Blue Rx Essentialssm Formulary

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BLUE RX ESSENTIALSSM FORMULARY

HOW TO READ THE FORMULARY All drugs are listed by their generic names and/or most common proprietary (brand) name. Specific drug listings may be accessed either by generic (in lowercase) or brand name (in uppercase) and by therapeutic drug tier. Any drug not found in this formulary listing, or any formulary updates published by Wellmark, shall be considered excluded from your benefit. Once the product is located, the following items can be viewed: Drug Tier: Drugs are categorized within tiers on the formulary. Each tier is assigned a cost, which is determined by the member’s pharmacy benefit plan. You may refer to the formulary as a guide to select the most appropriate drugs and associated cost share. Pharmacy Durable Medical Equipment (RxDME): Devices available on this tier include select durable medical equipment (DME) that are used in conjunction with a drug and may be obtained from a pharmacy. Specialty Drugs: Specialty drugs are high-cost injectable, infused, oral or inhaled drugs for the ongoing treatment of a chronic condition. These drugs generally require close supervision and monitoring of the patient’s drug therapy. Specialty drugs may be categorized within tiers on the formulary or as drugs covered under your medical benefit. Specialty Drugs Preferred (SP-P): Drugs in this category will process with the preferred specialty drug cost-share. Specialty Drugs Non-Preferred (SP-NP): Drugs in this category will process with the non-preferred specialty cost-share, and will have a higher cost share than preferred specialty drugs. Specialty Medical (SP-M): Drugs in this category will be covered under your medical benefit. Drug Name: This lists the generic name for the product (lowercase) OR the brand name or common reference name for the product (UPPERCASE). Requirements/Limits: This lists Wellmark Pharmacy programs that may impact a particular drug or class of drugs and are described in the legend below.

HEALTH CARE REFORM PREVENTIVE DRUGS Preventive drugs with an “A” or “B” rating in the current recommendations of the United States Preventive Services Task Force (USPSTF) and immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention are not associated with any cost share for members on plans with this benefit. A complete list of recommendations and guidelines related to preventive services can be found at Healthcare.gov. Recommended preventive items and services are subject to change and are subject to medical management.

BENEFIT COVERAGE AND LIMITATIONS This printed formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments or a lack of coverage, which are not reflected in the Blue Rx Essentials formulary. Members should contact their Plan Sponsor or Wellmark Customer Service at the number on the back of their ID card if they have questions regarding their coverage. Please note that the formulary process is evolutionary, and changes can occur throughout the year. The following topics may or may not be applicable depending on the parameters of your specific benefits.

FORMULARY EXCEPTION PROCESS Drugs not included in this list shall be considered non-formulary and are NOT COVERED. In some instances, Wellmark will consider coverage exceptions. Coverage of non-formulary drugs may be requested by the health care professional through an exception request for a non-formulary prescription drug (outlined below). Generally, one of the following guidelines must be documented for an exception to be granted: All covered formulary drugs on any tier will be ineffective; OR All covered formulary drugs on any tier have been ineffective; OR All covered formulary drugs on any tier would not be as effective as the non-formulary drug; OR All covered formulary drugs would have adverse effects.

©2021 Wellmark, Inc. 1 COMMON DRUG EXCLUSIONS Due to benefit design parameters, some plan sponsors may choose to exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded drugs may include, but are not limited to: Over-the-counter (OTC) drugs or their equivalents unless otherwise specified in the formulary listing. Drug products used for cosmetic purposes. Experimental drug products, or any drug product used in an experimental manner. Replacement of a lost or stolen drug. Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA).

CONTACT INFORMATION The Blue Rx Essentials formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Wellmark encourages your input and feedback on how we can assist in improving this document and the formulary management process. Please direct your communications to: Wellmark Blue Cross and Blue Shield 1331 Grand Avenue P.O. Box 9232 Des Moines, IA 50306 In addition to the Blue Rx Essentials formulary, other quick reference guides are available at Wellmark.com.

© 2021 Wellmark, Inc. All Rights Reserved. Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Health Plan of Iowa, Inc., and Wellmark Blue Cross and Blue Shield of South Dakota. are independent licensees of the Blue Cross and Blue Shield Association.

1 TIER 1 2 TIER 2 3 TIER 3 4 SP-P 5 SP-NP 6 RX-DME 7 P&T 8 SP-M TYPE DESCRIPTION

There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. Amounts over the QL Quantity Limit specified quantity limits are not a covered benefit unless Post- Quantity Limit Prior Authorization is available. This indicates a drug requires prior authorization before it is covered under your benefit. Your health care provider will need to contact our PA Prior Authorization Pharmacy program at 800-600-8065. Hours of operation are Monday- Friday: 8 a.m. to 6 p.m. CST. This prescription drug may only be covered if you meet the minimum AL Age Limit or maximum age limit. This indicates a preferred biosimilar or generic specialty drug. Please Specialty Biosimilars and SBG read your enrollment information to see how specialty biosimilars and Specialty Generics specialty generics are covered specific to your plan. This indicates a drug requires prior authorization before it is covered under your benefit. Your health care provider will need to contact our Pharmacy program at 800-600- 8065. Hours of operation are Medical Necessity Prior MN-PA Monday - Friday: 8 a.m. to 6 p.m. CST. The intent of formulary Authorization medical necessity prior authorization is to confirm the appropriate coverage of the target drugs when evidence is provided documenting a trial and failure of the preferred formulary alternatives. A quantity limit on this drug limits the amount covered per prescription, or time period, and may vary based on the diagnosis. QLV Quantity Limit (Varies) Amounts over the quantity limit are not a covered benefit unless Post Quantity Limit Prior Authorization is available. This indicates a greater quantity may be covered under your benefit Post-Quantity Limit Prior if Post-Quantity Limit Prior Authorization is obtained. Your health PA-QL Authorization care provider will need to contact our Pharmacy program at 800-600- 8065. Hours of operation are Monday-Friday: 8 a.m. to 6 p.m. CST

©2021 Wellmark, Inc. 3 Indicates a generic equivalent is available for a brand name drug. In most cases, when you purchase a brand name drug that has an FDA-approved A-rated generic equivalent, Wellmark will pay only GA Generic Available what it would have paid for the equivalent generic drug. You will be responsible for your payment obligation for the equivalent generic drug and any remaining cost difference up to the maximum allowed fee for the brand name drug.

BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

butalbital-aspirin- butalbital-aspirin-caffeine TIER 1 caffeine 50-325-40 mg cap cataflam cataflam 50 mg tab TIER 1 celecoxib (50 mg cap, 100 celecoxib TIER 1 QL (60 PER 30 DAYS) mg cap, 200 mg cap) choline-mag choline-mag trisalicylate TIER 1 trisalicylate 500 mg/5ml liquid diclofenac epolamine 1.3 % diclofenac epolamine TIER 1 PA, QL (60 PER 30 DAY(S)) patch diclofenac potassium 50 mg diclofenac potassium TIER 1 tab diclofenac sodium (25 mg diclofenac sodium tab dr, 50 mg tab dr, 75 mg TIER 1 tab dr) diclofenac sodium 1.5 % diclofenac sodium TIER 1 QL (300 PER 30 DAY(S)) solution diclofenac sodium er 100 diclofenac sodium er TIER 1 mg tab er 24h diclofenac-misoprostol (50- diclofenac- 0.2 mg tab dr, 75-0.2 mg TIER 1 misoprostol tab dr) diflunisal diflunisal 500 mg tab TIER 1 ec-naproxen (375 mg tab ec-naproxen TIER 1 dr, 500 mg tab dr) etodolac (200 mg cap, 300 etodolac mg cap, 400 mg tab, 500 TIER 1 mg tab) etodolac er (er 400 mg tab etodolac er er 24h, er 500 mg tab er TIER 1 24h, er 600 mg tab er 24h) fenoprofen calcium (400 mg fenoprofen calcium TIER 1 cap, 600 mg tab) flurbiprofen (50 mg tab, 100 flurbiprofen TIER 1 mg tab) ibu (400 mg tab, 600 mg ibu TIER 1 tab, 800 mg tab) ibuprofen (400 mg tab, 600 ibuprofen TIER 1 mg tab, 800 mg tab)

©2021 Wellmark, Inc. 5 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS INDOCIN 25 MG/5ML PA, QL (1200 PER 30 INDOCIN SUSPENSION TIER 2 DAY(S)) indomethacin INDOCIN 50 MG SUPPOS INDOCIN TIER 3 indomethacin indomethacin (25 mg cap, indomethacin TIER 1 50 mg cap) indomethacin er 75 mg cap indomethacin er TIER 1 er ketoprofen (50 mg cap, 75 ketoprofen TIER 1 mg cap) KETOPROFEN ER 200 MG KETOPROFEN ER CAP ER 24H TIER 1 ketoprofen ketorolac ketorolac tromethamine (10 TIER 1 tromethamine mg tab, 30 mg/ml solution) klofensaid ii klofensaid ii 1.5 % solution TIER 1 QL (300 PER 30 DAY(S)) MECLOFENAMATE MECLOFENAMATE SODIUM (50 MG CAP, 100 TIER 1 SODIUM MG CAP) meclofenamate sodium mefenamic acid 250 mg mefenamic acid TIER 1 cap meloxicam (7.5 mg tab, 15 meloxicam TIER 1 mg tab) nabumetone (500 mg tab, nabumetone TIER 1 750 mg tab) naproxen (250 mg tab, 375 naproxen mg tab, 375 mg tab dr, 500 TIER 1 mg tab, 500 mg tab dr) naproxen sodium (275 mg naproxen sodium TIER 1 tab, 550 mg tab) oxaprozin oxaprozin 600 mg tab TIER 1 piroxicam (10 mg cap, 20 piroxicam TIER 1 mg cap) profeno profeno 600 mg tab TIER 1 relafen (500 mg tab, 750 relafen TIER 1 mg tab) salsalate (500 mg tab, 750 salsalate TIER 1 mg tab) sulindac (150 mg tab, 200 sulindac TIER 1 mg tab)

OPIOID ANALGESICS, LONG-ACTING

buprenorphine (5 patch wk, buprenorphine 7.5 patch wk, 10 patch wk, TIER 1 PA, QL (4 PER 25) 15 patch wk, 20 patch wk) EMBEDA (20-0.8 MG CAP ER, 30-1.2 MG CAP ER, EMBEDA TIER 3 PA, QL (60 PER 25) 100-4 MG CAP ER) morphine-naltrexone EMBEDA (50-2 MG CAP ER, 60-2.4 MG CAP ER, EMBEDA TIER 3 PA, QL (30 PER 25) 80-3.2 MG CAP ER) morphine-naltrexone fentanyl (12 patch 72hr, 25 patch 72hr, 37.5 patch 72hr, 50 patch 72hr, 62.5 fentanyl TIER 1 PA, QL (10 PER 25) patch 72hr, 75 patch 72hr, 87.5 patch 72hr, 100 patch 72hr) hydrocodone bitartrate er (er 20 mg tb24 deter, er 30 hydrocodone mg tb24 deter, er 40 mg TIER 1 PA, QL (30 PER 25) bitartrate er tb24 deter, er 60 mg tb24 deter, er 80 mg tb24 deter, er 120 mg tb24 deter) hydrocodone hydrocodone bitartrate er TIER 1 PA, QL (60 PER 25) bitartrate er 100 mg tb24 deter hydromorphone hcl er (er 8 mg tab er 24h, er 12 mg tab hydromorphone hcl er TIER 1 PA, QL (30 PER 25 DAY(S)) er 24h, er 16 mg tab er 24h, er 32 mg tab er 24h) levorphanol tartrate 2 mg levorphanol tartrate TIER 1 PA, QL (120 PER 25) tab methadone hcl (10 mg tab, methadone hcl TIER 1 PA, QL (60 PER 25) 10 mg/ml conc) methadone hcl 10 mg/5ml methadone hcl TIER 1 PA, QL (300 PER 25) solution methadone hcl 40 mg tab methadone hcl TIER 1 sol methadone hcl methadone hcl 5 mg tab TIER 1 PA, QL (90 PER 25) methadone hcl 5 mg/5ml methadone hcl TIER 1 PA, QL (450 PER 25) solution

©2021 Wellmark, Inc. 7 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS methadone hcl methadone hcl intensol 10 TIER 1 PA, QL (60 PER 25) intensol mg/ml conc methadose methadose 10 mg tab TIER 1 PA, QL (60 PER 25) methadose methadose 40 mg tab sol TIER 1 MORPHINE SULFATE ER (ER 10 MG CAP ER 24H, ER 20 MG CAP ER 24H, ER 30 MG CAP ER 24H, MORPHINE ER 40 MG CAP ER 24H, TIER 1 PA, QL (60 PER 25) SULFATE ER ER 100 MG CAP ER 24H, ER 100 MG TAB ER, ER 200 MG TAB ER) morphine sulfate morphine sulfate er (er 15 morphine sulfate er mg tab er, er 30 mg tab er, TIER 1 PA, QL (90 PER 25) er 60 mg tab er) morphine sulfate er (er 50 mg cap er 24h, er 60 mg morphine sulfate er TIER 1 PA, QL (30 PER 25) cap er 24h, er 80 mg cap er 24h) OXYCODONE HCL ER (ER 10 MG TB12 DETER, ER OXYCODONE HCL 20 MG TB12 DETER, ER TIER 2 PA, QL (60 PER 25) ER 80 MG TB12 DETER) oxycodone hcl oxycodone hcl er (er 15 mg oxycodone hcl er tb12 deter, er 30 mg tb12 TIER 1 PA, QL (60 PER 25) deter, er 60 mg tb12 deter) OXYCODONE HCL ER 40 OXYCODONE HCL MG TB12 DETER TIER 2 PA, QL (90 PER 25) ER oxycodone hcl OXYCONTIN (10 MG TB12 DETER, 15 MG TB12 DETER, 20 MG TB12 DETER, 30 MG TB12 OXYCONTIN TIER 2 PA, QL (60 PER 25) DETER, 60 MG TB12 DETER, 80 MG TB12 DETER) oxycodone hcl OXYCONTIN 40 MG TB12 OXYCONTIN DETER TIER 2 PA, QL (90 PER 25) oxycodone hcl

©2021 Wellmark, Inc. 8 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OXYMORPHONE HCL ER (ER 5 MG TAB ER 12H, ER 7.5 MG TAB ER 12H, ER OXYMORPHONE 10 MG TAB ER 12H, ER 15 TIER 1 PA, QL (60 PER 25) HCL ER MG TAB ER 12H, ER 30 MG TAB ER 12H, ER 40 MG TAB ER 12H) oxymorphone hcl OXYMORPHONE HCL ER OXYMORPHONE 20 MG TAB ER 12H TIER 1 PA, QL (90 PER 25) HCL ER oxymorphone hcl tramadol hcl er (biphasic) tramadol hcl er (er 100 mg tab er 24h, er TIER 1 PA, QL (30 PER 25) (biphasic) 200 mg tab er 24h, er 300 mg tab er 24h) tramadol hcl er (er 100 mg tramadol hcl er tab er 24h, er 200 mg tab er TIER 1 PA, QL (30 PER 25) 24h, er 300 mg tab er 24h)

OPIOID ANALGESICS, SHORT-ACTING

ABSTRAL (100 MCG SL TAB, 200 MCG SL TAB, 300 MCG SL TAB, 400 ABSTRAL TIER 3 PA MCG SL TAB, 600 MCG SL TAB, 800 MCG SL TAB) fentanyl citrate acetaminophen- acetaminophen-codeine #2 TIER 1 QL (400 PER 25) codeine #2 300-15 mg tab acetaminophen- acetaminophen-codeine #3 TIER 1 QL (360 PER 25) codeine #3 300-30 mg tab acetaminophen- acetaminophen-codeine #4 TIER 1 QL (180 PER 25) codeine #4 300-60 mg tab acetaminophen- acetaminophen-codeine TIER 1 QL (2700 PER 25) codeine 120-12 mg/5ml solution acetaminophen- acetaminophen-codeine TIER 1 QL (400 PER 25) codeine 300-15 mg tab acetaminophen- acetaminophen-codeine TIER 1 QL (360 PER 25) codeine 300-30 mg tab acetaminophen- acetaminophen-codeine TIER 1 QL (180 PER 25) codeine 300-60 mg tab apap-caff-dihydrocodeine apap-caff- (320.5-30-16 mg cap, 325- TIER 1 QL (300 PER 25) dihydrocodeine 30-16 mg tab) ascomp-codeine 50-325- ascomp-codeine TIER 1 40-30 mg cap aspirin-caff- aspirin-caff-dihydrocodeine TIER 1 dihydrocodeine 356.4-30-16 mg cap

©2021 Wellmark, Inc. 9 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS butalbital-apap-caff-cod butalbital-apap-caff- (50-300-40-30 mg cap, 50- TIER 1 cod 325-40-30 mg cap) butalbital-asa-caff- butalbital-asa-caff-codeine TIER 1 codeine 50-325-40-30 mg cap butorphanol tartrate 10 butorphanol tartrate TIER 1 QL (4 PER 30 DAYS) mg/ml solution carisoprodol-aspirin- carisoprodol-aspirin- TIER 1 codeine codeine 200-325-16 mg tab codeine sulfate (15 mg tab, codeine sulfate TIER 1 PA, QL (42 PER 25) 30 mg tab, 60 mg tab) dvorah dvorah 325-30-16 mg tab TIER 1 QL (300 PER 25) endocet (2.5-325 mg tab, 5- endocet TIER 1 QL (360 PER 25) 325 mg tab) endocet endocet 10-325 mg tab TIER 1 QL (180 PER 25) endocet endocet 7.5-325 mg tab TIER 1 QL (240 PER 25) fentanyl citrate (100 mcg tab, 200 mcg tab, 400 mcg fentanyl citrate TIER 1 PA tab, 600 mcg tab, 800 mcg tab) fentanyl citrate (200 mcg loz handle, 400 mcg loz handle, 600 mcg loz fentanyl citrate handle, 800 mcg loz TIER 1 PA handle, 1200 mcg loz handle, 1600 mcg loz handle) FENTORA 100 MCG TAB FENTORA TIER 3 PA, GA fentanyl citrate hydrocodone- acetaminophen (2.5-108 hydrocodone- mg/5ml solution, 5-217 TIER 1 QL (2700 PER 25) acetaminophen mg/10ml solution, 7.5-325 mg/15ml solution) hydrocodone- hydrocodone- acetaminophen (5-300 mg TIER 1 QL (240 PER 25) acetaminophen tab, 5-325 mg tab) hydrocodone- hydrocodone- acetaminophen (7.5-300 TIER 1 QL (180 PER 25) acetaminophen mg tab, 7.5-325 mg tab) hydrocodone- hydrocodone- acetaminophen 10-300 mg TIER 1 QL (180 PER 25 DAY(S)) acetaminophen tab hydrocodone- hydrocodone- acetaminophen 10-325 mg TIER 1 QL (180 PER 24) acetaminophen tab

©2021 Wellmark, Inc. 10 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS hydrocodone- hydrocodone- acetaminophen 10-660 mg TIER 1 acetaminophen tab hydrocodone- hydrocodone- acetaminophen 2.5-325 mg TIER 1 QL (360 PER 25) acetaminophen tab hydrocodone-ibuprofen (5- hydrocodone- 200 mg tab, 7.5-200 mg TIER 1 QL (50 PER 25) ibuprofen tab, 10-200 mg tab) hydromorphone hcl 1 mg/ml hydromorphone hcl TIER 1 PA, QL (600 PER 25) liquid hydromorphone hcl 2 mg hydromorphone hcl TIER 1 PA, QL (180 PER 25) tab HYDROMORPHONE HCL HYDROMORPHONE 3 MG SUPPOS TIER 1 PA, QL (120 PER 25) HCL hydromorphone hcl hydromorphone hcl 4 mg hydromorphone hcl TIER 1 PA, QL (150 PER 25) tab hydromorphone hcl 8 mg hydromorphone hcl TIER 1 PA, QL (60 PER 25) tab ibudone (5-200 mg tab, 10- ibudone TIER 1 QL (50 PER 25) 200 mg tab) LAZANDA (100 SOLUTION, 300 LAZANDA SOLUTION, 400 TIER 3 PA SOLUTION) fentanyl citrate lorcet lorcet 5-325 mg tab TIER 1 QL (240 PER 25) lorcet hd lorcet hd 10-325 mg tab TIER 1 QL (180 PER 24) lorcet plus lorcet plus 7.5-325 mg tab TIER 1 QL (180 PER 25) LORTAB 10-300 MG/15ML ELIXIR LORTAB TIER 3 QL (2025 PER 25) hydrocodone- acetaminophen meperidine hcl (50 mg tab, meperidine hcl TIER 1 PA, QL (18 PER 25) 100 mg tab) MEPERIDINE HCL 50 MEPERIDINE HCL MG/5ML SOLUTION TIER 1 PA, QL (90 PER 25) meperidine hcl morphine sulfate (30 mg morphine sulfate TIER 1 PA, QL (90 PER 25) suppos, 30 mg tab) MORPHINE SULFATE (5 MORPHINE MG SUPPOS, 10 MG TIER 1 PA, QL (180 PER 25) SULFATE SUPPOS, 15 MG TAB) morphine sulfate

©2021 Wellmark, Inc. 11 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS morphine sulfate morphine sulfate (concentrate) (20 mg/ml TIER 1 PA, QL (135 PER 25) (concentrate) solution, 100 mg/5ml solution) morphine sulfate 10 mg/5ml morphine sulfate TIER 1 PA, QL (900 PER 25) solution MORPHINE SULFATE 20 MORPHINE MG SUPPOS TIER 1 PA, QL (120 PER 25) SULFATE morphine sulfate morphine sulfate 20 mg/5ml morphine sulfate TIER 1 PA, QL (675 PER 25) solution oxycodone hcl (20 mg tab, oxycodone hcl TIER 1 PA, QL (90 PER 25) 100 mg/5ml conc) oxycodone hcl (5 mg cap, 5 oxycodone hcl TIER 1 PA, QL (180 PER 25) mg tab, 10 mg tab) oxycodone hcl oxycodone hcl 15 mg tab TIER 1 PA, QL (120 PER 25) oxycodone hcl oxycodone hcl 30 mg tab TIER 1 PA, QL (60 PER 25) oxycodone hcl 5 mg/5ml oxycodone hcl TIER 1 PA, QL (900 PER 25) solution oxycodone-acetaminophen oxycodone- (2.5-325 mg tab, 5-325 mg TIER 1 QL (360 PER 25) acetaminophen tab) oxycodone- oxycodone-acetaminophen TIER 1 QL (180 PER 25) acetaminophen 10-325 mg tab OXYCODONE- ACETAMINOPHEN 5-325 OXYCODONE- MG/5ML SOLUTION TIER 1 QL (1800 PER 25) ACETAMINOPHEN oxycodone w/ acetaminophen oxycodone- oxycodone-acetaminophen TIER 1 QL (240 PER 25) acetaminophen 7.5-325 mg tab oxycodone-aspirin 4.8355- oxycodone-aspirin TIER 1 QL (360 PER 25) 325 mg tab OXYCODONE- OXYCODONE- IBUPROFEN 5-400 MG TIER 1 QL (28 PER 25) IBUPROFEN TAB oxycodone-ibuprofen oxymorphone hcl oxymorphone hcl 10 mg tab TIER 1 PA, QL (90 PER 25) oxymorphone hcl oxymorphone hcl 5 mg tab TIER 1 PA, QL (180 PER 25) panlor panlor 325-30-16 mg tab TIER 1 QL (300 PER 25) pentazocine-naloxone pentazocine-naloxone hcl TIER 1 PA, QL (120 PER 25) hcl 50-0.5 mg tab

©2021 Wellmark, Inc. 12 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SUBSYS (100 MCG LIQUID, 200 MCG LIQUID, 400 MCG LIQUID, 600 MCG LIQUID, 800 MCG SUBSYS TIER 3 PA LIQUID, 1200 (600 X 2) MCG LIQUID, 1600 (800 X 2) MCG LIQUID) fentanyl tramadol hcl tramadol hcl 50 mg tab TIER 1 PA, QL (180 PER 25) tramadol- tramadol-acetaminophen TIER 1 QL (40 PER 25) acetaminophen 37.5-325 mg tab trezix trezix 320.5-30-16 mg cap TIER 1 QL (300 PER 25) VERDROCET 2.5-325 MG TAB VERDROCET TIER 1 QL (360 PER 25), GA hydrocodone- acetaminophen vicodin vicodin 5-300 mg tab TIER 1 QL (240 PER 25) vicodin es vicodin es 7.5-300 mg tab TIER 1 QL (180 PER 25) vicodin hp vicodin hp 10-300 mg tab TIER 1 QL (180 PER 25 DAY(S)) xylon xylon 10-200 mg tab TIER 1 QL (50 PER 25) ZAMICET 10-325 MG/15ML SOLUTION ZAMICET TIER 1 QL (2700 PER 25 DAY(S)) hydrocodone- acetaminophen

ANESTHETICS

LOCAL ANESTHETICS

7t lido 7t lido 2 % gel TIER 1 glydo glydo 2 % prsyr TIER 1 lidocaine lidocaine 5 % ointment TIER 1 lidocaine lidocaine 5 % patch TIER 1 QL (3 PER DAY) LIDOCAINE HCL 4 % LIDOCAINE HCL SOLUTION TIER 1 lidocaine hcl (mouth-throat) lidocaine hcl lidocaine hcl urethral/mucosal (2 % gel, TIER 1 urethral/mucosal 2 % prsyr) lidocaine pak lidocaine pak 5 % ointment TIER 1 lidocaine viscous hcl 2 % lidocaine viscous hcl TIER 1 solution lidocaine-prilocaine 2.5-2.5 lidocaine-prilocaine TIER 1 % cream

©2021 Wellmark, Inc. 13 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NAYZILAM 5 MG/0.1ML NAYZILAM SOLUTION TIER 3 PA, QL (10 PER 30 DAY(S)) midazolam (anticonvulsant) premium lidocaine 5 % premium lidocaine TIER 1 ointment

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium 333 acamprosate calcium TIER 1 mg tab dr disulfiram (250 mg tab, 500 disulfiram TIER 1 mg tab) naltrexone hcl naltrexone hcl 50 mg tab TIER 1

OPIOID DEPENDENCE TREATMENTS

buprenorphine hcl (2 mg sl buprenorphine hcl TIER 1 tab, 8 mg sl tab) buprenorphine hcl-naloxone hcl (-naloxone 2-0.5 mg film, -naloxone 2-0.5 mg sl buprenorphine hcl- tab, -naloxone 4-1 mg film, TIER 1 naloxone hcl -naloxone 8-2 mg film, - naloxone 8-2 mg sl tab, - naloxone 12-3 mg film)

OPIOID REVERSAL AGENTS

KLOXXADO 8 MG/0.1ML KLOXXADO LIQUID TIER 2 naloxone hcl naloxone hcl (0.4 mg/ml naloxone hcl soln cart, 2 mg/2ml soln TIER 1 prsyr) NARCAN 4 MG/0.1ML NARCAN LIQUID TIER 2 naloxone hcl

ANTIBACTERIALS

AMINOGLYCOSIDES

ARIKAYCE 590 MG/8.4ML ARIKAYCE SUSPENSION SP-P QL (236 PER 28 DAY(S)) amikacin sulfate liposome GENTAK 0.3 % OINTMENT GENTAK TIER 1 GA gentamicin sulfate (ophth)

©2021 Wellmark, Inc. 14 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS gentamicin sulfate (0.1 % cream, 0.1 % ointment, 0.3 gentamicin sulfate TIER 1 % ointment, 0.3 % solution, 10 mg/ml solution) neomycin sulfate 500 mg neomycin sulfate TIER 1 tab paromomycin sulfate 250 paromomycin sulfate TIER 1 mg cap tobramycin tobramycin 0.3 % solution TIER 1 tobramycin sulfate (1.2 gm recon soln, 1.2 gm/30ml tobramycin sulfate solution, 2 gm/50ml TIER 1 solution, 10 mg/ml solution, 80 mg/2ml solution) TOBREX 0.3 % OINTMENT TOBREX TIER 3 tobramycin (ophth)

ANTIBACTERIALS, OTHER

AEMCOLO 194 MG TAB AEMCOLO DR TIER 3 QL (6 PER 3 DAY(S)) rifamycin sodium ALTABAX 1 % OINTMENT ALTABAX TIER 3 retapamulin azuphen mb azuphen mb 120 mg cap TIER 1 BACITRACIN 500 BACITRACIN UNIT/GM OINTMENT TIER 1 bacitracin (ophthalmic) benzoyl peroxide- benzoyl peroxide- TIER 1 erythromycin erythromycin 5-3 % gel CLEOCIN 100 MG SUPPOS CLEOCIN TIER 3 clindamycin phosphate vaginal CLEOCIN PHOSPHATE (300 MG/2ML SOLUTION, CLEOCIN 600 MG/4ML SOLUTION, TIER 1 GA PHOSPHATE 900 MG/6ML SOLUTION) clindamycin phosphate clindacin etz clindacin etz 1 % swab TIER 1 clindacin-p clindacin-p 1 % swab TIER 1 clindamycin hcl (75 mg cap, clindamycin hcl TIER 1 150 mg cap, 300 mg cap) clindamycin palmitate clindamycin palmitate hcl TIER 1 hcl 75 mg/5ml recon soln

©2021 Wellmark, Inc. 15 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS clindamycin phosphate (1 % gel, 1 % lotion, 1 % clindamycin swab, 2 % cream, 300 TIER 1 phosphate mg/2ml solution, 600 mg/4ml solution, 900 mg/6ml solution) clindamycin clindamycin phosphate 1 % TIER 1 PA phosphate foam clindamycin clindamycin phosphate 1 % TIER 1 QL (180 PER 30 DAY(S)) phosphate solution CLINDESSE 2 % CREAM CLINDESSE clindamycin phosphate TIER 3 (one dose) colistimethate sodium colistimethate sodium (cba) SP-M (cba) 150 mg recon soln COLY-MYCIN M 150 MG COLY-MYCIN M RECON SOLN SP-M GA colistimethate sodium FIRVANQ (25 MG/ML RECON SOLN, 50 MG/ML FIRVANQ TIER 2 QL (450 PER 23 DAY(S)) RECON SOLN) vancomycin hcl fosfomycin fosfomycin tromethamine 3 TIER 1 tromethamine gm packet hyolev mb hyolev mb 81 mg tab TIER 1 HYOPHEN 81.6 MG TAB methenamine-hyosc- HYOPHEN TIER 1 GA methylene blue-benzoic acid-phenyl sal KIMYRSA 1200 MG KIMYRSA RECON SOLN SP-M oritavancin diphosphate linezolid (100 mg/5ml recon linezolid TIER 1 susp, 600 mg tab) mafenide acetate 5 % mafenide acetate TIER 1 packet me/naphos/mb/hyo1 81.6 me/naphos/mb/hyo1 TIER 1 mg tab methenamine methenamine hippurate 1 TIER 1 hippurate gm tab methenamine methenamine mandelate TIER 1 mandelate (0.5 gm tab, 1 gm tab) metronidazole (0.75 % gel, metronidazole 250 mg tab, 375 mg cap, TIER 1 500 mg tab)

©2021 Wellmark, Inc. 16 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS mupirocin mupirocin 2 % ointment TIER 1 mupirocin calcium 2 % mupirocin calcium TIER 1 QL (60 PER 30 DAY(S)) cream nitrofurantoin 25 mg/5ml nitrofurantoin TIER 1 suspension nitrofurantoin macrocrystal nitrofurantoin (25 mg cap, 50 mg cap, TIER 1 macrocrystal 100 mg cap) nitrofurantoin nitrofurantoin monohyd TIER 1 monohyd macro macro 100 mg cap NUVESSA 1.3 % GEL NUVESSA TIER 3 metronidazole vaginal phosphasal phosphasal 81.6 mg tab TIER 1 PRIMSOL 50 MG/5ML PRIMSOL SOLUTION TIER 3 trimethoprim hcl SIVEXTRO 200 MG TAB SIVEXTRO TIER 3 tedizolid phosphate SOLOSEC 2 GM PACKET SOLOSEC TIER 3 secnidazole SULFAMYLON 85 MG/GM SULFAMYLON CREAM TIER 3 mafenide acetate tinidazole (250 mg tab, 500 tinidazole TIER 1 mg tab) trimethoprim trimethoprim 100 mg tab TIER 1 TRIMPEX 50 MG/5ML TRIMPEX SOLUTION TIER 3 trimethoprim hcl ur n-c ur n-c 81.6 mg tab TIER 1 uramit mb uramit mb 118 mg cap TIER 1 urelle urelle 81 mg tab TIER 1 uretron d/s uretron d/s 81.6 mg tab TIER 1 uribel uribel 118 mg cap TIER 1 URIMAR-T 120 MG TAB methenamine-hyosc- URIMAR-T TIER 3 methylene blue-sod phos- phenyl sal urin ds urin ds 81.6 mg tab TIER 1 uro-458 uro-458 81 mg tab TIER 1 uro-mp uro-mp 118 mg cap TIER 1 urophen mb urophen mb 81.6 mg tab TIER 1 uryl uryl 81.6 mg tab TIER 1

©2021 Wellmark, Inc. 17 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ustell ustell 120 mg cap TIER 1 uticap uticap 120 mg cap TIER 1 utira-c utira-c 81.6 mg tab TIER 1 utrona-c utrona-c 81.6 mg tab TIER 1 vancomycin hcl (125 mg vancomycin hcl TIER 3 QL (80 PER 23 DAY(S)) cap, 250 mg cap) vancomycin hcl (5 gm vancomycin hcl recon soln, 750 mg recon TIER 1 soln) VANCOMYCIN HCL 250 VANCOMYCIN HCL MG RECON SOLN TIER 3 vancomycin hcl vandazole vandazole 0.75 % gel TIER 1 vilamit mb vilamit mb 118 mg cap TIER 1 vilevev mb vilevev mb 81 mg tab TIER 1 XIFAXAN (200 MG TAB, XIFAXAN 550 MG TAB) TIER 2 rifaximin

BETA-LACTAM, CEPHALOSPORINS

cefaclor (125 mg/5ml recon susp, 250 mg cap, 250 cefaclor mg/5ml recon susp, 375 TIER 1 mg/5ml recon susp, 500 mg cap) CEFACLOR ER 500 MG CEFACLOR ER TAB ER 12H TIER 3 cefaclor monohydrate cefadroxil (1 gm tab, 250 mg/5ml recon susp, 500 mg cefadroxil TIER 1 cap, 500 mg/5ml recon susp) cefdinir (125 mg/5ml recon cefdinir susp, 250 mg/5ml recon TIER 1 susp, 300 mg cap) cefditoren pivoxil (200 mg cefditoren pivoxil TIER 1 tab, 400 mg tab) cefepime hcl 1 gm recon cefepime hcl TIER 2 soln CEFEPIME-DEXTROSE 1- CEFEPIME- 5 GM-%(50ML) RECON TIER 2 DEXTROSE SOLN cefepime hcl-dextrose

©2021 Wellmark, Inc. 18 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS cefixime (100 mg/5ml recon cefixime susp, 200 mg/5ml recon TIER 1 susp, 400 mg cap) cefpodoxime proxetil (50 mg/5ml recon susp, 100 mg cefpodoxime proxetil TIER 1 tab, 100 mg/5ml recon susp, 200 mg tab) cefprozil (125 mg/5ml recon susp, 250 mg tab, 250 cefprozil TIER 1 mg/5ml recon susp, 500 mg tab) ceftibuten (180 mg/5ml ceftibuten TIER 1 recon susp, 400 mg cap) ceftriaxone sodium (1 gm ceftriaxone sodium recon soln, 250 mg recon TIER 1 soln, 500 mg recon soln) cefuroxime axetil (250 mg cefuroxime axetil TIER 1 tab, 500 mg tab) cephalexin (125 mg/5ml recon susp, 250 mg cap, cephalexin 250 mg tab, 250 mg/5ml TIER 1 recon susp, 500 mg cap, 500 mg tab, 750 mg cap) MAXIPIME 1 GM RECON MAXIPIME SOLN TIER 2 GA cefepime hcl SPECTRACEF 400 MG SPECTRACEF TAB TIER 3 GA cefditoren pivoxil SUPRAX (100 MG CHEW TAB, 200 MG CHEW TAB, SUPRAX 500 MG/5ML RECON TIER 3 SUSP) cefixime

BETA-LACTAM, OTHER

AZACTAM 1 GM RECON AZACTAM SOLN TIER 2 GA aztreonam aztreonam aztreonam 1 gm recon soln TIER 2

BETA-LACTAM, PENICILLINS

amoxicillin (125 mg chew tab, 125 mg/5ml recon susp, 200 mg/5ml recon susp, 250 mg cap, 250 mg amoxicillin TIER 1 chew tab, 250 mg/5ml recon susp, 400 mg/5ml recon susp, 500 mg cap, 500 mg tab, 875 mg tab) amoxicillin-pot clavulanate (200-28.5 mg chew tab, 200-28.5 mg/5ml recon susp, 250-125 mg tab, 250- amoxicillin-pot 62.5 mg/5ml recon susp, TIER 1 clavulanate 400-57 mg chew tab, 400- 57 mg/5ml recon susp, 500- 125 mg tab, 600-42.9 mg/5ml recon susp, 875- 125 mg tab) amoxicillin-pot amoxicillin-pot clavulanate TIER 1 clavulanate er er 1000-62.5 mg tab er 12h AMPICILLIN 500 MG CAP AMPICILLIN TIER 1 ampicillin AUGMENTIN 125-31.25 MG/5ML RECON SUSP AUGMENTIN TIER 3 amoxicillin & pot clavulanate BICILLIN L-A (600000 UNIT/ML SUSPENSION, 1200000 UNIT/2ML BICILLIN L-A TIER 1 SUSPENSION, 2400000 UNIT/4ML SUSPENSION) penicillin g benzathine dicloxacillin sodium (250 dicloxacillin sodium TIER 1 mg cap, 500 mg cap) penicillin v potassium (125 mg/5ml recon soln, 250 mg penicillin v potassium TIER 1 tab, 250 mg/5ml recon soln, 500 mg tab)

MACROLIDES

AZASITE 1 % SOLUTION AZASITE TIER 3 azithromycin (ophth) azithromycin (100 mg/5ml recon susp, 200 mg/5ml azithromycin TIER 1 recon susp, 250 mg tab, 500 mg tab, 600 mg tab)

©2021 Wellmark, Inc. 20 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS clarithromycin (125 mg/5ml recon susp, 250 mg tab, clarithromycin TIER 1 250 mg/5ml recon susp, 500 mg tab) clarithromycin er 500 mg clarithromycin er TIER 1 tab er 24h DIFICID 200 MG TAB DIFICID TIER 3 fidaxomicin e.e.s. 400 e.e.s. 400 400 mg tab TIER 1 ERY 2 % PAD ERY TIER 1 GA erythromycin (acne aid) ery-tab (250 mg tab dr, 333 ery-tab TIER 1 mg tab dr, 500 mg tab dr) ERYTHROCIN STEARATE ERYTHROCIN 250 MG TAB TIER 1 STEARATE erythromycin stearate erythromycin (2 % gel, 2 % pad, 2 % solution, 5 mg/gm erythromycin ointment, 250 mg tab dr, TIER 1 333 mg tab dr, 500 mg tab dr) erythromycin base (250 mg cp dr part, 250 mg tab, 250 erythromycin base TIER 1 mg tab dr, 333 mg tab dr, 500 mg tab, 500 mg tab dr) erythromycin ethylsuccinate erythromycin (200 mg/5ml recon susp, TIER 1 ethylsuccinate 400 mg tab, 400 mg/5ml recon susp) KLARITY-A 1 % KLARITY-A SOLUTION TIER 3 azithromycin (ophth) romycin romycin 5 mg/gm ointment TIER 1

QUINOLONES

BAXDELA 450 MG TAB BAXDELA TIER 3 delafloxacin meglumine BESIVANCE 0.6 % BESIVANCE SUSPENSION TIER 3 besifloxacin hcl CETRAXAL 0.2 % CETRAXAL SOLUTION TIER 3 ciprofloxacin hcl (otic) CILOXAN 0.3 % CILOXAN OINTMENT TIER 3 ciprofloxacin hcl (ophth)

©2021 Wellmark, Inc. 21 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ciprofloxacin (250 (5%) ciprofloxacin recon susp, 500 (10%) TIER 1 recon susp) ciprofloxacin hcl (0.2 % solution, 0.3 % solution, ciprofloxacin hcl TIER 1 100 mg tab, 250 mg tab, 500 mg tab, 750 mg tab) CIPROFLOXACIN- CIPROFLOX HCL ER (ER CIPROFLOXACIN- 500 MG TAB ER 24H, ER TIER 1 CIPROFLOX HCL ER 1000 MG TAB ER 24H) ciprofloxacin-ciprofloxacin hcl gatifloxacin gatifloxacin 0.5 % solution TIER 1 levofloxacin (0.5 % solution, 25 mg/ml solution, 250 mg levofloxacin TIER 1 tab, 500 mg tab, 750 mg tab) moxifloxacin hcl (0.5 % moxifloxacin hcl TIER 1 solution, 400 mg tab) moxifloxacin hcl (2x moxifloxacin hcl (2x day) TIER 1 day) 0.5 % solution ofloxacin (0.3 % solution, ofloxacin TIER 1 300 mg tab, 400 mg tab)

SULFONAMIDES

AVC VAGINAL 15 % AVC VAGINAL CREAM TIER 3 sulfanilamide vaginal silver sulfadiazine 1 % silver sulfadiazine TIER 1 cream ssd ssd 1 % cream TIER 1 sulfacetamide sodium (10 sulfacetamide sodium TIER 1 % ointment, 10 % solution) sulfacetamide sodium sulfacetamide sodium TIER 1 (acne) (acne) 10 % lotion SULFADIAZINE 500 MG SULFADIAZINE TAB TIER 1 sulfadiazine sulfamethoxazole- sulfamethoxazole- trimethoprim (200-40 TIER 1 trimethoprim mg/5ml suspension, 400-80 mg tab, 800-160 mg tab) sulfatrim pediatric 200-40 sulfatrim pediatric TIER 1 mg/5ml suspension

TETRACYCLINES

avidoxy avidoxy 100 mg tab TIER 1 coremino (45 mg tab er coremino 24h, 90 mg tab er 24h, 135 TIER 1 PA mg tab er 24h) demeclocycline hcl (150 mg demeclocycline hcl TIER 1 tab, 300 mg tab) DOXYCYCLINE 40 MG DOXYCYCLINE CAP DR TIER 3 PA doxycycline (rosacea) doxycycline hyclate (20 mg doxycycline hyclate tab, 50 mg cap, 100 mg TIER 1 cap, 100 mg tab) doxycycline hyclate (50 mg doxycycline hyclate tab dr, 75 mg tab dr, 100 TIER 1 PA mg tab dr, 150 mg tab dr) doxycycline monohydrate (25 mg/5ml recon susp, 50 doxycycline mg cap, 50 mg tab, 75 mg TIER 1 monohydrate tab, 100 mg cap, 100 mg tab) minocycline hcl (50 mg cap, 50 mg tab, 75 mg cap, 75 minocycline hcl TIER 1 mg tab, 100 mg cap, 100 mg tab) minocycline hcl er (er 45 mg tab er 24h, er 90 mg tab minocycline hcl er TIER 1 PA er 24h, er 135 mg tab er 24h) mondoxyne nl (50 mg cap, mondoxyne nl TIER 1 100 mg cap) morgidox (50 mg cap, 100 morgidox TIER 1 mg cap) okebo okebo 100 mg cap TIER 1 ORACEA 40 MG CAP DR ORACEA TIER 3 PA doxycycline (rosacea) SOLODYN (55 MG TAB ER 24H, 65 MG TAB ER 24H, 80 MG TAB ER 24H, 105 SOLODYN TIER 1 PA, GA MG TAB ER 24H, 115 MG TAB ER 24H) minocycline hcl soloxide soloxide 150 mg tab dr TIER 1 PA tetracycline hcl (250 mg tetracycline hcl TIER 1 cap, 500 mg cap)

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

DIACOMIT (250 MG CAP, PA, QL (360 PER 30 DIACOMIT 250 MG PACKET) SP-P DAY(S)) stiripentol DIACOMIT (500 MG CAP, PA, QL (180 PER 30 DIACOMIT 500 MG PACKET) SP-P DAY(S)) stiripentol EPIDIOLEX 100 MG/ML PA, QL (600 PER 30 EPIDIOLEX SOLUTION SP-P DAY(S)) cannabidiol FINTEPLA 2.2 MG/ML SOLUTION PA, QL (360 PER 30 FINTEPLA SP-NP fenfluramine hcl DAY(S)) (anticonvulsant) levetiracetam (100 mg/ml solution, 250 mg tab, 500 levetiracetam TIER 1 mg tab, 750 mg tab, 1000 mg tab) levetiracetam er (er 500 mg levetiracetam er tab er 24h, er 750 mg tab er TIER 1 24h) roweepra (500 mg tab, 750 roweepra TIER 1 mg tab, 1000 mg tab) roweepra xr (500 mg tab er roweepra xr TIER 1 24h, 750 mg tab er 24h)

CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN 300 MG CAP CELONTIN TIER 2 methsuximide ethosuximide (250 mg cap, ethosuximide TIER 1 250 mg/5ml solution) zonisamide (25 mg cap, 50 zonisamide TIER 1 mg cap, 100 mg cap)

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

clobazam clobazam 10 mg tab TIER 1 PA, QL (120 PER 30 DAYS) clobazam 2.5 mg/ml clobazam TIER 1 PA, QL (480 PER 30 DAYS) suspension clobazam clobazam 20 mg tab TIER 1 PA, QL (60 PER 30 DAYS)

©2021 Wellmark, Inc. 24 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DIASTAT ACUDIAL (10 MG DIASTAT ACUDIAL GEL, 20 MG GEL) TIER 3 GA diazepam (anticonvulsant) DIASTAT PEDIATRIC 2.5 DIASTAT PEDIATRIC MG GEL TIER 3 GA diazepam (anticonvulsant) diazepam (2.5 mg gel, 10 diazepam TIER 1 mg gel, 20 mg gel) divalproex sodium (125 mg divalproex sodium cap dr, 125 mg tab dr, 250 TIER 1 mg tab dr, 500 mg tab dr) divalproex sodium er (er divalproex sodium er 250 mg tab er 24h, er 500 TIER 1 mg tab er 24h) gabapentin (100 mg cap, 250 mg/5ml solution, 300 gabapentin mg cap, 300 mg/6ml TIER 1 solution, 400 mg cap, 600 mg tab, 800 mg tab) phenobarbital (15 mg tab, 16.2 mg tab, 20 mg/5ml elixir, 20 mg/5ml solution, phenobarbital TIER 1 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg tab, 97.2 mg tab, 100 mg tab) pregabalin er (er 82.5 mg pregabalin er tab er 24h, er 165 mg tab er TIER 1 24h, er 330 mg tab er 24h) primidone (50 mg tab, 250 primidone TIER 1 mg tab) tiagabine hcl (2 mg tab, 4 tiagabine hcl mg tab, 12 mg tab, 16 mg TIER 1 tab) valproate sodium 250 valproate sodium TIER 1 mg/5ml solution valproic acid (250 mg cap, valproic acid TIER 1 250 mg/5ml solution) VALTOCO 10 MG DOSE VALTOCO 10 MG 10 MG/0.1ML LIQUID TIER 3 PA, QL (5 PER 30 DAY(S)) DOSE diazepam (anticonvulsant) VALTOCO 15 MG DOSE VALTOCO 15 MG 7.5 MG/0.1ML LIQD THPK TIER 3 PA, QL (10 PER 30 DAY(S)) DOSE diazepam (anticonvulsant)

©2021 Wellmark, Inc. 25 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VALTOCO 20 MG DOSE VALTOCO 20 MG 10 MG/0.1ML LIQD THPK TIER 3 PA, QL (10 PER 30 DAY(S)) DOSE diazepam (anticonvulsant) VALTOCO 5 MG DOSE 5 VALTOCO 5 MG MG/0.1ML LIQUID TIER 3 PA, QL (5 PER 30 DAY(S)) DOSE diazepam (anticonvulsant) QL (180 PER 30 DAYS), vigabatrin (500 mg packet, vigabatrin SP-P SBG (Specialty Biosimilars 500 mg tab) and Specialty generics) QL (180 PER 30 DAYS), vigadrone vigadrone 500 mg packet SP-P SBG (Specialty Biosimilars and Specialty generics)

GLUTAMATE REDUCING AGENTS

felbamate (400 mg tab, 600 felbamate mg tab, 600 mg/5ml TIER 1 suspension) lamotrigine (5 mg chew tab, 25 mg chew tab, 25 mg tab, 25 mg tab disp, 50 mg tab lamotrigine TIER 1 disp, 100 mg tab, 100 mg tab disp, 150 mg tab, 200 mg tab, 200 mg tab disp) lamotrigine er (er 25 mg tab er 24h, er 50 mg tab er 24h, er 100 mg tab er 24h, er lamotrigine er TIER 1 200 mg tab er 24h, er 250 mg tab er 24h, er 300 mg tab er 24h) subvenite (25 mg tab, 100 subvenite mg tab, 150 mg tab, 200 TIER 1 mg tab) topiramate (15 mg cap sprink, 25 mg cap sprink, topiramate TIER 1 25 mg tab, 50 mg tab, 100 mg tab, 200 mg tab) topiramate er (er 25 mg cp24 sprnk, er 50 mg cp24 sprnk, er 100 mg cp24 topiramate er TIER 1 sprnk, er 150 mg cp24 sprnk, er 200 mg cp24 sprnk)

SODIUM CHANNEL AGENTS

carbamazepine (100 mg carbamazepine chew tab, 100 mg/5ml TIER 1 suspension, 200 mg tab)

©2021 Wellmark, Inc. 26 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS carbamazepine er (er 100 mg cap er 12h, er 100 mg tab er 12h, er 200 mg cap carbamazepine er TIER 1 er 12h, er 200 mg tab er 12h, er 300 mg cap er 12h, er 400 mg tab er 12h) DILANTIN 30 MG CAP DILANTIN TIER 3 phenytoin sodium extended epitol epitol 200 mg tab TIER 1 oxcarbazepine (150 mg tab, oxcarbazepine 300 mg tab, 300 mg/5ml TIER 1 suspension, 600 mg tab) PEGANONE 250 MG TAB PEGANONE TIER 2 ethotoin phenytoin (50 mg chew tab, phenytoin 100 mg/4ml suspension, TIER 1 125 mg/5ml suspension) phenytoin infatabs 50 mg phenytoin infatabs TIER 1 chew tab phenytoin sodium extended phenytoin sodium (100 mg cap, 200 mg cap, TIER 1 extended 300 mg cap) rufinamide (200 mg tab, rufinamide TIER 1 PA, QL (240 PER 30 DAYS) 400 mg tab) rufinamide 40 mg/ml rufinamide TIER 1 PA, QL (2400 PER 30 DAYS) suspension VIMPAT (10 MG/ML SOLUTION, 50 MG TAB, VIMPAT 100 MG TAB, 150 MG TAB, TIER 2 200 MG TAB) lacosamide

ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHER

AJOVY 225 MG/1.5ML AJOVY SOLN A-INJ SP-P PA, QL (1 PER 28 DAY(S)) fremanezumab-vfrm ERGOLOID MESYLATES 1 ERGOLOID MG TAB TIER 1 MESYLATES ergoloid mesylates

CHOLINESTERASE INHIBITORS

donepezil hcl (5 mg tab, 5 donepezil hcl mg tab disp, 10 mg tab, 10 TIER 1 mg tab disp, 23 mg tab)

©2021 Wellmark, Inc. 27 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS galantamine hydrobromide galantamine (4 mg tab, 8 mg tab, 12 mg TIER 1 hydrobromide tab) galantamine hydrobromide galantamine er (er 8 mg cap er 24h, er TIER 1 hydrobromide er 16 mg cap er 24h, er 24 mg cap er 24h) rivastigmine (4.6 mg/24hr patch 24hr, 9.5 mg/24hr rivastigmine TIER 1 patch 24hr, 13.3 mg/24hr patch 24hr) rivastigmine tartrate (1.5 rivastigmine tartrate mg cap, 3 mg cap, 4.5 mg TIER 1 cap, 6 mg cap)

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

memantine hcl (2 mg/ml PA, QL (300 PER 30 memantine hcl solution, 10 mg/5ml TIER 1 DAY(S)) solution) memantine hcl (5 mg tab, memantine hcl TIER 1 10 mg tab) memantine hcl er (er 7 mg cap er 24h, er 14 mg cap er memantine hcl er TIER 1 24h, er 21 mg cap er 24h, er 28 mg cap er 24h)

ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

bupropion hcl (75 mg tab, bupropion hcl TIER 1 100 mg tab) bupropion hcl er (sr) (er 100 mg tab er 12h, er 150 mg bupropion hcl er (sr) TIER 1 tab er 12h, er 200 mg tab er 12h) bupropion hcl er (xl) (er 150 bupropion hcl er (xl) mg tab er 24h, er 300 mg TIER 1 tab er 24h) CHLORDIAZEPOXIDE- AMITRIPTYLINE (5-12.5 CHLORDIAZEPOXID MG TAB, 10-25 MG TAB) TIER 1 E-AMITRIPTYLINE chlordiazepoxide- amitriptyline

©2021 Wellmark, Inc. 28 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS mirtazapine (7.5 mg tab, 15 mg tab, 15 mg tab disp, 30 mirtazapine TIER 1 mg tab, 30 mg tab disp, 45 mg tab, 45 mg tab disp) olanzapine-fluoxetine hcl olanzapine-fluoxetine (3-25 mg cap, 6-25 mg cap, TIER 1 hcl 6-50 mg cap, 12-25 mg cap, 12-50 mg cap) PERPHENAZINE- AMITRIPTYLINE (2-10 MG PERPHENAZINE- TAB, 2-25 MG TAB, 4-10 TIER 1 AMITRIPTYLINE MG TAB, 4-25 MG TAB, 4- 50 MG TAB) perphenazine-amitriptyline

MONOAMINE OXIDASE INHIBITORS

EMSAM (6 MG/24HR PATCH 24HR, 9 MG/24HR EMSAM PATCH 24HR, 12 TIER 3 MG/24HR PATCH 24HR) selegiline MARPLAN 10 MG TAB MARPLAN TIER 2 isocarboxazid phenelzine sulfate 15 mg phenelzine sulfate TIER 1 tab tranylcypromine tranylcypromine sulfate 10 TIER 1 sulfate mg tab

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)

citalopram hydrobromide citalopram (10 mg tab, 20 mg tab, 40 TIER 1 hydrobromide mg tab) citalopram citalopram hydrobromide 10 PA, QL (600 PER 30 TIER 1 hydrobromide mg/5ml solution DAY(S)) desvenlafaxine er (er 50 mg desvenlafaxine er tab er 24h, er 100 mg tab er TIER 1 PA, QL (30 PER 30 DAYS) 24h) desvenlafaxine succinate er desvenlafaxine (er 25 mg tab er 24h, er 50 TIER 1 QL (30 PER 30 DAYS) succinate er mg tab er 24h, er 100 mg tab er 24h) escitalopram oxalate (5 mg escitalopram oxalate tab, 5 mg/5ml solution, 10 TIER 1 mg tab, 20 mg tab)

©2021 Wellmark, Inc. 29 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FLUOXETINE HCL (10 MG CAP, 20 MG CAP, 20 FLUOXETINE HCL MG/5ML SOLUTION, 40 TIER 1 MG CAP, 90 MG CAP DR) fluoxetine hcl fluoxetine hcl (pmdd) (10 fluoxetine hcl (pmdd) TIER 1 mg cap, 20 mg cap) fluvoxamine maleate (25 fluvoxamine maleate mg tab, 50 mg tab, 100 mg TIER 1 tab) fluvoxamine maleate er (er fluvoxamine maleate 100 mg cap er 24h, er 150 TIER 1 PA er mg cap er 24h) MAPROTILINE HCL (25 MG TAB, 50 MG TAB, 75 MAPROTILINE HCL TIER 1 MG TAB) maprotiline hcl nefazodone hcl (50 mg tab, nefazodone hcl 100 mg tab, 150 mg tab, TIER 1 200 mg tab, 250 mg tab) paroxetine hcl (10 mg tab, paroxetine hcl 20 mg tab, 30 mg tab, 40 TIER 1 mg tab) paroxetine hcl er (er 12.5 mg tab er 24h, er 25 mg tab paroxetine hcl er TIER 1 er 24h, er 37.5 mg tab er 24h) paroxetine mesylate 7.5 mg paroxetine mesylate TIER 1 QL (30 PER 30 DAYS) cap sertraline hcl (20 mg/ml sertraline hcl conc, 25 mg tab, 50 mg tab, TIER 1 100 mg tab) trazodone hcl (50 mg tab, trazodone hcl TIER 1 100 mg tab, 150 mg tab) venlafaxine hcl (25 mg tab, venlafaxine hcl 37.5 mg tab, 50 mg tab, 75 TIER 1 mg tab, 100 mg tab) venlafaxine hcl er (er 37.5 mg cap er 24h, er 75 mg venlafaxine hcl er TIER 1 cap er 24h, er 150 mg cap er 24h) VIIBRYD (10 MG TAB, 20 VIIBRYD MG TAB, 40 MG TAB) TIER 3 PA vilazodone hcl

TRICYCLICS

amitriptyline hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 amitriptyline hcl TIER 1 mg tab, 100 mg tab, 150 mg tab) AMOXAPINE (25 MG TAB, 50 MG TAB, 100 MG TAB, AMOXAPINE TIER 1 150 MG TAB) amoxapine clomipramine hcl (25 mg clomipramine hcl TIER 1 cap, 50 mg cap, 75 mg cap) desipramine hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 desipramine hcl TIER 1 mg tab, 100 mg tab, 150 mg tab) doxepin hcl (10 mg cap, 10 mg/ml conc, 25 mg cap, 50 doxepin hcl TIER 1 mg cap, 75 mg cap, 100 mg cap, 150 mg cap) imipramine hcl (10 mg tab, imipramine hcl TIER 1 25 mg tab, 50 mg tab) nortriptyline hcl (10 mg cap, nortriptyline hcl 25 mg cap, 50 mg cap, 75 TIER 1 mg cap) nortriptyline hcl 10 mg/5ml PA, QL (2400 PER 30 nortriptyline hcl TIER 1 solution DAY(S)) protriptyline hcl (5 mg tab, protriptyline hcl TIER 1 10 mg tab) trimipramine maleate (25 trimipramine maleate mg cap, 50 mg cap, 100 mg TIER 1 cap)

ANTIEMETICS

ANTIEMETICS, OTHER

compro compro 25 mg suppos TIER 1 metoclopramide hcl (5 mg tab, 5 mg/5ml solution, 10 metoclopramide hcl TIER 1 mg tab, 10 mg/10ml solution) perphenazine (2 mg tab, 4 perphenazine mg tab, 8 mg tab, 16 mg TIER 1 tab) phenadoz (12.5 mg suppos, phenadoz TIER 1 25 mg suppos)

©2021 Wellmark, Inc. 31 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS phenergan (12.5 mg phenergan suppos, 25 mg suppos, 50 TIER 1 mg suppos) prochlorperazine 25 mg prochlorperazine TIER 1 suppos prochlorperazine prochlorperazine maleate TIER 1 maleate (5 mg tab, 10 mg tab) promethazine hcl (12.5 mg suppos, 12.5 mg tab, 25 mg promethazine hcl TIER 1 suppos, 25 mg tab, 50 mg suppos, 50 mg tab) PROMETHEGAN (12.5 MG SUPPOS, 25 MG PROMETHEGAN SUPPOS, 50 MG TIER 1 GA SUPPOS) promethazine hcl scopolamine 1 mg/3days scopolamine TIER 1 patch 72hr trimethobenzamide trimethobenzamide hcl 300 TIER 1 hcl mg cap

EMETOGENIC THERAPY ADJUNCTS

AKYNZEO 300-0.5 MG AKYNZEO CAP TIER 3 netupitant-palonosetron ANZEMET (50 MG TAB, ANZEMET 100 MG TAB) TIER 2 dolasetron mesylate aprepitant (40 mg cap, 80 & 125 mg cap, 80 & 125 mg aprepitant TIER 1 misc, 80 mg cap, 125 mg cap) CESAMET 1 MG CAP CESAMET TIER 2 nabilone dronabinol (2.5 mg cap, 5 dronabinol TIER 1 mg cap, 10 mg cap) EMEND 125 MG/5ML EMEND RECON SUSP TIER 2 aprepitant granisetron hcl granisetron hcl 1 mg tab TIER 1 ondansetron (4 mg tab ondansetron TIER 1 disp, 8 mg tab disp) ondansetron hcl (4 mg tab, ondansetron hcl TIER 1 8 mg tab, 24 mg tab) ondansetron hcl 4 mg/5ml ondansetron hcl TIER 1 QL (300 PER 30 DAYS) solution

ANTIFUNGALS

bio-statin bio-statin powder TIER 1 ciclodan (0.77 % cream, 8 ciclodan TIER 1 % solution) ciclopirox (0.77 % gel, 1 % ciclopirox TIER 1 shampoo, 8 % solution) ciclopirox olamine (0.77 % ciclopirox olamine TIER 1 cream, 0.77 % suspension) clotrimazole clotrimazole 10 mg troche TIER 1 CRESEMBA 186 MG CAP CRESEMBA TIER 3 isavuconazonium sulfate econazole nitrate 1 % econazole nitrate TIER 1 QL (170 PER 30 DAY(S)) cream ERTACZO 2 % CREAM ERTACZO TIER 3 sertaconazole nitrate EXELDERM 1 % CREAM EXELDERM TIER 3 sulconazole nitrate fluconazole (10 mg/ml recon susp, 40 mg/ml recon fluconazole susp, 50 mg tab, 100 mg TIER 1 tab, 150 mg tab, 200 mg tab) flucytosine (250 mg cap, flucytosine TIER 1 500 mg cap) griseofulvin microsize (125 griseofulvin microsize mg/5ml suspension, 500 TIER 1 mg tab) griseofulvin griseofulvin ultramicrosize TIER 1 ultramicrosize (125 mg tab, 250 mg tab) GYNAZOLE-1 2 % CREAM GYNAZOLE-1 butoconazole nitrate (one TIER 3 dose) itraconazole (10 mg/ml itraconazole TIER 1 PA solution, 100 mg cap) ketoconazole (2 % ketoconazole TIER 1 shampoo, 200 mg tab) ketoconazole ketoconazole 2 % cream TIER 1 QL (240 PER 30 DAY(S)) ketoconazole ketoconazole 2 % foam TIER 1 QL (200 PER 30 DAY(S)) ketodan ketodan 2 % foam TIER 1 QL (200 PER 30 DAY(S)) luliconazole luliconazole 1 % cream TIER 1

©2021 Wellmark, Inc. 33 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LUZU 1 % CREAM LUZU TIER 3 GA luliconazole miconazole-zinc oxide- miconazole-zinc petrolat 0.25-15-81.35 % TIER 1 oxide-petrolat ointment naftifine hcl (1 % cream, 1 naftifine hcl TIER 1 % gel, 2 % cream) NATACYN 5 % NATACYN SUSPENSION TIER 3 natamycin NOXAFIL 40 MG/ML NOXAFIL SUSPENSION TIER 3 posaconazole nyamyc 100000 unit/gm nyamyc TIER 1 powder nyata 100000 unit/gm nyata TIER 1 powder nystatin (100000 unit/gm cream, 100000 unit/gm ointment, 100000 unit/gm nystatin TIER 1 powder, 100000 unit/ml suspension, 500000 unit tab) nystatin-triamcinolone nystatin-triamcinolone TIER 1 (cream, ointment) nystop 100000 unit/gm nystop TIER 1 powder ORAVIG 50 MG TAB ORAVIG TIER 3 miconazole (mouth-throat) posaconazole 100 mg tab posaconazole TIER 1 dr SULCONAZOLE NITRATE SULCONAZOLE 1 % CREAM TIER 1 NITRATE sulconazole nitrate terbinafine hcl terbinafine hcl 250 mg tab TIER 1 terconazole (0.4 % cream, terconazole 0.8 % cream, 80 mg TIER 1 suppos) VFEND IV 200 MG RECON VFEND IV SOLN TIER 2 GA voriconazole voriconazole (40 mg/ml voriconazole recon susp, 50 mg tab, 200 TIER 1 mg tab) voriconazole 200 mg recon voriconazole TIER 2 soln

ANTIGOUT AGENTS

allopurinol (100 mg tab, 300 allopurinol TIER 1 mg tab) colchicine (0.6 mg cap, 0.6 colchicine TIER 1 mg tab) colchicine-probenecid 0.5- colchicine-probenecid TIER 1 500 mg tab febuxostat (40 mg tab, 80 febuxostat TIER 1 mg tab) probenecid probenecid 500 mg tab TIER 1

ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS

dihydroergotamine dihydroergotamine TIER 1 mesylate mesylate 1 mg/ml solution ERGOMAR 2 MG SL TAB ERGOMAR TIER 3 ergotamine tartrate ergotamine-caffeine 1-100 ergotamine-caffeine TIER 1 mg tab migergot migergot 2-100 mg suppos TIER 1

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

almotriptan malate (6.25 almotriptan malate TIER 1 QL (12 PER 30 DAYS) mg tab, 12.5 mg tab) eletriptan eletriptan hydrobromide (20 TIER 1 PA, QL (12 PER 30 DAYS) hydrobromide mg tab, 40 mg tab) frovatriptan succinate 2.5 frovatriptan succinate TIER 1 PA, QL (18 PER 30 DAYS) mg tab naratriptan hcl (1 mg tab, naratriptan hcl TIER 1 QL (12 PER 30 DAYS) 2.5 mg tab) rizatriptan benzoate (5 mg rizatriptan benzoate tab, 5 mg tab disp, 10 mg TIER 1 QL (18 PER 30 DAYS) tab, 10 mg tab disp) sumatriptan 20 mg/act sumatriptan TIER 1 QL (12 PER 30 DAYS) solution sumatriptan 5 mg/act sumatriptan TIER 1 QL (24 PER 30 DAYS) solution sumatriptan succinate (25 sumatriptan succinate mg tab, 50 mg tab, 100 mg TIER 1 QL (12 PER 30 DAYS) tab) sumatriptan succinate (6 sumatriptan succinate soln a-inj, 6 soln prsyr, 6 TIER 1 PA, QL (12 PER 30 DAYS) solution)

©2021 Wellmark, Inc. 35 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS sumatriptan succinate 4 sumatriptan succinate TIER 1 PA, QL (18 PER 30 DAYS) mg/0.5ml soln a-inj sumatriptan succinate sumatriptan succinate refill TIER 1 PA, QL (18 PER 30 DAYS) refill 4 mg/0.5ml soln cart sumatriptan succinate sumatriptan succinate refill TIER 1 PA, QL (12 PER 30 DAYS) refill 6 mg/0.5ml soln cart sumatriptan-naproxen sumatriptan-naproxen TIER 1 PA, QL (9 PER 30 DAYS) sodium sodium 85-500 mg tab zolmitriptan (2.5 mg zolmitriptan TIER 1 PA, QL (12 PER 30 DAYS) solution, 5 mg solution) zolmitriptan (2.5 mg tab, 2.5 zolmitriptan mg tab disp, 5 mg tab, 5 mg TIER 1 QL (12 PER 30 DAYS) tab disp)

ANTIMIGRAINE AGENTS, OTHER

AIMOVIG (140 MG DOSE) AIMOVIG (140 MG 70 MG/ML SOLN A-INJ SP-P PA, QL (1 PER 30 DAY(S)) DOSE) erenumab-aooe AIMOVIG (70 MG/ML SOLN A-INJ, 140 MG/ML AIMOVIG SP-P PA, QL (1 PER 30 DAY(S)) SOLN A-INJ) erenumab-aooe AJOVY 225 MG/1.5ML AJOVY SOLN PRSYR SP-P PA, QL (3 PER 90 DAY(S)) fremanezumab-vfrm EMGALITY (120 MG/ML SOLN A-INJ, 120 MG/ML EMGALITY SP-P PA, QL (1 PER 28 DAY(S)) SOLN PRSYR) galcanezumab-gnlm EMGALITY (300 MG EMGALITY (300 MG DOSE) 100 MG/ML SOLN SP-P PA, QL (1 PER 28 DAY(S)) DOSE) PRSYR galcanezumab-gnlm

PROPHYLACTIC

VYEPTI 100 MG/ML VYEPTI SOLUTION SP-M PA eptinezumab-jjmr

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

GUANIDINE HCL 125 MG GUANIDINE HCL TAB TIER 3 guanidine hcl pyridostigmine pyridostigmine bromide (60 TIER 1 bromide mg tab, 60 mg/5ml solution)

©2021 Wellmark, Inc. 36 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS pyridostigmine pyridostigmine bromide er TIER 1 bromide er 180 mg tab er RUZURGI 10 MG TAB PA, QL (240 PER 30 RUZURGI SP-P amifampridine DAY(S))

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone (25 mg tab, 100 dapsone TIER 1 mg tab) rifabutin rifabutin 150 mg cap TIER 1

ANTITUBERCULARS

cycloserine cycloserine 250 mg cap TIER 1 ethambutol hcl (100 mg tab, ethambutol hcl TIER 1 400 mg tab) ISONIAZID (50 MG/5ML SYRUP, 100 MG TAB, 300 ISONIAZID TIER 1 MG TAB) isoniazid PASER 4 GM PACKET PASER TIER 1 aminosalicylic acid PRETOMANID 200 MG PRETOMANID TAB TIER 3 QL (30 PER 30 DAY(S)) pretomanid PRIFTIN 150 MG TAB PRIFTIN TIER 3 rifapentine pyrazinamide pyrazinamide 500 mg tab TIER 1 rifampin (150 mg cap, 300 rifampin TIER 1 mg cap) RIFATER 50-120-300 MG TAB RIFATER TIER 3 isoniazid-rifampin w/ pyrazinamide SIRTURO 100 MG TAB SIRTURO TIER 3 bedaquiline fumarate TRECATOR 250 MG TAB TRECATOR TIER 3 ethionamide

ANTINEOPLASTICS

ALKYLATING AGENTS

CYCLOPHOSPHAMIDE (1 CYCLOPHOSPHAMI GM/5ML SOLUTION, 500 SP-M DE MG/2.5ML SOLUTION) cyclophosphamide cyclophosphamide (25 mg cyclophosphamide TIER 1 cap, 50 mg cap) GLEOSTINE (5 MG CAP, 10 MG CAP, 40 MG CAP, GLEOSTINE TIER 2 100 MG CAP) lomustine HEXALEN 50 MG CAP HEXALEN TIER 2 altretamine LEUKERAN 2 MG TAB LEUKERAN TIER 2 chlorambucil MATULANE 50 MG CAP MATULANE TIER 2 procarbazine hcl melphalan melphalan 2 mg tab TIER 1 MYLERAN 2 MG TAB MYLERAN TIER 2 busulfan temozolomide (5 mg cap, 20 mg cap, 100 mg cap, SBG (Specialty Biosimilars temozolomide SP-P 140 mg cap, 180 mg cap, and Specialty generics) 250 mg cap) VALCHLOR 0.016 % GEL VALCHLOR mechlorethamine hcl SP-P (topical)

ANTIANDROGENS

abiraterone acetate (250 SBG (Specialty Biosimilars abiraterone acetate SP-P mg tab, 500 mg tab) and Specialty generics) bicalutamide bicalutamide 50 mg tab TIER 1 ERLEADA 60 MG TAB ERLEADA SP-P apalutamide flutamide flutamide 125 mg cap TIER 1 nilutamide nilutamide 150 mg tab TIER 1 NUBEQA 300 MG TAB NUBEQA SP-P darolutamide XTANDI 40 MG CAP XTANDI SP-P enzalutamide

ANTIANGIOGENIC AGENTS

POMALYST (1 MG CAP, 2 MG CAP, 3 MG CAP, 4 MG POMALYST SP-P CAP) pomalidomide REVLIMID (2.5 MG CAP, 5 MG CAP, 10 MG CAP, 15 REVLIMID MG CAP, 20 MG CAP, 25 SP-P MG CAP) lenalidomide THALOMID (50 MG CAP, 100 MG CAP, 150 MG THALOMID SP-P CAP, 200 MG CAP) thalidomide

ANTIESTROGENS/MODIFIERS

EMCYT 140 MG CAP EMCYT estramustine phosphate SP-P sodium SOLTAMOX 10 MG/5ML SOLTAMOX SOLUTION TIER 2 PA tamoxifen citrate tamoxifen citrate (10 mg tamoxifen citrate TIER 1 PA tab, 20 mg tab) toremifene citrate 60 mg toremifene citrate TIER 1 tab

ANTIMETABOLITES

capecitabine (150 mg tab, SBG (Specialty Biosimilars capecitabine SP-P 500 mg tab) and Specialty generics) DROXIA (200 MG CAP, 300 MG CAP, 400 MG DROXIA CAP) TIER 3 hydroxyurea (sickle cell anemia) FLUOROURACIL (2 % SOLUTION, 5 % CREAM, 5 FLUOROURACIL TIER 1 % SOLUTION) fluorouracil (topical) hydroxyurea hydroxyurea 500 mg cap TIER 1 mercaptopurine mercaptopurine 50 mg tab TIER 1

ANTINEOPLASTICS, OTHER

ALUNBRIG (30 MG TAB, 90 & 180 MG TAB THPK, ALUNBRIG SP-P 90 MG TAB, 180 MG TAB) brigatinib AYVAKIT (25 MG TAB, 50 MG TAB, 100 MG TAB, 200 AYVAKIT SP-P MG TAB, 300 MG TAB) avapritinib BALVERSA (3 MG TAB, 4 BALVERSA MG TAB, 5 MG TAB) SP-P erdafitinib BRUKINSA 80 MG CAP BRUKINSA SP-P zanubrutinib HEMANGEOL 4.28 MG/ML HEMANGEOL SOLUTION TIER 3 propranolol hcl IDHIFA (50 MG TAB, 100 IDHIFA MG TAB) SP-P enasidenib mesylate INQOVI 35-100 MG TAB INQOVI SP-NP QL (5 PER 28 DAY(S)) decitabine-cedazuridine leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, leucovorin calcium TIER 1 25 mg tab, 50 mg recon soln) LONSURF (15-6.14 MG LONSURF TAB, 20-8.19 MG TAB) SP-P trifluridine-tipiracil LYSODREN 500 MG TAB LYSODREN TIER 2 mitotane NINLARO (2.3 MG CAP, 3 NINLARO MG CAP, 4 MG CAP) SP-P ixazomib citrate ONUREG (200 MG TAB, ONUREG 300 MG TAB) SP-P azacitidine PEMAZYRE (4.5 MG TAB, PEMAZYRE 9 MG TAB, 13.5 MG TAB) SP-P pemigatinib

©2021 Wellmark, Inc. 40 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PHESGO (60-60-2000 SOLUTION, 80-40-2000 PHESGO SOLUTION) SP-M pertuzumab-trastuzumab- hyaluronidase-zzxf QINLOCK 50 MG TAB QINLOCK SP-P ripretinib RETEVMO (40 MG CAP, RETEVMO 80 MG CAP) SP-P selpercatinib ROZLYTREK 100 MG CAP ROZLYTREK SP-P QL (30 PER 30 DAY(S)) entrectinib ROZLYTREK 200 MG CAP ROZLYTREK SP-P QL (90 PER 30 DAY(S)) entrectinib RUBRACA (200 MG TAB, 250 MG TAB, 300 MG RUBRACA SP-P TAB) rucaparib camsylate RYDAPT 25 MG CAP RYDAPT SP-P midostaurin SYLATRON (200 MCG KIT, 300 MCG KIT, 600 MCG SYLATRON KIT) SP-P peginterferon alfa-2b (antineoplastic) SYNRIBO 3.5 MG RECON SOLN SYNRIBO SP-M omacetaxine mepesuccinate TABRECTA (150 MG TAB, TABRECTA 200 MG TAB) SP-P capmatinib hcl TAZVERIK 200 MG TAB TAZVERIK SP-P tazemetostat hbr TECARTUS TECARTUS SUSPENSION SP-M brexucabtagene autoleucel TIBSOVO 250 MG TAB TIBSOVO SP-P ivosidenib TURALIO 200 MG CAP PA, QL (120 PER 30 TURALIO SP-P pexidartinib hcl DAY(S)) VITRAKVI (20 MG/ML SOLUTION, 25 MG CAP, VITRAKVI SP-P 100 MG CAP) larotrectinib sulfate

©2021 Wellmark, Inc. 41 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VIZIMPRO (15 MG TAB, 30 VIZIMPRO MG TAB, 45 MG TAB) SP-P dacomitinib XOSPATA 40 MG TAB XOSPATA SP-P gilteritinib fumarate XPOVIO (100 MG ONCE WEEKLY) (MG 20 MG TAB XPOVIO (100 MG THPK, MG 50 MG TAB SP-P ONCE WEEKLY) THPK) selinexor XPOVIO (40 MG ONCE WEEKLY) (MG 20 MG TAB XPOVIO (40 MG THPK, MG 40 MG TAB SP-P ONCE WEEKLY) THPK) selinexor XPOVIO (40 MG TWICE WEEKLY) (MG 20 MG TAB XPOVIO (40 MG THPK, MG 40 MG TAB SP-P TWICE WEEKLY) THPK) selinexor XPOVIO (60 MG ONCE WEEKLY) (MG 20 MG TAB XPOVIO (60 MG THPK, MG 60 MG TAB SP-P ONCE WEEKLY) THPK) selinexor XPOVIO (60 MG TWICE XPOVIO (60 MG WEEKLY) 20 MG TAB SP-P TWICE WEEKLY) THPK selinexor XPOVIO (80 MG ONCE WEEKLY) (MG 20 MG TAB XPOVIO (80 MG THPK, MG 40 MG TAB SP-P ONCE WEEKLY) THPK) selinexor XPOVIO (80 MG TWICE XPOVIO (80 MG WEEKLY) 20 MG TAB SP-P TWICE WEEKLY) THPK selinexor ZEJULA 100 MG CAP ZEJULA SP-P niraparib tosylate ZOLINZA 100 MG CAP ZOLINZA SP-P vorinostat

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole anastrozole 1 mg tab TIER 1 PA exemestane exemestane 25 mg tab TIER 1 PA

ENZYME INHIBITORS

SBG (Specialty Biosimilars etoposide etoposide 50 mg cap SP-P and Specialty generics) GAVRETO 100 MG CAP GAVRETO SP-P pralsetinib HYCAMTIN (0.25 MG CAP, HYCAMTIN 1 MG CAP) SP-P topotecan hcl LORBRENA (25 MG TAB, LORBRENA 100 MG TAB) SP-P lorlatinib PIQRAY (200 MG DAILY PIQRAY (200 MG DOSE) 200 MG TAB THPK SP-P DAILY DOSE) alpelisib PIQRAY (250 MG DAILY PIQRAY (250 MG DOSE) 200 & 50 MG TAB SP-P DAILY DOSE) THPK alpelisib PIQRAY (300 MG DAILY PIQRAY (300 MG DOSE) 2 X 150 MG TAB SP-P DAILY DOSE) THPK alpelisib

MOLECULAR TARGET INHIBITORS

AFINITOR (2.5 MG TAB, AFINITOR 7.5 MG TAB) SP-NP QL (60 PER 30 DAYS), GA everolimus AFINITOR 10 MG TAB AFINITOR SP-P QL (60 PER 30 DAYS) everolimus AFINITOR 5 MG TAB AFINITOR SP-NP QL (120 PER 30 DAYS), GA everolimus AFINITOR DISPERZ (2 MG TAB SOL, 3 MG TAB SOL, AFINITOR DISPERZ SP-P 5 MG TAB SOL) everolimus ALECENSA 150 MG CAP ALECENSA SP-P alectinib hcl BOSULIF (100 MG TAB, 400 MG TAB, 500 MG BOSULIF SP-P TAB) bosutinib BRAFTOVI (50 MG CAP, BRAFTOVI 75 MG CAP) SP-P encorafenib

©2021 Wellmark, Inc. 43 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CABOMETYX (20 MG TAB, CABOMETYX 40 MG TAB, 60 MG TAB) SP-P cabozantinib s-malate CALQUENCE 100 MG CAP CALQUENCE TIER 2 acalabrutinib CAPRELSA (100 MG TAB, CAPRELSA 300 MG TAB) SP-P vandetanib COMETRIQ (100 MG COMETRIQ (100 MG DAILY DOSE) 80 & 20 MG SP-P DAILY DOSE) KIT cabozantinib s-malate COMETRIQ (140 MG COMETRIQ (140 MG DAILY DOSE) 3 X 20 MG & SP-P DAILY DOSE) 80 MG KIT cabozantinib s-malate COMETRIQ (60 MG DAILY COMETRIQ (60 MG DOSE) 20 MG KIT SP-P DAILY DOSE) cabozantinib s-malate COPIKTRA (15 MG CAP, COPIKTRA 25 MG CAP) SP-P duvelisib COTELLIC 20 MG TAB COTELLIC SP-P cobimetinib fumarate DAURISMO (25 MG TAB, DAURISMO 100 MG TAB) SP-P glasdegib maleate ERIVEDGE 150 MG CAP ERIVEDGE SP-P vismodegib erlotinib hcl (25 mg tab, 100 SBG (Specialty Biosimilars erlotinib hcl SP-P mg tab, 150 mg tab) and Specialty generics) QL (60 PER 30 DAYS), SBG everolimus (2.5 mg tab, 7.5 everolimus SP-P (Specialty Biosimilars and mg tab) Specialty generics) QL (120 PER 30 DAYS), everolimus everolimus 5 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) FARYDAK (10 MG CAP, 15 FARYDAK MG CAP, 20 MG CAP) SP-P panobinostat lactate GILOTRIF (20 MG TAB, 30 GILOTRIF MG TAB, 40 MG TAB) SP-P afatinib dimaleate

©2021 Wellmark, Inc. 44 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS IBRANCE (75 MG CAP, 75 MG TAB, 100 MG CAP, IBRANCE 100 MG TAB, 125 MG SP-P CAP, 125 MG TAB) palbociclib ICLUSIG (10 MG TAB, 15 MG TAB, 30 MG TAB, 45 ICLUSIG SP-P MG TAB) ponatinib hcl imatinib mesylate (100 mg SBG (Specialty Biosimilars imatinib mesylate SP-P tab, 400 mg tab) and Specialty generics) IMBRUVICA (70 MG CAP, 140 MG CAP, 140 MG IMBRUVICA TAB, 280 MG TAB, 420 MG SP-P TAB, 560 MG TAB) ibrutinib INLYTA (1 MG TAB, 5 MG INLYTA TAB) SP-P axitinib INREBIC 100 MG CAP INREBIC SP-P QL (120 PER 30 DAY(S)) fedratinib hcl IRESSA 250 MG TAB IRESSA SP-P gefitinib JAKAFI (5 MG TAB, 10 MG TAB, 15 MG TAB, 20 MG JAKAFI SP-P TAB, 25 MG TAB) ruxolitinib phosphate KANJINTI (150 MG RECON SOLN, 420 MG KANJINTI SP-M RECON SOLN) trastuzumab-anns KISQALI (200 MG DOSE) KISQALI (200 MG 200 MG TAB THPK SP-P DOSE) ribociclib succinate KISQALI (400 MG DOSE) KISQALI (400 MG 200 MG TAB THPK SP-P DOSE) ribociclib succinate KISQALI (600 MG DOSE) KISQALI (600 MG 200 MG TAB THPK SP-P DOSE) ribociclib succinate KISQALI FEMARA (400 MG DOSE) 200 & 2.5 MG KISQALI FEMARA TAB THPK SP-P (400 MG DOSE) ribociclib succinate- letrozole

©2021 Wellmark, Inc. 45 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KISQALI FEMARA (600 MG DOSE) 200 & 2.5 MG KISQALI FEMARA TAB THPK SP-P (600 MG DOSE) ribociclib succinate- letrozole KISQALI FEMARA(200 MG KISQALI DOSE) 200 & 2.5 MG TAB FEMARA(200 MG THPK SP-P DOSE) ribociclib succinate- letrozole KOSELUGO (10 MG CAP, KOSELUGO 25 MG CAP) SP-P PA, QL (4 PER DAY(S)) selumetinib sulfate QL (180 PER 30 DAYS), lapatinib ditosylate 250 mg lapatinib ditosylate SP-P SBG (Specialty Biosimilars tab and Specialty generics) LENVIMA (10 MG DAILY LENVIMA (10 MG DOSE) 10 MG CAP THPK SP-P DAILY DOSE) lenvatinib mesylate LENVIMA (12 MG DAILY LENVIMA (12 MG DOSE) 3 X 4 MG CAP SP-P DAILY DOSE) THPK lenvatinib mesylate LENVIMA (14 MG DAILY LENVIMA (14 MG DOSE) 10 & 4 MG CAP SP-P DAILY DOSE) THPK lenvatinib mesylate LENVIMA (18 MG DAILY LENVIMA (18 MG DOSE) 10 MG & 2 X 4 MG SP-P DAILY DOSE) CAP THPK lenvatinib mesylate LENVIMA (20 MG DAILY LENVIMA (20 MG DOSE) 2 X 10 MG CAP SP-P DAILY DOSE) THPK lenvatinib mesylate LENVIMA (24 MG DAILY LENVIMA (24 MG DOSE) 2 X 10 MG & 4 MG SP-P DAILY DOSE) CAP THPK lenvatinib mesylate LENVIMA (4 MG DAILY LENVIMA (4 MG DOSE) 4 MG CAP THPK SP-P DAILY DOSE) lenvatinib mesylate LENVIMA (8 MG DAILY LENVIMA (8 MG DOSE) 2 X 4 MG CAP SP-P DAILY DOSE) THPK lenvatinib mesylate

©2021 Wellmark, Inc. 46 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LYNPARZA (50 MG CAP, 100 MG TAB, 150 MG LYNPARZA SP-P TAB) olaparib MEKINIST (0.5 MG TAB, 2 MG TAB) MEKINIST SP-P trametinib dimethyl sulfoxide MEKTOVI 15 MG TAB MEKTOVI SP-P binimetinib NERLYNX 40 MG TAB NERLYNX TIER 2 neratinib maleate NEXAVAR 200 MG TAB NEXAVAR SP-P sorafenib tosylate ODOMZO 200 MG CAP ODOMZO SP-P sonidegib phosphate OGIVRI (150 MG RECON SOLN, 420 MG RECON OGIVRI SP-M SOLN) trastuzumab-dkst SPRYCEL (20 MG TAB, 50 MG TAB, 70 MG TAB, 80 SPRYCEL MG TAB, 100 MG TAB, 140 SP-P MG TAB) dasatinib STIVARGA 40 MG TAB STIVARGA SP-P regorafenib sunitinib malate (12.5 mg SBG (Specialty Biosimilars sunitinib malate cap, 25 mg cap, 37.5 mg SP-P and Specialty generics) cap, 50 mg cap) SUTENT (25 MG CAP, SUTENT 37.5 MG CAP, 50 MG CAP) SP-NP GA sunitinib malate SUTENT 12.5 MG CAP SBG (Specialty Biosimilars SUTENT SP-NP sunitinib malate and Specialty generics), GA TAFINLAR (50 MG CAP, TAFINLAR 75 MG CAP) SP-P dabrafenib mesylate TAGRISSO (40 MG TAB, TAGRISSO 80 MG TAB) SP-P osimertinib mesylate TALZENNA (0.25 MG CAP, TALZENNA 1 MG CAP) SP-P PA talazoparib tosylate TASIGNA (50 MG CAP, 150 MG CAP, 200 MG TASIGNA SP-P CAP) nilotinib hcl

©2021 Wellmark, Inc. 47 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TRAZIMERA (150 MG RECON SOLN, 420 MG TRAZIMERA SP-M RECON SOLN) trastuzumab-qyyp TUKYSA (50 MG TAB, 150 TUKYSA MG TAB) SP-P tucatinib VENCLEXTA (10 MG TAB, VENCLEXTA 50 MG TAB, 100 MG TAB) SP-P venetoclax VENCLEXTA STARTING VENCLEXTA PACK 10 & 50 & 100 MG SP-P STARTING PACK TAB THPK venetoclax VERZENIO (50 MG TAB, 100 MG TAB, 150 MG TAB, VERZENIO SP-NP 200 MG TAB) abemaciclib VOTRIENT 200 MG TAB VOTRIENT SP-P pazopanib hcl XALKORI (200 MG CAP, XALKORI 250 MG CAP) SP-P crizotinib ZELBORAF 240 MG TAB ZELBORAF SP-P vemurafenib ZYDELIG (100 MG TAB, ZYDELIG 150 MG TAB) SP-P idelalisib ZYKADIA (150 MG CAP, ZYKADIA 150 MG TAB) SP-P ceritinib

MONOCLONAL ANTIBODY/ANTIBODY-DRUG CONJUGATE

AVASTIN (100 MG/4ML SOLUTION, 400 MG/16ML MN-PA (Medically Necessary AVASTIN SP-M SOLUTION) Prior Authorization) bevacizumab BLENREP 100 MG RECON BLENREP SOLN SP-M belantamab mafodotin-blmf DARZALEX FASPRO 1800-30000 MG-UT/15ML DARZALEX FASPRO SOLUTION SP-M daratumumab- hyaluronidase-fihj

©2021 Wellmark, Inc. 48 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HERCEPTIN (150 MG RECON SOLN, 440 MG MN-PA (Medically Necessary HERCEPTIN SP-M RECON SOLN) Prior Authorization) trastuzumab HERZUMA (150 MG RECON SOLN, 420 MG HERZUMA SP-M RECON SOLN) trastuzumab-pkrb MONJUVI 200 MG RECON MONJUVI SOLN SP-M tafasitamab-cxix POLIVY (30 MG RECON SOLN, 140 MG RECON POLIVY SP-M SOLN) polatuzumab vedotin-piiq RIABNI (100 MG/10ML SOLUTION, 500 MG/50ML RIABNI SP-M PA SOLUTION) rituximab-arrx

RETINOIDS

SBG (Specialty Biosimilars bexarotene bexarotene 75 mg cap SP-P and Specialty generics) PANRETIN 0.1 % GEL PANRETIN TIER 3 alitretinoin TARGRETIN 1 % GEL TARGRETIN SP-P bexarotene (topical) tretinoin tretinoin 10 mg cap TIER 1

TREATMENT ADJUNCTS

MESNEX 400 MG TAB MESNEX TIER 2 mesna

ANTIPARASITICS

ANTIHELMINTHICS

albendazole albendazole 200 mg tab TIER 1 ivermectin (0.5 % lotion, 3 ivermectin TIER 1 mg tab) praziquantel praziquantel 600 mg tab TIER 1

ANTIPROTOZOALS

ALINIA 100 MG/5ML QL (540 PER 10 DAY(S)), ALINIA RECON SUSP TIER 3 PA-QL (QL varies) nitazoxanide

©2021 Wellmark, Inc. 49 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ALINIA 500 MG TAB QL (20 PER 10 DAY(S)), PA- ALINIA TIER 3 nitazoxanide QL (QL varies), GA atovaquone 750 mg/5ml atovaquone TIER 1 suspension atovaquone-proguanil hcl atovaquone-proguanil (62.5-25 mg tab, 250-100 TIER 1 hcl mg tab) chloroquine chloroquine phosphate (250 TIER 1 phosphate mg tab, 500 mg tab) COARTEM 20-120 MG COARTEM TAB TIER 3 artemether-lumefantrine DARAPRIM 25 MG TAB DARAPRIM TIER 2 GA pyrimethamine hydroxychloroquine hydroxychloroquine sulfate TIER 1 sulfate 200 mg tab IMPAVIDO 50 MG CAP IMPAVIDO TIER 3 miltefosine mefloquine hcl mefloquine hcl 250 mg tab TIER 1 QL (20 PER 10 DAY(S)), PA- nitazoxanide nitazoxanide 500 mg tab TIER 1 QL (QL varies) pentamidine pentamidine isethionate TIER 1 isethionate 300 mg recon soln primaquine primaquine phosphate 26.3 TIER 1 phosphate (15 base) mg tab pyrimethamine pyrimethamine 25 mg tab TIER 1 quinine sulfate quinine sulfate 324 mg cap TIER 1

PEDICULICIDES/SCABICIDES

acticin acticin 5 % cream TIER 1 CROTAN 10 % LOTION CROTAN TIER 1 crotamiton EURAX 10 % CREAM EURAX TIER 3 crotamiton LINDANE 1 % SHAMPOO LINDANE TIER 1 lindane malathion malathion 0.5 % lotion TIER 1 NATROBA 0.9 % NATROBA SUSPENSION TIER 3 spinosad permethrin permethrin 5 % cream TIER 1 SPINOSAD 0.9 % SPINOSAD SUSPENSION TIER 3 spinosad

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mesylate (0.5 benztropine mesylate TIER 1 mg tab, 1 mg tab, 2 mg tab) trihexyphenidyl hcl (0.4 trihexyphenidyl hcl mg/ml solution, 2 mg tab, 5 TIER 1 mg tab)

ANTIPARKINSON AGENTS, OTHER

amantadine hcl (50 mg/5ml amantadine hcl syrup, 100 mg cap, 100 mg TIER 1 tab) carbidopa-levodopa- entacapone (12.5-50-200 mg tab, 18.75-75-200 mg carbidopa-levodopa- tab, 25-100-200 mg tab, TIER 1 entacapone 31.25-125-200 mg tab, 37.5-150-200 mg tab, 50- 200-200 mg tab) entacapone entacapone 200 mg tab TIER 1 NOURIANZ (20 MG TAB, NOURIANZ 40 MG TAB) SP-NP PA, QL (30 PER 30 DAY(S)) istradefylline ONGENTYS 25 MG CAP ONGENTYS TIER 3 PA, QL (1 PER 1 DAY(S)) opicapone ONGENTYS 50 MG CAP ONGENTYS TIER 3 PA, QL (30 PER 30 DAY(S)) opicapone STALEVO 100 25-100-200 MG TAB STALEVO 100 TIER 3 GA carbidopa-levodopa- entacapone STALEVO 125 31.25-125- 200 MG TAB STALEVO 125 TIER 3 GA carbidopa-levodopa- entacapone STALEVO 150 37.5-150- 200 MG TAB STALEVO 150 TIER 3 GA carbidopa-levodopa- entacapone STALEVO 200 50-200-200 MG TAB STALEVO 200 TIER 3 GA carbidopa-levodopa- entacapone

©2021 Wellmark, Inc. 51 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS STALEVO 50 12.5-50-200 MG TAB STALEVO 50 TIER 3 GA carbidopa-levodopa- entacapone STALEVO 75 18.75-75-200 MG TAB STALEVO 75 TIER 3 GA carbidopa-levodopa- entacapone tolcapone tolcapone 100 mg tab TIER 1 PA

DOPAMINE AGONISTS

APOKYN 30 MG/3ML APOKYN SOLN CART SP-M apomorphine hydrochloride bromocriptine bromocriptine mesylate (2.5 TIER 1 mesylate mg tab, 5 mg cap) KYNMOBI (10 MG FILM, 15 MG FILM, 20 MG FILM, KYNMOBI SP-NP PA, QL (5 PER DAY(S)) 25 MG FILM, 30 MG FILM) apomorphine hydrochloride KYNMOBI TITRATION KIT KYNMOBI 10/15/20/25/30 MG KIT SP-NP PA, QL (1 PER RX) TITRATION KIT apomorphine hydrochloride NEUPRO (1 MG/24HR PATCH 24HR, 2 MG/24HR PATCH 24HR, 3 MG/24HR PATCH 24HR, 4 MG/24HR NEUPRO TIER 3 PA PATCH 24HR, 6 MG/24HR PATCH 24HR, 8 MG/24HR PATCH 24HR) rotigotine pramipexole dihydrochloride (0.125 mg pramipexole tab, 0.25 mg tab, 0.5 mg TIER 1 dihydrochloride tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab) pramipexole dihydrochloride er (er 0.375 mg tab er 24h, er 0.75 mg pramipexole tab er 24h, er 1.5 mg tab er TIER 1 PA dihydrochloride er 24h, er 2.25 mg tab er 24h, er 3 mg tab er 24h, er 3.75 mg tab er 24h, er 4.5 mg tab er 24h)

©2021 Wellmark, Inc. 52 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ropinirole hcl (0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg ropinirole hcl TIER 1 tab, 3 mg tab, 4 mg tab, 5 mg tab) ropinirole hcl er (er 2 mg tab er 24h, er 4 mg tab er ropinirole hcl er 24h, er 6 mg tab er 24h, er TIER 1 PA 8 mg tab er 24h, er 12 mg tab er 24h)

DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa carbidopa 25 mg tab TIER 1 carbidopa-levodopa (10- 100 mg tab disp, 25-100 carbidopa-levodopa TIER 2 mg tab disp, 25-250 mg tab disp) carbidopa-levodopa (10- carbidopa-levodopa 100 mg tab, 25-100 mg tab, TIER 1 25-250 mg tab) carbidopa-levodopa er (er carbidopa-levodopa 25-100 mg tab er, er 50- TIER 1 er 200 mg tab er)

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

rasagiline mesylate (0.5 mg rasagiline mesylate TIER 1 tab, 1 mg tab) selegiline hcl (5 mg cap, 5 selegiline hcl TIER 1 mg tab) XADAGO (50 MG TAB, 100 XADAGO MG TAB) TIER 3 PA safinamide mesylate

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

chlorpromazine hcl (10 mg chlorpromazine hcl tab, 25 mg tab, 50 mg tab, TIER 1 100 mg tab, 200 mg tab) FLUPHENAZINE HCL (1 MG TAB, 2.5 MG TAB, 2.5 FLUPHENAZINE MG/5ML ELIXIR, 5 MG TIER 1 HCL TAB, 5 MG/ML CONC, 10 MG TAB) fluphenazine hcl haloperidol (0.5 mg tab, 1 haloperidol mg tab, 2 mg tab, 5 mg tab, TIER 1 10 mg tab, 20 mg tab)

©2021 Wellmark, Inc. 53 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS haloperidol lactate 2 mg/ml haloperidol lactate TIER 1 conc loxapine succinate (5 mg loxapine succinate cap, 10 mg cap, 25 mg cap, TIER 1 50 mg cap) PIMOZIDE (1 MG TAB, 2 PIMOZIDE MG TAB) TIER 1 pimozide thioridazine hcl (10 mg tab, thioridazine hcl 25 mg tab, 50 mg tab, 100 TIER 1 mg tab) thiothixene (1 mg cap, 2 mg thiothixene TIER 1 cap, 5 mg cap, 10 mg cap) trifluoperazine hcl (1 mg trifluoperazine hcl tab, 2 mg tab, 5 mg tab, 10 TIER 1 mg tab)

2ND GENERATION/ATYPICAL

aripiprazole (2 mg tab, 5 mg tab, 10 mg tab, 10 mg aripiprazole tab disp, 15 mg tab, 15 mg TIER 1 tab disp, 20 mg tab, 30 mg tab) aripiprazole 1 mg/ml PA, QL (900 PER 30 aripiprazole TIER 1 solution DAY(S)) asenapine maleate (2.5 mg asenapine maleate sl tab, 5 mg sl tab, 10 mg sl TIER 1 tab) LATUDA (20 MG TAB, 40 MG TAB, 60 MG TAB, 80 LATUDA TIER 3 MG TAB, 120 MG TAB) lurasidone hcl olanzapine (2.5 mg tab, 5 mg tab, 5 mg tab disp, 7.5 mg tab, 10 mg tab, 10 mg olanzapine TIER 1 tab disp, 15 mg tab, 15 mg tab disp, 20 mg tab, 20 mg tab disp) paliperidone er (er 1.5 mg tab er 24h, er 3 mg tab er paliperidone er TIER 1 24h, er 6 mg tab er 24h, er 9 mg tab er 24h) quetiapine fumarate (25 mg tab, 50 mg tab, 100 mg tab, quetiapine fumarate TIER 1 200 mg tab, 300 mg tab, 400 mg tab)

©2021 Wellmark, Inc. 54 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS quetiapine fumarate er (er 50 mg tab er 24h, er 150 quetiapine fumarate mg tab er 24h, er 200 mg TIER 1 er tab er 24h, er 300 mg tab er 24h, er 400 mg tab er 24h) risperidone (0.25 mg tab disp, 0.5 mg tab disp, 1 mg risperidone TIER 1 PA tab disp, 2 mg tab disp, 3 mg tab disp, 4 mg tab disp) risperidone (0.25 mg tab, risperidone 0.5 mg tab, 1 mg tab, 2 mg TIER 1 tab, 3 mg tab, 4 mg tab) risperidone 1 mg/ml PA, QL (480 PER 30 risperidone TIER 1 solution DAY(S)) risperidone m-tab (0.5 mg tab disp, 1 mg tab disp, 2 risperidone m-tab TIER 1 PA mg tab disp, 3 mg tab disp, 4 mg tab disp) VRAYLAR (1.5 & 3 MG CAP THPK, 1.5 MG CAP, 3 VRAYLAR MG CAP, 4.5 MG CAP, 6 TIER 3 PA, QL (30 PER 30 DAYS) MG CAP) cariprazine hcl ziprasidone hcl (20 mg cap, ziprasidone hcl 40 mg cap, 60 mg cap, 80 TIER 1 mg cap)

TREATMENT-RESISTANT

clozapine (12.5 mg tab disp, 25 mg tab, 25 mg tab clozapine disp, 50 mg tab, 100 mg TIER 1 tab, 100 mg tab disp, 200 mg tab, 200 mg tab disp) CLOZAPINE 200 MG TAB CLOZAPINE DISP TIER 1 GA clozapine

ANTISPASTICITY AGENTS

baclofen (10 mg tab, 20 mg baclofen TIER 1 tab) BOTOX (100 RECON BOTOX SOLN, 200 RECON SOLN) SP-M PA, QL (400 PER DAY(S)) onabotulinumtoxina dantrolene sodium (25 mg dantrolene sodium cap, 50 mg cap, 100 mg TIER 1 cap) tizanidine hcl (2 mg tab, 4 tizanidine hcl TIER 1 mg tab)

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

JULUCA 50-25 MG TAB JULUCA dolutegravir sodium- TIER 2 rilpivirine hcl PREVYMIS (240 MG TAB, PREVYMIS 480 MG TAB) TIER 3 letermovir valganciclovir hcl (50 mg/ml valganciclovir hcl TIER 1 recon soln, 450 mg tab) ZIRGAN 0.15 % GEL ZIRGAN TIER 3 ganciclovir ophthalmic

ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil adefovir dipivoxil 10 mg tab TIER 1 BARACLUDE 0.05 MG/ML PA, QL (630 PER 30 BARACLUDE SOLUTION TIER 3 DAY(S)) entecavir entecavir (0.5 mg tab, 1 mg entecavir TIER 1 tab) EPIVIR HBV 5 MG/ML EPIVIR HBV SOLUTION TIER 3 lamivudine (hbv) lamivudine lamivudine 100 mg tab TIER 1 VEMLIDY 25 MG TAB VEMLIDY tenofovir alafenamide SP-P fumarate

ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS

DAKLINZA (30 MG TAB, 60 QL (28 PER 28 DAY(S)), DAKLINZA MG TAB, 90 MG TAB) SP-NP MN-PA (Medically Necessary daclatasvir dihydrochloride Prior Authorization) EPCLUSA 200-50 MG TAB EPCLUSA SP-P PA, QL (28 PER 28 DAY(S)) sofosbuvir-velpatasvir EPCLUSA 400-100 MG EPCLUSA TAB SP-P PA, QL (28 PER 28 DAYS) sofosbuvir-velpatasvir HARVONI (33.75-150 MG PACKET, 45-200 MG HARVONI SP-P PA, QL (28 PER 28 DAY(S)) PACKET, 45-200 MG TAB) ledipasvir-sofosbuvir HARVONI 90-400 MG TAB HARVONI SP-P PA, QL (28 PER 28 DAYS) ledipasvir-sofosbuvir

©2021 Wellmark, Inc. 56 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LEDIPASVIR- LEDIPASVIR- SOFOSBUVIR 90-400 MG SP-P PA, QL (28 PER 28 DAYS) SOFOSBUVIR TAB ledipasvir-sofosbuvir MAVYRET 100-40 MG TAB MAVYRET SP-P PA, QL (84 PER 28 DAY(S)) glecaprevir-pibrentasvir QL (28 PER 28 DAYS), MN- OLYSIO 150 MG CAP OLYSIO SP-NP PA (Medically Necessary simeprevir sodium Prior Authorization) SOFOSBUVIR- SOFOSBUVIR- VELPATASVIR 400-100 SP-P PA, QL (28 PER 28 DAYS) VELPATASVIR MG TAB sofosbuvir-velpatasvir SOVALDI (150 MG QL (28 PER 28 DAY(S)), PACKET, 200 MG SOVALDI SP-NP MN-PA (Medically Necessary PACKET, 200 MG TAB) Prior Authorization) sofosbuvir QL (28 PER 28 DAYS), MN- SOVALDI 400 MG TAB SOVALDI SP-NP PA (Medically Necessary sofosbuvir Prior Authorization) TECHNIVIE 12.5-75-50 MG QL (56 PER 28 DAYS), MN- TAB TECHNIVIE SP-NP PA (Medically Necessary ombitasvir-paritaprevir- Prior Authorization) ritonavir VIEKIRA PAK 12.5-75-50 QL (112 PER 28 DAYS), MN- &250 MG TAB THPK VIEKIRA PAK SP-NP PA (Medically Necessary ombitasvir-paritaprevir- Prior Authorization) ritonavir-dasabuvir VIEKIRA XR 200-8.33-50- QL (84 PER 28 DAYS), MN- 33.33 MG TAB ER 24H VIEKIRA XR SP-NP PA (Medically Necessary ombitasvir-paritaprevir- Prior Authorization) ritonavir-dasabuvir VOSEVI 400-100-100 MG TAB VOSEVI SP-P PA, QL (28 PER 28 DAY(S)) sofosbuvir-velpatasvir- voxilaprevir QL (28 PER 28 DAYS), MN- ZEPATIER 50-100 MG TAB ZEPATIER SP-NP PA (Medically Necessary elbasvir-grazoprevir Prior Authorization)

ANTI-HEPATITIS C (HCV) AGENTS, OTHER

moderiba moderiba 200 mg tab TIER 1 PEG-INTRON REDIPEN PEG-INTRON 120 MCG/0.5ML KIT SP-P REDIPEN peginterferon alfa-2b

©2021 Wellmark, Inc. 57 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PEGASYS (180 MCG/0.5ML SOLUTION, PEGASYS SP-P PA, QL (4 PER 28 DAYS) 180 MCG/ML SOLUTION) peginterferon alfa-2a PEGASYS PROCLICK PEGASYS (135 SOLUTION, 180 SP-P PA, QL (4 PER 28 DAYS) PROCLICK SOLUTION) peginterferon alfa-2a PEGINTRON 50 PEGINTRON MCG/0.5ML KIT SP-P peginterferon alfa-2b REBETOL 40 MG/ML REBETOL SOLUTION TIER 3 ribavirin (hepatitis c) ribasphere (200 mg cap, ribasphere TIER 1 200 mg tab) ribavirin (200 mg cap, 200 ribavirin TIER 1 mg tab)

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

GENVOYA 150-150-200-10 MG TAB GENVOYA elvitegravir-cobicistat- TIER 2 emtricitabine-tenofovir alafenamide ISENTRESS (25 MG CHEW TAB, 100 MG ISENTRESS TIER 2 CHEW TAB, 400 MG TAB) raltegravir potassium ISENTRESS 100 MG ISENTRESS PACKET TIER 3 raltegravir potassium ISENTRESS HD 600 MG ISENTRESS HD TAB TIER 2 raltegravir potassium STRIBILD 150-150-200- 300 MG TAB STRIBILD TIER 2 elvitegravir-cobicistat- emtricitabine-tenofovir df SYMTUZA 800-150-200-10 MG TAB SYMTUZA darunavir-cobicistat- TIER 2 emtricitabine-tenofovir alafenamide

©2021 Wellmark, Inc. 58 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TIVICAY (10 MG TAB, 25 TIVICAY MG TAB, 50 MG TAB) TIER 2 dolutegravir sodium TIVICAY PD 5 MG TAB TIVICAY PD SOL TIER 2 dolutegravir sodium

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

COMPLERA 200-25-300 MG TAB COMPLERA emtricitabine-rilpivirine- TIER 2 tenofovir disoproxil fumarate DELSTRIGO 100-300-300 MG TAB DELSTRIGO doravirine-lamivudine- TIER 2 tenofovir disoproxil fumarate EDURANT 25 MG TAB EDURANT TIER 2 rilpivirine hcl efavirenz (50 mg cap, 200 efavirenz TIER 1 mg cap, 600 mg tab) efavirenz-emtricitab- efavirenz-emtricitab- tenofovir 600-200-300 mg TIER 1 tenofovir tab etravirine (100 mg tab, 200 etravirine TIER 1 mg tab) INTELENCE 25 MG TAB INTELENCE TIER 2 etravirine nevirapine (50 mg/5ml nevirapine TIER 1 suspension, 200 mg tab) nevirapine er (er 100 mg nevirapine er tab er 24h, er 400 mg tab er TIER 1 24h) ODEFSEY 200-25-25 MG TAB ODEFSEY emtricitabine-rilpivirine- TIER 2 tenofovir alafenamide fumarate PIFELTRO 100 MG TAB PIFELTRO TIER 2 doravirine RESCRIPTOR (100 MG RESCRIPTOR TAB, 200 MG TAB) TIER 2 delavirdine mesylate

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

abacavir sulfate (20 mg/ml abacavir sulfate TIER 1 solution, 300 mg tab) abacavir sulfate- abacavir sulfate-lamivudine TIER 1 lamivudine 600-300 mg tab abacavir-lamivudine- abacavir-lamivudine- zidovudine 300-150-300 mg TIER 1 zidovudine tab CIMDUO 300-300 MG TAB CIMDUO lamivudine-tenofovir TIER 2 disoproxil fumarate didanosine (200 mg cap dr, didanosine 250 mg cap dr, 400 mg cap TIER 1 dr) emtricitabine emtricitabine 200 mg cap TIER 1 emtricitabine-tenofovir df emtricitabine-tenofovir (100-150 mg tab, 133-200 TIER 1 df mg tab, 167-250 mg tab, 200-300 mg tab) EMTRIVA 10 MG/ML EMTRIVA SOLUTION TIER 2 emtricitabine lamivudine (10 mg/ml lamivudine solution, 150 mg tab, 300 TIER 1 mg tab) lamivudine- lamivudine-zidovudine 150- TIER 1 zidovudine 300 mg tab stavudine (15 mg cap, 20 stavudine mg cap, 30 mg cap, 40 mg TIER 1 cap) TEMIXYS 300-300 MG TAB TEMIXYS TIER 2 lamivudine-tenofovir disoproxil fumarate tenofovir disoproxil tenofovir disoproxil TIER 1 fumarate fumarate 300 mg tab VIDEX (2 GM RECON SOLN, 4 GM RECON VIDEX TIER 3 SOLN) didanosine VIDEX EC 125 MG CAP VIDEX EC DR TIER 3 didanosine

©2021 Wellmark, Inc. 60 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VIREAD (150 MG TAB, 200 MG TAB, 250 MG TAB) VIREAD TIER 2 tenofovir disoproxil fumarate VIREAD 40 MG/GM POWDER VIREAD TIER 3 tenofovir disoproxil fumarate ZERIT 1 MG/ML RECON ZERIT SOLN TIER 3 stavudine zidovudine (50 mg/5ml zidovudine syrup, 100 mg cap, 300 mg TIER 1 tab)

ANTI-HIV AGENTS, OTHER

BIKTARVY 50-200-25 MG TAB BIKTARVY bictegravir-emtricitabine- TIER 2 tenofovir alafenamide fumarate CABENUVA (400 600 MG/2ML SUSP, 600 900 CABENUVA SP-M MG/3ML SUSP) cabotegravir & rilpivirine DESCOVY 200-25 MG TAB DESCOVY emtricitabine-tenofovir TIER 2 PA alafenamide fumarate DOVATO 50-300 MG TAB DOVATO dolutegravir sodium- TIER 2 lamivudine efavirenz-lamivudine- efavirenz-lamivudine- tenofovir (400-300-300 mg TIER 1 tenofovir tab, 600-300-300 mg tab) FUZEON 90 MG RECON FUZEON SOLN SP-P enfuvirtide RUKOBIA 600 MG TAB ER RUKOBIA 12H SP-P fostemsavir tromethamine SELZENTRY (25 MG TAB, 75 MG TAB, 150 MG TAB, SELZENTRY TIER 2 300 MG TAB) maraviroc SELZENTRY 20 MG/ML SELZENTRY SOLUTION TIER 3 maraviroc

©2021 Wellmark, Inc. 61 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TRIUMEQ 600-50-300 MG TAB TRIUMEQ TIER 2 abacavir-dolutegravir- lamivudine TYBOST 150 MG TAB TYBOST TIER 2 cobicistat

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS 100 MG/ML APTIVUS SOLUTION TIER 3 tipranavir APTIVUS 250 MG CAP APTIVUS TIER 2 tipranavir atazanavir sulfate (150 mg atazanavir sulfate cap, 200 mg cap, 300 mg TIER 1 cap) CRIXIVAN (200 MG CAP, CRIXIVAN 400 MG CAP) TIER 2 indinavir sulfate EVOTAZ 300-150 MG TAB EVOTAZ TIER 3 atazanavir sulfate-cobicistat fosamprenavir fosamprenavir calcium 700 TIER 1 calcium mg tab INVIRASE (200 MG CAP, INVIRASE 500 MG TAB) TIER 2 saquinavir mesylate LEXIVA 50 MG/ML LEXIVA SUSPENSION TIER 3 fosamprenavir calcium lopinavir-ritonavir (100-25 lopinavir-ritonavir mg tab, 200-50 mg tab, TIER 1 400-100 mg/5ml solution) NORVIR (80 MG/ML SOLUTION, 100 MG NORVIR TIER 3 PACKET) ritonavir NORVIR 100 MG CAP NORVIR TIER 2 ritonavir PREZCOBIX 800-150 MG PREZCOBIX TAB TIER 3 darunavir-cobicistat PREZISTA (75 MG TAB, 150 MG TAB, 600 MG TAB, PREZISTA TIER 2 800 MG TAB) darunavir ethanolate

©2021 Wellmark, Inc. 62 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PREZISTA 100 MG/ML PREZISTA SUSPENSION TIER 3 darunavir ethanolate REYATAZ 50 MG PACKET REYATAZ TIER 3 atazanavir sulfate ritonavir ritonavir 100 mg tab TIER 1 VIRACEPT (250 MG TAB, VIRACEPT 625 MG TAB) TIER 2 nelfinavir mesylate

ANTI-INFLUENZA AGENTS

oseltamivir phosphate (6 oseltamivir phosphate mg/ml recon susp, 30 mg TIER 1 cap, 45 mg cap, 75 mg cap) RELENZA DISKHALER 5 RELENZA MG/BLISTER AER POW TIER 2 DISKHALER BA zanamivir RIMANTADINE HCL 100 RIMANTADINE HCL MG TAB TIER 1 rimantadine hydrochloride

ANTIHERPETIC AGENTS

acyclovir (5 % cream, 5 % ointment, 200 mg cap, 200 acyclovir TIER 1 mg/5ml suspension, 400 mg tab, 800 mg tab) famciclovir (125 mg tab, famciclovir TIER 1 250 mg tab, 500 mg tab) trifluridine trifluridine 1 % solution TIER 1 valacyclovir hcl (1 gm tab, valacyclovir hcl TIER 1 500 mg tab)

ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl (5 mg tab, 7.5 buspirone hcl mg tab, 10 mg tab, 15 mg TIER 1 tab, 30 mg tab) meprobamate (200 mg tab, meprobamate TIER 1 400 mg tab)

BENZODIAZEPINES

alprazolam (0.25 mg tab, 0.25 mg tab disp, 0.5 mg alprazolam tab, 0.5 mg tab disp, 1 mg TIER 1 tab, 1 mg tab disp, 2 mg tab, 2 mg tab disp) alprazolam er (er 0.5 mg tab er 24h, er 1 mg tab er alprazolam er TIER 1 24h, er 2 mg tab er 24h, er 3 mg tab er 24h) ALPRAZOLAM INTENSOL ALPRAZOLAM 1 MG/ML CONC TIER 1 INTENSOL alprazolam alprazolam xr (0.5 mg tab er 24h, 1 mg tab er 24h, 2 alprazolam xr TIER 1 mg tab er 24h, 3 mg tab er 24h) chlordiazepoxide hcl (5 mg chlordiazepoxide hcl TIER 1 cap, 10 mg cap, 25 mg cap) clonazepam (0.125 mg tab disp, 0.25 mg tab disp, 0.5 clonazepam mg tab, 0.5 mg tab disp, 1 TIER 1 mg tab, 1 mg tab disp, 2 mg tab, 2 mg tab disp) clorazepate dipotassium clorazepate (3.75 mg tab, 7.5 mg tab, TIER 1 dipotassium 15 mg tab) diazepam (2 mg tab, 5 mg diazepam tab, 5 mg/5ml solution, 5 TIER 1 mg/ml conc, 10 mg tab) diazepam intensol 5 mg/ml diazepam intensol TIER 1 conc lorazepam (0.5 mg tab, 1 lorazepam mg tab, 2 mg tab, 2 mg/ml TIER 1 conc) lorazepam intensol 2 mg/ml lorazepam intensol TIER 1 conc oxazepam (10 mg cap, 15 oxazepam TIER 1 mg cap, 30 mg cap)

BIPOLAR AGENTS

MOOD STABILIZERS

LITHIUM 8 MEQ/5ML LITHIUM SOLUTION TIER 3 lithium lithium carbonate (150 mg lithium carbonate cap, 300 mg cap, 300 mg TIER 1 tab, 600 mg cap) lithium carbonate er (er 300 lithium carbonate er mg tab er, er 450 mg tab TIER 1 er)

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose (25 mg tab, 50 acarbose TIER 1 mg tab, 100 mg tab) alogliptin benzoate (6.25 alogliptin benzoate mg tab, 12.5 mg tab, 25 mg TIER 1 tab) alogliptin-metformin hcl alogliptin-metformin (12.5-1000 mg tab, 12.5- TIER 1 hcl 500 mg tab) alogliptin-pioglitazone (12.5-15 mg tab, 12.5-30 alogliptin-pioglitazone mg tab, 12.5-45 mg tab, 25- TIER 1 15 mg tab, 25-30 mg tab, 25-45 mg tab) AVANDAMET 2-1000 MG TAB AVANDAMET TIER 2 rosiglitazone maleate- metformin hcl BYDUREON (2 MG PEN, 2 BYDUREON MG SRER) TIER 2 QL (4 PER 28 DAYS) exenatide BYDUREON BCISE 2 BYDUREON BCISE MG/0.85ML A-INJ TIER 2 QL (4 PER 28 DAY(S)) exenatide BYETTA 10 MCG PEN 10 BYETTA 10 MCG MCG/0.04ML SOLN PEN TIER 3 QL (1 PER 30 DAYS) PEN exenatide BYETTA 5 MCG PEN 5 BYETTA 5 MCG PEN MCG/0.02ML SOLN PEN TIER 3 QL (1 PER 30 DAYS) exenatide

©2021 Wellmark, Inc. 65 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CHLORPROPAMIDE (100 CHLORPROPAMIDE MG TAB, 250 MG TAB) TIER 1 chlorpropamide FARXIGA (5 MG TAB, 10 FARXIGA MG TAB) TIER 2 dapagliflozin propanediol glimepiride (1 mg tab, 2 mg glimepiride TIER 1 tab, 4 mg tab) glipizide (5 mg tab, 10 mg glipizide TIER 1 tab) glipizide er (er 2.5 mg tab glipizide er er 24h, er 5 mg tab er 24h, TIER 1 er 10 mg tab er 24h) glipizide xl (2.5 mg tab er glipizide xl 24h, 5 mg tab er 24h, 10 TIER 1 mg tab er 24h) glipizide-metformin hcl (2.5- glipizide-metformin 250 mg tab, 2.5-500 mg TIER 1 hcl tab, 5-500 mg tab) glyburide (1.25 mg tab, 2.5 glyburide TIER 1 mg tab, 5 mg tab) glyburide micronized (1.5 glyburide micronized TIER 1 mg tab, 3 mg tab, 6 mg tab) glyburide-metformin (1.25- glyburide-metformin 250 mg tab, 2.5-500 mg TIER 1 tab, 5-500 mg tab) GLYXAMBI (10-5 MG TAB, GLYXAMBI 25-5 MG TAB) TIER 2 empagliflozin-linagliptin JANUMET (50-1000 MG JANUMET TAB, 50-500 MG TAB) TIER 2 sitagliptin-metformin hcl JANUMET XR (50-1000 MG TAB ER 24H, 50-500 JANUMET XR MG TAB ER 24H, 100-1000 TIER 2 MG TAB ER 24H) sitagliptin-metformin hcl JANUVIA (25 MG TAB, 50 JANUVIA MG TAB, 100 MG TAB) TIER 2 sitagliptin phosphate JARDIANCE (10 MG TAB, JARDIANCE 25 MG TAB) TIER 2 empagliflozin metformin hcl (500 mg tab, metformin hcl TIER 1 850 mg tab, 1000 mg tab) metformin hcl 500 mg/5ml PA, QL (765 PER 30 metformin hcl TIER 1 solution DAY(S))

©2021 Wellmark, Inc. 66 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS metformin hcl er (er 500 mg metformin hcl er tab er 24h, er 750 mg tab er TIER 1 24h) miglitol (25 mg tab, 50 mg miglitol TIER 1 tab, 100 mg tab) nateglinide (60 mg tab, 120 nateglinide TIER 1 mg tab) OZEMPIC (0.25 OR 0.5 OZEMPIC (0.25 OR MG/DOSE) 2 MG/1.5ML TIER 2 QL (1 PER 28 DAY(S)) 0.5 MG/DOSE) SOLN PEN semaglutide OZEMPIC (1 MG/DOSE) (2 OZEMPIC (1 MG/1.5ML SOLN PEN, 4 TIER 2 QL (2 PER 28 DAY(S)) MG/DOSE) MG/3ML SOLN PEN) semaglutide pioglitazone hcl (15 mg tab, pioglitazone hcl TIER 1 30 mg tab, 45 mg tab) pioglitazone hcl- pioglitazone hcl-glimepiride TIER 1 glimepiride (30-2 mg tab, 30-4 mg tab) pioglitazone hcl-metformin pioglitazone hcl- hcl (-metformin 15-500 mg TIER 1 metformin hcl tab, -metformin 15-850 mg tab) repaglinide (0.5 mg tab, 1 repaglinide TIER 1 mg tab, 2 mg tab) REPAGLINIDE- REPAGLINIDE- METFORMIN HCL (1-500 TIER 1 METFORMIN HCL MG TAB, 2-500 MG TAB) repaglinide-metformin hcl RIOMET ER 500 MG/5ML PA, QL (765 PER 30 RIOMET ER SRER TIER 2 DAY(S)) metformin hcl SYMLINPEN 120 2700 SYMLINPEN 120 MCG/2.7ML SOLN PEN TIER 2 pramlintide acetate SYMLINPEN 60 1500 SYMLINPEN 60 MCG/1.5ML SOLN PEN TIER 2 pramlintide acetate SYNJARDY (5-1000 MG TAB, 5-500 MG TAB, 12.5- SYNJARDY 1000 MG TAB, 12.5-500 TIER 2 MG TAB) empagliflozin-metformin hcl

©2021 Wellmark, Inc. 67 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SYNJARDY XR (5-1000 MG TAB ER 24H, 10-1000 MG TAB ER 24H, 12.5- SYNJARDY XR TIER 2 1000 MG TAB ER 24H, 25- 1000 MG TAB ER 24H) empagliflozin-metformin hcl TOLAZAMIDE (250 MG TOLAZAMIDE TAB, 500 MG TAB) TIER 1 tolazamide TOLBUTAMIDE 500 MG TOLBUTAMIDE TAB TIER 1 tolbutamide TRIJARDY XR (5-2.5-1000 MG TAB ER 24H, 10-5- 1000 MG TAB ER 24H, 12.5-2.5-1000 MG TAB ER TRIJARDY XR TIER 2 24H, 25-5-1000 MG TAB ER 24H) empagliflozin-linagliptin- metformin VICTOZA 18 MG/3ML VICTOZA SOLN PEN TIER 2 QL (3 PER 30 DAYS) liraglutide XIGDUO XR (2.5-1000 MG TAB ER 24H, 5-1000 MG TAB ER 24H, 5-500 MG XIGDUO XR TAB ER 24H, 10-1000 MG TIER 2 TAB ER 24H, 10-500 MG TAB ER 24H) dapagliflozin-metformin hcl

GLYCEMIC AGENTS

BAQSIMI ONE PACK 3 BAQSIMI ONE PACK MG/DOSE POWDER TIER 2 QL (2 PER RX) glucagon BAQSIMI TWO PACK 3 BAQSIMI TWO PACK MG/DOSE POWDER TIER 2 QL (2 PER RX) glucagon GLUCAGEN HYPOKIT 1 GLUCAGEN MG RECON SOLN TIER 2 HYPOKIT glucagon hcl (rdna) glucagon emergency 1 mg glucagon emergency TIER 1 kit GLUCAGON EMERGENCY GLUCAGON 1 MG/ML RECON SOLN TIER 2 QL (2 PER RX) EMERGENCY glucagon hcl

©2021 Wellmark, Inc. 68 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GVOKE HYPOPEN 1- PACK (0.5 MG/0.1ML GVOKE HYPOPEN SOLN A-INJ, 1 MG/0.2ML TIER 2 QL (2 PER FILL(S)) 1-PACK SOLN A-INJ) glucagon GVOKE HYPOPEN 2- PACK (0.5 MG/0.1ML GVOKE HYPOPEN SOLN A-INJ, 1 MG/0.2ML TIER 2 QL (2 PER FILL(S)) 2-PACK SOLN A-INJ) glucagon GVOKE PFS (0.5 MG/0.1ML SOLN PRSYR, GVOKE PFS 1 MG/0.2ML SOLN TIER 2 QL (2 PER RX) PRSYR) glucagon

INSULINS

BASAGLAR KWIKPEN 100 BASAGLAR UNIT/ML SOLN PEN TIER 2 KWIKPEN insulin glargine FIASP 100 UNIT/ML SOLUTION FIASP TIER 2 insulin aspart (with niacinamide) FIASP FLEXTOUCH 100 UNIT/ML SOLN PEN FIASP FLEXTOUCH TIER 2 insulin aspart (with niacinamide) FIASP PENFILL 100 UNIT/ML SOLN CART FIASP PENFILL TIER 2 insulin aspart (with niacinamide) HUMULIN R U-500 HUMULIN R U-500 (CONCENTRATED) 500 TIER 2 (CONCENTRATED) UNIT/ML SOLUTION insulin regular (human) HUMULIN R U-500 HUMULIN R U-500 KWIKPEN 500 UNIT/ML TIER 2 KWIKPEN SOLN PEN insulin regular (human) INSULIN ASP PROT & ASP FLEXPEN (70-30) 100 INSULIN ASP PROT UNIT/ML SUSP PEN TIER 2 & ASP FLEXPEN insulin aspart protamine & aspart (human) INSULIN ASPART 100 INSULIN ASPART UNIT/ML SOLUTION TIER 2 insulin aspart

©2021 Wellmark, Inc. 69 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS INSULIN ASPART INSULIN ASPART FLEXPEN 100 UNIT/ML TIER 2 FLEXPEN SOLN PEN insulin aspart INSULIN ASPART INSULIN ASPART PENFILL 100 UNIT/ML TIER 2 PENFILL SOLN CART insulin aspart INSULIN ASPART PROT & ASPART (70-30) 100 INSULIN ASPART UNIT/ML SUSPENSION TIER 2 PROT & ASPART insulin aspart protamine & aspart (human) INSULIN LISPRO (1 UNIT INSULIN LISPRO (1 DIAL) 100 UNIT/ML SOLN MN-PA (Medically Necessary TIER 3 UNIT DIAL) PEN Prior Authorization) insulin lispro INSULIN LISPRO 100 MN-PA (Medically Necessary INSULIN LISPRO UNIT/ML SOLUTION TIER 3 Prior Authorization) insulin lispro INSULIN LISPRO JUNIOR INSULIN LISPRO KWIKPEN 100 UNIT/ML MN-PA (Medically Necessary TIER 3 JUNIOR KWIKPEN SOLN PEN Prior Authorization) insulin lispro INSULIN LISPRO PROT & LISPRO (75-25) 100 INSULIN LISPRO MN-PA (Medically Necessary UNIT/ML SUSP PEN TIER 3 PROT & LISPRO Prior Authorization) insulin lispro protamine & lispro LEVEMIR 100 UNIT/ML LEVEMIR SOLUTION TIER 2 insulin detemir LEVEMIR FLEXTOUCH LEVEMIR 100 UNIT/ML SOLN PEN TIER 2 FLEXTOUCH insulin detemir LYUMJEV 100 UNIT/ML MN-PA (Medically Necessary LYUMJEV SOLUTION TIER 3 Prior Authorization) insulin lispro-aabc LYUMJEV KWIKPEN (100 SOLN PEN, 200 SOLN MN-PA (Medically Necessary LYUMJEV KWIKPEN TIER 3 PEN) Prior Authorization) insulin lispro-aabc NOVOLIN 70/30 (70-30) 100 UNIT/ML NOVOLIN 70/30 SUSPENSION TIER 2 insulin nph isophane & reg (human)

©2021 Wellmark, Inc. 70 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NOVOLIN 70/30 FLEXPEN (70-30) 100 UNIT/ML NOVOLIN 70/30 SUSP PEN TIER 2 FLEXPEN insulin nph isophane & reg (human) NOVOLIN 70/30 FLEXPEN RELION (70-30) 100 NOVOLIN 70/30 UNIT/ML SUSP PEN TIER 2 FLEXPEN RELION insulin nph isophane & reg (human) NOVOLIN 70/30 RELION (70-30) 100 UNIT/ML NOVOLIN 70/30 SUSPENSION TIER 2 RELION insulin nph isophane & reg (human) NOVOLIN N 100 UNIT/ML SUSPENSION NOVOLIN N TIER 2 insulin nph (human) (isophane) NOVOLIN N FLEXPEN 100 NOVOLIN N UNIT/ML SUSP PEN TIER 2 FLEXPEN insulin nph (human) (isophane) NOVOLIN N FLEXPEN RELION 100 UNIT/ML NOVOLIN N SUSP PEN TIER 2 FLEXPEN RELION insulin nph (human) (isophane) NOVOLIN N RELION 100 UNIT/ML SUSPENSION NOVOLIN N RELION TIER 2 insulin nph (human) (isophane) NOVOLIN R 100 UNIT/ML NOVOLIN R SOLUTION TIER 2 insulin regular (human) NOVOLIN R FLEXPEN 100 NOVOLIN R UNIT/ML SOLN PEN TIER 2 FLEXPEN insulin regular (human) NOVOLIN R FLEXPEN NOVOLIN R RELION 100 UNIT/ML TIER 2 FLEXPEN RELION SOLN PEN insulin regular (human) NOVOLIN R RELION 100 NOVOLIN R RELION UNIT/ML SOLUTION TIER 2 insulin regular (human) NOVOLOG 100 UNIT/ML NOVOLOG SOLUTION TIER 2 insulin aspart

©2021 Wellmark, Inc. 71 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NOVOLOG 70/30 FLEXPEN RELION (70-30) NOVOLOG 70/30 100 UNIT/ML SUSP PEN TIER 2 FLEXPEN RELION insulin aspart protamine & aspart (human) NOVOLOG FLEXPEN 100 NOVOLOG UNIT/ML SOLN PEN TIER 2 FLEXPEN insulin aspart NOVOLOG FLEXPEN NOVOLOG RELION 100 UNIT/ML TIER 2 FLEXPEN RELION SOLN PEN insulin aspart NOVOLOG MIX 70/30 (70- 30) 100 UNIT/ML NOVOLOG MIX SUSPENSION TIER 2 70/30 insulin aspart protamine & aspart (human) NOVOLOG MIX 70/30 FLEXPEN (70-30) 100 NOVOLOG MIX UNIT/ML SUSP PEN TIER 2 70/30 FLEXPEN insulin aspart protamine & aspart (human) NOVOLOG MIX 70/30 RELION (70-30) 100 NOVOLOG MIX UNIT/ML SUSPENSION TIER 2 70/30 RELION insulin aspart protamine & aspart (human) NOVOLOG PENFILL 100 NOVOLOG PENFILL UNIT/ML SOLN CART TIER 2 insulin aspart NOVOLOG RELION 100 NOVOLOG RELION UNIT/ML SOLUTION TIER 2 insulin aspart SEMGLEE (100 SOLN MN-PA (Medically Necessary SEMGLEE PEN, 100 SOLUTION) TIER 3 Prior Authorization) insulin glargine TRESIBA 100 UNIT/ML TRESIBA SOLUTION TIER 2 insulin degludec TRESIBA FLEXTOUCH TRESIBA (100 SOLN PEN, 200 TIER 2 FLEXTOUCH SOLN PEN) insulin degludec

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS

COUMADIN (1 MG TAB, 2 MG TAB, 2.5 MG TAB, 3 MG TAB, 4 MG TAB, 5 MG COUMADIN TIER 2 GA TAB, 6 MG TAB, 7.5 MG TAB, 10 MG TAB) warfarin sodium ELIQUIS (2.5 MG TAB, 5 ELIQUIS MG TAB) TIER 2 apixaban ELIQUIS DVT/PE ELIQUIS DVT/PE STARTER PACK 5 MG TIER 2 STARTER PACK TAB THPK apixaban enoxaparin sodium (30 mg/0.3ml solution, 40 mg/0.4ml solution, 60 mg/0.6ml solution, 80 enoxaparin sodium mg/0.8ml solution, 100 TIER 1 mg/ml solution, 120 mg/0.8ml solution, 150 mg/ml solution, 300 mg/3ml solution) fondaparinux sodium (2.5 mg/0.5ml solution, 5 fondaparinux sodium mg/0.4ml solution, 7.5 TIER 1 mg/0.6ml solution, 10 mg/0.8ml solution) FRAGMIN (2500 UNIT/0.2ML SOLUTION, 5000 UNIT/0.2ML SOLUTION, 7500 UNIT/0.3ML SOLUTION, 10000 UNIT/ML SOLUTION, 12500 FRAGMIN TIER 2 UNIT/0.5ML SOLUTION, 15000 UNIT/0.6ML SOLUTION, 18000 UNT/0.72ML SOLUTION, 95000 UNIT/3.8ML SOLUTION) dalteparin sodium

©2021 Wellmark, Inc. 73 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HEPARIN LOCK FLUSH (1 SOLUTION, 2 SOLUTION, HEPARIN LOCK 10 SOLUTION, 100 TIER 1 FLUSH SOLUTION) heparin sodium (porcine) lock flush heparin sodium (porcine) heparin sodium (5000 solution, 10000 TIER 1 (porcine) solution) heparin sodium heparin sodium (porcine) pf TIER 1 (porcine) pf 5000 unit/0.5ml solution heparin sodium lock heparin sodium lock flush TIER 1 flush 100 unit/ml solution IPRIVASK 15 MG RECON IPRIVASK SOLN SP-M desirudin jantoven (1 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 jantoven TIER 1 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab, 10 mg tab) PRADAXA (75 MG CAP, 110 MG CAP, 150 MG MN-PA (Medically Necessary PRADAXA CAP) TIER 3 Prior Authorization) dabigatran etexilate mesylate warfarin sodium (1 mg tab, 2 mg tab, 2.5 mg tab, 3 mg warfarin sodium tab, 4 mg tab, 5 mg tab, 6 TIER 1 mg tab, 7.5 mg tab, 10 mg tab) XARELTO (2.5 MG TAB, 10 MG TAB, 15 MG TAB, XARELTO TIER 2 20 MG TAB) rivaroxaban XARELTO STARTER XARELTO STARTER PACK 15 & 20 MG TAB TIER 2 PACK THPK rivaroxaban

BLOOD FORMATION MODIFIERS

anagrelide hcl (0.5 mg cap, anagrelide hcl TIER 1 1 mg cap)

©2021 Wellmark, Inc. 74 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ARANESP (ALBUMIN FREE) (10 MCG/0.4ML SOLN PRSYR, 25 MCG/0.42ML SOLN PRSYR, 25 MCG/ML SOLUTION, 40 MCG/0.4ML SOLN PRSYR, 40 MCG/ML SOLUTION, 60 MCG/0.3ML SOLN PRSYR, 60 MCG/ML ARANESP (ALBUMIN SOLUTION, 100 SP-P FREE) MCG/0.5ML SOLN PRSYR, 100 MCG/ML SOLUTION, 150 MCG/0.3ML SOLN PRSYR, 200 MCG/0.4ML SOLN PRSYR, 200 MCG/ML SOLUTION, 300 MCG/0.6ML SOLN PRSYR, 300 MCG/ML SOLUTION, 500 MCG/ML SOLN PRSYR) darbepoetin alfa CABLIVI 11 MG KIT CABLIVI SP-P caplacizumab-yhdp DOPTELET 20 MG TAB DOPTELET SP-P QL (60 PER 30 DAY(S)) avatrombopag maleate EPOGEN (2000 SOLUTION, 3000 SOLUTION, 4000 MN-PA (Medically Necessary EPOGEN SOLUTION, 10000 SP-P Prior Authorization) SOLUTION, 20000 SOLUTION) epoetin alfa FULPHILA 6 MG/0.6ML SBG (Specialty Biosimilars FULPHILA SOLN PRSYR SP-P and Specialty generics) pegfilgrastim-jmdb GRANIX (300 MCG/0.5ML SOLN PRSYR, 300 MCG/ML SOLUTION, 480 MN-PA (Medically Necessary GRANIX MCG/0.8ML SOLN PRSYR, SP-NP Prior Authorization) 480 MCG/1.6ML SOLUTION) tbo-filgrastim LEUKINE 250 MCG MN-PA (Medically Necessary LEUKINE RECON SOLN SP-NP Prior Authorization) sargramostim

©2021 Wellmark, Inc. 75 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MIRCERA (30 SOLN PRSYR, 50 SOLN PRSYR, 75 SOLN PRSYR, 100 SOLN PRSYR, 150 SOLN MN-PA (Medically Necessary MIRCERA SP-P PRSYR, 200 SOLN Prior Authorization) PRSYR) methoxy polyethylene glycol-epoetin beta MOZOBIL 24 MG/1.2ML MOZOBIL SOLUTION SP-M plerixafor MULPLETA 3 MG TAB MULPLETA SP-P QL (7 PER 14 DAY(S)) lusutrombopag NEULASTA 6 MG/0.6ML MN-PA (Medically Necessary NEULASTA SOLN PRSYR SP-P Prior Authorization) pegfilgrastim NEULASTA ONPRO 6 NEULASTA ONPRO MG/0.6ML PREF SY KT SP-P PA pegfilgrastim NEUPOGEN (300 MCG/0.5ML SOLN PRSYR, 300 MCG/ML SOLUTION, MN-PA (Medically Necessary NEUPOGEN 480 MCG/0.8ML SOLN SP-NP Prior Authorization) PRSYR, 480 MCG/1.6ML SOLUTION) filgrastim NIVESTYM (300 MCG/0.5ML SOLN PRSYR, 300 MCG/ML SOLUTION, SBG (Specialty Biosimilars NIVESTYM 480 MCG/0.8ML SOLN SP-P and Specialty generics) PRSYR, 480 MCG/1.6ML SOLUTION) filgrastim-aafi NPLATE (125 MCG RECON SOLN, 250 MCG NPLATE RECON SOLN, 500 MCG SP-M RECON SOLN) romiplostim NYVEPRIA 6 MG/0.6ML SBG (Specialty Biosimilars NYVEPRIA SOLN PRSYR SP-P and Specialty generics) pegfilgrastim-apgf PROCRIT (2000 SOLUTION, 3000 SOLUTION, 4000 SOLUTION, 10000 MN-PA (Medically Necessary PROCRIT SP-P SOLUTION, 20000 Prior Authorization) SOLUTION, 40000 SOLUTION) epoetin alfa

©2021 Wellmark, Inc. 76 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROMACTA (12.5 MG PROMACTA PACKET, 25 MG PACKET) SP-P QL (90 PER 30 DAY(S)) eltrombopag olamine PROMACTA (25 MG TAB, PROMACTA 50 MG TAB) SP-P QL (90 PER 30 DAYS) eltrombopag olamine PROMACTA 12.5 MG TAB PROMACTA SP-P QL (30 PER 30 DAYS) eltrombopag olamine PROMACTA 75 MG TAB PROMACTA SP-P QL (60 PER 30 DAYS) eltrombopag olamine REBLOZYL (25 MG RECON SOLN, 75 MG REBLOZYL SP-M PA RECON SOLN) luspatercept-aamt RETACRIT (2000 SOLUTION, 3000 SOLUTION, 4000 SOLUTION, 10000 SBG (Specialty Biosimilars RETACRIT SP-P SOLUTION, 20000 and Specialty generics) SOLUTION, 40000 SOLUTION) epoetin alfa-epbx TAVALISSE (100 MG TAB, TAVALISSE 150 MG TAB) SP-P PA fostamatinib disodium UDENYCA 6 MG/0.6ML SBG (Specialty Biosimilars UDENYCA SOLN PRSYR SP-P and Specialty generics) pegfilgrastim-cbqv ZARXIO (300 MCG/0.5ML SOLN PRSYR, 480 SBG (Specialty Biosimilars ZARXIO SP-P MCG/0.8ML SOLN PRSYR) and Specialty generics) filgrastim-sndz ZIEXTENZO 6 MG/0.6ML SBG (Specialty Biosimilars ZIEXTENZO SOLN PRSYR SP-P and Specialty generics) pegfilgrastim-bmez

HEMOSTASIS AGENTS

ADVATE (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 RECON SOLN, 3000 ADVATE SP-M RECON SOLN, 4000 RECON SOLN) antihemophilic factor (rcmb) plasma/albumin free (rahf- pfm) ADYNOVATE (250 RECON SOLN, 500 RECON SOLN, 750 RECON SOLN, 1000 RECON SOLN, 1500 ADYNOVATE RECON SOLN, 2000 SP-M RECON SOLN, 3000 RECON SOLN) antihemophilic factor (recombinant) pegylated AFSTYLA (250 KIT, 500 KIT, 1000 KIT, 1500 KIT, 2000 KIT, 2500 KIT, 3000 AFSTYLA SP-M KIT) antihemophilic factor (recombinant) single chain ALPHANATE (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 ALPHANATE SP-M RECON SOLN) antihemophilic factor/von willebrand factor complex (human) ALPHANATE/VWF COMPLEX/HUMAN (250 RECON SOLN, 500 RECON SOLN, 1000 ALPHANATE/VWF RECON SOLN, 1500 SP-M COMPLEX/HUMAN RECON SOLN, 2000 RECON SOLN) antihemophilic factor/von willebrand factor complex (human)

©2021 Wellmark, Inc. 78 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ALPHANINE SD (500 RECON SOLN, 1000 ALPHANINE SD RECON SOLN, 1500 SP-M RECON SOLN) coagulation factor ix ALPROLIX (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 2000 RECON SOLN, 3000 ALPROLIX RECON SOLN, 4000 SP-M RECON SOLN) coagulation factor ix (recomb) fc fusion protein (rfixfc) aminocaproic acid (0.25 aminocaproic acid gm/ml solution, 500 mg tab, TIER 1 1000 mg tab) BEBULIN 200-1200 UNIT BEBULIN RECON SOLN SP-M factor ix complex BENEFIX (250 KIT, 500 KIT, 1000 KIT, 2000 KIT, BENEFIX 3000 KIT) SP-M coagulation factor ix (recombinant) COAGADEX (250 RECON SOLN, 500 RECON SOLN) COAGADEX SP-M coagulation factor x (human) ELOCTATE (250 RECON SOLN, 500 RECON SOLN, 750 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 RECON SOLN, 3000 ELOCTATE SP-M RECON SOLN, 4000 RECON SOLN, 5000 RECON SOLN, 6000 RECON SOLN) antihemophilic factor (rcmb) fc fusion protein(bdd-rfviiifc) FEIBA (500 RECON SOLN, 1000 RECON SOLN, 2500 FEIBA RECON SOLN) SP-M antiinhibitor coagulant complex FEIBA NF RECON SOLN FEIBA NF antiinhibitor coagulant SP-M complex

©2021 Wellmark, Inc. 79 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HELIXATE FS (250 KIT, 500 KIT, 1000 KIT, 2000 HELIXATE FS KIT, 3000 KIT) SP-M antihemophilic factor (recombinant) HEMLIBRA (30 MG/ML SOLUTION, 60 MG/0.4ML SOLUTION, 105 MG/0.7ML HEMLIBRA SP-M SOLUTION, 150 MG/ML SOLUTION) emicizumab-kxwh HEMOFIL M (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1700 HEMOFIL M SP-M RECON SOLN) antihemophilic factor (human) HUMATE-P (250-600 RECON SOLN, 500-1200 RECON SOLN, 1000-2400 HUMATE-P RECON SOLN) SP-M antihemophilic factor/von willebrand factor complex (human) IDELVION (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 2000 RECON SOLN, 3500 IDELVION SP-M RECON SOLN) coagulation factor ix recomb albumin fusion protein (rix-fp) IXINITY (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 IXINITY SP-M RECON SOLN, 3000 RECON SOLN) coagulation factor ix (recombinant) JIVI (500 RECON SOLN, 1000 RECON SOLN, 2000 RECON SOLN, 3000 JIVI RECON SOLN) SP-M antihemophil fact(rcmb) pegylated-aucl (bdd-rfviii peg-aucl)

©2021 Wellmark, Inc. 80 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KOATE (250 RECON SOLN, 500 RECON SOLN, KOATE 1000 RECON SOLN) SP-M antihemophilic factor (human) KOATE-DVI (250 RECON SOLN, 500 RECON SOLN, KOATE-DVI 1000 RECON SOLN) SP-M antihemophilic factor (human) KOGENATE FS (250 KIT, 500 KIT, 1000 KIT, 2000 KOGENATE FS KIT, 3000 KIT) SP-M antihemophilic factor (recombinant) KOGENATE FS BIO-SET (250 KIT, 500 KIT, 1000 KOGENATE FS BIO- KIT, 2000 KIT, 3000 KIT) SP-M SET antihemophilic factor (recombinant) KOVALTRY (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 2000 RECON SOLN, 3000 KOVALTRY SP-M RECON SOLN) antihemophilic factor (rcmb) plasma/albumin free (rahf- pfm) MONOCLATE-P (1000 KIT, 1500 KIT) MONOCLATE-P SP-M antihemophilic factor (human) MONONINE 1000 UNIT MONONINE RECON SOLN SP-M coagulation factor ix NOVOEIGHT (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 NOVOEIGHT SP-M RECON SOLN, 3000 RECON SOLN) antihemophilic factor (rcmb) bd truncated (bd trunc-rfviii)

©2021 Wellmark, Inc. 81 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NOVOSEVEN RT (1 MG RECON SOLN, 2 MG RECON SOLN, 5 MG NOVOSEVEN RT RECON SOLN, 8 MG SP-M RECON SOLN) coagulation factor viia (recombinant) NUWIQ (250 KIT, 250 RECON SOLN, 500 KIT, 500 RECON SOLN, 1000 KIT, 1000 RECON SOLN, 2000 KIT, 2000 RECON SOLN, 2500 KIT, 2500 NUWIQ SP-M RECON SOLN, 3000 KIT, 3000 RECON SOLN, 4000 KIT, 4000 RECON SOLN) antihemophilic factor (rcmb) simoctocog alfa(bdd- rfviii,sim) OBIZUR 500 UNIT RECON SOLN OBIZUR antihemophilic factor SP-M (recombinant porcine) (rpfviii) PROFILNINE (500 RECON SOLN, 1000 RECON PROFILNINE SOLN, 1500 RECON SP-M SOLN) factor ix complex PROFILNINE SD 500 UNIT PROFILNINE SD RECON SOLN SP-M factor ix complex REBINYN (500 RECON SOLN, 1000 RECON SOLN, 2000 RECON REBINYN SOLN) SP-M coagulation factor ix (recombinant) glycopegylated RECOMBINATE (220-400 RECON SOLN, 401-800 RECON SOLN, 801-1240 RECON SOLN, 1241-1800 RECOMBINATE SP-M RECON SOLN, 1801-2400 RECON SOLN) antihemophilic factor (recombinant)

©2021 Wellmark, Inc. 82 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RIXUBIS (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 2000 RIXUBIS RECON SOLN, 3000 SP-M RECON SOLN) coagulation factor ix (recombinant) SEVENFACT (1 MG RECON SOLN, 5 MG SEVENFACT RECON SOLN) SP-M coagulation factor viia (recombinant)-jncw tranexamic acid tranexamic acid 650 mg tab TIER 1 VONVENDI (650 RECON SOLN, 1300 RECON VONVENDI SOLN) SP-M von willebrand factor (recombinant) WILATE (500-500 KIT, 1000-1000 KIT) WILATE antihemophilic factor/von SP-M willebrand factor complex (human) XYNTHA (250 KIT, 500 KIT, 1000 KIT, 2000 KIT) XYNTHA antihemophilic factor (rcmb) SP-M moroctocog alfa(bdd- rfviii,mor) XYNTHA SOLOFUSE (250 KIT, 500 KIT, 1000 KIT, 2000 KIT, 3000 KIT) XYNTHA SOLOFUSE SP-M antihemophilic factor (rcmb) moroctocog alfa(bdd- rfviii,mor)

PLATELET MODIFYING AGENTS

ADAKVEO 100 MG/10ML ADAKVEO SOLUTION SP-M PA crizanlizumab-tmca aspirin-dipyridamole aspirin-dipyridamole er 25- TIER 1 er 200 mg cap er 12h BRILINTA (60 MG TAB, 90 BRILINTA MG TAB) TIER 2 ticagrelor cilostazol (50 mg tab, 100 cilostazol TIER 1 mg tab) clopidogrel bisulfate (75 mg clopidogrel bisulfate TIER 1 tab, 300 mg tab)

©2021 Wellmark, Inc. 83 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS dipyridamole (25 mg tab, 50 dipyridamole TIER 1 mg tab, 75 mg tab) OXBRYTA 500 MG TAB PA, QL (84 PER 28 DAY(S)), OXBRYTA SP-NP voxelotor PA-QL (140/28 days) prasugrel hcl (5 mg tab, 10 prasugrel hcl TIER 1 mg tab)

COAGULANTS

phytonadione phytonadione 5 mg tab TIER 1

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

clonidine (0.1 mg/24hr patch wk, 0.2 mg/24hr clonidine TIER 1 patch wk, 0.3 mg/24hr patch wk) clonidine hcl (0.1 mg tab, clonidine hcl TIER 1 0.2 mg tab, 0.3 mg tab) guanfacine hcl (1 mg tab, 2 guanfacine hcl TIER 1 QL (30 PER 30 DAY(S)) mg tab) methyldopa (250 mg tab, methyldopa TIER 1 500 mg tab) midodrine hcl (2.5 mg tab, 5 midodrine hcl TIER 1 mg tab, 10 mg tab)

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate (1 mg doxazosin mesylate tab, 2 mg tab, 4 mg tab, 8 TIER 1 mg tab) phenoxybenzamine phenoxybenzamine hcl 10 TIER 1 hcl mg cap prazosin hcl (1 mg cap, 2 prazosin hcl TIER 1 mg cap, 5 mg cap) terazosin hcl (1 mg cap, 2 terazosin hcl mg cap, 5 mg cap, 10 mg TIER 1 cap)

ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil (4 mg candesartan cilexetil tab, 8 mg tab, 16 mg tab, TIER 1 32 mg tab) EDARBI (40 MG TAB, 80 EDARBI MG TAB) TIER 3 azilsartan medoxomil

©2021 Wellmark, Inc. 84 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EPROSARTAN EPROSARTAN MESYLATE 600 MG TAB TIER 1 MESYLATE eprosartan mesylate irbesartan (75 mg tab, 150 irbesartan TIER 1 mg tab, 300 mg tab) losartan potassium (25 mg losartan potassium TIER 1 tab, 50 mg tab, 100 mg tab) olmesartan medoxomil (5 olmesartan mg tab, 20 mg tab, 40 mg TIER 1 medoxomil tab) telmisartan (20 mg tab, 40 telmisartan TIER 1 mg tab, 80 mg tab) valsartan (40 mg tab, 80 valsartan mg tab, 160 mg tab, 320 TIER 1 mg tab)

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

benazepril hcl (5 mg tab, 10 benazepril hcl mg tab, 20 mg tab, 40 mg TIER 1 tab) captopril (12.5 mg tab, 25 captopril mg tab, 50 mg tab, 100 mg TIER 1 tab) enalapril maleate (2.5 mg enalapril maleate tab, 5 mg tab, 10 mg tab, TIER 1 20 mg tab) enalapril maleate 1 mg/ml PA, QL (1200 PER 30 enalapril maleate TIER 1 solution DAY(S)) fosinopril sodium (10 mg fosinopril sodium TIER 1 tab, 20 mg tab, 40 mg tab) lisinopril (2.5 mg tab, 5 mg lisinopril tab, 10 mg tab, 20 mg tab, TIER 1 30 mg tab, 40 mg tab) moexipril hcl (7.5 mg tab, moexipril hcl TIER 1 15 mg tab) perindopril erbumine (2 mg perindopril erbumine TIER 1 tab, 4 mg tab, 8 mg tab) QBRELIS 1 MG/ML PA, QL (1200 PER 30 QBRELIS SOLUTION TIER 3 DAY(S)) lisinopril quinapril hcl (5 mg tab, 10 quinapril hcl mg tab, 20 mg tab, 40 mg TIER 1 tab) ramipril (1.25 mg cap, 2.5 ramipril mg cap, 5 mg cap, 10 mg TIER 1 cap)

ANTIARRHYTHMICS

amiodarone hcl (100 mg amiodarone hcl tab, 200 mg tab, 400 mg TIER 1 tab) disopyramide disopyramide phosphate TIER 1 phosphate (100 mg cap, 150 mg cap) dofetilide (125 mcg cap, dofetilide TIER 1 250 mcg cap, 500 mcg cap) flecainide acetate (50 mg flecainide acetate tab, 100 mg tab, 150 mg TIER 1 tab) mexiletine hcl (150 mg cap, mexiletine hcl TIER 1 200 mg cap, 250 mg cap) MULTAQ 400 MG TAB MULTAQ TIER 3 dronedarone hcl NORPACE CR (100 MG CAP ER 12H, 150 MG CAP NORPACE CR TIER 3 ER 12H) disopyramide phosphate pacerone (100 mg tab, 200 pacerone TIER 1 mg tab, 400 mg tab) propafenone hcl (150 mg propafenone hcl tab, 225 mg tab, 300 mg TIER 1 tab) propafenone hcl er (er 225 mg cap er 12h, er 325 mg propafenone hcl er TIER 1 cap er 12h, er 425 mg cap er 12h) quinidine gluconate er 324 quinidine gluconate er TIER 1 mg tab er QUINIDINE SULFATE (200 QUINIDINE MG TAB, 300 MG TAB) TIER 1 SULFATE quinidine sulfate sorine (80 mg tab, 120 mg sorine tab, 160 mg tab, 240 mg TIER 1 tab) sotalol hcl (80 mg tab, 120 sotalol hcl mg tab, 160 mg tab, 240 TIER 1 mg tab) sotalol hcl (af) (80 mg tab, sotalol hcl (af) TIER 1 120 mg tab, 160 mg tab)

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl (200 mg cap, acebutolol hcl TIER 1 400 mg cap) atenolol (25 mg tab, 50 mg atenolol TIER 1 tab, 100 mg tab) betaxolol hcl (10 mg tab, 20 betaxolol hcl TIER 1 mg tab) bisoprolol fumarate (5 mg bisoprolol fumarate TIER 1 tab, 10 mg tab) BYSTOLIC (2.5 MG TAB, 5 MG TAB, 10 MG TAB, 20 BYSTOLIC TIER 3 MG TAB) nebivolol hcl carvedilol (3.125 mg tab, carvedilol 6.25 mg tab, 12.5 mg tab, TIER 1 25 mg tab) carvedilol phosphate er (er carvedilol phosphate 10 mg cap er 24h, er 20 mg TIER 1 er cap er 24h, er 40 mg cap er 24h, er 80 mg cap er 24h) labetalol hcl (100 mg tab, labetalol hcl TIER 1 200 mg tab, 300 mg tab) metoprolol succinate er (er metoprolol succinate 25 mg tab er 24h, er 50 mg TIER 1 er tab er 24h, er 100 mg tab er 24h, er 200 mg tab er 24h) metoprolol tartrate (25 mg metoprolol tartrate TIER 1 tab, 50 mg tab, 100 mg tab) nadolol (20 mg tab, 40 mg nadolol TIER 1 tab, 80 mg tab) pindolol (5 mg tab, 10 mg pindolol TIER 1 tab) propranolol hcl (10 mg tab, 20 mg tab, 20 mg/5ml propranolol hcl solution, 40 mg tab, 40 TIER 1 mg/5ml solution, 60 mg tab, 80 mg tab) propranolol hcl er (er 60 mg cap er 24h, er 80 mg cap er propranolol hcl er TIER 1 24h, er 120 mg cap er 24h, er 160 mg cap er 24h) timolol maleate (5 mg tab, timolol maleate TIER 1 10 mg tab, 20 mg tab)

CALCIUM CHANNEL BLOCKING AGENTS

afeditab cr (30 mg tab er afeditab cr TIER 1 24h, 60 mg tab er 24h) amlodipine besylate (2.5 amlodipine besylate mg tab, 5 mg tab, 10 mg TIER 1 tab) cartia xt (120 mg cap er 24h, 180 mg cap er 24h, cartia xt TIER 1 240 mg cap er 24h, 300 mg cap er 24h) dilt-xr (120 mg cap er 24h, dilt-xr 180 mg cap er 24h, 240 mg TIER 1 cap er 24h) diltiazem cd (120 mg cap er 24h, 180 mg cap er 24h, diltiazem cd TIER 1 240 mg cap er 24h, 300 mg cap er 24h) diltiazem hcl (25 mg/5ml diltiazem hcl solution, 30 mg tab, 60 mg TIER 1 tab, 90 mg tab, 120 mg tab) diltiazem hcl er (er 60 mg cap er 12h, er 90 mg cap er 12h, er 120 mg cap er 12h, diltiazem hcl er TIER 1 er 120 mg cap er 24h, er 180 mg cap er 24h, er 240 mg cap er 24h) diltiazem hcl er beads (er beads 120 mg cap er 24h, er beads 180 mg cap er 24h, er beads 240 mg cap diltiazem hcl er beads TIER 1 er 24h, er beads 300 mg cap er 24h, er beads 360 mg cap er 24h, er beads 420 mg cap er 24h)

©2021 Wellmark, Inc. 88 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS diltiazem hcl er coated beads (er beads 120 mg cap er 24h, er beads 180 mg cap er 24h, er beads 180 mg tab er 24h, er beads 240 mg cap er 24h, diltiazem hcl er er beads 240 mg tab er TIER 1 coated beads 24h, er beads 300 mg cap er 24h, er beads 300 mg tab er 24h, er beads 360 mg cap er 24h, er beads 360 mg tab er 24h, er beads 420 mg tab er 24h) felodipine er (er 2.5 mg tab felodipine er er 24h, er 5 mg tab er 24h, TIER 1 er 10 mg tab er 24h) isradipine (2.5 mg cap, 5 isradipine TIER 1 mg cap) KATERZIA 1 MG/ML PA, QL (300 PER 30 KATERZIA SUSPENSION TIER 3 DAY(S)) amlodipine benzoate matzim la (180 mg tab er 24h, 240 mg tab er 24h, matzim la 300 mg tab er 24h, 360 mg TIER 1 tab er 24h, 420 mg tab er 24h) nicardipine hcl (20 mg cap, nicardipine hcl TIER 1 30 mg cap) nifediac cc (30 mg tab er nifediac cc TIER 1 24h, 60 mg tab er 24h) nifedipine (10 mg cap, 20 nifedipine TIER 1 mg cap) nifedipine er (er 30 mg tab nifedipine er er 24h, er 60 mg tab er 24h, TIER 1 er 90 mg tab er 24h) nifedipine er osmotic nifedipine er osmotic release (er 30 mg tab er TIER 1 release 24h, er 60 mg tab er 24h, er 90 mg tab er 24h) nimodipine nimodipine 30 mg cap TIER 1

©2021 Wellmark, Inc. 89 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS nisoldipine er (er 8.5 mg tab er 24h, er 17 mg tab er 24h, er 20 mg tab er 24h, er 25.5 nisoldipine er TIER 1 mg tab er 24h, er 30 mg tab er 24h, er 34 mg tab er 24h, er 40 mg tab er 24h) NYMALIZE (30 MG/10ML SOLUTION, 60 MG/20ML NYMALIZE TIER 3 SOLUTION) nimodipine taztia xt (120 mg cap er 24h, 180 mg cap er 24h, taztia xt 240 mg cap er 24h, 300 mg TIER 1 cap er 24h, 360 mg cap er 24h) tiadylt er (er 120 mg cap er 24h, er 180 mg cap er 24h, er 240 mg cap er 24h, er tiadylt er TIER 1 300 mg cap er 24h, er 360 mg cap er 24h, er 420 mg cap er 24h) verapamil hcl (40 mg tab, verapamil hcl TIER 1 80 mg tab, 120 mg tab) VERAPAMIL HCL ER (ER 100 MG CAP ER 24H, ER 120 MG CAP ER 24H, ER 120 MG TAB ER, ER 180 MG CAP ER 24H, ER 180 MG TAB ER, ER 200 MG VERAPAMIL HCL ER TIER 1 CAP ER 24H, ER 240 MG CAP ER 24H, ER 240 MG TAB ER, ER 300 MG CAP ER 24H, ER 360 MG CAP ER 24H) verapamil hcl VERELAN 360 MG CAP VERELAN ER 24H TIER 3 verapamil hcl VERELAN PM 100 MG VERELAN PM CAP ER 24H TIER 3 GA verapamil hcl

CARDIOVASCULAR AGENTS, OTHER

aliskiren fumarate (150 mg aliskiren fumarate TIER 1 tab, 300 mg tab) amiloride- amiloride- hydrochlorothiazide 5-50 TIER 1 hydrochlorothiazide mg tab

©2021 Wellmark, Inc. 90 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS amlodipine besy-benazepril hcl (2.5-10 mg cap, 5-10 amlodipine besy- mg cap, 5-20 mg cap, 5-40 TIER 1 benazepril hcl mg cap, 10-20 mg cap, 10- 40 mg cap) amlodipine besylate- amlodipine besylate- valsartan (5-160 mg tab, 5- TIER 1 valsartan 320 mg tab, 10-160 mg tab, 10-320 mg tab) amlodipine-atorvastatin (2.5-10 mg tab, 2.5-20 mg tab, 2.5-40 mg tab, 5-10 mg amlodipine- tab, 5-20 mg tab, 5-40 mg TIER 1 atorvastatin tab, 5-80 mg tab, 10-10 mg tab, 10-20 mg tab, 10-40 mg tab, 10-80 mg tab) amlodipine-olmesartan (5- amlodipine- 20 mg tab, 5-40 mg tab, 10- TIER 1 olmesartan 20 mg tab, 10-40 mg tab) amlodipine-valsartan-hctz (5-160-12.5 mg tab, 5-160- amlodipine-valsartan- 25 mg tab, 10-160-12.5 mg TIER 1 hctz tab, 10-160-25 mg tab, 10- 320-25 mg tab) atenolol- atenolol-chlorthalidone (50- TIER 1 chlorthalidone 25 mg tab, 100-25 mg tab) benazepril- benazepril- hydrochlorothiazide (5-6.25 TIER 1 hydrochlorothiazide mg tab, 10-12.5 mg tab, 20- 12.5 mg tab, 20-25 mg tab) bisoprolol- bisoprolol- hydrochlorothiazide (2.5- TIER 1 hydrochlorothiazide 6.25 mg tab, 5-6.25 mg tab, 10-6.25 mg tab) candesartan cilexetil-hctz candesartan cilexetil- (16-12.5 mg tab, 32-12.5 TIER 1 hctz mg tab, 32-25 mg tab) CAPTOPRIL- HYDROCHLOROTHIAZIDE CAPTOPRIL- (25-15 MG TAB, 25-25 MG HYDROCHLOROTHI TAB, 50-15 MG TAB, 50-25 TIER 1 AZIDE MG TAB) captopril & hydrochlorothiazide CORLANOR (5 MG TAB, CORLANOR 7.5 MG TAB) TIER 3 PA, QL (60 PER 30 DAY(S)) ivabradine hcl

©2021 Wellmark, Inc. 91 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CORLANOR 5 MG/5ML PA, QL (450 PER 30 CORLANOR SOLUTION TIER 3 DAY(S)) ivabradine hcl digitek (125 mcg tab, 250 digitek TIER 1 mcg tab) digox (125 mcg tab, 250 digox TIER 1 mcg tab) digoxin (0.05 mg/ml digoxin solution, 125 mcg tab, 250 TIER 1 mcg tab) EDARBYCLOR (40-12.5 MG TAB, 40-25 MG TAB) EDARBYCLOR TIER 3 azilsartan medoxomil- chlorthalidone enalapril- enalapril- hydrochlorothiazide (5-12.5 TIER 1 hydrochlorothiazide mg tab, 10-25 mg tab) ENTRESTO (24-26 MG TAB, 49-51 MG TAB, 97- ENTRESTO TIER 2 PA, QL (60 PER 30 DAYS) 103 MG TAB) sacubitril-valsartan fosinopril sodium-hctz (10- fosinopril sodium-hctz 12.5 mg tab, 20-12.5 mg TIER 1 tab) irbesartan- irbesartan- hydrochlorothiazide (150- TIER 1 hydrochlorothiazide 12.5 mg tab, 300-12.5 mg tab) isoxsuprine hcl (10 mg tab, isoxsuprine hcl TIER 1 20 mg tab) LANOXIN (62.5 MCG TAB, LANOXIN 187.5 MCG TAB) TIER 3 digoxin lisinopril- lisinopril- hydrochlorothiazide (10- TIER 1 hydrochlorothiazide 12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab) losartan potassium-hctz losartan potassium- (50-12.5 mg tab, 100-12.5 TIER 1 hctz mg tab, 100-25 mg tab) METHYLDOPA- HYDROCHLOROTHIAZIDE METHYLDOPA- (250-15 MG TAB, 250-25 HYDROCHLOROTHI TIER 1 MG TAB) AZIDE methyldopa & hydrochlorothiazide

©2021 Wellmark, Inc. 92 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS metoprolol- metoprolol- hydrochlorothiazide (50-25 TIER 1 hydrochlorothiazide mg tab, 100-25 mg tab, 100-50 mg tab) metyrosine metyrosine 250 mg cap TIER 1 moexipril- moexipril- hydrochlorothiazide (7.5- TIER 1 hydrochlorothiazide 12.5 mg tab, 15-12.5 mg tab, 15-25 mg tab) nadolol- nadolol- bendroflumethiazide (40-5 TIER 1 bendroflumethiazide mg tab, 80-5 mg tab) olmesartan medoxomil-hctz olmesartan (20-12.5 mg tab, 40-12.5 TIER 1 medoxomil-hctz mg tab, 40-25 mg tab) olmesartan-amlodipine-hctz (20-5-12.5 mg tab, 40-10- olmesartan- 12.5 mg tab, 40-10-25 mg TIER 1 amlodipine-hctz tab, 40-5-12.5 mg tab, 40- 5-25 mg tab) pentoxifylline er 400 mg tab pentoxifylline er TIER 1 er PROPRANOLOL-HCTZ (40-25 MG TAB, 80-25 MG PROPRANOLOL- TAB) TIER 1 HCTZ propranolol & hydrochlorothiazide quinapril- quinapril- hydrochlorothiazide (10- TIER 1 hydrochlorothiazide 12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab) ranolazine er (er 500 mg ranolazine er tab er 12h, er 1000 mg tab TIER 1 er 12h) spironolactone-hctz 25-25 spironolactone-hctz TIER 1 mg tab telmisartan-amlodipine (40- telmisartan- 10 mg tab, 40-5 mg tab, 80- TIER 1 amlodipine 10 mg tab, 80-5 mg tab) telmisartan-hctz (40-12.5 telmisartan-hctz mg tab, 80-12.5 mg tab, 80- TIER 1 25 mg tab)

©2021 Wellmark, Inc. 93 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS trandolapril-verapamil hcl er trandolapril-verapamil (er 1-240 mg tab er, er 2- TIER 1 hcl er 180 mg tab er, er 2-240 mg tab er, er 4-240 mg tab er) triamterene-hctz (37.5-25 triamterene-hctz mg cap, 37.5-25 mg tab, TIER 1 75-50 mg tab) valsartan- hydrochlorothiazide (80- valsartan- 12.5 mg tab, 160-12.5 mg TIER 1 hydrochlorothiazide tab, 160-25 mg tab, 320- 12.5 mg tab, 320-25 mg tab) VERQUVO (2.5 MG TAB, 5 VERQUVO MG TAB, 10 MG TAB) TIER 3 PA, QL (30 PER 30 DAY(S)) vericiguat VYNDAMAX 61 MG CAP VYNDAMAX SP-P PA, QL (30 PER 30 DAY(S)) tafamidis VYNDAQEL 20 MG CAP PA, QL (120 PER 30 VYNDAQEL tafamidis meglumine SP-P DAY(S)) (cardiac)

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide (125 mg tab, acetazolamide TIER 1 250 mg tab) acetazolamide er 500 mg acetazolamide er TIER 1 cap er 12h KEVEYIS 50 MG TAB KEVEYIS SP-P dichlorphenamide

DIURETICS, LOOP

bumetanide (0.5 mg tab, 1 bumetanide TIER 1 mg tab, 2 mg tab) ethacrynic acid ethacrynic acid 25 mg tab TIER 1 furosemide (8 mg/ml solution, 10 mg/ml solution, furosemide TIER 1 20 mg tab, 40 mg tab, 80 mg tab) torsemide (5 mg tab, 10 mg torsemide TIER 1 tab, 20 mg tab, 100 mg tab)

DIURETICS, POTASSIUM-SPARING

amiloride hcl amiloride hcl 5 mg tab TIER 1 CAROSPIR 25 MG/5ML PA, QL (600 PER 30 CAROSPIR SUSPENSION TIER 3 DAY(S)) spironolactone

©2021 Wellmark, Inc. 94 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS eplerenone (25 mg tab, 50 eplerenone TIER 1 mg tab) spironolactone (25 mg tab, spironolactone TIER 1 50 mg tab, 100 mg tab) triamterene (50 mg cap, triamterene TIER 1 100 mg cap)

DIURETICS, THIAZIDE

chlorothiazide (250 mg tab, chlorothiazide TIER 1 500 mg tab) chlorthalidone (25 mg tab, chlorthalidone TIER 1 50 mg tab) DIURIL 250 MG/5ML DIURIL SUSPENSION TIER 3 chlorothiazide hydrochlorothiazide (12.5 hydrochlorothiazide mg cap, 12.5 mg tab, 25 TIER 1 mg tab, 50 mg tab) indapamide (1.25 mg tab, indapamide TIER 1 2.5 mg tab) METHYCLOTHIAZIDE 5 METHYCLOTHIAZID MG TAB TIER 1 E methyclothiazide metolazone (2.5 mg tab, 5 metolazone TIER 1 mg tab, 10 mg tab)

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

fenofibrate (48 mg tab, 50 mg cap, 54 mg tab, 67 mg fenofibrate cap, 134 mg cap, 145 mg TIER 1 tab, 150 mg cap, 160 mg tab, 200 mg cap) fenofibrate micronized (43 mg cap, 67 mg cap, 130 mg fenofibrate micronized TIER 1 cap, 134 mg cap, 200 mg cap) fenofibric acid (45 mg cap fenofibric acid TIER 1 dr, 135 mg cap dr) gemfibrozil gemfibrozil 600 mg tab TIER 1 LIPOFEN (50 MG CAP, LIPOFEN 150 MG CAP) TIER 3 GA fenofibrate

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

atorvastatin calcium (10 mg atorvastatin calcium tab, 20 mg tab, 40 mg tab, TIER 1 80 mg tab) fluvastatin sodium (20 mg fluvastatin sodium TIER 1 cap, 40 mg cap) fluvastatin sodium er 80 mg fluvastatin sodium er TIER 1 tab er 24h LIVALO (1 MG TAB, 2 MG LIVALO TAB, 4 MG TAB) TIER 2 pitavastatin calcium lovastatin (10 mg tab, 20 lovastatin TIER 1 mg tab, 40 mg tab) pravastatin sodium (10 mg pravastatin sodium tab, 20 mg tab, 40 mg tab, TIER 1 80 mg tab) rosuvastatin calcium (5 mg rosuvastatin calcium tab, 10 mg tab, 20 mg tab, TIER 1 40 mg tab) simvastatin (5 mg tab, 10 simvastatin mg tab, 20 mg tab, 40 mg TIER 1 tab, 80 mg tab) ZYPITAMAG (1 MG TAB, 2 ZYPITAMAG MG TAB, 4 MG TAB) TIER 2 pitavastatin magnesium

DYSLIPIDEMICS, OTHER

cholestyramine (4 gm cholestyramine TIER 1 packet, 4 gm/dose powder) cholestyramine light (4 gm cholestyramine light TIER 1 packet, 4 gm/dose powder) colesevelam hcl (3.75 gm colesevelam hcl TIER 1 packet, 625 mg tab) colestipol hcl (1 gm tab, 5 colestipol hcl TIER 1 gm granules, 5 gm packet) ezetimibe ezetimibe 10 mg tab TIER 1 ezetimibe-simvastatin (10- 10 mg tab, 10-20 mg tab, ezetimibe-simvastatin TIER 1 10-40 mg tab, 10-80 mg tab) icosapent ethyl icosapent ethyl 1 gm cap TIER 3 PA, QL (4 PER DAY(S))

©2021 Wellmark, Inc. 96 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS JUXTAPID (5 MG CAP, 10 MG CAP, 20 MG CAP, 30 JUXTAPID MG CAP, 40 MG CAP, 60 SP-P PA, QL (30 PER 30 DAYS) MG CAP) lomitapide mesylate KYNAMRO 200 MG/ML KYNAMRO SOLN PRSYR SP-P PA, QL (4 PER 28 DAYS) mipomersen sodium NIACIN NIACIN (ANTIHYPERLIPIDEMIC) (ANTIHYPERLIPIDE TIER 3 500 MG TAB MIC) niacin (antihyperlipidemic) niacin er niacin er (antihyperlipidemic) (er 500 TIER 1 (antihyperlipidemic) mg tab er, er 750 mg tab er, er 1000 mg tab er) NIACOR 500 MG TAB NIACOR TIER 3 niacin (antihyperlipidemic) PRALUENT (75 MG/ML QL (2 PER 28 DAY(S)), MN- SOLN A-INJ, 150 MG/ML PRALUENT TIER 3 PA (Medically Necessary SOLN A-INJ) Prior Authorization) alirocumab prevalite (4 gm packet, 4 prevalite TIER 1 gm/dose powder) REPATHA 140 MG/ML REPATHA SOLN PRSYR TIER 3 PA, QL (2 PER 28 DAY(S)) evolocumab REPATHA PUSHTRONEX REPATHA SYSTEM 420 MG/3.5ML PUSHTRONEX TIER 3 PA, QL (1 PER 30 DAYS) SOLN CART SYSTEM evolocumab REPATHA SURECLICK REPATHA 140 MG/ML SOLN A-INJ TIER 3 PA, QL (2 PER 28 DAY(S)) SURECLICK evolocumab VASCEPA 0.5 GM CAP PA, QL (4 PER DAY(S)), VASCEPA TIER 3 icosapent ethyl QLV (QL varies) VASCEPA 1 GM CAP VASCEPA TIER 3 PA, QL (4 PER DAY(S)), GA icosapent ethyl

VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine hcl (10 mg tab, hydralazine hcl 25 mg tab, 50 mg tab, 100 TIER 1 mg tab) minoxidil (2.5 mg tab, 10 minoxidil TIER 1 mg tab)

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

isoditrate er isoditrate er 40 mg tab er TIER 1 isosorbide dinitrate (5 mg isosorbide dinitrate tab, 10 mg tab, 20 mg tab, TIER 1 30 mg tab) ISOSORBIDE DINITRATE ISOSORBIDE ER 40 MG TAB ER TIER 1 GA DINITRATE ER isosorbide dinitrate isosorbide isosorbide mononitrate (10 TIER 1 mononitrate mg tab, 20 mg tab) isosorbide mononitrate er isosorbide (er 30 mg tab er 24h, er 60 TIER 1 mononitrate er mg tab er 24h, er 120 mg tab er 24h) minitran (0.1 patch 24hr, minitran 0.2 patch 24hr, 0.4 patch TIER 1 24hr, 0.6 patch 24hr) NITRO-BID 2 % NITRO-BID OINTMENT TIER 3 nitroglycerin NITRO-DUR 0.8 MG/HR NITRO-DUR PATCH 24HR TIER 3 nitroglycerin NITRO-TIME (2.5 MG CAP ER, 6.5 MG CAP ER, 9 MG NITRO-TIME TIER 1 GA CAP ER) nitroglycerin nitroglycerin (0.1 mg/hr patch 24hr, 0.2 mg/hr patch 24hr, 0.3 mg sl tab, 0.4 mg sl tab, 0.4 mg/hr patch nitroglycerin TIER 1 24hr, 0.4 mg/spray solution, 0.6 mg sl tab, 0.6 mg/hr patch 24hr, 400 mcg/spray aero soln) nitroglycerin er (er 2.5 mg nitroglycerin er cap er, er 6.5 mg cap er, er TIER 1 9 mg cap er) NITROMIST 400 NITROMIST MCG/SPRAY AERO SOLN TIER 3 GA nitroglycerin

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

amphetamine- dextroamphet er (er 5 mg cap er 24h, er 10 mg cap er amphetamine- 24h, er 15 mg cap er 24h, TIER 1 PA dextroamphet er er 20 mg cap er 24h, er 25 mg cap er 24h, er 30 mg cap er 24h) amphetamine- dextroamphetamine (5 mg amphetamine- tab, 7.5 mg tab, 10 mg tab, TIER 1 dextroamphetamine 12.5 mg tab, 15 mg tab, 20 mg tab, 30 mg tab) dexedrine dexedrine 10 mg tab TIER 1 dextroamphetamine sulfate dextroamphetamine (5 mg tab, 5 mg/5ml TIER 1 sulfate solution, 10 mg tab) dextroamphetamine sulfate dextroamphetamine er (er 5 mg cap er 24h, er TIER 1 PA sulfate er 10 mg cap er 24h, er 15 mg cap er 24h) methamphetamine hcl 5 mg methamphetamine hcl TIER 1 tab procentra procentra 5 mg/5ml solution TIER 1 VYVANSE (10 MG CAP, 10 MG CHEW TAB, 20 MG CAP, 20 MG CHEW TAB, 30 MG CAP, 30 MG CHEW TAB, 40 MG CAP, 40 MG VYVANSE CHEW TAB, 50 MG CAP, TIER 3 PA 50 MG CHEW TAB, 60 MG CAP, 60 MG CHEW TAB, 70 MG CAP) lisdexamfetamine dimesylate zenzedi (5 mg tab, 10 mg zenzedi TIER 1 tab)

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

atomoxetine hcl (10 mg atomoxetine hcl cap, 18 mg cap, 25 mg cap, TIER 1 QL (60 PER 30 DAYS) 40 mg cap, 60 mg cap) atomoxetine hcl (80 mg atomoxetine hcl TIER 1 QL (30 PER 30 DAYS) cap, 100 mg cap)

©2021 Wellmark, Inc. 99 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS clonidine hcl er 0.1 mg tab clonidine hcl er TIER 1 er 12h dexmethylphenidate hcl dexmethylphenidate (2.5 mg tab, 5 mg tab, 10 TIER 1 hcl mg tab) dexmethylphenidate hcl er (er 5 mg cap er 24h, er 10 mg cap er 24h, er 15 mg dexmethylphenidate cap er 24h, er 20 mg cap er TIER 1 PA hcl er 24h, er 25 mg cap er 24h, er 30 mg cap er 24h, er 35 mg cap er 24h, er 40 mg cap er 24h) guanfacine hcl er (er 1 mg tab er 24h, er 2 mg tab er guanfacine hcl er TIER 1 24h, er 3 mg tab er 24h, er 4 mg tab er 24h) metadate er metadate er 20 mg tab er TIER 1 PA methylphenidate hcl (2.5 mg chew tab, 5 mg chew tab, 5 mg tab, 5 mg/5ml methylphenidate hcl TIER 1 solution, 10 mg chew tab, 10 mg tab, 10 mg/5ml solution, 20 mg tab) methylphenidate hcl er (cd) (er 10 mg cap er, er 20 mg methylphenidate hcl cap er, er 30 mg cap er, er TIER 1 PA er (cd) 40 mg cap er, er 50 mg cap er, er 60 mg cap er) methylphenidate hcl er (er 10 mg tab er, er 18 mg tab er, er 18 mg tab er 24h, er 20 mg tab er, er 27 mg tab methylphenidate hcl er, er 27 mg tab er 24h, er TIER 1 PA er 36 mg tab er, er 36 mg tab er 24h, er 54 mg tab er, er 54 mg tab er 24h, er 72 mg tab er) methylphenidate hcl er (la) (er 10 mg cap er 24h, er 20 methylphenidate hcl mg cap er 24h, er 30 mg TIER 1 PA er (la) cap er 24h, er 40 mg cap er 24h, er 60 mg cap er 24h) QUILLIVANT XR 25 QUILLIVANT XR MG/5ML SRER TIER 3 PA methylphenidate hcl

CENTRAL NERVOUS SYSTEM, OTHER

AUSTEDO (6 MG TAB, 9 AUSTEDO MG TAB, 12 MG TAB) SP-P deutetrabenazine bac bac 50-325-40 mg tab TIER 1 butalbital- butalbital-acetaminophen TIER 1 acetaminophen 50-325 mg tab butalbital-apap 50-325 mg butalbital-apap TIER 1 tab butalbital-apap-caffeine butalbital-apap- (50-300-40 mg cap, 50- TIER 1 caffeine 325-40 mg cap, 50-325-40 mg tab) capacet capacet 50-325-40 mg cap TIER 1 esgic esgic 50-325-40 mg cap TIER 1 EVRYSDI 0.75 MG/ML PA, QL (120 PER 24 EVRYSDI RECON SOLN SP-P DAY(S)) risdiplam INGREZZA (40 MG CAP, INGREZZA 80 MG CAP) SP-P PA valbenazine tosylate INGREZZA 60 MG CAP INGREZZA SP-P PA, QL (1 PER 1 DAY(S)) valbenazine tosylate marten-tab marten-tab 50-325 mg tab TIER 1 phrenilin forte 50-300-40 phrenilin forte TIER 1 mg cap RADICAVA 30 MG/100ML RADICAVA SOLUTION SP-M PA edaravone riluzole riluzole 50 mg tab TIER 1 TEGSEDI 284 MG/1.5ML TEGSEDI SOLN PRSYR SP-P PA, QL (4 PER 28 DAY(S)) inotersen sodium TENCON 50-325 MG TAB TENCON TIER 1 GA butalbital-acetaminophen QL (240 PER 30 DAYS), tetrabenazine tetrabenazine 12.5 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) QL (120 PER 30 DAYS), tetrabenazine tetrabenazine 25 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics)

FIBROMYALGIA AGENTS

duloxetine hcl (20 mg cp dr part, 30 mg cp dr part, 40 duloxetine hcl TIER 1 mg cp dr part, 60 mg cp dr part) pregabalin (25 mg cap, 50 mg cap, 75 mg cap, 100 mg pregabalin cap, 150 mg cap, 200 mg TIER 1 cap, 225 mg cap, 300 mg cap) pregabalin 20 mg/ml PA, QL (900 PER 30 pregabalin TIER 1 solution DAY(S)) SAVELLA (12.5 MG TAB, 25 MG TAB, 50 MG TAB, SAVELLA TIER 3 QL (60 PER 30 DAY(S)) 100 MG TAB) milnacipran hcl SAVELLA TITRATION SAVELLA PACK 12.5 & 25 & 50 MG TIER 3 QL (1 PER LIFETIME) TITRATION PACK MISC milnacipran hcl

MULTIPLE SCLEROSIS AGENTS

AUBAGIO (7 MG TAB, 14 AUBAGIO MG TAB) SP-P PA, QL (30 PER 30 DAYS) teriflunomide AVONEX 30 MCG KIT AVONEX SP-NP PA, QL (4 PER 28 DAYS) interferon beta-1a AVONEX PEN 30 AVONEX PEN MCG/0.5ML AUT-IJ KIT SP-NP PA, QL (4 PER 28 DAYS) interferon beta-1a AVONEX PREFILLED 30 AVONEX MCG/0.5ML PREF SY KT SP-NP PA, QL (4 PER 28 DAYS) PREFILLED interferon beta-1a BAFIERTAM 95 MG CAP BAFIERTAM DR SP-P PA, QL (4 PER DAY(S)) monomethyl fumarate BETASERON 0.3 MG KIT BETASERON SP-P PA, QL (15 PER 30 DAYS) interferon beta-1b COPAXONE 40 MG/ML PA, QL (12 PER 28 DAYS), COPAXONE SOLN PRSYR SP-P GA glatiramer acetate QL (60 PER 30 DAYS), SBG dalfampridine er 10 mg tab dalfampridine er SP-P (Specialty Biosimilars and er 12h Specialty generics)

©2021 Wellmark, Inc. 102 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PA, QL (60 PER 30 DAYS), dimethyl fumarate (120 mg dimethyl fumarate SP-P SBG (Specialty Biosimilars cap dr, 240 mg cap dr) and Specialty generics) PA, QL (1 PER FILL), SBG dimethyl fumarate dimethyl fumarate starter SP-P (Specialty Biosimilars and starter pack pack 120 & 240 mg misc Specialty generics) QL (15 PER 30 DAYS), MN- EXTAVIA 0.3 MG KIT EXTAVIA SP-NP PA (Medically Necessary interferon beta-1b Prior Authorization) GILENYA 0.25 MG CAP GILENYA SP-P PA, QL (30 PER 30 DAY(S)) fingolimod hcl GILENYA 0.5 MG CAP GILENYA SP-P PA, QL (30 PER 30 DAYS) fingolimod hcl PA, QL (12 PER 28 DAYS), glatiramer acetate 40 mg/ml glatiramer acetate SP-P SBG (Specialty Biosimilars soln prsyr and Specialty generics) PA, QL (12 PER 28 DAYS), glatopa glatopa 40 mg/ml soln prsyr SP-P SBG (Specialty Biosimilars and Specialty generics) KESIMPTA 20 MG/0.4ML KESIMPTA SOLN A-INJ SP-NP PA, QL (1 PER 28 DAY(S)) ofatumumab (ms) LEMTRADA 12 MG/1.2ML MN-PA (Medically Necessary LEMTRADA SOLUTION SP-M Prior Authorization) alemtuzumab (ms) MAVENCLAD (10 TABS) MAVENCLAD (10 10 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (4 TABS) 10 MAVENCLAD (4 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (5 TABS) 10 MAVENCLAD (5 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (6 TABS) 10 MAVENCLAD (6 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (7 TABS) 10 MAVENCLAD (7 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis)

©2021 Wellmark, Inc. 103 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MAVENCLAD (8 TABS) 10 MAVENCLAD (8 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (9 TABS) 10 MAVENCLAD (9 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAYZENT 0.25 MG TAB PA, QL (112 PER 28 MAYZENT SP-P siponimod fumarate DAY(S)) MAYZENT 2 MG TAB MAYZENT SP-P PA, QL (30 PER 30 DAY(S)) siponimod fumarate MAYZENT STARTER MAYZENT STARTER PACK 12 X 0.25 MG TAB SP-P PA, QL (12 PER 5 DAY(S)) PACK THPK siponimod fumarate OCREVUS 300 MG/10ML MN-PA (Medically Necessary OCREVUS SOLUTION SP-M Prior Authorization) ocrelizumab PLEGRIDY (125 SOLN PLEGRIDY PEN, 125 SOLN PRSYR) SP-NP PA, QL (2 PER 28 DAYS) peginterferon beta-1a PLEGRIDY 125 PLEGRIDY MCG/0.5ML SOLN PRSYR SP-NP PA, QL (2 PER 28 DAY(S)) peginterferon beta-1a PLEGRIDY STARTER PACK (PACK 63 94 SOLN PLEGRIDY PEN, PACK 63 94 SOLN SP-NP PA, QL (1 PER 28 DAYS) STARTER PACK PRSYR) peginterferon beta-1a REBIF (22 SOLN PRSYR, REBIF 44 SOLN PRSYR) SP-P PA, QL (12 PER 28 DAYS) interferon beta-1a REBIF REBIDOSE (22 SOLN A-INJ, 44 SOLN A- REBIF REBIDOSE SP-P PA, QL (12 PER 28 DAYS) INJ) interferon beta-1a REBIF REBIDOSE REBIF REBIDOSE TITRATION PACK 6X8.8 & SP-P PA, QL (12 PER 28 DAYS) TITRATION PACK 6X22 MCG SOLN A-INJ interferon beta-1a REBIF TITRATION PACK REBIF TITRATION 6X8.8 & 6X22 MCG SOLN SP-P PA, QL (12 PER 28 DAYS) PACK PRSYR interferon beta-1a

©2021 Wellmark, Inc. 104 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TYSABRI 300 MG/15ML TYSABRI CONC SP-M PA, QL (1 PER 28 DAYS) natalizumab VUMERITY (STARTER) QL (106 PER 30 DAY(S)), VUMERITY 231 MG CAP DR SP-NP MN-PA (Medically Necessary (STARTER) diroximel fumarate Prior Authorization) VUMERITY 231 MG CAP QL (120 PER 30 DAY(S)), VUMERITY DR SP-NP MN-PA (Medically Necessary diroximel fumarate Prior Authorization) QL (30 PER 30 DAY(S)), ZEPOSIA 0.92 MG CAP ZEPOSIA SP-NP MN-PA (Medically Necessary ozanimod hcl Prior Authorization) ZEPOSIA 7-DAY STARTER PACK 4 X QL (1 PER LIFETIME), MN- ZEPOSIA 7-DAY 0.23MG & 3 X 0.46MG SP-NP PA (Medically Necessary STARTER PACK CAP THPK Prior Authorization) ozanimod hcl ZEPOSIA STARTER KIT QL (1 PER LIFETIME), MN- ZEPOSIA STARTER 0.23MG & 0.46MG & SP-NP PA (Medically Necessary KIT 0.92MG CAP THPK Prior Authorization) ozanimod hcl

DENTAL AND ORAL AGENTS

cevimeline hcl cevimeline hcl 30 mg cap TIER 1 chlorhexidine chlorhexidine gluconate TIER 1 gluconate 0.12 % solution DEBACTEROL 30-50 % SOLUTION DEBACTEROL TIER 3 sulfuric acid-sulfonated phenolics oralone oralone 0.1 % paste TIER 1 paroex paroex 0.12 % solution TIER 1 periogard periogard 0.12 % solution TIER 1 pilocarpine hcl (5 mg tab, pilocarpine hcl TIER 1 7.5 mg tab) triamcinolone triamcinolone acetonide TIER 1 acetonide (0.1 % cream, 0.1 % paste)

DERMATOLOGICAL AGENTS

accutane (10 mg cap, 20 accutane mg cap, 30 mg cap, 40 mg TIER 1 cap) acitretin (10 mg cap, 17.5 acitretin TIER 1 mg cap, 25 mg cap) adapalene adapalene 0.3 % gel TIER 1 PA

©2021 Wellmark, Inc. 105 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS amnesteem (10 mg cap, 20 amnesteem TIER 1 mg cap, 40 mg cap) avita (0.025 % cream, avita TIER 1 PA 0.025 % gel) azelaic acid azelaic acid 15 % gel TIER 1 calcipotriene (0.005 % calcipotriene foam, 0.005 % ointment, TIER 1 0.005 % solution) calcipotriene 0.005 % calcipotriene TIER 1 QL (120 PER 30 DAY(S)) cream CALCIPOTRIENE 0.005 % CALCIPOTRIENE FOAM TIER 3 GA calcipotriene calcipotriene-betameth calcipotriene- diprop 0.005-0.064 % TIER 1 QL (120 PER 30 DAY(S)) betameth diprop ointment calcipotriene-betameth calcipotriene- diprop 0.005-0.064 % TIER 1 betameth diprop suspension calcitrene calcitrene 0.005 % ointment TIER 1 calcitriol calcitriol 3 mcg/gm ointment TIER 1 claravis (10 mg cap, 20 mg claravis TIER 1 cap, 30 mg cap, 40 mg cap) clindamycin phos-benzoyl clindamycin phos- perox (1-5 % gel, 1.2-2.5 % TIER 1 PA benzoyl perox gel, 1.2-5 % gel) clindamycin-tretinoin 1.2- clindamycin-tretinoin TIER 1 PA 0.025 % gel clotrimazole- clotrimazole- betamethasone (% cream, TIER 1 betamethasone % lotion) COSENTYX (300 MG COSENTYX (300 MG DOSE) 150 MG/ML SOLN SP-P PA, QL (2 PER 28 DAYS) DOSE) PRSYR secukinumab COSENTYX 75 MG/0.5ML COSENTYX SOLN PRSYR SP-P PA, QL (1 PER 28 DAY(S)) secukinumab COSENTYX COSENTYX SENSOREADY (300 MG) SENSOREADY (300 SP-P PA, QL (2 PER 28 DAYS) 150 MG/ML SOLN A-INJ MG) secukinumab dapsone (5 % gel, 7.5 % dapsone TIER 1 PA gel)

©2021 Wellmark, Inc. 106 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DUPIXENT (200 MG/1.14ML SOLN PEN, 200 MG/1.14ML SOLN DUPIXENT PRSYR, 300 MG/2ML SP-P PA, QL (2 PER 28 DAY(S)) SOLN PEN, 300 MG/2ML SOLN PRSYR) dupilumab DUROLANE 60 MG/3ML PRSYR MN-PA (Medically Necessary DUROLANE SP-M sodium hyaluronate Prior Authorization) (viscosupplement) EUCRISA 2 % OINTMENT EUCRISA TIER 3 PA crisaborole FINACEA 15 % FOAM FINACEA TIER 3 PA azelaic acid FLUOROPLEX 1 % FLUOROPLEX CREAM TIER 3 PA fluorouracil (topical) fluorouracil fluorouracil 0.5 % cream TIER 1 PA fluorouracil fluorouracil 5 % cream TIER 1 hydrocort-pramoxine hydrocort-pramoxine TIER 1 (perianal) (perianal) 2.5-1 % cream hydrocortisone ace- hydrocortisone ace- TIER 1 pramoxine pramoxine 1-1 % cream ILUMYA 100 MG/ML SOLN QL (2 PER 28 DAY(S)), MN- ILUMYA PRSYR SP-M PA (Medically Necessary tildrakizumab-asmn Prior Authorization) imiquimod imiquimod 3.75 % cream TIER 1 PA imiquimod imiquimod 5 % cream TIER 1 imiquimod pump 3.75 % imiquimod pump TIER 1 PA cream isotretinoin (10 mg cap, 20 isotretinoin mg cap, 30 mg cap, 40 mg TIER 1 cap) ivermectin ivermectin 1 % cream TIER 1 PA lidocaine-hydrocort lidocaine-hydrocort TIER 1 (perianal) (perianal) 3-0.5 % cream lidocaine-hydrocortisone lidocaine- ace (2.8-0.55 % gel, 3-0.5 TIER 1 hydrocortisone ace % kit, 3-1 % kit, 3-2.5 % kit) lidocort lidocort 3-0.5 % cream TIER 1 methoxsalen rapid 10 mg methoxsalen rapid TIER 1 cap

©2021 Wellmark, Inc. 107 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS metronidazole (0.75 % metronidazole cream, 0.75 % gel, 0.75 % TIER 1 lotion, 1 % gel) myorisan (10 mg cap, 20 myorisan mg cap, 30 mg cap, 40 mg TIER 1 cap) neuac neuac 1.2-5 % gel TIER 1 PA PICATO (0.015 % GEL, PICATO 0.05 % GEL) TIER 3 PA ingenol mebutate pimecrolimus pimecrolimus 1 % cream TIER 1 QL (100 PER 30 DAY(S)) PODOCON 25 % PODOCON SOLUTION TIER 1 podophyllum resin podofilox podofilox 0.5 % solution TIER 1 PROCORT 1.85-1.15 % CREAM PROCORT TIER 3 hydrocortisone acetate w/ pramoxine PROCTOFOAM HC 1-1 % FOAM PROCTOFOAM HC TIER 3 hydrocortisone acetate w/ pramoxine REGRANEX 0.01 % GEL REGRANEX TIER 3 becaplermin rosadan (0.75 % cream, rosadan TIER 1 0.75 % gel) SANTYL 250 UNIT/GM SANTYL OINTMENT TIER 3 collagenase SCENESSE 16 MG SCENESSE IMPLANT SP-M PA afamelanotide acetate selenium sulfide 2.5 % selenium sulfide TIER 1 lotion SILIQ 210 MG/1.5ML QL (2 PER 28 DAY(S)), MN- SILIQ SOLN PRSYR SP-NP PA (Medically Necessary brodalumab Prior Authorization) SKYRIZI (150 MG DOSE) SKYRIZI (150 MG 75 MG/0.83ML PREF SY SP-P PA, QL (2 PER 84 DAY(S)) DOSE) KT risankizumab-rzaa SORILUX 0.005 % FOAM SORILUX TIER 3 GA calcipotriene

©2021 Wellmark, Inc. 108 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS STELARA (45 MG/0.5ML SOLN PRSYR, 45 PA, QLV (Quantity Limit STELARA MG/0.5ML SOLUTION, 90 SP-P Varies), PA-QL (for Crohn's MG/ML SOLN PRSYR) Disease) ustekinumab STELARA 130 MG/26ML STELARA SOLUTION SP-M PA, QL (4 PER FILL) ustekinumab (iv) SULFACETAMIDE- SULFUR IN UREA 10-5 % SULFACETAMIDE- GEL TIER 1 SULFUR IN UREA sulfacetamide sodium- sulfur in urea vehicle tacrolimus (0.03 % tacrolimus TIER 1 ointment, 0.1 % ointment) TALTZ (80 MG/ML SOLN QL (1 PER 28 DAY(S)), MN- A-INJ, 80 MG/ML SOLN TALTZ SP-NP PA (Medically Necessary PRSYR) Prior Authorization) ixekizumab tazarotene tazarotene 0.1 % cream TIER 1 TAZORAC (0.05 % TAZORAC CREAM, 0.05 % GEL) TIER 3 tazarotene TREMFYA (100 MG/ML QL (1 PER 56 DAY(S)), MN- SOLN PEN, 100 MG/ML TREMFYA SP-NP PA (Medically Necessary SOLN PRSYR) Prior Authorization) guselkumab tretinoin (0.01 % gel, 0.025 % cream, 0.025 % gel, 0.05 tretinoin TIER 1 PA % cream, 0.05 % gel, 0.1 % cream) tretinoin microsphere (0.04 tretinoin microsphere TIER 1 PA % gel, 0.1 % gel) tretinoin microsphere pump tretinoin microsphere (pump 0.04 % gel, pump TIER 1 PA pump 0.1 % gel) VECTICAL 3 MCG/GM VECTICAL OINTMENT TIER 3 GA calcitriol (topical) VEREGEN 15 % VEREGEN OINTMENT TIER 3 PA sinecatechins zenatane (10 mg cap, 20 zenatane mg cap, 30 mg cap, 40 mg TIER 1 cap)

ELECTROLYTES/MINERALS/METALS/VITAMINS

ELECTROLYTE/MINERAL REPLACEMENT

bd posiflush bd posiflush 0.9 % solution TIER 1 calcium acetate calcium acetate 667 mg tab TIER 1 CRYSVITA (10 MG/ML SOLUTION, 20 MG/ML CRYSVITA SOLUTION, 30 MG/ML SP-M PA SOLUTION) burosumab-twza DOJOLVI 100 % LIQUID DOJOLVI SP-P PA triheptanoin EFFER-K (10 EFFER TAB, 20 EFFER TAB) EFFER-K TIER 3 potassium bicarbonate- citric acid effervescent pot effervescent pot chloride 25 TIER 1 chloride meq effer tab K-PHOS 500 MG TAB K-PHOS potassium phosphate TIER 3 monobasic K-TAB 8 MEQ TAB ER K-TAB TIER 3 GA potassium chloride klor-con (8 tab er, 20 klor-con TIER 1 packet) klor-con 10 klor-con 10 10 meq tab er TIER 1 klor-con m10 klor-con m10 10 meq tab er TIER 1 klor-con m15 klor-con m15 15 meq tab er TIER 1 klor-con m20 klor-con m20 20 meq tab er TIER 1 klor-con sprinkle (8 cap er, klor-con sprinkle TIER 1 10 cap er) levocarnitine (1 gm/10ml levocarnitine TIER 1 solution, 330 mg tab) levocarnitine sf 1 gm/10ml levocarnitine sf TIER 1 solution LOKELMA (5 GM PACKET, 10 GM PACKET) LOKELMA SP-P sodium zirconium cyclosilicate

©2021 Wellmark, Inc. 110 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MONOFERRIC 1000 MONOFERRIC MG/10ML SOLUTION SP-M ferric derisomaltose monoject flush monoject flush syringe 0.9 TIER 1 syringe % solution monoject sodium monoject sodium chloride TIER 1 chloride flush flush 0.9 % solution normal saline flush 0.9 % normal saline flush TIER 1 solution POT BICARB-POT POT BICARB-POT CHLORIDE 25 MEQ TIER 1 GA CHLORIDE EFFER TAB potassium bicarb & chloride potassium chloride (10 % solution, 20 meq packet, 20 potassium chloride meq/15ml (10%) solution, TIER 1 40 meq/15ml (20%) solution) potassium chloride crys er potassium chloride (crys er 10 tab er, crys er TIER 1 crys er 15 tab er, crys er 20 tab er) potassium chloride er (er 8 cap er, er 8 tab er, er 10 potassium chloride er TIER 1 cap er, er 10 tab er, er 20 tab er) saline flush saline flush 0.9 % solution TIER 1 saline flush zr 0.9 % saline flush zr TIER 1 solution sodium bicarbonate (4.2 % sodium bicarbonate TIER 1 solution, 7.5 % solution) sodium chloride (0.9 % sodium chloride solution, 4 meq/ml solution, TIER 1 23.4 % solution) sodium chloride (pf) 0.9 % sodium chloride (pf) TIER 1 solution sodium chloride flush 0.9 % sodium chloride flush TIER 1 solution swabflush saline flush 0.9 swabflush saline flush TIER 1 % solution

ELECTROLYTE/MINERAL/METAL MODIFIERS

CHEMET 100 MG CAP CHEMET TIER 2 succimer SBG (Specialty Biosimilars clovique clovique 250 mg cap SP-P and Specialty generics)

©2021 Wellmark, Inc. 111 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS deferasirox (90 mg packet, 90 mg tab, 125 mg tab sol, 180 mg packet, 180 mg tab, SBG (Specialty Biosimilars deferasirox SP-P 250 mg tab sol, 360 mg and Specialty generics) packet, 360 mg tab, 500 mg tab sol) deferasirox granules (granules 90 mg packet, SBG (Specialty Biosimilars deferasirox granules SP-P granules 180 mg packet, and Specialty generics) granules 360 mg packet) SBG (Specialty Biosimilars deferiprone deferiprone 500 mg tab SP-P and Specialty generics) FERRIPROX (100 MG/ML FERRIPROX SOLUTION, 1000 MG TAB) SP-P deferiprone FERRIPROX TWICE-A- FERRIPROX TWICE- DAY 1000 MG TAB SP-P A-DAY deferiprone JADENU SPRINKLE 90 JADENU SPRINKLE MG PACKET SP-NP GA deferasirox JYNARQUE (15 MG TAB THPK, 30 & 15 MG TAB THPK, 45 & 15 MG TAB JYNARQUE THPK, 60 & 30 MG TAB SP-P PA, QL (56 PER 28 DAY(S)) THPK, 90 & 30 MG TAB THPK) tolvaptan JYNARQUE (15 MG TAB, PA, QL (60 PER 30 DAYS), JYNARQUE 30 MG TAB) SP-P GA tolvaptan kionex kionex (15gm/60mlsuspension, TIER 1 powder) sodium polystyrene sulfonate (15 gm/60ml sodium polystyrene suspension, 30 gm/120ml TIER 1 sulfonate suspension, 50 gm/200ml suspension, powder) SPS 15 GM/60ML SUSPENSION SPS TIER 1 GA sodium polystyrene sulfonate PA, QL (60 PER 30 DAYS), tolvaptan (15 mg tab, 30 tolvaptan SP-P SBG (Specialty Biosimilars mg tab) and Specialty generics) SBG (Specialty Biosimilars trientine hcl trientine hcl 250 mg cap SP-P and Specialty generics)

PHOSPHATE BINDERS

calcium acetate (phos calcium acetate (phos binder) (667 mg cap, 667 TIER 1 binder) mg tab) lanthanum carbonate (500 lanthanum carbonate mg chew tab, 750 mg chew TIER 1 tab, 1000 mg chew tab) phospha 250 neutral 155- phospha 250 neutral TIER 1 852-130 mg tab phospho-trin 250 phospho-trin 250 neutral TIER 1 neutral 155-852-130 mg tab phosphorous 155-852-130 phosphorous TIER 1 mg tab sevelamer carbonate (0.8 sevelamer carbonate gm packet, 2.4 gm packet, TIER 1 800 mg tab) sevelamer hcl (400 mg tab, sevelamer hcl TIER 1 800 mg tab) VELPHORO 500 MG VELPHORO CHEW TAB TIER 3 sucroferric oxyhydroxide VELTASSA (8.4 GM PACKET, 16.8 GM VELTASSA PACKET, 25.2 GM SP-P PACKET) patiromer sorbitex calcium virt-phos 250 neutral 155- virt-phos 250 neutral TIER 1 852-130 mg tab

VITAMINS

ATABEX EC 29-1 MG TAB DR ATABEX EC TIER 2 prenatal vit w/ docusate- iron carbonyl-folic acid ATABEX OB 29-1 MG TAB prenatal vit w/ fe ATABEX OB TIER 2 bisglycinate chelate-folic acid BP FOLINATAL PLUS B 1 MG TAB BP FOLINATAL prenatal w/ calcium TIER 2 PLUS B carbonate-vit b6-vit b12- folic acid

©2021 Wellmark, Inc. 113 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BP MULTINATAL PLUS (30-1 MG TAB, 40-1 MG BP MULTINATAL CHEW TAB) TIER 2 PLUS prenatal without a vit w/ fe fumarate-folic acid COMPLETE NATAL DHA 29-1-200 & 250 MG MISC COMPLETE NATAL prenatal mv & min w/fe TIER 2 DHA bisglyc-fe prot succ-fa-ca- omega 3 COMPLETENATE 29-1 MG CHEW TAB COMPLETENATE TIER 2 prenatal vit w/ ferrous fumarate-folic acid CONCEPT OB 130-92.4-1 MG CAP CONCEPT OB prenatal without a vit w/ fe TIER 2 fum-iron polysacch complex -fa cyanocobalamin 1000 cyanocobalamin TIER 1 mcg/ml solution FOLIVANE-OB 130-92.4-1 MG CAP FOLIVANE-OB prenatal without a vit w/ fe TIER 2 fum-iron polysacch complex -fa HEMENATAL OB + DHA 28-6-1 & 203 MG MISC HEMENATAL OB + prenatal vit w/ fe poly TIER 2 DHA cmplx-fe heme polypept-fa & omega 3 INATAL GT TAB INATAL GT prenatal vit w/ docusate- TIER 2 iron carbonyl-folic acid MYNATAL (90-1MGTAB, CAP) MYNATAL TIER 2 prenatal vit w/ docusate- iron carbonyl-folic acid MYNATAL ADVANCE TAB MYNATAL ADVANCE TIER 2 prenatal vit w/ docusate- iron carbonyl-folic acid MYNATE 90 PLUS TAB ER MYNATE 90 PLUS TIER 2 prenatal vit w/ docusate-fe fumarate-folic acid

©2021 Wellmark, Inc. 114 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NATALVIT TAB NATALVIT prenatal vit w/ ferrous TIER 2 fumarate-folic acid O-CAL PRENATAL TAB O-CAL PRENATAL prenatal vit w/ ferrous TIER 2 fumarate-folic acid OBSTETRIX DHA 29-1 & 387 MG MISC OBSTETRIX DHA TIER 2 prenatal w/fe carbonyl-fa- dss-omega 3 fatty acids OBSTETRIX EC 29-1 MG TAB OBSTETRIX EC TIER 2 prenatal vit w/ docusate- iron carbonyl-folic acid PNV PRENATAL PLUS MULTIVIT+DHA 27-1 & 312 PNV PRENATAL MG MISC PLUS TIER 2 prenatal vit w/ ferrous MULTIVIT+DHA fumarate-fa-omega 3 fatty acids PNV TABS 29-1 29-1 MG TAB PNV TABS 29-1 TIER 2 prenatal vit w/ iron carbonyl-folic acid PNV-VP-U 106.5-1 MG CAP PNV-VP-U TIER 2 prenatal without a vit w/ fe fumarate-folic acid PR NATAL 400 29-1-200 & 400 MG MISC PR NATAL 400 prenatal mv & min w/fe TIER 2 bisglyc-fe prot succ-fa-ca- omega 3 PR NATAL 400 EC 29-1- 200 & 400 MG (DR) MISC PR NATAL 400 EC prenatal mv & min w/fe TIER 2 bisglyc-fe prot succ-fa-ca- omega 3 PR NATAL 430 29-1-200 & 430 MG MISC PR NATAL 430 prenatal mv & min w/fe TIER 2 bisglyc-fe prot succ-fa-ca- omega 3

©2021 Wellmark, Inc. 115 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PR NATAL 430 EC 29-1- 200 & 430 MG (DR) MISC PR NATAL 430 EC prenatal mv & min w/fe TIER 2 bisglyc-fe prot succ-fa-ca- omega 3 PRENAISSANCE NEXT PRENAISSANCE 1.2 MG TAB TIER 2 NEXT prenatal w/ calcium-vit b6- folic acid-ginger PRENATA 29-1 MG CHEW TAB PRENATA TIER 2 prenatal without a vit w/ fe fumarate-folic acid PRENATABS FA 29-1 MG TAB PRENATABS FA TIER 2 prenatal vit w/ ferrous fumarate-folic acid PRENATABS RX 29-1 MG TAB PRENATABS RX TIER 2 prenatal vit w/ iron carbonyl-folic acid PRENATAL 19 (19CHEWTAB, 19TAB, 1929-1MGCHEWTAB, PRENATAL 19 TIER 2 1929-1MGTAB) prenatal vit w/ docusate-fe fumarate-folic acid PRENATAL PLUS IRON PRENATAL PLUS 29-1 MG TAB TIER 2 IRON prenatal vit w/ iron carbonyl-folic acid PRENATAL-U 106.5-1 MG CAP PRENATAL-U TIER 2 prenatal without a vit w/ fe fumarate-folic acid PRETAB 29-1 MG TAB PRETAB prenatal vit w/ ferrous TIER 2 fumarate-folic acid PROVIDA OB 20-20-1.25 MG CAP PROVIDA OB prenatal without a vit w/ fe TIER 2 fum-iron polysacch complex -fa

©2021 Wellmark, Inc. 116 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PUREFE OB PLUS 162- 115.2-1 MG CAP PUREFE OB PLUS prenatal without a vit w/ fe TIER 2 fum-iron polysacch complex -fa SE-NATAL 19 (19 MG CHEW TAB, 19 MG TAB) SE-NATAL 19 TIER 2 prenatal vit w/ docusate-fe fumarate-folic acid TARON-BC 20-1 MG & 2 X 25 MG MISC TARON-BC TIER 2 prenatal without vit a w/ iron carbonyl-folic acid & vit b6 THRIVITE RX 29-1 MG TAB THRIVITE RX TIER 2 prenatal vit w/ iron carbonyl-folic acid TL FOLATE 27-0.5-0.5 MG TAB TL FOLATE prenatal vit w/ ferrous TIER 2 fumarate-l methylfolate-folic acid TRIADVANCE 90-1 MG TAB TRIADVANCE TIER 2 prenatal vit w/ docusate- iron carbonyl-folic acid TRINATAL GT 90-1 MG TAB TRINATAL GT TIER 2 prenatal vit w/ docusate- iron carbonyl-folic acid TRINATAL RX 1 60-1 MG TAB TRINATAL RX 1 TIER 2 prenatal vit w/ ferrous fumarate-folic acid TRINATE TAB TRINATE prenatal vit w/ ferrous TIER 2 fumarate-folic acid TRIVEEN-DUO DHA 29-1- 200 & 400 MG MISC TRIVEEN-DUO DHA prenatal mv & min w/fe TIER 2 bisglyc-fe prot succ-fa-ca- omega 3 VIL-RX 29-1 MG TAB VIL-RX prenatal vit w/ iron TIER 2 carbonyl-folic acid

©2021 Wellmark, Inc. 117 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VINATE AZ EXTRA 29-1 MG TAB VINATE AZ EXTRA prenatal vit w/ fe TIER 2 bisglycinate chelate-folic acid VINATE C 30-1 MG TAB VINATE C prenatal without a vit w/ fe TIER 2 fumarate-folic acid VINATE CALCIUM 27-1 MG TAB VINATE CALCIUM prenatal vit w/ iron TIER 2 carbonyl-fe gluconate-folic acid VINATE IC 162-115.2-1 MG CAP VINATE IC prenatal without a vit w/ fe TIER 2 fum-iron polysacch complex -fa VINATE II 29-1 MG TAB prenatal vit w/ fe VINATE II TIER 2 bisglycinate chelate-folic acid VINATE M 27-1 MG TAB VINATE M prenatal vit w/ selenium-fe TIER 2 fumarate-folic acid VINATE ONE 60-1 MG TAB VINATE ONE TIER 2 prenatal vit w/ ferrous fumarate-folic acid VIRT NATE 28-1 MG TAB VIRT NATE prenatal vit w/ ferrous TIER 2 fumarate-folic acid VIRT-ADVANCE 90-1 MG TAB VIRT-ADVANCE TIER 2 prenatal vit w/ docusate- iron carbonyl-folic acid VIRT-VITE GT 90-1 MG TAB VIRT-VITE GT TIER 2 prenatal vit w/ docusate- iron carbonyl-folic acid VOL-NATE 28-1 MG TAB VOL-NATE prenatal vit w/ ferrous TIER 2 fumarate-folic acid VOL-TAB RX 29-1 MG TAB VOL-TAB RX prenatal vit w/ iron TIER 2 carbonyl-folic acid

©2021 Wellmark, Inc. 118 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VP-GGR-B6 PRENATAL VP-GGR-B6 1.2 MG TAB TIER 2 PRENATAL prenatal w/ calcium-vit b6- folic acid-ginger VP-HEME OB + DHA 28-6- 1 & 203 MG MISC VP-HEME OB + DHA prenatal vit w/ fe poly TIER 2 cmplx-fe heme polypept-fa & omega 3

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

chlordiazepoxide- chlordiazepoxide-clidinium TIER 1 clidinium 5-2.5 mg cap CUVPOSA 1 MG/5ML PA, QL (1350 PER 30 CUVPOSA SOLUTION TIER 3 DAY(S)) glycopyrrolate dicyclomine hcl (10 mg cap, dicyclomine hcl 10 mg/5ml solution, 20 mg TIER 1 tab) ed-spaz ed-spaz 0.125 mg tab disp TIER 1 glycopyrrolate (1 mg tab, 2 glycopyrrolate TIER 1 mg tab) hyoscyamine sulfate (0.125 mg sl tab, 0.125 mg tab, hyoscyamine sulfate 0.125 mg tab disp, 0.125 TIER 1 mg/5ml elixir, 0.125 mg/ml solution) hyoscyamine sulfate hyoscyamine sulfate er TIER 1 er 0.375 mg tab er 12h hyoscyamine sulfate hyoscyamine sulfate sl TIER 1 sl 0.125 mg sl tab hyosyne (0.125 mg/5ml hyosyne TIER 1 elixir, 0.125 mg/ml solution) methscopolamine methscopolamine bromide TIER 1 bromide (2.5 mg tab, 5 mg tab) nulev nulev 0.125 mg tab disp TIER 1 oscimin (0.125 mg sl tab, oscimin 0.125 mg tab, 0.125 mg tab TIER 1 disp) oscimin sr 0.375 mg tab er oscimin sr TIER 1 12h PROPANTHELINE PROPANTHELINE BROMIDE 15 MG TAB TIER 1 BROMIDE propantheline bromide

GASTROINTESTINAL AGENTS, OTHER

alvimopan alvimopan 12 mg cap TIER 1 amoxicill-clarithro- amoxicill-clarithro-lansopraz TIER 1 lansopraz misc CHENODAL 250 MG TAB CHENODAL TIER 2 chenodiol cromolyn sodium 100 cromolyn sodium TIER 1 mg/5ml conc DIPHENOXYLATE- DIPHENOXYLATE- ATROPINE (MG TAB, TIER 1 ATROPINE MG/5ML LIQUID) diphenoxylate w/ atropine GATTEX 5 MG KIT GATTEX SP-M teduglutide (rdna) IMCIVREE 10 MG/ML IMCIVREE SOLUTION SP-NP PA, QL (9 PER 30 DAY(S)) setmelanotide acetate MOTEGRITY (1 MG TAB, 2 MN-PA (Medically Necessary MOTEGRITY MG TAB) TIER 3 Prior Authorization) prucalopride succinate MOVANTIK (12.5 MG TAB, MOVANTIK 25 MG TAB) TIER 2 PA naloxegol oxalate opium 10 mg/ml (1%) opium TIER 1 tincture PAREGORIC 2 MG/5ML PAREGORIC TINCTURE TIER 1 paregoric RELISTOR (8 MG/0.4ML QL (30 PER 30 DAYS), MN- SOLUTION, 12 MG/0.6ML RELISTOR TIER 3 PA (Medically Necessary SOLUTION) Prior Authorization) methylnaltrexone bromide RELISTOR 150 MG TAB MN-PA (Medically Necessary RELISTOR TIER 3 methylnaltrexone bromide Prior Authorization) ursodiol (250 mg tab, 300 ursodiol TIER 1 mg cap, 500 mg tab)

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine (300 mg tab, 400 cimetidine TIER 1 mg tab, 800 mg tab) cimetidine hcl (300 mg/5ml cimetidine hcl solution, 400 mg/6.67ml TIER 1 solution)

©2021 Wellmark, Inc. 120 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS famotidine (40 mg tab, 40 famotidine TIER 1 mg/5ml recon susp) nizatidine (15 mg/ml nizatidine solution, 150 mg cap, 300 TIER 1 mg cap) ranitidine hcl (15 mg/ml syrup, 75 mg/5ml syrup, ranitidine hcl 150 mg cap, 150 mg/10ml TIER 1 syrup, 300 mg cap, 300 mg tab)

IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl (0.5 mg tab, 1 alosetron hcl TIER 1 mg tab) LINZESS (72 MCG CAP, 145 MCG CAP, 290 MCG LINZESS TIER 2 CAP) linaclotide lubiprostone (8 mcg cap, 24 lubiprostone TIER 1 mcg cap) TRULANCE 3 MG TAB TRULANCE TIER 3 plecanatide VIBERZI (75 MG TAB, 100 VIBERZI MG TAB) TIER 3 eluxadoline

LAXATIVES

CASCARA SAGRADA 1 CASCARA GM/ML FL EXTRACT TIER 2 SAGRADA cascara sagrada CLENPIQ 10-3.5-12 MG- GM -GM/160ML SOLUTION CLENPIQ TIER 3 sodium picosulfate- magnesium oxide- anhydrous citric acid constulose 10 gm/15ml constulose TIER 1 solution enulose 10 gm/15ml enulose TIER 1 solution GAVILYTE-C 240 GM RECON SOLN GAVILYTE-C TIER 1 GA peg 3350-kcl-sod bicarb- sod chloride-sod sulfate gavilyte-g 236 gm recon gavilyte-g TIER 1 soln

©2021 Wellmark, Inc. 121 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS gavilyte-n with flavor gavilyte-n with flavor pack TIER 1 pack 420 gm recon soln generlac 10 gm/15ml generlac TIER 1 solution GOLYTELY 227.1 GM RECON SOLN GOLYTELY TIER 3 peg 3350-kcl-sod bicarb- sod chloride-sod sulfate lactulose (10 gm/15ml lactulose solution, 20 gm/30ml TIER 1 solution) lactulose lactulose encephalopathy TIER 1 encephalopathy 10 gm/15ml solution OSMOPREP 1.102-0.398 GM TAB OSMOPREP sodium phosphate TIER 2 monobasic-sodium phosphate dibasic peg 3350-kcl-na peg 3350-kcl-na bicarb-nacl TIER 1 bicarb-nacl 420 gm recon soln peg 3350/electrolytes 240 peg 3350/electrolytes TIER 1 gm recon soln peg-3350/electrolytes 236 peg-3350/electrolytes TIER 1 gm recon soln peg- peg- 3350/electrolytes/asc 3350/electrolytes/ascorbat TIER 1 orbat 100 gm recon soln peg-kcl-nacl-nasulf-na peg-kcl-nacl-nasulf-na asc- TIER 1 asc-c c 100 gm recon soln PLENVU 140 GM RECON SOLN PLENVU peg 3350-kcl-nacl-na TIER 3 sulfate-na ascorbate- ascorbic acid PREPOPIK 10-3.5-12 MG- GM-GM PACKET PREPOPIK sodium picosulfate- TIER 3 magnesium oxide- anhydrous citric acid SUPREP BOWEL PREP KIT 17.5-3.13-1.6 SUPREP BOWEL GM/177ML SOLUTION TIER 2 PREP KIT sodium sulfate-potassium sulfate-magnesium sulfate

©2021 Wellmark, Inc. 122 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SUTAB 1479-225-188 MG TAB SUTAB TIER 3 sodium sulfate-magnesium sulfate-potassium chloride trilyte trilyte 420 gm recon soln TIER 1

PROTECTANTS

misoprostol (100 mcg tab, misoprostol TIER 1 200 mcg tab) sucralfate (1 gm tab, 1 sucralfate TIER 1 gm/10ml suspension)

PROTON PUMP INHIBITORS

ACIPHEX SPRINKLE (5 MG CAP SPRINK, 10 MG PA, QL (30 PER 30 DAYS), ACIPHEX SPRINKLE TIER 3 CAP SPRINK) PA-QL (60 / 30 days) rabeprazole sodium cvs lansoprazole 15 mg tab cvs lansoprazole TIER 1 PA-QL (90 / 30 days) dr disp DEXILANT (30 MG CAP PA, QL (30 PER 30 DAYS), DEXILANT DR, 60 MG CAP DR) TIER 3 PA-QL (60 / 30 days) dexlansoprazole esomeprazole magnesium esomeprazole (10 mg packet, 20 mg PA, QL (60 PER 30 DAYS), TIER 1 magnesium packet, 40 mg cap dr, 40 PA-QL (90 / 30 days) mg packet) ESOMEPRAZOLE ESOMEPRAZOLE STRONTIUM 49.3 MG CAP PA, QL (60 PER 30 DAYS), TIER 3 STRONTIUM DR PA-QL (90 / 30 days) esomeprazole strontium lansoprazole (15 mg tab dr PA, QL (60 PER 30 DAYS), lansoprazole TIER 1 disp, 30 mg tab dr disp) PA-QL (90 / 30 days) QL (60 PER 30 DAYS), PA- lansoprazole lansoprazole 30 mg cap dr TIER 1 QL (90 / 30 days) omeprazole (10 mg cap dr, QL (60 PER 30 DAYS), PA- omeprazole TIER 1 40 mg cap dr) QL (90 / 30 days) pantoprazole sodium (20 QL (60 PER 30 DAYS), PA- pantoprazole sodium TIER 1 mg tab dr, 40 mg tab dr) QL (90 / 30 days) pantoprazole sodium 40 mg PA, QL (60 PER 30 DAYS), pantoprazole sodium TIER 1 packet PA-QL (90 / 30 days) PRILOSEC (2.5 MG PA, QL (60 PER 30 DAYS), PRILOSEC PACKET, 10 MG PACKET) TIER 3 PA-QL (90 / 30 days) omeprazole magnesium RABEPRAZOLE SODIUM RABEPRAZOLE PA, QL (30 PER 30 DAYS), 10 MG CAP SPRINK TIER 3 SODIUM PA-QL (60 / 30 days) rabeprazole sodium

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

ALDURAZYME 2.9 ALDURAZYME MG/5ML SOLUTION SP-M laronidase CARBAGLU 200 MG TAB CARBAGLU SP-P carglumic acid CERDELGA 84 MG CAP CERDELGA SP-P PA eliglustat tartrate CEREZYME 400 UNIT MN-PA (Medically Necessary CEREZYME RECON SOLN SP-M Prior Authorization) imiglucerase CREON (3000-9500 CP DR PART, 6000 CP DR PART, 12000 CP DR PART, 24000-76000 CP DR CREON TIER 2 PART, 36000 CP DR PART) pancrelipase (lipase- protease-amylase) CYSTADANE POWDER CYSTADANE SP-P betaine CYSTAGON (50 MG CAP, CYSTAGON 150 MG CAP) TIER 2 cysteamine bitartrate ELAPRASE 6 MG/3ML ELAPRASE SOLUTION SP-M idursulfase ELELYSO 200 UNIT ELELYSO RECON SOLN SP-M PA taliglucerase alfa FABRAZYME (5 MG RECON SOLN, 35 MG FABRAZYME SP-M RECON SOLN) agalsidase beta GALAFOLD 123 MG CAP GALAFOLD SP-P PA, QL (14 PER 28 DAY(S)) migalastat hcl GIVLAARI 189 MG/ML GIVLAARI SOLUTION SP-M PA givosiran sodium LUMIZYME 50 MG RECON LUMIZYME SOLN SP-M alglucosidase alfa PA, SBG (Specialty miglustat miglustat 100 mg cap SP-P Biosimilars and Specialty generics)

©2021 Wellmark, Inc. 124 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NAGLAZYME 1 MG/ML NAGLAZYME SOLUTION SP-M galsulfase nitisinone (2 mg cap, 5 mg SBG (Specialty Biosimilars nitisinone SP-P cap, 10 mg cap) and Specialty generics) OCALIVA 10 MG TAB OCALIVA SP-P PA, QL (60 PER 30 DAYS) obeticholic acid OCALIVA 5 MG TAB OCALIVA SP-P PA, QL (30 PER 30 DAYS) obeticholic acid ORFADIN (4 MG/ML SUSPENSION, 20 MG ORFADIN SP-P CAP) nitisinone OXLUMO 94.5 MG/0.5ML OXLUMO SOLUTION SP-M PA lumasiran sodium PALYNZIQ (2.5 MG/0.5ML SOLN PRSYR, 10 PALYNZIQ MG/0.5ML SOLN PRSYR, SP-P PA 20 MG/ML SOLN PRSYR) pegvaliase-pqpz PANCREAZE (2600 CP DR PART, 2600-8800 CP DR PART, 4200 CP DR PART, 10500 CP DR PART, 16800 CP DR PART, PANCREAZE TIER 2 21000 CP DR PART, 37000-97300 CP DR PART) pancrelipase (lipase- protease-amylase) PERTZYE (4000 CP DR PART, 8000 CP DR PART, 16000 CP DR PART, PERTZYE 24000-86250 CP DR TIER 2 PART) pancrelipase (lipase- protease-amylase) PROCYSBI (25 MG CAP DR, 75 MG CAP DR, 75 PROCYSBI MG PACKET, 300 MG SP-P PACKET) cysteamine bitartrate RAVICTI 1.1 GM/ML RAVICTI LIQUID SP-P PA, QL (525 PER 30 DAYS) glycerol phenylbutyrate

©2021 Wellmark, Inc. 125 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS sapropterin dihydrochloride sapropterin SBG (Specialty Biosimilars (100 mg packet, 100 mg SP-P dihydrochloride and Specialty generics) tab, 500 mg packet) sodium phenylbutyrate (3 sodium SBG (Specialty Biosimilars gm/tsp powder, 500 mg SP-P phenylbutyrate and Specialty generics) tab) STRENSIQ (18 MG/0.45ML SOLUTION, 28 MG/0.7ML SOLUTION, 40 MG/ML STRENSIQ SP-P PA SOLUTION, 80 MG/0.8ML SOLUTION) asfotase alfa SUCRAID 8500 UNIT/ML SUCRAID SOLUTION TIER 2 sacrosidase VIOKACE (10440-39150 TAB, 20880 TAB) VIOKACE TIER 2 pancrelipase (lipase- protease-amylase) VPRIV 400 UNIT RECON MN-PA (Medically Necessary VPRIV SOLN SP-M Prior Authorization) velaglucerase alfa ZENPEP (3000-14000 CP DR PART, 5000-24000 CP DR PART, 10000-32000 CP DR PART, 15000- 47000 CP DR PART, ZENPEP 20000-63000 CP DR TIER 2 PART, 25000-79000 CP DR PART, 40000-126000 CP DR PART) pancrelipase (lipase- protease-amylase) ZOKINVY (50 MG CAP, 75 ZOKINVY MG CAP) SP-P QLV (Quantity Limit Varies) lonafarnib

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

darifenacin hydrobromide darifenacin er (er 7.5 mg tab er 24h, er TIER 1 hydrobromide er 15 mg tab er 24h) flavoxate hcl flavoxate hcl 100 mg tab TIER 1 oxybutynin chloride (5 mg oxybutynin chloride TIER 1 tab, 5 mg/5ml syrup)

©2021 Wellmark, Inc. 126 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS oxybutynin chloride er (er 5 mg tab er 24h, er 10 mg tab oxybutynin chloride er TIER 1 er 24h, er 15 mg tab er 24h) solifenacin succinate (5 mg solifenacin succinate TIER 1 tab, 10 mg tab) tolterodine tartrate (1 mg tolterodine tartrate TIER 1 tab, 2 mg tab) tolterodine tartrate er (er 2 tolterodine tartrate er mg cap er 24h, er 4 mg cap TIER 1 er 24h) TOVIAZ (4 MG TAB ER TOVIAZ 24H, 8 MG TAB ER 24H) TIER 3 QL (30 PER 30 DAYS) fesoterodine fumarate trospium chloride trospium chloride 20 mg tab TIER 1 trospium chloride er 60 mg trospium chloride er TIER 1 cap er 24h

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl er 10 mg tab alfuzosin hcl er TIER 1 er 24h dutasteride dutasteride 0.5 mg cap TIER 1 dutasteride- dutasteride-tamsulosin hcl TIER 1 tamsulosin hcl 0.5-0.4 mg cap finasteride finasteride 5 mg tab TIER 1 silodosin (4 mg cap, 8 mg silodosin TIER 1 QL (30 PER 30 DAYS) cap) tadalafil (10 mg tab, 20 mg tadalafil TIER 1 QL (6 PER 30 DAYS) tab) tadalafil (2.5 mg tab, 5 mg tadalafil TIER 1 QL (30 PER 30 DAYS) tab) tamsulosin hcl tamsulosin hcl 0.4 mg cap TIER 1

GENITOURINARY AGENTS, OTHER

bethanechol chloride (5 mg bethanechol chloride tab, 10 mg tab, 25 mg tab, TIER 1 50 mg tab) CAVERJECT (20 MCG RECON SOLN, 40 MCG CAVERJECT TIER 3 QL (6 PER 30 DAYS) RECON SOLN) alprostadil (vasodilator) CAVERJECT IMPULSE (10 CAVERJECT MCG KIT, 20 MCG KIT) TIER 3 QL (6 PER 30 DAYS) IMPULSE alprostadil (vasodilator)

©2021 Wellmark, Inc. 127 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CYTRA K CRYSTALS CYTRA K 3300-1002 MG PACKET TIER 1 GA CRYSTALS potassium citrate-citric acid D-PENAMINE 125 MG TAB D-PENAMINE TIER 2 penicillamine EDEX (10 MCG KIT, 20 EDEX MCG KIT, 40 MCG KIT) TIER 3 QL (6 PER 30 DAYS) alprostadil (vasodilator) ELMIRON 100 MG CAP ELMIRON pentosan polysulfate TIER 3 sodium K-PHOS NO 2 305-700 MG TAB K-PHOS NO 2 TIER 3 potassium & sodium acid phosphates LITHOSTAT 250 MG TAB LITHOSTAT TIER 3 acetohydroxamic acid MUSE (125 MCG PELLET, 250 MCG PELLET, 500 MUSE MCG PELLET, 1000 MCG TIER 3 QL (6 PER 30 DAYS) PELLET) alprostadil (vasodilator) penicillamine penicillamine 250 mg tab SP-P phenazo phenazo 200 mg tab TIER 1 phenazopyridine hcl 200 phenazopyridine hcl TIER 1 mg tab pot & sod cit-cit ac 550- pot & sod cit-cit ac TIER 1 500-334 mg/5ml solution potassium citrate er (er 5 potassium citrate er (540 tab er, er 10 (1080 tab TIER 1 er, er 15 (1620 tab er) potassium citrate-citric acid potassium citrate- (1100-334 mg/5ml solution, TIER 1 citric acid 3300-1002 mg packet) sildenafil citrate (25 mg tab, sildenafil citrate TIER 1 QL (6 PER 30 DAYS) 50 mg tab, 100 mg tab) sod citrate-citric acid 500- sod citrate-citric acid TIER 1 334 mg/5ml solution taron-crystals 3300-1002 taron-crystals TIER 1 mg packet THIOLA EC (EC 100 MG TAB DR, EC 300 MG TAB THIOLA EC SP-P DR) tiopronin tiopronin tiopronin 100 mg tab SP-P

©2021 Wellmark, Inc. 128 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS tricitrates 550-500-334 tricitrates TIER 1 mg/5ml solution vardenafil hcl (2.5 mg tab, 5 vardenafil hcl mg tab, 10 mg tab, 10 mg TIER 1 QL (6 PER 30 DAYS) tab disp, 20 mg tab) virtrate-2 500-334 mg/5ml virtrate-2 TIER 1 solution virtrate-3 550-500-334 virtrate-3 TIER 1 mg/5ml solution virtrate-k 1100-334 mg/5ml virtrate-k TIER 1 solution

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

ACTHAR 80 UNIT/ML GEL ACTHAR SP-M PA corticotropin ala-cort ala-cort 2.5 % cream TIER 1 alclometasone dipropionate alclometasone (0.05 % cream, 0.05 % TIER 1 dipropionate ointment) AMCINONIDE (0.1 % CREAM, 0.1 % LOTION, AMCINONIDE TIER 1 0.1 % OINTMENT) amcinonide baycadron baycadron 0.5 mg/5ml elixir TIER 1 beser beser 0.05 % lotion TIER 1 betamethasone betamethasone dipropionate (0.05 % TIER 1 dipropionate cream, 0.05 % lotion, 0.05 % ointment) betamethasone betamethasone dipropionate aug (0.05 % TIER 1 dipropionate aug cream, 0.05 % gel, 0.05 % lotion, 0.05 % ointment) betamethasone valerate betamethasone (0.1 % cream, 0.1 % lotion, TIER 1 valerate 0.1 % ointment, 0.12 % foam) BRYHALI 0.01 % LOTION BRYHALI TIER 3 QL (200 PER 30 DAY(S)) halobetasol propionate CAPEX 0.01 % SHAMPOO CAPEX TIER 3 fluocinolone acetonide clobetasol prop clobetasol prop emollient TIER 1 emollient base base 0.05 % cream

©2021 Wellmark, Inc. 129 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS clobetasol propionate (0.05 % cream, 0.05 % foam, 0.05 % gel, 0.05 % liquid, clobetasol propionate TIER 1 0.05 % lotion, 0.05 % ointment, 0.05 % shampoo, 0.05 % solution) clobetasol propionate clobetasol propionate e TIER 1 e 0.05 % cream clobetasol propionate clobetasol propionate TIER 1 emulsion emulsion 0.05 % foam clocortolone pivalate 0.1 % clocortolone pivalate TIER 1 QL (90 PER 30 DAY(S)) cream clocortolone pivalate clocortolone pivalate pump TIER 1 QL (90 PER 30 DAY(S)) pump 0.1 % cream clodan clodan 0.05 % shampoo TIER 1 cormax scalp cormax scalp application TIER 1 application 0.05 % solution CORTISONE ACETATE 25 CORTISONE MG TAB TIER 3 ACETATE cortisone acetate decadron (0.5 mg tab, 0.5 decadron mg/5ml elixir, 0.75 mg tab, TIER 1 4 mg tab, 6 mg tab) deltasone deltasone 20 mg tab TIER 1 DEPO-MEDROL 20 MG/ML DEPO-MEDROL SUSPENSION TIER 1 methylprednisolone acetate desonide (0.05 % cream, desonide 0.05 % lotion, 0.05 % TIER 1 ointment) desoximetasone (0.05 % cream, 0.05 % gel, 0.05 % desoximetasone ointment, 0.25 % cream, TIER 1 0.25 % liquid, 0.25 % ointment) dexamethasone (0.5 mg tab, 0.5 mg/5ml elixir, 0.5 dexamethasone mg/5ml solution, 0.75 mg TIER 1 tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab) DEXAMETHASONE DEXAMETHASONE INTENSOL 1 MG/ML TIER 1 INTENSOL CONC dexamethasone dexamethasone sod dexamethasone sod phosphate pf 10 mg/ml TIER 1 phosphate pf solution

©2021 Wellmark, Inc. 130 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS dexamethasone sodium dexamethasone phosphate 20 mg/5ml TIER 1 sodium phosphate solution EMFLAZA (6 MG TAB, 18 MG TAB, 22.75 MG/ML EMFLAZA SUSPENSION, 30 MG SP-P PA TAB, 36 MG TAB) deflazacort EPIFOAM 1-1 % FOAM EPIFOAM TIER 3 pramoxine-hc fludrocortisone fludrocortisone acetate 0.1 TIER 1 acetate mg tab fluocinolone acetonide fluocinolone (0.01 % cream, 0.01 % TIER 1 acetonide solution, 0.025 % cream, 0.025 % ointment) fluocinolone fluocinolone acetonide body TIER 1 acetonide body 0.01 % oil fluocinolone fluocinolone acetonide TIER 1 acetonide scalp scalp 0.01 % oil fluocinonide (0.05 % cream, fluocinonide 0.05 % gel, 0.05 % TIER 1 ointment, 0.05 % solution) fluocinonide fluocinonide 0.1 % cream TIER 1 QL (120 PER 30 DAY(S)) fluocinonide fluocinonide emulsified TIER 1 emulsified base base 0.05 % cream flurandrenolide (0.05 % flurandrenolide TIER 1 cream, 0.05 % ointment) flurandrenolide 0.05 % flurandrenolide TIER 1 QL (120 PER 30 DAY(S)) lotion fluticasone propionate fluticasone propionate (0.005 % ointment, 0.05 % TIER 1 cream, 0.05 % lotion) halobetasol propionate halobetasol (0.05 % cream, 0.05 % TIER 1 propionate ointment) hydrocort-pramoxine hydrocort-pramoxine TIER 1 (perianal) (perianal) 2.5-1 % cream hydrocortisone (2.5 % cream, 2.5 % lotion, 2.5 % hydrocortisone TIER 1 ointment, 5 mg tab, 10 mg tab, 20 mg tab) hydrocortisone ace- hydrocortisone ace- TIER 1 pramoxine pramoxine 2.5-1 % cream hydrocortisone butyr hydrocortisone butyr lipo TIER 1 QL (60 PER 30 DAY(S)) lipo base base 0.1 % cream

©2021 Wellmark, Inc. 131 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS hydrocortisone butyrate hydrocortisone (0.1 % cream, 0.1 % lotion, TIER 1 butyrate 0.1 % ointment, 0.1 % solution) hydrocortisone hydrocortisone valerate (0.2 TIER 1 valerate % cream, 0.2 % ointment) IMPOYZ 0.025 % CREAM IMPOYZ TIER 3 clobetasol propionate ISTURISA 1 MG TAB PA, QL (240 PER 30 ISTURISA SP-NP osilodrostat phosphate DAY(S)) ISTURISA 10 MG TAB PA, QL (180 PER 30 ISTURISA SP-NP osilodrostat phosphate DAY(S)) ISTURISA 5 MG TAB PA, QL (360 PER 30 ISTURISA SP-NP osilodrostat phosphate DAY(S)) KENALOG 10 MG/ML KENALOG SUSPENSION TIER 3 triamcinolone acetonide KORLYM 300 MG TAB PA, QL (120 PER 30 KORLYM mifepristone SP-P DAY(S)) (hyperglycemia) lokara lokara 0.05 % lotion TIER 1 MEDROL 2 MG TAB MEDROL TIER 3 methylprednisolone methylprednisolone (4 mg methylprednisolone tab, 4 mg tab thpk, 8 mg TIER 1 tab, 16 mg tab, 32 mg tab) methylprednisolone methylprednisolone sodium TIER 1 sodium succ succ 500 mg recon soln MILLIPRED 5 MG TAB MILLIPRED TIER 3 prednisolone mometasone furoate (0.1 % mometasone furoate cream, 0.1 % ointment, 0.1 TIER 1 % solution) nolix nolix 0.05 % cream TIER 1 nolix nolix 0.05 % lotion TIER 1 QL (120 PER 30 DAY(S)) NUCORT 2 % LOTION NUCORT hydrocortisone acetate TIER 3 (topical) PRAMOSONE (1-1 % CREAM, 1-1 % LOTION, 1- PRAMOSONE TIER 1 2.5 % LOTION) pramoxine-hc PREDNICARBATE (0.1 % CREAM, 0.1 % PREDNICARBATE TIER 1 OINTMENT) prednicarbate

©2021 Wellmark, Inc. 132 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS prednisolone (15 solution, prednisolone TIER 1 15 syrup) prednisolone sodium phosphate (6.7 (5 base) mg/5ml solution, 10 mg tab prednisolone sodium disp, 10 mg/5ml solution, TIER 1 phosphate 15 mg tab disp, 15 mg/5ml solution, 20 mg/5ml solution, 25 mg/5ml solution, 30 mg tab disp) prednisolone sodium prednisolone sodium phosphate 25 mg/5ml TIER 1 phosphate solution prednisone (1 mg tab, 2.5 mg tab, 5 mg (21) tab thpk, 5 mg (48) tab thpk, 5 mg prednisone tab, 5 mg/5ml solution, 10 TIER 1 mg (21) tab thpk, 10 mg (48) tab thpk, 10 mg tab, 20 mg tab, 50 mg tab) PREDNISONE INTENSOL PREDNISONE 5 MG/ML CONC TIER 1 INTENSOL prednisone SOLU-CORTEF (100 MG RECON SOLN, 250 MG RECON SOLN, 500 MG SOLU-CORTEF TIER 1 RECON SOLN) hydrocortisone sod succinate SOLU-MEDROL 500 MG RECON SOLN SOLU-MEDROL TIER 1 GA methylprednisolone sod succ TEXACORT 2.5 % TEXACORT SOLUTION TIER 3 hydrocortisone (topical) tovet tovet 0.05 % foam TIER 1 triamcinolone acetonide (0.025 % cream, 0.025 % lotion, 0.025 % ointment, triamcinolone 0.1 % cream, 0.1 % lotion, TIER 1 acetonide 0.1 % ointment, 0.5 % cream, 0.5 % ointment, 40 mg/ml suspension) triamcinolone triamcinolone acetonide TIER 1 QL (4.5 PER 1 DAY(S)) acetonide 0.147 mg/gm aero soln triderm (0.1 % cream, 0.5 triderm TIER 1 % cream)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

desmopressin ace desmopressin ace spray TIER 1 spray refrig refrig 0.01 % solution desmopressin acetate (0.1 desmopressin acetate TIER 1 mg tab, 0.2 mg tab) DESMOPRESSIN DESMOPRESSIN ACETATE 1.5 MG/ML TIER 3 ACETATE SOLUTION desmopressin acetate desmopressin acetate desmopressin acetate TIER 1 spray spray 0.01 % solution GENOTROPIN (5 MG RECON SOLN, 12 MG MN-PA (Medically Necessary GENOTROPIN SP-NP RECON SOLN) Prior Authorization) somatropin GENOTROPIN MINIQUICK (0.2 MG RECON SOLN, 0.4 MG RECON SOLN, 0.6 MG RECON SOLN, 0.8 MG RECON SOLN, 1 MG GENOTROPIN RECON SOLN, 1.2 MG MN-PA (Medically Necessary SP-NP MINIQUICK RECON SOLN, 1.4 MG Prior Authorization) RECON SOLN, 1.6 MG RECON SOLN, 1.8 MG RECON SOLN, 2 MG RECON SOLN) somatropin HUMATROPE (5 MG RECON SOLN, 6 MG RECON SOLN, 12 MG MN-PA (Medically Necessary HUMATROPE SP-NP RECON SOLN, 24 MG Prior Authorization) RECON SOLN) somatropin INCRELEX 40 MG/4ML INCRELEX SOLUTION SP-P PA mecasermin NORDITROPIN FLEXPRO (5 MG/1.5ML SOLN PEN, NORDITROPIN 10 MG/1.5ML SOLN PEN, SP-P PA FLEXPRO 15 MG/1.5ML SOLN PEN, 30 MG/3ML SOLN PEN) somatropin NUTROPIN AQ NUSPIN 10 NUTROPIN AQ MN-PA (Medically Necessary 10 MG/2ML SOLN PEN SP-NP NUSPIN 10 Prior Authorization) somatropin

©2021 Wellmark, Inc. 134 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NUTROPIN AQ NUSPIN 20 NUTROPIN AQ MN-PA (Medically Necessary 20 MG/2ML SOLN PEN SP-NP NUSPIN 20 Prior Authorization) somatropin NUTROPIN AQ NUSPIN 5 NUTROPIN AQ MN-PA (Medically Necessary 5 MG/2ML SOLN PEN SP-NP NUSPIN 5 Prior Authorization) somatropin OMNITROPE (5 MG/1.5ML SOLN CART, 5.8 MG MN-PA (Medically Necessary OMNITROPE RECON SOLN, 10 SP-NP Prior Authorization) MG/1.5ML SOLN CART) somatropin SAIZEN (5 MG RECON SOLN, 8.8 MG RECON MN-PA (Medically Necessary SAIZEN SOLN) SP-NP Prior Authorization) somatropin (non- refrigerated) SAIZEN CLICK.EASY 8.8 MG RECON SOLN MN-PA (Medically Necessary SAIZEN CLICK.EASY SP-NP somatropin (non- Prior Authorization) refrigerated) SAIZENPREP 8.8 MG RECON SOLN MN-PA (Medically Necessary SAIZENPREP SP-NP somatropin (non- Prior Authorization) refrigerated) SEROSTIM (4 MG RECON SOLN, 5 MG RECON SOLN, 6 MG RECON MN-PA (Medically Necessary SEROSTIM SP-NP SOLN) Prior Authorization) somatropin (non- refrigerated) STIMATE 1.5 MG/ML STIMATE SOLUTION TIER 3 desmopressin acetate ZOMACTON (5 MG RECON SOLN, 10 MG MN-PA (Medically Necessary ZOMACTON SP-NP RECON SOLN) Prior Authorization) somatropin ZOMACTON (FOR ZOMA- ZOMACTON (FOR JET 10) 10 MG RECON MN-PA (Medically Necessary SP-NP ZOMA-JET 10) SOLN Prior Authorization) somatropin ZORBTIVE 8.8 MG RECON SOLN MN-PA (Medically Necessary ZORBTIVE SP-NP somatropin (non- Prior Authorization) refrigerated)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

ANABOLIC STEROIDS

ANADROL-50 50 MG TAB ANADROL-50 TIER 2 oxymetholone oxandrolone (2.5 mg tab, oxandrolone TIER 1 10 mg tab)

ANDROGENS

ANDROXY 10 MG TAB ANDROXY TIER 3 fluoxymesterone danazol (50 mg cap, 100 danazol TIER 1 mg cap, 200 mg cap) methyltestosterone 10 mg methyltestosterone TIER 1 PA cap testosterone (1.62 % gel, 12.5 mg/act (1%) gel, 20.25 mg/1.25gm (1.62%) gel, 20.25 mg/act (1.62%) gel, testosterone TIER 2 PA 25 mg/2.5gm (1%) gel, 30 mg/act solution, 40.5 mg/2.5gm (1.62%) gel, 50 mg/5gm (1%) gel) testosterone 10 mg/act testosterone TIER 3 PA (2%) gel testosterone cypionate (100 testosterone mg/ml solution, 200 mg/ml TIER 1 cypionate solution) testosterone testosterone enanthate 200 TIER 1 enanthate mg/ml solution VOGELXO 50 MG/5GM VOGELXO (1%) GEL TIER 3 PA, GA testosterone

ESTROGENS

afirmelle 0.1-20 mg-mcg afirmelle TIER 1 tab altavera 0.15-30 mg-mcg altavera TIER 1 tab alyacen 1/35 1-35 mg-mcg alyacen 1/35 TIER 1 tab alyacen 7/7/7 0.5/0.75/1-35 alyacen 7/7/7 TIER 1 mg-mcg tab amabelz (0.5-0.1 mg tab, 1- amabelz TIER 1 0.5 mg tab)

©2021 Wellmark, Inc. 136 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS amethia 0.15-0.03 &0.01 amethia TIER 1 mg tab amethia lo 0.1-0.02 & 0.01 amethia lo TIER 1 mg tab amethyst amethyst 90-20 mcg tab TIER 1 ANGELIQ (0.25-0.5 MG ANGELIQ TAB, 0.5-1 MG TAB) TIER 3 drospirenone-estradiol ANNOVERA 0.013-0.15 MG/24HR RING ANNOVERA TIER 3 segesterone acetate-ethinyl estradiol apri apri 0.15-30 mg-mcg tab TIER 1 aranelle 0.5/1/0.5-35 mg- aranelle TIER 1 mcg tab ashlyna 0.15-0.03 &0.01 ashlyna TIER 1 mg tab aubra aubra 0.1-20 mg-mcg tab TIER 1 aubra eq 0.1-20 mg-mcg aubra eq TIER 1 tab aurovela 1.5/30 1.5-30 mg- aurovela 1.5/30 TIER 1 mcg tab aurovela 1/20 1-20 mg-mcg aurovela 1/20 TIER 1 tab aurovela 24 fe 1-20 mg- aurovela 24 fe TIER 1 mcg(24) tab aurovela fe 1.5/30 1.5-30 aurovela fe 1.5/30 TIER 1 mg-mcg tab aurovela fe 1/20 1-20 mg- aurovela fe 1/20 TIER 1 mcg tab aviane aviane 0.1-20 mg-mcg tab TIER 1 ayuna ayuna 0.15-30 mg-mcg tab TIER 1 azurette 0.15-0.02/0.01 mg azurette TIER 1 (21/5) tab BALCOLTRA 0.1-20 MG- MCG(21) TAB BALCOLTRA levonorgestrel-ethinyl TIER 3 estradiol-ferrous bisglycinate balziva balziva 0.4-35 mg-mcg tab TIER 1 bekyree 0.15-0.02/0.01 mg bekyree TIER 1 (21/5) tab blisovi 24 fe 1-20 mg- blisovi 24 fe TIER 1 mcg(24) tab

©2021 Wellmark, Inc. 137 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS blisovi fe 1.5/30 1.5-30 mg- blisovi fe 1.5/30 TIER 1 mcg tab blisovi fe 1/20 1-20 mg-mcg blisovi fe 1/20 TIER 1 tab briellyn briellyn 0.4-35 mg-mcg tab TIER 1 camrese 0.15-0.03 &0.01 camrese TIER 1 mg tab camrese lo 0.1-0.02 & 0.01 camrese lo TIER 1 mg tab caziant 0.1/0.125/0.15 - caziant TIER 1 0.025 mg tab charlotte 24 fe 1-20 mg- charlotte 24 fe TIER 1 mcg(24) chew tab chateal 0.15-30 mg-mcg chateal TIER 1 tab chateal eq 0.15-30 mg-mcg chateal eq TIER 1 tab CLIMARA PRO 0.045- CLIMARA PRO 0.015 MG/DAY PATCH WK TIER 3 estradiol-levonorgestrel COMBIPATCH (0.05-0.14 PATCH TW, 0.05-0.25 COMBIPATCH PATCH TW) TIER 3 estradiol & norethindrone acetate covaryx covaryx 1.25-2.5 mg tab TIER 1 covaryx hs 0.625-1.25 mg covaryx hs TIER 1 tab cryselle-28 0.3-30 mg-mcg cryselle-28 TIER 1 tab cyclafem 1/35 1-35 mg-mcg cyclafem 1/35 TIER 1 tab cyclafem 7/7/7 0.5/0.75/1- cyclafem 7/7/7 TIER 1 35 mg-mcg tab cyred cyred 0.15-30 mg-mcg tab TIER 1 cyred eq 0.15-30 mg-mcg cyred eq TIER 1 tab dasetta 1/35 1-35 mg-mcg dasetta 1/35 TIER 1 tab dasetta 7/7/7 0.5/0.75/1-35 dasetta 7/7/7 TIER 1 mg-mcg tab daysee 0.15-0.03 &0.01 mg daysee TIER 1 tab

©2021 Wellmark, Inc. 138 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DELESTROGEN (20 MG/ML OIL, 40 MG/ML DELESTROGEN TIER 1 GA OIL) estradiol valerate delyla delyla 0.1-20 mg-mcg tab TIER 1 DEPO-ESTRADIOL 5 DEPO-ESTRADIOL MG/ML OIL TIER 1 estradiol cypionate desogestrel-ethinyl desogestrel-ethinyl estradiol (0.15-0.02/0.01 TIER 1 estradiol mg (21/5) tab, 0.15-30 mg- mcg tab) DIVIGEL (0.25 MG/0.25GM GEL, 0.5 MG/0.5GM GEL, 0.75 MG/0.75GM GEL, 1 DIVIGEL TIER 3 MG/GM GEL, 1.25 MG/1.25GM GEL) estradiol dolishale dolishale 90-20 mcg tab TIER 1 dotti (0.025 mg/24hr patch tw, 0.0375 mg/24hr patch dotti tw, 0.05 mg/24hr patch tw, TIER 1 QL (8 PER 28 DAYS) 0.075 mg/24hr patch tw, 0.1 mg/24hr patch tw) drospiren-eth estrad- drospiren-eth estrad- levomefol (3-0.02-0.451 mg TIER 1 levomefol tab, 3-0.03-0.451 mg tab) drospirenone-ethinyl drospirenone-ethinyl estradiol (3-0.02 mg tab, 3- TIER 1 estradiol 0.03 mg tab) eemt eemt 1.25-2.5 mg tab TIER 1 eemt hs eemt hs 0.625-1.25 mg tab TIER 1 elinest elinest 0.3-30 mg-mcg tab TIER 1 eluryng 0.12-0.015 mg/24hr eluryng TIER 1 ring emoquette 0.15-30 mg-mcg emoquette TIER 1 tab enpresse-28 50-30/75-40/ enpresse-28 TIER 1 125-30 mcg tab enskyce 0.15-30 mg-mcg enskyce TIER 1 tab est estrogens-methyltest est estrogens- (rogens-methylt0.625-1.25 TIER 1 methyltest mg tab, rogens- methylt1.25-2.5 mg tab)

©2021 Wellmark, Inc. 139 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS est estrogens- est estrogens-methyltest ds TIER 1 methyltest ds 1.25-2.5 mg tab est estrogens- est estrogens-methyltest hs TIER 1 methyltest hs 0.625-1.25 mg tab estarylla 0.25-35 mg-mcg estarylla TIER 1 tab estradiol (0.025 mg/24hr patch tw, 0.0375 mg/24hr patch tw, 0.05 mg/24hr estradiol TIER 1 QL (8 PER 28 DAYS) patch tw, 0.075 mg/24hr patch tw, 0.1 mg/24hr patch tw) estradiol (0.025 mg/24hr patch wk, 0.0375 mg/24hr patch wk, 0.05 mg/24hr patch wk, 0.06 mg/24hr estradiol patch wk, 0.075 mg/24hr TIER 1 patch wk, 0.1 mg/24hr patch wk, 0.1 mg/gm cream, 0.5 mg tab, 1 mg tab, 2 mg tab, 10 mcg tab) estradiol valerate (20 mg/ml estradiol valerate TIER 1 oil, 40 mg/ml oil) estradiol-norethindrone estradiol- acet (0.5-0.1 mg tab, 1-0.5 TIER 1 norethindrone acet mg tab) ESTRING 2 MG RING ESTRING TIER 3 estradiol vaginal ESTROGEL 0.75 MG/1.25 ESTROGEL GM (0.06%) GEL TIER 3 estradiol ESTROPIPATE (0.75 MG TAB, 1.5 MG TAB, 3 MG ESTROPIPATE TIER 1 TAB) estropipate ethynodiol diac-eth ethynodiol diac-eth estradiol (1-35 tab, 1-50 TIER 1 estradiol tab) etonogestrel-ethinyl etonogestrel-ethinyl estradiol 0.12-0.015 TIER 1 estradiol mg/24hr ring EVAMIST 1.53 MG/SPRAY EVAMIST SOLUTION TIER 3 estradiol

©2021 Wellmark, Inc. 140 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FALESSA 20-1-0.1 MCG- MG KIT FALESSA TIER 3 levonorgestrel-ethinyl estradiol & folic acid falmina falmina 0.1-20 mg-mcg tab TIER 1 fayosim 42-21-21-7 days fayosim TIER 1 tab femynor 0.25-35 mg-mcg femynor TIER 1 tab fyavolv (0.5-2.5 tab, 1-5 fyavolv TIER 1 tab) gemmily 1-20 mg-mcg(24) gemmily TIER 1 cap gianvi gianvi 3-0.02 mg tab TIER 1 gildagia gildagia 0.4-35 mg-mcg tab TIER 1 hailey 1.5/30 1.5-30 mg- hailey 1.5/30 TIER 1 mcg tab hailey 24 fe 1-20 mg- hailey 24 fe TIER 1 mcg(24) tab hailey fe 1.5/30 1.5-30 mg- hailey fe 1.5/30 TIER 1 mcg tab hailey fe 1/20 1-20 mg-mcg hailey fe 1/20 TIER 1 tab iclevia iclevia 0.15-0.03 mg tab TIER 1 introvale introvale 0.15-0.03 mg tab TIER 1 isibloom 0.15-30 mg-mcg isibloom TIER 1 tab jaimiess 0.15-0.03 &0.01 jaimiess TIER 1 mg tab jasmiel jasmiel 3-0.02 mg tab TIER 1 jevantique lo 0.5-2.5 mg- jevantique lo TIER 1 mcg tab jinteli jinteli 1-5 mg-mcg tab TIER 1 jolessa jolessa 0.15-0.03 mg tab TIER 1 juleber juleber 0.15-30 mg-mcg tab TIER 1 junel 1.5/30 1.5-30 mg-mcg junel 1.5/30 TIER 1 tab junel 1/20 junel 1/20 1-20 mg-mcg tab TIER 1 junel fe 1.5/30 1.5-30 mg- junel fe 1.5/30 TIER 1 mcg tab junel fe 1/20 1-20 mg-mcg junel fe 1/20 TIER 1 tab junel fe 24 1-20 mg- junel fe 24 TIER 1 mcg(24) tab

©2021 Wellmark, Inc. 141 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS kaitlib fe 0.8-25 mg-mcg kaitlib fe TIER 1 chew tab kalliga kalliga 0.15-30 mg-mcg tab TIER 1 kariva 0.15-0.02/0.01 mg kariva TIER 1 (21/5) tab kelnor 1/35 1-35 mg-mcg kelnor 1/35 TIER 1 tab kelnor 1/50 1-50 mg-mcg kelnor 1/50 TIER 1 tab kimidess 0.15-0.02/0.01 mg kimidess TIER 1 (21/5) tab kurvelo 0.15-30 mg-mcg kurvelo TIER 1 tab larin 1.5/30 1.5-30 mg-mcg larin 1.5/30 TIER 1 tab larin 1/20 larin 1/20 1-20 mg-mcg tab TIER 1 larin 24 fe 1-20 mg-mcg(24) larin 24 fe TIER 1 tab larin fe 1.5/30 1.5-30 mg- larin fe 1.5/30 TIER 1 mcg tab larin fe 1/20 1-20 mg-mcg larin fe 1/20 TIER 1 tab larissia larissia 0.1-20 mg-mcg tab TIER 1 layolis fe 0.8-25 mg-mcg layolis fe TIER 1 chew tab leena 0.5/1/0.5-35 mg-mcg leena TIER 1 tab lessina lessina 0.1-20 mg-mcg tab TIER 1 levonest 50-30/75-40/ 125- levonest TIER 1 30 mcg tab levonorg-eth estrad levonorg-eth estrad triphasic 50-30/75-40/ 125- TIER 1 triphasic 30 mcg tab levonorgest-eth est & levonorgest-eth est & eth TIER 1 eth est est 42-21-21-7 days tab levonorgest-eth estrad 91- levonorgest-eth day (0.1-0.02 & 0.01 mg TIER 1 estrad 91-day tab, 0.15-0.03 &0.01 mg tab, 0.15-0.03 mg tab) levonorgestrel-ethinyl levonorgestrel-ethinyl estrad (0.1-20 mg-mcg tab, TIER 1 estrad 0.15-30 mg-mcg tab, 90-20 mcg tab) levora 0.15/30 (28) 0.15-30 levora 0.15/30 (28) TIER 1 mg-mcg tab

©2021 Wellmark, Inc. 142 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lillow lillow 0.15-30 mg-mcg tab TIER 1 LO LOESTRIN FE 1 MG-10 MCG / 10 MCG TAB LO LOESTRIN FE norethindrone acetate- TIER 3 ethinyl estradiol-fe fum (biphasic) lo-zumandimine 3-0.02 mg lo-zumandimine TIER 1 tab loestrin 1.5/30 (21) 1.5-30 loestrin 1.5/30 (21) TIER 1 mg-mcg tab loestrin 1/20 (21) 1-20 mg- loestrin 1/20 (21) TIER 1 mcg tab loestrin fe 1.5/30 1.5-30 loestrin fe 1.5/30 TIER 1 mg-mcg tab loestrin fe 1/20 1-20 mg- loestrin fe 1/20 TIER 1 mcg tab lojaimiess 0.1-0.02 & 0.01 lojaimiess TIER 1 mg tab lomedia 24 fe 1-20 mg- lomedia 24 fe TIER 1 mcg(24) tab lopreeza (0.5-0.1 mg tab, 1- lopreeza TIER 1 0.5 mg tab) loryna loryna 3-0.02 mg tab TIER 1 low-ogestrel 0.3-30 mg-mcg low-ogestrel TIER 1 tab lutera lutera 0.1-20 mg-mcg tab TIER 1 lyllana (0.025 mg/24hr patch tw, 0.0375 mg/24hr patch tw, 0.05 mg/24hr lyllana TIER 1 QL (8 PER 28 DAYS) patch tw, 0.075 mg/24hr patch tw, 0.1 mg/24hr patch tw) marlissa 0.15-30 mg-mcg marlissa TIER 1 tab melodetta 24 fe 1-20 mg- melodetta 24 fe TIER 1 mcg(24) chew tab MENEST (0.3 MG TAB, 0.625 MG TAB, 1.25 MG MENEST TIER 3 TAB) esterified estrogens MENOSTAR 14 MENOSTAR MCG/24HR PATCH WK TIER 3 estradiol merzee 1-20 mg-mcg(24) merzee TIER 1 cap

©2021 Wellmark, Inc. 143 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS mibelas 24 fe 1-20 mg- mibelas 24 fe TIER 1 mcg(24) chew tab microgestin 1.5/30 1.5-30 microgestin 1.5/30 TIER 1 mg-mcg tab microgestin 1/20 1-20 mg- microgestin 1/20 TIER 1 mcg tab microgestin 24 fe 1-20 mg- microgestin 24 fe TIER 1 mcg tab microgestin fe 1.5/30 1.5-30 microgestin fe 1.5/30 TIER 1 mg-mcg tab microgestin fe 1/20 1-20 microgestin fe 1/20 TIER 1 mg-mcg tab mili mili 0.25-35 mg-mcg tab TIER 1 mimvey mimvey 1-0.5 mg tab TIER 1 mimvey lo mimvey lo 0.5-0.1 mg tab TIER 1 mono-linyah 0.25-35 mg- mono-linyah TIER 1 mcg tab mononessa 0.25-35 mg- mononessa TIER 1 mcg tab myzilra 50-30/75-40/ 125- myzilra TIER 1 30 mcg tab NATAZIA 3/2-2/2-3/1 MG NATAZIA TAB TIER 3 estradiol valerate-dienogest necon 0.5/35 (28) 0.5-35 necon 0.5/35 (28) TIER 1 mg-mcg tab NECON 1/50 (28) 1-50 MG- NECON 1/50 (28) MCG TAB TIER 3 norethindrone & mestranol necon 7/7/7 0.5/0.75/1-35 necon 7/7/7 TIER 1 mg-mcg tab nikki nikki 3-0.02 mg tab TIER 1 norethin ace-eth estrad-fe (1-20 mg-mcg tab, 1-20 norethin ace-eth mg-mcg(24) cap, 1-20 mg- TIER 1 estrad-fe mcg(24) chew tab, 1-20 mg-mcg(24) tab, 1.5-30 mg-mcg tab) norethin-eth estradiol-fe norethin-eth estradiol- (0.4-35 chew tab, 0.8-25 TIER 1 fe chew tab) norethindrone acet-ethinyl norethindrone acet- est (1-20 mg-mcg tab, 1-20 TIER 1 ethinyl est mg-mcg(24) chew tab, 1.5- 30 mg-mcg tab)

©2021 Wellmark, Inc. 144 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS norethindrone-eth norethindrone-eth estradiol TIER 1 estradiol (0.5-2.5 tab, 1-5 tab) norgestim-eth estrad norgestim-eth estrad triphasic (mg-25 mcg tab, TIER 1 triphasic mg-35 mcg tab) norgestimate-eth norgestimate-eth estradiol TIER 1 estradiol 0.25-35 mg-mcg tab nortrel 0.5/35 (28) 0.5-35 nortrel 0.5/35 (28) TIER 1 mg-mcg tab nortrel 1/35 (21) 1-35 mg- nortrel 1/35 (21) TIER 1 mcg tab nortrel 1/35 (28) 1-35 mg- nortrel 1/35 (28) TIER 1 mcg tab nortrel 7/7/7 0.5/0.75/1-35 nortrel 7/7/7 TIER 1 mg-mcg tab nylia 7/7/7 0.5/0.75/1-35 nylia 7/7/7 TIER 1 mg-mcg tab nymyo nymyo 0.25-35 mg-mcg tab TIER 1 ocella ocella 3-0.03 mg tab TIER 1 OGESTREL 0.5-50 MG- MCG TAB OGESTREL TIER 1 norgestrel & ethinyl estradiol orsythia orsythia 0.1-20 mg-mcg tab TIER 1 philith philith 0.4-35 mg-mcg tab TIER 1 pimtrea 0.15-0.02/0.01 mg pimtrea TIER 1 (21/5) tab pirmella 1/35 1-35 mg-mcg pirmella 1/35 TIER 1 tab pirmella 7/7/7 0.5/0.75/1-35 pirmella 7/7/7 TIER 1 mg-mcg tab portia-28 0.15-30 mg-mcg portia-28 TIER 1 tab PREFEST 1/1-0.09 MG PREFEST (15/15) TAB TIER 3 estradiol-norgestimate PREMARIN (0.3 MG TAB, 0.45 MG TAB, 0.625 MG TAB, 0.625 MG/GM PREMARIN TIER 2 CREAM, 0.9 MG TAB, 1.25 MG TAB) estrogens, conjugated

©2021 Wellmark, Inc. 145 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PREMPHASE 0.625-5 MG TAB PREMPHASE conjugated estrogens- TIER 2 medroxyprogesterone acetate PREMPRO (0.3-1.5 MG TAB, 0.45-1.5 MG TAB, 0.625-2.5 MG TAB, 0.625-5 PREMPRO MG TAB) TIER 2 conjugated estrogens- medroxyprogesterone acetate previfem 0.25-35 mg-mcg previfem TIER 1 tab quasense quasense 0.15-0.03 mg tab TIER 1 rajani rajani 3-0.02-0.451 mg tab TIER 1 reclipsen 0.15-30 mg-mcg reclipsen TIER 1 tab rivelsa rivelsa 42-21-21-7 days tab TIER 1 setlakin setlakin 0.15-0.03 mg tab TIER 1 simliya 0.15-0.02/0.01 mg simliya TIER 1 (21/5) tab simpesse 0.15-0.03 &0.01 simpesse TIER 1 mg tab sprintec 28 0.25-35 mg- sprintec 28 TIER 1 mcg tab sronyx sronyx 0.1-20 mg-mcg tab TIER 1 syeda syeda 3-0.03 mg tab TIER 1 tarina 24 fe 1-20 mg- tarina 24 fe TIER 1 mcg(24) tab tarina fe 1/20 1-20 mg-mcg tarina fe 1/20 TIER 1 tab tarina fe 1/20 eq 1-20 mg- tarina fe 1/20 eq TIER 1 mcg tab taysofy 1-20 mg-mcg(24) taysofy TIER 1 cap tilia fe 1-20/1-30/1-35 mg- tilia fe TIER 1 mcg tab tri femynor 0.18/0.215/0.25 tri femynor TIER 1 mg-35 mcg tab tri-estarylla 0.18/0.215/0.25 tri-estarylla TIER 1 mg-35 mcg tab tri-legest fe 1-20/1-30/1-35 tri-legest fe TIER 1 mg-mcg tab

©2021 Wellmark, Inc. 146 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS tri-linyah 0.18/0.215/0.25 tri-linyah TIER 1 mg-35 mcg tab tri-lo-estarylla tri-lo-estarylla 0.18/0.215/0.25 mg-25 mcg TIER 1 tab tri-lo-marzia tri-lo-marzia 0.18/0.215/0.25 mg-25 mcg TIER 1 tab tri-lo-mili 0.18/0.215/0.25 tri-lo-mili TIER 1 mg-25 mcg tab tri-lo-sprintec tri-lo-sprintec 0.18/0.215/0.25 mg-25 mcg TIER 1 tab tri-mili 0.18/0.215/0.25 mg- tri-mili TIER 1 35 mcg tab tri-nymyo 0.18/0.215/0.25 tri-nymyo TIER 1 mg-35 mcg tab tri-previfem 0.18/0.215/0.25 tri-previfem TIER 1 mg-35 mcg tab tri-sprintec 0.18/0.215/0.25 tri-sprintec TIER 1 mg-35 mcg tab tri-vylibra 0.18/0.215/0.25 tri-vylibra TIER 1 mg-35 mcg tab tri-vylibra lo 0.18/0.215/0.25 tri-vylibra lo TIER 1 mg-25 mcg tab trinessa (28) trinessa (28) 0.18/0.215/0.25 mg-35 mcg TIER 1 tab trinessa lo 0.18/0.215/0.25 trinessa lo TIER 1 mg-25 mcg tab trivora (28) 50-30/75-40/ trivora (28) TIER 1 125-30 mcg tab TWIRLA 120-30 MCG/24HR PATCH WK TWIRLA TIER 3 levonorgestrel-ethinyl estradiol TYBLUME 0.1-20 MG-MCG CHEW TAB TYBLUME TIER 3 levonorgestrel & eth estradiol tydemy 3-0.03-0.451 mg tydemy TIER 1 tab velivet 0.1/0.125/0.15 - velivet TIER 1 0.025 mg tab vestura vestura 3-0.02 mg tab TIER 1

©2021 Wellmark, Inc. 147 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS vienva vienva 0.1-20 mg-mcg tab TIER 1 viorele 0.15-0.02/0.01 mg viorele TIER 1 (21/5) tab volnea 0.15-0.02/0.01 mg volnea TIER 1 (21/5) tab vyfemla vyfemla 0.4-35 mg-mcg tab TIER 1 vylibra vylibra 0.25-35 mg-mcg tab TIER 1 wera wera 0.5-35 mg-mcg tab TIER 1 wymzya fe 0.4-35 mg-mcg wymzya fe TIER 1 chew tab xulane 150-35 mcg/24hr xulane TIER 1 patch wk yuvafem yuvafem 10 mcg tab TIER 1 zafemy 150-35 mcg/24hr zafemy TIER 1 patch wk zarah zarah 3-0.03 mg tab TIER 1 zenchent 0.4-35 mg-mcg zenchent TIER 1 tab zenchent fe 0.4-35 mg-mcg zenchent fe TIER 1 chew tab zovia 1/35 (28) 1-35 mg- zovia 1/35 (28) TIER 1 mcg tab zovia 1/35e (28) 1-35 mg- zovia 1/35e (28) TIER 1 mcg tab zovia 1/50e (28) 1-50 mg- zovia 1/50e (28) TIER 1 mcg tab zumandimine zumandimine 3-0.03 mg tab TIER 1

PROGESTERONE AGONISTS/ANTAGONISTS

ELLA 30 MG TAB ELLA TIER 3 ulipristal acetate

PROGESTINS

camila camila 0.35 mg tab TIER 1 CRINONE 4 % GEL CRINONE TIER 3 progesterone (vaginal) deblitane deblitane 0.35 mg tab TIER 1 DEPO-SUBQ PROVERA 104 104 MG/0.65ML SUSP DEPO-SUBQ PRSYR TIER 3 PROVERA 104 medroxyprogesterone acetate (contraceptive) errin errin 0.35 mg tab TIER 1

©2021 Wellmark, Inc. 148 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS heather heather 0.35 mg tab TIER 1 HYDROXYPROGESTERO NE CAPROATE 1.25 HYDROXYPROGEST GM/5ML SOLUTION SP-M ERONE CAPROATE hydroxyprogesterone caproate (antineoplastic) hydroxyprogesterone hydroxyprogesterone SP-M QL (250 PER WEEK(S)) caproate caproate 250 mg/ml oil incassia incassia 0.35 mg tab TIER 1 jencycla jencycla 0.35 mg tab TIER 1 jolivette jolivette 0.35 mg tab TIER 1 KYLEENA 19.5 MG IUD KYLEENA SP-M levonorgestrel (iud) LILETTA (52 MG) 19.5 LILETTA (52 MG) MCG/DAY IUD SP-M levonorgestrel (iud) lyleq lyleq 0.35 mg tab TIER 1 lyza lyza 0.35 mg tab TIER 1 MAKENA 250 MG/ML OIL MAKENA hydroxyprogesterone SP-M QL (250 PER WEEK(S)), GA caproate MAKENA 275 MG/1.1ML SOLN A-INJ MAKENA SP-M QL (4 PER 28 DAY(S)) hydroxyprogesterone caproate medroxyprogesterone acetate (2.5 mg tab, 5 mg medroxyprogesterone tab, 10 mg tab, 150 mg/ml TIER 1 acetate susp prsyr, 150 mg/ml suspension) megestrol acetate (20 mg tab, 40 mg tab, 40 mg/ml megestrol acetate suspension, 400 mg/10ml TIER 1 suspension, 625 mg/5ml suspension) MIRENA (52 MG) 20 MIRENA (52 MG) MCG/24HR IUD SP-M levonorgestrel (iud) nora-be nora-be 0.35 mg tab TIER 1 norethindrone norethindrone 0.35 mg tab TIER 1 norethindrone acetate 5 mg norethindrone acetate TIER 1 tab norlyda norlyda 0.35 mg tab TIER 1 norlyroc norlyroc 0.35 mg tab TIER 1

©2021 Wellmark, Inc. 149 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS progesterone (50 mg/ml oil, progesterone TIER 1 100 mg cap, 200 mg cap) sharobel sharobel 0.35 mg tab TIER 1 SKYLA 13.5 MG IUD SKYLA SP-M levonorgestrel (iud) SLYND 4 MG TAB SLYND TIER 3 drospirenone tulana tulana 0.35 mg tab TIER 1

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

DUAVEE 0.45-20 MG TAB DUAVEE conjugated estrogens- TIER 3 bazedoxifene OSPHENA 60 MG TAB OSPHENA TIER 3 ospemifene raloxifene hcl raloxifene hcl 60 mg tab TIER 1 PA

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

euthyrox (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 euthyrox TIER 1 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab) levo-t (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 mcg levo-t tab, 125 mcg tab, 137 mcg TIER 1 tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 300 mcg tab) levothyroxine sodium (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 levothyroxine sodium mcg tab, 112 mcg tab, 125 TIER 1 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 300 mcg tab) levoxyl (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 levoxyl TIER 1 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab) liothyronine sodium (5 mcg liothyronine sodium tab, 25 mcg tab, 50 mcg TIER 1 tab)

©2021 Wellmark, Inc. 150 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS np thyroid (15 mg tab, 30 np thyroid mg tab, 60 mg tab, 90 mg TIER 1 tab, 120 mg tab) SYNTHROID (25 MCG TAB, 50 MCG TAB, 75 MCG TAB, 88 MCG TAB, 100 MCG TAB, 112 MCG SYNTHROID TAB, 125 MCG TAB, 137 TIER 2 GA MCG TAB, 150 MCG TAB, 175 MCG TAB, 200 MCG TAB, 300 MCG TAB) levothyroxine sodium thyroid (15 mg tab, 30 mg thyroid tab, 60 mg tab, 90 mg tab, TIER 1 120 mg tab) unithroid (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 unithroid mcg tab, 125 mcg tab, 137 TIER 1 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 300 mcg tab)

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

BYNFEZIA PEN 2500 MCG/ML (2.8 ML) SOLN BYNFEZIA PEN SP-P PEN octreotide acetate cabergoline cabergoline 0.5 mg tab TIER 1 ELIGARD (7.5 MG KIT, 22.5 MG KIT, 30 MG KIT, ELIGARD SP-M 45 MG KIT) leuprolide acetate FENSOLVI (6 MONTH) 45 FENSOLVI (6 MG (PED) KIT SP-M MONTH) leuprolide acetate (cpp) (6 month) FIRMAGON (240 MG FIRMAGON (240 MG DOSE) 120 MG/VIAL SP-M DOSE) RECON SOLN degarelix acetate FIRMAGON 80 MG FIRMAGON RECON SOLN SP-M degarelix acetate

©2021 Wellmark, Inc. 151 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LUPANETA PACK (PACK3.755MGKIT, LUPANETA PACK PACK11.255MGKIT) SP-M leuprolide acetate & norethindrone acetate LUPRON DEPOT (1- LUPRON DEPOT (1- MONTH) (3.75 MG KIT, 7.5 SP-M MONTH) MG KIT) leuprolide acetate LUPRON DEPOT (3- MONTH) (11.25 MG KIT, LUPRON DEPOT (3- 22.5 MG KIT) SP-M MONTH) leuprolide acetate (3 month) LUPRON DEPOT (4- LUPRON DEPOT (4- MONTH) 30 MG KIT SP-M MONTH) leuprolide acetate (4 month) LUPRON DEPOT (6- LUPRON DEPOT (6- MONTH) 45 MG KIT SP-M MONTH) leuprolide acetate (6 month) LUPRON DEPOT-PED (1- LUPRON DEPOT- MONTH) (7.5 MG KIT, SP-M PED (1-MONTH) 11.25 MG KIT, 15 MG KIT) leuprolide acetate (cpp) LUPRON DEPOT-PED (3- MONTH) (11.25 MG KIT, LUPRON DEPOT- 30 MG KIT) SP-M PED (3-MONTH) leuprolide acetate (cpp) (3 month) MYCAPSSA 20 MG CAP MYCAPSSA DR SP-NP PA, QL (4 PER DAY(S)) octreotide acetate octreotide acetate (50 mcg/ml solution, 100 mcg/ml solution, 200 SBG (Specialty Biosimilars octreotide acetate mcg/ml solution, 500 SP-P and Specialty generics) mcg/ml solution, 1000 mcg/5ml solution, 1000 mcg/ml solution) ORGOVYX 120 MG TAB ORGOVYX SP-P relugolix SANDOSTATIN LAR SANDOSTATIN LAR DEPOT (10 MG KIT, 20 SP-M DEPOT MG KIT, 30 MG KIT) octreotide acetate

©2021 Wellmark, Inc. 152 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SIGNIFOR (0.3 MG/ML SOLUTION, 0.6 MG/ML SIGNIFOR SOLUTION, 0.9 MG/ML SP-P SOLUTION) pasireotide diaspartate SOMATULINE DEPOT (60 MG/0.2ML SOLUTION, 90 SOMATULINE MG/0.3ML SOLUTION, 120 SP-M DEPOT MG/0.5ML SOLUTION) lanreotide acetate SOMAVERT (10 MG RECON SOLN, 15 MG RECON SOLN, 20 MG MN-PA (Medically Necessary SOMAVERT RECON SOLN, 25 MG SP-P Prior Authorization) RECON SOLN, 30 MG RECON SOLN) pegvisomant TRELSTAR MIXJECT (3.75 MG RECON SUSP, 11.25 TRELSTAR MIXJECT MG RECON SUSP, 22.5 SP-M MG RECON SUSP) triptorelin pamoate

HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole (5 mg tab, 10 methimazole TIER 1 mg tab) propylthiouracil propylthiouracil 50 mg tab TIER 1

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTS

BERINERT 500 UNIT KIT MN-PA (Medically Necessary BERINERT c1 esterase inhibitor SP-M Prior Authorization) (human) CINRYZE 500 UNIT RECON SOLN CINRYZE SP-M PA c1 esterase inhibitor (human) HAEGARDA (2000 RECON SOLN, 3000 RECON HAEGARDA SOLN) SP-P PA c1 esterase inhibitor (human) PA, SBG (Specialty icatibant acetate 30 mg/3ml icatibant acetate SP-P Biosimilars and Specialty solution generics)

©2021 Wellmark, Inc. 153 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KALBITOR 10 MG/ML KALBITOR SOLUTION SP-M PA ecallantide ORLADEYO (110 MG CAP, ORLADEYO 150 MG CAP) SP-P PA, QL (30 PER 30 DAY(S)) berotralstat hcl RUCONEST 2100 UNIT RECON SOLN RUCONEST SP-M PA c1 esterase inhibitor (recombinant) PA, SBG (Specialty sajazir sajazir 30 mg/3ml solution SP-P Biosimilars and Specialty generics) TAKHZYRO 300 MG/2ML TAKHZYRO SOLUTION SP-P PA lanadelumab-flyo

IMMUNE SUPPRESSANTS

ASTAGRAF XL (0.5 MG CAP ER 24H, 1 MG CAP ASTAGRAF XL ER 24H, 5 MG CAP ER SP-P 24H) tacrolimus AVSOLA 100 MG RECON AVSOLA SOLN SP-M PA infliximab-axxq azathioprine azathioprine 50 mg tab TIER 1 CELLCEPT (200 MG/ML RECON SUSP, 250 MG CELLCEPT TIER 2 GA CAP, 500 MG TAB) mycophenolate mofetil MN-PA (Medically Necessary CIMZIA 2 X 200 MG KIT CIMZIA SP-NP Prior Authorization), QLV certolizumab pegol (Quantity Limit Varies) CIMZIA PREFILLED 2 X MN-PA (Medically Necessary CIMZIA PREFILLED 200 MG/ML KIT SP-NP Prior Authorization), QLV certolizumab pegol (Quantity Limit Varies) CIMZIA STARTER KIT 6 X QL (1 PER LIFETIME), MN- CIMZIA STARTER 200 MG/ML KIT SP-NP PA (Medically Necessary KIT certolizumab pegol Prior Authorization) cyclosporine (25 mg cap, cyclosporine TIER 1 100 mg cap) cyclosporine modified (25 cyclosporine modified mg cap, 50 mg cap, 100 mg TIER 1 cap, 100 mg/ml solution)

©2021 Wellmark, Inc. 154 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ENBREL (25 MG RECON SOLN, 25 MG/0.5ML SOLN ENBREL PRSYR, 50 MG/ML SOLN SP-P PA, QL (8 PER 28 DAYS) PRSYR) etanercept ENBREL 25 MG/0.5ML ENBREL SOLUTION SP-P PA, QL (8 PER 28 DAY(S)) etanercept ENBREL MINI 50 MG/ML ENBREL MINI SOLN CART SP-P PA, QL (8 PER 28 DAY(S)) etanercept ENBREL SURECLICK 50 ENBREL MG/ML SOLN A-INJ SP-P PA, QL (8 PER 28 DAYS) SURECLICK etanercept ENSPRYNG 120 MG/ML ENSPRYNG SOLN PRSYR SP-P PA satralizumab-mwge ENTYVIO 300 MG RECON ENTYVIO SOLN SP-M PA vedolizumab ENVARSUS XR (0.75 MG TAB ER 24H, 1 MG TAB ENVARSUS XR ER 24H, 4 MG TAB ER SP-P 24H) tacrolimus everolimus (0.25 mg tab, SBG (Specialty Biosimilars everolimus SP-P 0.5 mg tab, 0.75 mg tab) and Specialty generics) GAMIFANT (10 MG/2ML SOLUTION, 50 MG/10ML GAMIFANT SOLUTION, 100 MG/20ML SP-M SOLUTION) emapalumab-lzsg gengraf (25 mg cap, 50 mg gengraf cap, 100 mg cap, 100 TIER 1 mg/ml solution) HUMIRA (10 MG/0.1ML PREF SY KT, 20 MG/0.2ML PREF SY KT, HUMIRA SP-P PA, QL (4 PER 28 DAY(S)) 40 MG/0.4ML PREF SY KT) adalimumab HUMIRA (10 MG/0.2ML PREF SY KT, 20 MG/0.4ML PREF SY KT, HUMIRA SP-P PA, QL (4 PER 28 DAYS) 40 MG/0.8ML PREF SY KT) adalimumab

©2021 Wellmark, Inc. 155 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HUMIRA 80 MG/0.8ML HUMIRA PEN KIT SP-P PA, QL (1 PER LIFETIME) adalimumab HUMIRA PEDIATRIC CROHNS START (80 & HUMIRA PEDIATRIC 40MG/0.4ML PREF SY KT, SP-P PA, QL (1 PER LIFETIME) CROHNS START 80 PREF SY KT) adalimumab HUMIRA PEDIATRIC HUMIRA PEDIATRIC CROHNS START 40 SP-P PA, QL (4 PER 28 DAYS) CROHNS START MG/0.8ML PREF SY KT adalimumab HUMIRA PEN 40 HUMIRA PEN MG/0.4ML PEN KIT SP-P PA, QL (4 PER 28 DAY(S)) adalimumab HUMIRA PEN 40 HUMIRA PEN MG/0.8ML PEN KIT SP-P PA, QL (4 PER 28 DAYS) adalimumab HUMIRA PEN-CD/UC/HS HUMIRA PEN- STARTER 40 MG/0.8ML SP-P PA, QL (4 PER 28 DAYS) CD/UC/HS STARTER PEN KIT adalimumab HUMIRA PEN-CD/UC/HS HUMIRA PEN- STARTER 80 MG/0.8ML SP-P PA, QL (1 PER LIFETIME) CD/UC/HS STARTER PEN KIT adalimumab HUMIRA PEN-PEDIATRIC HUMIRA PEN- UC START 80 MG/0.8ML PEDIATRIC UC SP-P PA, QL (1 PER LIFETIME) PEN KIT START adalimumab HUMIRA PEN- HUMIRA PEN- PS/UV/ADOL HS START PS/UV/ADOL HS SP-P PA, QL (4 PER 28 DAYS) 40 MG/0.8ML PEN KIT START adalimumab HUMIRA PEN- HUMIRA PEN- PSOR/UVEIT STARTER 80 PSOR/UVEIT MG/0.8ML & 40MG/0.4ML SP-P PA, QL (1 PER LIFETIME) STARTER PEN KIT adalimumab INFLECTRA 100 MG INFLECTRA RECON SOLN SP-M PA infliximab-dyyb KINERET 100 MG/0.67ML MN-PA (Medically Necessary KINERET SOLN PRSYR SP-NP Prior Authorization), QLV anakinra (Quantity Limit Varies) LUPKYNIS 7.9 MG CAP LUPKYNIS SP-NP PA, QL (6 PER DAY(S)) voclosporin

©2021 Wellmark, Inc. 156 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS methotrexate methotrexate 2.5 mg tab TIER 1 methotrexate sodium (2.5 methotrexate sodium mg tab, 50 mg/2ml solution, TIER 1 250 mg/10ml solution) methotrexate sodium (pf) (1 methotrexate sodium gm/40ml solution, 50 TIER 1 (pf) mg/2ml solution, 250 mg/10ml solution) mycophenolate mofetil (200 mycophenolate mg/ml recon susp, 250 mg TIER 1 mofetil cap, 500 mg tab) mycophenolate sodium mycophenolate (180 mg tab dr, 360 mg tab TIER 1 sodium dr) NEORAL (25 MG CAP, 100 MG CAP, 100 MG/ML NEORAL SOLUTION) TIER 3 GA cyclosporine modified (for microemulsion) OLUMIANT (1 MG TAB, 2 QL (30 PER 30 DAY(S)), OLUMIANT MG TAB) SP-NP MN-PA (Medically Necessary baricitinib Prior Authorization) ORENCIA (50 MG/0.4ML SOLN PRSYR, 87.5 QL (4 PER 28 DAY(S)), MN- ORENCIA MG/0.7ML SOLN PRSYR, SP-NP PA (Medically Necessary 125 MG/ML SOLN PRSYR) Prior Authorization) abatacept ORENCIA 250 MG RECON ORENCIA SOLN SP-M PA, QL (4 PER 28 DAY(S)) abatacept ORENCIA CLICKJECT 125 QL (4 PER 28 DAY(S)), MN- ORENCIA MG/ML SOLN A-INJ SP-NP PA (Medically Necessary CLICKJECT abatacept Prior Authorization) OTREXUP (10 SOLN A- INJ, 12.5 SOLN A-INJ, 15 SOLN A-INJ, 17.5 SOLN A- INJ, 20 SOLN A-INJ, 22.5 OTREXUP SP-M SOLN A-INJ, 25 SOLN A- INJ) methotrexate (antirheumatic) PROGRAF (0.2 MG PACKET, 0.5 MG CAP, 1 PROGRAF MG CAP, 1 MG PACKET, 5 TIER 3 GA MG CAP) tacrolimus

©2021 Wellmark, Inc. 157 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RASUVO (7.5 MG/0.15ML SOLN A-INJ, 10 MG/0.2ML SOLN A-INJ, 12.5 MG/0.25ML SOLN A-INJ, 15 MG/0.3ML SOLN A-INJ, 17.5 MG/0.35ML SOLN A- RASUVO INJ, 20 MG/0.4ML SOLN A- SP-M INJ, 22.5 MG/0.45ML SOLN A-INJ, 25 MG/0.5ML SOLN A-INJ, 30 MG/0.6ML SOLN A-INJ) methotrexate (antirheumatic) REDITREX (7.5 MG/0.3ML SOLN PRSYR, 10 MG/0.4ML SOLN PRSYR, 12.5 MG/0.05ML SOLN PRSYR, 15 MG/0.6ML SOLN PRSYR, 17.5 REDITREX MG/0.7ML SOLN PRSYR, SP-M 20 MG/0.8ML SOLN PRSYR, 22.5 MG/0.9ML SOLN PRSYR, 25 MG/ML SOLN PRSYR) methotrexate (antirheumatic) REMICADE 100 MG REMICADE RECON SOLN SP-M PA infliximab RENFLEXIS 100 MG RENFLEXIS RECON SOLN SP-M PA infliximab-abda RINVOQ 15 MG TAB ER RINVOQ 24H SP-P PA, QL (30 PER 30 DAY(S)) upadacitinib SANDIMMUNE (25 MG CAP, 100 MG CAP, 100 SANDIMMUNE TIER 3 GA MG/ML SOLUTION) cyclosporine SIMPONI (50 MG/0.5ML SOLN A-INJ, 50 MG/0.5ML QL (1 PER 30 DAYS), MN- SOLN PRSYR, 100 MG/ML SIMPONI SP-NP PA (Medically Necessary SOLN A-INJ, 100 MG/ML Prior Authorization) SOLN PRSYR) golimumab SIMPONI ARIA 50 MG/4ML SIMPONI ARIA SOLUTION SP-M PA golimumab

©2021 Wellmark, Inc. 158 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS sirolimus (0.5 mg tab, 1 mg sirolimus TIER 1 tab, 2 mg tab) PA, QL (1200 PER 30 sirolimus sirolimus 1 mg/ml solution TIER 1 DAY(S)) tacrolimus (0.5 mg cap, 1 tacrolimus TIER 1 mg cap, 5 mg cap) UPLIZNA 100 MG/10ML UPLIZNA SOLUTION SP-M PA inebilizumab-cdon XATMEP 2.5 MG/ML XATMEP SOLUTION TIER 3 PA methotrexate XELJANZ 10 MG TAB XELJANZ SP-P PA, QL (60 PER 28 DAY(S)) tofacitinib citrate XELJANZ 5 MG TAB XELJANZ SP-P PA, QL (60 PER 30 DAYS) tofacitinib citrate XELJANZ XR 11 MG TAB XELJANZ XR ER 24H SP-P PA, QL (30 PER 30 DAYS) tofacitinib citrate XELJANZ XR 22 MG TAB XELJANZ XR ER 24H SP-P PA, QL (30 PER 30 DAY(S)) tofacitinib citrate ZORTRESS (0.25 MG TAB, 0.5 MG TAB, 0.75 MG TAB, ZORTRESS 1 MG TAB) SP-P everolimus (immunosuppressant)

IMMUNIZING AGENTS, PASSIVE

ASCENIV 5 GM/50ML SOLUTION ASCENIV SP-M PA immune globulin (human)- slra BIVIGAM (5 GM/50ML SOLUTION, 10 GM/100ML BIVIGAM SP-M PA SOLUTION) immune globulin (human) iv CARIMUNE NF (6 GM RECON SOLN, 12 GM CARIMUNE NF SP-M PA RECON SOLN) immune globulin (human) iv

©2021 Wellmark, Inc. 159 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CUTAQUIG (1 GM/6ML SOLUTION, 1.65 GM/10ML SOLUTION, 2 GM/12ML SOLUTION, 3.3 GM/20ML CUTAQUIG SOLUTION, 4 GM/24ML SP-M PA SOLUTION, 8 GM/48ML SOLUTION) immune globulin (human)- hipp CUVITRU (1 GM/5ML SOLUTION, 2 GM/10ML SOLUTION, 4 GM/20ML SOLUTION, 8 GM/40ML CUVITRU SP-M PA SOLUTION, 10 GM/50ML SOLUTION) immune globulin (human) subcutaneous CYTOGAM 50 MG/ML INJECTABLE CYTOGAM SP-M cytomegalovirus immune globulin (human) FLEBOGAMMA DIF (0.5 GM/10ML SOLUTION, 2.5 GM/50ML SOLUTION, 5 GM/100ML SOLUTION, 5 GM/50ML SOLUTION, 10 FLEBOGAMMA DIF SP-M PA GM/100ML SOLUTION, 10 GM/200ML SOLUTION, 20 GM/200ML SOLUTION, 20 GM/400ML SOLUTION) immune globulin (human) iv GAMASTAN INJECTABLE GAMASTAN SP-M immune globulin (human) im GAMMAGARD (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GAMMAGARD GM/100ML SOLUTION, 20 SP-M PA GM/200ML SOLUTION, 30 GM/300ML SOLUTION) immune globulin (human) iv or subcutaneous GAMMAGARD S/D LESS GAMMAGARD S/D IGA (5 GM RECON SOLN, SP-M PA LESS IGA 10 GM RECON SOLN) immune globulin (human) iv

©2021 Wellmark, Inc. 160 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GAMMAKED (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML GAMMAKED SP-M PA SOLUTION, 20 GM/200ML SOLUTION) immune globulin (human) iv or subcutaneous GAMMAPLEX (5 GM/100ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML SOLUTION, 10 GAMMAPLEX SP-M PA GM/200ML SOLUTION, 20 GM/200ML SOLUTION, 20 GM/400ML SOLUTION) immune globulin (human) iv GAMUNEX-C (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML GAMUNEX-C SOLUTION, 20 GM/200ML SP-M PA SOLUTION, 40 GM/400ML SOLUTION) immune globulin (human) iv or subcutaneous HIZENTRA (1 GM/5ML SOLN PRSYR, 1 GM/5ML SOLUTION, 2 GM/10ML SOLN PRSYR, 2 GM/10ML SOLUTION, 4 GM/20ML HIZENTRA SP-M PA SOLN PRSYR, 4 GM/20ML SOLUTION, 10 GM/50ML SOLUTION) immune globulin (human) subcutaneous HYPERRHO S/D (250 SOLN PRSYR, 1500 SOLN HYPERRHO S/D PRSYR) SP-M rho d immune globulin (human)

©2021 Wellmark, Inc. 161 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HYQVIA (2.5 GM/25ML KIT, 5 GM/50ML KIT, 10 GM/100ML KIT, 20 GM/200ML KIT, 30 HYQVIA SP-M PA GM/300ML KIT) immune globulin (human)- hyaluronidase (human recombinant) MICRHOGAM ULTRA- MICRHOGAM FILTERED PLUS 250 UNIT ULTRA-FILTERED SOLN PRSYR SP-M PLUS rho d immune globulin (human) OCTAGAM (1 GM/20ML SOLUTION, 2 GM/20ML SOLUTION, 2.5 GM/50ML SOLUTION, 5 GM/100ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML OCTAGAM SP-M PA SOLUTION, 10 GM/200ML SOLUTION, 20 GM/200ML SOLUTION, 25 GM/500ML SOLUTION, 30 GM/300ML SOLUTION) immune globulin (human) iv PANZYGA (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML PANZYGA SOLUTION, 20 GM/200ML SP-M PA SOLUTION, 30 GM/300ML SOLUTION) immune globulin (human)- ifas PRIVIGEN (5 GM/50ML SOLUTION, 10 GM/100ML SOLUTION, 20 GM/200ML PRIVIGEN SP-M PA SOLUTION, 40 GM/400ML SOLUTION) immune globulin (human) iv RHOGAM ULTRA- FILTERED PLUS 1500 RHOGAM ULTRA- UNIT SOLN PRSYR SP-M FILTERED PLUS rho d immune globulin (human) RHOPHYLAC 1500 UNIT/2ML SOLN PRSYR RHOPHYLAC SP-M rho d immune globulin (human)

©2021 Wellmark, Inc. 162 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VARIZIG 125 UNIT/1.2ML SOLUTION VARIZIG SP-M varicella-zoster immune globulin (human) XEMBIFY (1 GM/5ML SOLUTION, 2 GM/10ML SOLUTION, 4 GM/20ML XEMBIFY SOLUTION, 10 GM/50ML SP-M PA SOLUTION) immune globulin (human)- klhw

IMMUNOMODULATORS

ACTEMRA (80 MG/4ML SOLUTION, 200 MG/10ML ACTEMRA SOLUTION, 400 MG/20ML SP-M PA, QL (40 PER 28 DAYS) SOLUTION) tocilizumab ACTEMRA 162 MG/0.9ML QL (4 PER 28 DAYS), MN- ACTEMRA SOLN PRSYR SP-NP PA (Medically Necessary tocilizumab Prior Authorization) ACTEMRA ACTPEN 162 QL (4 PER 28 DAY(S)), MN- ACTEMRA ACTPEN MG/0.9ML SOLN A-INJ SP-NP PA (Medically Necessary tocilizumab Prior Authorization) ACTIMMUNE 2000000 ACTIMMUNE UNIT/0.5ML SOLUTION SP-P interferon gamma-1b ARCALYST 220 MG ARCALYST RECON SOLN SP-P rilonacept BENLYSTA (200 MG/ML SOLN A-INJ, 200 MG/ML BENLYSTA SP-P SOLN PRSYR) belimumab ILARIS (150 MG RECON SOLN, 150 MG/ML ILARIS SP-M SOLUTION) canakinumab KEVZARA (150 SOLN A- INJ, 150 SOLN PRSYR, QL (2 PER 28 DAY(S)), MN- KEVZARA 200 SOLN A-INJ, 200 SP-NP PA (Medically Necessary SOLN PRSYR) Prior Authorization) sarilumab leflunomide (10 mg tab, 20 leflunomide TIER 1 mg tab) OTEZLA 10 & 20 & 30 MG OTEZLA TAB THPK SP-P PA, QL (2 PER LIFETIME) apremilast

©2021 Wellmark, Inc. 163 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OTEZLA 30 MG TAB OTEZLA SP-P PA, QL (60 PER 30 DAYS) apremilast PALFORZIA (12 MG DAILY DOSE) 2 X 1 MG & 10 MG PALFORZIA (12 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (120 MG DAILY DOSE) 20 MG & PALFORZIA (120 MG 100 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (160 MG DAILY DOSE) 3 X 20 MG & PALFORZIA (160 MG 100 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (20 MG DAILY PALFORZIA (20 MG DOSE) 20 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (200 MG DAILY DOSE) 2 X 100 MG PALFORZIA (200 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (240 MG DAILY DOSE) 2 X 20 MG & PALFORZIA (240 MG 2 X 100 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (3 MG DAILY PALFORZIA (3 MG DOSE) 3 X 1 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (300 MG MAINTENANCE) 300 MG PALFORZIA (300 MG PACKET SP-NP PA, QL (30 PER 30 DAY(S)) MAINTENANCE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (300 MG TITRATION) 300 MG PALFORZIA (300 MG PACKET SP-NP PA, QL (30 PER 30 DAY(S)) TITRATION) peanut (arachis hypogaea) allergen powder-dnfp

©2021 Wellmark, Inc. 164 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PALFORZIA (40 MG DAILY PALFORZIA (40 MG DOSE) 2 X 20 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (6 MG DAILY PALFORZIA (6 MG DOSE) 6 X 1 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (80 MG DAILY PALFORZIA (80 MG DOSE) 4 X 20 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA INITIAL ESCALATION 0.5 & 1 & 1.5 PALFORZIA INITIAL & 3 & 6 MG CSPK SP-NP PA, QL (1 PER FILL(S)) ESCALATION peanut (arachis hypogaea) allergen powder-dnfp RIDAURA 3 MG CAP RIDAURA TIER 2 auranofin SYNAGIS (50 MG/0.5ML SOLUTION, 100 MG/ML SYNAGIS SP-M PA, QL (5 PER 6 MONTH(S)) SOLUTION) palivizumab

VACCINES

ACTHIB RECON SOLN ACTHIB haemophilus b polysac conj TIER 2 vac ADACEL 5-2-15.5 LF- MCG/0.5 SUSPENSION ADACEL tetanus toxoid-diphtheria- TIER 2 acellular pertussis adsorb (tdap) AFLURIA SUSPENSION AFLURIA TIER 2 influenza virus vaccine split AFLURIA PRESERVATIVE AFLURIA FREE 0.5 ML SUSP PRESERVATIVE PRSYR TIER 2 FREE influenza virus vaccine split preservative free AFLURIA QUADRIVALENT (0.25 ML SUSP PRSYR, AFLURIA 0.5 ML SUSP PRSYR, TIER 2 QUADRIVALENT SUSPENSION) influenza virus vaccine split quadrivalent

©2021 Wellmark, Inc. 165 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BEXSERO SUSP PRSYR meningococcal vac group b BEXSERO TIER 2 (recombant omv adjuvanted) BOOSTRIX 5-2.5-18.5 LF- MCG/0.5 SUSPENSION BOOSTRIX tetanus toxoid-diphtheria- TIER 2 acellular pertussis adsorb (tdap) DAPTACEL 23-15-5 SUSPENSION DAPTACEL TIER 2 diphtheria, acellular pertussis & tetanus toxoids DIPHTHERIA-TETANUS DIPHTHERIA- TOXOIDS DT 25-5 TETANUS TOXOIDS LFU/0.5ML SUSPENSION TIER 2 DT diphtheria-tetanus toxoids (dt) ENGERIX-B (10 MCG/0.5ML SUSPENSION, 20 ENGERIX-B TIER 2 MCG/ML SUSPENSION) hepatitis b vaccine (recomb) FLUAD 0.5 ML SUSP PRSYR FLUAD influenza virus vaccine TIER 2 types a & b surface antigen adjuvant FLUAD QUADRIVALENT 0.5 ML PRSYR FLUAD influenza virus vacc types a TIER 2 QUADRIVALENT & b surf antigen adjuvant quad FLUARIX QUADRIVALENT FLUARIX 0.5 ML SUSP PRSYR TIER 2 QUADRIVALENT influenza virus vaccine split quadrivalent FLUBLOK SOLUTION influenza virus vaccine FLUBLOK TIER 2 recombinant hemagglutinin (ha) FLUBLOK QUADRIVALENT 0.5 ML FLUBLOK SOLN PRSYR TIER 2 QUADRIVALENT influenza virus vac recomb hemagglutinin (ha) quadrivalent

©2021 Wellmark, Inc. 166 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FLUCELVAX QUADRIVALENT (0.5MLSUSPPRSYR, FLUCELVAX SUSPENSION) TIER 2 QUADRIVALENT influenza virus vaccine tissue-cultured subunit quadrivalent FLULAVAL QUADRIVALENT FLULAVAL (0.5MLSUSPPRSYR, TIER 2 QUADRIVALENT SUSPENSION) influenza virus vaccine split quadrivalent FLUMIST 10E6.5-7.5 FLUMIST LIQUID TIER 2 influenza virus vaccine live FLUMIST QUADRIVALENT FLUMIST SUSPENSION TIER 2 QUADRIVALENT influenza virus vaccine live quadrivalent FLUVIRIN (0.5MLSUSPPRSYR, FLUVIRIN SUSPENSION) TIER 2 influenza virus vaccine types a & b surface antigen FLUZONE HIGH-DOSE 0.5 FLUZONE HIGH- ML SUSP PRSYR TIER 2 DOSE influenza virus vaccine split high-dose preservative free FLUZONE HIGH-DOSE QUADRIVALENT 0.7 ML FLUZONE HIGH- SUSP PRSYR DOSE TIER 2 influenza virus vac split QUADRIVALENT high-dose quad preservative free FLUZONE QUADRIVALENT (0.25 ML SUSP PRSYR, 0.5 ML SUSP PRSYR, 0.5 ML FLUZONE SUSPENSION, 9 TIER 2 QUADRIVALENT MCG/STRAIN SUSP PEN, SUSPENSION) influenza virus vaccine split quadrivalent

©2021 Wellmark, Inc. 167 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GARDASIL 9 (9SUSPENSION, 9SUSPPRSYR) GARDASIL 9 TIER 2 human papillomavirus (hpv) 9-valent recombinant vaccine HAVRIX (720 U/0.5ML SUSPENSION, 1440 U/ML HAVRIX TIER 2 SUSPENSION) hepatitis a vaccine HEPLISAV-B (20 SOLN PRSYR, 20 SOLUTION) HEPLISAV-B TIER 2 hepatitis b vaccine recombinant adjuvanted HIBERIX 10 MCG RECON SOLN HIBERIX TIER 2 haemophilus b polysac conj vac INFANRIX 25-58-10 SUSPENSION INFANRIX TIER 2 diphtheria, acellular pertussis & tetanus toxoids IPOL INJECTABLE IPOL TIER 2 poliovirus vaccine, ipv JANSSEN COVID-19 VACCINE 0.5 ML JANSSEN COVID-19 SUSPENSION TIER 2 VACCINE covid-19 (sars-cov-2) adenovirus vaccine KINRIX SUSPENSION diph-tetanus tox ad-acell KINRIX TIER 2 pertussis & polio virus, ipv vac M-M-R II RECON SOLN M-M-R II measles, mumps & rubella TIER 2 virus vaccines MENACTRA (4MCG/0.5MLINJECTABLE , INJECTABLE) MENACTRA TIER 2 meningococcal (a,c,y&w- 135) polysaccharide conjugate vaccine MENQUADFI INJECTABLE MENQUADFI meningococcal (a,c,y&w- TIER 2 135) polysaccharide conjugate vaccine

©2021 Wellmark, Inc. 168 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MENVEO RECON SOLN meningococcal (a,c,y&w- MENVEO TIER 2 135) oligosaccharide conjugate vac MODERNA COVID-19 VACCINE 100 MCG/0.5ML MODERNA COVID- SUSPENSION TIER 2 19 VACCINE covid-19 (sars-cov-2) mrna virus vaccine PEDIARIX SUSPENSION diph-tetanus tox-acell pert- PEDIARIX TIER 2 hepatitis b recomb-polio ipv vac PEDVAX HIB 7.5 MCG/0.5ML SUSPENSION PEDVAX HIB TIER 2 haemophilus b polysac conj vac PENTACEL RECON SUSP PENTACEL TIER 2 diph-ac pert-tet tox ad-polio ipv-haemophil b poly vac PFIZER-BIONTECH COVID-19 VACC 30 PFIZER-BIONTECH MCG/0.3ML SUSPENSION TIER 2 COVID-19 VACC covid-19 (sars-cov-2) mrna virus vaccine PNEUMOVAX 23 25 MCG/0.5ML INJECTABLE PNEUMOVAX 23 TIER 2 pneumococcal vac polyvalent PREVNAR 13 SUSPENSION PREVNAR 13 TIER 2 pneumococcal 13-valent conjugate vaccine PROQUAD RECON SUSP PROQUAD TIER 2 measles-mumps-rubella- varicella virus vaccines QUADRACEL SUSPENSION QUADRACEL diph-tetanus tox ad-acell TIER 2 pertussis & polio virus, ipv vac

©2021 Wellmark, Inc. 169 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RECOMBIVAX HB (5 MCG/0.5ML SUSPENSION, 10 MCG/ML SUSPENSION, RECOMBIVAX HB TIER 2 40 MCG/ML SUSPENSION) hepatitis b vaccine (recomb) ROTARIX RECON SUSP ROTARIX TIER 2 rotavirus vaccine, live oral ROTATEQ SOLUTION ROTATEQ rotavirus vaccine, live oral TIER 2 pentavalent SHINGRIX 50 MCG/0.5ML RECON SUSP SHINGRIX TIER 2 AL (At least 50 yrs old) zoster vaccine recombinant adjuvanted TDVAX 2-2 LF/0.5ML SUSPENSION TDVAX TIER 2 tetanus-diphtheria toxoids (td) TENIVAC 5-2 LFU INJECTABLE TENIVAC TIER 2 tetanus-diphtheria toxoids (td) TETANUS-DIPHTHERIA TETANUS- TOXOIDS TD 2-2 LF/0.5ML DIPHTHERIA SUSPENSION TIER 2 TOXOIDS TD tetanus-diphtheria toxoids (td) TRUMENBA SUSP PRSYR TRUMENBA TIER 2 meningococcal group b vaccine (recombinant) TWINRIX 720-20 ELU- MCG/ML SUSP PRSYR TWINRIX hepatitis a (inactivated)- TIER 2 hepatitis b (recombinant) vaccines VAQTA (25 UNIT/0.5ML SUSPENSION, 50 VAQTA TIER 2 UNIT/ML SUSPENSION) hepatitis a vaccine VARIVAX 1350 PFU/0.5ML VARIVAX INJECTABLE TIER 2 varicella virus vaccine live

©2021 Wellmark, Inc. 170 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VAXELIS (SUSPENSION, SUSPPRSYR) VAXELIS diph-tet tox-acell pert ad- TIER 2 polio ipv-hib-hepatitis b recomb XOFLUZA (40 MG DOSE) (OFLUZA MG 1 40 MG XOFLUZA (40 MG TAB THPK, OFLUZA MG 2 TIER 3 DOSE) 20 MG TAB THPK) baloxavir marboxil XOFLUZA (80 MG DOSE) (OFLUZA MG 1 80 MG XOFLUZA (80 MG TAB THPK, OFLUZA MG 2 TIER 3 DOSE) 40 MG TAB THPK) baloxavir marboxil

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

balsalazide disodium 750 balsalazide disodium TIER 1 mg cap DIPENTUM 250 MG CAP DIPENTUM TIER 2 olsalazine sodium mesalamine (1.2 gm tab dr, 4 gm enema, 400 mg cap mesalamine TIER 1 dr, 800 mg tab dr, 1000 mg suppos) mesalamine er 0.375 gm mesalamine er TIER 1 cap er 24h PENTASA (250 MG CAP PENTASA ER, 500 MG CAP ER) TIER 3 mesalamine

GLUCOCORTICOIDS

anucort-hc anucort-hc 25 mg suppos TIER 1 budesonide budesonide 3 mg cp dr part TIER 1 budesonide er 9 mg tab er budesonide er TIER 1 24h colocort 100 mg/60ml colocort TIER 1 enema hemmorex-hc (25 mg hemmorex-hc TIER 1 suppos, 30 mg suppos) hydrocortisone hydrocortisone (perianal) (1 TIER 1 (perianal) % cream, 2.5 % cream) hydrocortisone 100 hydrocortisone TIER 1 mg/60ml enema

©2021 Wellmark, Inc. 171 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS hydrocortisone hydrocortisone acetate (25 TIER 1 acetate mg suppos, 30 mg suppos) procto-med hc procto-med hc 2.5 % cream TIER 1 procto-pak procto-pak 1 % cream TIER 1 proctosol hc proctosol hc 2.5 % cream TIER 1 proctozone-hc proctozone-hc 2.5 % cream TIER 1 UCERIS 2 MG/ACT FOAM UCERIS TIER 3 budesonide (intrarectal)

SULFONAMIDES

sulfasalazine (500 mg tab, sulfasalazine TIER 1 500 mg tab dr)

METABOLIC BONE DISEASE AGENTS

alendronate sodium (5 mg alendronate sodium tab, 10 mg tab, 35 mg tab, TIER 1 40 mg tab, 70 mg tab) calcitonin (salmon) 200 calcitonin (salmon) TIER 1 unit/act solution calcitriol (0.25 mcg cap, 0.5 calcitriol TIER 1 mcg cap) calcitriol calcitriol 1 mcg/ml solution TIER 3 cinacalcet hcl (30 mg tab, SBG (Specialty Biosimilars cinacalcet hcl SP-P 60 mg tab, 90 mg tab) and Specialty generics) doxercalciferol (0.5 mcg doxercalciferol cap, 1 mcg cap, 2.5 mcg TIER 1 cap) ergocalciferol (1.25 mg ergocalciferol (50000 ut) cap, 50000 unit TIER 1 cap) ETIDRONATE DISODIUM ETIDRONATE (200 MG TAB, 400 MG TIER 1 DISODIUM TAB) etidronate disodium EVENITY 105 MG/1.17ML EVENITY SOLN PRSYR SP-M PA, QL (2 PER 28 DAY(S)) romosozumab-aqqg FORTEO 620 MCG/2.48ML PA, QL (24 PER MONTH(S)), FORTEO SOLN PEN SP-NP MN-PA (Medically Necessary teriparatide (recombinant) Prior Authorization) ibandronate sodium 150 mg ibandronate sodium TIER 1 tab

©2021 Wellmark, Inc. 172 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NATPARA (25 MCG CARTRIDGE, 50 MCG CARTRIDGE, 75 MCG NATPARA CARTRIDGE, 100 MCG SP-M CARTRIDGE) parathyroid hormone (recombinant) paricalcitol (1 mcg cap, 2 paricalcitol TIER 1 mcg cap, 4 mcg cap) PROLIA 60 MG/ML SOLN PROLIA PRSYR SP-M denosumab RAYALDEE 30 MCG CAP RAYALDEE ER TIER 3 calcifediol RECLAST 5 MG/100ML RECLAST SOLUTION SP-M GA zoledronic acid risedronate sodium (5 mg risedronate sodium tab, 30 mg tab, 35 mg tab, TIER 1 35 mg tab dr, 150 mg tab) TERIPARATIDE TERIPARATIDE (RECOMBINANT) 620 SP-P PA (RECOMBINANT) MCG/2.48ML SOLN PEN teriparatide (recombinant) TYMLOS 3120 QL (24 PER MONTH(S)), TYMLOS MCG/1.56ML SOLN PEN SP-NP MN-PA (Medically Necessary abaloparatide Prior Authorization) vitamin d vitamin d (ergocalciferol) TIER 1 (ergocalciferol) 1.25 mg (50000 ut) cap XGEVA 120 MG/1.7ML XGEVA SOLUTION SP-M denosumab zoledronic acid (4 mg recon soln, 4 mg/100ml solution, zoledronic acid SP-M 4 mg/5ml conc, 5 mg/100ml solution) ZOMETA (4 MG/100ML SOLUTION, 4 MG/5ML ZOMETA SP-M GA CONC) zoledronic acid

MISCELLANEOUS THERAPEUTIC AGENTS

QL (150 PER 30 DAYS), MN- ACCU-CHEK AVIVA PLUS ACCU-CHEK AVIVA PA (Medically Necessary STRIP TIER 3 PLUS Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 173 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- ACCU-CHEK COMPACT ACCU-CHEK PA (Medically Necessary PLUS STRIP TIER 3 COMPACT PLUS Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ACCU-CHEK GUIDE PA (Medically Necessary ACCU-CHEK GUIDE STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ACCU-CHEK SMARTVIEW ACCU-CHEK PA (Medically Necessary STRIP TIER 3 SMARTVIEW Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ACCUTREND GLUCOSE ACCUTREND PA (Medically Necessary STRIP TIER 3 GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ADVANCE INTUITION ADVANCE PA (Medically Necessary TEST STRIP TIER 3 INTUITION TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ADVOCATE REDI-CODE ADVOCATE REDI- PA (Medically Necessary STRIP TIER 3 CODE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ADVOCATE REDI-CODE+ ADVOCATE REDI- PA (Medically Necessary TEST STRIP TIER 3 CODE+ TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ADVOCATE TEST STRIP PA (Medically Necessary ADVOCATE TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) AEROCHAMBER MINI AEROCHAMBER CHAMBER DEVICE RX-DME MINI CHAMBER spacer/aerosol-holding chambers AEROCHAMBER MV MISC AEROCHAMBER MV RX-DME spacer/aerosol-holding chambers AEROCHAMBER PLUS AEROCHAMBER FLO-VU MISC RX-DME PLUS FLO-VU spacer/aerosol-holding chambers

©2021 Wellmark, Inc. 174 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS AEROCHAMBER PLUS AEROCHAMBER FLO-VU LARGE MISC PLUS FLO-VU RX-DME spacer/aerosol-holding LARGE chambers AEROCHAMBER PLUS AEROCHAMBER FLO-VU MEDIUM MISC PLUS FLO-VU RX-DME spacer/aerosol-holding MEDIUM chambers AEROCHAMBER PLUS AEROCHAMBER FLO-VU SMALL MISC PLUS FLO-VU RX-DME spacer/aerosol-holding SMALL chambers AEROCHAMBER PLUS AEROCHAMBER FLO-VU W/MASK MISC PLUS FLO-VU RX-DME spacer/aerosol-holding W/MASK chambers AEROCHAMBER PLUS AEROCHAMBER FLOW VU MISC RX-DME PLUS FLOW VU spacer/aerosol-holding chambers AEROCHAMBER AEROCHAMBER W/FLOWSIGNAL MISC RX-DME W/FLOWSIGNAL spacer/aerosol-holding chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS MISC RX-DME STAT PLUS spacer/aerosol-holding chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS CHAMBR MISC STAT PLUS RX-DME spacer/aerosol-holding CHAMBR chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS/LARGE MISC RX-DME STAT PLUS/LARGE spacer/aerosol-holding chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS/MEDIUM MISC RX-DME STAT PLUS/MEDIUM spacer/aerosol-holding chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS/SMALL MISC RX-DME STAT PLUS/SMALL spacer/aerosol-holding chambers AEROVENT PLUS DEVICE AEROVENT PLUS RX-DME spacer/aerosol-holding chambers

©2021 Wellmark, Inc. 175 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- AGAMATRIX AMP TEST AGAMATRIX AMP PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- AGAMATRIX JAZZ TEST AGAMATRIX JAZZ PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- AGAMATRIX KEYNOTE AGAMATRIX PA (Medically Necessary TEST STRIP TIER 3 KEYNOTE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- AGAMATRIX PRESTO AGAMATRIX PA (Medically Necessary TEST STRIP TIER 3 PRESTO TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) ARIAL CHAMBER DEVICE ARIAL CHAMBER RX-DME spacer/aerosol-holding chambers ASCENSIA AUTODISC ASCENSIA TEST DISK TIER 3 AUTODISC TEST glucose blood QL (150 PER 30 DAYS), MN- ASSURE 4 TEST STRIP PA (Medically Necessary ASSURE 4 TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- ASSURE II CHECK PA (Medically Necessary ASSURE II CHECK STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ASSURE PLATINUM PA (Medically Necessary ASSURE PLATINUM STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ASSURE PRISM MULTI ASSURE PRISM PA (Medically Necessary TEST STRIP TIER 3 MULTI TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ASSURE PRO TEST PA (Medically Necessary ASSURE PRO TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) BD SWAB SINGLE USE BD SWAB SINGLE REGULAR PAD TIER 2 USE REGULAR alcohol swabs

©2021 Wellmark, Inc. 176 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- BLOOD GLUCOSE TEST BLOOD GLUCOSE PA (Medically Necessary (TESTSTRIP, TESTSTRIP) TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- BLULINK GLUCOSE TEST BLULINK GLUCOSE PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) BREATHE EASE LARGE BREATHE EASE DEVICE RX-DME LARGE spacer/aerosol-holding chambers BREATHE EASE MEDIUM BREATHE EASE DEVICE RX-DME MEDIUM spacer/aerosol-holding chambers BREATHE EASE SMALL BREATHE EASE DEVICE RX-DME SMALL spacer/aerosol-holding chambers BREATHERITE MISC BREATHERITE spacer/aerosol-holding RX-DME chambers BREATHERITE COLL BREATHERITE SPACER ADULT MISC COLL SPACER RX-DME spacer/aerosol-holding ADULT chambers BREATHERITE COLL BREATHERITE SPACER CHILD MISC COLL SPACER RX-DME spacer/aerosol-holding CHILD chambers BREATHERITE COLL BREATHERITE SPACER INFANT MISC COLL SPACER RX-DME spacer/aerosol-holding INFANT chambers BREATHERITE RIGID BREATHERITE SPACER/MASK MISC RIGID RX-DME spacer/aerosol-holding SPACER/MASK chambers BREATHERITE SPACER BREATHERITE NEONATE MISC RX-DME SPACER NEONATE spacer/aerosol-holding chambers BREATHERITE SPACER BREATHERITE SMALL CHILD MISC SPACER SMALL RX-DME spacer/aerosol-holding CHILD chambers

©2021 Wellmark, Inc. 177 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BREATHERITE/LARGE BREATHERITE/LAR MASK MISC RX-DME GE MASK spacer/aerosol-holding chambers BREATHERITE/MEDIUM BREATHERITE/MEDI MASK MISC RX-DME UM MASK spacer/aerosol-holding chambers BREATHERITE/SMALL BREATHERITE/SMA MASK MISC RX-DME LL MASK spacer/aerosol-holding chambers BREEZE 2 TEST DISK BREEZE 2 TEST TIER 3 glucose blood BRONCHITOL BRONCHITOL TOLERANCE TEST 40 MG SP-NP PA, QL (10 PER DAY(S)) TOLERANCE TEST CAP mannitol (cystic fibrosis) QL (150 PER 30 DAYS), MN- CAREONE BLOOD CAREONE BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CARESENS N GLUCOSE CARESENS N PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CARETOUCH TEST PA (Medically Necessary CARETOUCH TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) CHEK-STIX CONTROL CHEK-STIX STRIP TIER 2 CONTROL acetone (urine) test CHEMSTRIP 10 MD CHEMSTRIP 10 MD STRIP TIER 2 multiple urine tests CHEMSTRIP 10/SG CHEMSTRIP 10/SG STRIP TIER 2 multiple urine tests CHEMSTRIP 2 GP STRIP CHEMSTRIP 2 GP TIER 2 multiple urine tests CHEMSTRIP 5 OB STRIP CHEMSTRIP 5 OB TIER 2 multiple urine tests CHEMSTRIP 7 STRIP CHEMSTRIP 7 TIER 2 multiple urine tests

©2021 Wellmark, Inc. 178 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CHEMSTRIP 9 STRIP CHEMSTRIP 9 TIER 2 multiple urine tests CHEMSTRIP K STRIP CHEMSTRIP K TIER 2 acetone (urine) test CHEMSTRIP UGK STRIP CHEMSTRIP UGK TIER 2 urine glucose-ketones test QL (150 PER 30 DAYS), MN- CLEVER CHEK AUTO- CLEVER CHEK PA (Medically Necessary CODE TEST STRIP TIER 3 AUTO-CODE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CLEVER CHEK AUTO- CLEVER CHEK PA (Medically Necessary CODE VOICE STRIP TIER 3 AUTO-CODE VOICE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CLEVER CHEK TEST CLEVER CHEK PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CLEVER CHOICE AUTO- CLEVER CHOICE PA (Medically Necessary CODE TEST STRIP TIER 3 AUTO-CODE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) CLEVER CHOICE HOLDING CHAMBER CLEVER CHOICE DEVICE RX-DME HOLDING CHAMBER spacer/aerosol-holding chambers QL (150 PER 30 DAYS), MN- CLEVER CHOICE MICRO CLEVER CHOICE PA (Medically Necessary TEST STRIP TIER 3 MICRO TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CLEVER CHOICE NO CLEVER CHOICE PA (Medically Necessary CODING STRIP TIER 3 NO CODING Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CLEVER CHOICE TALK CLEVER CHOICE PA (Medically Necessary SYSTEM STRIP TIER 3 TALK SYSTEM Prior Authorization), PA-QL glucose blood (300 / 30 days) CLINISTIX STRIP CLINISTIX glucose urine test-(glucose TIER 2 oxidase) COMBISTIX STRIP COMBISTIX TIER 2 multiple urine tests

©2021 Wellmark, Inc. 179 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS COMPACT SPACE COMPACT SPACE CHAMBER DEVICE RX-DME CHAMBER spacer/aerosol-holding chambers COMPACT SPACE CHAMBER/LG MASK COMPACT SPACE DEVICE RX-DME CHAMBER/LG MASK spacer/aerosol-holding chambers COMPACT SPACE COMPACT SPACE CHAMBER/MED MASK CHAMBER/MED DEVICE RX-DME MASK spacer/aerosol-holding chambers COMPACT SPACE COMPACT SPACE CHAMBER/SM MASK CHAMBER/SM DEVICE RX-DME MASK spacer/aerosol-holding chambers CONTOUR NEXT TEST CONTOUR NEXT QL (150 PER 30 DAYS), PA- STRIP TIER 2 TEST QL (300 / 30 days) glucose blood CONTOUR TEST STRIP QL (150 PER 30 DAYS), PA- CONTOUR TEST TIER 2 glucose blood QL (300 / 30 days) QL (150 PER 30 DAYS), MN- COOL BLOOD COOL BLOOD GLUCOSE PA (Medically Necessary GLUCOSE TEST TEST STRIPS STRIP TIER 3 Prior Authorization), PA-QL STRIPS glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CVS ADVANCED CVS ADVANCED PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CVS GLUCOSE CVS GLUCOSE METER PA (Medically Necessary METER TEST TEST STRIPS STRIP TIER 3 Prior Authorization), PA-QL STRIPS glucose blood (300 / 30 days) CVS KETONE CARE CVS KETONE CARE STRIP TIER 2 urine glucose-ketones test QL (150 PER 30 DAYS), MN- D-CARE BLOOD D-CARE BLOOD PA (Medically Necessary GLUCOSE STRIP TIER 3 GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) DIASTIX STRIP DIASTIX glucose urine test-(glucose TIER 2 oxidase)

©2021 Wellmark, Inc. 180 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- DIATHRIVE BLOOD DIATHRIVE BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- DIATHRIVE GLUCOSE DIATHRIVE PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- DIATHRIVE+ GLUCOSE DIATHRIVE+ PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- DIATRUE PLUS TEST DIATRUE PLUS PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) DURAXIN 300-200-20 MG CAP DURAXIN acetaminophen- TIER 1 GA salicylamide- phenyltoloxamine EASIVENT MISC EASIVENT spacer/aerosol-holding RX-DME chambers EASIVENT MASK LARGE EASIVENT MASK MISC RX-DME LARGE spacer/aerosol-holding chambers EASIVENT MASK MEDIUM EASIVENT MASK MISC RX-DME MEDIUM spacer/aerosol-holding chambers EASIVENT MASK SMALL EASIVENT MASK MISC RX-DME SMALL spacer/aerosol-holding chambers QL (150 PER 30 DAYS), MN- EASY PLUS BLOOD EASY PLUS BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASY PLUS II GLUCOSE EASY PLUS II PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASY STEP TEST STRIP PA (Medically Necessary EASY STEP TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days)

©2021 Wellmark, Inc. 181 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- EASY TALK BLOOD EASY TALK BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) EASY TOUCH QL (150 PER 30 DAYS), MN- EASY TOUCH HEALTHPRO GLUCOSE PA (Medically Necessary HEALTHPRO TIER 3 STRIP Prior Authorization), PA-QL GLUCOSE glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASY TOUCH TEST PA (Medically Necessary EASY TOUCH TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASY TRAK BLOOD EASY TRAK BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASY TRAK II GLUCOSE EASY TRAK II PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASYGLUCO STRIP PA (Medically Necessary EASYGLUCO TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- EASYGLUCO PLUS PA (Medically Necessary EASYGLUCO PLUS STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASYMAX 15 TEST PA (Medically Necessary EASYMAX 15 TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASYMAX TEST STRIP PA (Medically Necessary EASYMAX TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- EASYPLUS BLOOD EASYPLUS BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASYPRO PLUS STRIP PA (Medically Necessary EASYPRO PLUS TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) ed-flex ed-flex 300-200-20 mg cap TIER 1 QL (150 PER 30 DAYS), MN- ELEMENT COMPACT ELEMENT PA (Medically Necessary TEST STRIP TIER 3 COMPACT TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 182 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- ELEMENT TEST STRIP PA (Medically Necessary ELEMENT TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- EMBRACE BLOOD EMBRACE BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EMBRACE EVO EMBRACE EVO BLOOD PA (Medically Necessary BLOOD GLUCOSE GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EMBRACE PRO EMBRACE PRO PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EMBRACE TALK EMBRACE TALK PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EQ BLOOD GLUCOSE EQ BLOOD PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) EQ SPACE CHAMBER EQ SPACE ANTI-STATIC DEVICE CHAMBER ANTI- RX-DME spacer/aerosol-holding STATIC chambers EQ SPACE CHAMBER EQ SPACE ANTI-STATIC L DEVICE CHAMBER ANTI- RX-DME spacer/aerosol-holding STATIC L chambers EQ SPACE CHAMBER EQ SPACE ANTI-STATIC M DEVICE CHAMBER ANTI- RX-DME spacer/aerosol-holding STATIC M chambers EQ SPACE CHAMBER EQ SPACE ANTI-STATIC S DEVICE CHAMBER ANTI- RX-DME spacer/aerosol-holding STATIC S chambers EUFLEXXA 20 MG/2ML SOLN PRSYR MN-PA (Medically Necessary EUFLEXXA SP-M sodium hyaluronate Prior Authorization) (viscosupplement) QL (150 PER 30 DAYS), MN- EVENCARE + EVENCARE + BLOOD PA (Medically Necessary BLOOD GLUCOSE GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 183 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- EVENCARE BLOOD EVENCARE BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EVENCARE G2 TEST EVENCARE G2 PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EVENCARE G3 TEST EVENCARE G3 PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EVENCARE MINI EVENCARE MINI PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EVENCARE EVENCARE PROVIEW PA (Medically Necessary PROVIEW GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL GLUCOSE TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EVOLUTION AUTOCODE EVOLUTION PA (Medically Necessary STRIP TIER 3 AUTOCODE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EZ SMART BLOOD EZ SMART BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EZ SMART PLUS EZ SMART PLUS PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FASTTAKE TEST STRIP PA (Medically Necessary FASTTAKE TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- FIFTY50 GLUCOSE TEST FIFTY50 GLUCOSE PA (Medically Necessary 2.0 STRIP TIER 3 TEST 2.0 Prior Authorization), PA-QL glucose blood (300 / 30 days) FLEXICHAMBER DEVICE FLEXICHAMBER spacer/aerosol-holding RX-DME chambers

©2021 Wellmark, Inc. 184 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FLEXICHAMBER ADULT FLEXICHAMBER MASK/SMALL MISC ADULT RX-DME spacer/aerosol-holding MASK/SMALL chamber supplies - masks FLEXICHAMBER CHILD FLEXICHAMBER MASK/LARGE MISC RX-DME CHILD MASK/LARGE spacer/aerosol-holding chamber supplies - masks FLEXICHAMBER CHILD FLEXICHAMBER MASK/SMALL MISC RX-DME CHILD MASK/SMALL spacer/aerosol-holding chamber supplies - masks QL (150 PER 30 DAYS), MN- FORA 6 CONNECT PA (Medically Necessary FORA 6 CONNECT STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA BLOOD GLUCOSE FORA BLOOD PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA D15G BLOOD FORA D15G BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA D20 BLOOD FORA D20 BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA D40/G31 BLOOD FORA D40/G31 PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA G20 BLOOD FORA G20 BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA G30/PREM V10 FORA G30/PREM PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 V10 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA GD20 TEST STRIP PA (Medically Necessary FORA GD20 TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA GD50 BLOOD FORA GD50 BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 185 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- FORA GTEL BLOOD FORA GTEL BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) FORA GTEL BLOOD FORA GTEL BLOOD KETONE TEST STRIP TIER 2 KETONE TEST ketone blood test QL (150 PER 30 DAYS), MN- FORA TN'G ADVANCE FORA TN'G PA (Medically Necessary PRO STRIP TIER 3 ADVANCE PRO Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA TN'G/TN'G VOICE FORA TN'G/TN'G PA (Medically Necessary STRIP TIER 3 VOICE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA V10 BLOOD FORA V10 BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA V12 BLOOD FORA V12 BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA V20 BLOOD FORA V20 BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA V30A BLOOD FORA V30A BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORACARE GD40 TEST FORACARE GD40 PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORACARE PREMIUM FORACARE PA (Medically Necessary V10 TEST STRIP TIER 3 PREMIUM V10 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORACARE TEST N GO FORACARE TEST N PA (Medically Necessary TEST STRIP TIER 3 GO TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORTISCARE G1 TEST FORTISCARE G1 PA (Medically Necessary STRIP STRIP TIER 3 TEST STRIP Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 186 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- FORTISCARE TEST PA (Medically Necessary FORTISCARE TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FREESTYLE INSULINX FREESTYLE PA (Medically Necessary TEST STRIP TIER 3 INSULINX TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FREESTYLE LITE TEST FREESTYLE LITE PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FREESTYLE FREESTYLE PRECISION PA (Medically Necessary PRECISION NEO NEO TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FREESTYLE TEST PA (Medically Necessary FREESTYLE TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GE100 BLOOD GLUCOSE GE100 BLOOD PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) GEL-ONE 30 MG/3ML PA, MN-PA (Medically GEL-ONE PRSYR SP-M Necessary Prior cross-linked hyaluronate Authorization) GELSYN-3 16.8 MG/2ML SOLN PRSYR MN-PA (Medically Necessary GELSYN-3 SP-M sodium hyaluronate Prior Authorization) (viscosupplement) QL (150 PER 30 DAYS), MN- GENSTRIP 50 STRIP PA (Medically Necessary GENSTRIP 50 TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- GENULTIMATE TEST GENULTIMATE PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) GENVISC 850 25 MG/2.5ML SOLN PRSYR MN-PA (Medically Necessary GENVISC 850 SP-M sodium hyaluronate Prior Authorization) (viscosupplement) QL (150 PER 30 DAYS), MN- GHT TEST STRIP PA (Medically Necessary GHT TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days)

©2021 Wellmark, Inc. 187 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- GLUCO PERFECT 3 TEST GLUCO PERFECT 3 PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GLUCOCARD 01 SENSOR GLUCOCARD 01 PA (Medically Necessary PLUS STRIP TIER 3 SENSOR PLUS Prior Authorization), PA-QL glucose blood (300 / 30 days) GLUCOCARD QL (150 PER 30 DAYS), MN- GLUCOCARD EXPRESSION TEST PA (Medically Necessary TIER 3 EXPRESSION TEST STRIP Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GLUCOCARD SHINE GLUCOCARD SHINE PA (Medically Necessary TEST STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GLUCOCARD VITAL TEST GLUCOCARD VITAL PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GLUCOCARD X-SENSOR GLUCOCARD X- PA (Medically Necessary STRIP TIER 3 SENSOR Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GLUCOCOM TEST PA (Medically Necessary GLUCOCOM TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GLUCONAVII GLUCONAVII BLOOD PA (Medically Necessary BLOOD GLUCOSE GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GLUCOSE METER TEST GLUCOSE METER PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GNP EASY TOUCH GNP EASY TOUCH PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) GNP TRUE METRIX QL (150 PER 30 DAYS), MN- GNP TRUE METRIX GLUCOSE STRIPS PA (Medically Necessary TIER 3 GLUCOSE STRIPS STRIP Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GOJJI BLOOD GLUCOSE GOJJI BLOOD PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 188 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GOJJI BLOOD KETONE GOJJI BLOOD TEST STRIP TIER 2 KETONE TEST ketone blood test QL (150 PER 30 DAYS), MN- GOJJI BLOOD TEST GOJJI BLOOD TEST PA (Medically Necessary STRIP/LANCETS STRIP TIER 3 STRIP/LANCETS Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GOODSENSE BLOOD GOODSENSE PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- HARMONY BLOOD HARMONY BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) HEMA-COMBISTIX HEMA-COMBISTIX STRIP TIER 2 multiple urine tests QL (150 PER 30 DAYS), MN- HW EMBRACE PRO HW EMBRACE PRO PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- HW EMBRACE TALK HW EMBRACE TALK PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) HYALGAN (20 SOLN PRSYR, 20 SOLUTION) MN-PA (Medically Necessary HYALGAN SP-M sodium hyaluronate Prior Authorization) (viscosupplement) HYMOVIS 24 MG/3ML MN-PA (Medically Necessary HYMOVIS SOLN PRSYR SP-M Prior Authorization) hyaluronan QL (150 PER 30 DAYS), MN- IGLUCOSE TEST STRIPS IGLUCOSE TEST PA (Medically Necessary STRIP TIER 3 STRIPS Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- IN TOUCH BLOOD IN TOUCH BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- INFINITY BLOOD INFINITY BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- INFINITY VOICE STRIP PA (Medically Necessary INFINITY VOICE TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days)

©2021 Wellmark, Inc. 189 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS INSPIRACHAMBER/LARG INSPIRACHAMBER/L E DEVICE RX-DME ARGE spacer/aerosol-holding chambers INSPIRACHAMBER/MEDI INSPIRACHAMBER/ UM DEVICE RX-DME MEDIUM spacer/aerosol-holding chambers INSPIRACHAMBER/MOUT INSPIRACHAMBER/ HPIECE DEVICE RX-DME MOUTHPIECE spacer/aerosol-holding chambers INSPIRACHAMBER/SMAL INSPIRACHAMBER/ L DEVICE RX-DME SMALL spacer/aerosol-holding chambers INSPIREASE MISC INSPIREASE spacer/aerosol-holding RX-DME chambers INSULIN PEN INSULIN PEN NEEDLE TIER 2 NEEDLE insulin pen needle INSULIN SYRINGE INSULIN SYRINGE TIER 2 insulin syringe INSULIN SYRINGE INSULIN SYRINGE NEEDLE TIER 2 NEEDLE insulin syringe needle INTRAROSA 6.5 MG INTRAROSA INSERT TIER 3 prasterone vaginal IODINE STRONG 5 % IODINE STRONG SOLUTION TIER 3 iodine strong (lugol's) ISOMETHEPTENE- CAFFEINE-APAP 65-20- ISOMETHEPTENE- 325 MG TAB TIER 1 CAFFEINE-APAP isometheptene-caffeine- acetaminophen KETO-DIASTIX STRIP KETO-DIASTIX TIER 2 urine glucose-ketones test KETONE TEST STRIP KETONE TEST TIER 2 acetone (urine) test KETOSTIX STRIP KETOSTIX TIER 2 acetone (urine) test QL (150 PER 30 DAYS), MN- KROGER BLOOD KROGER BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 190 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- KROGER KROGER HEALTHPRO PA (Medically Necessary HEALTHPRO GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL GLUCOSE TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- KROGER PREMIUM KROGER PREMIUM PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- KROGER TEST STRIP PA (Medically Necessary KROGER TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) LABSTIX STRIP LABSTIX TIER 2 multiple urine tests LANCETS LANCETS TIER 2 QL (150 PER 30 DAY(S)) lancets LANCETS QL (150 PER 30 DAYS), PA- LANCETS TIER 2 lancets QL (300 / 30 days) LIBERTY NEXT QL (150 PER 30 DAYS), MN- LIBERTY NEXT GENERATION TEST PA (Medically Necessary TIER 3 GENERATION TEST STRIP Prior Authorization), PA-QL glucose blood (300 / 30 days) LITEAIRE DEVICE LITEAIRE spacer/aerosol-holding RX-DME chambers MASK VORTEX MISC MASK VORTEX spacer/aerosol-holding RX-DME chamber supplies - masks MASK MASK VORTEX/CHILD/FROG VORTEX/CHILD/FRO MISC RX-DME G spacer/aerosol-holding chamber supplies - masks MASK MASK VORTEX/TODDLER/LADY VORTEX/TODDLER/ BUG MISC RX-DME LADYBUG spacer/aerosol-holding chamber supplies - masks QL (150 PER 30 DAYS), MN- MEIJER BLOOD MEIJER BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- MEIJER ESSENTIAL MEIJER ESSENTIAL PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 191 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- MEIJER PREMIUM MEIJER PREMIUM PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- MEIJER TRUETEST TEST MEIJER TRUETEST PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- MEIJER TRUETRACK MEIJER PA (Medically Necessary TEST STRIP TIER 3 TRUETRACK TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) methergine methergine 0.2 mg tab TIER 1 methylergonovine methylergonovine maleate TIER 1 maleate 0.2 mg tab MICROCHAMBER (DEVICE, MISC) MICROCHAMBER RX-DME spacer/aerosol-holding chambers QL (150 PER 30 DAYS), MN- MICRODOT TEST STRIP PA (Medically Necessary MICRODOT TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) MICROSPACER MISC MICROSPACER spacer/aerosol-holding RX-DME chambers QL (150 PER 30 DAYS), MN- MM EASY TOUCH MM EASY TOUCH PA (Medically Necessary GLUCOSE STRIP TIER 3 GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) MONOVISC 88 MG/4ML MN-PA (Medically Necessary MONOVISC SOLN PRSYR SP-M Prior Authorization) hyaluronan MULTISTIX STRIP MULTISTIX TIER 2 multiple urine tests MULTISTIX 10 SG STRIP MULTISTIX 10 SG TIER 2 multiple urine tests MULTISTIX 5 STRIP MULTISTIX 5 TIER 2 multiple urine tests MULTISTIX 7 STRIP MULTISTIX 7 TIER 2 multiple urine tests MULTISTIX 8 STRIP MULTISTIX 8 TIER 2 multiple urine tests MULTISTIX 9 STRIP MULTISTIX 9 TIER 2 multiple urine tests

©2021 Wellmark, Inc. 192 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MULTISTIX 9 SG STRIP MULTISTIX 9 SG TIER 2 multiple urine tests QL (150 PER 30 DAYS), MN- MYGLUCOHEALTH TEST MYGLUCOHEALTH PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- NEUTEK 2TEK TEST PA (Medically Necessary NEUTEK 2TEK TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- NOVA MAX GLUCOSE NOVA MAX PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) NOVA MAX PLUS NOVA MAX PLUS KETONE TEST STRIP TIER 2 KETONE TEST ketone blood test OMNIPOD DASH 5 PACK OMNIPOD DASH 5 PODS MISC RX-DME QL (30 PER 30 DAY(S)) PACK PODS insulin infusion disposable pump ON CALL EXPRESS QL (150 PER 30 DAYS), MN- ON CALL EXPRESS BLOOD GLUCOSE PA (Medically Necessary TIER 3 BLOOD GLUCOSE STRIP Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ON CALL PLUS BLOOD ON CALL PLUS PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ON CALL VIVID BLOOD ON CALL VIVID PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ONE DROP TEST STRIP PA (Medically Necessary ONE DROP TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) ONETOUCH TEST STRIP QL (150 PER 30 DAYS), PA- ONETOUCH TEST TIER 2 glucose blood QL (300 / 30 days) ONETOUCH ULTRA QL (150 PER 30 DAYS), PA- ONETOUCH ULTRA STRIP TIER 2 QL (300 / 30 days) glucose blood ONETOUCH VERIO QL (150 PER 30 DAYS), PA- ONETOUCH VERIO STRIP TIER 2 QL (300 / 30 days) glucose blood

©2021 Wellmark, Inc. 193 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OPTICHAMBER OPTICHAMBER ADVANTAGE MISC RX-DME ADVANTAGE spacer/aerosol-holding chambers OPTICHAMBER OPTICHAMBER ADVANTAGE-LG MASK ADVANTAGE-LG MISC RX-DME MASK spacer/aerosol-holding chambers OPTICHAMBER OPTICHAMBER ADVANTAGE-MED MASK ADVANTAGE-MED MISC RX-DME MASK spacer/aerosol-holding chambers OPTICHAMBER OPTICHAMBER ADVANTAGE-SM MASK ADVANTAGE-SM MISC RX-DME MASK spacer/aerosol-holding chambers OPTICHAMBER DIAMOND OPTICHAMBER (DEVICE, MISC) RX-DME DIAMOND spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-LG MASK OPTICHAMBER DEVICE RX-DME DIAMOND-LG MASK spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-MD MASK OPTICHAMBER MISC RX-DME DIAMOND-MD MASK spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-SM MASK OPTICHAMBER MISC RX-DME DIAMOND-SM MASK spacer/aerosol-holding chambers OPTICHAMBER FACE OPTICHAMBER MASK-LARGE MISC RX-DME FACE MASK-LARGE spacer/aerosol-holding chambers OPTICHAMBER FACE OPTICHAMBER MASK-MEDIUM MISC FACE MASK- RX-DME spacer/aerosol-holding MEDIUM chambers

©2021 Wellmark, Inc. 194 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OPTICHAMBER FACE OPTICHAMBER MASK-SMALL MISC RX-DME FACE MASK-SMALL spacer/aerosol-holding chambers OPTIHALER (DEVICE, MISC) OPTIHALER RX-DME spacer/aerosol-holding chambers QL (150 PER 30 DAYS), MN- OPTIUM TEST STRIP PA (Medically Necessary OPTIUM TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- OPTIUMEZ TEST STRIP PA (Medically Necessary OPTIUMEZ TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- OPTUMRX BLOOD OPTUMRX BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) ORTHOVISC 30 MG/2ML ORTHOVISC SOLN PRSYR SP-M PA hyaluronan PANDA MASK LARGE PANDA MASK MISC RX-DME LARGE spacer/aerosol-holding chamber supplies - masks PANDA MASK MEDIUM PANDA MASK MISC RX-DME MEDIUM spacer/aerosol-holding chamber supplies - masks PANDA MASK SMALL PANDA MASK MISC RX-DME SMALL spacer/aerosol-holding chamber supplies - masks PARAGARD PARAGARD INTRAUTERINE COPPER INTRAUTERINE SP-M IUD COPPER copper (iud) PEDIATRIC PANDA MASK PEDIATRIC PANDA MISC RX-DME MASK spacer/aerosol-holding chamber supplies - masks QL (150 PER 30 DAYS), MN- PHARMACIST CHOICE PHARMACIST PA (Medically Necessary AUTOCODE STRIP TIER 3 CHOICE AUTOCODE Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 195 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- PHARMACIST PHARMACIST CHOICE PA (Medically Necessary CHOICE NO NO CODING STRIP TIER 3 Prior Authorization), PA-QL CODING glucose blood (300 / 30 days) POCKET CHAMBER DEVICE POCKET CHAMBER RX-DME spacer/aerosol-holding chambers QL (150 PER 30 DAYS), MN- POCKETCHEM EZ TEST POCKETCHEM EZ PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- PRECISION PCX STRIP PA (Medically Necessary PRECISION PCX TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- PRECISION PCX PLUS PRECISION PCX PA (Medically Necessary TEST STRIP TIER 3 PLUS TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- PRECISION POINT OF PRECISION POINT PA (Medically Necessary CARE TEST STRIP TIER 3 OF CARE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- PRECISION QID TEST PRECISION QID PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- PRECISION XTRA BLOOD PRECISION XTRA PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) PRECISION XTRA PRECISION XTRA KETONE STRIP TIER 2 KETONE ketone blood test QL (150 PER 30 DAYS), MN- PREMIUM BLOOD PREMIUM BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) PRO COMFORT SPACER PRO COMFORT ADULT MISC RX-DME SPACER ADULT spacer/aerosol-holding chambers PRO COMFORT SPACER PRO COMFORT CHILD MISC RX-DME SPACER CHILD spacer/aerosol-holding chambers

©2021 Wellmark, Inc. 196 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PRO COMFORT SPACER PRO COMFORT INFANT DEVICE RX-DME SPACER INFANT spacer/aerosol-holding chambers QL (150 PER 30 DAYS), MN- PRO VOICE V8/V9 PRO VOICE V8/V9 PA (Medically Necessary GLUCOSE STRIP TIER 3 GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) PROCARE PROCARE SPACER/ADULT MASK SPACER/ADULT DEVICE RX-DME MASK spacer/aerosol-holding chambers PROCARE PROCARE SPACER/CHILD MASK SPACER/CHILD DEVICE RX-DME MASK spacer/aerosol-holding chambers QL (150 PER 30 DAYS), MN- PRODIGY NO PRODIGY NO CODING PA (Medically Necessary CODING BLOOD BLOOD GLUC STRIP TIER 3 Prior Authorization), PA-QL GLUC glucose blood (300 / 30 days) PTS PANELS KETONE PTS PANELS TEST STRIP TIER 2 KETONE TEST ketone blood test QL (150 PER 30 DAYS), MN- QUINTET AC BLOOD QUINTET AC BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- QUINTET BLOOD QUINTET BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) RA ALCOHOL SWABS 70 RA ALCOHOL % PAD TIER 2 SWABS alcohol swabs QL (150 PER 30 DAYS), MN- RA TRUETEST TEST PA (Medically Necessary RA TRUETEST TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- REFUAH PLUS REFUAH PLUS BLOOD PA (Medically Necessary BLOOD GLUCOSE GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- RELION BLOOD RELION BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 197 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- RELION RELION CONFIRM/MICRO PA (Medically Necessary CONFIRM/MICRO TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) RELION KETONE STRIP RELION KETONE TIER 2 acetone (urine) test RELION KETONE TEST RELION KETONE STRIP TIER 2 TEST acetone (urine) test QL (150 PER 30 DAYS), MN- RELION PREMIER TEST RELION PREMIER PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- RELION PRIME TEST RELION PRIME PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- RELION TRUE RELION TRUE METRIX PA (Medically Necessary METRIX TEST TEST STRIPS STRIP TIER 3 Prior Authorization), PA-QL STRIPS glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- RELION ULTIMA TEST RELION ULTIMA PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- REVEAL BLOOD REVEAL BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- REXALL BLOOD REXALL BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- RIGHTEST GS100 BLOOD RIGHTEST GS100 PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- RIGHTEST GS300 BLOOD RIGHTEST GS300 PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- RIGHTEST GS550 BLOOD RIGHTEST GS550 PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- RIGHTEST GT333 BLOOD RIGHTEST GT333 PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 198 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RITEFLO DEVICE RITEFLO spacer/aerosol-holding RX-DME chambers SM ALCOHOL PREP SM ALCOHOL PREP (70%PAD, PAD) TIER 2 alcohol swabs QL (150 PER 30 DAYS), MN- SMART SENSE PREMIUM SMART SENSE PA (Medically Necessary TEST STRIP TIER 3 PREMIUM TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- SMART SENSE VALUE SMART SENSE PA (Medically Necessary TEST STRIP TIER 3 VALUE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- SMARTEST BLOOD SMARTEST BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) SODIUM HYALURONATE SODIUM 20 MG/2ML SOLN PRSYR MN-PA (Medically Necessary SP-M HYALURONATE sodium hyaluronate Prior Authorization) (viscosupplement) SOLESTA 50-15 MG/ML GEL SOLESTA SP-M dextranomer-sodium hyaluronate SOLIRIS 300 MG/30ML SOLIRIS SOLUTION SP-M PA eculizumab QL (150 PER 30 DAYS), MN- SOLUS V2 TEST STRIP PA (Medically Necessary SOLUS V2 TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) SUPARTZ FX 25 MG/2.5ML SOLN PRSYR MN-PA (Medically Necessary SUPARTZ FX SP-M sodium hyaluronate Prior Authorization) (viscosupplement) QL (150 PER 30 DAYS), MN- SURE EDGE TEST PA (Medically Necessary SURE EDGE TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- SURE-TEST SURE-TEST EASYPLUS PA (Medically Necessary EASYPLUS MINI MINI TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- SURECHEK BLOOD SURECHEK BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 199 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- SURESTEP TEST STRIP PA (Medically Necessary SURESTEP TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) SYNVISC 16 MG/2ML SYNVISC SOLN PRSYR SP-M PA hylan SYNVISC ONE 48 MG/6ML SYNVISC ONE SOLN PRSYR SP-M PA hylan QL (150 PER 30 DAYS), MN- TELCARE BLOOD TELCARE BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- TGT BLOOD GLUCOSE TGT BLOOD PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) THYROGEN 1.1 MG THYROGEN RECON SOLN SP-M thyrotropin alfa TRILURON 20 MG/2ML SOLN PRSYR MN-PA (Medically Necessary TRILURON SP-M sodium hyaluronate Prior Authorization) (viscosupplement) TRIVISC 25 MG/2.5ML SOLN PRSYR MN-PA (Medically Necessary TRIVISC SP-M sodium hyaluronate Prior Authorization) (viscosupplement) QL (150 PER 30 DAYS), MN- TRUE FOCUS TRUE FOCUS BLOOD PA (Medically Necessary BLOOD GLUCOSE GLUCOSE STRIP STRIP TIER 3 Prior Authorization), PA-QL STRIP glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- TRUE METRIX TRUE METRIX BLOOD PA (Medically Necessary BLOOD GLUCOSE GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) TRUE METRIX PRO QL (150 PER 30 DAYS), MN- TRUE METRIX PRO BLOOD GLUCOSE PA (Medically Necessary TIER 3 BLOOD GLUCOSE STRIP Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- TRUETEST TEST STRIP PA (Medically Necessary TRUETEST TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- TRUETRACK TEST PA (Medically Necessary TRUETRACK TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 200 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- ULTIMA TEST STRIP PA (Medically Necessary ULTIMA TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) ULTOMIRIS (300 MG/30ML SOLUTION, 300 MG/3ML ULTOMIRIS SOLUTION, 1100 SP-M PA MG/11ML SOLUTION) ravulizumab-cwvz QL (150 PER 30 DAYS), MN- ULTRATRAK PRO TEST ULTRATRAK PRO PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ULTRATRAK ULTIMATE ULTRATRAK PA (Medically Necessary TEST STRIP TIER 3 ULTIMATE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- UNISTRIP1 GENERIC UNISTRIP1 PA (Medically Necessary STRIP TIER 3 GENERIC Prior Authorization), PA-QL glucose blood (300 / 30 days) URISTIX STRIP URISTIX TIER 2 multiple urine tests URISTIX 4 STRIP URISTIX 4 TIER 2 multiple urine tests VALVED HOLDING VALVED HOLDING CHAMBER DEVICE RX-DME CHAMBER spacer/aerosol-holding chambers QL (150 PER 30 DAYS), MN- VERASENS BLOOD VERASENS BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- VICTORY AGM-4000 TEST VICTORY AGM-4000 PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) VISCO-3 25 MG/2.5ML PA, MN-PA (Medically SOLN PRSYR VISCO-3 SP-M Necessary Prior sodium hyaluronate Authorization) (viscosupplement) VISTOGARD 10 GM PACKET VISTOGARD SP-P uridine triacetate (emergency treatment) QL (150 PER 30 DAYS), MN- VIVAGUARD INO TEST VIVAGUARD INO PA (Medically Necessary STRIPS STRIP TIER 3 TEST STRIPS Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2021 Wellmark, Inc. 201 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- VOCAL POINT VOCAL POINT BLOOD PA (Medically Necessary BLOOD GLUCOSE GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) VORTEX VALVED HOLDING CHAMBER VORTEX VALVED DEVICE RX-DME HOLDING CHAMBER spacer/aerosol-holding chambers WATCHHALER DEVICE WATCHHALER spacer/aerosol-holding RX-DME chambers QL (150 PER 30 DAYS), MN- WAVESENSE PRESTO WAVESENSE PA (Medically Necessary STRIP TIER 3 PRESTO Prior Authorization), PA-QL glucose blood (300 / 30 days)

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

ak-poly-bac 500-10000 ak-poly-bac TIER 1 unit/gm ointment AKTEN 3.5 % GEL AKTEN TIER 3 lidocaine hcl (ophth) altacaine altacaine 0.5 % solution TIER 1 altafrin (2.5 % solution, 10 altafrin TIER 1 % solution) atropine sulfate 1 % atropine sulfate TIER 1 solution bacitra-neomycin- bacitra-neomycin- TIER 1 polymyxin-hc polymyxin-hc 1 % ointment bacitracin-polymyxin bacitracin-polymyxin b 500- TIER 1 b 10000 unit/gm ointment BETADINE OPHTHALMIC BETADINE PREP 5 % SOLUTION TIER 3 OPHTHALMIC PREP povidone-iodine (ophth) BLEPHAMIDE 10-0.2 % SUSPENSION BLEPHAMIDE TIER 3 sulfacetamide sod- prednisolone BLEPHAMIDE S.O.P. 10- 0.2 % OINTMENT BLEPHAMIDE S.O.P. TIER 3 sulfacetamide sod- prednisolone

©2021 Wellmark, Inc. 202 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS cyclopentolate hcl (0.5 % cyclopentolate hcl solution, 1 % solution, 2 % TIER 1 solution) CYSTADROPS 0.37 % CYSTADROPS SOLUTION SP-P QL (4 PER 28 DAY(S)) cysteamine hcl CYSTARAN 0.44 % CYSTARAN SOLUTION SP-P cysteamine hcl HOMATROPAIRE 5 % HOMATROPAIRE SOLUTION TIER 1 GA homatropine hbr homatropine hbr 5 % homatropine hbr TIER 1 solution ISOPTO ATROPINE 1 % SOLUTION ISOPTO ATROPINE TIER 1 GA atropine sulfate (ophthalmic) LACRISERT 5 MG INSERT LACRISERT TIER 3 artificial tear insert mydral (0.5 % solution, 1 % mydral TIER 1 solution) neo-polycin 3.5-400-10000 neo-polycin TIER 1 ointment neo-polycin hc 1 % neo-polycin hc TIER 1 ointment neomycin-bacitracin zn- neomycin-bacitracin polymyx (3.5-400- TIER 1 zn-polymyx 10000ointment, 5-400- 10000ointment) neomycin-polymyxin- neomycin-polymyxin- dexameth (ointment, TIER 1 dexameth suspension) NEOMYCIN-POLYMYXIN- NEOMYCIN- GRAMICIDIN 1.75-10000- POLYMYXIN- .025 SOLUTION TIER 1 GRAMICIDIN neomycin-polymyxin- gramicidin NEOMYCIN-POLYMYXIN- HC 3.5-10000-1 NEOMYCIN- SUSPENSION TIER 1 POLYMYXIN-HC neomycin-polymyxin-hc (ophth) OXERVATE 0.002 % OXERVATE SOLUTION SP-P PA, QL (8 PER LIFETIME) cenegermin-bkbj

©2021 Wellmark, Inc. 203 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS phenylephrine hcl (2.5 % phenylephrine hcl TIER 1 solution, 10 % solution) poly-dex 3.5-10000-0.1 poly-dex TIER 1 ointment polycin 500-10000 unit/gm polycin TIER 1 ointment polymyxin b-trimethoprim polymyxin b- 10000-0.1 unit/ml-% TIER 1 trimethoprim solution PRED-G 0.3-1 % SUSPENSION PRED-G TIER 3 gentamicin-prednisolone acetate PRED-G S.O.P. 0.3-0.6 % OINTMENT PRED-G S.O.P. TIER 3 gentamicin-prednisolone acetate proparacaine hcl 0.5 % proparacaine hcl TIER 1 solution RESTASIS 0.05 % RESTASIS EMULSION TIER 2 cyclosporine (ophth) RESTASIS MULTIDOSE RESTASIS 0.05 % EMULSION TIER 2 MULTIDOSE cyclosporine (ophth) sulfacetamide- sulfacetamide-prednisolone TIER 1 prednisolone 10-0.23 % solution TEPEZZA 500 MG RECON TEPEZZA SOLN SP-M PA teprotumumab-trbw tetcaine tetcaine 0.5 % solution TIER 1 tetracaine hcl 0.5 % tetracaine hcl TIER 1 solution tetravisc tetravisc 0.5 % solution TIER 1 tetravisc forte 0.5 % tetravisc forte TIER 1 solution TOBRADEX 0.3-0.1 % TOBRADEX OINTMENT TIER 3 tobramycin-dexamethasone TOBRADEX ST 0.3-0.05 % TOBRADEX ST SUSPENSION TIER 3 tobramycin-dexamethasone tobramycin- tobramycin-dexamethasone TIER 1 dexamethasone 0.3-0.1 % suspension tropicamide (0.5 % solution, tropicamide TIER 1 1 % solution)

©2021 Wellmark, Inc. 204 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VISUDYNE 15 MG RECON VISUDYNE SOLN SP-M verteporfin XIIDRA 5 % SOLUTION XIIDRA TIER 2 lifitegrast ZYLET 0.5-0.3 % SUSPENSION ZYLET TIER 3 loteprednol etabonate- tobramycin

OPHTHALMIC ANTI-ALLERGY AGENTS

ALOCRIL 2 % SOLUTION ALOCRIL TIER 3 nedocromil sodium (ophth) ALOMIDE 0.1 % ALOMIDE SOLUTION TIER 3 lodoxamide tromethamine azelastine hcl 0.05 % azelastine hcl TIER 1 solution bepotastine besilate 1.5 % bepotastine besilate TIER 1 solution cromolyn sodium 4 % cromolyn sodium TIER 1 solution EMADINE 0.05 % EMADINE SOLUTION TIER 3 emedastine difumarate epinastine hcl 0.05 % epinastine hcl TIER 1 solution LASTACAFT 0.25 % LASTACAFT SOLUTION TIER 3 alcaftadine

OPHTHALMIC ANTI-INFLAMMATORIES

ACUVAIL 0.45 % SOLUTION ACUVAIL TIER 3 ketorolac tromethamine (ophth) ALREX 0.2 % ALREX SUSPENSION TIER 3 loteprednol etabonate bromfenac sodium bromfenac sodium (once- TIER 1 (once-daily) daily) 0.09 % solution BROMFENAC SODIUM BROMFENAC 0.09 % SOLUTION TIER 1 SODIUM bromfenac sodium (ophth)

©2021 Wellmark, Inc. 205 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DEXAMETHASONE DEXAMETHASONE SODIUM PHOSPHATE 0.1 SODIUM % SOLUTION TIER 1 PHOSPHATE dexamethasone sodium phosphate (ophth) diclofenac sodium 0.1 % diclofenac sodium TIER 1 solution DUREZOL 0.05 % DUREZOL EMULSION TIER 3 difluprednate FLAREX 0.1 % FLAREX SUSPENSION TIER 3 fluorometholone acetate fluorometholone 0.1 % fluorometholone TIER 1 suspension flurbiprofen sodium 0.03 % flurbiprofen sodium TIER 1 solution FML 0.1 % OINTMENT FML TIER 3 fluorometholone (ophth) ketorolac tromethamine ketorolac (0.4 % solution, 0.5 % TIER 1 tromethamine solution) LOTEMAX 0.5 % LOTEMAX OINTMENT TIER 3 loteprednol etabonate LOTEMAX SM 0.38 % GEL LOTEMAX SM TIER 3 loteprednol etabonate loteprednol etabonate (0.5 loteprednol etabonate TIER 1 % gel, 0.5 % suspension) MAXIDEX 0.1 % MAXIDEX SUSPENSION TIER 3 dexamethasone (ophth) PRED MILD 0.12 % SUSPENSION PRED MILD TIER 3 prednisolone acetate (ophth) prednisolone acetate 1 % prednisolone acetate TIER 1 suspension PREDNISOLONE SODIUM PREDNISOLONE PHOSPHATE 1 % SODIUM SOLUTION TIER 1 PHOSPHATE prednisolone sodium phosphate (ophth) PROLENSA 0.07 % PROLENSA SOLUTION TIER 3 bromfenac sodium (ophth)

OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P 0.1 % ALPHAGAN P SOLUTION TIER 3 brimonidine tartrate apraclonidine hcl 0.5 % apraclonidine hcl TIER 1 solution betaxolol hcl betaxolol hcl 0.5 % solution TIER 1 BETIMOL (0.25 % SOLUTION, 0.5 % BETIMOL TIER 2 SOLUTION) timolol BETOPTIC-S 0.25 % BETOPTIC-S SUSPENSION TIER 2 betaxolol hcl (ophth) brimonidine tartrate (0.15 % brimonidine tartrate TIER 1 solution, 0.2 % solution) brinzolamide 1 % brinzolamide TIER 1 suspension carteolol hcl carteolol hcl 1 % solution TIER 1 COMBIGAN 0.2-0.5 % SOLUTION COMBIGAN TIER 3 brimonidine tartrate-timolol maleate dorzolamide hcl 2 % dorzolamide hcl TIER 1 solution dorzolamide hcl- dorzolamide hcl-timolol mal TIER 1 timolol mal 22.3-6.8 mg/ml solution dorzolamide hcl- dorzolamide hcl-timolol mal TIER 1 timolol mal pf pf 2-0.5 % solution IOPIDINE 1 % SOLUTION IOPIDINE TIER 3 apraclonidine hcl levobunolol hcl 0.5 % levobunolol hcl TIER 1 solution methazolamide (25 mg tab, methazolamide TIER 1 50 mg tab) METIPRANOLOL 0.3 % METIPRANOLOL SOLUTION TIER 1 metipranolol PHOSPHOLINE IODIDE PHOSPHOLINE 0.125 % RECON SOLN TIER 3 IODIDE echothiophate iodide pilocarpine hcl (1 % pilocarpine hcl solution, 2 % solution, 4 % TIER 1 solution)

©2021 Wellmark, Inc. 207 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SIMBRINZA 1-0.2 % SUSPENSION SIMBRINZA TIER 3 brinzolamide-brimonidine tartrate timolol maleate (0.25 % gel f soln, 0.25 % solution, 0.5 timolol maleate TIER 1 % (daily) solution, 0.5 % gel f soln, 0.5 % solution) timolol maleate timolol maleate ocudose TIER 1 ocudose 0.5 % solution timolol maleate pf 0.5 % timolol maleate pf TIER 1 solution

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

bimatoprost bimatoprost 0.03 % solution TIER 1 DURYSTA 10 MCG DURYSTA IMPLANT SP-M bimatoprost latanoprost 0.005 % latanoprost TIER 1 solution LUMIGAN 0.01 % LUMIGAN SOLUTION TIER 2 bimatoprost travoprost (bak free) 0.004 travoprost (bak free) TIER 1 % solution

OTIC AGENTS

acetasol hc acetasol hc 2-1 % solution TIER 1 acetic acid acetic acid 2 % solution TIER 1 CIPRO HC 0.2-1 % SUSPENSION CIPRO HC TIER 3 ciprofloxacin- hydrocortisone ciprofloxacin- ciprofloxacin- dexamethasone 0.3-0.1 % TIER 1 dexamethasone suspension COLY-MYCIN S 3.3-3-10- 0.5 MG/ML SUSPENSION COLY-MYCIN S TIER 3 neomycin-colistin-hc- thonzonium CORTISPORIN-TC 3.3-3- 10-0.5 MG/ML CORTISPORIN-TC SUSPENSION TIER 3 neomycin-colistin-hc- thonzonium flac flac 0.01 % oil TIER 1

©2021 Wellmark, Inc. 208 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS fluocinolone fluocinolone acetonide 0.01 TIER 1 acetonide % oil hydrocortisone-acetic hydrocortisone-acetic acid TIER 1 acid 1-2 % solution neomycin-polymyxin-hc (1 % solution, 3.5-10000-1 neomycin-polymyxin- solution, 3.5-10000-1 TIER 1 hc suspension, 3.5-10000-1 solution)

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ALVESCO (80 AERO MN-PA (Medically Necessary ALVESCO SOLN, 160 AERO SOLN) TIER 3 Prior Authorization) ciclesonide ASMANEX (120 METERED DOSES) 220 MCG/INH ASMANEX (120 AER POW BA TIER 1 METERED DOSES) mometasone furoate (inhalation) ASMANEX (14 METERED DOSES) 220 MCG/INH ASMANEX (14 AER POW BA TIER 1 METERED DOSES) mometasone furoate (inhalation) ASMANEX (30 METERED DOSES) (110 AER POW ASMANEX (30 BA, 220 AER POW BA) TIER 1 METERED DOSES) mometasone furoate (inhalation) ASMANEX (60 METERED DOSES) 220 MCG/INH ASMANEX (60 AER POW BA TIER 1 METERED DOSES) mometasone furoate (inhalation) ASMANEX (7 METERED DOSES) 110 MCG/INH ASMANEX (7 AER POW BA TIER 1 METERED DOSES) mometasone furoate (inhalation) ASMANEX HFA (50 AEROSOL, 100 AEROSOL, 200 ASMANEX HFA TIER 1 AEROSOL) mometasone furoate (inhalation)

©2021 Wellmark, Inc. 209 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BECONASE AQ 42 MCG/SPRAY BECONASE AQ SUSPENSION TIER 3 PA beclomethasone diprop monohyd budesonide (0.25 budesonide suspension, 0.5 TIER 1 suspension, 1 suspension) FLOVENT DISKUS (50 AER POW BA, 100 AER POW BA, 250 AER POW MN-PA (Medically Necessary FLOVENT DISKUS TIER 3 BA) Prior Authorization) fluticasone propionate (inhalation) FLOVENT HFA (44 AEROSOL, 110 MN-PA (Medically Necessary FLOVENT HFA AEROSOL, 220 TIER 3 Prior Authorization) AEROSOL) fluticasone propionate hfa FLUNISOLIDE 25 MCG/ACT (0.025%) FLUNISOLIDE TIER 1 SOLUTION flunisolide (nasal) mometasone furoate 50 mometasone furoate TIER 1 PA mcg/act suspension PULMICORT FLEXHALER PULMICORT (90 AER POW BA, 180 MN-PA (Medically Necessary TIER 3 FLEXHALER AER POW BA) Prior Authorization) budesonide (inhalation) QVAR (40 AERO SOLN, 80 AERO SOLN) QVAR TIER 1 beclomethasone dipropionate QVAR REDIHALER (40 AERO BA, 80 AERO BA) QVAR REDIHALER TIER 1 beclomethasone dipropionate hfa TRELEGY ELLIPTA (100- 62.5-25 AER POW BA, TRELEGY ELLIPTA 200-62.5-25 AER POW BA) TIER 2 fluticasone-umeclidinium- vilanterol

ANTIHISTAMINES

azelastine hcl (0.1 % azelastine hcl solution, 0.15 % solution, TIER 1 137 mcg/spray solution)

©2021 Wellmark, Inc. 210 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BROMPHENIRAMINE BROMPHENIRAMIN TANNATE 12 MG CHEW TIER 1 E TANNATE TAB brompheniramine tannate carbinoxamine carbinoxamine maleate (4 TIER 1 maleate mg tab, 4 mg/5ml solution) CLEMASTINE FUMARATE CLEMASTINE 2.68 MG TAB TIER 1 FUMARATE clemastine fumarate cyproheptadine hcl (2 cyproheptadine hcl TIER 1 mg/5ml syrup, 4 mg tab) DESLORATADINE (2.5 MG TAB DISP, 5 MG TAB, 5 DESLORATADINE TIER 1 MG TAB DISP) desloratadine diphenhydramine hcl 50 diphenhydramine hcl TIER 1 mg/ml solution hydroxyzine hcl (10 mg tab, hydroxyzine hcl 10 mg/5ml syrup, 25 mg TIER 1 tab, 50 mg tab) hydroxyzine pamoate (25 hydroxyzine pamoate mg cap, 50 mg cap, 100 mg TIER 1 cap) olopatadine hcl 0.6 % olopatadine hcl TIER 1 solution promethazine hcl (6.25 promethazine hcl TIER 1 solution, 6.25 syrup)

ANTILEUKOTRIENES

montelukast sodium (4 mg montelukast sodium chew tab, 4 mg packet, 5 TIER 1 mg chew tab, 10 mg tab) zafirlukast (10 mg tab, 20 zafirlukast TIER 1 mg tab) zileuton er 600 mg tab er zileuton er TIER 1 12h

BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT HFA 17 ATROVENT HFA MCG/ACT AERO SOLN TIER 2 ipratropium bromide hfa ipratropium bromide (0.02 ipratropium bromide % solution, 0.03 % solution, TIER 1 0.06 % solution)

©2021 Wellmark, Inc. 211 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SPIRIVA HANDIHALER 18 SPIRIVA MCG CAP TIER 2 HANDIHALER tiotropium bromide monohydrate SPIRIVA RESPIMAT (1.25 AERO SOLN, 2.5 AERO SPIRIVA RESPIMAT SOLN) TIER 2 tiotropium bromide monohydrate TUDORZA PRESSAIR 400 TUDORZA MCG/ACT AER POW BA TIER 3 PRESSAIR aclidinium bromide

BRONCHODILATORS, SYMPATHOMIMETIC

ADRENACLICK (0.15 MG/0.15ML SOLN A-INJ, ADRENACLICK 0.3 MG/0.3ML SOLN A- TIER 3 QL (2 PER RX), GA INJ) epinephrine (anaphylaxis) ADRENALIN 1 MG/ML ADRENALIN SOLUTION TIER 1 epinephrine (anaphylaxis) albuterol sulfate (0.63 mg/3ml nebu soln, 1.25 mg/3ml nebu soln, 2 mg tab, 2 mg/5ml syrup, (2.5 albuterol sulfate TIER 1 mg/3ml) 0.083% nebu soln, 2.5 mg/0.5ml nebu soln, 4 mg tab, (5 mg/ml) 0.5% nebu soln) albuterol sulfate er (er 4 mg albuterol sulfate er tab er 12h, er 8 mg tab er TIER 1 12h) albuterol sulfate hfa 108 (90 albuterol sulfate hfa TIER 1 base) mcg/act aero soln arformoterol tartrate 15 arformoterol tartrate TIER 1 mcg/2ml nebu soln epinephrine (0.15 mg/0.15ml soln a-inj, 0.15 epinephrine TIER 3 QL (2 PER RX) mg/0.3ml soln a-inj, 0.3 mg/0.3ml soln a-inj) epinephrine hcl epinephrine hcl (nasal) 0.1 TIER 1 (nasal) % solution epinephrine hcl 1 mg/ml epinephrine hcl TIER 1 solution

©2021 Wellmark, Inc. 212 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EPIPEN 2-PAK 0.3 EPIPEN 2-PAK MG/0.3ML SOLN A-INJ TIER 2 QL (2 PER RX), GA epinephrine (anaphylaxis) EPIPEN JR 2-PAK 0.15 EPIPEN JR 2-PAK MG/0.3ML SOLN A-INJ TIER 2 QL (2 PER RX), GA epinephrine (anaphylaxis) formoterol fumarate 20 formoterol fumarate TIER 1 mcg/2ml nebu soln levalbuterol hcl (0.31 mg/3ml nebu soln, 0.63 levalbuterol hcl mg/3ml nebu soln, 1.25 TIER 1 mg/0.5ml nebu soln, 1.25 mg/3ml nebu soln) levalbuterol tartrate 45 levalbuterol tartrate TIER 2 mcg/act aerosol METAPROTERENOL SULFATE (10 MG TAB, 10 METAPROTERENOL MG/5ML SYRUP, 20 MG TIER 1 SULFATE TAB) metaproterenol sulfate SEREVENT DISKUS 50 SEREVENT DISKUS MCG/DOSE AER POW BA TIER 2 salmeterol xinafoate STRIVERDI RESPIMAT 2.5 STRIVERDI MCG/ACT AERO SOLN TIER 3 RESPIMAT olodaterol hcl SYMJEPI (0.15 SOLN PRSYR, 0.3 SOLN SYMJEPI TIER 2 QL (2 PER FILL(S)) PRSYR) epinephrine (anaphylaxis) terbutaline sulfate (2.5 mg terbutaline sulfate TIER 1 tab, 5 mg tab)

CYSTIC FIBROSIS AGENTS

BRONCHITOL 40 MG CAP BRONCHITOL SP-NP PA, QL (20 PER 1 DAY(S)) mannitol (cystic fibrosis) CAYSTON 75 MG RECON CAYSTON SOLN SP-P aztreonam lysine KALYDECO (50 MG PACKET, 75 MG PACKET, KALYDECO SP-P PA, QL (56 PER 28 DAYS) 150 MG TAB) ivacaftor KALYDECO 25 MG KALYDECO PACKET SP-P PA, QL (56 PER 28 DAY(S)) ivacaftor

©2021 Wellmark, Inc. 213 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KITABIS PAK 300 MG/5ML KITABIS PAK NEBU SOLN SP-NP GA tobramycin ORKAMBI (100-125 MG PACKET, 150-188 MG ORKAMBI SP-P PA, QL (56 PER 28 DAY(S)) PACKET) lumacaftor-ivacaftor ORKAMBI (100-125 MG ORKAMBI TAB, 200-125 MG TAB) SP-P PA, QL (112 PER 28 DAYS) lumacaftor-ivacaftor PULMOZYME 1 MG/ML PULMOZYME SOLUTION SP-P dornase alfa SYMDEKO (50-75 75 MG TAB THPK, 100-150 150 SYMDEKO SP-P PA, QL (56 PER 28 DAY(S)) MG TAB THPK) tezacaftor-ivacaftor TOBI PODHALER 28 MG TOBI PODHALER CAP SP-P tobramycin tobramycin (300 mg/4ml SBG (Specialty Biosimilars tobramycin nebu soln, 300 mg/5ml SP-P and Specialty generics) nebu soln) TRIKAFTA 100-50-75 & 150 MG TAB THPK TRIKAFTA SP-P PA, QL (84 PER 28 DAY(S)) elexacaftor-tezacaftor- ivacaftor TRIKAFTA 50-25-37.5 & 75 MG TAB THPK TRIKAFTA SP-P PA, QL (3 PER DAY(S)) elexacaftor-tezacaftor- ivacaftor

MAST CELL STABILIZERS

cromolyn sodium 20 cromolyn sodium TIER 1 mg/2ml nebu soln

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

caffeine citrate (20 mg/ml caffeine citrate solution, 60 mg/3ml TIER 1 solution) DALIRESP (250 MCG TAB, DALIRESP 500 MCG TAB) TIER 3 roflumilast theochron (100 mg tab er theochron 12h, 200 mg tab er 12h, TIER 1 300 mg tab er 12h)

©2021 Wellmark, Inc. 214 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS theophylline 80 mg/15ml theophylline TIER 1 solution theophylline er (er 100 mg tab er 12h, er 200 mg tab er 12h, er 300 mg tab er 12h, theophylline er TIER 1 er 400 mg tab er 24h, er 450 mg tab er 12h, er 600 mg tab er 24h)

PULMONARY ANTIHYPERTENSIVES

ADEMPAS (0.5 MG TAB, 1 MG TAB, 1.5 MG TAB, 2 ADEMPAS SP-P PA, QL (90 PER 30 DAYS) MG TAB, 2.5 MG TAB) riociguat PA, QL (60 PER 30 DAYS), alyq alyq 20 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) PA, QL (30 PER 30 DAYS), ambrisentan (5 mg tab, 10 ambrisentan SP-P SBG (Specialty Biosimilars mg tab) and Specialty generics) PA, QL (60 PER 30 DAY(S)), bosentan (62.5 mg tab, 125 bosentan SP-P SBG (Specialty Biosimilars mg tab) and Specialty generics) epoprostenol sodium (0.5 epoprostenol sodium mg recon soln, 1.5 mg SP-M PA recon soln) FLOLAN (0.5 MG RECON SOLN, 1.5 MG RECON FLOLAN SP-M PA, GA SOLN) epoprostenol sodium OPSUMIT 10 MG TAB OPSUMIT SP-P PA, QL (30 PER 30 DAYS) macitentan ORENITRAM (0.125 MG TAB ER, 0.25 MG TAB ER, ORENITRAM 1 MG TAB ER, 2.5 MG TAB SP-P PA ER, 5 MG TAB ER) treprostinil diolamine REMODULIN (20 SOLUTION, 50 SOLUTION, 100 REMODULIN SP-M PA, GA SOLUTION, 200 SOLUTION) treprostinil REVATIO 10 MG/12.5ML SOLUTION REVATIO SP-M PA, GA sildenafil citrate (pulmonary hypertension)

©2021 Wellmark, Inc. 215 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS sildenafil citrate 10 sildenafil citrate SP-M PA mg/12.5ml solution PA, QL (720 PER 30 DAYS), sildenafil citrate 10 mg/ml sildenafil citrate SP-P SBG (Specialty Biosimilars recon susp and Specialty generics) PA, QL (360 PER 30 DAYS), sildenafil citrate sildenafil citrate 20 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) PA, QL (60 PER 30 DAYS), tadalafil (pah) tadalafil (pah) 20 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) TRACLEER 32 MG TAB PA, QL (120 PER 30 TRACLEER SOL SP-P DAY(S)) bosentan treprostinil (20 solution, 50 treprostinil solution, 100 solution, 200 SP-M PA solution) TYVASO 0.6 MG/ML TYVASO SOLUTION SP-P PA, QL (30 PER 30 DAYS) treprostinil TYVASO REFILL 0.6 TYVASO REFILL MG/ML SOLUTION SP-P PA, QL (30 PER 30 DAYS) treprostinil TYVASO STARTER 0.6 TYVASO STARTER MG/ML SOLUTION SP-P PA, QL (30 PER 30 DAYS) treprostinil UPTRAVI (200 MCG TAB, 400 MCG TAB, 600 MCG TAB, 800 MCG TAB, 1000 UPTRAVI MCG TAB, 1200 MCG SP-P PA, QL (60 PER 30 DAYS) TAB, 1400 MCG TAB, 1600 MCG TAB) selexipag UPTRAVI 200 & 800 MCG UPTRAVI TAB THPK SP-P PA, QL (1 PER LIFETIME) selexipag VELETRI (0.5 MG RECON SOLN, 1.5 MG RECON VELETRI SP-M PA, GA SOLN) epoprostenol sodium VENTAVIS (10 MCG/ML SOLUTION, 20 MCG/ML VENTAVIS SP-P PA, QL (9 PER DAY) SOLUTION) iloprost

PULMONARY FIBROSIS AGENTS

ESBRIET (267 MG TAB, PA, QL (2403 PER 1 ESBRIET 801 MG TAB) SP-P DAY(S)) pirfenidone ESBRIET 267 MG CAP ESBRIET SP-P PA, QL (270 PER 30 DAYS) pirfenidone OFEV (100 MG CAP, 150 OFEV MG CAP) SP-P PA, QL (60 PER 30 DAYS) nintedanib esylate

RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine (10 % acetylcysteine TIER 1 solution, 20 % solution) ADVAIR DISKUS (100-50 AER POW BA, 250-50 AER ADVAIR DISKUS POW BA, 500-50 AER TIER 1 GA POW BA) fluticasone-salmeterol ADVAIR HFA (45-21 AEROSOL, 115-21 ADVAIR HFA AEROSOL, 230-21 TIER 2 AEROSOL) fluticasone-salmeterol ANORO ELLIPTA 62.5-25 ANORO ELLIPTA MCG/INH AER POW BA TIER 2 umeclidinium-vilanterol benzonatate (100 mg cap, benzonatate TIER 1 200 mg cap) BREO ELLIPTA (100-25 AER POW BA, 200-25 AER BREO ELLIPTA POW BA) TIER 2 fluticasone furoate- vilanterol bromfed dm 30-2-10 bromfed dm TIER 1 mg/5ml syrup budesonide-formoterol budesonide- MN-PA (Medically Necessary fumarate (80-4.5 aerosol, TIER 1 formoterol fumarate Prior Authorization) 160-4.5 aerosol) CINQAIR 100 MG/10ML CINQAIR SOLUTION SP-M PA reslizumab COMBIVENT RESPIMAT COMBIVENT 20-100 MCG/ACT AERO TIER 2 RESPIMAT SOLN ipratropium-albuterol

©2021 Wellmark, Inc. 217 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS difil-g forte 100-100 mg/5ml difil-g forte TIER 1 liquid FASENRA 30 MG/ML FASENRA SOLN PRSYR SP-M PA benralizumab FASENRA PEN 30 MG/ML FASENRA PEN SOLN A-INJ SP-M PA benralizumab fluticasone-salmeterol (55- 14 aer pow ba, 113-14 aer fluticasone-salmeterol TIER 1 pow ba, 232-14 aer pow ba) giltuss pediatric 2.5-7.5-88 giltuss pediatric TIER 1 mg/ml liquid hydrocod polst-cpm hydrocod polst-cpm polst er TIER 1 polst er 10-8 mg/5ml susp hydrocodone- hydrocodone-homatropine TIER 1 homatropine (mg tab, mg/5ml syrup) hydromet 5-1.5 mg/5ml hydromet TIER 1 syrup HYPERSAL 3.5 % NEBU HYPERSAL SOLN TIER 3 sodium chloride (inhalant) ipratropium-albuterol 0.5- ipratropium-albuterol TIER 1 2.5 (3) mg/3ml solution nebusal nebusal 3 % nebu soln TIER 1 NUCALA (100 MG/ML SOLN A-INJ, 100 MG/ML NUCALA SP-M PA, QL (1 PER 28 DAY(S)) SOLN PRSYR) mepolizumab NUCALA 100 MG RECON NUCALA SOLN SP-M PA, QL (1 PER 28 DAYS) mepolizumab phenylephrine- phenylephrine-guaifenesin TIER 1 guaifenesin 1.5-20 mg/ml liquid promethazine vc 6.25-5 promethazine vc TIER 1 mg/5ml syrup promethazine vc plain 6.25- promethazine vc plain TIER 1 5 mg/5ml solution promethazine promethazine vc/codeine TIER 1 vc/codeine 6.25-5-10 mg/5ml syrup promethazine- promethazine-codeine TIER 1 codeine (solution, syrup) promethazine-dm (solution, promethazine-dm TIER 1 syrup)

©2021 Wellmark, Inc. 218 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS promethazine-phenyleph- promethazine- codeine 6.25-5-10 mg/5ml TIER 1 phenyleph-codeine syrup promethazine- promethazine- phenylephrine 6.25-5 TIER 1 phenylephrine mg/5ml syrup pseudoeph- pseudoeph-bromphen-dm TIER 1 bromphen-dm 30-2-10 mg/5ml syrup pseudoeph-chlorphen- pseudoeph- hydrocod 60-4-5 mg/5ml TIER 1 chlorphen-hydrocod solution pulmosal pulmosal 7 % nebu soln TIER 1 sodium chloride (0.9 % nebu soln, 3 % nebu soln, 7 sodium chloride TIER 1 % nebu soln, 10 % nebu soln) STIOLTO RESPIMAT 2.5- 2.5 MCG/ACT AERO SOLN STIOLTO RESPIMAT TIER 2 tiotropium bromide- olodaterol hcl SYMBICORT (80-4.5 AEROSOL, 160-4.5 SYMBICORT AEROSOL) TIER 2 GA budesonide-formoterol fumarate dihydrate tussigon tussigon 5-1.5 mg tab TIER 1 XOLAIR (150 MG RECON SOLN, 150 MG/ML SOLN XOLAIR SP-M PA, QL (8 PER 28 DAY(S)) PRSYR) omalizumab XOLAIR 75 MG/0.5ML XOLAIR SOLN PRSYR SP-M PA, QL (2 PER 28 DAY(S)) omalizumab

SKELETAL MUSCLE RELAXANTS

carisoprodol (250 mg tab, carisoprodol TIER 1 350 mg tab) carisoprodol-aspirin 200- carisoprodol-aspirin TIER 1 325 mg tab chlorzoxazone (375 mg tab, chlorzoxazone TIER 1 500 mg tab, 750 mg tab) cyclobenzaprine hcl (5 mg cyclobenzaprine hcl TIER 1 tab, 10 mg tab) DYSPORT (300 RECON DYSPORT SOLN, 500 RECON SOLN) SP-M PA, QL (1500 PER DAY(S)) abobotulinumtoxina

©2021 Wellmark, Inc. 219 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lorzone (375 mg tab, 750 lorzone TIER 1 mg tab) metaxall metaxall 800 mg tab TIER 1 metaxalone (400 mg tab, metaxalone TIER 1 800 mg tab) methocarbamol (500 mg methocarbamol TIER 1 tab, 750 mg tab) MYOBLOC (2500 UNIT/0.5ML SOLUTION, QL (10000 PER DAY(S)), 5000 UNIT/ML SOLUTION, MYOBLOC SP-M MN-PA (Medically Necessary 10000 UNIT/2ML Prior Authorization) SOLUTION) rimabotulinumtoxinb orphenadrine citrate orphenadrine citrate er 100 TIER 1 er mg tab er 12h vanadom vanadom 350 mg tab TIER 1 XEOMIN (50 RECON SOLN, 100 RECON SOLN, XEOMIN SP-M PA, QL (400 PER DAY(S)) 200 RECON SOLN) incobotulinumtoxina

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

estazolam (1 mg tab, 2 mg estazolam TIER 1 tab) eszopiclone (1 mg tab, 2 eszopiclone TIER 1 PA mg tab, 3 mg tab) FLURAZEPAM HCL (15 FLURAZEPAM HCL MG CAP, 30 MG CAP) TIER 1 flurazepam hcl temazepam (7.5 mg cap, temazepam 15 mg cap, 22.5 mg cap, 30 TIER 1 mg cap) triazolam (0.125 mg tab, triazolam TIER 1 0.25 mg tab) XYWAV 500 MG/ML SOLUTION PA, QL (540 PER 30 XYWAV calcium, magnesium, SP-NP DAY(S)) potassium, & sodium oxybates zaleplon (5 mg cap, 10 mg zaleplon TIER 1 cap) zolpidem tartrate (1.75 mg zolpidem tartrate TIER 1 PA sl tab, 3.5 mg sl tab)

©2021 Wellmark, Inc. 220 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS zolpidem tartrate (5 mg tab, zolpidem tartrate TIER 1 10 mg tab) zolpidem tartrate er (er 6.25 zolpidem tartrate er mg tab er, er 12.5 mg tab TIER 1 PA er)

SLEEP DISORDERS, OTHER

armodafinil (50 mg tab, 150 armodafinil mg tab, 200 mg tab, 250 TIER 1 PA, QL (30 PER 30 DAYS) mg tab) BUTISOL SODIUM 30 MG BUTISOL SODIUM TAB TIER 3 butabarbital sodium doxepin hcl (3 mg tab, 6 mg doxepin hcl TIER 1 PA tab) HETLIOZ 20 MG CAP HETLIOZ SP-P PA, QL (30 PER 30 DAYS) tasimelteon modafinil (100 mg tab, 200 modafinil TIER 1 PA, QL (60 PER 30 DAYS) mg tab) ramelteon ramelteon 8 mg tab TIER 1 PA SECONAL 100 MG CAP SECONAL TIER 3 secobarbital sodium XYREM 500 MG/ML XYREM SOLUTION SP-P PA, QL (540 PER 30 DAYS) sodium oxybate

SLEEP DISORDER AGENTS, OTHERS

WAKIX (4.45 MG TAB, 17.8 WAKIX MG TAB) SP-NP PA, QL (60 PER 30 DAY(S)) pitolisant hcl

Uncategorized

Unclassified

ABECMA SUSPENSION ABECMA SP-M idecabtagene vicleucel ADUHELM (170 MG/1.7ML SOLUTION, 300 MG/3ML ADUHELM P&T SOLUTION) aducanumab-avwa

©2021 Wellmark, Inc. 221 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS AZSTARYS (26.1-5.2 MG CAP, 39.2-7.8 MG CAP, 52.3-10.4 MG CAP) AZSTARYS P&T PA, QL (1 PER DAY(S)) serdexmethylphenidate chloride- dexmethylphenidate hcl BYLVAY (400 MCG CAP, BYLVAY 1200 MCG CAP) P&T odevixibat BYLVAY (PELLETS) (200 MCG CAP SPRINK, 600 BYLVAY (PELLETS) P&T MCG CAP SPRINK) odevixibat COSELA 300 MG RECON COSELA SOLN SP-M trilaciclib dihydrochloride CYCLOPHOSPHAMIDE CYCLOPHOSPHAMI (25 MG TAB, 50 MG TAB) TIER 1 DE cyclophosphamide EMPAVELI 1080 MG/20ML EMPAVELI SOLUTION P&T pegcetacoplan ENGERIX-B (10 MCG/0.5ML INJECTABLE, ENGERIX-B 20 MCG/ML INJECTABLE) TIER 2 hepatitis b vaccine (recomb) EVKEEZA (345 MG/2.3ML SOLUTION, 1200 MG/8ML EVKEEZA SP-M PA SOLUTION) evinacumab-dgnb FOTIVDA (0.89 MG CAP, FOTIVDA 1.34 MG CAP) SP-P QL (21 PER 28 DAY(S)) tivozanib hcl HETLIOZ LQ 4 MG/ML HETLIOZ LQ SUSPENSION SP-P PA, QL (5 PER 1 DAY(S)) tasimelteon JEMPERLI 500 MG/10ML JEMPERLI SOLUTION SP-M dostarlimab-gxly KERENDIA (10 MG TAB, KERENDIA 20 MG TAB) P&T finerenone LUMAKRAS 120 MG TAB LUMAKRAS SP-P sotorasib

©2021 Wellmark, Inc. 222 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MARGENZA 250 MG/10ML MARGENZA SOLUTION SP-M margetuximab-cmkb NEXTSTELLIS 3-14.2 MG NEXTSTELLIS TAB TIER 3 drospirenone-estetrol NEXVIAZYME 100 MG NEXVIAZYME RECON SOLN P&T avalglucosidase alfa-ngpt NULIBRY 9.5 MG RECON SOLN NULIBRY SP-M fosdenopterin hydrobromide PEPAXTO 20 MG RECON PEPAXTO SOLN SP-M melphalan flufenamide hcl QL (1 PER 1 DAY(S)), MN- PONVORY 20 MG TAB PONVORY SP-NP PA (Medically Necessary ponesimod Prior Authorization) PONVORY STARTER QL (1 PER 14 DAY(S)), MN- PONVORY PACK 2,3,4,5,6,7,8,9 & 10 SP-NP PA (Medically Necessary STARTER PACK MG TAB THPK Prior Authorization) ponesimod PREVNAR 20 0.5 ML SUSP PRSYR PREVNAR 20 TIER 2 pneumococcal 20-valent conjugate vaccine REZUROCK 200 MG TAB REZUROCK P&T belumosudil mesylate RYBREVANT 350 MG/7ML RYBREVANT SOLUTION SP-M amivantamab-vmjw RYLAZE 10 MG/0.5ML SOLUTION RYLAZE asparaginase erwinia SP-M chrysanthemi (recombinant)-rywn SAPHNELO 300 MG/2ML SAPHNELO SOLUTION P&T anifrolumab-fnia SKYRIZI (150 MG/ML SOLN A-INJ, 150 MG/ML SKYRIZI SP-P PA, QL (1 PER 84 DAY(S)) SOLN PRSYR) risankizumab-rzaa TEPMETKO 225 MG TAB TEPMETKO SP-P tepotinib hcl

©2021 Wellmark, Inc. 223 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TRUSELTIQ (100MG TRUSELTIQ (100MG DAILY DOSE) 100 MG SP-P DAILY DOSE) CAP THPK infigratinib phosphate TRUSELTIQ (125MG TRUSELTIQ (125MG DAILY DOSE) 100 & 25 SP-P DAILY DOSE) MG CAP THPK infigratinib phosphate TRUSELTIQ (50MG DAILY TRUSELTIQ (50MG DOSE) 25 MG CAP THPK SP-P DAILY DOSE) infigratinib phosphate TRUSELTIQ (75MG DAILY TRUSELTIQ (75MG DOSE) 25 MG CAP THPK SP-P DAILY DOSE) infigratinib phosphate UKONIQ 200 MG TAB UKONIQ SP-P umbralisib tosylate UPTRAVI 1800 MCG UPTRAVI RECON SOLN SP-M selexipag WELIREG 40 MG TAB WELIREG P&T belzutifan XELJANZ 1 MG/ML XELJANZ SOLUTION SP-P PA, QL (10 PER 1 DAY(S)) tofacitinib citrate XTANDI (40 MG TAB, 80 XTANDI MG TAB) SP-P enzalutamide ZEGALOGUE (0.6 SOLN ZEGALOGUE A-INJ, 0.6 SOLN PRSYR) TIER 3 dasiglucagon hcl ZYNLONTA 10 MG ZYNLONTA RECON SOLN SP-M loncastuximab tesirine-lpyl

©2021 Wellmark, Inc. 224 Index of covered drugs Acuvail 205 A ACYCLOVIR 63 ABACAVIR SULFATE 60 Adacel 165 ABACAVIR SULFATE-LAMIVUDINE 60 Adakveo 83 ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE 60 ADALIMUMAB 155,156 ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE 62 ADAPALENE 105 ABALOPARATIDE 173 ADEFOVIR DIPIVOXIL 56 ABATACEPT 157 Adempas 215 Abecma 221 Adrenaclick 212 ABEMACICLIB 48 Adrenalin 212 ABIRATERONE ACETATE 38,39 ADUCANUMAB-AVWA 221 ABOBOTULINUMTOXINA 219 Aduhelm 221 Abstral 9 Advair Diskus 217 ACALABRUTINIB 44 Advair HFA 217 ACAMPROSATE CALCIUM 14 Advance Intuition Test 174 ACARBOSE 65 Advate 78 Accu-Chek Aviva Plus 173 Advocate Redi-Code 174 Accu-Chek Compact Plus 174 Advocate Redi-Code+ Test 174 Accu-Chek Guide 174 Advocate Test 174 Accu-Chek SmartView 174 Adynovate 78 Accutrend Glucose 174 Aemcolo 15 ACEBUTOLOL HCL 87 AeroChamber Mini Chamber 174 ACETAMINOPHEN W/ CODEINE 9 AeroChamber MV 174 ACETAMINOPHEN-CAFF-DIHYDROCOD 9,10,12,13 AeroChamber Plus Flo-Vu 174 ACETAMINOPHEN-SALICYLAMIDE- AeroChamber Plus Flo-Vu Large 175 PHENYLTOLOXAMINE 181 AeroChamber Plus Flo-Vu Medium 175 Acetaminophen-Salicylamide-Phenyltoloxamine 182 AeroChamber Plus Flo-Vu Small 175 ACETAZOLAMIDE 94 AeroChamber Plus Flo-Vu w/Mask 175 ACETIC ACID (OTIC) 208 AeroChamber Plus Flow VU 175 ACETOHYDROXAMIC ACID 128 AeroChamber w/FLOWSIGnal 175 ACETONE (URINE) TEST 178,179,190,198 AeroChamber Z-Stat Plus 175 Acetone (Urine) Test 190 AeroChamber Z-Stat Plus Chambr 175 ACETYLCYSTEINE 217 AeroChamber Z-Stat Plus/Large 175 AcipHex Sprinkle 123 AeroChamber Z-Stat Plus/Medium 175 ACITRETIN 105 AeroChamber Z-Stat Plus/Small 175 ACLIDINIUM BROMIDE 212 AeroVent Plus 175 Actemra 163 AFAMELANOTIDE ACETATE 108 Actemra ACTPen 163 AFATINIB DIMALEATE 44 Acthar 129 Afinitor 43 ActHIB 165 Afinitor Disperz 43 Actimmune 163 Afluria 165

©2021 Wellmark, Inc. 225 Afluria Preservative Free 165 AlphaNine SD 79 Afluria Quadrivalent 165 ALPRAZOLAM 64 Afstyla 78 ALPRAZolam Intensol 64 AGALSIDASE BETA 124 Alprolix 79 AgaMatrix AMP Test 176 ALPROSTADIL (VASODILATOR) 127,128 AgaMatrix Jazz Test 176 Alrex 205 AgaMatrix KeyNote Test 176 Altabax 15 AgaMatrix Presto Test 176 ALTRETAMINE 38 Aimovig 36 Alunbrig 40 Aimovig (140 MG Dose) 36 Alvesco 209 Ajovy 27,36 ALVIMOPAN 120 Akten 202 AMANTADINE HCL 51 Akynzeo 32 AMBRISENTAN 215 ALBENDAZOLE 49 AMCINONIDE 129 ALBUTEROL SULFATE 212 Amcinonide 129 ALCAFTADINE 205 AMIFAMPRIDINE 37 ALCLOMETASONE DIPROPIONATE 129 AMIKACIN SULFATE LIPOSOME 14 ALCOHOL SWABS 176,197,199 AMILORIDE & HYDROCHLOROTHIAZIDE 90 Aldurazyme 124 AMILORIDE HCL 94 Alecensa 43 AMINOCAPROIC ACID 79 ALECTINIB HCL 43 AMINOSALICYLIC ACID 37 ALEMTUZUMAB (MS) 103 AMIODARONE HCL 86 ALENDRONATE SODIUM 172 AMITRIPTYLINE HCL 31 ALFUZOSIN HCL 127 AMIVANTAMAB-VMJW 223 ALGLUCOSIDASE ALFA 124 AMLODIPINE BENZOATE 89 Alinia 49,50 AMLODIPINE BESYLATE 88 ALIROCUMAB 97 AMLODIPINE BESYLATE-ATORVASTATIN ALISKIREN FUMARATE 90 CALCIUM 91 ALITRETINOIN 49 AMLODIPINE BESYLATE-BENAZEPRIL HCL 91 ALLOPURINOL 35 AMLODIPINE BESYLATE-OLMESARTAN ALMOTRIPTAN MALATE 35 MEDOXOMIL 91 Alocril 205 AMLODIPINE BESYLATE-VALSARTAN 91 ALOGLIPTIN BENZOATE 65 AMLODIPINE-VALSARTAN- ALOGLIPTIN-METFORMIN HCL 65 HYDROCHLOROTHIAZIDE 91 ALOGLIPTIN-PIOGLITAZONE 65 AMOXAPINE 31 Alomide 205 Amoxapine 31 ALOSETRON HCL 121 AMOXICILLIN 20 ALPELISIB 43 AMOXICILLIN & POT CLAVULANATE 20 Alphagan P 207 AMOXICILLIN-CLARITHROMYCIN W/ Alphanate 78 LANSOPRAZOLE 120 Alphanate/VWF Complex/Human 78 AMPHETAMINE-DEXTROAMPHETAMINE 99

©2021 Wellmark, Inc. 226 AMPICILLIN 20 APRACLONIDINE HCL 207 Ampicillin 20 APREMILAST 163,164 Anadrol-50 136 APREPITANT 32 ANAGRELIDE HCL 74 Aptivus 62 ANAKINRA 156 Aranesp (Albumin Free) 75 ANASTROZOLE 42 Arcalyst 163 Androxy 136 ARFORMOTEROL TARTRATE 212 Angeliq 137 Arial Chamber 176 ANIFROLUMAB-FNIA 223 Arikayce 14 Annovera 137 ARIPIPRAZOLE 54 Anoro Ellipta 217 ARMODAFINIL 221 ANTIHEMOPHIL FACT(RCMB) PEGYLATED-AUCL ARTEMETHER-LUMEFANTRINE 50 (BDD-RFVIII PEG-AUCL) 80 ARTIFICIAL TEAR INSERT 203 ANTIHEMOPHILIC FACTOR (HUMAN) 80,81 Asceniv 159 ANTIHEMOPHILIC FACTOR (RCMB) BD Ascensia Autodisc Test 176 TRUNCATED (BD TRUNC-RFVIII) 81 ASENAPINE MALEATE 54 ANTIHEMOPHILIC FACTOR (RCMB) FC FUSION ASFOTASE ALFA 126 PROTEIN(BDD-RFVIIIFC) 79 Asmanex (120 Metered Doses) 209 ANTIHEMOPHILIC FACTOR (RCMB) Asmanex (14 Metered Doses) 209 MOROCTOCOG ALFA(BDD-RFVIII,MOR) 83 Asmanex (30 Metered Doses) 209 ANTIHEMOPHILIC FACTOR (RCMB) Asmanex (60 Metered Doses) 209 PLASMA/ALBUMIN FREE (RAHF-PFM) 78,81 Asmanex (7 Metered Doses) 209 ANTIHEMOPHILIC FACTOR (RCMB) SIMOCTOCOG Asmanex HFA 209 ALFA(BDD-RFVIII,SIM) 82 ASPARAGINASE ERWINIA CHRYSANTHEMI ANTIHEMOPHILIC FACTOR (RECOMBINANT (RECOMBINANT)-RYWN 223 PORCINE) (RPFVIII) 82 ASPIRIN-CAFFEINE-DIHYDROCODEINE ANTIHEMOPHILIC FACTOR BITARTRATE 9 (RECOMBINANT) 80,81,82 ASPIRIN-DIPYRIDAMOLE 83 ANTIHEMOPHILIC FACTOR (RECOMBINANT) Assure 4 Test 176 PEGYLATED 78 Assure II Check 176 ANTIHEMOPHILIC FACTOR (RECOMBINANT) Assure Platinum 176 SINGLE CHAIN 78 Assure Prism multi Test 176 ANTIHEMOPHILIC FACTOR/VON WILLEBRAND Assure Pro Test 176 FACTOR COMPLEX (HUMAN) 78,80,83 Astagraf XL 154 ANTIINHIBITOR COAGULANT COMPLEX 79 Atabex EC 113 Antiinhibitor Coagulant Complex 79 Atabex OB 113 Anzemet 32 ATAZANAVIR SULFATE 62,63 APALUTAMIDE 38 ATAZANAVIR SULFATE-COBICISTAT 62 APIXABAN 73 ATENOLOL 87 Apokyn 52 ATENOLOL & CHLORTHALIDONE 91 APOMORPHINE HYDROCHLORIDE 52 ATOMOXETINE HCL 99

©2021 Wellmark, Inc. 227 ATORVASTATIN CALCIUM 96 BACITRACIN-POLYMYXIN B (OPHTH) 202,204 ATOVAQUONE 50 BACLOFEN 55 ATOVAQUONE-PROGUANIL HCL 50 Bafiertam 102 Atropine Sulfate (Ophthalmic) 202 Balcoltra 137 ATROPINE SULFATE (OPHTHALMIC) 203 BALOXAVIR MARBOXIL 171 Atrovent HFA 211 BALSALAZIDE DISODIUM 171 Aubagio 102 Balversa 40 Augmentin 20 Baqsimi One Pack 68 AURANOFIN 165 Baqsimi Two Pack 68 Austedo 101 Baraclude 56 AVALGLUCOSIDASE ALFA-NGPT 223 BARICITINIB 157 Avandamet 65 Basaglar KwikPen 69 AVAPRITINIB 40 Baxdela 21 Avastin 48 BD Swab Single Use Regular 176 AVATROMBOPAG MALEATE 75 Bebulin 79 AVC Vaginal 22 BECAPLERMIN 108 Avonex 102 BECLOMETHASONE DIPROP MONOHYD 210 Avonex Pen 102 BECLOMETHASONE DIPROPIONATE 210 Avonex Prefilled 102 BECLOMETHASONE DIPROPIONATE HFA 210 Avsola 154 Beconase AQ 210 AXITINIB 45 BEDAQUILINE FUMARATE 37 Ayvakit 40 BELANTAMAB MAFODOTIN-BLMF 48 AZACITIDINE 40 BELIMUMAB 163 Azactam 19 BELUMOSUDIL MESYLATE 223 AzaSite 20 BELZUTIFAN 224 AZATHIOPRINE 154 BENAZEPRIL & HYDROCHLOROTHIAZIDE 91 AZELAIC ACID 106,107 BENAZEPRIL HCL 85 AZELASTINE HCL 210 BeneFIX 79 AZELASTINE HCL (OPHTH) 205 Benlysta 163 AZILSARTAN MEDOXOMIL 84 BENRALIZUMAB 218 AZILSARTAN MEDOXOMIL-CHLORTHALIDONE 92 BENZONATATE 217 AZITHROMYCIN 20 BENZOYL PEROXIDE-ERYTHROMYCIN 15 AZITHROMYCIN (OPHTH) 20,21 BENZTROPINE MESYLATE 51 Azstarys 222 BENZYL ALCOHOL (PEDICULICIDE) 51 AZTREONAM 19 BEPOTASTINE BESILATE 205 AZTREONAM LYSINE 213 Berinert 153 BEROTRALSTAT HCL 154 B BESIFLOXACIN HCL 21 Bacitracin 15 Besivance 21 BACITRACIN (OPHTHALMIC) 15 Betadine Ophthalmic Prep 202 BACITRACIN-POLY-NEOMYCIN-HC 202,203 BETAINE 124

©2021 Wellmark, Inc. 228 BETAMETHASONE DIPROPIONATE (TOPICAL) 129 BreatheRite Coll Spacer Adult 177 BETAMETHASONE DIPROPIONATE BreatheRite Coll Spacer Child 177 AUGMENTED 129 BreatheRite Coll Spacer Infant 177 BETAMETHASONE VALERATE 129 BreatheRite Rigid Spacer/Mask 177 Betaseron 102 BreatheRite Spacer Neonate 177 BETAXOLOL HCL 87 BreatheRite Spacer Small Child 177 BETAXOLOL HCL (OPHTH) 207 BreatheRite/Large Mask 178 BETHANECHOL CHLORIDE 127 BreatheRite/Medium Mask 178 Betimol 207 BreatheRite/Small Mask 178 Betoptic-S 207 Breeze 2 Test 178 BEVACIZUMAB 48 Breo Ellipta 217 BEXAROTENE 49 BREXUCABTAGENE AUTOLEUCEL 41 BEXAROTENE (TOPICAL) 49 BRIGATINIB 40 Bexsero 166 Brilinta 83 BICALUTAMIDE 38 BRIMONIDINE TARTRATE 207 Bicillin L-A 20 BRIMONIDINE TARTRATE-TIMOLOL MALEATE 207 BICTEGRAVIR-EMTRICITABINE-TENOFOVIR BRINZOLAMIDE 207 ALAFENAMIDE FUMARATE 61 BRINZOLAMIDE-BRIMONIDINE TARTRATE 208 Biktarvy 61 BRODALUMAB 108 BIMATOPROST 208 Bromfenac Sodium 205 BINIMETINIB 47 BROMFENAC SODIUM (OPHTH) 205,206 BISOPROLOL & HYDROCHLOROTHIAZIDE 91 BROMOCRIPTINE MESYLATE 52 BISOPROLOL FUMARATE 87 BROMPHENIRAMINE TANNATE 211 Bivigam 159 Brompheniramine Tannate 211 Blenrep 48 Bronchitol 213 Blephamide 202 Bronchitol Tolerance Test 178 Blephamide S.O.P. 202 Brukinsa 40 Blood Glucose Test 177 Bryhali 129 BluLink Glucose Test 177 BUDESONIDE 171 Boostrix 166 BUDESONIDE (INHALATION) 210 BOSENTAN 215,216 BUDESONIDE (INTRARECTAL) 172 Bosulif 43 BUDESONIDE-FORMOTEROL FUMARATE BOSUTINIB 43 DIHYDRATE 217,219 Botox 55 BUMETANIDE 94 BP FoliNatal Plus B 113 BUPRENORPHINE 7 BP MultiNatal Plus 114 BUPRENORPHINE HCL 14 Braftovi 43 BUPRENORPHINE HCL-NALOXONE HCL Breathe Ease Large 177 DIHYDRATE 14 Breathe Ease Medium 177 BUPROPION HCL 28 Breathe Ease Small 177 BUROSUMAB-TWZA 110 BreatheRite 177 BUSPIRONE HCL 63

©2021 Wellmark, Inc. 229 BUSULFAN 38 Calquence 44 BUTABARBITAL SODIUM 221 CANAKINUMAB 163 BUTALBITAL-ACETAMINOPHEN 101 CANDESARTAN CILEXETIL 84 BUTALBITAL-ACETAMINOPHEN-CAFFEINE 101,102 CANDESARTAN CILEXETIL- BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ HYDROCHLOROTHIAZIDE 91 CODEINE 10 CANNABIDIOL 24 BUTALBITAL-ASPIRIN-CAFFEINE 5 CAPECITABINE 39 BUTALBITAL-ASPIRIN-CAFFEINE W/COD 9,10 Capex 129 Butisol Sodium 221 CAPLACIZUMAB-YHDP 75 BUTOCONAZOLE NITRATE (ONE DOSE) 33 CAPMATINIB HCL 41 BUTORPHANOL TARTRATE 10 Caprelsa 44 Bydureon 65 CAPTOPRIL 85 Bydureon BCise 65 CAPTOPRIL & HYDROCHLOROTHIAZIDE 91 Byetta 10 MCG Pen 65 Captopril-Hydrochlorothiazide 91 Byetta 5 MCG Pen 65 Carbaglu 124 Bylvay 222 CARBAMAZEPINE 26,27 Bylvay (Pellets) 222 Carbamazepine 27 Bynfezia Pen 151 CARBIDOPA 53 Bystolic 87 CARBIDOPA-LEVODOPA 53 CARBIDOPA-LEVODOPA-ENTACAPONE 51,52 C CARBINOXAMINE MALEATE 211 C1 ESTERASE INHIBITOR (HUMAN) 153 CareOne Blood Glucose Test 178 C1 ESTERASE INHIBITOR (RECOMBINANT) 154 CareSens N Glucose Test 178 Cabenuva 61 CareTouch Test 178 CABERGOLINE 151 CARGLUMIC ACID 124 Cablivi 75 Carimune NF 159 Cabometyx 44 CARIPRAZINE HCL 55 CABOTEGRAVIR & RILPIVIRINE 61 CARISOPRODOL 219,220 CABOZANTINIB S-MALATE 44 CARISOPRODOL W/ ASPIRIN 219 CAFFEINE CITRATE 214 CARISOPRODOL W/ ASPIRIN & CODEINE 10 CALCIFEDIOL 173 CaroSpir 94 CALCIPOTRIENE 106,108 CARTEOLOL HCL (OPHTH) 207 Calcipotriene 106 CARVEDILOL 87 CALCIPOTRIENE-BETAMETHASONE CARVEDILOL PHOSPHATE 87 DIPROPIONATE 106 CASCARA SAGRADA 121 CALCITONIN (SALMON) 172 Cascara Sagrada 121 CALCITRIOL 172 Caverject 127 CALCITRIOL (TOPICAL) 106,109 Caverject Impulse 127 CALCIUM ACETATE (PHOSPHATE BINDER) 110,113 Cayston 213 CALCIUM, MAGNESIUM, POTASSIUM, & SODIUM CEFACLOR 18 OXYBATES 220 Cefaclor ER 18

©2021 Wellmark, Inc. 230 CEFACLOR MONOHYDRATE 18 Chlordiazepoxide-Amitriptyline 28 CEFADROXIL 18 CHLORHEXIDINE GLUCONATE (MOUTH- CEFDINIR 18 THROAT) 105 CEFDITOREN PIVOXIL 18,19 CHLOROQUINE PHOSPHATE 50 CEFEPIME HCL 18,19 CHLOROTHIAZIDE 95 CEFEPIME HCL-DEXTROSE 18 CHLORPROMAZINE HCL 53 Cefepime-Dextrose 18 CHLORPROPAMIDE 66 CEFIXIME 19 ChlorproPAMIDE 66 CEFPODOXIME PROXETIL 19 CHLORTHALIDONE 95 CEFPROZIL 19 CHLORZOXAZONE 219,220 CEFTIBUTEN 19 CHOLESTYRAMINE 96 CEFTRIAXONE SODIUM 19 CHOLESTYRAMINE LIGHT 96,97 CEFUROXIME AXETIL 19 CHOLINE & MAG SALICYLATE 5 CELECOXIB 5 CHOLINE FENOFIBRATE 95 CellCept 154 CICLESONIDE 209 Celontin 24 CICLOPIROX 33 CENEGERMIN-BKBJ 203 CICLOPIROX OLAMINE 33 CEPHALEXIN 19 CILOSTAZOL 83 Cerdelga 124 Ciloxan 21 Cerezyme 124 Cimduo 60 CERITINIB 48 CIMETIDINE 120 CERTOLIZUMAB PEGOL 154 CIMETIDINE HCL 120 Cesamet 32 Cimzia 154 Cetraxal 21 Cimzia Prefilled 154 CEVIMELINE HCL 105 Cimzia Starter Kit 154 Chek-Stix Control 178 CINACALCET HCL 172 Chemet 111 Cinqair 217 Chemstrip 10 MD 178 Cinryze 153 Chemstrip 10/SG 178 Cipro HC 208 Chemstrip 2 GP 178 CIPROFLOXACIN 22 Chemstrip 5 OB 178 CIPROFLOXACIN HCL 22 Chemstrip 7 178 CIPROFLOXACIN HCL (OPHTH) 21 Chemstrip 9 179 CIPROFLOXACIN HCL (OTIC) 21 Chemstrip K 179 Ciprofloxacin-Ciproflox HCl ER 22 Chemstrip uGK 179 CIPROFLOXACIN-CIPROFLOXACIN HCL 22 Chenodal 120 CIPROFLOXACIN-DEXAMETHASONE 208 CHENODIOL 120 CIPROFLOXACIN-HYDROCORTISONE 208 CHLORAMBUCIL 38 CITALOPRAM HYDROBROMIDE 29 CHLORDIAZEPOXIDE HCL 64 CLADRIBINE (MULTIPLE SCLEROSIS) 103,104 Chlordiazepoxide HCl-Clidinium Bromide 119 CLARITHROMYCIN 21 CHLORDIAZEPOXIDE-AMITRIPTYLINE 28 CLEMASTINE FUMARATE 211

©2021 Wellmark, Inc. 231 Clemastine Fumarate 211 Coagadex 79 Clenpiq 121 COAGULATION FACTOR IX 79,81 Cleocin 15 COAGULATION FACTOR IX (RECOMB) FC FUSION Cleocin Phosphate 15 PROTEIN (RFIXFC) 79 Clever Chek Auto-Code Test 179 COAGULATION FACTOR IX Clever Chek Auto-Code Voice 179 (RECOMBINANT) 79,80,83 Clever Chek Test 179 COAGULATION FACTOR IX (RECOMBINANT) Clever Choice Auto-Code Test 179 GLYCOPEGYLATED 82 Clever Choice Holding Chamber 179 COAGULATION FACTOR IX RECOMB ALBUMIN Clever Choice Micro Test 179 FUSION PROTEIN (RIX-FP) 80 Clever Choice No Coding 179 COAGULATION FACTOR VIIA (RECOMBINANT) 82 Clever Choice Talk System 179 COAGULATION FACTOR VIIA (RECOMBINANT)- Climara Pro 138 JNCW 83 CLINDAMYCIN HCL 15 COAGULATION FACTOR X (HUMAN) 79 CLINDAMYCIN PALMITATE HYDROCHLORIDE 15 Coartem 50 CLINDAMYCIN PHOSPHATE 15,16 COBICISTAT 62 CLINDAMYCIN PHOSPHATE (ONE DOSE) 16 COBIMETINIB FUMARATE 44 CLINDAMYCIN PHOSPHATE (TOPICAL) 15,16 CODEINE SULFATE 10 CLINDAMYCIN PHOSPHATE VAGINAL 15 COLCHICINE 35 CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE COLCHICINE W/ PROBENECID 35 (REFRIGERATE) 106,108 COLESEVELAM HCL 96 CLINDAMYCIN PHOSPHATE-TRETINOIN 106 COLESTIPOL HCL 96 Clindesse 16 COLISTIMETHATE SODIUM 16 Clinistix 179 COLLAGENASE 108 CLOBAZAM 24 Coly-Mycin M 16 CLOBETASOL PROPIONATE 130,132 Coly-Mycin S 208 CLOBETASOL PROPIONATE EMOLLIENT Combigan 207 BASE 129,130 CombiPatch 138 CLOBETASOL PROPIONATE EMULSION 130,133 Combistix 179 CLOCORTOLONE PIVALATE 130 Combivent Respimat 217 CLOMIPRAMINE HCL 31 Cometriq (100 mg Daily Dose) 44 CLONAZEPAM 64 Cometriq (140 mg Daily Dose) 44 CLONIDINE 84 Cometriq (60 mg Daily Dose) 44 CLONIDINE HCL 84 Compact Space Chamber 180 CLONIDINE HCL (ADHD) 100 Compact Space Chamber/Lg Mask 180 CLOPIDOGREL BISULFATE 83 Compact Space Chamber/Med Mask 180 CLORAZEPATE DIPOTASSIUM 64 Compact Space Chamber/Sm Mask 180 CLOTRIMAZOLE 33 Complera 59 CLOTRIMAZOLE W/ BETAMETHASONE 106 Complete Natal DHA 114 CLOZAPINE 55 CompleteNate 114 cloZAPine 55 Concept OB 114

©2021 Wellmark, Inc. 232 CONJUGATED ESTROGENS-BAZEDOXIFENE 150 CVS Advanced Glucose Test 180 CONJUGATED ESTROGENS- CVS Glucose Meter Test Strips 180 MEDROXYPROGESTERONE ACETATE 146 CVS Ketone Care 180 Contour Next Test 180 CYANOCOBALAMIN 114 Contour Test 180 CYCLOBENZAPRINE HCL 219 Cool Blood Glucose Test Strips 180 CYCLOPENTOLATE HCL 203 Copaxone 102 CYCLOPHOSPHAMIDE 38,222 Copiktra 44 Cyclophosphamide 38,222 COPPER (IUD) 195 CYCLOSERINE 37 Corlanor 91,92 CYCLOSPORINE 154,158 CORTICOTROPIN 129 CYCLOSPORINE (OPHTH) 204 CORTISONE ACETATE 130 CYCLOSPORINE MODIFIED (FOR Cortisone Acetate 130 MICROEMULSION) 154,155,157 Cortisporin-TC 208 CYPROHEPTADINE HCL 211 Cosela 222 Cystadane 124 Cosentyx 106 Cystadrops 203 Cosentyx (300 MG Dose) 106 Cystagon 124 Cosentyx Sensoready (300 MG) 106 Cystaran 203 Cotellic 44 CYSTEAMINE BITARTRATE 124,125 Coumadin 73 CYSTEAMINE HCL 203 COVID-19 (SARS-COV-2) ADENOVIRUS Cytogam 160 VACCINE 168 CYTOMEGALOVIRUS IMMUNE GLOBULIN COVID-19 (SARS-COV-2) MRNA VIRUS (HUMAN) 160 VACCINE 169 Cytra K Crystals 128 Creon 124 Cresemba 33 D Crinone 148 D-Care Blood Glucose 180 CRISABOROLE 107 D-Penamine 128 Crixivan 62 DABIGATRAN ETEXILATE MESYLATE 74 CRIZANLIZUMAB-TMCA 83 DABRAFENIB MESYLATE 47 CRIZOTINIB 48 DACLATASVIR DIHYDROCHLORIDE 56 CROMOLYN SODIUM 214 DACOMITINIB 42 CROMOLYN SODIUM (MASTOCYTOSIS) 120 Daklinza 56 CROMOLYN SODIUM (OPHTH) 205 DALFAMPRIDINE 102 CROSS-LINKED HYALURONATE 187 Daliresp 214 CROTAMITON 50 DALTEPARIN SODIUM 73 Crotan 50 DANAZOL 136 Crysvita 110 DANTROLENE SODIUM 55 Cutaquig 160 DAPAGLIFLOZIN PROPANEDIOL 66 Cuvitru 160 DAPAGLIFLOZIN-METFORMIN HCL 68 Cuvposa 119 DAPSONE 37

©2021 Wellmark, Inc. 233 DAPSONE (TOPICAL) 106 DESOGESTREL & ETHINYL Daptacel 166 ESTRADIOL 137,138,139,141,142,146 Daraprim 50 DESOGESTREL-ETHINYL ESTRADIOL DARATUMUMAB-HYALURONIDASE-FIHJ 48 (BIPHASIC) 137,142,145,146,148 DARBEPOETIN ALFA 75 DESOGESTREL-ETHINYL ESTRADIOL DARIFENACIN HYDROBROMIDE 126 (TRIPHASIC) 138,147 DAROLUTAMIDE 38 DESONIDE 130,132 DARUNAVIR ETHANOLATE 62,63 DESOXIMETASONE 130 DARUNAVIR-COBICISTAT 62 DESVENLAFAXINE 29 DARUNAVIR-COBICISTAT-EMTRICITABINE- DESVENLAFAXINE SUCCINATE 29 TENOFOVIR ALAFENAMIDE 58 DEUTETRABENAZINE 101 Darzalex Faspro 48 Dexamethasone 129 DASATINIB 47 DEXAMETHASONE 130 DASIGLUCAGON HCL 224 DEXAMETHASONE (OPHTH) 206 Daurismo 44 Dexamethasone Intensol 130 Debacterol 105 DEXAMETHASONE SODIUM PHOSPHATE 130,131 DECITABINE-CEDAZURIDINE 40 Dexamethasone Sodium Phosphate 206 DEFERASIROX 112 DEXAMETHASONE SODIUM PHOSPHATE DEFERIPRONE 112 (OPHTH) 206 DEFLAZACORT 131 Dexilant 123 DEGARELIX ACETATE 151 DEXLANSOPRAZOLE 123 DELAFLOXACIN MEGLUMINE 21 DEXMETHYLPHENIDATE HCL 100 DELAVIRDINE MESYLATE 59 DEXTRANOMER-SODIUM HYALURONATE 199 Delestrogen 139 DEXTROAMPHETAMINE SULFATE 99 Delstrigo 59 Diacomit 24 DEMECLOCYCLINE HCL 23 Diastat AcuDial 25 DENOSUMAB 173 Diastat Pediatric 25 Depo-Estradiol 139 Diastix 180 DEPO-Medrol 130 Diathrive Blood Glucose Test 181 Depo-SubQ Provera 104 148 Diathrive Glucose Test 181 Descovy 61 Diathrive+ Glucose Test 181 DESIPRAMINE HCL 31 DiaTrue Plus Test 181 DESIRUDIN 74 DIAZEPAM 64 DESLORATADINE 211 DIAZEPAM (ANTICONVULSANT) 25,26 Desloratadine 211 DICHLORPHENAMIDE 94 DESMOPRESSIN ACETATE 134,135 DICLOFENAC EPOLAMINE 5 Desmopressin Acetate 134 DICLOFENAC POTASSIUM 5 DESMOPRESSIN ACETATE SPRAY 134 DICLOFENAC SODIUM 5 DESMOPRESSIN ACETATE SPRAY DICLOFENAC SODIUM (OPHTH) 206 REFRIGERATED 134 DICLOFENAC SODIUM (TOPICAL) 5,6 DICLOFENAC W/ MISOPROSTOL 5

©2021 Wellmark, Inc. 234 DICLOXACILLIN SODIUM 20 DOLUTEGRAVIR SODIUM-RILPIVIRINE HCL 56 DICYCLOMINE HCL 119 DONEPEZIL HYDROCHLORIDE 27 DIDANOSINE 60 Doptelet 75 Dificid 21 DORAVIRINE 59 DIFLUNISAL 5 DORAVIRINE-LAMIVUDINE-TENOFOVIR DIFLUPREDNATE 206 DISOPROXIL FUMARATE 59 DIGOXIN 92 DORNASE ALFA 214 DIHYDROERGOTAMINE MESYLATE 35 DORZOLAMIDE HCL 207 Dilantin 27 DORZOLAMIDE HCL-TIMOLOL MALEATE 207 DILTIAZEM HCL 88 DOSTARLIMAB-GXLY 222 DILTIAZEM HCL COATED BEADS 88,89 Dovato 61 DILTIAZEM HCL EXTENDED RELEASE BEADS 88,90 DOXAZOSIN MESYLATE 84 DIMETHYL FUMARATE 103 DOXEPIN HCL 31 Dipentum 171 DOXEPIN HCL (SLEEP) 221 DIPH-AC PERT-TET TOX AD-POLIO IPV- DOXERCALCIFEROL 172 HAEMOPHIL B POLY VAC 169 Doxycycline 23 DIPH-TET TOX-ACELL PERT AD-POLIO IPV-HIB- DOXYCYCLINE (MONOHYDRATE) 23 HEPATITIS B RECOMB 171 DOXYCYCLINE (ROSACEA) 23 DIPH-TETANUS TOX AD-ACELL PERTUSSIS & DOXYCYCLINE CALCIUM 24 POLIO VIRUS, IPV VAC 168,169 DOXYCYCLINE HYCLATE 23 DIPH-TETANUS TOX-ACELL PERT-HEPATITIS B DRONABINOL 32 RECOMB-POLIO IPV VAC 169 DRONEDARONE HCL 86 DIPHENHYDRAMINE HCL 211 DROSPIRENONE 150 DIPHENOXYLATE W/ ATROPINE 120 DROSPIRENONE-ESTETROL 223 Diphenoxylate-Atropine 120 DROSPIRENONE-ESTRADIOL 137 DIPHTHERIA, ACELLULAR PERTUSSIS & TETANUS DROSPIRENONE-ETHINYL TOXOIDS 166,168 ESTRADIOL 139,141,143,144,145,146,147,148 DIPHTHERIA-TETANUS TOXOIDS (DT) 166 DROSPIRENONE-ETHINYL ESTRADIOL- Diphtheria-Tetanus Toxoids DT 166 LEVOMEFOLATE CALCIUM 139,146,147 DIPYRIDAMOLE 84 Droxia 39 DIROXIMEL FUMARATE 105 Duavee 150 DISOPYRAMIDE PHOSPHATE 86 DULOXETINE HCL 102 DISULFIRAM 14 DUPILUMAB 107 Diuril 95 Dupixent 107 DIVALPROEX SODIUM 25 Duraxin 181 Divigel 139 Durezol 206 DOFETILIDE 86 Durolane 107 Dojolvi 110 Durysta 208 DOLASETRON MESYLATE 32 DUTASTERIDE 127 DOLUTEGRAVIR SODIUM 59 DUTASTERIDE-TAMSULOSIN HCL 127 DOLUTEGRAVIR SODIUM-LAMIVUDINE 61 DUVELISIB 44

©2021 Wellmark, Inc. 235 DYPHYLLINE-GUAIFENESIN 218 Element Test 183 Dysport 219 ELETRIPTAN HYDROBROMIDE 35 ELEXACAFTOR-TEZACAFTOR-IVACAFTOR 214 E Eligard 151 EasiVent 181 ELIGLUSTAT TARTRATE 124 EasiVent Mask Large 181 Eliquis 73 EasiVent Mask Medium 181 Eliquis DVT/PE Starter Pack 73 EasiVent Mask Small 181 Ella 148 Easy Plus Blood Glucose Test 181 Elmiron 128 Easy Plus II Glucose Test 181 Eloctate 79 Easy Step Test 181 ELTROMBOPAG OLAMINE 77 Easy Talk Blood Glucose Test 182 ELUXADOLINE 121 Easy Touch HealthPro Glucose 182 ELVITEGRAVIR-COBICISTAT-EMTRICITABINE- Easy Touch Test 182 TENOFOVIR ALAFENAMIDE 58 Easy Trak Blood Glucose Test 182 ELVITEGRAVIR-COBICISTAT-EMTRICITABINE- Easy Trak II Glucose Test 182 TENOFOVIR DF 58 EasyGluco 182 Emadine 205 EasyGluco Plus 182 EMAPALUMAB-LZSG 155 EasyMax 15 Test 182 Embeda 7 EasyMax Test 182 Embrace Blood Glucose Test 183 EasyPlus Blood Glucose Test 182 Embrace Evo Blood Glucose Test 183 EasyPRO Plus 182 Embrace Pro Glucose Test 183 ECALLANTIDE 154 Embrace Talk Glucose Test 183 ECHOTHIOPHATE IODIDE 207 Emcyt 39 ECONAZOLE NITRATE 33 EMEDASTINE DIFUMARATE 205 ECULIZUMAB 199 Emend 32 EDARAVONE 101 Emflaza 131 Edarbi 84 Emgality 36 Edarbyclor 92 Emgality (300 MG Dose) 36 Edex 128 EMICIZUMAB-KXWH 80 Edurant 59 EMPAGLIFLOZIN 66 EFAVIRENZ 59 EMPAGLIFLOZIN-LINAGLIPTIN 66 EFAVIRENZ-EMTRICITABINE-TENOFOVIR EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN 68 DISOPROXIL FUMARATE 59 EMPAGLIFLOZIN-METFORMIN HCL 67,68 EFAVIRENZ-LAMIVUDINE-TENOFOVIR Empaveli 222 DISOPROXIL FUMARATE 61 Emsam 29 Effer-K 110 EMTRICITABINE 60 Elaprase 124 EMTRICITABINE-RILPIVIRINE-TENOFOVIR ELBASVIR-GRAZOPREVIR 57 ALAFENAMIDE FUMARATE 59 Elelyso 124 EMTRICITABINE-RILPIVIRINE-TENOFOVIR Element Compact Test 182 DISOPROXIL FUMARATE 59

©2021 Wellmark, Inc. 236 EMTRICITABINE-TENOFOVIR ALAFENAMIDE EPTINEZUMAB-JJMR 36 FUMARATE 61 EQ Blood Glucose Test 183 EMTRICITABINE-TENOFOVIR DISOPROXIL EQ Space Chamber Anti-Static 183 FUMARATE 60 EQ Space Chamber Anti-Static L 183 Emtriva 60 EQ Space Chamber Anti-Static M 183 ENALAPRIL MALEATE 85 EQ Space Chamber Anti-Static S 183 ENALAPRIL MALEATE & ERDAFITINIB 40 HYDROCHLOROTHIAZIDE 92 ERENUMAB-AOOE 36 ENASIDENIB MESYLATE 40 Ergocalciferol 172 Enbrel 155 ERGOCALCIFEROL 173 Enbrel Mini 155 ERGOLOID MESYLATES 27 Enbrel SureClick 155 Ergoloid Mesylates 27 ENCORAFENIB 43 Ergomar 35 ENFUVIRTIDE 61 ERGOTAMINE TARTRATE 35 Engerix-B 166,222 ERGOTAMINE W/ CAFFEINE 35 ENOXAPARIN SODIUM 73 Erivedge 44 Enspryng 155 Erleada 38 ENTACAPONE 51 ERLOTINIB HCL 44 ENTECAVIR 56 Ertaczo 33 ENTRECTINIB 41 Ery 21 Entresto 92 Erythrocin Stearate 21 Entyvio 155 ERYTHROMYCIN (ACNE AID) 21 Envarsus XR 155 Erythromycin (Ophth) 21 ENZALUTAMIDE 38,224 ERYTHROMYCIN BASE 21 Epclusa 56 ERYTHROMYCIN ETHYLSUCCINATE 21 Epidiolex 24 ERYTHROMYCIN STEARATE 21 Epifoam 131 Esbriet 217 Epinastine HCl (Ophth) 205 ESCITALOPRAM OXALATE 29 EPINEPHRINE (ANAPHYLAXIS) 212,213 ESOMEPRAZOLE MAGNESIUM 123 Epinephrine HCl 212 ESOMEPRAZOLE STRONTIUM 123 EPINEPHRINE HCL (NASAL) 212 Esomeprazole Strontium 123 EpiPen 2-Pak 213 ESTAZOLAM 220 EpiPen Jr 2-Pak 213 ESTERIFIED ESTROGENS 143 Epivir HBV 56 ESTERIFIED ESTROGENS & EPLERENONE 95 METHYLTESTOSTERONE 138,139,140 EPOETIN ALFA 75,76 ESTRADIOL 139,140,143 EPOETIN ALFA-EPBX 77 ESTRADIOL & NORETHINDRONE Epogen 75 ACETATE 136,138,140,143,144 EPOPROSTENOL SODIUM 215,216 ESTRADIOL CYPIONATE 139 EPROSARTAN MESYLATE 85 ESTRADIOL VAGINAL 140,148 Eprosartan Mesylate 85 ESTRADIOL VALERATE 139,140

©2021 Wellmark, Inc. 237 ESTRADIOL VALERATE-DIENOGEST 144 Evrysdi 101 ESTRADIOL-LEVONORGESTREL 138 Exelderm 33 ESTRADIOL-NORGESTIMATE 145 EXEMESTANE 42 ESTRAMUSTINE PHOSPHATE SODIUM 39 EXENATIDE 65 Estring 140 Extavia 103 Estrogel 140 Ez Smart Blood Glucose Test 184 ESTROGENS, CONJUGATED 145 Ez Smart Plus Glucose Test 184 ESTROPIPATE 140 EZETIMIBE 96 Estropipate 140 EZETIMIBE-SIMVASTATIN 96 ESZOPICLONE 220 ETANERCEPT 155 F ETHACRYNIC ACID 94 Fabrazyme 124 ETHAMBUTOL HCL 37 FACTOR IX COMPLEX 79,82 ETHIONAMIDE 37 FaLessa 141 ETHOSUXIMIDE 24 FAMCICLOVIR 63 ETHOTOIN 27 FAMOTIDINE 121 ETHYNODIOL DIACET & ETH ESTRAD 140,142,148 Farxiga 66 ETIDRONATE DISODIUM 172 Farydak 44 Etidronate Disodium 172 Fasenra 218 ETODOLAC 5 Fasenra Pen 218 ETONOGESTREL-ETHINYL ESTRADIOL 139,140 FastTake Test 184 ETOPOSIDE 43 FEBUXOSTAT 35 ETRAVIRINE 59 FEDRATINIB HCL 45 Eucrisa 107 Feiba 79 Euflexxa 183 Feiba NF 79 Eurax 50 FELBAMATE 26 Evamist 140 FELODIPINE 89 EvenCare + Blood Glucose Test 183 FENFLURAMINE HCL (ANTICONVULSANT) 24 EvenCare Blood Glucose Test 184 FENOFIBRATE 95 EvenCare G2 Test 184 FENOFIBRATE MICRONIZED 95 EvenCare G3 Test 184 FENOPROFEN CALCIUM 5,6 EvenCare Mini Glucose Test 184 Fensolvi (6 Month) 151 EvenCare ProView Glucose Test 184 FENTANYL 7,13 Evenity 172 FENTANYL CITRATE 9,10,11 EVEROLIMUS 43,44 Fentora 10 EVEROLIMUS (IMMUNOSUPPRESSANT) 155,159 FERRIC DERISOMALTOSE 111 EVINACUMAB-DGNB 222 Ferriprox 112 Evkeeza 222 Ferriprox Twice-A-Day 112 EVOLOCUMAB 97 FESOTERODINE FUMARATE 127 Evolution Autocode 184 Fiasp 69 Evotaz 62 Fiasp FlexTouch 69

©2021 Wellmark, Inc. 238 Fiasp PenFill 69 FLUOCINONIDE 131 FIDAXOMICIN 21 FLUOCINONIDE EMULSIFIED BASE 131 Fifty50 Glucose Test 2.0 184 FLUOROMETHOLONE (OPHTH) 206 FILGRASTIM 76 FLUOROMETHOLONE ACETATE 206 FILGRASTIM-AAFI 76 Fluoroplex 107 FILGRASTIM-SNDZ 77 Fluorouracil 39 Finacea 107 FLUOROURACIL (TOPICAL) 39,107 FINASTERIDE 127 FLUOXETINE HCL 30 FINERENONE 222 FLUoxetine HCl 30 FINGOLIMOD HCL 103 Fluoxetine HCl (PMDD) 30 Fintepla 24 FLUOXYMESTERONE 136 Firmagon 151 FLUPHENAZINE HCL 53 Firmagon (240 MG Dose) 151 FluPHENAZine HCl 53 Firvanq 16 FLURANDRENOLIDE 131,132 Flarex 206 FLURAZEPAM HCL 220 FLAVOXATE HCL 126 Flurazepam HCl 220 Flebogamma DIF 160 FLURBIPROFEN 5 FLECAINIDE ACETATE 86 FLURBIPROFEN SODIUM 206 Flexichamber 184 FLUTAMIDE 38 Flexichamber Adult Mask/Small 185 FLUTICASONE FUROATE-VILANTEROL 217 Flexichamber Child Mask/Large 185 FLUTICASONE PROPIONATE 129,131 Flexichamber Child Mask/Small 185 FLUTICASONE PROPIONATE (INHALATION) 210 Flolan 215 FLUTICASONE PROPIONATE HFA 210 Flovent Diskus 210 FLUTICASONE-SALMETEROL 217,218 Flovent HFA 210 FLUTICASONE-UMECLIDINIUM-VILANTEROL 210 Fluad 166 FLUVASTATIN SODIUM 96 Fluad Quadrivalent 166 Fluvirin 167 Fluarix Quadrivalent 166 FLUVOXAMINE MALEATE 30 Flublok 166 Fluzone High-Dose 167 Flublok Quadrivalent 166 Fluzone High-Dose Quadrivalent 167 Flucelvax Quadrivalent 167 Fluzone Quadrivalent 167 FLUCONAZOLE 33 FML 206 FLUCYTOSINE 33 Folivane-OB 114 FLUDROCORTISONE ACETATE 131 FONDAPARINUX SODIUM 73 Flulaval Quadrivalent 167 Fora 6 Connect 185 FluMist 167 FORA Blood Glucose Test 185 FluMist Quadrivalent 167 FORA D15g Blood Glucose Test 185 Flunisolide 210 FORA D20 Blood Glucose Test 185 FLUNISOLIDE (NASAL) 210 Fora D40/G31 Blood Glucose 185 FLUOCINOLONE ACETONIDE 129,131 FORA G20 Blood Glucose Test 185 FLUOCINOLONE ACETONIDE (OTIC) 208,209 FORA G30/Prem V10 Glucose Test 185

©2021 Wellmark, Inc. 239 Fora GD20 Test 185 GALCANEZUMAB-GNLM 36 FORA GD50 Blood Glucose Test 185 GALSULFASE 125 FORA GTel Blood Glucose Test 186 GamaSTAN 160 FORA GTel Blood Ketone Test 186 Gamifant 155 FORA TN'G Advance Pro 186 Gammagard 160 Fora TN'G/TN'G Voice 186 Gammagard S/D Less IgA 160 FORA V10 Blood Glucose Test 186 Gammaked 161 FORA V12 Blood Glucose Test 186 Gammaplex 161 FORA V20 Blood Glucose Test 186 Gamunex-C 161 FORA V30a Blood Glucose Test 186 GANCICLOVIR OPHTHALMIC 56 ForaCare GD40 Test 186 Gardasil 9 168 ForaCare premium V10 Test 186 GATIFLOXACIN (OPHTH) 22 ForaCare Test N Go Test 186 Gattex 120 FORMOTEROL FUMARATE 213 GaviLyte-C 121 Forteo 172 Gavreto 43 FortisCare G1 Test Strip 186 GE100 Blood Glucose Test 187 FortisCare Test 187 GEFITINIB 45 FOSAMPRENAVIR CALCIUM 62 Gel-One 187 FOSDENOPTERIN HYDROBROMIDE 223 Gelsyn-3 187 FOSFOMYCIN TROMETHAMINE 16 GEMFIBROZIL 95 FOSINOPRIL SODIUM 85 Genotropin 134 FOSINOPRIL SODIUM & Genotropin MiniQuick 134 HYDROCHLOROTHIAZIDE 92 GenStrip 50 187 FOSTAMATINIB DISODIUM 77 Gentak 14 FOSTEMSAVIR TROMETHAMINE 61 Gentamicin Sulfate 15 Fotivda 222 GENTAMICIN SULFATE (OPHTH) 14 Fragmin 73 GENTAMICIN-PREDNISOLONE ACETATE 204 FreeStyle InsuLinx Test 187 GenUltimate Test 187 FreeStyle Lite Test 187 GenVisc 850 187 FreeStyle Precision Neo Test 187 Genvoya 58 FreeStyle Test 187 GHT Test 187 FREMANEZUMAB-VFRM 27,36 Gilenya 103 FROVATRIPTAN SUCCINATE 35 Gilotrif 44 Fulphila 75 GILTERITINIB FUMARATE 42 FUROSEMIDE 94 Givlaari 124 Fuzeon 61 GIVOSIRAN SODIUM 124 GLASDEGIB MALEATE 44 G GLATIRAMER ACETATE 102,103 GABAPENTIN 25 GLECAPREVIR-PIBRENTASVIR 57 Galafold 124 Gleostine 38 GALANTAMINE HYDROBROMIDE 28 GLIMEPIRIDE 66

©2021 Wellmark, Inc. 240 GLIPIZIDE 66 Granix 75 GLIPIZIDE-METFORMIN HCL 66 GRISEOFULVIN MICROSIZE 33 GlucaGen HypoKit 68 GRISEOFULVIN ULTRAMICROSIZE 33 GLUCAGON 68,69 GUANFACINE HCL 84 GLUCAGON (RDNA) 68 GUANFACINE HCL (ADHD) 100 Glucagon Emergency 68 GUANIDINE HCL 36 GLUCAGON HCL 68 Guanidine HCl 36 GLUCAGON HCL (RDNA) 68 GUSELKUMAB 109 Gluco Perfect 3 Test 188 Gvoke HypoPen 1-Pack 69 Glucocard 01 Sensor Plus 188 Gvoke HypoPen 2-Pack 69 Glucocard Expression Test 188 Gvoke PFS 69 Glucocard Shine Test 188 Gynazole-1 33 Glucocard Vital Test 188 Glucocard X-Sensor 188 H GlucoCom Test 188 Haegarda 153 GlucoNavii Blood Glucose Test 188 HAEMOPHILUS B POLYSAC CONJ VAC 165,168,169 GLUCOSE HALOBETASOL PROPIONATE 129,131 BLOOD 173,174,176,177,178,179,180,181,182,183,18 HALOPERIDOL 53 4,185,186,187,188,189,190,191,192,193,195,196,197, HALOPERIDOL LACTATE 54 198,199,200,201,202 Harmony Blood Glucose Test 189 Glucose Harvoni 56 Blood 174,176,177,182,184,188,191,193,196,200 Havrix 168 Glucose Meter Test 188 Helixate FS 80 Glucose Urine Test-(Glucose Oxidase) 179 Hema-Combistix 189 GLUCOSE URINE TEST-(GLUCOSE OXIDASE) 180 Hemangeol 40 GLYBURIDE 66 HemeNatal OB + DHA 114 GLYBURIDE MICRONIZED 66 Hemlibra 80 GLYBURIDE-METFORMIN 66 Hemofil M 80 GLYCEROL PHENYLBUTYRATE 125 Heparin Lock Flush 74 GLYCOPYRROLATE 119 HEPARIN SODIUM (PORCINE) 74 Glyxambi 66 Heparin Sodium (Porcine) 74 GNP Easy Touch Glucose Test 188 Heparin Sodium (Porcine) Lock Flush 74 GNP True Metrix Glucose Strips 188 HEPARIN SODIUM (PORCINE) LOCK FLUSH 74 Gojji Blood Glucose Test 188 HEPATITIS A (INACTIVATED)-HEPATITIS B Gojji Blood Ketone Test 189 (RECOMBINANT) VACCINES 170 Gojji Blood Test Strip/Lancets 189 HEPATITIS A VACCINE 168,170 GOLIMUMAB 158 HEPATITIS B VACCINE (RECOMB) 166,170,222 Golytely 122 HEPATITIS B VACCINE RECOMBINANT GoodSense Blood Glucose 189 ADJUVANTED 168 GRANISETRON 33 Heplisav-B 168 GRANISETRON HCL 32 Herceptin 49

©2021 Wellmark, Inc. 241 Herzuma 49 HYDROCORTISONE ACETATE W/ Hetlioz 221 PRAMOXINE 107,108,131 Hetlioz LQ 222 HYDROCORTISONE BUTYRATE 132 Hexalen 38 HYDROCORTISONE BUTYRATE HYDROPHILIC Hiberix 168 LIPO BASE 131 Hizentra 161 HYDROCORTISONE SOD SUCCINATE 133 Homatropaire 203 HYDROCORTISONE VALERATE 132 HOMATROPINE HBR 203 HYDROCORTISONE W/ACETIC ACID 208,209 HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT HYDROMORPHONE HCL 7,11 RECOMBINANT VACCINE 168 HYDROmorphone HCl 11 Humate-P 80 HYDROXYCHLOROQUINE SULFATE 50 Humatrope 134 HYDROXYprogesterone Caproate 149 Humira 155,156 HYDROXYPROGESTERONE CAPROATE 149 Humira Pediatric Crohns Start 156 HYDROXYPROGESTERONE CAPROATE Humira Pen 156 (ANTINEOPLASTIC) 149 Humira Pen-CD/UC/HS Starter 156 HYDROXYUREA 39 Humira Pen-Pediatric UC Start 156 HYDROXYUREA (SICKLE CELL ANEMIA) 39 Humira Pen-Ps/UV/Adol HS Start 156 HYDROXYZINE HCL 211 Humira Pen-Psor/Uveit Starter 156 HYDROXYZINE PAMOATE 211 HumuLIN R U-500 (CONCENTRATED) 69 HYLAN 200 HumuLIN R U-500 KwikPen 69 Hymovis 189 HW Embrace Pro Glucose Test 189 Hyophen 16 HW Embrace Talk Glucose Test 189 HYOSCYAMINE SULFATE 119,120 Hyalgan 189 HyperRHO S/D 161 HYALURONAN 189,192,195 HyperSal 218 Hycamtin 43 Hyqvia 162 HYDRALAZINE HCL 97 HYDROCHLOROTHIAZIDE 95 I HYDROCODONE BITARTRATE 7 IBANDRONATE SODIUM 172 HYDROCODONE POLISTIREX- Ibrance 45 CHLORPHENIRAMINE POLISTIREX 218 IBRUTINIB 45 HYDROCODONE W/ HOMATROPINE 218,219 IBUPROFEN 5 HYDROCODONE-ACETAMINOPHEN 10,11,13 ICATIBANT ACETATE 153,154 Hydrocodone-Acetaminophen 11 Iclusig 45 HYDROCODONE-IBUPROFEN 11,13 ICOSAPENT ETHYL 96,97 HYDROCORTISONE 131 IDECABTAGENE VICLEUCEL 221 HYDROCORTISONE (INTRARECTAL) 171 IDELALISIB 48 HYDROCORTISONE (RECTAL) 171,172 Idelvion 80 HYDROCORTISONE (TOPICAL) 129,133 IDHIFA 40 HYDROCORTISONE ACETATE (RECTAL) 171,172 IDURSULFASE 124 HYDROCORTISONE ACETATE (TOPICAL) 132 iGlucose Test Strips 189

©2021 Wellmark, Inc. 242 Ilaris 163 INFLUENZA VIRUS VAC RECOMB ILOPROST 216 HEMAGGLUTININ (HA) QUADRIVALENT 166 Ilumya 107 INFLUENZA VIRUS VAC SPLIT HIGH-DOSE QUAD IMATINIB MESYLATE 45 PRESERVATIVE FREE 167 Imbruvica 45 INFLUENZA VIRUS VACC TYPES A & B SURF Imcivree 120 ANTIGEN ADJUVANT QUAD 166 IMIGLUCERASE 124 Influenza Virus Vaccine Live 167 IMIPRAMINE HCL 31 INFLUENZA VIRUS VACCINE LIVE IMIQUIMOD 107,110 QUADRIVALENT 167 IMMUNE GLOBULIN (HUMAN) IM 160 INFLUENZA VIRUS VACCINE RECOMBINANT IMMUNE GLOBULIN (HUMAN) IV 159,160,161,162 HEMAGGLUTININ (HA) 166 IMMUNE GLOBULIN (HUMAN) IV OR Influenza Virus Vaccine Split 165 SUBCUTANEOUS 160,161 INFLUENZA VIRUS VACCINE SPLIT HIGH-DOSE IMMUNE GLOBULIN (HUMAN) PRESERVATIVE FREE 167 SUBCUTANEOUS 160,161 INFLUENZA VIRUS VACCINE SPLIT IMMUNE GLOBULIN (HUMAN)-HIPP 160 PRESERVATIVE FREE 165 IMMUNE GLOBULIN (HUMAN)-HYALURONIDASE INFLUENZA VIRUS VACCINE SPLIT (HUMAN RECOMBINANT) 162 QUADRIVALENT 165,166,167 IMMUNE GLOBULIN (HUMAN)-IFAS 162 INFLUENZA VIRUS VACCINE TISSUE-CULTURED IMMUNE GLOBULIN (HUMAN)-KLHW 163 SUBUNIT QUADRIVALENT 167 IMMUNE GLOBULIN (HUMAN)-SLRA 159 INFLUENZA VIRUS VACCINE TYPES A & B Impavido 50 SURFACE ANTIGEN 167 Impoyz 132 INFLUENZA VIRUS VACCINE TYPES A & B In Touch Blood Glucose Test 189 SURFACE ANTIGEN ADJUVANT 166 Inatal GT 114 INGENOL MEBUTATE 108 INCOBOTULINUMTOXINA 220 Ingrezza 101 Increlex 134 Inlyta 45 INDAPAMIDE 95 INOTERSEN SODIUM 101 INDINAVIR SULFATE 62 Inqovi 40 Indocin 6 Inrebic 45 INDOMETHACIN 6 InspiraChamber/Large 190 INEBILIZUMAB-CDON 159 InspiraChamber/Medium 190 Infanrix 168 InspiraChamber/Mouthpiece 190 INFIGRATINIB PHOSPHATE 224 InspiraChamber/Small 190 Infinity Blood Glucose Test 189 Inspirease 190 Infinity Voice 189 Insulin Asp Prot & Asp FlexPen 69 Inflectra 156 INSULIN ASPART 69,70,71,72 INFLIXIMAB 158 Insulin Aspart 69 INFLIXIMAB-ABDA 158 INSULIN ASPART (WITH NIACINAMIDE) 69 INFLIXIMAB-AXXQ 154 Insulin Aspart FlexPen 70 INFLIXIMAB-DYYB 156 Insulin Aspart PenFill 70

©2021 Wellmark, Inc. 243 Insulin Aspart Prot & Aspart 70 ISOMETHEPTENE-CAFFEINE- INSULIN ASPART PROTAMINE & ASPART ACETAMINOPHEN 190 (HUMAN) 69,70,72 Isometheptene-Caffeine-APAP 190 INSULIN DEGLUDEC 72 ISONIAZID 37 INSULIN DETEMIR 70 Isoniazid 37 INSULIN GLARGINE 69,72 ISONIAZID-RIFAMPIN W/ PYRAZINAMIDE 37 INSULIN INFUSION DISPOSABLE PUMP 193 Isopto Atropine 203 INSULIN LISPRO 70 Isosorbide Dinitrate 98 Insulin Lispro 70 ISOSORBIDE DINITRATE 98 Insulin Lispro (1 Unit Dial) 70 Isosorbide Dinitrate ER 98 Insulin Lispro Junior KwikPen 70 ISOSORBIDE MONONITRATE 98 Insulin Lispro Prot & Lispro 70 ISOTRETINOIN 105,106,107,108,109 INSULIN LISPRO PROTAMINE & LISPRO 70 ISOXSUPRINE HCL 92 INSULIN LISPRO-AABC 70 ISRADIPINE 89 INSULIN NPH (HUMAN) (ISOPHANE) 71 ISTRADEFYLLINE 51 INSULIN NPH ISOPHANE & REG (HUMAN) 70,71 Isturisa 132 INSULIN PEN NEEDLE 190 ITRACONAZOLE 33 INSULIN REGULAR (HUMAN) 69,71 IVABRADINE HCL 91,92 INSULIN SYRINGE 190 IVACAFTOR 213 INSULIN SYRINGE NEEDLE 190 IVERMECTIN 49 Intelence 59 IVERMECTIN (ROSACEA) 107 INTERFERON BETA-1A 102,104 IVOSIDENIB 41 INTERFERON BETA-1B 102,103 IXAZOMIB CITRATE 40 INTERFERON GAMMA-1B 163 IXEKIZUMAB 109 Intrarosa 190 Ixinity 80 Invirase 62 Iodine Strong 190 J IODINE STRONG (LUGOL'S) 190 Jadenu Sprinkle 112 Iopidine 207 Jakafi 45 Ipol 168 Janssen COVID-19 Vaccine 168 IPRATROPIUM BROMIDE (NASAL) 211 Janumet 66 IPRATROPIUM BROMIDE HFA 211 Janumet XR 66 IPRATROPIUM-ALBUTEROL 217,218 Januvia 66 Iprivask 74 Jardiance 66 IRBESARTAN 85 Jemperli 222 IRBESARTAN-HYDROCHLOROTHIAZIDE 92 Jivi 80 Iressa 45 Juluca 56 ISAVUCONAZONIUM SULFATE 33 Juxtapid 97 Isentress 58 Jynarque 112 Isentress HD 58 ISOCARBOXAZID 29

©2021 Wellmark, Inc. 244 Koselugo 46 K Kovaltry 81 K-Phos 110 Kroger Blood Glucose Test 190 K-Phos No 2 128 Kroger HealthPro Glucose Test 191 K-Tab 110 Kroger Premium Glucose Test 191 Kalbitor 154 Kroger Test 191 Kalydeco 213 Kyleena 149 Kanjinti 45 Kynamro 97 Katerzia 89 Kynmobi 52 Kenalog 132 Kynmobi Titration Kit 52 Kerendia 222 Kesimpta 103 L Keto-Diastix 190 LABETALOL HCL 87 KETOCONAZOLE 33 Labstix 191 KETOCONAZOLE (TOPICAL) 33 LACOSAMIDE 27 KETONE BLOOD TEST 186,189,193,196,197 Lacrisert 203 Ketone Test 190 LACTULOSE 121,122 KETOPROFEN 6 LACTULOSE (ENCEPHALOPATHY) 121,122 Ketoprofen ER 6 LAMIVUDINE 60 KETOROLAC TROMETHAMINE 6 LAMIVUDINE (HBV) 56 KETOROLAC TROMETHAMINE (OPHTH) 205,206 LAMIVUDINE-TENOFOVIR DISOPROXIL Ketostix 190 FUMARATE 60 Keveyis 94 LAMIVUDINE-ZIDOVUDINE 60 Kevzara 163 LAMOTRIGINE 26 Kimyrsa 16 LANADELUMAB-FLYO 154 Kineret 156 LANCETS 191 Kinrix 168 Lanoxin 92 Kisqali (200 MG Dose) 45 LANREOTIDE ACETATE 153 Kisqali (400 MG Dose) 45 LANSOPRAZOLE 123 Kisqali (600 MG Dose) 45 LANTHANUM CARBONATE 113 Kisqali Femara (400 MG Dose) 45 LAPATINIB DITOSYLATE 46 Kisqali Femara (600 MG Dose) 46 LARONIDASE 124 Kisqali Femara(200 MG Dose) 46 LAROTRECTINIB SULFATE 41 Kitabis Pak 214 Lastacaft 205 Klarity-A 21 LATANOPROST 208 Kloxxado 14 Latuda 54 Koate 81 Lazanda 11 Koate-DVI 81 LEDIPASVIR-SOFOSBUVIR 56,57 Kogenate FS 81 Ledipasvir-Sofosbuvir 57 Kogenate FS Bio-Set 81 LEFLUNOMIDE 163 Korlym 132 Lemtrada 103

©2021 Wellmark, Inc. 245 LENALIDOMIDE 39 LEVONORGESTREL-ETHINYL ESTRADIOL & FOLIC LENVATINIB MESYLATE 46 ACID 141 Lenvima (10 MG Daily Dose) 46 LEVONORGESTREL-ETHINYL ESTRADIOL (91- Lenvima (12 MG Daily Dose) 46 DAY) 137,138,141,142,143,146 Lenvima (14 MG Daily Dose) 46 LEVONORGESTREL-ETHINYL ESTRADIOL Lenvima (18 MG Daily Dose) 46 (CONTINUOUS) 137,139,142 Lenvima (20 MG Daily Dose) 46 LEVONORGESTREL-ETHINYL ESTRADIOL- Lenvima (24 MG Daily Dose) 46 FERROUS BISGLYCINATE 137 Lenvima (4 MG Daily Dose) 46 LEVORPHANOL TARTRATE 7 Lenvima (8 MG Daily Dose) 46 LEVOTHYROXINE SODIUM 150,151 LETERMOVIR 56 Lexiva 62 LETROZOLE 43 Liberty Next Generation Test 191 LEUCOVORIN CALCIUM 40 LIDOCAINE 13,14 Leukeran 38 LIDOCAINE HCL 13 Leukine 75 Lidocaine HCl 13 LEUPROLIDE ACETATE 151,152 LIDOCAINE HCL (MOUTH-THROAT) 13 LEUPROLIDE ACETATE & NORETHINDRONE LIDOCAINE HCL (OPHTH) 202 ACETATE 152 LIDOCAINE-HYDROCORTISONE ACETATE LEUPROLIDE ACETATE (3 MONTH) 152 (RECTAL) 107 LEUPROLIDE ACETATE (4 MONTH) 152 LIDOCAINE-PRILOCAINE 13 LEUPROLIDE ACETATE (6 MONTH) 152 LIFITEGRAST 205 LEUPROLIDE ACETATE (CPP) 152 Liletta (52 MG) 149 LEUPROLIDE ACETATE (CPP) (3 MONTH) 152 LINACLOTIDE 121 LEUPROLIDE ACETATE (CPP) (6 MONTH) 151 LINDANE 50 LEVALBUTEROL HCL 213 Lindane 50 LEVALBUTEROL TARTRATE 213 LINEZOLID 16 Levemir 70 Linzess 121 Levemir FlexTouch 70 LIOTHYRONINE SODIUM 150 Levetiracetam 24 Lipofen 95 LEVETIRACETAM 24 LIRAGLUTIDE 68 LEVOBUNOLOL HCL 207 LISDEXAMFETAMINE DIMESYLATE 99 LEVOCARNITINE (METABOLIC MODIFIERS) 110 LISINOPRIL 85 LEVOFLOXACIN 22 LISINOPRIL & HYDROCHLOROTHIAZIDE 92 LEVONORGESTREL & ETH LiteAire 191 ESTRADIOL 136,137,138,139,141,142,143,145,146,14 LITHIUM 65 7,148 Lithium 65 LEVONORGESTREL (IUD) 149,150 LITHIUM CARBONATE 65 LEVONORGESTREL-ETH ESTRADIOL Lithostat 128 (TRIPHASIC) 139,142,144,147 Livalo 96 LEVONORGESTREL-ETHINYL ESTRADIOL 147 Lo Loestrin Fe 143 LODOXAMIDE TROMETHAMINE 205

©2021 Wellmark, Inc. 246 Lokelma 110 Lyumjev 70 LOMITAPIDE MESYLATE 97 Lyumjev KwikPen 70 LOMUSTINE 38 LONAFARNIB 126 M LONCASTUXIMAB TESIRINE-LPYL 224 M-M-R II 168 Lonsurf 40 MACITENTAN 215 LOPINAVIR-RITONAVIR 62 MAFENIDE ACETATE 16,17 LORAZEPAM 64 Makena 149 Lorbrena 43 MALATHION 50 LORLATINIB 43 MANNITOL (CYSTIC FIBROSIS) 178,213 Lortab 11 MAPROTILINE HCL 30 LOSARTAN POTASSIUM 85 Maprotiline HCl 30 LOSARTAN POTASSIUM & MARAVIROC 61 HYDROCHLOROTHIAZIDE 92 Margenza 223 Lotemax 206 MARGETUXIMAB-CMKB 223 Lotemax SM 206 Marplan 29 LOTEPREDNOL ETABONATE 205,206 Mask Vortex 191 LOTEPREDNOL ETABONATE-TOBRAMYCIN 205 Mask Vortex/Child/Frog 191 LOVASTATIN 96 Mask Vortex/Toddler/Ladybug 191 LOXAPINE SUCCINATE 54 Matulane 38 LUBIPROSTONE 121 Mavenclad (10 Tabs) 103 LULICONAZOLE 33,34 Mavenclad (4 Tabs) 103 LUMACAFTOR-IVACAFTOR 214 Mavenclad (5 Tabs) 103 Lumakras 222 Mavenclad (6 Tabs) 103 LUMASIRAN SODIUM 125 Mavenclad (7 Tabs) 103 Lumigan 208 Mavenclad (8 Tabs) 104 Lumizyme 124 Mavenclad (9 Tabs) 104 Lupaneta Pack 152 Mavyret 57 Lupkynis 156 Maxidex 206 Lupron Depot (1-Month) 152 Maxipime 19 Lupron Depot (3-Month) 152 Mayzent 104 Lupron Depot (4-Month) 152 Mayzent Starter Pack 104 Lupron Depot (6-Month) 152 MEASLES, MUMPS & RUBELLA VIRUS Lupron Depot-Ped (1-Month) 152 VACCINES 168 Lupron Depot-Ped (3-Month) 152 MEASLES-MUMPS-RUBELLA-VARICELLA VIRUS LURASIDONE HCL 54 VACCINES 169 LUSPATERCEPT-AAMT 77 MECASERMIN 134 LUSUTROMBOPAG 76 MECHLORETHAMINE HCL (TOPICAL) 38 Luzu 34 MECLOFENAMATE SODIUM 6 Lynparza 47 Meclofenamate Sodium 6 Lysodren 40 Medrol 132

©2021 Wellmark, Inc. 247 MEDROXYPROGESTERONE ACETATE 149 Metaproterenol Sulfate 213 MEDROXYPROGESTERONE ACETATE METAXALONE 220 (CONTRACEPTIVE) 148 METFORMIN HCL 66,67 MEFENAMIC ACID 6 Metformin HCl 67 MEFLOQUINE HCL 50 METHADONE HCL 7,8 MEGESTROL ACETATE (APPETITE) 149 Methadone HCl 8 Meijer Blood Glucose Test 191 METHAMPHETAMINE HCL 99 Meijer Essential Glucose Test 191 METHAZOLAMIDE 207 Meijer Premium Glucose Test 192 METHENAMINE HIPPURATE 16 Meijer TRUEtest Test 192 METHENAMINE MANDELATE 16 Meijer TRUEtrack Test 192 METHENAMINE-HYOSC-METHYLENE BLUE- Mekinist 47 BENZOIC ACID-PHENYL SAL 16,17 Mektovi 47 METHENAMINE-HYOSC-METHYLENE BLUE-SOD MELOXICAM 6 PHOS-PHENYL SAL 15,16,17,18 MELPHALAN 38 METHENAMINE-HYOSCAMINE-METHYLENE BLUE- MELPHALAN FLUFENAMIDE HCL 223 SODIUM PHOSPHATE 16,17 MEMANTINE HCL 28 METHIMAZOLE 153 Menactra 168 METHOCARBAMOL 220 Menest 143 METHOTREXATE 159 MENINGOCOCCAL (A,C,Y&W-135) METHOTREXATE (ANTIRHEUMATIC) 157,158 OLIGOSACCHARIDE CONJUGATE VAC 169 METHOTREXATE SODIUM 157 Meningococcal (A,C,Y&W-135) Polysaccharide METHOXSALEN RAPID 107 Conjugate Vaccine 168 METHOXY POLYETHYLENE GLYCOL-EPOETIN MENINGOCOCCAL (A,C,Y&W-135) BETA 76 POLYSACCHARIDE CONJUGATE VACCINE 168 METHSCOPOLAMINE BROMIDE 119 MENINGOCOCCAL GROUP B VACCINE METHSUXIMIDE 24 (RECOMBINANT) 170 METHYCLOTHIAZIDE 95 MENINGOCOCCAL VAC GROUP B (RECOMBANT Methyclothiazide 95 OMV ADJUVANTED) 166 METHYLDOPA 84 Menostar 143 METHYLDOPA & HYDROCHLOROTHIAZIDE 92 MenQuadfi 168 Methyldopa-Hydrochlorothiazide 92 Menveo 169 METHYLERGONOVINE MALEATE 192 MEPERIDINE HCL 11 METHYLNALTREXONE BROMIDE 120 Meperidine HCl 11 METHYLPHENIDATE HCL 100,101 MEPOLIZUMAB 218 METHYLPREDNISOLONE 132 MEPROBAMATE 63 METHYLPREDNISOLONE ACETATE 130 MERCAPTOPURINE 39,40 METHYLPREDNISOLONE SOD SUCC 132,133 MESALAMINE 171 METHYLTESTOSTERONE 136 MESNA 49 METIPRANOLOL 207 Mesnex 49 Metipranolol 207 METAPROTERENOL SULFATE 213 METOCLOPRAMIDE HCL 31

©2021 Wellmark, Inc. 248 METOLAZONE 95 Monjuvi 49 METOPROLOL & HYDROCHLOROTHIAZIDE 93 Monoclate-P 81 METOPROLOL SUCCINATE 87 Monoferric 111 METOPROLOL TARTRATE 87 MONOMETHYL FUMARATE 102 METRONIDAZOLE 16 Mononine 81 METRONIDAZOLE (TOPICAL) 108 Monovisc 192 METRONIDAZOLE VAGINAL 17,18 MONTELUKAST SODIUM 211 METYROSINE 93 MORPHINE SULFATE 8,11,12 MEXILETINE HCL 86 Morphine Sulfate 11,12 MICONAZOLE (MOUTH-THROAT) 34 Morphine Sulfate ER 8 MICONAZOLE-ZINC OXIDE-WHITE PETROLATUM34 MORPHINE-NALTREXONE 7 MICRhoGAM Ultra-Filtered Plus 162 Motegrity 120 Microchamber 192 Movantik 120 Microdot Test 192 MOXIFLOXACIN HCL 22 Microspacer 192 MOXIFLOXACIN HCL (OPHTH) 22 MIDAZOLAM (ANTICONVULSANT) 14 Mozobil 76 MIDODRINE HCL 84 Mulpleta 76 MIDOSTAURIN 41 Multaq 86 MIFEPRISTONE (HYPERGLYCEMIA) 132 MULTIPLE URINE MIGALASTAT HCL 124 TESTS 178,179,189,191,192,193,201 MIGLITOL 67 Multistix 192 MIGLUSTAT 124 Multistix 10 SG 192 Millipred 132 Multistix 5 192 MILNACIPRAN HCL 102 Multistix 7 192 MILTEFOSINE 50 Multistix 8 192 MINOCYCLINE HCL 23 Multistix 9 192 MINOXIDIL 97 Multistix 9 SG 193 MIPOMERSEN SODIUM 97 MUPIROCIN 17 Mircera 76 MUPIROCIN CALCIUM (TOPICAL) 17 Mirena (52 MG) 149 Muse 128 MIRTAZAPINE 29 Mycapssa 152 MISOPROSTOL 123 MYCOPHENOLATE MOFETIL 154,157 MITOTANE 40 MYCOPHENOLATE SODIUM 157 MM Easy Touch Glucose 192 MyGlucoHealth Test 193 MODAFINIL 221 Myleran 38 Moderna COVID-19 Vaccine 169 Mynatal 114 MOEXIPRIL HCL 85 Mynatal Advance 114 MOEXIPRIL-HYDROCHLOROTHIAZIDE 93 Mynate 90 Plus 114 MOMETASONE FUROATE 132 Myobloc 220 MOMETASONE FUROATE (INHALATION) 209 MOMETASONE FUROATE (NASAL) 210

©2021 Wellmark, Inc. 249 Nerlynx 47 N NETUPITANT-PALONOSETRON 32 NABILONE 32 Neulasta 76 NABUMETONE 6 Neulasta Onpro 76 NADOLOL 87 Neupogen 76 NADOLOL & BENDROFLUMETHIAZIDE 93 Neupro 52 NAFTIFINE HCL 34 Neutek 2Tek Test 193 Naglazyme 125 NEVIRAPINE 59 NALOXEGOL OXALATE 120 NexAVAR 47 NALOXONE HCL 14 Nextstellis 223 NALTREXONE HCL 14 Nexviazyme 223 NAPROXEN 5,6 NIACIN (ANTIHYPERLIPIDEMIC) 97 NAPROXEN SODIUM 6 Niacin (Antihyperlipidemic) 97 NARATRIPTAN HCL 35 Niacor 97 Narcan 14 NICARDIPINE HCL 89 Natacyn 34 NIFEDIPINE 88,89 NATALIZUMAB 105 Nifedipine 89 Natalvit 115 NILOTINIB HCL 47 NATAMYCIN 34 NILUTAMIDE 38 Natazia 144 NIMODIPINE 89,90 NATEGLINIDE 67 Ninlaro 40 Natpara 173 NINTEDANIB ESYLATE 217 Natroba 50 NIRAPARIB TOSYLATE 42 Nayzilam 14 NISOLDIPINE 90 NEBIVOLOL HCL 87 NITAZOXANIDE 49,50 Necon 1/50 (28) 144 NITISINONE 125 NEDOCROMIL SODIUM (OPHTH) 205 Nitro-Bid 98 NEFAZODONE HCL 30 Nitro-Dur 98 NELFINAVIR MESYLATE 63 Nitro-Time 98 NEOMYCIN SULFATE 15 NITROFURANTOIN 17 NEOMYCIN-BACITRACIN ZN-POLYMYXIN 203 NITROFURANTOIN MACROCRYSTAL 17 NEOMYCIN-COLISTIN-HC-THONZONIUM 208 NITROFURANTOIN MONOHYD MACRO 17 NEOMYCIN-POLYMY-DEXAMETH 203 NITROGLYCERIN 98 Neomycin-Polymy-Dexameth 204 NitroMist 98 NEOMYCIN-POLYMYXIN-GRAMICIDIN 203 Nivestym 76 Neomycin-Polymyxin-Gramicidin 203 NIZATIDINE 121 Neomycin-Polymyxin-HC 203 Norditropin FlexPro 134 NEOMYCIN-POLYMYXIN-HC (OPHTH) 203 NORELGESTROMIN-ETHINYL ESTRADIOL 148 Neomycin-Polymyxin-HC (Otic) 209 NORETHIN ACET & ESTRAD- Neoral 157 FE 137,138,141,142,143,144,146 NERATINIB MALEATE 47

©2021 Wellmark, Inc. 250 NORETHINDRONE & ETH NovoLIN R ReliOn 71 ESTRADIOL 136,137,138,141,144,145,148 NovoLOG 71 NORETHINDRONE & ETHINYL ESTRADIOL- NovoLOG 70/30 FlexPen ReliOn 72 FE 142,144,148 NovoLOG FlexPen 72 NORETHINDRONE & MESTRANOL 144 NovoLOG FlexPen ReliOn 72 NORETHINDRONE (CONTRACEPTIVE) 148,149,150 NovoLOG Mix 70/30 72 NORETHINDRONE ACET & ETH NovoLOG Mix 70/30 FlexPen 72 ESTRA 137,141,142,143,144 NovoLOG Mix 70/30 ReliOn 72 NORETHINDRONE ACETATE 149 NovoLOG PenFill 72 NORETHINDRONE ACETATE-ETHINYL NovoLOG ReliOn 72 ESTRADIOL 141,145 NovoSeven RT 82 NORETHINDRONE ACETATE-ETHINYL Noxafil 34 ESTRADIOL-FE 146 Nplate 76 NORETHINDRONE ACETATE-ETHINYL Nubeqa 38 ESTRADIOL-FE FUM (BIPHASIC) 143 Nucala 218 NORETHINDRONE-ETH ESTRADIOL NuCort 132 (TRIPHASIC) 136,137,138,142,144,145 Nulibry 223 NORGESTIMATE-ETHINYL Nutropin AQ NuSpin 10 134 ESTRADIOL 140,141,144,145,146,148 Nutropin AQ NuSpin 20 135 NORGESTIMATE-ETHINYL ESTRADIOL Nutropin AQ NuSpin 5 135 (TRIPHASIC) 145,146,147 Nuvessa 17 NORGESTREL & ETHINYL Nuwiq 82 ESTRADIOL 138,139,143,145 Nymalize 90 Norpace CR 86 NYSTATIN 33,34 NORTRIPTYLINE HCL 31 NYSTATIN (TOPICAL) 34 Norvir 62 NYSTATIN-TRIAMCINOLONE 34 Nourianz 51 Nyvepria 76 Nova Max Glucose Test 193 Nova Max Plus Ketone Test 193 O Novoeight 81 O-Cal Prenatal 115 NovoLIN 70/30 70 OBETICHOLIC ACID 125 NovoLIN 70/30 FlexPen 71 Obizur 82 NovoLIN 70/30 FlexPen Relion 71 Obstetrix DHA 115 NovoLIN 70/30 ReliOn 71 Obstetrix EC 115 NovoLIN N 71 Ocaliva 125 NovoLIN N FlexPen 71 OCRELIZUMAB 104 NovoLIN N FlexPen ReliOn 71 Ocrevus 104 NovoLIN N ReliOn 71 Octagam 162 NovoLIN R 71 OCTREOTIDE ACETATE 151,152 NovoLIN R FlexPen 71 Odefsey 59 NovoLIN R FlexPen ReliOn 71 ODEVIXIBAT 222

©2021 Wellmark, Inc. 251 Odomzo 47 OPIUM TINCTURE 120 OFATUMUMAB (MS) 103 Opsumit 215 Ofev 217 OptiChamber Advantage 194 OFLOXACIN 22 OptiChamber Advantage-Lg Mask 194 Ogestrel 145 OptiChamber Advantage-Med Mask 194 Ogivri 47 OptiChamber Advantage-Sm Mask 194 OLANZAPINE 54 OptiChamber Diamond 194 OLANZAPINE-FLUOXETINE HCL 29 OptiChamber Diamond-Lg Mask 194 OLAPARIB 47 OptiChamber Diamond-Md Mask 194 OLMESARTAN MEDOXOMIL 85 OptiChamber Diamond-Sm Mask 194 OLMESARTAN MEDOXOMIL-AMLODIPINE- OptiChamber Face Mask-Large 194 HYDROCHLOROTHIAZIDE 93 OptiChamber Face Mask-Medium 194 OLMESARTAN MEDOXOMIL- OptiChamber Face Mask-Small 195 HYDROCHLOROTHIAZIDE 93 OptiHaler 195 OLODATEROL HCL 213 Optium Test 195 OLOPATADINE HCL (NASAL) 211 OptiumEZ Test 195 OLSALAZINE SODIUM 171 OptumRx Blood Glucose Test 195 Olumiant 157 Oracea 23 Olysio 57 Oravig 34 OMACETAXINE MEPESUCCINATE 41 Orencia 157 OMALIZUMAB 219 Orencia ClickJect 157 OMBITASVIR-PARITAPREVIR-RITONAVIR 57 Orenitram 215 OMBITASVIR-PARITAPREVIR-RITONAVIR- Orfadin 125 DASABUVIR 57 Orgovyx 152 OMEPRAZOLE 123 ORITAVANCIN DIPHOSPHATE 16 OMEPRAZOLE MAGNESIUM 123 Orkambi 214 OmniPod Dash 5 Pack Pods 193 Orladeyo 154 Omnitrope 135 ORPHENADRINE CITRATE 220 On Call Express Blood Glucose 193 OrthoVisc 195 On Call Plus Blood Glucose 193 OSELTAMIVIR PHOSPHATE 63 On Call Vivid Blood Glucose 193 OSILODROSTAT PHOSPHATE 132 ONABOTULINUMTOXINA 55 OSIMERTINIB MESYLATE 47 Ondansetron 32 OsmoPrep 122 ONDANSETRON HCL 32 OSPEMIFENE 150 One Drop Test 193 Osphena 150 OneTouch Test 193 Otezla 163,164 OneTouch Ultra 193 Otrexup 157 OneTouch Verio 193 OXANDROLONE 136 Ongentys 51 OXAPROZIN 6 Onureg 40 OXAZEPAM 64 OPICAPONE 51 Oxbryta 84

©2021 Wellmark, Inc. 252 OXCARBAZEPINE 27 Panda Mask Medium 195 Oxervate 203 Panda Mask Small 195 Oxlumo 125 PANOBINOSTAT LACTATE 44 OXYBUTYNIN CHLORIDE 126,127 Panretin 49 OXYCODONE HCL 8,12 PANTOPRAZOLE SODIUM 123 OxyCODONE HCl ER 8 Panzyga 162 OXYCODONE W/ ACETAMINOPHEN 10,12 Paragard Intrauterine Copper 195 Oxycodone-Acetaminophen 12 PARATHYROID HORMONE (RECOMBINANT) 173 OXYCODONE-ASPIRIN 12 PAREGORIC 120 OXYCODONE-IBUPROFEN 12 Paregoric 120 Oxycodone-Ibuprofen 12 PARICALCITOL 173 OxyCONTIN 8 PAROMOMYCIN SULFATE 15 OXYMETHOLONE 136 PAROXETINE HCL 30 OXYMORPHONE HCL 9,12 Paroxetine HCl 30 OxyMORphone HCl ER 9 PAROXETINE MESYLATE (VASOMOTOR) 30 OZANIMOD HCL 105 Paser 37 Ozempic (0.25 or 0.5 MG/DOSE) 67 PASIREOTIDE DIASPARTATE 153 Ozempic (1 MG/DOSE) 67 PATIROMER SORBITEX CALCIUM 113 PAZOPANIB HCL 48 P PEANUT (ARACHIS HYPOGAEA) ALLERGEN PALBOCICLIB 45 POWDER-DNFP 164,165 Palforzia (12 MG Daily Dose) 164 Pediarix 169 Palforzia (120 MG Daily Dose) 164 Pediatric Panda Mask 195 Palforzia (160 MG Daily Dose) 164 Pedvax HIB 169 Palforzia (20 MG Daily Dose) 164 PEG 3350-KCL-NACL-NA SULFATE-NA Palforzia (200 MG Daily Dose) 164 ASCORBATE-ASCORBIC ACID 122 Palforzia (240 MG Daily Dose) 164 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD Palforzia (3 MG Daily Dose) 164 SULFATE 121,122 Palforzia (300 MG Maintenance) 164 PEG 3350-POTASSIUM CHLORIDE-SOD Palforzia (300 MG Titration) 164 BICARBONATE-SOD CHLORIDE 122,123 Palforzia (40 MG Daily Dose) 165 PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Palforzia (6 MG Daily Dose) 165 Chloride 122 Palforzia (80 MG Daily Dose) 165 Peg-Intron Redipen 57 Palforzia Initial Escalation 165 Peganone 27 PALIPERIDONE 54 Pegasys 58 PALIVIZUMAB 165 Pegasys ProClick 58 Palynziq 125 PEGCETACOPLAN 222 Pancreaze 125 PEGFILGRASTIM 76 PANCRELIPASE (LIPASE-PROTEASE- PEGFILGRASTIM-APGF 76 AMYLASE) 124,125,126 PEGFILGRASTIM-BMEZ 77 Panda Mask Large 195 PEGFILGRASTIM-CBQV 77

©2021 Wellmark, Inc. 253 PEGFILGRASTIM-JMDB 75 PHENYTOIN 27 PEGINTERFERON ALFA-2A 58 PHENYTOIN SODIUM EXTENDED 27 PEGINTERFERON ALFA-2B 57,58 Phesgo 41 PEGINTERFERON ALFA-2B (ANTINEOPLASTIC) 41 Phospholine Iodide 207 PEGINTERFERON BETA-1A 104 PHYTONADIONE 84 PegIntron 58 Picato 108 PEGVALIASE-PQPZ 125 Pifeltro 59 PEGVISOMANT 153 PILOCARPINE HCL 207 Pemazyre 40 PILOCARPINE HCL (ORAL) 105 PEMIGATINIB 40 PIMECROLIMUS 108 PENICILLAMINE 128 PIMOZIDE 54 PENICILLIN G BENZATHINE 20 Pimozide 54 PENICILLIN V POTASSIUM 20 PINDOLOL 87 Pentacel 169 PIOGLITAZONE HCL 67 PENTAMIDINE ISETHIONATE 50 PIOGLITAZONE HCL-GLIMEPIRIDE 67 Pentasa 171 PIOGLITAZONE HCL-METFORMIN HCL 67 PENTAZOCINE W/ NALOXONE 12 Piqray (200 MG Daily Dose) 43 PENTOSAN POLYSULFATE SODIUM 128 Piqray (250 MG Daily Dose) 43 PENTOXIFYLLINE 93 Piqray (300 MG Daily Dose) 43 Pepaxto 223 PIRFENIDONE 217 PERINDOPRIL ERBUMINE 85 PIROXICAM 6 Permethrin 50 PITAVASTATIN CALCIUM 96 PERMETHRIN 50 PITAVASTATIN MAGNESIUM 96 PERPHENAZINE 31 PITOLISANT HCL 221 PERPHENAZINE-AMITRIPTYLINE 29 PLECANATIDE 121 Perphenazine-Amitriptyline 29 Plegridy 104 PERTUZUMAB-TRASTUZUMAB-HYALURONIDASE- Plegridy Starter Pack 104 ZZXF 41 Plenvu 122 Pertzye 125 PLERIXAFOR 76 PEXIDARTINIB HCL 41 PNEUMOCOCCAL 13-VALENT CONJUGATE Pfizer-BioNTech COVID-19 Vacc 169 VACCINE 169 Pharmacist Choice Autocode 195 PNEUMOCOCCAL 20-VALENT CONJUGATE Pharmacist Choice No Coding 196 VACCINE 223 PHENAZOPYRIDINE HCL 128 PNEUMOCOCCAL VAC POLYVALENT 169 PHENELZINE SULFATE 29 Pneumovax 23 169 PHENOBARBITAL 25 PNV Prenatal Plus Multivit+DHA 115 PHENOXYBENZAMINE HCL 84 PNV Tabs 29-1 115 PHENYLEPHRINE HCL (MYDRIATIC) 204 PNV-VP-U 115 PHENYLEPHRINE HCL (OPHTH) 202 Pocket Chamber 196 PHENYLEPHRINE W/ DM-GG 218 PocketChem EZ Test 196 Phenylephrine-Guaifenesin 218 Podocon 108

©2021 Wellmark, Inc. 254 PODOFILOX 108 PRAZIQUANTEL 49 PODOPHYLLUM RESIN 108 PRAZOSIN HCL 84 POLATUZUMAB VEDOTIN-PIIQ 49 Precision PCx 196 POLIOVIRUS VACCINE, IPV 168 Precision PCX Plus Test 196 Polivy 49 Precision Point of Care Test 196 POLYMYXIN B-TRIMETHOPRIM 204 Precision QID Test 196 POMALIDOMIDE 39 Precision Xtra Blood Glucose 196 Pomalyst 39 Precision Xtra Ketone 196 PONATINIB HCL 45 Pred Mild 206 PONESIMOD 223 Pred-G 204 Ponvory 223 Pred-G S.O.P. 204 Ponvory Starter Pack 223 PREDNICARBATE 132 POSACONAZOLE 34 Prednicarbate 132 POT & SOD CITRATES W/CITRIC AC 128,129 PREDNISOLONE 132,133 Pot Bicarb-Pot Chloride 111 PREDNISOLONE ACETATE (OPHTH) 206 POT PHOSPHATE MONOBASIC W/ SOD PREDNISOLONE SODIUM PHOSPHATE 133 PHOSPHATE DIBASIC & MONOBASIC 113 PrednisoLONE Sodium Phosphate 206 POTASSIUM & SODIUM ACID PHOSPHATES 128 PREDNISOLONE SODIUM PHOSPHATE POTASSIUM BICARB & CHLORIDE 110,111 (OPHTH) 206 POTASSIUM BICARBONATE-CITRIC ACID 110 PREDNISONE 130,133 POTASSIUM CHLORIDE 110,111 PredniSONE Intensol 133 POTASSIUM CHLORIDE MICROENCAPSULATED Prefest 145 CRYSTALS ER 110,111 PREGABALIN 102 POTASSIUM CITRATE (ALKALINIZER) 128 PREGABALIN (ONCE-DAILY) 25 POTASSIUM CITRATE-CITRIC ACID 128,129 Premarin 145 POTASSIUM PHOSPHATE MONOBASIC 110 Premium Blood Glucose Test 196 POVIDONE-IODINE (OPHTH) 202 Premphase 146 PR Natal 400 115 Prempro 146 PR Natal 400 ec 115 Prenaissance Next 116 PR Natal 430 115 PreNata 116 PR Natal 430 ec 116 Prenatabs FA 116 Pradaxa 74 Prenatabs Rx 116 PRALSETINIB 43 Prenatal 19 116 Praluent 97 PRENATAL MV & MIN W/FE BISGLYC-FE PROT PRAMIPEXOLE DIHYDROCHLORIDE 52 SUCC-FA-CA-OMEGA 3 114,115,116,117 PRAMLINTIDE ACETATE 67 Prenatal Plus Iron 116 Pramosone 132 PRENATAL VIT W/ DOCUSATE-FE FUMARATE- PRAMOXINE-HC 131,132 FOLIC ACID 114,116,117 PRASTERONE VAGINAL 190 PRENATAL VIT W/ DOCUSATE-IRON CARBONYL- PRASUGREL HCL 84 FOLIC ACID 113,114,115,117,118 PRAVASTATIN SODIUM 96 Prenatal Vit w/ Docusate-Iron Carbonyl-Folic Acid 114

©2021 Wellmark, Inc. 255 PRENATAL VIT W/ FE BISGLYCINATE CHELATE- Priftin 37 FOLIC ACID 113 PriLOSEC 123 Prenatal Vit w/ Fe Bisglycinate Chelate-Folic Acid 118 PRIMAQUINE PHOSPHATE 50 PRENATAL VIT W/ FE POLY CMPLX-FE HEME PRIMIDONE 25 POLYPEPT-FA & OMEGA 3 114,119 Primsol 17 PRENATAL VIT W/ FERROUS FUMARATE-FA- Privigen 162 OMEGA 3 FATTY ACIDS 115 Pro Comfort Spacer Adult 196 PRENATAL VIT W/ FERROUS FUMARATE-FOLIC Pro Comfort Spacer Child 196 ACID 114,115,116,117,118 Pro Comfort Spacer Infant 197 PRENATAL VIT W/ FERROUS FUMARATE-L Pro Voice V8/V9 Glucose 197 METHYLFOLATE-FOLIC ACID 117 PROBENECID 35 PRENATAL VIT W/ IRON CARBONYL-FE PROCARBAZINE HCL 38 GLUCONATE-FOLIC ACID 118 Procare Spacer/Adult Mask 197 PRENATAL VIT W/ IRON CARBONYL-FOLIC Procare Spacer/Child Mask 197 ACID 115,116,117,118 PROCHLORPERAZINE 31,32 PRENATAL VIT W/ SELENIUM-FE FUMARATE- PROCHLORPERAZINE MALEATE 32 FOLIC ACID 118 ProCort 108 PRENATAL W/ CALCIUM CARBONATE-VIT B6-VIT Procrit 76 B12-FOLIC ACID 113 Proctofoam HC 108 PRENATAL W/ CALCIUM-VIT B6-FOLIC ACID- Procysbi 125 GINGER 116,119 Prodigy No Coding Blood Gluc 197 PRENATAL W/FE CARBONYL-FA-DSS-OMEGA 3 Profilnine 82 FATTY ACIDS 115 Profilnine SD 82 PRENATAL WITHOUT A VIT W/ FE FUM-IRON PROGESTERONE 150 POLYSACCH COMPLEX -FA 114,116,117,118 PROGESTERONE (VAGINAL) 148 Prenatal without A Vit w/ Fe Fumarate-Folic Prograf 157 Acid 114,118 Prolensa 206 PRENATAL WITHOUT A VIT W/ FE FUMARATE- Prolia 173 FOLIC ACID 115,116 Promacta 77 PRENATAL WITHOUT VIT A W/ IRON CARBONYL- PROMETHAZINE & PHENYLEPHRINE 218,219 FOLIC ACID & VIT B6 117 PROMETHAZINE HCL 31,32,211 Prenatal-U 116 PROMETHAZINE W/CODEINE 218 Prepopik 122 PROMETHAZINE-DM 218 PreTAB 116 PROMETHAZINE-PHENYLEPHRINE- PRETOMANID 37 CODEINE 218,219 Pretomanid 37 Promethegan 32 Prevnar 13 169 PROPAFENONE HCL 86 Prevnar 20 223 PROPANTHELINE BROMIDE 119 Prevymis 56 Propantheline Bromide 119 Prezcobix 62 PROPARACAINE HCL 204 Prezista 62,63 PROPRANOLOL & HYDROCHLOROTHIAZIDE 93

©2021 Wellmark, Inc. 256 PROPRANOLOL HCL 40,87 RALOXIFENE HCL 150 Propranolol-HCTZ 93 RALTEGRAVIR POTASSIUM 58 PROPYLTHIOURACIL 153 RAMELTEON 221 ProQuad 169 RAMIPRIL 85 PROTRIPTYLINE HCL 31 RANITIDINE HCL 121 Provida OB 116 RANOLAZINE 93 PRUCALOPRIDE SUCCINATE 120 RASAGILINE MESYLATE 53 PSEUDOEPHED-BROMPHEN-DM 217,219 Rasuvo 158 PSEUDOEPHED-CPM W/ HYDROCOD 219 Ravicti 125 PTS Panels Ketone Test 197 RAVULIZUMAB-CWVZ 201 Pulmicort Flexhaler 210 Rayaldee 173 Pulmozyme 214 Rebetol 58 PureFe OB Plus 117 Rebif 104 Purixan 40 Rebif Rebidose 104 PYRAZINAMIDE 37 Rebif Rebidose Titration Pack 104 PYRIDOSTIGMINE BROMIDE 36,37 Rebif Titration Pack 104 PYRIMETHAMINE 50 Rebinyn 82 Reblozyl 77 Q Reclast 173 Qbrelis 85 Recombinate 82 Qinlock 41 Recombivax HB 170 Quadracel 169 RediTrex 158 QUETIAPINE FUMARATE 54,55 RefuAH Plus Blood Glucose Test 197 Quillivant XR 100 REGORAFENIB 47 Quinapril HCl 85 Regranex 108 QUINAPRIL-HYDROCHLOROTHIAZIDE 93 Relenza Diskhaler 63 QUINIDINE GLUCONATE 86 Relexxii 101 QUINIDINE SULFATE 86 ReliOn Blood Glucose Test 197 QuiNIDine Sulfate 86 ReliOn Confirm/micro Test 198 QUININE SULFATE 50 ReliOn Ketone 198 Quintet AC Blood Glucose Test 197 ReliOn Ketone Test 198 Quintet Blood Glucose Test 197 ReliOn Premier Test 198 Qvar 210 ReliOn Prime Test 198 Qvar RediHaler 210 ReliOn True Metrix Test Strips 198 ReliOn Ultima Test 198 R Relistor 120 RA Alcohol Swabs 197 RELUGOLIX 152 RA TRUEtest Test 197 Remicade 158 RABEPRAZOLE SODIUM 123,124 Remodulin 215 RABEprazole Sodium 123 Renflexis 158 Radicava 101 REPAGLINIDE 67

©2021 Wellmark, Inc. 257 REPAGLINIDE-METFORMIN HCL 67 RIMANTADINE HYDROCHLORIDE 63 Repaglinide-Metformin HCl 67 Rinvoq 158 Repatha 97 RIOCIGUAT 215 Repatha Pushtronex System 97 Riomet ER 67 Repatha SureClick 97 RIPRETINIB 41 Rescriptor 59 RISANKIZUMAB-RZAA 108,223 RESLIZUMAB 217 RISDIPLAM 101 Restasis 204 RISEDRONATE SODIUM 173 Restasis Multidose 204 RISPERIDONE 55 Retacrit 77 RiteFlo 199 RETAPAMULIN 15 RITONAVIR 62,63 Retevmo 41 RITUXIMAB-ARRX 49 Revatio 215 RIVAROXABAN 74 Reveal Blood Glucose Test 198 RIVASTIGMINE 28 Revlimid 39 RIVASTIGMINE TARTRATE 28 Rexall Blood Glucose Test 198 Rixubis 83 Reyataz 63 RIZATRIPTAN BENZOATE 35 Rezurock 223 ROFLUMILAST 214 RHO D IMMUNE GLOBULIN (HUMAN) 161,162 ROMIPLOSTIM 76 RhoGAM Ultra-Filtered Plus 162 ROMOSOZUMAB-AQQG 172 Rhophylac 162 ROPINIROLE HYDROCHLORIDE 53 Riabni 49 ROSIGLITAZONE MALEATE-METFORMIN HCL 65 RIBAVIRIN (HEPATITIS C) 57,58 ROSUVASTATIN CALCIUM 96 RIBOCICLIB SUCCINATE 45 Rotarix 170 RIBOCICLIB SUCCINATE-LETROZOLE 45,46 RotaTeq 170 Ridaura 165 ROTAVIRUS VACCINE, LIVE ORAL 170 RIFABUTIN 37 ROTAVIRUS VACCINE, LIVE ORAL RIFAMPIN 37 PENTAVALENT 170 RIFAMYCIN SODIUM 15 ROTIGOTINE 52 RIFAPENTINE 37 Rozlytrek 41 Rifater 37 Rubraca 41 RIFAXIMIN 18 RUCAPARIB CAMSYLATE 41 Rightest GS100 Blood Glucose 198 Ruconest 154 Rightest GS300 Blood Glucose 198 RUFINAMIDE 27 Rightest GS550 Blood Glucose 198 Rukobia 61 Rightest GT333 Blood Glucose 198 RUXOLITINIB PHOSPHATE 45 RILONACEPT 163 Ruzurgi 37 RILPIVIRINE HCL 59 Rybrevant 223 RILUZOLE 101 Rydapt 41 RIMABOTULINUMTOXINB 220 Rylaze 223 RiMANTAdine HCl 63

©2021 Wellmark, Inc. 258 SERDEXMETHYLPHENIDATE CHLORIDE- S DEXMETHYLPHENIDATE HCL 222 SACROSIDASE 126 Serevent Diskus 213 SACUBITRIL-VALSARTAN 92 Serostim 135 SAFINAMIDE MESYLATE 53 SERTACONAZOLE NITRATE 33 Saizen 135 SERTRALINE HCL 30 Saizen Click.Easy 135 SETMELANOTIDE ACETATE 120 Saizenprep 135 SEVELAMER CARBONATE 113 SALMETEROL XINAFOATE 213 SEVELAMER HCL 113 SALSALATE 6 Sevenfact 83 Sancuso 33 Shingrix 170 SandIMMUNE 158 Signifor 153 SandoSTATIN LAR Depot 152 SILDENAFIL CITRATE 128 Santyl 108 SILDENAFIL CITRATE (PULMONARY Saphnelo 223 HYPERTENSION) 215,216 SAPROPTERIN DIHYDROCHLORIDE 126 Siliq 108 SAQUINAVIR MESYLATE 62 SILODOSIN 127 SARGRAMOSTIM 75 SILVER SULFADIAZINE 22 SARILUMAB 163 Simbrinza 208 SATRALIZUMAB-MWGE 155 SIMEPREVIR SODIUM 57 Savella 102 Simponi 158 Savella Titration Pack 102 Simponi Aria 158 Scenesse 108 SIMVASTATIN 96 SCOPOLAMINE 32 SINECATECHINS 109 Se-Natal 19 117 SIPONIMOD FUMARATE 104 SECNIDAZOLE 17 SIROLIMUS 159 SECOBARBITAL SODIUM 221 Sirturo 37 Seconal 221 SITAGLIPTIN PHOSPHATE 66 SECUKINUMAB 106 SITAGLIPTIN-METFORMIN HCL 66 SEGESTERONE ACETATE-ETHINYL Sivextro 17 ESTRADIOL 137 Skyla 150 SELEGILINE 29 Skyrizi 223 SELEGILINE HCL 53 Skyrizi (150 MG Dose) 108 SELENIUM SULFIDE 108 Slynd 150 SELEXIPAG 216,224 SM Alcohol Prep 199 SELINEXOR 42 Smart Sense Premium Test 199 SELPERCATINIB 41 Smart Sense Value Test 199 SELUMETINIB SULFATE 46 Smartest Blood Glucose Test 199 Selzentry 61 Sodium Bicarbonate 111 SEMAGLUTIDE 67 SODIUM CHLORIDE 111 Semglee 72 SODIUM CHLORIDE (INHALANT) 218,219

©2021 Wellmark, Inc. 259 SODIUM CHLORIDE FLUSH 110,111 Sovaldi 57 SODIUM CITRATE & CITRIC ACID 128,129 SPACER/AEROSOL-HOLDING CHAMBER Sodium Hyaluronate 199 SUPPLIES - MASKS 185,191,195 SODIUM HYALURONATE SPACER/AEROSOL-HOLDING (VISCOSUPPLEMENT) 107,183,187,189,199,200,201 CHAMBERS 174,175,176,177,178,179,180,181,183,18 SODIUM OXYBATE 221 4,190,191,192,194,195,196,197,199,201,202 SODIUM PHENYLBUTYRATE 126 Spacer/Aerosol-Holding Chambers 190,194 SODIUM PHOSPHATE MONOBASIC-SODIUM Spectracef 19 PHOSPHATE DIBASIC 122 SPINOSAD 50 SODIUM PICOSULFATE-MAGNESIUM OXIDE- Spinosad 50 ANHYDROUS CITRIC ACID 121,122 Spiriva HandiHaler 212 SODIUM POLYSTYRENE SULFONATE 112 Spiriva Respimat 212 SODIUM SULFATE-MAGNESIUM SULFATE- SPIRONOLACTONE 94,95 POTASSIUM CHLORIDE 123 SPIRONOLACTONE & HYDROCHLOROTHIAZIDE 93 SODIUM SULFATE-POTASSIUM SULFATE- Sprycel 47 MAGNESIUM SULFATE 122 SPS 112 SODIUM ZIRCONIUM CYCLOSILICATE 110 Stalevo 100 51 SOFOSBUVIR 57 Stalevo 125 51 SOFOSBUVIR-VELPATASVIR 56,57 Stalevo 150 51 Sofosbuvir-Velpatasvir 57 Stalevo 200 51 SOFOSBUVIR-VELPATASVIR-VOXILAPREVIR 57 Stalevo 50 52 Solesta 199 Stalevo 75 52 SOLIFENACIN SUCCINATE 127 STAVUDINE 60,61 Soliris 199 Stelara 109 Solodyn 23 Stimate 135 Solosec 17 Stiolto Respimat 219 Soltamox 39 STIRIPENTOL 24 Solu-CORTEF 133 Stivarga 47 SOLU-medrol 133 Strensiq 126 Solus V2 Test 199 Stribild 58 SOMATROPIN 134,135 Striverdi Respimat 213 SOMATROPIN (NON-REFRIGERATED) 135 Subsys 13 Somatuline Depot 153 SUCCIMER 111 Somavert 153 Sucraid 126 SONIDEGIB PHOSPHATE 47 SUCRALFATE 123 SORAFENIB TOSYLATE 47 SUCROFERRIC OXYHYDROXIDE 113 Sorilux 108 SULCONAZOLE NITRATE 33,34 SOTALOL HCL 86,87 Sulconazole Nitrate 34 SOTALOL HCL (AFIB/AFL) 86 SULFACETAMIDE SOD-PREDNISOLONE 202,204 SOTORASIB 222 SULFACETAMIDE SODIUM (ACNE) 22 Sotylize 87 SULFACETAMIDE SODIUM (OPHTH) 22

©2021 Wellmark, Inc. 260 SULFACETAMIDE SODIUM-SULFUR IN UREA Tabrecta 41 VEHICLE 109 TACROLIMUS 154,155,157,159 Sulfacetamide-Sulfur in Urea 109 TACROLIMUS (TOPICAL) 109 SULFADIAZINE 22 TADALAFIL 127 SulfADIAZINE 22 TADALAFIL (PULMONARY HYPERTENSION)215,216 SULFAMETHOXAZOLE-TRIMETHOPRIM 22 TAFAMIDIS 94 Sulfamylon 17 TAFAMIDIS MEGLUMINE (CARDIAC) 94 SULFANILAMIDE VAGINAL 22 TAFASITAMAB-CXIX 49 SULFASALAZINE 172 Tafinlar 47 SULFURIC ACID-SULFONATED PHENOLICS 105 Tagrisso 47 SULINDAC 6 Takhzyro 154 SUMATRIPTAN 35 TALAZOPARIB TOSYLATE 47 SUMATRIPTAN SUCCINATE 35,36 TALIGLUCERASE ALFA 124 SUMATRIPTAN-NAPROXEN SODIUM 36 Taltz 109 SUNITINIB MALATE 47 Talzenna 47 Supartz FX 199 TAMOXIFEN CITRATE 39 Suprax 19 TAMSULOSIN HCL 127 Suprep Bowel Prep Kit 122 Targretin 49 Sure Edge Test 199 Taron-Bc 117 Sure-Test EasyPlus Mini Test 199 Tasigna 47 SureChek Blood Glucose Test 199 TASIMELTEON 221,222 SureStep Test 200 Tavalisse 77 Sutab 123 TAZAROTENE 109 Sutent 47 TAZEMETOSTAT HBR 41 Sylatron 41 Tazorac 109 Symbicort 219 Tazverik 41 Symdeko 214 TBO-FILGRASTIM 75 Symjepi 213 TDVAX 170 SymlinPen 120 67 Tecartus 41 SymlinPen 60 67 Technivie 57 Symtuza 58 TEDIZOLID PHOSPHATE 17 Synagis 165 TEDUGLUTIDE (RDNA) 120 Synjardy 67 Tegsedi 101 Synjardy XR 68 Telcare Blood Glucose Test 200 Synribo 41 TELMISARTAN 85 Synthroid 151 TELMISARTAN-AMLODIPINE 93 Synvisc 200 TELMISARTAN-HYDROCHLOROTHIAZIDE 93 Synvisc One 200 TEMAZEPAM 220 Temixys 60 T TEMOZOLOMIDE 38 Tabloid 40 Tencon 101

©2021 Wellmark, Inc. 261 Tenivac 170 TILDRAKIZUMAB-ASMN 107 TENOFOVIR ALAFENAMIDE FUMARATE 56 TIMOLOL 207 TENOFOVIR DISOPROXIL FUMARATE 60,61 TIMOLOL MALEATE 87 Tepezza 204 TIMOLOL MALEATE (OPHTH) 208 Tepmetko 223 TINIDAZOLE 17 TEPOTINIB HCL 223 TIOPRONIN 128 TEPROTUMUMAB-TRBW 204 TIOTROPIUM BROMIDE MONOHYDRATE 212 TERAZOSIN HCL 84 TIOTROPIUM BROMIDE-OLODATEROL HCL 219 TERBINAFINE HCL 34 TIPRANAVIR 62 TERBUTALINE SULFATE 213 Tivicay 59 TERCONAZOLE VAGINAL 34 Tivicay PD 59 TERIFLUNOMIDE 102 TIVOZANIB HCL 222 TERIPARATIDE (RECOMBINANT) 172,173 TIZANIDINE HCL 55 Teriparatide (Recombinant) 173 TL Folate 117 TESTOSTERONE 136 Tobi Podhaler 214 TESTOSTERONE CYPIONATE 136 TobraDex 204 TESTOSTERONE ENANTHATE 136 TobraDex ST 204 TETANUS TOXOID-DIPHTHERIA-ACELLULAR TOBRAMYCIN 214 PERTUSSIS ADSORB (TDAP) 165,166 TOBRAMYCIN (OPHTH) 15 TETANUS-DIPHTHERIA TOXOIDS (TD) 170 TOBRAMYCIN SULFATE 15 Tetanus-Diphtheria Toxoids Td 170 TOBRAMYCIN-DEXAMETHASONE 204 TETRABENAZINE 101 Tobrex 15 TETRACAINE HCL (OPHTH) 202,204 TOCILIZUMAB 163 TETRACYCLINE HCL 23 TOFACITINIB CITRATE 159,224 Texacort 133 TOLAZAMIDE 68 TEZACAFTOR-IVACAFTOR 214 TOLAZamide 68 TGT Blood Glucose Test 200 TOLBUTAMIDE 68 THALIDOMIDE 39 TOLBUTamide 68 Thalomid 39 TOLCAPONE 52 THEOPHYLLINE 214,215 TOLMETIN SODIUM 7 THIOGUANINE 40 Tolmetin Sodium 7 Thiola EC 128 TOLTERODINE TARTRATE 127 THIORIDAZINE HCL 54 TOLVAPTAN 112 THIOTHIXENE 54 TOPIRAMATE 26 Thrivite Rx 117 TOPOTECAN HCL 43 Thyrogen 200 TOREMIFENE CITRATE 39 THYROID 151 TORSEMIDE 94 THYROTROPIN ALFA 200 Toviaz 127 TIAGABINE HCL 25 Tracleer 216 Tibsovo 41 TRAMADOL HCL 9,13 TICAGRELOR 83 TRAMADOL-ACETAMINOPHEN 13

©2021 Wellmark, Inc. 262 TRAMETINIB DIMETHYL SULFOXIDE 47 TRIMETHOBENZAMIDE HCL 32 Trandolapril 86 TRIMETHOPRIM 17 TRANDOLAPRIL-VERAPAMIL HCL 94 TRIMETHOPRIM HCL 17 TRANEXAMIC ACID 83 TRIMIPRAMINE MALEATE 31 TRANYLCYPROMINE SULFATE 29 Trimpex 17 TRASTUZUMAB 49 Trinatal GT 117 TRASTUZUMAB-ANNS 45 Trinatal Rx 1 117 TRASTUZUMAB-DKST 47 Trinate 117 TRASTUZUMAB-PKRB 49 TRIPTORELIN PAMOATE 153 TRASTUZUMAB-QYYP 48 Triumeq 62 TRAVOPROST 208 Triveen-Duo DHA 117 Trazimera 48 TriVisc 200 Trazodone HCl 30 Tropicamide 203 Trecator 37 TROPICAMIDE 204 Trelegy Ellipta 210 TROSPIUM CHLORIDE 127 Trelstar Mixject 153 True Focus Blood Glucose Strip 200 Tremfya 109 True Metrix Blood Glucose Test 200 TREPROSTINIL 215,216 True Metrix Pro Blood Glucose 200 TREPROSTINIL DIOLAMINE 215 TRUEtest Test 200 Tresiba 72 TrueTrack Test 200 Tresiba FlexTouch 72 Trulance 121 TRETINOIN 106,109 Trumenba 170 TRETINOIN (CHEMOTHERAPY) 49 Truseltiq (100MG Daily Dose) 224 TRETINOIN MICROSPHERE 109 Truseltiq (125MG Daily Dose) 224 TriAdvance 117 Truseltiq (50MG Daily Dose) 224 TRIAMCINOLONE ACETONIDE 132,133 Truseltiq (75MG Daily Dose) 224 TRIAMCINOLONE ACETONIDE (MOUTH) 105 TUCATINIB 48 TRIAMCINOLONE ACETONIDE (TOPICAL) 133 Tudorza Pressair 212 TRIAMTERENE 95 Tukysa 48 TRIAMTERENE & HYDROCHLOROTHIAZIDE 94 Turalio 41 TRIAZOLAM 220 Twinrix 170 TRIENTINE HCL 111,112 Twirla 147 TRIFLUOPERAZINE HCL 54 Tyblume 147 TRIFLURIDINE 63 Tybost 62 TRIFLURIDINE-TIPIRACIL 40 Tymlos 173 TRIHEPTANOIN 110 Tysabri 105 TRIHEXYPHENIDYL HCL 51 Tyvaso 216 Trijardy XR 68 Tyvaso Refill 216 Trikafta 214 Tyvaso Starter 216 TRILACICLIB DIHYDROCHLORIDE 222 Triluron 200

©2021 Wellmark, Inc. 263 Vancomycin HCl 18 U VANDETANIB 44 Uceris 172 Vaqta 170 Udenyca 77 VARDENAFIL HCL 129 Ukoniq 224 VARICELLA VIRUS VACCINE LIVE 170 Ulesfia 51 VARICELLA-ZOSTER IMMUNE GLOBULIN ULIPRISTAL ACETATE 148 (HUMAN) 163 Ultima Test 201 Varivax 170 Ultomiris 201 VariZIG 163 UltraTRAK PRO Test 201 Vascepa 97 UltraTRAK Ultimate Test 201 Vaxelis 171 UMBRALISIB TOSYLATE 224 Vectical 109 UMECLIDINIUM-VILANTEROL 217 VEDOLIZUMAB 155 Unistrip1 Generic 201 VELAGLUCERASE ALFA 126 UPADACITINIB 158 Veletri 216 Uplizna 159 Velphoro 113 Uptravi 216,224 Veltassa 113 URIDINE TRIACETATE (EMERGENCY Vemlidy 56 TREATMENT) 201 VEMURAFENIB 48 Urimar-T 17 Venclexta 48 URINE GLUCOSE-KETONES TEST 179,180,190 Venclexta Starting Pack 48 Uristix 201 VENETOCLAX 48 Uristix 4 201 VENLAFAXINE HCL 30 URSODIOL 120 Venlafaxine HCl 30 USTEKINUMAB 109 Ventavis 216 USTEKINUMAB (IV) 109 VERAPAMIL HCL 90 Verapamil HCl ER 90 V Verasens Blood Glucose Test 201 VALACYCLOVIR HCL 63 Verdrocet 13 VALBENAZINE TOSYLATE 101 Veregen 109 Valchlor 38 Verelan 90 VALGANCICLOVIR HCL 56 Verelan PM 90 VALPROATE SODIUM 25 VERICIGUAT 94 VALSARTAN 85 Verquvo 94 VALSARTAN-HYDROCHLOROTHIAZIDE 94 VERTEPORFIN 205 Valtoco 10 MG Dose 25 Verzenio 48 Valtoco 15 MG Dose 25 Vfend IV 34 Valtoco 20 MG Dose 26 Viberzi 121 Valtoco 5 MG Dose 26 Vibramycin 24 Valved Holding Chamber 201 Victory AGM-4000 Test 201 VANCOMYCIN HCL 16,18 Victoza 68

©2021 Wellmark, Inc. 264 Videx 60 VOXELOTOR 84 Videx EC 60 VP-GGR-B6 Prenatal 119 Viekira Pak 57 VP-Heme OB + DHA 119 Viekira XR 57 Vpriv 126 VIGABATRIN 26 Vraylar 55 Viibryd 30 Vumerity 105 Vil-Rx 117 Vumerity (Starter) 105 VILAZODONE HCL 30 Vyepti 36 Vimpat 27 Vyndamax 94 Vinate AZ Extra 118 Vyndaqel 94 Vinate C 118 Vyvanse 99 Vinate Calcium 118 Vinate IC 118 W Vinate II 118 Wakix 221 Vinate M 118 WARFARIN SODIUM 73,74 Vinate One 118 Warfarin Sodium 74 Viokace 126 Watchhaler 202 Viracept 63 WaveSense Presto 202 Viread 61 Welireg 224 Virt Nate 118 Wilate 83 Virt-Advance 118 Virt-Vite GT 118 X Visco-3 201 Xadago 53 VISMODEGIB 44 Xalkori 48 Vistogard 201 Xarelto 74 Visudyne 205 Xarelto Starter Pack 74 Vitrakvi 41 Xatmep 159 VivaGuard Ino Test Strips 201 Xeljanz 159,224 Vizimpro 42 Xeljanz XR 159 Vocal Point Blood Glucose Test 202 Xembify 163 VOCLOSPORIN 156 Xeomin 220 Vogelxo 136 Xgeva 173 Vol-Nate 118 Xifaxan 18 Vol-Tab Rx 118 Xigduo XR 68 VON WILLEBRAND FACTOR (RECOMBINANT) 83 Xiidra 205 Vonvendi 83 Xofluza (40 MG Dose) 171 VORICONAZOLE 34 Xofluza (80 MG Dose) 171 VORINOSTAT 42 Xolair 219 Vortex Valved Holding Chamber 202 Xospata 42 Vosevi 57 Xpovio (100 MG Once Weekly) 42 Votrient 48 Xpovio (40 MG Once Weekly) 42

©2021 Wellmark, Inc. 265 Xpovio (40 MG Twice Weekly) 42 Zomacton 135 Xpovio (60 MG Once Weekly) 42 Zomacton (for Zoma-Jet 10) 135 Xpovio (60 MG Twice Weekly) 42 Zometa 173 Xpovio (80 MG Once Weekly) 42 ZONISAMIDE 24 Xpovio (80 MG Twice Weekly) 42 Zorbtive 135 Xtandi 38,224 Zortress 159 Xyntha 83 ZOSTER VACCINE RECOMBINANT Xyntha Solofuse 83 ADJUVANTED 170 Xyrem 221 Zyclara Pump 110 Xywav 220 Zydelig 48 Zykadia 48 Y Zylet 205 Yonsa 39 Zynlonta 224 Zypitamag 96 Z ZAFIRLUKAST 211 ZALEPLON 220 Zamicet 13 ZANAMIVIR 63 ZANUBRUTINIB 40 Zarxio 77 Zegalogue 224 Zejula 42 Zelboraf 48 Zenpep 126 Zepatier 57 Zeposia 105 Zeposia 7-Day Starter Pack 105 Zeposia Starter Kit 105 Zerit 61 ZIDOVUDINE 61 Ziextenzo 77 ZILEUTON 211 ZIPRASIDONE HCL 55 Zirgan 56 Zokinvy 126 ZOLEDRONIC ACID 173 Zolinza 42 ZOLMITRIPTAN 36 ZOLPIDEM TARTRATE 220,221 Zolpidem Tartrate 221

Discrimination is against the law Wellmark complies with applicable federal civil rights laws and If you believe that Wellmark has failed to provide these services or does not discriminate on the basis of race, color, national origin, discriminated in another way on the basis of race, color, national age, disability or sex. Wellmark does not exclude people or treat origin, age, disability or sex, you can file a grievance with: Wellmark them differently because of their race, color, national origin, age, Civil Rights Coordinator, 1331 Grand Avenue, Station 5W189, disability or sex. Des Moines, IA 50309-2901, 515-376-4500, TTY 888-781-4262, Fax 515-376-9073, Email [email protected]. You can file a Wellmark provides: grievance in person, by mail, fax or email. If you need help filing • Free aids and services to people with disabilities so they may a grievance, the Wellmark Civil Rights Coordinator is available to communicate effectively with us, such as: help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights • Qualified sign language interpreters electronically through the Office for Civil Rights Complaint Portal • Written information in other formats (large print, audio, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail, accessible electronic formats, other formats) phone or fax at: U.S. Department of Health and Human Services, • Free language services to people whose primary language is 200 Independence Avenue S.W., Room 509F, HHH Building, not English, such as: Washington DC 20201, 800-368-1019, 800-537-7697 (TDD). • Qualified interpreters Complaint forms are available at http://www.hhs.gov/ocr/office/file/ • Information written in other languages index.html. If you need these services, call 800-524-9242.

ATENCIÓN: Si habla español, los servicios de asistencia de idiomas Geb Acht: Wann du Deitsch schwetze duscht, kannscht du Hilf in dei se encuentran disponibles gratuitamente para usted. Comuníquese al eegni Schprooch koschdefrei griege. Ruf 800-524-9242 odder (TTY: 800-524-9242 o al (TTY: 888-781-4262). 888-781-4262) uff.

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CHÚ Ý: Nếu quý vị nói tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ miễn phí có PAG-UKULAN NG PANSIN: Kung Tagalog ang wikang ginagamit mo, sẵn cho quý vị. Xin hãy liên hệ 800-524-9242 hoặc (TTY: 888-781-4262). may makukuha kang mga serbisyong tulong sa wika na walang bayad. Makipag-ugnayan sa 800-524-9242 o (TTY: 888-781-4262). NAPOMENA: Ako govorite hrvatski, dostupna Vam je besplatna podrška na Vašem jeziku. Kontaktirajte 800-524-9242 ili (tekstualni telefon za w>'k;oh.ng= erh>uwdR unDusdm< usdmw>rRpXRw>zH;w>rRwz.< vXwb.vXmbl;vJ< td.vXe*D>vDRI qJ;usd;ql osobe oštećena sluha: 888-781-4262). 800=524=9242 rhwrh> (TTY: 888=781=4262) wuh>I

ACHTUNG: Wenn Sie deutsch sprechen, stehen Ihnen kostenlose ВНИМАНИЕ! Если ваш родной язык русский, вам могут быть sprachliche Assistenzdienste zur Verfügung. Rufnummer: 800-524-9242 предоставлены бесплатные переводческие услуги. Обращайтесь oder (TTY: 888-781-4262). 800-524-9242 (телетайп: 888-781-4262).

सावधान: यदि तपाℂ नेपाली बोल्नन㔛 भने, तपाℂका लागि नि:शुल् 셂पमा भाषा सहायता تنبيه: إذا كنت تتحدث اللغة العربية, فإننا نوفر لك خدمات المساعدة اللغوية، المجانية. اتصل بالرقم सेवाह셂 उपलब㔧 गराइन㔛 । 800-524-9242 वा (TTY: 888-781-4262) मा सम्प㔕 गर्नुोस ् । 9242-524-800 أو )خدمة الهاتف النصي: 888-781-4262(.

ማሳሰቢያ፦ አማርኛ የሚናገሩ ከሆነ፣ የቋንቋ እገዛ አገልግሎቶች፣ ከክፍያ ነፃ፣ ສ່ ງຄວນເອິ ົາໃຈໃສ,່ ພາສາລາວ ຖາທ້ ານເວ່ າົ້ : ພວກເຮາມົ ບີ ລໍ ການິ ຄວາມຊວຍເຫ່ ຼອດື ານພາສາ້ ያገኛሉ። በ ወይም (በ ) ደውለው ያነጋግሩን። ໃຫທ້ ານໂດຍບ່ ່ ເສຍໍ ຄາ່ ຫຼ ື 800-524-9242 ຕດຕິ ່ ໍທ່ .ີ (TTY: 888-781-4262.) 800-524-9242 TTY: 888-781-4262

주의: 한국어 를 사용하시는 경우, 무료 언어 지원 서비스를 이용하실 HEETINA To a wolwa Fulfulde laabi walliinde dow wolde, naa e njobdi, ene 수 있습니다. 800-524-9242번 또는 (TTY: 888-781-4262)번으로 연락해 ngoodi ngam maaɗa. Heɓir 800-524-9242 malla (TTY: 888-781-4262). 주십시오. FUULEFFANNAA: Yo isin Oromiffaa, kan dubbattan taatan, tajaajiloonni ध्봾न रखᴂ : अगर आपकी भाषा हिन्饀 है, तो आपके लिए भाषा सहायता सेवाएँ, निःशुल् gargaarsa afaanii, kaffaltii malee, isiniif ni jiru. 800-524-9242 yookin (TTY: उपलब㔧 हℂ। 800-524-9242 पर संपर㔕 करᴂ या (TTY: 888-781-4262)। 888-781-4262) quunnamaa.

ATTENTION : si vous parlez français, des services d’assistance dans votre УВАГА! Якщо ви розмовляєте українською мовою, для вас доступні langue sont à votre disposition gratuitement. Appelez le 800 524 9242 (ou la безкоштовні послуги мовної підтримки. Зателефонуйте за номером ligne ATS au 888 781 4262). 800-524-9242 або (телетайп: 888-781-4262).

Ge’: Diné k’ehj7 y1n7[ti’go n7k1 bizaad bee 1k1’ adoowo[, t’11 jiik’4, n1h0l=. Koj8’ h0lne’ 800-524-9242 doodaii’ (TTY: 888-781-4262)

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