Anthem PPO & HDHP Essential Drug List

Essential Drug List Drug list — Four Tier Drug Plan Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA). Here are a few things to remember about the list: o You and your doctor can use it as a guide to choose drugs that are best for you. Drugs that aren’t on this list may not be covered by your plan and may cost you more out of pocket. o Your coverage has limitations and exclusions, which means there are certain rules about what's covered by your plan and what isn't. To find out more, view your Certificate/Evidence of Coverage or your Summary Plan Description by logging in at anthem.com and go to My Plan ->Benefits-> Plan Documents. o To help you see how the drug list works with your drug benefit, we've included some frequently asked questions (FAQ) about how the list is set up and what to do if a drug you take isn't on it. o This booklet is updated on a quarterly basis. To view the most up-to-date list of drugs for your plan - including drugs that have been added, generic drugs and more - log in at anthem.com/pharmacyinformation. If you have questions about your pharmacy benefits, we're here to help. Just call us at the Pharmacy Member Services number on your ID card. 55726MUMENABS

Essential Drug List What is a drug list? The drug list, also called a formulary, is a list of prescription medicines your plan covers. It includes hundreds of brand-name and generic drugs approved by the U.S. Food & Drug Administration (FDA). Is this a complete listing of all covered drugs? Yes, this is a complete listing of all the drugs on the drug list. But, it’s possible a drug(s) on this list may not be covered, depending on your plan’s design. Your coverage has limitations and exclusions, which means there are certain conditions that determine what’s covered by your plan and what isn’t. To find out more, read your Certificate/Evidence of Coverage or your Summary Plan Description, which you got when you signed up for your plan. How can I find a drug on the list? The drugs are listed in alphabetical order based on the name of their drug class, also called therapeutic class. You can search the PDF drug list by: o Drug name, using Ctrl + F on your keyboard, then type in the name of the drug you’re looking for. o Drug class, using the categories listed in alphabetical order. The Notes column will tell you if you need preapproval before you can take the drug (called prior authorization or PA), or if you need to try other drugs first for your treatment (called step therapy or ST). When I search the list, I see that each drug is on a tier. What are the tiers for? The drug list is set up in tiers or levels. We place drugs on different tiers based on how well they work to improve health, whether there are over-the-counter (OTC) options and their costs compared to other drugs used for the same type of treatment. Your share of the drug cost will depend on what tier a drug is on. The lower the tier, the lower your share of the cost. Here’s a breakdown of the tiers in your plan: o Tier 1 drugs have the lowest cost share for you. These are usually generic drugs that offer the best value compared to other drugs that treat the same conditions. Some plans split Tier 1 into Tier 1a and Tier 1b: • Tier 1a drugs have the lowest cost share. These are often generic drugs that offer the greatest value compared to others that treat the same conditions. • Tier 1b drugs have a low cost share. These are typically generic drugs that offer the greatest value compared to others that treat the same conditions. o Tier 2 drugs have a higher cost share than Tier 1. They may be preferred brand drugs, based on how well they work and their cost compared to other drugs used for the same type of treatment. Some are generic drugs that may cost more because they’re newer to the market. o Tier 3 drugs have the highest cost share. They often include non-preferred brand and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA or specialty drugs that are used to treat serious, long-term health conditions and that may need special handling. o Tier 4 drugs have the highest cost share and usually include specialty brand and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 4 may also include drugs recently approved by the FDA or specialty drugs used to treat serious, long-term health conditions and that may need special handling. How will I know if my drug is covered and how much will it cost? You can go online and with the Price a Medication tool, get pharmacy-specific drug coverage details and pricing from a number of local retail pharmacies in your zip code.

If my medicine isn’t on the drug list, what are my options? Here are a few things to think about: o If you want to take a drug that’s not on the drug list, you may have to pay the full cost for it. o You can also talk to your doctor or pharmacist to see if there’s another drug covered by your plan that will work just as well, or if generic or OTC drugs are an option. Only you and your doctor can decide what drugs are right for you. o You can search for generic drugs at anthem.com. OTC drugs aren’t shown on the list. o If a drug you’re taking isn’t covered, your doctor can ask us to review the coverage. This process is called preapproval or prior authorization. Your doctor can get the process started by calling the Member Services number on the back of your member ID card or by downloading a prior authorization form from our website and submitting it. If your request is approved, the amount you pay for the drug will depend on your plan’s benefit. o If the contraceptive you are taking is not on the formulary, your doctor can contact us if it is medically necessary because the preferred contraceptives are inappropriate for you, and we will waive your cost share. Who decides what drugs are on the list? The drugs on the list are reviewed through our Pharmacy and Therapeutics (P&T) process. In this process, a group of independent doctors, pharmacists and other health care professionals decides which drugs we include on our lists. This group meets regularly to look at new and existing drugs and recommends drugs based on how safe they are, how well they work and the value they offer our members. What’s the difference between brand-name and generic drugs? A brand-name drug is FDA-approved and usually available from only one manufacturer. It may be protected by a patent, which means it can only be made or sold by the company that has the patent. A generic drug is also FDA-approved and has the same active ingredients as the brand-name drug. But a generic drug is usually available only after the patent on the brand-name drug ends. It may look different, but a generic drug works the same as the brand-name drug. Does the drug list change, and how will I know if it does? Drugs on our list are reviewed on a regular basis. Sometimes, drugs are added, removed or moved to a different tier. We’ll let you know if a drug you take is taken off the list and, in some cases, if a drug you take is moved to a higher tier. You can always check the drug list to make sure medicines you take are still on it. You’ll find the most up-to-date drug list when you log in at anthem.com. Does my plan cover preventive drugs? We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA).

Key terms Here are some terms and notes you’ll find on the drug list. Brand name drugs are in UPPER CASE, bold type. Generic drugs are in lower case, plain type. $0 = preventive drugs. For some members, this product may be covered at 100% with $0 cost share with a prescription from your provider if specified criteria are met. AL = age limits. Some drugs require a prior authorization if your age does not meet drug manufacturer, Food and Drug Administration (FDA), or clinical recommendations. BE = benefit exclusion. This drug may not be covered depending on your plans design. To find out if your drug is covered, log into your member portal or use the Sydney app to Price a Medication and refer to your plan documents. DO = dose optimization. Usually, this means you may have to switch from taking a drug twice a day to taking it once a day at a higher strength. LD = limited distribution. These drugs are available only through certain pharmacies or wholesalers, depending on what the manufacturer decides. PA = prior authorization. You may need to get benefits approved before certain prescriptions can be filled. QL = quantity limits. There are limits on the amount of medicine covered within a certain amount of time. SP = specialty drugs. Specialty drugs are used to treat difficult, long-term conditions. You may need to get this drug through a specialty pharmacy. ST = step therapy. You may need to use another recommended drug first before a prescribed drug is covered. A note about opioid analgesics: In response to the opioid epidemic, the U.S. Food and Drug Administration (FDA) encouraged the development of painkillers that prevent misuse. You may pay less for these types of opioids in certain states. Drug(s) may be excluded from the list based on your plan's benefit design. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 55726MUMENABS Online Pharmacy Resources Find your closest network pharmacy, get the most up-to-date coverage information on your drug list including details about pricing your medication, brands and generics, dosage/strength options, and much more — when you log in at anthem.com.

Essential Drug List Four-Tier Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*....................................................................................................7 *AMINOGLYCOSIDES*............................................................................................................................................................................9 *ANALGESICS - ANTI-INFLAMMATORY*......................................................................................................................................... 9 *ANALGESICS - NONNARCOTIC*...................................................................................................................................................... 11 *ANALGESICS - OPIOID*...................................................................................................................................................................... 12 *ANDROGENS-ANABOLIC*..................................................................................................................................................................14 *ANORECTAL AND RELATED PRODUCTS*....................................................................................................................................14 *ANTHELMINTICS*................................................................................................................................................................................14 *ANTIANGINAL AGENTS*....................................................................................................................................................................14 *ANTIANXIETY AGENTS*.................................................................................................................................................................... 15 *ANTIARRHYTHMICS*......................................................................................................................................................................... 15 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS*............................................................................................................ 16 *ANTICOAGULANTS*............................................................................................................................................................................18 *ANTICONVULSANTS*..........................................................................................................................................................................18 *ANTIDEPRESSANTS*............................................................................................................................................................................20 *ANTIDIABETICS*.................................................................................................................................................................................. 21 *ANTIDIARRHEAL/PROBIOTIC AGENTS*...................................................................................................................................... 24 *ANTIDOTES AND SPECIFIC ANTAGONISTS*............................................................................................................................... 25 *ANTIEMETICS*......................................................................................................................................................................................25 *ANTIFUNGALS*..................................................................................................................................................................................... 26 *ANTIHISTAMINES*...............................................................................................................................................................................26 *ANTIHYPERLIPIDEMICS*..................................................................................................................................................................26 *ANTIHYPERTENSIVES*.......................................................................................................................................................................27 *ANTI-INFECTIVE AGENTS - MISC.*.................................................................................................................................................29 *ANTIMALARIALS*................................................................................................................................................................................30 *ANTIMYASTHENIC/CHOLINERGIC AGENTS*.............................................................................................................................30 *ANTIMYCOBACTERIAL AGENTS*.................................................................................................................................................. 30 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...............................................................................................................31 *ANTIPARKINSON AND RELATED THERAPY AGENTS*............................................................................................................ 34 *ANTIPSYCHOTICS/ANTIMANIC AGENTS*....................................................................................................................................34 *ANTIVIRALS*......................................................................................................................................................................................... 36 *BETA BLOCKERS*................................................................................................................................................................................ 38 *CALCIUM CHANNEL BLOCKERS*...................................................................................................................................................39 *CARDIOTONICS*...................................................................................................................................................................................40 *CARDIOVASCULAR AGENTS - MISC.*............................................................................................................................................40 *CEPHALOSPORINS*............................................................................................................................................................................. 41 *CONTRACEPTIVES*.............................................................................................................................................................................42 *CORTICOSTEROIDS*...........................................................................................................................................................................45 *COUGH/COLD/ALLERGY*..................................................................................................................................................................46 *DERMATOLOGICALS*........................................................................................................................................................................ 46 *DIAGNOSTIC PRODUCTS*..................................................................................................................................................................51 *DIGESTIVE AIDS*..................................................................................................................................................................................51 *DIURETICS*............................................................................................................................................................................................51 *ENDOCRINE AND METABOLIC AGENTS - MISC.*......................................................................................................................52 *ESTROGENS*..........................................................................................................................................................................................54 *FLUOROQUINOLONES*......................................................................................................................................................................54 *GASTROINTESTINAL AGENTS - MISC.*.........................................................................................................................................55 *GENERAL ANESTHETICS*.................................................................................................................................................................56 *GENITOURINARY AGENTS - MISCELLANEOUS*........................................................................................................................56 *GOUT AGENTS*.....................................................................................................................................................................................57 *HEMATOLOGICAL AGENTS - MISC.*.............................................................................................................................................57 *HEMATOPOIETIC AGENTS*..............................................................................................................................................................58 *HEMOSTATICS*.....................................................................................................................................................................................59 *HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS*............................................................................................................. 59 *LAXATIVES*...........................................................................................................................................................................................60 *LOCAL ANESTHETICS-PARENTERAL*..........................................................................................................................................62 *MACROLIDES*.......................................................................................................................................................................................62 *MEDICAL DEVICES AND SUPPLIES*.............................................................................................................................................. 62 5

*MIGRAINE PRODUCTS*......................................................................................................................................................................69 *MINERALS & ELECTROLYTES*.......................................................................................................................................................70 *MISCELLANEOUS THERAPEUTIC CLASSES*..............................................................................................................................71 *MOUTH/THROAT/DENTAL AGENTS*.............................................................................................................................................72 *MULTIVITAMINS*................................................................................................................................................................................ 73 *MUSCULOSKELETAL THERAPY AGENTS*.................................................................................................................................. 76 *NASAL AGENTS - SYSTEMIC AND TOPICAL*.............................................................................................................................. 76 *NEUROMUSCULAR AGENTS*........................................................................................................................................................... 76 *NUTRIENTS*...........................................................................................................................................................................................76 *OPHTHALMIC AGENTS*.....................................................................................................................................................................77 *OTIC AGENTS*.......................................................................................................................................................................................79 *OXYTOCICS*..........................................................................................................................................................................................80 *PASSIVE IMMUNIZING AND TREATMENT AGENTS*................................................................................................................80 *PENICILLINS*........................................................................................................................................................................................ 80 *PROGESTINS*.........................................................................................................................................................................................81 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*........................................................................................81 *RESPIRATORY AGENTS - MISC.*.....................................................................................................................................................85 *SULFONAMIDES*..................................................................................................................................................................................85 *TETRACYCLINES*................................................................................................................................................................................85 *THYROID AGENTS*..............................................................................................................................................................................86 *TOXOIDS*................................................................................................................................................................................................86 *ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS*..................................................................................................... 86 *URINARY ANTISPASMODICS*.......................................................................................................................................................... 87 *VACCINES*............................................................................................................................................................................................. 88 *VAGINAL AND RELATED PRODUCTS*.......................................................................................................................................... 90 *VASOPRESSORS*...................................................................................................................................................................................91 *VITAMINS*..............................................................................................................................................................................................91 6

Four-Tier CURRENT AS OF 8/1/2025 Drug Name Tier Notes *ADHD/ANTI- NARCOLEPSY/ANTI- OBESITY/ANOREXIANT S* *ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS*** clonidine hcl er oral tablet extended release 12 hour 1 or 1b* PA guanfacine hcl er oral tablet extended release 24 hour 1 or 1b* PA *ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR*** atomoxetine hcl oral capsule 1 or 1b* PA *AMPHETAMINE MIXTURES*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg 1 or 1b* PA; DO amphetamine-dextroamphet er oral capsule extended release 24 hour 20 mg, 25 mg, 30 mg 1 or 1b* PA; QL amphetamine- dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 5 mg, 7.5 mg 1 or 1b* PA; DO amphetamine- dextroamphetamine oral tablet 20 mg, 30 mg 1 or 1b* PA; QL amphet-dextroamphet 3-bead er oral capsule extended release 24 hour 2 PA; QL *AMPHETAMINES*** amphetamine sulfate oral tablet 10 mg 1 or 1b* QL amphetamine sulfate oral tablet 5 mg 1 or 1b* DO dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg 1 or 1b* PA; QL Drug Name Tier Notes dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg 1 or 1b* PA; DO dextroamphetamine sulfate oral solution 1 or 1b* PA; QL dextroamphetamine sulfate oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 7.5 mg 1 or 1b* PA; QL dextroamphetamine sulfate oral tablet 2.5 mg, 5 mg 1 or 1b* PA; DO lisdexamfetamine dimesylate oral capsule 10 mg, 20 mg, 30 mg 2 PA; DO lisdexamfetamine dimesylate oral capsule 40 mg, 50 mg, 60 mg, 70 mg 2 PA; QL lisdexamfetamine dimesylate oral tablet chewable 10 mg, 20 mg, 30 mg 2 PA; DO lisdexamfetamine dimesylate oral tablet chewable 40 mg, 50 mg, 60 mg 2 PA; QL procentra oral solution 1 or 1b* PA; QL zenzedi oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 7.5 mg 1 or 1b* PA; QL zenzedi oral tablet 2.5 mg, 5 mg 1 or 1b* PA; DO *ANALEPTICS*** caffeine citrate oral solution 2 *ANOREXIANTS NON- AMPHETAMINE*** benzphetamine hcl oral tablet 50 mg 1 or 1b* PA; BE; QL diethylpropion hcl er oral tablet extended release 24 hour 1 or 1b* PA; BE; QL diethylpropion hcl oral tablet 1 or 1b* PA; BE; QL phendimetrazine tartrate oral tablet 1 or 1b* PA; BE; QL phentermine hcl oral capsule 1 or 1b* PA; BE; QL phentermine hcl oral tablet 1 or 1b* PA; BE; QL *ANTI-OBESITY - GIP & GLP-1 RECEPTOR AGONISTS*** ZEPBOUND SUBCUTANEOUS SOLUTION AUTO- INJECTOR 2 PA; BE; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 7

Drug Name Tier Notes *ANTI-OBESITY - GLP-1 RECEPTOR AGONISTS*** SAXENDA SUBCUTANEOUS SOLUTION PEN- INJECTOR 3 PA; BE; QL WEGOVY SUBCUTANEOUS SOLUTION AUTO- INJECTOR 2 PA; BE; QL *HISTAMINE H3- RECEPTOR ANTAGONIST/INVERSE AGONISTS*** WAKIX ORAL TABLET 17.8 MG 4 PA; LD; QL; SP WAKIX ORAL TABLET 4.45 MG 4 PA; LD; DO; SP *LIPASE INHIBITORS*** orlistat oral capsule 2 PA; BE; QL *STIMULANTS - MISC.*** armodafinil oral tablet 2 PA; QL dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg 1 or 1b* ST; DO dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg 1 or 1b* ST; QL dexmethylphenidate hcl er oral capsule extended release 24 hour 30 mg, 35 mg, 40 mg 1 or 1b* PA; QL dexmethylphenidate hcl er oral capsule extended release 24 hour 5 mg 1 or 1b* PA; DO dexmethylphenidate hcl oral tablet 10 mg 1 or 1b* PA; QL dexmethylphenidate hcl oral tablet 2.5 mg, 5 mg 1 or 1b* PA; DO methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg 1 or 1b* PA; DO methylphenidate hcl er (cd) oral capsule extended release 40 mg, 50 mg, 60 mg 1 or 1b* PA; QL Drug Name Tier Notes methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg 1 or 1b* PA; DO methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg, 40 mg, 60 mg 1 or 1b* PA; QL methylphenidate hcl er (osm) oral tablet extended release 18 mg, 27 mg 1 or 1b* PA; DO methylphenidate hcl er (osm) oral tablet extended release 36 mg, 45 mg, 54 mg, 63 mg 1 or 1b* PA; QL METHYLPHENIDATE HCL ER (OSM) ORAL TABLET EXTENDED RELEASE 72 MG 1 or 1b* PA; QL methylphenidate hcl er (xr) oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg 1 or 1b* PA; DO methylphenidate hcl er (xr) oral capsule extended release 24 hour 40 mg, 50 mg, 60 mg 1 or 1b* PA; QL methylphenidate hcl er oral tablet extended release 10 mg 1 or 1b* PA; DO methylphenidate hcl er oral tablet extended release 20 mg 1 or 1b* PA; QL methylphenidate hcl er oral tablet extended release 24 hour 1 or 1b* PA; DO methylphenidate hcl oral solution 1 or 1b* PA; QL methylphenidate hcl oral tablet 10 mg, 5 mg 1 or 1b* PA; DO methylphenidate hcl oral tablet 20 mg 1 or 1b* PA; QL methylphenidate hcl oral tablet chewable 10 mg 1 or 1b* PA; QL methylphenidate hcl oral tablet chewable 2.5 mg 1 or 1b* ST; DO methylphenidate hcl oral tablet chewable 5 mg 1 or 1b* PA; DO methylphenidate transdermal patch 10 mg/9hr, 15 mg/9hr 2 ST; DO methylphenidate transdermal patch 20 mg/9hr, 30 mg/9hr 2 ST; QL modafinil oral tablet 100 mg 2 PA; DO modafinil oral tablet 200 mg 2 PA; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 8

Drug Name Tier Notes *AMINOGLYCOSIDES* *AMINOGLYCOSIDES** * amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml 2 gentamicin in saline intravenous solution 0.8-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9 mg/ml-% 2 gentamicin sulfate injection solution 2 neomycin sulfate oral tablet 1 or 1a* streptomycin sulfate intramuscular solution reconstituted 1 or 1b* tobramycin inhalation nebulization solution 4 LD; QL; SP tobramycin sulfate injection solution 2 QL tobramycin sulfate injection solution reconstituted 2 QL *ANALGESICS - ANTI- INFLAMMATORY* *ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS*** RINVOQ LQ ORAL SOLUTION 4 PA; LD; QL; SP RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 PA; LD; QL; SP XELJANZ ORAL SOLUTION 4 PA; LD; QL; SP XELJANZ ORAL TABLET 4 PA; LD; QL; SP XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 4 PA; LD; QL; SP Drug Name Tier Notes *ANTIRHEUMATIC ANTIMETABOLITES*** RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML 4 PA; LD; QL; SP *ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES*** HUMIRA (2 PEN) SUBCUTANEOUS AUTO- INJECTOR KIT 4 PA; LD; QL; SP HUMIRA (2 SYRINGE) SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML 4 PA; LD; QL; SP HUMIRA-CD/UC/HS STARTER SUBCUTANEOUS AUTO- INJECTOR KIT 80 MG/0.8ML 4 PA; LD; QL; SP HUMIRA- PSORIASIS/UVEIT STARTER SUBCUTANEOUS AUTO- INJECTOR KIT 4 PA; LD; QL; SP SIMLANDI (1 PEN) SUBCUTANEOUS AUTO- INJECTOR KIT 40 MG/0.4ML 4 PA; LD; QL; SP SIMLANDI (1 PEN) SUBCUTANEOUS AUTO- INJECTOR KIT 80 MG/0.8ML 4 PA; QL; SP SIMLANDI (1 SYRINGE) SUBCUTANEOUS PREFILLED SYRINGE KIT 4 PA; QL; SP SIMLANDI (2 PEN) SUBCUTANEOUS AUTO- INJECTOR KIT 4 PA; LD; QL; SP SIMLANDI (2 SYRINGE) SUBCUTANEOUS PREFILLED SYRINGE KIT 20 MG/0.2ML 4 PA; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 9

Drug Name Tier Notes SIMLANDI (2 SYRINGE) SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.4ML 4 PA; LD; QL SIMPONI ARIA INTRAVENOUS SOLUTION 4 PA; LD; SP SIMPONI SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP *CYCLOOXYGENASE 2 (COX-2) INHIBITORS*** celecoxib oral capsule 2 QL *GOLD COMPOUNDS*** RIDAURA ORAL CAPSULE 2 QL *NONSTEROIDAL ANTI- INFLAMMATORY AGENT COMBINATIONS*** diclofenac-misoprostol oral tablet delayed release 2 QL *NONSTEROIDAL ANTI- INFLAMMATORY AGENTS (NSAIDS)*** diclofenac potassium oral tablet 50 mg 1 or 1b* QL diclofenac sodium er oral tablet extended release 24 hour 1 or 1b* QL diclofenac sodium oral tablet delayed release 1 or 1b* QL ec-naproxen oral tablet delayed release 1 or 1b* etodolac er oral tablet extended release 24 hour 1 or 1b* QL etodolac oral capsule 1 or 1b* QL etodolac oral tablet 1 or 1b* QL flurbiprofen oral tablet 1 or 1b* QL ibu oral tablet 1 or 1a* QL ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 or 1a* QL indomethacin er oral capsule extended release 1 or 1b* QL Drug Name Tier Notes indomethacin oral capsule 25 mg, 50 mg 1 or 1b* QL ketoprofen er oral capsule extended release 24 hour 1 or 1b* QL ketorolac tromethamine injection solution 15 mg/ml 2 QL KETOROLAC TROMETHAMINE INJECTION SOLUTION 30 MG/ML 2 QL ketorolac tromethamine intramuscular solution 60 mg/2ml 2 QL ketorolac tromethamine oral tablet 1 or 1a* QL meclofenamate sodium oral capsule 1 or 1b* QL mefenamic acid oral capsule 1 or 1b* QL meloxicam oral tablet 1 or 1b* QL nabumetone oral tablet 1 or 1b* QL naproxen dr oral tablet delayed release 500 mg 1 or 1b* naproxen oral tablet 1 or 1b* QL naproxen oral tablet delayed release 1 or 1b* naproxen sodium oral tablet 275 mg, 550 mg 1 or 1b* QL oxaprozin oral tablet 1 or 1b* QL piroxicam oral capsule 1 or 1b* QL sulindac oral tablet 1 or 1b* QL tolmetin sodium oral capsule 2 QL *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** OTEZLA ORAL TABLET 4 PA; LD; QL; SP OTEZLA ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP *PYRIMIDINE SYNTHESIS INHIBITORS*** leflunomide oral tablet 2 QL *SELECTIVE COSTIMULATION MODULATORS*** ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 10

Drug Name Tier Notes ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP *SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 4 PA; LD; QL; SP ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML 4 PA; LD; QL; SP ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP *ANALGESICS - NONNARCOTIC* *ANALGESICS OTHER*** acetaminophen intravenous solution 1 or 1b* *ANALGESICS- SEDATIVES*** bac (butalbital-acetamin- caff) oral tablet 1 or 1b* QL butalbital-acetaminophen oral capsule 1 or 1b* QL butalbital-acetaminophen oral tablet 50-325 mg 1 or 1b* QL butalbital-apap-caffeine oral capsule 50-300-40 mg 1 or 1b* QL butalbital-apap-caffeine oral tablet 50-325-40 mg 1 or 1b* QL butalbital-aspirin-caffeine oral capsule 1 or 1b* QL tencon oral tablet 50-325 mg 1 or 1b* QL *SALICYLATES*** aspirin 81 oral tablet chewable 1 or 1a* $0 aspirin 81 oral tablet delayed release 1 or 1a* $0 aspirin adult low dose oral tablet delayed release 1 or 1a* $0 Drug Name Tier Notes aspirin adult low strength oral tablet delayed release 1 or 1a* $0 aspirin childrens oral tablet chewable 1 or 1a* $0 aspirin ec adult low dose oral tablet delayed release 1 or 1a* $0 aspirin ec low dose oral tablet delayed release 1 or 1a* $0 aspirin ec low strength oral tablet delayed release 1 or 1a* $0 aspirin low dose oral tablet chewable 1 or 1a* $0 aspirin low dose oral tablet delayed release 1 or 1a* $0 aspirin oral tablet chewable 1 or 1a* $0 aspirin oral tablet delayed release 81 mg 1 or 1a* $0 aspirin regimen oral tablet delayed release 1 or 1a* $0 bayer aspirin ec low dose oral tablet delayed release 1 or 1a* $0 bayer low dose oral tablet chewable 1 or 1a* $0 bayer low dose oral tablet delayed release 1 or 1a* $0 childrens aspirin oral tablet chewable 1 or 1a* $0 cvs aspirin adult low dose oral tablet chewable 1 or 1a* $0 cvs aspirin adult low strength oral tablet delayed release 1 or 1a* $0 cvs aspirin ec oral tablet delayed release 81 mg 1 or 1a* $0 cvs aspirin low dose oral tablet delayed release 1 or 1a* $0 cvs aspirin low strength oral tablet delayed release 1 or 1a* $0 diflunisal oral tablet 1 or 1b* QL ecotrin low strength oral tablet delayed release 1 or 1a* $0 eq aspirin adult low dose oral tablet delayed release 1 or 1a* $0 eq aspirin low dose oral tablet chewable 1 or 1a* $0 eq aspirin low dose oral tablet delayed release 1 or 1a* $0 eql aspirin low dose oral tablet chewable 1 or 1a* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 11

Drug Name Tier Notes eql aspirin low dose oral tablet delayed release 1 or 1a* $0 ft aspirin low dose oral tablet delayed release 1 or 1a* $0 ft aspirin oral tablet chewable 1 or 1a* $0 gnp adult aspirin low strength oral tablet chewable 1 or 1a* $0 gnp aspirin low dose oral tablet delayed release 1 or 1a* $0 gnp aspirin oral tablet delayed release 81 mg 1 or 1a* $0 goodsense aspirin low dose oral tablet delayed release 1 or 1a* $0 goodsense aspirin oral tablet chewable 1 or 1a* $0 h-e-b aspirin oral tablet delayed release 1 or 1a* $0 kls aspirin low dose oral tablet delayed release 1 or 1a* $0 kp aspirin oral tablet delayed release 1 or 1a* $0 mm aspirin oral tablet delayed release 1 or 1a* $0 qc aspirin low dose oral tablet chewable 1 or 1a* $0 qc aspirin low dose oral tablet delayed release 1 or 1a* $0 qc childrens aspirin oral tablet chewable 1 or 1a* $0 ra aspirin adult low dose oral tablet chewable 1 or 1a* $0 ra aspirin adult low strength oral tablet chewable 1 or 1a* $0 ra aspirin childrens oral tablet chewable 1 or 1a* $0 ra aspirin ec adult low st oral tablet delayed release 1 or 1a* $0 ra aspirin ec oral tablet delayed release 81 mg 1 or 1a* $0 sb childrens aspirin oral tablet chewable 1 or 1a* $0 sb low dose asa ec oral tablet delayed release 1 or 1a* $0 st joseph aspirin oral tablet delayed release 1 or 1a* $0 st joseph low dose oral tablet chewable 1 or 1a* $0 st joseph low dose oral tablet delayed release 1 or 1a* $0 Drug Name Tier Notes *ANALGESICS - OPIOID* *CODEINE COMBINATIONS*** acetaminophen-codeine oral solution 1 or 1a* AL; QL acetaminophen-codeine oral tablet 1 or 1a* AL; QL ascomp-codeine oral capsule 1 or 1b* AL; QL butalbital-apap-caff-cod oral capsule 1 or 1b* AL; QL butalbital-asa-caff-codeine oral capsule 1 or 1b* AL; QL *DIHYDROCODEINE COMBINATIONS*** apap-caff-dihydrocodeine oral capsule 1 or 1b* QL trezix oral capsule 320.5-30- 16 mg 1 or 1b* QL *HYDROCODONE COMBINATIONS*** hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 2.5-108 mg/5ml, 5- 217 mg/10ml, 7.5-325 mg/15ml 1 or 1b* QL hydrocodone-acetaminophen oral tablet 10-300 mg, 10- 325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg 1 or 1b* QL hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg 1 or 1b* QL *OPIOID AGONISTS*** codeine sulfate oral tablet 30 mg 2 AL; QL FENTANYL CITRATE (PF) INJECTION SOLUTION 100 MCG/2ML, 250 MCG/5ML 1 or 1b* fentanyl citrate (pf) injection solution 1000 mcg/20ml, 2500 mcg/50ml, 500 mcg/10ml 1 or 1b* fentanyl transdermal patch 72 hour 2 PA; QL hydrocodone bitartrate er oral tablet er 24 hour abuse- deterrent 1 or 1b* PA; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 12

Drug Name Tier Notes hydromorphone hcl er oral tablet extended release 24 hour 2 PA; QL hydromorphone hcl injection solution 4 mg/ml 1 or 1b* hydromorphone hcl oral liquid 1 or 1b* QL hydromorphone hcl oral tablet 1 or 1b* QL hydromorphone hcl pf injection solution 50 mg/5ml, 500 mg/50ml 1 or 1b* levorphanol tartrate oral tablet 3 mg 2 PA; QL meperidine hcl injection solution 100 mg/ml, 25 mg/ml, 50 mg/ml 1 or 1b* meperidine hcl oral solution 1 or 1b* QL meperidine hcl oral tablet 50 mg 1 or 1b* QL methadone hcl intensol oral concentrate 1 or 1b* PA; QL methadone hcl oral concentrate 1 or 1b* PA; QL methadone hcl oral solution 1 or 1b* PA; QL methadone hcl oral tablet 1 or 1b* PA; QL methadone hcl oral tablet soluble 1 or 1b* PA; QL methadose oral tablet soluble 1 or 1b* PA; QL mitigo injection solution 2 morphine sulfate (concentrate) oral solution 100 mg/5ml 1 or 1b* QL morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml 1 or 1b* morphine sulfate er beads oral capsule extended release 24 hour 2 PA; QL morphine sulfate er oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg 2 PA; QL morphine sulfate er oral tablet extended release 2 PA; QL morphine sulfate intravenous solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml 1 or 1b* morphine sulfate oral solution 1 or 1b* QL Drug Name Tier Notes morphine sulfate oral tablet 1 or 1b* QL oxycodone hcl oral capsule 2 QL oxycodone hcl oral concentrate 100 mg/5ml 2 QL oxycodone hcl oral solution 2 QL oxycodone hcl oral tablet 2 QL oxymorphone hcl er oral tablet extended release 12 hour 2 PA; QL oxymorphone hcl oral tablet 2 QL remifentanil hcl intravenous solution reconstituted 1 or 1b* SUFENTANIL CITRATE INTRAVENOUS SOLUTION 1 or 1b* tramadol hcl (er biphasic) oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg 2 PA; QL tramadol hcl (er biphasic) oral tablet extended release 24 hour 2 PA; QL tramadol hcl er oral tablet extended release 24 hour 2 PA; QL tramadol hcl oral tablet 100 mg, 50 mg 1 or 1b* AL; QL tramadol hcl oral tablet 25 mg 2 PA; QL *OPIOID COMBINATIONS*** endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg 1 or 1b* QL OXYCODONE- ACETAMINOPHEN ORAL SOLUTION 5-325 MG/5ML 1 or 1b* QL oxycodone-acetaminophen oral tablet 10-325 mg, 2.5- 325 mg, 5-325 mg, 7.5-325 mg 1 or 1b* QL *OPIOID PARTIAL AGONISTS*** buprenorphine hcl injection solution 0.3 mg/ml 2 buprenorphine hcl sublingual tablet sublingual 1 or 1b* QL buprenorphine hcl-naloxone hcl sublingual film 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 13

Drug Name Tier Notes buprenorphine hcl-naloxone hcl sublingual tablet sublingual 1 or 1b* QL buprenorphine transdermal patch weekly 2 PA; QL butorphanol tartrate injection solution 2 butorphanol tartrate nasal solution 1 or 1b* QL nalbuphine hcl injection solution 2 QL pentazocine-naloxone hcl oral tablet 1 or 1b* QL *TRAMADOL COMBINATIONS*** tramadol-acetaminophen oral tablet 1 or 1b* AL; QL *ANDROGENS- ANABOLIC* *ANDROGENS*** danazol oral capsule 2 QL DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 1 or 1b* PA testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml 1 or 1b* PA testosterone enanthate intramuscular solution 1 or 1b* PA testosterone transdermal gel 1.62 %, 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%) 2 PA; QL testosterone transdermal solution 2 PA; QL XYOSTED SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 PA *ANORECTAL AND RELATED PRODUCTS* *INTRARECTAL STEROIDS*** budesonide rectal foam 2 QL hydrocortisone rectal enema 1 or 1b* Drug Name Tier Notes *NITRATE VASODILATING AGENTS*** nitroglycerin rectal ointment 2 QL *RECTAL ANESTHETIC/STEROIDS *** hydrocortisone ace- pramoxine external cream 1- 1 % 1 or 1b* *RECTAL STEROIDS*** hydrocortisone (perianal) external cream 1 or 1b* PROCTOCORT EXTERNAL CREAM 1 or 1b* procto-med hc external cream 1 or 1b* proctosol hc external cream 1 or 1b* proctozone-hc external cream 1 or 1b* *ANTHELMINTICS* *ANTHELMINTICS*** albendazole oral tablet 1 or 1b* PA; QL ivermectin oral tablet 1 or 1b* QL praziquantel oral tablet 2 *ANTIANGINAL AGENTS* *ANTIANGINALS- OTHER*** ranolazine er oral tablet extended release 12 hour 2 QL *NITRATES*** isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg 1 or 1b* isosorbide dinitrate oral tablet 40 mg 2 isosorbide mononitrate er oral tablet extended release 24 hour 1 or 1b* NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR 2 nitroglycerin in d5w intravenous solution 1 or 1b* nitroglycerin sublingual tablet sublingual 1 or 1b* nitroglycerin transdermal patch 24 hour 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 14

Drug Name Tier Notes nitroglycerin translingual solution 2 *ANTIANXIETY AGENTS* *ANTIANXIETY AGENTS - MISC.*** buspirone hcl oral tablet 1 or 1b* droperidol injection solution 1 or 1b* hydroxyzine hcl intramuscular solution 1 or 1b* hydroxyzine hcl oral syrup 1 or 1b* hydroxyzine hcl oral tablet 1 or 1b* hydroxyzine pamoate oral capsule 1 or 1a* meprobamate oral tablet 3 *BENZODIAZEPINES*** alprazolam er oral tablet extended release 24 hour 1 or 1b* QL alprazolam oral tablet 1 or 1b* QL alprazolam oral tablet dispersible 1 or 1b* QL alprazolam xr oral tablet extended release 24 hour 1 or 1b* QL chlordiazepoxide hcl oral capsule 1 or 1b* QL clorazepate dipotassium oral tablet 1 or 1b* QL diazepam injection solution 10 mg/2ml 1 or 1a* diazepam intensol oral concentrate 1 or 1a* QL diazepam oral concentrate 1 or 1a* QL diazepam oral solution 5 mg/5ml 1 or 1a* diazepam oral tablet 1 or 1a* QL lorazepam injection solution 1 or 1b* lorazepam intensol oral concentrate 1 or 1b* QL lorazepam oral concentrate 2 mg/ml 1 or 1b* QL lorazepam oral tablet 1 or 1b* QL oxazepam oral capsule 2 QL Drug Name Tier Notes *ANTIARRHYTHMICS* *ANTIARRHYTHMICS - MISC.*** adenosine intravenous solution 12 mg/4ml, 6 mg/2ml 1 or 1b* *ANTIARRHYTHMICS TYPE I-A*** disopyramide phosphate oral capsule 2 NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 2 procainamide hcl injection solution 2 quinidine gluconate er oral tablet extended release 2 quinidine sulfate oral tablet 1 or 1a* *ANTIARRHYTHMICS TYPE I-B*** lidocaine hcl (cardiac) intravenous solution prefilled syringe 50 mg/5ml 1 or 1b* lidocaine hcl (cardiac) pf intravenous solution prefilled syringe 1 or 1b* lidocaine in d5w intravenous solution 4-5 mg/ml-%, 8-5 mg/ml-% 1 or 1b* mexiletine hcl oral capsule 2 *ANTIARRHYTHMICS TYPE I-C*** flecainide acetate oral tablet 2 QL propafenone hcl er oral capsule extended release 12 hour 2 propafenone hcl oral tablet 2 *ANTIARRHYTHMICS TYPE III*** amiodarone hcl intravenous solution 1 or 1b* amiodarone hcl oral tablet 100 mg, 400 mg 1 or 1b* amiodarone hcl oral tablet 200 mg 1 or 1b* QL dofetilide oral capsule 4 LD ibutilide fumarate intravenous solution 1 or 1b* pacerone oral tablet 100 mg 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 15

Drug Name Tier Notes pacerone oral tablet 200 mg 1 or 1b* QL *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *ADRENERGIC COMBINATIONS*** ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/ACT 2 QL BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/ACT, 200-25 MCG/ACT, 50-25 MCG/INH 2 QL BREYNA INHALATION AEROSOL 1 or 1b* QL BREZTRI AEROSPHERE INHALATION AEROSOL 2 QL budesonide-formoterol fumarate inhalation aerosol 1 or 1b* QL COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 2 QL fluticasone furoate-vilanterol inhalation aerosol powder breath activated 100-25 mcg/act, 200-25 mcg/act 2 QL fluticasone-salmeterol inhalation aerosol 1 or 1b* QL fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/act, 113-14 mcg/act, 232-14 mcg/act, 250-50 mcg/act, 500-50 mcg/act, 55- 14 mcg/act 1 or 1b* QL ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 or 1b* QL STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT 2 QL TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/ACT, 200-62.5-25 MCG/ACT 2 QL Drug Name Tier Notes umeclidinium-vilanterol inhalation aerosol powder breath activated 1 or 1b* QL wixela inhub inhalation aerosol powder breath activated 100-50 mcg/act, 250-50 mcg/act, 500-50 mcg/act 1 or 1b* QL *ANTI-IGE MONOCLONAL ANTIBODIES*** XOLAIR SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; QL; SP *ANTI- INFLAMMATORY AGENTS*** cromolyn sodium inhalation nebulization solution 1 or 1b* *BETA ADRENERGICS*** albuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcg/act 1 or 1b* QL albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml 1 or 1b* QL ALBUTEROL SULFATE INHALATION NEBULIZATION SOLUTION (5 MG/ML) 0.5% 1 or 1b* QL albuterol sulfate oral syrup 1 or 1b* albuterol sulfate oral tablet 1 or 1b* arformoterol tartrate inhalation nebulization solution 2 QL formoterol fumarate inhalation nebulization solution 2 QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 16

Drug Name Tier Notes levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml 2 QL levalbuterol tartrate inhalation aerosol 1 or 1b* ST; QL PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 2 QL SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/ACT 2 QL terbutaline sulfate injection solution 1 or 1b* terbutaline sulfate oral tablet 1 or 1b* *BRONCHODILATORS - ANTICHOLINERGICS*** ATROVENT HFA INHALATION AEROSOL SOLUTION 2 QL ipratropium bromide inhalation solution 1 or 1b* QL SPIRIVA HANDIHALER INHALATION CAPSULE 2 QL SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT 2 QL tiotropium bromide monohydrate inhalation capsule 2 QL *INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)*** FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP NUCALA SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP Drug Name Tier Notes NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; QL; SP *LEUKOTRIENE RECEPTOR ANTAGONISTS*** montelukast sodium oral packet 1 or 1b* QL montelukast sodium oral tablet 1 or 1b* QL montelukast sodium oral tablet chewable 1 or 1b* QL zafirlukast oral tablet 1 or 1b* QL *SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** roflumilast oral tablet 2 QL *STEROID INHALANTS*** ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 2 QL budesonide inhalation suspension 1 or 1b* QL fluticasone propionate diskus inhalation aerosol powder breath activated 2 QL fluticasone propionate hfa inhalation aerosol 2 QL QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 2 QL *THYMIC STROMAL LYMPHOPOIETIN (TSLP) ANTAGONISTS*** TEZSPIRE SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP TEZSPIRE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP *XANTHINES*** aminophylline intravenous solution 1 or 1b* ELIXOPHYLLIN ORAL ELIXIR 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 17

Drug Name Tier Notes THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 QL theophylline er oral tablet extended release 12 hour 100 mg, 200 mg 1 or 1b* theophylline er oral tablet extended release 12 hour 300 mg, 450 mg 1 or 1b* QL theophylline er oral tablet extended release 24 hour 1 or 1b* QL theophylline oral elixir 1 or 1b* QL theophylline oral solution 1 or 1b* QL *ANTICOAGULANTS* *COUMARIN ANTICOAGULANTS*** jantoven oral tablet 1 or 1a* warfarin sodium oral tablet 1 or 1a* *DIRECT FACTOR XA INHIBITORS*** ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY PACK 2 QL ELIQUIS ORAL TABLET 2 QL rivaroxaban oral tablet 2 QL XARELTO ORAL SUSPENSION RECONSTITUTED 2 QL XARELTO ORAL TABLET 2 QL XARELTO STARTER PACK ORAL TABLET THERAPY PACK 2 QL *HEPARINS AND HEPARINOID-LIKE AGENTS*** bd heparin posiflush intravenous solution 2 heparin (porcine) in nacl intravenous solution 1000- 0.9 ut/500ml-%, 2000-0.9 unit/l-% 2 heparin na (pork) lock flsh pf intravenous solution 2 heparin sod (porcine) in d5w intravenous solution 40-5 unit/ml-% 2 Drug Name Tier Notes heparin sod (pork) lock flush intravenous solution 10 unit/ml, 100 unit/ml 2 heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml 2 heparin sodium (porcine) pf injection solution 1000 unit/ml, 5000 unit/0.5ml 2 *LOW MOLECULAR WEIGHT HEPARINS*** enoxaparin sodium injection solution 300 mg/3ml 1 or 1b* QL enoxaparin sodium injection solution prefilled syringe 1 or 1b* QL FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/4ML, 95000 UNIT/3.8ML 3 QL FRAGMIN SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 QL *SYNTHETIC HEPARINOID-LIKE AGENTS*** fondaparinux sodium subcutaneous solution 1 or 1b* QL *ANTICONVULSANTS* *AMPA GLUTAMATE RECEPTOR ANTAGONISTS*** perampanel oral tablet 2 *ANTICONVULSANTS - BENZODIAZEPINES*** clobazam oral suspension 2.5 mg/ml 2 QL clobazam oral tablet 2 QL clonazepam oral tablet 1 or 1b* QL clonazepam oral tablet dispersible 1 or 1b* QL diazepam rectal gel 1 or 1b* QL *ANTICONVULSANTS - MISC.*** carbamazepine er oral capsule extended release 12 hour 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 18

Drug Name Tier Notes carbamazepine er oral tablet extended release 12 hour 1 or 1b* QL carbamazepine oral suspension 1 or 1b* QL carbamazepine oral tablet 1 or 1b* QL carbamazepine oral tablet chewable 1 or 1b* QL EPIDIOLEX ORAL SOLUTION 4 PA; LD; SP epitol oral tablet 1 or 1b* QL eslicarbazepine acetate oral tablet 200 mg, 400 mg 2 DO eslicarbazepine acetate oral tablet 600 mg, 800 mg 2 QL gabapentin oral capsule 1 or 1b* DO gabapentin oral solution 2 QL gabapentin oral tablet 600 mg, 800 mg 1 or 1b* QL lacosamide intravenous solution 2 lacosamide oral solution 2 QL lacosamide oral tablet 2 QL lamotrigine er oral tablet extended release 24 hour 100 mg, 25 mg, 50 mg 1 or 1b* DO lamotrigine er oral tablet extended release 24 hour 200 mg, 250 mg, 300 mg 1 or 1b* QL lamotrigine oral kit 21 x 25 mg & 7 x 50 mg, 25 & 50 & 100 mg, 42 x 50 mg & 14x100 mg 1 or 1b* QL lamotrigine oral tablet 1 or 1b* DO lamotrigine oral tablet chewable 1 or 1b* QL lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg 1 or 1b* QL lamotrigine oral tablet dispersible 50 mg 1 or 1b* DO lamotrigine starter kit-blue oral kit 1 or 1b* QL lamotrigine starter kit-green oral kit 1 or 1b* QL lamotrigine starter kit-orange oral kit 1 or 1b* QL levetiracetam er oral tablet extended release 24 hour 2 QL Drug Name Tier Notes levetiracetam intravenous solution 2 levetiracetam oral solution 2 QL levetiracetam oral tablet 1000 mg 2 QL levetiracetam oral tablet 250 mg, 500 mg, 750 mg 2 DO oxcarbazepine er oral tablet extended release 24 hour 150 mg, 300 mg 2 DO oxcarbazepine er oral tablet extended release 24 hour 600 mg 2 QL oxcarbazepine oral suspension 1 or 1b* QL oxcarbazepine oral tablet 1 or 1b* QL pregabalin oral capsule 2 QL pregabalin oral solution 2 QL primidone oral tablet 1 or 1b* QL roweepra oral tablet 500 mg 2 DO rufinamide oral suspension 2 QL rufinamide oral tablet 200 mg 2 DO rufinamide oral tablet 400 mg 2 QL subvenite oral tablet 1 or 1b* DO subvenite starter kit-blue oral kit 1 or 1b* QL subvenite starter kit-green oral kit 1 or 1b* QL subvenite starter kit-orange oral kit 1 or 1b* QL topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, 200 mg, 50 mg 1 or 1b* QL topiramate er oral capsule er 24 hour sprinkle 25 mg 1 or 1b* DO topiramate er oral capsule extended release 24 hour 100 mg, 200 mg, 50 mg 2 QL topiramate er oral capsule extended release 24 hour 25 mg 2 DO topiramate oral capsule sprinkle 15 mg, 25 mg 1 or 1b* QL topiramate oral tablet 100 mg, 25 mg, 50 mg 1 or 1b* DO topiramate oral tablet 200 mg 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 19

Drug Name Tier Notes zonisamide oral capsule 2 QL *CARBAMATES*** felbamate oral suspension 2 QL felbamate oral tablet 2 QL *GABA MODULATORS*** tiagabine hcl oral tablet 2 QL vigabatrin oral packet 4 LD; QL; SP vigabatrin oral tablet 4 LD; QL; SP vigadrone oral packet 4 LD; QL VIGADRONE ORAL TABLET 4 LD; QL; SP *HYDANTOINS*** DILANTIN ORAL CAPSULE 30 MG 2 fosphenytoin sodium injection solution 2 PHENYTEK ORAL CAPSULE 1 or 1b* phenytoin infatabs oral tablet chewable 1 or 1b* phenytoin oral suspension 125 mg/5ml 1 or 1b* phenytoin oral tablet chewable 1 or 1b* phenytoin sodium extended oral capsule 1 or 1b* phenytoin sodium injection solution 1 or 1b* *SUCCINIMIDES*** ethosuximide oral capsule 1 or 1b* QL ethosuximide oral solution 1 or 1b* QL methsuximide oral capsule 2 QL *VALPROIC ACID*** divalproex sodium er oral tablet extended release 24 hour 1 or 1b* QL divalproex sodium oral capsule delayed release sprinkle 1 or 1b* QL divalproex sodium oral tablet delayed release 1 or 1b* QL valproate sodium intravenous solution 100 mg/ml, 500 mg/5ml 1 or 1b* valproic acid oral capsule 1 or 1b* QL valproic acid oral solution 1 or 1b* Drug Name Tier Notes *ANTIDEPRESSANTS* *ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)*** mirtazapine oral tablet 1 or 1b* mirtazapine oral tablet dispersible 1 or 1b* *ANTIDEPRESSANTS - MISC.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg 1 or 1b* DO bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg 1 or 1b* QL bupropion hcl er (xl) oral tablet extended release 24 hour 1 or 1b* QL bupropion hcl oral tablet 100 mg 1 or 1b* QL bupropion hcl oral tablet 75 mg 1 or 1b* DO *MONOAMINE OXIDASE INHIBITORS (MAOIS)*** phenelzine sulfate oral tablet 1 or 1b* QL tranylcypromine sulfate oral tablet 1 or 1b* QL *SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)*** citalopram hydrobromide oral solution 1 or 1b* citalopram hydrobromide oral tablet 1 or 1b* escitalopram oxalate oral solution 1 or 1b* escitalopram oxalate oral tablet 1 or 1b* fluoxetine hcl oral capsule 1 or 1b* fluoxetine hcl oral capsule delayed release 1 or 1b* fluoxetine hcl oral solution 1 or 1b* fluoxetine hcl oral tablet 10 mg, 20 mg 1 or 1b* fluvoxamine maleate er oral capsule extended release 24 hour 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 20

Drug Name Tier Notes fluvoxamine maleate oral tablet 1 or 1b* paroxetine hcl er oral tablet extended release 24 hour 1 or 1b* paroxetine hcl oral suspension 2 paroxetine hcl oral tablet 1 or 1b* sertraline hcl oral concentrate 1 or 1b* sertraline hcl oral tablet 1 or 1b* *SEROTONIN MODULATORS*** nefazodone hcl oral tablet 100 mg, 50 mg 1 or 1b* DO nefazodone hcl oral tablet 150 mg, 200 mg, 250 mg 1 or 1b* QL trazodone hcl oral tablet 100 mg, 150 mg, 50 mg 1 or 1a* DO trazodone hcl oral tablet 300 mg 1 or 1a* QL TRINTELLIX ORAL TABLET 10 MG, 5 MG 3 DO TRINTELLIX ORAL TABLET 20 MG 3 QL vilazodone hcl oral tablet 10 mg, 20 mg 1 or 1b* DO vilazodone hcl oral tablet 40 mg 1 or 1b* QL *SEROTONIN- NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)*** desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg 1 or 1b* QL desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg, 50 mg 1 or 1b* DO duloxetine hcl oral capsule delayed release particles 2 QL venlafaxine hcl er oral capsule extended release 24 hour 1 or 1b* QL venlafaxine hcl er oral tablet extended release 24 hour 225 mg 1 or 1b* QL venlafaxine hcl oral tablet 1 or 1b* QL Drug Name Tier Notes *TRICYCLIC AGENTS*** amitriptyline hcl oral tablet 10 mg, 25 mg, 50 mg, 75 mg 1 or 1a* DO amitriptyline hcl oral tablet 100 mg, 150 mg 1 or 1a* QL amoxapine oral tablet 100 mg, 150 mg 1 or 1b* QL amoxapine oral tablet 25 mg, 50 mg 1 or 1b* DO clomipramine hcl oral capsule 25 mg 1 or 1b* DO clomipramine hcl oral capsule 50 mg, 75 mg 1 or 1b* QL desipramine hcl oral tablet 10 mg, 25 mg, 50 mg, 75 mg 2 DO desipramine hcl oral tablet 100 mg, 150 mg 2 QL doxepin hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg 1 or 1b* DO doxepin hcl oral capsule 100 mg, 150 mg 1 or 1b* QL doxepin hcl oral concentrate 1 or 1b* QL imipramine hcl oral tablet 10 mg, 25 mg 1 or 1b* DO imipramine hcl oral tablet 50 mg 1 or 1b* QL imipramine pamoate oral capsule 100 mg, 75 mg 1 or 1b* DO imipramine pamoate oral capsule 125 mg, 150 mg 1 or 1b* QL nortriptyline hcl oral capsule 10 mg, 25 mg 1 or 1b* DO nortriptyline hcl oral capsule 50 mg, 75 mg 1 or 1b* QL nortriptyline hcl oral solution 1 or 1b* QL protriptyline hcl oral tablet 10 mg 2 QL protriptyline hcl oral tablet 5 mg 2 DO trimipramine maleate oral capsule 1 or 1b* QL *ANTIDIABETICS* *ALPHA-GLUCOSIDASE INHIBITORS*** acarbose oral tablet 1 or 1b* QL miglitol oral tablet 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 21

Drug Name Tier Notes *BIGUANIDES*** metformin hcl er oral tablet extended release 24 hour 1 or 1b* QL metformin hcl oral solution 3 PA; QL metformin hcl oral tablet 1000 mg, 500 mg 1 or 1b* QL metformin hcl oral tablet 850 mg 1 or 1b* $0; QL *DIABETIC OTHER*** BAQSIMI ONE PACK NASAL POWDER 3 QL BAQSIMI TWO PACK NASAL POWDER 3 QL diazoxide oral suspension 2 GLUCAGON EMERGENCY INJECTION KIT 1 or 1b* QL GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED 3 QL GVOKE HYPOPEN 1- PACK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 QL GVOKE HYPOPEN 2- PACK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 QL GVOKE KIT SUBCUTANEOUS SOLUTION 3 QL GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 1 MG/0.2ML 3 QL ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 QL ZEGALOGUE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 QL *DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS*** alogliptin benzoate oral tablet 1 or 1b* ST; QL JANUVIA ORAL TABLET 2 ST; QL Drug Name Tier Notes *DIPEPTIDYL PEPTIDASE-4 INHIBITOR-BIGUANIDE COMBINATIONS*** alogliptin-metformin hcl oral tablet 1 or 1b* ST; QL JANUMET ORAL TABLET 2 ST; QL JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2 ST; QL *DPP-4 INHIBITOR- THIAZOLIDINEDIONE COMBINATIONS*** alogliptin-pioglitazone oral tablet 12.5-30 mg, 25-15 mg, 25-30 mg, 25-45 mg 1 or 1b* ST; QL *HUMAN INSULIN*** HUMALOG INJECTION SOLUTION 2 QL HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 QL HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML, 200 UNIT/ML 2 QL HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR 2 QL HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR 2 QL HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION 2 QL HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 2 QL HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR 2 QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 22

Drug Name Tier Notes HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 2 QL HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR 2 QL HUMULIN N SUBCUTANEOUS SUSPENSION 2 QL HUMULIN R INJECTION SOLUTION 2 QL HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 2 PA; QL HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 PA; QL INSULIN LISPRO (1 UNIT DIAL) SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 ST; QL INSULIN LISPRO INJECTION SOLUTION 2 QL INSULIN LISPRO JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 QL INSULIN LISPRO PROT & LISPRO SUBCUTANEOUS SUSPENSION PEN- INJECTOR 2 QL LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 QL LANTUS SUBCUTANEOUS SOLUTION 2 QL LYUMJEV INJECTION SOLUTION 2 QL LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 QL Drug Name Tier Notes TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 QL TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 QL TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 QL TRESIBA SUBCUTANEOUS SOLUTION 2 QL *INCRETIN MIMETIC AGENTS (GIP & GLP-1 RECEPTOR AGONISTS)*** MOUNJARO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 2 PA; QL *INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)*** liraglutide subcutaneous solution pen-injector 2 PA; QL OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 MG/3ML 2 PA; QL OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- INJECTOR 4 MG/3ML 2 PA; QL OZEMPIC (2 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 PA; QL RYBELSUS ORAL TABLET 2 PA; QL TRULICITY SUBCUTANEOUS SOLUTION AUTO- INJECTOR 2 PA; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 23

Drug Name Tier Notes *INSULIN-INCRETIN MIMETIC COMBINATIONS*** SOLIQUA SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 ST; QL XULTOPHY SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 ST; QL *MEGLITINIDE ANALOGUES*** nateglinide oral tablet 2 QL repaglinide oral tablet 2 QL *PROGESTERONE RECEPTOR ANTAGONISTS*** mifepristone oral tablet 300 mg 4 PA; LD; QL *SGLT2 INHIBITOR - DPP-4 INHIBITOR - BIGUANIDE COMB*** TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2 ST; QL *SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS*** GLYXAMBI ORAL TABLET 2 ST; QL *SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS*** dapagliflozin propanediol oral tablet 2 ST; QL FARXIGA ORAL TABLET 2 ST; QL JARDIANCE ORAL TABLET 2 ST; QL *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** dapagliflozin pro-metformin er oral tablet extended release 24 hour 2 ST; QL SYNJARDY ORAL TABLET 2 ST; QL Drug Name Tier Notes SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2 ST; QL XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2 ST; QL *SULFONYLUREA- BIGUANIDE COMBINATIONS*** glipizide-metformin hcl oral tablet 1 or 1b* QL glyburide-metformin oral tablet 1 or 1b* QL *SULFONYLUREAS*** glimepiride oral tablet 1 mg, 2 mg, 4 mg 1 or 1b* QL glipizide er oral tablet extended release 24 hour 1 or 1a* QL glipizide oral tablet 1 or 1a* QL glyburide micronized oral tablet 1 or 1b* QL glyburide oral tablet 1 or 1b* QL *SULFONYLUREA- THIAZOLIDINEDIONE COMBINATIONS*** pioglitazone hcl-glimepiride oral tablet 1 or 1b* ST; QL *THIAZOLIDINEDIONE- BIGUANIDE COMBINATIONS*** pioglitazone hcl-metformin hcl oral tablet 1 or 1b* ST; QL *THIAZOLIDINEDIONES *** pioglitazone hcl oral tablet 1 or 1b* ST; QL *ANTIDIARRHEAL/PRO BIOTIC AGENTS* *ANTIPERISTALTIC AGENTS*** diphenoxylate-atropine oral liquid 1 or 1b* diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 or 1b* loperamide hcl oral capsule 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 24

Drug Name Tier Notes *ANTIDOTES AND SPECIFIC ANTAGONISTS* *ANTIDOTES - CHELATING AGENTS*** deferasirox granules oral packet 4 PA; LD; SP deferasirox oral packet 4 PA; LD; SP deferasirox oral tablet 4 PA; LD; SP deferasirox oral tablet soluble 4 PA; LD; SP deferiprone oral tablet 4 PA; LD *ANTIDOTES AND SPECIFIC ANTAGONISTS*** acetylcysteine intravenous solution 2 fomepizole intravenous solution 1.5 gm/1.5ml 1 or 1b* methylene blue (antidote) intravenous solution 1 or 1b* methylene blue intravenous solution 50 mg/10ml 1 or 1b* SODIUM THIOSULFATE INTRAVENOUS SOLUTION 250 MG/ML 1 or 1b* *BENZODIAZEPINE ANTAGONISTS*** flumazenil intravenous solution 1 or 1b* *OPIOID ANTAGONISTS*** KLOXXADO NASAL LIQUID 2 QL naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml 1 or 1b* QL naloxone hcl injection solution cartridge 1 or 1b* QL naloxone hcl injection solution prefilled syringe 1 or 1b* QL naloxone hcl nasal liquid 1 or 1b* QL naltrexone hcl oral tablet 1 or 1b* OPVEE NASAL SOLUTION 2 QL REXTOVY NASAL LIQUID 2 QL Drug Name Tier Notes ZIMHI INJECTION SOLUTION PREFILLED SYRINGE 2 QL *ANTIEMETICS* *5-HT3 RECEPTOR ANTAGONISTS*** granisetron hcl intravenous solution 1 mg/ml, 4 mg/4ml 2 LD granisetron hcl oral tablet 2 LD; QL ondansetron hcl +rfid injection solution 2 ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml 2 ondansetron hcl injection solution prefilled syringe 2 LD ondansetron hcl oral solution 2 LD; QL ondansetron hcl oral tablet 2 LD; QL ondansetron oral tablet dispersible 16 mg 2 QL ondansetron oral tablet dispersible 4 mg, 8 mg 2 LD; QL palonosetron hcl intravenous solution 0.25 mg/5ml 2 LD palonosetron hcl intravenous solution prefilled syringe 2 LD *ANTIEMETIC COMBINATIONS*** doxylamine-pyridoxine oral tablet delayed release 1 or 1b* PA; QL *ANTIEMETICS - ANTICHOLINERGIC*** meclizine hcl oral tablet 25 mg 1 or 1a* meclizine hcl oral tablet 50 mg 1 or 1b* scopolamine transdermal patch 72 hour 1 or 1b* trimethobenzamide hcl oral capsule 1 or 1b* *ANTIEMETICS - MISCELLANEOUS*** dronabinol oral capsule 2 QL *SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS*** aprepitant oral 2 LD; QL aprepitant oral capsule 2 LD; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 25

Drug Name Tier Notes fosaprepitant dimeglumine intravenous solution reconstituted 2 LD; QL *ANTIFUNGALS* *ANTIFUNGALS*** amphotericin b intravenous solution reconstituted 2 amphotericin b liposome intravenous suspension reconstituted 2 flucytosine oral capsule 2 PA griseofulvin microsize oral suspension 1 or 1b* griseofulvin microsize oral tablet 1 or 1b* griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 1 or 1b* nystatin oral tablet 1 or 1b* terbinafine hcl oral tablet 1 or 1b* *IMIDAZOLES*** ketoconazole oral tablet 1 or 1b* QL *TRIAZOLES*** fluconazole in sodium chloride intravenous solution 200-0.9 mg/100ml-%, 400- 0.9 mg/200ml-% 1 or 1b* fluconazole oral suspension reconstituted 1 or 1b* QL fluconazole oral tablet 1 or 1b* QL itraconazole oral capsule 2 PA; QL itraconazole oral solution 2 PA; QL posaconazole intravenous solution 2 posaconazole oral suspension 2 PA; QL posaconazole oral tablet delayed release 2 PA; QL voriconazole oral suspension reconstituted 2 PA; QL voriconazole oral tablet 2 PA; QL *ANTIHISTAMINES* *ANTIHISTAMINES - ETHANOLAMINES*** carbinoxamine maleate er oral suspension extended release 1 or 1b* ST; QL carbinoxamine maleate oral solution 1 or 1b* ST Drug Name Tier Notes carbinoxamine maleate oral tablet 4 mg 1 or 1b* ST clemastine fumarate oral tablet 2.68 mg 1 or 1b* ST; QL diphenhydramine hcl injection solution 2 *ANTIHISTAMINES - NON-SEDATING*** cetirizine hcl oral solution 1 or 1b* BE; QL desloratadine oral tablet 3 QL desloratadine oral tablet dispersible 3 QL levocetirizine dihydrochloride oral tablet 1 or 1b* BE; QL *ANTIHISTAMINES - PHENOTHIAZINES*** promethazine hcl injection solution 1 or 1a* promethazine hcl oral solution 1 or 1a* QL promethazine hcl oral tablet 1 or 1a* QL promethazine hcl rectal suppository 12.5 mg, 25 mg 2 QL promethegan rectal suppository 2 QL *ANTIHISTAMINES - PIPERIDINES*** cyproheptadine hcl oral syrup 1 or 1b* cyproheptadine hcl oral tablet 1 or 1b* *ANTIHYPERLIPIDEMI CS* *ANTIHYPERLIPIDEMI CS - MISC.*** icosapent ethyl oral capsule 2 PA; QL omega-3-acid ethyl esters oral capsule 1 or 1b* PA; QL VASCEPA ORAL CAPSULE 2 PA; QL *BILE ACID SEQUESTRANTS*** cholestyramine light oral packet 2 QL cholestyramine light oral powder 2 QL cholestyramine oral packet 2 QL cholestyramine oral powder 2 QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 26

Drug Name Tier Notes colesevelam hcl oral packet 3 QL colesevelam hcl oral tablet 2 QL colestipol hcl oral granules 1 or 1b* QL colestipol hcl oral packet 1 or 1b* QL colestipol hcl oral tablet 1 or 1b* QL prevalite oral packet 2 QL prevalite oral powder 2 QL *FIBRIC ACID DERIVATIVES*** fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg 1 or 1b* QL fenofibrate oral capsule 1 or 1b* QL fenofibrate oral tablet 120 mg, 40 mg 3 ST; QL fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg 1 or 1b* QL fenofibric acid oral capsule delayed release 1 or 1b* QL fenofibric acid oral tablet 1 or 1b* QL gemfibrozil oral tablet 1 or 1b* QL *HMG COA REDUCTASE INHIBITORS*** atorvastatin calcium oral tablet 10 mg, 20 mg 1 or 1b* DO; $0 atorvastatin calcium oral tablet 40 mg 1 or 1b* DO atorvastatin calcium oral tablet 80 mg 1 or 1b* QL fluvastatin sodium oral capsule 1 or 1b* DO; $0 lovastatin oral tablet 10 mg, 20 mg 1 or 1b* DO; $0 lovastatin oral tablet 40 mg 1 or 1b* $0; QL pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg 1 or 1b* DO; $0 pravastatin sodium oral tablet 80 mg 1 or 1b* $0; QL rosuvastatin calcium oral tablet 10 mg, 5 mg 2 DO; $0 rosuvastatin calcium oral tablet 20 mg 2 DO rosuvastatin calcium oral tablet 40 mg 2 QL simvastatin oral tablet 10 mg, 20 mg, 5 mg 1 or 1b* DO; $0 simvastatin oral tablet 40 mg 1 or 1b* $0; QL Drug Name Tier Notes simvastatin oral tablet 80 mg 1 or 1b* PA; QL *INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB*** ezetimibe-simvastatin oral tablet 2 ST; QL *INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS*** ezetimibe oral tablet 2 QL *NICOTINIC ACID DERIVATIVES*** niacin (antihyperlipidemic) oral tablet 1 or 1b* ST; QL niacin er (antihyperlipidemic) oral tablet extended release 1 or 1b* ST; QL niacor oral tablet 1 or 1b* ST; QL *PCSK9 INHIBITORS*** REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 3 PA; QL REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 PA; QL REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 PA; QL *ANTIHYPERTENSIVES * *ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS*** amlodipine besy-benazepril hcl oral capsule 1 or 1b* QL trandolapril-verapamil hcl er oral tablet extended release 1 or 1b* QL *ACE INHIBITORS & THIAZIDE/THIAZIDE- LIKE*** benazepril- hydrochlorothiazide oral tablet 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 27

Drug Name Tier Notes captopril- hydrochlorothiazide oral tablet 1 or 1b* QL enalapril-hydrochlorothiazide oral tablet 1 or 1b* QL fosinopril sodium-hctz oral tablet 1 or 1b* QL lisinopril- hydrochlorothiazide oral tablet 1 or 1b* QL quinapril- hydrochlorothiazide oral tablet 1 or 1b* QL *ACE INHIBITORS*** benazepril hcl oral tablet 1 or 1a* QL captopril oral tablet 1 or 1b* QL enalapril maleate oral solution 2 QL enalapril maleate oral tablet 1 or 1b* QL enalaprilat intravenous solution 1 or 1b* fosinopril sodium oral tablet 1 or 1b* QL lisinopril oral tablet 1 or 1a* QL moexipril hcl oral tablet 1 or 1b* QL perindopril erbumine oral tablet 1 or 1b* QL quinapril hcl oral tablet 1 or 1b* QL ramipril oral capsule 1 or 1b* QL trandolapril oral tablet 1 or 1b* QL *AGENTS FOR PHEOCHROMOCYTOM A*** metyrosine oral capsule 1 or 1b* PA; LD; QL; SP phenoxybenzamine hcl oral capsule 2 PA; QL phentolamine mesylate injection solution reconstituted 1 or 1b* *ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER COMB*** amlodipine besylate- valsartan oral tablet 1 or 1b* QL amlodipine-olmesartan oral tablet 1 or 1b* QL telmisartan-amlodipine oral tablet 1 or 1b* QL Drug Name Tier Notes *ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE- LIKE*** candesartan cilexetil-hctz oral tablet 1 or 1b* QL irbesartan- hydrochlorothiazide oral tablet 1 or 1b* QL losartan potassium-hctz oral tablet 1 or 1b* QL olmesartan medoxomil-hctz oral tablet 1 or 1b* QL telmisartan-hctz oral tablet 1 or 1b* QL valsartan- hydrochlorothiazide oral tablet 1 or 1b* QL *ANGIOTENSIN II RECEPTOR ANTAGONISTS*** candesartan cilexetil oral tablet 16 mg, 32 mg 1 or 1b* QL candesartan cilexetil oral tablet 4 mg, 8 mg 1 or 1b* DO irbesartan oral tablet 150 mg, 75 mg 1 or 1b* DO irbesartan oral tablet 300 mg 1 or 1b* QL losartan potassium oral tablet 100 mg, 50 mg 1 or 1b* QL losartan potassium oral tablet 25 mg 1 or 1b* DO olmesartan medoxomil oral tablet 20 mg, 5 mg 1 or 1b* DO olmesartan medoxomil oral tablet 40 mg 1 or 1b* QL telmisartan oral tablet 20 mg, 40 mg 1 or 1b* DO telmisartan oral tablet 80 mg 1 or 1b* QL VALSARTAN ORAL SOLUTION 2 PA; QL valsartan oral tablet 160 mg, 320 mg 1 or 1b* QL valsartan oral tablet 40 mg, 80 mg 1 or 1b* DO *ANGIOTENSIN II RECEPTOR ANT-CA CHANNEL BLOCKER- THIAZIDES*** amlodipine-valsartan-hctz oral tablet 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 28

Drug Name Tier Notes olmesartan-amlodipine-hctz oral tablet 1 or 1b* QL *ANTIADRENERGICS - CENTRALLY ACTING*** clonidine hcl oral tablet 1 or 1a* QL clonidine transdermal patch weekly 2 QL guanfacine hcl oral tablet 1 or 1b* methyldopa oral tablet 1 or 1b* QL *ANTIADRENERGICS - PERIPHERALLY ACTING*** doxazosin mesylate oral tablet 1 or 1b* QL prazosin hcl oral capsule 1 or 1b* terazosin hcl oral capsule 1 or 1b* QL *BETA BLOCKER & DIURETIC COMBINATIONS*** atenolol-chlorthalidone oral tablet 1 or 1b* QL bisoprolol- hydrochlorothiazide oral tablet 1 or 1b* QL metoprolol- hydrochlorothiazide oral tablet 1 or 1b* QL *DIRECT RENIN INHIBITORS*** aliskiren fumarate oral tablet 150 mg 2 DO aliskiren fumarate oral tablet 300 mg 2 QL *SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)*** eplerenone oral tablet 2 *VASODILATORS*** hydralazine hcl injection solution 2 hydralazine hcl oral tablet 1 or 1b* minoxidil oral tablet 1 or 1b* Drug Name Tier Notes *ANTI-INFECTIVE AGENTS - MISC.* *ANTI-INFECTIVE AGENTS - MISC.*** metronidazole oral capsule 1 or 1a* metronidazole oral tablet 250 mg, 500 mg 1 or 1a* pentamidine isethionate inhalation solution reconstituted 2 LD pentamidine isethionate injection solution reconstituted 4 LD tinidazole oral tablet 1 or 1b* QL TRIMETHOPRIM ORAL TABLET 1 or 1a* XIFAXAN ORAL TABLET 3 PA; QL *ANTI-INFECTIVE MISC. - COMBINATIONS*** sulfamethoxazole- trimethoprim intravenous solution 2 sulfamethoxazole- trimethoprim oral suspension 1 or 1a* sulfamethoxazole- trimethoprim oral tablet 1 or 1a* sulfatrim pediatric oral suspension 1 or 1a* *ANTIPROTOZOAL AGENTS*** atovaquone oral suspension 2 nitazoxanide oral tablet 2 QL *CARBAPENEM COMBINATIONS*** imipenem-cilastatin intravenous solution reconstituted 2 *CARBAPENEMS*** meropenem intravenous solution reconstituted 1 gm, 500 mg 2 *CHLORAMPHENICALS *** chloramphenicol sod succinate intravenous solution reconstituted 2 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 29

Drug Name Tier Notes *GLYCOPEPTIDES*** vancomycin hcl intravenous solution reconstituted 100 gm 2 QL vancomycin hcl oral capsule 2 QL vancomycin hcl oral solution reconstituted 25 mg/ml, 50 mg/ml 2 QL VANCOMYCIN HCL ORAL SOLUTION RECONSTITUTED 250 MG/5ML 2 QL *LEPROSTATICS*** dapsone oral tablet 2 *LINCOSAMIDES*** clindamycin hcl oral capsule 1 or 1b* clindamycin palmitate hcl oral solution reconstituted 1 or 1b* clindamycin phosphate in d5w intravenous solution 1 or 1b* clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml 1 or 1b* *MONOBACTAMS*** aztreonam injection solution reconstituted 2 *OXAZOLIDINONES*** linezolid intravenous solution 600 mg/300ml 1 or 1b* linezolid oral suspension reconstituted 1 or 1b* PA; QL linezolid oral tablet 1 or 1b* PA; QL *POLYMYXINS*** colistimethate sodium (cba) injection solution reconstituted 2 polymyxin b sulfate injection solution reconstituted 2 *URINARY ANTI- INFECTIVES*** fosfomycin tromethamine oral packet 1 or 1b* methenamine hippurate oral tablet 2 nitrofurantoin macrocrystal oral capsule 1 or 1b* nitrofurantoin monohyd macro oral capsule 1 or 1b* Drug Name Tier Notes nitrofurantoin oral suspension 25 mg/5ml, 50 mg/10ml 1 or 1b* *ANTIMALARIALS* *ANTIMALARIAL COMBINATIONS*** atovaquone-proguanil hcl oral tablet 1 or 1b* *ANTIMALARIALS*** chloroquine phosphate oral tablet 1 or 1a* HYDROXYCHLOROQUI NE SULFATE ORAL TABLET 100 MG, 300 MG, 400 MG 1 or 1b* QL hydroxychloroquine sulfate oral tablet 200 mg 1 or 1b* QL mefloquine hcl oral tablet 1 or 1b* QL pyrimethamine oral tablet 1 or 1b* PA; QL quinine sulfate oral capsule 1 or 1b* PA; QL *ANTIMYASTHENIC/CH OLINERGIC AGENTS* *ANTIMYASTHENIC/CH OLINERGIC AGENTS*** pyridostigmine bromide er oral tablet extended release 2 pyridostigmine bromide oral solution 2 pyridostigmine bromide oral tablet 2 *ANTIMYCOBACTERIA L AGENTS* *ANTIMYCOBACTERIA L AGENTS*** cycloserine oral capsule 1 or 1b* ethambutol hcl oral tablet 2 isoniazid injection solution 1 or 1a* isoniazid oral syrup 1 or 1a* isoniazid oral tablet 1 or 1a* PRIFTIN ORAL TABLET 2 pyrazinamide oral tablet 2 rifabutin oral capsule 2 rifampin intravenous solution reconstituted 2 rifampin oral capsule 2 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 30

Drug Name Tier Notes *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *ALKYLATING AGENTS*** MYLERAN ORAL TABLET 4 LD *ANDROGEN BIOSYNTHESIS INHIBITORS*** abiraterone acetate oral tablet 4 PA; LD; QL; SP ABIRTEGA ORAL TABLET 4 PA; LD; QL; SP *ANTIADRENALS*** LYSODREN ORAL TABLET 4 LD; QL *ANTIANDROGENS*** bicalutamide oral tablet 2 LD; QL ERLEADA ORAL TABLET 4 PA; LD; QL; SP nilutamide oral tablet 4 LD; QL NUBEQA ORAL TABLET 4 PA; LD; QL; SP XTANDI ORAL CAPSULE 4 PA; LD; QL; SP XTANDI ORAL TABLET 4 PA; LD; QL; SP *ANTIESTROGENS*** SOLTAMOX ORAL SOLUTION 2 LD; $0 tamoxifen citrate oral tablet 2 LD; $0 toremifene citrate oral tablet 4 LD *ANTIMETABOLITES*** capecitabine oral tablet 4 PA; LD; SP mercaptopurine oral suspension 2 PA; LD mercaptopurine oral tablet 2 LD methotrexate sodium (pf) injection solution 1 gm/40ml, 1000 mg/40ml, 250 mg/10ml, 50 mg/2ml 1 or 1b* LD methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml 1 or 1b* LD methotrexate sodium injection solution reconstituted 1 or 1b* LD methotrexate sodium oral tablet 2 LD Drug Name Tier Notes TABLOID ORAL TABLET 2 LD TREXALL ORAL TABLET 2 ST; LD *ANTINEOPLASTIC - ALK INHIBITORS*** ALECENSA ORAL CAPSULE 2 PA; LD; QL; SP ALUNBRIG ORAL TABLET 2 PA; LD; QL ALUNBRIG ORAL TABLET THERAPY PACK 2 PA; LD; QL XALKORI ORAL CAPSULE 4 PA; LD; QL; SP *ANTINEOPLASTIC - ANTI-HER2 AGENTS*** HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG 4 LD; SP KANJINTI INTRAVENOUS SOLUTION RECONSTITUTED 4 LD; SP *ANTINEOPLASTIC - BCR-ABL KINASE INHIBITORS*** BOSULIF ORAL CAPSULE 2 PA; LD; QL; SP BOSULIF ORAL TABLET 2 PA; LD; QL; SP dasatinib oral tablet 1 or 1b* PA; LD; QL; SP imatinib mesylate oral tablet 1 or 1b* PA; LD; QL; SP nilotinib hcl oral capsule 4 PA; LD; QL; SP *ANTINEOPLASTIC - BRAF KINASE INHIBITORS*** TAFINLAR ORAL CAPSULE 4 PA; LD; QL; SP ZELBORAF ORAL TABLET 4 PA; LD; QL; SP *ANTINEOPLASTIC - BTK INHIBITORS*** CALQUENCE ORAL TABLET 4 PA; LD; QL IMBRUVICA ORAL CAPSULE 2 PA; LD; QL IMBRUVICA ORAL SUSPENSION 2 PA; LD; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 31

Drug Name Tier Notes IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG 2 PA; LD; QL *ANTINEOPLASTIC - EGFR INHIBITORS*** erlotinib hcl oral tablet 1 or 1b* PA; LD; QL; SP gefitinib oral tablet 4 PA; LD; QL; SP GILOTRIF ORAL TABLET 4 PA; LD; QL *ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS*** ERIVEDGE ORAL CAPSULE 4 PA; LD; QL; SP *ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS*** ZOLINZA ORAL CAPSULE 4 PA; LD; QL; SP *ANTINEOPLASTIC - IMMUNOMODULATORS *** POMALYST ORAL CAPSULE 4 PA; LD; QL; SP *ANTINEOPLASTIC - MEK INHIBITORS*** MEKINIST ORAL TABLET 4 PA; LD; QL; SP *ANTINEOPLASTIC - MTOR KINASE INHIBITORS*** everolimus oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg 4 PA; LD; SP everolimus oral tablet soluble 4 PA; LD; SP TORPENZ ORAL TABLET 4 PA; LD; SP *ANTINEOPLASTIC - MULTIKINASE INHIBITORS*** CABOMETYX ORAL TABLET 2 PA; LD; QL; SP CAPRELSA ORAL TABLET 4 PA; LD; QL COMETRIQ (100 MG DAILY DOSE) ORAL KIT 80 & 20 MG 4 PA; LD; QL; SP COMETRIQ (140 MG DAILY DOSE) ORAL KIT 3 X 20 MG & 80 MG 4 PA; LD; QL; SP Drug Name Tier Notes COMETRIQ (60 MG DAILY DOSE) ORAL KIT 4 PA; LD; QL; SP lapatinib ditosylate oral tablet 4 PA; LD; QL; SP pazopanib hcl oral tablet 4 PA; LD; QL; SP sorafenib tosylate oral tablet 4 PA; LD; QL; SP STIVARGA ORAL TABLET 4 PA; LD; QL; SP sunitinib malate oral capsule 4 PA; LD; QL; SP *ANTINEOPLASTIC - TROPOMYOSIN RECEPTOR KINASE INHIBITORS*** VITRAKVI ORAL CAPSULE 4 PA; LD; QL; SP VITRAKVI ORAL SOLUTION 4 PA; LD; QL; SP *ANTINEOPLASTIC COMBINATIONS*** HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 4 LD; SP *ANTINEOPLASTICS MISC.*** ACTIMMUNE SUBCUTANEOUS SOLUTION 4 PA; LD; SP hydroxyurea oral capsule 2 LD MATULANE ORAL CAPSULE 4 LD *AROMATASE INHIBITORS*** anastrozole oral tablet 2 LD; $0 exemestane oral tablet 2 LD; $0 letrozole oral tablet 2 LD; $0 *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** IBRANCE ORAL CAPSULE 4 PA; LD; QL; SP IBRANCE ORAL TABLET 4 PA; LD; QL; SP KISQALI (200 MG DOSE) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP KISQALI (400 MG DOSE) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 32

Drug Name Tier Notes KISQALI (600 MG DOSE) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP VERZENIO ORAL TABLET 4 PA; LD; QL; SP *FOLIC ACID ANTAGONISTS RESCUE AGENTS*** leucovorin calcium injection solution 1 or 1b* LD leucovorin calcium injection solution reconstituted 1 or 1b* LD leucovorin calcium oral tablet 2 *GONADOTROPIN RELEASING HORMONE (GNRH) ANTAGONISTS*** FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; QL; SP FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG 4 PA; LD; QL; SP ORGOVYX ORAL TABLET 4 PA; LD; QL *IMIDAZOTETRAZINES *** temozolomide oral capsule 4 PA; LD; QL; SP *JANUS ASSOCIATED KINASE (JAK) INHIBITORS*** JAKAFI ORAL TABLET 4 PA; LD; QL; SP *LHRH ANALOGS*** leuprolide acetate injection kit 4 PA; LD; SP TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 4 PA; LD; QL; SP *MITOTIC INHIBITORS*** etoposide oral capsule 4 LD; SP *NITROGEN MUSTARDS AND RELATED ANALOGUES*** cyclophosphamide oral capsule 4 LD; SP Drug Name Tier Notes LEUKERAN ORAL TABLET 2 LD *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS*** LYNPARZA ORAL TABLET 4 PA; LD; QL; SP ZEJULA ORAL TABLET 4 PA; LD; QL; SP *PROGESTINS- ANTINEOPLASTIC*** megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 800 mg/20ml 1 or 1b* LD megestrol acetate oral tablet 1 or 1b* LD *RETINOIDS*** tretinoin oral capsule 2 LD *SELECTIVE RETINOID X RECEPTOR AGONISTS*** bexarotene oral capsule 4 PA; LD; QL; SP *TOPOISOMERASE I INHIBITORS*** HYCAMTIN ORAL CAPSULE 4 PA; LD; SP *URINARY TRACT PROTECTIVE AGENTS*** mesna intravenous solution 1 or 1b* PA; LD mesna oral tablet 2 PA; LD *VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS*** AVASTIN INTRAVENOUS SOLUTION 4 PA; LD; SP INLYTA ORAL TABLET 2 PA; LD; QL; SP LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 33

Drug Name Tier Notes LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP MVASI INTRAVENOUS SOLUTION 4 PA; LD; SP *ANTIPARKINSON AND RELATED THERAPY AGENTS* *ANTIPARKINSON ANTICHOLINERGICS*** benztropine mesylate injection solution 1 or 1a* benztropine mesylate oral tablet 1 or 1a* trihexyphenidyl hcl oral solution 1 or 1a* trihexyphenidyl hcl oral tablet 1 or 1a* *ANTIPARKINSON DOPAMINERGICS*** amantadine hcl oral capsule 1 or 1b* QL amantadine hcl oral solution 1 or 1b* QL amantadine hcl oral tablet 1 or 1b* QL bromocriptine mesylate oral capsule 1 or 1b* bromocriptine mesylate oral tablet 1 or 1b* *ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS*** rasagiline mesylate oral tablet 2 QL selegiline hcl oral capsule 2 selegiline hcl oral tablet 2 *CENTRAL/PERIPHERA L COMT INHIBITORS*** tolcapone oral tablet 2 PA; QL *DECARBOXYLASE INHIBITORS*** carbidopa oral tablet 2 Drug Name Tier Notes *LEVODOPA COMBINATIONS*** carbidopa-levodopa er oral tablet extended release 25- 100 mg, 50-200 mg 2 carbidopa-levodopa oral tablet 1 or 1b* carbidopa-levodopa oral tablet dispersible 2 carbidopa-levodopa- entacapone oral tablet 12.5- 50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25- 125-200 mg, 37.5-150-200 mg, 50-200-200 mg 2 *NONERGOLINE DOPAMINE RECEPTOR AGONISTS*** apomorphine hcl subcutaneous solution cartridge 4 PA; LD; QL; SP pramipexole dihydrochloride er oral tablet extended release 24 hour 1 or 1b* QL pramipexole dihydrochloride oral tablet 1 or 1b* QL ropinirole hcl er oral tablet extended release 24 hour 1 or 1b* ropinirole hcl oral tablet 1 or 1b* *PERIPHERAL COMT INHIBITORS*** entacapone oral tablet 2 QL *ANTIPSYCHOTICS/ANT IMANIC AGENTS* *ANTIMANIC AGENTS*** lithium carbonate er oral tablet extended release 1 or 1a* QL lithium carbonate oral capsule 1 or 1a* QL lithium carbonate oral tablet 1 or 1a* QL lithium oral solution 1 or 1b* *ANTIPSYCHOTICS - MISC.*** CAPLYTA ORAL CAPSULE 10.5 MG, 21 MG 3 ST; DO CAPLYTA ORAL CAPSULE 42 MG 3 ST; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 34

Drug Name Tier Notes lurasidone hcl oral tablet 120 mg 2 AL lurasidone hcl oral tablet 20 mg, 40 mg 2 DO; AL lurasidone hcl oral tablet 60 mg, 80 mg 2 AL; QL VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG 2 ST; DO VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG 2 ST; QL ziprasidone hcl oral capsule 20 mg, 40 mg 2 DO; AL ziprasidone hcl oral capsule 60 mg, 80 mg 2 AL; QL ziprasidone mesylate intramuscular solution reconstituted 2 AL; QL *BENZISOXAZOLES*** paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg 2 DO paliperidone er oral tablet extended release 24 hour 6 mg, 9 mg 2 QL risperidone microspheres er intramuscular suspension reconstituted er 2 AL; QL risperidone oral solution 1 or 1b* AL; QL risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 or 1b* DO; AL risperidone oral tablet 3 mg, 4 mg 1 or 1b* AL; QL risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg 2 DO; AL risperidone oral tablet dispersible 3 mg, 4 mg 2 AL; QL *BUTYROPHENONES*** haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml 1 or 1b* AL; QL haloperidol lactate injection solution 5 mg/ml 1 or 1b* AL haloperidol lactate oral concentrate 2 mg/ml 1 or 1b* AL; QL haloperidol oral tablet 0.5 mg, 1 mg, 2 mg 1 or 1b* DO; AL haloperidol oral tablet 10 mg, 20 mg, 5 mg 1 or 1b* AL; QL Drug Name Tier Notes *DIBENZODIAZEPINES* ** clozapine oral tablet 100 mg, 200 mg 2 AL; QL clozapine oral tablet 25 mg, 50 mg 2 DO; AL clozapine oral tablet dispersible 100 mg, 150 mg, 200 mg 2 AL; QL clozapine oral tablet dispersible 12.5 mg, 25 mg 2 DO; AL *DIBENZO-OXEPINO PYRROLES*** asenapine maleate sublingual tablet sublingual 10 mg 2 AL; QL asenapine maleate sublingual tablet sublingual 2.5 mg, 5 mg 2 DO; AL *DIBENZOTHIAZEPINE S*** quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg 2 DO; AL quetiapine fumarate er oral tablet extended release 24 hour 300 mg, 400 mg, 50 mg 2 AL; QL quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 or 1b* DO; AL quetiapine fumarate oral tablet 150 mg, 300 mg, 400 mg 1 or 1b* AL; QL *DIBENZOXAZEPINES** * loxapine succinate oral capsule 10 mg, 25 mg, 5 mg 1 or 1b* DO; AL loxapine succinate oral capsule 50 mg 1 or 1b* AL; QL *DIHYDROINDOLONES* ** molindone hcl oral tablet 10 mg, 5 mg 2 DO; AL molindone hcl oral tablet 25 mg 2 AL; QL *PHENOTHIAZINES*** chlorpromazine hcl injection solution 1 or 1b* AL CHLORPROMAZINE HCL ORAL CONCENTRATE 1 or 1b* AL; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 35

Drug Name Tier Notes chlorpromazine hcl oral tablet 10 mg, 25 mg, 50 mg 1 or 1b* DO; AL chlorpromazine hcl oral tablet 100 mg, 200 mg 1 or 1b* AL; QL compro rectal suppository 1 or 1b* AL fluphenazine decanoate injection solution 1 or 1b* AL fluphenazine hcl injection solution 1 or 1b* AL fluphenazine hcl oral concentrate 1 or 1b* AL; QL fluphenazine hcl oral elixir 1 or 1b* AL; QL fluphenazine hcl oral tablet 1 mg, 2.5 mg, 5 mg 1 or 1b* DO; AL fluphenazine hcl oral tablet 10 mg 1 or 1b* AL; QL perphenazine oral tablet 16 mg, 4 mg, 8 mg 1 or 1b* AL; QL perphenazine oral tablet 2 mg 1 or 1b* DO; AL prochlorperazine edisylate injection solution 10 mg/2ml 1 or 1b* AL prochlorperazine maleate oral tablet 1 or 1a* AL prochlorperazine rectal suppository 1 or 1b* AL thioridazine hcl oral tablet 10 mg, 25 mg, 50 mg 1 or 1b* DO; AL thioridazine hcl oral tablet 100 mg 1 or 1b* AL; QL trifluoperazine hcl oral tablet 1 mg, 2 mg 1 or 1b* DO; AL trifluoperazine hcl oral tablet 10 mg, 5 mg 1 or 1b* AL; QL *QUINOLINONE DERIVATIVES*** aripiprazole oral solution 2 AL; QL aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 5 mg 2 DO; AL aripiprazole oral tablet 20 mg, 30 mg 2 AL; QL aripiprazole oral tablet dispersible 2 AL; QL REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG 3 ST; DO REXULTI ORAL TABLET 3 MG, 4 MG 3 ST; QL Drug Name Tier Notes *THIENBENZODIAZEPI NES*** olanzapine intramuscular solution reconstituted 2 AL; QL olanzapine oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg 1 or 1b* DO; AL olanzapine oral tablet 15 mg, 20 mg 1 or 1b* AL; QL olanzapine oral tablet dispersible 10 mg, 5 mg 2 DO; AL olanzapine oral tablet dispersible 15 mg, 20 mg 2 AL; QL *THIOXANTHENES*** thiothixene oral capsule 1 mg, 2 mg, 5 mg 1 or 1b* PA; DO thiothixene oral capsule 10 mg 1 or 1b* PA; QL *ANTIVIRALS* *ANTIRETROVIRAL COMBINATIONS*** abacavir sulfate-lamivudine oral tablet 2 LD; QL BIKTARVY ORAL TABLET 4 LD; QL CIMDUO ORAL TABLET 4 LD; QL DESCOVY ORAL TABLET 120-15 MG 2 LD; QL DESCOVY ORAL TABLET 200-25 MG 2 LD; $0; QL DOVATO ORAL TABLET 4 LD; QL efavirenz-emtricitab-tenofo df oral tablet 4 LD; QL efavirenz-lamivudine- tenofovir oral tablet 4 LD; QL emtricitabine-tenofovir df oral tablet 100-150 mg, 133- 200 mg, 167-250 mg 1 or 1b* LD; QL emtricitabine-tenofovir df oral tablet 200-300 mg 1 or 1b* LD; $0; QL emtricitab-rilpivir-tenofov df oral tablet 1 or 1b* PA; LD; QL GENVOYA ORAL TABLET 4 LD; QL lamivudine-zidovudine oral tablet 2 LD; QL lopinavir-ritonavir oral tablet 4 LD; QL STRIBILD ORAL TABLET 4 LD; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 36

Drug Name Tier Notes TRIUMEQ ORAL TABLET 4 LD; QL TRIUMEQ PD ORAL TABLET SOLUBLE 4 LD; QL *ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY INHIBITOR)*** maraviroc oral tablet 4 LD; QL *ANTIRETROVIRALS - FUSION INHIBITORS*** FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; QL *ANTIRETROVIRALS - INTEGRASE INHIBITORS*** ISENTRESS ORAL TABLET 4 LD; QL ISENTRESS ORAL TABLET CHEWABLE 4 LD; QL TIVICAY ORAL TABLET 50 MG 4 LD; QL TIVICAY PD ORAL TABLET SOLUBLE 4 LD; QL *ANTIRETROVIRALS - PROTEASE INHIBITORS*** APTIVUS ORAL CAPSULE 4 PA; LD; QL atazanavir sulfate oral capsule 4 LD; QL darunavir oral tablet 4 LD; QL fosamprenavir calcium oral tablet 4 LD; QL PREZISTA ORAL SUSPENSION 4 LD; QL PREZISTA ORAL TABLET 150 MG, 75 MG 4 LD; QL REYATAZ ORAL PACKET 4 LD; QL ritonavir oral tablet 4 LD; QL *ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES*** EDURANT ORAL TABLET 4 PA; LD; QL efavirenz oral tablet 4 LD; QL etravirine oral tablet 4 PA; LD; QL Drug Name Tier Notes INTELENCE ORAL TABLET 25 MG 4 PA; LD; QL nevirapine er oral tablet extended release 24 hour 400 mg 4 LD; QL nevirapine oral suspension 4 LD; QL nevirapine oral tablet 4 LD; QL *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- PURINES*** abacavir sulfate oral solution 4 LD; QL abacavir sulfate oral tablet 4 LD; QL *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- PYRIMIDINES*** emtricitabine oral capsule 4 LD; $0; QL EMTRIVA ORAL SOLUTION 4 LD; QL lamivudine oral solution 4 LD; QL lamivudine oral tablet 150 mg, 300 mg 4 PA; LD; QL *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- THYMIDINES*** zidovudine oral capsule 4 LD; QL zidovudine oral syrup 4 LD; QL zidovudine oral tablet 4 LD; QL *ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES*** tenofovir disoproxil fumarate oral tablet 4 LD; $0; QL VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG 4 LD; QL *ANTIVIRAL COMBINATIONS*** PAXLOVID (150/100) ORAL TABLET THERAPY PACK 2 QL PAXLOVID (300/100 & 150/100) ORAL TABLET THERAPY PACK 2 QL PAXLOVID (300/100) ORAL TABLET THERAPY PACK 2 QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 37

Drug Name Tier Notes *CMV AGENTS*** valganciclovir hcl oral solution reconstituted 4 LD valganciclovir hcl oral tablet 4 LD *HEPATITIS B AGENTS*** adefovir dipivoxil oral tablet 4 PA; LD; QL; SP BARACLUDE ORAL SOLUTION 4 PA; LD; QL entecavir oral tablet 4 PA; LD; QL lamivudine oral tablet 100 mg 4 PA; LD; QL VEMLIDY ORAL TABLET 4 PA; LD; QL; SP *HEPATITIS C AGENT - COMBINATIONS*** EPCLUSA ORAL PACKET 4 PA; LD; QL; SP EPCLUSA ORAL TABLET 4 PA; LD; QL; SP HARVONI ORAL PACKET 4 PA; LD; QL; SP HARVONI ORAL TABLET 4 PA; LD; QL; SP VOSEVI ORAL TABLET 4 PA; LD; QL; SP *HEPATITIS C AGENTS*** ribavirin oral capsule 4 LD; QL; SP ribavirin oral tablet 200 mg 4 LD; QL; SP *HERPES AGENTS - PURINE ANALOGUES*** acyclovir oral capsule 1 or 1b* acyclovir oral suspension 1 or 1b* acyclovir oral tablet 1 or 1b* acyclovir sodium intravenous solution 1 or 1b* valacyclovir hcl oral tablet 1 or 1b* QL *HERPES AGENTS - THYMIDINE ANALOGUES*** famciclovir oral tablet 1 or 1b* QL *INFLUENZA AGENTS*** rimantadine hcl oral tablet 1 or 1b* Drug Name Tier Notes *MISC. ANTIVIRALS*** LAGEVRIO ORAL CAPSULE 3 QL *NEURAMINIDASE INHIBITORS*** oseltamivir phosphate oral capsule 1 or 1b* QL oseltamivir phosphate oral suspension reconstituted 1 or 1b* QL RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/ACT 2 QL *PA ENDONUCLEASE INHIBITORS*** XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK 1 X 40 MG 3 QL XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK 1 X 80 MG 3 QL *RSV AGENTS - NUCLEOSIDE ANALOGUES*** ribavirin inhalation solution reconstituted 2 *BETA BLOCKERS* *ALPHA-BETA BLOCKERS*** carvedilol oral tablet 1 or 1b* QL carvedilol phosphate er oral capsule extended release 24 hour 2 QL labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 or 1b* QL labetalol hcl oral tablet 400 mg 2 QL *BETA BLOCKERS CARDIO-SELECTIVE*** acebutolol hcl oral capsule 1 or 1b* atenolol oral tablet 1 or 1a* betaxolol hcl oral tablet 1 or 1b* bisoprolol fumarate oral tablet 1 or 1b* esmolol hcl intravenous solution 100 mg/10ml 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 38

Drug Name Tier Notes metoprolol succinate er oral tablet extended release 24 hour 1 or 1b* metoprolol tartrate intravenous solution 5 mg/5ml 1 or 1a* metoprolol tartrate oral tablet 1 or 1a* nebivolol hcl oral tablet 2 *BETA BLOCKERS NON- SELECTIVE*** nadolol oral tablet 20 mg, 40 mg, 80 mg 1 or 1b* QL pindolol oral tablet 2 QL propranolol hcl er oral capsule extended release 24 hour 1 or 1b* QL propranolol hcl intravenous solution 1 or 1b* propranolol hcl oral solution 1 or 1b* QL propranolol hcl oral tablet 1 or 1b* QL sotalol hcl (af) oral tablet 2 QL sotalol hcl oral tablet 2 QL timolol maleate oral tablet 1 or 1b* QL *CALCIUM CHANNEL BLOCKERS* *CALCIUM CHANNEL BLOCKERS*** amlodipine besylate oral tablet 10 mg 1 or 1b* QL amlodipine besylate oral tablet 2.5 mg, 5 mg 1 or 1b* DO cartia xt oral capsule extended release 24 hour 120 mg 1 or 1b* DO cartia xt oral capsule extended release 24 hour 180 mg, 240 mg, 300 mg 1 or 1b* QL diltiazem hcl er beads oral capsule extended release 24 hour 120 mg 1 or 1b* DO diltiazem hcl er beads oral capsule extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 or 1b* QL diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg 1 or 1b* DO Drug Name Tier Notes diltiazem hcl er coated beads oral capsule extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg 1 or 1b* QL diltiazem hcl er oral capsule extended release 12 hour 120 mg, 90 mg 1 or 1b* QL diltiazem hcl er oral capsule extended release 12 hour 60 mg 1 or 1b* DO diltiazem hcl er oral capsule extended release 24 hour 120 mg 1 or 1b* DO diltiazem hcl er oral capsule extended release 24 hour 180 mg, 240 mg 1 or 1b* QL diltiazem hcl er oral tablet extended release 24 hour 120 mg 1 or 1b* DO diltiazem hcl er oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 or 1b* QL diltiazem hcl intravenous solution 1 or 1b* diltiazem hcl oral tablet 120 mg, 90 mg 1 or 1b* QL diltiazem hcl oral tablet 30 mg, 60 mg 1 or 1b* DO dilt-xr oral capsule extended release 24 hour 120 mg 1 or 1b* DO dilt-xr oral capsule extended release 24 hour 180 mg, 240 mg 1 or 1b* QL felodipine er oral tablet extended release 24 hour 10 mg 1 or 1b* QL felodipine er oral tablet extended release 24 hour 2.5 mg, 5 mg 1 or 1b* DO isradipine oral capsule 2.5 mg 1 or 1b* DO isradipine oral capsule 5 mg 1 or 1b* QL levamlodipine maleate oral tablet 2.5 mg 1 or 1b* ST; DO levamlodipine maleate oral tablet 5 mg 1 or 1b* ST; QL matzim la oral tablet extended release 24 hour 1 or 1b* QL nicardipine hcl oral capsule 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 39

Drug Name Tier Notes nifedipine er oral tablet extended release 24 hour 2 QL nifedipine er osmotic release oral tablet extended release 24 hour 30 mg 2 DO nifedipine er osmotic release oral tablet extended release 24 hour 60 mg, 90 mg 2 QL nifedipine oral capsule 10 mg 2 DO nifedipine oral capsule 20 mg 2 QL nimodipine oral capsule 2 QL nimodipine oral solution 2 QL nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 8.5 mg 1 or 1b* DO nisoldipine er oral tablet extended release 24 hour 25.5 mg, 30 mg, 34 mg, 40 mg 1 or 1b* QL tiadylt er oral capsule extended release 24 hour 120 mg 1 or 1b* DO tiadylt er oral capsule extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 or 1b* QL verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg 1 or 1b* DO verapamil hcl er oral capsule extended release 24 hour 200 mg, 240 mg, 300 mg, 360 mg 1 or 1b* QL verapamil hcl er oral tablet extended release 120 mg 1 or 1b* DO verapamil hcl er oral tablet extended release 180 mg, 240 mg 1 or 1b* QL verapamil hcl intravenous solution 1 or 1b* verapamil hcl oral tablet 120 mg 1 or 1b* QL verapamil hcl oral tablet 40 mg, 80 mg 1 or 1b* DO *CARDIOTONICS* *CARDIAC GLYCOSIDES*** digoxin injection solution 1 or 1b* digoxin oral solution 1 or 1b* QL digoxin oral tablet 125 mcg, 62.5 mcg 1 or 1b* DO Drug Name Tier Notes digoxin oral tablet 250 mcg 1 or 1b* QL LANOXIN PEDIATRIC INJECTION SOLUTION 2 *INOTROPES*** dobutamine hcl intravenous solution 12.5 mg/ml, 250 mg/20ml 1 or 1b* milrinone lactate in dextrose intravenous solution 1 or 1b* milrinone lactate intravenous solution 10 mg/10ml, 20 mg/20ml, 50 mg/50ml 1 or 1b* *CARDIOVASCULAR AGENTS - MISC.* *CALCIUM CHANNEL BLOCKER & HMG COA REDUCTASE INHIBIT COMB*** amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-80 mg 1 or 1b* QL amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg 1 or 1b* DO *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** ENTRESTO ORAL CAPSULE SPRINKLE 3 QL ENTRESTO ORAL TABLET 3 QL *NITRATE & VASODILATOR COMBINATIONS*** isosorb dinitrate-hydralazine oral tablet 20-37.5 mg 2 QL *PROSTAGLANDIN VASODILATORS*** alprostadil injection solution 1 or 1b* ORENITRAM ORAL TABLET EXTENDED RELEASE 4 PA; LD; SP treprostinil injection solution 4 PA; LD; SP VENTAVIS INHALATION SOLUTION 4 PA; LD; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 40

Drug Name Tier Notes *PULM HYPERTEN- SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC)*** ADEMPAS ORAL TABLET 4 PA; LD; QL; SP *PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS*** ambrisentan oral tablet 4 PA; LD; QL; SP bosentan oral tablet 4 PA; LD; QL; SP OPSUMIT ORAL TABLET 4 PA; LD; QL; SP TRACLEER ORAL TABLET SOLUBLE 4 PA; LD; QL; SP *PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS*** alyq oral tablet 4 PA; LD; QL; SP sildenafil citrate oral suspension reconstituted 4 PA; LD; QL; SP sildenafil citrate oral tablet 20 mg 4 PA; LD; QL; SP tadalafil (pah) oral tablet 4 PA; LD; QL; SP *PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST*** UPTRAVI INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; QL UPTRAVI ORAL TABLET 4 PA; LD; QL; SP *SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS*** sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg 1 or 1b* PA tadalafil oral tablet 10 mg, 20 mg 1 or 1b* PA tadalafil oral tablet 2.5 mg, 5 mg 1 or 1b* PA; QL vardenafil hcl oral tablet dispersible 1 or 1b* PA Drug Name Tier Notes *SEPTAL AGENTS - ABLATION** dehydrated alcohol intra- arterial solution 2 *SINUS NODE INHIBITORS** ivabradine hcl oral tablet 2 PA; QL *CEPHALOSPORINS* *CEPHALOSPORINS - 1ST GENERATION*** cefadroxil oral capsule 1 or 1b* cefadroxil oral suspension reconstituted 1 or 1b* cefadroxil oral tablet 1 or 1b* cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm, 3 gm, 500 mg 2 cefazolin sodium intravenous solution reconstituted 1 gm 2 cephalexin oral capsule 1 or 1a* cephalexin oral suspension reconstituted 1 or 1a* cephalexin oral tablet 1 or 1a* *CEPHALOSPORINS - 2ND GENERATION*** CEFACLOR ER ORAL TABLET EXTENDED RELEASE 12 HOUR 2 cefaclor oral capsule 1 or 1b* cefaclor oral suspension reconstituted 250 mg/5ml 1 or 1b* cefotetan disodium injection solution reconstituted 1 gm, 2 gm 2 cefoxitin sodium intravenous solution reconstituted 2 cefprozil oral suspension reconstituted 1 or 1b* cefprozil oral tablet 1 or 1b* cefuroxime axetil oral tablet 1 or 1b* cefuroxime sodium injection solution reconstituted 750 mg 2 cefuroxime sodium intravenous solution reconstituted 1.5 gm 2 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 41

Drug Name Tier Notes *CEPHALOSPORINS - 3RD GENERATION*** cefdinir oral capsule 1 or 1b* cefdinir oral suspension reconstituted 1 or 1b* cefixime oral capsule 2 cefixime oral suspension reconstituted 2 cefpodoxime proxetil oral suspension reconstituted 2 cefpodoxime proxetil oral tablet 2 ceftazidime injection solution reconstituted 1 gm, 6 gm 2 ceftazidime intravenous solution reconstituted 2 ceftriaxone sodium in dextrose intravenous solution 2 ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg 2 ceftriaxone sodium intravenous solution reconstituted 2 tazicef injection solution reconstituted 1 gm 2 tazicef intravenous solution reconstituted 2 *CEPHALOSPORINS - 4TH GENERATION*** cefepime hcl injection solution reconstituted 1 gm 2 cefepime hcl intravenous solution reconstituted 2 gm 2 *CONTRACEPTIVES* *BIPHASIC CONTRACEPTIVES - ORAL*** azurette oral tablet 1 or 1b* $0 desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5) 1 or 1b* $0 kariva oral tablet 1 or 1b* $0 LO LOESTRIN FE ORAL TABLET 2 pimtrea oral tablet 1 or 1b* $0 simliya oral tablet 1 or 1b* $0 viorele oral tablet 1 or 1b* $0 Drug Name Tier Notes volnea oral tablet 1 or 1b* $0 *COMBINATION CONTRACEPTIVES - ORAL*** afirmelle oral tablet 1 or 1a* $0 altavera oral tablet 1 or 1a* $0 alyacen 1/35 oral tablet 1 or 1a* $0 apri oral tablet 1 or 1a* $0 aubra eq oral tablet 1 or 1a* $0 aurovela 1.5/30 oral tablet 1 or 1a* $0 aurovela 1/20 oral tablet 1 or 1a* $0 aurovela 24 fe oral tablet 1 or 1a* $0 aurovela fe 1.5/30 oral tablet 1 or 1a* $0 aurovela fe 1/20 oral tablet 1 or 1a* $0 aviane oral tablet 1 or 1a* $0 ayuna oral tablet 1 or 1a* $0 balziva oral tablet 1 or 1a* $0 blisovi 24 fe oral tablet 1 or 1a* $0 blisovi fe 1.5/30 oral tablet 1 or 1a* $0 blisovi fe 1/20 oral tablet 1 or 1a* $0 briellyn oral tablet 1 or 1a* $0 charlotte 24 fe oral tablet chewable 1 or 1a* $0 chateal eq oral tablet 1 or 1a* $0 cryselle-28 oral tablet 1 or 1a* $0 cyred eq oral tablet 1 or 1a* $0 dasetta 1/35 (28) oral tablet 1 or 1a* $0 delyla oral tablet 1 or 1a* $0 drospiren-eth estrad- levomefol oral tablet 1 or 1b* $0 drospirenone-ethinyl estradiol oral tablet 1 or 1b* $0 elinest oral tablet 1 or 1a* $0 enskyce oral tablet 0.15-30 mg-mcg 1 or 1a* $0 estarylla oral tablet 1 or 1a* $0 ethynodiol diac-eth estradiol oral tablet 1 or 1a* $0 falmina oral tablet 1 or 1a* $0 FEIRZA 1.5/30 ORAL TABLET 1 or 1a* $0 FEIRZA 1/20 ORAL TABLET 1 or 1a* $0 FINZALA ORAL TABLET CHEWABLE 1 or 1a* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 42

Drug Name Tier Notes GALBRIELA ORAL TABLET CHEWABLE 1 or 1b* $0 gemmily oral capsule 1 or 1b* $0 hailey 1.5/30 oral tablet 1 or 1a* $0 hailey 24 fe oral tablet 1 or 1a* $0 hailey fe 1.5/30 oral tablet 1 or 1a* $0 hailey fe 1/20 oral tablet 1 or 1a* $0 isibloom oral tablet 1 or 1a* $0 jasmiel oral tablet 1 or 1b* $0 JOYEAUX ORAL TABLET 1 or 1b* $0 juleber oral tablet 1 or 1a* $0 junel 1.5/30 oral tablet 1 or 1a* $0 junel 1/20 oral tablet 1 or 1a* $0 junel fe 1.5/30 oral tablet 1 or 1a* $0 junel fe 1/20 oral tablet 1 or 1a* $0 junel fe 24 oral tablet 1 or 1a* $0 kaitlib fe oral tablet chewable 1 or 1b* $0 kalliga oral tablet 1 or 1a* $0 kelnor 1/35 oral tablet 1 or 1a* $0 kelnor 1/50 oral tablet 1 or 1a* $0 kurvelo oral tablet 1 or 1a* $0 larin 1.5/30 oral tablet 1 or 1a* $0 larin 1/20 oral tablet 1 or 1a* $0 larin 24 fe oral tablet 1 or 1a* $0 larin fe 1.5/30 oral tablet 1 or 1a* $0 larin fe 1/20 oral tablet 1 or 1a* $0 lessina oral tablet 1 or 1a* $0 levonorgest-eth estradiol-iron oral tablet 1 or 1b* $0 levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg 1 or 1a* $0 levora 0.15/30 (28) oral tablet 1 or 1a* $0 loestrin 1.5/30 (21) oral tablet 1 or 1a* $0 loestrin 1/20 (21) oral tablet 1 or 1a* $0 loestrin fe 1.5/30 oral tablet 1 or 1a* $0 loestrin fe 1/20 oral tablet 1 or 1a* $0 loryna oral tablet 1 or 1b* $0 low-ogestrel oral tablet 1 or 1a* $0 lo-zumandimine oral tablet 1 or 1b* $0 lutera oral tablet 1 or 1a* $0 Drug Name Tier Notes marlissa oral tablet 1 or 1a* $0 merzee oral capsule 1 or 1b* $0 MIBELAS 24 FE ORAL TABLET CHEWABLE 1 or 1a* $0 microgestin 1.5/30 oral tablet 1 or 1a* $0 microgestin 1/20 oral tablet 1 or 1a* $0 microgestin fe 1.5/30 oral tablet 1 or 1a* $0 microgestin fe 1/20 oral tablet 1 or 1a* $0 mili oral tablet 1 or 1a* $0 MINZOYA ORAL TABLET 1 or 1b* $0 mono-linyah oral tablet 1 or 1a* $0 necon 0.5/35 (28) oral tablet 1 or 1a* $0 nikki oral tablet 1 or 1b* $0 norethin ace-eth estrad-fe oral capsule 1 or 1b* $0 norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5- 30 mg-mcg 1 or 1a* $0 norethin ace-eth estrad-fe oral tablet chewable 1 or 1a* $0 norethindrone acet-ethinyl est oral tablet 1 or 1a* $0 norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg 1 or 1a* $0 nortrel 0.5/35 (28) oral tablet 1 or 1a* $0 nortrel 1/35 (21) oral tablet 1 or 1a* $0 nortrel 1/35 (28) oral tablet 1 or 1a* $0 nylia 1/35 oral tablet 1 or 1a* $0 ocella oral tablet 1 or 1b* $0 philith oral tablet 1 or 1a* $0 portia-28 oral tablet 1 or 1a* $0 reclipsen oral tablet 1 or 1a* $0 sprintec 28 oral tablet 1 or 1a* $0 sronyx oral tablet 1 or 1a* $0 syeda oral tablet 1 or 1b* $0 tarina 24 fe oral tablet 1 or 1a* $0 tarina fe 1/20 eq oral tablet 1 or 1a* $0 taysofy oral capsule 1 or 1b* $0 TURQOZ ORAL TABLET 1 or 1a* $0 VALTYA 1/50 ORAL TABLET 1 or 1a* $0 vestura oral tablet 1 or 1b* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 43

Drug Name Tier Notes vienva oral tablet 1 or 1a* $0 vyfemla oral tablet 1 or 1a* $0 vylibra oral tablet 1 or 1a* $0 wera oral tablet 1 or 1a* $0 wymzya fe oral tablet chewable 1 or 1b* $0 XELRIA FE ORAL TABLET CHEWABLE 1 or 1b* $0 zovia 1/35 (28) oral tablet 1 or 1a* $0 zumandimine oral tablet 1 or 1b* $0 *COMBINATION CONTRACEPTIVES - TRANSDERMAL*** norelgestromin-eth estradiol transdermal patch weekly 1 or 1b* $0 xulane transdermal patch weekly 1 or 1b* $0 zafemy transdermal patch weekly 1 or 1b* $0 *COMBINATION CONTRACEPTIVES - VAGINAL*** eluryng vaginal ring 1 or 1b* $0 ENILLORING VAGINAL RING 1 or 1b* $0 etonogestrel-ethinyl estradiol vaginal ring 1 or 1b* $0 HALOETTE VAGINAL RING 1 or 1b* $0 *CONTINUOUS CONTRACEPTIVES - ORAL*** amethyst oral tablet 1 or 1b* $0 dolishale oral tablet 1 or 1b* $0 levonorgestrel-ethinyl estrad oral tablet 90-20 mcg 1 or 1b* $0 *EMERGENCY CONTRACEPTIVES*** aftera oral tablet 1 or 1b* $0 afterpill oral tablet 1 or 1b* $0 econtra one-step oral tablet 1 or 1b* $0 ELLA ORAL TABLET 2 $0 HER STYLE ORAL TABLET 1 or 1b* $0 levonorgestrel oral tablet 1.5 mg 1 or 1b* $0 my choice oral tablet 1 or 1b* $0 Drug Name Tier Notes my way oral tablet 1 or 1b* $0 new day oral tablet 1 or 1b* $0 opcicon one-step oral tablet 1 or 1b* $0 option 2 oral tablet 1 or 1b* $0 react oral tablet 1 or 1b* $0 take action oral tablet 1 or 1b* $0 *EXTENDED-CYCLE CONTRACEPTIVES - ORAL*** ashlyna oral tablet 1 or 1b* $0 camrese lo oral tablet 1 or 1b* $0 camrese oral tablet 1 or 1b* $0 daysee oral tablet 1 or 1b* $0 iclevia oral tablet 1 or 1b* $0 introvale oral tablet 1 or 1b* $0 jaimiess oral tablet 1 or 1b* $0 jolessa oral tablet 1 or 1b* $0 levonorgest-eth est & eth est oral tablet 1 or 1b* $0 levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 mg 1 or 1b* $0 lojaimiess oral tablet 1 or 1b* $0 rivelsa oral tablet 1 or 1b* $0 ROSYRAH ORAL TABLET 1 or 1b* $0 setlakin oral tablet 1 or 1b* $0 simpesse oral tablet 1 or 1b* $0 *PROGESTIN CONTRACEPTIVES - INJECTABLE*** DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 2 $0 medroxyprogesterone acetate intramuscular suspension 1 or 1b* $0 medroxyprogesterone acetate intramuscular suspension prefilled syringe 1 or 1b* $0 *PROGESTIN CONTRACEPTIVES - ORAL*** camila oral tablet 1 or 1b* $0 deblitane oral tablet 1 or 1b* $0 EMZAHH ORAL TABLET 1 or 1b* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 44

Drug Name Tier Notes errin oral tablet 1 or 1b* $0 heather oral tablet 1 or 1b* $0 incassia oral tablet 1 or 1b* $0 jencycla oral tablet 1 or 1b* $0 lyleq oral tablet 1 or 1b* $0 lyza oral tablet 1 or 1b* $0 MELEYA ORAL TABLET 1 or 1b* $0 nora-be oral tablet 1 or 1b* $0 norethindrone oral tablet 1 or 1b* $0 norlyroc oral tablet 1 or 1b* $0 OPILL ORAL TABLET 2 $0 sharobel oral tablet 1 or 1b* $0 *TRIPHASIC CONTRACEPTIVES - ORAL*** alyacen 7/7/7 oral tablet 1 or 1a* $0 aranelle oral tablet 1 or 1a* $0 dasetta 7/7/7 oral tablet 1 or 1a* $0 enpresse-28 oral tablet 1 or 1a* $0 leena oral tablet 1 or 1a* $0 levonest oral tablet 1 or 1a* $0 levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125- 30 mcg 1 or 1a* $0 norgestim-eth estrad triphasic oral tablet 1 or 1b* $0 nortrel 7/7/7 oral tablet 1 or 1a* $0 nylia 7/7/7 oral tablet 1 or 1a* $0 tilia fe oral tablet 1 or 1b* $0 tri-estarylla oral tablet 1 or 1b* $0 tri-legest fe oral tablet 1 or 1b* $0 tri-linyah oral tablet 1 or 1b* $0 tri-lo-estarylla oral tablet 1 or 1b* $0 tri-lo-marzia oral tablet 1 or 1b* $0 tri-lo-mili oral tablet 1 or 1b* $0 tri-lo-sprintec oral tablet 1 or 1b* $0 tri-mili oral tablet 1 or 1b* $0 tri-sprintec oral tablet 1 or 1b* $0 trivora (28) oral tablet 1 or 1a* $0 tri-vylibra lo oral tablet 1 or 1b* $0 tri-vylibra oral tablet 1 or 1b* $0 velivet oral tablet 1 or 1a* $0 XARAH FE ORAL TABLET 1 or 1b* $0 Drug Name Tier Notes *CORTICOSTEROIDS* *GLUCOCORTICOSTER OIDS*** budesonide er oral tablet extended release 24 hour 2 QL budesonide oral capsule delayed release particles 2 QL dexameth sod phos (pf) +rfid injection solution prefilled syringe 1 or 1b* DEXAMETHASONE INTENSOL ORAL CONCENTRATE 2 dexamethasone oral elixir 1 or 1a* dexamethasone oral solution 1 or 1a* dexamethasone oral tablet 1 or 1a* dexamethasone oral tablet therapy pack 1 or 1b* dexamethasone sod phos +rfid injection solution prefilled syringe 1 or 1b* dexamethasone sod phosphate pf injection solution 1 or 1b* DEXAMETHASONE SOD PHOSPHATE PF INJECTION SOLUTION PREFILLED SYRINGE 1 or 1b* dexamethasone sodium phosphate injection solution 100 mg/10ml, 120 mg/30ml, 20 mg/5ml 1 or 1b* DEXAMETHASONE SODIUM PHOSPHATE INJECTION SOLUTION PREFILLED SYRINGE 1 or 1b* hidex 6-day oral tablet therapy pack 1 or 1b* hydrocortisone oral tablet 1 or 1b* hydrocortisone sod suc (pf) injection solution reconstituted 1 or 1b* methylprednisolone oral tablet 1 or 1a* methylprednisolone oral tablet therapy pack 1 or 1a* methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg, 500 mg 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 45

Drug Name Tier Notes prednisolone oral solution 1 or 1a* prednisolone oral tablet 2 prednisolone sodium phosphate oral solution 10 mg/5ml, 15 mg/5ml, 20 mg/5ml, 25 mg/5ml, 5 mg/5ml 1 or 1a* prednisolone sodium phosphate oral tablet dispersible 1 or 1a* QL prednisone oral solution 1 or 1a* prednisone oral tablet 1 or 1a* prednisone oral tablet therapy pack 1 or 1a* SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 1000 MG, 250 MG, 500 MG 3 taperdex 12-day oral tablet therapy pack 1 or 1b* taperdex 6-day oral tablet therapy pack 1 or 1b* taperdex 7-day oral tablet therapy pack 1.5 mg (27) 1 or 1b* *MINERALOCORTICOI DS*** fludrocortisone acetate oral tablet 1 or 1b* *COUGH/COLD/ALLER GY* *ANTITUSSIVE - NONNARCOTIC*** benzonatate oral capsule 1 or 1b* *ANTITUSSIVE - OPIOID*** hydrocodone bit-homatrop mbr oral solution 1 or 1a* AL; QL hydrocodone bit-homatrop mbr oral tablet 1 or 1a* PA; QL hydromet oral solution 1 or 1a* AL; QL *ANTITUSSIVE- EXPECTORANT*** g tussin ac oral solution 1 or 1a* AL; QL guaifenesin-codeine oral solution 1 or 1a* AL; QL maxi-tuss ac oral solution 1 or 1a* AL; QL Drug Name Tier Notes *DECONGESTANT & ANTIHISTAMINE*** promethazine-phenylephrine oral syrup 1 or 1b* QL *MISC. RESPIRATORY INHALANTS*** NEBUSAL INHALATION NEBULIZATION SOLUTION 3 % 2 PULMOSAL INHALATION NEBULIZATION SOLUTION 1 or 1b* sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 %, 7 % 2 *MUCOLYTICS*** acetylcysteine inhalation solution 2 *NON-NARC ANTITUSSIVE- ANTIHISTAMINE*** promethazine-dm oral syrup 1 or 1a* QL *NON-NARC ANTITUSSIVE- DECONGESTANT- ANTIHISTAMINE*** bromphen-pseudoeph-dm oral syrup 1 or 1b* pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml 1 or 1b* *OPIOID ANTITUSSIVE- ANTIHISTAMINE*** hydrocod poli-chlorphe poli er oral suspension extended release 1 or 1b* AL; QL promethazine-codeine oral solution 1 or 1a* AL; QL *OPIOID ANTITUSSIVE- DECONGESTANT- ANTIHISTAMINE*** POLY-TUSSIN AC ORAL LIQUID 10-4-10 MG/5ML 2 AL; QL *DERMATOLOGICALS* *ACNE ANTIBIOTICS*** clindacin etz external swab 1 or 1b* QL CLINDACIN EXTERNAL FOAM 1 or 1b* QL clindacin-p external swab 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 46

Drug Name Tier Notes clindamycin phos (once- daily) external gel 1 or 1b* QL clindamycin phos (twice- daily) external gel 1 or 1b* QL clindamycin phosphate external foam 1 or 1b* QL clindamycin phosphate external lotion 1 or 1b* QL clindamycin phosphate external solution 1 or 1b* QL clindamycin phosphate external swab 1 or 1b* QL dapsone external gel 3 ST; QL ery external pad 1 or 1b* QL erythromycin external gel 1 or 1b* QL erythromycin external solution 1 or 1b* QL sulfacetamide sodium (acne) external lotion 1 or 1b* *ACNE COMBINATIONS*** adapalene-benzoyl peroxide external gel 1 or 1b* PA; QL benzoyl peroxide- erythromycin external gel 1 or 1b* QL clindamycin phos-benzoyl perox external gel 1.2-3.75 % 2 QL clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, 1.2-5 % 1 or 1b* QL clindamycin-tretinoin external gel 3 PA; QL neuac external gel 1 or 1b* QL *ACNE PRODUCTS*** accutane oral capsule 2 PA adapalene external cream 1 or 1b* PA; QL adapalene external gel 0.3 % 1 or 1b* PA; QL adapalene external pad 1 or 1b* PA; QL amnesteem oral capsule 10 mg, 20 mg, 40 mg 2 PA AMNESTEEM ORAL CAPSULE 30 MG 2 PA claravis oral capsule 2 PA isotretinoin oral capsule 2 PA tretinoin external cream 1 or 1b* PA; QL tretinoin external gel 1 or 1b* PA; QL Drug Name Tier Notes tretinoin microsphere external gel 0.04 %, 0.1 % 1 or 1b* PA; QL tretinoin microsphere pump external gel 0.04 %, 0.1 % 1 or 1b* PA; QL zenatane oral capsule 2 PA *ANTIBIOTICS - TOPICAL*** gentamicin sulfate external cream 1 or 1b* QL gentamicin sulfate external ointment 1 or 1b* QL mupirocin external ointment 1 or 1b* QL *ANTIFUNGALS - TOPICAL COMBINATIONS*** clotrimazole-betamethasone external cream 1 or 1b* QL clotrimazole-betamethasone external lotion 1 or 1b* QL nystatin-triamcinolone external cream 1 or 1b* QL nystatin-triamcinolone external ointment 1 or 1b* QL *ANTIFUNGALS - TOPICAL*** ciclodan external solution 1 or 1b* QL ciclopirox external gel 1 or 1b* QL ciclopirox external shampoo 1 or 1b* QL ciclopirox external solution 1 or 1b* QL ciclopirox olamine external cream 1 or 1b* QL ciclopirox olamine external suspension 1 or 1b* QL KLAYESTA EXTERNAL POWDER 1 or 1b* QL naftifine hcl external cream 2 ST; QL naftifine hcl external gel 2 % 2 ST; QL nyamyc external powder 1 or 1b* QL nystatin external cream 1 or 1b* QL nystatin external ointment 1 or 1b* QL nystatin external powder 1 or 1b* QL nystop external powder 1 or 1b* QL *ANTINEOPLASTIC ANTIMETABOLITES - TOPICAL*** fluorouracil external cream 5 % 1 or 1b* AL; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 47

Drug Name Tier Notes fluorouracil external solution 1 or 1b* AL; QL *ANTINEOPLASTIC OR PREMALIGNANT LESIONS - TOPICAL NSAID'S*** diclofenac sodium external gel 3 % 2 PA; QL *ANTIPRURITICS - TOPICAL*** doxepin hcl external cream 2 PA; QL *ANTIPSORIATICS - SYSTEMIC*** acitretin oral capsule 2 QL COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO- INJECTOR 150 MG/ML 4 PA; LD; QL; SP COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP COSENTYX UNOREADY SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP methoxsalen rapid oral capsule 4 LD; SP SELARSDI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; QL; SP SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML 4 PA; LD; QL; SP Drug Name Tier Notes STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP TALTZ SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP TREMFYA ONE-PRESS SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP TREMFYA PEN SUBCUTANEOUS SOLUTION AUTO- INJECTOR 100 MG/ML 4 PA; LD; QL; SP TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML 4 PA; LD; QL; SP *ANTIPSORIATICS*** calcipotriene external cream 1 or 1b* QL calcipotriene external foam 3 ST; QL calcipotriene external ointment 1 or 1b* QL calcipotriene external solution 1 or 1b* QL calcitrene external ointment 1 or 1b* QL calcitriol external ointment 1 or 1b* QL tazarotene external cream 1 or 1b* QL tazarotene external gel 2 QL *ANTISEBORRHEIC PRODUCTS*** selenium sulfide external lotion 1 or 1a* QL *ANTIVIRALS - TOPICAL*** acyclovir external cream 1 or 1b* PA; QL acyclovir external ointment 1 or 1b* QL penciclovir external cream 2 PA; QL *ATOPIC DERMATITIS - JANUS KINASE (JAK) INHIBITORS*** OPZELURA EXTERNAL CREAM 3 PA; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 48

Drug Name Tier Notes *ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES*** DUPIXENT SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; SP DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML, 300 MG/2ML 4 PA; LD; SP *BURN PRODUCTS*** silver sulfadiazine external cream 1 or 1a* ssd external cream 1 or 1a* *CORTICOSTEROIDS - TOPICAL*** ala-cort external cream 1 % 1 or 1a* QL alclometasone dipropionate external cream 1 or 1b* QL alclometasone dipropionate external ointment 1 or 1b* QL betamethasone dipropionate aug external cream 1 or 1b* QL betamethasone dipropionate aug external gel 1 or 1b* QL betamethasone dipropionate aug external lotion 1 or 1b* QL betamethasone dipropionate aug external ointment 1 or 1b* QL betamethasone dipropionate external cream 1 or 1b* QL betamethasone dipropionate external lotion 1 or 1b* QL betamethasone dipropionate external ointment 1 or 1b* QL betamethasone valerate external cream 1 or 1b* QL betamethasone valerate external lotion 1 or 1b* QL betamethasone valerate external ointment 1 or 1b* QL clobetasol propionate e external cream 1 or 1b* QL clobetasol propionate emulsion external foam 1 or 1b* QL clobetasol propionate external cream 0.05 % 1 or 1b* QL Drug Name Tier Notes clobetasol propionate external foam 1 or 1b* QL clobetasol propionate external gel 1 or 1b* QL clobetasol propionate external liquid 1 or 1b* QL clobetasol propionate external lotion 1 or 1b* QL clobetasol propionate external ointment 1 or 1b* QL clobetasol propionate external shampoo 1 or 1b* QL clobetasol propionate external solution 1 or 1b* QL clodan external shampoo 1 or 1b* QL desonide external cream 1 or 1b* QL desonide external gel 1 or 1b* QL desonide external lotion 1 or 1b* QL desonide external ointment 1 or 1b* QL fluocinolone acetonide body external oil 1 or 1b* QL fluocinolone acetonide external cream 1 or 1b* QL fluocinolone acetonide external ointment 1 or 1b* QL fluocinolone acetonide external solution 1 or 1b* QL fluocinolone acetonide scalp external oil 1 or 1b* QL fluocinonide emulsified base external cream 1 or 1b* QL fluocinonide external cream 1 or 1b* QL fluocinonide external gel 1 or 1b* QL fluocinonide external ointment 1 or 1b* QL fluocinonide external solution 1 or 1b* QL fluticasone propionate external cream 1 or 1b* QL fluticasone propionate external lotion 1 or 1b* QL fluticasone propionate external ointment 1 or 1b* QL halobetasol propionate external cream 1 or 1b* QL halobetasol propionate external ointment 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 49

Drug Name Tier Notes hydrocortisone external cream 2.5 % 1 or 1a* QL hydrocortisone external lotion 2.5 % 1 or 1a* QL hydrocortisone external ointment 2.5 % 1 or 1a* QL mometasone furoate external cream 1 or 1b* QL mometasone furoate external ointment 1 or 1b* QL mometasone furoate external solution 1 or 1b* QL tovet external foam 1 or 1b* QL triamcinolone acetonide external cream 1 or 1a* QL triamcinolone acetonide external lotion 1 or 1a* QL triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % 1 or 1a* QL triderm external cream 0.5 % 1 or 1a* QL *IMIDAZOLE-RELATED ANTIFUNGALS - TOPICAL*** econazole nitrate external cream 1 or 1b* QL ketoconazole external cream 1 or 1b* QL ketoconazole external foam 3 QL ketoconazole external shampoo 2 % 1 or 1b* QL ketodan external foam 3 QL luliconazole external cream 1 or 1b* ST; QL oxiconazole nitrate external cream 3 ST; QL sulconazole nitrate external cream 1 or 1b* ST; QL sulconazole nitrate external solution 1 or 1b* ST; QL *IMMUNOMODULATOR S IMIDAZOQUINOLINAMI NES - TOPICAL*** imiquimod external cream 1 or 1b* QL imiquimod pump external cream 1 or 1b* ST; QL *KERATOLYTIC/ANTIM ITOTIC/VESICANT AGENTS*** podofilox external gel 2 QL Drug Name Tier Notes podofilox external solution 1 or 1b* QL *LOCAL ANESTHETICS - TOPICAL*** glydo external prefilled syringe 2 lidocaine external ointment 5 % 2 QL lidocaine external patch 5 % 2 PA; QL lidocaine hcl external solution 2 QL lidocaine hcl urethral/mucosal external gel 2 lidocaine hcl urethral/mucosal external prefilled syringe 2 TRIDACAINE II EXTERNAL PATCH 2 PA; QL TRIDACAINE III EXTERNAL PATCH 2 PA; QL *MACROLIDE IMMUNOSUPPRESSANT S - TOPICAL*** pimecrolimus external cream 1 or 1b* ST; QL tacrolimus external ointment 1 or 1b* ST; QL *OXABOROLE- RELATED ANTIFUNGALS - TOPICAL*** tavaborole external solution 2 ST; QL *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL*** EUCRISA EXTERNAL OINTMENT 3 ST; QL *ROSACEA AGENTS*** azelaic acid external gel 1 or 1b* QL brimonidine tartrate external gel 2 QL ivermectin external cream 2 QL metronidazole external cream 1 or 1b* QL metronidazole external gel 1 or 1b* QL metronidazole external lotion 1 or 1b* QL ZILXI EXTERNAL FOAM 2 QL *SCABICIDES & PEDICULICIDES*** crotan external lotion 2 QL malathion external lotion 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 50

Drug Name Tier Notes permethrin external cream 1 or 1b* QL PRURADIK EXTERNAL LOTION 2 spinosad external suspension 1 or 1b* QL *STEROID-LOCAL ANESTHETIC COMBINATIONS*** PRAMOSONE EXTERNAL CREAM 1-1 % 2 PRAMOSONE EXTERNAL LOTION 2 *TAR PRODUCTS*** coal tar external solution 1 or 1b* *TOPICAL ANESTHETIC COMBINATIONS*** lidocaine-prilocaine external cream 2 QL lidocaine-prilocaine external kit 2 QL *TOPICAL SELECTIVE RETINOID X RECEPTOR AGONISTS*** bexarotene external gel 4 PA; LD; QL; SP *TOPICAL STEROID COMBINATIONS*** calcipotriene-betameth diprop external ointment 3 ST; QL calcipotriene-betameth diprop external suspension 3 ST; QL *TYPE II 5-ALPHA REDUCTASE INHIBITORS*** finasteride oral tablet 1 mg 1 or 1b* *DIAGNOSTIC PRODUCTS* *DIAGNOSTIC TESTS*** ACCU-CHEK AVIVA PLUS IN VITRO STRIP 2 QL ACCU-CHEK GUIDE TEST IN VITRO STRIP 2 QL ACCU-CHEK SMARTVIEW IN VITRO STRIP 2 QL ACCUTREND GLUCOSE IN VITRO STRIP 2 QL FREESTYLE INSULINX TEST IN VITRO STRIP 2 QL Drug Name Tier Notes FREESTYLE LITE TEST IN VITRO STRIP 2 QL FREESTYLE PRECISION NEO TEST IN VITRO STRIP 2 QL FREESTYLE TEST IN VITRO STRIP 2 QL *DIGESTIVE AIDS* *DIGESTIVE ENZYMES*** CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 2 QL VIOKACE ORAL TABLET 3 QL ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000- 47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 40000- 126000 UNIT, 5000-24000 UNIT, 60000-189600 UNIT 2 QL *DIURETICS* *CARBONIC ANHYDRASE INHIBITORS*** acetazolamide er oral capsule extended release 12 hour 1 or 1b* acetazolamide oral tablet 1 or 1b* acetazolamide sodium injection solution reconstituted 1 or 1b* dichlorphenamide oral tablet 4 PA; LD; QL methazolamide oral tablet 2 ORMALVI ORAL TABLET 4 PA; LD; QL *DIURETIC COMBINATIONS*** amiloride- hydrochlorothiazide oral tablet 1 or 1b* spironolactone-hctz oral tablet 1 or 1b* triamterene-hctz oral capsule 37.5-25 mg 1 or 1a* triamterene-hctz oral tablet 1 or 1a* *LOOP DIURETICS*** bumetanide injection solution 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 51

Drug Name Tier Notes bumetanide oral tablet 1 or 1b* ethacrynic acid oral tablet 2 furosemide oral solution 10 mg/ml, 8 mg/ml 1 or 1a* furosemide oral tablet 1 or 1a* torsemide oral tablet 1 or 1b* *OSMOTIC DIURETICS*** mannitol intravenous solution 20 %, 25 % 1 or 1b* osmitrol intravenous solution 10 %, 20 % 1 or 1b* *POTASSIUM SPARING DIURETICS*** amiloride hcl oral tablet 2 spironolactone oral suspension 1 or 1b* spironolactone oral tablet 1 or 1a* triamterene oral capsule 2 *THIAZIDES AND THIAZIDE-LIKE DIURETICS*** chlorothiazide sodium intravenous solution reconstituted 1 or 1b* chlorthalidone oral tablet 25 mg, 50 mg 1 or 1a* hydrochlorothiazide oral capsule 1 or 1a* hydrochlorothiazide oral tablet 1 or 1a* indapamide oral tablet 1 or 1b* metolazone oral tablet 1 or 1b* *ENDOCRINE AND METABOLIC AGENTS - MISC.* *ABORTIFACIENT - PROGESTERONE RECEPTOR ANTAGONISTS*** mifepristone oral tablet 200 mg 1 or 1b* *BISPHOSPHONATES*** alendronate sodium oral solution 1 or 1b* QL alendronate sodium oral tablet 10 mg, 35 mg, 70 mg 1 or 1b* QL Drug Name Tier Notes FOSAMAX PLUS D ORAL TABLET 2 QL ibandronate sodium oral tablet 1 or 1b* QL risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg 1 or 1b* QL risedronate sodium oral tablet delayed release 1 or 1b* QL *CALCIMIMETIC AGENTS*** cinacalcet hcl oral tablet 4 PA; LD; QL *CALCITONINS*** calcitonin (salmon) injection solution 4 LD calcitonin (salmon) nasal solution 2 QL *CARNITINE REPLENISHER - AGENTS*** levocarnitine intravenous solution 2 levocarnitine oral solution 2 levocarnitine oral tablet 2 levocarnitine sf oral solution 2 *DOPAMINE RECEPTOR AGONISTS*** cabergoline oral tablet 1 or 1b* QL *GNRH/LHRH ANTAGONISTS*** ORILISSA ORAL TABLET 2 PA; QL *GROWTH HORMONE RECEPTOR ANTAGONISTS*** SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; QL; SP *GROWTH HORMONES*** GENOTROPIN MINIQUICK SUBCUTANEOUS PREFILLED SYRINGE 4 PA; LD; QL; SP GENOTROPIN SUBCUTANEOUS CARTRIDGE 4 PA; LD; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 52

Drug Name Tier Notes HUMATROPE INJECTION CARTRIDGE 4 PA; LD; QL; SP SKYTROFA SUBCUTANEOUS CARTRIDGE 4 PA; LD; QL; SP *HEREDITARY TYROSINEMIA TYPE 1 (HT-1) TREATMENT - AGENTS*** nitisinone oral capsule 10 mg, 2 mg, 5 mg 4 PA; LD; SP nitisinone oral capsule 20 mg 4 PA; LD *HOMOCYSTINURIA TREATMENT - AGENTS*** betaine oral powder 4 LD *HYPERAMMONEMIA TREATMENT - AGENTS*** carglumic acid oral tablet soluble 4 PA; LD *HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS*** calcitriol intravenous solution 1 mcg/ml 1 or 1b* PA calcitriol oral capsule 1 or 1b* PA calcitriol oral solution 2 PA doxercalciferol intravenous solution 2 PA doxercalciferol oral capsule 2 PA paricalcitol oral capsule 2 PA *HYPOPHOSPHATASIA (HPP) AGENTS*** STRENSIQ SUBCUTANEOUS SOLUTION 4 PA; LD *LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS*** SYNAREL NASAL SOLUTION 4 PA; LD; QL; SP *OVULATION STIMULANTS- GONADOTROPINS*** GONAL-F INJECTION SOLUTION RECONSTITUTED 4 PA; LD; SP Drug Name Tier Notes GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION PEN- INJECTOR 300 UNIT/0.5ML, 450 UNT/0.75ML 4 PA; LD; SP GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION PEN- INJECTOR 900 UNT/1.44ML 4 PA GONAL-F RFF SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; SP NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT 4 PA; LD; SP *OVULATION STIMULANTS- SYNTHETIC*** CLOMID ORAL TABLET 1 or 1b* PA clomiphene citrate oral tablet 1 or 1b* PA *PHENYLKETONURIA TREATMENT - AGENTS*** JAVYGTOR ORAL PACKET 4 PA; LD JAVYGTOR ORAL TABLET 4 PA; LD sapropterin dihydrochloride oral packet 4 PA; LD; SP sapropterin dihydrochloride oral tablet 4 PA; LD; SP *RANK LIGAND (RANKL) INHIBITORS*** PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP *SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)*** raloxifene hcl oral tablet 1 or 1b* $0; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 53

Drug Name Tier Notes *SELECTIVE VASOPRESSIN V2- RECEPTOR ANTAGONISTS*** tolvaptan oral tablet 4 PA; LD; QL; SP tolvaptan oral tablet therapy pack 4 PA; LD; QL *SOMATOSTATIC AGENTS*** LANREOTIDE ACETATE SUBCUTANEOUS SOLUTION 4 PA; LD; QL; SP SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 4 PA; LD; QL; SP *UREA CYCLE DISORDER - AGENTS*** PHEBURANE ORAL PELLET 4 PA; LD; QL; SP sodium phenylbutyrate oral powder 3 gm/tsp 4 PA; LD; QL; SP sodium phenylbutyrate oral tablet 4 PA; LD; QL; SP *VASOPRESSIN*** desmopressin ace spray refrig nasal solution 1 or 1b* desmopressin acetate injection solution 1 or 1b* LD desmopressin acetate oral tablet 1 or 1b* LD; QL desmopressin acetate pf injection solution 1 or 1b* LD desmopressin acetate spray nasal solution 1 or 1b* vasopressin +rfid intravenous solution 2 vasopressin intravenous solution 2 *ESTROGENS* *ESTROGEN & PROGESTIN*** ABIGALE LO ORAL TABLET 1 or 1b* BIJUVA ORAL CAPSULE 2 QL CLIMARA PRO TRANSDERMAL PATCH WEEKLY 2 QL Drug Name Tier Notes COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 2 QL estradiol-norethindrone acet oral tablet 1 or 1b* fyavolv oral tablet 1 or 1b* jinteli oral tablet 1 or 1b* mimvey oral tablet 1 or 1b* norethindrone-eth estradiol oral tablet 1 or 1b* PREMPHASE ORAL TABLET 2 PREMPRO ORAL TABLET 2 *ESTROGENS*** dotti transdermal patch twice weekly 1 or 1b* QL estradiol oral tablet 1 or 1b* estradiol transdermal gel 2 QL estradiol transdermal patch twice weekly 1 or 1b* QL estradiol transdermal patch weekly 1 or 1b* QL estradiol valerate intramuscular oil 1 or 1b* EVAMIST TRANSDERMAL SOLUTION 2 QL lyllana transdermal patch twice weekly 1 or 1b* QL MENEST ORAL TABLET 2 PREMARIN INJECTION SOLUTION RECONSTITUTED 2 PREMARIN ORAL TABLET 2 QL *FLUOROQUINOLONES * *FLUOROQUINOLONES *** ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg 1 or 1b* ciprofloxacin in d5w intravenous solution 2 levofloxacin in d5w intravenous solution 2 levofloxacin intravenous solution 2 QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 54

Drug Name Tier Notes levofloxacin oral solution 2 levofloxacin oral tablet 1 or 1b* moxifloxacin hcl oral tablet 2 ofloxacin oral tablet 300 mg, 400 mg 1 or 1b* *GASTROINTESTINAL AGENTS - MISC.* *GALLSTONE SOLUBILIZING AGENTS*** ursodiol oral capsule 300 mg 2 ursodiol oral tablet 2 *GASTROINTESTINAL ANTIALLERGY AGENTS*** cromolyn sodium oral concentrate 1 or 1b* *GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS*** lubiprostone oral capsule 2 QL *GASTROINTESTINAL STIMULANTS*** metoclopramide hcl injection solution 1 or 1a* metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml 1 or 1a* QL metoclopramide hcl oral tablet 1 or 1a* QL metoclopramide hcl oral tablet dispersible 5 mg 1 or 1a* QL *IBS AGENT - GUANYLATE CYCLASE- C (GC-C) AGONISTS*** LINZESS ORAL CAPSULE 2 QL *IBS AGENT - SELECTIVE 5-HT3 RECEPTOR ANTAGONISTS*** alosetron hcl oral tablet 2 PA; QL *INFLAMMATORY BOWEL AGENTS*** balsalazide disodium oral capsule 1 or 1b* QL mesalamine er oral capsule extended release 24 hour 2 QL Drug Name Tier Notes mesalamine oral capsule delayed release 2 QL mesalamine oral tablet delayed release 2 QL mesalamine rectal enema 2 QL mesalamine rectal suppository 2 QL mesalamine-cleanser rectal kit 2 QL PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG 2 QL sulfasalazine oral tablet 1 or 1b* QL sulfasalazine oral tablet delayed release 1 or 1b* QL *INTEGRIN RECEPTOR ANTAGONISTS*** ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; QL; SP *INTERLEUKIN ANTAGONISTS*** SELARSDI INTRAVENOUS SOLUTION 4 PA; QL; SP SKYRIZI INTRAVENOUS SOLUTION 4 PA; LD; QL; SP SKYRIZI SUBCUTANEOUS SOLUTION CARTRIDGE 4 PA; LD; QL; SP STELARA INTRAVENOUS SOLUTION 4 PA; LD; QL; SP TREMFYA CROHNS INDUCTION SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; QL; SP TREMFYA INTRAVENOUS SOLUTION 4 PA; QL; SP TREMFYA PEN SUBCUTANEOUS SOLUTION AUTO- INJECTOR 200 MG/2ML 4 PA; QL; SP TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/2ML 4 PA; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 55

Drug Name Tier Notes *INTESTINAL ACIDIFIERS*** enulose oral solution 1 or 1b* generlac oral solution 1 or 1b* lactulose encephalopathy oral solution 10 gm/15ml 1 or 1b* *PERIPHERAL OPIOID RECEPTOR ANTAGONISTS*** alvimopan oral capsule 1 or 1b* *PEROXISOME PROLIFERATOR- ACTIVATED RECEPTOR AGONISTS*** IQIRVO ORAL TABLET 4 PA; LD; QL; SP *PHOSPHATE BINDER AGENTS*** calcium acetate (phos binder) oral capsule 2 QL calcium acetate oral tablet 667 mg 2 QL ferric citrate oral tablet 2 QL lanthanum carbonate oral tablet chewable 2 QL sevelamer carbonate oral packet 2 QL sevelamer carbonate oral tablet 2 QL sevelamer hcl oral tablet 2 QL *TUMOR NECROSIS FACTOR ALPHA BLOCKERS*** AVSOLA INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP INFLIXIMAB INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP *GENERAL ANESTHETICS* *ANESTHETICS - MISC.*** etomidate intravenous solution 1 or 1b* Drug Name Tier Notes fresenius propoven intravenous emulsion 1000 mg/100ml, 200 mg/20ml, 500 mg/50ml 1 or 1b* ketamine hcl injection solution 50 mg/ml 1 or 1b* propofol intravenous emulsion 1000 mg/100ml, 200 mg/20ml, 500 mg/50ml 1 or 1b* *BARBITURATE ANESTHETICS*** methohexital sodium injection solution reconstituted 1 or 1b* *VOLATILE ANESTHETICS*** desflurane inhalation solution 1 or 1b* isoflurane inhalation solution 1 or 1b* sevoflurane inhalation solution 1 or 1b* terrell inhalation solution 1 or 1b* *GENITOURINARY AGENTS - MISCELLANEOUS* *5-ALPHA REDUCTASE INHIBITORS*** dutasteride oral capsule 1 or 1b* QL finasteride oral tablet 5 mg 1 or 1b* QL *ALPHA 1- ADRENOCEPTOR ANTAGONISTS*** alfuzosin hcl er oral tablet extended release 24 hour 1 or 1b* QL silodosin oral capsule 2 QL tamsulosin hcl oral capsule 1 or 1b* QL *ANTI-INFECTIVE GENITOURINARY IRRIGANTS*** neomycin-polymyxin b gu irrigation solution 2 *CITRATES*** potassium citrate er oral tablet extended release 1 or 1b* *GENITOURINARY IRRIGANTS*** acetic acid irrigation solution 1 or 1b* argyle sterile saline irrigation solution 2 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 56

Drug Name Tier Notes curity sterile saline irrigation solution 2 glycine irrigation solution 1 or 1b* glycine urologic irrigation solution 1 or 1b* sodium chloride irrigation solution 0.9 % 2 *PROSTATIC HYPERTROPHY AGENT COMBINATIONS*** dutasteride-tamsulosin hcl oral capsule 1 or 1b* QL *URINARY STONE AGENTS*** tiopronin oral tablet 2 PA; LD; QL tiopronin oral tablet delayed release 2 PA; LD; QL VENXXIVA ORAL TABLET DELAYED RELEASE 2 PA; LD; QL *GOUT AGENTS* *GOUT AGENT COMBINATIONS*** colchicine-probenecid oral tablet 1 or 1b* *GOUT AGENTS*** allopurinol oral tablet 100 mg, 300 mg 1 or 1a* QL allopurinol sodium intravenous solution reconstituted 1 or 1b* colchicine oral tablet 2 QL febuxostat oral tablet 2 ST; QL *URICOSURICS*** probenecid oral tablet 1 or 1b* *HEMATOLOGICAL AGENTS - MISC.* *BRADYKININ B2 RECEPTOR ANTAGONISTS*** icatibant acetate subcutaneous solution prefilled syringe 4 PA; LD; QL; SP sajazir subcutaneous solution prefilled syringe 4 PA; LD; QL *C1 ESTERASE INHIBITORS*** BERINERT INTRAVENOUS KIT 4 PA; LD; QL; SP Drug Name Tier Notes HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; QL; SP RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; QL; SP *DIRECT-ACTING P2Y12 INHIBITORS*** BRILINTA ORAL TABLET 2 QL ticagrelor oral tablet 1 or 1b* QL *GLYCOPROTEIN IIB/IIIA RECEPTOR INHIBITORS*** eptifibatide intravenous solution 20 mg/10ml, 200 mg/100ml, 75 mg/100ml 2 tirofiban hcl in nacl intravenous solution 2 *HEMATORHEOLOGIC AGENTS*** pentoxifylline er oral tablet extended release 1 or 1b* *PHOSPHODIESTERASE III INHIBITORS*** cilostazol oral tablet 2 *PLASMA EXPANDERS*** hetastarch-nacl intravenous solution 1 or 1b* lmd in d5w intravenous solution 1 or 1b* lmd in nacl intravenous solution 1 or 1b* *PLASMA KALLIKREIN INHIBITORS - MONOCLONAL ANTIBODIES*** TAKHZYRO SUBCUTANEOUS SOLUTION 4 PA; LD; QL; SP TAKHZYRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 57

Drug Name Tier Notes *PLASMA KALLIKREIN INHIBITORS*** KALBITOR SUBCUTANEOUS SOLUTION 4 PA; LD; QL; SP *PLATELET AGGREGATION INHIBITOR COMBINATIONS*** aspirin-dipyridamole er oral capsule extended release 12 hour 1 or 1b* QL *PLATELET AGGREGATION INHIBITORS*** dipyridamole oral tablet 2 *PROTAMINE*** protamine sulfate intravenous solution 1 or 1b* *QUINAZOLINE AGENTS*** anagrelide hcl oral capsule 1 or 1b* QL *THIENOPYRIDINE DERIVATIVES*** clopidogrel bisulfate oral tablet 1 or 1b* QL prasugrel hcl oral tablet 2 QL *HEMATOPOIETIC AGENTS* *AGENTS FOR GAUCHER DISEASE*** CERDELGA ORAL CAPSULE 2 PA; LD; QL; SP miglustat oral capsule 2 PA; LD; QL; SP YARGESA ORAL CAPSULE 2 PA; LD; QL; SP *AMINO ACIDS*** l-glutamine oral packet 4 PA; LD; SP *COBALAMINS*** cyanocobalamin injection solution 1000 mcg/ml 1 or 1a* hydroxocobalamin acetate intramuscular solution 1 or 1b* *CYTOTOXIC AGENTS*** DROXIA ORAL CAPSULE 2 Drug Name Tier Notes *ERYTHROPOIESIS- STIMULATING AGENTS (ESAS)*** ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML 4 PA; LD; QL; SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP PROCRIT INJECTION SOLUTION 4 PA; LD; QL; SP RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML 4 PA; LD; QL; SP *FOLIC ACID/FOLATE COMBINATIONS*** foltabs 800 oral tablet 1 or 1b* $0 *FOLIC ACID/FOLATES*** cvs folic acid oral tablet 800 mcg 1 or 1a* $0 fa-8 oral capsule 1 or 1b* $0 folate oral tablet 1 or 1a* $0 folic acid injection solution 1 or 1a* folic acid oral capsule 0.8 mg 1 or 1b* $0 folic acid oral tablet 1 mg 1 or 1a* folic acid oral tablet 400 mcg, 800 mcg 1 or 1a* $0 ft folic acid oral tablet 1 or 1a* $0 gnp folic acid oral tablet 1 or 1a* $0 kp folic acid oral tablet 800 mcg 1 or 1a* $0 qc folic acid oral tablet 1 or 1a* $0 ra folic acid oral tablet 1 or 1a* $0 true folic acid oral tablet 400 mcg 1 or 1a* $0 yl folic acid oral tablet 1 or 1a* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 58

Drug Name Tier Notes *GRANULOCYTE COLONY- STIMULATING FACTORS (G-CSF)*** NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT 4 PA; LD; QL; SP NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP UDENYCA ONBODY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP UDENYCA SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 4 PA; LD; SP *IRON*** FERAHEME INTRAVENOUS SOLUTION 4 PA; LD; QL; SP FERRLECIT INTRAVENOUS SOLUTION 4 PA; LD; QL; SP ferumoxytol intravenous solution 4 PA; LD; QL; SP INFED INJECTION SOLUTION 4 PA; LD; SP na ferric gluc cplx in sucrose intravenous solution 4 PA; LD; QL; SP VENOFER INTRAVENOUS SOLUTION 4 PA; LD; QL; SP *THROMBOPOIETIN (TPO) RECEPTOR AGONISTS*** eltrombopag olamine oral packet 12.5 mg 4 PA; LD; DO; SP eltrombopag olamine oral packet 25 mg 4 PA; LD; QL; SP eltrombopag olamine oral tablet 12.5 mg, 25 mg 4 PA; LD; DO; SP Drug Name Tier Notes eltrombopag olamine oral tablet 50 mg, 75 mg 4 PA; LD; QL; SP *HEMOSTATICS* *HEMOSTATICS - SYSTEMIC*** aminocaproic acid intravenous solution 1 or 1b* aminocaproic acid oral solution 2 QL aminocaproic acid oral tablet 1000 mg 2 aminocaproic acid oral tablet 500 mg 2 QL tranexamic acid intravenous solution 1000 mg/10ml 2 tranexamic acid oral tablet 1 or 1b* QL *HYPNOTICS/SEDATIVE S/SLEEP DISORDER AGENTS* *BARBITURATE HYPNOTICS*** pentobarbital sodium injection solution 1 or 1b* phenobarbital oral elixir 1 or 1b* QL phenobarbital oral tablet 100 mg, 60 mg, 64.8 mg, 97.2 mg 1 or 1b* QL phenobarbital oral tablet 15 mg, 16.2 mg, 30 mg, 32.4 mg 1 or 1b* DO phenobarbital sodium injection solution 1 or 1b* *BENZODIAZEPINE HYPNOTICS*** estazolam oral tablet 1 or 1b* QL flurazepam hcl oral capsule 1 or 1b* QL midazolam hcl (pf) +rfid injection solution 1 or 1b* midazolam hcl (pf) injection solution 1 or 1b* midazolam hcl injection solution 10 mg/10ml, 10 mg/2ml, 25 mg/5ml, 5 mg/ml, 50 mg/10ml 1 or 1b* midazolam hcl oral syrup 1 or 1b* QL midazolam-sodium chloride (pf) intravenous solution 100-0.9 mg/100ml-%, 50-0.9 mg/50ml-% 1 or 1b* quazepam oral tablet 1 or 1b* QL temazepam oral capsule 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 59

Drug Name Tier Notes triazolam oral tablet 1 or 1b* QL *HYPNOTICS - TRICYCLIC AGENTS*** doxepin hcl oral tablet 2 ST; QL *NON- BENZODIAZEPINE - GABA-RECEPTOR MODULATORS*** eszopiclone oral tablet 1 or 1b* QL zaleplon oral capsule 1 or 1b* QL zolpidem tartrate er oral tablet extended release 1 or 1b* QL zolpidem tartrate oral tablet 1 or 1b* QL zolpidem tartrate sublingual tablet sublingual 2 ST; QL *SELECTIVE ALPHA2- ADRENORECEPTOR AGONIST SEDATIVES*** dexmedetomidine hcl in nacl intravenous solution 200 mcg/50ml, 400 mcg/100ml, 80 mcg/20ml 1 or 1b* dexmedetomidine hcl intravenous solution 200 mcg/2ml 1 or 1b* *SELECTIVE MELATONIN RECEPTOR AGONISTS*** ramelteon oral tablet 2 QL tasimelteon oral capsule 4 PA; LD; QL *LAXATIVES* *BOWEL EVACUANT COMBINATIONS*** GAVILYTE-C ORAL SOLUTION RECONSTITUTED 1 or 1a* $0; QL gavilyte-g oral solution reconstituted 1 or 1a* $0; QL GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 1 or 1a* $0; QL na sulfate-k sulfate-mg sulf oral solution 17.5-3.13-1.6 gm/177ml 1 or 1b* $0; QL peg 3350-kcl-na bicarb-nacl oral solution reconstituted 1 or 1a* $0; QL Drug Name Tier Notes peg-3350/electrolytes oral solution reconstituted 1 or 1a* $0; QL peg- 3350/electrolytes/ascorbat oral solution reconstituted 1 or 1b* $0; QL peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 1 or 1b* $0; QL SUTAB ORAL TABLET 2 QL *LAXATIVES - MISCELLANEOUS*** clearlax oral powder 1 or 1b* $0 constulose oral solution 1 or 1b* QL cvs purelax oral packet 1 or 1b* $0 cvs purelax oral powder 1 or 1b* $0 eq clearlax oral powder 1 or 1b* $0 eq laxative oral packet 1 or 1b* $0 eql clearlax oral powder 1 or 1b* $0 ft clearlax oral powder 1 or 1b* $0 gavilax oral powder 1 or 1b* $0 glycolax oral powder 1 or 1b* $0 gnp clearlax oral packet 1 or 1b* $0 gnp clearlax oral powder 1 or 1b* $0 goodsense clearlax oral powder 1 or 1b* $0 healthylax oral packet 1 or 1b* $0 kls laxaclear oral powder 1 or 1b* $0 KRISTALOSE ORAL PACKET 2 ST; QL LACTULOSE ORAL PACKET 10 GM 2 ST; QL lactulose oral packet 20 gm 2 ST; QL lactulose oral solution 1 or 1b* QL mm clearlax oral powder 1 or 1b* $0 peg 3350 oral packet 1 or 1b* $0 peg 3350 oral powder 1 or 1b* $0 polyethylene glycol 3350 oral packet 17 gm 1 or 1b* $0 polyethylene glycol 3350 oral powder 1 or 1b* $0 qc natura-lax oral powder 1 or 1b* $0 ra laxative oral powder 1 or 1b* $0 sb polyethylene glycol 3350 oral powder 1 or 1b* $0 smooth lax oral packet 1 or 1b* $0 smooth lax oral powder 1 or 1b* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 60

Drug Name Tier Notes true laxative oral powder 1 or 1b* $0 *SALINE LAXATIVES*** citrate of magnesia oral solution 1 or 1a* $0 citroma oral solution 1 or 1a* $0 cvs magnesium citrate oral solution 1 or 1a* $0 cvs milk of magnesia oral suspension 1200 mg/15ml 1 or 1b* $0 dulcolax milk of magnesia oral suspension 1 or 1b* $0 dulcolax oral suspension 1 or 1b* $0 eq magnesium citrate oral solution 1 or 1a* $0 eql magnesium citrate oral solution 1 or 1a* $0 FRESKARO MAGNESIUM CITRATE ORAL SOLUTION 1 or 1a* $0 ft magnesium citrate oral solution 1 or 1a* $0 ft milk of magnesia oral suspension 1 or 1b* $0 gentle laxative oral suspension 1 or 1b* $0 gnp magnesium citrate oral solution 1 or 1a* $0 gnp milk of magnesia oral suspension 1 or 1b* $0 goodsense magnesium citrate oral solution 1 or 1a* $0 goodsense milk of magnesia oral suspension 1 or 1b* $0 magnesium citrate oral solution 1.745 gm/30ml 1 or 1a* $0 milk of magnesia oral suspension 1 or 1b* $0 ONELAX MAGNESIUM CITRATE ORAL SOLUTION 1 or 1a* $0 phillips milk of magnesia oral suspension 400 mg/5ml 1 or 1b* $0 qc magnesium citrate oral solution 1 or 1a* $0 qc milk of magnesia oral suspension 1 or 1b* $0 ra magnesium citrate oral solution 1 or 1a* $0 Drug Name Tier Notes ra milk of magnesia oral suspension 1 or 1b* $0 sb magnesium citrate oral solution 1 or 1a* $0 sb milk of magnesia oral suspension 1 or 1b* $0 *STIMULANT LAXATIVES*** bisacodyl ec oral tablet delayed release 1 or 1a* $0 cvs c-lax laxative oral tablet delayed release 1 or 1a* $0 cvs gentle laxative oral tablet delayed release 1 or 1a* $0 cvs gentle laxative womens oral tablet delayed release 1 or 1a* $0 eq gentle laxative oral tablet delayed release 1 or 1a* $0 eql gentle laxative oral tablet delayed release 1 or 1a* $0 eql laxative oral tablet delayed release 1 or 1a* $0 ex-lax ultra oral tablet delayed release 1 or 1a* $0 FLEET STIMULANT ORAL TABLET DELAYED RELEASE 1 or 1a* $0 ft laxative oral tablet delayed release 1 or 1a* $0 gentle laxative oral tablet delayed release 1 or 1a* $0 gnp gentle laxative oral tablet delayed release 1 or 1a* $0 gnp womens gentle laxative oral tablet delayed release 1 or 1a* $0 goodsense bisacodyl laxative oral tablet delayed release 1 or 1a* $0 kp bisacodyl oral tablet delayed release 1 or 1a* $0 qc gentle laxative oral tablet delayed release 1 or 1a* $0 qc gentle laxative womens oral tablet delayed release 1 or 1a* $0 qc laxative oral tablet delayed release 1 or 1a* $0 ra laxative oral tablet delayed release 1 or 1a* $0 ra womens laxative oral tablet delayed release 1 or 1a* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 61

Drug Name Tier Notes sb bisacodyl laxative ec oral tablet delayed release 1 or 1a* $0 sb gentle lax-women oral tablet delayed release 1 or 1a* $0 womans laxative oral tablet delayed release 1 or 1a* $0 womens laxative oral tablet delayed release 1 or 1a* $0 *LOCAL ANESTHETICS- PARENTERAL* *LOCAL ANESTHETIC & SYMPATHOMIMETIC** * bupivacaine-epinephrine (pf) injection solution 0.25% - 1:200000, 0.5% -1:200000 1 or 1b* lidocaine-epinephrine (pf) injection solution 1.5 %- 1:200000, 2 %-1:200000 1 or 1b* lidocaine-epinephrine injection solution 0.5 %- 1:200000, 2 %-1:100000 1 or 1b* sensorcaine/epinephrine injection solution 1 or 1b* sensorcaine-mpf/epinephrine injection solution 0.25% - 1:200000 1 or 1b* *LOCAL ANESTHETICS - AMIDES*** bupivacaine hcl (pf) injection solution 1 or 1b* lidocaine hcl (pf) injection solution 1 or 1b* lidocaine hcl injection solution 0.5 % 1 or 1b* polocaine injection solution 1 or 1b* polocaine-mpf injection solution 1 or 1b* ropivacaine hcl injection solution 10 mg/ml, 5 mg/ml, 7.5 mg/ml 1 or 1b* ROPIVACAINE HCL INJECTION SOLUTION 2 MG/ML 1 or 1b* sensorcaine injection solution 1 or 1b* sensorcaine-mpf injection solution 1 or 1b* Drug Name Tier Notes *LOCAL ANESTHETICS - ESTERS*** chloroprocaine hcl (pf) injection solution 1 or 1b* *MACROLIDES* *AZITHROMYCIN*** azithromycin intravenous solution reconstituted 500 mg 2 azithromycin oral suspension reconstituted 1 or 1b* azithromycin oral tablet 250 mg, 500 mg, 600 mg 1 or 1b* *CLARITHROMYCIN*** clarithromycin er oral tablet extended release 24 hour 1 or 1b* clarithromycin oral suspension reconstituted 1 or 1b* clarithromycin oral tablet 1 or 1b* *ERYTHROMYCINS*** e.e.s. 400 oral tablet 1 or 1b* erythromycin base oral capsule delayed release particles 1 or 1b* erythromycin base oral tablet 1 or 1b* erythromycin base oral tablet delayed release 1 or 1b* erythromycin ethylsuccinate oral suspension reconstituted 2 erythromycin lactobionate intravenous solution reconstituted 2 erythromycin oral tablet delayed release 1 or 1b* *MEDICAL DEVICES AND SUPPLIES* *CERVICAL CAPS*** FEMCAP VAGINAL DEVICE 2 $0 *CONDOMS - FEMALE*** FC2 FEMALE CONDOM 2 $0; QL *DIAPHRAGMS*** CAYA VAGINAL DIAPHRAGM 2 $0 WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 62

Drug Name Tier Notes WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 2 $0 WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 2 $0 WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 2 $0 WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 2 $0 WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 2 $0 WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 2 $0 WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 2 $0 *GLUCOSE MONITORING TEST SUPPLIES*** ACCU-CHEK FASTCLIX LANCET KIT 2 QL ACCU-CHEK FASTCLIX LANCETS 2 QL ACCU-CHEK SAFE-T PRO LANCETS 2 QL ACCU-CHEK SOFTCLIX LANCET DEV KIT 2 QL ACCU-CHEK SOFTCLIX LANCETS 2 QL COAGUCHEK LANCETS 2 QL DEXCOM G6 RECEIVER DEVICE 2 PA; QL DEXCOM G6 SENSOR 2 PA; QL DEXCOM G6 TRANSMITTER 2 PA; QL DEXCOM G7 RECEIVER DEVICE 2 PA; QL DEXCOM G7 SENSOR 2 PA; QL FREESTYLE LANCETS 2 QL FREESTYLE LIBRE 14 DAY READER DEVICE 2 PA; QL FREESTYLE LIBRE 14 DAY SENSOR 2 PA; QL FREESTYLE LIBRE 2 PLUS SENSOR 2 PA; QL Drug Name Tier Notes FREESTYLE LIBRE 2 READER DEVICE 2 PA; QL FREESTYLE LIBRE 2 SENSOR 2 PA; QL FREESTYLE LIBRE 3 PLUS SENSOR 2 PA; QL FREESTYLE LIBRE 3 READER DEVICE 2 PA; QL FREESTYLE LIBRE 3 SENSOR 2 PA; QL FREESTYLE LIBRE READER DEVICE 2 PA; QL FREESTYLE UNISTICK II LANCETS 2 QL *INSULIN ADMINISTRATION SUPPLIES*** OMNIPOD 5 DEXG7G6 INTRO GEN 5 KIT 2 PA; QL OMNIPOD 5 DEXG7G6 PODS GEN 5 2 PA; QL OMNIPOD 5 LIBRE2 G6 INTRO G5 KIT 2 PA; QL OMNIPOD 5 LIBRE2 PLUS G6 PODS 2 PA; QL OMNIPOD DASH INTRO (GEN 4) KIT 2 PA; QL OMNIPOD DASH PDM (GEN 4) KIT 2 PA; QL OMNIPOD DASH PODS (GEN 4) 2 PA; QL TWIIST REFILL KIT KIT 2 PA; QL TWIIST REFILL KIT/INFUSION SET KIT 2 PA; QL TWIIST STARTER KIT KIT 2 PA; QL *NEEDLES & SYRINGES*** 1ST TIER UNIFINE PENTIPS 3 ST; QL 1ST TIER UNIFINE PENTIPS PLUS 3 ST; QL ADVOCATE INSULIN PEN NEEDLE 3 ST; QL ADVOCATE INSULIN PEN NEEDLES 3 ST; QL ADVOCATE INSULIN SYRINGE 3 ST; QL aq insulin syringe 3 ST; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 63

Drug Name Tier Notes aqinject pen needle 3 ST; QL ASSURE ID DUO PRO PEN NEEDLES 3 QL ASSURE ID PRO PEN NEEDLES 3 QL ASSURE ID SAFETY PEN NEEDLES 30G X 8 MM 3 ST; QL aum insulin safety pen needle 3 ST; QL AUM MINI INSULIN PEN NEEDLE 3 ST; QL aum pen needle 3 ST; QL AUM READYGARD DUO PEN NEEDLE 3 ST; QL AUM SAFETY PEN NEEDLE 3 ST; QL AURORA PEN NEEDLES 3 ST; QL BD AUTOSHIELD DUO 2 QL BD INS SYR ULTRAFINE 1/2UNIT 2 QL BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.3 ML 2 QL BD INSULIN SYRINGE 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, U-100 1 ML 2 QL BD INSULIN SYRINGE HALF-UNIT 2 QL BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML 2 QL BD INSULIN SYRINGE U/F 30G X 1/2" 1 ML 2 QL BD INSULIN SYRINGE U-500 2 QL BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML 2 QL BD PEN NEEDLE MICRO ULTRAFINE 2 QL BD PEN NEEDLE MINI ULTRAFINE 2 QL Drug Name Tier Notes BD PEN NEEDLE NANO 2ND GEN 2 QL BD PEN NEEDLE NANO ULTRAFINE 2 QL BD PEN NEEDLE ORIG ULTRAFINE 2 QL BD PEN NEEDLE SHORT ULTRAFINE 2 QL BD SAFETYGLIDE INSULIN SYRINGE 2 QL BD VEO INSULIN SYR U/F 1/2UNIT 2 QL BD VEO INSULIN SYR ULTRAFINE 2 QL CAREFINE PEN NEEDLES 3 ST; QL CAREONE INSULIN SYRINGE 3 ST; QL CAREONE UNIFINE PENTIPS PLUS 3 ST; QL CARETOUCH INSULIN SYRINGE 3 ST; QL CARETOUCH PEN NEEDLES 3 ST; QL CLEVER CHOICE COMFORT EZ 29G X 12MM , 33G X 4 MM 3 ST; QL COMFORT EZ INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML 3 ST; QL COMFORT EZ INSULIN SYRINGE 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML 3 QL COMFORT EZ MICRO PEN NEEDLES 3 ST; QL COMFORT EZ PEN NEEDLES 3 ST; QL COMFORT EZ PRO PEN NEEDLES 30G X 8 MM , 31G X 4 MM 3 ST; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 64

Drug Name Tier Notes COMFORT EZ PRO PEN NEEDLES 31G X 5 MM 3 QL COMFORT EZ SHORT PEN NEEDLES 3 ST; QL COMFORT TOUCH INSULIN PEN NEED 3 ST; QL DIATHRIVE PEN NEEDLE 3 ST; QL DROPLET INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 15/64" 0.3 ML, 30G X 15/64" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 1/4" 0.3 ML, 31G X 1/4" 0.5 ML, 31G X 1/4" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML 3 ST; QL DROPLET INSULIN SYRINGE 30G X 15/64" 0.5 ML 3 QL DROPLET MICRON 3 QL DROPLET PEN NEEDLES 3 ST; QL DROPSAFE SAFETY PEN NEEDLES 3 ST; QL DROPSAFE SAFETY SYRINGE/NEEDLE 3 ST; QL DRUG MART UNIFINE PENTIPS 29G X 12MM , 31G X 6 MM , 31G X 8 MM 3 ST; QL DRUG MART UNIFINE PENTIPS PLUS 3 ST; QL easy comfort insulin syringe 29g x 5/16" 0.5 ml, 29g x 5/16" 1 ml, 31g x 1/2" 0.3 ml, 31g x 5/16" 0.3 ml 3 ST; QL EASY COMFORT INSULIN SYRINGE 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML, 32G X 5/16" 0.5 ML, 32G X 5/16" 1 ML 3 ST; QL Drug Name Tier Notes easy comfort pen needles 29g x 4mm , 29g x 5mm 3 ST; QL EASY COMFORT PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM 3 ST; QL EASY GLIDE PEN NEEDLES 3 ST; QL EASY TOUCH FLIPLOCK INSULIN SY 3 ST; QL EASY TOUCH INSULIN BARRELS 3 ST; QL EASY TOUCH INSULIN SAFETY SYR 3 ST; QL EASY TOUCH INSULIN SYRINGE 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML 3 ST; QL EASY TOUCH INSULIN SYRINGE 27G X 5/8" 1 ML 3 QL EASY TOUCH PEN NEEDLES 3 ST; QL EASY TOUCH SAFETY PEN NEEDLES 3 ST; QL EASY TOUCH SHEATHLOCK SYRINGE 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML 3 ST; QL EMBECTA AUTOSHIELD DUO 2 QL EMBECTA INS SYR U/F 1/2 UNIT 2 QL EMBECTA INSULIN SYR ULTRAFINE 2 QL EMBECTA INSULIN SYRINGE 2 QL EMBECTA INSULIN SYRINGE U-100 2 QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 65

Drug Name Tier Notes EMBECTA INSULIN SYRINGE U-500 2 QL EMBECTA PEN NEEDLE NANO 2 QL EMBECTA PEN NEEDLE NANO 2 GEN 2 QL EMBECTA PEN NEEDLE ULTRAFINE 2 QL EMBRACE PEN NEEDLES 3 ST; QL FIFTY50 PEN NEEDLES 3 ST; QL FIFTY50 SUPERIOR COMFORT SYR 3 ST; QL GLOBAL EASE INJECT PEN NEEDLES 3 ST; QL GLOBAL EASY GLIDE INSULIN SYR 3 ST; QL GLOBAL EASY GLIDE PEN NEEDLES 3 ST; QL GLOBAL INJECT EASE INSULIN SYR 3 ST; QL GLOBAL INSULIN SYRINGES 3 ST; QL GLUCOPRO INSULIN SYRINGE 3 ST; QL GNP INSULIN SYRINGE 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML 3 ST; QL GNP INSULIN SYRINGES 3 ST; QL GNP INSULIN SYRINGES 28GX1/2" 3 ST; QL GNP INSULIN SYRINGES 29GX1/2" 3 ST; QL GNP INSULIN SYRINGES 30GX5/16" 3 ST; QL GNP INSULIN SYRINGES 31GX5/16" 3 ST; QL gnp pen needles 3 ST; QL GNP ULTICARE PEN NEEDLES 3 ST; QL GNP ULTIGUARD SAFEPACK NEEDLE 3 ST; QL GNP ULTRA COM INSULIN SYRINGE 28G X 1/2" 1 ML 3 ST; QL HEALTHWISE INSULIN SYR/NEEDLE 3 ST; QL HEALTHWISE MICRON PEN NEEDLES 3 ST; QL Drug Name Tier Notes HEALTHWISE SHORT PEN NEEDLES 3 ST; QL H-E-B INCONTROL PEN NEEDLES 3 ST; QL H-E-B INCONTROL UNIFINE PENTIP 3 ST; QL HM ULTICARE INSULIN SYRINGE 3 ST; QL HM ULTICARE MINI PEN NEEDLES 3 ST; QL HM ULTICARE SHORT PEN NEEDLES 3 ST; QL INCONTROL ULTICARE PEN NEEDLES 3 ST; QL INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML 3 ST; QL insulin syringe-needle u-100 27g x 1/2" 0.5 ml, 27g x 1/2" 1 ml, 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 30g x 1/2" 1 ml 3 ST; QL INSULIN SYRINGE- NEEDLE U-100 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML 3 ST; QL INSUPEN PEN NEEDLES 29G X 12MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM 3 ST; QL INSUPEN32G EXTR3ME 3 KINRAY INSULIN SYRINGE 29G X 1/2" 0.5 ML 3 ST; QL KROGER PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 33G X 4 MM 3 ST; QL LEADER UNIFINE PENTIPS 3 ST; QL LEADER UNIFINE PENTIPS PLUS 3 ST; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 66

Drug Name Tier Notes LITETOUCH INSULIN SYRINGE 3 ST; QL LITETOUCH PEN NEEDLES 3 ST; QL MAGELLAN INSULIN SAFETY SYR 3 ST; QL MARATHON MEDICAL PENTIPS 3 ST; QL MAXICOMFORT II PEN NEEDLE 3 ST; QL MAXI-COMFORT INSULIN SYRINGE 3 ST; QL MAXI-COMFORT SAFETY PEN NEEDLE 3 ST; QL MAXICOMFORT SYR 27G X 1/2" 3 ST; QL MEDIC INSULIN SYRINGE 3 ST; QL MEDICINE SHOPPE PEN NEEDLES 29G X 12MM , 31G X 8 MM 3 ST; QL MEIJER PEN NEEDLES 3 ST; QL MICRODOT PEN NEEDLE 3 ST; QL MM INSULIN SYRINGE/NEEDLE 3 ST; QL MM PEN NEEDLES 3 ST; QL MONOJECT INSULIN SYRINGE 3 ST; QL MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML 3 ST; QL NOVOFINE PEN NEEDLE 3 ST; QL NOVOFINE PLUS PEN NEEDLE 3 ST; QL PC UNIFINE PENTIPS 31G X 5 MM , 31G X 6 MM , 31G X 8 MM 3 ST; QL pen needle/5-bevel tip 3 ST; QL PEN NEEDLES 3 ST; QL Drug Name Tier Notes PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM 3 ST; QL PENTIPS GENERIC PEN NEEDLES 3 ST; QL pip pen needles 31g x 5mm 3 ST; QL pip pen needles 32g x 4mm 3 ST; QL PRECISION SURE-DOSE SYRINGE 30G X 5/16" 0.3 ML 3 ST; QL PREFERRED PLUS UNIFINE PENTIPS 29G X 12MM 3 ST; QL PREVENT DROPSAFE PEN NEEDLES 3 ST; QL PREVENT SAFETY PEN NEEDLES 3 ST; QL PRO COMFORT INSULIN SYRINGE 3 ST; QL PRO COMFORT PEN NEEDLES 32G X 4 MM , 32G X 5 MM , 32G X 6 MM 3 ST; QL PRODIGY INSULIN SYRINGE 3 ST; QL PURE COMFORT PEN NEEDLE 3 ST; QL pure comfort safety pen needle 3 QL PX INSULIN SYRINGE 30G X 1/2" 0.5 ML 3 ST; QL PX MINI PEN NEEDLES 3 ST; QL QC PEN NEEDLES 3 ST; QL QC UNIFINE PENTIPS 3 ST; QL QUICK TOUCH INSULIN PEN NEEDLE 31G X 4 MM , 31G X 5 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM , 32G X 8 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM , 33G X 8 MM 3 ST; QL RA INSULIN SYRINGE 3 ST; QL RA PEN NEEDLES 3 ST; QL raya sure pen needle 3 ST; QL REALITY INSULIN SYRINGE 3 ST; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 67

Drug Name Tier Notes RELION INSULIN SYRINGE 29G X 1/2" 0.5 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML 3 ST; QL RELION PEN NEEDLES 31G X 6 MM , 31G X 8 MM , 32G X 4 MM 3 ST; QL safety pen needles 3 ST; QL SB INSULIN SYRINGE 3 ST; QL SECURESAFE INSULIN SYRINGE 3 ST; QL SECURESAFE SAFETY PEN NEEDLES 3 ST; QL SURE COMFORT INSULIN SYRINGE 3 ST; QL SURE COMFORT PEN NEEDLES 29G X 12.7MM , 30G X 8 MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM 3 ST; QL sure comfort pen needles 31g x 6 mm 3 ST; QL TECHLITE INSULIN SYRINGE 30G X 1/2" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML 3 ST; QL TECHLITE PEN NEEDLES 29G X 12MM , 31G X 5 MM 3 TECHLITE PEN NEEDLES 31G X 8 MM , 32G X 4 MM , 32G X 6 MM 3 ST; QL TECHLITE PLUS PEN NEEDLES 3 TODAYS HEALTH PEN NEEDLES 3 ST; QL TODAYS HEALTH SHORT PEN NEEDLE 3 ST; QL true comfort insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 32g x 5/16" 1 ml 3 ST; QL Drug Name Tier Notes TRUE COMFORT INSULIN SYRINGE 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML 3 ST; QL TRUE COMFORT PEN NEEDLES 3 ST; QL TRUE COMFORT PRO INSULIN SYR 3 ST; QL TRUE COMFORT PRO PEN NEEDLES 3 ST; QL true comfort safety pen needle 3 ST; QL TRUEPLUS 5-BEVEL PEN NEEDLES 29G X 12.7MM 3 QL TRUEPLUS 5-BEVEL PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM 3 ST; QL TRUEPLUS INSULIN SYRINGE 3 ST; QL ULTICARE INSULIN SAFETY SYR 3 ST; QL ULTICARE INSULIN SYR 1/2 UNIT 3 ST; QL ULTICARE INSULIN SYRINGE 3 ST; QL ULTICARE MICRO PEN NEEDLES 3 ST; QL ULTICARE MINI PEN NEEDLES 3 ST; QL ULTICARE PEN NEEDLES 29G X 12.7MM , 31G X 5 MM 3 ST; QL ULTICARE SHORT PEN NEEDLES 3 ST; QL ULTIGUARD SAFEPACK PEN NEEDLE 3 ST; QL ULTIGUARD SAFEPACK SYR/NEEDLE 3 ST; QL ULTILET PEN NEEDLE 3 ST; QL ULTRA COMFORT INSULIN SYRINGE 30G X 5/16" 0.3 ML 3 ST; QL ULTRA FLO INSULIN PEN NEEDLES 3 ST; QL ULTRA FLO INSULIN SYR 1/2 UNIT 3 ST; QL ULTRA FLO INSULIN SYRINGE 3 ST; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 68

Drug Name Tier Notes ULTRA THIN PEN NEEDLES 3 ST; QL ULTRACARE INSULIN SYRINGE 3 ST; QL ULTRACARE PEN NEEDLES 3 ST; QL ULTRA-THIN II INS SYR SHORT 3 ST; QL ULTRA-THIN II INSULIN SYRINGE 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML 3 ST; QL ULTRA-THIN II MINI PEN NEEDLE 3 ST; QL ULTRA-THIN II PEN NEEDLE SHORT 3 ST; QL ULTRA-THIN II PEN NEEDLES 3 ST; QL UNIFINE OTC PEN NEEDLES 3 ST; QL UNIFINE PENTIPS 3 ST; QL UNIFINE PENTIPS PLUS 3 ST; QL UNIFINE PROTECT PEN NEEDLE 30G X 5 MM 3 QL UNIFINE PROTECT PEN NEEDLE 30G X 8 MM , 32G X 4 MM 3 ST; QL UNIFINE SAFECONTROL PEN NEEDLE 3 ST; QL UNIFINE ULTRA PEN NEEDLE 3 ST; QL VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML, 29G X 5/16" 1 ML, 30G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML 3 ST; QL VANISHPOINT INSULIN SYRINGE 30G X 3/16" 0.5 ML, 30G X 3/16" 1 ML 3 QL VERIFINE INSULIN PEN NEEDLE 29G X 12MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM 3 ST; QL VERIFINE INSULIN PEN NEEDLE 31G X 5 MM 3 QL VERIFINE INSULIN SYRINGE 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML 3 ST; QL Drug Name Tier Notes VERIFINE INSULIN SYRINGE 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML 3 QL VERIFINE PLUS PEN NEEDLE 3 ST; QL WEGMANS UNIFINE PENTIPS PLUS 3 ST; QL ZEVRX INSULIN SYRINGE 3 ST; QL ZEVRX PEN NEEDLES 3 ST; QL *MIGRAINE PRODUCTS* *CALCITONIN GENE- RELATED PEPTIDE RECEPTOR ANTAG (CGRP)*** NURTEC ORAL TABLET DISPERSIBLE 2 PA; QL QULIPTA ORAL TABLET 2 PA; QL UBRELVY ORAL TABLET 2 ST; QL *CGRP RECEPTOR ANTAGONISTS - MONOCOLONAL ANTIBODIES*** AIMOVIG SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 PA; QL AJOVY SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 PA; QL AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 PA; QL EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 PA; QL EMGALITY SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 PA; QL EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 PA; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 69

Drug Name Tier Notes *ERGOT COMBINATIONS*** ergotamine-caffeine oral tablet 1 or 1b* migergot rectal suppository 1 or 1b* *MIGRAINE PRODUCTS*** dihydroergotamine mesylate injection solution 1 or 1b* PA; QL *SELECTIVE SEROTONIN AGONISTS 5-HT(1)*** almotriptan malate oral tablet 1 or 1b* QL eletriptan hydrobromide oral tablet 1 or 1b* QL frovatriptan succinate oral tablet 1 or 1b* ST; QL naratriptan hcl oral tablet 1 or 1b* QL rizatriptan benzoate oral tablet 1 or 1b* QL rizatriptan benzoate oral tablet dispersible 1 or 1b* QL sumatriptan nasal solution 1 or 1b* QL sumatriptan succinate oral tablet 1 or 1b* QL sumatriptan succinate refill subcutaneous solution cartridge 2 QL sumatriptan succinate subcutaneous solution 6 mg/0.5ml 2 QL sumatriptan succinate subcutaneous solution auto- injector 4 mg/0.5ml, 6 mg/0.5ml 2 QL zolmitriptan nasal solution 1 or 1b* ST; QL zolmitriptan oral tablet 1 or 1b* QL zolmitriptan oral tablet dispersible 1 or 1b* QL *MINERALS & ELECTROLYTES* *BICARBONATES*** sodium acetate intravenous solution 4 meq/ml 1 or 1b* sodium bicarbonate intravenous solution 4.2 %, 7.5 % 2 Drug Name Tier Notes *ELECTROLYTES & DEXTROSE*** dextrose in lactated ringers intravenous solution 1 or 1b* dextrose-sodium chloride intravenous solution 10-0.45 %, 5-0.2 %, 5-0.33 %, 5-0.45 %, 5-0.9 % 1 or 1b* kcl in dextrose-nacl intravenous solution 10-5- 0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.45 meq/l- %-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5- 0.45 meq/l-%-% 1 or 1b* potassium cl in dextrose 5% intravenous solution 10 meq/l, 20 meq/l 1 or 1b* *ELECTROLYTES PARENTERAL*** KCL (0.149%) IN NACL INTRAVENOUS SOLUTION 20-0.45 MEQ/L-% 1 or 1b* kcl (0.149%) in nacl intravenous solution 20-0.9 meq/l-% 1 or 1b* KCL (0.298%) IN NACL INTRAVENOUS SOLUTION 1 or 1b* lactated ringers intravenous solution 1 or 1b* multiple electro type 1 ph 5.5 intravenous solution 1 or 1b* multiple electro type 1 ph 7.4 intravenous solution 1 or 1b* ringers intravenous solution 1 or 1b* *FLUORIDE*** sodium fluoride oral solution 1.1 (0.5 f) mg/ml 1 or 1a* $0 sodium fluoride oral tablet 1 or 1a* $0 sodium fluoride oral tablet chewable 1 or 1a* $0 *MAGNESIUM*** MAGNESIUM SULFATE INJECTION SOLUTION 50 % 2 *MANGANESE*** manganese chloride intravenous solution 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 70

Drug Name Tier Notes *PHOSPHATE*** K-PHOS ORAL TABLET 2 phospha 250 neutral oral tablet 1 or 1b* phosphorous oral tablet 1 or 1b* phospho-trin k500 oral tablet 1 or 1b* potassium phosphates intravenous solution 45 mmole/15ml 1 or 1b* sodium phosphates intravenous solution 1 or 1b* *POTASSIUM*** klor-con 10 oral tablet extended release 1 or 1b* klor-con m10 oral tablet extended release 1 or 1a* klor-con m15 oral tablet extended release 1 or 1a* klor-con m20 oral tablet extended release 1 or 1a* klor-con oral packet 20 meq 1 or 1b* klor-con oral tablet extended release 1 or 1b* potassium chloride crys er oral tablet extended release 1 or 1a* potassium chloride er oral capsule extended release 1 or 1b* potassium chloride er oral tablet extended release 1 or 1b* potassium chloride intravenous solution 2 meq/ml 1 or 1b* potassium chloride oral packet 1 or 1b* potassium chloride oral solution 10 %, 20 meq/15ml (10%), 40 meq/15ml (20%) 1 or 1b* *SODIUM*** aquastat intravenous solution 2 AQUASTAT SFR INTRAVENOUS SOLUTION 2 bd posiflush intravenous solution 2 BD POSIFLUSH SAFESCRUB INTRAVENOUS SOLUTION 2 Drug Name Tier Notes monoject flush syringe intravenous solution 2 monoject sodium chloride flush intravenous solution 2 normal saline flush intravenous solution 2 saline flush intravenous solution 2 sodium chloride (pf) injection solution 2 sodium chloride injection solution 2.5 meq/ml 2 sodium chloride intravenous solution 0.45 %, 3 %, 5 % 2 *TRACE MINERALS*** SELENIOUS ACID INTRAVENOUS SOLUTION 40 MCG/ML 1 or 1b* *ZINC*** zinc sulfate intravenous solution 1 or 1b* *MISCELLANEOUS THERAPEUTIC CLASSES* *ANTILEPROTICS*** THALOMID ORAL CAPSULE 100 MG, 50 MG 4 PA; LD; QL; SP *CHELATING AGENTS*** penicillamine oral tablet 2 PA; LD; QL; SP trientine hcl oral capsule 250 mg 4 PA; LD; QL; SP *CYCLOSPORINE ANALOGS*** cyclosporine modified oral capsule 4 LD cyclosporine modified oral solution 4 LD cyclosporine oral capsule 4 LD gengraf oral capsule 100 mg, 25 mg 4 LD gengraf oral solution 4 LD *IMMUNOMODULATOR S FOR MYELODYSPLASTIC SYNDROMES*** lenalidomide oral capsule 4 PA; LD; QL; SP REVLIMID ORAL CAPSULE 4 PA; LD; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 71

Drug Name Tier Notes *INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS*** mycophenolate mofetil oral capsule 4 LD mycophenolate mofetil oral suspension reconstituted 4 LD mycophenolate mofetil oral tablet 4 LD mycophenolate sodium oral tablet delayed release 4 LD mycophenolic acid oral tablet delayed release 180 mg, 360 mg 4 LD *IRRIGATION SOLUTIONS*** argyle sterile water irrigation solution 1 or 1b* lactated ringers irrigation solution 1 or 1b* physiolyte irrigation solution 1 or 1b* physiosol irrigation irrigation solution 1 or 1b* sterile water for irrigation irrigation solution 1 or 1b* water for irrigation, sterile irrigation solution 1 or 1b* *MACROLIDE IMMUNOSUPPRESSANT S*** everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg, 1 mg 4 LD sirolimus oral solution 4 LD sirolimus oral tablet 4 LD tacrolimus oral capsule 4 LD *POTASSIUM REMOVING AGENTS*** LOKELMA ORAL PACKET 3 QL sodium polystyrene sulfonate oral powder 2 sps (sodium polystyrene sulf) rectal suspension 2 *PURINE ANALOGS*** azasan oral tablet 1 or 1b* LD azathioprine oral tablet 1 or 1b* LD Drug Name Tier Notes *SCLEROSING AGENTS*** sodium tetradecyl sulfate intravenous solution 1 or 1b* SOTRADECOL INTRAVENOUS SOLUTION 1 % 1 or 1b* sotradecol intravenous solution 3 % 1 or 1b* *MOUTH/THROAT/DEN TAL AGENTS* *ANESTHETICS TOPICAL ORAL*** lidocaine hcl mouth/throat solution 1 or 1a* QL lidocaine viscous hcl mouth/throat solution 1 or 1a* QL *ANTI-INFECTIVES - THROAT*** clotrimazole mouth/throat troche 1 or 1b* QL *ANTISEPTICS - MOUTH/THROAT*** chlorhexidine gluconate mouth/throat solution 1 or 1a* QL periogard mouth/throat solution 1 or 1a* QL *DENTAL PRODUCTS - COMBINATIONS*** sodium fluoride 5000 enamel dental gel 1 or 1b* sodium fluoride 5000 sensitive dental gel 1 or 1b* *FLUORIDE DENTAL PRODUCTS*** clinpro 5000 dental paste 1 or 1b* QL denta 5000 plus dental cream 1 or 1b* QL dentagel dental gel 1 or 1a* QL fluoridex daily renewal mouth/throat concentrate 1 or 1b* fluoridex dental paste 1 or 1b* QL fluoridex enhanced whitening dental paste 1 or 1b* QL fluorimax 5000 dental paste 1 or 1b* fraiche 5000 dental dental gel 1 or 1b* QL just right 5000 dental paste 1 or 1b* sf 5000 plus dental cream 1 or 1b* QL sf dental gel 1 or 1a* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 72

Drug Name Tier Notes sodium fluoride 5000 plus dental cream 1 or 1b* QL sodium fluoride 5000 ppm dental cream 1 or 1b* QL sodium fluoride 5000 ppm dental gel 1 or 1b* QL sodium fluoride 5000 ppm dental paste 1 or 1b* QL sodium fluoride dental cream 1 or 1b* QL sodium fluoride mouth/throat solution 1 or 1a* *SALIVA STIMULANTS*** cevimeline hcl oral capsule 2 pilocarpine hcl oral tablet 2 QL *STEROIDS - MOUTH/THROAT/DENT AL*** KOURZEQ MOUTH/THROAT PASTE 1 or 1b* oralone mouth/throat paste 1 or 1b* triamcinolone acetonide mouth/throat paste 1 or 1b* *MULTIVITAMINS* *B-COMPLEX VITAMINS*** b complex-b12 oral tablet 1 or 1b* $0 b-complex plus b-12 oral tablet 1 or 1b* $0 b-complex/b-12 oral tablet 1 or 1b* $0 ra b-complex oral tablet 1 or 1b* $0 ra b-complex with b-12 oral tablet 1 or 1b* $0 vitamin b complex oral tablet 1 or 1b* $0 vitamin b complex w/b-12 oral tablet 1 or 1b* $0 vitamin-b complex oral tablet 1 or 1b* $0 *B-COMPLEX W/ C & CALCIUM*** gnp b-complex plus vitamin c oral tablet 1 or 1b* $0 qc b-complex/vitamin c oral tablet 1 or 1b* $0 *B-COMPLEX W/ C & FOLIC ACID*** b complex-c-folic acid oral tablet 1 or 1b* $0 Drug Name Tier Notes b-complex balanced oral tablet 1 or 1b* $0 b-complex/vitamin c oral tablet 1 or 1b* $0 b-complex-c (w/folic acid) oral tablet 1 or 1b* $0 b-plex oral tablet 1 or 1b* $0 dialyvite 800 oral tablet 1 or 1b* $0 eql super b complex/vitamin c oral tablet 1 or 1b* $0 FULL SPECTRUM B/VITAMIN C ORAL TABLET 1 or 1b* $0 kp b complex-c oral tablet 1 or 1b* $0 nephro vitamins oral tablet 1 or 1b* $0 NEPHRO-VITE ORAL TABLET 1 or 1b* $0 renal vitamin oral tablet 1 or 1b* $0 rena-vite oral tablet 1 or 1b* $0 stress formula (folic acid) oral tablet 1 or 1b* $0 super b complex/fa/vit c oral tablet 1 or 1b* $0 super b-complex/vit c/fa oral tablet 1 or 1b* $0 *B-COMPLEX W/ C*** allbee/c oral tablet 1 or 1b* $0 b complex-c oral tablet 1 or 1b* $0 b-complex-c oral tablet 1 or 1b* $0 better b complex oral tablet 1 or 1b* $0 cvs b complex plus c oral tablet 1 or 1b* $0 cvs super b complex/c oral tablet 1 or 1b* $0 ft b-complex plus vitamin c oral tablet 1 or 1b* $0 super b complex/vitamin c oral tablet 1 or 1b* $0 super b-complex + vitamin c oral tablet 1 or 1b* $0 *B-COMPLEX W/ C- BIOTIN-E & FOLIC ACID*** B COMPLEX-C-BIOTIN- E-FA ORAL TABLET 2 $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 73

Drug Name Tier Notes *B-COMPLEX W/ FOLIC ACID*** b complex formula 1 (w/ fa) oral tablet 1 or 1b* $0 b-complex (folic acid) oral tablet 1 or 1b* $0 b-complex/electrolytes oral tablet 1 or 1b* $0 big 100 oral tablet 1 or 1b* $0 kobee oral tablet 1 or 1b* $0 *B-COMPLEX W/BIOTIN & FOLIC ACID*** b complex 100 tr oral tablet extended release 1 or 1b* $0 b-100 b-complex oral tablet 1 or 1b* $0 b-100 complex cr oral tablet extended release 1 or 1b* $0 b-100 tr oral tablet extended release 1 or 1b* $0 b-50 complex oral tablet 1 or 1b* $0 balance b-50 oral tablet 1 or 1b* $0 balanced b complex oral tablet 1 or 1b* $0 balanced b-100 oral tablet 1 or 1b* $0 balanced b-100 oral tablet extended release 1 or 1b* $0 balanced b-50/fa oral tablet 1 or 1b* $0 b-compleet-100 oral tablet 1 or 1b* $0 b-compleet-50 oral tablet 1 or 1b* $0 b-complex oral tablet 1 or 1b* $0 big 100 (biotin) oral tablet 1 or 1b* $0 complex b-100 oral tablet extended release 1 or 1b* $0 complex b-50 prolonged release oral tablet extended release 1 or 1b* $0 endur-b oral tablet extended release 1 or 1b* $0 eql b complex 50 oral tablet 1 or 1b* $0 eql b-100 complex oral tablet extended release 1 or 1b* $0 ft b-100 complex pr oral tablet extended release 1 or 1b* $0 gnp b-100 complex oral tablet extended release 1 or 1b* $0 gnp b-50 complex oral tablet extended release 1 or 1b* $0 Drug Name Tier Notes qc b50 prolonged release oral tablet extended release 1 or 1b* $0 quin b strong b-25 oral tablet 1 or 1b* $0 ra balanced b-100 cr oral tablet extended release 1 or 1b* $0 ra balanced b-100 oral tablet 1 or 1b* $0 ra balanced b-50 oral tablet 1 or 1b* $0 ra balanced b-50 tr oral tablet extended release 1 or 1b* $0 super b-complex oral tablet 1 or 1b* $0 super dec b-100 oral tablet 1 or 1b* $0 super quints b-50 oral tablet 1 or 1b* $0 yl balanced b-100 oral tablet 1 or 1b* $0 *PED MULTI VITAMINS W/FL & FE*** multi-vitamin/fluoride/iron oral solution 1 or 1b* *PED MV W/ FLUORIDE*** multivitamin w/fluoride oral tablet chewable 1 or 1b* $0 multi-vitamin/fluoride oral solution 1 or 1b* $0 *PED VITAMINS ACD W/ FLUORIDE*** tri-vite/fluoride oral solution 1 or 1b* $0 *PRENATAL MV & MIN W/FE-FA*** ATABEX EC ORAL TABLET DELAYED RELEASE 2 QL ATABEX OB ORAL TABLET 2 QL CLASSIC PRENATAL ORAL TABLET 2 $0; QL C-NATE DHA ORAL CAPSULE 2 QL COMPLETENATE ORAL TABLET CHEWABLE 2 QL CO-NATAL FA ORAL TABLET 2 QL CONCEPT DHA ORAL CAPSULE 2 QL CONCEPT OB ORAL CAPSULE 2 QL elite-ob oral tablet 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 74

Drug Name Tier Notes EQL PRENATAL FORMULA ORAL TABLET 2 $0; QL FOLIVANE-OB ORAL CAPSULE 85-1 MG 2 QL GNP PRENATAL ORAL TABLET 2 $0; QL inatal gt oral tablet 1 or 1b* QL M-NATAL PLUS ORAL TABLET 1 or 1b* QL NIVA-PLUS ORAL TABLET 2 QL ONE VITE WOMENS PLUS ORAL TABLET 2 QL pnv 27-ca/fe/fa oral tablet 2 ST; QL pnv prenatal plus multivit+dha oral 2 QL pnv-select oral tablet 1 or 1b* ST; QL PRENATAL (W/IRON & FA) ORAL TABLET 2 ST; $0; QL PRENATAL 19 ORAL TABLET 29-1 MG 2 QL prenatal 19 oral tablet chewable 1 or 1a* QL PRENATAL 19 ORAL TABLET CHEWABLE 29- 1 MG 2 QL PRENATAL COMPLETE ORAL TABLET 2 ST; $0; QL PRENATAL ORAL TABLET 27-1 MG 2 QL PRENATAL PLUS ORAL TABLET 2 QL PRENATAL PLUS VITAMIN/MINERAL ORAL TABLET 2 QL PRENATAL VITAMIN AND MINERAL ORAL TABLET 2 $0; QL PRENATAL VITAMINS ORAL TABLET 28-0.8 MG 2 $0; QL PRENATAL-U ORAL CAPSULE 2 QL PROVIDA OB ORAL CAPSULE 2 QL QC PRENATAL ORAL TABLET 2 $0; QL Drug Name Tier Notes RA PRENATAL ORAL TABLET 2 $0; QL SELECT-OB ORAL TABLET CHEWABLE 29- 1 MG 2 QL SE-NATAL 19 ORAL TABLET 2 QL SE-NATAL 19 ORAL TABLET CHEWABLE 2 QL TARON-C DHA ORAL CAPSULE 35-1 MG 2 QL THRIVITE RX ORAL TABLET 2 ST; QL TRINATAL RX 1 ORAL TABLET 2 QL trinate oral tablet 1 or 1a* QL VITAFOL GUMMIES ORAL TABLET CHEWABLE 2 QL WESTAB PLUS ORAL TABLET 2 QL *PRENATAL MV & MIN W/FE-FA-CA-OMEGA 3 FISH OIL*** COMPLETE NATAL DHA ORAL 29-1-200 & 200 MG 2 QL wesnatal dha complete oral 2 QL *PRENATAL MV & MIN W/FE-FA-DHA*** ENFAMIL EXPECTA ORAL 2 $0; QL pnv-dha oral capsule 1 or 1b* QL prena 1 true oral 2 PRENATAL MULTIVITAMIN + DHA ORAL 2 $0; QL *VITAMINS W/ LIPOTROPICS*** b complex formula 1 (lipotrop) oral tablet 1 or 1b* $0 balance b-100 oral tablet 1 or 1b* $0 balanced b-50 complex oral tablet 1 or 1b* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 75

Drug Name Tier Notes *MUSCULOSKELETAL THERAPY AGENTS* *CENTRAL MUSCLE RELAXANTS*** baclofen oral tablet 10 mg, 20 mg, 5 mg 1 or 1b* QL carisoprodol oral tablet 1 or 1b* QL chlorzoxazone oral tablet 375 mg, 750 mg 1 or 1b* ST; QL chlorzoxazone oral tablet 500 mg 1 or 1b* QL cyclobenzaprine hcl oral tablet 10 mg, 5 mg 1 or 1b* QL methocarbamol injection solution 1000 mg/10ml 1 or 1b* methocarbamol oral tablet 500 mg, 750 mg 1 or 1b* QL orphenadrine citrate er oral tablet extended release 12 hour 1 or 1b* QL orphenadrine citrate injection solution 1 or 1b* tizanidine hcl oral capsule 6 mg 1 or 1b* QL tizanidine hcl oral tablet 1 or 1b* QL *DIRECT MUSCLE RELAXANTS*** dantrolene sodium intravenous solution reconstituted 1 or 1b* dantrolene sodium oral capsule 2 revonto intravenous solution reconstituted 1 or 1b* *MUSCLE RELAXANT COMBINATIONS*** NORGESIC FORTE ORAL TABLET 1 or 1b* ST; QL norgesic oral tablet 1 or 1b* ST; QL ORPHENADRINE- ASPIRIN-CAFFEINE ORAL TABLET 25-385-30 MG 1 or 1b* ST; QL orphengesic forte oral tablet 50-770-60 mg 1 or 1b* ST; QL Drug Name Tier Notes *NASAL AGENTS - SYSTEMIC AND TOPICAL* *ANTIHISTAMINE- STEROID*** azelastine-fluticasone nasal suspension 3 QL *NASAL ANTICHOLINERGICS*** ipratropium bromide nasal solution 1 or 1b* QL *NASAL ANTIHISTAMINES*** azelastine hcl nasal solution 0.1 %, 137 mcg/spray 1 or 1b* QL olopatadine hcl nasal solution 1 or 1b* QL *NASAL STEROIDS*** fluticasone propionate nasal suspension 1 or 1a* BE; QL mometasone furoate nasal suspension 3 ST; BE; QL *NEUROMUSCULAR AGENTS* *BENZATHIAZOLES*** riluzole oral tablet 4 PA; LD; QL; SP *NONDEPOLARIZING MUSCLE RELAXANTS*** atracurium besylate intravenous solution 100 mg/10ml, 50 mg/5ml 1 or 1b* cisatracurium besylate (pf) intravenous solution 1 or 1b* cisatracurium besylate intravenous solution 20 mg/10ml 1 or 1b* rocuronium bromide intravenous solution 1 or 1b* vecuronium bromide intravenous solution reconstituted 1 or 1b* *NUTRIENTS* *AMINO ACID MIXTURES*** aminosyn ii intravenous solution 15 % 1 or 1b* clinisol sf intravenous solution 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 76

Drug Name Tier Notes plenamine intravenous solution 1 or 1b* REFRESH AA 15 PKU ORAL LIQUID 2 REFRESH AA 15 TYR ORAL LIQUID 2 *CARBOHYDRATES*** dextrose intravenous solution 10 % 1 or 1b* *OPHTHALMIC AGENTS* *ALPHA ADRENERGIC AGONIST & CARBONIC ANHYDRASE INHIB COMB*** SIMBRINZA OPHTHALMIC SUSPENSION 2 QL *BETA-BLOCKERS - OPHTHALMIC COMBINATIONS*** brimonidine tartrate-timolol ophthalmic solution 1 or 1b* QL dorzolamide hcl-timolol mal ophthalmic solution 1 or 1b* QL dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % 1 or 1b* QL *BETA-BLOCKERS - OPHTHALMIC*** betaxolol hcl ophthalmic solution 1 or 1b* QL BETOPTIC-S OPHTHALMIC SUSPENSION 2 QL carteolol hcl ophthalmic solution 1 or 1a* levobunolol hcl ophthalmic solution 0.5 % 1 or 1b* timolol hemihydrate ophthalmic solution 2 QL timolol maleate (once-daily) ophthalmic solution 1 or 1b* QL timolol maleate ocudose ophthalmic solution 1 or 1b* QL timolol maleate ophthalmic gel forming solution 1 or 1b* QL timolol maleate ophthalmic solution 1 or 1b* QL Drug Name Tier Notes timolol maleate pf ophthalmic solution 1 or 1b* QL *CYCLOPLEGIC MYDRIATICS*** cyclopentolate hcl ophthalmic solution 1 % 1 or 1b* QL phenylephrine hcl ophthalmic solution 10 % 1 or 1b* tropicamide ophthalmic solution 1 or 1b* *LYMPHOCYTE FUNCTION- ASSOCIATED ANTIGEN- 1 (LFA-1) ANTAG*** XIIDRA OPHTHALMIC SOLUTION 2 PA; QL *MIOTICS - DIRECT ACTING*** pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % 1 or 1b* *OPHTHALMIC - MULTIPLE RECEPTOR ANGIOGENESIS INHIBITORS*** VABYSMO INTRAVITREAL SOLUTION 4 PA; LD; SP VABYSMO INTRAVITREAL SOLUTION PREFILLED SYRINGE 4 PA; LD; SP *OPHTHALMIC ANTIALLERGIC*** azelastine hcl ophthalmic solution 1 or 1b* QL cromolyn sodium ophthalmic solution 1 or 1a* QL epinastine hcl ophthalmic solution 1 or 1b* QL *OPHTHALMIC ANTIBIOTICS*** bacitracin ophthalmic ointment 1 or 1b* QL ciprofloxacin hcl ophthalmic solution 1 or 1a* QL gatifloxacin ophthalmic solution 1 or 1b* QL gentamicin sulfate ophthalmic solution 1 or 1a* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 77

Drug Name Tier Notes levofloxacin ophthalmic solution 1 or 1b* QL moxifloxacin hcl (2x day) ophthalmic solution 1 or 1b* QL moxifloxacin hcl ophthalmic solution 2 QL ofloxacin ophthalmic solution 1 or 1a* QL tobramycin ophthalmic solution 1 or 1a* QL *OPHTHALMIC ANTI- INFECTIVE COMBINATIONS*** bacitracin-polymyxin b ophthalmic ointment 500- 10000 unit/gm 1 or 1a* QL neomycin-bacitracin zn- polymyx ophthalmic ointment 1 or 1b* QL neomycin-polymyxin- gramicidin ophthalmic solution 1.75-10000-.025 1 or 1b* QL neo-polycin ophthalmic ointment 1 or 1b* QL polycin ophthalmic ointment 1 or 1a* QL polymyxin b-trimethoprim ophthalmic solution 1 or 1a* QL *OPHTHALMIC ANTIVIRALS*** trifluridine ophthalmic solution 1 or 1b* QL *OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS*** brinzolamide ophthalmic suspension 1 or 1b* QL dorzolamide hcl ophthalmic solution 1 or 1b* QL *OPHTHALMIC DIAGNOSTIC PRODUCTS*** ak-fluor intravenous solution 10 % 1 or 1b* altafluor benox ophthalmic solution 1 or 1b* fluorescein intravenous solution 1 or 1b* fluorescein sodium intravenous solution 1 or 1b* Drug Name Tier Notes fluorescein-benoxinate ophthalmic solution 1 or 1b* *OPHTHALMIC IMMUNOMODULATORS *** cyclosporine ophthalmic emulsion 1 or 1b* PA; QL RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 % 2 PA; QL RESTASIS OPHTHALMIC EMULSION 2 PA; QL *OPHTHALMIC LOCAL ANESTHETICS*** proparacaine hcl ophthalmic solution 1 or 1b* tetracaine hcl ophthalmic solution 1 or 1b* *OPHTHALMIC NONSTEROIDAL ANTI- INFLAMMATORY AGENTS*** bromfenac sodium (once- daily) ophthalmic solution 2 QL bromfenac sodium ophthalmic solution 0.07 %, 0.075 % 2 QL diclofenac sodium ophthalmic solution 1 or 1b* QL flurbiprofen sodium ophthalmic solution 1 or 1b* QL ILEVRO OPHTHALMIC SUSPENSION 2 QL ketorolac tromethamine ophthalmic solution 1 or 1b* QL *OPHTHALMIC SELECTIVE ALPHA ADRENERGIC AGONISTS*** apraclonidine hcl ophthalmic solution 1 or 1b* brimonidine tartrate ophthalmic solution 0.1 % 2 QL brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 78

Drug Name Tier Notes *OPHTHALMIC STEROID COMBINATIONS*** bacitra-neomycin- polymyxin-hc ophthalmic ointment 1 or 1b* QL neomycin-polymyxin- dexameth ophthalmic ointment 1 or 1a* QL neomycin-polymyxin- dexameth ophthalmic suspension 1 or 1a* QL neomycin-polymyxin-hc ophthalmic suspension 3.5- 10000-1 1 or 1b* neo-polycin hc ophthalmic ointment 1 or 1b* QL sulfacetamide-prednisolone ophthalmic solution 1 or 1a* QL TOBRADEX OPHTHALMIC OINTMENT 2 tobramycin-dexamethasone ophthalmic suspension 1 or 1b* QL ZYLET OPHTHALMIC SUSPENSION 2 QL *OPHTHALMIC STEROIDS*** dexamethasone sodium phosphate ophthalmic solution 1 or 1b* difluprednate ophthalmic emulsion 1 or 1b* QL fluorometholone ophthalmic suspension 1 or 1b* LOTEMAX OPHTHALMIC OINTMENT 3 QL loteprednol etabonate ophthalmic gel 1 or 1b* QL loteprednol etabonate ophthalmic suspension 0.5 % 1 or 1b* QL prednisolone acetate ophthalmic suspension 1 or 1b* QL *OPHTHALMIC SULFONAMIDES*** sulfacetamide sodium ophthalmic ointment 1 or 1b* QL sulfacetamide sodium ophthalmic solution 1 or 1b* QL Drug Name Tier Notes *OPHTHALMICS - CYSTINOSIS AGENTS** CYSTARAN OPHTHALMIC SOLUTION 4 PA; LD; QL *PROSTAGLANDINS - OPHTHALMIC*** bimatoprost ophthalmic solution 2 latanoprost ophthalmic solution 1 or 1b* QL LUMIGAN OPHTHALMIC SOLUTION 0.01 % 2 QL tafluprost (pf) ophthalmic solution 2 QL travoprost (bak free) ophthalmic solution 1 or 1b* QL *VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) ANTAGONISTS*** BYOOVIZ INTRAVITREAL SOLUTION 4 PA; LD; SP CIMERLI INTRAVITREAL SOLUTION 4 PA; LD; SP EYLEA HD INTRAVITREAL SOLUTION 4 PA; LD; SP EYLEA INTRAVITREAL SOLUTION 4 PA; LD; SP EYLEA INTRAVITREAL SOLUTION PREFILLED SYRINGE 4 PA; LD; SP LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 4 PA; LD; SP *OTIC AGENTS* *OTIC AGENTS - MISCELLANEOUS*** acetic acid otic solution 1 or 1b* *OTIC ANTI- INFECTIVES*** ciprofloxacin hcl otic solution 1 or 1b* QL ofloxacin otic solution 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 79

Drug Name Tier Notes *OTIC STEROID-ANTI- INFECTIVE COMBINATIONS*** ciprofloxacin-dexamethasone otic suspension 1 or 1b* QL ciprofloxacin-fluocinolone pf otic solution 1 or 1b* QL neomycin-polymyxin-hc otic solution 1 or 1b* neomycin-polymyxin-hc otic suspension 1 or 1b* QL *OTIC STEROIDS*** fluocinolone acetonide otic oil 1 or 1b* hydrocortisone-acetic acid otic solution 1 or 1b* QL *OXYTOCICS* *ABORTIFACIENTS/CER VICAL RIPENING - PROSTAGLANDINS*** carboprost tromethamine intramuscular solution 1 or 1b* *OXYTOCICS*** methergine oral tablet 1 or 1b* methylergonovine maleate injection solution 1 or 1b* methylergonovine maleate oral tablet 1 or 1b* oxytocin injection solution 1 or 1b* *PASSIVE IMMUNIZING AND TREATMENT AGENTS* *ANTITOXINS- ANTIVENINS*** ANASCORP INTRAVENOUS SOLUTION RECONSTITUTED 2 ANTIVENIN LATRODECTUS MACTANS INJECTION KIT 2 ANTIVENIN MICRURUS FULVIUS INTRAVENOUS SOLUTION RECONSTITUTED 2 CROFAB INTRAVENOUS SOLUTION RECONSTITUTED 2 Drug Name Tier Notes *IMMUNE SERUMS*** CUTAQUIG SUBCUTANEOUS SOLUTION 4 PA; LD; SP GAMUNEX-C INJECTION SOLUTION 4 PA; LD; SP HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML 4 PA; LD; SP HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; SP OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 GM/200ML, 30 GM/300ML, 5 GM/100ML, 5 GM/50ML 4 PA; LD; SP XEMBIFY SUBCUTANEOUS SOLUTION 4 PA; LD; SP *PENICILLINS* *AMINOPENICILLINS** * amoxicillin oral capsule 1 or 1a* amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml 1 or 1a* amoxicillin oral tablet 1 or 1a* amoxicillin oral tablet chewable 125 mg, 250 mg 1 or 1a* ampicillin oral capsule 500 mg 1 or 1a* ampicillin sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg 2 ampicillin sodium intravenous solution reconstituted 2 *NATURAL PENICILLINS*** penicillin g potassium injection solution reconstituted 2 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 80

Drug Name Tier Notes penicillin g sodium injection solution reconstituted 2 penicillin v potassium oral solution reconstituted 1 or 1b* penicillin v potassium oral tablet 1 or 1b* pfizerpen injection solution reconstituted 2 *PENICILLIN COMBINATIONS*** amoxicillin-pot clavulanate er oral tablet extended release 12 hour 1 or 1b* amoxicillin-pot clavulanate oral suspension reconstituted 1 or 1b* amoxicillin-pot clavulanate oral tablet 1 or 1b* ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 3 (2-1) gm 2 ampicillin-sulbactam sodium intravenous solution reconstituted 2 AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125- 31.25 MG/5ML 2 piperacillin sod-tazobactam so intravenous solution reconstituted 13.5 (12-1.5) gm, 2.25 (2-0.25) gm, 3- 0.375 gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36- 4.5) gm 2 *PENICILLINASE- RESISTANT PENICILLINS*** dicloxacillin sodium oral capsule 1 or 1b* nafcillin sodium injection solution reconstituted 1 gm, 2 gm 2 nafcillin sodium intravenous solution reconstituted 10 gm 2 oxacillin sodium injection solution reconstituted 1 gm, 2 gm 2 oxacillin sodium intravenous solution reconstituted 2 Drug Name Tier Notes *PROGESTINS* *PROGESTINS*** GALLIFREY ORAL TABLET 1 or 1b* medroxyprogesterone acetate oral tablet 1 or 1a* QL megestrol acetate oral suspension 625 mg/5ml 1 or 1b* norethindrone acetate oral tablet 1 or 1b* progesterone intramuscular oil 1 or 1b* progesterone oral capsule 1 or 1b* QL *PSYCHOTHERAPEUTI C AND NEUROLOGICAL AGENTS - MISC.* *AGENTS FOR OPIOID WITHDRAWAL*** lofexidine hcl oral tablet 2 QL *ALCOHOL DETERRENTS*** acamprosate calcium oral tablet delayed release 2 QL disulfiram oral tablet 1 or 1b* *ANTI-CATAPLECTIC AGENTS*** sodium oxybate oral solution 4 PA; LD; QL *ANTIDEMENTIA AGENT COMBINATIONS*** memantine hcl-donepezil hcl oral capsule extended release 24 hour 2 QL *BENZODIAZEPINES & TRICYCLIC AGENTS*** chlordiazepoxide- amitriptyline oral tablet 1 or 1b* *CHOLINOMIMETICS - ACHE INHIBITORS*** donepezil hcl oral tablet 10 mg, 23 mg 1 or 1b* QL donepezil hcl oral tablet 5 mg 1 or 1b* DO donepezil hcl oral tablet dispersible 1 or 1b* QL galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg 2 QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 81

Drug Name Tier Notes galantamine hydrobromide er oral capsule extended release 24 hour 8 mg 2 DO galantamine hydrobromide oral solution 2 QL galantamine hydrobromide oral tablet 12 mg, 8 mg 2 QL galantamine hydrobromide oral tablet 4 mg 2 DO rivastigmine tartrate oral capsule 1.5 mg, 3 mg 2 DO rivastigmine tartrate oral capsule 4.5 mg, 6 mg 2 QL rivastigmine transdermal patch 24 hour 2 QL *MOVEMENT DISORDER DRUG THERAPY*** AUSTEDO ORAL TABLET 4 PA; LD; QL; SP AUSTEDO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 4 PA; LD; QL; SP AUSTEDO XR PATIENT TITRATION ORAL TABLET EXTENDED RELEASE THERAPY PACK 12 & 18 & 24 & 30 MG 4 PA; LD; QL; SP INGREZZA ORAL CAPSULE 40 MG 4 PA; LD; DO; SP INGREZZA ORAL CAPSULE 60 MG, 80 MG 4 PA; LD; QL; SP INGREZZA ORAL CAPSULE SPRINKLE 40 MG 4 PA; LD; DO; SP INGREZZA ORAL CAPSULE SPRINKLE 60 MG, 80 MG 4 PA; LD; QL; SP INGREZZA ORAL CAPSULE THERAPY PACK 4 PA; LD; QL; SP tetrabenazine oral tablet 4 PA; LD; QL; SP *MS AGENTS - PYRIMIDINE SYNTHESIS INHIBITORS*** teriflunomide oral tablet 4 PA; LD; QL; SP Drug Name Tier Notes *MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES*** MAVENCLAD (10 TABS) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP MAVENCLAD (4 TABS) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP MAVENCLAD (5 TABS) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP MAVENCLAD (6 TABS) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP MAVENCLAD (7 TABS) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP MAVENCLAD (8 TABS) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP MAVENCLAD (9 TABS) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP *MULTIPLE SCLEROSIS AGENTS - INTERFERONS*** AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 4 PA; LD; QL; SP AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 4 PA; LD; QL; SP BETASERON SUBCUTANEOUS KIT 4 PA; LD; QL; SP PLEGRIDY INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP PLEGRIDY SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 82

Drug Name Tier Notes PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP *MULTIPLE SCLEROSIS AGENTS - NRF2 PATHWAY ACTIVATORS*** dimethyl fumarate oral capsule delayed release 1 or 1b* PA; LD; QL; SP dimethyl fumarate starter pack oral capsule delayed release therapy pack 1 or 1b* PA; LD; QL; SP VUMERITY ORAL CAPSULE DELAYED RELEASE 4 PA; LD; QL; SP *MULTIPLE SCLEROSIS AGENTS - POTASSIUM CHANNEL BLOCKERS*** dalfampridine er oral tablet extended release 12 hour 1 or 1b* PA; LD; QL; SP *MULTIPLE SCLEROSIS AGENTS*** COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML 4 PA; LD; QL; SP glatiramer acetate subcutaneous solution prefilled syringe 4 PA; LD; QL; SP glatopa subcutaneous solution prefilled syringe 4 PA; LD; QL; SP Drug Name Tier Notes *N-METHYL-D- ASPARTATE (NMDA) RECEPTOR ANTAGONISTS*** memantine hcl er oral capsule extended release 24 hour 14 mg, 7 mg 2 DO memantine hcl er oral capsule extended release 24 hour 21 mg, 28 mg 2 QL memantine hcl oral solution 2 QL memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg 2 QL memantine hcl oral tablet 5 mg 2 DO *PHENOTHIAZINES & TRICYCLIC AGENTS*** perphenazine-amitriptyline oral tablet 1 or 1b* AL *POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS*** gabapentin (once-daily) oral tablet 2 PA; DO pregabalin er oral tablet extended release 24 hour 165 mg, 82.5 mg 2 PA; DO pregabalin er oral tablet extended release 24 hour 330 mg 2 PA; QL *PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS - SSRIS*** fluoxetine hcl (pmdd) oral tablet 10 mg 1 or 1b* DO fluoxetine hcl (pmdd) oral tablet 20 mg 1 or 1b* QL *PSYCHOTHERAPEUTI C AND NEUROLOGICAL AGENTS - MISC.*** pimozide oral tablet 1 or 1b* AL; QL *SMOKING DETERRENTS*** bupropion hcl er (smoking det) oral tablet extended release 12 hour 1 or 1b* $0; QL cvs nicotine mouth/throat gum 1 or 1b* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 83

Drug Name Tier Notes cvs nicotine mouth/throat lozenge 1 or 1b* $0 cvs nicotine polacrilex mouth/throat gum 1 or 1b* $0 cvs nicotine polacrilex mouth/throat lozenge 1 or 1b* $0 cvs nicotine transdermal patch 24 hour 1 or 1b* $0 eq nicotine mouth/throat lozenge 1 or 1b* $0 eq nicotine polacrilex mouth/throat gum 1 or 1b* $0 eq nicotine polacrilex mouth/throat lozenge 1 or 1b* $0 eq nicotine step 3 transdermal patch 24 hour 1 or 1b* $0 eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr 1 or 1b* $0 ft nicotine mini mouth/throat lozenge 1 or 1b* $0 ft nicotine mouth/throat gum 1 or 1b* $0 ft nicotine mouth/throat lozenge 1 or 1b* $0 ft nicotine transdermal patch 24 hour 1 or 1b* $0 gnp nicotine mini mouth/throat lozenge 1 or 1b* $0 gnp nicotine mouth/throat gum 1 or 1b* $0 gnp nicotine polacrilex mouth/throat gum 1 or 1b* $0 gnp nicotine polacrilex mouth/throat lozenge 1 or 1b* $0 gnp nicotine transdermal patch 24 hour 1 or 1b* $0 goodsense nicotine mouth/throat gum 1 or 1b* $0 goodsense nicotine mouth/throat lozenge 1 or 1b* $0 habitrol transdermal patch 24 hour 1 or 1b* $0 kls quit2 mouth/throat gum 1 or 1b* $0 kls quit2 mouth/throat lozenge 1 or 1b* $0 kls quit4 mouth/throat gum 1 or 1b* $0 kls quit4 mouth/throat lozenge 1 or 1b* $0 Drug Name Tier Notes NICODERM CQ TRANSDERMAL PATCH 24 HOUR 2 $0 NICORETTE MINI MOUTH/THROAT LOZENGE 2 $0 NICORETTE MOUTH/THROAT GUM 2 $0 NICORETTE MOUTH/THROAT LOZENGE 2 $0 NICORETTE STARTER KIT MOUTH/THROAT GUM 2 $0 nicotine mini mouth/throat lozenge 1 or 1b* $0 nicotine polacrilex mini mouth/throat lozenge 1 or 1b* $0 nicotine polacrilex mouth/throat gum 1 or 1b* $0 nicotine polacrilex mouth/throat lozenge 1 or 1b* $0 nicotine step 1 transdermal patch 24 hour 1 or 1b* $0 nicotine step 2 transdermal patch 24 hour 1 or 1b* $0 nicotine step 3 transdermal patch 24 hour 1 or 1b* $0 NICOTINE TRANSDERMAL KIT 2 $0 nicotine transdermal patch 24 hour 1 or 1b* $0 NICOTROL INHALATION INHALER 2 $0; QL NICOTROL NS NASAL SOLUTION 2 $0; QL qc nicotine transdermal system transdermal patch 24 hour 1 or 1b* $0 ra mini nicotine mouth/throat lozenge 1 or 1b* $0 ra nicotine gum mouth/throat gum 2 mg, 4 mg 1 or 1b* $0 ra nicotine mouth/throat gum 1 or 1b* $0 ra nicotine polacrilex mouth/throat lozenge 1 or 1b* $0 ra nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr 1 or 1b* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 84

Drug Name Tier Notes sm nicotine polacrilex mouth/throat gum 4 mg 1 or 1b* $0 thrive mouth/throat gum 2 mg 1 or 1b* $0 varenicline tartrate (starter) oral tablet therapy pack 2 $0; QL varenicline tartrate oral tablet 0.5 mg, 1 mg 2 $0; QL varenicline tartrate(continue) oral tablet 2 $0; QL *SPHINGOSINE 1- PHOSPHATE (S1P) RECEPTOR MODULATORS*** fingolimod hcl oral capsule 4 PA; LD; QL; SP MAYZENT ORAL TABLET 4 PA; LD; QL; SP MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK 4 PA; LD; QL; SP ZEPOSIA ORAL CAPSULE 4 PA; LD; QL; SP ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK 0.23MG &0.46MG 0.92MG(21) 4 PA; LD; QL; SP *THIENBENZODIAZEPI NES & SSRIS*** olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-50 mg 1 or 1b* AL; QL olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6-25 mg 1 or 1b* DO; AL *VASOMOTOR SYMPTOM AGENTS - SSRIS*** paroxetine mesylate oral capsule 1 or 1b* *RESPIRATORY AGENTS - MISC.* *CYSTIC FIBROSIS AGENT - COMBINATIONS*** TRIKAFTA ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP Drug Name Tier Notes TRIKAFTA ORAL THERAPY PACK 4 PA; LD; QL; SP *HYDROLYTIC ENZYMES*** PULMOZYME INHALATION SOLUTION 2.5 MG/2.5ML 4 PA; LD; QL; SP *PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS*** OFEV ORAL CAPSULE 4 PA; LD; QL; SP *PULMONARY FIBROSIS AGENTS*** pirfenidone oral capsule 4 PA; LD; QL; SP pirfenidone oral tablet 267 mg, 801 mg 4 PA; LD; QL; SP pirfenidone oral tablet 534 mg 4 PA; LD; QL *SULFONAMIDES* *SULFONAMIDES*** sulfadiazine oral tablet 2 *TETRACYCLINES* *TETRACYCLINES*** demeclocycline hcl oral tablet 2 doxy 100 intravenous solution reconstituted 2 QL doxycycline hyclate intravenous solution reconstituted 2 QL doxycycline hyclate oral capsule 1 or 1b* QL doxycycline hyclate oral tablet 100 mg, 20 mg 1 or 1b* QL doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg 1 or 1b* QL doxycycline monohydrate oral capsule 150 mg 3 ST; QL doxycycline monohydrate oral suspension reconstituted 1 or 1b* QL doxycycline monohydrate oral tablet 1 or 1b* QL minocycline hcl oral capsule 1 or 1b* QL minocycline hcl oral tablet 1 or 1b* QL mondoxyne nl oral capsule 100 mg 1 or 1b* QL tetracycline hcl oral capsule 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 85

Drug Name Tier Notes *THYROID AGENTS* *ANTITHYROID AGENTS*** methimazole oral tablet 1 or 1a* propylthiouracil oral tablet 1 or 1b* *THYROID HORMONES*** euthyrox oral tablet 1 or 1b* levo-t oral tablet 1 or 1b* levothyroxine sodium oral capsule 2 levothyroxine sodium oral tablet 1 or 1a* levoxyl oral tablet 1 or 1a* liothyronine sodium intravenous solution 1 or 1b* liothyronine sodium oral tablet 1 or 1b* unithroid oral tablet 1 or 1a* *TOXOIDS* *TOXOID COMBINATIONS*** ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF- MCG/0.5 2 $0 BOOSTRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5 2 $0 INFANRIX INTRAMUSCULAR SUSPENSION 2 $0 KINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 PEDIARIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 PENTACEL INTRAMUSCULAR SUSPENSION RECONSTITUTED 2 $0 Drug Name Tier Notes QUADRACEL INTRAMUSCULAR SUSPENSION 2 $0 QUADRACEL INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU 2 $0 VAXELIS INTRAMUSCULAR SUSPENSION 2 VAXELIS INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 *ULCER DRUGS/ANTISPASMODI CS/ANTICHOLINERGIC S* *ANTICHOLINERGIC COMBINATIONS*** chlordiazepoxide-clidinium oral capsule 1 or 1b* *ANTISPASMODICS*** dicyclomine hcl intramuscular solution 2 dicyclomine hcl oral capsule 1 or 1a* dicyclomine hcl oral solution 10 mg/5ml 1 or 1a* dicyclomine hcl oral tablet 1 or 1a* *H-2 ANTAGONISTS*** cimetidine hcl oral solution 300 mg/5ml 1 or 1b* cimetidine oral tablet 300 mg, 400 mg, 800 mg 1 or 1b* famotidine (pf) intravenous solution 1 or 1b* famotidine intravenous solution 200 mg/20ml, 40 mg/4ml 1 or 1b* famotidine oral suspension reconstituted 1 or 1b* famotidine oral tablet 40 mg 1 or 1b* famotidine premixed intravenous solution 1 or 1b* nizatidine oral capsule 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 86

Drug Name Tier Notes *MISC. ANTI-ULCER*** sucralfate oral suspension 2 sucralfate oral tablet 1 or 1b* *PROTON PUMP INHIBITORS*** esomeprazole magnesium oral capsule delayed release 40 mg 1 or 1b* esomeprazole magnesium oral packet 1 or 1b* lansoprazole oral capsule delayed release 15 mg 1 or 1b* BE lansoprazole oral capsule delayed release 30 mg 1 or 1b* omeprazole oral capsule delayed release 1 or 1b* pantoprazole sodium oral tablet delayed release 1 or 1b* *QUATERNARY ANTICHOLINERGICS*** glycopyrrolate injection solution 1 or 1b* glycopyrrolate oral solution 2 glycopyrrolate oral tablet 1 mg, 2 mg 1 or 1b* glycopyrrolate pf +rfid injection solution prefilled syringe 1 or 1b* GLYCOPYRROLATE PF INJECTION SOLUTION PREFILLED SYRINGE 0.2 MG/ML, 0.4 MG/2ML 1 or 1b* methscopolamine bromide oral tablet 1 or 1b* *ULCER ANTI- INFECTIVE W/ BISMUTH COMBINATIONS*** bis subcit-metronid-tetracyc oral capsule 2 ST; QL bismuth/metronidaz/tetracycl in oral capsule 2 ST; QL *ULCER DRUGS - PROSTAGLANDINS*** misoprostol oral tablet 1 or 1a* Drug Name Tier Notes *URINARY ANTISPASMODICS* *URINARY ANTISPASMODIC - ANTIMUSCARINIC (ANTICHOLINERGIC)** * darifenacin hydrobromide er oral tablet extended release 24 hour 2 QL fesoterodine fumarate er oral tablet extended release 24 hour 2 QL oxybutynin chloride er oral tablet extended release 24 hour 1 or 1b* QL oxybutynin chloride oral solution 1 or 1b* QL oxybutynin chloride oral tablet 1 or 1b* QL solifenacin succinate oral tablet 2 QL tolterodine tartrate er oral capsule extended release 24 hour 1 or 1b* QL tolterodine tartrate oral tablet 1 or 1b* QL trospium chloride er oral capsule extended release 24 hour 2 QL trospium chloride oral tablet 2 QL *URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS*** mirabegron er oral tablet extended release 24 hour 2 QL MYRBETRIQ ORAL SUSPENSION RECONSTITUTED ER 3 PA; QL *URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS*** bethanechol chloride oral tablet 2 *URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS*** flavoxate hcl oral tablet 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 87

Drug Name Tier Notes *VACCINES* *BACTERIAL VACCINES*** ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED 2 $0 BCG VACCINE INJECTION SOLUTION RECONSTITUTED 2 $0 BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 BIOTHRAX INTRAMUSCULAR SUSPENSION 2 CAPVAXIVE INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 2 $0 HIBERIX INJECTION SOLUTION RECONSTITUTED 2 $0 MENQUADFI INTRAMUSCULAR SOLUTION 2 $0 MENVEO INTRAMUSCULAR SOLUTION 2 $0 MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED 2 $0 PEDVAX HIB INTRAMUSCULAR SUSPENSION 2 $0 PENBRAYA INTRAMUSCULAR SUSPENSION RECONSTITUTED 2 $0 PNEUMOVAX 23 INJECTION SOLUTION PREFILLED SYRINGE 2 $0 PREVNAR 20 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 Drug Name Tier Notes TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML 2 TYPHIM VI INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 2 VAXCHORA ORAL SUSPENSION RECONSTITUTED 2 VAXNEUVANCE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 VIVOTIF ORAL CAPSULE DELAYED RELEASE 2 *VIRAL VACCINE COMBINATIONS*** M-M-R II INJECTION SOLUTION RECONSTITUTED 2 $0 PRIORIX SUBCUTANEOUS SUSPENSION RECONSTITUTED 2 $0 PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED 2 $0 TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 *VIRAL VACCINES*** ABRYSVO INTRAMUSCULAR SOLUTION RECONSTITUTED 2 $0; QL ACAM2000 INJECTION SOLUTION RECONSTITUTED 2 $0 AFLURIA INTRAMUSCULAR SUSPENSION 2 $0; QL AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 88

Drug Name Tier Notes AREXVY INTRAMUSCULAR SUSPENSION RECONSTITUTED 2 PA; AL; $0; QL AUDENZ INTRAMUSCULAR EMULSION 2 $0 AUDENZ INTRAMUSCULAR PREFILLED SYRINGE 2 $0 COMIRNATY INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 DENGVAXIA SUBCUTANEOUS SUSPENSION RECONSTITUTED 2 ENGERIX-B INJECTION SUSPENSION 20 MCG/ML 2 $0 ENGERIX-B INJECTION SUSPENSION PREFILLED SYRINGE 2 $0 ERVEBO INTRAMUSCULAR SUSPENSION 2 FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0; QL FLUARIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0; QL FLUBLOK INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 2 $0; QL FLUCELVAX INTRAMUSCULAR SUSPENSION 2 $0; QL FLUCELVAX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0; QL FLULAVAL INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0; QL FLUMIST NASAL LIQUID 2 $0; QL Drug Name Tier Notes FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0; QL FLUZONE INTRAMUSCULAR SUSPENSION 2 $0; QL FLUZONE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0; QL GARDASIL 9 INTRAMUSCULAR SUSPENSION 2 $0 GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML 2 $0 HAVRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 2 $0 IMOVAX RABIES INTRAMUSCULAR SUSPENSION RECONSTITUTED 2 IPOL INJECTION INJECTABLE 2 $0 IXCHIQ INTRAMUSCULAR SOLUTION RECONSTITUTED 2 IXIARO INTRAMUSCULAR SUSPENSION 2 JYNNEOS SUBCUTANEOUS SUSPENSION 2 $0 MODERNA COVID-19 VAC 6M-11Y INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 89

Drug Name Tier Notes MRESVIA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 AL; $0; QL novavax covid-19 vaccine intramuscular suspension prefilled syringe 2 $0 PFIZER COVID-19 VAC- TRIS 5-11Y INTRAMUSCULAR SUSPENSION 10 MCG/0.3ML 2 $0 pfizer covid-19 vac-tris 6m- 4y intramuscular suspension 3 mcg/0.3ml 2 $0 RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED 2 RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML 2 $0 RECOMBIVAX HB INJECTION SUSPENSION PREFILLED SYRINGE 2 $0 ROTARIX ORAL SUSPENSION 2 $0 ROTATEQ ORAL SOLUTION 2 $0 SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML 2 $0 SPIKEVAX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 STAMARIL INJECTION SUSPENSION RECONSTITUTED 2 TICOVAC INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML 2 $0 Drug Name Tier Notes VARIVAX INJECTION SUSPENSION RECONSTITUTED 2 $0 VIMKUNYA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 YF-VAX SUBCUTANEOUS INJECTABLE 2 *VAGINAL AND RELATED PRODUCTS* *IMIDAZOLE-RELATED ANTIFUNGALS*** miconazole 3 vaginal suppository 1 or 1b* terconazole vaginal cream 1 or 1b* QL terconazole vaginal suppository 1 or 1b* QL *SPERMICIDES*** ENCARE VAGINAL SUPPOSITORY 2 $0 OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL 2 $0 TODAY SPONGE VAGINAL 2 $0 VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 2 $0 *VAGINAL ANTI- INFECTIVES*** CLEOCIN VAGINAL SUPPOSITORY 2 clindamycin phosphate vaginal cream 1 or 1b* metronidazole vaginal gel 1 or 1b* VANDAZOLE VAGINAL GEL 1 or 1b* *VAGINAL ESTROGENS*** estradiol vaginal cream 1 or 1b* QL estradiol vaginal tablet 1 or 1b* QL PREMARIN VAGINAL CREAM 2 QL yuvafem vaginal tablet 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 90

Drug Name Tier Notes *VAGINAL PROGESTINS*** ENDOMETRIN VAGINAL INSERT 2 PA *VASOPRESSORS* *ANAPHYLAXIS THERAPY AGENTS*** epinephrine (anaphylaxis) injection solution 1 or 1b* epinephrine injection solution auto-injector 1 or 1b* QL *NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS*** droxidopa oral capsule 4 PA; LD; QL; SP *VASOPRESSORS*** midodrine hcl oral tablet 2 *VITAMINS* *VITAMIN B-1*** thiamine hcl injection solution 1 or 1b* *VITAMIN D*** ergocalciferol oral capsule 1 or 1a* vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut), 50000 unit 1 or 1a* *VITAMIN K*** phytonadione injection solution 1 mg/0.5ml, 10 mg/ml 1 or 1b* phytonadione oral tablet 2 vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 91

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 92

Most plans include our convenient home delivery program at no extra cost to you. Find out more at anthem.com or call 833-236-6196. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Rev. 8/19 For information about your pharmacy benefit, log in at anthem.com. You’ll find the most up-to-date drug list and details about your benefits. If you still have questions, we’re here. Just call the Pharmacy Member Services number on your ID card.