL dapsone oral tablet 1 or 1b* *POLYMYXINS*** *LINCOSAMIDES*** colistimethate sodium (cba) CLEOCIN ORAL injection solution 1 or 1b* 3 CAPSULE reconstituted CLEOCIN ORAL COLY-MYCIN M SOLUTION 3 INJECTION SOLUTION 3 RECONSTITUTED RECONSTITUTED CLEOCIN PHOSPHATE polymyxin b sulfate injection 3 1 or 1b* INJECTION SOLUTION solution reconstituted CLEOCIN PHOSPHATE *STREPTOGRAMIN INTRAVENOUS 3 COMBINATIONS*** SOLUTION SYNERCID INTRAVENOUS clindamycin hcl oral capsule 1 or 1b* 3 SOLUTION clindamycin palmitate hcl 1 or 1b* RECONSTITUTED oral solution reconstituted clindamycin phosphate in 1 or 1b* d5w intravenous solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 47 Drug Name Tier Notes Drug Name Tier Notes *ANTIMALARIALS* NEOSTIGMINE *ANTIMALARIAL METHYLSULFATE COMBINATIONS*** INTRAVENOUS 3 SOLUTION 10 MG/10ML, atovaquone-proguanil hcl 1 or 1b* 5 MG/10ML oral tablet pyridostigmine bromide er COARTEM ORAL 1 or 1b* 3 oral tablet extended release TABLET pyridostigmine bromide oral MALARONE ORAL 1 or 1b* 3 solution TABLET pyridostigmine bromide oral 1 or 1b* *ANTIMALARIALS*** tablet ARAKODA ORAL 3 REGONOL TABLET INTRAVENOUS 3 chloroquine phosphate oral SOLUTION 1 or 1a* QL tablet RUZURGI ORAL 3 PA; QL; LD DARAPRIM ORAL TABLET 3 PA; QL; LD TABLET *ANTIMYASTHENIC/CH hydroxychloroquine sulfate OLINERGIC AGENTS*** 1 or 1b* QL oral tablet BLOXIVERZ KRINTAFEL ORAL INTRAVENOUS 3 3 TABLET SOLUTION FIRDAPSE ORAL mefloquine hcl oral tablet 1 or 1b* 3 PA; QL; LD TABLET PLAQUENIL ORAL 3 QL GUANIDINE HCL ORAL TABLET 3 TABLET PRIMAQUINE MESTINON ORAL PHOSPHATE ORAL 3 3 TABLET SOLUTION MESTINON ORAL pyrimethamine oral tablet 1 or 1b* PA; QL 3 TABLET QUALAQUIN ORAL 3 PA; QL CAPSULE MESTINON ORAL TABLET EXTENDED 3 quinine sulfate oral capsule 1 or 1b* PA; QL RELEASE *ANTIMYASTHENIC NEOSTIGMINE AGENTS* METHYLSULFATE *ANTIMYASTHENIC INTRAVENOUS 3 AGENTS*** SOLUTION 10 MG/10ML, BLOXIVERZ 5 MG/10ML INTRAVENOUS 3 pyridostigmine bromide er 1 or 1b* SOLUTION oral tablet extended release FIRDAPSE ORAL pyridostigmine bromide oral 3 PA; QL; LD 1 or 1b* TABLET solution GUANIDINE HCL ORAL pyridostigmine bromide oral 3 1 or 1b* TABLET tablet MESTINON ORAL REGONOL 3 SOLUTION INTRAVENOUS 3 MESTINON ORAL SOLUTION 3 TABLET RUZURGI ORAL 3 PA; QL; LD MESTINON ORAL TABLET TABLET EXTENDED 3 RELEASE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 48 Drug Name Tier Notes Drug Name Tier Notes *ANTIMYASTHENIC/CH isoniazid oral tablet 1 or 1a* OLINERGIC AGENTS* MYAMBUTOL ORAL 3 BLOXIVERZ TABLET 400 MG INTRAVENOUS 3 MYCOBUTIN ORAL 3 SOLUTION CAPSULE FIRDAPSE ORAL 3 PA; QL; LD PASER ORAL PACKET 3 TABLET PRETOMANID ORAL GUANIDINE HCL ORAL 3 3 TABLET TABLET PRIFTIN ORAL TABLET 2 MESTINON ORAL 3 SOLUTION pyrazinamide oral tablet 1 or 1b* MESTINON ORAL rifabutin oral capsule 1 or 1b* 3 TABLET RIFADIN INTRAVENOUS MESTINON ORAL 3 TABLET EXTENDED 3 SOLUTION RELEASE RECONSTITUTED RIFADIN ORAL NEOSTIGMINE 3 METHYLSULFATE CAPSULE INTRAVENOUS 3 rifampin intravenous solution 1 or 1b* SOLUTION 10 MG/10ML, reconstituted 5 MG/10ML rifampin oral capsule 1 or 1b* pyridostigmine bromide er 1 or 1b* RIFAMPIN+SYRSPEND oral tablet extended release 3 SF ORAL SUSPENSION pyridostigmine bromide oral 1 or 1b* SIRTURO ORAL solution 3 TABLET pyridostigmine bromide oral 1 or 1b* TRECATOR ORAL tablet 3 TABLET REGONOL *ANTINEOPLASTIC - INTRAVENOUS 3 BCL-2 INHIBITORS*** SOLUTION *ANTINEOPLASTIC - RUZURGI ORAL 3 PA; QL; LD BCL-2 INHIBITORS*** TABLET VENCLEXTA ORAL *ANTIMYCOBACTERIA 3 PA; QL; LD L AGENTS* TABLET *ANTI TB VENCLEXTA STARTING COMBINATIONS*** PACK ORAL TABLET 3 PA; QL; LD THERAPY PACK RIFAMATE ORAL 3 *ANTINEOPLASTIC - CAPSULE BISPECIFIC T-CELL RIFATER ORAL 2 ENGAGERS*** TABLET *ANTINEOPLASTIC - *ANTIMYCOBACTERIA BISPECIFIC T-CELL L AGENTS*** ENGAGERS*** CAPASTAT SULFATE BLINCYTO INJECTION SOLUTION 3 INTRAVENOUS 3 PA; QL; LD; SP RECONSTITUTED SOLUTION cycloserine oral capsule 1 or 1b* RECONSTITUTED ethambutol hcl oral tablet 1 or 1b* isoniazid injection solution 1 or 1a* isoniazid oral syrup 1 or 1a*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 49 Drug Name Tier Notes Drug Name Tier Notes *ANTINEOPLASTIC - *ANTINEOPLASTIC - FGFR KINASE XPO1 INHIBITORS*** INHIBITORS*** *ANTINEOPLASTIC - *ANTINEOPLASTIC - XPO1 INHIBITORS*** FGFR KINASE XPOVIO (100 MG ONCE INHIBITORS*** WEEKLY) ORAL 3 PA; QL; LD BALVERSA ORAL TABLET THERAPY 3 PA; QL; LD TABLET PACK *ANTINEOPLASTIC - XPOVIO (60 MG ONCE HORMONAL AND WEEKLY) ORAL 3 PA; QL; LD RELATED AGENT TABLET THERAPY COMBINATIONS*** PACK *ANTINEOPLASTIC - XPOVIO (80 MG ONCE HORMONAL AND WEEKLY) ORAL 3 PA; QL; LD RELATED AGENT TABLET THERAPY COMBINATIONS*** PACK LEUPROLIDE XPOVIO (80 MG TWICE ACETATE- WEEKLY) ORAL 3 PA; QL; LD BUPIVACAINE 3 TABLET THERAPY INTRAMUSCULAR PACK SOLUTION *ANTINEOPLASTIC OR *ANTINEOPLASTIC - PREMALIGNANT METHYLTRANSFERASE LESION AGENT - INHIBITORS*** COMB*** *ANTINEOPLASTIC - *ANTINEOPLASTIC OR METHYLTRANSFERASE PREMALIGNANT INHIBITORS*** LESION AGENT - TAZVERIK ORAL COMB*** 3 LD TABLET HYALUCIL-4 3 *ANTINEOPLASTIC - TRANSDERMAL CREAM TROPOMYOSIN ORMECA 3 RECEPTOR KINASE COMBINATION KIT INHIBITORS*** *ANTINEOPLASTICS *ANTINEOPLASTIC - AND ADJUNCTIVE TROPOMYOSIN THERAPIES* RECEPTOR KINASE *ALKYLATING INHIBITORS*** AGENTS*** ROZLYTREK ORAL 3 PA; QL; LD; SP BELRAPZO CAPSULE INTRAVENOUS 3 PA; QL; LD; SP VITRAKVI ORAL SOLUTION 3 PA; QL; SP CAPSULE 100 MG BENDAMUSTINE HCL VITRAKVI ORAL INTRAVENOUS 3 PA; QL; SP 3 PA; QL; LD; SP CAPSULE 25 MG SOLUTION VITRAKVI ORAL BENDEKA 3 PA; QL; LD; SP SOLUTION INTRAVENOUS 3 PA; QL; LD; SP SOLUTION busulfan intravenous solution 1 or 1b* SP BUSULFEX INTRAVENOUS 3 SP SOLUTION carboplatin intravenous 1 or 1b* SP solution * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 50 Drug Name Tier Notes Drug Name Tier Notes cisplatin intravenous solution *ANTIESTROGENS*** 100 mg/100ml, 200 1 or 1b* SP FARESTON ORAL 3 mg/200ml, 50 mg/50ml TABLET CISPLATIN SOLTAMOX ORAL INTRAVENOUS 2 $0 3 SOLUTION SOLUTION RECONSTITUTED tamoxifen citrate oral tablet 1 or 1b* $0 MYLERAN ORAL toremifene citrate oral tablet 1 or 1b* 2 TABLET *ANTIMETABOLITES*** oxaliplatin intravenous adrucil intravenous solution 1 or 1b* SP 1 or 1b* SP solution 2.5 gm/50ml, 500 mg/10ml oxaliplatin intravenous 1 or 1b* SP ALIMTA INTRAVENOUS solution reconstituted SOLUTION 3 PA; QL; SP paraplatin intravenous RECONSTITUTED 1 or 1b* SP solution ARRANON TEPADINA INJECTION INTRAVENOUS 3 SP SOLUTION 3 SP SOLUTION RECONSTITUTED azacitidine injection 1 or 1b* PA; QL; SP thiotepa injection solution suspension reconstituted 1 or 1b* SP reconstituted capecitabine oral tablet 1 or 1b* PA; QL; SP TREANDA cladribine intravenous INTRAVENOUS 1 or 1b* SP 3 PA; QL; SP solution 10 mg/10ml SOLUTION clofarabine intravenous RECONSTITUTED 1 or 1b* SP solution *ANDROGEN BIOSYNTHESIS CLOLAR INHIBITORS*** INTRAVENOUS 3 SP SOLUTION abiraterone acetate oral tablet 1 or 1b* PA; QL; SP cytarabine (pf) injection 1 or 1b* SP YONSA ORAL TABLET 3 PA; QL; LD; SP solution ZYTIGA ORAL TABLET 3 PA; QL; LD; SP cytarabine injection solution 1 or 1b* SP 250 MG DACOGEN ZYTIGA ORAL TABLET INTRAVENOUS 2 PA; QL; LD; SP 3 SP 500 MG SOLUTION *ANTIADRENALS*** RECONSTITUTED LYSODREN ORAL decitabine intravenous 2 LD 1 or 1b* SP TABLET solution reconstituted floxuridine injection solution *ANTIANDROGENS*** 1 or 1b* SP reconstituted bicalutamide oral tablet 1 or 1b* fludarabine phosphate CASODEX ORAL 1 or 1b* SP 3 intravenous solution TABLET fludarabine phosphate ERLEADA ORAL 2 PA; QL; LD; SP intravenous solution 1 or 1b* SP TABLET reconstituted flutamide oral capsule 1 or 1b* fluorouracil intravenous 1 or 1b* SP NILANDRON ORAL solution 3 QL TABLET FOLOTYN nilutamide oral tablet 1 or 1b* QL INTRAVENOUS 3 SP NUBEQA ORAL TABLET 3 PA; QL; LD; SP SOLUTION XTANDI ORAL 2 PA; QL; LD; SP CAPSULE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 51 Drug Name Tier Notes Drug Name Tier Notes GEMCITABINE HCL *ANTINEOPLASTIC - INTRAVENOUS 3 SP HEDGEHOG PATHWAY SOLUTION INHIBITORS*** gemcitabine hcl intravenous DAURISMO ORAL 1 or 1b* SP 3 PA; QL; LD; SP solution reconstituted TABLET INFUGEM ERIVEDGE ORAL 2 PA; QL; LD; SP INTRAVENOUS 3 SP CAPSULE SOLUTION ODOMZO ORAL 3 PA; QL; LD; SP mercaptopurine oral tablet 1 or 1b* CAPSULE methotrexate oral tablet 1 or 1b* *ANTINEOPLASTIC - methotrexate sodium (pf) HISTONE injection solution 1 gm/40ml, 1 or 1b* DEACETYLASE 250 mg/10ml, 50 mg/2ml INHIBITORS*** methotrexate sodium BELEODAQ INTRAVENOUS injection solution 250 1 or 1b* 3 PA; QL; SP mg/10ml, 50 mg/2ml SOLUTION RECONSTITUTED methotrexate sodium FARYDAK ORAL injection solution 1 or 1b* 3 PA; QL; LD; SP reconstituted CAPSULE 10 MG, 20 MG methotrexate sodium oral ISTODAX (OVERFILL) 1 or 1b* INTRAVENOUS tablet 3 PA; QL; LD; SP SOLUTION PURIXAN ORAL 3 PA; QL; LD RECONSTITUTED SUSPENSION ROMIDEPSIN TABLOID ORAL INTRAVENOUS 2 3 PA; QL; SP TABLET SOLUTION TREXALL ORAL RECONSTITUTED 2 TABLET ZOLINZA ORAL 2 PA; QL; SP VIDAZA INJECTION CAPSULE SUSPENSION 3 PA; QL; SP *ANTINEOPLASTIC - RECONSTITUTED IMMUNOMODULATORS XATMEP ORAL *** 3 PA; QL; SP SOLUTION POMALYST ORAL 3 PA; QL; LD; SP XELODA ORAL TABLET 3 PA; QL; SP CAPSULE *ANTINEOPLASTIC - *ANTINEOPLASTIC - AUTOLOGOUS MEK INHIBITORS*** CELLULAR COTELLIC ORAL 3 PA; QL; LD; SP IMMUNOTHERAPY*** TABLET PROVENGE MEKINIST ORAL 3 PA; QL; LD; SP INTRAVENOUS 3 PA; QL; LD TABLET SUSPENSION MEKTOVI ORAL 3 PA; QL; LD *ANTINEOPLASTIC - TABLET BRAF KINASE INHIBITORS*** *ANTINEOPLASTIC - MONOCLONAL BRAFTOVI ORAL 3 PA; QL; LD ANTIBODIES*** CAPSULE 75 MG ARZERRA TAFINLAR ORAL 3 PA; QL; LD; SP INTRAVENOUS 3 PA; QL; LD; SP CAPSULE CONCENTRATE ZELBORAF ORAL 2 PA; QL; LD; SP BAVENCIO TABLET INTRAVENOUS 3 PA; QL; LD; SP SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 52 Drug Name Tier Notes Drug Name Tier Notes CAMPATH PORTRAZZA INTRAVENOUS 3 INTRAVENOUS 3 LD; SP SOLUTION SOLUTION DARZALEX POTELIGEO INTRAVENOUS 3 PA; QL; LD; SP INTRAVENOUS 3 LD; SP SOLUTION SOLUTION EMPLICITI RITUXAN INTRAVENOUS INTRAVENOUS 3 PA; QL; SP 3 PA; QL; LD; SP SOLUTION SOLUTION RECONSTITUTED RUXIENCE ERBITUX INTRAVENOUS 3 PA; QL; SP INTRAVENOUS 3 PA; QL; SP SOLUTION SOLUTION SARCLISA GAZYVA INTRAVENOUS 3 SP INTRAVENOUS 3 PA; QL; LD; SP SOLUTION SOLUTION TECENTRIQ HERCEPTIN INTRAVENOUS 3 PA; QL; LD; SP INTRAVENOUS SOLUTION SOLUTION 3 LD; SP TRAZIMERA RECONSTITUTED 150 INTRAVENOUS 3 SP MG SOLUTION HERZUMA RECONSTITUTED INTRAVENOUS 3 SP TRUXIMA SOLUTION INTRAVENOUS 3 PA; QL; SP RECONSTITUTED SOLUTION IMFINZI INTRAVENOUS 3 PA; QL; LD; SP UNITUXIN SOLUTION INTRAVENOUS 3 LD KANJINTI SOLUTION INTRAVENOUS 3 LD; SP VECTIBIX SOLUTION INTRAVENOUS 3 PA; QL; SP RECONSTITUTED SOLUTION 100 MG/5ML, KEYTRUDA 400 MG/20ML INTRAVENOUS 3 PA; QL; LD; SP YERVOY SOLUTION INTRAVENOUS 3 PA; QL; SP LARTRUVO SOLUTION INTRAVENOUS 3 PA; QL; LD *ANTINEOPLASTIC - SOLUTION MTOR KINASE LIBTAYO INHIBITORS*** INTRAVENOUS 3 PA; QL; LD AFINITOR DISPERZ SOLUTION ORAL TABLET 3 PA; QL; SP LUMOXITI SOLUBLE INTRAVENOUS AFINITOR ORAL 3 PA; QL; LD; SP 2 PA; QL; SP SOLUTION TABLET 10 MG RECONSTITUTED AFINITOR ORAL OGIVRI INTRAVENOUS TABLET 2.5 MG, 5 MG, 3 PA; QL; SP SOLUTION 3 LD; SP 7.5 MG RECONSTITUTED everolimus oral tablet 2.5 OPDIVO INTRAVENOUS 1 or 1b* PA; QL; SP 3 PA; QL; LD; SP mg, 5 mg, 7.5 mg SOLUTION temsirolimus intravenous 1 or 1b* PA; QL; SP PERJETA solution INTRAVENOUS 3 PA; QL; LD; SP SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 53 Drug Name Tier Notes Drug Name Tier Notes TORISEL COMETRIQ (100 MG 3 PA; QL; LD INTRAVENOUS 3 PA; QL; SP DAILY DOSE) ORAL KIT SOLUTION COMETRIQ (140 MG 3 PA; QL; LD *ANTINEOPLASTIC - DAILY DOSE) ORAL KIT MULTIKINASE COMETRIQ (60 MG 3 PA; QL; LD INHIBITORS*** DAILY DOSE) ORAL KIT NEXAVAR ORAL 2 PA; QL; LD; SP erlotinib hcl oral tablet 1 or 1b* PA; QL; SP TABLET GILOTRIF ORAL RYDAPT ORAL 3 PA; QL; LD 3 PA; QL; SP TABLET CAPSULE GLEEVEC ORAL STIVARGA ORAL 3 PA; QL; SP 2 PA; QL; LD; SP TABLET TABLET ICLUSIG ORAL TABLET 2 PA; QL; LD SUTENT ORAL 2 PA; QL; SP CAPSULE imatinib mesylate oral tablet 1 or 1b* PA; QL; SP IMBRUVICA ORAL *ANTINEOPLASTIC - 3 PA; QL; LD PROTEASOME CAPSULE INHIBITORS*** IMBRUVICA ORAL 3 PA; QL; LD BORTEZOMIB TABLET INTRAVENOUS 3 PA; QL INLYTA ORAL TABLET 2 PA; QL; LD; SP SOLUTION RECONSTITUTED IRESSA ORAL TABLET 2 PA; QL; LD; SP KYPROLIS LENVIMA (10 MG DAILY INTRAVENOUS DOSE) ORAL CAPSULE 3 PA; QL; LD; SP 3 PA; QL; LD; SP SOLUTION THERAPY PACK RECONSTITUTED LENVIMA (12 MG DAILY NINLARO ORAL DOSE) ORAL CAPSULE 3 PA; QL; LD; SP 3 PA; QL; LD; SP CAPSULE THERAPY PACK VELCADE INJECTION LENVIMA (14 MG DAILY SOLUTION 3 PA; QL; SP DOSE) ORAL CAPSULE 3 PA; QL; LD; SP RECONSTITUTED THERAPY PACK *ANTINEOPLASTIC - LENVIMA (18 MG DAILY TYROSINE KINASE DOSE) ORAL CAPSULE 3 PA; QL; LD; SP INHIBITORS*** THERAPY PACK ALECENSA ORAL LENVIMA (20 MG DAILY 3 PA; QL; LD; SP CAPSULE DOSE) ORAL CAPSULE 3 PA; QL; LD; SP THERAPY PACK ALUNBRIG ORAL 3 PA; QL; LD; SP TABLET LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE 3 PA; QL; LD; SP ALUNBRIG ORAL THERAPY PACK TABLET THERAPY 3 PA; QL; LD; SP PACK LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE 3 PA; QL; LD; SP AYVAKIT ORAL 3 PA; QL; LD THERAPY PACK TABLET LENVIMA (8 MG DAILY BOSULIF ORAL TABLET 2 PA; QL; SP DOSE) ORAL CAPSULE 3 PA; QL; LD; SP BRUKINSA ORAL THERAPY PACK 3 PA; QL; LD CAPSULE LORBRENA ORAL 3 PA; QL; LD; SP CABOMETYX ORAL TABLET 3 PA; QL; LD; SP TABLET NERLYNX ORAL 3 PA; QL; LD; SP CALQUENCE ORAL TABLET 3 PA; QL; LD CAPSULE SPRYCEL ORAL 2 PA; QL; SP CAPRELSA ORAL TABLET 2 PA; QL; LD TABLET * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 54 Drug Name Tier Notes Drug Name Tier Notes TAGRISSO ORAL IDAMYCIN PFS 3 PA; QL; LD; SP TABLET INTRAVENOUS 3 SP TARCEVA ORAL SOLUTION 3 PA; QL; LD; SP TABLET idarubicin hcl intravenous 1 or 1b* SP TASIGNA ORAL solution 2 PA; QL; SP CAPSULE mitomycin intravenous 1 or 1b* SP TURALIO ORAL solution reconstituted 3 PA; QL; LD CAPSULE mitoxantrone hcl intravenous 1 or 1b* SP TYKERB ORAL TABLET 2 PA; QL; LD; SP concentrate VIZIMPRO ORAL mutamycin intravenous 3 PA; QL; LD; SP 1 or 1b* SP TABLET solution reconstituted VOTRIENT ORAL valrubicin intravesical 2 PA; QL; LD; SP 1 or 1b* SP TABLET solution XALKORI ORAL VALSTAR 2 PA; QL; LD; SP CAPSULE INTRAVESICAL 3 SP SOLUTION XOSPATA ORAL 3 PA; QL; LD TABLET *ANTINEOPLASTIC - ANTIBODY FOR ZYKADIA ORAL 3 PA; QL; LD; SP RADIOPHARMACEUTIC TABLET AL THERAPY*** *ANTINEOPLASTIC ZEVALIN Y-90 3 PA; QL; LD ANTIBIOTICS*** INTRAVENOUS KIT adriamycin intravenous 1 or 1b* SP *ANTINEOPLASTIC solution ANTIBODY-DRUG adriamycin intravenous COMPLEXES*** solution reconstituted 10 mg, 1 or 1b* SP ADCETRIS 50 mg INTRAVENOUS 3 PA; QL; LD; SP bleomycin sulfate injection SOLUTION 1 or 1b* SP solution reconstituted RECONSTITUTED COSMEGEN BESPONSA INTRAVENOUS INTRAVENOUS 3 SP 3 PA; QL; LD; SP SOLUTION SOLUTION RECONSTITUTED RECONSTITUTED dactinomycin intravenous ENHERTU 1 or 1b* SP INTRAVENOUS solution reconstituted 3 LD; SP SOLUTION DAUNORUBICIN HCL RECONSTITUTED INTRAVENOUS 3 SP SOLUTION KADCYLA INTRAVENOUS DOXIL INTRAVENOUS 3 PA; QL; SP 3 PA; QL; SP SOLUTION INJECTABLE RECONSTITUTED doxorubicin hcl intravenous 1 or 1b* SP MYLOTARG solution INTRAVENOUS doxorubicin hcl liposomal SOLUTION 3 PA; QL; LD; SP 1 or 1b* PA; QL; SP intravenous injectable RECONSTITUTED 4.5 ELLENCE MG INTRAVENOUS 3 PA; QL; SP PADCEV INTRAVENOUS SOLUTION SOLUTION 3 LD; SP epirubicin hcl intravenous RECONSTITUTED solution 200 mg/100ml, 50 1 or 1b* PA; QL; SP POLIVY INTRAVENOUS mg/25ml SOLUTION 3 PA; QL; LD; SP RECONSTITUTED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 55 Drug Name Tier Notes Drug Name Tier Notes *ANTINEOPLASTIC STRONTIUM CHLORIDE COMBINATIONS*** SR-89 INTRAVENOUS 3 HERCEPTIN HYLECTA SOLUTION SUBCUTANEOUS 3 LD; SP XOFIGO INTRAVENOUS 3 PA; QL; LD SOLUTION SOLUTION 30 MCCI/ML KISQALI FEMARA (400 *ANTINEOPLASTICS - MG DOSE) ORAL INTERLEUKINS*** 2 PA; QL; SP TABLET THERAPY ELZONRIS PACK INTRAVENOUS 3 PA; QL; LD; SP KISQALI FEMARA (600 SOLUTION MG DOSE) ORAL 2 PA; QL; SP PROLEUKIN TABLET THERAPY INTRAVENOUS 3 QL; SP PACK SOLUTION KISQALI FEMARA(200 RECONSTITUTED MG DOSE) ORAL 2 PA; QL; SP *ANTINEOPLASTICS - TABLET THERAPY PHOTOACTIVATED PACK AGENTS*** LONSURF ORAL 3 PA; QL; LD; SP PHOTOFRIN TABLET INTRAVENOUS 3 LD RITUXAN HYCELA SOLUTION SUBCUTANEOUS 3 LD; SP RECONSTITUTED SOLUTION *ANTINEOPLASTICS VYXEOS INTRAVENOUS MISC.*** SUSPENSION 3 LD ACTIMMUNE RECONSTITUTED 44-100 SUBCUTANEOUS 3 PA; QL; LD; SP MG SOLUTION *ANTINEOPLASTIC ALFERON N INJECTION 3 SP ENZYMES*** SOLUTION ASPARLAS arsenic trioxide intravenous 1 or 1b* SP INTRAVENOUS 3 PA; QL; LD; SP solution SOLUTION dacarbazine intravenous 1 or 1b* SP ERWINAZE INJECTION solution reconstituted SOLUTION 3 PA; QL; LD HYDREA ORAL RECONSTITUTED 3 CAPSULE ONCASPAR INJECTION 3 PA; QL; SP SOLUTION hydroxyurea oral capsule 1 or 1b* INTRON A INJECTION *ANTINEOPLASTIC 3 LD; SP RADIOPHARMACEUTIC SOLUTION ALS*** INTRON A INJECTION AZEDRA DOSIMETRIC SOLUTION 3 LD; SP INTRAVENOUS 3 PA; QL; LD RECONSTITUTED SOLUTION MATULANE ORAL 2 LD AZEDRA THERAPEUTIC CAPSULE INTRAVENOUS 3 PA; QL; LD NIPENT INTRAVENOUS SOLUTION SOLUTION 3 SP LUTATHERA RECONSTITUTED INTRAVENOUS 3 PA; QL; LD SYLATRON SOLUTION SUBCUTANEOUS KIT 3 PA; QL; LD; SP QUADRAMET 200 MCG, 300 MCG, 600 INTRAVENOUS 3 MCG SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 56 Drug Name Tier Notes Drug Name Tier Notes SYNRIBO *CHEMOTHERAPY SUBCUTANEOUS ADJUNCTS - 3 PA; QL; LD SOLUTION KERATINOCYTE RECONSTITUTED GROWTH FACTORS*** TICE BCG KEPIVANCE INTRAVESICAL INTRAVENOUS 3 SP 3 SUSPENSION SOLUTION RECONSTITUTED RECONSTITUTED TRISENOX *ESTROGEN RECEPTOR INTRAVENOUS 3 SP ANTAGONIST*** SOLUTION 12 MG/6ML FASLODEX *AROMATASE INTRAMUSCULAR 3 PA; QL; SP INHIBITORS*** SOLUTION 250 MG/5ML anastrozole oral tablet 1 or 1b* fulvestrant intramuscular 1 or 1b* PA; QL; SP ARIMIDEX ORAL solution 3 TABLET *ESTROGENS- AROMASIN ORAL ANTINEOPLASTIC*** 3 TABLET EMCYT ORAL CAPSULE 2 PA; QL exemestane oral tablet 1 or 1b* *FOLIC ACID FEMARA ORAL TABLET 3 ANTAGONISTS RESCUE AGENTS*** letrozole oral tablet 1 or 1b* KHAPZORY *CARBOXYPEPTIDASE INTRAVENOUS 3 PA; QL; LD; SP ENZYME AGENTS*** SOLUTION VORAXAZE RECONSTITUTED INTRAVENOUS leucovorin calcium injection 3 LD 1 or 1b* SOLUTION solution RECONSTITUTED leucovorin calcium injection 1 or 1b* *CARDIAC solution reconstituted PROTECTIVE leucovorin calcium oral AGENTS*** 1 or 1b* tablet dexrazoxane hcl intravenous 1 or 1b* SP solution reconstituted levoleucovorin calcium intravenous solution 1 or 1b* PA; QL TOTECT INTRAVENOUS reconstituted 50 mg SOLUTION 3 SP levoleucovorin calcium pf RECONSTITUTED 1 or 1b* intravenous solution ZINECARD INTRAVENOUS *GONADOTROPIN 3 SP SOLUTION RELEASING HORMONE RECONSTITUTED (GNRH) ANTAGONISTS*** *CHEMOTHERAPY ADJUNCTS - FIRMAGON (240 MG DOSE) SUBCUTANEOUS HYPERURICEMIA 3 SP AGENTS*** SOLUTION RECONSTITUTED ELITEK INTRAVENOUS SOLUTION 3 PA; QL; SP FIRMAGON SUBCUTANEOUS RECONSTITUTED 3 PA; QL; SP SOLUTION RECONSTITUTED 80 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 57 Drug Name Tier Notes Drug Name Tier Notes *IMIDAZOTETRAZINES DOCETAXEL *** INTRAVENOUS TEMODAR CONCENTRATE 160 3 PA; QL; SP INTRAVENOUS MG/8ML, 20 MG/ML, 200 2 PA; QL; SP SOLUTION MG/10ML, 80 MG/4ML RECONSTITUTED DOCETAXEL TEMODAR ORAL INTRAVENOUS 3 PA; QL; SP CAPSULE SOLUTION 160 3 PA; QL; SP MG/16ML, 20 MG/2ML, temozolomide oral capsule 1 or 1b* PA; QL; SP 80 MG/8ML *JANUS ASSOCIATED ETOPOPHOS KINASE (JAK) INTRAVENOUS 3 SP INHIBITORS*** SOLUTION INREBIC ORAL RECONSTITUTED 3 PA; QL; LD; SP CAPSULE etoposide intravenous JAKAFI ORAL TABLET 2 PA; QL; LD; SP solution 1 gm/50ml, 100 1 or 1b* SP mg/5ml, 500 mg/25ml *LHRH ANALOGS*** etoposide oral capsule 1 or 1b* SP ELIGARD 3 PA; QL; SP SUBCUTANEOUS KIT HALAVEN INTRAVENOUS 3 PA; QL; SP leuprolide acetate injection 1 or 1b* PA; QL; SP SOLUTION kit IXEMPRA KIT LUPRON DEPOT (1- INTRAVENOUS 3 PA; QL; SP MONTH) 3 PA; QL; SP SOLUTION INTRAMUSCULAR KIT RECONSTITUTED LUPRON DEPOT (3- JEVTANA MONTH) 3 PA; QL; SP INTRAVENOUS 3 PA; QL; SP INTRAMUSCULAR KIT SOLUTION LUPRON DEPOT (4- MARQIBO MONTH) 3 PA; QL; SP INTRAVENOUS 3 LD INTRAMUSCULAR KIT SUSPENSION LUPRON DEPOT (6- NAVELBINE MONTH) 3 PA; QL; SP INTRAVENOUS 3 SP INTRAMUSCULAR KIT SOLUTION TRELSTAR MIXJECT paclitaxel intravenous INTRAMUSCULAR 1 or 1b* SP 3 PA; QL; SP concentrate SUSPENSION RECONSTITUTED TAXOTERE INTRAVENOUS VANTAS 3 PA; QL; SP 3 PA; QL; SP CONCENTRATE 80 SUBCUTANEOUS KIT MG/4ML ZOLADEX TENIPOSIDE SUBCUTANEOUS 3 PA; QL; SP INTRAVENOUS 3 SP IMPLANT SOLUTION *MITOTIC toposar intravenous solution INHIBITORS*** 1 gm/50ml, 100 mg/5ml, 500 1 or 1b* SP ABRAXANE mg/25ml INTRAVENOUS vinblastine sulfate 3 PA; QL; SP 1 or 1b* SP SUSPENSION intravenous solution RECONSTITUTED vincristine sulfate 1 or 1b* SP intravenous solution vinorelbine tartrate 1 or 1b* SP intravenous solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 58 Drug Name Tier Notes Drug Name Tier Notes *NITROGEN *PROGESTINS- MUSTARDS*** ANTINEOPLASTIC*** ALKERAN DEPO-PROVERA INTRAVENOUS INTRAMUSCULAR 3 3 SP SOLUTION SUSPENSION 400 MG/ML RECONSTITUTED hydroxyprogesterone ALKERAN ORAL caproate intramuscular 1 or 1b* LD 3 SP TABLET solution cyclophosphamide injection megestrol acetate oral 1 or 1b* SP solution reconstituted suspension 40 mg/ml, 400 1 or 1b* cyclophosphamide oral mg/10ml 1 or 1b* SP capsule megestrol acetate oral tablet 1 or 1b* EVOMELA *RETINOIDS*** INTRAVENOUS 3 LD; SP tretinoin oral capsule 1 or 1b* SOLUTION RECONSTITUTED *SELECTIVE RETINOID X RECEPTOR IFEX INTRAVENOUS AGONISTS*** SOLUTION 3 SP RECONSTITUTED bexarotene oral capsule 1 or 1b* PA; QL; SP ifosfamide intravenous TARGRETIN ORAL 1 or 1b* SP 3 PA; QL; SP solution CAPSULE ifosfamide intravenous *TOPOISOMERASE I 1 or 1b* SP solution reconstituted 1 gm INHIBITORS*** IFOSFAMIDE CAMPTOSAR INTRAVENOUS INTRAVENOUS 3 SP 3 SP SOLUTION SOLUTION RECONSTITUTED 3 GM HYCAMTIN LEUKERAN ORAL INTRAVENOUS 2 3 SP TABLET SOLUTION RECONSTITUTED melphalan hcl intravenous 1 or 1b* SP HYCAMTIN ORAL solution reconstituted 2 PA; QL; SP CAPSULE melphalan oral tablet 1 or 1b* SP irinotecan hcl intravenous 1 or 1b* SP *NITROSOUREAS*** solution BICNU INTRAVENOUS ONIVYDE SOLUTION 3 SP INTRAVENOUS 3 LD RECONSTITUTED INJECTABLE carmustine intravenous 1 or 1b* SP TOPOTECAN HCL solution reconstituted INTRAVENOUS 3 SP GLEOSTINE ORAL SOLUTION CAPSULE 10 MG, 100 3 PA; QL topotecan hcl intravenous 1 or 1b* SP MG, 40 MG solution reconstituted GLIADEL WAFER 3 *URINARY TRACT IMPLANT WAFER PROTECTIVE ZANOSAR AGENTS*** INTRAVENOUS 3 SP ETHYOL SOLUTION INTRAVENOUS 3 PA; QL; SP RECONSTITUTED SOLUTION RECONSTITUTED mesna intravenous solution 1 or 1b* PA; QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 59 Drug Name Tier Notes Drug Name Tier Notes MESNEX trihexyphenidyl hcl oral 1 or 1a* INTRAVENOUS 3 PA; QL tablet SOLUTION *ANTIPARKINSON MESNEX ORAL TABLET 2 PA; QL DOPAMINERGICS*** *VASCULAR amantadine hcl oral capsule 1 or 1b* ENDOTHELIAL amantadine hcl oral syrup 1 or 1b* GROWTH FACTOR (VEGF) INHIBITORS*** amantadine hcl oral tablet 1 or 1b* bromocriptine mesylate oral AVASTIN 1 or 1b* INTRAVENOUS 3 PA; QL; SP capsule SOLUTION bromocriptine mesylate oral 1 or 1b* CYRAMZA tablet INTRAVENOUS 3 PA; QL; LD; SP GOCOVRI ORAL SOLUTION CAPSULE EXTENDED 3 PA; QL; LD MVASI INTRAVENOUS RELEASE 24 HOUR 137 3 PA; QL; LD; SP SOLUTION MG ZALTRAP GOCOVRI ORAL CAPSULE EXTENDED INTRAVENOUS 3 PA; QL; LD; SP 3 PA; DO; QL; LD SOLUTION RELEASE 24 HOUR 68.5 MG ZIRABEV INBRIJA INHALATION INTRAVENOUS 3 PA; QL; LD; SP 3 PA; QL; LD; SP SOLUTION CAPSULE *ANTI-OBESITY - GLP-1 OSMOLEX ER ORAL TABLET EXTENDED RECEPTOR 3 PA; DO; QL; LD AGONISTS*** RELEASE 24 HOUR 129 MG *ANTI-OBESITY - GLP-1 RECEPTOR OSMOLEX ER ORAL TABLET EXTENDED AGONISTS*** 3 PA; QL; LD RELEASE 24 HOUR 193 SAXENDA MG, 258 MG SUBCUTANEOUS 3 PA; QL PARLODEL ORAL SOLUTION PEN- 3 INJECTOR CAPSULE PARLODEL ORAL *ANTI-OBESITY AGENT 3 COMBINATIONS** TABLET *ANTI-OBESITY AGENT *ANTIPARKINSON COMBINATIONS** MONOAMINE OXIDASE INHIBITORS*** CONTRAVE ORAL AZILECT ORAL TABLET EXTENDED 3 PA; QL 3 RELEASE 12 HOUR TABLET rasagiline mesylate oral *ANTIPARKINSON 1 or 1b* AGENTS* tablet *ANTIPARKINSON selegiline hcl oral capsule 1 or 1b* ANTICHOLINERGICS*** selegiline hcl oral tablet 1 or 1b* benztropine mesylate 1 or 1a* XADAGO ORAL TABLET 3 PA; QL injection solution ZELAPAR ORAL benztropine mesylate oral 3 PA; QL 1 or 1a* TABLET DISPERSIBLE tablet *CENTRAL/PERIPHERA COGENTIN INJECTION 3 L COMT INHIBITORS*** SOLUTION TASMAR ORAL TABLET trihexyphenidyl hcl oral 3 PA; QL 1 or 1a* 100 MG solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 60 Drug Name Tier Notes Drug Name Tier Notes tolcapone oral tablet 1 or 1b* PA; QL NEUPRO *DECARBOXYLASE TRANSDERMAL PATCH 3 INHIBITORS*** 24 HOUR carbidopa oral tablet 1 or 1b* pramipexole dihydrochloride er oral tablet extended 1 or 1b* LODOSYN ORAL 3 release 24 hour TABLET pramipexole dihydrochloride 1 or 1b* *LEVODOPA oral tablet COMBINATIONS*** REQUIP XL ORAL carbidopa-levodopa er oral TABLET EXTENDED 3 tablet extended release 25- 1 or 1b* RELEASE 24 HOUR 12 100 mg, 50-200 mg MG, 6 MG carbidopa-levodopa oral ropinirole hcl er oral tablet 1 or 1b* 1 or 1b* tablet extended release 24 hour carbidopa-levodopa oral 1 or 1b* ropinirole hcl oral tablet 1 or 1b* tablet dispersible *PERIPHERAL COMT carbidopa-levodopa- 1 or 1b* INHIBITORS*** entacapone oral tablet COMTAN ORAL DUOPA ENTERAL 3 3 PA; QL; LD TABLET SUSPENSION entacapone oral tablet 1 or 1b* RYTARY ORAL CAPSULE EXTENDED 3 *ANTIPSYCHOTICS/ANT RELEASE IMANIC AGENTS* SINEMET ORAL *ANTIMANIC 3 TABLET AGENTS*** STALEVO 100 ORAL lithium carbonate er oral 3 1 or 1a* TABLET tablet extended release STALEVO 125 ORAL lithium carbonate oral 3 1 or 1a* TABLET capsule STALEVO 150 ORAL lithium carbonate oral tablet 1 or 1a* 3 TABLET LITHIUM ORAL 2 STALEVO 200 ORAL SOLUTION 3 TABLET LITHOBID ORAL STALEVO 50 ORAL TABLET EXTENDED 2 3 TABLET RELEASE STALEVO 75 ORAL *ANTIPSYCHOTICS - 3 TABLET MISC.*** CAPLYTA ORAL *NONERGOLINE 3 ST; QL DOPAMINE RECEPTOR CAPSULE AGONISTS*** EQUETRO ORAL APOKYN CAPSULE EXTENDED 3 SUBCUTANEOUS 3 PA; QL; LD; SP RELEASE 12 HOUR SOLUTION CARTRIDGE GEODON INTRAMUSCULAR MIRAPEX ER ORAL 2 TABLET EXTENDED 3 SOLUTION RELEASE 24 HOUR RECONSTITUTED GEODON ORAL MIRAPEX ORAL 3 ST; QL TABLET 0.125 MG, 0.5 CAPSULE 3 MG, 0.75 MG, 1 MG, 1.5 LATUDA ORAL TABLET 3 MG NUPLAZID ORAL 3 PA; QL; LD; SP CAPSULE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 61 Drug Name Tier Notes Drug Name Tier Notes NUPLAZID ORAL haloperidol decanoate 3 PA; QL; LD; SP TABLET 10 MG intramuscular solution 100 1 or 1b* VRAYLAR ORAL mg/ml, 50 mg/ml 3 ST; QL CAPSULE haloperidol lactate injection 1 or 1b* VRAYLAR ORAL solution 5 mg/ml CAPSULE THERAPY 3 ST; QL haloperidol lactate oral 1 or 1b* PACK concentrate ziprasidone hcl oral capsule 1 or 1b* haloperidol oral tablet 1 or 1b* ziprasidone mesylate *DIBENZODIAZEPINES* intramuscular solution 1 or 1b* ** reconstituted clozapine oral tablet 1 or 1b* *BENZISOXAZOLES*** clozapine oral tablet 1 or 1b* FANAPT ORAL TABLET 3 ST; QL dispersible FANAPT TITRATION CLOZARIL ORAL 3 ST; QL 2 PACK ORAL TABLET TABLET INVEGA ORAL TABLET VERSACLOZ ORAL 3 EXTENDED RELEASE 24 3 ST; QL SUSPENSION HOUR *DIBENZO-OXEPINO INVEGA SUSTENNA PYRROLES*** INTRAMUSCULAR SAPHRIS SUBLINGUAL 3 3 ST; QL SUSPENSION TABLET SUBLINGUAL PREFILLED SYRINGE SECUADO INVEGA TRINZA TRANSDERMAL PATCH 3 ST; QL INTRAMUSCULAR 3 24 HOUR SUSPENSION PREFILLED SYRINGE *DIBENZOTHIAZEPINE S*** paliperidone er oral tablet 1 or 1b* extended release 24 hour quetiapine fumarate er oral tablet extended release 24 1 or 1b* PERSERIS hour SUBCUTANEOUS 3 quetiapine fumarate oral PREFILLED SYRINGE 1 or 1b* tablet RISPERDAL CONSTA INTRAMUSCULAR SEROQUEL ORAL 2 3 ST; QL SUSPENSION TABLET RECONSTITUTED ER SEROQUEL XR ORAL RISPERDAL ORAL TABLET EXTENDED 3 ST; QL 3 ST; QL SOLUTION RELEASE 24 HOUR RISPERDAL ORAL *DIBENZOXAZEPINES** TABLET 0.5 MG, 1 MG, 2 3 ST; QL * MG, 3 MG, 4 MG ADASUVE INHALATION risperidone oral solution 1 or 1b* ST; QL AEROSOL POWDER 3 BREATH ACTIVATED risperidone oral tablet 1 or 1b* loxapine succinate oral risperidone oral tablet 1 or 1b* 1 or 1b* capsule dispersible *DIHYDROINDOLONES* *BUTYROPHENONES*** ** HALDOL DECANOATE molindone hcl oral tablet 1 or 1b* INTRAMUSCULAR 3 SOLUTION HALDOL INJECTION 3 SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 62 Drug Name Tier Notes Drug Name Tier Notes *PHENOTHIAZINES*** *THIENBENZODIAZEPI CHLORPROMAZINE NES*** HCL INJECTION 3 olanzapine intramuscular 1 or 1b* SOLUTION solution reconstituted chlorpromazine hcl oral olanzapine oral tablet 1 or 1b* 1 or 1b* tablet olanzapine oral tablet 1 or 1b* compro rectal suppository 1 or 1b* dispersible fluphenazine decanoate ZYPREXA 1 or 1b* injection solution INTRAMUSCULAR 3 fluphenazine hcl injection SOLUTION 1 or 1b* solution RECONSTITUTED fluphenazine hcl oral ZYPREXA ORAL 1 or 1b* 3 ST; QL concentrate TABLET fluphenazine hcl oral elixir 1 or 1b* ZYPREXA RELPREVV INTRAMUSCULAR 3 fluphenazine hcl oral tablet 1 or 1b* SUSPENSION perphenazine oral tablet 1 or 1b* RECONSTITUTED ZYPREXA ZYDIS ORAL prochlorperazine edisylate 3 ST; QL injection solution 10 mg/2ml, 1 or 1b* TABLET DISPERSIBLE 50 mg/10ml *THIOXANTHENES*** prochlorperazine maleate 1 or 1a* thiothixene oral capsule 1 or 1b* oral tablet *ANTIRETROVIRALS - prochlorperazine rectal 1 or 1b* CD4-DIRECTED POST- suppository ATTACHMENT thioridazine hcl oral tablet 1 or 1b* INHIBITOR*** trifluoperazine hcl oral tablet 1 or 1b* *ANTIRETROVIRALS - CD4-DIRECTED POST- *QUINOLINONE ATTACHMENT DERIVATIVES*** INHIBITOR*** ABILIFY MAINTENA TROGARZO INTRAMUSCULAR 3 INTRAVENOUS 3 PA; QL; LD PREFILLED SYRINGE SOLUTION ABILIFY MAINTENA *ANTIRETROVIRALS INTRAMUSCULAR 3 ADJUVANTS*** SUSPENSION RECONSTITUTED ER *ANTIRETROVIRALS ADJUVANTS*** ABILIFY MYCITE ORAL 3 ST; QL TABLET TYBOST ORAL TABLET 3 QL ABILIFY ORAL TABLET 3 ST; QL *ANTISENSE OLIGONUCLEOTIDE aripiprazole oral solution 1 or 1b* (ASO) INHIBITOR aripiprazole oral tablet 1 or 1b* AGENTS*** aripiprazole oral tablet *ANTISENSE 1 or 1b* dispersible OLIGONUCLEOTIDE ARISTADA INITIO (ASO) INHIBITOR INTRAMUSCULAR 3 AGENTS*** PREFILLED SYRINGE TEGSEDI SUBCUTANEOUS ARISTADA 3 PA; QL; LD INTRAMUSCULAR 3 SOLUTION PREFILLED PREFILLED SYRINGE SYRINGE REXULTI ORAL 3 ST; QL TABLET * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 63 Drug Name Tier Notes Drug Name Tier Notes *ANTISEPTICS & GENVOYA ORAL 2 QL DISINFECTANTS* TABLET *ANTISEPTICS & JULUCA ORAL TABLET 3 PA; QL DISINFECTANTS*** KALETRA ORAL 3 QL formaldehyde external SOLUTION 1 or 1b* solution 10 % KALETRA ORAL 2 QL FORMALDEHYDE TABLET EXTERNAL SOLUTION 3 lamivudine-zidovudine oral 1 or 1b* QL 37 % tablet GLUTARALDEHYDE lopinavir-ritonavir oral 2 1 or 1b* QL EXTERNAL SOLUTION solution *CHLORINE ODEFSEY ORAL 3 PA; QL ANTISEPTICS*** TABLET BENZALKONIUM PREZCOBIX ORAL 3 QL CHLORIDE EXTERNAL 3 TABLET SOLUTION , 50 % STRIBILD ORAL 2 QL *IODINE TABLET ANTISEPTICS*** SYMFI LO ORAL 2 QL IODINE TINCTURE TABLET EXTERNAL TINCTURE 2 3 % SYMFI ORAL TABLET 2 QL IODOFLEX EXTERNAL SYMTUZA ORAL 3 3 QL PAD TABLET IODOSORB EXTERNAL TEMIXYS ORAL 3 3 QL GEL TABLET TRIUMEQ ORAL *ANTIVIRALS* 2 TABLET *ANTIRETROVIRAL TRIZIVIR ORAL COMBINATIONS*** 3 QL TABLET abacavir sulfate-lamivudine 1 or 1b* QL oral tablet TRUVADA ORAL TABLET 100-150 MG, 2 QL abacavir-lamivudine- 1 or 1b* QL 133-200 MG, 167-250 MG zidovudine oral tablet *ANTIRETROVIRALS - ATRIPLA ORAL 2 ST; QL CCR5 ANTAGONISTS TABLET (ENTRY INHIBITOR)*** BIKTARVY ORAL SELZENTRY ORAL 2 QL 3 QL TABLET SOLUTION CIMDUO ORAL TABLET 3 QL SELZENTRY ORAL 2 QL COMBIVIR ORAL TABLET 3 QL TABLET *ANTIRETROVIRALS - COMPLERA ORAL FUSION INHIBITORS*** 2 PA; QL TABLET FUZEON DELSTRIGO ORAL SUBCUTANEOUS 3 QL 2 PA; QL TABLET SOLUTION DESCOVY ORAL RECONSTITUTED 3 ST; QL TABLET *ANTIRETROVIRALS - DOVATO ORAL TABLET 3 PA; QL INTEGRASE INHIBITORS*** EPZICOM ORAL 3 QL ISENTRESS HD ORAL TABLET 3 QL TABLET EVOTAZ ORAL TABLET 3 QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 64 Drug Name Tier Notes Drug Name Tier Notes ISENTRESS ORAL efavirenz oral tablet 1 or 1b* QL 3 QL PACKET INTELENCE ORAL 2 PA; QL ISENTRESS ORAL TABLET 2 QL TABLET nevirapine er oral tablet ISENTRESS ORAL extended release 24 hour 100 1 or 1b* 2 QL TABLET CHEWABLE mg TIVICAY ORAL TABLET 3 QL nevirapine er oral tablet *ANTIRETROVIRALS - extended release 24 hour 400 1 or 1b* QL PROTEASE mg INHIBITORS*** nevirapine oral suspension 1 or 1b* QL APTIVUS ORAL nevirapine oral tablet 1 or 1b* QL 2 PA; QL CAPSULE PIFELTRO ORAL 3 QL APTIVUS ORAL TABLET 2 PA; QL SOLUTION SUSTIVA ORAL 3 QL atazanavir sulfate oral CAPSULE 1 or 1b* QL capsule SUSTIVA ORAL TABLET 3 QL CRIXIVAN ORAL VIRAMUNE ORAL 3 QL CAPSULE 200 MG, 400 2 QL SUSPENSION MG VIRAMUNE ORAL fosamprenavir calcium oral 3 QL 1 or 1b* QL TABLET tablet VIRAMUNE XR ORAL INVIRASE ORAL TABLET EXTENDED 2 QL 3 QL TABLET RELEASE 24 HOUR 400 LEXIVA ORAL MG 2 QL SUSPENSION *ANTIRETROVIRALS - LEXIVA ORAL TABLET 3 QL RTI-NUCLEOSIDE NORVIR ORAL PACKET 3 QL ANALOGUES- PURINES*** NORVIR ORAL 2 QL SOLUTION abacavir sulfate oral solution 1 or 1b* QL NORVIR ORAL TABLET 3 QL abacavir sulfate oral tablet 1 or 1b* QL PREZISTA ORAL didanosine oral capsule 2 QL SUSPENSION delayed release 200 mg, 250 1 or 1b* QL mg PREZISTA ORAL didanosine oral capsule TABLET 150 MG, 600 2 QL 1 or 1b* MG, 75 MG, 800 MG delayed release 400 mg ZIAGEN ORAL REYATAZ ORAL 3 QL CAPSULE 150 MG, 200 3 QL SOLUTION MG, 300 MG ZIAGEN ORAL TABLET 3 QL REYATAZ ORAL *ANTIRETROVIRALS - 2 QL PACKET RTI-NUCLEOSIDE ritonavir oral tablet 1 or 1b* QL ANALOGUES- PYRIMIDINES*** VIRACEPT ORAL 2 QL EMTRIVA ORAL TABLET 2 QL SOLUTION *ANTIRETROVIRALS - EPIVIR ORAL RTI-NON-NUCLEOSIDE 3 QL ANALOGUES*** SOLUTION EDURANT ORAL EPIVIR ORAL TABLET 3 QL 2 PA; QL TABLET lamivudine oral solution 1 or 1b* QL efavirenz oral capsule 1 or 1b* QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 65 Drug Name Tier Notes Drug Name Tier Notes lamivudine oral tablet 150 VALCYTE ORAL 1 or 1b* QL mg, 300 mg SOLUTION 3 *ANTIRETROVIRALS - RECONSTITUTED RTI-NUCLEOSIDE VALCYTE ORAL 3 ANALOGUES- TABLET THYMIDINES*** valganciclovir hcl oral 1 or 1b* RETROVIR solution reconstituted INTRAVENOUS 2 valganciclovir hcl oral tablet 1 or 1b* SOLUTION *HEPATITIS B RETROVIR ORAL 3 QL AGENTS*** CAPSULE adefovir dipivoxil oral tablet 1 or 1b* SP RETROVIR ORAL 3 QL BARACLUDE ORAL SYRUP 2 SOLUTION stavudine oral capsule 1 or 1b* QL BARACLUDE ORAL 3 zidovudine oral capsule 1 or 1b* QL TABLET zidovudine oral syrup 1 or 1b* QL entecavir oral tablet 1 or 1b* zidovudine oral tablet 1 or 1b* QL EPIVIR HBV ORAL 3 *ANTIRETROVIRALS - SOLUTION RTI-NUCLEOTIDE EPIVIR HBV ORAL 3 ANALOGUES*** TABLET VIREAD ORAL POWDER 2 HEPSERA ORAL 3 SP VIREAD ORAL TABLET TABLET 2 150 MG, 200 MG, 250 MG lamivudine oral tablet 100 1 or 1b* VIREAD ORAL TABLET mg 3 300 MG VEMLIDY ORAL 3 SP *CMV AGENTS*** TABLET cidofovir intravenous *HEPATITIS C 1 or 1b* solution AGENTS*** CYTOVENE PEGASYS PROCLICK INTRAVENOUS SUBCUTANEOUS 3 SP 3 SP SOLUTION SOLUTION 180 RECONSTITUTED MCG/0.5ML FOSCAVIR PEGASYS INTRAVENOUS SUBCUTANEOUS 3 SP 3 SOLUTION 6000 SOLUTION MG/250ML PEGINTRON GANCICLOVIR SUBCUTANEOUS KIT 50 3 SP INTRAVENOUS 3 SP MCG/0.5ML SOLUTION ribavirin oral capsule 1 or 1b* SP GANCICLOVIR SODIUM ribavirin oral tablet 200 mg 1 or 1b* SP INTRAVENOUS 3 SP SOVALDI ORAL SOLUTION 3 PA; QL TABLET 200 MG ganciclovir sodium SOVALDI ORAL intravenous solution 1 or 1b* SP 3 PA; QL; SP reconstituted TABLET 400 MG PREVYMIS *HERPES AGENTS - INTRAVENOUS 3 PA; QL; SP PURINE SOLUTION ANALOGUES*** PREVYMIS ORAL acyclovir oral capsule 1 or 1b* 3 PA; QL; SP TABLET acyclovir oral suspension 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 66 Drug Name Tier Notes Drug Name Tier Notes acyclovir oral tablet 1 or 1b* *ANTI-VON acyclovir sodium intravenous WILLEBRAND FACTOR 1 or 1b* solution AGENTS*** SITAVIG BUCCAL *ANTI-VON 3 PA; QL TABLET WILLEBRAND FACTOR AGENTS*** valacyclovir hcl oral tablet 1 or 1b* CABLIVI INJECTION VALTREX ORAL 3 PA; QL; LD 3 KIT TABLET *ASSORTED CLASSES* ZOVIRAX ORAL 3 SUSPENSION *ANTILEPROTICS*** THALOMID ORAL *HERPES AGENTS - 2 PA; QL; SP THYMIDINE CAPSULE ANALOGUES*** *ASSORTED famciclovir oral tablet 1 or 1b* CLASSES*** NEXAVIR INJECTION *INFLUENZA 3 AGENTS*** SOLUTION PHENOL INJECTION rimantadine hcl oral tablet 1 or 1b* 3 SOLUTION *NEURAMINIDASE INHIBITORS*** *B-LYMPHOCYTE STIMULATOR (BLYS)- oseltamivir phosphate oral 1 or 1b* QL SPECIFIC capsule INHIBITORS*** oseltamivir phosphate oral 1 or 1b* QL BENLYSTA suspension reconstituted INTRAVENOUS 3 PA; QL; LD; SP RAPIVAB SOLUTION INTRAVENOUS 3 RECONSTITUTED SOLUTION BENLYSTA SUBCUTANEOUS RELENZA DISKHALER 3 PA; QL; LD; SP INHALATION AEROSOL SOLUTION AUTO- 2 QL POWDER BREATH INJECTOR ACTIVATED BENLYSTA TAMIFLU ORAL SUBCUTANEOUS 3 QL 3 PA; QL; LD; SP CAPSULE SOLUTION PREFILLED SYRINGE TAMIFLU ORAL SUSPENSION *CHELATING 3 QL RECONSTITUTED 6 AGENTS*** MG/ML clovique oral capsule 1 or 1b* PA; QL; SP *RSV AGENTS - CUPRIMINE ORAL 3 PA; QL NUCLEOSIDE CAPSULE 250 MG ANALOGUES*** DEPEN TITRATABS ribavirin inhalation solution 3 PA; QL 1 or 1b* ORAL TABLET reconstituted EDETATE DISODIUM VIRAZOLE INTRAVENOUS 3 INHALATION 3 SOLUTION SOLUTION RECONSTITUTED penicillamine oral tablet 1 or 1b* PA; QL SYPRINE ORAL 3 PA; QL; SP CAPSULE trientine hcl oral capsule 1 or 1b* PA; QL; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 67 Drug Name Tier Notes Drug Name Tier Notes *CONTINUOUS RENAL VITRASE INJECTION 3 REPLACEMENT SOLUTION THERAPY (CRRT) XIAFLEX INJECTION SOLUTIONS*** SOLUTION 3 PA; QL; LD PRISMASOL B22GK 4/0 RECONSTITUTED INTRAVENOUS 3 *FECAL SOLUTION INCONTINENCE PRISMASOL BGK 0/2.5 BULKING AGENT - INTRAVENOUS 3 COMBINATIONS*** SOLUTION SOLESTA INJECTION 3 LD; SP PRISMASOL BGK 2/0 GEL INTRAVENOUS 3 *HOMEOPATHIC SOLUTION PRODUCTS*** PRISMASOL BGK 2/3.5 ACUNOL ORAL TABLET 3 INTRAVENOUS 3 BHI URI-CONTROL SOLUTION 3 ORAL TABLET PRISMASOL BGK 4/2.5 COLCIGEL EXTERNAL INTRAVENOUS 3 3 SOLUTION GEL ECZEMOL ORAL PRISMASOL BK 0/0/1.2 3 INTRAVENOUS 3 TABLET SOLUTION ENGYSTOL INJECTION 3 *CYCLOSPORINE INJECTABLE ANALOGS*** HYLAFEM VAGINAL 3 cyclosporine intravenous SUPPOSITORY 1 or 1b* SP solution LYMPHOMYOSOT X cyclosporine modified oral INJECTION 3 1 or 1b* capsule INJECTABLE cyclosporine modified oral MORCIN EXTERNAL 1 or 1b* 3 solution CREAM cyclosporine oral capsule 1 or 1b* NEURALGO-RHEUM INJECTION 3 gengraf oral capsule 100 mg, 1 or 1b* INJECTABLE 25 mg PSORIZIDE FORTE 3 gengraf oral solution 1 or 1b* ORAL TABLET NEORAL ORAL PSORIZIDE ULTRA 2 3 CAPSULE ORAL TABLET NEORAL ORAL RAPID GEL RX 2 3 SOLUTION EXTERNAL GEL SANDIMMUNE SPASCUPREEL INTRAVENOUS 3 SP INJECTION 3 SOLUTION INJECTABLE SANDIMMUNE ORAL SPEEDGEL RX 2 3 CAPSULE EXTERNAL GEL SANDIMMUNE ORAL TRANZGEL EXTERNAL 2 3 SOLUTION GEL *ENZYMES*** TRAUMEEL EXTERNAL 3 AMPHADASE OINTMENT 3 INJECTION SOLUTION TRAUMEEL INJECTION 3 HYLENEX INJECTION INJECTABLE 3 SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 68 Drug Name Tier Notes Drug Name Tier Notes TRAUMEEL ORAL *IRRIGATION 3 TABLET SOLUTIONS*** WELLMIND VERTIGO argyle sterile water irrigation 3 1 or 1b* ORAL TABLET solution ZEEL INJECTION lactated ringers irrigation 3 1 or 1b* INJECTABLE solution *IMMUNE GLOBULIN physiolyte irrigation solution 1 or 1b* IMMUNOSUPPRESSANT physiosol irrigation irrigation 1 or 1b* S*** solution ATGAM INTRAVENOUS ringers irrigation irrigation 3 SP 1 or 1b* INJECTABLE solution THYMOGLOBULIN sterile water for irrigation INTRAVENOUS 1 or 1b* 3 SP irrigation solution SOLUTION RECONSTITUTED tis-u-sol irrigation solution 1 or 1b* water for irrigation, sterile *IMMUNOMODULATOR 1 or 1b* S FOR irrigation solution MYELODYSPLASTIC *MACROLIDE SYNDROMES*** IMMUNOSUPPRESSANT REVLIMID ORAL S*** 2 PA; QL; LD; SP CAPSULE ASTAGRAF XL ORAL *INOSINE CAPSULE EXTENDED 3 MONOPHOSPHATE RELEASE 24 HOUR DEHYDROGENASE ENVARSUS XR ORAL INHIBITORS*** TABLET EXTENDED 3 CELLCEPT RELEASE 24 HOUR INTRAVENOUS everolimus oral tablet 0.25 1 or 1b* INTRAVENOUS 3 SP mg, 0.5 mg, 0.75 mg SOLUTION RECONSTITUTED PROGRAF INTRAVENOUS 2 SP CELLCEPT ORAL 2 SOLUTION CAPSULE PROGRAF ORAL 2 CELLCEPT ORAL CAPSULE SUSPENSION 2 PROGRAF ORAL RECONSTITUTED 3 PACKET CELLCEPT ORAL 2 RAPAMUNE ORAL TABLET 3 SOLUTION mycophenolate mofetil hcl RAPAMUNE ORAL intravenous solution 1 or 1b* SP 2 reconstituted TABLET mycophenolate mofetil oral sirolimus oral solution 1 or 1b* 1 or 1b* capsule sirolimus oral tablet 1 or 1b* mycophenolate mofetil oral tacrolimus oral capsule 1 or 1b* 1 or 1b* suspension reconstituted ZORTRESS ORAL 2 mycophenolate mofetil oral TABLET 1 or 1b* tablet *MONOCLONAL mycophenolate sodium oral ANTIBODIES*** 1 or 1b* tablet delayed release GAMIFANT MYFORTIC ORAL INTRAVENOUS 3 PA; QL; LD; SP TABLET DELAYED 3 SOLUTION RELEASE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 69 Drug Name Tier Notes Drug Name Tier Notes SIMULECT ULTRABAG/DIANEAL INTRAVENOUS PD-2/1.5% DEX 3 SP 3 SOLUTION INTRAPERITONEAL RECONSTITUTED SOLUTION *PERITONIAL DIALYSIS ULTRABAG/DIANEAL SOLUTIONS*** PD-2/2.5% DEX 3 DELFLEX-LC/1.5% INTRAPERITONEAL DEXTROSE SOLUTION 3 INTRAPERITONEAL ULTRABAG/DIANEAL SOLUTION 344 MOSM/L PD-2/4.25%DEX 3 DELFLEX-LC/2.5% INTRAPERITONEAL DEXTROSE SOLUTION 3 INTRAPERITONEAL ULTRABAG/DIANEAL/1. SOLUTION 5% DEXTROSE 3 DELFLEX-LC/4.25% INTRAPERITONEAL DEXTROSE SOLUTION 3 INTRAPERITONEAL ULTRABAG/DIANEAL/2. SOLUTION 5% DEXTROSE 3 DELFLEX-SM/1.5% INTRAPERITONEAL DEXTROSE SOLUTION 2 INTRAPERITONEAL ULTRABAG/DIANEAL/4. SOLUTION 25% DEX 3 DELFLEX-SM/2.5% INTRAPERITONEAL DEXTROSE SOLUTION 3 INTRAPERITONEAL *POTASSIUM SOLUTION REMOVING RESINS*** DIANEAL LOW kionex oral suspension 1 or 1b* CALCIUM/1.5% DEX LOKELMA ORAL 3 3 INTRAPERITONEAL PACKET SOLUTION sodium polystyrene sulfonate 1 or 1b* DIANEAL LOW oral powder CALCIUM/2.5% DEX 3 sodium polystyrene sulfonate INTRAPERITONEAL 1 or 1b* SOLUTION oral suspension sodium polystyrene sulfonate DIANEAL LOW 1 or 1b* CALCIUM/4.25% DEX rectal suspension 3 INTRAPERITONEAL sps oral suspension 1 or 1b* SOLUTION VELTASSA ORAL 3 LD DIANEAL PD-2/1.5% PACKET DEXTROSE 3 *PROSTAGLANDINS*** INTRAPERITONEAL SOLUTION alprostadil injection solution 1 or 1b* DIANEAL PD-2/2.5% PROSTIN VR 3 DEXTROSE INJECTION SOLUTION 3 INTRAPERITONEAL *PURINE ANALOGS*** SOLUTION AZASAN ORAL TABLET 2 DIANEAL PD-2/4.25% DEXTROSE azathioprine oral tablet 1 or 1b* 3 INTRAPERITONEAL AZATHIOPRINE SOLUTION SODIUM INJECTION 3 EXTRANEAL SOLUTION INTRAPERITONEAL 3 RECONSTITUTED SOLUTION IMURAN ORAL TABLET 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 70 Drug Name Tier Notes Drug Name Tier Notes *SCLEROSING carvedilol phosphate er oral AGENTS*** capsule extended release 24 1 or 1b* ASCLERA hour INTRAVENOUS 3 COREG CR ORAL SOLUTION CAPSULE EXTENDED 3 ETHAMOLIN RELEASE 24 HOUR INTRAVENOUS 3 COREG ORAL TABLET 3 SOLUTION LABETALOL HCL POLIDOCANOL INTRAVENOUS 3 INTRAVENOUS 3 SOLUTION SOLUTION labetalol hcl oral tablet 1 or 1b* sodium tetradecyl sulfate 1 or 1b* *BETA BLOCKERS intravenous solution CARDIO-SELECTIVE*** SOTRADECOL acebutolol hcl oral capsule 1 or 1b* INTRAVENOUS 3 SOLUTION 1 % atenolol oral tablet 1 or 1a* sotradecol intravenous ATENOLOL+SYRSPEND 1 or 1b* 3 solution 3 % SF ORAL SUSPENSION VARITHENA betaxolol hcl oral tablet 1 or 1b* 3 LD INTRAVENOUS FOAM bisoprolol fumarate oral 1 or 1b* *SELECTIVE T-CELL tablet COSTIMULATION BREVIBLOC IN NACL BLOCKERS*** INTRAVENOUS 3 NULOJIX SOLUTION INTRAVENOUS 3 PA; QL; SP BREVIBLOC SOLUTION INTRAVENOUS 3 RECONSTITUTED SOLUTION 100 MG/10ML *ATOPIC DERMATITIS - BREVIBLOC PREMIXED MONOCLONAL DS INTRAVENOUS 3 ANTIBODIES*** SOLUTION *ATOPIC DERMATITIS - BREVIBLOC PREMIXED MONOCLONAL INTRAVENOUS 3 ANTIBODIES*** SOLUTION DUPIXENT BYSTOLIC ORAL SUBCUTANEOUS 3 3 PA; QL; SP TABLET SOLUTION PREFILLED esmolol hcl intravenous SYRINGE 1 or 1b* solution 100 mg/10ml *BACTERIAL MONOCLONAL ESMOLOL HCL ANTIBODIES*** INTRAVENOUS SOLUTION 2000 3 *BACTERIAL MG/100ML, 2500 MONOCLONAL MG/250ML ANTIBODIES*** esmolol hcl-sodium chloride 1 or 1b* ZINPLAVA intravenous solution INTRAVENOUS 3 PA; QL FIRST - METOPROLOL SOLUTION 3 ORAL SOLUTION *BETA BLOCKERS* KAPSPARGO SPRINKLE *ALPHA-BETA ORAL CAPSULE ER 24 3 BLOCKERS*** HOUR SPRINKLE carvedilol oral tablet 1 or 1b* LOPRESSOR ORAL 3 TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 71 Drug Name Tier Notes Drug Name Tier Notes metoprolol succinate er oral sotalol hcl oral tablet 1 or 1b* tablet extended release 24 1 or 1b* SOTYLIZE ORAL 3 hour SOLUTION metoprolol tartrate timolol maleate oral tablet 1 or 1b* intravenous solution 5 1 or 1a* mg/5ml *BILE ACID SYNTHESIS DISORDER AGENTS*** metoprolol tartrate intravenous solution 1 or 1a* *BILE ACID SYNTHESIS cartridge DISORDER AGENTS*** CHOLBAM ORAL metoprolol tartrate oral tablet 1 or 1a* 3 PA; QL; LD CAPSULE TENORMIN ORAL 3 TABLET *BIOLOGICALS MISC* TOPROL XL ORAL *ALLERGENIC TABLET EXTENDED 3 EXTRACTS*** RELEASE 24 HOUR ACACIA *BETA BLOCKERS NON- SUBCUTANEOUS 3 SELECTIVE*** SOLUTION BETAPACE AF ORAL ACREMONIUM 3 TABLET SUBCUTANEOUS 3 SOLUTION BETAPACE ORAL TABLET 120 MG, 160 3 ALDER MG, 80 MG SUBCUTANEOUS 3 SOLUTION CORGARD ORAL 3 TABLET ALTERNARIA SUBCUTANEOUS 3 HEMANGEOL ORAL 3 SOLUTION SOLUTION AMERICAN BEECH INDERAL LA ORAL SUBCUTANEOUS 3 CAPSULE EXTENDED 3 SOLUTION RELEASE 24 HOUR AMERICAN INDERAL XL ORAL COCKROACH 3 CAPSULE EXTENDED 3 SUBCUTANEOUS RELEASE 24 HOUR SOLUTION INNOPRAN XL ORAL AMERICAN ELM CAPSULE EXTENDED 3 SUBCUTANEOUS 3 RELEASE 24 HOUR SOLUTION nadolol oral tablet 20 mg, 40 1 or 1b* AMERICAN SYCAMORE mg, 80 mg SUBCUTANEOUS 3 pindolol oral tablet 1 or 1b* SOLUTION propranolol hcl er oral ARIZONA CYPRESS capsule extended release 24 1 or 1b* SUBCUTANEOUS 3 hour SOLUTION propranolol hcl intravenous AUREOBASIDIUM 1 or 1b* solution SUBCUTANEOUS 3 propranolol hcl oral solution 1 or 1b* SOLUTION propranolol hcl oral tablet 1 or 1b* AUSTRALIAN PINE SUBCUTANEOUS 3 sorine oral tablet 1 or 1b* SOLUTION sotalol hcl (af) oral tablet 1 or 1b* BAHIA SUBCUTANEOUS 3 SOTALOL HCL SOLUTION INTRAVENOUS 3 SOLUTION * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 72 Drug Name Tier Notes Drug Name Tier Notes BALD CYPRESS COCKLEBUR SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION BAYBERRY (WAX CORN POLLEN MYRTLE) SUBCUTANEOUS 3 3 SUBCUTANEOUS SOLUTION SOLUTION CURVULARIA BERMUDA GRASS SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION DANDELION BLACK WALNUT SUBCUTANEOUS 3 POLLEN SOLUTION 3 SUBCUTANEOUS DOG EPITHELIUM SOLUTION SUBCUTANEOUS 3 BLACK WILLOW SOLUTION SUBCUTANEOUS 3 DOG FENNEL SOLUTION SUBCUTANEOUS 3 BOTRYTIS SOLUTION SUBCUTANEOUS 3 DRECHSLERA SOLUTION SUBCUTANEOUS 3 BOX ELDER SOLUTION SUBCUTANEOUS 3 EASTERN SOLUTION COTTONWOOD 3 BROME SUBCUTANEOUS SUBCUTANEOUS 3 SOLUTION SOLUTION ENGLISH PLANTAIN CALIFORNIA PEPPER SUBCUTANEOUS 3 TREE SUBCUTANEOUS 3 SOLUTION SOLUTION EPICOCCUM CANDIDA ALBICANS SUBCUTANEOUS 3 EXTRACT INJECTION 3 SOLUTION SOLUTION FIRE ANT CANDIDA ALBICANS SUBCUTANEOUS 3 EXTRACT SOLUTION 3 SUBCUTANEOUS FUSARIUM SOLUTION SUBCUTANEOUS 3 CAT HAIR EXTRACT SOLUTION SUBCUTANEOUS 3 GERMAN COCKROACH SOLUTION SUBCUTANEOUS 3 CATTLE EPITHELIUM SOLUTION SUBCUTANEOUS 3 GOLDENROD SOLUTION SUBCUTANEOUS 3 CEDAR ELM SOLUTION SUBCUTANEOUS 3 GRASTEK SUBLINGUAL 3 PA; QL SOLUTION TABLET SUBLINGUAL CLADOSPORIUM HACKBERRY CLADOSPORIOIDES 3 SUBCUTANEOUS 3 SUBCUTANEOUS SOLUTION SOLUTION HONEY BEE VENOM CLADOSPORIUM PROTEIN INJECTION SPHAEROSPERMUM 3 3 SOLUTION SUBCUTANEOUS RECONSTITUTED SOLUTION * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 73 Drug Name Tier Notes Drug Name Tier Notes HONEY BEE VENOM MIXED VESPID VENOM SUBCUTANEOUS PROTEIN 3 SOLUTION SUBCUTANEOUS 3 RECONSTITUTED SOLUTION HORSE EPITHELIUM RECONSTITUTED SUBCUTANEOUS 3 MOUNTAIN CEDAR SOLUTION SUBCUTANEOUS 3 JOHNSON GRASS SOLUTION SUBCUTANEOUS 3 MOUSE EPITHELIUM SOLUTION SUBCUTANEOUS 3 JUNE GRASS POLLEN SOLUTION STANDARDIZED MUCOR 3 SUBCUTANEOUS SUBCUTANEOUS 3 SOLUTION SOLUTION KAPOK MUGWORT SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION KOCHIA OLIVE TREE SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION LAMBS QUARTERS ORCHARD GRASS SUBCUTANEOUS 3 POLLEN 3 SOLUTION SUBCUTANEOUS LENSCALE SOLUTION SUBCUTANEOUS 3 PALFORZIA (12 MG 3 PA; QL; SP SOLUTION DAILY DOSE) ORAL MEADOW FESCUE PALFORZIA (120 MG 3 PA; QL; SP GRASS POLLEN DAILY DOSE) ORAL 3 SUBCUTANEOUS PALFORZIA (160 MG 3 PA; QL; SP SOLUTION DAILY DOSE) ORAL MELALEUCA PALFORZIA (20 MG 3 PA; QL; SP SUBCUTANEOUS 3 DAILY DOSE) ORAL SOLUTION PALFORZIA (200 MG 3 PA; QL; SP MESQUITE DAILY DOSE) ORAL SUBCUTANEOUS 3 PALFORZIA (240 MG SOLUTION 3 PA; QL; SP DAILY DOSE) ORAL MITE (D. FARINAE) PALFORZIA (3 MG SUBCUTANEOUS 3 3 PA; QL; SP SOLUTION DAILY DOSE) ORAL MITE (D. PALFORZIA (300 MG PTERONYSSINUS) MAINTENANCE) ORAL 3 PA; QL; SP 3 SUBCUTANEOUS PACKET SOLUTION PALFORZIA (300 MG MIXED RAGWEED TITRATION) ORAL 3 PA; QL; SP SUBCUTANEOUS 3 PACKET SOLUTION PALFORZIA (40 MG 3 PA; QL; SP MIXED VESPID VENOM DAILY DOSE) ORAL PROTEIN INJECTION PALFORZIA (6 MG 3 3 PA; QL; SP SOLUTION DAILY DOSE) ORAL RECONSTITUTED PALFORZIA (80 MG 3 PA; QL; SP DAILY DOSE) ORAL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 74 Drug Name Tier Notes Drug Name Tier Notes PALFORZIA INITIAL ROUGH PIGWEED 3 PA; QL; SP ESCALATION ORAL SUBCUTANEOUS 3 PECAN POLLEN SOLUTION SUBCUTANEOUS 3 RUSSIAN THISTLE SOLUTION SUBCUTANEOUS 3 PENICILLIUM SOLUTION NOTATUM SACCHAROMYCES 3 SUBCUTANEOUS CEREVISIAE 3 SOLUTION SUBCUTANEOUS PERENNIAL RYE GRASS SOLUTION POLLEN SAGEBRUSH 3 SUBCUTANEOUS SUBCUTANEOUS 3 SOLUTION SOLUTION PHOMA EXIGUA SHAGBARK HICKORY SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION PRIVET SHEEP SORREL SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION QUEEN PALM SHORT RAGWEED SUBCUTANEOUS 3 POLLEN EXT 3 SOLUTION SUBCUTANEOUS RABBIT EPITHELIUM SOLUTION SUBCUTANEOUS 3 SPINY PIGWEED SOLUTION SUBCUTANEOUS 3 RAGWITEK SOLUTION SUBLINGUAL TABLET 3 PA; QL STEMPHYLIUM SUBLINGUAL SUBCUTANEOUS 3 RED BIRCH SOLUTION SUBCUTANEOUS 3 SWEET GUM SOLUTION SUBCUTANEOUS 3 RED CEDAR SOLUTION SUBCUTANEOUS 3 SWEET VERNAL GRASS SOLUTION POLLEN 3 RED MAPLE SUBCUTANEOUS SUBCUTANEOUS 3 SOLUTION SOLUTION TALL RAGWEED RED MULBERRY SUBCUTANEOUS 3 SUBCUTANEOUS 3 SOLUTION SOLUTION TIMOTHY GRASS RED TOP GRASS POLLEN ALLERGEN POLLEN SUBCUTANEOUS 3 3 SUBCUTANEOUS SOLUTION 10000 SOLUTION BAU/ML RHIZOPUS TIMOTHY GRASS SUBCUTANEOUS 3 POLLEN ALLERGEN SOLUTION SUBCUTANEOUS 3 PA; QL SOLUTION 100000 ROUGH MARSH ELDER BAU/ML SUBCUTANEOUS 3 SOLUTION TRICHOPHYTON SUBCUTANEOUS 3 SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 75 Drug Name Tier Notes Drug Name Tier Notes VENOMIL HONEY BEE WHITE-FACED HORNET 3 VENOM INJECTION KIT VENOM INJECTION 3 VENOMIL MIXED SOLUTION VESPID VENOM RECONSTITUTED 3 INJECTION SOLUTION YELLOW DOCK RECONSTITUTED SUBCUTANEOUS 3 VENOMIL WASP SOLUTION 3 VENOM INJECTION KIT YELLOW HORNET VENOMIL WHITE VENOM PROTEIN FACED HORNET 3 INJECTION SOLUTION 3 INJECTION KIT RECONSTITUTED 550 MCG VENOMIL YELLOW HORNET VENOM 3 YELLOW HORNET INJECTION KIT VENOM PROTEIN SUBCUTANEOUS 3 VENOMIL YELLOW SOLUTION JACKET VENOM 3 RECONSTITUTED INJECTION KIT YELLOW JACKET VIRGINIA LIVE OAK VENOM PROTEIN SUBCUTANEOUS 3 INJECTION SOLUTION 3 SOLUTION RECONSTITUTED 1300 WASP VENOM PROTEIN MCG, 550 MCG INJECTION SOLUTION 3 YELLOW JACKET RECONSTITUTED 1300 VENOM PROTEIN MCG, 550 MCG SUBCUTANEOUS 3 WASP VENOM PROTEIN SOLUTION SUBCUTANEOUS RECONSTITUTED 3 SOLUTION *CALCITONIN GENE- RECONSTITUTED RELATED PEPTIDE WESTERN JUNIPER (CGRP) RECEPTOR SUBCUTANEOUS 3 ANTAG*** SOLUTION *CALCITONIN GENE- WHITE ASH RELATED PEPTIDE SUBCUTANEOUS 3 (CGRP) RECEPTOR SOLUTION ANTAG*** WHITE BIRCH AIMOVIG SUBCUTANEOUS SUBCUTANEOUS 3 3 PA; QL SOLUTION SOLUTION AUTO- INJECTOR WHITE FACED HORNET VENOM AJOVY SUBCUTANEOUS SUBCUTANEOUS 3 3 PA; QL SOLUTION SOLUTION PREFILLED RECONSTITUTED SYRINGE WHITE MULBERRY EMGALITY (300 MG DOSE) SUBCUTANEOUS SUBCUTANEOUS 3 3 PA; QL SOLUTION SOLUTION PREFILLED SYRINGE WHITE OAK SUBCUTANEOUS 3 EMGALITY SUBCUTANEOUS SOLUTION 3 PA; QL SOLUTION AUTO- WHITE PINE INJECTOR SUBCUTANEOUS 3 SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 76 Drug Name Tier Notes Drug Name Tier Notes EMGALITY CARDIZEM CD ORAL SUBCUTANEOUS CAPSULE EXTENDED 3 PA; QL 3 SOLUTION PREFILLED RELEASE 24 HOUR 240 SYRINGE MG, 300 MG, 360 MG VYEPTI INTRAVENOUS CARDIZEM LA ORAL 3 PA; QL SOLUTION TABLET EXTENDED 3 DO *CALCITONIN GENE- RELEASE 24 HOUR 120 RELATED PEPTIDE MG, 180 MG RECEPTOR ANTAG CARDIZEM LA ORAL (CGRP)*** TABLET EXTENDED *CALCITONIN GENE- RELEASE 24 HOUR 240 3 RELATED PEPTIDE MG, 300 MG, 360 MG, 420 RECEPTOR ANTAG MG (CGRP)*** CARDIZEM ORAL NURTEC ORAL TABLET TABLET 120 MG, 30 MG, 3 3 ST; QL DISPERSIBLE 60 MG UBRELVY ORAL cartia xt oral capsule 3 ST; QL TABLET extended release 24 hour 120 1 or 1b* DO mg, 180 mg *CALCIUM CHANNEL BLOCKER-NSAID cartia xt oral capsule COMBINATIONS*** extended release 24 hour 240 1 or 1b* mg, 300 mg *CALCIUM CHANNEL BLOCKER-NSAID CLEVIPREX INTRAVENOUS COMBINATIONS*** 3 EMULSION 25 MG/50ML, CONSENSI ORAL 3 ST; QL 50 MG/100ML TABLET diltiazem hcl er beads oral *CALCIUM CHANNEL capsule extended release 24 1 or 1b* DO BLOCKERS* hour 120 mg, 180 mg, 360 *CALCIUM CHANNEL mg BLOCKERS*** diltiazem hcl er beads oral capsule extended release 24 AMLODIPINE 1 or 1b* BES+SYRSPEND SF 3 hour 240 mg, 300 mg, 420 ORAL SUSPENSION mg amlodipine besylate oral diltiazem hcl er coated beads 1 or 1b* tablet 10 mg oral capsule extended release 1 or 1b* DO 24 hour 120 mg, 180 mg amlodipine besylate oral 1 or 1b* DO tablet 2.5 mg, 5 mg diltiazem hcl er coated beads oral capsule extended release 1 or 1b* CALAN SR ORAL 24 hour 240 mg, 300 mg, 360 TABLET EXTENDED 3 mg RELEASE diltiazem hcl er coated beads CARDENE IV oral tablet extended release 1 or 1b* DO INTRAVENOUS 24 hour 180 mg SOLUTION 20-0.86 3 MG/200ML-%, 20-4.8 diltiazem hcl er coated beads oral tablet extended release MG/200ML-%, 40-0.83 1 or 1b* MG/200ML-% 24 hour 240 mg, 300 mg, 360 mg, 420 mg CARDIZEM CD ORAL CAPSULE EXTENDED diltiazem hcl er oral capsule 3 DO 1 or 1b* RELEASE 24 HOUR 120 extended release 12 hour MG, 180 MG diltiazem hcl intravenous 1 or 1b* solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 77 Drug Name Tier Notes Drug Name Tier Notes DILTIAZEM HCL nifedipine er osmotic release INTRAVENOUS oral tablet extended release 1 or 1b* DO 3 SOLUTION 24 hour 30 mg RECONSTITUTED nifedipine er osmotic release diltiazem hcl oral tablet 1 or 1b* oral tablet extended release 1 or 1b* DILTIAZEM HCL- 24 hour 60 mg, 90 mg DEXTROSE nifedipine oral capsule 1 or 1b* INTRAVENOUS 3 nimodipine oral capsule 1 or 1b* SOLUTION 125-5 MG/125ML-% nisoldipine er oral tablet extended release 24 hour 17 1 or 1b* DO DILTIAZEM HCL- mg, 20 mg, 8.5 mg SODIUM CHLORIDE INTRAVENOUS nisoldipine er oral tablet 3 extended release 24 hour SOLUTION 125-0.7 1 or 1b* MG/125ML-%, 125-0.9 25.5 mg, 30 mg, 34 mg, 40 MG/125ML-% mg NORVASC ORAL dilt-xr oral capsule extended 3 release 24 hour 120 mg, 180 1 or 1b* DO TABLET 10 MG mg NORVASC ORAL 3 DO dilt-xr oral capsule extended TABLET 2.5 MG, 5 MG 1 or 1b* release 24 hour 240 mg NYMALIZE ORAL 3 felodipine er oral tablet SOLUTION extended release 24 hour 10 1 or 1b* PROCARDIA ORAL 3 mg CAPSULE felodipine er oral tablet PROCARDIA XL ORAL extended release 24 hour 2.5 1 or 1b* DO TABLET EXTENDED 3 DO mg, 5 mg RELEASE 24 HOUR 30 isradipine oral capsule 1 or 1b* MG KATERZIA ORAL PROCARDIA XL ORAL 3 TABLET EXTENDED SUSPENSION 3 RELEASE 24 HOUR 60 matzim la oral tablet MG, 90 MG extended release 24 hour 180 1 or 1b* DO mg SULAR ORAL TABLET EXTENDED RELEASE 24 3 DO matzim la oral tablet HOUR 17 MG, 8.5 MG extended release 24 hour 240 1 or 1b* mg, 300 mg, 360 mg, 420 mg SULAR ORAL TABLET EXTENDED RELEASE 24 3 NICARDIPINE HCL IN HOUR 34 MG NACL INTRAVENOUS SOLUTION PREFILLED 3 taztia xt oral capsule SYRINGE 1-0.9 extended release 24 hour 120 1 or 1b* DO MG/10ML-% mg, 180 mg, 360 mg nicardipine hcl intravenous taztia xt oral capsule 1 or 1b* solution extended release 24 hour 240 1 or 1b* mg, 300 mg nicardipine hcl oral capsule 1 or 1b* tiadylt er oral capsule nifedipine er oral tablet extended release 24 hour 120 1 or 1b* DO extended release 24 hour 30 1 or 1b* DO mg, 180 mg, 360 mg mg tiadylt er oral capsule nifedipine er oral tablet extended release 24 hour 240 1 or 1b* extended release 24 hour 60 1 or 1b* mg, 300 mg, 420 mg mg, 90 mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 78 Drug Name Tier Notes Drug Name Tier Notes TIAZAC ORAL *PHOSPHODIESTERASE CAPSULE EXTENDED INHIBITORS*** 3 DO RELEASE 24 HOUR 120 milrinone lactate in dextrose 1 or 1b* MG, 180 MG, 360 MG intravenous solution TIAZAC ORAL milrinone lactate intravenous CAPSULE EXTENDED 3 solution 10 mg/10ml, 20 1 or 1b* RELEASE 24 HOUR 240 mg/20ml, 50 mg/50ml MG, 300 MG, 420 MG *CARDIOVASCULAR verapamil hcl er oral capsule AGENTS - MISC.* extended release 24 hour 100 1 or 1b* DO mg, 120 mg, 180 mg *CALCIUM CHANNEL BLOCKER & HMG COA verapamil hcl er oral capsule REDUCTASE INHIBIT extended release 24 hour 200 1 or 1b* COMB*** mg, 240 mg, 300 mg, 360 mg amlodipine-atorvastatin oral verapamil hcl er oral tablet tablet 10-10 mg, 10-20 mg, 1 or 1b* extended release 120 mg, 1 or 1b* 10-40 mg, 10-80 mg, 5-80 180 mg, 240 mg mg verapamil hcl intravenous 1 or 1b* amlodipine-atorvastatin oral solution tablet 2.5-10 mg, 2.5-20 mg, 1 or 1b* DO verapamil hcl oral tablet 1 or 1b* 2.5-40 mg, 5-10 mg, 5-20 VERELAN ORAL mg, 5-40 mg CAPSULE EXTENDED CADUET ORAL TABLET 3 DO RELEASE 24 HOUR 120 10-10 MG, 10-20 MG, 10- 3 MG, 180 MG 40 MG, 10-80 MG, 5-80 VERELAN ORAL MG CAPSULE EXTENDED CADUET ORAL TABLET 3 RELEASE 24 HOUR 240 5-10 MG, 5-20 MG, 5-40 3 DO MG, 360 MG MG VERELAN PM ORAL *NITRATE & CAPSULE EXTENDED VASODILATOR 3 DO RELEASE 24 HOUR 100 COMBINATIONS*** MG BIDIL ORAL TABLET 2 VERELAN PM ORAL *PERIPHERAL CAPSULE EXTENDED 3 VASODILATORS*** RELEASE 24 HOUR 200 papaverine hcl injection MG, 300 MG 1 or 1b* solution *CARDIOTONICS* *PROSTAGLANDIN - *CARDIAC IMPOTENCE GLYCOSIDES*** AGENTS*** digitek oral tablet 1 or 1b* CAVERJECT IMPULSE digox oral tablet 1 or 1b* INTRACAVERNOSAL 3 PA; QL digoxin injection solution 1 or 1b* KIT digoxin oral solution 1 or 1b* CAVERJECT INTRACAVERNOSAL digoxin oral tablet 1 or 1b* SOLUTION 3 PA; QL LANOXIN INJECTION RECONSTITUTED 40 3 SOLUTION 0.25 MG/ML MCG LANOXIN ORAL EDEX TABLET 125 MCG, 250 2 INTRACAVERNOSAL 3 PA; QL MCG, 62.5 MCG KIT LANOXIN PEDIATRIC MUSE URETHRAL 2 3 PA; QL INJECTION SOLUTION PELLET * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 79 Drug Name Tier Notes Drug Name Tier Notes *PROSTAGLANDIN TRACLEER ORAL 3 PA; QL; LD; SP VASODILATORS*** TABLET SOLUBLE epoprostenol sodium *PULMONARY intravenous solution 1 or 1b* PA; QL; LD; SP HYPERTENSION - reconstituted PHOSPHODIESTERASE FLOLAN INTRAVENOUS INHIBITORS*** SOLUTION 3 PA; QL; LD; SP ADCIRCA ORAL 3 PA; QL; SP RECONSTITUTED TABLET ORENITRAM ORAL alyq oral tablet 1 or 1b* PA; QL; SP TABLET EXTENDED 3 PA; QL; LD; SP REVATIO RELEASE INTRAVENOUS 3 PA; QL; SP REMODULIN SOLUTION INJECTION SOLUTION REVATIO ORAL 100 MG/20ML, 20 3 PA; QL; LD; SP SUSPENSION 3 PA; QL; SP MG/20ML, 200 MG/20ML, RECONSTITUTED 50 MG/20ML REVATIO ORAL 3 PA; QL; SP treprostinil injection solution 1 or 1b* PA; QL; LD; SP TABLET TYVASO INHALATION sildenafil citrate intravenous 3 PA; QL; LD; SP 1 or 1b* PA; QL; SP SOLUTION solution TYVASO REFILL sildenafil citrate oral 1 or 1b* PA; QL; SP INHALATION 3 PA; QL; LD; SP suspension reconstituted SOLUTION sildenafil citrate oral tablet 1 or 1b* PA; QL; SP TYVASO STARTER 20 mg INHALATION 3 PA; QL; LD; SP SOLUTION tadalafil (pah) oral tablet 1 or 1b* PA; QL; SP VELETRI *SELECTIVE CGMP INTRAVENOUS PHOSPHODIESTERASE 3 PA; QL; LD; SP SOLUTION TYPE 5 INHIBITORS*** RECONSTITUTED CIALIS ORAL TABLET 3 PA; QL VENTAVIS LEVITRA ORAL 3 PA; QL INHALATION 3 PA; QL; LD; SP TABLET 10 MG, 20 MG SOLUTION sildenafil citrate oral tablet 1 or 1b* PA; QL *PULM HYPERTEN- 100 mg, 25 mg, 50 mg SOLUBLE GUANYLATE STAXYN ORAL TABLET CYCLASE STIMULATOR 3 PA; QL (SGC)*** DISPERSIBLE ADEMPAS ORAL STENDRA ORAL 3 PA; QL; LD; SP 3 PA; QL TABLET TABLET *PULMONARY tadalafil oral tablet 1 or 1b* PA; QL HYPERTENSION - vardenafil hcl oral tablet 1 or 1b* PA; QL ENDOTHELIN vardenafil hcl oral tablet 1 or 1b* PA; QL RECEPTOR dispersible ANTAGONISTS*** VIAGRA ORAL TABLET 3 PA; QL ambrisentan oral tablet 1 or 1b* PA; QL; LD; SP *CEPHALOSPORIN bosentan oral tablet 1 or 1b* PA; QL; SP COMBINATIONS*** LETAIRIS ORAL 3 PA; QL; LD; SP *CEPHALOSPORIN TABLET COMBINATIONS*** OPSUMIT ORAL 3 PA; QL; LD; SP AVYCAZ TABLET INTRAVENOUS 3 TRACLEER ORAL SOLUTION 3 PA; QL; LD; SP TABLET RECONSTITUTED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 80 Drug Name Tier Notes Drug Name Tier Notes ZERBAXA cephalexin oral capsule 1 or 1a* INTRAVENOUS cephalexin oral suspension 3 1 or 1a* SOLUTION reconstituted RECONSTITUTED cephalexin oral tablet 1 or 1a* *CEPHALOSPORINS - KEFLEX ORAL SIDEROPHORES*** 3 CAPSULE *CEPHALOSPORINS - SIDEROPHORES*** *CEPHALOSPORINS - 2ND GENERATION*** FETROJA INTRAVENOUS CEFACLOR ER ORAL 3 SOLUTION TABLET EXTENDED 3 RECONSTITUTED RELEASE 12 HOUR *CEPHALOSPORINS* cefaclor oral capsule 1 or 1b* cefaclor oral suspension *CEPHALOSPORINS - 1 or 1b* 1ST GENERATION*** reconstituted cefadroxil oral capsule 1 or 1b* CEFOTAN INJECTION SOLUTION 3 cefadroxil oral suspension 1 or 1b* RECONSTITUTED reconstituted cefotetan disodium injection cefadroxil oral tablet 1 or 1b* solution reconstituted 1 gm, 1 or 1b* CEFAZOLIN IN SODIUM 2 gm CHLORIDE CEFOTETAN INTRAVENOUS 3 DISODIUM-DEXTROSE SOLUTION 2-0.9 INTRAVENOUS GM/100ML-%, 3-0.9 SOLUTION 3 GM/100ML-% RECONSTITUTED 1-3.58 cefazolin sodium injection GM-%(50ML), 2-2.08 GM- solution reconstituted 1 gm, 1 or 1b* %(50ML) 10 gm, 500 mg cefoxitin sodium injection 1 or 1b* CEFAZOLIN SODIUM solution reconstituted INJECTION SOLUTION cefoxitin sodium intravenous 3 1 or 1b* RECONSTITUTED 100 solution reconstituted GM, 300 GM CEFOXITIN SODIUM- CEFAZOLIN SODIUM DEXTROSE INTRAVENOUS INTRAVENOUS SOLUTION PREFILLED 3 SOLUTION 3 SYRINGE 1 GM/10ML, 2 RECONSTITUTED 1-4 GM/20ML GM-%(50ML), 2-2.2 GM- cefazolin sodium intravenous %(50ML) 1 or 1b* solution reconstituted cefprozil oral suspension 1 or 1b* CEFAZOLIN SODIUM- reconstituted DEXTROSE cefprozil oral tablet 1 or 1b* INTRAVENOUS 3 SOLUTION 1-4 cefuroxime axetil oral tablet 1 or 1b* GM/50ML-%, 2-4 cefuroxime sodium injection GM/100ML-% solution reconstituted 7.5 1 or 1b* CEFAZOLIN SODIUM- gm, 750 mg DEXTROSE cefuroxime sodium INTRAVENOUS intravenous solution 1 or 1b* SOLUTION 3 reconstituted 1.5 gm RECONSTITUTED 1-4 *CEPHALOSPORINS - GM-%(50ML), 2-3 GM- 3RD GENERATION*** %(50ML) cefdinir oral capsule 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 81 Drug Name Tier Notes Drug Name Tier Notes cefdinir oral suspension tazicef injection solution 1 or 1b* 1 or 1b* reconstituted reconstituted cefditoren pivoxil oral tablet 1 or 1b* TAZICEF cefixime oral capsule 1 or 1b* INTRAVENOUS 3 SOLUTION cefixime oral suspension 1 or 1b* tazicef intravenous solution reconstituted 1 or 1b* reconstituted cefotaxime sodium injection solution reconstituted 1 gm, 1 or 1b* *CEPHALOSPORINS - 2 gm, 500 mg 4TH GENERATION*** cefpodoxime proxetil oral cefepime hcl injection 1 or 1b* 1 or 1b* suspension reconstituted solution reconstituted cefpodoxime proxetil oral CEFEPIME HCL 1 or 1b* tablet INTRAVENOUS 3 SOLUTION CEFTAZIDIME AND DEXTROSE CEFEPIME-DEXTROSE INTRAVENOUS INTRAVENOUS SOLUTION SOLUTION 3 3 RECONSTITUTED 1-5 RECONSTITUTED 1-5 GM-%(50ML), 2-5 GM- GM-%(50ML), 2-5 GM- %(50ML) %(50ML) ceftazidime injection solution *CEPHALOSPORINS - reconstituted 1 gm, 2 gm, 6 1 or 1b* 5TH GENERATION*** gm TEFLARO ceftriaxone sodium in INTRAVENOUS 1 or 1b* 3 dextrose intravenous solution SOLUTION RECONSTITUTED ceftriaxone sodium injection solution reconstituted 1 gm, 1 or 1b* *CGRP RECEPTOR 2 gm, 250 mg, 500 mg ANTAGONISTS - MONOCOLONAL CEFTRIAXONE SODIUM ANTIBODIES*** INJECTION SOLUTION 3 RECONSTITUTED 100 *CGRP RECEPTOR GM ANTAGONISTS - MONOCOLONAL ceftriaxone sodium ANTIBODIES*** intravenous solution 1 or 1b* reconstituted AIMOVIG SUBCUTANEOUS 3 PA; QL CEFTRIAXONE SOLUTION AUTO- SODIUM-DEXTROSE INJECTOR INTRAVENOUS SOLUTION 3 AJOVY SUBCUTANEOUS RECONSTITUTED 1-3.74 3 PA; QL GM-%(50ML), 2-2.22 GM- SOLUTION PREFILLED %(50ML) SYRINGE SPECTRACEF ORAL EMGALITY (300 MG 3 DOSE) SUBCUTANEOUS TABLET 400 MG 3 PA; QL SOLUTION PREFILLED SUPRAX ORAL 3 SYRINGE CAPSULE EMGALITY SUPRAX ORAL SUBCUTANEOUS 3 PA; QL SUSPENSION 3 SOLUTION AUTO- RECONSTITUTED INJECTOR SUPRAX ORAL TABLET 3 CHEWABLE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 82 Drug Name Tier Notes Drug Name Tier Notes EMGALITY BALCOLTRA ORAL 3 $0 SUBCUTANEOUS TABLET 3 PA; QL SOLUTION PREFILLED balziva oral tablet 1 or 1a* $0 SYRINGE blisovi 24 fe oral tablet 1 or 1a* $0 VYEPTI INTRAVENOUS 3 PA; QL SOLUTION blisovi fe 1.5/30 oral tablet 1 or 1a* $0 *CIC AGENTS - blisovi fe 1/20 oral tablet 1 or 1a* $0 GUANYLATE CYCLASE- briellyn oral tablet 1 or 1a* $0 C (GC-C) AGONISTS*** chateal eq oral tablet 1 or 1a* $0 *CIC AGENTS - GUANYLATE CYCLASE- chateal oral tablet 1 or 1a* $0 C (GC-C) AGONISTS*** cryselle-28 oral tablet 1 or 1a* $0 TRULANCE ORAL cyclafem 1/35 oral tablet 1 or 1a* $0 3 ST; QL TABLET cyred eq oral tablet 1 or 1a* $0 *CONTRACEPTIVES* cyred oral tablet 1 or 1a* $0 *BIPHASIC dasetta 1/35 oral tablet 1 or 1a* $0 CONTRACEPTIVES - ORAL*** delyla oral tablet 1 or 1a* $0 desogestrel-ethinyl estradiol azurette oral tablet 1 or 1b* $0 1 or 1a* $0 oral tablet 0.15-30 mg-mcg bekyree oral tablet 1 or 1b* $0 drospiren-eth estrad- 1 or 1b* $0 desogestrel-ethinyl estradiol levomefol oral tablet oral tablet 0.15-0.02/0.01 mg 1 or 1b* $0 drospirenone-ethinyl (21/5) 1 or 1b* $0 estradiol oral tablet kariva oral tablet 1 or 1b* $0 elinest oral tablet 1 or 1a* $0 LO LOESTRIN FE ORAL 2 $0 TABLET emoquette oral tablet 1 or 1a* $0 enskyce oral tablet 0.15-30 pimtrea oral tablet 1 or 1b* $0 1 or 1a* $0 mg-mcg simliya oral tablet 1 or 1b* $0 estarylla oral tablet 1 or 1a* $0 viorele oral tablet 1 or 1b* $0 ethynodiol diac-eth estradiol 1 or 1a* $0 volnea oral tablet 1 or 1b* $0 oral tablet *COMBINATION FALESSA ORAL KIT 20- 3 CONTRACEPTIVES - 1-0.1 MCG-MG ORAL*** falmina oral tablet 1 or 1a* $0 afirmelle oral tablet 1 or 1a* $0 femynor oral tablet 1 or 1a* $0 altavera oral tablet 1 or 1a* $0 gianvi oral tablet 1 or 1b* $0 alyacen 1/35 oral tablet 1 or 1a* $0 hailey 1.5/30 oral tablet 1 or 1a* $0 apri oral tablet 1 or 1a* $0 hailey 24 fe oral tablet 1 or 1a* $0 aubra eq oral tablet 1 or 1a* $0 isibloom oral tablet 1 or 1a* $0 aubra oral tablet 1 or 1a* $0 jasmiel oral tablet 1 or 1b* $0 aurovela 1.5/30 oral tablet 1 or 1a* $0 juleber oral tablet 1 or 1a* $0 aurovela 1/20 oral tablet 1 or 1a* $0 junel 1.5/30 oral tablet 1 or 1a* $0 aurovela 24 fe oral tablet 1 or 1a* $0 junel 1/20 oral tablet 1 or 1a* $0 aurovela fe 1.5/30 oral tablet 1 or 1a* $0 junel fe 1.5/30 oral tablet 1 or 1a* $0 aurovela fe 1/20 oral tablet 1 or 1a* $0 junel fe 1/20 oral tablet 1 or 1a* $0 aviane oral tablet 1 or 1a* $0 junel fe 24 oral tablet 1 or 1a* $0 ayuna oral tablet 1 or 1a* $0 kaitlib fe oral tablet chewable 1 or 1b* $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 83 Drug Name Tier Notes Drug Name Tier Notes kalliga oral tablet 1 or 1a* $0 norgestimate-eth estradiol 1 or 1a* $0 kelnor 1/35 oral tablet 1 or 1a* $0 oral tablet 0.25-35 mg-mcg kelnor 1/50 oral tablet 1 or 1a* $0 nortrel 0.5/35 (28) oral tablet 1 or 1a* $0 kurvelo oral tablet 1 or 1a* $0 nortrel 1/35 (21) oral tablet 1 or 1a* $0 larin 1.5/30 oral tablet 1 or 1a* $0 nortrel 1/35 (28) oral tablet 1 or 1a* $0 larin 1/20 oral tablet 1 or 1a* $0 ocella oral tablet 1 or 1b* $0 larin 24 fe oral tablet 1 or 1a* $0 ogestrel oral tablet 1 or 1a* $0 larin fe 1.5/30 oral tablet 1 or 1a* $0 orsythia oral tablet 1 or 1a* $0 larin fe 1/20 oral tablet 1 or 1a* $0 philith oral tablet 1 or 1a* $0 larissia oral tablet 1 or 1a* $0 pirmella 1/35 oral tablet 1 or 1a* $0 layolis fe oral tablet portia-28 oral tablet 1 or 1a* $0 1 or 1b* $0 chewable previfem oral tablet 1 or 1a* $0 lessina oral tablet 1 or 1a* $0 reclipsen oral tablet 1 or 1a* $0 levonorgestrel-ethinyl estrad sprintec 28 oral tablet 1 or 1a* $0 oral tablet 0.1-20 mg-mcg, 1 or 1a* $0 sronyx oral tablet 1 or 1a* $0 0.15-30 mg-mcg syeda oral tablet 1 or 1b* $0 levora 0.15/30 (28) oral 1 or 1a* $0 tablet tarina 24 fe oral tablet 1 or 1a* $0 lillow oral tablet 1 or 1a* $0 tarina fe 1/20 eq oral tablet 1 or 1a* $0 loryna oral tablet 1 or 1b* $0 tarina fe 1/20 oral tablet 1 or 1a* $0 TAYTULLA ORAL low-ogestrel oral tablet 1 or 1a* $0 3 $0 CAPSULE lo-zumandimine oral tablet 1 or 1b* $0 tydemy oral tablet 1 or 1b* $0 lutera oral tablet 1 or 1a* $0 vienva oral tablet 1 or 1a* $0 marlissa oral tablet 1 or 1a* $0 vyfemla oral tablet 1 or 1a* $0 melodetta 24 fe oral tablet 1 or 1a* $0 chewable vylibra oral tablet 1 or 1a* $0 mibelas 24 fe oral tablet wera oral tablet 1 or 1a* $0 1 or 1a* $0 chewable wymzya fe oral tablet 1 or 1b* $0 microgestin 1.5/30 oral tablet 1 or 1a* $0 chewable microgestin 1/20 oral tablet 1 or 1a* $0 zarah oral tablet 1 or 1b* $0 microgestin fe 1.5/30 oral zovia 1/35e (28) oral tablet 1 or 1a* $0 1 or 1a* $0 tablet zumandimine oral tablet 1 or 1b* $0 microgestin fe 1/20 oral 1 or 1a* $0 *COMBINATION tablet CONTRACEPTIVES - mili oral tablet 1 or 1a* $0 TRANSDERMAL*** xulane transdermal patch mono-linyah oral tablet 1 or 1a* $0 1 or 1b* $0 weekly necon 0.5/35 (28) oral tablet 1 or 1a* $0 *COMBINATION nikki oral tablet 1 or 1b* $0 CONTRACEPTIVES - norethin ace-eth estrad-fe VAGINAL*** 1 or 1a* $0 oral tablet ANNOVERA VAGINAL 3 $0 norethin ace-eth estrad-fe RING 1 or 1a* $0 oral tablet chewable eluryng vaginal ring 1 or 1b* $0 norethindrone acet-ethinyl etonogestrel-ethinyl estradiol 1 or 1a* $0 1 or 1b* $0 est oral tablet vaginal ring norethin-eth estradiol-fe oral 1 or 1b* $0 tablet chewable * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 84 Drug Name Tier Notes Drug Name Tier Notes *CONTINUOUS *FOUR PHASE CONTRACEPTIVES - CONTRACEPTIVES - ORAL*** ORAL*** amethyst oral tablet 1 or 1b* $0 NATAZIA ORAL 3 $0 levonorgestrel-ethinyl estrad TABLET 1 or 1b* $0 oral tablet 90-20 mcg *PROGESTIN *COPPER CONTRACEPTIVES - CONTRACEPTIVES - IMPLANTS*** IUD*** (NEW) NEXPLANON PARAGARD SUBCUTANEOUS 3 LD; SP INTRAUTERINE IMPLANT COPPER *PROGESTIN 3 INTRAUTERINE CONTRACEPTIVES - INTRAUTERINE INJECTABLE*** DEVICE DEPO-SUBQ PROVERA *COPPER 104 SUBCUTANEOUS 3 $0 CONTRACEPTIVES - SUSPENSION IUD*** PREFILLED SYRINGE PARAGARD medroxyprogesterone acetate 1 or 1b* $0 INTRAUTERINE intramuscular suspension COPPER 3 medroxyprogesterone acetate INTRAUTERINE intramuscular suspension 1 or 1b* $0 INTRAUTERINE prefilled syringe DEVICE *PROGESTIN *EMERGENCY CONTRACEPTIVES - CONTRACEPTIVES*** IUD*** ELLA ORAL TABLET 3 $0 KYLEENA *EXTENDED-CYCLE INTRAUTERINE 3 LD; SP CONTRACEPTIVES - INTRAUTERINE ORAL*** DEVICE amethia lo oral tablet 1 or 1b* $0 LILETTA (52 MG) INTRAUTERINE amethia oral tablet 1 or 1b* $0 3 LD; SP INTRAUTERINE ashlyna oral tablet 1 or 1b* $0 DEVICE 19.5 MCG/DAY camrese lo oral tablet 1 or 1b* $0 MIRENA (52 MG) INTRAUTERINE camrese oral tablet 1 or 1b* $0 3 LD; SP INTRAUTERINE daysee oral tablet 1 or 1b* $0 DEVICE fayosim oral tablet 1 or 1b* $0 SKYLA INTRAUTERINE introvale oral tablet 1 or 1b* $0 INTRAUTERINE 3 LD; SP jaimiess oral tablet 1 or 1b* $0 DEVICE jolessa oral tablet 1 or 1b* $0 *PROGESTIN CONTRACEPTIVES - levonorgest-eth est & eth est 1 or 1b* $0 ORAL*** oral tablet camila oral tablet 1 or 1b* $0 levonorgest-eth estrad 91-day 1 or 1b* $0 oral tablet deblitane oral tablet 1 or 1b* $0 lojaimiess oral tablet 1 or 1b* $0 errin oral tablet 1 or 1b* $0 rivelsa oral tablet 1 or 1b* $0 heather oral tablet 1 or 1b* $0 setlakin oral tablet 1 or 1b* $0 incassia oral tablet 1 or 1b* $0 simpesse oral tablet 1 or 1b* $0 jencycla oral tablet 1 or 1b* $0 lyza oral tablet 1 or 1b* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 85 Drug Name Tier Notes Drug Name Tier Notes nora-be oral tablet 1 or 1b* $0 *CORTICOSTEROIDS* norethindrone oral tablet 1 or 1b* $0 *GLUCOCORTICOSTER norlyda oral tablet 1 or 1b* $0 OIDS*** budesonide er oral tablet norlyroc oral tablet 1 or 1b* $0 1 or 1b* extended release 24 hour sharobel oral tablet 1 or 1b* $0 budesonide oral capsule 1 or 1b* SLYND ORAL TABLET 3 delayed release particles tulana oral tablet 1 or 1b* $0 CORTEF ORAL TABLET 3 *TRIPHASIC cortisone acetate oral tablet 1 or 1b* CONTRACEPTIVES - ORAL*** decadron oral tablet 1 or 1a* alyacen 7/7/7 oral tablet 1 or 1a* $0 DEPO-MEDROL INJECTION 3 aranelle oral tablet 1 or 1a* $0 SUSPENSION caziant oral tablet 1 or 1a* $0 DEXABLISS ORAL cyclafem 7/7/7 oral tablet 1 or 1a* $0 TABLET THERAPY 3 PACK dasetta 7/7/7 oral tablet 1 or 1a* $0 DEXAMETHASONE (LA) enpresse-28 oral tablet 1 or 1a* $0 INJECTION 3 leena oral tablet 1 or 1a* $0 SUSPENSION levonest oral tablet 1 or 1a* $0 DEXAMETHASONE levonorg-eth estrad triphasic INTENSOL ORAL 2 oral tablet 50-30/75-40/ 125- 1 or 1a* $0 CONCENTRATE 30 mcg dexamethasone oral elixir 1 or 1a* norgestim-eth estrad triphasic dexamethasone oral solution 1 or 1a* 1 or 1b* $0 oral tablet dexamethasone oral tablet 1 or 1a* nortrel 7/7/7 oral tablet 1 or 1a* $0 dexamethasone oral tablet 1 or 1b* pirmella 7/7/7 oral tablet 1 or 1a* $0 therapy pack tilia fe oral tablet 1 or 1b* $0 dexamethasone sod tri femynor oral tablet 1 or 1b* $0 phosphate pf injection 1 or 1b* solution tri-estarylla oral tablet 1 or 1b* $0 DEXAMETHASONE SOD tri-legest fe oral tablet 1 or 1b* $0 PHOSPHATE PF 3 tri-linyah oral tablet 1 or 1b* $0 INJECTION SOLUTION PREFILLED SYRINGE tri-lo-estarylla oral tablet 1 or 1b* $0 dexamethasone sodium tri-lo-marzia oral tablet 1 or 1b* $0 1 or 1b* phosphate injection solution tri-lo-mili oral tablet 1 or 1b* $0 dexpak 10 day oral tablet 1 or 1b* tri-lo-sprintec oral tablet 1 or 1b* $0 therapy pack tri-mili oral tablet 1 or 1b* $0 dexpak 13 day oral tablet 1 or 1b* tri-previfem oral tablet 1 or 1b* $0 therapy pack dexpak 6 day oral tablet tri-sprintec oral tablet 1 or 1b* $0 1 or 1b* therapy pack trivora (28) oral tablet 1 or 1a* $0 DXEVO 11-DAY ORAL tri-vylibra lo oral tablet 1 or 1b* $0 TABLET THERAPY 3 tri-vylibra oral tablet 1 or 1b* $0 PACK EMFLAZA ORAL velivet oral tablet 1 or 1a* $0 3 PA; QL; LD SUSPENSION EMFLAZA ORAL 3 PA; QL; LD TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 86 Drug Name Tier Notes Drug Name Tier Notes ENTOCORT EC ORAL prednisolone sodium CAPSULE DELAYED 3 phosphate oral tablet 1 or 1a* RELEASE PARTICLES dispersible hydrocortisone oral tablet 1 or 1b* PREDNISONE KENALOG INJECTION INTENSOL ORAL 3 3 SUSPENSION CONCENTRATE KENALOG-80 prednisone oral solution 1 or 1a* INJECTION 3 prednisone oral tablet 1 or 1a* SUSPENSION prednisone oral tablet 1 or 1a* MEDROL ORAL therapy pack TABLET 16 MG, 32 MG, 4 3 RAYOS ORAL TABLET 3 ST; QL MG, 8 MG DELAYED RELEASE MEDROL ORAL 2 SOLU-CORTEF TABLET 2 MG INJECTION SOLUTION 3 MEDROL ORAL RECONSTITUTED TABLET THERAPY 3 SOLU-MEDROL PACK INJECTION SOLUTION 3 methylprednisolone acetate RECONSTITUTED injection suspension 40 1 or 1b* taperdex 12-day oral tablet 1 or 1b* mg/ml therapy pack METHYLPREDNISOLON taperdex 6-day oral tablet E ACETATE INJECTION 1 or 1b* 3 therapy pack SUSPENSION 50 MG/ML, taperdex 7-day oral tablet 80 MG/ML 1 or 1b* therapy pack 1.5 mg (27) methylprednisolone oral 1 or 1a* TOPIDEX INJECTION tablet 3 KIT methylprednisolone oral 1 or 1a* tablet therapy pack triamcinolone acetonide injection suspension 40 1 or 1b* methylprednisolone sodium mg/ml succ injection solution 1 or 1b* reconstituted 1000 mg, 125 TRIAMCINOLONE mg, 40 mg, 500 mg ACETONIDE INJECTION 3 SUSPENSION 50 MG/ML MILLIPRED DP 12-DAY ORAL TABLET 3 TRIAMCINOLONE THERAPY PACK DIACETATE INJECTION 3 SUSPENSION MILLIPRED DP ORAL TABLET THERAPY 3 UCERIS ORAL TABLET PACK EXTENDED RELEASE 24 3 HOUR MILLIPRED ORAL 3 TABLET ZILRETTA INTRA- ARTICULAR ORAPRED ODT ORAL 3 LD 3 SUSPENSION TABLET DISPERSIBLE RECONSTITUTED ER PEDIAPRED ORAL 3 *MINERALOCORTICOI SOLUTION DS*** prednisolone oral solution 1 or 1a* fludrocortisone acetate oral 1 or 1b* prednisolone sodium tablet phosphate oral solution 10 *STEROID mg/5ml, 15 mg/5ml, 20 1 or 1a* COMBINATIONS*** mg/5ml, 25 mg/5ml, 6.7 (5 ACTIVE INJECTION base) mg/5ml 3 BLM-1 INJECTION KIT

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 87 Drug Name Tier Notes Drug Name Tier Notes ACTIVE INJECTION BM P-CARE K80MX 3 3 INJECTION KIT INJECTION KIT ACTIVE INJECTION DL POD-CARE 100CMX 3 3 INJECTION KIT INJECTION KIT ACTIVE INJECTION POD-CARE 100KMX 3 3 DLM INJECTION KIT INJECTION KIT ACTIVE INJECTION KIT POINT OF CARE KM 3 3 L INJECTION KIT INJECTION KIT ACTIVE INJECTION KL- POINT OF CARE L.2 3 3 3 COMBINATION KIT INJECTION KIT ACTIVE INJECTION KM POINT OF CARE L.5 3 3 INJECTION KIT INJECTION KIT ACTIVE INJECTION LM- POINT OF CARE LM 3 3 DEP-2 INJECTION KIT DEP 2 INJECTION KIT ACTIVE INJECTION M-1 READYSHARP ANESTH 3 INJECTION KIT + BETAMETH 3 BETAMETHASONE INJECTION KIT COMBO INJECTION 3 READYSHARP ANESTH SUSPENSION + DEXAMETH 3 betamethasone sod phos & INJECTION KIT acet injection suspension 6 1 or 1b* READYSHARP ANESTH (3-3) mg/ml + METHYLPRED 3 BETAMETHASONE SOD INJECTION KIT PHOS & ACET TRIAMCINOLONE- INJECTION 3 BUPIVACAINE 3 SUSPENSION 7 (4-3) INJECTION MG/ML SUSPENSION CELESTONE SOLUSPAN *COUGH/COLD/ALLER INJECTION 3 GY* SUSPENSION *ANTITUSSIVE - DEXAMETHASONE ACE NONNARCOTIC*** & SOD PHOS 3 benzonatate oral capsule 1 or 1b* INJECTION TESSALON PERLES SUSPENSION 3 ORAL CAPSULE JTT PHYSICIANS 3 COMBINATION KIT *ANTITUSSIVE - OPIOID*** LT INJECTION KIT 3 hydrocodone-homatropine INJECTION KIT 1 or 1a* oral syrup METHYLPREDNISOLON hydrocodone-homatropine E ACE-LIDO INJECTION 3 1 or 1a* SUSPENSION oral tablet METHYLPREDNISOLON hydromet oral syrup 1 or 1a* E-BUPIVACAINE 3 *ANTITUSSIVE- INJECTION EXPECTORANT*** SUSPENSION CODITUSSIN AC ORAL P-CARE D40MX 3 3 LIQUID INJECTION KIT g tussin ac oral solution 1 or 1a* P-CARE D80MX 3 INJECTION KIT guaiatussin ac oral syrup 1 or 1a* P-CARE K40MX guaifenesin ac oral syrup 1 or 1a* 3 INJECTION KIT

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 88 Drug Name Tier Notes Drug Name Tier Notes guaifenesin-codeine oral NEBUSAL INHALATION 1 or 1a* solution NEBULIZATION 2 MAR-COF CG SOLUTION 6 % EXPECTORANT ORAL 2 pulmosal inhalation 1 or 1b* LIQUID nebulization solution M-CLEAR WC ORAL sodium chloride inhalation 2 SOLUTION nebulization solution 0.9 %, 1 or 1b* NINJACOF-XG ORAL 10 %, 3 %, 7 % 3 LIQUID *MUCOLYTICS*** trymine cg oral liquid 1 or 1a* acetylcysteine inhalation 1 or 1b* virtussin a/c oral solution 1 or 1a* solution virtussin ac w/alc oral liquid 1 or 1a* *NON-NARC ANTITUSSIVE- *ANTITUSSIVE- ANTIHISTAMINE*** EXPECTORANTS- DECONGESTANT*** promethazine-dm oral syrup 1 or 1a* CODITUSSIN DAC ORAL *NON-NARC 3 LIQUID ANTITUSSIVE- DECONGESTANT- GILTUSS TR ORAL 2 ANTIHISTAMINE*** TABLET bromfed dm oral syrup 1 or 1b* LORTUSS EX ORAL NEOTUSS PLUS ORAL LIQUID 30-10-100 2 2 MG/5ML LIQUID pseudoeph-bromphen-dm TUSNEL C ORAL SYRUP 2 1 or 1b* oral syrup 30-2-10 mg/5ml virtussin dac oral solution 1 or 1b* *OPIOID ANTITUSSIVE- *DECONGESTANT & ANTIHISTAMINE*** ANTIHISTAMINE*** hydrocod polst-cpm polst er CLARINEX-D 12 HOUR oral suspension extended 1 or 1b* ORAL TABLET 3 ST; QL release EXTENDED RELEASE 12 promethazine-codeine oral HOUR 1 or 1a* solution promethazine-phenylephrine 1 or 1b* promethazine-codeine oral oral syrup 1 or 1a* syrup SEMPREX-D ORAL 3 ST; QL CAPSULE TUSSICAPS ORAL CAPSULE EXTENDED 2 *DECONGESTANT W/ RELEASE 12 HOUR 10-8 EXPECTORANT*** MG GILPHEX TR ORAL 3 TUXARIN ER ORAL TABLET TABLET EXTENDED 3 *IODINE RELEASE 12 HOUR EXPECTORANTS*** TUZISTRA XR ORAL SSKI ORAL SOLUTION 3 SUSPENSION 3 EXTENDED RELEASE *MISC. RESPIRATORY Z-TUSS AC ORAL INHALANTS*** 2 LIQUID HYPERSAL INHALATION *OPIOID ANTITUSSIVE- 3 NEBULIZATION DECONGESTANT- SOLUTION ANTIHISTAMINE*** nebusal inhalation CAPCOF ORAL SYRUP 3 1 or 1b* nebulization solution 3 %

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 89 Drug Name Tier Notes Drug Name Tier Notes HISTEX-AC ORAL TRIKAFTA ORAL 3 SYRUP TABLET THERAPY 3 PA; QL; LD MAR-COF BP ORAL PACK 3 LIQUID *DERMATOLOGICALS* MAXI-TUSS CD ORAL *ACNE ANTIBIOTICS*** 2 LIQUID ACZONE EXTERNAL 3 ST; QL M-END PE ORAL GEL 3 LIQUID AMZEEQ EXTERNAL 3 PA; QL POLY-TUSSIN AC ORAL FOAM 2 LIQUID 10-4-10 MG/5ML CLEOCIN-T EXTERNAL 3 ST; QL promethazine-phenyleph- GEL 1 or 1b* codeine oral syrup CLEOCIN-T EXTERNAL 3 ST; QL PRO-RED AC ORAL LOTION 3 SYRUP 5-1-9 MG/5ML clindacin etz external swab 1 or 1b* RYDEX ORAL LIQUID 2 clindacin-p external swab 1 or 1b* *CYCLIN-DEPENDENT CLINDAGEL EXTERNAL 3 ST; QL KINASES (CDK) GEL INHIBITORS*** clindamycin phosphate 1 or 1b* *CYCLIN-DEPENDENT external foam KINASES (CDK) clindamycin phosphate INHIBITORS*** 1 or 1b* ST; QL external gel IBRANCE ORAL 2 PA; QL; LD; SP clindamycin phosphate CAPSULE 1 or 1b* external lotion IBRANCE ORAL 3 PA; QL; SP clindamycin phosphate TABLET 1 or 1b* external solution KISQALI (200 MG DOSE) clindamycin phosphate ORAL TABLET 2 PA; QL; SP 1 or 1b* THERAPY PACK external swab KISQALI (400 MG DOSE) dapsone external gel 1 or 1b* ST; QL ORAL TABLET 2 PA; QL; SP ery external pad 1 or 1b* THERAPY PACK ERYGEL EXTERNAL 3 KISQALI (600 MG DOSE) GEL ORAL TABLET 2 PA; QL; SP THERAPY PACK erythromycin external gel 1 or 1b* VERZENIO ORAL erythromycin external 3 PA; QL; LD; SP 1 or 1b* TABLET solution EVOCLIN EXTERNAL *CYSTIC FIBROSIS 3 ST; QL AGENT - FOAM COMBINATIONS*** KLARON EXTERNAL 3 *CYSTIC FIBROSIS LOTION AGENT - sulfacetamide sodium (acne) 1 or 1b* COMBINATIONS*** external lotion ORKAMBI ORAL *ACNE 3 PA; QL; LD PACKET COMBINATIONS*** ORKAMBI ORAL ACANYA EXTERNAL 3 PA; QL; LD 3 ST; QL TABLET GEL SYMDEKO ORAL adapalene-benzoyl peroxide 1 or 1b* TABLET THERAPY 3 PA; QL; LD external gel PACK BENZACLIN EXTERNAL 3 ST; QL GEL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 90 Drug Name Tier Notes Drug Name Tier Notes BENZACLIN WITH SULFACETAMIDE- 3 ST; QL PUMP EXTERNAL GEL SULFUR IN UREA 3 BENZAMYCIN EXTERNAL EMULSION 3 ST; QL EXTERNAL GEL sulfamez wash external 1 or 1b* benzoyl perox- emulsion hydrocortisone external 1 or 1b* VELTIN EXTERNAL 3 ST; QL lotion GEL BENZOYL PEROXIDE ZACARE EXTERNAL 3 FORTE- HC EXTERNAL 3 KIT LOTION ZIANA EXTERNAL GEL 3 ST; QL benzoyl peroxide- 1 or 1b* *ACNE PRODUCTS*** erythromycin external gel ABSORICA LD ORAL 3 PA; QL bp 10-1 external emulsion 1 or 1b* CAPSULE bp cleansing wash external ABSORICA ORAL 1 or 1b* 3 PA; QL emulsion CAPSULE clindamycin phos-benzoyl adapalene external cream 1 or 1b* PA; QL perox external gel 1-5 %, 1 or 1b* 1.2-2.5 %, 1.2-5 % adapalene external gel 1 or 1b* PA; QL clindamycin-tretinoin adapalene external pad 1 or 1b* PA; QL 1 or 1b* external gel ADAPALENE 3 PA; QL CLINOIN EXTERNAL EXTERNAL SOLUTION 3 CREAM AKLIEF EXTERNAL 3 ST; QL EPIDUO EXTERNAL CREAM 3 PA; QL GEL ALTRENO EXTERNAL 3 PA; QL EPIDUO FORTE LOTION 3 PA; QL EXTERNAL GEL amnesteem oral capsule 2 PA; QL; CTT1 neuac external gel 1 or 1b* ATRALIN EXTERNAL 3 PA; QL ONEXTON EXTERNAL GEL 2 GEL avita external cream 1 or 1b* PA; QL resorcinol-sulfur external 1 or 1b* avita external gel 1 or 1b* PA; QL lotion AZELEX EXTERNAL 3 PA; QL sss 10-5 external cream 1 or 1b* CREAM sss 10-5 external foam 1 or 1b* BENZAC AC WASH 3 sulfacetamide sodium-sulfur EXTERNAL LIQUID external cream 10-2 %, 10-5 1 or 1b* benzepro short contact 1 or 1b* % external foam sulfacetamide sodium-sulfur BENZIQ EXTERNAL 1 or 1b* PA; QL 3 external liquid 9-4 % GEL sulfacetamide sodium-sulfur BENZIQ LS EXTERNAL 1 or 1b* 3 external lotion 10-5 % GEL SULFACETAMIDE benziq wash external liquid 1 or 1b* SODIUM-SULFUR 3 BENZOYL PEROXIDE EXTERNAL 3 SUSPENSION 10-5 % EXTERNAL GEL 6.5 % benzoyl peroxide external gel sulfacetamide sodium-sulfur 1 or 1b* PA; QL 1 or 1b* external suspension 8-4 % 8 % sulfacetamide sod-sulfur bp wash external liquid 2.5 1 or 1b* 1 or 1b* wash external kit %, 7 % claravis oral capsule 2 PA; QL; CTT1

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 91 Drug Name Tier Notes Drug Name Tier Notes DIFFERIN EXTERNAL BACLOFEN EXTERNAL 3 PA; QL 3 CREAM CREAM DIFFERIN EXTERNAL ENOVARX-TRAMADOL 3 PA; QL 2 GEL 0.3 % EXTERNAL CREAM DIFFERIN EXTERNAL *ANTIBIOTIC STEROID 3 PA; QL LOTION COMBINATIONS - FABIOR EXTERNAL TOPICAL*** 3 ST; QL FOAM CORTISPORIN 3 isotretinoin oral capsule 2 PA; QL; CTT1 EXTERNAL CREAM CORTISPORIN myorisan oral capsule 2 PA; QL; CTT1 3 EXTERNAL OINTMENT RETIN-A EXTERNAL 3 PA; QL NEO-SYNALAR CREAM 3 EXTERNAL CREAM RETIN-A EXTERNAL 3 PA; QL GEL *ANTIBIOTICS - TOPICAL*** RETIN-A MICRO 3 PA; QL ALTABAX EXTERNAL EXTERNAL GEL 2 OINTMENT RETIN-A MICRO PUMP 3 PA; QL CENTANY AT EXTERNAL GEL 3 EXTERNAL KIT RIAX EXTERNAL FOAM 3 CENTANY EXTERNAL 3 tretinoin external cream 1 or 1b* PA; QL OINTMENT tretinoin external gel 1 or 1b* PA; QL gentamicin sulfate external 1 or 1b* tretinoin microsphere cream 1 or 1b* PA; QL external gel gentamicin sulfate external 1 or 1b* tretinoin microsphere pump ointment 1 or 1b* PA; QL external gel mupirocin calcium external 1 or 1b* ZACLIR CLEANSING cream 3 EXTERNAL LOTION 8 % mupirocin external ointment 1 or 1b* zenatane oral capsule 2 PA; QL; CTT1 XEPI EXTERNAL 3 *AGENTS FOR CREAM EXTERNAL GENITAL *ANTIFUNGALS - AND PERIANAL TOPICAL WARTS*** COMBINATIONS*** VEREGEN EXTERNAL ACTIVE-PREP KIT V 3 3 OINTMENT EXTERNAL CREAM *AGENTS FOR FACIAL clotrimazole-betamethasone 1 or 1b* WRINKLES - external cream RETINOIDS*** clotrimazole-betamethasone 1 or 1b* refissa external cream 1 or 1b* PA; QL external lotion RENOVA EXTERNAL EXODERM EXTERNAL 3 PA; QL 3 CREAM LOTION RENOVA PUMP FUNGIMEZ EXTERNAL 3 PA; QL 3 EXTERNAL CREAM SOLUTION tretinoin (emollient) external iodoquimez-hc external 1 or 1b* PA; QL 1 or 1b* cream cream *ANALGESICS - miconazole-zinc oxide- 1 or 1b* TOPICAL*** petrolat external ointment ACTIVE-TRAMADOL nystatin-triamcinolone 2 1 or 1b* EXTERNAL CREAM external cream

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 92 Drug Name Tier Notes Drug Name Tier Notes nystatin-triamcinolone diclofenac sodium 1 or 1b* 1 or 1b* external ointment transdermal gel 1 % RECURA EXTERNAL ENOVARX- 3 CREAM DICLOFENAC SODIUM 3 VUSION EXTERNAL TRANSDERMAL CREAM 3 OINTMENT FLECTOR 3 ST; QL XOLEGEL COREPAK TRANSDERMAL PATCH 3 EXTERNAL KIT KETOPHENE RAPIDPAQ 3 XOLEGEL DUO/HEAD & EXTERNAL CREAM SHOULDERS 3 KETOROLAC EXTERNAL KIT TROMETHAMINE 3 XOLEGEL DUO/XOLEX EXTERNAL GEL 3 EXTERNAL KIT PENNSAID *ANTIFUNGALS - TRANSDERMAL 3 ST; QL TOPICAL*** SOLUTION 2 % REXAPHENAC ciclopirox external gel 1 or 1b* 3 TRANSDERMAL CREAM ciclopirox external shampoo 1 or 1b* VOLTAREN 3 ST; QL ciclopirox external solution 1 or 1b* TRANSDERMAL GEL ciclopirox olamine external 1 or 1b* *ANTI- cream INFLAMMATORY ciclopirox olamine external COMBINATIONS - 1 or 1b* suspension TOPICAL*** LOPROX EXTERNAL ACTIVE-PREP KIT I 3 ST; QL 3 CREAM EXTERNAL CREAM LOPROX EXTERNAL ACTIVE-PREP KIT II 3 3 SHAMPOO EXTERNAL CREAM LOPROX EXTERNAL ACTIVE-PREP KIT III 3 ST; QL 3 SUSPENSION EXTERNAL CREAM MENTAX EXTERNAL AIF #2 DRUG 3 ST; QL CREAM PREPARATION KIT 3 EXTERNAL CREAM naftifine hcl external cream 1 or 1b* ST; QL AIF #3 DRUG naftifine hcl external gel 1 or 1b* ST; QL PREPARATION KIT 3 NAFTIN EXTERNAL EXTERNAL CREAM 3 ST; QL CREAM 2 % BIIFENAC 1000 NAFTIN EXTERNAL EXTERNAL THERAPY 3 3 ST; QL GEL PACK nyamyc external powder 1 or 1b* BIIFENAC 500 nystatin external cream 1 or 1b* EXTERNAL THERAPY 3 PACK nystatin external ointment 1 or 1b* DFS/MS/MENTH/CAP nystatin external powder 1 or 1b* PAK COMBINATION 3 nystop external powder 1 or 1b* KIT *ANTI- DUAL COMPLEX INFLAMMATORY FORMULA 1 KIT 3 AGENTS - TOPICAL*** EXTERNAL CREAM ACTIVE-KETOPROFEN FBL KIT EXTERNAL 3 3 EXTERNAL CREAM CREAM diclofenac epolamine K.B.G.L IN TERODERM 3 ST; QL; CTT1 3 transdermal patch EXTERNAL CREAM

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 93 Drug Name Tier Notes Drug Name Tier Notes LIDOPROFEN *ANTINEOPLASTIC 3 EXTERNAL CREAM RETINOIDS - NP #2 DRUG TOPICAL*** PREPARATION KIT 3 PANRETIN EXTERNAL 3 SP EXTERNAL CREAM GEL TRIPLE COMPLEX *ANTIPRURITICS - FORMULA 3 KIT 3 TOPICAL*** EXTERNAL CREAM doxepin hcl external cream 1 or 1b* PA; QL VOPAC GB EXTERNAL PRUDOXIN EXTERNAL 3 3 PA; QL CREAM CREAM VOPAC KT EXTERNAL ZONALON EXTERNAL 3 3 PA; QL CREAM CREAM VP FC KIT EXTERNAL 3 *ANTIPSORIATICS - CREAM SYSTEMIC*** VP GKL KIT EXTERNAL 3 acitretin oral capsule 1 or 1b* CREAM COSENTYX (300 MG *ANTINEOPLASTIC DOSE) SUBCUTANEOUS 3 PA; QL; LD; SP ALKYLATING AGENTS - SOLUTION PREFILLED TOPICAL*** SYRINGE VALCHLOR EXTERNAL 3 PA; QL; LD COSENTYX GEL SENSOREADY (300 MG) *ANTINEOPLASTIC SUBCUTANEOUS 3 PA; QL; LD; SP ANTIMETABOLITES - SOLUTION AUTO- TOPICAL*** INJECTOR CARAC EXTERNAL COSENTYX 2 CREAM SENSOREADY PEN EFUDEX EXTERNAL SUBCUTANEOUS 3 PA; QL; LD; SP 3 ST; QL CREAM SOLUTION AUTO- INJECTOR 150 MG/ML FLUOROPLEX 3 ST; QL EXTERNAL CREAM COSENTYX SUBCUTANEOUS fluorouracil external cream 3 PA; QL; LD; SP 3 ST; QL; CTT1 SOLUTION PREFILLED 0.5 % SYRINGE fluorouracil external cream 5 1 or 1b* ILUMYA % SUBCUTANEOUS 3 PA; QL; LD; SP fluorouracil external solution 1 or 1b* SOLUTION PREFILLED SYRINGE TOLAK EXTERNAL 3 ST; QL methoxsalen rapid oral CREAM 1 or 1b* SP capsule *ANTINEOPLASTIC OR OXSORALEN ULTRA PREMALIGNANT 3 SP LESIONS - TOPICAL ORAL CAPSULE MISC.*** SILIQ SUBCUTANEOUS PICATO EXTERNAL SOLUTION PREFILLED 3 PA; QL; SP 3 ST; QL GEL SYRINGE *ANTINEOPLASTIC OR SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREMALIGNANT 3 PA; QL; SP LESIONS - TOPICAL PREFILLED SYRINGE NSAID'S*** KIT diclofenac sodium SORIATANE ORAL 1 or 1b* PA; QL 3 transdermal gel 3 % CAPSULE 10 MG, 25 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 94 Drug Name Tier Notes Drug Name Tier Notes STELARA SODIUM SUBCUTANEOUS 3 PA; QL; SP SULFACETAMIDE 3 SOLUTION 45 MG/0.5ML WASH EXTERNAL STELARA LIQUID SUBCUTANEOUS *ANTISEBORRHEIC 3 PA; QL; SP SOLUTION PREFILLED PRODUCTS*** SYRINGE OVACE WASH 3 TALTZ SUBCUTANEOUS EXTERNAL LIQUID SOLUTION AUTO- 3 PA; QL; LD; SP selenium sulfide external 1 or 1a* INJECTOR lotion TALTZ SUBCUTANEOUS sodium sulfacetamide 1 or 1b* SOLUTION PREFILLED 3 PA; QL; LD; SP external shampoo SYRINGE sulfacetamide sodium 1 or 1b* TREMFYA external gel SUBCUTANEOUS 3 PA; QL; SP sulfacetamide sodium SOLUTION PEN- 1 or 1b* INJECTOR external liquid TREMFYA *ANTIVIRAL TOPICAL SUBCUTANEOUS COMBINATIONS*** 3 PA; QL; SP SOLUTION PREFILLED XERESE EXTERNAL 3 PA; QL SYRINGE CREAM *ANTIPSORIATICS*** *ANTIVIRALS - calcipotriene external cream 1 or 1b* TOPICAL*** CALCIPOTRIENE acyclovir external cream 1 or 1b* PA; QL 3 EXTERNAL FOAM acyclovir external ointment 1 or 1b* calcipotriene external DENAVIR EXTERNAL 1 or 1b* 3 PA; QL ointment CREAM calcipotriene external ZOVIRAX EXTERNAL 1 or 1b* 3 PA; QL solution CREAM calcitrene external ointment 1 or 1b* ZOVIRAX EXTERNAL 3 calcitriol external ointment 1 or 1b* OINTMENT DOVONEX EXTERNAL *ASTRINGENTS*** 3 CREAM XERAC AC EXTERNAL 2 SORILUX EXTERNAL SOLUTION 3 FOAM *BURN PRODUCTS*** tazarotene external cream 1 or 1b* mafenide acetate external 1 or 1b* TAZORAC EXTERNAL packet 2 CREAM 0.05 % SILVADENE EXTERNAL 3 TAZORAC EXTERNAL CREAM 3 ST; QL CREAM 0.1 % silver sulfadiazine external 1 or 1a* TAZORAC EXTERNAL cream 2 GEL ssd external cream 1 or 1a* VECTICAL EXTERNAL SULFAMYLON 3 3 OINTMENT EXTERNAL CREAM *ANTISEBORRHEIC SULFAMYLON 3 COMBINATIONS*** EXTERNAL PACKET PROMISEB EXTERNAL 3 *CORTICOSTEROIDS - CREAM TOPICAL*** ALA SCALP EXTERNAL 3 ST; QL LOTION * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 95 Drug Name Tier Notes Drug Name Tier Notes ala-cort external cream 1 % 1 or 1a* QL clobetasol propionate 1 or 1b* ala-cort external cream 2.5 % 1 or 1a* external foam alclometasone dipropionate clobetasol propionate 1 or 1b* 1 or 1b* external cream external gel alclometasone dipropionate clobetasol propionate 1 or 1b* 1 or 1b* external ointment external liquid clobetasol propionate amcinonide external cream 3 ST; QL; CTT1 1 or 1b* external lotion amcinonide external lotion 3 ST; QL; CTT1 clobetasol propionate AMCINONIDE 1 or 1b* 3 ST; QL external ointment EXTERNAL OINTMENT clobetasol propionate APEXICON E 1 or 1b* 3 ST; QL external shampoo EXTERNAL CREAM clobetasol propionate 1 or 1b* beser external lotion 3 ST; QL; CTT1 external solution betamethasone dipropionate CLOBEX EXTERNAL 1 or 1b* 3 ST; QL aug external cream LOTION betamethasone dipropionate CLOBEX EXTERNAL 1 or 1b* ST; QL 3 ST; QL aug external gel SHAMPOO betamethasone dipropionate CLOBEX SPRAY 1 or 1b* ST; QL 3 ST; QL aug external lotion EXTERNAL LIQUID betamethasone dipropionate clocortolone pivalate external 1 or 1b* 1 or 1b* ST; QL aug external ointment cream betamethasone dipropionate 3 ST; QL; CTT1 clodan external shampoo 1 or 1b* external cream CLODERM EXTERNAL betamethasone dipropionate 3 ST; QL 3 ST; QL; CTT1 CREAM external lotion CORDRAN EXTERNAL betamethasone dipropionate 3 ST; QL 3 ST; QL; CTT1 CREAM external ointment CORDRAN EXTERNAL betamethasone valerate 3 ST; QL 3 ST; QL; CTT1 LOTION external cream CORDRAN EXTERNAL betamethasone valerate 3 ST; QL 3 ST; QL; CTT1 OINTMENT external foam CORDRAN EXTERNAL betamethasone valerate 3 ST; QL 3 ST; QL; CTT1 TAPE external lotion CUTIVATE EXTERNAL betamethasone valerate 3 ST; QL 3 ST; QL; CTT1 LOTION external ointment DERMA-SMOOTHE/FS BRYHALI EXTERNAL 3 ST; QL 3 ST; QL BODY EXTERNAL OIL LOTION DESONATE EXTERNAL CAPEX EXTERNAL 3 ST; QL 3 ST; QL GEL SHAMPOO desonide external cream 3 ST; QL; CTT1 clobetasol prop emollient 1 or 1b* base external cream desonide external lotion 3 ST; QL; CTT1 clobetasol propionate e desonide external ointment 3 ST; QL; CTT1 1 or 1b* external cream DESOWEN EXTERNAL 3 ST; QL clobetasol propionate CREAM 1 or 1b* emulsion external foam desoximetasone external 3 ST; QL; CTT1 clobetasol propionate cream 1 or 1b* external cream desoximetasone external gel 3 ST; QL; CTT1

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 96 Drug Name Tier Notes Drug Name Tier Notes desoximetasone external halobetasol propionate 3 ST; QL; CTT1 1 or 1b* liquid external ointment desoximetasone external HALOG EXTERNAL 3 ST; QL; CTT1 3 ST; QL ointment CREAM diflorasone diacetate external HALOG EXTERNAL 3 ST; QL; CTT1 3 ST; QL cream OINTMENT diflorasone diacetate external hydrocortisone butyr lipo 3 ST; QL; CTT1 3 ST; QL; CTT1 ointment base external cream DIPROLENE AF hydrocortisone butyrate 3 3 ST; QL; CTT1 EXTERNAL CREAM external cream DIPROLENE EXTERNAL hydrocortisone butyrate 3 ST; QL 3 ST; QL; CTT1 OINTMENT external lotion fluocinolone acetonide body hydrocortisone butyrate 3 ST; QL; CTT1 3 ST; QL; CTT1 external oil external ointment fluocinolone acetonide hydrocortisone butyrate 3 ST; QL; CTT1 3 ST; QL; CTT1 external cream external solution fluocinolone acetonide hydrocortisone external 3 ST; QL; CTT1 1 or 1a* QL external ointment cream 1 %, 2.5 % fluocinolone acetonide hydrocortisone external 3 ST; QL; CTT1 1 or 1a* external solution lotion 2.5 % fluocinolone acetonide scalp hydrocortisone external 3 ST; QL; CTT1 1 or 1a* QL external oil ointment 1 %, 2.5 % fluocinonide emulsified base hydrocortisone valerate 1 or 1b* 3 ST; QL; CTT1 external cream external cream fluocinonide external cream 1 or 1b* hydrocortisone valerate 3 ST; QL; CTT1 fluocinonide external gel 1 or 1b* ST; QL external ointment fluocinonide external IMPOYZ EXTERNAL 1 or 1b* 3 ST; QL ointment CREAM fluocinonide external KENALOG EXTERNAL 1 or 1b* 3 ST; QL solution AEROSOL SOLUTION flurandrenolide external LEXETTE EXTERNAL 3 ST; QL; CTT1 3 ST; QL cream FOAM flurandrenolide external LOCOID EXTERNAL 3 ST; QL; CTT1 3 ST; QL lotion CREAM flurandrenolide external LOCOID EXTERNAL 3 ST; QL; CTT1 3 ST; QL ointment LOTION fluticasone propionate LOCOID EXTERNAL 3 ST; QL; CTT1 3 ST; QL external cream SOLUTION fluticasone propionate LOCOID LIPOCREAM 3 ST; QL; CTT1 3 ST; QL external lotion EXTERNAL CREAM fluticasone propionate LUXIQ EXTERNAL 3 ST; QL; CTT1 3 ST; QL external ointment FOAM mometasone furoate external halcinonide external cream 1 or 1b* ST; QL 1 or 1b* cream halobetasol propionate 1 or 1b* mometasone furoate external external cream 1 or 1b* ointment HALOBETASOL mometasone furoate external PROPIONATE 3 ST; QL 1 or 1b* EXTERNAL FOAM solution nolix external cream 3 ST; QL; CTT1

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 97 Drug Name Tier Notes Drug Name Tier Notes nolix external lotion 3 ST; QL; CTT1 triderm external cream 0.5 % 1 or 1a* ST; QL OLUX EXTERNAL TRIDESILON 3 ST; QL 3 ST; QL FOAM EXTERNAL CREAM OLUX-E EXTERNAL ULTRAVATE 3 ST; QL 3 ST; QL FOAM EXTERNAL LOTION PANDEL EXTERNAL VANOS EXTERNAL 3 ST; QL 3 ST; QL CREAM CREAM prednicarbate external cream 3 ST; QL; CTT1 VERDESO EXTERNAL 3 ST; QL prednicarbate external FOAM 3 ST; QL; CTT1 ointment *DEPIGMENTING PSORCON EXTERNAL AGENTS*** 3 ST; QL CREAM blanche external cream 1 or 1b* SERNIVO EXTERNAL EPIQUIN MICRO 3 ST; QL 3 EMULSION EXTERNAL CREAM SYNALAR EXTERNAL melpaque hp external cream 1 or 1b* 3 ST; QL CREAM remergent hq external cream 1 or 1b* SYNALAR EXTERNAL tl hydroquinone external 3 ST; QL 1 or 1b* OINTMENT cream SYNALAR EXTERNAL 3 ST; QL *DEPIGMENTING SOLUTION COMBINATIONS*** TEMOVATE EXTERNAL TRI-LUMA EXTERNAL 3 ST; QL 3 CREAM CREAM TEMOVATE EXTERNAL 3 ST; QL *EMOLLIENT OINTMENT COMBINATIONS*** TEXACORT EXTERNAL 3 ST; QL lactic acid e external cream 1 or 1b* SOLUTION *EMOLLIENT/KERATO TOPICORT EXTERNAL 3 ST; QL LYTIC AGENTS*** CREAM cerovel external lotion 1 or 1b* TOPICORT EXTERNAL 3 ST; QL HYDRO 40 EXTERNAL GEL 3 FOAM TOPICORT EXTERNAL 3 ST; QL urea external cream 40 %, 45 OINTMENT 1 or 1b* %, 47 % TOPICORT SPRAY 3 ST; QL UREA EXTERNAL EXTERNAL LIQUID 3 FOAM tovet external foam 1 or 1b* urea external suspension 40 triamcinolone acetonide 1 or 1b* 1 or 1a* ST; QL % external aerosol solution urea nail external gel 45 % 1 or 1b* triamcinolone acetonide 1 or 1a* external cream urea-c40 external lotion 1 or 1b* triamcinolone acetonide uredeb external cream 1 or 1b* 1 or 1a* external lotion uremez-40 external cream 1 or 1b* triamcinolone acetonide URESOL EXTERNAL 3 external ointment 0.025 %, 1 or 1a* CREAM 0.1 %, 0.5 % *EMOLLIENT/KERATO triamcinolone acetonide 1 or 1a* ST; QL LYTIC external ointment 0.05 % COMBINATIONS*** trianex external ointment 1 or 1a* ST; QL LATRIX XM EXTERNAL 3 triderm external cream 0.1 % 1 or 1a* EMULSION urea hydrating external foam 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 98 Drug Name Tier Notes Drug Name Tier Notes *EMOLLIENTS*** LUZU EXTERNAL 3 ST; QL ammonium lactate external CREAM 1 or 1b* cream NIZORAL EXTERNAL 3 ST; QL ammonium lactate external SHAMPOO 1 or 1b* lotion oxiconazole nitrate external 1 or 1b* ST; QL lactic acid external lotion 1 or 1b* cream sodium hyaluronate external OXISTAT EXTERNAL 1 or 1b* 3 ST; QL gel CREAM OXISTAT EXTERNAL *ENZYMES - 3 ST; QL TOPICAL*** LOTION SANTYL EXTERNAL sulconazole nitrate external 3 1 or 1b* ST; QL OINTMENT cream sulconazole nitrate external *EYELID CLEANSERS & 1 or 1b* ST; QL LUBRICANTS*** solution AVENOVA EXTERNAL XOLEGEL EXTERNAL 3 3 SOLUTION GEL *GLABELLAR LINES *IMMUNOMODULATOR (FROWN LINES) S AGENTS*** IMIDAZOQUINOLINAMI NES - TOPICAL*** BOTOX COSMETIC INTRAMUSCULAR ALDARA EXTERNAL 3 PA; QL 3 ST; QL SOLUTION CREAM RECONSTITUTED imiquimod external cream 1 or 1b* *IMIDAZOLE-RELATED imiquimod pump external 1 or 1b* ST; QL ANTIFUNGALS - cream TOPICAL*** ZYCLARA EXTERNAL 3 ST; QL clotrimazole external cream 1 or 1b* CREAM clotrimazole external ZYCLARA PUMP 1 or 1b* 3 ST; QL solution EXTERNAL CREAM econazole nitrate external *KERATOLYTIC 1 or 1b* cream AND/OR ANTIMITOTIC ECOZA EXTERNAL COMBINATIONS*** 3 ST; QL FOAM GORDOFILM 2 ERTACZO EXTERNAL EXTERNAL SOLUTION 3 ST; QL CREAM PYROGALLIC ACID 3 EXELDERM EXTERNAL EXTERNAL OINTMENT 3 ST; QL CREAM SALVAX DUO PLUS 3 EXELDERM EXTERNAL EXTERNAL KIT 3 ST; QL SOLUTION *KERATOLYTIC/ANTIM EXTINA EXTERNAL ITOTIC AGENTS*** 3 FOAM CONDYLOX EXTERNAL 3 JUBLIA EXTERNAL GEL 3 SOLUTION podofilox external solution 1 or 1b* ketoconazole external cream 1 or 1b* SALEX EXTERNAL KIT ketoconazole external foam 1 or 1b* 6 % (CREAM), 6 % 3 (LOTION) ketoconazole external 1 or 1b* shampoo 2 % salicylic acid external cream 1 or 1b* luliconazole external cream 1 or 1b* ST; QL salicylic acid external foam 1 or 1b* salicylic acid external gel 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 99 Drug Name Tier Notes Drug Name Tier Notes salicylic acid external lotion 1 or 1b* *MACROLIDE salicylic acid external IMMUNOSUPPRESSANT 1 or 1b* shampoo S - TOPICAL*** salicylic acid external ELIDEL EXTERNAL 1 or 1b* 3 ST; QL solution 26 % CREAM SALVAX EXTERNAL pimecrolimus external cream 1 or 1b* ST; QL 3 FOAM PROTOPIC EXTERNAL 3 ST; QL *LINIMENT OINTMENT COMBINATIONS*** tacrolimus external ointment 1 or 1b* ST; QL MEDI-DERM-RX *MISC. 3 EXTERNAL CREAM DERMATOLOGICAL MEDROX-RX PRODUCTS*** 2 EXTERNAL OINTMENT ALEVAMAX EXTERNAL 3 *LINIMENTS*** CREAM METHYL SALICYLATE ATOPICLAIR 3 3 EXTERNAL LIQUID EXTERNAL CREAM TURPENTINE EMULSION SB 3 3 EXTERNAL SPIRIT EXTERNAL EMULSION ILIDERM EXTERNAL *LOCAL ANESTHETICS 3 - TOPICAL*** EMULSION EHA EXTERNAL NEOSALUS EXTERNAL 2 3 LOTION FOAM glydo external prefilled NUVAIL EXTERNAL 1 or 1b* 3 syringe SOLUTION PENLEN EXTERNAL lidocaine external patch 5 % 1 or 1b* 3 EMULSION LIDOCAINE HCL PRESERA EXTERNAL EXTERNAL CREAM 4.12 3 3 % FOAM lidocaine hcl external REMIGEN EXTERNAL 1 or 1b* 3 solution CREAM lidocaine hcl XERALUX EXTERNAL 1 or 1b* 3 urethral/mucosal external gel CREAM lidocaine hcl *MISC. TOPICAL urethral/mucosal external 1 or 1b* COMBINATIONS*** prefilled syringe NUSURGEPAK LIDODERM EXTERNAL SURGICAL PREP/CARE 3 3 PATCH EXTERNAL KIT pramox external gel 1 or 1b* PRE & POST SX POUCH EXTERNAL THERAPY 3 premium lidocaine external 1 or 1b* PACK ointment *MISC. TOPICAL*** QUTENZA (2 PATCH) 2 LD BORIC ACID EXTERNAL EXTERNAL KIT 3 GRANULES QUTENZA EXTERNAL 2 LD QBREXZA EXTERNAL KIT 3 PA; QL PAD zionodil 100 external lotion 1 or 1b* ZTLIDO EXTERNAL 3 PA; QL PATCH

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 100 Drug Name Tier Notes Drug Name Tier Notes *ORNITHINE SOOLANTRA 3 DECARBOXYLASE EXTERNAL CREAM (ODC) INHIBITORS - *SCABICIDES & TOPICAL*** PEDICULICIDES*** VANIQA EXTERNAL 3 crotan external lotion 1 or 1b* CREAM ELIMITE EXTERNAL 3 *PHOTODYNAMIC CREAM THERAPY AGENTS - TOPICAL*** lindane external shampoo 1 or 1b* AMELUZ EXTERNAL malathion external lotion 1 or 1b* 3 GEL NATROBA EXTERNAL 3 LEVULAN KERASTICK SUSPENSION EXTERNAL SOLUTION 3 OVIDE EXTERNAL 3 RECONSTITUTED LOTION *PROSTAGLANDINS - permethrin external cream 1 or 1b* TOPICAL*** SKLICE EXTERNAL 3 bimatoprost external solution 1 or 1b* LOTION LATISSE EXTERNAL 3 spinosad external suspension 1 or 1b* SOLUTION SULFURATED LIME 3 *ROSACEA AGENTS*** EXTERNAL SOLUTION azelaic acid external gel 1 or 1b* *SCAR TREATMENT doxycycline oral capsule PRODUCTS*** 3 ST; QL; CTT1 delayed release RECEDO EXTERNAL 3 FINACEA EXTERNAL GEL 2 FOAM *SKIN CLEANSERS*** FINACEA EXTERNAL EPICYN EXTERNAL 3 3 GEL SOLUTION ivermectin external cream 1 or 1b* ESSENTRA WIPES 9X9" 3 METROCREAM EXTERNAL 3 ST; QL EXTERNAL CREAM *SKIN METROGEL EXTERNAL PROTECTANTS*** 3 ST; QL GEL benzoin compound external 1 or 1b* METROLOTION tincture 3 ST; QL EXTERNAL LOTION BENZOIN EXTERNAL 3 metronidazole external cream 1 or 1b* TINCTURE metronidazole external gel 1 or 1b* *SKIN TISSUE REPLACEMENTS*** metronidazole external lotion 1 or 1b* AFFINITY EXTERNAL MIRVASO EXTERNAL 3 3 SHEET GEL AMNIOFIX INJECTION NORITATE EXTERNAL 3 ST; QL SUSPENSION 3 CREAM RECONSTITUTED ORACEA ORAL AMPHENOL-40 CAPSULE DELAYED 3 INJECTION 3 RELEASE SUSPENSION RHOFADE EXTERNAL RECONSTITUTED 3 CREAM APLIGRAF EXTERNAL 3 LD rosadan external cream 1 or 1b* DISK rosadan external gel 1 or 1b* BIOVANCE EXTERNAL 3 SHEET * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 101 Drug Name Tier Notes Drug Name Tier Notes DERMAGRAFT PALINGEN INOVOFLO 3 EXTERNAL SHEET INJECTION 3 EPICORD EXTERNAL INJECTABLE 3 SHEET PALINGEN MEMBRANE 3 EPIFIX EXTERNAL DISK 3 EXTERNAL SHEET EPIFIX EXTERNAL PALINGEN XPLUS 3 SHEET HYDROMEMBRANE 3 EXTERNAL SHEET EPIFIX MICRONIZED INJECTION PALINGEN XPLUS SUSPENSION 3 MEMBRANE EXTERNAL 3 RECONSTITUTED 100 SHEET MG, 160 MG, 40 MG STRAVIX EXTERNAL 3 GRAFIX CORE 1.5CM X SHEET 3 2CM EXTERNAL TRUSKIN EXTERNAL 3 GRAFIX CORE 16MM SHEET 3 EXTERNAL *STEROID-LOCAL GRAFIX CORE 2CM X ANESTHETIC 3 3CM EXTERNAL COMBINATIONS*** GRAFIX CORE 3CM X EPIFOAM EXTERNAL 3 3 4CM EXTERNAL FOAM GRAFIX CORE 5CM X lidocaine-hydrocortisone ace 3 1 or 1b* 5CM EXTERNAL external cream 1-1 % GRAFIX PRIME 1.5CM X PRAMOSONE 3 2CM EXTERNAL EXTERNAL CREAM 1-1 2 % GRAFIX PRIME 16MM 3 PRAMOSONE EXTERNAL 2 EXTERNAL LOTION GRAFIX PRIME 2CM X 3 3CM EXTERNAL *TAR PRODUCTS*** GRAFIX PRIME 3CM X coal tar external solution 1 or 1b* 3 4CM EXTERNAL *TISSUE GRAFIX PRIME 5CM X REPLACEMENTS*** 3 5CM EXTERNAL AFFINITY EXTERNAL 3 GRAFIX XC 7.5CM X SHEET 3 15CM EXTERNAL AMNIOFIX INJECTION KARDIAMEMBRANE SUSPENSION 3 3 EXTERNAL SHEET RECONSTITUTED NEOX 100 EXTERNAL AMPHENOL-40 3 INJECTION SHEET 3 SUSPENSION NEOX CORD 1K 3 RECONSTITUTED EXTERNAL SHEET APLIGRAF EXTERNAL NUSHIELD EXTERNAL 3 LD 3 DISK DISK BIOVANCE EXTERNAL NUSHIELD EXTERNAL 3 3 SHEET SHEET DERMAGRAFT 3 PALINGEN FLOW EXTERNAL SHEET INJECTION 3 EPICORD EXTERNAL INJECTABLE 3 SHEET PALINGEN HYDROMEMBRANE 3 EPIFIX EXTERNAL DISK 3 EXTERNAL SHEET * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 102 Drug Name Tier Notes Drug Name Tier Notes EPIFIX EXTERNAL PALINGEN XPLUS 3 SHEET HYDROMEMBRANE 3 EPIFIX MICRONIZED EXTERNAL SHEET INJECTION PALINGEN XPLUS SUSPENSION 3 MEMBRANE EXTERNAL 3 RECONSTITUTED 100 SHEET MG, 160 MG, 40 MG STRAVIX EXTERNAL 3 GRAFIX CORE 1.5CM X SHEET 3 2CM EXTERNAL TRUSKIN EXTERNAL 3 GRAFIX CORE 16MM SHEET 3 EXTERNAL *TOPICAL ANESTHETIC GRAFIX CORE 2CM X COMBINATIONS*** 3 3CM EXTERNAL 1ST MEDX-PATCH/ GRAFIX CORE 3CM X LIDOCAINE EXTERNAL 3 3 4CM EXTERNAL PATCH 4-0.0375-5-20 % GRAFIX CORE 5CM X DERMACINRX 3 5CM EXTERNAL DUOPATCH GRAFIX PRIME 1.5CM X PHARMAPAK 3 3 2CM EXTERNAL EXTERNAL THERAPY PACK GRAFIX PRIME 16MM 3 EXTERNAL DERMACINRX NEUROTRAL GRAFIX PRIME 2CM X 3 PHARMAPAK 3 3CM EXTERNAL EXTERNAL THERAPY GRAFIX PRIME 3CM X PACK 3 4CM EXTERNAL FLEXIN EXTERNAL 3 GRAFIX PRIME 5CM X PATCH 3 5CM EXTERNAL LEVATIO EXTERNAL 3 GRAFIX XC 7.5CM X PATCH 3 15CM EXTERNAL lidocaine-prilocaine external 1 or 1b* KARDIAMEMBRANE kit 3 EXTERNAL SHEET LIDOCAINE- NEOX 100 EXTERNAL TETRACAINE 3 3 PA; QL SHEET EXTERNAL CREAM 7-7 % NEOX CORD 1K 3 LIDOTHOL EXTERNAL EXTERNAL SHEET 3 PATCH NUSHIELD EXTERNAL 3 MEDI-DERM/L-RX DISK 2 EXTERNAL CREAM NUSHIELD EXTERNAL 3 MEDI-PATCH RX SHEET 3 EXTERNAL PATCH PALINGEN FLOW PLIAGLIS EXTERNAL INJECTION 3 3 PA; QL INJECTABLE CREAM PREMIUM SCAR PALINGEN 3 HYDROMEMBRANE 3 EXTERNAL PATCH EXTERNAL SHEET PREPIV SUPPLY 3 PALINGEN INOVOFLO COMBINATION KIT INJECTION 3 SOOTHEE EXTERNAL 3 INJECTABLE PATCH 0.5-0.0375-5-2 % PALINGEN MEMBRANE 3 EXTERNAL SHEET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 103 Drug Name Tier Notes Drug Name Tier Notes SX1 MEDICATED POST- XEROFORM OIL OPERATIVE EXTERNAL 3 EMULSION GAUZE 3 KIT EXTERNAL PAD SYNERA EXTERNAL XEROFORM OIL 3 PA; QL PATCH EMULSION STRIP 3 VENIPUNCTURE PX1 EXTERNAL PHLEBOTOMY 3 XEROFORM OIL ROLL 3 EXTERNAL KIT 4"X9' EXTERNAL vexatrol external kit 1 or 1b* XEROFORM PETROLAT *TOPICAL SELECTIVE GAUZE 1"X8" 3 RETINOID X RECEPTOR EXTERNAL AGONISTS*** XEROFORM PETROLAT TARGRETIN EXTERNAL GAUZE 5"X9" 3 2 PA; QL; SP GEL EXTERNAL *TOPICAL STEROID XEROFORM PETROLAT COMBINATIONS*** PATCH 2"X2" 3 EXTERNAL PAD calcipotriene-betameth 1 or 1b* diprop external ointment XEROFORM PETROLAT PATCH 4"X4" 3 calcipotriene-betameth 1 or 1b* EXTERNAL PAD diprop external suspension XEROFORM DUOBRII EXTERNAL 3 PA; QL PETROLATUM ROLL 3 LOTION 4"X9' EXTERNAL ENSTILAR EXTERNAL 3 *WOUND FOAM CLEANSERS/DECUBITU SYNALAR (OINTMENT) S ULCER THERAPY*** 3 ST; QL EXTERNAL KIT ATRAPRO DERMAL TACLONEX EXTERNAL SPRAY EXTERNAL 3 3 OINTMENT LIQUID TACLONEX EXTERNAL MICROCYN EXTERNAL 3 3 SUSPENSION GEL MICROCYN EXTERNAL trivix external kit 1 or 1b* 3 LIQUID 0.023 % *TYPE II 5-ALPHA REDUCTASE MICROCYN SKIN AND INHIBITORS*** WOUND EXTERNAL 3 GEL finasteride oral tablet 1 mg 1 or 1b* *WOUND DRESSINGS*** PROPECIA ORAL 3 ACTICOAT 7 TABLET 2 EXTERNAL PAD *WOUND CARE - ACTICOAT 7 GROWTH FACTOR 2 AGENTS*** EXTERNAL SHEET REGRANEX EXTERNAL ACTICOAT ABSORBENT 3 2 GEL EXTERNAL ACTICOAT ABSORBENT *WOUND CARE 2 COMBINATIONS*** EXTERNAL PAD REXASIL PATCH & ACTICOAT VITAMIN E LIQ 3 ANTIMICROBIAL 2 EXTERNAL KIT EXTERNAL PAD XEROFORM OIL ACTICOAT EXTERNAL EMULSION 2"X2" 3 SHEET 16"X16" , 4"X4" , 3 EXTERNAL PAD 4"X48" , 4"X8" , 8"X16" * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 104 Drug Name Tier Notes Drug Name Tier Notes ACTICOAT EXTERNAL CARRASYN HYDROGEL 2 SHEET 5"X5" WOUND DRESS 3 ACTICOAT FLEX 3 EXTERNAL GEL 2 4"X4" EXTERNAL PAD CURITY HYPERTONIC 3 ACTICOAT FLEX 3 NACL STRIP EXTERNAL 2 EXTERNAL SHEET CURITY NACL ACTICOAT FLEX 7 DRESSING 6"X6-3/4" 2 2 EXTERNAL SHEET EXTERNAL PAD ACTICOAT MOISTURE DIAB EXTERNAL GEL 3 CONTROL EXTERNAL 2 DIAB F.D.G. FREEZE- 3 PAD 2"X2" DRIED EXTERNAL GEL ACTICOAT MOISTURE DURAFIBER AG 3 CONTROL EXTERNAL 3 EXTERNAL PAD PAD 4"X4" , 4"X8" DURAFIBER EXTERNAL 3 ACTICOAT SITE PAD 2 EXTERNAL DISK ENDOFORM DERMAL ACTICOAT SURGICAL TEMPLATE EXTERNAL 3 3 EXTERNAL PAD SHEET ALLEVYN AG ENDOFORM ADHESIVE EXTERNAL DERMAL/FENESTRATE 3 2 PAD 12.5X12.5CM , D EXTERNAL SHEET 17.5X17.5CM , 7.5X7.5CM HYDROFERA BLUE 2 ALLEVYN AG GENTLE 4"X4" EXTERNAL PAD BORDER EXTERNAL HYDROFERA BLUE 2 2 PAD 12.5X12.5CM , 6"X6" EXTERNAL PAD 17.5X17.5CM , 7.5X7.5CM HYDROFERA BLUE ALLEVYN AG GENTLE 3 FOAM DRESSING 2 EXTERNAL PAD EXTERNAL PAD ALLEVYN AG NON- HYDROFERA BLUE ADHESIVE EXTERNAL 2 FOAM/TUNNELING 2 PAD 2"X2" , 4"X4" , EXTERNAL PAD 6"X6" , 8"X8" HYDROFERA BLUE ALLEVYN AG SACRUM 2 MRF DRESSING 2 6-3/4" EXTERNAL EXTERNAL PAD ALLEVYN AG SACRUM 2 HYDROFERA BLUE 9"X9" EXTERNAL READY FOAM 2 ALLEVYN GENTLE EXTERNAL PAD 2 EXTERNAL PAD HYGEL EXTERNAL GEL 3 AQUACEL AG BURN 2.5 % 3 EXTERNAL PAD KENDALL ALGINATE 3 ARIDA EXTERNAL GEL 3 12" ROPE EXTERNAL AVO CREAM KENDALL ALGINATE 3 EXTERNAL EMULSION DRESS 2"X2" 2 BIAFINE EXTERNAL EXTERNAL PAD 3 EMULSION KENDALL ALGINATE BIOSTEP AG EXTERNAL DRESS 4"X4" 2 2 SHEET EXTERNAL PAD BIOSTEP EXTERNAL KENDALL ALGINATE 2 SHEET DRESS 4"X8" 2 EXTERNAL PAD

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 105 Drug Name Tier Notes Drug Name Tier Notes KENDALL AMORPHOUS OASIS ULTRA TRI- WOUND EXTERNAL 3 LAYER MATRIX 2 GEL EXTERNAL SHEET KENDALL HYDROGEL 7X10CM , 7X20CM GAUZE 2"X2" 3 OASIS WOUND MATRIX EXTERNAL PAD FENESTRATED 3 KENDALL HYDROGEL EXTERNAL SHEET GAUZE 4"X4" 3 3X3.5CM , 3X7CM EXTERNAL PAD PICO WOUND THERAPY KENDALL HYDROGEL SYSTEM EXTERNAL 3 GAUZE 4"X8" 3 KIT EXTERNAL PAD PRUTECT EXTERNAL 3 KENDALL HYDROGEL EMULSION WOUND DRESS 3 RADIAGEL EXTERNAL 3 EXTERNAL GEL KERAGEL EXTERNAL RESTORE SILVER 3 GEL DRESSING EXTERNAL 2 KERAGELT EXTERNAL PAD 2"X2" , 4"X4" , 3 GEL 4"X4.75" , 4"X5" , 6"X8" LUXAMEND EXTERNAL RTD WOUND CARE 3 CREAM DRESSING EXTERNAL 2 PAD MEDIHONEY CA SILVASORB EXTERNAL ALGINATE 2"X2" 2 3 EXTERNAL PAD GEL MEDIHONEY CA SILVRSTAT WOUND ALGINATE 4"X5" 2 DRESSING EXTERNAL 3 EXTERNAL PAD GEL SONAFINE EXTERNAL MEDIHONEY 3 WOUND/BURN EMULSION 2 DRESSING EXTERNAL TEGADERM AG MESH 2 GEL EXTERNAL PAD MEDIHONEY THERAHONEY 3 WOUND/BURN EXTERNAL GEL 2 DRESSING EXTERNAL THERAHONEY 3 PAD EXTERNAL SHEET MEDIHONEY VASCUDERM WOUND/BURN 3 HYDROGEL EXTERNAL 3 DRESSING EXTERNAL GEL PASTE *DIAGNOSTIC MIRODERM BIOLOGIC PRODUCTS* MATRIX FENES 3 EXTERNAL SHEET *DIAGNOSTIC TESTS*** ACCU-CHEK AVIVA MIRODERM BIOLOGIC 2 QL WOUND MATRIX 3 PLUS IN VITRO STRIP EXTERNAL SHEET ACCU-CHEK COMPACT 2 QL OASIS ULTRA MATRIX PLUS IN VITRO STRIP FENESTRATED 3 ACCU-CHEK GUIDE IN 2 QL EXTERNAL SHEET VITRO STRIP OASIS ULTRA TRI- ACCU-CHEK LAYER MATRIX 3 SMARTVIEW IN VITRO 2 QL EXTERNAL SHEET STRIP 5X7CM

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 106 Drug Name Tier Notes Drug Name Tier Notes ACCUTREND GLUCOSE CLEVER CHEK AUTO- 2 QL IN VITRO STRIP CODE VOICE IN VITRO 3 ST; QL ADVANCE INTUITION STRIP 3 ST; QL TEST IN VITRO STRIP CLEVER CHEK TEST IN 3 ST; QL ADVANCE MICRO- VITRO STRIP DRAW TEST IN VITRO 3 ST; QL CLEVER CHOICE STRIP AUTO-CODE TEST IN 3 ST; QL ADVOCATE REDI-CODE VITRO STRIP 3 ST; QL IN VITRO STRIP CLEVER CHOICE ADVOCATE REDI- MICRO TEST IN VITRO 3 ST; QL CODE+ TEST IN VITRO 3 ST; QL STRIP STRIP CLEVER CHOICE NO ADVOCATE TEST IN CODING IN VITRO 3 ST; QL 3 ST; QL VITRO STRIP STRIP AGAMATRIX AMP TEST CLEVER CHOICE TALK 3 ST; QL IN VITRO STRIP SYSTEM IN VITRO 3 ST; QL STRIP AGAMATRIX JAZZ 3 ST; QL CONTOUR NEXT TEST TEST IN VITRO STRIP 3 ST; QL IN VITRO STRIP AGAMATRIX KEYNOTE 3 ST; QL CONTOUR TEST IN TEST IN VITRO STRIP 3 ST; QL VITRO STRIP AGAMATRIX PRESTO 3 ST; QL TEST IN VITRO STRIP COOL BLOOD GLUCOSE TEST STRIPS 3 ST; QL ASSURE 3 TEST IN 3 ST; QL IN VITRO STRIP VITRO STRIP CVS ADVANCED ASSURE 4 TEST IN 3 ST; QL GLUCOSE TEST IN 3 ST; QL VITRO STRIP VITRO STRIP ASSURE II CHECK IN 3 ST; QL CVS GLUCOSE METER VITRO STRIP TEST STRIPS IN VITRO 3 ST; QL ASSURE II IN VITRO STRIP 3 ST; QL STRIP D-CARE BLOOD ASSURE PLATINUM IN GLUCOSE IN VITRO 3 ST; QL 3 ST; QL VITRO STRIP STRIP ASSURE PRISM MULTI DIATHRIVE BLOOD 3 ST; QL TEST IN VITRO STRIP GLUCOSE TEST IN 3 ST; QL VITRO STRIP ASSURE PRO TEST IN 3 ST; QL DIATHRIVE GLUCOSE VITRO STRIP 3 ST; QL TEST IN VITRO STRIP BIOSCANNER GLUCOSE 3 ST; QL DIATRUE PLUS TEST IN TEST IN VITRO STRIP 3 ST; QL VITRO STRIP BLOOD GLUCOSE TEST 3 ST; QL DUO-CARE TEST IN IN VITRO STRIP 3 ST; QL VITRO STRIP CAREONE BLOOD EASY PLUS II GLUCOSE GLUCOSE TEST IN 3 ST; QL 3 ST; QL VITRO STRIP TEST IN VITRO STRIP CARESENS N GLUCOSE EASY STEP TEST IN 3 ST; QL 3 ST; QL TEST IN VITRO STRIP VITRO STRIP CARETOUCH TEST IN EASY TALK BLOOD 3 ST; QL VITRO STRIP GLUCOSE TEST IN 3 ST; QL VITRO STRIP CLEVER CHEK AUTO- EASY TOUCH TEST IN CODE TEST IN VITRO 3 ST; QL 3 ST; QL STRIP VITRO STRIP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 107 Drug Name Tier Notes Drug Name Tier Notes EASY TRAK BLOOD EVENCARE PROVIEW GLUCOSE TEST IN 3 ST; QL GLUCOSE TEST IN 3 ST; QL VITRO STRIP VITRO STRIP EASYGLUCO IN VITRO EVOLUTION 3 ST; QL STRIP AUTOCODE IN VITRO 3 ST; QL EASYGLUCO PLUS IN STRIP 3 ST; QL VITRO STRIP EXACTECH R-S-G TEST 3 ST; QL EASYMAX 15 TEST IN IN VITRO STRIP 3 ST; QL VITRO STRIP EXACTECH TEST IN 3 ST; QL EASYMAX TEST IN VITRO STRIP 3 ST; QL VITRO STRIP EZ SMART BLOOD EASYPLUS BLOOD GLUCOSE TEST IN 3 ST; QL GLUCOSE TEST IN 3 ST; QL VITRO STRIP VITRO STRIP EZ SMART PLUS EASYPRO BLOOD GLUCOSE TEST IN 3 ST; QL GLUCOSE TEST IN 3 ST; QL VITRO STRIP VITRO STRIP FIFTY50 GLUCOSE EASYPRO PLUS IN TEST 2.0 IN VITRO 3 ST; QL 3 ST; QL VITRO STRIP STRIP ELEMENT COMPACT FORA BLOOD GLUCOSE 3 ST; QL 3 ST; QL TEST IN VITRO STRIP TEST IN VITRO STRIP ELEMENT TEST IN FORA D15G BLOOD 3 ST; QL VITRO STRIP GLUCOSE TEST IN 3 ST; QL VITRO STRIP EMBRACE BLOOD GLUCOSE TEST IN 3 ST; QL FORA D20 BLOOD VITRO STRIP GLUCOSE TEST IN 3 ST; QL VITRO STRIP EMBRACE EVO BLOOD GLUCOSE TEST IN 3 ST; QL FORA D40/G31 BLOOD VITRO STRIP GLUCOSE IN VITRO 3 ST; QL STRIP EMBRACE PRO GLUCOSE TEST IN 3 ST; QL FORA G20 BLOOD VITRO STRIP GLUCOSE TEST IN 3 ST; QL VITRO STRIP EMBRACE TALK GLUCOSE TEST IN 3 ST; QL FORA G30/PREM V10 VITRO STRIP GLUCOSE TEST IN 3 ST; QL VITRO STRIP EQ BLOOD GLUCOSE 3 ST; QL FORA GD20 TEST IN TEST IN VITRO STRIP 3 ST; QL VITRO STRIP EVENCARE + BLOOD GLUCOSE TEST IN 3 ST; QL FORA GD50 BLOOD VITRO STRIP GLUCOSE TEST IN 3 ST; QL VITRO STRIP EVENCARE BLOOD GLUCOSE TEST IN 3 ST; QL FORA GTEL BLOOD VITRO STRIP GLUCOSE TEST IN 3 ST; QL VITRO STRIP EVENCARE G2 TEST IN 3 ST; QL FORA TN'G/TN'G VOICE VITRO STRIP 3 ST; QL IN VITRO STRIP EVENCARE G3 TEST IN 3 ST; QL VITRO STRIP FORA V10 BLOOD GLUCOSE TEST IN 3 ST; QL EVENCARE MINI VITRO STRIP GLUCOSE TEST IN 3 ST; QL VITRO STRIP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 108 Drug Name Tier Notes Drug Name Tier Notes FORA V12 BLOOD GLUCONAVII BLOOD GLUCOSE TEST IN 3 ST; QL GLUCOSE TEST IN 3 ST; QL VITRO STRIP VITRO STRIP FORA V20 BLOOD GLUCOSE METER TEST 3 ST; QL GLUCOSE TEST IN 3 ST; QL IN VITRO STRIP VITRO STRIP GNP EASY TOUCH FORA V30A BLOOD GLUCOSE TEST IN 3 ST; QL GLUCOSE TEST IN 3 ST; QL VITRO STRIP VITRO STRIP GOJJI BLOOD FORACARE GD40 TEST GLUCOSE TEST IN 3 ST; QL 3 ST; QL IN VITRO STRIP VITRO STRIP FORACARE PREMIUM GOJJI BLOOD TEST V10 TEST IN VITRO 3 ST; QL STRIP/LANCETS IN 3 ST; QL STRIP VITRO STRIP FORACARE TEST N GO GOODSENSE BLOOD 3 ST; QL TEST IN VITRO STRIP GLUCOSE IN VITRO 3 ST; QL FORTISCARE TEST IN STRIP 3 ST; QL VITRO STRIP HARMONY BLOOD FREESTYLE INSULINX GLUCOSE TEST IN 3 ST; QL 3 ST; QL TEST IN VITRO STRIP VITRO STRIP FREESTYLE LITE TEST HW EMBRACE PRO 3 ST; QL IN VITRO STRIP GLUCOSE TEST IN 3 ST; QL VITRO STRIP FREESTYLE PRECISION NEO TEST IN VITRO 3 ST; QL HW EMBRACE TALK STRIP GLUCOSE TEST IN 3 ST; QL VITRO STRIP FREESTYLE TEST IN 3 ST; QL IGLUCOSE TEST STRIPS VITRO STRIP 3 ST; QL IN VITRO STRIP GE100 BLOOD GLUCOSE TEST IN 3 ST; QL IN TOUCH BLOOD VITRO STRIP GLUCOSE TEST IN 3 ST; QL VITRO STRIP GENULTIMATE TEST IN 3 ST; QL VITRO STRIP INFINITY BLOOD GLUCOSE TEST IN 3 ST; QL GHT TEST IN VITRO 3 ST; QL VITRO STRIP STRIP INFINITY VOICE IN GLUCO PERFECT 3 3 ST; QL 3 ST; QL VITRO STRIP TEST IN VITRO STRIP KROGER BLOOD GLUCOCARD 01 GLUCOSE TEST IN 3 ST; QL SENSOR PLUS IN VITRO 3 ST; QL VITRO STRIP STRIP KROGER HEALTHPRO GLUCOCARD GLUCOSE TEST IN 3 ST; QL EXPRESSION TEST IN 3 ST; QL VITRO STRIP VITRO STRIP KROGER PREMIUM GLUCOCARD SHINE 3 ST; QL GLUCOSE TEST IN 3 ST; QL TEST IN VITRO STRIP VITRO STRIP GLUCOCARD VITAL KROGER TEST IN 3 ST; QL 3 ST; QL TEST IN VITRO STRIP VITRO STRIP GLUCOCARD X-SENSOR 3 ST; QL LIBERTY NEXT IN VITRO STRIP GENERATION TEST IN 3 ST; QL GLUCOCOM TEST IN VITRO STRIP 3 ST; QL VITRO STRIP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 109 Drug Name Tier Notes Drug Name Tier Notes LIBERTY TEST IN PHARMACIST CHOICE 3 ST; QL VITRO STRIP NO CODING IN VITRO 3 ST; QL MEIJER BLOOD STRIP GLUCOSE TEST IN 3 ST; QL POCKETCHEM EZ TEST 3 ST; QL VITRO STRIP IN VITRO STRIP MEIJER ESSENTIAL PRECISION PCX IN 3 ST; QL GLUCOSE TEST IN 3 ST; QL VITRO STRIP VITRO STRIP PRECISION PCX PLUS 3 ST; QL MEIJER PREMIUM TEST IN VITRO STRIP GLUCOSE TEST IN 3 ST; QL PRECISION POINT OF VITRO STRIP CARE TEST IN VITRO 3 ST; QL MEIJER TRUETEST STRIP 3 ST; QL TEST IN VITRO STRIP PRECISION QID TEST IN 3 ST; QL MEIJER TRUETRACK VITRO STRIP 3 ST; QL TEST IN VITRO STRIP PRECISION SOF-TACT 3 ST; QL MICRODOT TEST IN TEST IN VITRO STRIP 3 ST; QL VITRO STRIP PRECISION XTRA MM EASY TOUCH BLOOD GLUCOSE IN 3 ST; QL GLUCOSE IN VITRO 3 ST; QL VITRO STRIP STRIP PREMIUM BLOOD MYGLUCOHEALTH GLUCOSE TEST IN 3 ST; QL 3 ST; QL TEST IN VITRO STRIP VITRO STRIP NEUTEK 2TEK TEST IN PRO VOICE V8/V9 3 ST; QL VITRO STRIP GLUCOSE IN VITRO 3 ST; QL NOVA MAX GLUCOSE STRIP 3 ST; QL TEST IN VITRO STRIP PRODIGY NO CODING ON CALL EXPRESS BLOOD GLUC IN VITRO 3 ST; QL BLOOD GLUCOSE IN 3 ST; QL STRIP VITRO STRIP PTS PANELS GLUCOSE 3 ST; QL ON CALL PLUS BLOOD TEST IN VITRO STRIP GLUCOSE IN VITRO 3 ST; QL QUICKTEK TEST IN 3 ST; QL STRIP VITRO STRIP ON CALL VIVID BLOOD QUINTET AC BLOOD GLUCOSE IN VITRO 3 ST; QL GLUCOSE TEST IN 3 ST; QL STRIP VITRO STRIP ONE DROP TEST IN QUINTET BLOOD 3 ST; QL VITRO STRIP GLUCOSE TEST IN 3 ST; QL ONETOUCH ULTRA VITRO STRIP 2 BLUE IN VITRO STRIP RA TRUETEST TEST IN 3 ST; QL ONETOUCH VERIO IN VITRO STRIP 2 QL VITRO STRIP REFUAH PLUS BLOOD OPTIUM TEST IN VITRO GLUCOSE TEST IN 3 ST; QL 3 ST; QL STRIP VITRO STRIP OPTIUMEZ TEST IN RELION BLOOD 3 ST; QL VITRO STRIP GLUCOSE TEST IN 3 ST; QL VITRO STRIP OPTUMRX BLOOD GLUCOSE TEST IN 3 ST; QL RELION VITRO STRIP CONFIRM/MICRO TEST 3 ST; QL IN VITRO STRIP PHARMACIST CHOICE RELION PREMIER TEST AUTOCODE IN VITRO 3 ST; QL 3 ST; QL STRIP IN VITRO STRIP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 110 Drug Name Tier Notes Drug Name Tier Notes RELION PRIME TEST IN TRUETEST TEST IN 3 ST; QL 3 ST; QL VITRO STRIP VITRO STRIP RELION ULTIMA TEST TRUETRACK TEST IN 3 ST; QL 3 ST; QL IN VITRO STRIP VITRO STRIP REVEAL BLOOD ULTIMA TEST IN VITRO 3 ST; QL GLUCOSE TEST IN 3 ST; QL STRIP VITRO STRIP ULTRATRAK PRO TEST 3 ST; QL REXALL BLOOD IN VITRO STRIP GLUCOSE TEST IN 3 ST; QL ULTRATRAK VITRO STRIP ULTIMATE TEST IN 3 ST; QL RIGHTEST GS100 VITRO STRIP BLOOD GLUCOSE IN 3 ST; QL UNISTRIP1 GENERIC IN 3 ST; QL VITRO STRIP VITRO STRIP RIGHTEST GS300 VERASENS BLOOD BLOOD GLUCOSE IN 3 ST; QL GLUCOSE TEST IN 3 ST; QL VITRO STRIP VITRO STRIP RIGHTEST GS550 VICTORY AGM-4000 3 ST; QL BLOOD GLUCOSE IN 3 ST; QL TEST IN VITRO STRIP VITRO STRIP VIVAGUARD INO TEST 3 ST; QL SMART SENSE STRIPS IN VITRO STRIP PREMIUM TEST IN 3 ST; QL VITRO STRIP VOCAL POINT BLOOD GLUCOSE TEST IN 3 ST; QL SMART SENSE VALUE 3 ST; QL VITRO STRIP TEST IN VITRO STRIP *DIGESTIVE AIDS* SMARTEST BLOOD GLUCOSE TEST IN 3 ST; QL *DIGESTIVE VITRO STRIP ENZYMES*** SOLUS V2 TEST IN CREON ORAL CAPSULE 3 ST; QL VITRO STRIP DELAYED RELEASE 2 PARTICLES SUPREME TEST IN 3 ST; QL VITRO STRIP PANCREAZE ORAL CAPSULE DELAYED 3 ST; QL SURE EDGE TEST IN 3 ST; QL RELEASE PARTICLES VITRO STRIP PERTZYE ORAL SURECHEK BLOOD CAPSULE DELAYED 3 ST; QL GLUCOSE TEST IN 3 ST; QL RELEASE PARTICLES VITRO STRIP SUCRAID ORAL 3 PA; QL; LD SURE-TEST EASYPLUS SOLUTION MINI TEST IN VITRO 3 ST; QL VIOKACE ORAL STRIP 3 TABLET TELCARE BLOOD GLUCOSE TEST IN 3 ST; QL ZENPEP ORAL VITRO STRIP CAPSULE DELAYED RELEASE PARTICLES TGT BLOOD GLUCOSE 3 ST; QL 10000-32000 UNIT, 15000- TEST IN VITRO STRIP 47000 UNIT, 20000-63000 2 TRUE FOCUS BLOOD UNIT, 25000-79000 UNIT, GLUCOSE STRIP IN 3 ST; QL 3000-14000 UNIT, 40000- VITRO STRIP 126000 UNIT, 5000-24000 TRUE METRIX BLOOD UNIT GLUCOSE TEST IN 3 ST; QL VITRO STRIP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 111 Drug Name Tier Notes Drug Name Tier Notes *DIRECT-ACTING P2Y12 ethacrynate sodium INHIBITORS*** intravenous solution 1 or 1b* *DIRECT-ACTING P2Y12 reconstituted INHIBITORS*** ethacrynic acid oral tablet 1 or 1b* BRILINTA ORAL FUROSEMIDE IN 2 TABLET SODIUM CHLORIDE 3 KENGREAL INTRAVENOUS INTRAVENOUS SOLUTION 3 SOLUTION furosemide injection solution 1 or 1a* RECONSTITUTED 10 mg/ml *DIURETICS* furosemide oral solution 10 1 or 1a* *CARBONIC mg/ml, 8 mg/ml ANHYDRASE furosemide oral tablet 1 or 1a* INHIBITORS*** LASIX ORAL TABLET 3 acetazolamide er oral capsule 1 or 1b* SODIUM EDECRIN extended release 12 hour INTRAVENOUS 3 acetazolamide oral tablet 1 or 1b* SOLUTION acetazolamide sodium RECONSTITUTED injection solution 1 or 1b* torsemide oral tablet 1 or 1b* reconstituted *OSMOTIC KEVEYIS ORAL DIURETICS*** 3 PA; QL; LD TABLET mannitol intravenous 1 or 1b* methazolamide oral tablet 1 or 1b* solution 20 %, 25 % *DIURETIC osmitrol intravenous solution 1 or 1b* COMBINATIONS*** *POTASSIUM SPARING ALDACTAZIDE ORAL DIURETICS*** 3 TABLET ALDACTONE ORAL 3 amiloride- TABLET hydrochlorothiazide oral 1 or 1b* amiloride hcl oral tablet 1 or 1b* tablet CAROSPIR ORAL DYAZIDE ORAL 3 3 SUSPENSION CAPSULE DYRENIUM ORAL MAXZIDE ORAL 3 3 CAPSULE TABLET spironolactone oral tablet 1 or 1a* MAXZIDE-25 ORAL 3 TABLET triamterene oral capsule 1 or 1b* spironolactone-hctz oral *THIAZIDES AND 1 or 1b* tablet THIAZIDE-LIKE DIURETICS*** triamterene-hctz oral capsule 1 or 1a* 37.5-25 mg chlorothiazide oral tablet 1 or 1b* triamterene-hctz oral tablet 1 or 1a* chlorothiazide sodium intravenous solution 1 or 1b* *LOOP DIURETICS*** reconstituted bumetanide injection solution 1 or 1b* chlorthalidone oral tablet 25 1 or 1a* bumetanide oral tablet 1 or 1b* mg, 50 mg BUMEX ORAL TABLET 3 DIURIL ORAL 3 EDECRIN ORAL SUSPENSION 3 TABLET hydrochlorothiazide oral 1 or 1a* capsule

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 112 Drug Name Tier Notes Drug Name Tier Notes hydrochlorothiazide oral FOSAMAX PLUS D 1 or 1a* 2 tablet ORAL TABLET indapamide oral tablet 1 or 1b* ibandronate sodium metolazone oral tablet 1 or 1b* intravenous solution 3 1 or 1b* mg/3ml SODIUM DIURIL INTRAVENOUS ibandronate sodium oral 3 1 or 1b* ST; QL SOLUTION tablet RECONSTITUTED pamidronate disodium *DOPAMINE AND intravenous solution 30 1 or 1b* SP NOREPINEPHRINE mg/10ml, 90 mg/10ml REUPTAKE INHIBITORS PAMIDRONATE (DNRIS)*** DISODIUM 3 SP *DOPAMINE AND INTRAVENOUS NOREPINEPHRINE SOLUTION 6 MG/ML REUPTAKE INHIBITORS pamidronate disodium (DNRIS)*** intravenous solution 1 or 1b* SP SUNOSI ORAL TABLET reconstituted 3 PA; QL 150 MG RECLAST SUNOSI ORAL TABLET INTRAVENOUS 3 PA; QL; SP 3 PA; DO; QL 75 MG SOLUTION *ENDOCRINE AND risedronate sodium oral METABOLIC AGENTS - tablet 150 mg, 30 mg, 35 mg, 1 or 1b* MISC.* 5 mg risedronate sodium oral *ABORTIFACIENT - 1 or 1b* PROGESTERONE tablet delayed release RECEPTOR zoledronic acid intravenous 1 or 1b* PA; QL; SP ANTAGONISTS*** concentrate MIFEPREX ORAL ZOLEDRONIC ACID 3 TABLET INTRAVENOUS 3 PA; QL; SP mifepristone oral tablet 1 or 1b* SOLUTION 4 MG/100ML zoledronic acid intravenous *BISPHOSPHONATES*** 1 or 1b* PA; QL; SP solution 5 mg/100ml ACTONEL ORAL TABLET 150 MG, 30 MG, 3 *CALCIMIMETIC 35 MG, 5 MG AGENTS*** alendronate sodium oral cinacalcet hcl oral tablet 1 or 1b* PA; QL 1 or 1b* solution PARSABIV alendronate sodium oral INTRAVENOUS 3 PA; QL tablet 10 mg, 35 mg, 5 mg, 1 or 1b* SOLUTION 70 mg SENSIPAR ORAL 3 PA; QL ATELVIA ORAL TABLET TABLET DELAYED 3 *CALCITONINS*** RELEASE calcitonin (salmon) nasal 1 or 1b* BINOSTO ORAL solution TABLET 3 MIACALCIN INJECTION 3 EFFERVESCENT SOLUTION BONIVA INTRAVENOUS 3 *CARNITINE SOLUTION REPLENISHER - BONIVA ORAL TABLET AGENTS*** 3 ST; QL 150 MG CARNITOR FOSAMAX ORAL INTRAVENOUS 3 3 TABLET 70 MG SOLUTION * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 113 Drug Name Tier Notes Drug Name Tier Notes CARNITOR ORAL *GROWTH HORMONE 3 SOLUTION RELEASING CARNITOR ORAL HORMONES (GHRH)*** 3 TABLET EGRIFTA CARNITOR SF ORAL SUBCUTANEOUS 3 3 PA; QL; LD SOLUTION SOLUTION RECONSTITUTED 1 MG LEVOCARNITINE 3 INJECTION SOLUTION EGRIFTA SV SUBCUTANEOUS 3 PA; QL; LD levocarnitine oral solution 1 or 1b* SOLUTION levocarnitine oral tablet 1 or 1b* RECONSTITUTED levocarnitine sf oral solution 1 or 1b* *GROWTH HORMONES*** *CORTICOTROPIN*** GENOTROPIN ACTHAR INJECTION 3 PA; QL; LD; SP MINIQUICK GEL SUBCUTANEOUS 3 PA; QL; SP *DOPAMINE RECEPTOR SOLUTION AGONISTS*** RECONSTITUTED cabergoline oral tablet 1 or 1b* GENOTROPIN SUBCUTANEOUS *FABRY DISEASE - 3 PA; QL; SP AGENTS*** SOLUTION RECONSTITUTED FABRAZYME INTRAVENOUS HUMATROPE 3 PA; QL; LD; SP SOLUTION INJECTION SOLUTION 3 PA; QL; SP RECONSTITUTED RECONSTITUTED GALAFOLD ORAL NORDITROPIN 3 PA; QL; LD FLEXPRO CAPSULE 3 PA; QL; SP SUBCUTANEOUS *GAA DEFICIENCY SOLUTION TREATMENT - AGENTS*** NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS 3 PA; QL; SP LUMIZYME SOLUTION INTRAVENOUS 3 PA; QL; LD; SP SOLUTION NUTROPIN AQ NUSPIN RECONSTITUTED 20 SUBCUTANEOUS 3 PA; QL; SP SOLUTION *GNRH/LHRH ANTAGONISTS*** NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS 3 PA; QL; SP CETROTIDE SOLUTION SUBCUTANEOUS KIT 3 PA; QL; SP 0.25 MG OMNITROPE SUBCUTANEOUS 3 PA; QL; SP GANIRELIX ACETATE SOLUTION SUBCUTANEOUS 3 PA; QL; SP SOLUTION PREFILLED OMNITROPE SUBCUTANEOUS SYRINGE 3 PA; QL; SP SOLUTION ORILISSA ORAL 3 PA; QL RECONSTITUTED TABLET SAIZEN INJECTION *GROWTH HORMONE SOLUTION 3 PA; QL; SP RECEPTOR RECONSTITUTED ANTAGONISTS*** SAIZENPREP SOMAVERT INJECTION SOLUTION 3 PA; QL; SP SUBCUTANEOUS 3 PA; QL; LD; SP RECONSTITUTED SOLUTION RECONSTITUTED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 114 Drug Name Tier Notes Drug Name Tier Notes SEROSTIM RAYALDEE ORAL SUBCUTANEOUS CAPSULE EXTENDED 3 PA; QL SOLUTION 3 PA; QL; LD RELEASE RECONSTITUTED 4 MG, ROCALTROL ORAL 3 PA; QL 5 MG, 6 MG CAPSULE ZOMACTON ROCALTROL ORAL SUBCUTANEOUS 3 PA; QL 3 PA; QL; SP SOLUTION SOLUTION RECONSTITUTED ZEMPLAR INTRAVENOUS 3 PA; QL ZORBTIVE SOLUTION SUBCUTANEOUS 3 PA; QL; SP ZEMPLAR ORAL SOLUTION 3 PA; QL RECONSTITUTED CAPSULE 1 MCG, 2 MCG *HEREDITARY *INSULIN-LIKE TYROSINEMIA TYPE 1 GROWTH FACTORS (HT-1) TREATMENT - (SOMATOMEDINS)*** AGENTS*** INCRELEX nitisinone oral capsule 1 or 1b* PA; QL; LD SUBCUTANEOUS 3 PA; QL; LD; SP SOLUTION NITYR ORAL TABLET 3 PA; QL; LD *LHRH/GNRH AGONIST ORFADIN ORAL 3 PA; QL; LD ANALOG PITUITARY CAPSULE SUPPRESSANTS*** ORFADIN ORAL 3 PA; QL; LD LUPRON DEPOT-PED (1- SUSPENSION MONTH) 3 PA; QL; SP *HOMOCYSTINURIA INTRAMUSCULAR KIT TREATMENT - LUPRON DEPOT-PED (3- AGENTS*** MONTH) 3 PA; QL; SP CYSTADANE ORAL INTRAMUSCULAR KIT 3 LD POWDER SUPPRELIN LA 3 PA; QL; LD; SP *HYPERAMMONEMIA SUBCUTANEOUS KIT TREATMENT - SYNAREL NASAL 3 PA; QL; SP AGENTS*** SOLUTION CARBAGLU ORAL 3 PA; QL; LD TRIPTODUR TABLET INTRAMUSCULAR 3 PA; QL; LD *HYPERPARATHYROID SUSPENSION TREATMENT - VITAMIN RECONSTITUTED ER D ANALOGS*** *MUCOPOLYSACCHARI calcitriol intravenous DOSIS I (MPS I) - 1 or 1b* PA; QL solution 1 mcg/ml AGENTS*** calcitriol oral capsule 1 or 1b* PA; QL ALDURAZYME calcitriol oral solution 1 or 1b* PA; QL INTRAVENOUS 3 PA; QL; LD; SP SOLUTION doxercalciferol intravenous 1 or 1b* PA; QL solution *MUCOPOLYSACCHARI DOSIS II (MPS II) - doxercalciferol oral capsule 1 or 1b* PA; QL AGENTS*** HECTOROL ELAPRASE INTRAVENOUS 3 PA; QL INTRAVENOUS 3 PA; QL; LD; SP SOLUTION SOLUTION paricalcitol intravenous 1 or 1b* PA; QL solution paricalcitol oral capsule 1 or 1b* PA; QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 115 Drug Name Tier Notes Drug Name Tier Notes *MUCOPOLYSACCHARI *PARATHYROID DOSIS VI (MPS VI) - HORMONE AND AGENTS*** DERIVATIVES*** NAGLAZYME FORTEO INTRAVENOUS 3 PA; QL; LD; SP SUBCUTANEOUS 3 PA; QL; SP SOLUTION SOLUTION PEN- *OVULATION INJECTOR STIMULANTS- NATPARA GONADOTROPINS*** SUBCUTANEOUS 3 PA; QL; LD; SP CHORIONIC CARTRIDGE GONADOTROPIN TERIPARATIDE INTRAMUSCULAR 3 PA; QL; SP (RECOMBINANT) SOLUTION SUBCUTANEOUS 3 RECONSTITUTED SOLUTION PEN- FOLLISTIM AQ INJECTOR SUBCUTANEOUS 3 PA; QL; SP TYMLOS SOLUTION SUBCUTANEOUS 3 PA; QL; SP GONAL-F INJECTION SOLUTION PEN- SOLUTION 3 PA; QL; SP INJECTOR RECONSTITUTED *PHENYLKETONURIA GONAL-F RFF TREATMENT - REDIJECT AGENTS*** 3 PA; QL; SP SUBCUTANEOUS KUVAN ORAL PACKET 2 PA; QL; LD; SP SOLUTION KUVAN ORAL TABLET 2 PA; QL; LD; SP GONAL-F RFF SOLUBLE SUBCUTANEOUS 3 PA; QL; SP PALYNZIQ SOLUTION SUBCUTANEOUS 3 PA; QL; LD; SP RECONSTITUTED SOLUTION PREFILLED MENOPUR SYRINGE SUBCUTANEOUS 3 PA; QL; SP *RANK LIGAND SOLUTION (RANKL) RECONSTITUTED INHIBITORS*** NOVAREL PROLIA INTRAMUSCULAR SUBCUTANEOUS 2 PA; QL; SP 3 PA; QL; SP SOLUTION SOLUTION PREFILLED RECONSTITUTED SYRINGE OVIDREL XGEVA SUBCUTANEOUS 3 PA; QL; SP SUBCUTANEOUS 3 PA; QL; SP INJECTABLE SOLUTION PREGNYL *SELECTIVE INTRAMUSCULAR 3 PA; QL; SP ESTROGEN RECEPTOR SOLUTION MODULATORS RECONSTITUTED (SERMS)*** *OVULATION EVISTA ORAL TABLET 3 STIMULANTS- OSPHENA ORAL SYNTHETIC*** 3 PA; QL TABLET clomiphene citrate oral tablet 1 or 1b* PA; QL raloxifene hcl oral tablet 1 or 1b* $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 116 Drug Name Tier Notes Drug Name Tier Notes *SELECTIVE *V1A/V2-ARGININE VASOPRESSIN V2- VASOPRESSIN (AVP) RECEPTOR RECEPTOR ANTAGONISTS*** ANTAGONISTS*** JYNARQUE ORAL VAPRISOL 3 PA; QL; LD TABLET INTRAVENOUS 3 JYNARQUE ORAL SOLUTION TABLET THERAPY 3 PA; QL; LD *VASOPRESSIN*** PACK DDAVP INJECTION 3 SAMSCA ORAL TABLET 3 PA; QL; LD; SP SOLUTION 4 MCG/ML *SOMATOSTATIC DDAVP NASAL 3 AGENTS*** SOLUTION octreotide acetate injection DDAVP ORAL TABLET 3 solution 100 mcg/ml, 1000 DDAVP RHINAL TUBE 1 or 1b* PA; QL; SP 3 mcg/ml, 200 mcg/ml, 50 NASAL SOLUTION mcg/ml, 500 mcg/ml desmopressin ace spray 1 or 1b* SANDOSTATIN refrig nasal solution INJECTION SOLUTION 3 PA; QL; SP desmopressin acetate 100 MCG/ML, 50 1 or 1b* MCG/ML, 500 MCG/ML injection solution desmopressin acetate oral SANDOSTATIN LAR 1 or 1b* DEPOT 3 PA; QL; SP tablet INTRAMUSCULAR KIT desmopressin acetate spray 1 or 1b* SIGNIFOR LAR nasal solution INTRAMUSCULAR 3 PA; QL; LD NOCDURNA SUSPENSION SUBLINGUAL TABLET 3 PA; QL RECONSTITUTED ER SUBLINGUAL SIGNIFOR STIMATE NASAL 3 SUBCUTANEOUS 3 PA; QL; LD SOLUTION SOLUTION VASOSTRICT SOMATULINE DEPOT INTRAVENOUS 3 SUBCUTANEOUS 3 PA; QL; LD; SP SOLUTION SOLUTION *ERYTHROID *UREA CYCLE MATURATION DISORDER - AGENTS*** AGENTS*** AMMONUL *ERYTHROID INTRAVENOUS 3 MATURATION SOLUTION AGENTS*** BUPHENYL ORAL 3 PA; QL; LD REBLOZYL POWDER 3 GM/TSP SUBCUTANEOUS 3 LD; SP BUPHENYL ORAL SOLUTION 3 PA; QL; LD TABLET RECONSTITUTED RAVICTI ORAL LIQUID 3 PA; QL; LD; SP *ESTROGEN COMBINATIONS*** sod benz-sod phenylacet 1 or 1b* intravenous solution *ESTROGEN COMBINATIONS*** sodium phenylbutyrate oral 1 or 1b* PA; QL BI-EST 50:50 powder 3 gm/tsp 3 TRANSDERMAL CREAM sodium phenylbutyrate oral 1 or 1b* PA; QL tablet

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 117 Drug Name Tier Notes Drug Name Tier Notes *ESTROGEN- *ESTROGENS*** ANDROGEN- ALORA TRANSDERMAL PROGESTIN*** PATCH TWICE 3 *ESTROGEN- WEEKLY ANDROGEN- CLIMARA PROGESTIN*** TRANSDERMAL PATCH 3 BI-EST PROGEST- WEEKLY TESTOSTERONE 3 DELESTROGEN 3 TRANSDERMAL CREAM INTRAMUSCULAR OIL *ESTROGENS* DEPO-ESTRADIOL 3 *ESTROGEN & INTRAMUSCULAR OIL PROGESTIN*** DIVIGEL 2 ACTIVELLA ORAL TRANSDERMAL GEL 3 TABLET 1-0.5 MG dotti transdermal patch twice 1 or 1b* amabelz oral tablet 1 or 1b* weekly ANGELIQ ORAL EC-RX ESTRADIOL 3 3 TABLET TRANSDERMAL CREAM BI-EST 80:20 ELESTRIN 3 PROGESTERONE 3 TRANSDERMAL GEL TRANSDERMAL CREAM ESTRACE ORAL 3 BIEST/PROGESTERONE TABLET 3 TRANSDERMAL CREAM estradiol oral tablet 1 or 1b* BIJUVA ORAL CAPSULE 3 ST; QL estradiol transdermal patch 1 or 1b* CLIMARA PRO twice weekly TRANSDERMAL PATCH 2 estradiol transdermal patch 1 or 1b* WEEKLY weekly COMBIPATCH estradiol valerate TRANSDERMAL PATCH 2 intramuscular oil 20 mg/ml, 1 or 1b* TWICE WEEKLY 40 mg/ml estradiol-norethindrone acet ESTROGEL 1 or 1b* 3 oral tablet TRANSDERMAL GEL ESTRIOL- EVAMIST PROGESTERONE 3 TRANSDERMAL 2 MICRO TRANSDERMAL SOLUTION CREAM MENEST ORAL TABLET FEMHRT LOW DOSE 3 0.3 MG, 0.625 MG, 1.25 2 ORAL TABLET MG fyavolv oral tablet 1 or 1b* MENOSTAR jinteli oral tablet 1 or 1b* TRANSDERMAL PATCH 3 lopreeza oral tablet 1-0.5 mg 1 or 1b* WEEKLY mimvey oral tablet 1 or 1b* MINIVELLE TRANSDERMAL PATCH 3 norethindrone-eth estradiol 1 or 1b* TWICE WEEKLY oral tablet PREMARIN INJECTION PREFEST ORAL 3 SOLUTION 2 TABLET RECONSTITUTED PREMPHASE ORAL PREMARIN ORAL 2 2 TABLET TABLET PREMPRO ORAL 2 TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 118 Drug Name Tier Notes Drug Name Tier Notes VIVELLE-DOT *FLUOROQUINOLONES TRANSDERMAL PATCH 3 * TWICE WEEKLY *FLUOROQUINOLONES *ESTROGEN- *** SELECTIVE ESTROGEN AVELOX RECEPTOR INTRAVENOUS 3 MODULATOR COMB*** SOLUTION *ESTROGEN- BAXDELA SELECTIVE ESTROGEN INTRAVENOUS 3 RECEPTOR SOLUTION MODULATOR COMB*** RECONSTITUTED DUAVEE ORAL TABLET 3 PA; QL BAXDELA ORAL 3 *FARNESOID X TABLET RECEPTOR (FXR) CIPRO ORAL AGONISTS*** SUSPENSION 3 QL *FARNESOID X RECONSTITUTED RECEPTOR (FXR) CIPRO ORAL TABLET 3 QL AGONISTS*** 250 MG, 500 MG OCALIVA ORAL 3 PA; QL; LD; SP ciprofloxacin hcl oral tablet 1 or 1b* QL TABLET ciprofloxacin in d5w 1 or 1b* *FENTANYL intravenous solution COMBINATIONS*** LEVAQUIN ORAL 3 QL *FENTANYL TABLET 500 MG, 750 MG COMBINATIONS*** levofloxacin in d5w 1 or 1b* FENTANYL CIT- intravenous solution ROPIVACAINE-NACL EPIDURAL SOLUTION levofloxacin intravenous 3 1 or 1b* 0.2-0.2-0.9 MG/100ML-%, solution 0.3-0.2-0.9 MG/150ML-%, levofloxacin oral solution 1 or 1b* QL 0.4-0.1-0.9 MG/200ML-% levofloxacin oral tablet 1 or 1b* QL FENTANYL- moxifloxacin hcl in nacl BUPIVACAINE-NACL 1 or 1b* EPIDURAL SOLUTION intravenous solution 0.2-0.1-0.9 MG/100ML-%, MOXIFLOXACIN HCL 0.2-0.125-0.9 MG/100ML- 3 INTRAVENOUS 3 %, 0.5-0.0625-0.9 SOLUTION MG/250ML-%, 0.5-0.1-0.9 moxifloxacin hcl oral tablet 1 or 1b* MG/250ML-%, 0.5-0.125- 0.9 MG/250ML-% ofloxacin oral tablet 300 mg 1 or 1b* QL FENTANYL- ofloxacin oral tablet 400 mg 1 or 1b* BUPIVACAINE-NACL 3 *GABA RECEPTOR INJECTION SOLUTION MODULATOR - *FLUOROCYCLINES*** NEUROACTIVE STEROID*** *FLUOROCYCLINES*** *GABA RECEPTOR XERAVA MODULATOR - INTRAVENOUS 3 NEUROACTIVE SOLUTION STEROID*** RECONSTITUTED ZULRESSO INTRAVENOUS 3 PA; QL; LD; SP SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 119 Drug Name Tier Notes Drug Name Tier Notes *GASTROINTESTINAL *GLUCAGON-LIKE AGENTS - MISC.* PEPTIDE-2 (GLP-2) *GALLSTONE ANALOGS*** SOLUBILIZING GATTEX 3 PA; QL; LD; SP AGENTS*** SUBCUTANEOUS KIT ACTIGALL ORAL *IBS AGENT - 3 CAPSULE GUANYLATE CYCLASE- CHENODAL ORAL C (GC-C) AGONISTS*** 3 PA; QL; LD TABLET LINZESS ORAL 2 URSO 250 ORAL CAPSULE 3 TABLET *IBS AGENT - URSO FORTE ORAL SELECTIVE 5-HT3 3 TABLET RECEPTOR ANTAGONISTS*** ursodiol oral capsule 1 or 1b* alosetron hcl oral tablet 1 or 1b* PA; QL ursodiol oral tablet 1 or 1b* LOTRONEX ORAL URSODIOL+SYRSPEND 3 PA; QL 3 TABLET SF ORAL SUSPENSION *INFLAMMATORY *GASTROINTESTINAL BOWEL AGENTS*** ANTIALLERGY AGENTS*** APRISO ORAL CAPSULE EXTENDED RELEASE 24 3 cromolyn sodium oral 1 or 1b* HOUR concentrate ASACOL HD ORAL GASTROCROM ORAL 3 TABLET DELAYED 3 ST; QL CONCENTRATE RELEASE *GASTROINTESTINAL AZULFIDINE EN-TABS CHLORIDE CHANNEL ORAL TABLET 3 ACTIVATORS*** DELAYED RELEASE AMITIZA ORAL AZULFIDINE ORAL 2 3 CAPSULE TABLET *GASTROINTESTINAL balsalazide disodium oral 1 or 1b* STIMULANTS*** capsule DEXPANTHENOL CANASA RECTAL 3 3 INJECTION SOLUTION SUPPOSITORY metoclopramide hcl injection COLAZAL ORAL 1 or 1a* 3 solution CAPSULE metoclopramide hcl oral DELZICOL ORAL solution 10 mg/10ml, 5 1 or 1a* CAPSULE DELAYED 3 ST; QL mg/5ml RELEASE metoclopramide hcl oral DIPENTUM ORAL 1 or 1a* 3 ST; QL tablet CAPSULE METOCLOPRAMIDE LIALDA ORAL TABLET 3 ST; QL HCL ORAL TABLET 3 DELAYED RELEASE DISPERSIBLE 10 MG mesalamine er oral capsule metoclopramide hcl oral 1 or 1b* 1 or 1a* extended release 24 hour tablet dispersible 5 mg mesalamine oral capsule 1 or 1b* REGLAN ORAL TABLET 3 delayed release mesalamine oral tablet 1 or 1b* delayed release mesalamine rectal enema 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 120 Drug Name Tier Notes Drug Name Tier Notes mesalamine rectal FOSRENOL ORAL 1 or 1b* suppository TABLET CHEWABLE 3 ST; QL mesalamine-cleanser rectal 1000 MG, 500 MG, 750 1 or 1b* kit MG lanthanum carbonate oral PENTASA ORAL 1 or 1b* CAPSULE EXTENDED 2 tablet chewable RELEASE PHOSLYRA ORAL 3 ST; QL ROWASA RECTAL KIT 3 SOLUTION SFROWASA RECTAL RENAGEL ORAL 3 3 ST; QL ENEMA TABLET 800 MG RENVELA ORAL sulfasalazine oral tablet 1 or 1b* 3 ST; QL PACKET sulfasalazine oral tablet 1 or 1b* RENVELA ORAL delayed release 3 ST; QL TABLET *INTESTINAL sevelamer carbonate oral ACIDIFIERS*** 1 or 1b* packet enulose oral solution 1 or 1b* sevelamer carbonate oral 1 or 1b* generlac oral solution 1 or 1b* tablet lactulose encephalopathy oral 1 or 1b* sevelamer hcl oral tablet 1 or 1b* solution VELPHORO ORAL 3 ST; QL *PERIPHERAL OPIOID TABLET CHEWABLE RECEPTOR ANTAGONISTS*** *TUMOR NECROSIS FACTOR ALPHA ENTEREG ORAL 3 BLOCKERS*** CAPSULE CIMZIA PREFILLED MOVANTIK ORAL 3 PA; QL; SP 2 SUBCUTANEOUS KIT TABLET CIMZIA STARTER KIT RELISTOR ORAL 3 PA; QL; SP 3 ST; QL SUBCUTANEOUS KIT TABLET CIMZIA RELISTOR SUBCUTANEOUS KIT 2 3 PA; QL; SP SUBCUTANEOUS 3 ST; QL X 200 MG SOLUTION 12 MG/0.6ML, 8 MG/0.4ML INFLECTRA INTRAVENOUS SYMPROIC ORAL 3 PA; QL; SP 3 ST; QL SOLUTION TABLET RECONSTITUTED *PHOSPHATE BINDER REMICADE AGENTS*** INTRAVENOUS 3 PA; QL; SP AURYXIA ORAL SOLUTION 3 ST; QL TABLET RECONSTITUTED calcium acetate (phos binder) RENFLEXIS 1 or 1b* INTRAVENOUS oral capsule 3 PA; QL; LD; SP SOLUTION calcium acetate (phos binder) 1 or 1b* RECONSTITUTED oral tablet *GENERAL calcium acetate oral tablet 1 or 1b* ANESTHETICS* 667 mg *ANESTHETICS - FOSRENOL ORAL 3 ST; QL MISC.*** PACKET AMIDATE INTRAVENOUS 3 SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 121 Drug Name Tier Notes Drug Name Tier Notes ANESTHESIA S/I-40 FORANE INHALATION 3 3 INTRAVENOUS KIT SOLUTION ANESTHESIA S/I-40A isoflurane inhalation solution 1 or 1b* 3 INTRAVENOUS KIT sevoflurane inhalation 1 or 1b* ANESTHESIA S/I-40H solution 3 INTRAVENOUS KIT SUPRANE INHALATION 3 ANESTHESIA S/I-40S SOLUTION 3 INTRAVENOUS KIT terrell inhalation solution 1 or 1b* DIPRIVAN ULTANE INHALATION 3 INTRAVENOUS SOLUTION EMULSION 100 3 MG/10ML, 1000 *GENITOURINARY MG/100ML, 200 AGENTS - MG/20ML, 500 MG/50ML MISCELLANEOUS* etomidate intravenous *5-ALPHA REDUCTASE 1 or 1b* solution INHIBITORS*** AVODART ORAL fresenius propoven 3 intravenous emulsion 1000 CAPSULE 1 or 1b* mg/100ml, 200 mg/20ml, dutasteride oral capsule 1 or 1b* 500 mg/50ml finasteride oral tablet 5 mg 1 or 1b* KETALAR INJECTION 3 PROSCAR ORAL SOLUTION 3 TABLET ketamine hcl injection *ALPHA 1- solution 10 mg/ml, 100 1 or 1b* ADRENOCEPTOR mg/ml, 50 mg/ml ANTAGONISTS*** KETAMINE HCL INTRAVENOUS alfuzosin hcl er oral tablet 3 1 or 1b* SOLUTION PREFILLED extended release 24 hour SYRINGE CARDURA XL ORAL KETAMINE HCL- TABLET EXTENDED 3 SODIUM CHLORIDE RELEASE 24 HOUR INTRAVENOUS FLOMAX ORAL 3 SOLUTION PREFILLED 3 CAPSULE SYRINGE 10-0.9 MG/ML- RAPAFLO ORAL 3 %, 100-0.9 MG/10ML-%, CAPSULE 50-0.9 MG/5ML-% silodosin oral capsule 1 or 1b* propofol intravenous emulsion 1000 mg/100ml, 1 or 1b* tamsulosin hcl oral capsule 1 or 1b* 200 mg/20ml, 500 mg/50ml UROXATRAL ORAL *BARBITURATE TABLET EXTENDED 3 ANESTHETICS*** RELEASE 24 HOUR BREVITAL SODIUM *ANTI-INFECTIVE INJECTION SOLUTION GENITOURINARY 3 RECONSTITUTED 2.5 IRRIGANTS*** GM, 500 MG neomycin-polymyxin b gu 1 or 1b* METHOHEXITAL irrigation solution SODIUM INTRAVENOUS 3 *CITRATES*** SOLUTION PREFILLED pot & sod cit-cit ac oral SYRINGE 100 MG/10ML 1 or 1b* solution *VOLATILE potassium citrate er oral ANESTHETICS*** 1 or 1b* tablet extended release desflurane inhalation solution 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 122 Drug Name Tier Notes Drug Name Tier Notes potassium citrate-citric acid *INTERSTITIAL 1 or 1b* oral solution CYSTITIS AGENTS*** sod citrate-citric acid oral ELMIRON ORAL 1 or 1b* 3 solution CAPSULE taron-crystals oral packet 1 or 1b* RIMSO-50 tricitrates oral solution 1 or 1b* INTRAVESICAL 3 SOLUTION UROCIT-K 10 ORAL TABLET EXTENDED 3 *PHOSPHATES*** RELEASE K-PHOS NO 2 ORAL 3 UROCIT-K 15 ORAL TABLET TABLET EXTENDED 3 *PROSTATIC RELEASE HYPERTROPHY AGENT UROCIT-K 5 ORAL COMBINATIONS*** TABLET EXTENDED 3 dutasteride-tamsulosin hcl 1 or 1b* RELEASE oral capsule *CYSTINOSIS JALYN ORAL CAPSULE 3 AGENTS*** *URINARY CYSTAGON ORAL ANALGESICS*** 3 LD; SP CAPSULE phenazo oral tablet 200 mg 1 or 1a* PROCYSBI ORAL *URINARY STONE CAPSULE DELAYED 3 ST; QL; LD AGENTS*** RELEASE LITHOSTAT ORAL PROCYSBI ORAL 3 3 ST; QL TABLET PACKET THIOLA EC ORAL *GENITOURINARY TABLET DELAYED 3 PA; QL; LD IRRIGANTS*** RELEASE acetic acid irrigation solution 1 or 1b* THIOLA ORAL TABLET 3 PA; QL; LD aminoacetic acid irrigation 1 or 1b* *GLYCOPEPTIDES*** solution *GLYCOPEPTIDES*** argyle sterile saline irrigation 1 or 1b* solution DALVANCE INTRAVENOUS curity sterile saline irrigation 3 1 or 1b* SOLUTION solution RECONSTITUTED glycine irrigation solution 1 or 1b* FIRVANQ ORAL glycine urologic irrigation SOLUTION 3 PA; QL 1 or 1b* solution RECONSTITUTED RENACIDIN ORBACTIV 3 IRRIGATION SOLUTION INTRAVENOUS 3 RESECTISOL SOLUTION 3 IRRIGATION SOLUTION RECONSTITUTED sodium chloride irrigation VANCOCIN HCL ORAL 1 or 1b* 3 PA; QL solution 0.9 % CAPSULE 125 MG SORBITOL IRRIGATION VANCOCIN ORAL 3 3 PA; QL SOLUTION CAPSULE SORBITOL-MANNITOL 3 IRRIGATION SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 123 Drug Name Tier Notes Drug Name Tier Notes VANCOMYCIN HCL IN allopurinol sodium DEXTROSE intravenous solution 1 or 1b* INTRAVENOUS reconstituted SOLUTION 1-5 3 ALOPRIM GM/200ML-%, 500-5 INTRAVENOUS 3 MG/100ML-%, 750-5 SOLUTION MG/150ML-% RECONSTITUTED VANCOMYCIN HCL IN colchicine oral capsule 3 ST; QL; CTT1 NACL INTRAVENOUS SOLUTION 1-0.9 colchicine oral tablet 2 CTT1 GM/200ML-%, 1-0.9 COLCRYS ORAL 2 QL GM/250ML-%, 1.25-0.9 TABLET GM/250ML-%, 1.5-0.9 3 GM/250ML-%, 1.75-0.9 febuxostat oral tablet 1 or 1b* ST; QL GM/250ML-%, 2-0.9 GLOPERBA ORAL 3 ST; QL GM/500ML-%, 500-0.9 SOLUTION MG/100ML-%, 750-0.9 KRYSTEXXA MG/150ML-% INTRAVENOUS 3 PA; QL; LD; SP VANCOMYCIN HCL SOLUTION INTRAVENOUS MITIGARE ORAL 3 ST; QL SOLUTION 1000 CAPSULE MG/200ML, 1500 3 MG/300ML, 2000 ULORIC ORAL TABLET 3 ST; QL MG/400ML, 500 ZYLOPRIM ORAL 3 MG/100ML TABLET vancomycin hcl intravenous *URICOSURICS*** solution reconstituted 1 gm, 1 or 1b* probenecid oral tablet 1 or 1b* 10 gm, 100 gm, 5 gm, 500 mg, 750 mg *HEMATOLOGICAL AGENTS - MISC.* VANCOMYCIN HCL INTRAVENOUS *ANTIHEMOPHILIC SOLUTION 3 PRODUCTS*** RECONSTITUTED 1.25 ADVATE INTRAVENOUS GM, 1.5 GM, 250 MG SOLUTION 3 PA; QL; SP vancomycin hcl oral capsule 1 or 1b* PA; QL RECONSTITUTED VANCOMYCIN HCL ADYNOVATE INTRAVENOUS ORAL SOLUTION 3 PA; QL 3 PA; QL; SP RECONSTITUTED SOLUTION RECONSTITUTED VANCOMYCIN+SYRSPE AFSTYLA ND SF ORAL 3 3 PA; QL; SP SUSPENSION INTRAVENOUS KIT VIBATIV ALPHANATE/VWF INTRAVENOUS COMPLEX/HUMAN SOLUTION 3 INTRAVENOUS 3 PA; QL; SP RECONSTITUTED 750 SOLUTION MG RECONSTITUTED *GOUT AGENTS* ALPHANINE SD INTRAVENOUS *GOUT AGENT 3 PA; QL; SP SOLUTION COMBINATIONS*** RECONSTITUTED colchicine-probenecid oral 1 or 1b* ALPROLIX tablet INTRAVENOUS 3 PA; QL; SP *GOUT AGENTS*** SOLUTION allopurinol oral tablet 1 or 1a* RECONSTITUTED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 124 Drug Name Tier Notes Drug Name Tier Notes BENEFIX KCENTRA 3 PA; QL; SP 3 INTRAVENOUS KIT INTRAVENOUS KIT COAGADEX KOATE INTRAVENOUS INTRAVENOUS SOLUTION 3 PA; QL; SP SOLUTION 3 PA; QL; SP RECONSTITUTED RECONSTITUTED 250 KOATE-DVI UNIT INTRAVENOUS COAGADEX SOLUTION 3 PA; QL; SP INTRAVENOUS RECONSTITUTED 1000 SOLUTION 3 PA; QL; LD; SP UNIT RECONSTITUTED 500 KOATE-DVI UNIT INTRAVENOUS CORIFACT SOLUTION 3 SP 3 PA; QL; LD; SP INTRAVENOUS KIT RECONSTITUTED 250 ELOCTATE UNIT, 500 UNIT INTRAVENOUS KOGENATE FS 3 PA; QL; SP 3 PA; QL; SP SOLUTION INTRAVENOUS KIT RECONSTITUTED KOVALTRY ESPEROCT INTRAVENOUS 3 PA; QL; SP INTRAVENOUS SOLUTION 3 PA; QL; LD; SP SOLUTION RECONSTITUTED RECONSTITUTED MONONINE FEIBA INTRAVENOUS INTRAVENOUS SOLUTION SOLUTION 3 PA; QL; SP RECONSTITUTED 1000 3 PA; QL; SP RECONSTITUTED 1000 UNIT, 2500 UNIT, 500 UNIT UNIT NOVOEIGHT FIBRYGA INTRAVENOUS 3 PA; QL; LD; SP INTRAVENOUS SOLUTION 3 PA; QL SOLUTION RECONSTITUTED RECONSTITUTED NOVOSEVEN RT HEMOFIL M INTRAVENOUS 3 PA; QL; SP INTRAVENOUS SOLUTION SOLUTION RECONSTITUTED 3 PA; QL; SP RECONSTITUTED 1000 NUWIQ INTRAVENOUS 3 PA; QL; SP UNIT, 1700 UNIT, 250 KIT UNIT, 500 UNIT NUWIQ INTRAVENOUS HUMATE-P SOLUTION 3 PA; QL; SP INTRAVENOUS RECONSTITUTED SOLUTION 3 PA; QL; SP RECONSTITUTED 1000- OBIZUR INTRAVENOUS 2400 UNIT, 250-600 UNIT, SOLUTION 3 PA; QL; LD; SP 500-1200 UNIT RECONSTITUTED IDELVION PROFILNINE INTRAVENOUS INTRAVENOUS 3 PA; QL; SP 3 PA; QL; SP SOLUTION SOLUTION RECONSTITUTED RECONSTITUTED IXINITY INTRAVENOUS PROFILNINE SD SOLUTION 3 PA; QL; SP INTRAVENOUS RECONSTITUTED SOLUTION 3 PA; QL; SP RECONSTITUTED 1000 JIVI INTRAVENOUS UNIT, 1500 UNIT SOLUTION 3 PA; QL; SP RECONSTITUTED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 125 Drug Name Tier Notes Drug Name Tier Notes REBINYN RUCONEST INTRAVENOUS INTRAVENOUS 3 PA; QL; SP 3 PA; QL; LD; SP SOLUTION SOLUTION RECONSTITUTED RECONSTITUTED RECOMBINATE *COMPLEMENT INTRAVENOUS INHIBITORS*** 3 PA; QL; SP SOLUTION SOLIRIS INTRAVENOUS 3 PA; QL; LD; SP RECONSTITUTED SOLUTION 300 MG/30ML RIASTAP ULTOMIRIS INTRAVENOUS 3 PA; QL INTRAVENOUS 3 PA; QL; LD; SP SOLUTION SOLUTION RECONSTITUTED *CYCLOPENTYLTRIAZ RIXUBIS INTRAVENOUS OLOPYRIMIDINE SOLUTION 3 PA; QL; SP (CPTP) RECONSTITUTED DERIVATIVES*** TRETTEN BRILINTA ORAL INTRAVENOUS 2 3 PA; QL; LD; SP TABLET SOLUTION RECONSTITUTED KENGREAL INTRAVENOUS 3 VONVENDI SOLUTION INTRAVENOUS 3 PA; QL; LD; SP RECONSTITUTED SOLUTION RECONSTITUTED *GLYCOPROTEIN IIB/IIIA RECEPTOR WILATE INTRAVENOUS 3 PA; QL; SP INHIBITORS*** KIT AGGRASTAT XYNTHA INTRAVENOUS 3 INTRAVENOUS KIT 1000 3 PA; QL; SP CONCENTRATE UNIT, 2000 UNIT, 250 UNIT, 500 UNIT AGGRASTAT INTRAVENOUS XYNTHA SOLOFUSE 3 PA; QL; SP SOLUTION 12.5-0.9 3 INTRAVENOUS KIT MG/250ML-%, 5-0.9 *BRADYKININ B2 MG/100ML-% RECEPTOR eptifibatide intravenous ANTAGONISTS*** solution 20 mg/10ml, 200 1 or 1b* FIRAZYR mg/100ml, 75 mg/100ml SUBCUTANEOUS 3 PA; QL; LD; SP INTEGRILIN SOLUTION INTRAVENOUS icatibant acetate SOLUTION 20 MG/10ML, 3 1 or 1b* PA; QL; SP subcutaneous solution 200 MG/100ML, 75 *C1 INHIBITORS*** MG/100ML BERINERT *HEMATORHEOLOGIC 3 PA; QL; LD; SP INTRAVENOUS KIT AGENTS*** pentoxifylline er oral tablet CINRYZE 1 or 1b* INTRAVENOUS extended release 3 PA; QL; LD; SP SOLUTION *HEMIN*** RECONSTITUTED PANHEMATIN HAEGARDA INTRAVENOUS SUBCUTANEOUS SOLUTION 3 3 PA; QL; LD; SP SOLUTION RECONSTITUTED 350 RECONSTITUTED MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 126 Drug Name Tier Notes Drug Name Tier Notes *HUMAN PROTEIN C*** OCTAPLAS BLOOD GROUP A CEPROTIN 3 INTRAVENOUS INTRAVENOUS 3 LD; SP SOLUTION SOLUTION RECONSTITUTED OCTAPLAS BLOOD GROUP AB *PHOSPHODIESTERASE 3 III INHIBITORS*** INTRAVENOUS SOLUTION cilostazol oral tablet 1 or 1b* OCTAPLAS BLOOD *PLASMA GROUP B 3 EXPANDERS*** INTRAVENOUS HESPAN INTRAVENOUS SOLUTION 3 SOLUTION OCTAPLAS BLOOD hetastarch-nacl intravenous GROUP O 1 or 1b* 3 solution INTRAVENOUS SOLUTION HEXTEND plasbumin-25 intravenous INTRAVENOUS 3 1 or 1b* SOLUTION solution lmd in d5w intravenous plasbumin-5 intravenous 1 or 1b* 1 or 1b* solution solution lmd in nacl intravenous PLASMANATE 1 or 1b* solution INTRAVENOUS 3 SOLUTION *PLASMA KALLIKREIN INHIBITORS*** THROMBATE III INTRAVENOUS 3 KALBITOR SOLUTION SUBCUTANEOUS 3 PA; QL; LD; SP RECONSTITUTED SOLUTION *PLATELET *PLASMA PROTEINS*** AGGREGATION albuked 25 intravenous INHIBITOR 1 or 1b* solution COMBINATIONS*** albuked 5 intravenous AGGRENOX ORAL 1 or 1b* solution CAPSULE EXTENDED 3 albumin human intravenous RELEASE 12 HOUR 1 or 1b* solution aspirin-dipyridamole er oral ALBUMINEX capsule extended release 12 1 or 1b* INTRAVENOUS 3 hour SOLUTION ASPIRIN-OMEPRAZOLE albumin-zlb intravenous ORAL TABLET 3 PA; QL 1 or 1b* solution DELAYED RELEASE alburx intravenous solution 1 or 1b* YOSPRALA ORAL TABLET DELAYED 3 PA; QL albutein intravenous solution 1 or 1b* RELEASE flexbumin intravenous 1 or 1b* *PLATELET solution AGGREGATION human albumin grifols INHIBITORS*** 1 or 1b* intravenous solution dipyridamole oral tablet 1 or 1b* kedbumin intravenous 1 or 1b* DURLAZA ORAL solution CAPSULE EXTENDED 3 PA; QL RELEASE 24 HOUR

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 127 Drug Name Tier Notes Drug Name Tier Notes *PROTAMINE*** ELELYSO protamine sulfate intravenous INTRAVENOUS 1 or 1b* 3 PA; QL; LD; SP solution SOLUTION RECONSTITUTED *QUINAZOLINE AGENTS*** miglustat oral capsule 1 or 1b* PA; QL; SP AGRYLIN ORAL VPRIV INTRAVENOUS 3 CAPSULE SOLUTION 3 PA; QL; LD; SP RECONSTITUTED anagrelide hcl oral capsule 1 or 1b* ZAVESCA ORAL 3 PA; QL; LD *THIENOPYRIDINE CAPSULE DERIVATIVES*** *COBALAMIN clopidogrel bisulfate oral 1 or 1b* COMBINATIONS*** tablet abaneu-sl sublingual tablet EFFIENT ORAL TABLET 2 CTT1 3 sublingual 10 MG FOLTRATE ORAL EFFIENT ORAL TABLET 3 3 DO TABLET 5 MG LIPO-B PLAVIX ORAL TABLET 3 INTRAMUSCULAR 3 75 MG SOLUTION prasugrel hcl oral tablet 10 1 or 1b* NEURIN-SL mg SUBLINGUAL TABLET 3 prasugrel hcl oral tablet 5 mg 1 or 1b* DO SUBLINGUAL *TISSUE PLASMINOGEN VIT B12-METHIONINE- INOS-CHOL ACTIVATORS*** 3 INTRAMUSCULAR ACTIVASE SOLUTION INTRAVENOUS 3 SOLUTION *COBALAMINS*** RECONSTITUTED cyanocobalamin injection 1 or 1a* CATHFLO ACTIVASE solution 1000 mcg/ml INJECTION SOLUTION 3 CYANOCOBALAMIN RECONSTITUTED INJECTION SOLUTION 3 RETAVASE HALF-KIT 2000 MCG/ML INTRAVENOUS KIT 1 X 3 hydroxocobalamin acetate 1 or 1b* 10 UNIT intramuscular solution RETAVASE METHYLCOBALAMIN INTRAVENOUS KIT 2 X 3 INJECTION SOLUTION 3 10 UNIT RECONSTITUTED TNKASE INTRAVENOUS NASCOBAL NASAL 3 3 KIT SOLUTION *HEMATOPOIETIC VITAMIN DEFICIENCY AGENTS* SYSTEM-B12 3 *AGENTS FOR INJECTION KIT GAUCHER DISEASE*** *CXCR4 RECEPTOR CERDELGA ORAL ANTAGONIST*** 3 PA; QL; LD; SP CAPSULE MOZOBIL CEREZYME SUBCUTANEOUS 3 PA; QL; LD; SP INTRAVENOUS SOLUTION SOLUTION 3 PA; QL; LD; SP *CYTOTOXIC RECONSTITUTED 400 AGENTS*** UNIT DROXIA ORAL 2 CAPSULE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 128 Drug Name Tier Notes Drug Name Tier Notes SIKLOS ORAL TABLET 3 PA; QL; SP ANIMI-3 ORAL 3 *ERYTHROPOIESIS- CAPSULE STIMULATING AGENTS ANIMI-3/VITAMIN D 3 (ESAS)*** ORAL CAPSULE ARANESP (ALBUMIN B-6 FOLIC ACID ORAL 3 FREE) INJECTION CAPSULE 8.333-100-1 MG SOLUTION 100 MCG/ML, BP VIT 3 ORAL 3 PA; QL; SP 3 200 MCG/ML, 25 CAPSULE MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML CENFOL ORAL TABLET 3 ARANESP (ALBUMIN fabb oral tablet 1 or 1b* FREE) INJECTION fa-vitamin b-6-vitamin b-12 3 PA; QL; SP 1 or 1b* SOLUTION PREFILLED oral tablet SYRINGE folbee oral tablet 1 or 1b* EPOGEN INJECTION FOLGARD RX ORAL SOLUTION 10000 3 UNIT/ML, 2000 UNIT/ML, 3 PA; QL; SP TABLET 20000 UNIT/ML, 3000 FOLI-D ORAL TABLET 3 UNIT/ML, 4000 UNIT/ML folplex 2.2 oral tablet 1 or 1b* MIRCERA INJECTION nufol oral tablet 1 or 1b* SOLUTION PREFILLED 3 PA; QL; LD TALIVA ORAL SYRINGE 3 CAPSULE PROCRIT INJECTION 3 PA; QL; SP SOLUTION virt-gard oral tablet 1 or 1b* RETACRIT INJECTION VITAMEZ ORAL 3 PA; QL; SP 3 SOLUTION CAPSULE *ERYTHROPOIETINS*** *FOLIC ACID/FOLATES*** ARANESP (ALBUMIN FREE) INJECTION folic acid injection solution 1 or 1a* SOLUTION 100 MCG/ML, 3 PA; QL; SP folic acid oral tablet 1 mg 1 or 1a* 200 MCG/ML, 25 *GRANULOCYTE MCG/ML, 300 MCG/ML, COLONY- 40 MCG/ML, 60 MCG/ML STIMULATING ARANESP (ALBUMIN FACTORS (G-CSF)*** FREE) INJECTION 3 PA; QL; SP FULPHILA SOLUTION PREFILLED SUBCUTANEOUS SYRINGE 3 PA; QL; SP SOLUTION PREFILLED EPOGEN INJECTION SYRINGE SOLUTION 10000 GRANIX UNIT/ML, 2000 UNIT/ML, 3 PA; QL; SP SUBCUTANEOUS 3 PA; QL; SP 20000 UNIT/ML, 3000 SOLUTION UNIT/ML, 4000 UNIT/ML GRANIX MIRCERA INJECTION SUBCUTANEOUS SOLUTION PREFILLED 3 PA; QL; LD 3 PA; QL; SP SOLUTION PREFILLED SYRINGE SYRINGE PROCRIT INJECTION 3 PA; QL; SP NEULASTA ONPRO SOLUTION SUBCUTANEOUS RETACRIT INJECTION 3 PA; QL; SP 3 PA; QL; SP PREFILLED SYRINGE SOLUTION KIT *FOLIC ACID/FOLATE COMBINATIONS*** airavite oral tablet 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 129 Drug Name Tier Notes Drug Name Tier Notes NEULASTA FERROTRIN ORAL 3 SUBCUTANEOUS CAPSULE 3 PA; QL; SP SOLUTION PREFILLED FOLIVANE-PLUS ORAL 3 SYRINGE CAPSULE NEUPOGEN INJECTION foltrin oral capsule 1 or 1b* SOLUTION 300 MCG/ML, 3 PA; QL; SP FUSION PLUS ORAL 480 MCG/1.6ML 3 CAPSULE NEUPOGEN INJECTION hematinic plus vit/minerals SOLUTION PREFILLED 3 PA; QL; SP 1 or 1b* SYRINGE oral tablet NIVESTYM INJECTION HEMATOGEN FA ORAL 3 PA; QL; SP 3 SOLUTION CAPSULE NIVESTYM INJECTION hematogen forte oral capsule 1 or 1b* SOLUTION PREFILLED 3 PA; QL; SP hematogen oral capsule 1 or 1b* SYRINGE HEMATRON-AF ORAL 3 UDENYCA TABLET SUBCUTANEOUS 3 PA; QL; SP HEMOCYTE PLUS ORAL SOLUTION PREFILLED 3 SYRINGE CAPSULE hemocyte-plus oral tablet ZARXIO INJECTION 1 or 1b* SOLUTION PREFILLED 3 PA; QL; SP 106-1 mg SYRINGE ICAR-C PLUS ORAL 3 ZIEXTENZO TABLET SUBCUTANEOUS INTEGRA PLUS ORAL 3 PA; QL; LD; SP 3 SOLUTION PREFILLED CAPSULE SYRINGE IROSPAN 24/6 ORAL 3 *GRANULOCYTE/MACR IS 24/6 ORAL 3 OPHAGE COLONY- STIMULATING k-tan plus oral capsule 1 or 1b* FACTOR(GM-CSF)*** MULTIGEN FOLIC 3 LEUKINE INJECTION ORAL TABLET SOLUTION 3 PA; QL; SP MULTIGEN ORAL 3 RECONSTITUTED TABLET *IRON MULTIGEN PLUS ORAL 3 COMBINATIONS*** TABLET ACTIVE FE ORAL NEPHRON FA ORAL 3 3 TABLET TABLET CENTRATEX ORAL NIFEREX ORAL 3 3 CAPSULE TABLET chromagen oral capsule 1 or 1b* polysaccharide iron forte oral 1 or 1b* corvita 150 oral tablet 1 or 1b* capsule CORVITE 150 ORAL purevit dualfe plus oral 3 1 or 1b* TABLET 150-1.25 MG capsule CORVITE FE ORAL se-tan plus oral capsule 1 or 1b* 3 TABLET TARON FORTE ORAL 3 ferocon oral capsule 1 or 1b* CAPSULE ferotrinsic oral capsule 1 or 1b* tl-hem 150 oral tablet 1 or 1b* ferrocite plus oral tablet 1 or 1b* tricon oral capsule 1 or 1b* FERRO-PLEX trigels-f forte oral capsule 1 or 1b* HEMATINIC ORAL 3 VIRT-FEFA PLUS ORAL 3 TABLET CAPSULE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 130 Drug Name Tier Notes Drug Name Tier Notes *IRON W/ FOLIC NPLATE ACID*** SUBCUTANEOUS FOLIVANE-F ORAL SOLUTION 3 PA; QL 3 CAPSULE RECONSTITUTED 125 MCG FUSION SPRINKLES 3 ORAL PACKET NPLATE SUBCUTANEOUS hematinic/folic acid oral 1 or 1b* SOLUTION 3 PA; QL; SP tablet RECONSTITUTED 250 hemocyte-f oral tablet 1 or 1b* MCG, 500 MCG INTEGRA F ORAL PROMACTA ORAL 3 3 PA; QL; LD; SP CAPSULE PACKET 12.5 MG PROMACTA ORAL *IRON*** 3 PA; QL PACKET 25 MG FERAHEME PROMACTA ORAL INTRAVENOUS 3 3 PA; QL; LD; SP SOLUTION TABLET FERRLECIT *HEMOGLOBIN S (HBS) INTRAVENOUS 3 POLYMERIZATION SOLUTION INHIBITORS*** INFED INJECTION *HEMOGLOBIN S (HBS) 3 SOLUTION POLYMERIZATION INHIBITORS*** INJECTAFER OXBRYTA ORAL INTRAVENOUS 3 3 PA; QL; LD; SP SOLUTION TABLET na ferric gluc cplx in sucrose *HEMOSTATICS* 1 or 1b* intravenous solution *HEMOSTATIC TRIFERIC COMBINATIONS - HEMODIALYSIS 3 TOPICAL*** PACKET ARTISS EXTERNAL 3 TRIFERIC SOLUTION HEMODIALYSIS 3 THROMBI-GEL 10 3 SOLUTION EXTERNAL PAD VENOFER THROMBI-GEL 100 3 INTRAVENOUS 3 EXTERNAL PAD SOLUTION THROMBI-GEL 40 3 *IRON-B12-FOLATE*** EXTERNAL PAD FERIVA 21/7 ORAL THROMBI-PAD 3 3 TABLET EXTERNAL PAD FERRALET 90 ORAL TISSEEL EXTERNAL 3 3 TABLET KIT FERRAPLUS 90 ORAL TISSEEL EXTERNAL 3 3 TABLET SOLUTION *THROMBOPOIETIN *HEMOSTATICS - (TPO) RECEPTOR SYSTEMIC*** AGONISTS*** AMICAR ORAL DOPTELET ORAL 3 3 PA; QL; LD; SP SOLUTION TABLET 20 MG AMICAR ORAL TABLET 3 MULPLETA ORAL 3 PA; QL; SP aminocaproic acid TABLET 1 or 1b* intravenous solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 131 Drug Name Tier Notes Drug Name Tier Notes aminocaproic acid oral RECOTHROM 1 or 1b* solution EXTERNAL SOLUTION 3 aminocaproic acid oral tablet 1 or 1b* RECONSTITUTED CYKLOKAPRON RECOTHROM SPRAY INTRAVENOUS KIT EXTERNAL 3 3 SOLUTION 1000 SOLUTION MG/10ML RECONSTITUTED LYSTEDA ORAL SURGICEL FIBRILLAR 3 3 TABLET EXTERNAL PAD tranexamic acid intravenous SURGICEL NU-KNIT 1 or 1b* 3 solution 1000 mg/10ml EXTERNAL PAD SYRINGE AVITENE tranexamic acid oral tablet 1 or 1b* 3 EXTERNAL TRANEXAMIC ACID- TACHOSIL EXTERNAL NACL INTRAVENOUS 3 3 SOLUTION PATCH *HEMOSTATICS - THROMBIN-JMI TOPICAL*** EPISTAXIS EXTERNAL 3 KIT ACTIFOAM COLLAGEN 3 THROMBIN-JMI SPONGE EXTERNAL 3 EXTERNAL KIT AVITENE EXTERNAL 3 PAD THROMBIN-JMI EXTERNAL SOLUTION 3 AVITENE FLOUR 3 RECONSTITUTED EXTERNAL POWDER THROMBOGEN ENDO AVITENE 3 3 EXTERNAL KIT EXTERNAL THROMBOGEN GEL-FLOW NT EXTERNAL SOLUTION 3 EXTERNAL PREFILLED 3 RECONSTITUTED SYRINGE ULTRAFOAM SPONGE 3 GELFOAM 2X6.25X7CM EXTERNAL COMPRESSED SIZE 100 3 ULTRAFOAM SPONGE EXTERNAL 3 8X12.5X1CM EXTERNAL GELFOAM DENTAL ULTRAFOAM SPONGE PACK SIZE 4 3 3 EXTERNAL 8X12.5X3CM EXTERNAL ULTRAFOAM SPONGE GELFOAM 3 MOUTH/THROAT 3 8X25X1CM EXTERNAL POWDER ULTRAFOAM SPONGE 3 GELFOAM SPONGE 8X6.25X1CM EXTERNAL 3 EXTERNAL *HEPATITIS C AGENT - GELFOAM SPONGE COMBINATIONS*** 3 SIZE 100 EXTERNAL *HEPATITIS C AGENT - GELFOAM SPONGE COMBINATIONS*** 3 SIZE 200 EXTERNAL EPCLUSA ORAL 3 PA; QL; SP GELFOAM SPONGE TABLET 3 SIZE 50 EXTERNAL HARVONI ORAL 3 PA; QL INSTAT EXTERNAL PAD 3 TABLET 45-200 MG INTERCEED (TC7) HARVONI ORAL 3 3 PA; QL; SP EXTERNAL PAD TABLET 90-400 MG INTERCEED EXTERNAL 3 PAD * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 132 Drug Name Tier Notes Drug Name Tier Notes LEDIPASVIR- PHENOBARBITAL SOFOSBUVIR ORAL 3 PA; QL; SP SODIUM INJECTION 3 TABLET SOLUTION 65 MG/ML MAVYRET ORAL SECONAL ORAL 3 PA; QL; SP 3 TABLET CAPSULE SOFOSBUVIR- *BENZODIAZEPINE VELPATASVIR ORAL 3 PA; QL; SP HYPNOTICS*** TABLET DORAL ORAL TABLET 3 VIEKIRA PAK ORAL estazolam oral tablet 1 or 1b* TABLET THERAPY 3 PA; QL; SP PACK flurazepam hcl oral capsule 1 or 1b* HALCION ORAL VOSEVI ORAL TABLET 3 PA; QL; SP 3 TABLET ZEPATIER ORAL 3 PA; QL; SP midazolam hcl (pf) injection TABLET 1 or 1b* solution *HEREDITARY OROTIC ACIDURIA TREATMENT midazolam hcl injection - AGENTS** solution 10 mg/10ml, 10 mg/2ml, 2 mg/2ml, 25 1 or 1b* *HEREDITARY OROTIC mg/5ml, 5 mg/5ml, 5 mg/ml, ACIDURIA TREATMENT 50 mg/10ml - AGENTS** MIDAZOLAM HCL XURIDEN ORAL 3 PA; QL; LD INTRAVENOUS 3 PACKET SOLUTION 150 MG/30ML *HISTAMINE H3- midazolam hcl oral syrup 1 or 1b* RECEPTOR ANTAGONIST/INVERSE MIDAZOLAM HCL- AGONISTS*** SODIUM CHLORIDE INTRAVENOUS 3 *HISTAMINE H3- SOLUTION 100-0.9 RECEPTOR MG/100ML-%, 50-0.9 ANTAGONIST/INVERSE MG/50ML-% AGONISTS*** MIDAZOLAM HCL- WAKIX ORAL TABLET 3 PA; QL; LD; SP SODIUM CHLORIDE 17.8 MG INTRAVENOUS WAKIX ORAL TABLET PA; DO; QL; LD; SOLUTION PREFILLED 3 3 4.45 MG SP SYRINGE 2-0.9 MG/2ML- *HYPNOTICS* %, 5-0.9 MG/5ML-%, 55- 0.9 MG/55ML-% *BARBITURATE MIDAZOLAM+SYRSPEN HYPNOTICS*** 3 D SF ORAL SUSPENSION AMYTAL SODIUM INJECTION SOLUTION 3 MIDAZOLAM-SODIUM CHLORIDE RECONSTITUTED 3 INTRAVENOUS NEMBUTAL INJECTION 3 SOLUTION SOLUTION quazepam oral tablet 1 or 1b* pentobarbital sodium 1 or 1b* RESTORIL ORAL injection solution 3 CAPSULE phenobarbital oral solution 1 or 1b* temazepam oral capsule 1 or 1b* phenobarbital oral tablet 1 or 1b* triazolam oral tablet 1 or 1b* phenobarbital sodium 1 or 1b* injection solution 130 mg/ml *HYPNOTICS - TRICYCLIC AGENTS*** doxepin hcl oral tablet 1 or 1b* ST; QL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 133 Drug Name Tier Notes Drug Name Tier Notes SILENOR ORAL *SELECTIVE 3 ST; QL TABLET MELATONIN *NON- RECEPTOR BENZODIAZEPINE - AGONISTS*** GABA-RECEPTOR HETLIOZ ORAL 3 PA; QL; LD MODULATORS*** CAPSULE AMBIEN CR ORAL ramelteon oral tablet 1 or 1b* ST; QL TABLET EXTENDED 3 ST; QL ROZEREM ORAL 3 ST; QL RELEASE TABLET AMBIEN ORAL TABLET 3 ST; QL *HYPOPHOSPHATASIA EDLUAR SUBLINGUAL (HPP) AGENTS*** 3 ST; QL TABLET SUBLINGUAL *HYPOPHOSPHATASIA eszopiclone oral tablet 1 or 1b* (HPP) AGENTS*** INTERMEZZO STRENSIQ SUBLINGUAL TABLET 3 ST; QL SUBCUTANEOUS 3 PA; QL; LD SUBLINGUAL 1.75 MG SOLUTION LUNESTA ORAL *IBS AGENT - 5-HT4 3 ST; QL TABLET RECEPTOR PARTIAL zaleplon oral capsule 1 or 1b* ST; QL AGONISTS*** zolpidem tartrate er oral *IBS AGENT - 5-HT4 1 or 1b* ST; QL tablet extended release RECEPTOR PARTIAL AGONISTS*** zolpidem tartrate oral tablet 1 or 1b* ZELNORM ORAL zolpidem tartrate sublingual 3 ST; QL 1 or 1b* ST; QL TABLET tablet sublingual *IBS AGENT - MU- ZOLPIMIST ORAL 3 ST; QL OPIOID RECEPTOR SOLUTION AGONISTS*** *SELECTIVE ALPHA2- *IBS AGENT - MU- ADRENORECEPTOR OPIOID RECEPTOR AGONIST AGONISTS*** SEDATIVES*** VIBERZI ORAL TABLET 3 PA; QL dexmedetomidine hcl in nacl 1 or 1b* intravenous solution *IMPOTENCE AGENT COMBINATIONS*** DEXMEDETOMIDINE HCL INTRAVENOUS *IMPOTENCE AGENT SOLUTION 1000 3 COMBINATIONS*** MCG/10ML, 400 BI-MIX MCG/4ML INTRACAVERNOSAL 3 dexmedetomidine hcl SOLUTION intravenous solution 200 1 or 1b* RECONSTITUTED mcg/2ml QUAD-MIX INTRACAVERNOSAL DEXMEDETOMIDINE 3 HCL-DEXTROSE SOLUTION 3 INTRAVENOUS RECONSTITUTED SOLUTION SUPER BI-MIX INTRACAVERNOSAL PRECEDEX 3 INTRAVENOUS SOLUTION SOLUTION 200 RECONSTITUTED MCG/2ML, 200 3 SUPER QUAD-MIX MCG/50ML, 400 INTRACAVERNOSAL 3 MCG/100ML, 80 SOLUTION MCG/20ML RECONSTITUTED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 134 Drug Name Tier Notes Drug Name Tier Notes SUPER TRI-MIX *INSULIN-LIKE INTRACAVERNOSAL GROWTH FACTOR-1 3 SOLUTION RECEPTOR RECONSTITUTED INHIBITORS(IGF-1R)*** *IMPOTENCE AGENTS - *INSULIN-LIKE OTHER*** GROWTH FACTOR-1 *IMPOTENCE AGENTS - RECEPTOR OTHER*** INHIBITORS(IGF-1R)*** PHENYLEPHRINE HCL TEPEZZA INTRAVENOUS INTRACAVERNOSAL 3 3 LD; SP SOLUTION SOLUTION RECONSTITUTED *IN VITRO/LOCK ANTICOAGULANTS*** *INTEGRIN RECEPTOR ANTAGONISTS*** *IN VITRO/LOCK ANTICOAGULANTS*** *INTEGRIN RECEPTOR ANTAGONISTS*** ACD FORMULA A IN 3 VITRO SOLUTION ENTYVIO INTRAVENOUS ACD-A NOCLOT-50 IN 3 PA; QL; SP 3 SOLUTION VITRO SOLUTION RECONSTITUTED ANTICOAGULANT CIT *INTERLEUKIN DEXT SOLN A IN VITRO 3 ANTAGONISTS*** SOLUTION *INTERLEUKIN ANTICOAGULANT ANTAGONISTS*** SODIUM CITRATE IN 3 VITRO SOLUTION STELARA INTRAVENOUS 3 PA; QL; SP TRICITRASOL IN VITRO 3 SOLUTION CONCENTRATE *INTERLEUKIN-5 *INSULIN-INCRETIN ANTAGONISTS (IGG1 MIMETIC KAPPA)*** COMBINATIONS*** *INTERLEUKIN-5 *INSULIN-INCRETIN ANTAGONISTS (IGG1 MIMETIC KAPPA)*** COMBINATIONS*** FASENRA PEN SOLIQUA SUBCUTANEOUS SUBCUTANEOUS 3 PA; QL; LD 3 ST; QL SOLUTION AUTO- SOLUTION PEN- INJECTOR INJECTOR FASENRA XULTOPHY SUBCUTANEOUS SUBCUTANEOUS 3 PA; QL; LD; SP 3 ST; QL SOLUTION PREFILLED SOLUTION PEN- SYRINGE INJECTOR NUCALA SUBCUTANEOUS 3 PA; QL; LD; SP SOLUTION AUTO- INJECTOR NUCALA SUBCUTANEOUS 3 PA; QL; LD; SP SOLUTION PREFILLED SYRINGE NUCALA SUBCUTANEOUS 3 PA; QL; LD; SP SOLUTION RECONSTITUTED * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 135 Drug Name Tier Notes Drug Name Tier Notes *INTERLEUKIN-5 NULYTELY WITH ANTAGONISTS (IGG4 FLAVOR PACKS ORAL 3 KAPPA)*** SOLUTION *INTERLEUKIN-5 RECONSTITUTED ANTAGONISTS (IGG4 PCP 100 COMBINATION 3 KAPPA)*** KIT CINQAIR peg 3350-kcl-na bicarb-nacl 1 or 1a* $0 INTRAVENOUS 3 PA; QL; LD; SP oral solution reconstituted SOLUTION peg-3350/electrolytes oral 1 or 1a* $0 *INTERLEUKIN-6 (IL-6) solution reconstituted ANTAGONISTS*** peg-prep oral kit 1 or 1b* $0 *INTERLEUKIN-6 (IL-6) PLENVU ORAL ANTAGONISTS*** SOLUTION 3 SYLVANT RECONSTITUTED INTRAVENOUS PREPOPIK ORAL 3 PA; QL; LD; SP 3 SOLUTION PACKET RECONSTITUTED SUPREP BOWEL PREP 2 *ISOCITRATE KIT ORAL SOLUTION DEHYDROGENASE-1 trilyte oral solution (IDH1) INHIBITORS*** 1 or 1a* $0 reconstituted *ISOCITRATE DEHYDROGENASE-1 *LAXATIVES - (IDH1) INHIBITORS*** MISCELLANEOUS*** TIBSOVO ORAL constulose oral solution 1 or 1b* 3 PA; QL; LD TABLET KRISTALOSE ORAL 3 *ISOCITRATE PACKET DEHYDROGENASE-2 LACTULOSE ORAL 1 or 1b* (IDH2) INHIBITORS*** PACKET *ISOCITRATE lactulose oral solution 1 or 1b* DEHYDROGENASE-2 (IDH2) INHIBITORS*** *LUBRICANT LAXATIVES*** IDHIFA ORAL TABLET 3 PA; QL; LD; SP mineral oil heavy oral oil 1 or 1b* *LAXATIVES* *SALINE LAXATIVE *BOWEL EVACUANT MIXTURES*** COMBINATIONS*** OSMOPREP ORAL CLENPIQ ORAL 3 3 TABLET SOLUTION *STIMULANT gavilyte-c oral solution 1 or 1a* $0 LAXATIVES*** reconstituted CASCARA SAGRADA gavilyte-g oral solution 3 1 or 1a* $0 ORAL FLUID EXTRACT reconstituted *LEPTIN gavilyte-h oral kit 1 or 1b* $0 ANALOGUES*** gavilyte-n with flavor pack 1 or 1a* $0 *LEPTIN oral solution reconstituted ANALOGUES*** GOLYTELY ORAL MYALEPT SOLUTION 3 SUBCUTANEOUS 3 PA; QL; LD RECONSTITUTED SOLUTION MOVIPREP ORAL RECONSTITUTED SOLUTION 3 RECONSTITUTED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 136 Drug Name Tier Notes Drug Name Tier Notes *LHRH/GNRH AGONIST XYLOCAINE/EPINEPHR ANALOG INE INJECTION 3 COMBINATIONS*** SOLUTION *LHRH/GNRH AGONIST XYLOCAINE- ANALOG MPF/EPINEPHRINE 3 COMBINATIONS*** INJECTION SOLUTION LUPANETA PACK *LOCAL ANESTHETIC 3 PA; QL; SP COMBINATION KIT COMBINATIONS*** *LOCAL ANESTHETICS- ACTIVE INJECTION LM- 3 PARENTERAL* 2 INJECTION KIT *LOCAL ANESTHETIC LIDOCAINE-SODIUM & BICARBONATE 3 SYMPATHOMIMETIC** INJECTION SOLUTION * PREFILLED SYRINGE articadent dental injection P-CARE 100MX 3 CTT1 3 solution cartridge INJECTION KIT bupivacaine-epinephrine (pf) POINT OF CARE LM-2.2 3 injection solution 0.25% - 1 or 1b* INJECTION KIT 1:200000, 0.5% -1:200000 POINT OF CARE LM-2.5 3 bupivacaine-epinephrine INJECTION KIT injection solution 0.25% - 1 or 1b* READYSHARP-A 3 1:200000, 0.5% -1:200000 INJECTION KIT CITANEST FORTE *LOCAL ANESTHETICS DENTAL INJECTION 3 - AMIDES*** SOLUTION BUPIVACAINE lidocaine-epinephrine FISIOPHARMA 3 injection solution 0.5 %- INJECTION SOLUTION 1:200000, 1 %-1:100000, 1.5 1 or 1b* bupivacaine hcl (pf) injection %-1:200000, 2 %-1:100000, 1 or 1b* 2 %-1:200000, 2 %-1:50000 solution bupivacaine hcl injection MARCAINE/EPINEPHRI 1 or 1b* NE INJECTION 3 solution 0.25 %, 0.5 % SOLUTION BUPIVACAINE HCL MARCAINE/EPINEPHRI INJECTION SOLUTION 3 NE PF INJECTION 3 312.5 MG/10ML SOLUTION BUPIVACAINE HCL ORABLOC INJECTION INJECTION SOLUTION 3 PREFILLED SYRINGE SOLUTION CARTRIDGE 3 125 MG/4ML, 250 RECK SOLUTION 3 MG/8ML, 312.5 PREFILLED SYRINGE MG/10ML, 625 MG/20ML sensorcaine/epinephrine 1 or 1b* BUPIVACAINE HCL- injection solution NACL EPIDURAL 3 sensorcaine-mpf/epinephrine SOLUTION PREFILLED injection solution 0.25% - 1 or 1b* SYRINGE 0.25-0.9 % 1:200000, 0.5% -1:200000 bupivacaine in dextrose 1 or 1b* SENSORCAINE- intrathecal solution MPF/EPINEPHRINE bupivacaine spinal 3 1 or 1b* INJECTION SOLUTION intrathecal solution 0.75-1:200000 % CARBOCAINE xylocaine dental injection 3 1 or 1b* INJECTION SOLUTION solution

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 137 Drug Name Tier Notes Drug Name Tier Notes CARBOCAINE XYLOCAINE 3 PRESERVATIVE-FREE 3 INJECTION SOLUTION INJECTION SOLUTION XYLOCAINE-MPF CITANEST PLAIN INJECTION SOLUTION 3 DENTAL INJECTION 3 0.5 %, 1 %, 1.5 %, 2 % SOLUTION ZINGO INTRADERMAL 3 EXPAREL INJECTION JET-INJECTOR 3 SUSPENSION *LOCAL ANESTHETICS lidocaine hcl (pf) injection - ESTERS*** 1 or 1b* solution chloroprocaine hcl (pf) 1 or 1b* lidocaine hcl injection injection solution 1 or 1b* solution 0.5 %, 1 %, 2 % CLOROTEKAL LIDOCAINE HCL INTRATHECAL 3 INJECTION SOLUTION SOLUTION 3 PREFILLED SYRINGE 60 NESACAINE INJECTION 3 MG/3ML SOLUTION lidocaine hcl intradermal jet- NESACAINE-MPF 1 or 1b* 3 injector INJECTION SOLUTION LIDOCAINE IN 3 *LYMPHOCYTE DEXTROSE SOLUTION FUNCTION- MARCAINE INJECTION ASSOCIATED ANTIGEN- 3 SOLUTION 1 (LFA-1) ANTAG*** MARCAINE *LYMPHOCYTE PRESERVATIVE FREE 3 FUNCTION- INJECTION SOLUTION ASSOCIATED ANTIGEN- MARCAINE SPINAL 1 (LFA-1) ANTAG*** INTRATHECAL 3 XIIDRA OPHTHALMIC 3 PA; QL SOLUTION SOLUTION MONOJECT BONE *LYSOSOMAL ACID MARROW BIOPSY 3 LIPASE (LAL) INJECTION KIT DEFICIENCY - NAROPIN INJECTION AGENTS*** 3 SOLUTION *LYSOSOMAL ACID polocaine injection solution 1 or 1b* LIPASE (LAL) DEFICIENCY - polocaine-mpf injection 1 or 1b* AGENTS*** solution KANUMA ropivacaine hcl injection INTRAVENOUS 3 PA; QL; LD; SP solution 10 mg/ml, 2 mg/ml, 1 or 1b* SOLUTION 5 mg/ml, 7.5 mg/ml *MACROLIDES* ROPIVACAINE HCL INJECTION SOLUTION 3 *AZITHROMYCIN*** 33.4 MG/ML azithromycin intravenous ROPIVACAINE HCL solution reconstituted 500 1 or 1b* INJECTION SOLUTION 3 mg PREFILLED SYRINGE azithromycin oral packet 1 or 1b* QL ROPIVACAINE HCL- azithromycin oral suspension 1 or 1b* QL NACL EPIDURAL 3 reconstituted SOLUTION 0.15-0.9 % azithromycin oral tablet 250 1 or 1b* QL sensorcaine injection solution 1 or 1b* mg, 500 mg, 600 mg sensorcaine-mpf injection 1 or 1b* solution * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 138 Drug Name Tier Notes Drug Name Tier Notes ZITHROMAX erythromycin ethylsuccinate 1 or 1b* INTRAVENOUS oral tablet 3 SOLUTION erythromycin oral tablet 1 or 1b* RECONSTITUTED delayed release ZITHROMAX ORAL 3 QL *FIDAXOMICIN*** PACKET DIFICID ORAL TABLET 3 ZITHROMAX ORAL SUSPENSION 3 QL *MEDICAL DEVICES* RECONSTITUTED *CERVICAL CAPS*** ZITHROMAX ORAL FEMCAP VAGINAL 3 QL 2 $0 TABLET 250 MG, 500 MG DEVICE ZITHROMAX TRI-PAK 3 QL *DENTAL ORAL TABLET DESENSITIZING ZITHROMAX Z-PAK PRODUCTS*** 3 QL ORAL TABLET REMESENSE DENTAL 3 *CLARITHROMYCIN*** *DENTIFRICES*** clarithromycin er oral tablet MI PASTE DENTAL 1 or 1b* 3 extended release 24 hour PASTE clarithromycin oral MI PASTE PLUS 1 or 1b* 3 suspension reconstituted DENTAL PASTE clarithromycin oral tablet 1 or 1b* *DIAPHRAGMS*** *ERYTHROMYCINS*** CAYA VAGINAL 2 $0 e.e.s. 400 oral tablet 1 or 1b* DIAPHRAGM E.E.S. GRANULES ORAL OMNIFLEX SUSPENSION 3 DIAPHRAGM VAGINAL 3 RECONSTITUTED DIAPHRAGM ERYPED 200 ORAL WIDE-SEAL SUSPENSION 3 DIAPHRAGM 60 2 $0 RECONSTITUTED VAGINAL DIAPHRAGM ERYPED 400 ORAL WIDE-SEAL SUSPENSION 3 DIAPHRAGM 65 2 $0 RECONSTITUTED VAGINAL DIAPHRAGM ery-tab oral tablet delayed WIDE-SEAL 1 or 1b* release DIAPHRAGM 70 2 $0 VAGINAL DIAPHRAGM ERYTHROCIN LACTOBIONATE WIDE-SEAL INTRAVENOUS DIAPHRAGM 75 2 $0 3 SOLUTION VAGINAL DIAPHRAGM RECONSTITUTED 500 WIDE-SEAL MG DIAPHRAGM 80 2 $0 erythrocin stearate oral tablet VAGINAL DIAPHRAGM 1 or 1b* 250 mg WIDE-SEAL erythromycin base oral DIAPHRAGM 85 2 $0 capsule delayed release 1 or 1b* VAGINAL DIAPHRAGM particles WIDE-SEAL erythromycin base oral tablet 1 or 1b* DIAPHRAGM 90 2 $0 VAGINAL DIAPHRAGM erythromycin base oral tablet 1 or 1b* delayed release WIDE-SEAL DIAPHRAGM 95 2 $0 erythromycin ethylsuccinate 1 or 1b* VAGINAL DIAPHRAGM oral suspension reconstituted

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 139 Drug Name Tier Notes Drug Name Tier Notes *GLUCOSE ALTERNATE SITE 2 MONITORING TEST LANCING DEVICE SUPPLIES*** AQUA LANCE 1ST TIER UNILET ADJUSTABLE LANCING 2 2 COMFORTOUCH DEVICE ACCU-CHEK FASTCLIX AQUALANCE LANCETS 2 2 LANCET KIT 30G ACCU-CHEK FASTCLIX ASSURE COMFORT 2 2 LANCETS LANCETS 28G ACCU-CHEK ASSURE HAEMOLANCE 2 MULTICLIX LANCET 2 PLUS HIGH DEV KIT ASSURE HAEMOLANCE 2 ACCU-CHEK PLUS LOW 2 MULTICLIX LANCETS ASSURE HAEMOLANCE 2 ACCU-CHEK SAFE-T PLUS MICRO 2 PRO LANCETS ASSURE HAEMOLANCE 2 ACCU-CHEK SOFTCLIX PLUS NORMAL 2 LANCET DEV KIT ASSURE HAEMOLANCE 2 ACCU-CHEK SOFTCLIX PLUS PED 2 LANCETS ASSURE LANCE 2 ACTI-LANCE 28G 2 LANCETS ACTI-LANCE LITE ASSURE LANCE 2 2 LANCETS 28G LANCETS 21G ACTI-LANCE SPECIAL ASSURE LANCE PLUS 2 2 LANCETS 17G SAFETY 25G ACTI-LANCE ASSURE LANCE PLUS 2 2 UNIVERSAL 23G SAFETY 30G ADJUSTABLE LANCING ASSURE LANCE SAFETY 2 2 DEVICE LANCET 28G ADVANCED MOBILE ASSURE LANCETS 2 2 LANCET AURORA LANCET 2 ADVOCATE LANCETS 2 SUPER THIN 30G ADVOCATE LANCETS AURORA LANCET THIN 2 2 30G 23G ADVOCATE LANCING AUTO-LANCET 2 2 DEVICE AUTO-LANCET MINI 2 ADVOCATE RAPID- AUTOLET II CLINISAFE 2 2 SAFE LANCING KIT ADVOCATE SAFETY AUTOLET LANCING 2 2 LANCETS DEVICE ADVOCATE SAFETY AUTOLET LITE 2 2 LANCETS 26G CLINISAFE KIT AGAMATRIX ULTRA- AUTOLET LITE 2 2 THIN LANCETS STARTER PACK KIT AIMSCO TWIST 2 AUTOLET MINI 2 LANCETS 32G AUTOLET PLATFORMS 2 AIMSCO TWIST 2 LANCETS 33G AUTOLET PLUS 2

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 140 Drug Name Tier Notes Drug Name Tier Notes BD LANCET CVS LANCETS MICRO 2 2 ULTRAFINE 30G THIN 33G BD LANCET CVS LANCETS 2 2 ULTRAFINE 33G ORIGINAL BD MICROTAINER CVS LANCETS THIN 26G 2 2 LANCETS CVS LANCETS ULTRA 2 BULLSEYE MINI THIN 30G 2 SAFETY LANCETS CVS LANCETS ULTRA- 2 BULLSEYE SAFETY THIN 30G 2 LANCETS CVS LANCING DEVICE 2 CARDIOCOM LANCING CVS ULTRA THIN 2 2 DEVICE LANCETS CAREONE ADVANCED DIATHRIVE LANCET 2 2 LANCING DEV ULTRA THIN 30 CAREONE LANCET 2 DIATHRIVE LANCETS 2 THIN 23G DIATHRIVE LANCING CAREONE LANCET 2 2 DEVICE ULTRA THIN 28G DROPLET LANCETS 2 CARESENS LANCETS 2 ULTRA THIN 30G CARETOUCH DROPLET LANCING 2 2 LANCING/EJECTOR DEVICE CARETOUCH SAFETY DRUG MART LANCETS 2 2 LANCETS THIN 26G CARETOUCH SAFETY DRUG MART LANCING 2 2 LANCETS 26G DEVICE CARETOUCH TWIST DRUG MART ON-THE- 2 2 LANCETS 28G GO LANCET 30G CARETOUCH TWIST DRUG MART UNILET 2 2 LANCETS 30G LANCETS 28G CARETOUCH TWIST DRUG MART UNILET 2 2 LANCETS 33G LANCETS 30G CLEANLET LANCETS DRUG MART UNILET 2 2 28G LANCETS 33G CLEVER CHEK EASY COMFORT 2 2 LANCETS LANCETS CLEVER CHOICE EASY COMFORT 2 2 LANCETS 21G LANCETS TWIST TOP CLEVER CHOICE EASY MINI EJECT 2 2 LANCETS 23G LANCING DEVICE CLEVER CHOICE EASY MINI LANCING 2 2 LANCETS 28G DEVICE COAGUCHEK LANCETS 2 EASY TOUCH LANCETS 2 COMFORT ASSURED 21G 2 LANCETS 28G EASY TOUCH LANCETS 2 COMFORT ASSURED 23G 2 LANCETS 33G EASY TOUCH LANCETS 2 COMFORT LANCETS 2 26G CVS LANCETS 21G 2 EASY TOUCH LANCETS 2 28G * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 141 Drug Name Tier Notes Drug Name Tier Notes EASY TOUCH LANCETS FINE 30 2 2 28G/TWIST FINGERSTIX LANCETS 2 EASY TOUCH LANCETS 2 FORA LANCETS 2 30G FORA LANCING EASY TOUCH LANCETS 2 2 DEVICE 32G FREDS PHARMACY EASY TOUCH LANCETS 2 2 AUTOLET LANCING 32G/TWIST FREDS PHARMACY EASY TOUCH LANCING 2 2 UNILET LANC 28G DEVICE FREDS PHARMACY EASY TOUCH SAFETY 2 2 UNILET LANC 30G LANCETS 21G FREESTYLE LANCETS 2 EASY TOUCH SAFETY 2 FREESTYLE UNISTICK LANCETS 23G 2 II LANCETS EASY TOUCH SAFETY 2 GENTEEL BUTTERFLY LANCETS 26G 2 TOUCH LANCET EASY TOUCH SAFETY 2 GENTEEL CONTACT LANCETS 28G 2 TIPS (BLUE) EASY TWIST & CAP 2 GENTEEL CONTACT LANCETS 2 TIPS (CLEAR) EMBRACE LANCETS 2 GENTEEL CONTACT ULTRA THIN 30G 2 TIPS (GREEN) EQL COLOR LANCETS 2 GENTEEL CONTACT 21G 2 TIPS (ORANGE) EQL COLOR LANCETS 2 GENTEEL CONTACT MICRO 33G 2 TIPS (RAINBOW) EQL SUPER THIN 2 GENTEEL CONTACT LANCETS 30G 2 TIPS (VIOLET) EQL THIN LANCETS 2 GENTEEL CONTACT 26G 2 TIPS (YELLOW) E-Z JECT LANCET 2 GENTEEL LANCING MICRO-THIN 33G 2 DEVICE (BLACK) E-Z JECT LANCET 2 GENTEEL LANCING SUPER THIN 30G 2 DEVICE (BLUE) E-Z JECT LANCETS 2 GENTEEL LANCING 2 E-Z JECT LANCETS 21G 2 DEVICE (GOLD) E-Z JECT LANCETS GENTEEL LANCING 2 2 THIN 26G DEVICE (PINK) EZ SMART BLOOD GENTEEL LANCING 2 2 GLUCOSE LANCETS DEVICE (WHITE) EZ-LETS LANCETS 21G 2 GENTEEL LANCING 2 EZ-LETS LANCETS 26G 2 DEVICE(PLATNM) EZ-LETS LANCETS 28G 2 GENTEEL LANCING 2 EZ-LETS LANCETS 30G 2 DEVICE(PURPLE) FIFTY50 SAFETY SEAL GENTEEL LANCING 2 2 LANCETS DEVICE(SILVER) FIFTY50 UNILET GENTEEL LANCING KIT 2 2 LANCETS 33G (BLUE) KIT

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 142 Drug Name Tier Notes Drug Name Tier Notes GENTEEL NOZZLES 2 GOODSENSE LANCING 2 GENTLE-LET GP DEVICE 2 LANCETS HAEMOLANCE 2 GENTLE-LET LANCETS 2 HAEMOLANCE LOW 2 GENTLE-LET FLOW LANCETS 2 PLATFORMS HAEMOLANCE PLUS 2 GLOBAL INJECT EASE HAEMOLANCE PLUS 2 2 LANCETS 28G HIGH FLOW GLOBAL INJECT EASE HAEMOLANCE PLUS 2 2 LANCETS 30G LOW FLOW GLOBAL LANCING HAEMOLANCE PLUS 2 2 DEVICE MAX FLOW GLUCOCOM LANCETS HAEMOLANCE PLUS 2 2 28G PEDIATRIC FLOW GLUCOCOM LANCETS HEALTH CARE 2 2 30G LANCING DEVICE GLUCOCOM LANCETS HEALTHY ACCENTS 2 2 33G LANCING DEVICE GNP LANCETS 2 HEALTHY ACCENTS 2 GNP LANCETS 21G 2 UNILET LANCETS GNP LANCETS MICRO H-E-B INCONTROL ADV 2 2 THIN 33G LANCING GNP LANCETS SUPER H-E-B INCONTROL 2 2 THIN 30G LANCETS 28G H-E-B INCONTROL GNP LANCETS THIN 2 2 LANCETS 30G GNP LANCETS THIN 2 H-E-B INCONTROL 26G 2 LANCETS 33G GNP MICRO THIN 2 HYPOLANCE AST LANCETS 33G 2 LANCING KIT GNP SUPER THIN 2 LANCETS 30G HY-VEE LANCETS 2 GOJJI LANCING HY-VEE THIN LANCETS 2 2 DEVICE/CLEAR CAP IN TOUCH LANCING 2 GOJJI STERILE DEVICE 2 LANCETS IN TOUCH STERILE 2 GOODSENSE COLOR LANCETS 30G 2 LANCETS 33G KINNEY LANCETS 2 GOODSENSE LANCETS KINNEY THIN LANCETS 2 2 26G UNIV KROGER AUTOLET 2 GOODSENSE LANCETS LANCING DEVICE 2 30G KROGER HEALTHPRO 2 GOODSENSE LANCETS LANCET 26G 2 30G UNIV KROGER HEALTHPRO 2 GOODSENSE LANCETS LANCET 30G 2 33G KROGER HEALTHPRO 2 GOODSENSE LANCETS LANCET 33G 2 33G UNIV KROGER LANCETS 2 KROGER LANCETS 21G 2

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 143 Drug Name Tier Notes Drug Name Tier Notes KROGER LANCETS LIVE BETTER LANCET 2 2 MICRO THIN 33G SUPER THIN KROGER LANCETS LIVE BETTER LANCET 2 2 SUPER THIN ULTRA THIN KROGER LANCETS LONGS LANCETS 2 2 THIN STANDARD KROGER LANCETS LONGS LANCETS THIN 2 2 THIN 26G LONGS LANCETS 2 KROGER LANCETS ULTRA THIN 2 ULTRATHIN 30G MEDICHOICE SAFETY 2 KROGER LANCING LANCET 2 DEVICE MEDICHOICE SAFETY 2 LANCET DEVICE 2 LANCET EXTRA LANCET DEVICE WITH MEDICHOICE SAFETY 2 2 EJECTOR LANCET NORM LANCET MEDISENSE THIN 2 2 TRANSPORTER CASE LANCETS LANCETS 2 MEDLANCE EXTRA 21G 2 LANCETS 28G 2 MEDLANCE LITE 25G 2 LANCETS 30G 2 MEDLANCE PLUS 2 LANCETS MICRO THIN EXTRA 21G 2 33G MEDLANCE PLUS 2 LANCETS SUPER THIN LANCETS 2 28G MEDLANCE PLUS LITE 2 LANCETS THIN 2 25G MEDLANCE PLUS LANCETS ULTRA FINE 2 2 SPECIAL 0.8MM LANCETS ULTRA THIN 2 MEDLANCE PLUS LANCETS ULTRA THIN 2 2 SUPERLITE 30G 30G MEDLANCE PLUS 2 LANCING DEVICE 2 UNIVERSAL 21G LANZO 2 MEDLANCE 2 LEADER ADVANCED UNIVERSAL 21G 2 LANCING DEVICE MEIJER LANCETS 2 LIBERTY MEDICAL 2 MEIJER LANCETS THIN 2 LANCETS MEIJER LANCETS LIBERTY MINI 2 2 UNIVERSAL 21G LANCING DEVICE MEIJER LANCETS 2 LIFESCAN UNISTIK 2 2 UNIVERSAL 30G LIFESCAN UNISTIK II MEIJER LANCETS 2 2 LANCETS UNIVERSAL 33G LITE TOUCH LANCETS 2 MEIJER SUPER THIN 2 LITE TOUCH LANCING LANCETS 2 PEN MICROLET LANCETS 2 LITETOUCH LANCETS 2 MICROLET NEXT 2 LIVE BETTER ADV LANCING DEVICE 2 LANCING DEVICE MINI LANCING DEVICE 2 MM LANCING DEVICE 2

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 144 Drug Name Tier Notes Drug Name Tier Notes MM TWIST LANCETS 2 ONETOUCH FINEPOINT 2 MONOLET LANCETS 2 LANCETS MONOLET OPD ONETOUCH SURESOFT 2 2 LANCETS LANCING DEV MONOLETTOR SAFETY ONETOUCH 2 2 LANCETS ULTRASOFT LANCETS MPD SAFETY LANCET PC LANCETS SUPER 2 2 21G THIN 30G MPD SAFETY LANCET PENLET II BLOOD 2 2 23G SAMPLER KIT MPD SAFETY LANCET PENLET II 2 2 28G REPLACEMENT CAP MPD SAFETY LANCET PERFECT LANCETS 28G 2 2 30G PERFECT LANCETS 30G 2 MULTI-LANCET PHARMACIST CHOICE 2 2 DEVICE LANCETS MULTI-LANCET PHARMACY COUNTER 2 2 DEVICE 2 KIT LANCETS MYGLUCOHEALTH PIP LANCETS 28G 2 2 LANCETS 30G PIP LANCETS 30G 2 NOVA SAFETY PRECISION THINS GP 2 2 LANCETS 23G LANCETS NOVA SAFETY PREFERRED PLUS 2 2 LANCETS 28G LANCETS COLORED NOVA SUREFLEX PREFERRED PLUS 2 2 LANCETS LANCETS THIN NOVA SUREFLEX PRESSURE ACTIVAT 2 2 LANCING DEVICE SAFETY LANCET ON CALL LANCETS 2 PRO COMFORT 2 ON CALL LANCING LANCETS 30G 2 DEVICE PRO COMFORT 2 ON CALL PLUS LANCETS 31G 2 LANCETS PRODIGY LANCETS 28G 2 ON CALL PLUS PRODIGY LANCING 2 2 LANCING DEVICE DEVICE ONETOUCH CLUB PRODIGY SAFETY 2 2 LANCETS FINE PT LANCETS 26G ONETOUCH DELICA PRODIGY TWIST TOP 2 2 LANCETS 30G LANCETS 28G ONETOUCH DELICA PSS SELECT GP 2 2 LANCETS 33G LANCETS ONETOUCH DELICA PSS SELECT 2 2 LANCING DEV PLATFORMS ONETOUCH DELICA PSS SELECT SAFETY 2 2 PLUS LANCET30G LANCETS ONETOUCH DELICA PUSH BUTTON SAFETY 2 2 PLUS LANCET33G LANCETS ONETOUCH DELICA 2 PLUS LANCING * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 145 Drug Name Tier Notes Drug Name Tier Notes PUSH BUTTON SAFETY RELION LANCING 2 2 LANCETS 28G DEVICE KIT PX ADVANCED RELION ULTRA THIN 2 2 LANCING DEVICE LANCETS 30G PX LANCET AUTO RELION ULTRA THIN 2 2 INJECTOR PLUS LANCETS PX LANCETS ULTRA REXALL LANCETS 2 2 THIN ULTRA THIN 30G PX LANCETS ULTRA RIGHTEST ALTERNATE 2 2 THIN 28G SITE ADAPT QC ADVANCED RIGHTEST GD500 2 2 LANCING DEVICE LANCING DEVICE QC LANCETS SUPER RIGHTEST GL300 2 2 THIN 30G LANCETS QC LANCETS ULTRA SAFE-T-LANCE 2 2 THIN SAFE-T-LANCE PLUS 2 QC UNILET LANCETS SAFETY LANCET 2 2 28G 21G/PRESSURE ACT QC UNILET LANCETS SAFETY LANCET 2 2 MICRO THIN 23G/PRESSURE ACT RA E-ZJECT COLOR SAFETY LANCET 2 2 LANCETS 33G 28G/PRESSURE ACT RA E-ZJECT LANCETS SAFETY LANCET 2 2 28G 30G/PRESSURE ACT RA E-ZJECT LANCETS 2 SAFETY LANCETS 2 THIN 26G SAFETY LANCETS 21G 2 RA E-ZJECT LANCETS 2 THIN 28G SAFETY LANCETS 28G 2 RA E-ZJECT LANCETS SAFETY LET LANCETS 2 2 ULTRA THIN SAFETY SEAL LANCETS 2 RA LANCING DEVICE 2 SAPS HEALTH TWIST 2 READYLANCE SAFETY TOP LANCETS 2 LANCETS SAPS TWIST TOP 2 REALITY LANCETS 2 LANCETS REALITY TRIGGER SAPSCARE TWIST TOP 2 2 LANCETS LANCETS RELION LANCET SB LANCETS THIN 2 2 DEVICES 30G SB LANCETS ULTRA 2 RELION LANCETS THIN 2 MICRO-THIN 33G SELECT-LITE 2 RELION LANCETS DEVICE/LANCETS KIT 2 STANDARD 21G SELECT-LITE LANCING 2 RELION LANCETS THIN DEVICE 2 26G SHOPKO AUTOLET 2 RELION LANCETS LANCING DEVICE 2 ULTRA-THIN 30G SHOPKO ON-THE-GO 2 RELION LANCING LANCETS 30G 2 DEVICE SHOPKO UNILET 2 LANCETS 28G

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 146 Drug Name Tier Notes Drug Name Tier Notes SHOPKO UNILET SURE-LANCE ULTRA 2 2 LANCETS 30G THIN LANCETS SIDE BUTTON SAFETY SURELITE LANCETS 2 2 LANCET SURE-PEN 2 SIMPLE DIAGNOSTICS SURE-TOUCH LANCETS 2 2 LANCING DEV UNIVERSAL SINGLE-LET 2 TECHLITE AST 2 SM LANCETS 33G 2 LANCETS SM TRUEDRAW TECHLITE LANCETS 2 2 LANCING DEVICE TECHLITE LANCETS 2 SMART DIABETES 30G 2 VANTAGE LANCING TGT LANCET MICRO 2 SMART SENSE COLOR THIN 33G 2 LANCETS 33G TGT LANCET THIN 26G 2 SMART SENSE TGT LANCET ULTRA 2 2 STANDARD LANCETS THIN 30G SMART SENSE SUPER 2 TGT LANCING DEVICE 2 THIN LANCETS THINLETS GP LANCETS 2 SMART SENSE THIN 2 TODAYS HEALTH LANCETS 26G 2 LANCING DEVICE SMARTEST LANCETS 2 TODAYS HEALTH THIN 28G 2 LANCETS 28G SOLUS V2 LANCETS 28G 2 TODAYS HEALTH THIN SOLUS V2 LANCING 2 2 LANCETS 30G DEVICE TOPCARE LANCETS SOLUS V2 TWIST 2 2 MICRO-THIN 33G LANCETS 30G TRAVEL LANCETS 2 STERILANCE PA 2 TRAVEL LANCETS 2 STERILANCE TL 2 ADVANCED 28G SUPER THIN LANCETS 2 TRUE COMFORT TWIST 2 SURE COMFORT TOP LANCETS 2 LANCETS 18G TRUEDRAW LANCING 2 SURE COMFORT DEVICE 2 LANCETS 21G TRUEPLUS LANCETS 2 SURE COMFORT 26G 2 LANCETS 23G TRUEPLUS LANCETS 2 SURE COMFORT 28G 2 LANCETS 28G TRUEPLUS LANCETS 2 SURE COMFORT 30G 2 LANCETS 30G TRUEPLUS LANCETS 2 SURE COMFORT 33G 2 LANCING PEN TRUEPLUS SAFETY 2 SURE-LANCE FLAT LANCETS 28G 2 LANCETS ULTI-LANCE 2 SURE-LANCE LANCETS AUTOMATIC 2 26G ULTILET CLASSIC 2 SURE-LANCE THIN LANCETS 2 LANCETS 28G ULTILET LANCETS 2

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 147 Drug Name Tier Notes Drug Name Tier Notes ULTILET SAFETY UNISTIK CZT 2 2 LANCETS COMFORT ULTILET SAFETY UNISTIK CZT NORMAL 2 2 LANCETS 23G UNISTIK PRO SAFETY 2 ULTRA THIN LANCETS LANCET 2 31G UNISTIK SAFETY 2 ULTRA-CARE LANCETS LANCETS 28G 2 30G UNISTIK SAFETY 2 ULTRALANCE 2 LANCETS 30G ULTRA-THIN II AUTO UNISTIK TOUCH 2 2 LANCET SAFETY LANC 21G ULTRA-THIN II UNISTIK TOUCH 2 2 LANCETS SAFETY LANC 23G UNILET UNISTIK TOUCH 2 COMFORTOUCH 2 SAFETY LANC 28G LANCET UNISTIK TOUCH 2 UNILET EXCELITE 2 SAFETY LANC 30G UNILET EXCELITE II 2 UNIVERSAL 1 LANCETS 2 UNILET G.P. LANCET 2 THIN 26G UNILET G.P. SUPERLITE UNIVERSAL 1 LANCETS 2 2 LANCET THIN 33G UNILET GP 28 ULTRA UNIVERSAL 1 LANCETS 2 2 THIN ULTRA THIN VALUE PLUS LANCET UNILET LANCET 2 2 STANDARD 21G UNILET MICRO-THIN 2 VALUE PLUS LANCETS 33G 2 SUPER THIN UNILET SUPERLITE 2 VALUE PLUS LANCETS LANCET 2 THIN 26G UNILET SUPER-THIN 2 VALUE PLUS LANCING 30G 2 DEVICE UNILET ULTRA-THIN 2 VALUMARK LANCET 28G 2 SUPER THIN 30G UNISTIK 1 2 VALUMARK LANCET 2 UNISTIK 2 2 ULTRA THIN 28G UNISTIK 2 COMFORT 2 VIDA MIA AUTOLET 2 UNISTIK 2 EXTRA 2 LANCING DEV VIDA MIA UNILET UNISTIK 2 NEONATAL 2 2 LANCETS 28G UNISTIK 2 NORMAL 2 VIDA MIA UNILET 2 UNISTIK 2 SUPER 2 LANCETS 30G UNISTIK 3 2 VIVAGUARD LANCETS 2 ST; QL UNISTIK 3 COMFORT 2 VIVAGUARD LANCING 2 UNISTIK 3 EXTRA 2 DEVICE UNISTIK 3 GENTLE 2 WALGREENS ADV 2 UNISTIK 3 NEONATAL 2 TRAVEL LANCETS UNISTIK 3 NORMAL 2 WALGREENS LANCETS 2 WALGREENS LANCETS 2 MICRO THIN * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 148 Drug Name Tier Notes Drug Name Tier Notes WALGREENS LANCETS BD INSULIN SYRINGE 2 SUPER THIN ULTRAFINE 29G X 1/2" WALGREENS THIN 0.3 ML, 29G X 1/2" 0.5 2 2 LANCETS ML, 30G X 1/2" 0.5 ML, 31G X 5/16" 0.5 ML WALGREENS ULTRA 2 THIN LANCETS BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 1 2 ST; QL *NEEDLES & ML, 30G X 1/2" 0.3 ML SYRINGES*** BD PEN NEEDLE MICRO 1ST TIER UNIFINE 2 3 ST; QL U/F PENTIPS BD PEN NEEDLE MINI 1ST TIER UNIFINE 2 3 ST; QL U/F PENTIPS PLUS BD PEN NEEDLE NANO ABOUTTIME PEN 2 ST; QL 3 ST; QL 2ND GEN NEEDLE BD PEN NEEDLE NANO ADVOCATE INSULIN 2 3 ST; QL U/F PEN NEEDLES BD PEN NEEDLE ADVOCATE INSULIN 2 3 ST; QL ORIGINAL U/F SYRINGE BD PEN NEEDLE SHORT ASSURE ID INSULIN 2 3 ST; QL U/F SAFETY SYR BD SAFETYGLIDE ASSURE ID SAFETY PEN 3 INSULIN SYRINGE 29G NEEDLES X 1/2" 0.3 ML, 30G X 5/16" 0.5 ML, 31G X AURORA PEN NEEDLES 3 ST; QL 2 15/64" 0.3 ML, 31G X AURORA UNIFINE 3 ST; QL 15/64" 0.5 ML, 31G X PENTIPS 15/64" 1 ML, 31G X 5/16" BD AUTOSHIELD 29G X 0.3 ML 2 ST; QL 5MM , 29G X 8MM BD SAFETYGLIDE BD AUTOSHIELD DUO 2 INSULIN SYRINGE 29G 2 ST; QL BD INSULIN SYR X 1/2" 0.5 ML ULTRAFINE II 31G X BD SAFETY-LOK 2 ST; QL 2 5/16" 0.3 ML, 31G X 5/16" INSULIN SYRINGE 0.5 ML BD VEO INSULIN 2 BD INSULIN SYRINGE SYRINGE U/F 25G X 1" 1 ML, 25G X CAREFINE PEN 3 ST; QL 5/8" 1 ML, 26G X 1/2" 1 NEEDLES ML, 27.5G X 5/8" 2 ML, 2 CAREONE INSULIN 27G X 1/2" 1 ML, 29G X 3 ST; QL 1/2" 0.3 ML, 29G X 1/2" SYRINGE 0.5 ML, 29G X 1/2" 1 ML, CAREONE UNIFINE 3 ST; QL U-100 1 ML PENTIPS BD INSULIN SYRINGE CAREONE UNIFINE MICROFINE 27G X 5/8" 1 3 ST; QL 2 PENTIPS PLUS ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML CARETOUCH INSULIN SYRINGE 28G X 5/16" 1 3 ST; QL BD INSULIN SYRINGE 2 ML U/F CARETOUCH INSULIN BD INSULIN SYRINGE 2 SYRINGE 29G X 5/16" 1 3 U/F 1/2UNIT ML BD INSULIN SYRINGE CARETOUCH PEN 2 3 ST; QL U-500 NEEDLES

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 149 Drug Name Tier Notes Drug Name Tier Notes CLEVER CHOICE EASY COMFORT PEN 3 ST; QL COMFORT EZ NEEDLES 31G X 6 MM , CLICKFINE PEN 32G X 4 MM , 33G X 4 3 ST; QL 3 ST; QL NEEDLES MM , 33G X 5 MM , 33G X 6 MM COMFORT ASSIST 3 ST; QL EASY GLIDE PEN INSULIN SYRINGE 3 ST; QL NEEDLES COMFORT EZ INSULIN 3 ST; QL EASY TOUCH SYRINGE 3 ST; QL FLIPLOCK INSULIN SY COMFORT EZ MICRO 3 ST; QL EASY TOUCH INSULIN PEN NEEDLES 3 ST; QL SAFETY SYR COMFORT EZ PEN 3 ST; QL EASY TOUCH INSULIN NEEDLES 3 ST; QL SYRINGE COMFORT EZ SHORT 3 ST; QL EASY TOUCH PEN PEN NEEDLES 3 ST; QL NEEDLES DROPLET INSULIN EASY TOUCH SAFETY SYRINGE 29G X 1/2" 0.3 3 ST; QL ML, 29G X 1/2" 0.5 ML, PEN NEEDLES 29G X 1/2" 1 ML, 30G X EASY TOUCH 1/2" 0.3 ML, 30G X 1/2" 3 SHEATHLOCK 0.5 ML, 30G X 15/64" 0.5 SYRINGE 29G X 1/2" 1 3 ST; QL ML, 30G X 5/16" 0.5 ML, ML, 30G X 1/2" 1 ML, 30G 31G X 15/64" 0.5 ML, 31G X 5/16" 1 ML, 31G X 5/16" X 5/16" 0.5 ML 1 ML DROPLET INSULIN ELITE-THIN INSULIN SYRINGE 30G X 1/2" 1 SYRINGE 28G X 1/2" 0.5 ML, 30G X 15/64" 0.3 ML, ML, 28G X 1/2" 1 ML, 28G 30G X 15/64" 1 ML, 30G X X 5/16" 1 ML, 29G X 1/2" 5/16" 0.3 ML, 30G X 5/16" 3 ST; QL 0.5 ML, 29G X 1/2" 1 ML, 3 ST; QL 1 ML, 31G X 15/64" 0.3 29G X 5/16" 1 ML, 30G X ML, 31G X 15/64" 1 ML, 5/16" 0.5 ML, 30G X 5/16" 31G X 5/16" 0.3 ML, 31G 1 ML, 31G X 5/16" 0.3 ML, X 5/16" 1 ML 31G X 5/16" 0.5 ML, 31G DROPLET MICRON 3 X 5/16" 1 ML DROPLET PEN ELITE-THIN INSULIN 3 ST; QL NEEDLES SYRINGE 28G X 5/16" 0.5 3 ML, 29G X 5/16" 0.5 ML DROPSAFE SAFETY PEN 3 NEEDLES EQL INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X DRUG MART UNIFINE 3 ST; QL 1/2" 0.5 ML, 29G X 1/2" 1 PENTIPS ML, 30G X 5/16" 0.3 ML, 3 ST; QL DRUG MART UNIFINE 30G X 5/16" 0.5 ML, 30G 3 ST; QL PENTIPS PLUS X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 EASY COMFORT ML, 31G X 5/16" 1 ML INSULIN SYRINGE 30G EXEL COMFORT POINT X 1/2" 0.5 ML, 30G X 1/2" 3 ST; QL 1 ML, 30G X 5/16" 0.5 ML, INSULIN SYR 3 ST; QL 30G X 5/16" 1 ML, 31G X EXEL COMFORT POINT 3 ST; QL 5/16" 0.5 ML, 31G X 5/16" PEN NEEDLE 1 ML, 32G X 5/16" 0.5 ML, 32G X 5/16" 1 ML FIFTY50 PEN NEEDLES 3 ST; QL FIFTY50 SUPERIOR EASY COMFORT PEN 3 ST; QL NEEDLES 31G X 5 MM , 3 COMFORT SYR 31G X 8 MM FREDS PHARMACY 3 ST; QL UNIFINE PENTIP+ * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 150 Drug Name Tier Notes Drug Name Tier Notes FREDS PHARMACY HEALTHWISE SHORT 3 ST; QL UNIFINE PENTIPS PEN NEEDLES 31G X 8 3 ST; QL FREESTYLE PRECISION MM 3 ST; QL INS SYR HEALTHWISE UNIFINE 3 ST; QL GLOBAL EASE INJECT PENTIPS 3 ST; QL PEN NEEDLES HEALTHY ACCENTS 3 ST; QL GLOBAL EASY GLIDE UNIFINE PENTIP INSULIN SYR 31G X H-E-B INCONTROL PEN 3 ST; QL 15/64" 0.3 ML, 31G X 3 NEEDLES 15/64" 0.5 ML, 31G X H-E-B INCONTROL 3 ST; QL 15/64" 1 ML UNIFINE PENTIP GLOBAL EASY GLIDE HM ULTICARE INSULIN 3 ST; QL INSULIN SYR 31G X 3 ST; QL SYRINGE 5/16" 0.3 ML HM ULTICARE SHORT GLOBAL EASY GLIDE 3 ST; QL 3 ST; QL PEN NEEDLES PEN NEEDLES INSULIN SYRINGE 27G GLOBAL INJECT EASE 3 ST; QL X 1/2" 0.5 ML, 27G X 1/2" INSULIN SYR 1 ML, 28G X 1/2" 0.5 ML, GLOBAL INSULIN 28G X 1/2" 1 ML, 29G X 3 ST; QL SYRINGES 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, GLUCOPRO INSULIN 3 ST; QL SYRINGE 30G X 1/2" 0.3 30G X 1/2" 0.5 ML, 30G X ML, 30G X 5/16" 0.3 ML, 1/2" 1 ML, 30G X 5/16" 0.3 30G X 5/16" 0.5 ML, 30G 3 ST; QL ML, 30G X 5/16" 0.5 ML, X 5/16" 1 ML, 31G X 5/16" 30G X 5/16" 1 ML, 31G X 0.3 ML, 31G X 5/16" 0.5 5/16" 0.3 ML, 31G X 5/16" ML, 31G X 5/16" 1 ML 0.5 ML, 31G X 5/16" 1 ML INSULIN SYRINGE 29G GLUCOPRO INSULIN 3 SYRINGE 30G X 1/2" 0.5 3 X 1" 0.3 ML ML, 30G X 1/2" 1 ML INSULIN 3 ST; QL GNP CLICKFINE PEN SYRINGE/NEEDLE 3 ST; QL NEEDLES INSULIN SYRINGE- 3 ST; QL GNP INSULIN SYRINGE 3 ST; QL NEEDLE U-100 GNP ULTRA COM INSUPEN PEN NEEDLES 3 ST; QL 3 ST; QL INSULIN SYRINGE INSUPEN SENSITIVE 3 ST; QL GOODSENSE INSUPEN ULTRAFIN 30G CLICKFINE PEN 3 ST; QL X 8 MM , 31G X 6 MM , 3 ST; QL NEEDLE 31G X 8 MM GOODSENSE PEN KINRAY INSULIN 3 ST; QL 3 ST; QL NEEDLE PENFINE SYRINGE HEALTHWISE INSULIN KMART VALU INSULIN 3 3 ST; QL SYR/NEEDLE SYRINGE 29G HEALTHWISE MICRON KMART VALU INSULIN 3 3 ST; QL PEN NEEDLES SYRINGE 30G HEALTHWISE MINI PEN 3 ST; QL NEEDLES HEALTHWISE PEN 3 ST; QL NEEDLES HEALTHWISE SHORT PEN NEEDLES 31G X 5 3 MM

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 151 Drug Name Tier Notes Drug Name Tier Notes KROGER INSULIN MONOJECT INSULIN 3 ST; QL SYRINGE 29G X 1/2" 0.3 SYRINGE ML, 29G X 1/2" 0.5 ML, MONOJECT ULTRA 29G X 1/2" 1 ML, 30G X COMFORT SYRINGE 5/16" 0.3 ML, 30G X 5/16" 3 ST; QL 28G X 1/2" 0.5 ML, 28G X 0.5 ML, 30G X 5/16" 1 ML, 1/2" 1 ML, 29G X 1/2" 0.3 31G X 5/16" 0.3 ML, 31G ML, 29G X 1/2" 0.5 ML, 3 ST; QL X 5/16" 0.5 ML, 31G X 29G X 1/2" 1 ML, 30G X 5/16" 1 ML 5/16" 0.3 ML, 30G X 5/16" KROGER PEN NEEDLES 0.5 ML, 31G X 5/16" 0.3 3 29G X 12MM ML, 31G X 5/16" 0.5 ML KROGER PEN NEEDLES MS INSULIN SYRINGE 31G X 5 MM , 31G X 6 31G X 5/16" 0.3 ML, 31G 3 ST; QL 3 ST; QL MM , 31G X 8 MM , 32G X X 5/16" 0.5 ML, 31G X 4 MM , 33G X 4 MM 5/16" 1 ML LEADER INSULIN NOVOFINE 32G X 6 MM 3 ST; QL 3 ST; QL SYRINGE NOVOFINE 3 ST; QL LEADER UNIFINE AUTOCOVER 3 ST; QL PENTIPS NOVOFINE PLUS 3 ST; QL LEADER UNIFINE NOVOTWIST 32G X 5 3 ST; QL 3 ST; QL PENTIPS PLUS MM LITETOUCH INSULIN 3 ST; QL PC UNIFINE PENTIPS 3 ST; QL SYRINGE PEN NEEDLES 3 ST; QL LITETOUCH PEN 3 ST; QL NEEDLES PEN NEEDLES 1/2" 3 ST; QL LONGS INSULIN PEN NEEDLES 3/16" 3 ST; QL SYRINGE 31G X 5/16" 0.5 3 ST; QL PEN NEEDLES 5/16" 3 ST; QL ML PENTIPS 3 ST; QL MAGELLAN INSULIN 3 ST; QL SAFETY SYR PRECISION SUREDOSE PLUS SYR 29G X 1/2" 0.3 3 MARATHON MEDICAL 3 ST; QL ML PENTIPS PRECISION SUREDOSE MAXICOMFORT II PEN 3 ST; QL PLUS SYR 29G X 1/2" 1 3 ST; QL NEEDLE ML MAXI-COMFORT 3 ST; QL PRECISION SURE-DOSE INSULIN SYRINGE SYRINGE 28G X 1/2" 0.5 3 MAXI-COMFORT ML, 28G X 1/2" 1 ML, 30G 3 ST; QL SAFETY PEN NEEDLE X 3/8" 0.5 ML MAXICOMFORT SYR PRECISION SURE-DOSE 3 ST; QL 27G X 1/2" SYRINGE 29G X 1/2" 0.5 3 ST; QL ML, 30G X 5/16" 0.3 ML MEDIC INSULIN 3 ST; QL PREFERRED PLUS SYRINGE 3 ST; QL INSULIN SYRINGE MEDICINE SHOPPE PEN 3 ST; QL PREFERRED PLUS NEEDLES 3 ST; QL UNIFINE PENTIPS MEIJER PEN NEEDLES 3 ST; QL PREVENT SAFETY PEN MICRODOT PEN 3 ST; QL 3 ST; QL NEEDLES NEEDLE PRO COMFORT MM INSULIN 3 ST; QL 3 ST; QL INSULIN SYRINGE SYRINGE/NEEDLE PRO COMFORT PEN 3 ST; QL MM PEN NEEDLES 3 ST; QL NEEDLES

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 152 Drug Name Tier Notes Drug Name Tier Notes PRODIGY INSULIN SURE-JECT INSULIN 3 ST; QL 3 ST; QL SYRINGE SYRINGE PURE COMFORT PEN TECHLITE INSULIN 3 ST; QL NEEDLE SYRINGE 29G X 1/2" 0.3 PX EXTRA SHORT PEN ML, 29G X 1/2" 1 ML, 30G 3 ST; QL NEEDLES X 1/2" 0.3 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 3 ST; QL PX INSULIN SYRINGE 3 ST; QL 30G X 5/16" 1 ML, 31G X 30G X 1/2" 0.5 ML 15/64" 0.3 ML, 31G X PX MINI PEN NEEDLES 3 ST; QL 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML PX PEN NEEDLE 3 ST; QL TECHLITE INSULIN PX SHORTLENGTH PEN 3 ST; QL SYRINGE 29G X 1/2" 0.5 NEEDLES ML, 30G X 1/2" 0.5 ML, 3 QC PEN NEEDLES 3 ST; QL 30G X 5/16" 0.5 ML, 31G QC UNIFINE PENTIPS 3 ST; QL X 15/64" 0.5 ML, 31G X 5/16" 0.5 ML RA INSULIN SYRINGE 3 ST; QL TECHLITE PEN 3 ST; QL RA PEN NEEDLES 3 ST; QL NEEDLES REALITY INSULIN TODAYS HEALTH MINI 3 ST; QL SYRINGE 28G X 1/2" 0.5 3 PEN NEEDLES ML, 28G X 1/2" 1 ML TODAYS HEALTH PEN 3 ST; QL REALITY INSULIN NEEDLES SYRINGE 29G X 1/2" 0.5 3 ST; QL TODAYS HEALTH ML, 29G X 1/2" 1 ML 3 ST; QL SHORT PEN NEEDLE RELION INSULIN 3 ST; QL TOPCARE CLICKFINE SYRINGE 3 ST; QL PEN NEEDLES RELI-ON INSULIN 3 ST; QL TOPCARE ULTRA SYRINGE 3 ST; QL COMFORT INS SYR RELION MINI PEN 3 ST; QL TRUE COMFORT NEEDLES 3 INSULIN SYRINGE RELION PEN NEEDLES 3 ST; QL TRUE COMFORT PEN RELION SHORT PEN 3 ST; QL 3 ST; QL NEEDLES NEEDLES TRUEPLUS 5-BEVEL SAFESNAP INSULIN 3 3 ST; QL PEN NEEDLES SYRINGE TRUEPLUS INSULIN SAFETY INSULIN 3 ST; QL 3 ST; QL SYRINGE SYRINGES TRUEPLUS PEN 3 SB INSULIN SYRINGE 3 ST; QL NEEDLES SECURESAFE INSULIN ULTICARE INSULIN 3 ST; QL 3 ST; QL SYRINGE SAFETY SYR SHOPKO UNIFINE ULTICARE INSULIN 3 ST; QL 3 ST; QL PENTIPS SYRINGE SHOPKO UNIFINE ULTICARE MICRO PEN 3 ST; QL 3 ST; QL PENTIPS PLUS NEEDLES SURE COMFORT ULTICARE MINI PEN 3 ST; QL 3 ST; QL INSULIN SYRINGE NEEDLES SURE COMFORT PEN ULTICARE PEN 3 ST; QL 3 ST; QL NEEDLES NEEDLES SURE-FINE PEN ULTICARE SHORT PEN 3 ST; QL 3 ST; QL NEEDLES NEEDLES

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 153 Drug Name Tier Notes Drug Name Tier Notes ULTIGUARD SAFEPACK VANISHPOINT INSULIN 3 ST; QL PEN NEEDLE SYRINGE 29G X 1/2" 1 ML, 29G X 5/16" 1 ML, ULTILET INSULIN 3 ST; QL SYRINGE 30G X 1/2" 0.5 30G X 1/2" 0.5 ML, 30G X ML, 30G X 1/2" 1 ML, 30G 5/16" 0.5 ML, 30G X 5/16" X 5/16" 0.3 ML, 30G X 1 ML 5/16" 0.5 ML, 30G X 5/16" VANISHPOINT INSULIN 1 ML, 31G X 1/4" 0.3 ML, 3 ST; QL SYRINGE 30G X 3/16" 0.5 3 31G X 1/4" 1 ML, 31G X ML, 30G X 3/16" 1 ML 15/64" 0.3 ML, 31G X VIDA MIA UNIFINE 3 ST; QL 15/64" 0.5 ML, 31G X PENTIPS 5/16" 0.3 ML, 31G X 5/16" 1 ML VP INSULIN SYRINGE 3 ST; QL ULTILET INSULIN WEGMANS UNIFINE 3 ST; QL 3 ST; QL SYRINGE SHORT PENTIPS PLUS ULTILET PEN NEEDLE 3 ST; QL *OSTOMY SUPPLIES*** KANGAROO BALLOON ULTRA COMFORT 2 INSULIN SYRINGE 30G 3 ST; QL 12FR/0.8CM KIT X 5/16" 0.3 ML KANGAROO BALLOON 2 ULTRA FLO INSULIN 12FR/1.2CM KIT 3 ST; QL PEN NEEDLES KANGAROO BALLOON 2 ULTRA FLO INSULIN 12FR/1.5CM KIT 2 ST; QL SYRINGE KANGAROO BALLOON 2 ULTRA THIN PEN 12FR/1.7CM KIT 3 ST; QL NEEDLES KANGAROO BALLOON 2 ULTRACARE INSULIN 12FR/1CM KIT 3 SYRINGE KANGAROO BALLOON 2 ULTRACARE PEN 12FR/2.3CM KIT 3 ST; QL NEEDLES KANGAROO BALLOON 2 ULTRA-COMFORT 12FR/2.5CM KIT 3 ST; QL INSULIN SYRINGE KANGAROO BALLOON 2 ULTRA-THIN II INS SYR 12FR/2.7CM KIT 3 ST; QL SHORT KANGAROO BALLOON 2 ULTRA-THIN II INSULIN 12FR/2CM KIT SYRINGE 29G X 1/2" 0.5 3 ST; QL KANGAROO BALLOON 2 ML, 29G X 1/2" 1 ML 12FR/3.5CM KIT ULTRA-THIN II MINI KANGAROO BALLOON 3 ST; QL 2 PEN NEEDLE 12FR/3CM KIT ULTRA-THIN II PEN KANGAROO BALLOON 3 ST; QL 2 NEEDLE SHORT 12FR/4.5CM KIT ULTRA-THIN II PEN KANGAROO BALLOON 3 ST; QL 2 NEEDLES 12FR/4CM KIT UNIFINE PENTIPS 3 ST; QL KANGAROO BALLOON 2 UNIFINE PENTIPS PLUS 3 ST; QL 12FR/5CM KIT KANGAROO BALLOON UNIFINE 2 SAFECONTROL PEN 3 ST; QL 14FR/0.8CM KIT NEEDLE KANGAROO BALLOON 2 VALUE HEALTH 14FR/1.2CM KIT 3 ST; QL INSULIN SYRINGE KANGAROO BALLOON 2 VALUMARK PEN 14FR/1.5CM KIT 3 ST; QL NEEDLES * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 154 Drug Name Tier Notes Drug Name Tier Notes KANGAROO BALLOON KANGAROO BALLOON 2 2 14FR/1.7CM KIT 16FR/5CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 14FR/1CM KIT 18FR/0.8CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 14FR/2.3CM KIT 18FR/1.2CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 14FR/2.5CM KIT 18FR/1.5CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 14FR/2.7CM KIT 18FR/1.7CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 14FR/2CM KIT 18FR/1CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 14FR/3.5CM KIT 18FR/2.3CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 14FR/3CM KIT 18FR/2.5CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 14FR/4.5CM KIT 18FR/2.7CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 14FR/4CM KIT 18FR/2CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 14FR/5CM KIT 18FR/3.5CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 16FR/0.8CM KIT 18FR/3CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 16FR/1.2CM KIT 18FR/4.5CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 16FR/1.5CM KIT 18FR/4CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 16FR/1.7CM KIT 18FR/5CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 16FR/1CM KIT 20FR/0.8CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 16FR/2.3CM KIT 20FR/1.2CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 16FR/2.5CM KIT 20FR/1.5CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 16FR/2.7CM KIT 20FR/1.7CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 16FR/2CM KIT 20FR/1CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 16FR/3.5CM KIT 20FR/2.3CM KIT KANGAROO BALLOON KANGAROO BALLOON 2 2 16FR/3CM KIT 20FR/2CM KIT KANGAROO BALLOON NUTRIPORT BALLOON 2 2 16FR/4.5CM KIT 20FR/2.5CM KIT KANGAROO BALLOON NUTRIPORT BALLOON 2 2 16FR/4CM KIT 20FR/2.7CM KIT

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 155 Drug Name Tier Notes Drug Name Tier Notes NUTRIPORT BALLOON *MELANOCORTIN 2 20FR/3.5CM KIT RECEPTOR NUTRIPORT BALLOON AGONISTS*** 2 20FR/4.5CM KIT *MELANOCORTIN NUTRIPORT BALLOON RECEPTOR 2 20FR/4CM KIT AGONISTS*** NUTRIPORT BALLOON VYLEESI 2 SUBCUTANEOUS 20FR/5CM KIT 3 PA; QL; LD SOLUTION AUTO- NUTRIPORT BALLOON 2 INJECTOR 24FR/0.8CM KIT *MIGRAINE NUTRIPORT BALLOON 2 PRODUCTS* 24FR/1.2CM KIT *ERGOT NUTRIPORT BALLOON 2 COMBINATIONS*** 24FR/1.5CM KIT CAFERGOT ORAL NUTRIPORT BALLOON 3 2 TABLET 24FR/1.7CM KIT ergotamine-caffeine oral NUTRIPORT BALLOON 1 or 1b* 2 tablet 24FR/1CM KIT migergot rectal suppository 1 or 1b* NUTRIPORT BALLOON 2 24FR/2.3CM KIT *MIGRAINE COMBINATIONS*** NUTRIPORT BALLOON 2 24FR/2.5CM KIT MIGRAINE PACK COMBINATION 3 NUTRIPORT BALLOON 2 THERAPY PACK 24FR/2.7CM KIT *MIGRAINE PRODUCTS NUTRIPORT BALLOON 2 - NSAIDS*** 24FR/2CM KIT CAMBIA ORAL PACKET 3 ST; QL NUTRIPORT BALLOON 2 24FR/3.5CM KIT *MIGRAINE PRODUCTS*** NUTRIPORT BALLOON 2 D.H.E. 45 INJECTION 24FR/3CM KIT 3 PA; QL SOLUTION NUTRIPORT BALLOON 2 dihydroergotamine mesylate 24FR/4.5CM KIT 1 or 1b* PA; QL injection solution NUTRIPORT BALLOON 2 dihydroergotamine mesylate 24FR/4CM KIT 1 or 1b* ST; QL nasal solution *MELANOCORTIN RECEPTOR AGONISTS ERGOMAR (UV PROTECTIVE)*** SUBLINGUAL TABLET 3 SUBLINGUAL *MELANOCORTIN MIGRANAL NASAL RECEPTOR AGONISTS 3 ST; QL (UV PROTECTIVE)*** SOLUTION SCENESSE *SELECTIVE SUBCUTANEOUS 3 SEROTONIN AGONIST- IMPLANT NSAID COMBINATIONS*** sumatriptan-naproxen 1 or 1b* ST; QL sodium oral tablet TREXIMET ORAL 3 ST; QL TABLET 85-500 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 156 Drug Name Tier Notes Drug Name Tier Notes *SELECTIVE sumatriptan succinate SEROTONIN AGONISTS subcutaneous solution auto- 1 or 1b* QL 5-HT(1)*** injector 4 mg/0.5ml, 6 almotriptan malate oral tablet 1 or 1b* QL mg/0.5ml AMERGE ORAL sumatriptan succinate 3 ST; QL TABLET subcutaneous solution 1 or 1b* QL prefilled syringe 6 mg/0.5ml eletriptan hydrobromide oral 1 or 1b* QL TOSYMRA NASAL tablet 3 ST; QL SOLUTION FROVA ORAL TABLET 3 ST; QL ZEMBRACE frovatriptan succinate oral 1 or 1b* ST; QL SYMTOUCH tablet SUBCUTANEOUS 3 ST; QL IMITREX NASAL SOLUTION AUTO- 3 ST; QL SOLUTION INJECTOR IMITREX ORAL zolmitriptan oral tablet 1 or 1b* QL 3 ST; QL TABLET zolmitriptan oral tablet 1 or 1b* QL IMITREX STATDOSE dispersible REFILL ZOMIG NASAL 3 ST; QL 3 ST; QL SUBCUTANEOUS SOLUTION SOLUTION CARTRIDGE ZOMIG ORAL TABLET 3 ST; QL IMITREX STATDOSE ZOMIG ZMT ORAL SYSTEM 3 ST; QL SUBCUTANEOUS 3 ST; QL TABLET DISPERSIBLE SOLUTION AUTO- *MINERALS & INJECTOR ELECTROLYTES* IMITREX *BICARBONATES*** SUBCUTANEOUS 3 ST; QL SODIUM ACETATE SOLUTION INTRAVENOUS 3 MAXALT ORAL TABLET SOLUTION 2 MEQ/ML 3 ST; QL 10 MG sodium acetate intravenous 1 or 1b* MAXALT-MLT ORAL solution 4 meq/ml TABLET DISPERSIBLE 3 ST; QL sodium bicarbonate 10 MG intravenous solution 4.2 %, 1 or 1b* naratriptan hcl oral tablet 1 or 1b* QL 7.5 % ONZETRA XSAIL NASAL *CALCIUM 3 ST; QL EXHALER POWDER COMBINATIONS*** RELPAX ORAL TABLET 3 ST; QL CALCIFOL ORAL 3 rizatriptan benzoate oral WAFER 1 or 1b* QL tablet CALCIUM rizatriptan benzoate oral GLUCONATE-NACL 1 or 1b* QL tablet dispersible INTRAVENOUS SOLUTION 1-0.675 3 sumatriptan nasal solution 1 or 1b* QL GM/50ML-%, 1-0.9 sumatriptan succinate oral GM/100ML-%, 2-0.675 1 or 1b* QL tablet GM/100ML-%, 2-0.9 GM/100ML-% sumatriptan succinate refill CALCIUM-FOLIC ACID subcutaneous solution 1 or 1b* QL 3 cartridge PLUS D ORAL WAFER sumatriptan succinate *CALCIUM*** subcutaneous solution 6 1 or 1b* QL CALCIUM GLUCONATE mg/0.5ml INTRAVENOUS 3 SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 157 Drug Name Tier Notes Drug Name Tier Notes *ELECTROLYTES & NORMOSOL-R IN D5W DEXTROSE*** INTRAVENOUS 3 DEXTROSE SOLUTION 5%/ELECTROLYTE #48 potassium chloride in 3 INTRAVENOUS dextrose intravenous solution 1 or 1b* SOLUTION 20-5 meq/l-%, 40-5 meq/l-% dextrose in lactated ringers *ELECTROLYTES 1 or 1b* intravenous solution PARENTERAL*** DEXTROSE-NACL hyperlyte-cr intravenous 1 or 1b* INTRAVENOUS concentrate 3 SOLUTION 10-0.2 %, 5- ISOLYTE-S 0.3 % INTRAVENOUS 3 dextrose-nacl intravenous SOLUTION solution 10-0.45 %, 2.5-0.45 1 or 1b* ISOLYTE-S PH 7.4 %, 5-0.2 %, 5-0.225 %, 5- INTRAVENOUS 3 0.33 %, 5-0.45 %, 5-0.9 % SOLUTION DEXTROSE-SODIUM KCL-LIDOCAINE-NACL CHLORIDE INTRAVENOUS 3 INTRAVENOUS 3 SOLUTION SOLUTION 5-0.225 %, 5- lactated ringers intravenous 0.3 % 1 or 1b* solution dextrose-sodium chloride intravenous solution 5-0.45 1 or 1b* NORMOSOL-R %, 5-0.9 % INTRAVENOUS 3 SOLUTION ELLIOTTS B INTRATHECAL 3 NORMOSOL-R PH 7.4 SOLUTION INTRAVENOUS 3 SOLUTION IONOSOL-MB IN D5W INTRAVENOUS 3 PLASMA-LYTE 148 SOLUTION INTRAVENOUS 3 SOLUTION ISOLYTE-P IN D5W INTRAVENOUS 3 PLASMA-LYTE A SOLUTION INTRAVENOUS 3 SOLUTION kcl in dextrose-nacl intravenous solution 0.15-5- potassium chloride in nacl intravenous solution 20-0.45 0.45 %, 10-5-0.45 meq/l-%- 1 or 1b* %, 20-5-0.2 meq/l-%-%, 20- 1 or 1b* meq/l-%, 20-0.9 meq/l-%, 5-0.45 meq/l-%-%, 20-5-0.9 40-0.9 meq/l-% meq/l-%-%, 30-5-0.45 meq/l- ringers intravenous solution 1 or 1b* %-%, 40-5-0.45 meq/l-%-% TPN ELECTROLYTES KCL IN DEXTROSE- INTRAVENOUS 3 NACL INTRAVENOUS CONCENTRATE SOLUTION 20-5-0.225 3 *FLUORIDE MEQ/L-%-%, 40-5-0.9 COMBINATIONS*** MEQ/L-%-% KCL-LACTATED FLORIVA ORAL LIQUID 3 RINGERS-D5W *FLUORIDE*** 3 INTRAVENOUS FLUORABON ORAL 3 SOLUTION SOLUTION NORMOSOL-M IN D5W fluoritab oral solution 1 or 1a* $0 INTRAVENOUS 3 SOLUTION fluoritab oral tablet chewable 1 or 1a* $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 158 Drug Name Tier Notes Drug Name Tier Notes flura-drops oral solution 0.55 POTASSIUM 1 or 1a* $0 (0.25 f) mg/drop PHOSPHATES(71 MEQ 3 ludent oral tablet chewable 1 or 1a* $0 K) INTRAVENOUS SOLUTION nafrinse drops oral solution 1 or 1a* $0 sodium phosphates nafrinse oral tablet chewable 1 or 1a* $0 intravenous solution 15 1 or 1b* sodium fluoride oral solution 1 or 1a* $0 mmole/5ml, 45 mmole/15ml virt-phos 250 neutral oral sodium fluoride oral tablet 1 or 1a* $0 1 or 1b* tablet sodium fluoride oral tablet 1 or 1a* $0 chewable *POTASSIUM COMBINATIONS*** *MAGNESIUM EFFER-K ORAL TABLET COMBINATIONS*** 3 EFFERVESCENT 10 MEQ MAGNEBIND 400 ORAL 3 pot bicarb-pot chloride oral TABLET 1 or 1b* tablet effervescent *MAGNESIUM*** *POTASSIUM*** magnesium chloride injection 1 or 1b* effer-k oral tablet solution 1 or 1b* effervescent 25 meq MAGNESIUM SULFATE IN D5W INTRAVENOUS klor-con 10 oral tablet 3 1 or 1b* SOLUTION 1-5 extended release GM/100ML-% klor-con m10 oral tablet 1 or 1a* magnesium sulfate injection extended release 1 or 1b* solution 50 % klor-con m15 oral tablet 1 or 1a* MAGNESIUM SULFATE extended release INTRAVENOUS 3 klor-con m20 oral tablet 1 or 1a* SOLUTION extended release MAGNESIUM SULFATE- klor-con oral packet 20 meq 1 or 1b* NACL INTRAVENOUS 3 klor-con oral tablet extended SOLUTION 2-0.9 1 or 1b* GM/50ML-% release klor-con sprinkle oral *MANGANESE*** 1 or 1b* capsule extended release manganese chloride 1 or 1b* k-prime oral tablet intravenous solution 1 or 1b* effervescent manganese sulfate 1 or 1b* K-TAB ORAL TABLET intravenous solution 3 EXTENDED RELEASE *PHOSPHATE*** potassium acetate GLYCOPHOS intravenous solution 2 1 or 1b* INTRAVENOUS 3 meq/ml SOLUTION potassium bicarbonate oral 1 or 1b* K-PHOS ORAL TABLET 2 tablet effervescent K-PHOS-NEUTRAL potassium chloride crys er 3 1 or 1a* ORAL TABLET oral tablet extended release phospha 250 neutral oral potassium chloride er oral 1 or 1b* 1 or 1b* tablet capsule extended release phosphorous oral tablet 1 or 1b* potassium chloride er oral 1 or 1b* phospho-trin 250 neutral oral tablet extended release 1 or 1b* tablet

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 159 Drug Name Tier Notes Drug Name Tier Notes POTASSIUM CHLORIDE MULTITRACE-4 INTRAVENOUS NEONATAL 3 SOLUTION 10 INTRAVENOUS MEQ/100ML, 10 SOLUTION 3 MEQ/50ML, 20 MULTITRACE-4 MEQ/100ML, 20 PEDIATRIC 3 MEQ/50ML, 40 INTRAVENOUS MEQ/100ML SOLUTION potassium chloride multitrace-5 concentrate 1 or 1b* intravenous solution 2 1 or 1b* intravenous solution meq/ml MULTITRACE-5 potassium chloride oral 1 or 1b* INTRAVENOUS 3 packet SOLUTION potassium chloride oral THE LIQUILIFT TRACE 3 solution 20 meq/15ml (10%), 1 or 1b* INTRAVENOUS KIT 40 meq/15ml (20%) TRACE ELEMENTS *SODIUM*** 4/PEDIATRIC 3 LIQUIVIDA INTRAVENOUS HYDRATION 3 SOLUTION INTRAVENOUS KIT *TRACE MINERALS*** monoject flush syringe chromic chloride intravenous 1 or 1b* 1 or 1b* intravenous solution solution monoject sodium chloride cupric chloride intravenous 1 or 1b* 1 or 1b* flush intravenous solution solution normal saline flush 1 or 1b* SELENIOUS ACID intravenous solution INTRAVENOUS 3 saline flush intravenous SOLUTION 1 or 1b* solution selenium intravenous 1 or 1b* saline flush zr intravenous solution 1 or 1b* solution *ZINC*** sodium chloride (pf) GALZIN ORAL 1 or 1b* 3 injection solution CAPSULE sodium chloride flush zinc chloride intravenous 1 or 1b* 1 or 1b* intravenous solution solution sodium chloride injection zinc sulfate intravenous 1 or 1b* 1 or 1b* solution 2.5 meq/ml solution 1 mg/ml, 5 mg/ml sodium chloride intravenous ZINC SULFATE solution 0.45 %, 0.9 %, 3 %, 1 or 1b* INTRAVENOUS 3 4 meq/ml, 5 % SOLUTION 3 MG/ML swabflush saline flush 1 or 1b* *MISC. ANTIVIRALS*** intravenous solution *MISC. ANTIVIRALS*** *TRACE MINERAL FAVIPIRAVIR ORAL COMBINATIONS*** 3 TABLET multitrace-4 concentrate 1 or 1b* intravenous solution REMDESIVIR INTRAVENOUS 3 MULTITRACE-4 SOLUTION INTRAVENOUS 3 RECONSTITUTED SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 160 Drug Name Tier Notes Drug Name Tier Notes *MISCELLANEOUS *ANESTHETICS THERAPEUTIC TOPICAL ORAL*** CLASSES* lidocaine hcl mouth/throat 1 or 1a* *MISCELLANEOUS solution THERAPEUTIC lidocaine viscous hcl 1 or 1a* CLASSES*** mouth/throat solution NEXAVIR INJECTION topex topical anesthetic 3 1 or 1b* SOLUTION mouth/throat aerosol PHENOL INJECTION 3 *ANTI-INFECTIVES - SOLUTION THROAT*** *MIXED ALLERGENIC clotrimazole mouth/throat 1 or 1b* EXTRACTS*** lozenge *MIXED ALLERGENIC clotrimazole mouth/throat 1 or 1b* EXTRACTS*** troche DUST MITE MIXED nystatin mouth/throat ALLERGEN EXT 1 or 1b* 3 suspension SUBCUTANEOUS ORAVIG BUCCAL SOLUTION 3 TABLET MIXED ASPERGILLUS SUBCUTANEOUS 3 *ANTISEPTIC SOLUTION COMBINATIONS - MOUTH/THROAT*** MIXED FEATHERS SUBCUTANEOUS 3 DEBACTEROL SOLUTION MOUTH/THROAT 3 SOLUTION ODACTRA SUBLINGUAL TABLET 3 PA; QL *ANTISEPTICS - SUBLINGUAL MOUTH/THROAT*** ORALAIR SUBLINGUAL chlorhexidine gluconate 3 PA; QL; LD 1 or 1a* TABLET SUBLINGUAL mouth/throat solution SORREL/DOCK MIX paroex mouth/throat solution 1 or 1a* SUBCUTANEOUS 3 PERIDEX SOLUTION MOUTH/THROAT 3 *MONOBACTAMS*** SOLUTION periogard mouth/throat *MONOBACTAMS*** 1 or 1a* solution AZACTAM INJECTION SOLUTION 3 *DENTAL PRODUCTS - RECONSTITUTED COMBINATIONS*** aztreonam injection solution NAFRINSE DAILY 1 or 1b* reconstituted ACIDULATED MOUTH/THROAT 3 CAYSTON INHALATION SOLUTION SOLUTION 3 LD RECONSTITUTED RECONSTITUTED PREVIDENT 5000 *MOUTH/THROAT/DEN ENAMEL PROTECT 3 TAL AGENTS* DENTAL PASTE *ANESTHETICS PREVIDENT 5000 TOPICAL ORAL - SENSITIVE DENTAL 3 COMBINATIONS*** PASTE FIRST-MOUTHWASH BLM MOUTH/THROAT 3 SUSPENSION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 161 Drug Name Tier Notes Drug Name Tier Notes *DRY MOUTH AGENTS *PROTECTANTS - AND ARTIFICIAL MOUTH/THROAT*** SALIVA*** EPISIL AQUORAL MOUTH/THROAT 3 MOUTH/THROAT 3 LIQUID SOLUTION GELX MOUTH/THROAT 3 BOCASAL GEL MOUTH/THROAT 3 MUCOTROL PACKET MOUTH/THROAT 3 CAPHOSOL WAFER MOUTH/THROAT 3 MUGARD SOLUTION MOUTH/THROAT 3 NEUTRASAL LIQUID MOUTH/THROAT 3 ORAFATE PACKET MOUTH/THROAT 3 NUMOISYN PASTE MOUTH/THROAT 3 ORAMAGICRX LIQUID MOUTH/THROAT 3 NUMOISYN SUSPENSION MOUTH/THROAT 3 RECONSTITUTED LOZENGE SALICEPT *FLUORIDE DENTAL MOUTH/THROAT 3 PRODUCTS*** SUSPENSION cavarest dental gel 1 or 1b* RECONSTITUTED dentagel dental gel 1 or 1a* *SALIVA STIMULANTS*** easygel dental gel 1 or 1b* cevimeline hcl oral capsule 1 or 1b* NAFRINSE EVOXAC ORAL DAILY/NEUTRAL 3 MOUTH/THROAT 3 CAPSULE SOLUTION pilocarpine hcl oral tablet 1 or 1b* RECONSTITUTED SALAGEN ORAL 3 NAFRINSE WEEKLY TABLET MOUTH/THROAT 3 *STEROIDS - SOLUTION MOUTH/THROAT*** RECONSTITUTED oralone mouth/throat paste 1 or 1b* neutral sodium fluoride 1 or 1a* triamcinolone acetonide mouth/throat solution 1 or 1b* mouth/throat paste PREVIDENT 5000 BOOSTER PLUS 3 *MUCOPOLYSACCHARI DENTAL PASTE DOSIS IV (MPS IV) - AGENTS*** PREVIDENT 5000 DRY 3 MOUTH DENTAL GEL *MUCOPOLYSACCHARI DOSIS IV (MPS IV) - PREVIDENT 5000 PLUS 3 AGENTS*** DENTAL CREAM VIMIZIM PREVIDENT DENTAL 3 INTRAVENOUS 3 PA; QL; LD; SP GEL SOLUTION PREVIDENT MOUTH/THROAT 3 SOLUTION sf dental gel 1 or 1a*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 162 Drug Name Tier Notes Drug Name Tier Notes *MUCOPOLYSACCHARI *MULTIPLE VITAMINS DOSIS VII (MPS VII) - W/ MINERALS & AGENTS*** FLUORIDE-IRON-FOLIC *MUCOPOLYSACCHARI ACID*** DOSIS VII (MPS VII) - *MULTIPLE VITAMINS AGENTS*** W/ MINERALS & MEPSEVII FLUORIDE-IRON-FOLIC INTRAVENOUS 3 PA; QL; LD ACID*** SOLUTION QUFLORA FE ORAL 3 *MULTIPLE SCLEROSIS TABLET CHEWABLE AGENTS - *MULTIPLE VITAMINS ANTIMETABOLITES*** WITH FOLIC ACID*** *MULTIPLE SCLEROSIS *MULTIPLE VITAMINS AGENTS - WITH FOLIC ACID*** ANTIMETABOLITES*** GENICIN VITA-Q ORAL 3 MAVENCLAD (10 TABS) TABLET ORAL TABLET 3 PA; QL; LD; SP *MULTIVITAMINS* THERAPY PACK *B-COMPLEX MAVENCLAD (4 TABS) VITAMINS*** ORAL TABLET 3 PA; QL; LD; SP THERAPY PACK B-COMPLEX INJECTION 3 MAVENCLAD (5 TABS) INJECTABLE ORAL TABLET 3 PA; QL; LD; SP THERAPY PACK *B-COMPLEX W/ C & FOLIC ACID*** MAVENCLAD (6 TABS) ORAL TABLET 3 PA; QL; LD; SP b-plex oral tablet 1 or 1b* THERAPY PACK dexifol oral tablet 1 or 1b* MAVENCLAD (7 TABS) dialyvite oral tablet 1 or 1b* ORAL TABLET 3 PA; QL; LD; SP THERAPY PACK folbee plus oral tablet 1 or 1b* MAVENCLAD (8 TABS) genicin vita-s oral tablet 1 or 1b* ORAL TABLET 3 PA; QL; LD; SP hylavite oral tablet 1 or 1b* THERAPY PACK mynephrocaps oral capsule 1 or 1b* MAVENCLAD (9 TABS) mynephron oral capsule 1 or 1b* ORAL TABLET 3 PA; QL; LD; SP NEPHRO-VITE RX ORAL THERAPY PACK 3 TABLET *MULTIPLE VITAMINS & FLUORIDE-FOLIC renal oral capsule 1 or 1b* ACID*** reno caps oral capsule 1 or 1b* *MULTIPLE VITAMINS triphrocaps oral capsule 1 or 1b* & FLUORIDE-FOLIC virt-caps oral capsule 1 or 1b* ACID*** vp-vite rx oral tablet 1 or 1b* MULTIVITAMIN/FLUOR IDE ORAL TABLET *B-COMPLEX W/ C- 3 CHEWABLE 0.25-0.3 MG, BIOTIN-D-ZINC & 0.5-0.3 MG, 1-0.3 MG FOLIC ACID*** VITAL-D RX ORAL 3 TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 163 Drug Name Tier Notes Drug Name Tier Notes *B-COMPLEX W/ C- DIALYVITE SUPREME D 3 BIOTIN-E & FOLIC ORAL TABLET ACID*** OCUVEL ORAL 2 RENATABS ORAL CAPSULE 0.5 MG 3 TABLET ONEVITE ORAL 3 *B-COMPLEX W/ C- TABLET BIOTIN-E-FOLIC ACID STROVITE FORTE 3 & IRON*** ORAL SYRUP RENATABS WITH IRON SYNAGEX ORAL 3 3 ORAL CAPSULE *B-COMPLEX W/ C- SYNATEK ORAL 3 BIOTIN-E-MINERALS & CAPSULE FOLIC ACID*** THRIVITE 19 ORAL DIALYVITE 3000 ORAL 2 3 TABLET 1 MG TABLET UDAMIN SP ORAL DIALYVITE 5000 ORAL 3 3 TABLET TABLET *MULTIPLE VITAMINS *B-COMPLEX W/ C-ZN W/ MINERALS*** & FOLIC ACID*** BACMIN ORAL TABLET 3 DIALYVITE/ZINC ORAL 3 TABLET biocel oral tablet 1 or 1b* NEPHPLEX RX ORAL b-plex plus oral tablet 1 or 1b* 3 TABLET FORTAVIT ORAL 3 *B-COMPLEX W/ CAPSULE LYSINE-MIN-FE & lysiplex plus oral tablet 1 or 1b* FOLIC ACID*** NICAZEL FORTE ORAL NUTRIVIT ORAL 3 2 TABLET LIQUID NICAZEL ORAL 3 *B-COMPLEX W/ TABLET LYSINE-ZN & FOLIC NUTRICAP ORAL ACID*** 3 TABLET SUPERVITE ORAL 3 LIQUID nutrifac zx oral tablet 1 or 1b* *BIOFLAVONOID REQ 49+ ORAL TABLET 3 PRODUCTS*** SIDEROL ORAL 2 ADRENAL C FORMULA TABLET 3 ORAL TABLET STROVITE FORTE 3 *IRON W/ VITAMINS*** ORAL TABLET VITAFOL ORAL STROVITE ONE ORAL 3 3 TABLET TABLET *MULTIPLE VITAMINS SUPPORT ORAL LIQUID 3 W/ MINERALS & v-c forte oral capsule 1 or 1b* CALCIUM-FOLIC vic-forte oral capsule 1 or 1b* ACID*** vita s forte oral tablet 1 or 1b* FOLGARD OS ORAL 3 TABLET vitacel oral tablet 1 or 1b* *MULTIPLE VITAMINS vita-min oral capsule 1 or 1b* W/ MINERALS & FOLIC VITAROCA PLUS ORAL 3 ACID*** TABLET corvita oral tablet 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 164 Drug Name Tier Notes Drug Name Tier Notes *MULTIVITAMINS*** QUFLORA GUMMIES INFUVITE ADULT ORAL TABLET 2 INTRAVENOUS 3 CHEWABLE INJECTABLE QUFLORA PEDIATRIC 3 M.V.I. ADULT ORAL SOLUTION INTRAVENOUS 3 QUFLORA PEDIATRIC INJECTABLE ORAL TABLET 3 *PED MULTI VITAMINS CHEWABLE W/FL & FE*** *PED VITAMINS ACD & multi-vit/iron/fluoride oral FA W/ FLUORIDE*** 1 or 1b* solution TRI-VI-FLOR ORAL 3 multivitamin/fluoride/iron SUSPENSION 1 or 1b* oral solution TRI-VI-FLORO ORAL 3 multi-vitamin/fluoride/iron SUSPENSION 1 or 1b* oral solution *PED VITAMINS ACD W/ POLY-VI-FLOR/IRON FLUORIDE*** 3 ORAL SUSPENSION adc/f (0.5mg/ml) oral 1 or 1b* $0 POLY-VI-FLOR/IRON solution ORAL TABLET 3 tri-vitamin/fluoride oral 1 or 1b* $0 CHEWABLE solution QUFLORA FE tri-vite/fluoride oral solution 1 or 1b* $0 PEDIATRIC ORAL 3 vitamins acd-fluoride oral 1 or 1b* $0 LIQUID solution *PED MULTIPLE *PEDIATRIC MULTIPLE VITAMINS W/ VITAMINS*** MINERALS & C*** INFUVITE PEDIATRIC vitamax pediatric oral 1 or 1b* INTRAVENOUS 3 solution SOLUTION *PED MV W/ M.V.I. PEDIATRIC FLUORIDE*** INTRAVENOUS 3 FLORIVA PLUS ORAL SOLUTION 3 SOLUTION RECONSTITUTED multivitamin/fluoride oral *PRENATAL MV & MIN 1 or 1b* $0 solution W/FE-FA*** multi-vitamin/fluoride oral ATABEX EC ORAL 1 or 1b* $0 solution TABLET DELAYED 3 multivitamin/fluoride oral RELEASE tablet chewable 0.25 mg, 0.5 1 or 1b* $0 ATABEX OB ORAL 3 mg, 1 mg TABLET multivitamins/fluoride oral AZESCHEW 1 or 1b* $0 tablet chewable 0.5 mg PRENATAL/POSTNATAL 3 mvc-fluoride oral tablet ORAL TABLET 1 or 1b* $0 chewable CHEWABLE POLY-VI-FLOR FS ORAL BAL-CARE DHA ORAL 3 3 STRIP CITRANATAL B-CALM 3 POLY-VI-FLOR ORAL ORAL 3 SUSPENSION CITRANATAL BLOOM 3 POLY-VI-FLOR ORAL ORAL TABLET 3 TABLET CHEWABLE CITRANATAL RX ORAL 3 TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 165 Drug Name Tier Notes Drug Name Tier Notes C-NATE DHA ORAL NESTABS DHA ORAL 3 3 CAPSULE NESTABS ORAL 3 COMPLETENATE ORAL TABLET 2 TABLET CHEWABLE NIVA-PLUS ORAL 3 CO-NATAL FA ORAL TABLET 3 TABLET OB COMPLETE ONE 3 CONCEPT DHA ORAL ORAL CAPSULE 3 CAPSULE OB COMPLETE ORAL 3 CONCEPT OB ORAL TABLET 3 CAPSULE OB COMPLETE PETITE 3 DUET DHA 400 ORAL 3 ORAL CAPSULE DUET DHA BALANCED OB COMPLETE 3 ORAL 25-1 & 267 MG PREMIER ORAL 3 elite-ob oral tablet 1 or 1b* TABLET ENBRACE HR ORAL OB COMPLETE/DHA 3 3 CAPSULE ORAL CAPSULE FOLIVANE-OB ORAL OBSTETRIX DHA ORAL 3 2 CAPSULE OBSTETRIX EC ORAL 3 inatal gt oral tablet 1 or 1b* TABLET O-CAL PRENATAL KOSHER PRENATAL 3 PLUS IRON ORAL 3 ORAL TABLET TABLET PNV FOLIC ACID + 3 MARNATAL-F ORAL IRON ORAL TABLET 3 CAPSULE PNV PRENATAL PLUS 3 M-VIT ORAL TABLET 3 MULTIVIT+DHA ORAL MYNATAL ADVANCE PNV PRENATAL PLUS 3 ORAL TABLET MULTIVITAMIN ORAL 2 TABLET MYNATAL ORAL 3 PNV TABS 29-1 ORAL CAPSULE 2 TABLET MYNATAL ORAL 3 PNV-OMEGA ORAL TABLET 3 CAPSULE MYNATAL PLUS ORAL 2 TABLET PRENA1 PEARL ORAL CAPSULE EXTENDED 3 MYNATAL-Z ORAL 2 RELEASE TABLET PRENARA ORAL 3 MYNATE 90 PLUS ORAL CAPSULE TABLET EXTENDED 2 PRENATA ORAL RELEASE 3 TABLET CHEWABLE NATACHEW ORAL TABLET CHEWABLE 28- 3 prenatabs rx oral tablet 1 or 1a* 1 MG prenatal 19 oral tablet 1 or 1a* NATALVIT ORAL PRENATAL 19 ORAL 3 3 TABLET TABLET 29-1 MG NEEVO DHA ORAL prenatal 19 oral tablet 3 1 or 1a* CAPSULE 27-1.13 MG chewable NEONATAL COMPLETE PRENATAL 19 ORAL 3 ORAL TABLET TABLET CHEWABLE 29- 3 NEONATAL PLUS ORAL 1 MG 3 TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 166 Drug Name Tier Notes Drug Name Tier Notes PRENATAL ORAL VINATE II ORAL 2 2 TABLET 27-1 MG TABLET PRENATAL PLUS IRON VINATE M ORAL 2 2 ORAL TABLET TABLET PRENATAL VITAMIN VINATE ONE ORAL 2 PLUS LOW IRON ORAL 2 TABLET TABLET VIRT-C DHA ORAL 3 PRENATAL-U ORAL CAPSULE 2 CAPSULE VIRT-NATE DHA ORAL 3 PRENATE ELITE ORAL CAPSULE 3 TABLET 20-0.6-0.4 MG VIRT-PN PLUS ORAL 3 PRENATVITE CAPSULE COMPLETE ORAL 3 VITAFOL GUMMIES TABLET ORAL TABLET 3 PRENATVITE PLUS CHEWABLE 3 ORAL TABLET VITAFOL-NANO ORAL 3 PRENATVITE RX ORAL TABLET 3 TABLET VITAFOL-OB ORAL 3 PREPLUS ORAL TABLET 2 TABLET VITAPEARL ORAL PRETAB ORAL TABLET 2 CAPSULE EXTENDED 3 PRIMACARE ORAL RELEASE 3 CAPSULE VITATHELY WITH 3 PROVIDA OB ORAL GINGER ORAL TABLET 3 CAPSULE VIVA DHA ORAL 3 RELNATE DHA ORAL CAPSULE 3 CAPSULE VOL-PLUS ORAL 2 SELECT-OB ORAL TABLET 3 TABLET CHEWABLE VOL-TAB RX ORAL 2 SE-NATAL 19 ORAL TABLET 2 TABLET VP-HEME OB + DHA 3 SE-NATAL 19 ORAL ORAL 2 TABLET CHEWABLE VP-PNV-DHA ORAL 3 TARON-C DHA ORAL CAPSULE 3 CAPSULE ZALVIT ORAL TABLET 3 THRIVITE RX ORAL ZATEAN-PN PLUS ORAL 2 3 TABLET CAPSULE TRICARE ORAL *PRENATAL MV & MIN 3 TABLET W/FE-FA-CA-OMEGA 3 TRICARE PRENATAL FISH OIL*** DHA ONE ORAL 3 COMPLETE NATAL 3 CAPSULE 27-1-500 MG DHA ORAL TRINATAL RX 1 ORAL PR NATAL 400 EC ORAL 2 2 TABLET PR NATAL 400 ORAL 2 trinate oral tablet 1 or 1a* PR NATAL 430 EC ORAL 2 TRI-TABS DHA ORAL 3 PR NATAL 430 ORAL 2 VINATE DHA RF ORAL TRIVEEN-DUO DHA 3 2 CAPSULE ORAL

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 167 Drug Name Tier Notes Drug Name Tier Notes *PRENATAL MV & MIN TRISTART DHA ORAL 3 W/FE-FA-DHA*** CAPSULE CITRANATAL 90 DHA TRISTART ONE ORAL 3 3 ORAL 90-1 & 300 MG CAPSULE CITRANATAL ASSURE VIRT-PN DHA ORAL 3 3 ORAL 35-1 & 300 MG CAPSULE CITRANATAL BLOOM VITAFOL FE+ ORAL 3 3 DHA ORAL CAPSULE CITRANATAL DHA VITAFOL ULTRA ORAL 3 3 ORAL CAPSULE CITRANATAL VITAFOL-OB+DHA 3 HARMONY ORAL 3 ORAL CAPSULE 27-1-260 MG VITAFOL-ONE ORAL 3 CITRANATAL MEDLEY CAPSULE 3 ORAL CAPSULE VITAMEDMD ONE NESTABS ONE ORAL RX/QUATREFOLIC 3 3 CAPSULE ORAL CAPSULE OBSTETRIX ONE ORAL VITATRUE ORAL 3 3 CAPSULE ZATEAN-PN DHA ORAL 3 PNV-DHA+DOCUSATE CAPSULE 3 ORAL CAPSULE *PRENATAL MV & PRENA 1 TRUE ORAL 3 MINERALS W/FA*** PRENAISSANCE ORAL PRENATE ORAL 3 3 CAPSULE TABLET CHEWABLE PRENAISSANCE PLUS *PRENATAL 3 ORAL CAPSULE VITAMINS*** PRENATAL + DHA PREMESISRX ORAL 3 2 ORAL THERAPY PACK TABLET PRENATE DHA ORAL PRENA1 ORAL TABLET 2 CAPSULE 18-0.6-0.4-300 3 CHEWABLE MG PRENATE AM ORAL 3 PRENATE ENHANCE TABLET 3 ORAL CAPSULE VITAMEDMD PRENATE ESSENTIAL REDICHEW RX ORAL 3 ORAL CAPSULE 18-0.6- 3 TABLET CHEWABLE 1.4 0.4-300 MG MG PRENATE MINI ORAL *SPECIALTY VITAMINS CAPSULE 18-0.6-0.4-350 3 PRODUCTS*** MG SUPPORT-500 ORAL 3 PRENATE PIXIE ORAL CAPSULE 3 CAPSULE urosex oral tablet 1 or 1b* PRENATE RESTORE 3 VITA-RX DIABETIC ORAL CAPSULE VITAMIN ORAL 3 R-NATAL OB ORAL CAPSULE 3 CAPSULE *VITAMINS A & D*** SELECT-OB+DHA ORAL 3 COD LIVER OIL ORAL 3 TARON-PREX ORAL OIL 3 CAPSULE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 168 Drug Name Tier Notes Drug Name Tier Notes *MUSCULAR GABLOFEN DYSTROPHY INTRATHECAL AGENTS*** SOLUTION PREFILLED *MUSCULAR SYRINGE 10000 3 DYSTROPHY MCG/20ML, 20000 AGENTS*** MCG/20ML, 40000 MCG/20ML, 50 MCG/ML EXONDYS 51 INTRAVENOUS 3 PA; QL; LD LIORESAL SOLUTION INTRATHECAL 3 SOLUTION VYONDYS 53 INTRAVENOUS 3 PA; QL; LD lorzone oral tablet 1 or 1b* ST; QL SOLUTION metaxalone oral tablet 1 or 1b* ST; QL *MUSCULOSKELETAL methocarbamol injection 1 or 1b* THERAPY AGENTS* solution 1000 mg/10ml *ARTICULAR methocarbamol oral tablet 1 or 1b* CARTILAGE REPAIR orphenadrine citrate er oral THERAPY*** tablet extended release 12 1 or 1b* CARTICEL INTRA- hour 3 ARTICULAR IMPLANT orphenadrine citrate injection 1 or 1b* *CENTRAL MUSCLE solution RELAXANTS*** OZOBAX ORAL 3 ACTIVE- SOLUTION CYCLOBENZAPRINE 3 ROBAXIN INJECTION TRANSDERMAL CREAM SOLUTION 1000 3 ST; QL AMRIX ORAL CAPSULE MG/10ML EXTENDED RELEASE 24 3 ST; QL ROBAXIN-750 ORAL 3 ST; QL HOUR TABLET baclofen intrathecal solution 1 or 1b* SKELAXIN ORAL 3 ST; QL baclofen oral tablet 1 or 1b* TABLET carisoprodol oral tablet 1 or 1b* SOMA ORAL TABLET 3 ST; QL CHLORZOXAZONE TABRADOL FUSEPAQ 1 or 1b* ST; QL 3 ORAL TABLET 250 MG ORAL SUSPENSION chlorzoxazone oral tablet 375 TABRADOL RAPIDPAQ 1 or 1b* ST; QL 3 mg, 750 mg ORAL SUSPENSION cyclobenzaprine hcl er oral tizanidine hcl oral capsule 1 or 1b* capsule extended release 24 1 or 1b* ST; QL tizanidine hcl oral tablet 1 or 1b* hour ZANAFLEX ORAL cyclobenzaprine hcl oral 3 ST; QL 1 or 1b* CAPSULE tablet ZANAFLEX ORAL 3 ST; QL CYCLOPHENE TABLET RAPIDPAQ 3 TRANSDERMAL CREAM *DIRECT MUSCLE RELAXANTS*** fexmid oral tablet 1 or 1b* ST; QL DANTRIUM FIRST-BACLOFEN INTRAVENOUS 3 3 ORAL SUSPENSION SOLUTION GABLOFEN RECONSTITUTED INTRATHECAL DANTRIUM ORAL SOLUTION 10000 3 3 CAPSULE 25 MG, 50 MG MCG/20ML, 20000 MCG/20ML, 40000 MCG/20ML * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 169 Drug Name Tier Notes Drug Name Tier Notes dantrolene sodium ORTHOVISC INTRA- intravenous solution 1 or 1b* ARTICULAR SOLUTION 3 PA; QL; SP reconstituted PREFILLED SYRINGE dantrolene sodium oral SODIUM 1 or 1b* capsule HYALURONATE INTRA- 3 PA; QL; SP revonto intravenous solution ARTICULAR SOLUTION 1 or 1b* reconstituted PREFILLED SYRINGE RYANODEX SUPARTZ FX INTRA- INTRAVENOUS ARTICULAR SOLUTION 3 PA; QL; SP 3 SUSPENSION PREFILLED SYRINGE RECONSTITUTED SYNVISC INTRA- *MUSCLE RELAXANT ARTICULAR SOLUTION 3 PA; QL; SP COMBINATIONS*** PREFILLED SYRINGE carisoprodol-aspirin oral SYNVISC ONE INTRA- 1 or 1b* tablet ARTICULAR SOLUTION 3 PA; QL; SP PREFILLED SYRINGE carisoprodol-aspirin-codeine 1 or 1b* oral tablet TRILURON INTRA- ARTICULAR SOLUTION 3 PA; QL; SP CYCLO/GABA 10/300 3 PREFILLED SYRINGE ORAL THERAPY PACK VISCO-3 INTRA- METAXALL CP 3 ARTICULAR SOLUTION 3 PA; QL; SP COMBINATION KIT PREFILLED SYRINGE orphenadrine-aspirin-caffeine 1 or 1b* *NASAL AGENTS - oral tablet 50-770-60 mg SYSTEMIC AND orphengesic forte oral tablet 1 or 1b* ST; QL TOPICAL* *VISCOSUPPLEMENTS* *ANTIHISTAMINE- ** STEROID*** azelastine-fluticasone nasal DUROLANE INTRA- 1 or 1b* ARTICULAR 3 PA; QL suspension PREFILLED SYRINGE DYMISTA NASAL 3 EUFLEXXA INTRA- SUSPENSION ARTICULAR SOLUTION 3 PA; QL; SP *NASAL PREFILLED SYRINGE ANTICHOLINERGICS*** GEL-ONE INTRA- ipratropium bromide nasal 1 or 1b* ARTICULAR 3 PA; QL; SP solution PREFILLED SYRINGE *NASAL GELSYN-3 INTRA- ANTIHISTAMINES*** ARTICULAR SOLUTION 3 PA; QL; SP PREFILLED SYRINGE azelastine hcl nasal solution 1 or 1b* HYALGAN INTRA- olopatadine hcl nasal 3 PA; QL; SP 1 or 1b* ARTICULAR SOLUTION solution PATANASE NASAL HYALGAN INTRA- 3 ARTICULAR SOLUTION 3 PA; QL; SP SOLUTION PREFILLED SYRINGE *NASAL STEROIDS*** HYMOVIS INTRA- BECONASE AQ NASAL 3 ST; QL ARTICULAR SOLUTION 3 PA; QL; LD; SP SUSPENSION PREFILLED SYRINGE flunisolide nasal solution 25 3 ST; QL; CTT1 MONOVISC INTRA- mcg/act (0.025%) ARTICULAR SOLUTION 3 PA; QL; SP mometasone furoate nasal 3 ST; QL; CTT1 PREFILLED SYRINGE suspension

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 170 Drug Name Tier Notes Drug Name Tier Notes NASONEX NASAL *NEUROMUSCULAR 3 ST; QL SUSPENSION AGENTS* OMNARIS NASAL *BENZATHIAZOLES*** 3 ST; QL SUSPENSION RILUTEK ORAL 3 SP PROPEL MINI NASAL TABLET 3 IMPLANT riluzole oral tablet 1 or 1b* SP PROPEL NASAL TIGLUTIK ORAL 3 3 LD IMPLANT SUSPENSION QNASL CHILDRENS *DEPOLARIZING NASAL AEROSOL 3 ST; QL MUSCLE SOLUTION RELAXANTS*** QNASL NASAL ANECTINE INJECTION 3 ST; QL 3 AEROSOL SOLUTION SOLUTION XHANCE NASAL QUELICIN INJECTION 3 PA; QL 3 EXHALER SUSPENSION SOLUTION ZETONNA NASAL succinylcholine chloride 3 ST; QL 1 or 1b* AEROSOL SOLUTION injection solution *TOPICAL SUCCINYLCHOLINE DECONGESTANTS*** CHLORIDE ADRENALIN NASAL INTRAVENOUS 3 3 SOLUTION SOLUTION PREFILLED *NASAL SYRINGE 140 MG/7ML ANESTHETICS*** *NEUROMUSCULAR *NASAL BLOCKING AGENT - ANESTHETICS*** NEUROTOXINS*** COCAINE HCL NASAL BOTOX INJECTION 3 SOLUTION SOLUTION 3 PA; QL; SP RECONSTITUTED GOPRELTO NASAL 3 SOLUTION DYSPORT INTRAMUSCULAR NUMBRINO NASAL 3 PA; QL; SP 3 SOLUTION SOLUTION RECONSTITUTED *NEPRILYSIN INHIB MYOBLOC (ARNI)-ANGIOTENSIN II INTRAMUSCULAR 3 PA; QL; SP RECEPT ANTAG SOLUTION COMB*** XEOMIN *NEPRILYSIN INHIB INTRAMUSCULAR 3 PA; QL; LD; SP (ARNI)-ANGIOTENSIN II SOLUTION RECEPT ANTAG RECONSTITUTED COMB*** *NONDEPOLARIZING ENTRESTO ORAL 3 PA; QL MUSCLE TABLET RELAXANTS*** *NEUROGENIC atracurium besylate ORTHOSTATIC intravenous solution 100 1 or 1b* HYPOTENSION (NOH) - mg/10ml, 50 mg/5ml AGENTS*** cisatracurium besylate (pf) 1 or 1b* *NEUROGENIC intravenous solution ORTHOSTATIC cisatracurium besylate HYPOTENSION (NOH) - 1 or 1b* AGENTS*** intravenous solution NORTHERA ORAL 3 LD; SP CAPSULE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 171 Drug Name Tier Notes Drug Name Tier Notes NIMBEX INTRAVENOUS *NUTRIENTS* SOLUTION 10 MG/5ML, 3 *AMINO ACID 20 MG/10ML, 200 MIXTURES*** MG/20ML aminoamrms oral capsule 1 or 1b* pancuronium bromide 1 or 1b* intravenous solution 1 mg/ml AMINOPROTECT INTRAVENOUS 3 rocuronium bromide 1 or 1b* SOLUTION intravenous solution aminoreliefrms oral capsule 1 or 1b* ROCURONIUM BROMIDE AMINOSYN II INTRAVENOUS 3 INTRAVENOUS 3 SOLUTION PREFILLED SOLUTION 10 %, 15 % SYRINGE 100 MG/10ML AMINOSYN-PF VECURONIUM INTRAVENOUS 3 BROMIDE SOLUTION INTRAVENOUS 3 CLINIMIX E/DEXTROSE SOLUTION PREFILLED (2.75/5) INTRAVENOUS 3 SYRINGE SOLUTION vecuronium bromide CLINIMIX E/DEXTROSE intravenous solution 1 or 1b* (4.25/10) INTRAVENOUS 3 reconstituted SOLUTION *N-METHYL-D- CLINIMIX E/DEXTROSE ASPARTIC ACID (4.25/5) INTRAVENOUS 3 (NMDA) RECEPTOR SOLUTION ANTAGONISTS*** CLINIMIX E/DEXTROSE *N-METHYL-D- (5/15) INTRAVENOUS 3 ASPARTIC ACID SOLUTION (NMDA) RECEPTOR ANTAGONISTS*** CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS 3 SPRAVATO (56 MG SOLUTION DOSE) NASAL 3 PA; QL; LD SOLUTION THERAPY CLINIMIX/DEXTROSE PACK (4.25/10) INTRAVENOUS 3 SOLUTION SPRAVATO (84 MG DOSE) NASAL CLINIMIX/DEXTROSE 3 PA; QL; LD SOLUTION THERAPY (4.25/5) INTRAVENOUS 3 PACK SOLUTION *NSAID-DIETARY CLINIMIX/DEXTROSE MANAGEMENT (5/15) INTRAVENOUS 3 COMBINATIONS*** SOLUTION *NSAID-DIETARY CLINIMIX/DEXTROSE MANAGEMENT (5/20) INTRAVENOUS 3 COMBINATIONS*** SOLUTION clinisol sf intravenous PRASTERA ORAL KIT 3 1 or 1b* solution *NSAID-VITAMINS AND/OR MINERALS FREAMINE HBC COMBINATIONS*** INTRAVENOUS 3 SOLUTION *NSAID-VITAMINS AND/OR MINERALS FREAMINE III COMBINATIONS*** INTRAVENOUS 3 SOLUTION 10 % EQUAPAX/IBUPROFEN/ hepatamine intravenous MINREX ORAL 3 1 or 1b* THERAPY PACK solution * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 172 Drug Name Tier Notes Drug Name Tier Notes NEPHRAMINE DEXTROSE INTRAVENOUS 3 INTRAVENOUS 3 SOLUTION SOLUTION 20 %, 40 % plenamine intravenous *LIPIDS*** 1 or 1b* solution CLINOLIPID PREMASOL INTRAVENOUS 3 INTRAVENOUS 3 EMULSION SOLUTION 10 % INTRALIPID PROCALAMINE INTRAVENOUS 3 INTRAVENOUS 3 EMULSION SOLUTION NEOKE MCT70 ORAL 2 PROSOL INTRAVENOUS POWDER 3 SOLUTION NUTRILIPID SYNTHAMIN 17 INTRAVENOUS 3 INTRAVENOUS 3 EMULSION 20 % SOLUTION OMEGAVEN TRAVASOL INTRAVENOUS 3 INTRAVENOUS 3 EMULSION SOLUTION SMOFLIPID TROPHAMINE INTRAVENOUS 3 INTRAVENOUS 3 EMULSION SOLUTION *LIPOTROPIC *AMINO ACIDS- COMBINATIONS*** SINGLE*** LECITHIN ORAL 3 ARGININE HCL GRANULES 3 INJECTION SOLUTION LIPO INTRAMUSCULAR 3 ELCYS INTRAVENOUS SOLUTION 3 SOLUTION LIPO-C GLUTATHIONE INTRAMUSCULAR 3 3 INJECTION SOLUTION SOLUTION GLUTATHIONE *MISC. NUTRITIONAL INTRAVENOUS 3 SUBSTANCES SOLUTION COMBINATIONS*** GLYCINE INJECTION CARDIOVID PLUS ORAL 3 3 SOLUTION CAPSULE LYSINE HCL *PROTEIN 3 INJECTION SOLUTION COMBINATIONS*** n-acetyl-l-cysteine oral TRI-AMINO INJECTION 1 or 1b* 3 capsule SOLUTION NEOKE ALCAR ORAL *ONCOLYTIC VIRAL 3 POWDER AGENTS - HSV1*** TAURINE INJECTION *ONCOLYTIC VIRAL 3 SOLUTION AGENTS - HSV1*** TRYPTOPHAN ORAL IMLYGIC 3 CAPSULE INTRALESIONAL 3 LD *CARBOHYDRATES*** SUSPENSION dextrose intravenous solution 10 %, 250 mg/ml, 30 %, 5 %, 1 or 1b* 70 %

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 173 Drug Name Tier Notes Drug Name Tier Notes *OPHTHALMIC TIMOPTIC AGENTS* OPHTHALMIC 3 *ALPHA ADRENERGIC SOLUTION AGONIST & CARBONIC TIMOPTIC-XE ANHYDRASE INHIB OPHTHALMIC GEL 3 COMB*** FORMING SOLUTION SIMBRINZA *CYCLOPLEGIC OPHTHALMIC 2 MYDRIATIC SUSPENSION COMBINATIONS*** *ARTIFICIAL TEAR CYCLOMYDRIL INSERTS*** OPHTHALMIC 3 LACRISERT SOLUTION 3 PA; QL OPHTHALMIC INSERT *CYCLOPLEGIC *BETA-BLOCKERS - MYDRIATICS*** OPHTHALMIC altafrin ophthalmic solution 1 or 1b* COMBINATIONS*** 10 %, 2.5 % COMBIGAN ATROPINE SULFATE OPHTHALMIC 2 OPHTHALMIC 3 SOLUTION SOLUTION COSOPT OPHTHALMIC CYCLOGYL 3 SOLUTION OPHTHALMIC 3 COSOPT PF SOLUTION OPHTHALMIC 3 cyclopentolate hcl 1 or 1b* SOLUTION 2-0.5 % ophthalmic solution dorzolamide hcl-timolol mal ISOPTO ATROPINE 1 or 1b* pf ophthalmic solution OPHTHALMIC 3 *BETA-BLOCKERS - SOLUTION OPHTHALMIC*** MYDRIACYL betaxolol hcl ophthalmic OPHTHALMIC 3 1 or 1b* solution SOLUTION BETIMOL phenylephrine hcl OPHTHALMIC 3 ophthalmic solution 10 %, 1 or 1b* SOLUTION 2.5 % tropicamide ophthalmic BETOPTIC-S 1 or 1b* OPHTHALMIC 2 solution SUSPENSION *MIOTICS - carteolol hcl ophthalmic CHOLINESTERASE 1 or 1a* solution INHIBITORS*** ISTALOL OPHTHALMIC PHOSPHOLINE IODIDE 3 OPHTHALMIC SOLUTION 3 SOLUTION levobunolol hcl ophthalmic 1 or 1b* RECONSTITUTED solution 0.5 % *MIOTICS - DIRECT timolol maleate ophthalmic 1 or 1b* ACTING*** gel forming solution ISOPTO CARPINE timolol maleate ophthalmic 1 or 1b* OPHTHALMIC 3 solution SOLUTION TIMOPTIC OCUDOSE MIOCHOL-E OPHTHALMIC 3 INTRAOCULAR 3 SOLUTION SOLUTION RECONSTITUTED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 174 Drug Name Tier Notes Drug Name Tier Notes MIOSTAT gatifloxacin ophthalmic 1 or 1b* INTRAOCULAR 3 solution SOLUTION gentak ophthalmic ointment 1 or 1a* pilocarpine hcl ophthalmic gentamicin sulfate 1 or 1b* 1 or 1a* solution 1 %, 2 %, 4 % ophthalmic solution *OPHTHALMIC levofloxacin ophthalmic 1 or 1b* ANTIALLERGIC*** solution ALOCRIL MITOSOL 3 OPHTHALMIC 3 ST; QL OPHTHALMIC KIT SOLUTION MOXEZA OPHTHALMIC 3 ALOMIDE SOLUTION OPHTHALMIC 3 ST; QL moxifloxacin hcl (2x day) SOLUTION 1 or 1b* ophthalmic solution azelastine hcl ophthalmic 1 or 1b* moxifloxacin hcl ophthalmic solution 1 or 1b* solution BEPREVE OPHTHALMIC 3 ST; QL OCUFLOX SOLUTION OPHTHALMIC 3 SOLUTION cromolyn sodium ophthalmic 1 or 1a* ofloxacin ophthalmic solution 1 or 1a* solution epinastine hcl ophthalmic 1 or 1b* tobramycin ophthalmic solution 1 or 1a* solution LASTACAFT TOBREX OPHTHALMIC OPHTHALMIC 3 ST; QL 3 SOLUTION OINTMENT olopatadine hcl ophthalmic TOBREX OPHTHALMIC 1 or 1b* ST; QL 3 solution SOLUTION PAZEO OPHTHALMIC VIGAMOX 3 ST; QL SOLUTION OPHTHALMIC 3 SOLUTION ZERVIATE OPHTHALMIC 3 ST; QL ZYMAXID SOLUTION OPHTHALMIC 3 SOLUTION *OPHTHALMIC ANTIBIOTICS*** *OPHTHALMIC ANTIFUNGAL*** AZASITE OPHTHALMIC 3 SOLUTION NATACYN OPHTHALMIC 3 bacitracin ophthalmic 1 or 1b* SUSPENSION ointment *OPHTHALMIC ANTI- BESIVANCE INFECTIVE OPHTHALMIC 3 COMBINATIONS*** SUSPENSION ak-poly-bac ophthalmic 1 or 1a* CILOXAN ointment OPHTHALMIC 3 OINTMENT bacitracin-polymyxin b ophthalmic ointment 500- 1 or 1a* CILOXAN 10000 unit/gm OPHTHALMIC 3 SOLUTION MOXIFLOXACIN HCL- BSS INTRAVITREAL 3 ciprofloxacin hcl ophthalmic 1 or 1a* SOLUTION solution erythromycin ophthalmic 1 or 1a* ointment * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 175 Drug Name Tier Notes Drug Name Tier Notes neomycin-bacitracin zn- fluor-i-strips a.t. ophthalmic 1 or 1b* polymyx ophthalmic 1 or 1b* strip ointment FLURA-SAFE neomycin-polymyxin- OPHTHALMIC 3 gramicidin ophthalmic 1 or 1b* SOLUTION solution 1.75-10000-.025 glostrips ophthalmic strip 1 1 or 1b* neo-polycin ophthalmic mg 1 or 1b* ointment lissamine green ophthalmic 1 or 1b* polycin ophthalmic ointment 1 or 1a* strip polymyxin b-trimethoprim PAREMYD 1 or 1a* ophthalmic solution OPHTHALMIC 3 POLYTRIM SOLUTION OPHTHALMIC 3 proparacaine-fluorescein 1 or 1b* SOLUTION ophthalmic solution *OPHTHALMIC ROSE GLO 3 ANTISEPTICS*** OPHTHALMIC STRIP BETADINE *OPHTHALMIC OPHTHALMIC PREP ENZYMES*** 3 OPHTHALMIC JETREA SOLUTION INTRAVITREAL 3 PA; QL; LD *OPHTHALMIC SOLUTION 0.375 ANTIVIRALS*** MG/0.3ML trifluridine ophthalmic *OPHTHALMIC 1 or 1b* solution IMMUNOMODULATORS ZIRGAN OPHTHALMIC *** 3 GEL CEQUA OPHTHALMIC 3 PA; QL *OPHTHALMIC SOLUTION CARBONIC RESTASIS MULTIDOSE ANHYDRASE OPHTHALMIC 3 PA; QL INHIBITORS*** EMULSION 0.05 % AZOPT OPHTHALMIC RESTASIS 2 SUSPENSION OPHTHALMIC 3 PA; QL TRUSOPT EMULSION OPHTHALMIC 3 *OPHTHALMIC SOLUTION IRRIGATION *OPHTHALMIC SOLUTIONS*** DIAGNOSTIC balanced salt intraocular 1 or 1b* PRODUCTS*** solution ak-fluor intravenous solution BSS INTRAOCULAR 1 or 1b* 3 10 % SOLUTION AK-FLUOR *OPHTHALMIC LOCAL INTRAVENOUS 3 ANESTHETICS*** SOLUTION 25 % AKTEN OPHTHALMIC 3 altafluor benox ophthalmic GEL 1 or 1b* solution ALCAINE fluorescein-benoxinate OPHTHALMIC 3 1 or 1b* ophthalmic solution SOLUTION FLUORESCITE proparacaine hcl ophthalmic 1 or 1b* INTRAVENOUS 3 solution SOLUTION tetracaine hcl ophthalmic 1 or 1b* solution * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 176 Drug Name Tier Notes Drug Name Tier Notes *OPHTHALMIC brimonidine tartrate 1 or 1b* NONSTEROIDAL ANTI- ophthalmic solution INFLAMMATORY IOPIDINE AGENTS*** OPHTHALMIC 3 ACULAR LS SOLUTION 1 % OPHTHALMIC 3 *OPHTHALMIC SOLUTION STEROID ACULAR OPHTHALMIC COMBINATIONS*** 3 SOLUTION bacitra-neomycin- ACUVAIL polymyxin-hc ophthalmic 1 or 1b* OPHTHALMIC 3 ointment SOLUTION BLEPHAMIDE bromfenac sodium (once- OPHTHALMIC 3 1 or 1b* daily) ophthalmic solution SUSPENSION BROMSITE BLEPHAMIDE S.O.P. OPHTHALMIC 3 OPHTHALMIC 3 SOLUTION OINTMENT diclofenac sodium DOUBLE PM 1 or 1b* ophthalmic solution OPHTHALMIC 3 flurbiprofen sodium SOLUTION 1 or 1b* ophthalmic solution RECONSTITUTED ILEVRO OPHTHALMIC MAXITROL 2 SUSPENSION OPHTHALMIC 3 OINTMENT ketorolac tromethamine 1 or 1b* ophthalmic solution MAXITROL OPHTHALMIC 3 NEVANAC SUSPENSION OPHTHALMIC 3 SUSPENSION neomycin-polymyxin- dexameth ophthalmic 1 or 1a* PROLENSA ointment OPHTHALMIC 3 SOLUTION neomycin-polymyxin- dexameth ophthalmic 1 or 1a* *OPHTHALMIC suspension 3.5-10000-0.1 PHOTODYNAMIC THERAPY AGENTS*** neomycin-polymyxin-hc ophthalmic suspension 3.5- 1 or 1b* VISUDYNE 10000-1 INTRAVENOUS 3 LD; SP neo-polycin hc ophthalmic SOLUTION 1 or 1b* RECONSTITUTED ointment PRED-G OPHTHALMIC *OPHTHALMIC 3 SELECTIVE ALPHA SUSPENSION ADRENERGIC PRED-G S.O.P. AGONISTS*** OPHTHALMIC 3 ALPHAGAN P OINTMENT OPHTHALMIC 2 sulfacetamide-prednisolone 1 or 1a* SOLUTION 0.1 % ophthalmic solution ALPHAGAN P TOBRADEX OPHTHALMIC 3 OPHTHALMIC 2 SOLUTION 0.15 % OINTMENT apraclonidine hcl ophthalmic TOBRADEX 1 or 1b* solution OPHTHALMIC 3 SUSPENSION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 177 Drug Name Tier Notes Drug Name Tier Notes TOBRADEX ST LOTEMAX OPHTHALMIC 3 OPHTHALMIC 3 SUSPENSION OINTMENT tobramycin-dexamethasone LOTEMAX 1 or 1b* ophthalmic suspension OPHTHALMIC 3 TRIPLE PMB SUSPENSION OPHTHALMIC LOTEMAX SM 3 3 SOLUTION OPHTHALMIC GEL RECONSTITUTED loteprednol etabonate 1 or 1b* TRIPLE PMK ophthalmic suspension OPHTHALMIC 3 MAXIDEX SOLUTION OPHTHALMIC 3 RECONSTITUTED SUSPENSION ZYLET OPHTHALMIC 2 OZURDEX SUSPENSION INTRAVITREAL 3 PA; QL; LD; SP *OPHTHALMIC IMPLANT STEROIDS*** PRED FORTE ALREX OPHTHALMIC OPHTHALMIC 3 3 SUSPENSION SUSPENSION dexamethasone sodium PRED MILD phosphate ophthalmic 1 or 1b* OPHTHALMIC 3 solution SUSPENSION DEXTENZA prednisolone acetate 3 1 or 1b* OPHTHALMIC INSERT ophthalmic suspension DEXYCU PREDNISOLONE INTRAOCULAR 3 SODIUM PHOSPHATE 3 SUSPENSION OPHTHALMIC DUREZOL SOLUTION OPHTHALMIC 2 RETISERT EMULSION INTRAVITREAL 3 PA; QL; LD; SP FLAREX OPHTHALMIC IMPLANT 3 SUSPENSION TRIESENCE fluorometholone ophthalmic INTRAOCULAR 3 1 or 1b* suspension SUSPENSION YUTIQ INTRAVITREAL FML FORTE 3 PA; QL; LD OPHTHALMIC 3 IMPLANT SUSPENSION *OPHTHALMIC FML LIQUIFILM SULFONAMIDES*** OPHTHALMIC 3 BLEPH-10 SUSPENSION OPHTHALMIC 3 FML OPHTHALMIC SOLUTION 3 OINTMENT sulfacetamide sodium 1 or 1b* ILUVIEN ophthalmic ointment INTRAVITREAL 3 PA; QL; LD; SP sulfacetamide sodium 1 or 1b* IMPLANT ophthalmic solution INVELTYS *OPHTHALMIC OPHTHALMIC 3 SURGICAL AIDS - SUSPENSION COMBINATIONS*** LOTEMAX DISCOVISC 2 OPHTHALMIC GEL INTRAOCULAR 3 SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 178 Drug Name Tier Notes Drug Name Tier Notes DUOVISC *OPHTHALMICS - 3 INTRAOCULAR KIT CYSTINOSIS AGENTS** OMIDRIA CYSTARAN INTRAOCULAR 3 OPHTHALMIC 3 PA; QL; LD SOLUTION SOLUTION VISCOAT *PROSTAGLANDINS - INTRAOCULAR 3 OPHTHALMIC*** SOLUTION bimatoprost ophthalmic 1 or 1b* *OPHTHALMIC solution SURGICAL AIDS*** LUMIGAN AMVISC INTRAOCULAR OPHTHALMIC 2 3 SOLUTION SOLUTION 0.01 % AMVISC PLUS TRAVATAN Z INTRAOCULAR 3 OPHTHALMIC 2 SOLUTION SOLUTION BIOLON INTRAOCULAR travoprost (bak free) 3 LD 1 or 1b* SOLUTION ophthalmic solution CELLUGEL VYZULTA INTRAOCULAR 3 OPHTHALMIC 3 SOLUTION SOLUTION GELFILM XALATAN 3 OPHTHALMIC FILM OPHTHALMIC 3 HEALON GV SOLUTION INTRAOCULAR 3 XELPROS SOLUTION OPHTHALMIC 3 HEALON EMULSION INTRAOCULAR 3 ZIOPTAN OPHTHALMIC 3 SOLUTION SOLUTION HEALON PRO *VASCULAR INTRAOCULAR 3 ENDOTHELIAL SOLUTION GROWTH FACTOR HEALON5 (VEGF) INTRAOCULAR 3 ANTAGONISTS*** SOLUTION BEOVU INTRAVITREAL 3 PA; QL; LD; SP HEALON5 PRO SOLUTION INTRAOCULAR 3 EYLEA INTRAVITREAL 3 PA; QL; LD; SP SOLUTION SOLUTION MEMBRANEBLUE EYLEA INTRAVITREAL OPHTHALMIC 3 SOLUTION PREFILLED 3 PA; QL; LD SOLUTION SYRINGE ocucoat viscoadherent LUCENTIS 1 or 1b* intraocular solution INTRAVITREAL 3 PA; QL; LD; SP PROVISC SOLUTION INTRAOCULAR 3 LUCENTIS SOLUTION INTRAVITREAL 3 PA; QL; LD; SP VISIONBLUE SOLUTION PREFILLED OPHTHALMIC 3 SYRINGE SOLUTION MACUGEN INTRAOCULAR 3 PA; QL; LD; SP SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 179 Drug Name Tier Notes Drug Name Tier Notes *OPHTHALMIC KINASE *OTIC AGENTS* INHIBITORS - *OTIC AGENTS - COMBINATIONS*** MISCELLANEOUS*** *OPHTHALMIC KINASE acetic acid otic solution 1 or 1b* INHIBITORS - COMBINATIONS*** *OTIC ANALGESIC COMBINATIONS*** ROCKLATAN OPHTHALMIC 3 cortic-nd otic solution 1 or 1b* SOLUTION OTICIN HC NR OTIC 3 *OPHTHALMIC NERVE SOLUTION GROWTH FACTORS*** PRAMOTIC OTIC 3 *OPHTHALMIC NERVE LIQUID GROWTH FACTORS*** *OTIC ANTI- OXERVATE INFECTIVES*** OPHTHALMIC 3 PA; QL; LD CETRAXAL OTIC 3 SOLUTION SOLUTION *OPHTHALMIC ciprofloxacin hcl otic 1 or 1b* PHOTOENHANCER solution COMBINATIONS*** ofloxacin otic solution 1 or 1b* *OPHTHALMIC PHOTOENHANCER OTIPRIO COMBINATIONS*** INTRATYMPANIC 3 SUSPENSION PHOTREXA VISCOUS *OTIC STEROID-ANTI- OPHTHALMIC 3 INFECTIVE SOLUTION PREFILLED COMBINATIONS*** SYRINGE CIPRO HC OTIC PHOTREXA-PHOTREXA 3 VISCOUS KIT SUSPENSION OPHTHALMIC 3 CIPRODEX OTIC 2 SOLUTION PREFILLED SUSPENSION SYRINGE ciprofloxacin-fluocinolone pf 1 or 1b* *OPHTHALMIC RHO otic solution KINASE INHIBITORS*** COLY-MYCIN S OTIC 3 *OPHTHALMIC RHO SUSPENSION KINASE INHIBITORS*** CORTISPORIN-TC OTIC 3 RHOPRESSA SUSPENSION OPHTHALMIC 3 neomycin-polymyxin-hc otic 1 or 1b* SOLUTION solution *OPIOID ANTAGONIST neomycin-polymyxin-hc otic 1 or 1b* COMBINATIONS*** suspension *OPIOID ANTAGONIST OTOVEL OTIC 2 COMBINATIONS*** SOLUTION NALTREXONE *OTIC STEROIDS*** SUBCUTANEOUS 3 IMPLANT DERMOTIC OTIC OIL 3 *OREXIN RECEPTOR flac otic oil 1 or 1b* ANTAGONISTS*** fluocinolone acetonide otic 1 or 1b* *OREXIN RECEPTOR oil ANTAGONISTS*** hydrocortisone-acetic acid 1 or 1b* BELSOMRA ORAL otic solution 3 ST; QL TABLET

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 180 Drug Name Tier Notes Drug Name Tier Notes *OXABOROLE- *PA ENDONUCLEASE RELATED INHIBITORS*** ANTIFUNGALS - *PA ENDONUCLEASE TOPICAL*** INHIBITORS*** *OXABOROLE- XOFLUZA (40 MG DOSE) RELATED ORAL TABLET 3 ANTIFUNGALS - THERAPY PACK TOPICAL*** XOFLUZA (80 MG DOSE) KERYDIN EXTERNAL 3 ST; QL ORAL TABLET 3 SOLUTION THERAPY PACK *OXYTOCICS* *PASSIVE IMMUNIZING *ABORTIFACIENTS/CER AGENTS - VICAL RIPENING - COMBINATIONS*** PROSTAGLANDINS*** *PASSIVE IMMUNIZING carboprost tromethamine AGENTS - 1 or 1b* intramuscular solution COMBINATIONS*** CERVIDIL VAGINAL HYQVIA 3 3 PA; QL; SP INSERT SUBCUTANEOUS KIT HEMABATE *PASSIVE IMMUNIZING INTRAMUSCULAR 3 AGENTS* SOLUTION *ANTITOXINS- PREPIDIL VAGINAL ANTIVENINS*** 3 GEL ANASCORP PROSTIN E2 VAGINAL INTRAVENOUS 3 3 SUPPOSITORY SOLUTION *OXYTOCICS*** RECONSTITUTED methergine oral tablet 1 or 1b* ANAVIP INTRAVENOUS SOLUTION 3 methylergonovine maleate 1 or 1b* RECONSTITUTED injection solution ANTIVENIN methylergonovine maleate LATRODECTUS 1 or 1b* 3 oral tablet MACTANS INJECTION oxytocin injection solution 1 or 1b* KIT OXYTOCIN-LACTATED ANTIVENIN MICRURUS RINGERS FULVIUS INTRAVENOUS 3 INTRAVENOUS 3 SOLUTION 20 UNIT/L, 30 SOLUTION UNIT/500ML RECONSTITUTED OXYTOCIN-SODIUM CROFAB INTRAVENOUS CHLORIDE SOLUTION 3 INTRAVENOUS RECONSTITUTED 3 SOLUTION 15-0.9 *ANTIVIRAL UT/250ML-%, 30-0.9 MONOCLONAL UT/500ML-% ANTIBODIES*** PITOCIN INJECTION 3 SYNAGIS SOLUTION INTRAMUSCULAR 3 PA; QL; SP SOLUTION *IMMUNE SERUMS*** ASCENIV INTRAVENOUS 3 PA; QL; LD; SP SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 181 Drug Name Tier Notes Drug Name Tier Notes BIVIGAM HIZENTRA INTRAVENOUS 3 PA; QL; SP SUBCUTANEOUS SOLUTION 5 GM/50ML SOLUTION 1 GM/5ML, 10 3 PA; QL; LD; SP CARIMUNE NF GM/50ML, 2 GM/10ML, 4 INTRAVENOUS GM/20ML SOLUTION 3 PA; QL; SP HIZENTRA RECONSTITUTED 12 SUBCUTANEOUS 3 PA; QL GM, 6 GM SOLUTION PREFILLED CUTAQUIG SYRINGE SUBCUTANEOUS 3 PA; QL; LD HYPERHEP B S/D SOLUTION INTRAMUSCULAR 3 SP CUVITRU SOLUTION SUBCUTANEOUS 3 PA; QL; SP HYPERRAB INJECTION SOLUTION SOLUTION 1500 3 SP CYTOGAM UNIT/5ML, 300 UNIT/ML INTRAVENOUS 3 SP HYPERRAB INJECTION INJECTABLE SOLUTION 900 3 FLEBOGAMMA DIF UNIT/3ML INTRAVENOUS 3 PA; QL; SP HYPERRAB S/D 3 SP SOLUTION INJECTION SOLUTION GAMASTAN HYPERRHO S/D INTRAMUSCULAR 3 PA; QL; SP INTRAMUSCULAR 3 SP INJECTABLE SOLUTION PREFILLED GAMASTAN S/D SYRINGE INTRAMUSCULAR 3 PA; QL; SP HYPERTET S/D INJECTABLE INTRAMUSCULAR 3 GAMMAGARD INJECTABLE 3 PA; QL; SP INJECTION SOLUTION IMOGAM RABIES-HT 3 SP GAMMAGARD S/D LESS INJECTION SOLUTION IGA INTRAVENOUS KEDRAB INJECTION 3 PA; QL; SP 3 SP SOLUTION SOLUTION RECONSTITUTED MICRHOGAM ULTRA- GAMMAKED FILTERED PLUS INJECTION SOLUTION 1 INTRAMUSCULAR 3 SP GM/10ML, 10 GM/100ML, 3 PA; QL; SP SOLUTION PREFILLED 20 GM/200ML, 5 SYRINGE GM/50ML NABI-HB GAMMAPLEX INTRAMUSCULAR 3 SP INTRAVENOUS SOLUTION SOLUTION 10 OCTAGAM GM/100ML, 10 3 PA; QL; LD; SP INTRAVENOUS GM/200ML, 20 SOLUTION 1 GM/20ML, GM/200ML, 20 10 GM/100ML, 10 GM/400ML, 5 GM/100ML, GM/200ML, 2 GM/20ML, 3 PA; QL; SP 5 GM/50ML 2.5 GM/50ML, 20 GAMUNEX-C GM/200ML, 25 3 PA; QL; SP INJECTION SOLUTION GM/500ML, 5 GM/100ML, HEPAGAM B 5 GM/50ML 3 SP INJECTION SOLUTION OCTAGAM INTRAVENOUS 3 PA; QL SOLUTION 30 GM/300ML

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 182 Drug Name Tier Notes Drug Name Tier Notes PANZYGA *PENICILLINS* INTRAVENOUS 3 PA; QL; SP *AMINOPENICILLINS** SOLUTION * PRIVIGEN amoxicillin oral capsule 1 or 1a* INTRAVENOUS 3 PA; QL; SP amoxicillin oral suspension SOLUTION 1 or 1a* reconstituted RHOGAM ULTRA- FILTERED PLUS amoxicillin oral tablet 1 or 1a* INTRAMUSCULAR 3 SP amoxicillin oral tablet 1 or 1a* SOLUTION PREFILLED chewable 125 mg, 250 mg SYRINGE ampicillin oral capsule 500 1 or 1a* RHOPHYLAC mg INJECTION SOLUTION 3 SP PREFILLED SYRINGE ampicillin sodium injection solution reconstituted 1 gm, 1 or 1b* VARIZIG 125 mg, 2 gm, 250 mg, 500 INTRAMUSCULAR 3 mg SOLUTION ampicillin sodium WINRHO SDF 3 SP intravenous solution 1 or 1b* INJECTION SOLUTION reconstituted XEMBIFY *NATURAL SUBCUTANEOUS 3 PA; QL; LD PENICILLINS*** SOLUTION BICILLIN L-A *PCSK9 INHIBITORS*** INTRAMUSCULAR 3 *PCSK9 INHIBITORS*** SUSPENSION PRALUENT PENICILLIN G POT IN SUBCUTANEOUS DEXTROSE 3 PA; QL 3 SOLUTION AUTO- INTRAVENOUS INJECTOR SOLUTION REPATHA penicillin g potassium PUSHTRONEX SYSTEM injection solution 1 or 1b* 3 PA; QL SUBCUTANEOUS reconstituted SOLUTION CARTRIDGE PENICILLIN G PROCAINE REPATHA 3 SUBCUTANEOUS INTRAMUSCULAR 3 PA; QL SOLUTION PREFILLED SUSPENSION SYRINGE penicillin g sodium injection 1 or 1b* REPATHA SURECLICK solution reconstituted SUBCUTANEOUS penicillin v potassium oral 3 PA; QL 1 or 1b* SOLUTION AUTO- solution reconstituted INJECTOR penicillin v potassium oral 1 or 1b* *PEDIATRIC MULTIPLE tablet VITAMINS & MINERALS pfizerpen injection solution W/ FLUORIDE*** 1 or 1b* reconstituted *PEDIATRIC MULTIPLE VITAMINS & MINERALS *PENICILLIN W/ FLUORIDE*** COMBINATIONS*** FLORIVA ORAL amoxicillin-pot clavulanate 3 TABLET CHEWABLE er oral tablet extended 1 or 1b* release 12 hour amoxicillin-pot clavulanate 1 or 1b* oral suspension reconstituted

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 183 Drug Name Tier Notes Drug Name Tier Notes amoxicillin-pot clavulanate nafcillin sodium injection 1 or 1b* oral tablet solution reconstituted 1 gm, 1 or 1b* amoxicillin-pot clavulanate 2 gm 1 or 1b* oral tablet chewable NAFCILLIN SODIUM ampicillin-sulbactam sodium INJECTION SOLUTION 3 injection solution RECONSTITUTED 10 GM 1 or 1b* reconstituted 1.5 (1-0.5) gm, nafcillin sodium intravenous 1 or 1b* 3 (2-1) gm solution reconstituted ampicillin-sulbactam sodium OXACILLIN SODIUM IN intravenous solution 1 or 1b* DEXTROSE 3 reconstituted INTRAVENOUS AUGMENTIN ES-600 SOLUTION ORAL SUSPENSION 3 oxacillin sodium injection RECONSTITUTED solution reconstituted 1 gm, 1 or 1b* AUGMENTIN ORAL 2 gm SUSPENSION oxacillin sodium intravenous 2 1 or 1b* RECONSTITUTED 125- solution reconstituted 31.25 MG/5ML *PERITONEAL AUGMENTIN ORAL DIALYSIS SUSPENSION SOLUTIONS*** 3 RECONSTITUTED 250- *PERITONEAL 62.5 MG/5ML DIALYSIS AUGMENTIN ORAL SOLUTIONS*** 3 TABLET 500-125 MG DELFLEX-LC/1.5% BICILLIN C-R 900/300 DEXTROSE 3 INTRAMUSCULAR 3 INTRAPERITONEAL SUSPENSION SOLUTION 344 MOSM/L BICILLIN C-R DELFLEX-LC/2.5% INTRAMUSCULAR 3 DEXTROSE 3 SUSPENSION INTRAPERITONEAL piperacillin sod-tazobactam SOLUTION so intravenous solution 1 or 1b* DELFLEX-LC/4.25% reconstituted DEXTROSE 3 UNASYN INJECTION INTRAPERITONEAL SOLUTION SOLUTION 3 RECONSTITUTED 1.5 (1- DELFLEX-SM/1.5% 0.5) GM, 3 (2-1) GM DEXTROSE 2 UNASYN INTRAVENOUS INTRAPERITONEAL SOLUTION SOLUTION 3 RECONSTITUTED 15 (10- DELFLEX-SM/2.5% 5) GM DEXTROSE 3 ZOSYN INTRAVENOUS INTRAPERITONEAL 3 SOLUTION SOLUTION *PENICILLINASE- DIANEAL LOW CALCIUM/1.5% DEX RESISTANT 3 PENICILLINS*** INTRAPERITONEAL SOLUTION dicloxacillin sodium oral 1 or 1b* capsule DIANEAL LOW CALCIUM/2.5% DEX 3 NAFCILLIN SODIUM IN INTRAPERITONEAL DEXTROSE 3 SOLUTION INTRAVENOUS SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 184 Drug Name Tier Notes Drug Name Tier Notes DIANEAL LOW COPIKTRA ORAL 3 PA; QL; LD CALCIUM/4.25% DEX CAPSULE 3 INTRAPERITONEAL PIQRAY (200 MG DAILY SOLUTION DOSE) ORAL TABLET 3 PA; QL; SP DIANEAL PD-2/1.5% THERAPY PACK DEXTROSE 3 PIQRAY (250 MG DAILY INTRAPERITONEAL DOSE) ORAL TABLET 3 PA; QL; SP SOLUTION THERAPY PACK DIANEAL PD-2/2.5% PIQRAY (300 MG DAILY DEXTROSE 3 DOSE) ORAL TABLET 3 PA; QL; SP INTRAPERITONEAL THERAPY PACK SOLUTION ZYDELIG ORAL 3 PA; QL; LD; SP DIANEAL PD-2/4.25% TABLET DEXTROSE 3 INTRAPERITONEAL *PHOSPHODIESTERASE SOLUTION 4 (PDE4) INHIBITORS - TOPICAL*** EXTRANEAL INTRAPERITONEAL 3 *PHOSPHODIESTERASE SOLUTION 4 (PDE4) INHIBITORS - TOPICAL*** ULTRABAG/DIANEAL PD-2/1.5% DEX EUCRISA EXTERNAL 3 3 ST; QL INTRAPERITONEAL OINTMENT SOLUTION *PHOSPHODIESTERASE ULTRABAG/DIANEAL 4 (PDE4) INHIBITORS*** PD-2/2.5% DEX 3 *PHOSPHODIESTERASE INTRAPERITONEAL 4 (PDE4) INHIBITORS*** SOLUTION OTEZLA ORAL TABLET 3 PA; QL; SP ULTRABAG/DIANEAL PD-2/4.25%DEX OTEZLA ORAL TABLET 3 3 PA; QL; SP INTRAPERITONEAL THERAPY PACK SOLUTION *PLASMA KALLIKREIN INHIBITORS - ULTRABAG/DIANEAL/1. MONOCLONAL 5% DEXTROSE 3 ANTIBODIES*** INTRAPERITONEAL SOLUTION *PLASMA KALLIKREIN INHIBITORS - ULTRABAG/DIANEAL/2. MONOCLONAL 5% DEXTROSE 3 ANTIBODIES*** INTRAPERITONEAL SOLUTION TAKHZYRO ULTRABAG/DIANEAL/4. SUBCUTANEOUS 3 PA; QL; LD; SP 25% DEX SOLUTION 3 INTRAPERITONEAL *PLEUROMUTILINS*** SOLUTION *PLEUROMUTILINS*** *PHOSPHATIDYLINOSI XENLETA TOL 3-KINASE (PI3K) INTRAVENOUS 3 LD INHIBITORS*** SOLUTION *PHOSPHATIDYLINOSI XENLETA ORAL 3 PA; QL; LD TOL 3-KINASE (PI3K) TABLET INHIBITORS*** ALIQOPA INTRAVENOUS 3 PA; QL; LD SOLUTION RECONSTITUTED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 185 Drug Name Tier Notes Drug Name Tier Notes *POLY (ADP-RIBOSE) GRALISE STARTER 2 PA; QL POLYMERASE (PARP) ORAL INHIBITORS** LYRICA CR ORAL *POLY (ADP-RIBOSE) TABLET EXTENDED 3 PA; DO; QL POLYMERASE (PARP) RELEASE 24 HOUR 165 INHIBITORS** MG, 82.5 MG LYNPARZA ORAL LYRICA CR ORAL 3 PA; QL; LD; SP TABLET TABLET EXTENDED 3 PA; QL RUBRACA ORAL RELEASE 24 HOUR 330 3 PA; QL; LD; SP TABLET MG TALZENNA ORAL *POSTHERPETIC 3 PA; QL; LD; SP CAPSULE NEURALGIA(PHN)/NEU ROPATHIC PAIN COMB ZEJULA ORAL 3 PA; QL; LD AGENTS*** CAPSULE *POSTHERPETIC *POLY (ADP-RIBOSE) NEURALGIA(PHN)/NEU POLYMERASE (PARP) ROPATHIC PAIN COMB INHIBITORS*** AGENTS*** *POLY (ADP-RIBOSE) CONVENIENCE PAK POLYMERASE (PARP) COMBINATION 3 INHIBITORS*** THERAPY PACK LYNPARZA ORAL 3 PA; QL; LD; SP *POTASSIUM TABLET REMOVING AGENTS*** RUBRACA ORAL 3 PA; QL; LD; SP *POTASSIUM TABLET REMOVING AGENTS*** TALZENNA ORAL 3 PA; QL; LD; SP kionex oral suspension 1 or 1b* CAPSULE LOKELMA ORAL ZEJULA ORAL 3 3 PA; QL; LD PACKET CAPSULE sodium polystyrene sulfonate 1 or 1b* *POSTHERPETIC oral powder NEURALGIA (PHN) sodium polystyrene sulfonate COMBINATION 1 or 1b* AGENTS*** oral suspension sodium polystyrene sulfonate *POSTHERPETIC 1 or 1b* NEURALGIA (PHN) rectal suspension COMBINATION sps oral suspension 1 or 1b* AGENTS*** VELTASSA ORAL 3 LD CONVENIENCE PAK PACKET COMBINATION 3 *PRENATAL MV & THERAPY PACK MINERALS W/FA *POSTHERPETIC WITHOUT IRON*** NEURALGIA *PRENATAL MV & (PHN)/NEUROPATHIC MINERALS W/FA PAIN AGENTS*** WITHOUT IRON*** *POSTHERPETIC PRENATE ORAL 3 NEURALGIA TABLET CHEWABLE (PHN)/NEUROPATHIC PAIN AGENTS*** *PROGESTINS* GRALISE ORAL *PROGESTINS*** 2 PA; DO; QL TABLET 300 MG AYGESTIN ORAL 3 GRALISE ORAL TABLET 2 PA; QL TABLET 600 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 186 Drug Name Tier Notes Drug Name Tier Notes EC-RX PROGESTERONE *PROTEIN- 3 TRANSDERMAL CREAM CARBOHYDRATE-LIPID hydroxyprogesterone WITH ELECTROLYTE 1 or 1b* PA; QL; SP caproate intramuscular oil COMBINATIONS*** MAKENA *PROTEIN- 3 PA; QL; LD; SP INTRAMUSCULAR OIL CARBOHYDRATE-LIPID WITH ELECTROLYTE MAKENA COMBINATIONS*** SUBCUTANEOUS 3 PA; QL; LD; SP SOLUTION AUTO- KABIVEN INJECTOR INTRAVENOUS 3 EMULSION medroxyprogesterone acetate 1 or 1a* oral tablet PERIKABIVEN INTRAVENOUS 3 MEGACE ES ORAL 3 EMULSION SUSPENSION *PSYCHOTHERAPEUTI megestrol acetate oral 1 or 1b* C AND NEUROLOGICAL suspension 625 mg/5ml AGENTS - MISC.* norethindrone acetate oral 1 or 1b* *ALCOHOL tablet DETERRENTS*** PROGESTERONE acamprosate calcium oral 1 or 1b* COMPOUNDING KIT 3 tablet delayed release TRANSDERMAL CREAM ANTABUSE ORAL progesterone intramuscular 3 1 or 1b* TABLET oil disulfiram oral tablet 1 or 1b* progesterone micronized oral 1 or 1b* capsule *ANTI-CATAPLECTIC AGENTS*** PROGESTERONE XYREM ORAL MICRONIZED 3 3 PA; QL; LD TRANSDERMAL CREAM SOLUTION PROMETRIUM ORAL *BENZODIAZEPINES & 3 CAPSULE TRICYCLIC AGENTS*** PROVERA ORAL chlordiazepoxide- 3 1 or 1b* TABLET amitriptyline oral tablet *PROTEASE- *CHOLINOMIMETICS - ACTIVATED ACHE INHIBITORS*** RECEPTOR-1 (PAR-1) ARICEPT ORAL 3 ANTAGONISTS*** TABLET *PROTEASE- donepezil hcl oral tablet 1 or 1b* ACTIVATED donepezil hcl oral tablet 1 or 1b* RECEPTOR-1 (PAR-1) dispersible ANTAGONISTS*** EXELON ZONTIVITY ORAL 3 PA; QL TRANSDERMAL PATCH 3 ST; QL TABLET 24 HOUR galantamine hydrobromide er oral capsule extended release 1 or 1b* 24 hour galantamine hydrobromide 1 or 1b* oral solution galantamine hydrobromide 1 or 1b* oral tablet

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 187 Drug Name Tier Notes Drug Name Tier Notes RAZADYNE ER ORAL PLEGRIDY STARTER CAPSULE EXTENDED 3 PACK SUBCUTANEOUS 3 PA; QL; LD; SP RELEASE 24 HOUR SOLUTION PEN- RAZADYNE ORAL INJECTOR 3 TABLET 4 MG PLEGRIDY STARTER rivastigmine tartrate oral PACK SUBCUTANEOUS 1 or 1b* 3 PA; QL; LD; SP capsule SOLUTION PREFILLED SYRINGE rivastigmine transdermal 1 or 1b* patch 24 hour PLEGRIDY SUBCUTANEOUS 3 PA; QL; LD; SP *FIBROMYALGIA SOLUTION PEN- AGENT - SNRIS*** INJECTOR SAVELLA ORAL 2 PLEGRIDY TABLET SUBCUTANEOUS 3 PA; QL; LD; SP SAVELLA TITRATION SOLUTION PREFILLED 2 PACK ORAL SYRINGE *MOVEMENT REBIF REBIDOSE SUBCUTANEOUS DISORDER DRUG 3 PA; QL; SP THERAPY*** SOLUTION AUTO- INJECTOR AUSTEDO ORAL 3 PA; QL; SP TABLET REBIF REBIDOSE TITRATION PACK INGREZZA ORAL 3 PA; DO; QL; LD SUBCUTANEOUS 3 PA; QL; SP CAPSULE 40 MG SOLUTION AUTO- INGREZZA ORAL INJECTOR 3 PA; QL; LD CAPSULE 80 MG REBIF SUBCUTANEOUS INGREZZA ORAL SOLUTION PREFILLED 3 PA; QL; SP CAPSULE THERAPY 3 PA; QL; LD SYRINGE PACK REBIF TITRATION tetrabenazine oral tablet 1 or 1b* PA; QL; SP PACK SUBCUTANEOUS 3 PA; QL; SP XENAZINE ORAL SOLUTION PREFILLED 3 PA; QL; LD; SP TABLET SYRINGE *MS AGENTS - *MULTIPLE SCLEROSIS PYRIMIDINE AGENTS - SYNTHESIS MONOCLONAL INHIBITORS*** ANTIBODIES*** AUBAGIO ORAL LEMTRADA 3 PA; QL; LD; SP TABLET INTRAVENOUS 3 PA; QL; LD; SP SOLUTION *MULTIPLE SCLEROSIS AGENTS - TYSABRI INTERFERONS*** INTRAVENOUS 3 PA; QL; LD; SP CONCENTRATE AVONEX PEN INTRAMUSCULAR 3 PA; QL; SP *MULTIPLE SCLEROSIS AUTO-INJECTOR KIT AGENTS - NRF2 PATHWAY AVONEX PREFILLED ACTIVATORS*** INTRAMUSCULAR 3 PA; QL; SP PREFILLED SYRINGE TECFIDERA ORAL 3 PA; QL; LD; SP KIT TECFIDERA ORAL BETASERON CAPSULE DELAYED 3 PA; QL; LD; SP 3 PA; QL; SP SUBCUTANEOUS KIT RELEASE EXTAVIA VUMERITY (STARTER) 3 PA; QL; SP SUBCUTANEOUS KIT ORAL CAPSULE 3 PA; QL; LD; SP DELAYED RELEASE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 188 Drug Name Tier Notes Drug Name Tier Notes VUMERITY ORAL *POSTHERPETIC CAPSULE DELAYED 3 PA; QL; LD; SP NEURALGIA (PHN) RELEASE AGENTS*** *MULTIPLE SCLEROSIS GRALISE ORAL 2 PA; DO; QL AGENTS - POTASSIUM TABLET 300 MG CHANNEL GRALISE ORAL 2 PA; QL BLOCKERS*** TABLET 600 MG AMPYRA ORAL TABLET GRALISE STARTER 2 PA; QL EXTENDED RELEASE 12 3 PA; QL; LD; SP ORAL HOUR LYRICA CR ORAL dalfampridine er oral tablet TABLET EXTENDED 1 or 1b* PA; QL; SP 3 PA; DO; QL extended release 12 hour RELEASE 24 HOUR 165 *MULTIPLE SCLEROSIS MG, 82.5 MG AGENTS*** LYRICA CR ORAL COPAXONE TABLET EXTENDED 3 PA; QL SUBCUTANEOUS RELEASE 24 HOUR 330 3 PA; QL; SP SOLUTION PREFILLED MG SYRINGE *PREMENSTRUAL glatiramer acetate DYSPHORIC DISORDER subcutaneous solution 3 PA; QL; CTT1; SP (PMDD) AGENTS - prefilled syringe SSRIS*** glatopa subcutaneous fluoxetine hcl (pmdd) oral 3 PA; QL; CTT1; SP 1 or 1b* DO solution prefilled syringe tablet 10 mg *N-METHYL-D- fluoxetine hcl (pmdd) oral 1 or 1b* ASPARTATE (NMDA) tablet 20 mg RECEPTOR SARAFEM ORAL 3 DO ANTAGONISTS*** TABLET 10 MG memantine hcl er oral SARAFEM ORAL 3 capsule extended release 24 1 or 1b* TABLET 20 MG hour *PSEUDOBULBAR memantine hcl oral solution 1 or 1b* AFFECT AGENT memantine hcl oral tablet 1 or 1b* COMBINATIONS*** NAMENDA ORAL NUEDEXTA ORAL 3 3 PA; QL TABLET CAPSULE NAMENDA TITRATION *PSYCHOTHERAPEUTI 3 PAK ORAL TABLET C AND NEUROLOGICAL NAMENDA XR ORAL AGENTS - MISC.*** CAPSULE EXTENDED 3 ergoloid mesylates oral tablet 1 or 1b* RELEASE 24 HOUR pimozide oral tablet 1 or 1b* NAMENDA XR *RESTLESS LEG TITRATION PACK SYNDROME (RLS) ORAL CAPSULE 2 AGENTS*** EXTENDED RELEASE 24 HOUR HORIZANT ORAL TABLET EXTENDED 3 PA; QL *PHENOTHIAZINES & RELEASE TRICYCLIC AGENTS*** *SMOKING perphenazine-amitriptyline 1 or 1b* DETERRENTS*** oral tablet bupropion hcl er (smoking det) oral tablet extended 1 or 1b* PA; QL; $0 release 12 hour

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 189 Drug Name Tier Notes Drug Name Tier Notes CHANTIX CONTINUING *PULMONARY MONTH PAK ORAL 3 PA; QL; $0 HYPERTENSION - TABLET PROSTACYCLIN CHANTIX ORAL RECEPTOR 3 PA; QL; $0 TABLET AGONIST*** CHANTIX STARTING *PULMONARY MONTH PAK ORAL 3 PA; QL; $0 HYPERTENSION - TABLET PROSTACYCLIN RECEPTOR NICOTROL 3 PA; QL; $0 AGONIST*** INHALATION INHALER UPTRAVI ORAL NICOTROL NS NASAL 3 PA; QL; LD; SP 3 PA; QL; $0 TABLET SOLUTION UPTRAVI ORAL *SPHINGOSINE 1- TABLET THERAPY 3 PA; QL; LD; SP PHOSPHATE (S1P) PACK RECEPTOR MODULATORS*** *RESPIRATORY AGENTS - MISC.* GILENYA ORAL 3 PA; QL; SP CAPSULE 0.5 MG *ALPHA-PROTEINASE INHIBITOR (HUMAN)*** MAYZENT ORAL 3 PA; QL; LD; SP TABLET ARALAST NP INTRAVENOUS *THIENBENZODIAZEPI SOLUTION 3 PA; QL; LD; SP NES & SSRIS*** RECONSTITUTED 1000 olanzapine-fluoxetine hcl MG, 500 MG 1 or 1b* oral capsule GLASSIA SYMBYAX ORAL INTRAVENOUS 3 PA; QL; LD; SP CAPSULE 12-50 MG, 3-25 3 SOLUTION MG, 6-25 MG, 6-50 MG PROLASTIN-C *VASOMOTOR INTRAVENOUS 3 PA; QL; LD SYMPTOM AGENTS - SOLUTION SSRIS*** PROLASTIN-C BRISDELLE ORAL INTRAVENOUS 3 CAPSULE SOLUTION 3 PA; QL; LD RECONSTITUTED 1000 paroxetine mesylate oral 1 or 1b* MG capsule ZEMAIRA *PULMONARY INTRAVENOUS FIBROSIS AGENTS - 3 PA; QL; LD; SP SOLUTION KINASE INHIBITORS*** RECONSTITUTED *PULMONARY *CFTR FIBROSIS AGENTS - POTENTIATORS*** KINASE INHIBITORS*** KALYDECO ORAL 3 PA; QL; LD OFEV ORAL CAPSULE 3 PA; QL; LD; SP PACKET *PULMONARY KALYDECO ORAL FIBROSIS AGENTS*** 3 PA; QL; LD TABLET *PULMONARY *HYDROLYTIC FIBROSIS AGENTS*** ENZYMES*** ESBRIET ORAL 3 PA; QL; LD; SP PULMOZYME CAPSULE INHALATION 3 SP ESBRIET ORAL TABLET 3 PA; QL; LD; SP SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 190 Drug Name Tier Notes Drug Name Tier Notes *PLEURAL *SELECTIVE SCLEROSING SEROTONIN AGONISTS AGENTS*** 5-HT(1F)*** SCLEROSOL *SELECTIVE INTRAPLEURAL SEROTONIN AGONISTS 3 INTRAPLEURAL 5-HT(1F)*** AEROSOL POWDER REYVOW ORAL 3 ST; QL STERILE TALC TABLET POWDER *SEPTAL AGENTS - INTRAPLEURAL 3 ABLATION** SUSPENSION RECONSTITUTED *SEPTAL AGENTS - ABLATION** STERITALC ABLYSINOL INTRA- INTRAPLEURAL 3 3 POWDER ARTERIAL SOLUTION *RESPIRATORY *SEROTONIN 1A AGENTS - MISC.*** RECEPT AGONIST/SEROTONIN CUROSURF 2A RECEPT ANTAG*** INTRATRACHEAL 3 SUSPENSION 120 *SEROTONIN 1A MG/1.5ML, 240 MG/3ML RECEPT AGONIST/SEROTONIN INFASURF 2A RECEPT ANTAG*** INTRATRACHEAL 3 SUSPENSION ADDYI ORAL TABLET 3 PA; QL SURVANTA *SEROTONIN INTRATRACHEAL 3 MODULATORS*** SUSPENSION *SEROTONIN *SCLEROSTIN MODULATORS*** INHIBITORS*** nefazodone hcl oral tablet 1 or 1b* *SCLEROSTIN trazodone hcl oral tablet 1 or 1a* INHIBITORS*** TRINTELLIX ORAL 3 ST; DO; QL EVENITY TABLET 10 MG, 5 MG SUBCUTANEOUS 3 PA; QL; SP TRINTELLIX ORAL SOLUTION PREFILLED 3 ST; QL SYRINGE TABLET 20 MG VIIBRYD ORAL TABLET *SEBORRHEIC 3 ST; DO; QL KERATOSIS 10 MG, 20 MG PRODUCTS** VIIBRYD ORAL TABLET 3 ST; QL *SEBORRHEIC 40 MG KERATOSIS VIIBRYD STARTER 3 ST; QL PRODUCTS** PACK ORAL KIT ESKATA EXTERNAL *SGLT2 INHIBITOR - 3 SOLUTION DPP-4 INHIBITOR - *SELECTIN BIGUANIDE COMB*** BLOCKERS*** *SGLT2 INHIBITOR - *SELECTIN DPP-4 INHIBITOR - BLOCKERS*** BIGUANIDE COMB*** ADAKVEO TRIJARDY XR ORAL INTRAVENOUS 3 PA; QL; SP TABLET EXTENDED 3 ST; QL SOLUTION RELEASE 24 HOUR

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 191 Drug Name Tier Notes Drug Name Tier Notes *SGLT2 INHIBITOR - *SPLEEN TYROSINE DPP-4 INHIBITOR KINASE (SYK) COMBINATIONS*** INHIBITORS*** *SGLT2 INHIBITOR - *SPLEEN TYROSINE DPP-4 INHIBITOR KINASE (SYK) COMBINATIONS*** INHIBITORS*** GLYXAMBI ORAL TAVALISSE ORAL 3 ST; QL 3 PA; QL; LD TABLET TABLET QTERN ORAL TABLET 3 ST; QL *STEROIDS - STEGLUJAN ORAL MOUTH/THROAT/DENT 3 ST; QL TABLET AL*** *SINUS NODE *STEROIDS - INHIBITORS** MOUTH/THROAT/DENT AL*** *SINUS NODE INHIBITORS** oralone mouth/throat paste 1 or 1b* CORLANOR ORAL triamcinolone acetonide 3 PA; QL 1 or 1b* SOLUTION mouth/throat paste CORLANOR ORAL *SULFONAMIDES* 2 PA; QL TABLET *SULFONAMIDES*** *SMALL INTERFERING SULFADIAZINE ORAL 3 RIBONUCLEIC ACID TABLET (SIRNA) AGENTS*** *TETRACYCLINES* *SMALL INTERFERING *TETRACYCLINES*** RIBONUCLEIC ACID ACTICLATE ORAL (SIRNA) AGENTS*** 3 ST; QL TABLET ONPATTRO INTRAVENOUS 3 PA; QL; LD avidoxy oral tablet 1 or 1b* SOLUTION coremino oral tablet 1 or 1b* ST; QL *SODIUM-GLUCOSE extended release 24 hour CO-TRANSPORTER 2 demeclocycline hcl oral 1 or 1b* INHIBITOR-BIGUANIDE tablet COMB*** DORYX MPC ORAL *SODIUM-GLUCOSE TABLET DELAYED 3 ST; QL CO-TRANSPORTER 2 RELEASE INHIBITOR-BIGUANIDE COMB*** DORYX ORAL TABLET DELAYED RELEASE 200 3 ST; QL INVOKAMET ORAL 3 ST; QL MG, 50 MG TABLET doxy 100 intravenous 1 or 1b* INVOKAMET XR ORAL solution reconstituted TABLET EXTENDED 3 ST; QL RELEASE 24 HOUR doxycycline hyclate intravenous solution 1 or 1b* SEGLUROMET ORAL 3 ST; QL reconstituted TABLET doxycycline hyclate oral SYNJARDY ORAL 1 or 1b* 2 ST; QL capsule TABLET doxycycline hyclate oral 1 or 1b* SYNJARDY XR ORAL tablet 100 mg, 20 mg, 50 mg TABLET EXTENDED 2 ST; QL doxycycline hyclate oral RELEASE 24 HOUR 1 or 1b* ST; QL tablet 150 mg, 75 mg XIGDUO XR ORAL TABLET EXTENDED 2 ST; QL RELEASE 24 HOUR

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 192 Drug Name Tier Notes Drug Name Tier Notes doxycycline hyclate oral *TETRAHYDROISOQUI tablet delayed release 100 NOLINES*** 1 or 1b* ST; QL mg, 150 mg, 200 mg, 50 mg, *TETRAHYDROISOQUI 75 mg NOLINES*** doxycycline monohydrate 1 or 1b* YONDELIS oral capsule INTRAVENOUS 3 LD; SP doxycycline monohydrate SOLUTION 1 or 1b* oral suspension reconstituted RECONSTITUTED doxycycline monohydrate *THYROID AGENTS* 1 or 1b* oral tablet *ANTITHYROID MINOCIN AGENTS*** INTRAVENOUS 3 methimazole oral tablet 1 or 1a* SOLUTION RECONSTITUTED propylthiouracil oral tablet 1 or 1b* MINOCIN ORAL TAPAZOLE ORAL 3 ST; QL 3 CAPSULE 50 MG TABLET minocycline hcl er oral tablet *THYROID 1 or 1b* ST; QL extended release 24 hour HORMONES*** ARMOUR THYROID minocycline hcl oral capsule 1 or 1b* 2 ORAL TABLET minocycline hcl oral tablet 1 or 1b* CYTOMEL ORAL 3 MINOLIRA ORAL TABLET TABLET EXTENDED 3 ST; QL RELEASE 24 HOUR euthyrox oral tablet 1 or 1b* mondoxyne nl oral capsule levo-t oral tablet 1 or 1b* 1 or 1b* 100 mg, 75 mg LEVOTHYROXINE morgidox oral capsule 100 SODIUM INTRAVENOUS 3 1 or 1b* mg SOLUTION NUTRIDOX ORAL KIT 3 levothyroxine sodium intravenous solution 1 or 1a* okebo oral capsule 75 mg 1 or 1b* reconstituted 100 mcg, 500 SEYSARA ORAL mcg 3 ST; QL TABLET LEVOTHYROXINE SOLODYN ORAL SODIUM INTRAVENOUS TABLET EXTENDED SOLUTION 3 RELEASE 24 HOUR 105 3 ST; QL RECONSTITUTED 200 MG, 115 MG, 55 MG, 65 MCG MG, 80 MG levothyroxine sodium oral 1 or 1a* TARGADOX ORAL tablet 3 ST; QL TABLET levoxyl oral tablet 1 or 1a* tetracycline hcl oral capsule 1 or 1b* liothyronine sodium 1 or 1b* VIBRAMYCIN ORAL intravenous solution 3 ST; QL CAPSULE liothyronine sodium oral 1 or 1b* VIBRAMYCIN ORAL tablet SUSPENSION 3 ST; QL NATURE-THROID ORAL 3 RECONSTITUTED TABLET VIBRAMYCIN ORAL 3 ST; QL np thyroid oral tablet 1 or 1a* SYRUP SYNTHROID ORAL 2 XIMINO ORAL TABLET CAPSULE EXTENDED 3 ST; QL thyroid oral tablet 120 mg, RELEASE 24 HOUR 1 or 1a* 15 mg, 30 mg, 60 mg, 90 mg

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 193 Drug Name Tier Notes Drug Name Tier Notes TIROSINT ORAL TENIVAC 3 CAPSULE INTRAMUSCULAR 3 $0 TIROSINT-SOL ORAL INJECTABLE 3 SOLUTION *TRANSTHYRETIN TRIOSTAT STABILIZERS*** INTRAVENOUS 3 *TRANSTHYRETIN SOLUTION STABILIZERS*** unithroid oral tablet 1 or 1a* VYNDAMAX ORAL 3 PA; QL; LD; SP WESTHROID ORAL CAPSULE TABLET 130 MG, 195 VYNDAQEL ORAL 3 3 PA; QL; LD; SP MG, 32.5 MG, 65 MG, 97.5 CAPSULE MG *TRYPTOPHAN WP THYROID ORAL HYDROXYLASE 3 TABLET INHIBITORS*** *TOXOIDS* *TRYPTOPHAN *TOXOID HYDROXYLASE COMBINATIONS*** INHIBITORS*** XERMELO ORAL ADACEL 3 PA; QL; LD INTRAMUSCULAR TABLET 3 $0 SUSPENSION 5-2-15.5 LF- *ULCER DRUGS* MCG/0.5 *ANTICHOLINERGIC BOOSTRIX COMBINATIONS*** INTRAMUSCULAR chlordiazepoxide-clidinium 3 $0 1 or 1b* SUSPENSION 5-2.5-18.5 oral capsule LF-MCG/0.5 LIBRAX ORAL 3 DAPTACEL CAPSULE INTRAMUSCULAR 3 $0 SUSPENSION 23-15-5 *ANTISPASMODICS*** DIPHTHERIA-TETANUS BENTYL TOXOIDS DT INTRAMUSCULAR 3 3 $0 INTRAMUSCULAR SOLUTION SUSPENSION dicyclomine hcl 1 or 1b* INFANRIX intramuscular solution INTRAMUSCULAR 3 $0 dicyclomine hcl oral capsule 1 or 1a* SUSPENSION dicyclomine hcl oral solution 1 or 1a* KINRIX INTRAMUSCULAR 3 $0 dicyclomine hcl oral tablet 1 or 1a* SUSPENSION *BELLADONNA ALKALOIDS*** PEDIARIX INTRAMUSCULAR 3 $0 ANASPAZ ORAL 3 SUSPENSION TABLET DISPERSIBLE PENTACEL ATROPEN INTRAMUSCULAR INTRAMUSCULAR 3 $0 3 SUSPENSION SOLUTION AUTO- RECONSTITUTED INJECTOR QUADRACEL atropine sulfate injection 1 or 1b* INTRAMUSCULAR 3 $0 solution 0.4 mg/ml, 1 mg/ml SUSPENSION ATROPINE SULFATE TDVAX INJECTION SOLUTION 8 3 INTRAMUSCULAR 3 $0 MG/20ML SUSPENSION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 194 Drug Name Tier Notes Drug Name Tier Notes atropine sulfate injection ACIPHEX SPRINKLE solution prefilled syringe 1 or 1b* ORAL CAPSULE 3 ST; QL 0.25 mg/5ml SPRINKLE ATROPINE SULFATE DEXILANT ORAL INTRAVENOUS CAPSULE DELAYED 2 ST; QL 3 SOLUTION PREFILLED RELEASE SYRINGE 1 MG/2.5ML esomeprazole magnesium 3 ST; QL; CTT1 hyoscyamine sulfate er oral oral capsule delayed release tablet extended release 12 1 or 1b* esomeprazole magnesium 3 ST; QL; CTT1 hour oral packet hyoscyamine sulfate sl 1 or 1b* esomeprazole sodium sublingual tablet sublingual intravenous solution 1 or 1b* *H-2 ANTAGONISTS*** reconstituted 40 mg cimetidine hcl oral solution 1 or 1b* lansoprazole oral capsule 3 ST; QL; CTT1 cimetidine oral tablet 1 or 1b* delayed release lansoprazole oral tablet famotidine intravenous 3 ST; QL; CTT1 solution 20 mg/2ml, 200 1 or 1b* delayed release dispersible mg/20ml, 40 mg/4ml NEXIUM I.V. famotidine oral suspension INTRAVENOUS 1 or 1b* 3 reconstituted SOLUTION RECONSTITUTED 40 MG famotidine oral tablet 20 mg, 1 or 1b* 40 mg NEXIUM ORAL CAPSULE DELAYED 3 ST; QL famotidine premixed 1 or 1b* RELEASE intravenous solution NEXIUM ORAL PACKET 3 ST; QL nizatidine oral capsule 1 or 1b* omeprazole oral capsule 1 or 1b* QL nizatidine oral solution 1 or 1b* delayed release PEPCID ORAL TABLET 3 pantoprazole sodium *MISC. ANTI-ULCER*** intravenous solution 1 or 1b* reconstituted CARAFATE ORAL 3 pantoprazole sodium oral SUSPENSION 1 or 1b* QL tablet delayed release CARAFATE ORAL 3 TABLET PREVACID ORAL CAPSULE DELAYED 3 ST; QL sucralfate oral suspension 1 or 1b* RELEASE sucralfate oral tablet 1 or 1b* PREVACID SOLUTAB *PROTON PUMP ORAL TABLET 3 ST; QL INHIBITOR-ANTACID DELAYED RELEASE COMBINATIONS*** DISPERSIBLE omeprazole-sodium PRILOSEC ORAL 3 ST; QL; CTT1 3 ST; QL bicarbonate oral packet PACKET ZEGERID ORAL PROTONIX 3 ST; QL CAPSULE INTRAVENOUS 3 ZEGERID ORAL SOLUTION 3 ST; QL PACKET RECONSTITUTED PROTONIX ORAL *PROTON PUMP 3 ST; QL INHIBITORS*** PACKET ACIPHEX ORAL PROTONIX ORAL TABLET DELAYED 3 ST; QL TABLET DELAYED 3 ST; QL RELEASE RELEASE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 195 Drug Name Tier Notes Drug Name Tier Notes RABEPRAZOLE misoprostol oral tablet 1 or 1a* SODIUM ORAL 3 ST; QL *URINARY ANTI- CAPSULE SPRINKLE INFECTIVES* rabeprazole sodium oral 3 ST; QL; CTT1 *URINARY ANTI- tablet delayed release INFECTIVES*** *QUATERNARY HIPREX ORAL TABLET 3 ANTICHOLINERGICS*** MACROBID ORAL CUVPOSA ORAL 3 3 CAPSULE SOLUTION MACRODANTIN ORAL GLYCATE ORAL 3 3 PA; QL CAPSULE TABLET methenamine hippurate oral glycopyrrolate injection 1 or 1b* 1 or 1b* tablet solution methenamine mandelate oral 1 or 1b* GLYCOPYRROLATE tablet 1 gm INTRAVENOUS MONUROL ORAL SOLUTION PREFILLED 3 3 SYRINGE 0.6 MG/3ML, 1 PACKET MG/5ML nitrofurantoin macrocrystal 1 or 1b* glycopyrrolate oral tablet 1 oral capsule 1 or 1b* mg, 2 mg nitrofurantoin monohyd 1 or 1b* GLYCOPYRROLATE macro oral capsule 3 ORAL TABLET 1.5 MG nitrofurantoin oral 1 or 1b* GLYCOPYRROLATE PF suspension INJECTION SOLUTION 3 *URINARY PREFILLED SYRINGE ANTISEPTIC- GLYRX-PF INJECTION ANTISPASMODIC &/OR 3 SOLUTION ANALGESICS*** methscopolamine bromide uretron d/s oral tablet 1 or 1b* 1 or 1b* oral tablet uryl oral tablet 1 or 1b* propantheline bromide oral 1 or 1b* uticap oral capsule 1 or 1b* tablet utrona-c oral tablet 1 or 1b* *ULCER ANTI- INFECTIVE W/ *URINARY BISMUTH ANTISPASMODICS* COMBINATIONS*** *BETA-3 ADRENERGIC AGONISTS*** PYLERA ORAL 3 CAPSULE MYRBETRIQ ORAL *ULCER ANTI- TABLET EXTENDED 3 INFECTIVE W/ PROTON RELEASE 24 HOUR PUMP INHIBITORS*** *URINARY ANTISPASMODIC - amoxicill-clarithro-lansopraz 1 or 1b* ANTIMUSCARINIC oral (ANTICHOLINERGIC)** OMECLAMOX-PAK 3 * ORAL darifenacin hydrobromide er TALICIA ORAL oral tablet extended release 1 or 1b* CAPSULE DELAYED 3 24 hour RELEASE DETROL LA ORAL *ULCER DRUGS - CAPSULE EXTENDED 3 ST; QL PROSTAGLANDINS*** RELEASE 24 HOUR CYTOTEC ORAL 3 DETROL ORAL TABLET 3 ST; QL TABLET * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 196 Drug Name Tier Notes Drug Name Tier Notes DITROPAN XL ORAL ENABLEX ORAL TABLET EXTENDED TABLET EXTENDED 3 ST; QL 3 ST; QL RELEASE 24 HOUR 10 RELEASE 24 HOUR 7.5 MG, 5 MG MG ENABLEX ORAL GELNIQUE TABLET EXTENDED TRANSDERMAL GEL 10 3 ST; QL 3 ST; QL RELEASE 24 HOUR 7.5 % MG oxybutynin chloride er oral GELNIQUE tablet extended release 24 1 or 1b* TRANSDERMAL GEL 10 3 ST; QL hour % oxybutynin chloride oral 1 or 1b* oxybutynin chloride er oral syrup tablet extended release 24 1 or 1b* oxybutynin chloride oral 1 or 1b* hour tablet oxybutynin chloride oral 1 or 1b* OXYTROL syrup TRANSDERMAL PATCH 3 ST; QL oxybutynin chloride oral TWICE WEEKLY 1 or 1b* tablet solifenacin succinate oral 1 or 1b* OXYTROL tablet TRANSDERMAL PATCH 3 ST; QL tolterodine tartrate er oral TWICE WEEKLY capsule extended release 24 1 or 1b* solifenacin succinate oral hour 1 or 1b* tablet tolterodine tartrate oral tablet 1 or 1b* tolterodine tartrate er oral TOVIAZ ORAL TABLET capsule extended release 24 1 or 1b* EXTENDED RELEASE 24 3 hour HOUR tolterodine tartrate oral tablet 1 or 1b* trospium chloride er oral TOVIAZ ORAL TABLET capsule extended release 24 1 or 1b* EXTENDED RELEASE 24 3 hour HOUR trospium chloride oral tablet 1 or 1b* trospium chloride er oral VESICARE ORAL 3 ST; QL capsule extended release 24 1 or 1b* TABLET hour *URINARY trospium chloride oral tablet 1 or 1b* ANTISPASMODICS - VESICARE ORAL BETA-3 ADRENERGIC 3 ST; QL TABLET AGONISTS*** *URINARY MYRBETRIQ ORAL ANTISPASMODIC - TABLET EXTENDED 3 ANTIMUSCARINICS RELEASE 24 HOUR (ANTICHOL)***(NEW) *URINARY darifenacin hydrobromide er ANTISPASMODICS - oral tablet extended release 1 or 1b* CHOLINERGIC 24 hour AGONISTS*** (NEW) DETROL LA ORAL bethanechol chloride oral 1 or 1b* CAPSULE EXTENDED 3 ST; QL tablet RELEASE 24 HOUR URECHOLINE ORAL 3 DETROL ORAL TABLET 3 ST; QL TABLET 25 MG, 50 MG DITROPAN XL ORAL TABLET EXTENDED 3 ST; QL RELEASE 24 HOUR 10 MG, 5 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 197 Drug Name Tier Notes Drug Name Tier Notes *URINARY PREVNAR 13 ANTISPASMODICS - INTRAMUSCULAR 2 $0 CHOLINERGIC SUSPENSION AGONISTS*** TRUMENBA bethanechol chloride oral INTRAMUSCULAR 1 or 1b* 3 $0 tablet SUSPENSION URECHOLINE ORAL PREFILLED SYRINGE 3 TABLET 25 MG, 50 MG TYPHIM VI INTRAMUSCULAR *URINARY 3 ANTISPASMODICS - SOLUTION 25 DIRECT MUSCLE MCG/0.5ML RELAXANTS*** (NEW) VAXCHORA ORAL flavoxate hcl oral tablet 1 or 1b* SUSPENSION 3 RECONSTITUTED *URINARY ANTISPASMODICS - VIVOTIF ORAL DIRECT MUSCLE CAPSULE DELAYED 2 RELAXANTS*** RELEASE flavoxate hcl oral tablet 1 or 1b* *VIRAL VACCINE COMBINATIONS*** *VACCINES* M-M-R II INJECTION *BACTERIAL SOLUTION 3 $0 VACCINES*** RECONSTITUTED ACTHIB PROQUAD INTRAMUSCULAR SUBCUTANEOUS 3 $0 3 $0 SOLUTION SUSPENSION RECONSTITUTED RECONSTITUTED BCG VACCINE TWINRIX INJECTION 3 $0 INTRAMUSCULAR 3 $0 INJECTABLE SUSPENSION BEXSERO PREFILLED SYRINGE INTRAMUSCULAR 3 $0 *VIRAL VACCINES*** SUSPENSION PREFILLED SYRINGE AFLURIA QUADRIVALENT 2 QL; $0 BIOTHRAX INTRAMUSCULAR INTRAMUSCULAR 3 SUSPENSION SUSPENSION AFLURIA HIBERIX INJECTION QUADRIVALENT SOLUTION 3 $0 INTRAMUSCULAR 2 QL; $0 RECONSTITUTED SUSPENSION MENACTRA PREFILLED SYRINGE INTRAMUSCULAR 3 $0 ENGERIX-B INJECTION INJECTABLE SUSPENSION 10 3 $0 MENVEO MCG/0.5ML, 20 MCG/ML INTRAMUSCULAR 3 $0 ENGERIX-B SOLUTION INTRAMUSCULAR 3 $0 RECONSTITUTED INJECTABLE PEDVAX HIB FLUAD INTRAMUSCULAR 3 $0 INTRAMUSCULAR 2 QL; $0 SUSPENSION SUSPENSION PNEUMOVAX 23 PREFILLED SYRINGE INJECTION 2 $0 INJECTABLE

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 198 Drug Name Tier Notes Drug Name Tier Notes FLUAD HAVRIX QUADRIVALENT INTRAMUSCULAR 2 3 $0 INTRAMUSCULAR SUSPENSION 1440 EL PREFILLED SYRINGE U/ML, 720 EL U/0.5ML FLUARIX HEPLISAV-B QUADRIVALENT INTRAMUSCULAR 3 $0 INTRAMUSCULAR 2 QL; $0 SOLUTION PREFILLED SUSPENSION SYRINGE PREFILLED SYRINGE IMOVAX RABIES FLUBLOK INTRAMUSCULAR 3 QUADRIVALENT INJECTABLE INTRAMUSCULAR 2 QL; $0 IPOL INJECTION 3 $0 SOLUTION PREFILLED INJECTABLE SYRINGE IXIARO FLUCELVAX INTRAMUSCULAR 3 QUADRIVALENT 2 QL; $0 SUSPENSION INTRAMUSCULAR SUSPENSION RABAVERT INTRAMUSCULAR 3 FLUCELVAX SUSPENSION QUADRIVALENT RECONSTITUTED INTRAMUSCULAR 2 QL; $0 SUSPENSION RECOMBIVAX HB PREFILLED SYRINGE INJECTION SUSPENSION 10 3 $0 FLULAVAL MCG/ML, 40 MCG/ML, 5 QUADRIVALENT 2 QL; $0 MCG/0.5ML INTRAMUSCULAR SUSPENSION ROTARIX ORAL SUSPENSION 3 $0 FLULAVAL RECONSTITUTED QUADRIVALENT ROTATEQ ORAL INTRAMUSCULAR 2 QL; $0 3 $0 SUSPENSION SOLUTION PREFILLED SYRINGE SHINGRIX FLUZONE HIGH-DOSE INTRAMUSCULAR INTRAMUSCULAR SUSPENSION 3 $0 2 QL; $0 SUSPENSION RECONSTITUTED 50 PREFILLED SYRINGE MCG/0.5ML FLUZONE STAMARIL INJECTION QUADRIVALENT SUSPENSION 3 2 QL; $0 INTRAMUSCULAR RECONSTITUTED SUSPENSION , 0.5 ML VAQTA INTRAMUSCULAR FLUZONE 3 $0 QUADRIVALENT SUSPENSION 25 INTRAMUSCULAR 2 QL; $0 UNIT/0.5ML, 50 UNIT/ML SUSPENSION VARIVAX PREFILLED SYRINGE SUBCUTANEOUS 3 $0 GARDASIL 9 INJECTABLE INTRAMUSCULAR 2 $0 YF-VAX SUSPENSION SUBCUTANEOUS 3 GARDASIL 9 INJECTABLE INTRAMUSCULAR 2 $0 ZOSTAVAX SUSPENSION SUBCUTANEOUS 2 $0 PREFILLED SYRINGE SUSPENSION RECONSTITUTED

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 199 Drug Name Tier Notes Drug Name Tier Notes *VAGINAL PRODUCTS* yuvafem vaginal tablet 1 or 1b* *IMIDAZOLE-RELATED *VAGINAL ANTIFUNGALS*** PROGESTINS*** GYNAZOLE-1 VAGINAL CRINONE VAGINAL 3 3 SP CREAM GEL 4 % miconazole 3 vaginal CRINONE VAGINAL 1 or 1b* 3 PA; QL; SP suppository GEL 8 % terconazole vaginal cream 1 or 1b* ENDOMETRIN 3 PA; QL terconazole vaginal VAGINAL INSERT 1 or 1b* suppository *VASOPRESSORS* *MISCELLANEOUS *ANAPHYLAXIS VAGINAL THERAPY AGENTS*** PRODUCTS*** ADRENALIN INJECTION 3 INTRAROSA VAGINAL SOLUTION 3 ST; QL INSERT AUVI-Q INJECTION *VAGINAL ANTI- SOLUTION AUTO- 3 ST; QL INFECTIVES*** INJECTOR CLEOCIN VAGINAL epinephrine injection 3 1 or 1b* CREAM solution auto-injector CLEOCIN VAGINAL EPIPEN 2-PAK 2 SUPPOSITORY INJECTION SOLUTION 3 ST; QL clindamycin phosphate AUTO-INJECTOR 1 or 1b* vaginal cream EPIPEN JR 2-PAK CLINDESSE VAGINAL INJECTION SOLUTION 3 ST; QL 3 CREAM AUTO-INJECTOR metronidazole vaginal gel 1 or 1b* SYMJEPI INJECTION SOLUTION PREFILLED 2 QL NUVESSA VAGINAL 3 SYRINGE GEL *VASOPRESSORS*** vandazole vaginal gel 1 or 1b* AKOVAZ *VAGINAL INTRAVENOUS 3 ESTROGENS*** SOLUTION ESTRACE VAGINAL 3 BIORPHEN CREAM INTRAVENOUS 3 estradiol vaginal cream 1 or 1b* SOLUTION dobutamine hcl intravenous estradiol vaginal tablet 1 or 1b* 1 or 1b* solution 250 mg/20ml ESTRING VAGINAL 3 dobutamine in d5w RING 1 or 1b* intravenous solution FEMRING VAGINAL 3 dopamine hcl intravenous RING 1 or 1b* solution 40 mg/ml IMVEXXY dopamine in d5w intravenous MAINTENANCE PACK 3 1 or 1b* VAGINAL INSERT solution IMVEXXY STARTER ephedrine sulfate injection 3 1 or 1b* PACK VAGINAL INSERT solution PREMARIN VAGINAL EPHEDRINE SULFATE 2 CREAM INTRAVENOUS 3 SOLUTION VAGIFEM VAGINAL 3 TABLET 10 MCG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 200 Drug Name Tier Notes Drug Name Tier Notes EPHEDRINE SULFATE- PHENYLEPHRINE HCL- NACL INTRAVENOUS NACL INTRAVENOUS SOLUTION PREFILLED SOLUTION 10-0.9 SYRINGE 10-0.9 MG/ML- MG/250ML-%, 20-0.9 3 3 %, 100-0.9 MG/10ML-%, MG/250ML-%, 40-0.9 25-0.9 MG/5ML-%, 50-0.9 MG/250ML-%, 50-0.9 MG/10ML-%, 50-0.9 MG/250ML-%, 80-0.9 MG/5ML-% MG/250ML-% EPINEPHRINE HCL- PHENYLEPHRINE HCL- DEXTROSE NACL INTRAVENOUS INTRAVENOUS 3 SOLUTION PREFILLED SOLUTION 4-5 SYRINGE 0.5-0.9 3 MG/250ML-% MG/5ML-%, 0.8-0.9 EPINEPHRINE HCL- MG/10ML-%, 1-0.9 NACL INTRAVENOUS MG/10ML-%, 20-0.9 3 SOLUTION 8-0.9 MG/50ML-% MG/250ML-% VAZCULEP EPINEPHRINE PF INTRAVENOUS 3 3 INJECTION SOLUTION SOLUTION EPINEPHRINE- *VESICOURETERAL DEXTROSE REFLUX (VUR) AGENT 3 INTRAVENOUS COMBINATIONS*** SOLUTION *VESICOURETERAL EPINEPHRINE-NACL REFLUX (VUR) AGENT INTRAVENOUS 3 COMBINATIONS*** SOLUTION DEFLUX INJECTION 3 GIAPREZA PREFILLED SYRINGE INTRAVENOUS 3 *VITAMINS* SOLUTION *PABA*** LEVOPHED aminobenzoate potassium 1 or 1b* INTRAVENOUS 3 oral packet SOLUTION *VITAMIN A*** midodrine hcl oral tablet 1 or 1b* AQUASOL A norepinephrine bitartrate 1 or 1b* INTRAMUSCULAR 3 intravenous solution SOLUTION 15 MG/ML NOREPINEPHRINE- *VITAMIN B-1*** DEXTROSE thiamine hcl injection INTRAVENOUS 1 or 1b* SOLUTION 4-5 3 solution MG/250ML-%, 8-5 *VITAMIN B-6*** MG/250ML-%, 8-5 pyridoxine hcl injection MG/500ML-% 1 or 1b* solution NOREPINEPHRINE- *VITAMIN C*** SODIUM CHLORIDE INTRAVENOUS ASCOR INTRAVENOUS 3 SOLUTION 16-0.9 3 SOLUTION MG/250ML-%, 4-0.9 ascorbic acid injection 1 or 1b* MG/250ML-%, 8-0.9 solution MG/250ML-% ASCORBIC ACID PHENYLEPHRINE HCL INTRAVENOUS 3 INTRAVENOUS 3 SOLUTION SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 201 Drug Name Tier Notes *VITAMIN D*** DRISDOL ORAL 3 CAPSULE ERGOCAL ORAL 2 CAPSULE ergocalciferol oral capsule 1 or 1a* vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 1 or 1a* ut) *VITAMIN E*** WHEAT GERM OIL 2 ORAL OIL *VITAMIN K*** MEPHYTON ORAL 3 TABLET phytonadione injection solution 1 mg/0.5ml, 10 1 or 1b* mg/ml phytonadione oral tablet 1 or 1b* vitamin k1 injection solution 1 or 1b* 1 mg/0.5ml, 10 mg/ml *X-LINKED HYPOPHOSPHATEMIA (XLH) TREATMENT - AGENTS*** *X-LINKED HYPOPHOSPHATEMIA (XLH) TREATMENT - AGENTS*** CRYSVITA SUBCUTANEOUS 3 PA; QL; LD; SP SOLUTION

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 05/01/2020 202 Most plans include our convenient home delivery program at no extra cost to you. Find out more at anthem.com or call 833-236-6196.

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

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

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

Rev. 8/19