QL (0.5 per 365 days); AGE (Min 7 Years) ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML

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1 Tier 1 Zero Cost Share Preventive Drugs 2018 Marketplace Plans Drug Name Requirements/Limits ADACEL(TDAP ADOLESDULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESDULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML aftera oral tablet 1.5 mg albuterol sulfate inhalation solution for nebulization 2.5 mg /3 ml (0.083 %) albuterol sulfate oral tablet 4 mg altavera (28) oral tablet mg alyacen 1/35 (28) oral tablet 1-35 mg-mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg amethia lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) amethia oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) apri oral tablet mg aranelle (28) oral tablet 0.5/1/ mg-mcg ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 atenolol oral tablet 100 mg, 25 mg, 50 mg atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg QL (30 per 30 days) aubra oral tablet mg-mcg aviane oral tablet mg-mcg azurette (28) oral tablet mgx21 /0.01 mg x 5 balziva (28) oral tablet mg-mcg bekyree (28) oral tablet mgx21 /0.01 mg x 5 benazepril oral tablet 10 mg, 5 mg benazepril oral tablet 20 mg, 40 mg QL (1 per 365 days); AGE (Min 10 Years BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML and Max 25 Years) bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG- LF/0.5ML brevicon (28) oral tablet mg-mcg briellyn oral tablet mg-mcg camila oral tablet 0.35 mg camrese lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) camrese oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) Page 1 10/25/2017

2 carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg caziant (28) oral tablet 0.1/.125/ mg-mcg CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG QL (336 per 365 days) CHANTIX ORAL TABLET 0.5 MG QL (672 per 365 days) CHANTIX ORAL TABLET 1 MG QL (336 per 365 days) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 QL (106 per 365 days) MG (11)- 1 MG (42) chateal oral tablet mg cholecalciferol (vitamin d3) oral capsule 50,000 unit citalopram oral tablet 10 mg, 20 mg, 40 mg cryselle (28) oral tablet mg-mcg cyclafem 1/35 (28) oral tablet 1-35 mg-mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg cyred oral tablet mg dasetta 1/35 (28) oral tablet 1-35 mg-mcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg daysee oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) deblitane oral tablet 0.35 mg decara oral capsule 50,000 unit deltasone oral tablet 20 mg delyla (28) oral tablet mg-mcg desog-e.estradiol/e.estradiol oral tablet mgx21 /0.01 mg x 5 desogestrel-ethinyl estradiol oral tablet mg dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 2 mg, 4 mg drospirenone-e.estradiol-lm.fa oral tablet mg (24) (4) drospirenone-ethinyl estradiol oral tablet mg drospirenone-ethinyl estradiol oral tablet mg econtra ez oral tablet 1.5 mg elinest oral tablet mg-mcg ELLA ORAL TABLET 30 MG emoquette oral tablet mg ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML enpresse oral tablet (6)/75-40 (5)/125-30(10) enskyce oral tablet mg errin oral tablet 0.35 mg estarylla oral tablet mg-mcg ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg fallback solo oral tablet 1.5 mg QL (3 per 365 days) QL (3 per 365 days) Page 2 10/25/2017

3 falmina (28) oral tablet mg-mcg famotidine oral tablet 20 mg fayosim oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg femynor oral tablet mg-mcg fluoxetine oral tablet 10 mg, 20 mg FLUOXETINE ORAL TABLET 60 MG furosemide oral tablet 20 mg, 40 mg, 80 mg GARDASIL (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML gianvi (28) oral tablet mg gildagia oral tablet mg-mcg gildess 1.5/30 (21) oral tablet mg-mcg gildess 1/20 (21) oral tablet 1-20 mg-mcg gildess 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) gildess fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) gildess fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) glimepiride oral tablet 1 mg, 2 mg, 4 mg glipizide oral tablet 10 mg, 5 mg haloperidol oral tablet 0.5 mg, 1 mg HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML heather oral tablet 0.35 mg hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 mg introvale oral tablets,dose pack,3 month 0.15 mg-30 mcg ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml isibloom oral tablet mg jencycla oral tablet 0.35 mg jolessa oral tablets,dose pack,3 month 0.15 mg-30 mcg jolivette oral tablet 0.35 mg juleber oral tablet mg junel 1.5/30 (21) oral tablet mg-mcg junel 1/20 (21) oral tablet 1-20 mg-mcg junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) Page 3 10/25/2017

4 kaitlib fe oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4) kariva (28) oral tablet mgx21 /0.01 mg x 5 kelnor 1/35 (28) oral tablet 1-35 mg-mcg kimidess (28) oral tablet mgx21 /0.01 mg x 5 kurvelo oral tablet mg l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) larin 1.5/30 (21) oral tablet mg-mcg larin 1/20 (21) oral tablet 1-20 mg-mcg larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) larissia oral tablet mg-mcg layolis fe oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4) leena 28 oral tablet 0.5/1/ mg-mcg lessina oral tablet mg-mcg levonest (28) oral tablet (6)/75-40 (5)/125-30(10) levonorgestrel oral tablet 0.75 mg levonorgestrel oral tablet 1.5 mg levonorgestrel-ethinyl estrad oral tablet mg-mcg levonorgestrel-ethinyl estrad oral tablet mg levonorgestrel-ethinyl estrad oral tablet mcg levonorg-eth estrad triphasic oral tablet (6)/75-40 (5)/125-30(10) levora-28 oral tablet mg lillow oral tablet mg lisinopril oral tablet 10 mg, 20 mg lisinopril oral tablet 2.5 mg, 30 mg, 40 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)/10 MCG (2) LO MINASTRIN FE ORAL COMBO PACK,TAB CHEW AND TABLET 1 MG-10 MCG (24)/10 MG (2) lomedia 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) loryna (28) oral tablet mg lovastatin oral tablet 10 mg, 20 mg, 40 mg low-ogestrel (28) oral tablet mg-mcg lutera (28) oral tablet mg-mcg lyza oral tablet 0.35 mg marlissa oral tablet mg medroxyprogesterone intramuscular suspension 150 mg/ml QL (60 per 30 days) Page 4 10/25/2017

5 medroxyprogesterone intramuscular syringe 150 mg/ml melodetta 24 fe oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4) MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML metformin oral tablet 1,000 mg, 500 mg, 850 mg metformin oral tablet extended release 24 hr 500 mg metoprolol tartrate oral tablet 100 mg, 50 mg metoprolol tartrate oral tablet 25 mg QL (0.5 per 365 days); AGE (Min 11 Years and Max 23 Years) QL (1 per 365 days); AGE (Min 11 Years and Max 23 Years) mibelas 24 fe oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4) microgestin 1.5/30 (21) oral tablet mg-mcg microgestin 1/20 (21) oral tablet 1-20 mg-mcg microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML mono-linyah oral tablet mg-mcg mononessa (28) oral tablet mg-mcg my way oral tablet 1.5 mg myzilra oral tablet (6)/75-40 (5)/125-30(10) NATAZIA ORAL TABLET 3 MG/2 MG-2 MG/ 2 MG-3 MG/1 MG necon 0.5/35 (28) oral tablet mg-mcg necon 1/35 (28) oral tablet 1-35 mg-mcg necon 1/50 (28) oral tablet 1-50 mg-mcg necon 10/11 (28) oral tablet /1-35 mg-mcg/mg-mcg necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg next choice one dose oral tablet 1.5 mg NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML nikki (28) oral tablet mg nora-be oral tablet 0.35 mg noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg- 35mcg(21) and 75 mg (7) noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg- 25mcg(24) and 75 mg (4) norethindrone (contraceptive) oral tablet 0.35 mg norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7) norethindrone-e.estradiol-iron oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4) Page 5 10/25/2017

6 norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg- 35 mcg (28) norgestimate-ethinyl estradiol oral tablet mg-mcg norinyl 1/35 (28) oral tablet 1-35 mg-mcg norlyda oral tablet 0.35 mg norlyroc oral tablet 0.35 mg nortrel 0.5/35 (28) oral tablet mg-mcg nortrel 1/35 (21) oral tablet 1-35 mg-mcg nortrel 1/35 (28) oral tablet 1-35 mg-mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg NUVARING VAGINAL RING MG/24 HR ocella oral tablet mg ogestrel (28) oral tablet mg-mcg opcicon one-step oral tablet 1.5 mg optimal d3 oral capsule 50,000 unit option-2 oral tablet 1.5 mg orsythia oral tablet mg-mcg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg philith oral tablet mg-mcg pimtrea (28) oral tablet mgx21 /0.01 mg x 5 pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg PNEUMOVAX 23 INJECTION SOLUTION 25 MCG/0.5 ML PNEUMOVAX 23 INJECTION SYRINGE 25 MCG/0.5 ML portia oral tablet mg pravastatin oral tablet 10 mg pravastatin oral tablet 20 mg, 40 mg, 80 mg prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg prednisone oral tablet 20 mg previfem oral tablet mg-mcg PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP TCID50/0.5 QUARTETTE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG quasense oral tablets,dose pack,3 month 0.15 mg-30 mcg rajani oral tablet mg (24) (4) ranitidine hcl oral tablet 150 mg ranitidine hcl oral tablet 300 mg react oral tablet 1.5 mg reclipsen (28) oral tablet mg RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML QL (1 per 28 days) QL (0.5 per 365 days) QL (0.5 per 365 days) QL (30 per 30 days) QL (30 per 30 days) QL (0.5 per 365 days) QL (3 per 365 days) QL (3 per 365 days) RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML rivelsa oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg- 25 mcg SAFYRAL ORAL TABLET MG (21) (7) Page 6 10/25/2017

7 setlakin oral tablets,dose pack,3 month 0.15 mg-30 mcg sharobel oral tablet 0.35 mg simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg simvastatin oral tablet 80 mg sprintec (28) oral tablet mg-mcg sronyx oral tablet mg-mcg syeda oral tablet mg tamoxifen oral tablet 10 mg, 20 mg tarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) TAYTULLA ORAL CAPSULE 1 MG-20 MCG (24)/75 MG (4) TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) trazodone oral tablet 100 mg, 150 mg, 50 mg tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) trinessa lo oral tablet 0.18/0.215/0.25 mg-25 mcg tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) trivora (28) oral tablet (6)/75-40 (5)/125-30(10) TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT - 20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML velivet triphasic regimen (28) oral tablet 0.1/.125/ mgmcg vestura (28) oral tablet mg vienva oral tablet mg-mcg viorele (28) oral tablet mgx21 /0.01 mg x 5 vyfemla (28) oral tablet mg-mcg wera (28) oral tablet mg-mcg QL (30 per 30 days) PA NSO; QL (30 per 30 days) QL (1.5 per 365 days); AGE (Min 10 Years and Max 25 Years) QL (4 per 365 days) QL (4 per 365 days) Page 7 10/25/2017

8 wymzya fe oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7) xulane transdermal patch weekly mcg/24 hr zarah oral tablet mg zenchent (28) oral tablet mg-mcg zenchent fe oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7) zeosa oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7) ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML zovia 1/35e (28) oral tablet 1-35 mg-mcg zovia 1/50e (28) oral tablet 1-50 mg-mcg QL (3 per 28 days) QL (1 per 365 days); AGE (Min 60 Years) For benefits or coverage questions call SummaCare Customer Service at (TTY ) or visit SummaCare does not discriminate on the basis of race, color, national origin, disability, age, sex, gender, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. Page 8 10/25/2017

Information for Vermont Prescribers of Prescription Drugs (Long Form)

Information for Vermont Prescribers of Prescription Drugs (Long Form) Beyaz (Drospirenone-Ethinyl Estradiol-Levomefolate Calcium) This list does not imply that the products on this chart are interchangeable