UPHP Advantage (HMO) (H ) and UPHP Choice (HMO) (H ) Updates

March, 2018 03/01/2018 clindacin p clindamycin phosphate 03/01/2018 glatiramer acetate 03/01/2018 glatiramer acetate 03/01/2018 oseltamivir phosphate 03/01/2018 oseltamivir phosphate 03/01/2018 ADACEL TDAP diphtheria,pertussis(acellular ),tetanus vaccine/pf 03/01/2018 levonorg-eth estrad eth estrad 03/01/2018 levonorg-eth estrad eth estrad glatiramer acetate ADD UM: QUANTITY 30 / 30 DAYS glatiramer acetate Specialty oseltamivir phosphate oseltamivir phosphate ADD UM: QUANTITY 720 / 365 OVER levonorgestrel/ethinyl and ethinyl levonorgestrel/ethinyl and ethinyl ADD UM: QUANTITY Preferred 91 / 91 DAYS 03/01/2018 PROLENSA bromfenac sodium Non-Preferred 03/01/2018 PROLENSA bromfenac sodium ADD UM: QUANTITY 12 / 365 OVER 03/01/2018 NYMALIZE nimodipine Specialty 03/01/2018 paroxetine mesylate 03/01/2018 paroxetine mesylate paroxetine mesylate ADD UM: QUANTITY 30 / 30 DAYS paroxetine mesylate Non-Preferred 03/01/2018 morphine sulfate morphine sulfate PAGE 1 UPDATED 09/2018

03/01/2018 glatiramer acetate 03/01/2018 glatiramer acetate glatiramer acetate ADD UM: QUANTITY 12 / 28 DAYS glatiramer acetate Specialty 03/01/2018 ZENPEP lipase/protease/amylase Preferred 03/01/2018 testosterone testosterone Non-Preferred 03/01/2018 GLYXAMBI empagliflozin/linagliptin Preferred 03/01/2018 GLYXAMBI empagliflozin/linagliptin ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 GLYXAMBI empagliflozin/linagliptin Preferred 03/01/2018 GLYXAMBI empagliflozin/linagliptin ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 doxycycline hyclate 03/01/2018 doxycycline hyclate doxycycline hyclate doxycycline hyclate 03/01/2018 methotrexate methotrexate sodium 03/01/2018 OPDIVO nivolumab Specialty 03/01/2018 HAVRIX hepatitis a virus vaccine/pf Preferred 03/01/2018 KADCYLA ado-trastuzumab emtansine Specialty 03/01/2018 VAQTA hepatitis a virus vaccine/pf Preferred 03/01/2018 VAQTA hepatitis a virus vaccine/pf Preferred 03/01/2018 piperacillintazobactam piperacillin sodium/tazobactam sodium 03/01/2018 XURIDEN uridine triacetate ADD UM: QUANTITY 120 / 30 DAYS 03/01/2018 XURIDEN uridine triacetate Specialty 03/01/2018 haloperidol decanoate haloperidol decanoate PAGE 2 UPDATED 09/2018

03/01/2018 meropenem meropenem 03/01/2018 oxaliplatin oxaliplatin 03/01/2018 XIIDRA lifitegrast ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 XIIDRA lifitegrast Non-Preferred 03/01/2018 TREANDA bendamustine hcl Specialty 03/01/2018 methylphenidate la 03/01/2018 methylphenidate la 03/01/2018 methylphenidate er methylphenidate hcl Non-Preferred methylphenidate hcl ADD UM: QUANTITY 30 / 30 DAYS methylphenidate hcl CHANGE UM: QUANTITY 30 / 30 days 30 / 30 DAYS 03/01/2018 RAYALDEE calcifediol Specialty 03/01/2018 NOVAREL chorionic gonadotropin, human Non-Preferred 03/01/2018 isibloom desogestrel-ethinyl 03/01/2018 klor-con potassium chloride 03/01/2018 XATMEP methotrexate Non-Preferred 03/01/2018 RADICAVA edaravone Specialty 03/01/2018 HUMALOG JUNIOR KWIKPEN insulin lispro Preferred 03/01/2018 RENFLEXIS infliximab-abda Specialty 03/01/2018 BAXDELA delafloxacin meglumine Specialty 03/01/2018 BAXDELA delafloxacin meglumine Specialty 03/01/2018 TREMFYA guselkumab Specialty 03/01/2018 SYNDROS dronabinol ADD UM: QUANTITY 120 / 30 DAYS PAGE 3 UPDATED 09/2018

03/01/2018 SYNDROS dronabinol Specialty 03/01/2018 BENLYSTA belimumab Specialty 03/01/2018 VOSEVI sofosbuvir/velpatasvir/voxila previr 03/01/2018 VOSEVI sofosbuvir/velpatasvir/voxila previr ADD UM: QUANTITY 84 / 365 OVER Specialty 03/01/2018 BENLYSTA belimumab Specialty 03/01/2018 IDHIFA enasidenib mesylate Specialty 03/01/2018 IDHIFA enasidenib mesylate ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 IDHIFA enasidenib mesylate ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 IDHIFA enasidenib mesylate Specialty 03/01/2018 NERLYNX neratinib maleate ADD UM: QUANTITY 180 / 30 DAYS 03/01/2018 NERLYNX neratinib maleate Specialty 03/01/2018 MAVYRET glecaprevir/pibrentasvir ADD UM: QUANTITY 336 / 365 OVER 03/01/2018 MAVYRET glecaprevir/pibrentasvir Specialty 03/01/2018 LYNPARZA olaparib Specialty 03/01/2018 LYNPARZA olaparib Specialty 03/01/2018 VYXEOS daunorubicin/cytarabine liposomal Specialty 03/01/2018 GOCOVRI amantadine hcl Specialty 03/01/2018 GOCOVRI amantadine hcl Specialty 03/01/2018 MYLOTARG gemtuzumab ozogamicin Specialty 03/01/2018 ALIQOPA copanlisib di-hcl Specialty 03/01/2018 profeno fenoprofen calcium Non-Preferred PAGE 4 UPDATED 09/2018

03/01/2018 LUPRON DEPOT-PED leuprolide acetate CHANGE UM: QUANTITY 1 / 112 days 1 / 84 OVER 03/01/2018 VABOMERE meropenem/vaborbactam Specialty 03/01/2018 VERZENIO abemaciclib Specialty 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 VERZENIO abemaciclib Specialty 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 VERZENIO abemaciclib Specialty 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 VERZENIO abemaciclib Specialty 03/01/2018 INGREZZA valbenazine tosylate Specialty 03/01/2018 INGREZZA valbenazine tosylate ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 CALQUENCE acalabrutinib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 CALQUENCE acalabrutinib Specialty 03/01/2018 BOSULIF bosutinib Specialty 03/01/2018 PREVYMIS letermovir Specialty 03/01/2018 PREVYMIS letermovir Specialty 03/01/2018 PREVYMIS letermovir Specialty 03/01/2018 PREVYMIS letermovir Specialty 03/01/2018 FASENRA benralizumab Specialty 03/01/2018 JULUCA dolutegravir sodium/rilpivirine hcl 03/01/2018 JULUCA dolutegravir sodium/rilpivirine hcl ADD UM: QUANTITY 30 / 30 DAYS Specialty PAGE 5 UPDATED 09/2018

03/01/2018 BYDUREON BCISE 03/01/2018 BYDUREON BCISE exenatide microspheres ADD UM: QUANTITY 3.4 / 28 DAYS exenatide microspheres Non-Preferred 03/01/2018 timolol maleate timolol maleate Non-Preferred 03/01/2018 TRISENOX arsenic trioxide Specialty 03/01/2018 potassium chloride potassium chloride 03/01/2018 efavirenz efavirenz 03/01/2018 scopolamine scopolamine 03/01/2018 dactinomycin dactinomycin Specialty 03/01/2018 vigabatrin vigabatrin Specialty 03/01/2018 TAMIFLU oseltamivir phosphate Non-Preferred 03/01/2018 TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 110 / 365 OVER 03/01/2018 eletriptan hbr eletriptan hydrobromide ADD UM: QUANTITY 12 / 30 OVER 03/01/2018 eletriptan hbr eletriptan hydrobromide Non-Preferred 03/01/2018 eletriptan hbr eletriptan hydrobromide Non-Preferred 03/01/2018 eletriptan hbr eletriptan hydrobromide ADD UM: QUANTITY 12 / 30 OVER 03/01/2018 fosamprenavir calcium fosamprenavir calcium Specialty 03/01/2018 bortezomib bortezomib Specialty 03/01/2018 moxifloxacin moxifloxacin hcl PAGE 6 UPDATED 09/2018

03/01/2018 amnesteem isotretinoin Non-Preferred 03/01/2018 amnesteem isotretinoin Non-Preferred 03/01/2018 amnesteem isotretinoin Non-Preferred 03/01/2018 lanthanum carbonate lanthanum carbonate Specialty 03/01/2018 aripiprazole aripiprazole ADD UM: QUANTITY 750 / 30 DAYS 03/01/2018 aripiprazole aripiprazole Non-Preferred 03/01/2018 lanthanum carbonate lanthanum carbonate Specialty 03/01/2018 NEVANAC nepafenac ADD UM: QUANTITY 6 / 30 OVER 03/01/2018 NEVANAC nepafenac Preferred 03/01/2018 dapsone dapsone Non-Preferred 03/01/2018 lanthanum carbonate lanthanum carbonate Specialty 03/01/2018 mesalamine mesalamine Preferred 03/01/2018 TAMIFLU oseltamivir phosphate Non-Preferred 03/01/2018 TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 112 / 365 OVER 03/01/2018 TAMIFLU oseltamivir phosphate Non-Preferred 03/01/2018 TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 60 / 365 OVER PAGE 7 UPDATED 09/2018

03/01/2018 ethynodiol-ethinyl 03/01/2018 sevelamer carbonate 03/01/2018 desogestrelethinyl 03/01/2018 norgestimateethinyl ethynodiol diacetate-ethinyl sevelamer carbonate Preferred desogestrel-ethinyl norgestimate-ethinyl 03/01/2018 HAVRIX hepatitis a virus vaccine/pf Preferred 03/01/2018 TWINRIX hepatitis a virus and hepatitis b virus vaccine/pf 03/01/2018 caspofungin acetate 03/01/2018 caspofungin acetate 03/01/2018 adapalenebenzoyl peroxide Preferred caspofungin acetate Specialty caspofungin acetate Specialty adapalene/benzoyl peroxide Non-Preferred 03/01/2018 prasugrel hcl prasugrel hcl Non-Preferred 03/01/2018 prasugrel hcl prasugrel hcl Non-Preferred 03/01/2018 VENTOLIN HFA albuterol sulfate Non-Preferred 03/01/2018 VENTOLIN HFA albuterol sulfate ADD UM: QUANTITY 48 / 30 DAYS 03/01/2018 carvedilol er carvedilol phosphate Preferred 03/01/2018 Non-Preferred 03/01/2018 peg 3350- electrolyte peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride PAGE 8 UPDATED 09/2018

03/01/2018 FYCOMPA perampanel CHANGE TIER Specialty Non-Preferred 03/01/2018 FYCOMPA perampanel CHANGE TIER Specialty Non-Preferred 03/01/2018 FYCOMPA perampanel CHANGE TIER Specialty Non-Preferred 03/01/2018 FYCOMPA perampanel CHANGE TIER Specialty Non-Preferred 03/01/2018 SUPRAX cefixime CHANGE TIER Specialty Preferred 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE TIER Non-Preferred Preferred 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE UM: QUANTITY 60 / 30 days 60 / 30 DAYS 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE TIER Non-Preferred Preferred 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE UM: QUANTITY 60 / 30 days 60 / 30 DAYS 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE UM: QUANTITY 60 / 30 days 60 / 30 DAYS 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE TIER Non-Preferred 03/01/2018 HUMULIN R U- 500 KWIKPEN 03/01/2018 HUMULIN R U- 500 Preferred insulin regular, human CHANGE TIER Specialty Preferred insulin regular, human CHANGE TIER Specialty Preferred 03/01/2018 duloxetine hcl duloxetine hcl CHANGE UM: QUANTITY 90 / 30 days 90 / 30 DAYS 03/01/2018 PROAIR HFA albuterol sulfate CHANGE UM: QUANTITY 17 / 30 days 17 / 30 DAYS 03/01/2018 RENVELA sevelamer carbonate CHANGE TIER Specialty Preferred 03/01/2018 sevelamer carbonate 03/01/2018 sevelamer carbonate sevelamer carbonate Preferred sevelamer carbonate CHANGE TIER Specialty Preferred PAGE 9 UPDATED 09/2018

03/01/2018 RENVELA sevelamer carbonate CHANGE TIER Specialty Preferred 03/01/2018 sevelamer carbonate 03/01/2018 sevelamer carbonate sevelamer carbonate Preferred sevelamer carbonate CHANGE TIER Specialty Preferred 03/01/2018 RENVELA sevelamer carbonate CHANGE TIER Specialty Preferred 03/01/2018 EMBEDA morphine sulfate/naltrexone hcl 03/01/2018 EMBEDA morphine sulfate/naltrexone hcl CHANGE TIER Specialty Preferred CHANGE TIER Specialty Preferred PAGE 10 UPDATED 09/2018

April, 2018 04/01/2018 medroxyprogeste rone acetate 04/01/2018 medroxyprogeste rone acetate medroxyprogesterone acetate medroxyprogesterone acetate 04/01/2018 altavera levonorgestrel-ethinyl 04/01/2018 kurvelo levonorgestrel-ethinyl CHANGE TIER CHANGE UM: QUANTITY 1 / 90 DAYS Preferred Preferred 04/01/2018 enskyce desogestrel-ethinyl Preferred 04/01/2018 SELZENTRY maraviroc 04/01/2018 EMFLAZA deflazacort 04/01/2018 EMFLAZA deflazacort 04/01/2018 EMFLAZA deflazacort 04/01/2018 EMFLAZA deflazacort 04/01/2018 EMFLAZA deflazacort 04/01/2018 levetiracetam er,roweepra xr levetiracetam CHANGE TIER Preferred 04/01/2018 HERCEPTIN trastuzumab 04/01/2018 SHINGRIX varicella-zoster virus glycoprotein e,rec/as01b adjuvant/pf 04/01/2018 ALUNBRIG brigatinib 04/01/2018 ALUNBRIG brigatinib ADD UM: QUANTITY 30 / 30 DAYS 04/01/2018 ALUNBRIG brigatinib PAGE 11 UPDATED 09/2018

04/01/2018 ALUNBRIG brigatinib ADD UM: QUANTITY 30 / 30 DAYS 04/01/2018 ALUNBRIG brigatinib 04/01/2018 ALUNBRIG brigatinib ADD UM: QUANTITY 60 / 365 OVER 04/01/2018 ELIQUIS apixaban 04/01/2018 ELIQUIS apixaban ADD UM: QUANTITY 148 / 368 OVER 04/01/2018 CINVANTI aprepitant 04/01/2018 ZENPEP lipase/protease/amylase 04/01/2018 Preferred 04/01/2018 tenofovir disoproxil fumarate tenofovir disoproxil fumarate Preferred 04/01/2018 atazanavir sulfate atazanavir sulfate Preferred 04/01/2018 atazanavir sulfate atazanavir sulfate Preferred 04/01/2018 atazanavir sulfate atazanavir sulfate Preferred 04/01/2018 doripenem doripenem Preferred 04/01/2018 levonorgestreleth levonorgestrel-ethinyl REMOVE UM: QUANTITY 91 / 91 days 04/01/2018 carvedilol er carvedilol phosphate Preferred 04/01/2018 carvedilol er carvedilol phosphate Preferred PAGE 12 UPDATED 09/2018

04/01/2018 carvedilol er carvedilol phosphate Preferred 04/01/2018 levetiracetam er,roweepra xr levetiracetam CHANGE TIER Preferred 04/01/2018 NUCALA mepolizumab CHANGE UM: QUANTITY 1 / 28 days 3 / 28 DAYS 04/01/2018 ZENPEP lipase/protease/amylase CHANGE TIER Specialty Preferred PAGE 13 UPDATED 09/2018

May, 2018 05/01/2018 naloxone hcl naloxone hcl 05/01/2018 XTAMPZA ER oxycodone myristate Preferred 05/01/2018 XTAMPZA ER oxycodone myristate Preferred 05/01/2018 XTAMPZA ER oxycodone myristate Preferred 05/01/2018 XTAMPZA ER oxycodone myristate Preferred 05/01/2018 XTAMPZA ER oxycodone myristate Preferred 05/01/2018 haloperidol lactate 05/01/2018 QVAR REDIHALER 05/01/2018 QVAR REDIHALER 05/01/2018 QVAR REDIHALER 05/01/2018 QVAR REDIHALER haloperidol lactate beclomethasone dipropionate beclomethasone dipropionate beclomethasone dipropionate beclomethasone dipropionate ADD UM: QUANTITY ADD UM: QUANTITY Preferred 21.2 / 30 DAYS Preferred 21.2 / 30 DAYS 05/01/2018 SYMDEKO tezacaftor/ivacaftor Specialty 05/01/2018 SYMDEKO tezacaftor/ivacaftor ADD UM: QUANTITY 56 / 28 DAYS 05/01/2018 ERLEADA apalutamide Specialty 05/01/2018 ERLEADA apalutamide ADD UM: QUANTITY 120 / 30 DAYS 05/01/2018 BIKTARVY bictegravir sodium/emtricitabine/tenofov ir alafenamide fumar 05/01/2018 BIKTARVY bictegravir sodium/emtricitabine/tenofov ir alafenamide fumar ADD UM: QUANTITY Specialty 30 / 30 DAYS PAGE 14 UPDATED 09/2018

05/01/2018 sumatriptan succnaproxen sod 05/01/2018 sumatriptan succnaproxen sod sumatriptan succinate/naproxen sodium sumatriptan succinate/naproxen sodium ADD UM: QUANTITY Specialty 9 / 30 OVER 05/01/2018 digox digoxin 05/01/2018 ZENPEP lipase/protease/amylase Preferred 05/01/2018 ZENPEP lipase/protease/amylase Preferred 05/01/2018 digox digoxin ADD UM: QUANTITY 30 / 30 DAYS 05/01/2018 ENDARI glutamine Specialty 05/01/2018 isotretinoin isotretinoin Non-Preferred 05/01/2018 isotretinoin isotretinoin Non-Preferred 05/01/2018 isotretinoin isotretinoin Non-Preferred 05/01/2018 nolix flurandrenolide Non-Preferred 05/01/2018 efavirenz efavirenz Specialty 05/01/2018 abacavir abacavir sulfate 05/01/2018 VIDEX EC didanosine Non-Preferred 05/01/2018 trientine hcl trientine hcl Specialty 05/01/2018 efavirenz efavirenz Specialty 05/01/2018 isotretinoin isotretinoin Non-Preferred 05/01/2018 levonorg-eth estrad eth estrad levonorgestrel/ethinyl and ethinyl PAGE 15 UPDATED 09/2018

05/01/2018 levonorg-eth estrad eth estrad levonorgestrel/ethinyl and ethinyl ADD UM: QUANTITY 91 / 91 DAYS 05/01/2018 memantine hcl er memantine hcl 05/01/2018 memantine hcl er memantine hcl ADD UM: QUANTITY 30 / 30 DAYS 05/01/2018 memantine hcl er memantine hcl 05/01/2018 memantine hcl er memantine hcl ADD UM: QUANTITY 30 / 30 DAYS 05/01/2018 memantine hcl er memantine hcl 05/01/2018 memantine hcl er memantine hcl ADD UM: QUANTITY 30 / 30 DAYS 05/01/2018 memantine hcl er memantine hcl 05/01/2018 memantine hcl er memantine hcl ADD UM: QUANTITY 30 / 30 DAYS PAGE 16 UPDATED 09/2018

June, 2018 06/01/2018 ABILIFY MAINTENA aripiprazole Specialty 06/01/2018 ALIMTA pemetrexed disodium Specialty 06/01/2018 DALIRESP roflumilast Non-Preferred 06/01/2018 EPIPEN 2-PAK epinephrine Preferred 06/01/2018 EPIPEN JR 2- PAK epinephrine Preferred 06/01/2018 glatopa glatiramer acetate Specialty 06/01/2018 glatopa glatiramer acetate ADD UM: QUANTITY 12 / 28 DAYS 06/01/2018 HAEGARDA c1 esterase inhibitor Specialty 06/01/2018 HAEGARDA c1 esterase inhibitor Specialty 06/01/2018 ILARIS canakinumab/pf Specialty 06/01/2018 ILARIS canakinumab/pf ADD UM: QUANTITY 2 / 28 DAYS 06/01/2018 IMBRUVICA ibrutinib Specialty 06/01/2018 IMBRUVICA ibrutinib Specialty 06/01/2018 IMBRUVICA ibrutinib Specialty 06/01/2018 IMBRUVICA ibrutinib Specialty 06/01/2018 IMBRUVICA ibrutinib Specialty 06/01/2018 INTRON A interferon alfa-2b,recomb. Specialty 06/01/2018 ISENTRESS HD raltegravir potassium Specialty 06/01/2018 lansoprazole lansoprazole Non-Preferred 06/01/2018 lansoprazole lansoprazole ADD UM: QUANTITY 30 / 30 DAYS PAGE 17 UPDATED 09/2018

06/01/2018 lansoprazole lansoprazole Non-Preferred 06/01/2018 lansoprazole lansoprazole ADD UM: QUANTITY 30 / 30 DAYS 06/01/2018 levoleucovorin calcium 06/01/2018 MAKENA hydroxyprogesterone caproate/pf 06/01/2018 melodetta 24 fe norethindrone acetateethinyl /ferrous fumarate levoleucovorin calcium Specialty Specialty 06/01/2018 mesalamine mesalamine Preferred 06/01/2018 ORFADIN nitisinone Preferred 06/01/2018 palonosetron hcl palonosetron hcl Non-Preferred 06/01/2018 PLEGRIDY peginterferon beta-1a Specialty 06/01/2018 PLEGRIDY peginterferon beta-1a ADD UM: QUANTITY 2 / 365 OVER 06/01/2018 RUBRACA rucaparib camsylate Specialty 06/01/2018 RUBRACA rucaparib camsylate ADD UM: QUANTITY 120 / 30 DAYS 06/01/2018 SYLVANT siltuximab Specialty 06/01/2018 SYMFI LO efavirenz/lamivudine/tenofov ir disoproxil fumarate 06/01/2018 SYMFI LO efavirenz/lamivudine/tenofov ir disoproxil fumarate ADD UM: QUANTITY Specialty 30 / 30 DAYS 06/01/2018 SYNAGIS palivizumab Specialty 06/01/2018 tiagabine hcl tiagabine hcl Non-Preferred 06/01/2018 tiagabine hcl tiagabine hcl Non-Preferred PAGE 18 UPDATED 09/2018

06/01/2018 TRESIBA FLEXTOUCH U- 100 06/01/2018 TRESIBA FLEXTOUCH U- 200 06/01/2018 tydemy drospirenone/ethinyl /levomefolate calcium insulin degludec Preferred insulin degludec Preferred Non-Preferred 06/01/2018 ZYTIGA abiraterone acetate Specialty 06/01/2018 diclofenac sodium 06/01/2018 hydrocortisonepramoxine diclofenac sodium CHANGE TIER Non-Preferred hydrocortisone acetate/pramoxine hcl 06/01/2018 kelnor 1-50 ethynodiol diacetate-ethinyl 06/01/2018 lamotrigine,lamot rigine (blue) 06/01/2018 lamotrigine,lamot rigine (green) 06/01/2018 lamotrigine,lamot rigine (orange) Non-Preferred lamotrigine lamotrigine Specialty lamotrigine 06/01/2018 palonosetron hcl palonosetron hcl 06/01/2018 ritonavir ritonavir 06/01/2018 triamcinolone acetonide triamcinolone acetonide 06/01/2018 VIRAMUNE nevirapine Specialty 06/01/2018 ORFADIN nitisinone CHANGE TIER Preferred Specialty PAGE 19 UPDATED 09/2018

July, 2018 07/01/2018 HUMIRA adalimumab Specialty 07/01/2018 HUMIRA PEDIATRIC CROHN'S adalimumab Specialty 07/01/2018 HUMIRA PEN adalimumab Specialty 07/01/2018 HUMIRA PEDIATRIC CROHN'S adalimumab Specialty 07/01/2018 HUMIRA adalimumab Specialty 07/01/2018 BENZNIDAZOLE benznidazole Preferred 07/01/2018 ZENPEP lipase/protease/amylase Preferred 07/01/2018 BENZNIDAZOLE benznidazole Preferred 07/01/2018 syeda ethinyl /drospirenone 07/01/2018 tri-vylibra norgestimate-ethinyl 07/01/2018 vylibra norgestimate-ethinyl 07/01/2018 TOUJEO MAX SOLOSTAR 07/01/2018 methylphenidate la,methylphenidat e er 07/01/2018 methylphenidate la,methylphenidat e er insulin glargine,human recombinant analog Preferred methylphenidate hcl methylphenidate hcl ADD UM: QUANTITY 180 / 30 DAYS PAGE 20 UPDATED 09/2018

07/01/2018 methylphenidate er 07/01/2018 methylphenidate er methylphenidate hcl methylphenidate hcl ADD UM: QUANTITY 30 / 30 DAYS 07/01/2018 TASIGNA nilotinib hcl Specialty 07/01/2018 epinephrine epinephrine CHANGE TIER Non-Preferred Preferred PAGE 21 UPDATED 09/2018

August, 2018 08/01/2018 baclofen baclofen 08/01/2018 ciprofloxacin hcl ciprofloxacin hcl 08/01/2018 colesevelam hcl colesevelam hcl Preferred 08/01/2018 estarylla norgestimate-ethinyl 08/01/2018 mili norgestimate-ethinyl 08/01/2018 tri-mili norgestimate-ethinyl 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl Preferred 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 30 / 30 DAYS 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl Preferred 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 60 / 30 DAYS 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl Preferred 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 30 / 30 DAYS 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl Preferred 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 60 / 30 DAYS 08/01/2018 HUMIRA adalimumab Specialty 08/01/2018 NORVIR ritonavir Specialty 08/01/2018 SYMFI efavirenz/lamivudine/tenofov ir disoproxil fumarate 08/01/2018 SYMFI efavirenz/lamivudine/tenofov ir disoproxil fumarate ADD UM: QUANTITY Specialty 30 / 30 DAYS 08/01/2018 TAVALISSE fostamatinib disodium Specialty PAGE 22 UPDATED 09/2018

08/01/2018 TAVALISSE fostamatinib disodium ADD UM: QUANTITY 60 / 30 DAYS 08/01/2018 TAVALISSE fostamatinib disodium Specialty 08/01/2018 TAVALISSE fostamatinib disodium ADD UM: QUANTITY 60 / 30 DAYS 08/01/2018 JYNARQUE tolvaptan Specialty 08/01/2018 JYNARQUE tolvaptan ADD UM: QUANTITY 56 / 28 DAYS 08/01/2018 JYNARQUE tolvaptan Specialty 08/01/2018 JYNARQUE tolvaptan ADD UM: QUANTITY 56 / 28 DAYS 08/01/2018 JYNARQUE tolvaptan Specialty 08/01/2018 JYNARQUE tolvaptan ADD UM: QUANTITY 56 / 28 DAYS 08/01/2018 cyclophosphamid e 08/01/2018 cyclophosphamid e cyclophosphamide CHANGE TIER Non-Preferred cyclophosphamide CHANGE TIER Non-Preferred 08/21/2018 GLEOSTINE lomustine Non-Preferred 08/21/2018 GLEOSTINE lomustine Non-Preferred 08/21/2018 GLEOSTINE lomustine Non-Preferred PAGE 23 UPDATED 09/2018