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addition to those on the PDL. The PDL is available on DHS’s website at are generic or biosimilar drugs?A generic drug is approved by the Food and Drug Administration (FDA) and has the same active ingredients asthe brand name drug. It produces the same clinical effect as the brand name drug.A biosimilar drug is an FDA-approved biologic drug (most often an injectable prescription drug) that is highlysimilar to an already-approved biological product. It has no clinically meaningful differences in terms of safetyand effectiveness. Biosimilar drugs are not the same as generic drugs, but like generics, biosimilar drugs mayoffer more affordable treatment options.Generic or biosimilar substitution means a generic version or biosimilar version of a drug is given instead of thebrand name or non-biosimilar version of the drug.HealthPartners will cover the brand name or non-biosimilar version of the drug only when:1. Your prescriber informs HealthPartners in writing that the brand name or non-biosimilar version of thedrug is medically necessary; OR2. HealthPartners may prefer the dispensing of certain brand name versions over the generic or nonbiosimilar version over the biosimilar version of the drug; OR3. Minnesota law requires the dispensing of the brand name or non-biosimilar version of the drug.Within the list of covered drugs, brand name drugs are capitalized (e.g., HUMALOG) and generic drugs are listedin lowercase italics (e.g., atorvastatin).What are over-the-counter drugs?Drugs and products that are available for purchase without a prescription are referred to as over-the-counter(OTC). Although an OTC product is available without a prescription, if a doctor writes a prescription for an OTCproduct, HealthPartners may cover it. Within the list of covered drugs, OTC drugs and products are marked withan OTC symbol.What are specialty drugs?Specialty drugs are used by people with complex or chronic diseases. These drugs often require special handling,dispensing, or monitoring by a specially trained pharmacist.If you are prescribed a drug that is on the HealthPartners Specialty Drug List, your prescriber will need to sendthe prescription to one of HealthPartners’ specialty pharmacies listed here.Name of Specialty Pharmacy: Cystic Fibrosis & Hemophilia MedicationsFairview Specialty PharmacyPhone: 612-672-5260 Toll-free: 1-800-595-7140 TTY: 711Fax: 1-866-347-4939Hours of Operation: Mon-Fri: 8 a.m. – 7 p.m. (CST) *call center onlySat: 8 a.m. – 4 p.m. (CST) *call center onlySun: ClosedOn-site prescription pick-upMon-Fri: 8 a.m. - 4 p.m. (CST)3

Sat: ClosedSun: pharmacyName of Specialty Pharmacy: Hemophilia MedicationsFairview Pharmacy – Center for Bleeding and Clotting DisordersPhone: 612-273-5006 Toll-free: 1-833-310-1499 TTY: 711Fax: 612-273-5010Hours of Operation: Mon-Fri: 8:30 a.m. – 4:30 p.m. (CST)Sat: ClosedSun: ClosedName of Specialty Pharmacy: Cystic Fibrosis & Hemophilia MedicationsChildren’s Home Care PharmacyPhone: 612-813-7206 Toll-free: 1-866-656-1020 TTY: 711Fax: 612-813-7207Hours of Operation: Mon-Fri: 8 a.m. – 4:30 p.m. (CST)Sat: ClosedSun: ClosedName of Specialty Pharmacy: Pulmonary Arterial Hypertension (PAH)Accredo Specialty PharmacyPhone: 1-866-344-4874 TTY: 711Fax: 1-888-302-1028Hours of Operation: Mon-Fri: 7 a.m. – 10 p.m. (CST)Sat: 7 a.m. – 4:30 p.m. (CST)Sun: Closedhttps://www.accredo.comAll other specialty medicationsName of Specialty Pharmacy: CVS Caremark Specialty PharmacyPhone: 1-800-368-1624 TTY: 711Fax: 1-800-441-5809Hours of Operation: Mon-Fri: 9 a.m. – 9 p.m. CSTSat: 10 a.m. – 2 p.m. CSTSun: ialtyYou will also need to call the specialty pharmacy where your prescription is sent to set up an account. You willneed to have your HealthPartners member identification card when you call the specialty pharmacy.4

What if a drug is not on the list of covered drugs?Not all drugs are covered. If a drug you want to take is not listed in the list of covered drugs, you can callMember Services at 952-967-7998 or 1-866-885-8880, TTY 711, and ask if the drug is covered. If not, it isconsidered a “non-formulary” drug. If you need a drug that is not included in the list of covered drugs, you canask HealthPartners to make an exception to cover it. You can also ask us to change the rules on your drug. Forexample, HealthPartners may limit the amount of a drug we will cover. If your drug has a limit, you can ask us tochange the limit and cover more. You can also ask us to drop step therapy restrictions or prior authorizationrequirements.To ask for an exception, call Member Services. A Member Services representative will work with you and yourprovider to help you ask for an exception. Once a complete request is submitted by your provider, we will giveyou a decision on your exception request within 24 hours.Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limitsmay include the following: Prior authorization: HealthPartners requires you or your doctor to get prior authorization for certaindrugs. This means that you will need to get approval from HealthPartners before you fill yourprescription. If you don’t get approval, HealthPartners may not cover the drug. Quantity limits: For certain drugs, HealthPartners limits the amount of the drug that we will cover. Age requirements: Some drugs have age requirements. A prior authorization may be neededdepending on your age and the specific drug prescribed.You can find out if your drug requires prior authorization, has quantity limits, or has an age requirement bylooking in this list of covered drugs. An exception to a drug restriction or limit can be made if your doctorsubmits a statement or documentation supporting the request. Go to Prescription Drugs in Section 7: CoveredServices of your Member Handbook for more information. You can also get more information about therestrictions applied to specific covered drugs by calling Member Services at 952-967-7998 or 1-866-885-8880,TTY 711, or by visiting our website at healthpartners.com/mhcpdruglist. Also go to “Can I ask for an exceptionto the coverage restrictions?” Excluded drugs: Some drugs are excluded from the list of covered drugs. This means they are not covered.Excluded drugs include the following: Drugs used to treat sexual or erectile dysfunction Drugs used to enhance fertility Drugs used for cosmetic purposes, including drugs to treat hair loss Drugs excluded from coverage by federal or state law Experimental drugs, investigational drugs, or drugs not approved by the FDA Medical cannabis5

Can I ask for an exception to the coverage restrictions?Yes. You or your health care provider can get the Pharmacy Administration – Prior Authorization/Exception Formfrom ndex.html or by calling Member Services at952-967-7998 or 1-866-885-8880, TTY 711. Your provider must return this form to the fax number or addresslisted on the document. To allow for a thorough review and to ensure that you or your health care provider getsa response within 24 hours, all information requested in the form should be provided, including documentationof which medications have been tried and failed, including the dosages used, and the reason for failure (e.g. sideeffects).What will a prescription cost?All copay information for prescriptions is listed in the Member Handbook in Section 6: Cost-Sharing. If you haveadditional questions, call Member Services at 952-967-7998 or 1-866-885-8880, TTY 711, or visit our website athealthpartners.com/mhcpdruglist.6

LEGENDTYPEPNPCDESCRIPTIONPreferred DrugNon-Preferred DrugCoveredTYPEDESCRIPTIONQLQuantity LimitThere is a limit on the amount of this drug that is covered perprescription, or within a specific time frame.PAPrior AuthorizationYou (or your physician) are required to get prior authorization beforeyou fill your prescription for this drug. Without prior approval, we maynot cover this drug.STStep TherapyIn some cases, you may be required to first try certain drugs to treatyour medical condition before we will cover another drug for thatcondition.AL1Age LimitThis prescription drug may only be covered if you meet the minimumor maximum age limit.Specialty DrugSpecialty drugs are high-cost drugs used to treat complex or rareconditions, such as multiple sclerosis, rheumatoid arthritis, hepatitisC, and hemophilia.AQ1Age Quantity LimitThere is a limit on the amount of drug covered per prescription, orwithin a specific time frame. Must also fall into the specified agerange.QLCQuantity Limit (Custom)There is a limit on the amount of this drug that is covered.Trial DrugMedicines marked with this symbol are in a trial drug program. Thefirst 6 fills may be limited to less than a month supply. If tolerated andeffective you will receive the remainder of the supply and pay nomore than one copay for each full month supply.Medical DrugMedicines marked with this symbol may be covered under yourmedical benefit. Go riteria/ for medicalbenefit criteria or log on to your secure account.STDMEDPAGE 7LAST UPDATED 05/2022

Opioid ProgramNew users will be limited to a 7 days supply for their first fill, and atotal of 14 days supply for each episode. Longer therapy requiresprior authorization: Provider attestation, that therapy for this patient isbeing managed per standard opioid prescribing guidelines, includingassessment and documentation of risk factors for chronic opioid use.ONCOncologyOncology (cancer) medicines must be filled at a specialty pharmacy,but are not subject to the specialty benefit. Your regular generic orbrand pharmacy copay or coinsurance will apply.OTCOTC DrugsMedicines marked with this symbol are considered over the counterOPPAGE 8LAST UPDATED 05/2022

DRUG DESCRIPTION (RX)TYPELIMITS & RESTRICTIONSALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTSphenoxybenzamine hclCPASELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENTalfuzosin hcl erPFLOMAXtamsulosin hclNPPARAPAFLOsilodosinNPPAsilodosinNPPAtamsulosin hclPANALGESICS AND ANTIPYRETICSANALGESICS AND ANTIPYRETICS, MISC.8 HOUR PAIN RELIEFacetaminophenOTCC8HR ARTHRITIS PAINacetaminophenOTCCacetaminophen 120 mg supposOTCCacetaminophen 160 mg/5 ml liqOTCCacetaminophen 160 mg/5 ml solOTCCacetaminophen 160 mg/5 ml suspOTCCacetaminophen 325 mg gelcapOTCCacetaminophen 325 mg tabletOTCCacetaminophen 500 mg capletOTCCacetaminophen 500 mg gelcapOTCCacetaminophen 500 mg tabletOTCCacetaminophen 650 mg supposOTCCPAGE 9LAST UPDATED 05/2022

DRUG DESCRIPTION (RX)TYPEacetaminophen erOTCCARTHRITIS PAIN RELIEFacetaminophenOTCCLIMITS & RESTRICTIONSbutalb-acetamin-caff 50-325-40CQL6 TABS / 1 DAYbutalbital-acetaminophn 50-325CQL6 TABS / 1 DAYQL1 TAB / 1 DAYCHILD PAIN RLF 160 MG/5 ML ELXOTCCCHILD PAIN-FEVER 160 MG/5 MLOTCCCHILD TYLENOL 160 MG POWD PKTacetaminophenCchildren's acetaminophenOTCCCHILDREN'S AUROPHEN PAIN-FEVEROTCCEQ ARTHRITIS PAIN ER 650 MGOTCCFEVERALLacetaminophenOTCCgnp acetaminophen 500 mg tabOTCCGNP PAIN RELIEF 500 MG CAPLETOTCCGNP PAIN RELIEF 500 MG GELCAPOTCCGRALISE ER 300 MG TABLETgabapentinNPGRALISE ER 600 MG TABLETgabapentinNPPAQLPAGS ARTHRITIS PAIN ER 650 MGacetaminophenOTCCHM PAIN RELIEF 325 MG TABLETOTCCHM PAIN RELIEF 500 MG GELCAPOTCCHM PAIN RELIEF 500 MG TABLETOTCCHM PAIN RELIEF ER 650 MG CPLTacetaminophenOTCCHM PAIN RELIEVER 500 MG TABLETOTCCPAGE 103 TABS / 1 DAYLAST UPDATED 05/2022

DRUG DESCRIPTION (RX)INFANTS' PAIN-FEVERTYPEOTCLIMITS & RESTRICTIONSCQLLYRICA CR 165 MG TABLETpregabalinNPLYRICA CR 330 MG TABLETpregabalinNPLYRICA CR 82.5 MG TABLETpregabalinNP1 TAB / 1 DAYPAQL2 TABS / 1 DAYPAQL1 TAB / 1 DAYPAM-PAPOTCCMAPAP 500 MG CAPSULEOTCCMAPAP 500 MG/15 ML LIQUIDOTCCNON-ASPIRIN CHILD'S DROPSOTCCPAIN RELIEF 160 MG/5 ML LIQUIDOTCCPAIN RELIEF 325 MG TABLETOTCCPAIN RELIEF ADULTOTCCPAIN RELIEVER 500 MG CAPLETOTCCPAIN RELIEVER 500 MG TABLETOTCCQLpregabalin er 165 mg tablet1 TAB / 1 DAYNPPAQLpregabalin er 330 mg tablet2 TABS / 1 DAYNPPAQLpregabalin er 82.5 mg tablet1 TAB / 1 DAYNPPASILAPAPOTCCSM PAIN RELIEVER 500 MG CAPLETOTCCSM PAIN RELIEVER 500 MG GELCAPOTCCSM PAIN RELIEVER 500 MG TABLETOTCCTENCONbutalbital/acetaminophenPAGE 11CQL6 TABS / 1 DAYLAST UPDATED 05/2022

DRUG DESCRIPTION IMITS & RESTRICTIONSQL6 CAPS / 1 DAYOPIATE AGONISTSAQ1acetamin-codein 300-30 mg/12.5CAt least 12 yrs old; 60 /1 DAYOPQLacetaminop-codeine 120-12 mg/5CAQ140 ML / 1 DAYAt least 12 yrs old; 60 /1 DAYOPAQ1acetaminophen-cod #2 tabletCAt least 12 yrs old; 8 /1 DAYOPAQ1acetaminophen-cod #3 tabletCAt least 12 yrs old; 8 /1 DAYOPAQ1acetaminophen-cod #4 tabletCAt least 12 yrs old; 8 /1 DAYOPasa-butalb-caffeine-codeineCQL6 CAPS / 1 DAYAL1At least 12 yrs oldOPASCOMP WITH CODEINEcodeine phosphate/butalbital/aspirin/caffeineCQL6 CAPS / 1 DAYAL1At least 12 yrs oldOPAQ1butalb-acetamin-caf-cod 50-325CAt least 12 yrs old; 6 /1 DAYOPAQ1butalbital compound-codeineCAt least 12 yrs old; 6 /1 DAYOPAQ1codeine sulfateCAt least 12 yrs old; 8 /1 DAYOPDURAGESICfentanylPAGE 12QLNP10 PATCHES / 30DAYSPALAST UPDATED 05/2022

DRUG DESCRIPTION (RX)TYPELIMITS & RESTRICTIONSQLENDOCET 10-325 MG TABLEToxycodone hcl/acetaminophenCENDOCET 5-325 MG TABLEToxycodone hcl/acetaminophenCENDOCET 7.5-325 MG TABLEToxycodone hcl/acetaminophenCOPQL8 TABS / 1 DAYOPQL7 TABS / 1 DAYOPQLfentanyl 100 mcg/hr patch5 TABS / 1 DAYNP10 PATCHES / 30DAYSPAQLfentanyl 12 mcg/hr patchNP10 PATCHES / 30DAYSPAQLfentanyl 25 mcg/hr patchP10 PATCHES / 30DAYSPAQLfentanyl 37.5 mcg/hr patchNP10 PATCHES / 30DAYSPAQLfentanyl 50 mcg/hr patchP10 PATCHES / 30DAYSPAQLfentanyl 62.5 mcg/hr patchNP10 PATCHES / 30DAYSPAQLfentanyl 75 mcg/hr patchNP10 PATCHES / 30DAYSPAQLfentanyl 87.5 mcg/hr patchNP10 PATCHES / 30DAYSPAQLhydrocodone er 10 mg capsuleNP4 CAPS / 1 DAYPAOPhydrocodone er 100 mg tabletNPPAhydrocodone er 120 mg tabletNPPAPAGE 13LAST UPDATED 05/2022

DRUG DESCRIPTION (RX)TYPELIMITS & RESTRICTIONSQLhydrocodone er 15 mg capsuleNP4 CAPS / 1 DAYPAOPQLhydrocodone er 20 mg capsuleNP4 CAPS / 1 DAYPAOPQLhydrocodone er 20 mg tablet4 TABS / 1 DAYNPPAQLhydrocodone er 30 mg capsuleNP2 CAPS / 1 DAYPAOPQLhydrocodone er 30 mg tablet2 TABS / 1 DAYNPPAQLhydrocodone er 40 mg capsuleNP2 CAPS / 1 DAYPAOPQLhydrocodone er 40 mg tablet2 TABS / 1 DAYNPPAQLhydrocodone er 50 mg capsuleNP1 CAP / 1 DAYPAOPQLhydrocodone er 60 mg tablet1 TAB / 1 DAYNPPAQLhydrocodone er 80 mg tablet1 TAB / 1 DAYNPPAQLhydrocodone-acetamin 10-325 mg8 TABS / 1 DAYCOPQLhydrocodone-acetamin 2.5-108/5120 ML / 1 DAYCOPQLhydrocodone-acetamin 5-217/10120 ML / 1 DAYCOPPAGE 14LAST UPDATED 05/2022

DRUG DESCRIPTION (RX)TYPELIMITS & RESTRICTIONSQLhydrocodone-acetamin 5-325 mg8 TABS / 1 DAYCOPQLhydrocodone-acetamin 7.5-3258 TABS / 1 DAYCOPQLhydrocodone-acetamn 7.5-325/15120 ML / 1 DAYCOPQLhydrocodone-ibuprofen 7.5-2008 TABS / 1 DAYCOPQLhydromorphone 1 mg/ml solution20 ML / 1 DAYCOPQLhydromorphone 2 mg tablet8 TABS / 1 DAYCOPQLhydromorphone 3 mg suppos4 SUPP / 1 DAYCOPQLhydromorphone 4 mg tablet5 TABS / 1 DAYCOPQLhydromorphone 5 mg/5 ml soln20 ML / 1 DAYCOPQLhydromorphone 8 mg tablet2 TABS / 1 DAYCOPQLhydromorphone hcl er 12 mg tab1 TAB / 1 DAYNPPAQLhydromorphone hcl er 16 mg tab2 TABS / 1 DAYNPPAQLhydromorphone hcl er 32 mg tab1 TAB / 1 DAYNPPAQLhydromorphone hcl er 8 mg tab4 TABS / 1 DAYNPPAHYSINGLA ER 100 MG TABLEThydrocodone bitartratePAGE 15NPPALAST UPDATED 05/2022

DRUG DESCRIPTION (RX)TYPEHYSINGLA ER 120 MG TABLEThydrocodone bitartrateNPHYSINGLA ER 20 MG TABLEThydrocodone bitartrateNPHYSINGLA ER 30 MG TABLEThydrocodone bitartrateNPHYSINGLA ER 40 MG TABLEThydrocodone bitartrateNPHYSINGLA ER 60 MG TABLEThydrocodone bitartrateNPHYSINGLA ER 80 MG TABLEThydrocodone bitartrateNPKADIAN ER 10 MG CAPSULEmorphine sulfateNPKADIAN ER 100 MG CAPSULEmorphine sulfateNPKADIAN ER 20 MG CAPSULEmorphine sulfateNPKADIAN ER 200 MG CAPSULEmorphine sulfateNPKADIAN ER 30 MG CAPSULEmorphine sulfateNPKADIAN ER 40 MG CAPSULEmorphine sulfateNPKADIAN ER 50 MG CAPSULEmorphine sulfateNPKADIAN ER 60 MG CAPSULEmorphine sulfateNPKADIAN ER 80 MG CAPSULEmorphine sulfateNPPAGE 16LIMITS & RESTRICTIONSPAQL4 TABS / 1 DAYPAQL2 TABS / 1 DAYPAQL2 TABS / 1 DAYPAQL1 TAB / 1 DAYPAQL1 TAB / 1 DAYPAQL4 CAPS / 1 DAYPAQL1 CAP / 1 DAYPAQL4 CAPS / 1 DAYPAQL1 CAP / 1 DAYPAQL2 CAPS / 1 DAYPAQL2 CAPS / 1 DAYPAQL1 CAP / 1 DAYPAQL1 CAP / 1 DAYPAQL1 CAP / 1 DAYPALAST UPDATED 05/2022

DRUG DESCRIPTION (RX)TYPELIMITS & RESTRICTIONSQLLORCEThydrocodone bitartrate/acetaminophenCLORCET HDhydrocodone bitartrate/acetaminophenCLORCET PLUShydrocodone bitartrate/acetaminophenCOPQL8 TABS / 1 DAYOPQL8 TABS / 1 DAYOPQLmethadone 10 mg/5 ml solution8 TABS / 1 DAY10 ML / 1 DAYNPPAQLmethadone 10 mg/ml oral conc2 ML / 1 DAYNPPAQLmethadone 40 mg tablet dispr1 TAB / 1 DAYNPPAQLmethadone 5 mg/5 ml solution20 ML / 1 DAYNPPAQLmethadone hcl 10 mg tablet2 TABS / 1 DAYNPPAQLmethadone hcl 5 mg tablet4 TABS / 1 DAYNPPAQLMETHADONE INTENSOLmethadone hclCMETHADOSE 40 MG TABLET DISPRmethadone hclCmorphine sulf 10 mg supposC2 ML / 1 DAYPAQL1 TAB / 1 DAYPAQL6 SUPP / 1 DAYOPQLmorphine sulf 10 mg/5 ml soln30 ML / 1 DAYCOPQLmorphine sulf 100 mg/5 ml conc4 ML / 1 DAYCOPQLmorphine sulf 20 mg suppos6 SUPP / 1 DAYCOPPAGE 17LAST UPDATED 05/2022

DRUG DESCRIPTION (RX)TYPELIMITS & RESTRICTIONSQLmorphine sulf 20 mg/5 ml soln20 ML / 1 DAYCOPQLmorphine sulf 30 mg suppos6 SUPP / 1 DAYCOPQLmorphine sulf 5 mg suppos6 SUPP / 1 DAYCOPQLmorphine sulf er 100 mg tablet1 TAB / 1 DAYPPAQLmorphine sulf er 15 mg tablet4 TABS / 1 DAYPPAQLmorphine sulf er 200 mg tablet1 TAB / 1 DAYPPAQLmorphine sulf er 30 mg tablet2 TABS / 1 DAYPPAQLmorphine sulf er 60 mg tablet1 TAB / 1 DAYPPAQLmorphine sulfate er 10 mg cap4 CAPS / 1 DAYNPPAQLmorphine sulfate er 100 mg cap1 CAP / 1 DAYNPPAQLmorphine sulfate er 120 mg cap1 CAP / 1 DAYNPPAQLmorphine sulfate er 20 mg cap4 CAPS / 1 DAYNPPAQLmorphine sulfate er 30 mg cap2 CAPS / 1 DAYNPPAQLmorphine sulfate er 40 mg cap2 CAPS / 1 DAYNPPAQLmorphine sulfate er 45 mg cap1 CAP / 1 DAYNPPAPAGE 18LAST UPDATED 05/2022

DRUG DESCRIPTION (RX)TYPELIMITS & RESTRICTIONSQLmorphine sulfate er 50 mg cap1 CAP / 1 DAYNPPAQLmorphine sulfate er 60 mg cap1 CAP / 1 DAYNPPAQLmorphine sulfate er 75 mg

· Receipt of Health Care Services · National Origin · Claims Experience · Race · Medical History · Color · Genetic Information · Religion . for a chronic or long-term condition are available up to a 90-day supply and are listed on the DHS 90-day Supply Prescription Drug List at .