2021 EMI BENEFITS GUIDE (via THT Health) by THT Health

Teachers Health Trust 2021 EMI Health Member Benefits Guide

Every Member is Important www.emihealth.com

Administered by Educators Health Plans Life, Accident, and Health, Inc. EMI Health Customer Service 801-270-2880 or 1-800-662-5851 Self Funded Employee Medical Benefit Plan All services are subject to the EMI Health Maximum Allowable Charge. When using a Non-participating Provider, the Covered Person is responsible for all fees in excess of the Maximum Allowable Charge. Teachers Health Trust #4087 Care Plus January 01, 2021 - December 31, 2021 Participating Non-Participating Provider Option Provider Option GENERAL INFORMATION YOU PAY Benefit Accumulator Calendar Year Dependent Age Limit 26 Out-of-Pocket Maximum (Per Person/Family Per Year). Please note * $6,850 / $13,700 $13,700 / $27,400 Medical Deductible (Per Person/Family Per Year). Please note ♦ $600 / $1,800 $2,500 / $10,000 Non-Preauthorization Patient Penalty Not Applicable No Coverage Non-Preauthorization Provider Sanction 50% Reduction in Payment Not Applicable PRESCRIPTION DRUG BENEFITS (If brand is purchased when generic is YOU PAY available, member pays the copay plus the difference between the generic and the brand price) Generic - 25% ($5 Min, $50 Max) Participating Pharmacy (30 day supply) Preferred - 25% ($100 Max) Non-Preferred - 40% ($50 Min) Not Covered Non-Participating Pharmacy Generic - 25% ($12.50 Min, $150 Max) Mail Order (90 day supply) Preferred - 25% ($300 Max) Non-Preferred - 40% ($125 Min) Specialty Pharmacy (90 day supply) 25% ($1,500 Max) All fills must be purchased through Express Scripts Specialty Pharmacy. Must enroll to receive: Specialty Pharmacy SaveOnSP Program 1-800-683-1074 $0 Copay http://emihealth.com/pdf/saveon.pdf PREVENTIVE SERVICES YOU PAY Routine Physical Exam (1 visit per Year) Covered 100% Not Covered Routine Gynecological Exam (1 visit per Year) Covered 100% Not Covered Family History Exam (1 visit per Year) Covered 100% Not Covered Routine Pap Smear & Mammogram (1 per Year) Covered 100% Not Covered Routine Well-Baby Exams Covered 100% Not Covered Covered Immunizations Covered 100% Not Covered Routine Vision Exam (1 visit per Year) Covered 100% Not Covered Routine Hearing Exam (1 visit per Year) Covered 100% Not Covered PHYSICIAN & PROFESSIONAL SERVICES YOU PAY Convenience Clinic $15 ♦40% Physician Office Visits (primary care) $10 office visit; 20% all other services ♦40% Physician Office Visits (secondary care) $20 office visit; 20% all other services ♦40% Physician Office Visits (after hours) $20 office visit; 20% all other services ♦40% Physician Visits (Inpatient) ♦20% ♦40% Physician Visits (Outpatient) ♦20% ♦40% Major Diagnostic Test, CT Scan, MRI, NMR (office) 20% ♦40% Minor Diagnostic Test, Radiology, Lab (office) 20% ♦40% Minor Diagnostic Test, Radiology, Lab (Inpatient) 20% ♦40% Minor Diagnostic Test, Radiology, Lab (Outpatient) 20% ♦40% Injections (office) 20% ♦40% Surgery (office) 20% ♦40% Surgery (Inpatient) ♦20% ♦40% Surgery (Outpatient) ♦20% ♦40% Anesthesiology (office) ♦20% ♦40% Anesthesiology (Inpatient) ♦20% ♦40% Anesthesiology (Outpatient) ♦20% ♦40% Routine Prenatal & Delivery (Dependent maternity included) $10 office visit; 20% all other services ♦40% Home Health and Hospice Care (in lieu of Hospital) (for supplies, see Medical 20% ♦40% Supplies and Equipment) Rehabilitation Therapy (Outpatient physical, speech or occupational - 20 visits per $20 ♦40% Year; Pre-Authorization required after 20 visits) Rehabilitation Therapy (Outpatient cardiac or pulmonary) $20 ♦40% Chiropractic Therapy (20 visits per Year) $20 ♦40% Acupuncture Services (20 visits per Year) $20 ♦40% 1

Teachers Health Trust #4087 January 01, 2021 - December 31, 2021

Care Plus Participating Provider Option 20% 20%

Non-Participating Provider Option ♦40% ♦40%

Allergy Testing Allergy Treatment/Serum YOU PAY HOSPITAL/FACILITY BENEFITS (Physician & Professional Services are not included in this section.) Medical/Surgical/Maternity/Intensive Care (semi-private room) $400 per day, $800 max per admission ♦40% Medical/Surgical/Maternity/Intensive Care (Inpatient Ancillary) Covered 100% ♦40% Skilled Nursing Facility (30 days per Year) (Admission must be within 5 days of $400 per day, $800 max per admission ♦40% discharge from Hospital Confinement) Medical/Surgical Care (Outpatient) $400 ♦40% Emergency Room (ER) - True Emergency $250 $250 Emergency Room (ER) - Non-Emergency $400 ♦40% Major Diagnostic Test, CT Scan, MRI, NMR (Outpatient) 20% ♦40% Minor Diagnostic Test, X-ray, Lab (Inpatient) 20% ♦40% Minor Diagnostic Test, X-ray, Lab (Outpatient) 20% ♦40% Newborn 20% 40% Urgent Care Clinic $50 ♦40% Eligible Preventive Services Covered 100% Not Covered REHABILITATION THERAPY BENEFIT YOU PAY Inpatient – physical, speech, occupational, cardiac, or pulmonary (40 days per $400 per day, $800 max per admission ♦40% person per Year) ACCIDENT AND LIFE THREATENING CONDITION YOU PAY Medical/Surgical – Physician/Facility/ER Covered as any other condition Covered as a Participating Benefit to Ambulance Land/Air (Accident & Life-threatening) 20% the Maximum Allowable Charge Orthodontic Injury Treatment *50% Dental Injury Treatment 20% TRANSPLANT BENEFIT YOU PAY Heart, Liver, Pancreas, Bone Marrow, Cornea, Lung, Kidney Covered as any other condition Not Covered MEDICAL SUPPLIES & EQUIPMENT YOU PAY Diabetic Testing Supplies (90 day supply) Covered 100% ♦40% Medical Supplies 20% ♦40% Medical Supplies (office) Covered 100% ♦40% Durable Medical Equipment/Prosthetics/Orthotic Devices 20% ♦40% Orthotic Supplies (foot inserts & arch supports) 20% ♦40% Growth Hormone 20% ♦40% MENTAL HEALTH & DRUG/ALCOHOL TREATMENT YOU PAY Inpatient Services (non-residential) $400 per day, $800 max per admission ♦40% Residential Treatment (30 days per Year) $400 per day, $800 max per admission ♦40% Partial Hospitalization and Intensive Outpatient Services $150 per day, $900 max per admission ♦40% Physician Office Visits $20 ♦40% Psychologist / LCSW / APRN / Psychiatrist ADDITIONAL BENEFITS YOU PAY Covered 100% up to $1000 Covered 100% up to $1000 Hearing Aids, including repair and replacement (per ear every five years) Covered 100% up to $300 Covered 100% up to $300 Wig or hairpiece (following chemotherapy or radiation course of treatment) TMJ Syndrome diagnosis & non-surgical treatment *50% Not Covered Orthognathic/Mandibular Osteotomy *50% Not Covered Total Parenteral Nutrition (TPN) *50% Not Covered Initial assessment and diagnosis of Primary Infertility *50% Not Covered Reduction Mammoplasty *50% Not Covered Services designated ♦ are subject to first dollar Medical Deductible Services designated *, premiums, balance-billed charges, charges for services this Plan doesn’t cover, amounts in excess of benefit limits, and penalties for failure to obtain Preauthorization, do not accumulate toward your Out-of-pocket Maximum. PROVIDER NETWORK EMI Health Care Plus Utah Cigna PPO Outside of Utah PLEASE NOTE: This is a summary only and does not guarantee benefits. All benefits are subject to the terms, limitations, and exclusions set forth in the Plan document and in the Summary Plan Description (SPD)/handbook of the Plan. Any discrepancies between this summary, the SPD/handbook, and the Plan document are resolved in favor of the Plan document. For more information, including Preauthorization, refer to the SPD/ handbook or the Plan document, or contact EMI Health Customer Service Department.

Corporate (801)262-7475 Customer Service (800)662-5851

EMIHealth.com DENTAL COVERAGE BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL DENTAL EXPENSES OUTLINE OF COVERAGE

Read Your Policy Carefully-This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!

Group: Plan: Administered by:

Teachers Health Trust (Plan #4087) Choice PPO Educators Health Plans Life, Accident & Health, a Utah Company

Effective Date: Benefit Year: Plan Type:

1/1/2021 Calendar Contributory / Self Funded

Type 1 - Preventive Oral Exams, Cleanings, X-rays, Fluoride

Type 2 - Basic Fillings, Oral Surgery

Type 3 - Major Crowns, Bridges, Prosthodontics

Type 4 - Orthodontics Dependent children ages 7 through 18 Adults Orthodontic Discount (All Members)

Endodontics Periodontics Sealants Space Maintainers

In-Network (Advantage Plus Network)

In-Network (Premier Network)

Out-of-Network

100%

100% up to MAC*

80%

80% up to MAC*

60%

50% up to MAC*

50%

Discount Only (Up to 25%) Up to 25% Discount

No Coverage No Discount

Type 2 - Basic Type 2 - Basic Type 2 - Basic Type 2 - Basic

Waiting periods Type 2 - Basic Type 3 - Major Type 4 - Orthodontics Deductible Per Person Family Max Deductible Applies To Annual Maximum Per Person

None None None $0.00 $0.00 N/A

$0.00 $0.00 N/A

$2,000.00

$0.00 $0.00 N/A $1,500.00

All maximums are combined up to limits above

Orthodontic Lifetime Maximum Network / Reimbursement Schedule

$1,000.00 Advantage Plus

Premier

Provisions / Limitations / Exclusions Exams (including Periodontal), Cleanings and Fluoride Fluoride Sealants Space Maintainers Bitewing X-Rays Periapical X-Rays Panoramic X-Ray Impacted Teeth Anesthesia - (Age 8 and over for the extraction of impacted teeth only) Anesthesia - (For children age 7 and under, once per year) Implants / Implant Abutments Crowns, Pontics, Abutments, Onlays and Dentures Fillings on the same surface

2 per year Up to age 16 Up to age 16 Up to age 16 Up to 4, twice per year 6 per year 1 every 3 years Covered in Type 2 - Basic Covered in Type 3 - Major** Covered in Type 3 - Major** Covered in Type 3 - Major 1 every 5 years per tooth 1 every 18 months

* All Services are subject to EMI Health Maximum Allowable Charge (MAC). When using a Non-participating Provider, the insured is responsible for all fees in excess of the Maximum Allowable Charge (MAC). ** Anesthesia is not subject to waiting periods.

Corporate (801)262-7475 Customer Service (800)662-5851

EMIHealth.com

Teachers Health Trust (Plan #4087)

Group: Plan:

VSP Plus 10-130

Effective Date: Plan Type:

1/1/2021 Contributory

In-Network Network

Out-of-Network VSP Choice Plus

WellVision Exam

$10 Co-pay

Up to $65

$10 Co-pay $10 Co-pay $10 Co-pay $10 Co-pay

Up to $30 Up to $50 Up to $65 Up to $100

Lenses (Glass or Plastic) Single Vision Lined Bifocal Lined Trifocal Lenticular

Lens Options Progressive (Standard no-line) Premium Progressive Options Custom Progressive Options Plastic Gradient Dye Solid Plastic Dye Photochromic Lenses Polycarbonate for Adults Polycarbonate for Children (under 18)

$55 Co-pay $95-$105 Co-pay $150-$175 Co-pay $17 Co-pay $15 Co-pay $70 Co-pay SV/$82 Co-Pay Multifocal $31 Co-pay SV/$35 Co-Pay Multifocal $0 Copay

Up to $50 (In lieu of Lined Bifocal reimbursement)

N/A

Coatings Scratch Resistant Coating Anti-Reflective Coating UV Protection Additional lens enhancements

$17 Co-pay $41 Co-pay $16 Co-pay Up to 25% Discount

N/A

Frames Allowance Based on Retail Pricing Additional Pairs of Glasses**

$130 Allowance at any VSP doctor or $70 at Costco, Sam's Club or Walmart Up to 20% Off Retail

Up to $80 N/A

Elective Contact Lenses In Lieu of Frame & Lenses Elective contact lens fitting, evaluation services and prescription contact lenses are covered up to plan allowance. 15% discount given off contact lens fitting and evaluation services, excluding materials.

$130 Allowance

Up to $115

Frequency Exam, Lenses, Frame or Contacts

Every 12 Months

Refractive Surgery LASIK***

Up to $500 in Savings

Not Covered

Notes This is a summary of plan benefits. The actual Policy will detail all plan limitations and exclusions. ** 20% discount off unlimited additional pairs of glasses offered through any VSP Choice Providers within 12 months of last covered eye exam. *** Discounts average 15-20% off or 5% off a promotional offer for laser surgery, including PRK, LASIK, Custom LASIK, and IntraLase3 Underwritten by: Educators Health Plans Life, Accident & Health

EHPL.V.VSP.OUT.A

TeleM ed icin e 1-877-872-0370

Reach a d oct or 24 / 7/ 365. Som e 70 % of d oct or visit s can b e h an d led over t h e p h on e, an d 4 0 % of u rg en t care visit s can b e m an ag ed u sin g TeleM ed icin e. Save t im e an d m on ey w h ile st ill g et t in g t h e t reat m en t you n eed t h rou g h EM I Healt h TeleM ed offered t h rou g h W ellVia.

W h en t o Use TeleM ed W ellVia d oct ors d iag n ose acu t e, n on -em erg en t m ed ical con d it ion s an d p rescrib e m ed icat ion s w h en clin ically ap p rop riat e. Sp eak w it h a d oct or an yt im e an d p ay n o con su lt at ion fee rat h er t h an p ayin g t h e h ig h cost s associat ed w it h off ice visit s, u rg en t care visit s, an d em erg en cy room visit s. Ju st call 1-8 77-8 72-0 370 .

Com m on Con d it ion s Acid Reflu x

Ear Pain*

Pin k Eye

Allerg ies

Fever

Rash es

Ast h m a

Gou t

Sin u s Con d it ion s

Blad d er In fect ion

Head ach e

Sore Th roat

Bron ch it is

Hem orrh oid s

St om ach Viru s

Cold & Flu

Hig h Blood Pressu re

Th yroid Con d it ion s

Con st ip at ion

Join t Pain

Urin ary Tract In fect ion s

Cou g h

Nau sea

Yeast In fect ion s

Com m on M ed icat ion s Alb u t erol

Flon ase

Lip it or

Alleg ra

Ib u p rofen 80 0 m g

Nason ex

Ast h m a

Levaq u in

M an y Ot h ers

*In accord an ce w it h t elem ed icin e g u id elin es, ear in fect ion s are on ly d iag n osed for p at ien t s t h at are 18 years of ag e or old er.

D ow n load t h e W ellVia m ob ile ap p 5

You r ID Card (f ron t ) It is im p or t an t t h at you p resen t you r ID card each t im e you receive ser vices. You r EM I Healt h ID card con t ain s a lot of u sefu l in form at ion for you an d you r p rovid er.

Card Fron t A B

G H

D I E

J K

EM I Healt h is you r in su ran ce carrier.

Th e em p loyee's n am e is list ed on t h e ID card . Covered d ep en d en t s are n ot list ed .

Th is is t h e n am e of you r m ed ical p lan an d also in d icat es you r p art icip at in g p rovid er n et w ork . To verify a p rovid er's st at u s, visit em ih ealt h .com or call 80 0 -662-5851. Th ese are you r b asic cop ay, coin su ran ce, an d d ed u ct ib le am ou n t s w h en you visit a p art icip at in g p rovid er. For m ore d et ailed b en ef it s in form at ion , see you r Su m m ary of Ben ef it s an d m em b er h an d b ook . Th is is you r m ed ical p art icip at in g p rovid er n et w ork w h en t ravelin g ou t sid e of Ut ah . To verify a p rovid er's st at u s, visit em ih ealt h .com or call 80 0 -662-5851.

You r u n iq u e m em b er n u m b er is req u ired in ord er t o verify coverag e, d et erm in e b en ef it s, an d p ay claim s for you an d you r d ep en d en t s.

Exp ress Scrip t s is you r Ph arm acy Ben ef it s M an ag er.

H I

Th ese are you r b asic p h arm acy cop ays an d coin su ran ce am ou n t s.

If you h ave d en t al coverag e w it h EM I Healt h , t h e n am e of you r d en t al p lan w ill ap p ear h ere. Th is also in d icat es you r d en t al p art icip at in g p rovid er n et w ork . To verify a p rovid er's st at u s, visit em ih ealt h .com or call 80 0 -662-5851. If t h is sect ion is n ot on you r card , you d o n ot h ave d en t al coverag e t h rou g h EM I Healt h .

If you h ave vision coverag e w it h EM I Healt h , t h e n am e of you r vision p lan w ill ap p ear h ere. Th is also in d icat es you r vision p art icip at in g p rovid er n et w ork . To verify a p rovid er's st at u s, visit em ih ealt h .com or call 80 0 -662-5851. If t h is sect ion is n ot on you r card , you d o n ot h ave vision coverag e t h rou g h EM I Healt h .

Th is is t h e p h on e n u m b er t o call for a Telem ed con su lt at ion w it h a W ellVia p h ysician . EM I Telem ed can elim in at e t h e n eed for off ice visit s for m an y com m on con d it ion s. If t h is sect ion is n ot on you r card , you d o n ot h ave TeleM ed services t h rou g h EM I Healt h .

You r ID Card (b ack )

Card Back

A D B E

Th is is t h e claim s su b m ission ad d ress for Ut ah m ed ical claim s an d all d en t al claim s. In m ost cases, you r p rovid er w ill su b m it claim s d irect ly t o EM I Healt h .

Th is is t h e t elep h on e n u m b er t o call for cu st om er service in q u iries.

Th ese are you r p art icip at in g p rovid er m ed ical n et w orks for Ut ah an d n at ion ally. To verify a p rovid er's st at u s, visit em ih ealt h .com or call 80 0 -662-5851.

Th is is t h e t elep h on e n u m b er t o call for p reau t h orizat ion s.

Th ese are you r p art icip at in g p rovid er d en t al n et w orks ou t sid e of Ut ah . To verify a p rovid er's st at u s, visit em ih ealt h .com or call 80 0 -662-5851. If t h is sect ion is n ot on you r card , you d o n ot h ave d en t al coverag e t h rou g h EM I Healt h .

M y EM I Healt h Accou n t Set u p All you r b en ef it an sw ers. On e w eb sit e. Fin d everyt h in g relat ed t o you r b en ef it s f rom g en eral p lan d ocu m en t s t o d et ailed claim s in form at ion .

Get St ar t ed 1. Go t o em ih ealt h .com . 2. Click Log in an d select M y EM I Healt h . 3. Select Reg ist er an d ch oose M em b er as t h e t yp e of accou n t . 4 . En t er t h e d at a t o id en t ify you rself an d click Con t in u e. * You w ill n eed you r M em b er ID fou n d on you r EM I Healt h ID card . Also, for you r secu rit y, you r p assw ord m u st b e at least six ch aract ers an d in clu d e a sp ecial ch aract er, e.g ., !, @, # , $, et c.

W h at You Can D o View b en ef it d escrip t ion s Ch eck claim s st at u s Ord er ID card s View EOBs Access t h e Sm art Cost Calcu lat or Review elig ib ilit y/en rollm en t st at u s M an ag e p rescrip t ion b en ef it s

M y EM I Healt h As a m em b er of EM I Heal t h , you h ave access t o t h e f ollow in g on lin e t ools an d ser vices.

My EMI Health

M y EM I Heal t h

M an ag e you r m ed ical, d en t al, vision , an d d isab ilit y p lan s: -

View b en ef it d escrip t ion s Review elig ib ilit y/en rollm en t st at u s Ch eck claim s st at u s View Exp lan at ion of Ben ef it s (EOBs) Ord er ID card s

im p or t an t You r Exp lan at ion of Ben ef it s (EOB) can on ly b e fou n d on lin e t h rou g h you r M y EM I Healt h accou n t .

Exp ress Scrip t s

It is im p ort an t t o n ot e t h at p ap er cop ies of you r EOB are n ot m ailed .

M an ag e you r p rescrip t ion b en ef it s: -

Ref ill p rescrip t ion s Ch eck ord er st at u s Price m ed icat ion s Locat e p art icip at in g p h arm acies SMART COST C A L C U L A TOR

Tran sp aren cy Tool

Com p are an d Save: - Com p are cost s of d ifferen t facilit ies - See t h e p rices of seein g sp ecif ic p rovid ers - Fin d t h e cost of a cert ain p roced u re

TeleM ed Care is ju st a p h on e call aw ay : - $0 p h ysician con su lt at ion s - 24 /7/365 access t o p h ysician care - Con ven ien ce of care f rom you r ow n h om e

Fin d Part icip at in g Provid ers Fin d in -n et w ork p rovid ers. Save M on ey.

Ut ah Provid er Search To search for m ed ical p rovid ers in Ut ah or d en t al an d vision p rovid ers b ot h in Ut ah an d n at ion ally, g o t o em ih eal t h .com an d click on Provid er Search alon g t h e u p p er p art of t h e h om e p ag e. 1. Select t h e n et w ork t yp e: M ed ical, D en t al or Vision an d ch oose you r p lan (fou n d on you r ID Card ). M ed ical Plan : Care Plu s D en t al Plan s: Prem ier, Ad van t ag e, Valu e, Su m m it , or Su m m it Plu s Vision Plan s: Op t icare, VSP Ch oice, or VSP Ch oice Plu s 2. Now , en t er you r p rovid er's d et ails an d click Search . Th at 's all t h ere is t o it ! You w ill see a list of p art icip at in g p rovid ers alon g w it h t h eir con t act in form at ion , ad d ress, an d t h e ab ilit y t o m ap t h e locat ion of t h eir off ices. You can also d ow n load t h e resu lt s as a PD F t o p rin t .

Nat ion al Cig n a PPO M ed ical Provid er Search To search for m ed ical p rovid ers ou t sid e Ut ah , g o t o em ih eal t h .com an d click on Provid er Search alon g t h e u p p er p art of t h e h om e p ag e. 1. Select m ed ical as t h e n et w ork t yp e an d ch oose Care Plu s as you r p lan . Select t h e st at e in w h ich you 'd like t o search . W h en you select a st at e ot h er t h an Ut ah , you w ill b e asked t o select a log o. Ch oose t h e Cig n a log o. 2. On ce on t h e Cig n a w eb sit e, ch oose t h e t yp e of p rovid er (D oct or, Hosp it al, Ph arm acy, or Facilit y). 3. Use you r cu rren t locat ion or in p u t t h e cit y/st at e in w h ich you 'd like t o search . 4 . Un d er Select a Plan , ch oose PPO, Ch oice Fu n d PPO 5. Un d er Look in g For , ch oose a sp ecialt y or facilit y t yp e. 6. Now , en t er you r p rovid er's d et ails an d click Search .

D ow n load Th e M ob ile Ap p To Search On Th e Go. In ad d it ion t o b ein g an ot h er con ven ien t w ay t o search for p rovid ers, t h e EM I Healt h m ob ile ap p allow s you t o d o even m ore. View you r ID Card .

View you r p lan g rid s

Up d at e you r p rof ile in form at ion like em ail ad d ress, p assw ord , or secu rit y q u est ion s.

View you r EOBs an d search b y p erson , service, d at e, an d m ore.

Access cu rren t an d p ast issu es of t h e Hop e Healt h n ew slet t er. Please Not e: Not all p lan s h ave p art icip at in g p rovid er b en ef it s ou t sid e of you r st at e of resid en ce. To con f irm you r b en ef it s, or if you h ave an y q u est ion s, p lease con t act t h e EM I Healt h cu st om er service t eam t oll f ree at 80 0.662.5851.

M ob ile Ap p You r b en ef it s. An y t im e. An yw h ere.

ID Card Access you r ID Card f rom an yw h ere at an y t im e.

Provid er Search

EOBs

Fin d in -n et w ork p rovid ers an d facilit ies.

View you r EOBs an d search b y p erson , service, d at e, an d m ore.

Plan In f orm at ion

Cu st om er Ser vice

View an d d ow n load you r p lan g rid s so you alw ays kn ow t h e b en ef it s you h ave.

Need t o t alk t o a p erson? No p rob lem . Call u s f rom t h e ap p .

Ot h er Feat u res - Access cu rren t an d p ast issu es of t h e Hop e Healt h n ew slet t er.

If you h aven 't reg ist ered you r accou n t , you can d o so in t h e ap p or on lin e at em ih ealt h .com .

- Up d at e you r p rof ile in form at ion like em ail ad d ress, p assw ord , or secu rit y q u est ion s.

Scan t h is QR cod e w it h you r p h on e t o d ow n load .

Read in g You r EOB

In t eg rat ed Care M an ag em en t On e con n ect ion f or all you r clin ical n eed s. EM I Healt h h as p art n ered w it h M ag ellan Rx M an ag em en t t o su p p ort ou r m em b ers t h rou g h t h eir w elln ess jou rn ey. W e offer a rob u st Healt h & W elln ess Prog ram . Th is p rog ram w orks t o en su re t h at m em b ers w it h com p lex m ed ical n eed s receive care in a cost effect ive an d t im ely m an n er.

How d o w e d o t h is? Nu rses, p h arm acist s, m en t al h ealt h social w orkers, an d w elln ess coach es w ork t og et h er w it h in t h e sam e t eam t o m ake su re t h e care, ad vice, an d assist an ce you n eed is con sist en t . Th is elim in at es w ast ed t im e an d d ecreases cost s t o b ot h you an d you r p lan .

Person al Care Th in k of an in t eg rat ed t eam in t h is w ay: you w on 't h ave t o rep eat you r st ory t o m u lt ip le p rofession als across d ifferen t d iscip lin es b ecau se t h e M ag ellan Rx M an ag em en t t eam sit s t og et h er an d w orks t og et h er so t h ey are m ore aw are of you an d you r n eed s. Keep h ealt h y an d en joy low ers cost s t h rou g h a h ealt h y lifest yle an d a resou rce t o h elp you t ake ad van t ag e of you r b en ef it s b ecau se w h en you are h ealt h y, everyon e is h ap p y.

Sm art Cost Calcu lat or Kn ow you r cost s b ef ore you g o. EM I Healt h 's Sm art Cost Calcu lat or allow s you t o com p are d ifferen t p roced u res, p rovid ers, an d h osp it als t o see est im at ed cost s b ased on you r search crit eria.

Proced u re Cost s See d at a f rom local h osp it als an d p rovid ers n ear you or search in a sp ecif ied area. See h ow m u ch sp ecif ic p roced u res t yp ically cost an d you r ou t of p ocket exp en ses. Provid er Review s Search for p rovid ers an d see t h e review s t h eir p at ien t s left . Th is t ool h elp s en su re you are visit in g a p rovid er t h at w ill m eet you r n eed s. Facilit y Locat ion s an d Cost s Get h osp it al an d clin ic d irect ion s, p at ien t review s, an d overall h osp it al rat in g s so you visit t h e p rop er facilit y t h at w ill t ake care of you r com p let e h ealt h care sit u at ion .

Here's h ow t o u se it 1. Log in t o you r M y EM I Healt h accou n t . 2. Click t h e Sm ar t Cost Calcu lat or b u t t on . 3. Search f or ser vices En t er t h e d oct or, h osp it al, or p roced u re you 're lookin g for. 4 . Com p are cost s Select t h e d oct or, h osp it al, or p roced u re t o see review s, com p are cost s, an d g et m ore d et ails on w h at you n eed .

*Ch an g e Healt h care is a cost t ran sp aren cy solu t ion t h e p rovid es p ricin g in form at ion on som e m ed ical services an d p rescrip t ion s. Th is in form at ion is in t en d ed t o b e an est im at e of t h e t ot al am ou n t you m ay exp ect t o p ay for t h e p rescrip t ion or service, an d is n ot g u aran t eed at t h e p oin t of care.

Preven t ive Care Preven t ive care d et ect s p ot en t ial p rob lem s early w h en t h ey are easier t o t reat . Th e Afford ab le Care Act (ACA) p rovid es for p reven t ive services rat ed A or B t o b e covered 10 0 p ercen t w h en received b y p art icip at in g p rovid ers. Preven t ive services are t h ose p rovid ed w h en n o sym p t om s or d iag n osed m ed ical con d it ion s exist . For services t o b e covered as p reven t ive, you r d oct or m u st b ill claim s w it h p reven t ive cod es. If a p reven t ive service id en t if ies a con d it ion t h at n eed s fu rt h er t est in g or t reat m en t , reg u lar cop aym en t s, coin su ran ce, or d ed u ct ib les m ay ap p ly. Here are som e som e p reven t ive ser vices covered w it h n o p at ien t cost : - Rou t in e p h ysical exam - Rou t in e vision exam - Rou t in e h earin g exam

- Rou t in e g yn ecolog ical exam - Rou t in e Pap sm ear - Screen in g m am m og ram

- Screen in g colon oscop y - FDA-ap p roved con t racep t ion

Im m u n izat ion s recom m en d ed b y t h e Ad visory Com m it t ee on Im m u n izat ion s Pract ices of t h e Cen t er for D isease Con t rols an d Preven t ion (CD C) are covered 10 0 p ercen t if received f rom a p art icip at in g p rovid er. As of Novem b er 20 17, t h ose recom m en d at ion s are as follow s:

Children VACCINE

Birt h 1 M o 2 M o 4 M o 6 M o 12 M o 15 M o 18 M o 19-23 M o 2-3 Yrs 4 -6 Yrs

Hep at it is B

Hep B

Rot aviru s

Hep B RV

D ip h t h eria, Tet an u s, Pert u ssis

Hep B RV

Hib

In act ivat ed Polioviru s

IPV

11-12 Yrs

13-18 Yrs

Hep B Cat ch Up

DTaP DTaP DTaP

Haem op h ilu s In flu en zae Typ e b

Hib

M easles, M u m p s, Ru b ella Varicella

DTaP

PCV PCV PCV

DTaP Cat ch Up

DTaP

DTaP Cat ch Up

Hib IPV

IPV

Polioviru s Cat ch Up

MMR

M M R Cat ch Up

Varicella

Pn eu m ococcal

7-10 Yrs

Varicella

Varicella Cat ch Up

PCV

In flu en za

In flu en za (Yearly)

Hep at it is A

Hep A (2 D oses)

Hep A Cat ch Up

M en in g ococcal

M en ACW Y M en ACW Y

Hu m an Pap illom aviru s

HPV

HPV Cat ch Up

Adults VACCINE

19-26 Yrs

D ip h t h eria, Tet an u s, Pert u ssis (Td /Td ap In flu en za Pn eu m ococcal Zost er (Sh in g les)*

27-49 50 -59 Yrs 60 -64 Yrs ? 65 Yrs Yrs On e d ose of Td ap ; t h en b oost w it h Td every 10 years On e d ose an n u ally 1 or 2 d oses 1 d ose Sh in g rix ÂŽ vaccin e: 2-d ose im m u n izat ion aft er 50 Zost avax ÂŽ vaccin e: 1-d ose aft er ag e 60

IF NOT RECEIVED AS A CHILD M easles M u m p s, Ru b ella Hu m an Pap illom aviru s Varicella

MMR HPV Varicella

*On ly on e of t h e sh in g les vaccin es are n ecessary. EM I Healt h covers b ot h old an d n ew vaccin es. If you h ave alread y h ad t h e sh in g les vaccin e, you d o n ot n eed t h e n ew vaccin e an d a secon d , u n n ecessary vaccin e is n ot covered b y EM I Healt h .

Fin d t h e fu ll list of p reven t ive services at h t t p ://b it .ly/USPSTF_AB. Th e list is su b ject t o ch an g e b ased on fed eral g u id elin es. Th is in form at ion d oes n ot ap p ly t o g ran d fat h ered p lan s. Please see you r su m m ary of b en ef it s an d m em b er h an d b ook on t h e d et ails of you r sp ecif ic p lan . 16

M ajor D iag n ost ic Test in g Preaut horizat ion Guidelines Ben ef it p reau t h orizat ion t o con f irm m ed ical n ecessit y is req u ired for cert ain services as p art of ou r com m it m en t t o h elp en su re all EM I Healt h m em b ers g et t h e ap p rop riat e care, at t h e ap p rop riat e t im e, in t h e ap p rop riat e set t in g . EM I Healt h con t in u ally m on it ors p roced u res req u irin g p reau t h orizat ion an d m akes ad ju st m en t s as n ecessary.

Recen t u p d at es For t h e n ew p lan year (p lan s ren ew in g on or aft er 07/0 1/20 20 ), m ajor d iag n ost ic t est s w ill req u ire p reau t h orizat ion .

Im p or t an t m em b er d et ails As a rem in d er, if t h e m em b er u ses a p art icip at in g p rovid er, t h e p rovid er (n ot t h e m em b er) is resp on sib le for p reau t h orizat ion . If t h e m em b er u ses a n on -p art icip at in g p rovid er for t reat m en t s or p roced u res req u irin g p reau t h orizat ion , t h e m em b er is resp on sib le for ob t ain in g p reau t h orizat ion , an d b en ef it s m ay b e d en ied or red u ced if p reau t h orizat ion is n ot ob t ain ed . Refer t o t h e p lan d ocu m en t for m ore in form at ion reg ard in g p reau t h orizat ion .

A h ear t f el t t h an k you We ap p reciat e t h e op p ort u n it y of p rovid in g you r h ealt h care coverag e. If you h ave an y q u est ion s ab ou t t h is n ot ice, p lease d o n ot h esit at e t o call or em ail u s. Ph on e: 80 0.662.5851 Em ail: cs@em ih ealt h .com

D iab et es M an ag em en t You r m ed ical p lan covers d iab et ic eq u ip m en t an d su p p lies u n d er t h e m ajor m ed ical b en ef it an d /or Prescrip t ion D ru g (Ph arm acy) Ben ef it . Con t act cu st om er service for t h e sp ecif ics of you r p lan . Here are som e com m on coverag es.

D iab et ic t est in g su p p lies D iab et ic t est in g su p p lies, su ch as b lood su g ar (g lu cose) t est st rip s, an d lan cet s, m ay b e covered t h rou g h you r M ajor M ed ical or Prescrip t ion D ru g Ben ef it :

M ajor M ed ical Ben ef it s Coverag e falls u n d er t h e M ed ical Su p p lies & Eq u ip m en t b en ef it . Refer t o t h e D iab et ic Test in g Su p p lies lin e it em of you r Sch ed u le of Ben ef it s for you r m em b er cost sh are. Th e follow in g su p p liers are p art icip at in g p rovid ers on EM I Healt h p lan s. If you ob t ain su p p lies t h rou g h an y ot h er m ed ical p rovid er or facilit y, b en ef it s are su b ject t o you r Non -Part icip at in g Provid er b en ef it op t ion , if an y. - Byram Healt h care - 80 0 -775-4372 - Ed g ep ark / Card in al - 877-215-2568 - JQ M ed ical Su p p ly - 80 1-942-8582

Prescrip t ion D ru g (Ph arm acy) Ben ef it Refer t o t h e Prescrip t ion D ru g sect ion of you r Sch ed u le of Ben ef it s for you r m em b er cost sh are. Th e 20 20 form u lary in clu d es On eTou ch an d Freest yle. All ot h er b ran d s are exclu d ed f rom coverag e.

Con t in u ou s Glu cose M on it orin g Syst em s (CGM S) an d Sen sors CGM S an d sen sors m ay b e covered t h rou g h you r M ajor M ed ical or Prescrip t ion D ru g Ben ef it , su b ject t o p reau t h orizat ion crit eria an d p lan review . Refer t o t h e D u rab le M ed ical Eq u ip m en t an d Prescrip t ion D ru g sect ion s of you r Sch ed u le of Ben ef it s for you r m em b er cost sh are.

In su lin p u m p an d in su lin p u m p su p p lies In su lin p u m p s are covered t h rou g h you r M ajor M ed ical Ben ef it , su b ject t o p reau t h orizat ion crit eria an d p lan review . Refer t o t h e D u rab le M ed ical Eq u ip m en t sect ion of you r Sch ed u le of Ben ef it s for you r m em b er cost sh are. In su lin p u m p su p p lies (cart rid g es an d in fu sion set s) m ay b e covered t h rou g h you r M ajor M ed ical or Prescrip t ion D ru g Ben ef it . Refer t o t h e D u rab le M ed ical Eq u ip m en t an d Prescrip t ion D ru g sect ion s of you r Sch ed u le of Ben ef it s for you r m em b er cost sh are.

D iab et es M an ag em en t In su lin In su lin is covered u n d er t h e Prescrip t ion D ru g Ben ef it . You m ay receive u p t o a 30 -d ay su p p ly p er ret ail cop aym en t or u p t o a 90 -d ay su p p ly p er m ail-ord er cop aym en t . Refer t o t h e Prescrip t ion D ru g sect ion of you r Sch ed u le of Ben ef it s for m em b er cost sh are. - Preferred in su lin cop aym en t s w ill b e cap p ed at $25 p er 30 -d ay su p p ly an d $75 p er 90 -d ay su p p ly t h rou g h t h e Cig n a/Exp ress Scrip t s Pat ien t Assu ran ce Prog ram . - Preferred in su lin s are Hu m alog , Hu m u lin , an d Lan t u s.

Prescrip t ion D ru g s Prescrip t ion d ru g s are covered u n d er t h e Prescrip t ion D ru g Ben ef it . Th is in clu d es Glu cag on , GLPI ag en t s (e.g ., Byet t a, Byd u reon , an d Trad jen t a), an d oral ag en t s for Typ e 2 d iab et es (e.g ., Glu cop h ag e, Avan d ia, an d Am aryl). Refer t o t h e Prescrip t ion D ru g sect ion of you r Sch ed u le of Ben ef it s for m em b er cost sh are. Blood su g ar t est in g m on it ors, g lu cose con t rol solu t ion s, an d w eig h t loss m ed icat ion s are NOT covered u n d er t h e M ajor M ed ical or Prescrip t ion D ru g Ben ef it s.

Ph arm acy, M ail Ord er & Ret ail 90 Get a 90 -d ay su p p ly of m ain t en an ce m ed icat ion s at t h ree p ar t icip at in g p h arm acies: Cost co, Sam 's Clu b , an d W alm art .

How D oes t h e 90 -D ay Ret ail Fill W ork ? 1. Ask you r d oct or for a p rescrip t ion for a 90 -d ay su p p ly (p lu s ref ills, as ap p licab le). 2.Take you r p rescrip t ion t o a Cost co, Sam ?s Clu b , or W alm art p h arm acy. 3.You w ill p ay t h ree t im es t h e 30 -d ay ret ail cop aym en t for you r p lan . Th e exact am ou n t you p ay w ill d ep en d on w h et h er you r m ed icat ion is g en eric, p referred , or n on -p referred b ran d . Please refer t o you r Su m m ary of Ben ef it s for t h e d et ails of you r p lan .

How D oes M ail Ord er W ork ? 1. Ask you r d oct or for a p rescrip t ion for a 90 -d ay su p p ly (p lu s ref ills, as ap p licab le). 2. If you n eed t o st art t akin g t h e m ed icat ion rig h t aw ay, ask for an ot h er p rescrip t ion for u p t o a 30 -d ay su p p ly t o b e ref illed at a ret ail p h arm acy. 3. Sen d t h e 90 -d ay p rescrip t ion , alon g w it h t h e com p let ed m ail-ord er form (w h ich can b e d ow n load ed f rom w w w .em ih ealt h .com ) an d t h e ap p rop riat e cop aym en t , t o Exp ress Scrip t s at t h e ad d ress on t h e form . (You m ay also ask you r d oct or t o fax you r ord er t o Exp ress Scrip t s) 4 . You w ill p ay t h e M ail-ord er Cop aym en t am ou n t in d icat ed on you r Su m m ary of Ben ef it s. Th e exact am ou n t w ill d ep en d on w h et h er you r m ed icat ion is g en eric, p referred , or n on -p referred b ran d . 5. Exp ress Scrip t s w ill p rocess t h e ord er an d ret u rn it via U.S. M ail or UPS, alon g w it h in st ru ct ion s for fu t u re ref ills. Allow u p t o 14 d ays for d elivery f rom t h e t im e you m ail t h e p rescrip t ion .

Not e Plan s en rolled in t h e Sm art 90 m ain t en an ce p rog ram are n ot elig ib le for t h is b en ef it .

Op ioid D isp osal EM I Heal t h t ak es t h e op ioid crisis ver y seriou sly, w h ich is w h y it is im p ort an t t o p rop erly d isp ose of op ioid m ed icat ion s. Im p rop er d isp osal of op ioid m ed icat ion s can lead t o ad d ict ion an d su fferin g b y ot h ers an d h arm fu l im p act s on t h e en viron m en t .

D O: D isp ose of lef t over or exp ired op ioid s. Keep in g left over or exp ired op ioid s arou n d is d an g erou s t o you an d ot h ers w h o m ay com e across t h ese m ed icat ion s. Use a local Rx d rop b ox. Th ese p erm an en t d rop sit es are f ree an d can b e fou n d at p art icip at in g p h arm acies an d law en forcem en t ag en cies t h rou g h ou t you r st at e. Fin d t h e n earest locat ion u sin g t h e D EA's w eb sit e h ere: d ead iverst ion .u sd oj.g ov/p u b d isp search /

D ON'T: Give lef t over op ioid s t o f rien d s or fam ily. M ost p eop le ad d ict ed t o op ioid s g et t h em f rom a fam ily m em b er. D o n ot b e t h e sou rce of t h eir ad d ict ion . Th row you r m ed icat ion s in t h e t rash . Peop le can st ill accid en t ally or in t en t ion ally com e across t h ese m ed icat ion s t h rou g h you r g arb ag e. Flu sh you r m ed icat ion s d ow n t h e sin k or t oilet . Flu sh in g op ioid s d ow n t h e sin k or t oilet can h arm b ot h t h e g rou n d w at er an d local w ild life.

By t h e n u m b ers You CAN m ak e a d if f eren ce.

116 Am erican s

Help p u t a STOP t o t h e op ioid ep id em ic .

d ie every d ay f rom op ioid overd ose. ose 4 0 % of all dopeatioidh s overd in volve a p rescrip t ion op ioid .

11.5 M illion p eop le Sou rces: 1. CD C/NCHS, Nat ion al Vit al St at ist ics Syst em s, M ort alit y. CD C W on d er, At lan t a, GA: US D ep art m en t of Healt h an d Hu m an Services, CD C;20 17. Ht t p s://w on d er.cd c.g ov. 2. h t t p ://u seon lyasd irect ed .org /t h row -ou t /

m isu sed p rescrip t ion op ioid s in 20 16.

The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list (formulary) that is at the core of your prescription plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate.

2021 Express Scripts National Preferred Formulary KEY [INJ] - Injectable Drug Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.

A ABILIFY MAINTENA [INJ] acetaminophen/codeine ACTEMRA [INJ] acyclovir ADEMPAS ADVAIR HFA ADVATE [INJ] ADYNOVATE [INJ] AFSTYLA [INJ] AIMOVIG [INJ] AJOVY [INJ] albuterol nebulization solution albuterol sulfate hfa (by Cipla, Par, Perrigo, Proficient Rx & Teva) ALECENSA alendronate allopurinol ALPHAGAN P 0.1% alprazolam ALUNBRIG amiodarone amitriptyline amlodipine amlodipine/benazepril amlodipine/valsartan amoxicillin amoxicillin/potassium clavulanate AMZEEQ anastrozole ANDRODERM ANORO ELLIPTA ARALAST NP [INJ] ARIKAYCE aripiprazole ARISTADA [INJ] ARMONAIR RESPICLICK ARNUITY ELLIPTA ASMANEX HFA ASMANEX TWISTHALER atenolol atenolol/chlorthalidone atomoxetine atorvastatin AUSTEDO AVONEX [INJ] AZASITE azelastine nasal spray azithromycin AZOPT

B baclofen

BAQSIMI BARACLUDE SOLUTION BAXDELA BD AUTOSHIELD DUO NEEDLES BD ULTRAFINE INSULIN SYRINGES BD ULTRAFINE PEN NEEDLES BELBUCA benazepril benzonatate BETASERON [INJ] BETHKIS BEVESPI AEROSPHERE BIKTARVY bisoprolol/hctz blisovi fe BOSULIF BREO ELLIPTA BRILINTA budesonide nebulization suspension bupropion bupropion ext-release buspirone butalbital/acetaminophen/ caffeine BYDUREON [INJ] BYETTA [INJ] BYSTOLIC

C CABOMETYX carbidopa/levodopa carvedilol cefdinir cefuroxime axetil celecoxib cephalexin CERDELGA CEREZYME [INJ] CETROTIDE [INJ] CHANTIX chlorhexidine gluconate chlorthalidone CIMDUO ciprofloxacin citalopram clarithromycin CLENPIQ clindamycin hcl clindamycin phosphate topical clindamycin phosphate/ benzoyl peroxide clobetasol propionate clomiphene citrate clonazepam clonidine clopidogrel clotrimazole/betamethasone dipropionate colchicine tablets COMBIGAN

PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card.

ergocalciferol ERIVEDGE ERLEADA erythromycin eye ointment ESBRIET escitalopram esomeprazole magnesium delayed-release ESPEROCT [INJ] D estradiol estradiol patches DALIRESP estradiol/norethindrone DAYTRANA acetate DESCOVY ESTRING desloratadine eszopiclone desvenlafaxine succinate etonogestrel-ee vaginal ring ext-release EUFLEXXA [INJ] dexamethasone DEXCOM RECEIVER, SENSOR, ezetimibe ezetimibe/simvastatin TRANSMITTER dexmethylphenidate ext-release F dextroamphetamine/ famotidine amphetamine FARXIGA dextroamphetamine/ amphetamine ext-release FASENRA [INJ] fenofibrate diazepam fenofibrate micronized diclofenac sodium fenofibric acid delayed-release delayed-release dicyclomine fentanyl patches digoxin FETZIMA diltiazem ext-release FINACEA FOAM diphenoxylate/atropine finasteride divalproex delayed-release FLECTOR divalproex ext-release FLOVENT DISKUS DIVIGEL FLOVENT HFA donepezil fluconazole doxazosin fluocinonide doxycycline hyclate fluoxetine doxycycline monohydrate fluticasone nasal spray DUAVEE folic acid DULERA FORTEO [INJ] duloxetine delayed-release FRAGMIN [INJ] DUPIXENT [INJ] FREESTYLE KITS/METERS: DYANAVEL XR FREESTYLE FREEDOM, DYMISTA FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, E FREESTYLE LITE EDARBI FREESTYLE LIBRE & LIBRE 2 EDARBYCLOR READER, SENSOR ELIQUIS FREESTYLE TEST STRIPS: ELOCTATE [INJ] FREESTYLE, EMGALITY [INJ] FREESTYLE INSULINX, EMVERM FREESTYLE LITE enalapril FULPHILA ENBREL [INJ] furosemide ENDOMETRIN FYCOMPA enoxaparin [INJ] ENSTILAR G ENTRESTO gabapentin EPCLUSA GAMMACORE EPIDIOLEX GELNIQUE epinephrine auto-injector gemfibrozil (by Mylan, Teva) [INJ] GENOTROPIN [INJ] EPIPEN, EPIPEN JR [INJ] COMBIPATCH COMBIVENT RESPIMAT COMETRIQ CORLANOR CREON cyanocobalamin [INJ] cyclobenzaprine

GENVOYA GILENYA GILOTRIF GLASSIA [INJ] glimepiride glipizide glipizide ext-release GLUCAGEN [INJ] GLUCAGON [INJ] glyburide GLYXAMBI GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT [INJ] GRASTEK guanfacine ext-release GVOKE [INJ]

H HARVONI HUMALOG [INJ] HUMIRA [INJ] HUMULIN [INJ] hydralazine hydrochlorothiazide hydrocodone/acetaminophen hydrocodone/ chlorpheniramine polistirex ext-release hydrocortisone topical hydromorphone hydroxychloroquine hydroxyzine hcl hydroxyzine pamoate HYSINGLA ER

I ibandronate IBRANCE ibuprofen INBRIJA INCRUSE ELLIPTA indomethacin INLYTA INVELTYS INVOKAMET INVOKAMET XR INVOKANA irbesartan IRESSA isosorbide mononitrate ext-release

J JANUMET, JANUMET XR JANUVIA JARDIANCE JIVI [INJ] JULUCA junel junel fe (continued)

Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com. 22 Â© 2020 Express Scripts. All Rights Reserved. CRP2005_003097.1 #1702 NP-A All trademarks are the property of their respective owners.

Page 1

PRMT22157-21 (09/04/20)

morphine sulfate ext-release MOVANTIK moxifloxacin eye solution mupirocin MUSE MVASI [INJ] MYDAYIS MYRBETRIQ

TRESIBA [INJ] triamcinolone topical ketoconazole topical pantoprazole delayed-release SAVELLA triamterene/hctz ketorolac paroxetine hcl SEGLUROMET TRIJARDY XR KITABIS PAK penicillin v potassium SEREVENT DISKUS tri-lo-marzia KOGENATE FS [INJ] PENTASA sertraline trinessa KOVALTRY [INJ] PERFOROMIST sildenafil TRIPTODUR [INJ] KUVAN PHOSLYRA SIMPONI 100 MG (for tri-sprintec KYLEENA PICATO ulcerative colitis only) [INJ] TRIUMEQ pioglitazone simvastatin TRULANCE N PLEGRIDY [INJ] SKYLA TRULICITY [INJ] L polymyxin/trimethoprim SKYRIZI [INJ] nabumetone TYMLOS [INJ] labetalol eye solution SOLIQUA [INJ] NAMZARIC lamotrigine SOLOSEC naproxen, naproxen sodium POMALYST U lansoprazole delayed-release NARCAN NASAL SPRAY potassium chloride SOMATULINE DEPOT [INJ] LANTUS [INJ] ext-release SPIRIVA HANDIHALER UCERIS FOAM NASCOBAL latanoprost eye solution pramipexole SPIRIVA RESPIMAT UPTRAVI NATESTO LATUDA pravastatin spironolactone NAYZILAM LEVEMIR [INJ] PRECISION XTRA METERS, sprintec neomycin/polymyxin/ V levetiracetam TEST STRIPS, SPRYCEL hydrocortisone ear solution levocetirizine B-KETONE STRIPS STEGLATRO valacyclovir NEXLETOL levofloxacin prednisolone acetate STEGLUJAN valsartan NEXLIZET levothyroxine sodium eye suspension STELARA SC [INJ] niacin ext-release valsartan/hctz LICART PATCHES prednisolone sodium STIOLTO RESPIMAT VARUBI nifedipine ext-release lidocaine patches phosphate STRENSIQ [INJ] VASCEPA NINLARO LINZESS SUBLOCADE [INJ] VELPHORO nitrofurantoin macrocrystal prednisone liothyronine pregabalin sulfamethoxazole/ venlafaxine NITYR LIPOFEN PREMARIN CREAM trimethoprim venlafaxine ext-release NIVESTYM [INJ] lisinopril PREMARIN TABLETS sumatriptan verapamil ext-release NORDITROPIN [INJ] lisinopril/hctz PREMPHASE SUNOSI VERZENIO nortriptyline LIVALO PREMPRO SUPREP VIBERZI NOVAREL [INJ] LO LOESTRIN FE PROCRIT [INJ] SUTENT VIIBRYD NOVOEIGHT [INJ] LOKELMA progesterone micronized SYMBICORT VIMPAT NOVOFINE AUTOSHIELD lorazepam PROLASTIN C [INJ] SYMFI VIOKACE NEEDLES LORBRENA promethazine SYMFI LO VIZIMPRO NOVOFINE NEEDLES losartan promethazine/ SYMJEPI [INJ] VOSEVI NOVOTWIST NEEDLES losartan/hctz dextromethorphan SYMLINPEN [INJ] NUBEQA VUMERITY LOTEMAX GEL/OINTMENT propranolol SYMPROIC NUCALA [INJ] VYVANSE LOTEMAX SM propranolol ext-release SYMTUZA NUEDEXTA loteprednol eye drops PULMICORT FLEXHALER SYNJARDY, SYNJARDY XR nystatin W lovastatin nystatin topical LUMIGAN warfarin Q T LUPANETA [INJ] O QNASL tacrolimus topical LUPRON DEPOT X QUDEXY XR tadalafil 3.75 MG, 11.25 MG [INJ] ODACTRA quetiapine TALICIA LUPRON DEPOT-PED [INJ] ODEFSEY XALKORI QUILLICHEW ER TALTZ [INJ] LYNPARZA ODOMZO XARELTO QUILLIVANT XR TALZENNA LYUMJEV [INJ] OFEV XELJANZ, XELJANZ XR quinapril tamoxifen ofloxacin XIFAXAN QVAR REDIHALER tamsulosin ext-release olanzapine XIGDUO XR M TASIGNA olmesartan XIIDRA MAYZENT TAYTULLA olmesartan/hctz XOLAIR [INJ] R meclizine TAZORAC GEL omega-3 acid ethyl esters XTANDI medroxyprogesterone omeprazole delayed-release rabeprazole delayed-release TAZORAC 0.05% CREAM XULTOPHY [INJ] meloxicam RAGWITEK TECFIDERA ondansetron XYREM metaxalone raloxifene TEGSEDI [INJ] ondansetron orally metformin ramipril TEKTURNA HCT disintegrating tablets Y metformin ext-release RASUVO [INJ] TEMIXYS ONETOUCH KITS/METERS: methimazole REBIF [INJ] terazosin YONSA ULTRA 2, ULTRAMINI, methocarbamol RECTIV terconazole vaginal YUPELRI VERIO, VERIO FLEX methotrexate RELISTOR [INJ] testosterone cypionate [INJ] yuvafem ONETOUCH TEST STRIPS: methylphenidate RELISTOR TABLETS THALOMID ULTRA, VERIO methylphenidate ext-release ONEXTON REMICADE [INJ] timolol maleate eye solution Z methylprednisolone REPATHA [INJ] tizanidine OPSUMIT metoclopramide RESTASIS TOBI PODHALER ZARXIO [INJ] ORALAIR metoprolol succinate RETACRIT [INJ] TOBRADEX OINTMENT ZEJULA ORILISSA ext-release REVLIMID TOBRADEX ST ZENPEP ORTHOVISC [INJ] metoprolol tartrate RHOPRESSA tobramycin eye solution ZEPATIER oseltamivir metronidazole RINVOQ ER tobramycin/dexamethasone ZEPOSIA OTEZLA metronidazole topical risperidone eye suspension ZERVIATE OTOVEL metronidazole vaginal rizatriptan topiramate ZIEXTENZO [INJ] OVIDREL [INJ] microgestin fe ropinirole TOUJEO [INJ] ZIOPTAN oxcarbazepine minocycline rosuvastatin TOVIAZ ZIRABEV [INJ] oxybutynin ext-release MIRENA RUBRACA TRACLEER SUSPENSION zolpidem oxycodone mirtazapine RUCONEST [INJ] tramadol zolpidem ext-release oxycodone/acetaminophen MIRVASO RUXIENCE [INJ] travoprost eye solution ZOMIG NASAL OXYCONTIN MITIGARE RYBELSUS TRAZIMERA [INJ] ZTLIDO OZEMPIC [INJ] mometasone trazodone ZUBSOLV MONOVISC [INJ] TRELEGY ELLIPTA ZYLET montelukast TREMFYA [INJ] ZYTIGA 500 MG Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com. 23 Â© 2020 Express Scripts. All Rights Reserved. CRP2005_003097.1 #1702 NP-A All trademarks are the property of their respective owners.

Page 2

PRMT22157-21 (09/04/20)

2021 National Preferred Formulary Exclusions The excluded medications shown below are not covered on the Express Scripts drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price. Take action to avoid paying full price. If you’re currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specific questions about your coverage, please call the number on your member ID card. Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund. These excluded medications do not apply to Medicare plans.

Drug Class ANTIINFECTIVES Antibiotic Agents - Vancomycins (Oral)

Excluded Medications

Preferred Alternatives

FIRVANQ

vancomycin capsules

Antifungal Agents (Oral)

TOLSURA

itraconazole

Antivirals (Oral)

SITAVIG

acyclovir oral or cream, famciclovir, valacyclovir

LUCEMYRA

clonidine

APTIOM

carbamazepine, oxcarbazepine, pregabalin, topiramate, VIMPAT

FINTEPLA

DIACOMIT, EPIDIOLEX

TOPIRAMATE ER CAPSULES

topiramate tablets, QUDEXY XR

VYEPTI

AIMOVIG, AJOVY, EMGALITY

GOCOVRI ER

amantadine capsules, amantadine tablets, amantadine oral solution

XADAGO, ZELAPAR

rasagiline, selegiline

Antipsychotics (Oral)

CAPLYTA

aripiprazole, olanzapine, quetiapine er, quetiapine fumarate, risperidone, ziprasidone, LATUDA

Antispasmodic Agents

OZOBAX

baclofen, tizanidine

Central Nervous System Stimulants

AMPHETAMINE ER SUSPENSION

dextroamphetamine er, dextroamphetamine/amphetamine er, DYANAVEL XR, MYDAYIS, QUILLICHEW ER, QUILLIVANT XR, VYVANSE

EMFLAZA

prednisone solution, prednisone tablets

EXONDYS 51, VYONDYS 53

No alternatives recommended

Lambert-Eaton Myasthenic Syndrome Agents

FIRDAPSE

RUZURGI

Long-Acting Opioid Oral Analgesics

EMBEDA, MORPHABOND ER, NUCYNTA ER, OXYCODONE ER, XTAMPZA ER

hydromorphone er, morphine sulfate er, oxymorphone er, HYSINGLA ER, OXYCONTIN

Multiple Sclerosis (Beta Interferons)

EXTAVIA

AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, PLEGRIDY, REBIF, REBIF REBIDOSE

APADAZ, BENZHYDROCODONE/ACETAMINOPHEN

hydrocodone/acetaminophen

NUCYNTA

hydrocodone/acetaminophen, morphine sulfate, oxycodone, tramadol, tramadol/acetaminophen

PRIMLEV

oxycodone/acetaminophen

BUNAVAIL

buprenorphine/naloxone, ZUBSOLV

EVZIO, NALOXONE AUTO-INJECTOR

naloxone syringes, NARCAN NASAL SPRAY

Neuropathic Agents

LYRICA CR

gabapentin, pregabalin

Sedative-Hypnotic Agents

DORAL, QUAZEPAM

estazolam, lorazepam

Serotonin/Norepinephrine Reuptake Inhibitor Antidepressants

DRIZALMA SPRINKLE

desvenlafaxine er, duloxetine, venlafaxine er, FETZIMA

Tardive Dyskinesia Therapy

INGREZZA

AUSTEDO

Transmucosal Fentanyl Analgesics

FENTANYL CITRATE BUCCAL TABLETS, FENTORA, LAZANDA, SUBSYS

fentanyl citrate lozenges

Miscellaneous Antidepressants

SPRAVATO

olanzapine/fluoxetine, bupropion, desvenlafaxine er, duloxetine, escitalopram, mirtazapine, sertraline

AUTONOMIC & CENTRAL NERVOUS SYSTEM Alpha-2 Adrenergic Agonists (for Opioid Withdrawal)

Anticonvulsants

Antimigraine Agents Antiparkinsonism Agents

Duchenne Muscular Dystrophy (DMD) Agents

Narcotic Analgesics & Combinations

Narcotic Antagonists

Page 24 3

204612 DL44109Q-SD-21 (09/04/2020)

Drug Class

Excluded Medications

Preferred Alternatives

EPANED

enalapril

QBRELIS

lisinopril

PRADAXA, SAVAYSA

ELIQUIS, XARELTO

INDERAL XL, INNOPRAN XL

propranolol er

KAPSPARGO SPRINKLE

metoprolol succinate

DUTOPROL

metoprolol tartrate/hydrochlorothiazide, metoprolol succinate er plus hydrochlorothiazide

Calcium Channel Blockers

KATERZIA

amlodipine

HMG & Cholesterol Inhibitor Combinations

ALTOPREV, EZALLOR SPRINKLE, SIMVASTATIN SUSPENSION

atorvastatin, fluvastatin er, lovastatin, pravastatin, rosuvastatin, simvastatin tablets, LIVALO

PCSK9 Inhibitors

PRALUENT

REPATHA

MINOCYCLINE ER CAPSULES, XIMINO

minocycline er tablets

Rosacea Agents (Oral)

DOXYCYCLINE 40 MG CAPSULES

doxycycline hyclate, doxycycline monohydrate

Topical Acne Combinations

EPIDUO FORTE

adapalene/benzoyl peroxide

Topical Acne/Antibiotic Combinations

VELTIN

clindamycin/benzoyl peroxide, clindamycin/tretinoin, erythromycin/benzoyl peroxide, ONEXTON

Topical Agents for Actinic Keratosis

CARAC, FLUOROURACIL 0.5% CREAM, IMIQUIMOD 3.75% CREAM PUMP, ZYCLARA

diclofenac 3% gel, fluorouracil 2% solution, fluorouracil 5% cream, imiquimod 5% cream, PICATO

Topical Antibiotics for Acne

CLINDAGEL, CLINDAMYCIN PHOSPHATE 1% GEL (BY OCEANSIDE)

clindamycin phosphate gel, erythromycin gel, AMZEEQ

Topical Antifungals

ECOZA, LULICONAZOLE, SULCONAZOLE, XOLEGEL

ciclopirox, econazole, ketoconazole, naftifine, oxiconazole

CLOCORTOLONE

betamethasone valerate, fluocinolone acetonide, triamcinolone acetonide

VERDESO FOAM

desonide 0.05% cream/lotion/ointment, desoximetasone 0.25% cream/ointment

Topical Retinoids for Acne

RETIN-A MICRO 0.06% & 0.08%

tretinoin microsphere 0.04% & 0.1%

Vitamin D Analogs (Topical)

CALCIPOTRIENE FOAM

calcipotriene, calcitriol

ALCORTIN A

hydrocortisone, mupirocin

LIDOCAINE/TETRACAINE

lidocaine cream, lidocaine/prilocaine cream

ASCENSIA (BREEZE, CONTOUR) ROCHE (ACCU-CHEK) TRIVIDIA (TRUETEST, TRUETRACK) ALL OTHER METERS & TEST STRIPS THAT ARE NOT LISTED AS PREFERRED

FREESTYLE KITS/METERS: FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE FREESTYLE TEST STRIPS: FREESTYLE, FREESTYLE INSULINX, FREESTYLE LITE ONETOUCH KITS/METERS: ULTRA2, ULTRAMINI, VERIO, VERIO FLEX ONETOUCH TEST STRIPS: ULTRA, VERIO PRECISION XTRA METERS, TEST STRIPS, B-KETONE STRIPS

ALOGLIPTIN, NESINA, ONGLYZA, TRADJENTA

JANUVIA

ALOGLIPTIN/METFORMIN, JENTADUETO, JENTADUETO XR, KAZANO, KOMBIGLYZE XR

JANUMET, JANUMET XR

ALOGLIPTIN/PIOGLITAZONE

pioglitazone plus JANUVIA

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors Combinations

QTERN

GLYXAMBI, STEGLUJAN

Glucagon-Like Peptide-1 Agonists

ADLYXIN, VICTOZA

BYDUREON, BYETTA, OZEMPIC, TRULICITY

NOVOLIN, RELION NOVOLIN

HUMULIN

ADMELOG, APIDRA, FIASP, INSULIN ASPART, INSULIN ASPART PROTAMINE, INSULIN LISPRO, NOVOLOG

HUMALOG, LYUMJEV

CARDIOVASCULAR ACE Inhibitors Anticoagulants

Beta Blockers & Combinations

DERMATOLOGICAL Oral Agents for Acne

Topical Corticosteroids

Miscellaneous Topical Dermatological Agents

DIABETES Blood Glucose Meters & Test Strips

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors & Combinations

Insulins

Page 25 4

204612 DL44109Q-SD-21 (09/04/2020)

Drug Class EAR/NOSE Nasal Steroids

Excluded Medications

Preferred Alternatives

BECONASE AQ, OMNARIS, ZETONNA

budesonide, flunisolide, fluticasone, mometasone, QNASL

CETRAXAL

ciprofloxacin ear solution, ofloxacin ear solution, OTOVEL

CIPROFLOXACIN/FLUOCINOLONE OTIC

ciprofloxacin/dexamethasone otic, OTOVEL

FENSOLVI

LUPRON DEPOT-PED, TRIPTODUR

Growth Hormones

HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, SAIZENPREP, ZOMACTON

GENOTROPIN, NORDITROPIN FLEXPRO

Somatostatin Analogs

SANDOSTATIN LAR DEPOT, SIGNIFOR LAR

SOMATULINE DEPOT

AVEED

testosterone cypionate, testosterone enanthate

JATENZO

testosterone (gel, packets, pump), ANDRODERM

KORLYM

ketoconazole, LYSODREN, SIGNIFOR

MYTESI

diphenoxylate/atropine, loperamide

AKYNZEO CAPSULES

granisetron, ondansetron, aprepitant, VARUBI TABLETS

EMEND POWDER PACKETS

aprepitant, VARUBI TABLETS

Bowel Evacuants

MOVIPREP, OSMOPREP

peg-electrolyte solution, CLENPIQ, SUPREP

Corticosteroids (Rectal Formulations)

CORTIFOAM

hydrocortisone enema, UCERIS FOAM

Helicobacter Pylori Agents

HELIDAC, PYLERA

lansoprazole/amoxicillin/clarithromycin, TALICIA

Hemorrhoidal Preparations

PROCTOFOAM-HC

pramoxine/hydrocortisone

Inflammatory Bowel Agents

DIPENTUM

balsalazide disodium, mesalamine dr, mesalamine er, sulfasalazine, PENTASA

Irritable Bowel Syndrome & Chronic Constipation Agents

AMITIZA

LINZESS, TRULANCE

Pancreatic Enzymes

PANCREAZE, PERTZYE

CREON, ZENPEP

Proton Pump Inhibitors

ACIPHEX SPRINKLE, ESOMEPRAZOLE STRONTIUM, NEXIUM PACKETS, PRILOSEC SUSPENSION, RABEPRAZOLE DR SPRINKLE

esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole, rabeprazole

ASPIRIN/OMEPRAZOLE DR, YOSPRALA DR

aspirin plus omeprazole, esomeprazole, lansoprazole, pantoprazole or rabeprazole

Chelating Agents

JADENU SPRINKLE

deferasirox

Erythropoiesis-Stimulating Agents

ARANESP, EPOGEN, MIRCERA

PROCRIT, RETACRIT

Factor VIII Recombinant Products

NUWIQ, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE

ADVATE, ADYNOVATE, AFSTYLA, ELOCTATE, ESPEROCT, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT

GRANIX, NEUPOGEN

NIVESTYM, ZARXIO

NEULASTA, UDENYCA

FULPHILA, ZIEXTENZO

OXBRYTA

hydroxyurea, ADAKVEO, DROXIA

SIKLOS

DROXIA

MULPLETA

DOPTELET

TAVALISSE

DOPTELET, PROMACTA, NPLATE

LEDIPASVIR/SOFOSBUVIR, MAVYRET, SOFOSBUVIR/VELPATASVIR, SOVALDI

EPCLUSA, HARVONI, VOSEVI, ZEPATIER

ATRIPLA, DELSTRIGO

BIKTARVY, GENVOYA, ODEFSEY, SYMFI, SYMFI LO, SYMTUZA, TRIUMEQ

COMPLERA

ODEFSEY

PIFELTRO

efavirenz, EDURANT

PREZCOBIX

atazanavir, ritonavir, KALETRA TABLETS, PREZISTA

STRIBILD

BIKTARVY, GENVOYA

Otic Fluoroquinolone Antibiotics ENDOCRINE (OTHER) Gonadotropin-Releasing Hormone (GnRH) Analogs (for Central Precocious Puberty)

Testosterone Products Miscellaneous Endocrine Drugs GASTROINTESTINAL Antidiarrheal Agents Antiemetics (Oral)

HEMATOLOGICAL Antiplatelet Agents

Granulocyte Colony Stimulating Factors

Sickle Cell Disease Agents

Thrombocytopenia Agents HEPATITIS Hepatitis C

HIV Antiretrovirals Note: Current patients established on therapy are allowed to continue therapy.

Page 26 5

204612 DL44109Q-SD-21 (09/04/2020)

Drug Class MUSCULOSKELETAL & RHEUMATOLOGY Gout Therapy

Excluded Medications

Preferred Alternatives

COLCHICINE CAPSULES

colchicine tablets, MITIGARE

FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES

fenoprofen calcium tablets, diclofenac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen

INDOMETHACIN 20 MG CAPSULES, KETOROLAC NASAL SPRAY, TIVORBEX, VIVLODEX, ZIPSOR, ZORVOLEX

diclofenac, etodolac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen, piroxicam

RELAFEN DS

nabumetone, diclofenac, ibuprofen, indomethacin, meloxicam, naproxen, piroxicam

DICLOFENAC EPOLAMINE PATCHES

FLECTOR PATCHES

PENNSAID

diclofenac sodium topical, FLECTOR PATCHES

CLIMARA PRO

COMBIPATCH

Estrogen & Estrogen Modifiers for Vaginal Symptoms

FEMRING, INTRAROSA

estradiol cream, estradiol patches, estradiol tablets, yuvafem, ESTRING, PREMARIN CREAM, PREMARIN TABLETS

Human Chorionic Gonadotropin

CHORIONIC GONADOTROPIN, PREGNYL

NOVAREL, OVIDREL

Ovulatory Stimulants (Follitropins)

FOLLISTIM AQ

GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT

Prenatal Vitamins

PREGENNA, TRINAZ

generic prenatal vitamins

Topical Estrogen Gels

ELESTRIN, ESTROGEL

DIVIGEL

CRINONE 4%

medroxyprogesterone, megestrol, norethindrone, progesterone

CRINONE 8%

ENDOMETRIN

AVASTIN

MVASI, ZIRABEV

Breast Cancer Agents

KISQALI, KISQALI FEMARA CO-PACK, PIQRAY

IBRANCE, VERZENIO

Chronic Lymphocytic Leukemia (CLL) Agents

CALQUENCE

IMBRUVICA, VENCLEXTA

Multiple Myeloma Agents

XPOVIO

DARZALEX, KYPROLIS, NINLARO, POMALYST, REVLIMID, THALOMID, VELCADE

Myelofibrosis Agents

INREBIC

JAKAFI

Prostate Cancer Agents

TRELSTAR

ELIGARD, FIRMAGON

Rituximab-Containing Agents

RITUXAN, RITUXAN HYCELA, TRUXIMA

RUXIENCE

Trastuzumab-Containing Agents

HERCEPTIN, HERCEPTIN HYLECTA, HERZUMA, OGIVRI, ONTRUZANT

KANJINTI, TRAZIMERA

Tyrosine Kinase Inhibitors

QINLOCK

imatinib, NEXAVAR, SPRYCEL, STIVARGA, SUTENT, TASIGNA, VOTRIENT

TIMOPTIC OCUDOSE

betaxolol drops, brimonidine 0.15% drops, brimonidine 0.2% drops, levobunolol drops, timolol drops, ALPHAGAN P 0.1%, AZOPT, COMBIGAN

Antiglaucoma Drugs (Ophthalmic Prostaglandins)

DURYSTA, XELPROS

bimatoprost drops, latanoprost drops, travoprost drops, LUMIGAN, ZIOPTAN

Ophthalmic Anti-Allergic

ALOCRIL, ALOMIDE, LASTACAFT, PAZEO

azelastine drops, cromolyn drops, epinastine drops, ketotifen drops, olopatadine drops, ZERVIATE

Ophthalmic Anti-Inflammatory

FML FORTE, FML S.O.P., MAXIDEX, PRED MILD

dexamethasone drops, fluorometholone drops, loteprednol drops, prednisolone drops, INVELTYS, LOTEMAX GEL/OINTMENT

Ophthalmic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

ACUVAIL, NEVANAC

bromfenac drops, diclofenac drops, ketorolac drops

Ophthalmic Quinolone Antibiotics

CILOXAN OINTMENT

ciprofloxacin drops, gatifloxacin drops, levofloxacin drops, moxifloxacin drops, ofloxacin drops

OSTEOARTHRITIS Hyaluronic Acid Derivatives

DUROLANE, GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN, HYMOVIS, SODIUM HYALURONATE, SUPARTZ FX, SYNVISC, SYNVISC-ONE, TRILURON, TRIVISC, VISCO-3

EUFLEXXA, MONOVISC, ORTHOVISC

OSTEOPOROSIS Bone Modifiers

EVENITY, PROLIA

alendronate, ibandronate, risedronate, zoledronic acid, FORTEO, TYMLOS

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) OBSTETRICAL & GYNECOLOGICAL Combination Patches

Vaginal Progesterones ONCOLOGY Bevacizumab-Containing Agents

OPHTHALMIC Antiglaucoma Drugs (Non-Prostaglandins)

Page 27 6

204612 DL44109Q-SD-21 (09/04/2020)

Drug Class RENAL DISEASE Nephropathic Cystinosis Medications

Excluded Medications

Preferred Alternatives

PROCYSBI

CYSTAGON

FOSRENOL POWDER PACKETS

lanthanum, sevelamer carbonate, sevelamer hcl, PHOSLYRA, VELPHORO

AUVI-Q, EPINEPHRINE AUTO-INJECTOR (BY IMPAX)

epinephrine auto-injector (by Mylan), EPIPEN, EPIPEN JR

Immunological Agents for Asthma

CINQAIR

FASENRA, NUCALA

Long-Acting Beta Agonist Inhalers

STRIVERDI RESPIMAT

SEREVENT DISKUS

Long-Acting Muscarinic Antagonist Inhalers

TUDORZA PRESSAIR

INCRUSE ELLIPTA, SPIRIVA HANDIHALER, SPIRIVA RESPIMAT

Long-Acting Muscarinic Antagonist/ Long-Acting Beta-Agonist Combination Inhalers

DUAKLIR PRESSAIR

ANORO ELLIPTA, BEVESPI AEROSPHERE, STIOLTO RESPIMAT

Pulmonary Anti-Inflammatory/ Beta-Agonist Combination Inhalers

AIRDUO RESPICLICK, BUDESONIDE/FORMOTEROL, FLUTICASONE/SALMETEROL (BY A-S MEDICATION, TEVA)

fluticasone/salmeterol (by Prasco, Proficient Rx), ADVAIR HFA, BREO ELLIPTA, DULERA, SYMBICORT

Short-Acting Beta2-Agonist Inhalers

ALBUTEROL SULFATE HFA (BY A-S MEDICATION, PRASCO), LEVALBUTEROL HFA, PROAIR DIGIHALER, PROAIR RESPICLICK, VENTOLIN HFA, XOPENEX HFA

albuterol sulfate hfa (by Cipla, Par, Perrigo, Proficient Rx & Teva)

PALFORZIA

No alternatives recommended

Cushing’s Agents

ISTURISA

SIGNIFOR

Gaucher Disease Agents

ELELYSO

CEREZYME

Hereditary Angioedema

BERINERT

RUCONEST

CUTAQUIG

SC: GAMMAGARD LIQUID, GAMUNEX-C, XEMBIFY

GAMMAKED

IV: GAMMAGARD LIQUID, GAMMAGARD S-D, GAMUNEX-C SC: GAMMAGARD LIQUID, GAMUNEX-C, XEMBIFY

HIZENTRA SYRINGES, HIZENTRA VIALS

SC: XEMBIFY

OTREXUP

RASUVO

Phosphate Binders RESPIRATORY Epinephrine Auto-Injector Systems

MISCELLANEOUS AGENTS Allergen Immunotherapy

Immune Globulins

Immunosuppressant Agents XATMEP

methotrexate

Nocturnal Polyuria Agents

NOCTIVA

desmopressin tablets

Polyneuropathy of Hereditary Transthyretin-Mediated Amyloidosis

ONPATTRO

TEGSEDI

Potassium Binders

VELTASSA

LOKELMA

Indication Based Management Drug Class

Excluded Medications

Preferred Alternatives

Spinal Conditions (nr-axSpA)

COSENTYX

TALTZ, CIMZIA

Inflammatory Conditions‡ where COSENTYX is indicated

COSENTYX

TALTZ, ENBREL, HUMIRA, OTEZLA, SKYRIZI, STELARA SC, TREMFYA, XELJANZ, XELJANZ XR

Drug Class

Inflammatory Conditions‡

Nonpreferred Medications All other Brand Name medications for Inflammatory Conditions are Nonpreferred. Approval may be granted following a coverage review. A trial of one or more Preferred medications is required prior to initiating therapy with a Nonpreferred medication. A formulary exception may be granted for a patient already established on therapy with a Nonpreferred medication.

Preferred Alternatives Preferred: ENBREL, HUMIRA, OTEZLA, RINVOQ ER, SKYRIZI, STELARA SC, TALTZ, TREMFYA, XELJANZ, XELJANZ XR Preferred after Step through HUMIRA: ACTEMRA ULCERATIVE COLITIS ONLY Preferred after Step through HUMIRA: SIMPONI 100 MG, XELJANZ, XELJANZ XR

‡ Please note that product placement for treatment of Inflammatory Conditions in the Inflammatory Conditions Care Value (ICCV) Program are subject to change throughout the year based upon changes in market dynamics, new indications for existing products, biosimilar and new product launches.

Page 28 7

204612 DL44109Q-SD-21 (09/04/2020)

Excluded Medications/Products at a Glance ABILIFY^ ACANYA^ ACIPHEX^ ACIPHEX SPRINKLE ACUVAIL ADCIRCA^ ADDERALL^ ADLYXIN ADMELOG AGGRENOX^ AIRDUO RESPICLICK AKYNZEO CAPSULES ALBUTEROL SULFATE HFA (BY A-S MEDICATION, PRASCO) ALCORTIN A ALOCRIL ALOGLIPTIN ALOGLIPTIN/METFORMIN ALOGLIPTIN/PIOGLITAZONE ALOMIDE ALTOPREV AMBIEN^, AMBIEN CR^ AMITIZA AMPHETAMINE ER SUSPENSION AMPYRA^ AMRIX^ ANDROGEL 1%^ ANDROGEL 1.62%^ ANUSOL-HC^ APADAZ APIDRA APTIOM ARANESP ARIMIDEX^ ASACOL HD^ ASCENSIA (BREEZE, CONTOUR) ASPIRIN/OMEPRAZOLE DR ATACAND^, ATACAND HCT^ ATRALIN^ ATRIPLA AUVI-Q AVALIDE^, AVAPRO^ AVASTIN AVEED AVODART^ AZOR^ BARACLUDE TABLETS^ BECONASE AQ BENICAR^, BENICAR HCT^ BENZHYDROCODONE/ ACETAMINOPHEN BERINERT BRISDELLE^ BUDESONIDE/FORMOTEROL BUNAVAIL BUPAP^ BUTRANS^ CALCIPOTRIENE FOAM CALQUENCE CAPLYTA CARAC CELEBREX^ CELEXA^ CETRAXAL CHORIONIC GONADOTROPIN CIALIS^ CILOXAN OINTMENT CINQAIR CIPROFLOXACIN/FLUOCINOLONE OTIC CLIMARA PRO CLINDAGEL CLINDAMYCIN PHOSPHATE 1% GEL (BY OCEANSIDE) CLOCORTOLONE COLCHICINE CAPSULES COMPLERA CONCERTA^ COREG^ CORTIFOAM COSENTYX COSOPT^ COZAAR^, HYZAAR^ CRESTOR^ CRINONE CUPRIMINE^

CUTAQUIG CYMBALTA^ CYTOMEL^ DELSTRIGO DELZICOL^ DETROL^, DETROL LA^ DICLOFENAC EPOLAMINE PATCHES DIOVAN^, DIOVAN HCT^ DIPENTUM DORAL DOXYCYCLINE 40 MG CAPSULES DRIZALMA SPRINKLE DUAKLIR PRESSAIR DURAGESIC^ DUROLANE DURYSTA DUTOPROL ECOZA EFFEXOR XR^ ELELYSO ELESTRIN ELIDEL^ EMBEDA EMEND CAPSULES^, TRIFOLD PACK^ EMEND POWDER PACKETS EMFLAZA EPANED EPIDUO^ EPIDUO FORTE EPINEPHRINE AUTO-INJECTOR (BY IMPAX) EPOGEN ESOMEPRAZOLE STRONTIUM ESTRACE CREAM^ ESTROGEL ESTROSTEP FE^ EVENITY EVZIO EXFORGE^, EXFORGE HCT^ EXJADE^ EXONDYS 51 EXTAVIA EZALLOR SPRINKLE FEMRING FENOPROFEN CAPSULES FENORTHO FENSOLVI FENTANYL CITRATE BUCCAL TABLETS FENTORA FIASP FINTEPLA FIRAZYR^ FIRDAPSE FIRVANQ FLUOROURACIL 0.5% CREAM FLUTICASONE/SALMETEROL (BY A-S MEDICATION, TEVA) FML FORTE, FML S.O.P. FOCALIN^, FOCALIN XR^ FOLLISTIM AQ FOSRENOL CHEWABLE TABLETS^ FOSRENOL POWDER PACKETS GAMMAKED GANIRELIX ACETATE^ GEL-ONE GELSYN-3 GENERESS FE^ GENVISC 850 GLEEVEC^ GLUCOPHAGE^, GLUCOPHAGE XR^ GLUMETZA^ GOCOVRI ER GRANIX HELIDAC HERCEPTIN, HERCEPTIN HYLECTA HERZUMA HIZENTRA SYRINGES HIZENTRA VIALS HUMATROPE HYALGAN HYMOVIS IMIQUIMOD 3.75% CREAM PUMP IMITREX^ INDERAL LA^ INDERAL XL

INDOMETHACIN 20 MG CAPSULES INGREZZA INNOPRAN XL INREBIC INSULIN ASPART, INSULIN ASPART PROTAMINE INSULIN LISPRO INTRAROSA INTUNIV^ ISTALOL^ ISTURISA JADENU^ JADENU SPRINKLE JATENZO JENTADUETO, JENTADUETO XR KAPSPARGO SPRINKLE KATERZIA KAZANO KEPPRA^, KEPPRA XR^ KETOROLAC NASAL SPRAY KISQALI, KISQALI FEMARA CO-PACK KOMBIGLYZE XR KORLYM LAMICTAL^, LAMICTAL ODT^, LAMICTAL XR^ LASTACAFT LAZANDA LEDIPASVIR/SOFOSBUVIR LETAIRIS^ LEVALBUTEROL HFA LEXAPRO^ LIALDA^ LIBRAX^ LIDOCAINE/TETRACAINE LIDODERM^ LIPITOR^ LOCOID^, LOCOID LIPOCREAM^ LOESTRIN^, LOESTRIN FE^ LOSEASONIQUE^ LOTREL^ LOTRONEX^ LOVENOX^ LUCEMYRA LULICONAZOLE LUNESTA^ LYRICA^ LYRICA CR MAVYRET MAXALT^, MAXALT MLT^ MAXIDEX MESTINON^ MICARDIS^, MICARDIS HCT^ MINASTRIN 24 FE^ MINIVELLE^ MINOCYCLINE ER CAPSULES MIRCERA MIRCETTE^ MORPHABOND ER MOVIPREP MULPLETA MYTESI NALFON CAPSULES NALOXONE AUTO-INJECTOR NAMENDA XR^ NASONEX^ NATROBA^ NESINA NEULASTA NEUPOGEN NEURONTIN^ NEVANAC NEXIUM CAPSULES^ NEXIUM PACKETS NOCTIVA NORCO^ NORVASC^ NOVOLIN NOVOLOG NOXAFIL TABLETS^ NUCYNTA NUCYNTA ER NUTROPIN AQ NUSPIN NUVIGIL^ NUWIQ OGIVRI

OMNARIS OMNITROPE ONGLYZA ONPATTRO ONTRUZANT ORTHO TRI-CYCLEN^, ORTHO TRI-CYCLEN LO^ OSMOPREP OTREXUP OXBRYTA OXYCODONE ER OZOBAX PALFORZIA PANCREAZE PATADAY^ PAZEO PENNSAID PERCOCET^ PERTZYE PIFELTRO PIQRAY PLAQUENIL^ PLAVIX^ PRADAXA PRALUENT PRAVACHOL^ PRED MILD PREGENNA PREGNYL PREVACID^, PREVACID SOLUTAB^ PREZCOBIX PRILOSEC SUSPENSION PRIMLEV PRISTIQ^ PROAIR DIGIHALER PROAIR HFA^ PROAIR RESPICLICK PROCTOFOAM-HC PROCYSBI PROLIA PROTONIX^ PROTONIX SUSPENSION^ PROVENTIL HFA^ PROVIGIL^ PROZAC^ PULMICORT RESPULES^ PYLERA QBRELIS QINLOCK QTERN QUARTETTE^ QUAZEPAM RABEPRAZOLE DR SPRINKLE RANEXA^ RAPAFLO^ RECOMBINATE RELAFEN DS RELION NOVOLIN RENAGEL^ RETIN-A MICRO 0.04% & 0.1%^ RETIN-A MICRO 0.06% & 0.08% RITUXAN, RITUXAN HYCELA ROCHE (ACCU-CHEK) ROZEREM^ SAFYRAL^ SAIZEN, SAIZENPREP SANDOSTATIN LAR DEPOT SAVAYSA SEASONIQUE^ SENSIPAR^ SEROQUEL^, SEROQUEL XR^ SIGNIFOR LAR SIKLOS SIMVASTATIN SUSPENSION SINGULAIR^ SITAVIG SODIUM HYALURONATE SOFOSBUVIR/VELPATASVIR SOVALDI SPRAVATO STRATTERA^ STRIBILD STRIVERDI RESPIMAT SUBSYS SULCONAZOLE

SUPARTZ FX SYNVISC, SYNVISC-ONE TARGRETIN CAPSULES^ TAVALISSE TAZORAC 0.1% CREAM^ TEKTURNA^ TESTIM^ TIKOSYN^ TIMOPTIC OCUDOSE TIVORBEX TOBI SOLUTION^ TOLSURA TOPAMAX^ TOPICORT SPRAY^ TOPIRAMATE ER CAPSULES TOPROL XL^ TRADJENTA TRANSDERM-SCOP^ TRAVATAN Z^ TRELSTAR TREXIMET^ TRIBENZOR^ TRICOR^ TRILEPTAL^ TRILURON TRINAZ TRIVIDIA (TRUETEST, TRUETRACK) TRIVISC TRUXIMA TUDORZA PRESSAIR UDENYCA ULORIC^ UROXATRAL^ VAGIFEM^ VALIUM^ VALTREX^ VANOS^ VELTASSA VELTIN VENTOLIN HFA VERDESO FOAM VESICARE^ VIAGRA^ VICTOZA VISCO-3 VIVELLE-DOT^ VIVLODEX VYEPTI VYONDYS 53 VYTORIN^ WELCHOL 3.75 GM PACKETS^ WELLBUTRIN SR^ WELLBUTRIN XL^ XADAGO XALATAN^ XANAX^, XANAX XR^ XATMEP XELPROS XENAZINE^ XIMINO XOLEGEL XOPENEX HFA XPOVIO XTAMPZA ER XYNTHA, XYNTHA SOLOFUSE YASMIN^ YOSPRALA DR ZAVESCA^ ZEGERID^ ZELAPAR ZETIA^ ZETONNA ZIPSOR ZOCOR^ ZOHYDRO ER^ ZOLOFT^ ZOMACTON ZOMIG TABLETS^, ZOMIG ZMT^ ZONEGRAN^ ZORVOLEX ZOVIRAX OINTMENT^ ZYCLARA ZYTIGA 250 MG^

^ Multisource brand exclusion – The generic equivalent of this brand-name medication is covered under your plan. FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. As new generic medications become available, additional multisource brand products may become excluded.

Page 29 8

204612 DL44109Q-SD-21 (09/04/2020)

Ut ah Hosp it al Net w ork An exp an sive n et w ork t o care f or you , w h erever you are.

Sal t Lak e Cou n t y Prim ary Ch ild ren 's Hosp it al U of U Hosp it al Bu rn Cen t er

LD S Hosp it al Log an Reg ion al Hosp it al

Joh n A. M oran Eye Cen t er

In t erm ou n t ain M ed ical Cen t er

Bear River Valley Hosp it al

TOSH - Th e Ort h op ed ic Sp ecialt y Hosp it al

Rivert on Hosp it al M cKay D ee Hosp it al

Alt a View Hosp it al D avis Hosp it al & M ed ical Cen t er Layt on Hosp it al Park Cit y Hosp it al M ou n t ain W est M ed ical Cen t er

Ash ley Valley M ed ical Cen t er

Heb er Valley Hosp it al Am erican Fork Hosp it al Orem Com m u n it y Hosp it al

Uin t ah Basin M ed ical Cen t er Ut ah Valley Hosp it al Cen t ral Valley M ed ical Cen t er Cast leview Hosp it al San p et e Valley Hosp it al D elt a Com m u n it y Hosp it al

Gu n n ison Valley Hosp it al

M oab Reg ion al Hosp it al

Sevier Valley Hosp it al Fillm ore Com m u n it y Hosp it al

M ilford M em orial Hosp it al

Ced ar Cit y Hosp it al

San Ju an Hosp it al Beaver Valley Hosp it al

Garf ield M em orial Hosp it al Blu e M ou n t ain Hosp it al

D ixie Reg ion al M ed ical Cen t er

Kan e Cou n t y Hosp it al

In t erm ou n t ain Healt h care Ow n ed Hosp it al Hu n t sm an In t erm ou n t ain Can cer Cen t er locat ed at t h is facilit y

In t erm ou n t ain In st aCare & Kid sCare Sal t Lak e Cou n t y

Salt Lake Clin ic In st aCare Taylorsville In st aCare/Kid sCare Nort h Cach e Valley In st aCare

W est Valley In st aCare

Hollad ay In st aCare M em orial In st aCare/Kid sCare Cot t on w ood In st aCare

Log an In st aCare

W est Jord an In st aCare/Kid sCare

Box Eld er In st aCare Nort h Og d en In st aCare

Sou t h rid g e In st aCare/Kid sCare

Sou t h Og d en In st aCare Hereford sh ire In st aCare

Layt on Parkw ay In st aCare Bou n t ifu l In st aCare/Kid sCare Park Cit y In st aCare Tooele In st aCare Heb er Valley In st aCare Leh i In st aCare Sarat og a Sp rin g s In st aCare

Am erican Fork In st aCare

Provo In st aCare

Nort h Orem In st aCare Sp rin g ville In st aCare Payson In st aCare

Ced ar Cit y In st aCare

Su n set In st aCare

Hu rrican e Valley In st aCare

River Road In st aCare

Alt a View In st aCare/Kid sCare D rap er In st aCare

5101 S Commerce Drive | Murray, Utah 84107 Local: 801.262.7475 Toll free: 800.662.5851

The EMI Health Mobile App Your benefits. Anytime. Anywhere. Access your ID Card, view EOBs, find a provider, and access customer service from the convenience of your phone. Download for free today!