a quality treatment program. Bright Health will generally cover the drugs listed in our formulary as long as the drug is medically necessary, and the prescription is

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PA – Prior Authorization QL – Quantity Limits ST – Step Therapy OTC – Over the counter i 202Bright Formulary(List of Cover ed Drugs) Bright Health Individual and Family Plans PLEASE READ: This document contains information about the drugs Bright Health covers in their Individual and Family plans. This formulary was updated on . For more recent information or other questions, please contact us at 833-661-1988 or visit www.brighthealthplan.com.

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PA – Prior Authorization QL – Quantity Limits ST – Step Therapy OTC – Over the counter ii Welcom e to Bright Enclosed you will find a list of the drugs included in our Bright Health Individual and Family plans from January 1, 202 – December 31, 202. As you review, be sure to haveyour medications on hand so you can confirm your prescriptions are covered and compare dosage and pricing of the drugs you take. Keep in mind, this document includes a comprehensive list of drugs (formulary) included in our Individual and Family plans. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. As a Bright Health ember, you must generally use in-network pharmacies to fill your prescriptions. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 202, and from time to time during the 202calendar year. Sincerely, Your Bright Health eam

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PA – Prior Authorization QL – Quantity Limits ST – Step Therapy OTC – Over the counter iii Frequent ly Ask ed Questions: Wh at is a Formu lary (dru g list)? A formular y is a lis t of covere d drugs selecte d by Brigh t Healt h in consultatio n wit h a tea m of healt h car e providers , whic h represents th e prescriptio n therapies believe d to be a necessar y par t of a qualit y treatmen t program . Brigh t Healt h wil l generall y cove r th e drugs liste d in our formular y as lon g as th e drug is medicall y necessary , an d th e prescriptio n is fille d at a Brigh t Healt h network pharmacy. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 202 formulary that was covered at the beginning of theyear, we will not discontinue or reduce coverage of the drug during the 202 coverage year exceptwhe n a new, les s expensi ve generi c drug become s availabl e or whe n ne w advers e information abo ut th e safet y or effectiveness o f a drug is release d. Thes e types o f change s ma y occ ur without notic e to yo u. We fee l it is importan t tha t yo u hav e continue d acces s fo r th e remainde r of the covera ge yea r to th e formular y drugs tha t wer e availabl e whe n yo u chos e our plan , exce pt for case s in whic h yo u ca n sav e additiona l money , or we ca n ensur e yo ur safety. If th e Foo d an d Drug Administratio n deems a dr ug on our formular y to be uns a manufacture r removes th e drug fro m th e market , we wil l immediatel y remov e th e drug fro m our formular y an d provi de notic e to members wh o tak e th e drug . To get update d informatio n about th e drugs covere d by Brigh t Health , pleas e contac t us. Our contac t informatio n appears o n the fron t an d bac k cove r pages. How do I us e th e Formulary? Ther e ar e two ways to fin d th e drugs yo u ta ke in th e formulary: 1.Medical Condition The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are If you know what your drug is used for, look for the category name in the list that begins below. Then look under the category name for your drug. 2.Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index at the end of the formu lary. The Index provides an alphabetical list of all the drugs included in

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PA – Prior Authorization QL – Quantity Limits ST – Step Therapy OTC – Over the counter iv this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Bright Health covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Bright Health requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from Bright not cover the drug. Quantity Limits: For certain drugs, Bright Health limits the amount of the drug that we will cover. For example, Bright He alth provides 15 tablets every 25 days per prescription for Zolpidem Tartrate 5mg. This may be in addition to a standard one -month or three -month supply. Step Therapy: In some cases, Bright Health requires you to first try certain drugs to treat your med ical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Bright Health may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Bright Health will th en cover Drug B.You can fi nd out if your dr ug has any additional requirements or limits by lookin g in the formulary. Yo u can also get more information abo ut the restrictions applie d to specific covered drugs by visiti ng our Website, www.brighthealthplan.com. We have poste d online documents that explai n our prior authorization restriction an d ste p therapy restrictions. You may also as k us to sen d yo u a copy. Our contact information, alon g with the date we last update d the formulary, appears on the front an d bac k cover pages. You can ask Bright Health to make an exception to these restrictions or limits or for a list of other, exception exception.

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PA – Prior Authorization QL – Quantity Limits ST – Step Therapy OTC – Over the counter v What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that Bright Health does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Bright Health. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Bright Health. You can ask Bright Health to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Bright Health Formulary? You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Bright Health limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater a mount. Generally, Bright Health will only approve your request for an exception if the alternative drugs treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the dru g you take. For more information If you have questions about Bright Health please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

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PA – Prior Authorization QL – Quantity Limits ST – Step Therapy OTC – Over the counter vi Our Formulary (drug list) The formulary below provides coverage information about the drugs covered by our Bright Individual and Family plans. If you have trouble finding your drug in the list, turn to the Index at the end of the formulary. The first column of the chart lists the d rug name. Brand name drugs are capitalized and generic drugs are listed in lower -case italics. The second column of the chart, Drug Tier, tells you which tier the drug falls under. Drug tiers are how we divide prescription drugs into different levels of co st. How much you will pay will depend you. The information in the Requirements/Limits column tells you if our plans have any special requirements for coverage of your drug. This formulary was updated on . For more recent information or other questions, please contact us at 833-661-1988 or visit www.brighthealthplan.com.

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PA – Prior Authorization ST – Step Therapy QL – Quantity Limit SP – Specialty Pharmacy 2 Drug Name Drug Tier Requirements/Limits *Stimulants – Misc.*** armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg 3 PA dexmethylphenidate hcl er oral capsule extended release 24 hour 15 mg, 30 mg, 40 mg 3 QL (30 EA per 30 days) dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg 2 methylphenidate hcl er (cd ) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg 3 QL (30 EA per 30 days) methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg 3 QL (30 EA per 30 days) methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg 3 QL (30 EA per 30 days) methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg 3 QL (30 EA per 30 days) methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml 2 methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 2 methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 mg 2 QL (180 EA per 30 days) modafinil oral tablet 100 mg, 200 mg 2 PA *AMINOGLYCOSIDES* *Aminoglycosides*** amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml 2 gentamicin in saline intravenous solution 0.8 – 0.9 mg/ml – % 2 gentamicin sulfate injection solution 10 mg/ml, 40 mg/ml 2 neomycin sulfate oral tablet 500 mg 2 streptomycin sulfate intramuscular solution reconstituted 1 gm 2 tobramycin inhalation nebulization solution 300 mg/5ml 5 PA; SP

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PA – Prior Authorization ST – Step Therapy QL – Quantity Limit SP – Specialty Pharmacy 3 Drug Name Drug Tier Requirements/Limits tobramycin sulfate injection solution 10 mg/ml, 80 mg/2ml 2 *ANALGESICS – ANTI – INFLAMMATORY* *Antirheumatic – Janus Kinase (Jak) Inhibitors*** RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 15 MG 5 PA; SP; QL (30 EA per 30 days) *Anti – Tnf – Alpha – Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML 5 PA; SP; QL (3 EA per 28 days) HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML 5 PA; SP; QL (2 EA per 28 days) HUMIRA PEN SUBCUTANEOUS PEN – INJECTOR KIT 40 MG/0.4ML 5 PA; SP; QL (2 EA per 28 days) HUMIRA PEN SUBCUTANEOUS PEN – INJECTOR KIT 40 MG/0.8ML 5 PA; SP; QL (6 EA per 28 days) HUMIRA PEN SUBCUTANEOUS PEN – INJECTOR KIT 80 MG/0.8ML 5 PA; SP; QL (3 EA per 28 days) HUMIRA PEN – CD/UC/HS STARTER SUBCUTANEOUS PEN – INJECTOR KIT 40 MG/0.8ML 5 PA; SP; QL (6 EA per 28 days) HUMIRA PEN – CD/UC/HS STARTER SUBCUTANEOUS PEN – INJECTOR KIT 80 MG/0.8ML 5 PA; SP; QL (3 EA per 28 days) HUMIRA PEN – PEDIATRIC UC START SUBCUTANEOUS PEN – INJECTOR KIT 80 MG/0.8ML 5 PA; SP; QL (3 EA per 28 days) HUMIRA PEN – PS/UV/ADOL HS START SUBCUTANEOUS PEN – INJECTOR KIT 40 MG/0.8ML 5 PA; SP; QL (6 EA per 28 days) HUMIRA PEN – PSOR/UVEIT STARTER SUBCUTANEOUS PEN – INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML 5 PA; SP; QL (3 EA per 28 days) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 40 MG/0.4ML 5 PA; SP; QL (2 EA per 28 days)

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PA – Prior Authorization ST – Step Therapy QL – Quantity Limit SP – Specialty Pharmacy 4 Drug Name Drug Tier Requirements/Limits HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML 5 PA; SP; QL (6 EA per 28 days) *Cyclooxygenase 2 (Cox – 2) Inhibitors*** celecoxib oral capsule 100 mg, 200 mg, 50 mg 3 QL (60 EA per 30 days) celecoxib oral capsule 400 mg 3 QL (30 EA per 30 days) *Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG 5 PA *Interleukin – 1 Blockers*** ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG 5 PA; SP *Interleukin – 6 Receptor Inhibitors*** KEVZARA SUBCUTANEOUS SOLUTION AUTO – INJECTOR 150 MG/1.14ML, 200 MG/1.14ML 5 PA; SP; QL (2.28 ML per 28 days) KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/1.14ML, 200 MG/1.14ML 5 PA; SP; QL (2.28 ML per 28 days) *Nonsteroidal Anti – Inflammatory Agent Combinations*** diclofenac – misoprostol oral tablet delayed release 50 – 0.2 mg, 75 – 0.2 mg 2 *Nonsteroidal Anti – Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 mg 2 diclofenac sodium er oral tablet extended release 24 hour 100 mg 2 diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg 2 etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg 4 etodolac oral capsule 200 mg, 300 mg 2 etodolac oral tablet 400 mg, 500 mg 2 fenoprofen calcium oral tablet 600 mg 2

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PA – Prior Authorization ST – Step Therapy QL – Quantity Limit SP – Specialty Pharmacy 5 Drug Name Drug Tier Requirements/Limits flurbiprofen oral tablet 100 mg, 50 mg 2 ibuprofen oral suspension 100 mg/5ml 2 ibuprofen oral tablet 400 mg, 600 mg, 800 mg 2 indomethacin oral capsule 25 mg, 50 mg 2 ketoprofen oral capsule 50 mg 2 QL (180 EA per 30 days) ketoprofen oral capsule 75 mg 2 QL (120 EA per 30 days) ketorolac tromethamine oral tablet 10 mg 2 QL (20 EA per 5 days) meclofenamate sodium oral capsule 100 mg, 50 mg 3 mefenamic acid oral capsule 250 mg 3 meloxicam oral tablet 15 mg, 7.5 mg 2 nabumetone oral tablet 500 mg 2 QL (120 EA per 30 days) nabumetone oral tablet 750 mg 2 QL (60 EA per 30 days) naproxen dr oral tablet delayed release 375 mg, 500 mg 2 naproxen oral tablet 250 mg, 375 mg, 500 mg 2 naproxen sodium oral tablet 275 mg, 550 mg 2 oxaprozin oral tablet 600 mg 2 QL (60 EA per 30 days) piroxicam oral capsule 10 mg, 20 mg 2 sulindac oral tablet 150 mg, 200 mg 2 tolmetin sodium oral capsule 400 mg 3 tolmetin sodium oral tablet 600 mg 3 *Phosphodiesterase 4 (Pde4) Inhibitors*** OTEZLA ORAL TABLET 30 MG 5 PA; SP; QL (60 EA per 30 days) OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG 5 PA; SP; QL (55 EA per 28 days) *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 mg 3 *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML 5 PA; SP; QL (4 ML per 28 days)

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