Essentials Formulary E1/E4 Effective 10-01-2021 LIST OF COVERED DRUGS How to use this list: On a high-deductible, health savings account (HSA)? Refer to the E1 formulary. For all covered drugs, once you have satisfied your medical deductible, you will pay your applicable coinsurance until you reach your out-of-pocket maximum for the plan year. The drug tiers do not apply. On a PPO plan? Refer to the E4 formulary. Your drugs fall into 4 tiers: Preferred Generic (1), Preferred Brand (2), Preferred Specialty (3) and Non- Preferred Drugs (4) Please see the chart on page v for information. Have questions? Please call customer service at 800-508-4722 (TTY:711), Monday through Friday, 5 a.m. to 8 p.m. Pacific Time. 052170 (09-28-2021) Essentials (E1/E4) List of Covered Drugs (Formulary) What is the list of covered drugs (Formulary)? This document contains a list of generic, brand and specialty drugs covered under your plan. How is the list of covered drugs developed? The drug list is developed with an independent committee of physicians, pharmacists and other healthcare providers called the Pharmacy and Therapeutics Committee. This independent committee reviews and selects drugs for coverage based on each drugs safety, effectiveness, and cost. The committee meets at least quarterly to review new drugs to market to determine placement on this list and also reviews new information related to safety, effectiveness, and cost for existing drugs to ensure the formulary remains up to date with current medical evidence. How do I use the Formulary? Drugs are listed by categories depending on the type of medical conditions that they are used to treat. If you know what your drug is used for, look for the category name in the list that below. Then look under the category name for your drug. If you are not sure what category to look under, you can also search for the drug in the Index. The Index provides an alphabetical list of all the drugs included in this document. Next to the name of the drug in the Index, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. How does this drug list help me understand my drug coverage? Drug coverage is based on your coverage contract. Coverage for a specific drug is subject to the rules outlined in your member booklet. This document will tell you if a drug is included on the formulary attached to your plan. Will this drug list (Formulary) change? This drug list (Formulary) is updated throughout the year. If you are taking a drug and it will be removed from the formulary or moved to a higher cost sharing tier, we will notify you of this change via letter. We also post information on upcoming formulary changes on our website on the “Drug List Changes” page. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These can be seen in the column next to the drug name on the list. These requirements and limits may include: • Prior Authorization: some drugs require prior approval before they are covered. ii • Quantity Limits: for some drugs, we limit the amount of the drug that we will cover. For example, we will cover 18 per 30-day supply of zolmitriptan oral tablets. • Step Therapy: for some drugs we require that you first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then we will then cover Drug B. Drugs subject to these restrictions will generally mean that your physician or healthcare provider may need to provide additional information on your medical condition before the drug will be covered at the pharmacy. Information on this process is on our website on the “Drugs Requiring Approval” page. Essentials (E1/E4) Formulary The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA) and generic drugs are listed in lower-case italics (e.g., metformin oral tablet). The information in the Requirements/Limits column tells you if we have any special requirements for coverage of your drug. iii COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA Prior Authorization Restriction You (or your physician) are required to get prior authorization from us before you fill your prescription for this drug. Without prior approval, we may not cover this drug. QL Quantity Limit Restriction We limit the amount of this drug that is covered per prescription, or within a specific time frame. ST Step Therapy Restriction Before we will provide coverage for this drug, you must first try another drug to treat your medical condition. This drug may only be covered if the other drug does not work for you. Other Special Requirements for Coverage LA Limited Access Drug This prescription may be available only at certain pharmacies. EX Excluded Drug This drug is excluded on the Essentials formulary. You will be responsible for the full cost of the drug at the pharmacy. ACA PV Affordable Care Act (ACA) Preventive The Affordable Care Act (ACA) makes Medication certain preventive medications available to you at no cost. Coverage of any medication flagged as “ACA PV” (including over-the- counter (OTC) medications) requires a prescription from a licensed health care provider. OCh Oral Chemo Oral Chemotherapy Drug. Certain oral chemotherapy drugs may be covered under your medical plan. Please check your member booklet for more details. SP Specialty Pharmacy In general, specialty drugs are drugs typically used to treat chronic, complex or rare conditions and may require enhanced clinical support. Specialty Drugs are generally limited to a month supply on dispense. Please check your member booklet for more details. iv The amount you pay for a covered drug will depend on if you have met any applicable deductible for the plan year, if you have met any applicable maximum out of pocket for the plan year and what tier the medication is on. More information on applicable deductibles and maximum out of pockets can be found in your member booklet. Essentials E1 Formulary Drug Tier Includes Formulary Drugs (1, 2, 3, Formulary Drugs include Generic (1), Preferred Brand (2), Preferred 4) Specialty (3) and Non-Preferred (4) Drugs. Medical plan cost shares apply to formulary drugs. Once you have satisfied your medical deductible, you will pay your applicable coinsurance until you reach your out of pocket maximum limit. Essentials E4 Formulary Drug Tier Includes Preferred Generic (1) Tier 1 is the lowest tier and includes preferred generic drugs. Preferred Brand (2) Tier 2 includes preferred brand drugs. Preferred Specialty (3) Tier 3 includes preferred specialty drugs. In general, specialty drugs are drugs typically used to treat chronic, complex, or rare conditions and may require enhanced clinical support. Specialty Drugs are generally limited to a month supply on dispense. Please check your member booklet for more details. Non-Preferred Drugs (4) Tier 4 includes generic, brand and specialty drugs. Non preferred drugs are lower value (more expensive and/or less safe and effective than their alternatives in Tier 1, Tier 2, or Tier 3.) v Drug Name Drug Tier Requirements / Limits ANTI - INFECTIVES ANTIFUNGAL AGENTS amphotericin b injection recon soln 50 mg 4 ANCOBON ORAL CAPSULE 250 MG, 500 MG 4 BREXAFEMME ORAL TABLET 150 MG 4 PA; ST clotrimazole mucous membrane troche 10 mg 1 CRESEMBA ORAL CAPSULE 186 MG 4 PA DIFLUCAN ORAL SUSPENSION FOR 4 RECONSTITUTION 10 MG/ML, 40 MG/ML DIFLUCAN ORAL TABLET 100 MG, 150 MG, 4 200 MG, 50 MG fluconazole oral suspension for reconstitution 10 1 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 1 50 mg flucytosine oral capsule 250 mg, 500 mg 4 griseofulvin microsize oral suspension 125 mg/5 1 ml griseofulvin microsize oral tablet 500 mg 1 griseofulvin ultramicrosize oral tablet 125 mg, 250 4 mg itraconazole oral capsule 100 mg 1 itraconazole oral solution 10 mg/ml 4 ketoconazole oral tablet 200 mg 1 NOXAFIL ORAL SUSPENSION 200 MG/5 ML 4 PA (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED EX RELEASE (DR/EC) 100 MG nystatin oral suspension 100,000 unit/ml 1 nystatin oral tablet 500,000 unit 1 ORAVIG BUCCAL MUCO-ADHESIVE EX BUCCAL TABLET 50 MG posaconazole oral tablet,delayed release (dr/ec) 4 100 mg SPORANOX ORAL SOLUTION 10 MG/ML 4 SPORANOX PULSEPAK ORAL CAPSULE 100 4 MG terbinafine hcl oral tablet 250 mg 1 1 Drug Name Drug Tier Requirements / Limits TOLSURA ORAL CAPSULE, SOLID EX DISPERSION 65 MG VFEND ORAL SUSPENSION FOR 4 RECONSTITUTION 200 MG/5 ML (40 MG/ML) VFEND ORAL TABLET 200 MG, 50 MG 4 voriconazole oral suspension for reconstitution 1 200 mg/5 ml (40 mg/ml) voriconazole oral tablet 200 mg, 50 mg 1 ANTIVIRALS abacavir oral solution 20 mg/ml 1 abacavir oral tablet 300 mg 1 abacavir-lamivudine oral tablet 600-300 mg 4 abacavir-lamivudine-zidovudine oral tablet 300- 1 150-300 mg acyclovir oral capsule 200 mg 1 acyclovir oral suspension 200 mg/5 ml 1 acyclovir oral tablet 400 mg, 800 mg 1 adefovir oral tablet 10 mg 1 amantadine hcl oral capsule 100 mg 1 amantadine hcl oral solution 50 mg/5 ml 1 amantadine hcl oral tablet 100 mg 1 APTIVUS ORAL CAPSULE 250 MG 2 atazanavir oral capsule 150 mg, 200 mg, 300 mg 1 ATRIPLA ORAL TABLET 600-200-300 MG EX BARACLUDE ORAL SOLUTION 0.05 MG/ML EX BARACLUDE ORAL TABLET 0.5 MG, 1 MG EX BIKTARVY ORAL TABLET 50-200-25