Blue Cross Blue ShieldCommercial Clinical Policy

2026 Health Ins. Market Individual, Small Group 6 T Formulary Form

Chat with GenHealth to automate any policy or prior auth task.


2026 Health Ins. Market Individual, Small Group 6 T Formulary

Indications

(1) Does the request meet this criterion: Tier 1 – Preferred Generic? 
(2) Does the request meet this criterion: Tier 2 – Non-preferred Generic? 
(3) Does the request meet this criterion: Tier 3 – Preferred Brand? 
(4) Does the request meet this criterion: Tier 4 – Non-preferred Brand? 
(5) Does the request meet this criterion: Tier 5 – Preferred Specialty? 

YesNoN/A
YesNoN/A
YesNoN/A

Sign up to see the rest of the questions

Unlock the remaining questions and the full coverage workflow.

Sign up for free
Effective Date

NA

Last Reviewed

NA

Original Document

  Reference



2626-D ND HIM © Prime Therapeutics LLC 05/26

Health Ins. Market Individual Small Group 6 T Formulary May 2026 Plan Year (Updated May 2026)

The formulary is regularly updated. Please visit bcbsnd.com or Prime Therapeutics website at www.MyPrime.com for the most up-to-date information.

Contents Introduction ....................................................... I How formulary drugs are selected .................... I Coverage considerations .................................. I Tiers ................................................................. II Affordable Care Act .......................................... II Specialty ......................................................... II Limited Distribution .......................................... II Step Therapy ................................................... II Prior Approval .................................................. II Dispensing Limits ............................................ III Providers ......................................................... III Abbreviation Key ............................................ IV

Therapeutic Class Drug List Anti-Infective Agents ........................................ 1 Biologicals ........................................................ 8 Antineoplastic Agents .................................... 11 Endocrine and Metabolic Drugs .................... 17 Cardiovascular Agents ................................... 27 Respiratory Agents ........................................ 34 Gastrointestinal Agents .................................. 37 Genitourinary Agents ..................................... 40 Central Nervous System Drugs ..................... 42 Analgesics and Anesthetics ........................... 51 Neuromuscular Drugs .................................... 56 Nutritional Products ....................................... 61 Hematological Agents .................................... 62 Topical Products ............................................ 66 Miscellaneous Products ................................. 75 Index .............................................................. 79

To search for a drug name within this PDF document, use the Control and F keys on your keyboard,
or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for
and click on Search.

Health Ins. Market Individual Small Group 6 T Formulary 2026 Plan Year (May 2026) I Introduction
The Blue Cross Blue Shield of North Dakota (BCBSND) Health Insurance Market Individual, Small Group Formulary contains covered drugs for a broad range of diseases.
Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). The reference brand is a non-formulary (non-preferred) drug. Some generic products have no reference brand. Brand prescription drugs are shown in capital letters followed by the generic name. The Blue Cross Blue Shield of North Dakota (BCBSND) Health Insurance Market Individual, Small Group Formulary is organized into broad categories (e.g. Anti-Infective drugs). Within most categories, drugs are sub- grouped by drug class (e.g. Penicillins) or by use for a specific medical condition (e.g. Diabetes).
To save the most money on prescription drugs, take this formulary with you each time you visit your provider. Consider asking your provider to prescribe generic and formulary drugs, if appropriate. Any and all decisions
that require or pertain to independent professional medical judgment or training, or the need for, and dosage of, a prescription drug, must be made solely by you and your provider in accordance with the patient/provider relationship. The current version of this formulary is available at the BCBSND website at bcbsnd.com or by calling the customer service number listed on your identification card. Online pharmacy tools are available through the Prime Therapeutics website at www.MyPrime.com. BCBSND members can find drug cost estimates or check
if a particular drug is on the BCBSND formulary.
Please refer to your benefit materials for coverage details and the plan website for current information as this formulary list will be reviewed periodically and is subject to change. How formulary drugs are selected
Formulary drugs are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from your health plan, reviews drugs regulated by the U.S. Food and Drug Administration (FDA).
Drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered. Newly marketed prescription drugs will not be covered until the Committee has had an opportunity to review the drug to determine whether the drug will be covered and, if so, which tier will apply. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list. Coverage considerations Most prescription drug benefit plans provide coverage for up to a 90-day supply of medication, with some exceptions. Some plans may exclude coverage for certain agents or drug categories, like those used for sexual dysfunction (example: Viagra) or infertility (example: Follistim AQ). You should refer to your benefit plan booklet for details about your particular benefits.

Health Ins. Market Individual Small Group 6 T Formulary 2026 Plan Year (May 2026) II Tiers This prescription benefit is multi-tiered, placing prescription drugs into one of six copay/coinsurance levels:
• Tier 1 – Preferred Generic
• Tier 2 – Non-preferred Generic • Tier 3 – Preferred Brand • Tier 4 – Non-preferred Brand • Tier 5 – Preferred Specialty
• Tier 6 – Non-preferred Specialty

Note: If a drug displays an “A” in the Drug Tier column, this indicates the drug may only be covered if a member meets the criteria for $0 copay under the Affordable Care Act.
Affordable Care Act Drugs marked in the ACA column are covered at $0 cost share when meeting the conditions outlined under the Affordable Care Act. Examples of categories of drugs that may be subject to limited or $0 cost share include aspirin, breast cancer preventive, fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation, vaccines, vitamin D supplements, HIV Pre-exposure prophylaxis (PrEP), and some contraceptive drugs and devices. If you do not find the drug you are searching for, consult or contact BCBSND to find out if the drug is available over the counter or is covered under your medical benefit.
Specialty Products Specialty Products are medications or drugs that may have other considerations such as special drug administration, limited availability, unique delivery and dispensing, or unique and/or required patient support or monitoring that are generally high cost. Limited Distribution Drugs marked as “Limited Distribution” have restrictions on where you may fill them, as only a limited number of pharmacies may have access to them. This may include requiring the use of a designated pharmacy to fill a prescription. Step Therapy Your benefit plan may include a step therapy program. This means you may need to try another proven,
cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. If a step therapy is required for a medication listed in this document, it will be noted next to the medication with a dot under the
Step Therapy column. Prior Approval Your benefit plan may require prior approval for certain drugs that are high-cost or have the potential for misuse. This means that your doctor will need to submit a prior approval request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. If a prior approval is required for a medication listed in this document, it will be noted next to the medication with a dot under the Prior Approval column.

Health Ins. Market Individual Small Group 6 T Formulary 2026 Plan Year (May 2026) III Dispensing Limits Drug dispensing limits help encourage medication use as intended by the FDA. Dispensing limits are placed on medications in certain drug categories. For the medications listed in this document, if a dispensing limit applies, it will be noted next to the medication with a dot under the Dispensing Limits column.
Limits may include: quantity of covered medication per prescription and/or quantity of covered medication in a given time period. If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows.
Providers Use of some products may be approved only after certain criteria are met. If prior approval is not obtained, benefits may be denied. A provider (or clinic personnel) should submit a written request for prior approval consideration.
Products in certain drug categories may have dispensing limits to encourage appropriate prescribing quantities as recommended by the FDA approved product labeling, or as otherwise clinically appropriate. Requests for a quantity that exceeds the dispensing limit should be submitted for consideration on the Dispensing Limits prior authorization request form. Products in certain drug categories may have a Step Therapy program to encourage utilizing the most cost- effective medication. This program requires the previous use of one or more drugs before coverage of a different drug is provided. Requests for medication that require a step therapy should be submitted on the Step Therapy forms available.

Health Ins. Market Individual Small Group 6 T Formulary 2026 Plan Year (May 2026) IV

Abbreviation Key aer................................................................... aerosol cap ................................................................ capsules chew ............................................................ chewable conc ........................................................ concentrate cr.................................................... controlled release dr ...................................................... delayed release ec ......................................................... enteric coated equiv ......................................................... equivalent er..................................................... extended release gm....................................................................... gram inhal ................................................................ inhaler inj ................................................................... injection liqd..................................................................... liquid mg................................................................ milligram ml .................................................................... milliliter nebu ............................................................ nebulizer odt. ...................................... orally disintegrating tabs oint ............................................................... ointment ophth ........................................................ ophthalmic osm ................................................... osmotic release pack ............................................................... packets powd ............................................................... powder pttw .............................................. twice-weekly patch sl ................................................................ sublingual soln ................................................................ solution suppos ................................................. suppositories susp ......................................................... suspension tab .................................................................... tablets td .............................................................. transdermal w/ ......................................................................... with

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 1 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ANTI-INFECTIVE AGENTS PENICILLINS AMOXICILLIN amoxicillin (trihydrate) chew tab 125 mg, 250 mg 4 amoxicillin (trihydrate) cap 250 mg, 500 mg 1 amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml 1 amoxicillin (trihydrate) tab 500 mg, 875 mg 1 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 1 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin) 2 amoxicillin & k clavulanate for susp 400-57 mg/5ml 2 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600) 2 amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg 2 amoxicillin & k clavulanate tab 250-125 mg 2 amoxicillin & k clavulanate tab 500-125 mg (Augmentin) 1 amoxicillin & k clavulanate tab 875-125 mg 1 ampicillin cap 500 mg 1 AUGMENTIN amoxicillin & k clavulanate for susp 125-31.25 mg/5ml 4 dicloxacillin sodium cap 250 mg, 500 mg 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution PENICILLIN V POTASSIUM penicillin v potassium for soln 125 mg/5ml, 250 mg/5ml 4 penicillin v potassium tab 250 mg, 500 mg 1 CEPHALOSPORINS CEFACLOR cefaclor cap 250 mg, 500 mg 4 cefadroxil cap 500 mg 1 cefadroxil for susp 250 mg/5ml, 500 mg/5ml 2 cefdinir cap 300 mg 1 cefdinir for susp 125 mg/5ml, 250 mg/5ml 2 CEFIXIME cefixime for susp 100 mg/5ml 2 cefixime for susp 200 mg/5ml (Suprax) 2 CEFPODOXIME PROXETIL cefpodoxime proxetil for susp 50 mg/5ml, 100 mg/5ml 4 cefpodoxime proxetil tab 100 mg, 200 mg 2 cefprozil for susp 125 mg/5ml, 250 mg/5ml 2 cefprozil tab 250 mg, 500 mg 2 cefuroxime axetil tab 250 mg 1 cefuroxime axetil tab 500 mg 2 cephalexin cap 250 mg, 500 mg 1 cephalexin cap 750 mg (Keflex) 2 cephalexin for susp 125 mg/5ml, 250 mg/5ml 2 MACROLIDES azithromycin for susp 100 mg/5ml (Zithromax) 2

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution azithromycin for susp 200 mg/5ml (Zithromax) 1 azithromycin tab 250 mg, 500 mg (Zithromax) 1 azithromycin tab 600 mg 2 CLARITHROMYCIN clarithromycin for susp 125 mg/5ml, 250 mg/5ml 4 clarithromycin tab er 24hr 500 mg 2 clarithromycin tab 250 mg, 500 mg 2 DIFICID fidaxomicin for susp 40 mg/ml 3 E.E.S. 400 erythromycin ethylsuccinate tab 400 mg 4 ERYTHROMYCIN DR erythromycin w/ delayed release particles cap 250 mg 4 erythromycin ethylsuccinate for susp 200 mg/5ml (E.e.s. granules) 2 erythromycin ethylsuccinate for susp 400 mg/5ml (Eryped 400) 2 erythromycin tab delayed release 250 mg, 333 mg, 500 mg 2 erythromycin tab 250 mg, 500 mg 2 fidaxomicin tab 200 mg (Dificid) 2 TETRACYCLINES demeclocycline hcl tab 150 mg, 300 mg 2 doxycycline hyclate cap 50 mg 1 doxycycline hyclate cap 100 mg (Vibramycin) 1 doxycycline hyclate tab 20 mg, 100 mg 1 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution doxycycline monohydrate cap 50 mg, 100 mg 1 doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) 2 doxycycline monohydrate tab 50 mg, 100 mg 1 doxycycline monohydrate tab 75 mg, 150 mg 2 minocycline hcl cap 50 mg 1 minocycline hcl cap 75 mg, 100 mg 2 NUZYRA omadacycline tosylate tab 150 mg (base equivalent) 4 • tetracycline hcl cap 250 mg, 500 mg 2 FLUOROQUINOLONES BAXDELA delafloxacin meglumine tab 450 mg (base equiv) 4 CIPRO ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) 4 ciprofloxacin hcl tab 250 mg (base equiv), 500 mg (base equiv) (Cipro) 1 ciprofloxacin hcl tab 750 mg (base equiv) 1 levofloxacin oral soln 25 mg/ ml 2 levofloxacin tab 250 mg, 500 mg, 750 mg 1 moxifloxacin hcl tab 400 mg (base equiv) 2 OFLOXACIN ofloxacin tab 300 mg, 400 mg 4 AMINOGLYCOSIDES HUMATIN paromomycin sulfate cap 250 mg 3 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 3 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution neomycin sulfate tab 500 mg 1 tobramycin nebu soln 300 mg/5ml (Tobi) 5 • SULFONAMIDES sulfadiazine tab 500 mg 2 ANTIMYCOBACTERIAL AGENTS CYCLOSERINE cycloserine cap 250 mg 4 ethambutol hcl tab 100 mg 2 ethambutol hcl tab 400 mg (Myambutol) 2 isoniazid syrup 50 mg/5ml 2 isoniazid tab 100 mg, 300 mg 1 PRETOMANID pretomanid tab 200 mg 3 • PRIFTIN rifapentine tab 150 mg 3 pyrazinamide tab 500 mg 2 rifabutin cap 150 mg (Mycobutin) 2 rifampin cap 150 mg, 300 mg 2 SIRTURO bedaquiline fumarate tab 20 mg (base equiv), 100 mg (base equiv) 5 • • ANTIFUNGALS CRESEMBA isavuconazonium sulfate cap 74.5 mg, 186 mg 4 • fluconazole for susp 10 mg/ ml, 40 mg/ml (Diflucan) 2 fluconazole tab 50 mg, 100 mg, 150 mg, 200 mg (Diflucan) 1 flucytosine cap 250 mg, 500 mg (Ancobon) 2 griseofulvin microsize susp 125 mg/5ml 2 griseofulvin microsize tab 500 mg 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution griseofulvin ultramicrosize tab 125 mg, 250 mg 2 itraconazole cap 100 mg (Sporanox) 2 itraconazole oral soln 10 mg/ ml (Sporanox) 2 ketoconazole tab 200 mg 2 NOXAFIL posaconazole for delayed release susp packet 300 mg 3 • nystatin tab 500000 unit 2 posaconazole susp 40 mg/ ml (Noxafil) 2 • posaconazole tab delayed release 100 mg (Noxafil) 2 • terbinafine hcl tab 250 mg 1 voriconazole for susp 40 mg/ml (Vfend) 2 • voriconazole tab 50 mg, 200 mg (Vfend) 2 • ANTIVIRALS abacavir sulfate soln 20 mg/ ml (base equiv) (Ziagen) 2 abacavir sulfate tab 300 mg (base equiv) (Ziagen) 2 abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) 2 acyclovir cap 200 mg 1 acyclovir susp 200 mg/5ml (Zovirax) 2 acyclovir tab 400 mg, 800 mg 1 adefovir dipivoxil tab 10 mg (Hepsera) 2 APRETUDE cabotegravir im extended release susp 600 mg/3ml 3 • • APTIVUS tipranavir cap 250 mg 4

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 4 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution atazanavir sulfate cap 150 mg (base equiv), 200 mg (base equiv), 300 mg (base equiv) (Reyataz) 2 BARACLUDE entecavir oral soln 0.05 mg/ml 3 BIKTARVY bictegravir- emtricitabine-tenofovir af tab 30-120-15 mg, 50-200-25 mg 3 CIMDUO lamivudine-tenofovir disoproxil fumarate tab 300-300 mg 3 COMPLERA emtricitabine- rilpivirine-tenofovir df tab 200-25-300 mg 3 darunavir tab 600 mg, 800 mg (Prezista) 2 DELSTRIGO doravirine- lamivudine-tenofovir df tab 100-300-300 mg 3 DESCOVY emtricitabine- tenofovir alafenamide fumarate tab 120-15 mg 3 DESCOVY emtricitabine- tenofovir alafenamide fumarate tab 200-25 mg 3 • DOVATO dolutegravir sodium- lamivudine tab 50-300 mg (base eq) 3 EDURANT rilpivirine hcl tab 25 mg (base equivalent) 4 EDURANT PED rilpivirine hcl tab for oral susp 2.5 mg (base equivalent) 4 efavirenz tab 600 mg (Sustiva) 2 efavirenz-emtricitabine- tenofovir df tab 600-200-300 mg (Atripla) 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution efavirenz-lamivudine- tenofovir df tab 600-300-300 mg (Symfi) 2 EFAVIRENZ/LAMIVUDINE/ TENO efavirenz-lamivudine- tenofovir df tab 400-300-300 mg 4 emtricitabine caps 200 mg (Emtriva) 2 emtricitabine-rilpivirine- tenofovir df tab 200-25-300 mg (Complera) 2 emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg, 133-200 mg, 167-250 mg (Truvada) 2 emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg (Truvada) 2 • EMTRIVA emtricitabine soln 10 mg/ml 4 entecavir tab 0.5 mg, 1 mg (Baraclude) 2 EPCLUSA sofosbuvir- velpatasvir pellet pack 150-37.5 mg, 200-50 mg 5 • • • EPCLUSA sofosbuvir- velpatasvir tab 200-50 mg 5 • • • etravirine tab 100 mg, 200 mg (Intelence) 2 EVOTAZ atazanavir sulfate- cobicistat tab 300-150 mg (base equiv) 3 famciclovir tab 125 mg, 250 mg, 500 mg 2 fosamprenavir calcium tab 700 mg (base equiv) (Lexiva) 2 GENVOYA elvitegrav-cobic- emtricitab-tenofov af tab 150-150-200-10 mg 3

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 5 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution HARVONI ledipasvir-sofosbuvir pellet pack 33.75-150 mg, 45-200 mg 5 • • • HARVONI ledipasvir-sofosbuvir tab 45-200 mg 5 • • • INTELENCE etravirine tab 25 mg 3 ISENTRESS raltegravir potassium chew tab 25 mg (base equiv), 100 mg (base equiv) 3 ISENTRESS raltegravir potassium packet for susp 100 mg (base equiv) 3 ISENTRESS raltegravir potassium tab 400 mg (base equiv) 3 ISENTRESS HD raltegravir potassium tab 600 mg (base equiv) 3 JULUCA dolutegravir sodium- rilpivirine hcl tab 50-25 mg (base eq) 3 LAGEVRIO molnupiravir cap 200 mg 3 • lamivudine oral soln 10 mg/ ml (Epivir) 2 lamivudine tab 100 mg (hbv) (Epivir hbv) 2 lamivudine tab 150 mg, 300 mg (Epivir) 2 lamivudine-zidovudine tab 150-300 mg (Combivir) 2 LEDIPASVIR/ SOFOSBUVIR ledipasvir- sofosbuvir tab 90-400 mg 4 • • • LIVTENCITY maribavir tab 200 mg 6 • • lopinavir-ritonavir tab 100-25 mg, 200-50 mg (Kaletra) 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution maraviroc tab 150 mg, 300 mg (Selzentry) 2 MAVYRET glecaprevir- pibrentasvir pellet pack 50-20 mg 5 • • • MAVYRET glecaprevir- pibrentasvir tab 100-40 mg 5 • • • NEVIRAPINE nevirapine susp 50 mg/5ml 4 nevirapine tab er 24hr 400 mg (Viramune xr) 2 nevirapine tab 200 mg 1 NORVIR ritonavir powder packet 100 mg 4 ODEFSEY emtricitabine- rilpivirine-tenofovir af tab 200-25-25 mg 3 oseltamivir phosphate cap 30 mg (base equiv), 45 mg (base equiv), 75 mg (base equiv) (Tamiflu) 2 oseltamivir phosphate for susp 6 mg/ml (base equiv) (Tamiflu) 2 PAXLOVID nirmatrelvir tab 6 x 150 mg & ritonavir tab 5 x 100 mg pak 3 • PAXLOVID nirmatrelvir tab 10 x 150 mg & ritonavir tab 10 x 100 mg pak 3 • PAXLOVID nirmatrelvir tab 20 x 150 mg & ritonavir tab 10 x 100 mg pak 3 • PEGASYS peginterferon alfa-2a inj 180 mcg/ml 5 • PEGASYS peginterferon alfa-2a soln prefilled syr 180 mcg/0.5ml 5 • PREVYMIS letermovir pellet pack 20 mg, 120 mg 4

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 6 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution PREVYMIS letermovir tab 240 mg, 480 mg 4 PREZCOBIX darunavir- cobicistat tab 675-150 mg, 800-150 mg 3 PREZISTA darunavir oral susp 100 mg/ml 3 PREZISTA darunavir tab 75 mg, 150 mg, 600 mg, 800 mg 3 RELENZA DISKHALER zanamivir aerosol powder breath activated 5 mg/act 4 REYATAZ atazanavir sulfate oral powder packet 50 mg (base equiv) 4 RIBAVIRIN ribavirin cap 200 mg 5 • RIBAVIRIN ribavirin tab 200 mg 5 • rilpivirine hcl tab 25 mg (base equivalent) (Edurant) 2 ritonavir tab 100 mg (Norvir) 2 RUKOBIA fostemsavir tromethamine tab er 12hr 600 mg 4 SELZENTRY maraviroc oral soln 20 mg/ml 4 SOFOSBUVIR/ VELPATASVIR sofosbuvir- velpatasvir tab 400-100 mg 5 • • • SOVALDI sofosbuvir pellet pack 150 mg, 200 mg 5 • • • SOVALDI sofosbuvir tab 200 mg, 400 mg 5 • • • STRIBILD elvitegrav-cobic- emtricitab-tenofovdf tab 150-150-200-300 mg 3 SUNLENCA lenacapavir sodium tab therapy pack 4 x 300 mg, 5 x 300 mg 6 • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution SUNLENCA lenacapavir sodium tab 300 mg 6 • • SYMTUZA darunavir-cobic- emtricitab-tenofov af tab 800-150-200-10 mg 3 tenofovir disoproxil fumarate tab 300 mg (Viread) 2 TIVICAY dolutegravir sodium tab 50 mg (base equiv) 3 TIVICAY PD dolutegravir sodium tab for oral susp 5 mg (base equiv) 3 TRIUMEQ abacavir- dolutegravir-lamivudine tab 600-50-300 mg 3 TRIUMEQ PD abacavir- dolutegravir-lamivudine tab for oral sus 60-5-30 mg 3 valacyclovir hcl tab 500 mg (Valtrex) 1 valacyclovir hcl tab 1 gm (Valtrex) 2 valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte) 2 valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) 2 VEMLIDY tenofovir alafenamide fumarate tab 25 mg 4 VIRACEPT nelfinavir mesylate tab 250 mg, 625 mg 4 VIREAD tenofovir disoproxil fumarate oral powder 40 mg/ gm 3 VIREAD tenofovir disoproxil fumarate tab 150 mg, 200 mg, 250 mg 3

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 7 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution VOSEVI sofosbuvir-velpatasvir- voxilaprevir tab 400-100-100 mg 5 • • • XOFLUZA baloxavir marboxil tab therapy pack 1 x 40 mg (40 mg dose), 1 x 80 mg (80 mg dose) 4 YEZTUGO lenacapavir sodium subcut soln 463.5 mg/1.5ml (prophylaxis) 3 YEZTUGO lenacapavir sodium tab 300 mg (prophylaxis) 3 zidovudine cap 100 mg (Retrovir) 2 zidovudine syrup 10 mg/ml (Retrovir) 2 zidovudine tab 300 mg 2 ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg, 250-100 mg (Malarone) 2 CHLOROQUINE PHOSPHATE chloroquine phosphate tab 250 mg 4 chloroquine phosphate tab 500 mg 2 COARTEM artemether- lumefantrine tab 20-120 mg 4 hydroxychloroquine sulfate tab 100 mg, 300 mg 1 hydroxychloroquine sulfate tab 200 mg (Plaquenil) 2 hydroxychloroquine sulfate tab 400 mg 2 mefloquine hcl tab 250 mg 1 primaquine phosphate tab 26.3 mg (15 mg base) (Primaquine phosphate) 2 pyrimethamine tab 25 mg (Daraprim) 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution quinine sulfate cap 324 mg (Qualaquin) 2 ANTHELMINTICS albendazole tab 200 mg (Albenza) 2 BENZNIDAZOLE benznidazole tab 12.5 mg, 100 mg 3 • EMVERM mebendazole chew tab 100 mg 4 ivermectin tab 3 mg (Stromectol) 2 praziquantel tab 600 mg (Biltricide) 2 ANTI-INFECTIVE AGENTS - MISC. atovaquone susp 750 mg/5ml (Mepron) 2 CAYSTON aztreonam lysine for inhal soln 75 mg (base equivalent) 6 • • clindamycin hcl cap 75 mg, 150 mg, 300 mg (Cleocin) 1 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr) 2 dapsone tab 25 mg, 100 mg 2 fosfomycin tromethamine powd pack 3 gm (base equivalent) (Monurol) 2 IMPAVIDO miltefosine cap 50 mg 3 LAMPIT nifurtimox tab 30 mg, 120 mg 4 • linezolid for susp 100 mg/5ml (Zyvox) 2 linezolid tab 600 mg (Zyvox) 2 methenamine hippurate tab 1 gm (Hiprex) 2 metronidazole tab 250 mg 1 metronidazole tab 500 mg (Flagyl) 1

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 8 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution nitazoxanide tab 500 mg 2 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin) 1 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin) 2 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid) 1 nitrofurantoin susp 25 mg/5ml 2 pentamidine isethionate for nebulization soln 300 mg (Nebupent) 2 SIVEXTRO tedizolid phosphate tab 200 mg 4 sulfamethoxazole- trimethoprim susp 200-40 mg/5ml 2 sulfamethoxazole- trimethoprim tab 400-80 mg (Bactrim) 1 sulfamethoxazole- trimethoprim tab 800-160 mg (Bactrim ds) 1 tinidazole tab 250 mg, 500 mg 2 trimethoprim tab 100 mg 2 vancomycin hcl cap 125 mg (base equivalent) (Vancocin hcl) 2 vancomycin hcl cap 250 mg (base equivalent) (Vancocin) 2 vancomycin hcl for oral soln 25 mg/ml (base equivalent), 50 mg/ml (base equivalent) (Firvanq) 2 XIFAXAN rifaximin tab 200 mg 4 XIFAXAN rifaximin tab 550 mg 3 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution BIOLOGICALS VACCINES ABRYSVO rsv pre-fusion f a&b vac recomb for im soln 120 mcg/0.5ml 3 ACTHIB haemophilus b polysaccharide conjugate vaccine for inj 3 AFLURIA 2025-2026 influenza virus vaccine split im susp 3 AFLURIA 2025-2026 influenza virus vaccine split pf susp pref syringe 0.5 ml 3 AREXVY rsvpref3 vaccine recomb adjuvanted for im susp 120 mcg/0.5ml 3 BEXSERO meningococcal vac b (recomb omv adjuv) inj prefilled syringe 3 CAPVAXIVE pneumococcal 21-valent conjugate vaccine soln pref syr 0.5ml 3 COMIRNATY 2025-26 covid-19 mrna vac tris-pfizer im susp pref syr 30 mcg/0.3ml 3 COMIRNATY/5-11Y/2025-26 covid-19 mrna vac tris-s 5-11y-pfizer im susp 10 mcg/0.3ml 3 ENGERIX-B hepatitis b vaccine (recombinant) susp pref syr 10 mcg/0.5ml, 20 mcg/ml 3 ENGERIX-B hepatitis b vaccine (recombinant) susp 20 mcg/ ml 3 FLUAD 2025-2026 influenza vac type a&b surface ant adj susp pref syr 0.5 ml 3 FLUARIX 2025-2026 influenza virus vaccine split pf susp pref syringe 0.5 ml 3

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 9 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution FLUBLOK 2025-2026 influenza virus vacc recombinant ha pf soln pref syr 0.5 ml 3 FLUCELVAX 2025-2026 influenza virus vac tiss-cult subunit im susp 3 FLUCELVAX 2025-2026 influenza virus vac tiss-cult subunit susp pref syr 0.5 ml 3 FLULAVAL 2025-2026 influenza virus vaccine split pf susp pref syringe 0.5 ml 3 FLUMIST NASAL VACCINE 202 influenza virus vaccine live intranasal liquid 3 FLUZONE HIGH-DOSE 2025-20 influenza virus vac split high-dose pf susp pref syr 0.5ml 3 FLUZONE 2025-2026 influenza virus vaccine split im susp 3 FLUZONE 2025-2026 influenza virus vaccine split pf susp pref syringe 0.5 ml 3 GARDASIL 9 human papillomavirus (hpv) 9-valent recomb vac im susp 3 GARDASIL 9 human papillomavirus (hpv) 9-valent recomb vac susp pref syr 3 HAVRIX hepatitis a vaccine susp prefilled syr 720 el unit/0.5ml, 1440 el unit/ml 3 HEPLISAV-B hepatitis b vaccine recomb adjuvanted pref syr 20 mcg/0.5ml 3 HIBERIX haemophilus b polysaccharide conjugate vac for inj 10 mcg 3 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution IMOVAX RABIES (H.D.C.V.) rabies virus vaccine, hdc for inj susp 4 IPOL INACTIVATED IPV poliovirus vaccine, ipv inj susp 3 JYNNEOS smallpox & monkeypox vac, live, non- replicating inj 0.5 ml 3 M-M-R II measles-mumps- rubella virus vaccines for inj soln 3 MENQUADFI meningococcal (a, c, y, and w-135) tetanus conjugate vaccine 3 MENVEO meningococcal (a, c, y, and w-135) oligo conj vac for inj 3 MENVEO meningococcal (a, c, y, and w-135) oligo conj vac im soln 3 MNEXSPIKE COVID-19 VACCIN covid-19 mrna vaccine-moderna im susp pref syr 10 mcg/0.2ml 3 MRESVIA rsv mrna pre-f vaccine im susp pref syr 50 mcg/0.5ml 3 NUVAXOVID COVID-19 VACCIN covid-19 subunit vacc-novavax im susp pref syr 5 mcg/0.5ml 3 PEDVAX HIB haemophilus b polysaccharide conj vac im susp 7.5 mcg/0.5 ml 4 PENBRAYA meningococcal acyw (tet conj)-mening b (rcmb) vacc for inj 3 PENMENVY meningococcal acwy (oligo conj)-mening b (rcmb) vacc for inj 3

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 10 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution PNEUMOVAX 23 pneumococcal vaccine polyvalent soln pref syr 25 mcg/0.5ml 4 PREVNAR 20 pneumococcal 20-valent conjugate vaccine sus pref syr 0.5 ml 3 PRIORIX measles-mumps- rubella virus vaccines for subcutaneous susp 3 PROQUAD measles-mumps- rubella-varicella virus vaccines for susp 4 RABAVERT rabies vaccine, pcec for inj 4 RECOMBIVAX HB hepatitis b vaccine (recombinant) susp pref syr 5 mcg/0.5ml, 10 mcg/ml 4 RECOMBIVAX HB hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml, 10 mcg/ml, 40 mcg/ml 4 ROTARIX rotavirus vaccine, live oral susp 4 ROTATEQ rotavirus vaccine, live oral pentavalent soln 4 SHINGRIX zoster vac recomb adjuvanted im susp pref syr 50 mcg/0.5ml 3 SHINGRIX zoster vac recombinant adjuvanted for im inj 50 mcg/0.5ml 3 SPIKEVAX COVID-19 VACCINE covid-19 mrna vac 6mo-11yr-moderna im susp pfs 25 mcg/0.25ml 3 SPIKEVAX COVID-19 VACCINE covid-19 mrna vaccine-moderna im susp pref syr 50 mcg/0.5ml 3 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution TRUMENBA meningococcal group b vac (recomb) im susp prefilled syr 4 TWINRIX hep a-hep b vaccine susp pref syr 720-20 elu- mcg/ml 4 VAQTA hepatitis a vaccine inj susp 25 unit/0.5ml, 50 unit/ ml 4 VAQTA hepatitis a vaccine susp prefilled syr 25 unit/0.5ml, 50 unit/ml 4 VARIVAX varicella virus vac live for inj 1350 pfu/0.5ml 4 VAXNEUVANCE pneumococcal 15-valent conjugate vaccine sus pref syr 0.5 ml 3 VIVOTIF typhoid vaccine cap delayed release 4 TOXOIDS ADACEL tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf- mcg/0.5ml 3 ADACEL tet-diph-acell pertuss ad pref syr 5-2-15.5 lf- mcg/0.5ml 3 BOOSTRIX tet-diph-acell pertuss ad pref syr 5-2.5-18.5 lf-mcg/0.5ml 3 DAPTACEL diph, acellular pert & tet tox inj 15 lf-23 mcg-5 lf/0.5ml 3 INFANRIX diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 3 KINRIX diph-tetanus-acell pert- polio, ipv vacc susp pref syr 0.5 ml 3 PEDIARIX diph-tet tox-acell pert-hep b-polio ipv vac susp pref syr 4

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 11 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution PENTACEL diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp 4 QUADRACEL diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 4 QUADRACEL diph-tetanus- acell pert-polio, ipv vacc susp pref syr 0.5 ml 4 TENIVAC tetanus-diphtheria toxoids (td) inj 5-2 lf/0.5ml 4 VAXELIS diph-tet tox-ac pert ad-polio ipv-hib-hep b rec susp pre syr 3 VAXELIS diph-tet tox-ac pert ad-polio ipv-hib-hepatitis b recmb susp 3 BIOLOGICALS MISC GRASTEK timothy grass pollen allergen ext sl tab 2800 bau 4 ODACTRA dust mite mixed ext sl tab 12 sq-hdm 4 RAGWITEK short ragweed pollen allergen extract sl tab 12 amb a 1-u 4 ANTINEOPLASTIC AGENTS ANTINEOPLASTICS abiraterone acetate tab 250 mg, 500 mg (Zytiga) 5 • • • ACTIMMUNE interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml) 5 • • AKEEGA niraparib tosylate- abiraterone acetate tab 50-500 mg, 100-500 mg 6 • • • • ALECENSA alectinib hcl cap 150 mg (base equivalent) 5 • • • • ALUNBRIG brigatinib tab initiation therapy pack 90 mg & 180 mg 5 • • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ALUNBRIG brigatinib tab 30 mg, 90 mg, 180 mg 5 • • • • anastrozole tab 1 mg (Arimidex) 1 • AUGTYRO repotrectinib cap 40 mg, 160 mg 6 • • • AVMAPKI FAKZYNJA CO- PACK avutometinib cap 0.8 mg & defactinib tab 200 mg therapy pack 6 • • • • AYVAKIT avapritinib tab 25 mg, 50 mg, 100 mg, 200 mg, 300 mg 5 • • • • BALVERSA erdafitinib tab 3 mg, 4 mg, 5 mg 6 • • • • BESREMI ropeginterferon alfa-2b-njft soln prefilled syr 500 mcg/ml 5 • • • • bexarotene cap 75 mg (Targretin) 5 • • bicalutamide tab 50 mg (Casodex) 1 BOSULIF bosutinib cap 50 mg, 100 mg 5 • • • • BOSULIF bosutinib tab 100 mg, 400 mg, 500 mg 5 • • • • BRAFTOVI encorafenib cap 75 mg 6 • • • • BRUKINSA zanubrutinib cap 80 mg 5 • • • • BRUKINSA zanubrutinib tab 160 mg 5 • • • • CABOMETYX cabozantinib s-malate tab 20 mg (base equivalent), 40 mg (base equivalent), 60 mg (base equivalent) 5 • • • • CALQUENCE acalabrutinib maleate tab 100 mg 5 • • • • capecitabine tab 150 mg, 500 mg (Xeloda) 5 • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 12 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution CAPRELSA vandetanib tab 100 mg, 300 mg 5 • • • • COMETRIQ cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit 5 • • • • COMETRIQ cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit 5 • • • • COMETRIQ cabozantinib s- malate cap 3 x 20 mg (60 mg dose) kit 5 • • • • COPIKTRA duvelisib cap 15 mg, 25 mg 6 • • • • COTELLIC cobimetinib fumarate tab 20 mg (base equivalent) 5 • • • • CYCLOPHOSPHAMIDE cyclophosphamide tab 50 mg 3 cyclophosphamide cap 25 mg, 50 mg (Cyclophosphamide) 2 dasatinib tab 20 mg, 50 mg, 70 mg, 80 mg, 100 mg, 140 mg (Sprycel) 5 • • • DAURISMO glasdegib maleate tab 25 mg (base equivalent), 100 mg (base equivalent) 6 • • • • ENSACOVE ensartinib hcl cap 25 mg (base equivalent), 100 mg (base equivalent) 6 • • • ERIVEDGE vismodegib cap 150 mg 5 • • • • ERLEADA apalutamide tab 60 mg, 240 mg 5 • • • • erlotinib hcl tab 25 mg (base equivalent), 100 mg (base equivalent), 150 mg (base equivalent) (Tarceva) 5 • • • ETOPOSIDE etoposide cap 50 mg 5 • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution everolimus tab for oral susp 2 mg, 3 mg, 5 mg (Afinitor disperz) 5 • • • everolimus tab 2.5 mg, 5 mg, 7.5 mg, 10 mg (Afinitor) 5 • • • exemestane tab 25 mg (Aromasin) 2 FOTIVDA tivozanib hcl cap 0.89 mg (base equivalent), 1.34 mg (base equivalent) 6 • • • • FRUZAQLA fruquintinib cap 1 mg, 5 mg 6 • • • GAVRETO pralsetinib cap 100 mg 6 • • • • gefitinib tab 250 mg (Iressa) 5 • • • GILOTRIF afatinib dimaleate tab 20 mg (base equivalent), 30 mg (base equivalent), 40 mg (base equivalent) 5 • • • • GLEOSTINE lomustine cap 10 mg, 40 mg, 100 mg 5 • GOMEKLI mirdametinib cap 1 mg, 2 mg 6 • • • GOMEKLI mirdametinib tab for oral susp 1 mg 6 • • • HERNEXEOS zongertinib tab 60 mg 6 • • • • HYCAMTIN topotecan hcl cap 0.25 mg (base equiv), 1 mg (base equiv) 5 • • hydroxyurea cap 500 mg (Hydrea) 2 IBRANCE palbociclib cap 75 mg, 100 mg, 125 mg 5 • • • • IBRANCE palbociclib tab 75 mg, 100 mg, 125 mg 5 • • • • IBTROZI taletrectinib adipate cap 200 mg 6 • • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 13 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ICLUSIG ponatinib hcl tab 10 mg (base equiv), 15 mg (base equiv), 30 mg (base equiv), 45 mg (base equiv) 5 • • • • IDHIFA enasidenib mesylate tab 50 mg (base equivalent), 100 mg (base equivalent) 6 • • • • imatinib mesylate tab 100 mg (base equivalent), 400 mg (base equivalent) (Gleevec) 5 • • • IMBRUVICA ibrutinib cap 70 mg, 140 mg 5 • • • • IMBRUVICA ibrutinib oral susp 70 mg/ml 5 • • • • IMBRUVICA ibrutinib tab 140 mg, 280 mg, 420 mg 5 • • • • INLYTA axitinib tab 1 mg, 5 mg 5 • • • • INQOVI decitabine- cedazuridine tab 35-100 mg 6 • • • • INREBIC fedratinib hcl cap 100 mg 6 • • • • IRESSA gefitinib tab 250 mg 5 • • • • ITOVEBI inavolisib tab 3 mg, 9 mg 5 • • • IWILFIN eflornithine hcl tab 192 mg 6 • • • JAKAFI ruxolitinib phosphate tab 5 mg (base equivalent), 10 mg (base equivalent), 15 mg (base equivalent), 20 mg (base equivalent), 25 mg (base equivalent) 5 • • • • JAYPIRCA pirtobrutinib tab 50 mg, 100 mg 6 • • • • KISQALI ribociclib succinate tab pack 200 mg daily dose, 400 mg daily dose (200 mg tab), 600 mg daily dose (200 mg tab) 5 • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution KOSELUGO selumetinib sulfate cap sprinkle 5 mg, 7.5 mg 6 • • • • KOSELUGO selumetinib sulfate cap 10 mg, 25 mg 6 • • • • KRAZATI adagrasib tab 200 mg 6 • • • • lapatinib ditosylate tab 250 mg (base equiv) (Tykerb) 5 • • • LAZCLUZE lazertinib mesylate tab 80 mg, 240 mg 6 • • • LENVIMA 10 MG DAILY DOSE lenvatinib cap therapy pack 10 mg (10 mg daily dose) 5 • • • • LENVIMA 12MG DAILY DOSE lenvatinib cap therapy pack 3 x 4 mg (12 mg daily dose) 5 • • • • LENVIMA 14 MG DAILY DOSE lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose) 5 • • • • LENVIMA 18 MG DAILY DOSE lenvatinib cap ther pack 10 mg & 2 x 4 mg (18 mg daily dose) 5 • • • • LENVIMA 20 MG DAILY DOSE lenvatinib cap therapy pack 2 x 10 mg (20 mg daily dose) 5 • • • • LENVIMA 24 MG DAILY DOSE lenvatinib cap ther pack 2 x 10 mg & 4 mg (24 mg daily dose) 5 • • • • LENVIMA 4 MG DAILY DOSE lenvatinib cap therapy pack 4 mg (4 mg daily dose) 5 • • • • LENVIMA 8 MG DAILY DOSE lenvatinib cap therapy pack 2 x 4 mg (8 mg daily dose) 5 • • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 14 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution letrozole tab 2.5 mg (Femara) 1 leucovorin calcium tab 5 mg, 15 mg, 25 mg 2 LEUKERAN chlorambucil tab 2 mg 5 • lomustine cap 10 mg, 40 mg, 100 mg (Gleostine) 5 • LONSURF trifluridine-tipiracil tab 15-6.14 mg, 20-8.19 mg 5 • • • • LORBRENA lorlatinib tab 25 mg, 100 mg 6 • • • • LUMAKRAS sotorasib tab 120 mg, 240 mg, 320 mg 6 • • • • LYNPARZA olaparib tab 100 mg, 150 mg 5 • • • • LYSODREN mitotane tab 500 mg 5 • • • LYTGOBI futibatinib tab therapy pack 4 mg (12 mg daily dose), 4 mg (16 mg daily dose), 4 mg (20 mg daily dose) 6 • • • • MATULANE procarbazine hcl cap 50 mg 5 • • • megestrol acetate susp 40 mg/ml 2 megestrol acetate tab 20 mg 1 megestrol acetate tab 40 mg 2 MEKINIST trametinib dimethyl sulfoxide for soln 0.05 mg/ml (base eq) 5 • • • MEKINIST trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent), 2 mg (base equivalent) 5 • • • MEKTOVI binimetinib tab 15 mg 6 • • • • mercaptopurine susp 2000 mg/100ml (20 mg/ml) (Purixan) 5 • mercaptopurine tab 50 mg 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution mesna tab 400 mg (Mesnex) 2 MESNEX mesna tab 400 mg 3 METHOTREXATE SODIUM methotrexate sodium inj 50 mg/2ml (25 mg/ml), 250 mg/10ml (25 mg/ml) 4 methotrexate sodium for inj 1 gm 2 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml), 250 mg/10ml (25 mg/ml) 1 methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) 2 methotrexate sodium tab 2.5 mg (base equiv) 1 MODEYSO dordaviprone hcl cap 125 mg 6 • • • • MYLERAN busulfan tab 2 mg 5 • NERLYNX neratinib maleate tab 40 mg (base equivalent) 6 • • • • nilotinib hcl cap 50 mg (base equivalent), 150 mg (base equivalent), 200 mg (base equivalent) (Tasigna) 5 • • • NILUTAMIDE nilutamide tab 150 mg 5 • NINLARO ixazomib citrate cap 2.3 mg (base equivalent), 3 mg (base equivalent), 4 mg (base equivalent) 5 • • • • NUBEQA darolutamide tab 300 mg 5 • • • ODOMZO sonidegib phosphate cap 200 mg (base equivalent) 5 • • • • OGSIVEO nirogacestat hydrobromide tab 100 mg, 150 mg 5 • • • • OJEMDA tovorafenib for oral susp 25 mg/ml 6 • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 15 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution OJEMDA tovorafenib tab 100 mg 6 • • • OJJAARA momelotinib dihydrochloride tab 100 mg, 150 mg, 200 mg 6 • • • • ONUREG azacitidine tab 200 mg, 300 mg 6 • • • ORGOVYX relugolix tab 120 mg 6 • • • • ORSERDU elacestrant hydrochloride tab 86 mg, 345 mg 6 • • • • pazopanib hcl tab 200 mg (base equiv) (Votrient) 5 • • • PEMAZYRE pemigatinib tab 4.5 mg, 9 mg, 13.5 mg 6 • • • • PIQRAY 200MG DAILY DOSE alpelisib tab therapy pack 200 mg daily dose 5 • • • PIQRAY 250MG DAILY DOSE alpelisib tab pack 250 mg daily dose (200 mg & 50 mg tabs) 5 • • • PIQRAY 300MG DAILY DOSE alpelisib tab pack 300 mg daily dose (2x150 mg tab) 5 • • • pomalidomide cap 1 mg, 2 mg, 3 mg, 4 mg (Pomalyst) 5 • • • POMALYST pomalidomide cap 1 mg, 2 mg, 3 mg, 4 mg 5 • • • • PURIXAN mercaptopurine susp 2000 mg/100ml (20 mg/ml) 5 • • QINLOCK ripretinib tab 50 mg 6 • • • • RETEVMO selpercatinib tab 40 mg, 80 mg, 120 mg, 160 mg 5 • • • • REVUFORJ revumenib citrate tab 25 mg, 110 mg, 160 mg 6 • • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution REZLIDHIA olutasidenib cap 150 mg 6 • • • • ROMVIMZA vimseltinib cap 14 mg, 20 mg, 30 mg 5 • • • ROZLYTREK entrectinib cap 100 mg, 200 mg 5 • • • • ROZLYTREK entrectinib pellet pack 50 mg 5 • • • • RUBRACA rucaparib camsylate tab 200 mg (base equivalent), 250 mg (base equivalent), 300 mg (base equivalent) 5 • • • • RYDAPT midostaurin cap 25 mg 5 • • • SCEMBLIX asciminib hcl tab 20 mg, 40 mg, 100 mg 5 • • • • SOLTAMOX tamoxifen citrate oral soln 10 mg/5ml (base equivalent) 4 sorafenib tosylate tab 200 mg (base equivalent) (Nexavar) 5 • • • STIVARGA regorafenib tab 40 mg 5 • • • • sunitinib malate cap 12.5 mg (base equivalent), 25 mg (base equivalent), 37.5 mg (base equivalent), 50 mg (base equivalent) (Sutent) 5 • • • TABLOID thioguanine tab 40 mg 5 • TABRECTA capmatinib hcl tab 150 mg, 200 mg 5 • • • TAFINLAR dabrafenib mesylate cap 50 mg (base equivalent), 75 mg (base equivalent) 5 • • • TAFINLAR dabrafenib mesylate tab for oral susp 10 mg (base equiv) 5 • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 16 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution TAGRISSO osimertinib mesylate tab 40 mg (base equivalent), 80 mg (base equivalent) 5 • • • • TALZENNA talazoparib tosylate cap 0.1 mg (base equivalent), 0.25 mg (base equivalent), 0.35 mg (base equivalent), 0.5 mg (base equivalent), 0.75 mg (base equivalent), 1 mg (base equivalent) 5 • • • • tamoxifen citrate tab 10 mg (base equivalent), 20 mg (base equivalent) 1 • TASIGNA nilotinib hcl cap 50 mg (base equivalent), 150 mg (base equivalent), 200 mg (base equivalent) 5 • • • temozolomide cap 5 mg, 20 mg 5 • • temozolomide cap 100 mg, 140 mg, 180 mg, 250 mg (Temodar) 5 • • TEPMETKO tepotinib hcl tab 225 mg 5 • • • • TIBSOVO ivosidenib tab 250 mg 5 • • • • toremifene citrate tab 60 mg (base equivalent) (Fareston) 5 • tretinoin cap 10 mg 5 • • TRUQAP capivasertib tab therapy pack 160 mg, 200 mg 6 • • • • TRUQAP capivasertib tab 200 mg 6 • • • • TUKYSA tucatinib tab 50 mg, 150 mg 6 • • • • TURALIO pexidartinib hcl cap 125 mg (base equivalent) 6 • • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution VANFLYTA quizartinib dihydrochloride tab 17.7 mg, 26.5 mg 6 • • • • VENCLEXTA venetoclax tab 10 mg, 50 mg, 100 mg 5 • • • • VENCLEXTA STARTING PACK venetoclax tab therapy starter pack 10 & 50 & 100 mg 5 • • • • VERZENIO abemaciclib tab 50 mg, 100 mg, 150 mg, 200 mg 5 • • • • VITRAKVI larotrectinib sulfate cap 25 mg (base equivalent), 100 mg (base equivalent) 5 • • • • VITRAKVI larotrectinib sulfate oral soln 20 mg/ml (base equivalent) 5 • • • • VIZIMPRO dacomitinib tab 15 mg, 30 mg, 45 mg 6 • • • • VONJO pacritinib citrate cap 100 mg 6 • • • • VORANIGO vorasidenib tab 10 mg, 40 mg 5 • • • • VOTRIENT pazopanib hcl tab 200 mg (base equiv) 5 • • • WELIREG belzutifan tab 40 mg 6 • • • • XALKORI crizotinib cap sprinkle 20 mg, 50 mg, 150 mg 5 • • • • XALKORI crizotinib cap 200 mg, 250 mg 5 • • • • XOSPATA gilteritinib fumarate tablet 40 mg (base equivalent) 6 • • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 17 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution XPOVIO selinexor tab therapy pack 10 mg (40 mg once weekly), 40 mg (40 mg twice weekly), 40 mg (80 mg once weekly), 50 mg (100 mg once weekly), 60 mg (60 mg once weekly) 6 • • • • XPOVIO selinexor tab therapy pack 80 mg (80 mg once weekly) 6 • • • XPOVIO 60 MG TWICE WEEKLY selinexor tab therapy pack 20 mg (60 mg twice weekly) 6 • • • • XPOVIO 80 MG TWICE WEEKLY selinexor tab therapy pack 20 mg (80 mg twice weekly) 6 • • • • XTANDI enzalutamide cap 40 mg 5 • • • • XTANDI enzalutamide tab 40 mg, 80 mg 5 • • • • YONSA abiraterone acetate micronized tab 125 mg 5 • • • • ZEJULA niraparib tosylate tab 100 mg (base equivalent), 200 mg (base equivalent), 300 mg (base equivalent) 5 • • • • ZELBORAF vemurafenib tab 240 mg 5 • • • • ZOLINZA vorinostat cap 100 mg 5 • • • • ZYDELIG idelalisib tab 100 mg, 150 mg 5 • • • • ZYKADIA ceritinib tab 150 mg 5 • • • • ENDOCRINE AND METABOLIC DRUGS CORTICOSTEROIDS budesonide delayed release particles cap 3 mg (Entocort ec) 2 DEXAMETHASONE dexamethasone soln 0.5 mg/5ml 4 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution dexamethasone elixir 0.5 mg/5ml 2 DEXAMETHASONE INTENSOL dexamethasone conc 1 mg/ml 4 dexamethasone tab 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg 1 fludrocortisone acetate tab 0.1 mg 1 hydrocortisone tab 5 mg, 10 mg, 20 mg (Cortef) 2 methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak) 1 methylprednisolone tab 4 mg, 16 mg, 32 mg (Medrol) 1 methylprednisolone tab 8 mg (Medrol) 2 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) 1 prednisolone sod phosphate oral soln 5 mg/5ml (base equiv) (Pediapred) 2 prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) 2 prednisolone soln 15 mg/5ml 2 PREDNISONE prednisone oral soln 5 mg/5ml 3 prednisone tab therapy pack 5 mg (21), 5 mg (48), 10 mg (21) 1 prednisone tab therapy pack 10 mg (48) 2 prednisone tab 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50 mg 1

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 18 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ANDROGEN-ANABOLIC danazol cap 50 mg, 100 mg, 200 mg 2 METHITEST methyltestosterone oral tab 10 mg 4 • testosterone cypionate im inj in oil 100 mg/ ml, 200 mg/ml (Depo- testosterone) 2 • TESTOSTERONE ENANTHATE testosterone enanthate im inj in oil 200 mg/ml 4 • testosterone td gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) (Androgel) 2 • testosterone td gel 12.5 mg/ act (1%) 2 • testosterone td gel 20.25 mg/act (1.62%) (Androgel pump) 2 • testosterone td soln 30 mg/ act 2 • ESTROGENS ANGELIQ drospirenone- estradiol tab 0.25-0.5 mg, 0.5-1 mg 4 BIJUVA estradiol-progesterone cap 0.5-100 mg, 1-100 mg 4 CLIMARA PRO estradiol- levonorgestrel td patch weekly 0.045-0.015 mg/day 3 COMBIPATCH estradiol- norethindrone ace td pttw 0.05-0.14 mg/day, 0.05-0.25 mg/day 4 DEPO-ESTRADIOL estradiol cypionate im in oil 5 mg/ml 4 DUAVEE conjugated estrogens-bazedoxifene tab 0.45-20 mg 3 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution estradiol & norethindrone acetate tab 0.5-0.1 mg 2 estradiol & norethindrone acetate tab 1-0.5 mg (Activella) 2 estradiol gel 0.06% (0.75 mg/1.25 gm metered- dose pump) (Estrogel) 2 estradiol tab 0.5 mg, 1 mg, 2 mg (Estrace) 1 estradiol td gel 0.25 mg/0.25gm (0.1%), 0.5 mg/0.5gm (0.1%), 0.75 mg/0.75gm (0.1%), 1 mg/gm (0.1%), 1.25 mg/1.25gm (0.1%) (Divigel) 2 estradiol td patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr (Vivelle-dot) 2 estradiol td patch weekly 0.025 mg/24hr, 0.0375 mg/24hr (37.5 mcg/24hr), 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr (Climara) 2 estradiol valerate im in oil 10 mg/ml, 20 mg/ml, 40 mg/ml (Delestrogen) 2 estrogens, conjugated tab 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, 1.25 mg (Premarin) 2 EVAMIST estradiol transdermal spray 1.53 mg/spray 4 MYFEMBREE relugolix- estradiol-norethindrone acetate tab 40-1-0.5 mg 3 • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 19 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution norethindrone acetate- ethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt) 2 norethindrone acetate- ethinyl estradiol tab 1 mg-5 mcg 2 ORIAHNN elagolix-estrad- noreth 300-1-0.5mg & elagolix 300mg cap pack 3 • • PREMARIN estrogens, conjugated tab 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, 1.25 mg 4 PREMPHASE conj est 0.625(14)/conj est- medroxypro ac tab 0.625-5mg(14) 4 PREMPRO conjugated estrogen-medroxyprogest acetate tab 0.3-1.5 mg, 0.45-1.5 mg, 0.625-2.5 mg, 0.625-5 mg 4 CONTRACEPTIVES ARANELLE norethindrone- eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg A • DEPO-SUBQ PROVERA 104 medroxyprogesterone acetate susp pref syr 104 mg/0.65ml A • desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette) A • desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg A • drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg (Beyaz) A • drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg (Safyral) A • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz) A • drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28) A • ELLA ulipristal acetate tab 30 mg A • ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg A • ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg A • levonor-eth est tab 0.15-0.02/0.025/0.03 mg &eth est 0.01 mg (Quartette) A • levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique) A • levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique) A • levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg A • levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg, 0.15 mg-30 mcg A • levonorgestrel tab 1.5 mg A • levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg- mcg A • levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg A • LO LOESTRIN FE norethin-eth estradiol-fe tab 1 mg-10 mcg (24)/10 mcg (2) A •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 20 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution medroxyprogesterone acetate im susp prefilled syr 150 mg/ml (Depo- provera contrac) A • medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac) A • NATAZIA estradiol valerate- dienogest tab 3 mg /2-2 mg/2-3 mg/1 mg 4 norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr A • norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg A • norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg, 1 mg-35 mcg A • norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg A • norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg (Generess fe) A • norethindrone ac- ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe) A • norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg, 1.5 mg-30 mcg A • norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg, 1.5 mg-30 mcg A • norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24) (Minastrin 24 fe) A • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution norethindrone ace- ethinyl estradiol-fe tab 1 mg-20 mcg (24) A • norethindrone tab 0.35 mg A • norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg- mcg A • norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg A • norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg- mcg, 0.18-35/0.215-35/0.25-35 mg- mcg A • norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg A • NUVARING etonogestrel- ethinyl estradiol va ring 0.12-0.015 mg/24hr A • OPILL norgestrel tab 0.075 mg A • TYBLUME levonorgestrel & ethinyl estradiol chew tab 0.1 mg-20 mcg 4 VELIVET desogest- ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg- mg 4 PROGESTINS medroxyprogesterone acetate tab 2.5 mg, 5 mg, 10 mg (Provera) 1 norethindrone acetate tab 5 mg (Aygestin) 2 progesterone cap 100 mg (Prometrium) 1 progesterone cap 200 mg (Prometrium) 2 progesterone im in oil 50 mg/ml 2

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 21 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution Antidiabetics acarbose tab 25 mg, 50 mg, 100 mg (Precose) 2 BAQSIMI ONE PACK glucagon nasal powder 3 mg/dose 3 BAQSIMI TWO PACK glucagon nasal powder 3 mg/dose 3 diazoxide susp 50 mg/ml (Proglycem) 2 FARXIGA dapagliflozin propanediol tab 5 mg (base equivalent), 10 mg (base equivalent) 3 glimepiride tab 1 mg, 2 mg, 4 mg (Amaryl) 1 GLIPIZIDE glipizide tab 2.5 mg 4 glipizide tab er 24hr 2.5 mg, 5 mg, 10 mg (Glucotrol xl) 1 glipizide tab 5 mg 1 glipizide tab 10 mg (Glucotrol) 1 glipizide-metformin hcl tab 2.5-250 mg, 2.5-500 mg, 5-500 mg 2 GLUCAGON EMERGENCY KIT FO glucagon hcl for inj 1 mg 3 glucagon for inj 1 mg 2 glyburide tab 1.25 mg, 2.5 mg, 5 mg 1 glyburide-metformin tab 1.25-250 mg, 2.5-500 mg, 5-500 mg 1 GLYXAMBI empagliflozin- linagliptin tab 10-5 mg, 25-5 mg 3 GVOKE HYPOPEN 1-PACK glucagon subcutaneous solution auto- injector 0.5 mg/0.1ml, 1 mg/0.2ml 3 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution GVOKE HYPOPEN 2-PACK glucagon subcutaneous solution auto- injector 0.5 mg/0.1ml, 1 mg/0.2ml 3 GVOKE KIT glucagon subcutaneous soln 1 mg/0.2ml 3 GVOKE PFS glucagon subcutaneous soln pref syringe 1 mg/0.2ml 3 JANUMET sitagliptin phosphate-metformin hcl tab 50-500 mg, 50-1000 mg 3 JANUMET XR sitagliptin phosphate-metformin hcl tab er 24hr 50-500 mg, 50-1000 mg, 100-1000 mg 3 JANUVIA sitagliptin phosphate tab 25 mg (base equiv), 50 mg (base equiv), 100 mg (base equiv) 3 JARDIANCE empagliflozin tab 10 mg, 25 mg 3 metformin hcl tab er 24hr 500 mg, 750 mg 1 metformin hcl tab 500 mg, 850 mg, 1000 mg 1 mifepristone tab 300 mg (Korlym) 5 • • • MOUNJARO tirzepatide soln auto-injector 2.5 mg/0.5ml, 5 mg/0.5ml, 7.5 mg/0.5ml, 10 mg/0.5ml, 12.5 mg/0.5ml, 15 mg/0.5ml 3 • • OZEMPIC semaglutide soln pen-inj 0.25 or 0.5 mg/dose (2 mg/3ml), 2 mg/dose (8 mg/3ml) 3 • • OZEMPIC semaglutide soln pen-inj 1 mg/dose (4 mg/3ml) 3 • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 22 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution pioglitazone hcl tab 15 mg (base equiv), 30 mg (base equiv), 45 mg (base equiv) (Actos) 1 pioglitazone hcl-metformin hcl tab 15-500 mg, 15-850 mg (Actoplus met) 2 repaglinide tab 0.5 mg, 1 mg 1 repaglinide tab 2 mg 2 RYBELSUS semaglutide tab 3 mg, 7 mg, 14 mg 3 • • SOLIQUA 100/33 insulin glargine-lixisenatide sol pen- inj 100-33 unit-mcg/ml 3 • SYNJARDY empagliflozin- metformin hcl tab 5-500 mg, 5-1000 mg, 12.5-500 mg, 12.5-1000 mg 3 SYNJARDY XR empagliflozin- metformin hcl tab er 24hr 5-1000 mg, 10-1000 mg, 12.5-1000 mg, 25-1000 mg 3 TRIJARDY XR empagliflozin- linaglip-metformin tab er 24hr 12.5-2.5-1000mg 3 TRIJARDY XR empagliflozin- linagliptin-metformin tab er 24hr 5-2.5-1000mg, 10-5-1000 mg, 25-5-1000 mg 3 TRULICITY dulaglutide soln auto-injector 0.75 mg/0.5ml, 1.5 mg/0.5ml, 3 mg/0.5ml, 4.5 mg/0.5ml 3 • • XIGDUO XR dapagliflozin prop-metformin hcl tab er 24hr 2.5-1000 mg, 5-500 mg, 5-1000 mg, 10-500 mg, 10-1000 mg 3 XULTOPHY 100/3.6 insulin degludec-liraglutide sol pen- inj 100-3.6 unit-mg/ml 3 • Rapid-Acting Insulins Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution FIASP insulin aspart (with niacinamide) inj 100 unit/ml 3 • FIASP FLEXTOUCH insulin aspart (with niacinamide) sol pen-inj 100 unit/ml 3 • FIASP PENFILL insulin aspart (with niacinamide) soln cartridge 100 unit/ml 3 • HUMALOG insulin lispro inj soln 100 unit/ml 3 • HUMALOG insulin lispro soln cartridge 100 unit/ml 3 • HUMALOG JUNIOR KWIKPEN insulin lispro soln pen-injector 100 unit/ml (0.5 unit dial) 3 • HUMALOG KWIKPEN insulin lispro soln pen-injector 100 unit/ml (1 unit dial), 200 unit/ ml 3 • HUMALOG TEMPO PEN insulin lispro soln pen- inj w/transmitter port 100 unit/ml 3 • LYUMJEV insulin lispro-aabc inj 100 unit/ml 3 • LYUMJEV KWIKPEN insulin lispro-aabc soln pen-injector 200 unit/ml 3 • LYUMJEV KWIKPEN insulin lispro-aabc soln pen-inj 100 unit/ml (1 unit dial) 3 • LYUMJEV TEMPO PEN insulin lispro-aabc soln pen-inj w/ transmit port 100 unit/ml 3 • NOVOLOG insulin aspart inj soln 100 unit/ml 3 • NOVOLOG FLEXPEN insulin aspart soln pen-injector 100 unit/ml 3 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 23 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution NOVOLOG FLEXPEN RELION insulin aspart soln pen-injector 100 unit/ml 3 • NOVOLOG PENFILL insulin aspart soln cartridge 100 unit/ml 3 • NOVOLOG RELION insulin aspart inj soln 100 unit/ml 3 • Short-Acting Insulins HUMULIN R insulin regular (human) inj 100 unit/ml 3 • HUMULIN R U-500 KWIKPEN insulin regular (human) soln pen-injector 500 unit/ml 3 • NOVOLIN R insulin regular (human) inj 100 unit/ml 3 • NOVOLIN R FLEXPEN insulin regular (human) soln pen- injector 100 unit/ml 3 • NOVOLIN R FLEXPEN RELION insulin regular (human) soln pen-injector 100 unit/ml 3 • NOVOLIN R RELION insulin regular (human) inj 100 unit/ ml 3 • Intermediate-Acting Insulins HUMALOG MIX 50/50 KWIKPEN insulin lispro prot & lispro sus pen-inj 100 unit/ ml (50-50) 3 • HUMALOG MIX 75/25 insulin lispro prot & lispro inj 100 unit/ml (75-25) 3 • HUMALOG MIX 75/25 KWIKPEN insulin lispro prot & lispro sus pen-inj 100 unit/ ml (75-25) 3 • HUMULIN N insulin nph (human) (isophane) inj 100 unit/ml 3 • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution HUMULIN N KWIKPEN insulin nph (human) (isophane) susp pen-injector 100 unit/ml 3 • HUMULIN 70/30 insulin nph isophane & regular human inj 100 unit/ml (70-30) 3 • HUMULIN 70/30 KWIKPEN insulin nph & regular susp pen-inj 100 unit/ml (70-30) 3 • NOVOLIN N insulin nph (human) (isophane) inj 100 unit/ml 3 • NOVOLIN N FLEXPEN insulin nph (human) (isophane) susp pen-injector 100 unit/ml 3 • NOVOLIN N FLEXPEN RELION insulin nph (human) (isophane) susp pen-injector 100 unit/ml 3 • NOVOLIN N RELION insulin nph (human) (isophane) inj 100 unit/ml 3 • NOVOLIN 70/30 insulin nph isophane & regular human inj 100 unit/ml (70-30) 3 • NOVOLIN 70/30 FLEXPEN insulin nph & regular susp pen-inj 100 unit/ml (70-30) 3 • NOVOLIN 70/30 FLEXPEN REL insulin nph & regular susp pen-inj 100 unit/ml (70-30) 3 • NOVOLIN 70/30 RELION insulin nph isophane & regular human inj 100 unit/ ml (70-30) 3 • NOVOLOG MIX 70/30 insulin aspart prot & aspart (human) inj 100 unit/ml (70-30) 3 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 24 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution NOVOLOG MIX 70/30 PREFILL insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30) 3 • NOVOLOG MIX 70/30 RELION insulin aspart prot & aspart (human) inj 100 unit/ ml (70-30) 3 • Basal Insulins INSULIN GLARGINE- YFGN insulin glargine-yfgn inj 100 unit/ml 3 • INSULIN GLARGINE- YFGN insulin glargine-yfgn soln pen-injector 100 unit/ml 3 • SEMGLEE insulin glargine-yfgn inj 100 unit/ml 3 • SEMGLEE insulin glargine-yfgn soln pen-injector 100 unit/ml 3 • TOUJEO MAX SOLOSTAR insulin glargine soln pen-injector 300 unit/ml (2 unit dial) 3 • TOUJEO SOLOSTAR insulin glargine soln pen-injector 300 unit/ml (1 unit dial) 3 • TRESIBA insulin degludec inj 100 unit/ml 3 • TRESIBA FLEXTOUCH insulin degludec soln pen-injector 100 unit/ml, 200 unit/ml 3 • THYROID AGENTS ARMOUR THYROID thyroid tab 15 mg (1/4 grain), 30 mg (1/2 grain), 60 mg (1 grain), 90 mg (1 1/2 grain), 120 mg (2 grain), 180 mg (3 grain), 240 mg (4 grain), 300 mg (5 grain) 4 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution LEVOTHYROXINE SODIUM levothyroxine sodium cap 13 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg 4 levothyroxine sodium tab 25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg (Synthroid) 1 liothyronine sodium tab 5 mcg (Cytomel) 1 liothyronine sodium tab 25 mcg, 50 mcg (Cytomel) 2 methimazole tab 5 mg, 10 mg (Tapazole) 1 NIVA THYROID thyroid tab 15 mg (1/4 grain), 30 mg (1/2 grain), 60 mg (1 grain), 90 mg (1 1/2 grain), 120 mg (2 grain) 4 NP THYROID 120 thyroid tab 120 mg (2 grain) 4 NP THYROID 15 thyroid tab 15 mg (1/4 grain) 4 NP THYROID 30 thyroid tab 30 mg (1/2 grain) 4 NP THYROID 60 thyroid tab 60 mg (1 grain) 4 NP THYROID 90 thyroid tab 90 mg (1 1/2 grain) 4 propylthiouracil tab 50 mg 2 SYNTHROID levothyroxine sodium tab 25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg 3

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 25 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution THYQUIDITY levothyroxine sodium oral solution 100 mcg/5ml 4 THYROID thyroid tab 15 mg (1/4 grain), 30 mg (1/2 grain), 60 mg (1 grain), 90 mg (1 1/2 grain), 120 mg (2 grain) 4 TIROSINT levothyroxine sodium cap 13 mcg, 25 mcg, 37.5 mcg, 44 mcg, 50 mcg, 62.5 mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg 4 TIROSINT-SOL levothyroxine sodium oral solution 13 mcg/ ml, 25 mcg/ml, 37.5 mcg/ml, 44 mcg/ml, 50 mcg/ml, 62.5 mcg/ml, 75 mcg/ml, 88 mcg/ ml, 100 mcg/ml, 112 mcg/ ml, 125 mcg/ml, 137 mcg/ ml, 150 mcg/ml, 175 mcg/ml, 200 mcg/ml 4 OXYTOCICS CERVIDIL dinoprostone vaginal inserts 10 mg 4 methylergonovine maleate tab 0.2 mg 2 PREPIDIL dinoprostone cervical gel 0.5 mg/3gm 4 ENDOCRINE and METABOLIC AGENTS - MISC. ACTHAR corticotropin inj gel 80 unit/ml 6 • • • alendronate sodium tab 10 mg, 35 mg 1 alendronate sodium tab 70 mg (Fosamax) 1 betaine powder for oral solution (Cystadane) 5 • cabergoline tab 0.5 mg 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution calcitonin (salmon) nasal soln 200 unit/act 2 calcitriol cap 0.25 mcg (Rocaltrol) 1 calcitriol cap 0.5 mcg (Rocaltrol) 2 carglumic acid soluble tab 200 mg (Carbaglu) 5 • • cinacalcet hcl tab 30 mg (base equiv), 60 mg (base equiv), 90 mg (base equiv) (Sensipar) 5 • • CRENESSITY crinecerfont cap 25 mg, 50 mg, 100 mg 6 • • • • CRENESSITY crinecerfont oral soln 50 mg/ml 6 • • • • DESMOPRESSIN ACETATE desmopressin acetate nasal spray soln 0.01% 4 desmopressin acetate inj 4 mcg/ml (Ddavp) 2 desmopressin acetate nasal spray soln 0.01% (refrigerated) 2 desmopressin acetate preservative free (pf) inj 4 mcg/ml (Ddavp) 2 desmopressin acetate tab 0.1 mg, 0.2 mg (Ddavp) 2 GALAFOLD migalastat hcl cap 123 mg (base equivalent) 6 • • • • GENOTROPIN somatropin for subcutaneous inj cartridge 5 mg, 12 mg (36 unit) 5 • • GENOTROPIN MINIQUICK somatropin for subcutaneous inj prefilled syr 0.2 mg, 0.4 mg, 0.6 mg, 0.8 mg, 1 mg, 1.2 mg, 1.4 mg, 1.6 mg, 1.8 mg, 2 mg 5 • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 26 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution glycerol phenylbutyrate liquid 1.1 gm/ml (Ravicti) 5 • ibandronate sodium tab 150 mg (base equivalent) (Boniva) 1 IMCIVREE setmelanotide acetate subcutaneous soln 10 mg/ml 6 • • • • INCRELEX mecasermin inj 40 mg/4ml (10 mg/ml) 5 • • ISTURISA osilodrostat phosphate tab 1 mg, 5 mg 6 • • • • JYNARQUE tolvaptan tab therapy pack 15 mg, 30 & 15 mg, 45 & 15 mg, 60 & 30 mg, 90 & 30 mg 5 • • • • JYNARQUE tolvaptan tab 15 mg, 30 mg 5 • • • • KERENDIA finerenone tab 10 mg, 20 mg, 40 mg 3 • • levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) 2 levocarnitine tab 330 mg (Carnitor) 2 MYALEPT metreleptin for subcutaneous inj 11.3 mg 6 • • • MYCAPSSA octreotide acetate cap delayed release 20 mg 6 • • nitisinone cap 2 mg, 5 mg, 10 mg, 20 mg (Orfadin) 5 • • NULIBRY fosdenopterin hydrobromide for iv soln 9.5 mg 4 • OMNITROPE somatropin for inj 5.8 mg 5 • • • OMNITROPE somatropin solution cartridge 5 mg/1.5ml, 10 mg/1.5ml 5 • • • OPFOLDA miglustat (gaa deficiency) cap 65 mg 6 • • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ORFADIN nitisinone susp 4 mg/ml 5 • • ORILISSA elagolix sodium tab 150 mg (base equiv), 200 mg (base equiv) 3 • • PALYNZIQ pegvaliase-pqpz subcutaneous soln pref syringe 2.5 mg/0.5ml, 10 mg/0.5ml, 20 mg/ml 6 • • • PHEBURANE sodium phenylbutyrate oral pellets 483 mg/gm 6 • • raloxifene hcl tab 60 mg (Evista) 2 • risedronate sodium tab 35 mg, 150 mg (Actonel) 2 sapropterin dihydrochloride powder packet 100 mg, 500 mg (Kuvan) 5 • • • sapropterin dihydrochloride tab 100 mg (Kuvan) 5 • • • SEPHIENCE sepiapterin powder packet 250 mg, 1000 mg 6 • • • SIGNIFOR pasireotide diaspartate inj 0.3 mg/ml (base equiv), 0.6 mg/ml (base equiv), 0.9 mg/ml (base equiv) 6 • • SKYTROFA lonapegsomatropin- tcgd for subcutaneous inj cartridge 0.7 mg, 1.4 mg, 1.8 mg, 2.1 mg, 2.5 mg, 3 mg, 3.6 mg, 4.3 mg, 5.2 mg, 6.3 mg, 7.6 mg, 9.1 mg, 11 mg 6 • • • SKYTROFA lonapegsomatropin- tcgd for subcutaneous inj cart 13.3 mg 6 • • • sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl) 5 • sodium phenylbutyrate tab 500 mg (Buphenyl) 5 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 27 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution SOMAVERT pegvisomant for inj 10 mg (as protein), 15 mg (as protein), 20 mg (as protein), 25 mg (as protein), 30 mg (as protein) 6 • • STRENSIQ asfotase alfa subcutaneous inj 18 mg/0.45ml, 28 mg/0.7ml, 40 mg/ml, 80 mg/0.8ml 5 • • • SYNAREL nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) (base eq) 6 • teriparatide soln pen-inj 560 mcg/2.24ml (Forteo) 5 • • • tolvaptan (hyponatremia) tab 15 mg, 30 mg (Samsca) 5 • • • TRYNGOLZA olezarsen sod subcut soln auto-inject 80 mg/0.8ml (base eq) 6 • • • • TYMLOS abaloparatide subcutaneous soln pen- injector 3120 mcg/1.56ml 5 • • • • VOXZOGO vosoritide for subcutaneous inj 0.4 mg, 0.56 mg, 1.2 mg 6 • • VYKAT XR diazoxide choline tab er 24hr 25 mg, 75 mg, 150 mg 6 • • • • YORVIPATH palopegteriparatide pen-inj 168 mcg/0.56ml (teriparatide eq), 294 mcg/0.98ml (teriparatide eq), 420 mcg/1.4ml (teriparatide eq) 6 • • • • CARDIOVASCULAR AGENTS CARDIOTONICS DIGOXIN digoxin oral soln 0.05 mg/ml 4 digoxin oral soln 0.05 mg/ml (Digoxin) 2 digoxin tab 62.5 mcg (0.0625 mg) (Lanoxin) 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution digoxin tab 125 mcg (0.125 mg), 250 mcg (0.25 mg) (Lanoxin) 1 LANOXIN digoxin tab 62.5 mcg (0.0625 mg), 125 mcg (0.125 mg), 250 mcg (0.25 mg) 4 ANTIANGINAL AGENTS isosorbide dinitrate tab 5 mg (Isordil titradose) 2 isosorbide dinitrate tab 10 mg, 20 mg, 30 mg 2 isosorbide mononitrate tab er 24hr 30 mg, 60 mg, 120 mg 1 isosorbide mononitrate tab 10 mg, 20 mg 4 NITRO-BID nitroglycerin oint 2% 4 NITRO-DUR nitroglycerin td patch 24hr 0.3 mg/hr, 0.8 mg/hr 4 NITRO-TIME nitroglycerin cap er 2.5 mg, 6.5 mg, 9 mg 4 nitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6 mg (Nitrostat) 1 nitroglycerin td patch 24hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr (Nitro- dur) 2 nitroglycerin tl soln 0.4 mg/ spray (400 mcg/spray) (Nitrolingual pumpspr) 2 ranolazine tab er 12hr 500 mg, 1000 mg (Ranexa) 2 BETA BLOCKERS acebutolol hcl cap 200 mg, 400 mg 2 atenolol tab 25 mg, 50 mg, 100 mg (Tenormin) 1

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 28 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution betaxolol hcl tab 10 mg, 20 mg 2 bisoprolol fumarate tab 5 mg 1 bisoprolol fumarate tab 10 mg 2 carvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25 mg (Coreg) 1 labetalol hcl tab 100 mg 1 labetalol hcl tab 200 mg, 300 mg 2 metoprolol succinate tab er 24hr 25 mg (tartrate equiv), 50 mg (tartrate equiv), 100 mg (tartrate equiv), 200 mg (tartrate equiv) (Toprol xl) 1 metoprolol tartrate tab 25 mg 1 metoprolol tartrate tab 50 mg, 100 mg (Lopressor) 1 nadolol tab 20 mg, 40 mg, 80 mg (Corgard) 2 nebivolol hcl tab 2.5 mg (base equivalent), 5 mg (base equivalent), 10 mg (base equivalent), 20 mg (base equivalent) (Bystolic) 1 pindolol tab 5 mg, 10 mg 2 PROPRANOLOL HCL propranolol hcl oral soln 40 mg/5ml 3 propranolol hcl cap er 24hr 60 mg, 80 mg (Inderal la) 1 propranolol hcl cap er 24hr 120 mg, 160 mg (Inderal la) 2 propranolol hcl tab 10 mg, 20 mg, 40 mg, 80 mg 1 propranolol hcl tab 60 mg 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution PROPRANOLOL HYDROCHLORIDE propranolol hcl oral soln 20 mg/5ml 4 sotalol hcl (afib/afl) tab 80 mg, 120 mg (Betapace af) 1 sotalol hcl (afib/afl) tab 160 mg (Betapace af) 2 sotalol hcl tab 80 mg, 120 mg (Betapace) 1 sotalol hcl tab 160 mg (Betapace) 2 sotalol hcl tab 240 mg 2 CALCIUM CHANNEL BLOCKERS amlodipine besylate tab 2.5 mg (base equivalent), 5 mg (base equivalent), 10 mg (base equivalent) (Norvasc) 1 diltiazem hcl cap er 12hr 60 mg, 90 mg 2 diltiazem hcl cap er 24hr 120 mg 1 diltiazem hcl cap er 24hr 180 mg, 240 mg 2 diltiazem hcl coated beads cap er 24hr 120 mg, 180 mg, 240 mg (Cardizem cd) 1 diltiazem hcl coated beads cap er 24hr 300 mg (Cardizem cd) 2 diltiazem hcl extended release beads cap er 24hr 120 mg, 180 mg (Tiazac) 1 diltiazem hcl extended release beads cap er 24hr 240 mg, 300 mg, 360 mg, 420 mg (Tiazac) 2 diltiazem hcl tab er 24hr 120 mg (Cardizem la) 2

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 29 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution diltiazem hcl tab 30 mg, 60 mg, 120 mg (Cardizem) 1 diltiazem hcl tab 90 mg 2 felodipine tab er 24hr 2.5 mg, 5 mg, 10 mg 1 nifedipine cap 10 mg, 20 mg 2 nifedipine tab er 24hr 30 mg, 60 mg, 90 mg 1 nifedipine tab er 24hr osmotic release 30 mg, 60 mg (Procardia xl) 1 nifedipine tab er 24hr osmotic release 90 mg (Procardia xl) 2 nimodipine cap 30 mg 2 verapamil hcl tab er 120 mg, 180 mg, 240 mg (Calan sr) 1 verapamil hcl tab 40 mg, 80 mg, 120 mg 1 ANTIARRHYTHMICS amiodarone hcl tab 100 mg 2 amiodarone hcl tab 200 mg 1 disopyramide phosphate cap 100 mg, 150 mg (Norpace) 2 dofetilide cap 125 mcg (0.125 mg), 250 mcg (0.25 mg), 500 mcg (0.5 mg) (Tikosyn) 2 flecainide acetate tab 50 mg 1 flecainide acetate tab 100 mg, 150 mg 2 mexiletine hcl cap 150 mg, 200 mg, 250 mg 2 MULTAQ dronedarone hcl tab 400 mg (base equivalent) 3 NORPACE CR disopyramide phosphate cap er 12hr 100 mg, 150 mg 4 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution propafenone hcl cap er 12hr 225 mg, 325 mg, 425 mg (Rythmol sr) 2 propafenone hcl tab 150 mg 1 propafenone hcl tab 225 mg, 300 mg 2 quinidine gluconate tab er 324 mg 2 QUINIDINE SULFATE quinidine sulfate tab 200 mg, 300 mg 4 ANTIHYPERTENSIVES amlodipine besylate- benazepril hcl cap 2.5-10 mg, 5-40 mg 1 amlodipine besylate- benazepril hcl cap 5-10 mg, 5-20 mg, 10-20 mg, 10-40 mg (Lotrel) 1 amlodipine besylate- olmesartan medoxomil tab 5-20 mg, 5-40 mg, 10-20 mg, 10-40 mg (Azor) 2 amlodipine besylate- valsartan tab 5-160 mg, 5-320 mg, 10-160 mg, 10-320 mg (Exforge) 2 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) 1 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) 1 benazepril & hydrochlorothiazide tab 5-6.25 mg 2 benazepril & hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg, 20-25 mg (Lotensin hct) 2 benazepril hcl tab 5 mg 1 benazepril hcl tab 10 mg, 20 mg, 40 mg (Lotensin) 1

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 30 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg, 5-6.25 mg, 10-6.25 mg (Ziac) 1 candesartan cilexetil tab 4 mg, 8 mg, 16 mg, 32 mg (Atacand) 2 captopril tab 12.5 mg, 25 mg, 50 mg, 100 mg 2 clonidine hcl tab 0.1 mg, 0.2 mg, 0.3 mg 1 clonidine td patch weekly 0.1 mg/24hr (Catapres-tts-1) 2 clonidine td patch weekly 0.2 mg/24hr (Catapres-tts-2) 2 clonidine td patch weekly 0.3 mg/24hr (Catapres-tts-3) 2 doxazosin mesylate tab 1 mg, 2 mg, 4 mg, 8 mg (Cardura) 1 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1 enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic) 1 enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20 mg (Vasotec) 1 eplerenone tab 25 mg, 50 mg (Inspra) 2 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg 2 fosinopril sodium tab 10 mg, 20 mg, 40 mg 1 guanfacine hcl tab 1 mg, 2 mg 2 hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg 1 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution irbesartan tab 75 mg, 150 mg, 300 mg (Avapro) 1 irbesartan- hydrochlorothiazide tab 150-12.5 mg, 300-12.5 mg (Avalide) 1 lisinopril & hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg, 20-25 mg (Zestoretic) 1 lisinopril tab 2.5 mg, 5 mg, 10 mg, 30 mg, 40 mg (Zestril) 1 lisinopril tab 20 mg (Prinivil) 1 losartan potassium & hydrochlorothiazide tab 50-12.5 mg, 100-12.5 mg, 100-25 mg (Hyzaar) 1 losartan potassium tab 25 mg, 50 mg, 100 mg (Cozaar) 1 METHYLDOPA methyldopa tab 500 mg 4 methyldopa tab 250 mg 2 metoprolol & hydrochlorothiazide tab 50-25 mg, 100-25 mg, 100-50 mg 2 minoxidil tab 2.5 mg, 10 mg 1 moexipril hcl tab 7.5 mg, 15 mg 2 olmesartan medoxomil tab 5 mg, 20 mg, 40 mg (Benicar) 1 olmesartan medoxomil- hydrochlorothiazide tab 20-12.5 mg, 40-12.5 mg, 40-25 mg (Benicar hct) 1

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 31 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution olmesartan-amlodipine- hydrochlorothiazide tab 20-5-12.5 mg, 40-5-12.5 mg, 40-5-25 mg, 40-10-12.5 mg, 40-10-25 mg (Tribenzor) 2 PERINDOPRIL ERBUMINE perindopril erbumine tab 2 mg, 8 mg 4 perindopril erbumine tab 4 mg 2 phenoxybenzamine hcl cap 10 mg (Dibenzyline) 2 prazosin hcl cap 1 mg, 2 mg (Minipress) 1 prazosin hcl cap 5 mg (Minipress) 2 quinapril hcl tab 5 mg, 10 mg, 20 mg, 40 mg (Accupril) 1 QUINAPRIL/ HYDROCHLOROTHIA quinapril- hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg, 20-25 mg 4 ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10 mg (Altace) 1 telmisartan tab 20 mg, 80 mg (Micardis) 1 telmisartan tab 40 mg (Micardis) 2 terazosin hcl cap 1 mg (base equivalent), 2 mg (base equivalent), 5 mg (base equivalent), 10 mg (base equivalent) 1 trandolapril tab 1 mg, 2 mg, 4 mg 1 valsartan tab 40 mg, 80 mg, 160 mg, 320 mg (Diovan) 1 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution valsartan- hydrochlorothiazide tab 80-12.5 mg, 160-12.5 mg, 160-25 mg (Diovan hct) 1 valsartan- hydrochlorothiazide tab 320-12.5 mg, 320-25 mg (Diovan hct) 2 VECAMYL mecamylamine hcl tab 2.5 mg 6 • • DIURETICS acetazolamide cap er 12hr 500 mg 2 acetazolamide tab 125 mg 1 acetazolamide tab 250 mg 2 amiloride hcl tab 5 mg 1 AMILORIDE/ HYDROCHLOROTHIA amiloride & hydrochlorothiazide tab 5-50 mg 4 bumetanide tab 0.5 mg (Bumex) 1 bumetanide tab 1 mg 1 bumetanide tab 2 mg 2 chlorthalidone tab 25 mg, 50 mg 1 DIURIL chlorothiazide susp 250 mg/5ml 4 ethacrynic acid tab 25 mg (Edecrin) 2 FUROSCIX furosemide subcutaneous cartridge kit 80 mg/10ml 6 • • • • FUROSEMIDE furosemide oral soln 10 mg/ml 4 furosemide tab 20 mg, 40 mg, 80 mg (Lasix) 1 hydrochlorothiazide cap 12.5 mg 1

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 32 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution hydrochlorothiazide tab 12.5 mg, 25 mg, 50 mg 1 indapamide tab 1.25 mg, 2.5 mg 1 methazolamide tab 25 mg, 50 mg 2 metolazone tab 2.5 mg 1 metolazone tab 5 mg, 10 mg 2 spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide) 2 spironolactone tab 25 mg, 50 mg, 100 mg (Aldactone) 1 torsemide tab 5 mg, 10 mg, 20 mg, 100 mg 1 triamterene & hydrochlorothiazide cap 37.5-25 mg 1 triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25) 1 triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) 1 VASOPRESSORS AUVI-Q epinephrine solution auto-injector 0.1 mg/0.1ml, 0.15 mg/0.15ml (1:1000), 0.3 mg/0.3ml (1:1000) 3 epinephrine solution auto- injector 0.15 mg/0.3ml (1:2000) (Epipen-jr 2-pak) 2 epinephrine solution auto- injector 0.3 mg/0.3ml (1:1000) (Epipen 2-pak) 2 midodrine hcl tab 2.5 mg, 5 mg, 10 mg 2 ANTIHYPERLIPIDEMICS Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution atorvastatin calcium tab 10 mg (base equivalent), 20 mg (base equivalent), 40 mg (base equivalent), 80 mg (base equivalent) (Lipitor) 1 cholestyramine light powder 4 gm/dose (Questran light) 2 cholestyramine powder 4 gm/dose (Questran) 2 colesevelam hcl tab 625 mg (Welchol) 2 colestipol hcl granule packets 5 gm (Colestid flavored) 2 colestipol hcl granules 5 gm (Colestid flavored) 2 colestipol hcl tab 1 gm (Colestid) 2 ezetimibe tab 10 mg (Zetia) 1 ezetimibe-simvastatin tab 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg (Vytorin) 2 fenofibrate micronized cap 67 mg, 134 mg, 200 mg 1 fenofibrate tab 48 mg, 145 mg (Tricor) 1 fenofibrate tab 54 mg, 160 mg 1 fluvastatin sodium cap 20 mg (base equivalent), 40 mg (base equivalent) 2 gemfibrozil tab 600 mg (Lopid) 1 icosapent ethyl cap 0.5 gm, 1 gm (Vascepa) 2 • • JUXTAPID lomitapide mesylate cap 5 mg (base equiv), 10 mg (base equiv), 20 mg (base equiv), 30 mg (base equiv) 6 • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 33 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution lovastatin tab 10 mg 1 lovastatin tab 20 mg, 40 mg 1 • NEXLETOL bempedoic acid tab 180 mg 3 • • NEXLIZET bempedoic acid- ezetimibe tab 180-10 mg 3 • • niacin tab er 500 mg (antihyperlipidemic), 750 mg (antihyperlipidemic), 1000 mg (antihyperlipidemic) (Niaspan) 2 pravastatin sodium tab 10 mg, 20 mg, 40 mg, 80 mg 1 • REPATHA evolocumab subcutaneous soln prefilled syringe 140 mg/ml 3 • • REPATHA SURECLICK evolocumab subcutaneous soln auto- injector 140 mg/ml 3 • • rosuvastatin calcium tab 5 mg, 10 mg, 20 mg, 40 mg (Crestor) 1 • simvastatin tab 5 mg 1 simvastatin tab 10 mg, 20 mg, 40 mg (Zocor) 1 • simvastatin tab 80 mg (Zocor) 1 VASCEPA icosapent ethyl cap 0.5 gm, 1 gm 2 • • CARDIOVASCULAR AGENTS - MISC. ADEMPAS riociguat tab 0.5 mg, 1 mg, 1.5 mg, 2 mg, 2.5 mg 6 • • • • ambrisentan tab 5 mg, 10 mg (Letairis) 5 • • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ATTRUBY acoramidis hcl tab pack 356 mg (712 mg twice daily) 5 • • • • bosentan tab for oral susp 32 mg (Tracleer) 5 • • • bosentan tab 62.5 mg, 125 mg (Tracleer) 5 • • • CAMZYOS mavacamten cap 2.5 mg, 5 mg, 10 mg, 15 mg 6 • • • • CORLANOR ivabradine hcl oral soln 5 mg/5ml (base equiv) 3 • • • ENTRESTO sacubitril- valsartan sprinkle cap 6-6 mg, 15-16 mg 3 isosorbide dinitrate- hydralazine hcl tab 20-37.5 mg (Bidil) 2 ivabradine hcl tab 5 mg (base equiv), 7.5 mg (base equiv) (Corlanor) 2 • • OPSUMIT macitentan tab 10 mg 5 • • • • ORENITRAM treprostinil diolamine tab er 0.125 mg (base equiv), 0.25 mg (base equiv), 1 mg (base equiv), 2.5 mg (base equiv), 5 mg (base equiv) 6 • • • ORENITRAM TITRATION KIT M treprostinil tab er titr pk (mo1) 126 x0.125mg & 42 x0.25mg, titr pk (mo2) 126 x0.125mg & 210 x0.25mg, titr pk(mo3)126x0.125mg&42x0.25mg&84x1mg 6 • • • • sacubitril-valsartan tab 24-26 mg, 49-51 mg, 97-103 mg (Entresto) 2 sildenafil citrate tab 20 mg (Revatio) 5 • • • tadalafil tab 20 mg (pah) (Adcirca) 5 • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 34 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution TYVASO treprostinil inhalation solution 0.6 mg/ml 6 • • • • TYVASO DPI MAINTENANCE KI treprostinil inh powder 16 mcg/cartridge, 32 mcg/ cartridge, 48 mcg/cartridge, 64 mcg/cartridge, 80 mcg/ cartridge, 112 x 32mcg & 112 x 64mcg, 112 x 48mcg & 112 x 64mcg 6 • • • • TYVASO DPI TITRATION KIT treprostinil inh powd 112 x 16mcg & 112 x 32mcg & 28 x 48mcg 6 • • • • TYVASO REFILL KIT treprostinil inhalation solution 0.6 mg/ml 6 • • • • TYVASO STARTER KIT treprostinil inhalation solution 0.6 mg/ml 6 • • • • UPTRAVI selexipag tab 200 mcg, 400 mcg, 600 mcg, 800 mcg, 1000 mcg, 1200 mcg, 1400 mcg, 1600 mcg 5 • • • • UPTRAVI TITRATION PACK selexipag tab therapy pack 200 mcg (140) & 800 mcg (60) 5 • • • • VYNDAMAX tafamidis cap 61 mg 5 • • • WINREVAIR sotatercept-csrk for subcutaneous soln kit 45 mg, 60 mg, 2 x 45 mg, 2 x 60 mg 6 • • • • YUTREPIA treprostinil sodium inhal cap 26.5 mcg, 53 mcg, 79.5 mcg, 106 mcg 6 • • • • RESPIRATORY AGENTS ANTIHISTAMINES carbinoxamine maleate tab 4 mg 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution CLEMASTINE FUMARATE clemastine fumarate tab 2.68 mg 4 cyproheptadine hcl syrup 2 mg/5ml 1 cyproheptadine hcl tab 4 mg 1 promethazine hcl oral soln 6.25 mg/5ml 1 promethazine hcl suppos 12.5 mg, 25 mg 2 promethazine hcl tab 12.5 mg, 25 mg, 50 mg 1 PROMETHEGAN promethazine hcl suppos 50 mg 4 RYCLORA dexchlorpheniramine maleate oral soln 2 mg/5ml 4 NASAL AGENTS - SYSTEMIC and TOPICAL azelastine hcl nasal spray 0.1% (137 mcg/spray) 1 fluticasone propionate nasal susp 50 mcg/act 1 ipratropium bromide nasal soln 0.03% (21 mcg/spray), 0.06% (42 mcg/spray) 2 olopatadine hcl nasal soln 0.6% (Patanase) 2 COUGH/COLD/ALLERGY acetylcysteine inhal soln 10%, 20% 2 guaifenesin-codeine soln 100-10 mg/5ml 1 NEBUSAL sodium chloride soln nebu 3% 2 promethazine w/ codeine syrup 6.25-10 mg/5ml 1 promethazine-dm syrup 6.25-15 mg/5ml 1 PULMOSAL sodium chloride soln nebu 7% 1

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 35 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution SODIUM CHLORIDE sodium chloride soln nebu 3% 2 SODIUM CHLORIDE sodium chloride soln nebu 7% 1 ANTIASTHMATIC and BRONCHODILATOR AGENTS ADVAIR HFA fluticasone- salmeterol inhal aerosol 45-21 mcg/act, 115-21 mcg/ act, 230-21 mcg/act 3 • albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) (Proventil hfa) 2 • albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 1 albuterol sulfate soln nebu 0.5% (5 mg/ml), 0.63 mg/3ml (base equiv), 1.25 mg/3ml (base equiv) 2 albuterol sulfate syrup 2 mg/5ml 1 albuterol sulfate tab 2 mg, 4 mg 2 ANORO ELLIPTA umeclidinium- vilanterol aero powd ba 62.5-25 mcg/act 3 • arformoterol tartrate soln nebu 15 mcg/2ml (base equiv) (Brovana) 2 ARNUITY ELLIPTA fluticasone furoate aerosol powder breath activ 50 mcg/act, 100 mcg/act, 200 mcg/act 3 • ASMANEX HFA mometasone furoate inhal aerosol suspension 50 mcg/act, 100 mcg/act, 200 mcg/act 3 • ASMANEX TWISTHALER 120 ME mometasone furoate inhal powd 220 mcg/act (breath activated) 3 • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ASMANEX TWISTHALER 30 MET mometasone furoate inhal powd 110 mcg/act (breath activated), 220 mcg/ act (breath activated) 3 • ASMANEX TWISTHALER 60 MET mometasone furoate inhal powd 220 mcg/act (breath activated) 3 • ATROVENT HFA ipratropium bromide hfa inhal aerosol 17 mcg/act 4 • BREO ELLIPTA fluticasone furoate-vilanterol aero powd ba 50-25 mcg/act, 100-25 mcg/act, 200-25 mcg/act 3 • BREZTRI AEROSPHERE budesonide- glycopyrrolate-formoterol aers 160-9-4.8 mcg/act 3 • budesonide inhalation susp 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml (Pulmicort) 2 COMBIVENT RESPIMAT ipratropium- albuterol inhal aerosol soln 20-100 mcg/act 3 • cromolyn sodium soln nebu 20 mg/2ml 2 DULERA mometasone furoate- formoterol fumarate aerosol 50-5 mcg/act, 100-5 mcg/ act, 200-5 mcg/act 3 • FASENRA PEN benralizumab subcutaneous soln auto- injector 30 mg/ml 5 • • • • FLUTICASONE PROPIONATE/ SA fluticasone-salmeterol aer powder ba 55-14 mcg/ act, 113-14 mcg/act, 232-14 mcg/act 2 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 36 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution fluticasone-salmeterol aer powder ba 100-50 mcg/ act, 250-50 mcg/act, 500-50 mcg/act (Advair diskus) 2 • INCRUSE ELLIPTA umeclidinium br aero powd breath act 62.5 mcg/act (base eq) 3 • ipratropium bromide hfa inhal aerosol 17 mcg/act (Atrovent hfa) 2 • ipratropium bromide inhal soln 0.02% 1 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml 2 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) (Xopenex concentrate) 2 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv), 0.63 mg/3ml (base equiv), 1.25 mg/3ml (base equiv) (Xopenex) 2 montelukast sodium chew tab 4 mg (base equiv), 5 mg (base equiv) (Singulair) 1 montelukast sodium tab 10 mg (base equiv) (Singulair) 1 NUCALA mepolizumab subcutaneous solution auto- injector 100 mg/ml 5 • • • • NUCALA mepolizumab subcutaneous solution pref syringe 40 mg/0.4ml, 100 mg/ml 5 • • • • QVAR REDIHALER beclomethasone diprop hfa breath act inh aer 40 mcg/act, 80 mcg/act 3 • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution roflumilast tab 250 mcg, 500 mcg (Daliresp) 2 SEREVENT DISKUS salmeterol xinafoate aer pow ba 50 mcg/act (base equiv) 3 • SPIRIVA RESPIMAT tiotropium bromide inhal aerosol 1.25 mcg/act, 2.5 mcg/act 3 • STIOLTO RESPIMAT tiotropium br- olodaterol inhal aero soln 2.5-2.5 mcg/act 3 • STRIVERDI RESPIMAT olodaterol hcl inhal aerosol soln 2.5 mcg/ act (base equiv) 3 • SYMBICORT budesonide- formoterol fumarate dihyd aerosol 80-4.5 mcg/act, 160-4.5 mcg/act 2 • terbutaline sulfate tab 2.5 mg, 5 mg 2 TEZSPIRE tezepelumab-ekko subcutaneous soln auto-inj 210 mg/1.91ml 5 • • • • THEO-24 theophylline cap er 24hr 100 mg, 200 mg, 300 mg, 400 mg 4 theophylline elixir 80 mg/15ml 2 theophylline soln 80 mg/15ml 2 theophylline tab er 12hr 300 mg, 450 mg 2 theophylline tab er 24hr 400 mg, 600 mg 2 TRELEGY ELLIPTA fluticasone- umeclidinium-vilanterol aepb 100-62.5-25 mcg/act, 200-62.5-25 mcg/act 3 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 37 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution VENTOLIN HFA albuterol sulfate inhal aero 108 mcg/ act (90mcg base equiv) 2 • XOLAIR omalizumab subcutaneous soln auto- injector 75 mg/0.5ml, 150 mg/ml, 300 mg/2ml 5 • • • XOLAIR omalizumab subcutaneous soln prefilled syringe 75 mg/0.5ml, 150 mg/ml, 300 mg/2ml 5 • • • zafirlukast tab 10 mg, 20 mg (Accolate) 2 zileuton tab er 12hr 600 mg 2 RESPIRATORY AGENTS - MISC. ALYFTREK vanzacaftor- tezacaftor-deutivacaftor tab 4-20-50 mg, 10-50-125 mg 5 • • • • BRINSUPRI brensocatib tab 10 mg, 25 mg 6 • • KALYDECO ivacaftor packet 5.8 mg, 13.4 mg, 25 mg, 50 mg, 75 mg 5 • • • • KALYDECO ivacaftor tab 150 mg 5 • • • • OFEV nintedanib esylate cap 100 mg (base equivalent), 150 mg (base equivalent) 6 • • • • ORKAMBI lumacaftor-ivacaftor granules packet 75-94 mg, 100-125 mg, 150-188 mg 6 • • • • ORKAMBI lumacaftor-ivacaftor tab 100-125 mg, 200-125 mg 6 • • • • PIRFENIDONE pirfenidone tab 534 mg 5 • • • pirfenidone cap 267 mg (Esbriet) 5 • • • pirfenidone tab 267 mg, 801 mg (Esbriet) 5 • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution PULMOZYME dornase alfa inhal soln 2.5 mg/2.5ml 5 • SYMDEKO tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 mg tab tbpk 5 • • • • SYMDEKO tezacaftor-ivacaftor 100-150 mg & ivacaftor 150 mg tab tbpk 5 • • • • TRIKAFTA elexacaf-tezacaf- ivacaf 80-40-60 mg& ivacaf 59.5mg thpk gran 5 • • • • TRIKAFTA elexacaf-tezacaf- ivacaf 100-50-75 mg& ivacaf 75mg thpk gran 5 • • • • TRIKAFTA elexacaf-tezacaf- ivacaf 50-25-37.5 mg & ivacaftor 75 mg tbpk 5 • • • • TRIKAFTA elexacaf-tezacaf- ivacaf 100-50-75 mg &ivacaftor 150 mg tbpk 5 • • • • GASTROINTESTINAL AGENTS LAXATIVES GAVILYTE-C peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm 4 lactulose solution 10 gm/15ml 2 peg 3350-kcl-na bicarb-nacl- na sulfate for soln 236 gm (Golytely) 1 • peg 3350-kcl-nacl-na sulfate- na ascorbate-c for soln 100 gm (Moviprep) 2 peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely) 2 • PEG-PREP bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit 4 sod sulfate-pot sulf- mg sulf oral sol 17.5-3.13-1.6 gm/177ml (Suprep bowel prep ki) 2

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 38 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution SUTAB sod sulfate-mg sulfate-pot chloride tab 1479-225-188 mg 4 ANTIDIARRHEALS diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil) 1 ULCER DRUGS cimetidine hcl soln 300 mg/5ml 2 dexlansoprazole cap delayed release 30 mg, 60 mg (Dexilant) 2 • dicyclomine hcl cap 10 mg 1 dicyclomine hcl oral soln 10 mg/5ml 2 dicyclomine hcl tab 20 mg 1 esomeprazole magnesium cap delayed release 20 mg (base eq), 40 mg (base eq) (Nexium) 1 • esomeprazole magnesium for delayed release susp packet 5 mg, 10 mg, 20 mg, 40 mg (Nexium) 2 • esomeprazole magnesium for delayed release susp pack 2.5 mg (Nexium) 2 • famotidine for susp 40 mg/5ml 2 famotidine tab 40 mg (Pepcid) 1 glycopyrrolate oral soln 1 mg/5ml (Cuvposa) 2 glycopyrrolate tab 1 mg, 2 mg 2 lansoprazole cap delayed release 30 mg (Prevacid) 1 • methscopolamine bromide tab 2.5 mg, 5 mg 2 misoprostol tab 100 mcg, 200 mcg (Cytotec) 1 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution NIZATIDINE nizatidine cap 300 mg 4 nizatidine cap 150 mg 2 omeprazole cap delayed release 10 mg, 20 mg, 40 mg 1 • pantoprazole sodium ec tab 20 mg (base equiv), 40 mg (base equiv) (Protonix) 1 • rabeprazole sodium ec tab 20 mg (Aciphex) 1 • sucralfate tab 1 gm (Carafate) 2 ANTIEMETICS aprepitant capsule therapy pack 80 & 125 mg (Emend tripack) 2 aprepitant capsule 40 mg, 125 mg 2 aprepitant capsule 80 mg (Emend) 2 dronabinol cap 2.5 mg, 5 mg, 10 mg (Marinol) 2 EMEND aprepitant for oral susp 125 mg (125 mg/5ml) 4 granisetron hcl tab 1 mg 2 ondansetron hcl oral soln 4 mg/5ml 2 ondansetron hcl tab 4 mg (Zofran) 1 ondansetron hcl tab 8 mg 1 ondansetron orally disintegrating tab 4 mg, 8 mg 1 scopolamine td patch 72hr 1 mg/3days (Transderm- scop) 2 trimethobenzamide hcl cap 300 mg 2

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 39 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution VARUBI rolapitant hcl tab therapy pack 2 x 90 mg (base equiv) 3 • DIGESTIVE AIDS CREON pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit, 6000-19000-30000 unit, 12000-38000-60000 unit, 24000-76000-120000 unit, 36000-114000-180000 unit 3 ZENPEP pancrelipase (lip-prot-amyl) dr cap 3000-10000-14000 unit, 5000-17000-24000 unit, 10000-32000-42000 unit, 15000-47000-63000 unit, 20000-63000-84000 unit, 25000-79000-105000 unit, 40000-126000-168000 unit, 60000-189600-252600 unit 3 GASTROINTESTINAL AGENTS- MISC. alosetron hcl tab 0.5 mg (base equiv), 1 mg (base equiv) (Lotronex) 2 AURYXIA ferric citrate tab 1 gm (210 mg ferric iron) 4 • • balsalazide disodium cap 750 mg (Colazal) 2 BYLVAY odevixibat cap 400 mcg, 1200 mcg 6 • • BYLVAY (PELLETS) odevixibat pellets cap sprinkle 200 mcg, 600 mcg 6 • • calcium acetate (phosphate binder) cap 667 mg (169 mg ca) 2 calcium acetate (phosphate binder) tab 667 mg 2 CIMZIA certolizumab pegol prefilled syringe kit 200 mg/ ml 6 • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution CIMZIA STARTER KIT certolizumab pegol prefilled syringe kit 200 mg/ ml 6 • • • cromolyn sodium oral conc 100 mg/5ml (Gastrocrom) 2 CTEXLI chenodiol (basds) tab 250 mg 5 • • • DIPENTUM olsalazine sodium cap 250 mg 4 ENTYVIO PEN vedolizumab soln auto-injector 108 mg/0.68ml 5 • • • • ferric citrate tab 1 gm (210 mg ferric iron) (Auryxia) 2 • IQIRVO elafibranor tab 80 mg 6 • • • • lactulose (encephalopathy) solution 10 gm/15ml 1 lanthanum carbonate chew tab 500 mg (elemental), 750 mg (elemental), 1000 mg (elemental) (Fosrenol) 2 • LIVDELZI seladelpar lysine cap 10 mg 6 • • • LIVMARLI maralixibat chloride oral soln 9.5 mg/ml, 19 mg/ ml 6 • • LIVMARLI maralixibat chloride tab 10 mg, 15 mg, 20 mg, 30 mg 6 • • lubiprostone cap 8 mcg, 24 mcg (Amitiza) 2 mesalamine cap er 24hr 0.375 gm (Apriso) 2 MESALAMINE DR mesalamine cap dr 400 mg 2 mesalamine enema 4 gm 2 mesalamine suppos 1000 mg (Canasa) 2 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 40 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution mesalamine tab delayed release 800 mg 2 mesalamine tab delayed release 1.2 gm (Lialda) 2 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv) 2 metoclopramide hcl tab 5 mg (base equivalent), 10 mg (base equivalent) (Reglan) 1 METOCLOPRAMIDE ODT metoclopramide hcl orally disintegrating tab 5 mg (base eq) 4 OMVOH mirikizumab-mrkz subcutaneous auto-inj 100 mg/ml & 200mg/2ml 5 • • • • OMVOH mirikizumab-mrkz subcutaneous pref syr 100 mg/ml & 200mg/2ml 5 • • • • OMVOH mirikizumab-mrkz subcutaneous sol prefill syringe 200 mg/2ml 5 • • • OMVOH mirikizumab-mrkz subcutaneous soln auto- injector 200 mg/2ml 5 • • • sevelamer carbonate packet 0.8 gm, 2.4 gm (Renvela) 2 • sevelamer carbonate tab 800 mg (Renvela) 2 • sevelamer hcl tab 400 mg 2 • SKYRIZI risankizumab-rzaa subcutaneous soln cartridge 180 mg/1.2ml, 360 mg/2.4ml 5 • • • sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs) 2 sulfasalazine tab 500 mg (Azulfidine) 1 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution SYMPROIC naldemedine tosylate tab 0.2 mg (base equivalent) 3 TREMFYA guselkumab soln auto-injector 200 mg/2ml 5 • • • TREMFYA guselkumab soln prefilled syringe 200 mg/2ml 5 • • • TREMFYA INDUCTION PACK FO guselkumab soln auto- injector 200 mg/2ml 5 • • • TRULANCE plecanatide tab 3 mg 3 ursodiol cap 300 mg 2 ursodiol tab 250 mg (Urso 250) 2 ursodiol tab 500 mg (Urso forte) 2 VIBERZI eluxadoline tab 75 mg, 100 mg 4 VOWST fecal microbiota spores, live-brpk caps 6 • • XERMELO telotristat ethyl tab 250 mg (as telotristat etiprate) 6 • • ZYMFENTRA 1- PEN infliximab-dyyb soln auto-injector kit 120 mg/ml 6 • • • • ZYMFENTRA 2- PEN infliximab-dyyb soln auto-injector kit 120 mg/ml 6 • • • • ZYMFENTRA 2- SYRINGE infliximab-dyyb soln prefilled syringe kit 120 mg/ml 6 • • • • GENITOURINARY AGENTS URINARY ANTISPASMODICS bethanechol chloride tab 5 mg, 10 mg, 25 mg, 50 mg 2 darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv), 15 mg (base equiv) 2

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 41 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution flavoxate hcl tab 100 mg 2 mirabegron tab er 24 hr 25 mg, 50 mg (Myrbetriq) 2 MYRBETRIQ mirabegron granules for oral extended release susp 8 mg/ml 3 MYRBETRIQ mirabegron tab er 24 hr 25 mg, 50 mg 3 oxybutynin chloride solution 5 mg/5ml 1 oxybutynin chloride tab er 24hr 5 mg, 10 mg (Ditropan xl) 1 oxybutynin chloride tab er 24hr 15 mg 1 oxybutynin chloride tab 5 mg 1 solifenacin succinate tab 5 mg, 10 mg (Vesicare) 1 tolterodine tartrate cap er 24hr 2 mg, 4 mg (Detrol la) 2 tolterodine tartrate tab 1 mg, 2 mg (Detrol) 2 trospium chloride cap er 24hr 60 mg 2 trospium chloride tab 20 mg 2 VAGINAL PRODUCTS clindamycin phosphate vaginal cream 2% (Cleocin) 2 ENCARE nonoxynol-9 vaginal suppos 100 mg A • estradiol vaginal cream 0.01% 2 estradiol vaginal tab 10 mcg (Vagifem) 2 ESTRING estradiol vaginal ring 2 mg (7.5 mcg/24hrs) 4 FEMRING estradiol acetate vaginal ring 0.05 mg/24hr, 0.1 mg/24hr 4 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution GYNAZOLE-1 butoconazole nitrate (one dose) vaginal cream 2% 4 metronidazole vaginal gel 0.75% 2 MICONAZOLE 3 miconazole nitrate vaginal suppos 200 mg 4 OPTIONS GYNOL II VAGINAL nonoxynol-9 gel 3% A • PHEXX lactic acid-citric acid- potassium bitartrate gel 1.8-1-0.4% A • PREMARIN estrogens, conjugated vaginal cream 0.625 mg/gm 4 terconazole vaginal cream 0.4%, 0.8% 2 terconazole vaginal suppos 80 mg 2 TODAY SPONGE nonoxynol-9 vaginal sponge 1000 mg A • VCF VAGINAL CONTRACEPTIVE nonoxynol-9 gel 4% A • VCF VAGINAL CONTRACEPTIVE nonoxynol-9 film 28% A • VCF VAGINAL CONTRACEPTIVE nonoxynol-9 foam 12.5% A • GENITOURINARY AGENTS - MISC. alfuzosin hcl tab er 24hr 10 mg (Uroxatral) 1 CYSTAGON cysteamine bitartrate cap 50 mg, 150 mg 5 • • dutasteride cap 0.5 mg (Avodart) 1 ELMIRON pentosan polysulfate sodium caps 100 mg 4

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 42 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution FILSPARI sparsentan tab 200 mg, 400 mg 6 • • • • finasteride tab 5 mg (Proscar) 1 K-PHOS NO 2 potassium & sodium acid phosphates tab 305-700 mg 3 LITHOSTAT acetohydroxamic acid tab 250 mg 4 potassium citrate tab er 5 meq (540 mg) (Urocit-k 5) 2 potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10) 2 potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15) 2 silodosin cap 4 mg, 8 mg (Rapaflo) 2 SODIUM CITRATE AND CITRIC sodium citrate & citric acid soln 500-334 mg/5ml 2 SODIUM CITRATE/CITRIC ACI sodium citrate & citric acid soln 500-334 mg/5ml 2 tamsulosin hcl cap 0.4 mg (Flomax) 1 tiopronin tab delayed release 100 mg, 300 mg (Thiola ec) 5 • • tiopronin tab 100 mg (Thiola) 5 • • VANRAFIA atrasentan hcl tab 0.75 mg 6 • • • • CENTRAL NERVOUS SYSTEM DRUGS ANTIANXIETY AGENTS alprazolam tab er 24hr 0.5 mg, 1 mg, 3 mg (Xanax xr) 1 alprazolam tab er 24hr 2 mg (Xanax xr) 2 alprazolam tab 0.25 mg, 0.5 mg, 1 mg, 2 mg (Xanax) 1 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution buspirone hcl tab 5 mg, 10 mg, 15 mg, 30 mg 1 chlordiazepoxide hcl cap 5 mg, 10 mg, 25 mg 1 clorazepate dipotassium tab 3.75 mg, 15 mg 2 clorazepate dipotassium tab 7.5 mg (Tranxene t) 2 diazepam conc 5 mg/ml 2 diazepam oral soln 1 mg/ml 1 diazepam tab 2 mg, 5 mg, 10 mg (Valium) 1 hydroxyzine hcl syrup 10 mg/5ml 2 hydroxyzine hcl tab 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate cap 25 mg, 50 mg (Vistaril) 1 lorazepam conc 2 mg/ml 2 lorazepam tab 0.5 mg, 1 mg, 2 mg (Ativan) 1 meprobamate tab 200 mg, 400 mg 2 oxazepam cap 10 mg, 15 mg, 30 mg 2 ANTIDEPRESSANTS amitriptyline hcl tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg 1 amitriptyline hcl tab 150 mg 2 amoxapine tab 25 mg 1 amoxapine tab 50 mg, 100 mg, 150 mg 2 bupropion hcl tab er 12hr 100 mg, 150 mg, 200 mg (Wellbutrin sr) 1 • bupropion hcl tab er 24hr 150 mg, 300 mg (Wellbutrin xl) 1 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 43 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution bupropion hcl tab 75 mg, 100 mg 1 • citalopram hydrobromide oral soln 10 mg/5ml 2 • citalopram hydrobromide tab 10 mg (base equiv), 20 mg (base equiv), 40 mg (base equiv) (Celexa) 1 • clomipramine hcl cap 25 mg, 50 mg, 75 mg (Anafranil) 2 desipramine hcl tab 10 mg (Norpramin) 1 desipramine hcl tab 25 mg (Norpramin) 2 desipramine hcl tab 50 mg, 75 mg, 100 mg, 150 mg 2 desvenlafaxine succinate tab er 24hr 25 mg (base equiv), 50 mg (base equiv), 100 mg (base equiv) (Pristiq) 2 • DOXEPIN HCL doxepin hcl conc 10 mg/ml 4 doxepin hcl cap 10 mg, 25 mg, 50 mg 1 doxepin hcl cap 75 mg, 100 mg, 150 mg 2 duloxetine hcl enteric coated pellets cap 20 mg (base eq), 30 mg (base eq), 60 mg (base eq) (Cymbalta) 1 • EMSAM selegiline td patch 24hr 6 mg/24hr, 9 mg/24hr, 12 mg/24hr 4 escitalopram oxalate soln 5 mg/5ml (base equiv) 2 • escitalopram oxalate tab 5 mg (base equiv), 10 mg (base equiv), 20 mg (base equiv) (Lexapro) 1 • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution FETZIMA levomilnacipran hcl cap er 24hr 20 mg (base equivalent), 40 mg (base equivalent), 80 mg (base equivalent), 120 mg (base equivalent) 4 • • FETZIMA TITRATION PACK levomilnacipran hcl cap er 24hr 20 & 40 mg therapy pack 4 • • FLUOXETINE DR fluoxetine hcl cap delayed release 90 mg 4 • • fluoxetine hcl cap 10 mg, 20 mg, 40 mg (Prozac) 1 • fluoxetine hcl solution 20 mg/5ml 2 • fluoxetine hcl tab 10 mg 1 • fluoxetine hcl tab 20 mg 2 • fluvoxamine maleate tab 25 mg, 50 mg 1 • fluvoxamine maleate tab 100 mg 2 • imipramine hcl tab 10 mg, 25 mg, 50 mg 1 MARPLAN isocarboxazid tab 10 mg 4 mirtazapine orally disintegrating tab 15 mg (Remeron soltab) 1 • mirtazapine orally disintegrating tab 30 mg, 45 mg (Remeron soltab) 2 • mirtazapine tab 7.5 mg 2 • mirtazapine tab 15 mg, 30 mg (Remeron) 1 • mirtazapine tab 45 mg 1 • NEFAZODONE HYDROCHLORIDE nefazodone hcl tab 50 mg, 100 mg, 150 mg, 200 mg, 250 mg 4

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 44 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75 mg (Pamelor) 1 nortriptyline hcl soln 10 mg/5ml 2 paroxetine hcl tab 10 mg, 20 mg, 30 mg, 40 mg (Paxil) 1 • PHENELZINE SULFATE phenelzine sulfate tab 15 mg 4 protriptyline hcl tab 5 mg, 10 mg 2 sertraline hcl oral concentrate for solution 20 mg/ml (Zoloft) 2 • sertraline hcl tab 25 mg, 50 mg, 100 mg (Zoloft) 1 • tranylcypromine sulfate tab 10 mg (Parnate) 2 trazodone hcl tab 50 mg, 100 mg, 150 mg 1 trimipramine maleate cap 25 mg, 50 mg, 100 mg 2 TRINTELLIX vortioxetine hbr tab 5 mg (base equiv), 10 mg (base equiv), 20 mg (base equiv) 4 • • venlafaxine hcl cap er 24hr 37.5 mg (base equivalent), 75 mg (base equivalent), 150 mg (base equivalent) (Effexor xr) 1 • venlafaxine hcl tab 25 mg (base equivalent), 37.5 mg (base equivalent), 50 mg (base equivalent), 75 mg (base equivalent), 100 mg (base equivalent) 1 • vilazodone hcl tab 10 mg, 20 mg, 40 mg (Viibryd) 2 • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ZURZUVAE zuranolone cap 20 mg, 25 mg, 30 mg 3 • ANTIPSYCHOTICS aripiprazole oral solution 1 mg/ml 2 • aripiprazole orally disintegrating tab 10 mg, 15 mg 2 • aripiprazole tab 2 mg, 5 mg, 10 mg, 15 mg, 20 mg (Abilify) 1 • aripiprazole tab 30 mg (Abilify) 2 • asenapine maleate sl tab 2.5 mg (base equiv), 5 mg (base equiv), 10 mg (base equiv) (Saphris) 2 • CAPLYTA lumateperone tosylate cap 10.5 mg, 21 mg, 42 mg 4 • chlorpromazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg, 200 mg 2 clozapine orally disintegrating tab 12.5 mg, 25 mg, 100 mg, 150 mg, 200 mg 2 • clozapine tab 25 mg (Clozaril) 1 • clozapine tab 50 mg, 100 mg, 200 mg (Clozaril) 2 • EQUETRO carbamazepine (mood) cap er 12hr 100 mg, 200 mg, 300 mg 4 FANAPT iloperidone tab 1 mg, 2 mg, 4 mg, 6 mg, 8 mg, 10 mg, 12 mg 4 • • FANAPT TITRATION PACK A iloperidone tab 1 mg & 2 mg & 4 mg & 6 mg titration pak 4 • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 45 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution FANAPT TITRATION PACK B iloperidone tab 1 mg & 2 mg & 6 mg & 8 mg titration pak 4 • • FANAPT TITRATION PACK C iloperidone tab 1 mg & 2 mg & 6 mg titration pak 4 • • FLUPHENAZINE HCL fluphenazine hcl oral conc 5 mg/ml 4 fluphenazine hcl tab 1 mg, 2.5 mg, 5 mg, 10 mg 2 FLUPHENAZINE HYDROCHLORID fluphenazine hcl elixir 2.5 mg/5ml 4 haloperidol lactate oral conc 2 mg/ml 2 haloperidol tab 0.5 mg, 1 mg 1 haloperidol tab 2 mg, 5 mg, 10 mg, 20 mg 2 LITHIUM CARBONATE lithium carbonate cap 150 mg, 300 mg, 600 mg 4 lithium carbonate cap 150 mg, 600 mg (Lithium carbonate) 1 lithium carbonate cap 300 mg 1 lithium carbonate tab er 300 mg (Lithobid) 1 lithium carbonate tab er 450 mg 1 lithium carbonate tab 300 mg 1 LITHOBID lithium carbonate tab er 300 mg 4 loxapine succinate cap 5 mg, 10 mg, 25 mg, 50 mg 2 lurasidone hcl tab 20 mg, 40 mg, 60 mg, 80 mg, 120 mg (Latuda) 2 • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution MOLINDONE HYDROCHLORIDE molindone hcl tab 5 mg, 10 mg, 25 mg 4 olanzapine orally disintegrating tab 5 mg, 10 mg, 15 mg, 20 mg (Zyprexa zydis) 2 • olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg (Zyprexa) 1 • olanzapine tab 20 mg (Zyprexa) 2 • paliperidone tab er 24hr 1.5 mg, 3 mg, 6 mg, 9 mg (Invega) 2 • perphenazine tab 2 mg, 4 mg, 8 mg, 16 mg 2 prochlorperazine maleate tab 5 mg (base equivalent), 10 mg (base equivalent) 1 prochlorperazine suppos 25 mg 2 quetiapine fumarate tab er 24hr 50 mg, 150 mg, 200 mg (Seroquel xr) 1 • quetiapine fumarate tab er 24hr 300 mg, 400 mg (Seroquel xr) 2 • quetiapine fumarate tab 25 mg, 50 mg, 100 mg, 200 mg, 300 mg, 400 mg (Seroquel) 1 • REXULTI brexpiprazole tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg 3 • RISPERIDONE ODT risperidone orally disintegrating tab 0.25 mg 4 • • risperidone orally disintegrating tab 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg 2 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 46 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution risperidone soln 1 mg/ml (Risperdal) 2 • risperidone tab 0.25 mg 1 • risperidone tab 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg (Risperdal) 1 • SECUADO asenapine td patch 24 hr 3.8 mg/24hr, 5.7 mg/24hr, 7.6 mg/24hr 4 • • thioridazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg 2 thiothixene cap 1 mg, 2 mg, 5 mg, 10 mg 2 trifluoperazine hcl tab 1 mg (base equivalent), 2 mg (base equivalent), 5 mg (base equivalent), 10 mg (base equivalent) 2 VERSACLOZ clozapine susp 50 mg/ml 4 • • VRAYLAR cariprazine hcl cap 0.5 mg (base equivalent), 0.75 mg (base equivalent), 1.5 mg (base equivalent), 3 mg (base equivalent), 4.5 mg (base equivalent), 6 mg (base equivalent) 3 • ziprasidone hcl cap 20 mg, 40 mg, 60 mg, 80 mg (Geodon) 2 • HYPNOTICS BELSOMRA suvorexant tab 5 mg, 10 mg, 15 mg, 20 mg 4 • • estazolam tab 1 mg, 2 mg 2 eszopiclone tab 1 mg, 2 mg, 3 mg (Lunesta) 1 • HETLIOZ LQ tasimelteon oral susp 4 mg/ml 6 • • • • PHENOBARBITAL phenobarbital elixir 20 mg/5ml 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution PHENOBARBITAL phenobarbital tab 15 mg, 16.2 mg, 30 mg, 60 mg, 100 mg 1 PHENOBARBITAL phenobarbital tab 32.4 mg, 64.8 mg, 97.2 mg 2 tasimelteon capsule 20 mg (Hetlioz) 5 • • • temazepam cap 15 mg, 30 mg (Restoril) 1 zaleplon cap 5 mg, 10 mg 1 • zolpidem tartrate tab er 6.25 mg (Ambien cr) 1 • zolpidem tartrate tab er 12.5 mg (Ambien cr) 2 • zolpidem tartrate tab 5 mg, 10 mg (Ambien) 1 • ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ ANOREXIANTS amphetamine- dextroamphetamine cap er 24hr 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg (Adderall xr) 2 • amphetamine- dextroamphetamine tab 5 mg (Adderall) 1 • amphetamine- dextroamphetamine tab 7.5 mg, 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg (Adderall) 2 • armodafinil tab 50 mg (Nuvigil) 1 armodafinil tab 150 mg, 200 mg, 250 mg (Nuvigil) 2

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 47 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution atomoxetine hcl cap 10 mg (base equiv), 18 mg (base equiv), 25 mg (base equiv), 40 mg (base equiv), 60 mg (base equiv), 80 mg (base equiv), 100 mg (base equiv) (Strattera) 2 • caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) 2 clonidine hcl tab er 12hr 0.1 mg (Kapvay) 2 • dexmethylphenidate hcl cap er 24 hr 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg (Focalin xr) 2 • dexmethylphenidate hcl tab 2.5 mg, 5 mg (Focalin) 1 • dexmethylphenidate hcl tab 10 mg (Focalin) 2 • dextroamphetamine sulfate cap er 24hr 5 mg, 10 mg, 15 mg (Dexedrine) 2 • dextroamphetamine sulfate oral solution 5 mg/5ml 2 • dextroamphetamine sulfate tab 5 mg, 10 mg 2 • guanfacine hcl tab er 24hr 1 mg (base equiv), 2 mg (base equiv), 3 mg (base equiv), 4 mg (base equiv) (Intuniv) 1 • liraglutide (weight mngmt) soln pen-inj 18 mg/3ml (6 mg/ml) (Saxenda) 2 • • lisdexamfetamine dimesylate cap 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg (Vyvanse) 2 • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution lisdexamfetamine dimesylate chew tab 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg (Vyvanse) 2 • methamphetamine hcl tab 5 mg 2 • methylphenidate hcl cap er 10 mg (cd), 20 mg (cd), 30 mg (cd), 40 mg (cd), 50 mg (cd), 60 mg (cd) 2 • methylphenidate hcl cap er 24hr 10 mg (la), 20 mg (la), 30 mg (la), 40 mg (la) (Ritalin la) 2 • methylphenidate hcl cap er 24hr 60 mg (la) 2 • methylphenidate hcl chew tab 2.5 mg, 5 mg, 10 mg 2 • methylphenidate hcl soln 5 mg/5ml, 10 mg/5ml (Methylin) 2 • methylphenidate hcl tab er osmotic release (osm) 18 mg, 27 mg, 36 mg, 54 mg (Concerta) 2 • methylphenidate hcl tab er osmotic release (osm) 72 mg 1 • methylphenidate hcl tab er 10 mg, 20 mg 2 • methylphenidate hcl tab 5 mg, 10 mg (Ritalin) 1 • methylphenidate hcl tab 20 mg (Ritalin) 2 • METHYLPHENIDATE HYDROCHLO methylphenidate hcl tab er diffusion 27 mg, diffusion 36 mg, diffusion 54 mg 2 METHYLPHENIDATE HYDROCHLO methylphenidate hcl tab er 24hr 18 mg 1 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 48 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution METHYLPHENIDATE HYDROCHLO methylphenidate hcl tab er 24hr 27 mg, 36 mg, 54 mg 4 • modafinil tab 100 mg, 200 mg (Provigil) 2 ORLISTAT orlistat cap 120 mg 4 • • phentermine hcl cap 15 mg, 30 mg, 37.5 mg 1 • • phentermine hcl tab 8 mg 2 • • phentermine hcl tab 37.5 mg (Adipex-p) 1 • • phentermine hcl-topiramate cap er 24hr 3.75-23 mg, 7.5-46 mg, 11.25-69 mg, 15-92 mg (Qsymia) 2 • • SUNOSI solriamfetol hcl tab 75 mg (base equiv), 150 mg (base equiv) 3 • • WAKIX pitolisant hcl tab 4.45 mg (base equivalent), 17.8 mg (base equivalent) 6 • • • • WEGOVY semaglutide (weight management) tab 1.5 mg, 4 mg, 9 mg, 25 mg 3 • • WEGOVY semaglutide (weight mngmt) soln auto- injector 0.25 mg/0.5ml, 0.5 mg/0.5ml, 1 mg/0.5ml, 1.7 mg/0.75ml, 2.4 mg/0.75ml 3 • • XENICAL orlistat cap 120 mg 4 • • ZEPBOUND tirzepatide (weight mngmt) soln auto-injector 2.5 mg/0.5ml, 5 mg/0.5ml, 7.5 mg/0.5ml, 10 mg/0.5ml, 12.5 mg/0.5ml, 15 mg/0.5ml 3 • • PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS - MISC. acamprosate calcium tab delayed release 333 mg 2 AQNEURSA levacetylleucine for susp packet 1 gm 6 • • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution AUSTEDO deutetrabenazine tab 6 mg, 9 mg, 12 mg 6 • • • AUSTEDO XR deutetrabenazine tab er 24hr 6 mg, 12 mg, 18 mg, 24 mg, 30 mg, 36 mg, 42 mg, 48 mg 6 • • • AUSTEDO XR PATIENT TITRAT deutetrabenazine tab er titration pack 12 & 18 & 24 & 30 mg 6 • • • AVONEX interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml 5 • • • AVONEX PEN interferon beta-1a im auto-injector kit 30 mcg/0.5ml 5 • • • BETASERON interferon beta-1b for inj kit 0.3 mg 5 • • • bupropion hcl (smoking deterrent) tab er 12hr 150 mg A • CHLORDIAZEPOXIDE/ AMITRIPT chlordiazepoxide- amitriptyline tab 5-12.5 mg, 10-25 mg 4 cladribine tab therapy pack 10 mg (4 tabs), 10 mg (5 tabs), 10 mg (6 tabs), 10 mg (7 tabs), 10 mg (8 tabs), 10 mg (9 tabs), 10 mg (10 tabs) (Mavenclad) 5 • • • dalfampridine tab er 12hr 10 mg (Ampyra) 5 • dimethyl fumarate capsule delayed release 120 mg, 240 mg (Tecfidera) 4 • • • dimethyl fumarate capsule dr starter pack 120 mg & 240 mg (Tecfidera starter pa) 4 • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 49 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution disulfiram tab 250 mg, 500 mg 2 donepezil hydrochloride orally disintegrating tab 5 mg, 10 mg 1 donepezil hydrochloride tab 5 mg, 10 mg (Aricept) 1 donepezil hydrochloride tab 23 mg (Aricept) 2 fingolimod hcl cap 0.5 mg (base equiv) (Gilenya) 5 • • • GALANTAMINE HYDROBROMIDE galantamine hydrobromide oral soln 4 mg/ml 4 galantamine hydrobromide cap er 24hr 8 mg, 16 mg, 24 mg (Razadyne er) 2 galantamine hydrobromide tab 4 mg, 8 mg, 12 mg 2 GILENYA fingolimod hcl cap 0.25 mg (base equiv) 6 • • • glatiramer acetate soln prefilled syringe 20 mg/ml, 40 mg/ml (Copaxone) 5 • • • INGREZZA valbenazine tosylate cap therapy pack 40 mg (7) & 80 mg (21) 6 • • • • INGREZZA valbenazine tosylate cap 40 mg (base equiv), 60 mg (base equiv), 80 mg (base equiv) 6 • • • • INGREZZA valbenazine tosylate capsule sprinkle 40 mg (base equiv), 60 mg (base equiv), 80 mg (base equiv) 6 • • • • KESIMPTA ofatumumab soln auto-injector 20 mg/0.4ml 5 • • • lofexidine hcl tab 0.18 mg (base equivalent) (Lucemyra) 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution LUMRYZ sodium oxybate pack for oral er susp 4.5 gm, 6 gm, 7.5 gm, 9 gm 6 • • • • LUMRYZ STARTER PACK sodium oxybate pack for er susp 4.5 & 6 & 7.5 gm starter pak 6 • • • • MAVENCLAD cladribine tab therapy pack 10 mg (4 tabs), 10 mg (5 tabs), 10 mg (6 tabs), 10 mg (7 tabs), 10 mg (8 tabs), 10 mg (9 tabs), 10 mg (10 tabs) 5 • • • • MAYZENT siponimod fumarate tab 0.25 mg (base equiv), 1 mg (base equiv), 2 mg (base equiv) 5 • • • • MAYZENT STARTER PACK siponimod fumarate tab 0.25 mg (7) starter pack 5 • • • • MAYZENT STARTER PACK siponimod fumarate tab 0.25 mg (12) starter pack 5 • • • • memantine hcl oral solution 2 mg/ml 2 memantine hcl tab 5 mg, 10 mg (Namenda) 1 MEMANTINE HCL TITRATION P memantine hcl tab 28 x 5 mg & 21 x 10 mg titration pack 4 milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & 50 mg (42) pak (Savella titration pa) 2 • milnacipran hcl tab 12.5 mg, 25 mg, 50 mg, 100 mg (Savella) 2 • nicotine polacrilex gum 2 mg, 4 mg A • nicotine polacrilex lozenge 2 mg, 4 mg A •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 50 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution nicotine td patch 24hr 7 mg/24hr, 14 mg/24hr, 21 mg/24hr A • NICOTINE TRANSDERMAL SYST nicotine td patch 24 hr kit 21-14-7 mg/24hr A • NICOTROL NS nicotine nasal spray 10 mg/ml (0.5 mg/ spray) A • PERPHENAZINE/ AMITRIPTYLIN perphenazine- amitriptyline tab 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg 4 PIMOZIDE pimozide tab 1 mg, 2 mg 4 PLEGRIDY peginterferon beta-1a soln auto-injector 125 mcg/0.5ml 5 • • • • PLEGRIDY peginterferon beta-1a soln prefilled syringe 125 mcg/0.5ml 5 • • • • PLEGRIDY peginterferon beta-1a im soln prefilled syr 125 mcg/0.5ml 5 • • • • PLEGRIDY STARTER PACK peginterferon beta-1a soln auto-inj 63 & 94 mcg/0.5ml pack 5 • • • • PLEGRIDY STARTER PACK peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack 5 • • • • REBIF interferon beta-1a soln pref syr 22 mcg/0.5ml, 44 mcg/0.5ml 5 • • • REBIF REBIDOSE interferon beta-1a soln auto-inj 22 mcg/0.5ml, 44 mcg/0.5ml 5 • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution REBIF REBIDOSE TITRATION interferon beta-1a auto-inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml 5 • • • REBIF TITRATION PACK interferon beta-1a pref syr 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml 5 • • • rivastigmine tartrate cap 1.5 mg (base equivalent), 3 mg (base equivalent), 4.5 mg (base equivalent), 6 mg (base equivalent) 2 rivastigmine td patch 24hr 4.6 mg/24hr, 9.5 mg/24hr, 13.3 mg/24hr (Exelon) 2 SAVELLA milnacipran hcl tab 12.5 mg, 25 mg, 50 mg, 100 mg 4 • • SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & 50 mg (42) pak 4 • • sodium oxybate oral solution 500 mg/ml (Xyrem) 5 • • • • teriflunomide tab 7 mg, 14 mg (Aubagio) 5 • • • tetrabenazine tab 12.5 mg, 25 mg (Xenazine) 5 • • • varenicline tartrate tab 0.5 mg (base equiv), 1 mg (base equiv) A • varenicline tartrate tab 11 x 0.5 mg & 42 x 1 mg start pack A • VUMERITY diroximel fumarate capsule delayed release 231 mg 5 • • • • WAINUA eplontersen sodium subcutaneous soln auto-inj 45 mg/0.8ml 6 • • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 51 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution XYWAV calcium, mag, potassium, & sod oxybates oral soln 500 mg/ml 6 • • • • ZEPOSIA ozanimod hcl cap 0.92 mg 5 • • • ZEPOSIA STARTER KIT ozanimod cap pack 4 x 0.23 mg & 3 x 0.46 mg & 21 x 0.92 mg 5 • • • ZEPOSIA 7-DAY STARTER PAC ozanimod cap pack 4 x 0.23 mg & 3 x 0.46 mg 5 • • • ANALGESICS AND ANESTHETICS ANALGESICS - NON-NARCOTIC aspirin chew tab 81 mg A • aspirin tab delayed release 81 mg A • butalbital-acetaminophen tab 50-325 mg 2 • butalbital-acetaminophen- caffeine tab 50-325-40 mg (Esgic) 1 • butalbital-aspirin-caffeine cap 50-325-40 mg 2 • diflunisal tab 500 mg 2 JOURNAVX suzetrigine tab 50 mg 4 TENCON butalbital- acetaminophen tab 50-325 mg 4 • ANALGESICS - NARCOTIC acetaminophen w/ codeine tab 300-15 mg (Tylenol/ codeine) 1 • acetaminophen w/ codeine tab 300-30 mg 1 • acetaminophen w/ codeine tab 300-60 mg 2 • ACETAMINOPHEN/ CODEINE acetaminophen w/ codeine soln 120-12 mg/5ml 4 • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution BELBUCA buprenorphine hcl buccal film 75 mcg (base equivalent), 150 mcg (base equivalent), 300 mcg (base equivalent), 450 mcg (base equivalent), 600 mcg (base equivalent), 750 mcg (base equivalent), 900 mcg (base equivalent) 3 buprenorphine hcl sl tab 2 mg (base equiv), 8 mg (base equiv) 2 buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv), 4-1 mg (base equiv), 8-2 mg (base equiv), 12-3 mg (base equiv) (Suboxone) 2 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv), 8-2 mg (base equiv) 2 buprenorphine td patch weekly 5 mcg/hr, 7.5 mcg/ hr, 10 mcg/hr, 15 mcg/hr, 20 mcg/hr (Butrans) 2 butalbital-acetaminophen- caff w/ cod cap 50-325-40-30 mg 2 • butalbital-aspirin- caff w/ codeine cap 50-325-40-30 mg 2 • butorphanol tartrate nasal soln 10 mg/ml 2 • BUTRANS buprenorphine td patch weekly 5 mcg/hr, 7.5 mcg/hr, 10 mcg/hr, 15 mcg/ hr, 20 mcg/hr 4 codeine sulfate tab 30 mg (Codeine sulfate) 2 • DISKETS methadone hcl tab for oral susp 40 mg 2 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 52 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution fentanyl td patch 72hr 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr (Duragesic) 2 • • HYDROCODONE BITARTRATE ER hydrocodone bitartrate cap er 12hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg 4 • • HYDROCODONE BITARTRATE/ AC hydrocodone- acetaminophen tab 2.5-325 mg 3 • hydrocodone- acetaminophen soln 7.5-325 mg/15ml 2 • hydrocodone- acetaminophen tab 10-325 mg, 5-325 mg, 7.5-325 mg 1 • hydrocodone-ibuprofen tab 7.5-200 mg 2 • hydromorphone hcl liqd 1 mg/ml (Dilaudid) 2 • hydromorphone hcl tab er 24hr 8 mg, 12 mg, 16 mg, 32 mg 2 • • hydromorphone hcl tab 2 mg, 4 mg (Dilaudid) 1 • hydromorphone hcl tab 8 mg (Dilaudid) 2 • methadone hcl conc 10 mg/ ml (Methadose) 2 • methadone hcl soln 5 mg/5ml, 10 mg/5ml (Methadone hcl) 2 • methadone hcl tab for oral susp 40 mg 2 • methadone hcl tab 5 mg 1 • methadone hcl tab 10 mg 2 • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution morphine sulfate oral soln 10 mg/5ml 1 • morphine sulfate oral soln 20 mg/5ml (Morphine sulfate) 2 • morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 2 • morphine sulfate tab er 15 mg (Ms contin) 1 • • morphine sulfate tab er 30 mg, 60 mg, 100 mg, 200 mg (Ms contin) 2 • • morphine sulfate tab 15 mg (Morphine sulfate) 1 • morphine sulfate tab 30 mg (Morphine sulfate) 2 • NUCYNTA ER tapentadol hcl tab er 12hr 50 mg, 100 mg, 150 mg, 200 mg, 250 mg 4 • • oxycodone hcl conc 100 mg/5ml (20 mg/ml) 2 • oxycodone hcl soln 5 mg/5ml 2 • oxycodone hcl tab 5 mg (Roxicodone) 1 • oxycodone hcl tab 10 mg 1 • oxycodone hcl tab 15 mg, 30 mg (Roxicodone) 2 • oxycodone hcl tab 20 mg 2 • oxycodone w/ acetaminophen tab 2.5-325 mg, 7.5-325 mg, 10-325 mg (Percocet) 2 • oxycodone w/ acetaminophen tab 5-325 mg (Percocet) 1 • OXYCONTIN oxycodone hcl tab er 12hr deter 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg 3 • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 53 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution oxymorphone hcl tab 5 mg, 10 mg 2 • OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab er 12hr 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg, 30 mg, 40 mg 4 • • SUBOXONE buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv), 4-1 mg (base equiv), 8-2 mg (base equiv), 12-3 mg (base equiv) 4 tramadol hcl tab er 24hr 100 mg, 200 mg, 300 mg 2 • • tramadol hcl tab 50 mg (Ultram) 1 • tramadol-acetaminophen tab 37.5-325 mg (Ultracet) 1 • ZUBSOLV buprenorphine hcl- naloxone hcl sl tab 0.7-0.18 mg (base eq), 1.4-0.36 mg (base eq), 2.9-0.71 mg (base eq), 5.7-1.4 mg (base eq), 8.6-2.1 mg (base eq), 11.4-2.9 mg (base eq) 3 ANALGESICS - ANTI-INFLAMMATORY ADALIMUMAB-AATY CD/UC/ HS adalimumab-aaty auto- injector kit 80 mg/0.8ml 5 • • • ADALIMUMAB-AATY 1-PEN KIT adalimumab-aaty auto- injector kit 40 mg/0.4ml, 80 mg/0.8ml 5 • • • ADALIMUMAB-AATY 2-PEN KIT adalimumab-aaty auto- injector kit 40 mg/0.4ml 5 • • • ADALIMUMAB-AATY 2- SYRINGE adalimumab- aaty prefilled syringe kit 20 mg/0.2ml, 40 mg/0.4ml 5 • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ADALIMUMAB- ADAZ adalimumab-adaz soln auto-injector 40 mg/0.4ml, 80 mg/0.8ml 5 • • • ADALIMUMAB- ADAZ adalimumab-adaz soln prefilled syringe 10 mg/0.1ml, 20 mg/0.2ml, 40 mg/0.4ml 5 • • • ARCALYST rilonacept for inj 220 mg 6 • • • • AURANOFIN auranofin cap 3 mg 4 celecoxib cap 50 mg, 100 mg, 200 mg (Celebrex) 1 celecoxib cap 400 mg (Celebrex) 2 diclofenac potassium tab 50 mg 2 diclofenac sodium tab delayed release 25 mg 2 diclofenac sodium tab delayed release 50 mg, 75 mg 1 diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50) 2 diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75) 2 ENBREL etanercept subcutaneous inj 25 mg/0.5ml 5 • • • ENBREL etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml, 50 mg/ ml 5 • • • ENBREL MINI etanercept subcutaneous solution cartridge 50 mg/ml 5 • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 54 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ENBREL SURECLICK etanercept subcutaneous solution auto- injector 50 mg/ml 5 • • • etodolac cap 200 mg, 300 mg 2 etodolac tab 400 mg (Lodine) 2 etodolac tab 500 mg 2 FLURBIPROFEN flurbiprofen tab 50 mg, 100 mg 4 HADLIMA adalimumab-bwwd soln prefilled syringe 40 mg/0.4ml, 40 mg/0.8ml 5 • • • HADLIMA PUSHTOUCH adalimumab- bwwd soln auto-injector 40 mg/0.4ml, 40 mg/0.8ml 5 • • • ibuprofen tab 400 mg, 600 mg, 800 mg 1 indomethacin cap er 75 mg 1 indomethacin cap 25 mg, 50 mg 1 ketorolac tromethamine tab 10 mg 1 • KEVZARA sarilumab subcutaneous soln prefilled syringe 200 mg/1.14ml 6 • • • KEVZARA sarilumab subcutaneous solution auto- injector 150 mg/1.14ml, 200 mg/1.14ml 6 • • • leflunomide tab 10 mg, 20 mg (Arava) 2 MECLOFENAMATE SODIUM meclofenamate sodium cap 50 mg, 100 mg 4 mefenamic acid cap 250 mg 2 meloxicam tab 7.5 mg, 15 mg (Mobic) 1 nabumetone tab 500 mg, 750 mg 1 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution naproxen sodium tab 275 mg, 550 mg 2 naproxen tab 250 mg, 375 mg 1 naproxen tab 500 mg (Naprosyn) 1 OLUMIANT baricitinib tab 1 mg, 2 mg, 4 mg 6 • • • • ORENCIA abatacept subcutaneous soln prefilled syringe 50 mg/0.4ml, 87.5 mg/0.7ml, 125 mg/ml 6 • • • ORENCIA CLICKJECT abatacept subcutaneous soln auto- injector 125 mg/ml 6 • • • OTEZLA apremilast tab starter therapy pack 4 x 10 mg & 51 x 20 mg, 10 mg & 20 mg & 30 mg 5 • • • OTEZLA apremilast tab 20 mg, 30 mg 5 • • • OTEZLA XR apremilast tab er 24hr 75 mg 5 • • • OTEZLA/OTEZLA XR 28 DAY T apremilast tab start pack 10 mg & 20 mg & 30 mg & (er) 75 mg 5 • • • oxaprozin tab 600 mg (Daypro) 2 piroxicam cap 10 mg, 20 mg (Feldene) 2 RASUVO methotrexate soln pf auto-injector 7.5 mg/0.15ml, 10 mg/0.2ml, 12.5 mg/0.25ml, 15 mg/0.3ml, 17.5 mg/0.35ml, 20 mg/0.4ml, 22.5 mg/0.45ml, 25 mg/0.5ml, 30 mg/0.6ml 3 RIDAURA auranofin cap 3 mg 4 RINVOQ upadacitinib tab er 24hr 15 mg, 30 mg, 45 mg 5 • • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 55 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution RINVOQ LQ upadacitinib oral soln 1 mg/ml 5 • • • • SIMLANDI adalimumab-ryvk prefilled syringe kit 20 mg/0.2ml, 40 mg/0.4ml 5 • • • SIMLANDI 1-PEN KIT adalimumab-ryvk auto- injector kit 40 mg/0.4ml, 80 mg/0.8ml 5 • • • SIMLANDI 2-PEN KIT adalimumab-ryvk auto- injector kit 40 mg/0.4ml 5 • • • SIMPONI golimumab subcutaneous soln auto- injector 100 mg/ml 5 • • • SIMPONI golimumab subcutaneous soln prefilled syringe 100 mg/ml 5 • • • sulindac tab 150 mg, 200 mg 1 TYENNE tocilizumab-aazg subcutaneous soln auto-inj 162 mg/0.9ml 5 • • • TYENNE tocilizumab-aazg subcutaneous soln pref syr 162 mg/0.9ml 5 • • • XELJANZ tofacitinib citrate oral soln 1 mg/ml (base equivalent) 5 • • • XELJANZ tofacitinib citrate tab 5 mg (base equivalent), 10 mg (base equivalent) 5 • • • XELJANZ XR tofacitinib citrate tab er 24hr 11 mg (base equivalent), 22 mg (base equivalent) 5 • • • MIGRAINE PRODUCTS AIMOVIG erenumab-aooe subcutaneous soln auto- injector 70 mg/ml, 140 mg/ml 3 • • AJOVY fremanezumab-vfrm subcutaneous soln auto-inj 225 mg/1.5ml 3 • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution AJOVY fremanezumab-vfrm subcutaneous soln pref syr 225 mg/1.5ml 3 • • dihydroergotamine mesylate inj 1 mg/ml (D.h.e. 45) 2 eletriptan hydrobromide tab 20 mg (base equivalent), 40 mg (base equivalent) (Relpax) 2 • EMGALITY galcanezumab- gnlm subcutaneous soln auto-injector 120 mg/ml 3 • • EMGALITY galcanezumab- gnlm subcutaneous soln prefilled syr 100 mg/ml, 120 mg/ml 3 • • ERGOMAR ergotamine tartrate sl tab 2 mg 4 ERGOTAMINE TARTRATE/ CAFFE ergotamine w/ caffeine tab 1-100 mg 4 frovatriptan succinate tab 2.5 mg (base equivalent) (Frova) 2 • • naratriptan hcl tab 1 mg (base equiv), 2.5 mg (base equiv) (Amerge) 2 • NURTEC rimegepant sulfate tab disint 75 mg 3 • • QULIPTA atogepant tab 10 mg, 30 mg, 60 mg 3 • • REYVOW lasmiditan succinate tab 50 mg, 100 mg 3 • • rizatriptan benzoate oral disintegrating tab 5 mg (base eq) 1 • rizatriptan benzoate oral disintegrating tab 10 mg (base eq) (Maxalt-mlt) 1 • rizatriptan benzoate tab 5 mg (base equivalent) 1 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 56 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt) 1 • sumatriptan nasal spray 5 mg/act, 20 mg/act (Imitrex) 2 • sumatriptan succinate inj 6 mg/0.5ml (Imitrex) 2 • sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys) 2 • sumatriptan succinate tab 25 mg, 50 mg, 100 mg (Imitrex) 1 • UBRELVY ubrogepant tab 50 mg, 100 mg 3 • • zolmitriptan tab 2.5 mg, 5 mg (Zomig) 2 • GOUT AGENTS allopurinol tab 100 mg, 300 mg (Zyloprim) 1 colchicine tab 0.6 mg (Colcrys) 2 colchicine w/ probenecid tab 0.5-500 mg 2 febuxostat tab 40 mg, 80 mg (Uloric) 2 probenecid tab 500 mg 2 NEUROMUSCULAR DRUGS ANTICONVULSANTS APTIOM eslicarbazepine acetate tab 200 mg, 400 mg, 600 mg, 800 mg 3 brivaracetam oral soln 10 mg/ml (Briviact) 2 brivaracetam tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg (Briviact) 2 BRIVIACT brivaracetam oral soln 10 mg/ml 4 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution BRIVIACT brivaracetam tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg 4 CARBAMAZEPINE carbamazepine chew tab 200 mg 4 carbamazepine cap er 12hr 100 mg, 200 mg, 300 mg (Carbatrol) 2 carbamazepine chew tab 100 mg 2 carbamazepine susp 100 mg/5ml (Tegretol) 2 carbamazepine tab er 12hr 100 mg, 200 mg, 400 mg (Tegretol-xr) 2 carbamazepine tab 200 mg (Tegretol) 2 CARBATROL carbamazepine cap er 12hr 100 mg, 200 mg, 300 mg 4 CELONTIN methsuximide cap 300 mg 4 clobazam suspension 2.5 mg/ml (Onfi) 2 clobazam tab 10 mg, 20 mg (Onfi) 2 clonazepam orally disintegrating tab 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg 2 clonazepam tab 0.5 mg, 1 mg, 2 mg (Klonopin) 1 DIACOMIT stiripentol cap 250 mg, 500 mg 6 • DIACOMIT stiripentol packet 250 mg, 500 mg 6 • diazepam rectal gel delivery system 2.5 mg 2 diazepam rectal gel delivery system 10 mg, 20 mg (Diastat acudial) 2

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 57 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution DILANTIN phenytoin sodium extended cap 30 mg, 100 mg 4 DILANTIN INFATABS phenytoin chew tab 50 mg 4 DILANTIN-125 phenytoin susp 125 mg/5ml 4 divalproex sodium cap delayed release sprinkle 125 mg (Depakote sprinkles) 2 divalproex sodium tab delayed release 125 mg, 250 mg, 500 mg (Depakote) 1 divalproex sodium tab er 24 hr 250 mg, 500 mg (Depakote er) 2 EPIDIOLEX cannabidiol soln 100 mg/ml 5 • • • eslicarbazepine acetate tab 200 mg, 400 mg, 600 mg, 800 mg (Aptiom) 2 ethosuximide cap 250 mg (Zarontin) 2 ethosuximide soln 250 mg/5ml (Zarontin) 2 felbamate susp 600 mg/5ml (Felbatol) 2 felbamate tab 400 mg, 600 mg (Felbatol) 2 FINTEPLA fenfluramine hcl oral soln 2.2 mg/ml 6 • • FYCOMPA perampanel susp 0.5 mg/ml 4 FYCOMPA perampanel tab 2 mg, 4 mg, 6 mg, 8 mg, 10 mg, 12 mg 4 gabapentin cap 100 mg, 300 mg, 400 mg (Neurontin) 1 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution gabapentin oral soln 250 mg/5ml (Neurontin) 2 gabapentin tab 600 mg, 800 mg (Neurontin) 1 lacosamide oral solution 10 mg/ml (Vimpat) 2 lacosamide tab 50 mg, 100 mg, 150 mg, 200 mg (Vimpat) 2 lamotrigine orally disintegrating tab 25 mg, 50 mg, 100 mg, 200 mg (Lamictal odt) 2 lamotrigine tab chewable dispersible 5 mg, 25 mg (Lamictal chewable di) 2 lamotrigine tab er 24hr 25 mg, 50 mg, 100 mg, 200 mg, 250 mg, 300 mg (Lamictal xr) 2 lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg (Lamictal) 1 levetiracetam oral soln 100 mg/ml (Keppra) 2 levetiracetam tab er 24hr 500 mg, 750 mg (Keppra xr) 2 levetiracetam tab 250 mg, 500 mg (Keppra) 1 levetiracetam tab 750 mg, 1000 mg (Keppra) 2 methsuximide cap 300 mg (Celontin) 2 MYSOLINE primidone tab 50 mg, 250 mg 4 NAYZILAM midazolam nasal spray soln 5 mg/0.1 ml 4 ONFI clobazam suspension 2.5 mg/ml 4 ONFI clobazam tab 10 mg, 20 mg 4

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 58 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) 2 oxcarbazepine tab er 24hr 150 mg, 300 mg, 600 mg (Oxtellar xr) 2 oxcarbazepine tab 150 mg (Trileptal) 1 oxcarbazepine tab 300 mg, 600 mg (Trileptal) 2 perampanel susp 0.5 mg/ml (Fycompa) 2 perampanel tab 2 mg, 4 mg, 6 mg, 8 mg, 10 mg, 12 mg (Fycompa) 2 phenytoin chew tab 50 mg (Dilantin infatabs) 2 phenytoin sodium extended cap 100 mg (Dilantin) 2 phenytoin sodium extended cap 200 mg, 300 mg (Phenytek) 2 phenytoin susp 125 mg/5ml (Dilantin-125) 2 pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg, 225 mg, 300 mg (Lyrica) 1 • pregabalin soln 20 mg/ml (Lyrica) 2 • PRIMIDONE primidone tab 125 mg 4 primidone tab 50 mg (Mysoline) 1 primidone tab 250 mg (Mysoline) 2 TEGRETOL carbamazepine susp 100 mg/5ml 4 TEGRETOL carbamazepine tab 200 mg 4 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution TEGRETOL- XR carbamazepine tab er 12hr 100 mg, 200 mg, 400 mg 4 tiagabine hcl tab 2 mg, 4 mg (Gabitril) 2 TIAGABINE HYDROCHLORIDE tiagabine hcl tab 12 mg, 16 mg 2 topiramate cap er 24hr sprinkle 25 mg, 50 mg, 100 mg, 150 mg, 200 mg (Qudexy xr) 2 topiramate sprinkle cap 15 mg, 25 mg (Topamax sprinkle) 2 topiramate tab 25 mg, 50 mg, 100 mg, 200 mg (Topamax) 1 valproate sodium oral soln 250 mg/5ml (base equiv) 2 valproic acid cap 250 mg 2 VALTOCO 10 MG DOSE diazepam nasal spray 10 mg/0.1 ml 4 VALTOCO 15 MG DOSE diazepam nasal spray ther pack 2 x 7.5 mg/0.1ml (15 mg dose) 4 VALTOCO 20 MG DOSE diazepam nasal spray ther pack 2 x 10 mg/0.1ml (20 mg dose) 4 VALTOCO 5 MG DOSE diazepam nasal spray 5 mg/0.1 ml 4 vigabatrin powd pack 500 mg (Sabril) 5 • • vigabatrin tab 500 mg (Sabril) 5 • • VIMPAT lacosamide oral solution 10 mg/ml 4

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 59 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution VIMPAT lacosamide tab 50 mg, 100 mg, 150 mg, 200 mg 4 XCOPRI cenobamate tab pack 100 mg & 150 mg tabs (250 mg daily dose) 4 XCOPRI cenobamate tab pack 150 mg & 200 mg tabs (350 mg daily dose) 4 XCOPRI cenobamate tab titration pack 14 x 12.5 mg & 14 x 25 mg, 14 x 50 mg & 14 x 100 mg, 14 x 150 mg & 14 x 200 mg 4 XCOPRI cenobamate tab 25 mg, 50 mg, 100 mg, 150 mg, 200 mg 4 ZARONTIN ethosuximide cap 250 mg 4 ZARONTIN ethosuximide soln 250 mg/5ml 4 zonisamide cap 25 mg (Zonegran) 1 zonisamide cap 50 mg 1 zonisamide cap 100 mg (Zonegran) 2 ZTALMY ganaxolone susp 50 mg/ml 6 • • ANTIPARKINSON AGENTS amantadine hcl cap 100 mg 2 amantadine hcl soln 50 mg/5ml 2 APOKYN apomorphine hcl soln cartridge 30 mg/3ml 6 • • apomorphine hcl soln cartridge 30 mg/3ml (Apokyn) 5 • benztropine mesylate tab 0.5 mg, 1 mg, 2 mg 1 bromocriptine mesylate cap 5 mg (base equivalent) (Parlodel) 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel) 2 carbidopa & levodopa orally disintegrating tab 10-100 mg, 25-100 mg, 25-250 mg 2 carbidopa & levodopa tab er 25-100 mg, 50-200 mg 2 carbidopa & levodopa tab 10-100 mg (Sinemet) 1 carbidopa & levodopa tab 25-100 mg (Sinemet) 2 carbidopa & levodopa tab 25-250 mg 2 carbidopa tab 25 mg (Lodosyn) 2 carbidopa-levodopa- entacapone tabs 12.5-50-200 mg (Stalevo 50) 2 carbidopa-levodopa- entacapone tabs 18.75-75-200 mg (Stalevo 75) 2 carbidopa-levodopa- entacapone tabs 25-100-200 mg (Stalevo 100) 2 carbidopa-levodopa- entacapone tabs 31.25-125-200 mg (Stalevo 125) 2 carbidopa-levodopa- entacapone tabs 37.5-150-200 mg (Stalevo 150) 2 carbidopa-levodopa- entacapone tabs 50-200-200 mg (Stalevo 200) 2 DUOPA carbidopa-levodopa enteral susp 4.63-20 mg/ml 4 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 60 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution entacapone tab 200 mg (Comtan) 2 INBRIJA levodopa inhal powder cap 42 mg 5 • • NEUPRO rotigotine td patch 24hr 1 mg/24hr, 2 mg/24hr, 3 mg/24hr, 4 mg/24hr, 6 mg/24hr, 8 mg/24hr 4 ONAPGO apomorphine hcl soln cartridge 98 mg/20ml 6 • pramipexole dihydrochloride tab 0.125 mg, 0.5 mg, 0.75 mg, 1 mg (Mirapex) 1 pramipexole dihydrochloride tab 0.25 mg, 1.5 mg 1 rasagiline mesylate tab 0.5 mg (base equiv), 1 mg (base equiv) (Azilect) 2 ropinirole hydrochloride tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg 1 RYTARY carbidopa & levodopa cap er 23.75-95 mg, 36.25-145 mg, 48.75-195 mg, 61.25-245 mg 4 selegiline hcl cap 5 mg 2 selegiline hcl tab 5 mg 2 tolcapone tab 100 mg (Tasmar) 2 TRIHEXYPHENIDYL HCL trihexyphenidyl hcl oral soln 0.4 mg/ml 4 trihexyphenidyl hcl tab 2 mg, 5 mg 1 VYALEV foscarbidopa- foslevodopa subcutaneous inj 12-240 mg/ml 6 • NEUROMUSCULAR AGENTS DAYBUE trofinetide oral soln 200 mg/ml 6 • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution DAYBUE STIX trofinetide oral powder packet 5000 mg, 6000 mg, 8000 mg 6 • • DUVYZAT givinostat hcl oral susp 8.86 mg/ml 6 • • • EVRYSDI risdiplam for soln 0.75 mg/ml 6 • • • • EVRYSDI risdiplam tab 5 mg 6 • • • • RADICAVA ORS edaravone oral susp 105 mg/5ml 6 • • • • RADICAVA ORS STARTER KIT edaravone oral susp 105 mg/5ml 6 • • • • riluzole tab 50 mg (Rilutek) 5 • SKYCLARYS omaveloxolone cap 50 mg 6 • MUSCULOSKELETAL THERAPY AGENTS baclofen tab 10 mg, 20 mg 1 carisoprodol tab 250 mg (Soma) 2 carisoprodol tab 350 mg (Soma) 1 chlorzoxazone tab 500 mg 2 cyclobenzaprine hcl tab 5 mg, 10 mg 1 dantrolene sodium cap 25 mg, 50 mg (Dantrium) 2 dantrolene sodium cap 100 mg 2 metaxalone tab 400 mg 2 metaxalone tab 800 mg (Skelaxin) 2 methocarbamol tab 500 mg, 750 mg 1 orphenadrine citrate tab er 12hr 100 mg 2 SOHONOS palovarotene cap 1 mg, 1.5 mg, 2.5 mg, 5 mg, 10 mg 6 • • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 61 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution tizanidine hcl tab 2 mg (base equivalent) 1 tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) 1 ANTIMYASTHENIC AGENTS pyridostigmine bromide oral soln 60 mg/5ml (Mestinon) 2 pyridostigmine bromide tab 60 mg (Mestinon) 2 NUTRITIONAL PRODUCTS VITAMINS cholecalciferol cap 1.25 mg (50000 unit) 1 ergocalciferol cap 1.25 mg (50000 unit) (Drisdol) 1 phytonadione tab 5 mg (Mephyton) 2 MULTIVITAMINS BRAND PRENATAL VITAMINS - VARIOUS 3 MINERALS and ELECTROLYTES FLORICAL sodium fluoride w/ calcium carb cap 8.3-364 mg A • FLORICAL sodium fluoride w/ calcium carb tab 8.3-364 mg A • FLORIVA sodium fluoride- vitamin d liqd drops 0.25 mg/ ml-400 unit/ml 4 • FLUORIDE sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf), 0.5 mg f (from 1.1 mg naf), 1 mg f (from 2.2 mg naf) 1 • MONOCAL sodium monofluorophosphate- calcium carb tab 22.75-625 mg A • PHOSPHA 250 NEUTRAL pot phos monobasic w/sod phos di & monobas tab 155-852-130mg 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution PHOSPHO-TRIN K500 potassium phosphate monobasic tab 500 mg 2 PHOSPHO-TRIN 250 NEUTRAL pot phos monobasic w/sod phos di & monobas tab 155-852-130mg 2 PHOSPHOROUS pot phos monobasic w/sod phos di & monobas tab 155-852-130mg 2 potassium chloride cap er 8 meq, 10 meq 1 potassium chloride microencapsulated crys er tab 10 meq, 20 meq 1 potassium chloride microencapsulated crys er tab 15 meq 2 potassium chloride oral soln 10% (20 meq/15ml), 20% (40 meq/15ml) 2 potassium chloride powder packet 20 meq 2 potassium chloride tab er 8 meq (600 mg) 1 potassium chloride tab er 10 meq, 20 meq (1500 mg) (K- tab) 1 SODIUM FLUORIDE sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf), 0.5 mg f (from 1.1 mg naf), 1 mg f (from 2.2 mg naf) 1 • SODIUM FLUORIDE sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) A • SODIUM FLUORIDE sodium fluoride tab 0.5 mg f (from 1.1 mg naf), 1 mg f (from 2.2 mg naf) 4 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 62 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution WES-PHOS 250 NEUTRAL pot phos monobasic w/sod phos di & monobas tab 155-852-130mg 4 HEMATOLOGICAL AGENTS HEMATOPOIETIC AGENTS ARANESP ALBUMIN FREE darbepoetin alfa soln inj 25 mcg/ml, 40 mcg/ml, 60 mcg/ml, 100 mcg/ml, 200 mcg/ml 5 • ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 10 mcg/0.4ml, 25 mcg/0.42ml, 40 mcg/0.4ml, 60 mcg/0.3ml, 100 mcg/0.5ml, 150 mcg/0.3ml, 200 mcg/0.4ml, 300 mcg/0.6ml, 500 mcg/ml 5 • carbonyl iron susp 15 mg/1.25ml (elemental iron) A • CERDELGA eliglustat tartrate cap 84 mg (base equivalent) 5 • • • • cyanocobalamin inj 1000 mcg/ml 1 eltrombopag olamine powder pack for susp 25 mg (base equiv), 12.5 mg (base eq) (Promacta) 5 • • • eltrombopag olamine tab 12.5 mg (base equiv), 25 mg (base equiv), 50 mg (base equiv), 75 mg (base equiv) (Promacta) 5 • • • FERRETTS CHEWABLE IRON carbonyl iron chew tab 18 mg (elemental iron) A • ferrous sulfate soln 75 mg/ ml (15 mg/ml elemental fe), 220 mg/5ml (44 mg/5ml elemental fe) A • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ferrous sulfate soln 300 mg/5ml (60 mg/5ml elemental fe) A • folic acid cap 0.8 mg A • folic acid tab 400 mcg, 800 mcg A • folic acid tab 1 mg 1 glutamine (sickle cell) powd pack 5 gm (Endari) 5 • • HYDROXOCOBALAMIN hydroxocobalamin acetate inj 1000 mcg/ml (base equivalent) 4 IRON CHEWS PEDIATRIC carbonyl iron chew tab 15 mg (elemental iron) A • IRON UP polysaccharide iron complex liquid 15 mg/0.5ml (fe equiv) 3 MULPLETA lusutrombopag tab 3 mg 5 • • • NOVAFERRUM PEDIATRIC DROP polysaccharide iron complex liquid 15 mg/ml (fe equiv) 3 RETACRIT epoetin alfa-epbx inj 2000 unit/ml, 3000 unit/ ml, 4000 unit/ml, 10000 unit/ ml, 20000 unit/ml, 40000 unit/ml 5 • SIKLOS hydroxyurea tab 100 mg, 1000 mg 4 XOLREMDI mavorixafor cap 100 mg 6 • • • • ANTICOAGULANTS dabigatran etexilate mesylate cap 75 mg (etexilate base eq), 110 mg (etexilate base eq), 150 mg (etexilate base eq) (Pradaxa) 2 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 63 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ELIQUIS apixaban cap sprinkle 0.15 mg 3 • ELIQUIS apixaban tab for oral susp pack 3 x 0.5 mg (1.5 mg), 4 x 0.5 mg (2 mg) 3 • ELIQUIS apixaban tab for oral susp 0.5 mg 3 • ELIQUIS apixaban tab 2.5 mg, 5 mg 3 • ELIQUIS STARTER PACK apixaban tab starter pack 5 mg 3 • enoxaparin sodium inj soln pref syr 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml, 100 mg/ml, 120 mg/0.8ml, 150 mg/ml (Lovenox) 2 • enoxaparin sodium inj 300 mg/3ml (Lovenox) 2 • fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml, 10 mg/0.8ml (Arixtra) 2 • FRAGMIN dalteparin sodium soln prefilled syr 2500 unit/0.2ml, 5000 unit/0.2ml, 7500 unit/0.3ml, 10000 unit/ ml, 12500 unit/0.5ml, 15000 unit/0.6ml, 18000 unit/0.72ml 4 • FRAGMIN dalteparin sodium subcutaneous soln 10000 unit/4ml, 95000 unit/3.8ml 4 • HEPARIN SODIUM heparin sodium (porcine) pf inj 5000 unit/ml 4 heparin sodium (porcine) inj 1000 unit/ml, 5000 unit/ml, 10000 unit/ml, 20000 unit/ ml 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution heparin sodium (porcine) pf inj 1000 unit/ml, 5000 unit/0.5ml 2 PRADAXA dabigatran etexilate mesylate pellet pack 20 mg, 30 mg, 40 mg, 50 mg, 110 mg, 150 mg 4 • rivaroxaban for susp 1 mg/ ml (Xarelto) 2 • rivaroxaban tab 2.5 mg (Xarelto) 2 • warfarin sodium tab 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg, 10 mg 1 XARELTO rivaroxaban for susp 1 mg/ml 3 • XARELTO rivaroxaban tab 2.5 mg, 10 mg, 15 mg, 20 mg 3 • XARELTO STARTER PACK rivaroxaban tab starter therapy pack 15 mg & 20 mg 3 • HEMOSTATICS tranexamic acid tab 650 mg (Lysteda) 2 HEMATOLOGICAL AGENTS - MISC. ADVATE antihemophilic factor recomb (rahf-pfm) for inj 250 unit, 500 unit, 1000 unit, 1500 unit, 2000 unit, 3000 unit, 4000 unit 5 • • ADYNOVATE antihemophilic factor recomb pegylated for inj 250 unit, 500 unit, 750 unit, 1000 unit, 1500 unit, 2000 unit, 3000 unit 5 • • AFSTYLA antihemophilic fact rcmb single chain for inj kit 250 unit, 500 unit, 1000 unit, 1500 unit, 2000 unit, 2500 unit, 3000 unit 5 • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 64 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ALPHANATE antihemophilic factor/vwf (human) for inj 250 unit, 500 unit, 1000 unit, 1500 unit, 2000 unit 6 • • • ALPHANINE SD coagulation factor ix for inj 500 unit, 1000 unit, 1500 unit 6 • • ALPROLIX coagulation factor ix (recomb) (rfixfc) for inj 250 unit, 500 unit, 1000 unit, 2000 unit, 3000 unit, 4000 unit 6 • • • ALTUVIIIO antihemophilic fact rcmb fc-vwf-xten-ehtl for inj 250 unit, 500 unit, 1000 unit, 2000 unit, 3000 unit, 4000 unit 5 • • anagrelide hcl cap 0.5 mg (Agrylin) 2 anagrelide hcl cap 1 mg 2 ANDEMBRY garadacimab- gxii soln auto-injector 200 mg/1.2ml 5 • • • aspirin-dipyridamole cap er 12hr 25-200 mg 2 BENEFIX coagulation factor ix (recombinant) for inj kit 250 unit, 500 unit, 1000 unit, 2000 unit, 3000 unit 6 • • CABLIVI caplacizumab-yhdp for inj kit 11 mg 6 • • • cilostazol tab 50 mg, 100 mg 1 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) 1 COAGADEX coagulation factor x (human) for inj 250 unit, 500 unit 6 • • CORIFACT factor xiii concentrate (human) for inj kit 1000-1600 unit 6 • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution DAWNZERA donidalorsen sodium subcutaneous soln auto-inj 80 mg/0.8ml 5 • • • dipyridamole tab 25 mg, 50 mg, 75 mg 2 ELOCTATE antihemophilic factor rcmb (bdd-rfviiifc) for inj 250 unit, 500 unit, 750 unit, 1000 unit, 1500 unit, 2000 unit, 3000 unit, 4000 unit, 5000 unit, 6000 unit 5 • • EMPAVELI pegcetacoplan subcutaneous soln 1080 mg/20ml (54 mg/ml) 5 • • • • ESPEROCT antihemophilic factor recomb glycopeg-exei for inj 500 unit, 1000 unit, 1500 unit, 2000 unit, 3000 unit, 4000 unit 5 • • • FABHALTA iptacopan hcl cap 200 mg 5 • • • • FEIBA antiinhibitor coagulant complex for iv soln 500 unit, 1000 unit, 2500 unit 6 • FIBRYGA fibrinogen conc (human) inj approximately 1 gm (900-1300 mg) 6 • FIBRYGA fibrinogen concentrate (human) for iv soln 2 gm 6 • HAEGARDA c1 esterase inhibitor (human) for subcutaneous inj 2000 unit, 3000 unit 5 • • • • HEMLIBRA emicizumab- kxwh subcutaneous soln 12 mg/0.4ml (30 mg/ml) 6 • • • HEMLIBRA emicizumab-kxwh subcutaneous soln 30 mg/ ml, 60 mg/0.4ml (150 mg/ ml), 105 mg/0.7ml (150 mg/ ml), 150 mg/ml, 300 mg/2ml (150 mg/ml) 6 • • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 65 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution HEMOFIL M antihemophilic factor (human) for inj 250 unit, 500 unit, 1000 unit, 1700 unit 6 • • HUMATE-P antihemophilic factor/vwf (human) for inj 250-600 unit, 500-1200 unit, 1000-2400 unit 6 • • HYMPAVZI marstacimab-hncq subcutaneous soln auto-inj 150 mg/ml 6 • • • icatibant acetate subcutaneous soln pref syr 30 mg/3ml (Firazyr) 5 • • • • IDELVION coagulation factor ix (recomb) (rix-fp) for inj 250 unit, 500 unit, 1000 unit, 2000 unit, 3500 unit 6 • • IXINITY coagulation factor ix (recombinant) for inj 500 unit, 1000 unit, 1500 unit, 3000 unit 6 • • • JIVI antihemophil fact rcmb(bdd-rfviii peg-aucl) for inj 500 unit 5 • • JIVI antihemophil fact rcmb(bdd-rfviii peg-aucl)for inj 1000 unit, 2000 unit, 3000 unit, 4000 unit 5 • • KOATE antihemophilic factor (human) for inj 250 unit, 500 unit, 1000 unit 6 • • KOATE-DVI antihemophilic factor (human) for inj 1000 unit 6 • • KOVALTRY antihemophilic factor recomb (rahf-pfm) for inj 250 unit, 500 unit, 1000 unit, 2000 unit, 3000 unit 5 • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution NOVOEIGHT antihemophilic fact rcmb (bd trunc-rfviii) for inj 250 unit, 500 unit, 1000 unit, 1500 unit, 2000 unit, 3000 unit 5 • • NOVOSEVEN RT coagulation factor viia (recomb) for inj 1 mg (1000 mcg), 2 mg (2000 mcg), 5 mg (5000 mcg), 8 mg (8000 mcg) 6 • • • NUWIQ antihemophil fact rcmb (bdd-rfviii,sim) for inj kit 250 unit, 500 unit 6 • • • NUWIQ antihemophil fact rcmb(bdd-rfviii,sim) for inj kit 1000 unit, 1500 unit, 2000 unit, 2500 unit, 3000 unit, 4000 unit 6 • • • NUWIQ antihemophilic fact rcmb (bdd-rfviii,sim) for inj 1000 unit, 1500 unit, 2000 unit, 2500 unit, 3000 unit, 4000 unit 6 • • • NUWIQ antihemophilic factor rcmb (bdd-rfviii,sim) for inj 250 unit, 500 unit 6 • • • OBIZUR antihemophilic factor (recomb porc) rpfviii for inj 500 unit 6 • • ORLADEYO berotralstat hcl cap 110 mg, 150 mg 6 • • • • ORLADEYO berotralstat hcl pellet pack 72 mg, 96 mg, 108 mg, 132 mg 6 • • • pentoxifylline tab er 400 mg 2 prasugrel hcl tab 5 mg (base equiv), 10 mg (base equiv) (Effient) 2 PROFILNINE factor ix complex for inj 500 unit, 1000 unit, 1500 unit 6 • • PYRUKYND mitapivat sulfate tab 5 mg, 20 mg, 50 mg 5 • • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 66 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution PYRUKYND TAPER PACK mitapivat sulfate tab therapy pack 5 mg, 7 x 20 mg & 7 x 5 mg, 7 x 50 mg & 7 x 20 mg 5 • • • • REBINYN coagulation factor ix recomb glycopegylated for inj 500 unt, 1000 unt, 2000 unt, 3000 unt 6 • • • RECOMBINATE antihemophilic factor recomb (rfviii) for inj 220-400 unit, 401-800 unit, 801-1240 unit, 1241-1800 unit, 1801-2400 unit 6 • • RIASTAP fibrinogen conc (human) inj approximately 1 gm (900-1300 mg) 6 • • RIXUBIS coagulation factor ix (recombinant) for inj 250 unit, 500 unit, 1000 unit, 2000 unit, 3000 unit 6 • • SEVENFACT coagulation factor viia (recom)-jncw for inj 1 mg (1000 mcg), 2 mg (2000 mcg), 5 mg (5000 mcg) 6 • • • TAKHZYRO lanadelumab-flyo soln pref syringe 150 mg/ml, 300 mg/2ml (150 mg/ml) 5 • • • • TAVALISSE fostamatinib disodium tab 100 mg (base equivalent), 150 mg (base equivalent) 6 • • • • ticagrelor tab 60 mg, 90 mg (Brilinta) 2 TRETTEN coagulation factor xiii a-subunit for inj 2500 unit 6 • • VONVENDI von willebrand factor (recombinant) for inj 650 unit, 1300 unit 6 • • WILATE antihemophilic factor/ vwf (human) for inj 500-500 unit kit 6 • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution WILATE antihemophilic factor/vwf (human) for inj 1000-1000 unit kit 6 • • XYNTHA antihemophil fact rcmb (bdd-rfviii,mor) for inj kit 250 unit, 500 unit 6 • • XYNTHA antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 1000 unit, 2000 unit 6 • • XYNTHA SOLOFUSE antihemophil fact rcmb (bdd-rfviii,mor) for inj kit 250 unit, 500 unit 6 • • XYNTHA SOLOFUSE antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 1000 unit, 2000 unit, 3000 unit 6 • • ZONTIVITY vorapaxar sulfate tab 2.08 mg (base equivalent) 4 TOPICAL PRODUCTS OPHTHALMIC AGENTS ALOCRIL nedocromil sodium ophth soln 2% 4 APRACLONIDINE apraclonidine hcl ophth soln 0.5% (base equivalent) 4 ATROPINE SULFATE atropine sulfate ophth soln 1% 4 atropine sulfate ophth soln 1% (Atropine sulfate) 2 AZASITE azithromycin ophth soln 1% 4 azelastine hcl ophth soln 0.05% 1 BACITRACIN/POLYMYXIN B bacitracin-polymyxin b ophth oint 4 bepotastine besilate ophth soln 1.5% (Bepreve) 2

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 67 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution BESIVANCE besifloxacin hcl ophth susp 0.6% (base equiv) 3 BETAXOLOL HCL betaxolol hcl ophth soln 0.5% 4 bimatoprost ophth soln 0.01% (Lumigan) 2 brimonidine tartrate ophth soln 0.2% 1 brimonidine tartrate-timolol maleate ophth soln 0.2-0.5% (Combigan) 2 brinzolamide ophth susp 1% (Azopt) 2 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) 2 CARTEOLOL HCL carteolol hcl ophth soln 1% 4 ciprofloxacin hcl ophth soln 0.3% (base equivalent) (Ciloxan) 1 CROMOLYN SODIUM cromolyn sodium ophth soln 4% 4 CYCLOMYDRIL cyclopentolate w/ phenylephrine ophth soln 0.2-1% 4 cyclopentolate hcl ophth soln 1% (Cyclogyl) 1 CYSTADROPS cysteamine hcl ophth soln 0.37% (base equivalent) 6 • • CYSTARAN cysteamine hcl ophth soln 0.44% (base equivalent) 6 • • DEXAMETHASONE SODIUM PHOS dexamethasone sodium phosphate ophth soln 0.1% 4 diclofenac sodium ophth soln 0.1% 1 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution difluprednate ophth emulsion 0.05% (Durezol) 2 dorzolamide hcl ophth soln 2% (Trusopt) 1 dorzolamide hcl-timolol maleate ophth soln 2-0.5% (Cosopt) 1 epinastine hcl ophth soln 0.05% 2 erythromycin ophth oint 5 mg/gm 1 fluorometholone ophth susp 0.1% (Fml liquifilm) 2 FLURBIPROFEN SODIUM flurbiprofen sodium ophth soln 0.03% 4 gatifloxacin ophth soln 0.5% (Zymaxid) 2 gentamicin sulfate ophth soln 0.3% 1 ketorolac tromethamine ophth soln 0.4% (Acular ls) 2 ketorolac tromethamine ophth soln 0.5% (Acular) 1 latanoprost ophth soln 0.005% (Xalatan) 1 • LEVOBUNOLOL HCL levobunolol hcl ophth soln 0.5% 4 LOTEMAX loteprednol etabonate ophth oint 0.5% 4 LOTEMAX SM loteprednol etabonate ophth gel 0.38% 4 loteprednol etabonate ophth gel 0.5% (Lotemax) 2 loteprednol etabonate ophth susp 0.5% (Lotemax) 2 LUMIGAN bimatoprost ophth soln 0.01% 4 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 68 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution moxifloxacin hcl ophth soln 0.5% (base equiv) (Vigamox) 2 NATACYN natamycin ophth susp 5% 3 neomycin-polymyxin- dexamethasone ophth oint 0.1% (Maxitrol) 1 neomycin-polymyxin- dexamethasone ophth susp 0.1% (Maxitrol) 1 NEOMYCIN/POLYMYXIN/ BACITR bacitracin- polymyxin-neomycin-hc ophth oint 1% 4 NEOMYCIN/POLYMYXIN/ BACITR neomycin- bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 4 NEOMYCIN/POLYMYXIN/ GRAMIC neomycin- polymy-gramicid op sol 1.75-10000-0.025mg-unt- mg/ml 4 ofloxacin ophth soln 0.3% (Ocuflox) 1 OXERVATE cenegermin-bkbj ophth soln 0.002% (20 mcg/ ml) 6 • • • • phenylephrine hcl ophth soln 2.5%, 10% 2 pilocarpine hcl ophth soln 1%, 2%, 4% (Isopto carpine) 2 polymyxin b-trimethoprim ophth soln 10000 unit/ ml-0.1% (Polytrim) 1 prednisolone acetate ophth susp 1% (Pred forte) 2 RESTASIS cyclosporine (ophth) emulsion 0.05% (pf) 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution RHOPRESSA netarsudil dimesylate ophth soln 0.02% 4 SIMBRINZA brinzolamide- brimonidine tartrate ophth susp 1-0.2% 3 SULFACETAMIDE SODIUM sulfacetamide sodium ophth soln 10% 4 SULFACETAMIDE SODIUM/ PRED sulfacetamide sodium- prednisolone ophth soln 10-0.23(0.25)% 4 tafluprost preservative free (pf) ophth soln 0.0015% (Zioptan) 2 • TETRACAINE HCL tetracaine hcl ophth soln 0.5% 4 tetracaine hcl ophth soln 0.5% 2 timolol maleate ophth soln 0.25%, 0.5% (Timoptic) 1 TOBRADEX tobramycin- dexamethasone ophth oint 0.3-0.1% 4 tobramycin ophth soln 0.3% (Tobrex) 1 tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex) 2 travoprost ophth soln 0.004% (benzalkonium free) (bak free) (Travatan z) 2 • TRIFLURIDINE trifluridine ophth soln 1% 3 XIIDRA lifitegrast ophth soln 5% 4 ZERVIATE cetirizine hcl ophth soln 0.24% (base equiv) 4 OTIC AGENTS acetic acid otic soln 2% 2

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 69 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ciprofloxacin hcl otic soln 0.2% (base equivalent) (Cetraxal) 2 ciprofloxacin- dexamethasone otic susp 0.3-0.1% (Ciprodex) 2 CORTISPORIN-TC neomycin- colistin-hc-thonzonium otic susp 3.3-3-10-0.5 mg/ml 4 fluocinolone acetonide (otic) oil 0.01% (Dermotic) 2 hydrocortisone w/ acetic acid otic soln 1-2% 2 neomycin-polymyxin-hc otic soln 1% 2 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ ml-1% 2 ofloxacin otic soln 0.3% 2 MOUTH/THROAT/DENTAL AGENTS cevimeline hcl cap 30 mg (Evoxac) 2 chlorhexidine gluconate soln 0.12% (Peridex) 1 CLINPRO 5000 sodium fluoride paste 1.1% 1 • clotrimazole troche 10 mg 2 DENTA 5000 PLUS sodium fluoride cream 1.1% 1 • DENTAGEL sodium fluoride gel 1.1% (0.5% f) 1 • EASYGEL stannous fluoride gel 0.4% A • FLUORIDEX DAILY DEFENSE sodium fluoride paste 1.1% 1 • FLUORIDEX DAILY RENEWAL stannous fluoride conc 0.63% 2 • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution FLUORIDEX ENHANCED WHITEN sodium fluoride paste 1.1% 1 • FLUORIDEX SENSITIVITY REL sodium fluoride- potassium nitrate gel 1.1-5% 3 • FLUORIMAX 5000 sodium fluoride paste 1.1% 1 • JUST RIGHT 5000 sodium fluoride paste 1.1% 1 • lidocaine hcl viscous soln 2% 1 nystatin susp 100000 unit/ml 1 ORAVIG miconazole buccal tab 50 mg (mouth-throat) 4 PARODONTAX stannous fluoride paste 0.454% A • PERIOMED stannous fluoride conc 0.63% A • pilocarpine hcl tab 5 mg, 7.5 mg (Salagen) 2 SENSODYNE COMPLETE PROTEC stannous fluoride paste 0.454% A • SENSODYNE RAPID RELIEF stannous fluoride paste 0.454% A • SENSODYNE REPAIR & PROTEC stannous fluoride paste 0.454% A • SENSODYNE SENSITIVITY & G stannous fluoride paste 0.454% A • SENSODYNE SENSITIVITY GUM stannous fluoride paste 0.454% A • SF sodium fluoride gel 1.1% (0.5% f) 1 • SF 5000 PLUS sodium fluoride cream 1.1% 1 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 70 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution SODIUM FLUORIDE sodium fluoride cream 1.1% 1 • SODIUM FLUORIDE sodium fluoride gel 1.1% (0.5% f) 1 • SODIUM FLUORIDE 5000 PLUS sodium fluoride cream 1.1% 1 • SODIUM FLUORIDE 5000 PPM sodium fluoride gel 1.1% (0.5% f) 1 • SODIUM FLUORIDE 5000 PPM sodium fluoride paste 1.1% 1 • SODIUM FLUORIDE 5000 PPM sodium fluoride- potassium nitrate gel 1.1-5% 3 • SODIUM FLUORIDE/ POTASSIUM sodium fluoride-potassium nitrate gel 1.1-5% 3 • stannous fluoride gel 0.4% A • triamcinolone acetonide dental paste 0.1% 2 ANORECTAL AGENTS ANALPRAM HC hydrocortisone acetate w/ pramoxine perianal cream 2.5-1% 4 ANALPRAM HC hydrocortisone acetate w/ pramoxine perianal lotn 2.5-1% 4 ANUCORT-HC hydrocortisone acetate suppos 25 mg 2 ANUSOL-HC hydrocortisone acetate suppos 25 mg 2 CORTIFOAM hydrocortisone acetate perianal foam 10% (90 mg/dose) 3 HEMMOREX- HC hydrocortisone acetate suppos 25 mg 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution HYDROCORTISONE hydrocortisone perianal cream 1% 4 HYDROCORTISONE ACETATE hydrocortisone acetate suppos 25 mg 2 hydrocortisone enema 100 mg/60ml (Cortenema) 2 hydrocortisone perianal cream 2.5% (Anusol-hc) 2 nitroglycerin oint 0.4% (Rectiv) 2 PROCTOCORT hydrocortisone perianal cream 1% 4 PROCTOFOAM HC hydrocortisone acetate w/ pramoxine perianal foam 1-1% 4 DERMATOLOGICALS acitretin cap 10 mg, 25 mg (Soriatane) 2 acitretin cap 17.5 mg 2 acyclovir oint 5% (Zovirax) 2 ADBRY tralokinumab-ldrm subcutaneous soln auto- injector 300 mg/2ml 5 • • • • ADBRY tralokinumab-ldrm subcutaneous soln prefilled syr 150 mg/ml 5 • • • • ALCLOMETASONE DIPROPIONAT alclometasone dipropionate oint 0.05% 4 • alclometasone dipropionate cream 0.05% 2 • azelaic acid gel 15% (Finacea) 2 BETAMETHASONE DIPROPIONAT betamethasone dipropionate augmented gel 0.05% 4 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 71 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution betamethasone dipropionate augmented cream 0.05% (Diprolene af) 1 • betamethasone dipropionate augmented lotion 0.05% 2 • betamethasone dipropionate augmented oint 0.05% (Diprolene) 2 • betamethasone dipropionate cream 0.05% 2 • betamethasone dipropionate lotion 0.05% 2 • betamethasone dipropionate oint 0.05% 2 • BETAMETHASONE VALERATE betamethasone valerate lotion 0.1% (base equivalent) 4 • betamethasone valerate cream 0.1% (base equivalent) 2 • betamethasone valerate oint 0.1% (base equivalent) 2 • BIMZELX bimekizumab-bkzx subcutaneous soln auto- injector 160 mg/ml, 320 mg/2ml 6 • • • BIMZELX bimekizumab-bkzx subcutaneous soln prefilled syr 160 mg/ml, 320 mg/2ml 6 • • • brimonidine tartrate gel 0.33% (base equivalent) (Mirvaso) 2 CALCIPOTRIENE calcipotriene soln 0.005% (50 mcg/ml) 4 calcipotriene cream 0.005% (Dovonex) 2 CALCITRIOL calcitriol oint 3 mcg/gm 4 CIBINQO abrocitinib tab 50 mg, 100 mg, 200 mg 5 • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution ciclopirox gel 0.77% 2 ciclopirox olamine cream 0.77% (base equiv) (Loprox) 1 ciclopirox olamine susp 0.77% (base equiv) 2 ciclopirox shampoo 1% (Loprox shampoo) 2 ciclopirox solution 8% (Penlac Nail Lacquer) 2 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% 2 clindamycin phosphate gel 1% (twice-daily) 2 clindamycin phosphate lotion 1% (Cleocin-t) 2 clindamycin phosphate soln 1% 2 clindamycin phosphate swab 1% 2 clobetasol propionate cream 0.05% (Temovate) 2 • clobetasol propionate emollient base cream 0.05% 2 • clobetasol propionate foam 0.05% 2 • clobetasol propionate gel 0.05% 2 • clobetasol propionate oint 0.05% (Temovate) 2 • clobetasol propionate soln 0.05% 2 • CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1% 4 • clotrimazole w/ betamethasone cream 1-0.05% 2

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 72 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution COSENTYX secukinumab subcutaneous pref syr 150 mg/ml (300 mg dose) 5 • • • • COSENTYX secukinumab subcutaneous soln prefilled syringe 75 mg/0.5ml, 150 mg/ml 5 • • • • COSENTYX SENSOREADY PEN secukinumab subcutaneous auto-inj 150 mg/ml (300 mg dose) 5 • • • • COSENTYX SENSOREADY PEN secukinumab subcutaneous soln auto- injector 150 mg/ml 5 • • • • COSENTYX UNOREADY secukinumab subcutaneous soln auto- injector 300 mg/2ml 5 • • • • CROTAN crotamiton lotion 10% 4 desonide cream 0.05% (Desowen) 2 • desonide oint 0.05% 2 • desoximetasone cream 0.25% (Topicort) 2 • desoximetasone oint 0.25% (Topicort) 2 • diclofenac sodium soln 1.5% 2 • DIFLORASONE DIACETATE diflorasone diacetate cream 0.05% 4 • DUPIXENT dupilumab subcutaneous soln auto- injector 200 mg/1.14ml, 300 mg/2ml 5 • • • DUPIXENT dupilumab subcutaneous soln prefilled syringe 200 mg/1.14ml, 300 mg/2ml 5 • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution EBGLYSS lebrikizumab-lbkz solution prefilled syringe 250 mg/2ml 5 • • • • EBGLYSS lebrikizumab-lbkz subcutaneous soln auto- inject 250 mg/2ml 5 • • • • econazole nitrate cream 1% 2 ENSTILAR calcipotriene- betamethasone dipropionate foam 0.005-0.064% 4 ERY erythromycin pads 2% 4 ERYTHROMYCIN erythromycin gel 2% 4 erythromycin soln 2% 2 EXELDERM sulconazole nitrate cream 1% 4 EXELDERM sulconazole nitrate solution 1% 4 FILSUVEZ birch triterpenes gel 10% 6 • • fluocinolone acetonide cream 0.01% 2 • fluocinolone acetonide oil 0.01% (body oil) (Derma- smoothe/fs bod) 2 • fluocinolone acetonide oil 0.01% (scalp oil) (Derma- smoothe/fs sca) 2 • fluocinolone acetonide oint 0.025% (Synalar) 2 • fluocinolone acetonide soln 0.01% (Synalar) 2 • fluocinonide cream 0.05% 2 • fluocinonide cream 0.1% (Vanos) 2 • fluocinonide emulsified base cream 0.05% 2 • fluocinonide oint 0.05% 2 • fluocinonide soln 0.05% 2 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 73 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution FLUOROURACIL fluorouracil soln 2% 4 fluorouracil cream 5% (Efudex) 2 fluorouracil soln 5% 2 fluticasone propionate cream 0.05% 2 • fluticasone propionate oint 0.005% 2 • gentamicin sulfate cream 0.1% 2 gentamicin sulfate oint 0.1% 2 halobetasol propionate cream 0.05% 2 • HYDROCORTISONE hydrocortisone lotion 2.5% 4 • HYDROCORTISONE BUTYRATE hydrocortisone butyrate cream 0.1% 4 • hydrocortisone cream 2.5% 1 • hydrocortisone oint 2.5% 1 • hydrocortisone valerate cream 0.2% 2 • HYFTOR sirolimus gel 0.2% 4 • imiquimod cream 5% (Aldara) 2 isotretinoin cap 10 mg, 20 mg, 30 mg, 40 mg (Absorica) 2 ivermectin cream 1% (Soolantra) 2 ketoconazole cream 2% 2 ketoconazole shampoo 2% 1 lactic acid (ammonium lactate) cream 12% 2 lactic acid (ammonium lactate) lotion 12% 1 lidocaine hcl soln 4% 2 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution LIDOCAINE HYDROCHLORIDE J lidocaine hcl urethral/ mucosal gel 2% 4 lidocaine oint 5% 1 lidocaine patch 5% (Lidoderm) 2 lidocaine-prilocaine cream 2.5-2.5% 1 malathion lotion 0.5% (Ovide) 2 METHOXSALEN methoxsalen rapid cap 10 mg 4 metronidazole cream 0.75% (Metrocream) 2 metronidazole gel 0.75% 2 metronidazole gel 1% (Metrogel) 2 mometasone furoate cream 0.1% 2 • mometasone furoate oint 0.1% 1 • mometasone furoate solution 0.1% (lotion) 2 • mupirocin oint 2% 1 naftifine hcl cream 2% (Naftifine hydrochlor) 2 NAFTIFINE HYDROCHLORIDE naftifine hcl cream 1% 4 NATROBA spinosad susp 0.9% 4 NEMLUVIO nemolizumab- ilto for subcutaneous auto- injector 30 mg 5 • • • • nystatin cream 100000 unit/ gm 1 nystatin oint 100000 unit/gm 1 nystatin topical powder 100000 unit/gm 2

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 74 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution nystatin-triamcinolone cream 100000-0.1 unit/gm- % 2 nystatin-triamcinolone oint 100000-0.1 unit/gm-% 1 oxiconazole nitrate cream 1% (Oxistat) 2 permethrin cream 5% (Elimite) 2 pimecrolimus cream 1% (Elidel) 2 • PODOFILOX podofilox soln 0.5% 4 SANTYL collagenase oint 250 unit/gm 4 SELARSDI ustekinumab-aekn soln prefilled syringe 45 mg/0.5ml, 90 mg/ml 5 • • • SELARSDI ustekinumab- aekn subcutaneous soln 45 mg/0.5ml 5 • • • SELENIUM SULFIDE selenium sulfide lotion 2.5% 4 silver sulfadiazine cream 1% (Silvadene) 1 SKYRIZI risankizumab-rzaa soln prefilled syringe 150 mg/ml 5 • • • SKYRIZI PEN risankizumab- rzaa soln auto-injector 150 mg/ml 5 • • • SOTYKTU deucravacitinib tab 6 mg 5 • • • SPEVIGO spesolimab-sbzo subcutaneous soln pref syr 150 mg/ml, 300 mg/2ml 6 • • • SPINOSAD spinosad susp 0.9% 4 STEQEYMA ustekinumab- stba soln prefilled syringe 45 mg/0.5ml, 90 mg/ml 5 • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution SULCONAZOLE NITRATE sulconazole nitrate cream 1% 4 SULCONAZOLE NITRATE sulconazole nitrate solution 1% 4 sulfacetamide sodium lotion 10% (acne) (Klaron) 2 SULFAMYLON mafenide acetate cream 85 mg/gm 4 tacrolimus oint 0.03%, 0.1% (Protopic) 2 • tazarotene cream 0.1% (Tazorac) 2 • tazarotene gel 0.05% (Tazorac) 2 • TREMFYA guselkumab soln pen-injector 100 mg/ml 5 • • • TREMFYA guselkumab soln prefilled syringe 100 mg/ml 5 • • • TREMFYA PEN guselkumab soln auto-injector 100 mg/ml 5 • • • tretinoin cream 0.025%, 0.05%, 0.1% (Retin-a) 2 • tretinoin gel 0.01% (Retin-a) 2 • TRIAMCINOLONE ACETONIDE triamcinolone acetonide lotion 0.025% 4 • triamcinolone acetonide cream 0.025%, 0.1%, 0.5% 1 • triamcinolone acetonide lotion 0.1% 2 • triamcinolone acetonide oint 0.025%, 0.1%, 0.5% 1 • VALCHLOR mechlorethamine hcl gel 0.016% (base equivalent) 5 • • YESINTEK ustekinumab-kfce soln prefilled syringe 45 mg/0.5ml, 90 mg/ml 5 • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 75 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution YESINTEK ustekinumab- kfce subcutaneous soln 45 mg/0.5ml 5 • • • ZELSUVMI berdazimer sodium gel 10.3% 4 • • MISCELLANEOUS PRODUCTS ANTIDOTES CHEMET succimer cap 100 mg 3 deferiprone tab 500 mg, 1000 mg (Ferriprox) 5 • KLOXXADO naloxone hcl nasal spray 8 mg/0.1ml 3 naloxone hcl inj 0.4 mg/ml 1 naloxone hcl inj 4 mg/10ml 2 naloxone hcl nasal spray 4 mg/0.1ml (Narcan) 2 naloxone hcl soln prefilled syringe 0.4 mg/ml, 2 mg/2ml 2 NALOXONE HYDROCHLORIDE naloxone hcl soln cartridge 0.4 mg/ml 4 naltrexone hcl tab 50 mg 2 OPVEE nalmefene hcl nasal spray 2.7 mg/0.1ml (base equiv) 3 REXTOVY naloxone hcl nasal spray 4 mg/0.25ml 3 RIVIVE naloxone hcl nasal spray 3 mg/0.1ml 3 ZURNAI nalmefene hcl soln auto-injector 1.5 mg/0.5ml (base equiv) 3 DIAGNOSTIC PRODUCTS CONTOUR BLOOD GLUCOSE TES glucose blood test strip 3 • CONTOUR NEXT BLOOD GLUCOS glucose blood test strip 3 • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution CONTOUR PLUS BLOOD GLUCOS glucose blood test strip 3 • FREESTYLE PRECISION NEO B glucose blood test strip 3 • KETONE BLOOD TEST STRIPS - VARIOUS 4 OPTIUMEZ TEST STRIPS glucose blood test strip 3 • PRECISION XTRA BLOOD GLUC glucose blood test strip 3 • URINE TEST STRIPS - VARIOUS 4 MEDICAL DEVICES CAYA diaphragm arc-spring A • CONDOMS-MALE - VARIOUS A • CONTOUR BLOOD GLUCOSE MON blood glucose monitoring devices 3 CONTOUR NEXT BLOOD GLUCOS blood glucose monitoring kit w/ device 3 CONTOUR NEXT EZ BLOOD GLU blood glucose monitoring kit w/ device 3 CONTOUR NEXT GEN BLOOD GL blood glucose monitoring kit w/ device 3 CONTOUR NEXT LINK BLOOD G blood glucose monitoring kit w/ device 3 CONTOUR NEXT LINK WIRELES blood glucose monitoring kit w/ device 3 CONTOUR NEXT ONE BLOOD GL blood glucose monitoring kit w/ device 3

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 76 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution CONTOUR NEXT ONE BLOOD GL blood glucose monitoring kit 3 CONTOUR PLUS BLUE BLOOD G blood glucose monitoring kit w/ device 3 DEXCOM G6 RECEIVER continuous glucose system receiver 3 • • DEXCOM G6 SENSOR continuous glucose system sensor 3 • • DEXCOM G6 TRANSMITTER continuous glucose system transmitter 3 • • DEXCOM G7 RECEIVER continuous glucose system receiver 3 • • DEXCOM G7 SENSOR continuous glucose system sensor 3 • • DEXCOM G7 15 DAY SENSOR continuous glucose system sensor 3 • • FC2 FEMALE CONDOM condoms - female A • FEMCAP cervical cap 22 mm, 26 mm, 30 mm A • FREESTYLE LIBRE 14 DAY/ RE continuous glucose system receiver 3 • • FREESTYLE LIBRE 14 DAY/ SE continuous glucose system sensor 3 • • FREESTYLE LIBRE 2 PLUS/ SE continuous glucose system sensor 3 • • FREESTYLE LIBRE 2/ READER/ continuous glucose system receiver 3 • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution FREESTYLE LIBRE 2/ SENSOR/ continuous glucose system sensor 3 • • FREESTYLE LIBRE 3 PLUS/ SE continuous glucose system sensor 3 • • FREESTYLE LIBRE 3/ READER/ continuous glucose system receiver 3 • • FREESTYLE LIBRE 3/ SENSOR/ continuous glucose system sensor 3 • • FREESTYLE LIBRE/READER/ FL continuous glucose system receiver 3 • • FREESTYLE PRECISION NEO B blood glucose monitoring kit w/ device 3 INSULIN PEN NEEDLES - VARIOUS 3 INSULIN SYRINGES - VARIOUS 3 LANCETS - VARIOUS 3 OMNIFLEX DIAPHRAGM diaphragms A • OMNIPOD DASH PODS (GEN 4) insulin infusion disposable pump reservoir 3 • OMNIPOD 5 DEXCOM G7G6 INT insulin infusion disposable pump kit 3 • OMNIPOD 5 DEXCOM G7G6 POD insulin infusion disposable pump reservoir 3 • OMNIPOD 5 LIBRE2 PLUS G6 insulin infusion disposable pump kit 3 • OMNIPOD 5 LIBRE2 PLUS G6 insulin infusion disposable pump reservoir 3 •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 77 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 60 mm, 65 mm, 70 mm, 75 mm, 80 mm, 85 mm, 90 mm, 95 mm A • ASSORTED CLASSES ASTAGRAF XL tacrolimus cap er 24hr 0.5 mg, 1 mg, 5 mg 4 azathioprine tab 50 mg (Imuran) 2 azathioprine tab 75 mg, 100 mg 2 BENLYSTA belimumab subcutaneous solution auto- injector 200 mg/ml 6 • • • • BENLYSTA belimumab subcutaneous solution prefilled syringe 200 mg/ml 6 • • • • cyclosporine cap 25 mg, 100 mg (Sandimmune) 2 cyclosporine modified cap 25 mg, 100 mg (Neoral) 2 cyclosporine modified cap 50 mg 2 cyclosporine modified oral soln 100 mg/ml (Neoral) 2 ENSPRYNG satralizumab- mwge subcutaneous soln pref syringe 120 mg/ml 6 • • • • ENVARSUS XR tacrolimus tab er 24hr 0.75 mg, 1 mg, 4 mg 4 everolimus tab 0.25 mg, 0.5 mg, 0.75 mg, 1 mg (Zortress) 2 JOENJA leniolisib phosphate tab 70 mg 6 • • lenalidomide caps 2.5 mg (Revlimid) 5 • • • lenalidomide cap 5 mg, 10 mg, 15 mg, 20 mg, 25 mg (Revlimid) 5 • • • Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution LOKELMA sodium zirconium cyclosilicate for susp packet 5 gm, 10 gm 3 LUPKYNIS voclosporin cap 7.9 mg 6 • • • • mycophenolate mofetil cap 250 mg (Cellcept) 2 mycophenolate mofetil for oral susp 200 mg/ml (Cellcept) 2 mycophenolate mofetil tab 500 mg (Cellcept) 2 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv), 360 mg (mycophenolic acid equiv) (Myfortic) 2 MYHIBBIN mycophenolate mofetil oral susp 200 mg/ml 3 NEORAL cyclosporine modified cap 25 mg, 100 mg 4 NEORAL cyclosporine modified oral soln 100 mg/ml 4 penicillamine tab 250 mg (Depen titratabs) 5 • PROGRAF tacrolimus cap 0.5 mg, 1 mg, 5 mg 4 PROGRAF tacrolimus packet for susp 0.2 mg, 1 mg 4 REZUROCK belumosudil mesylate tab 200 mg 6 • • • • RHAPSIDO remibrutinib tab 25 mg 5 • • • SANDIMMUNE cyclosporine cap 25 mg, 100 mg 4 sirolimus oral soln 1 mg/ml (Rapamune) 2 sirolimus tab 0.5 mg, 1 mg, 2 mg (Rapamune) 2 sodium polystyrene sulfonate powder 2

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 78 Drug Name Drug Tier Prior Approval Step Therapy Dispensing Limits Specialty ACA Limited Distribution sodium polystyrene sulfonate susp 15 gm/60ml 2 SPS sodium polystyrene sulfonate rectal susp 30 gm/120ml 4 tacrolimus cap 0.5 mg, 1 mg, 5 mg (Prograf) 2 THALOMID thalidomide cap 50 mg, 100 mg 5 • • • • trientine hcl cap 250 mg (Syprine) 5 • VIJOICE alpelisib (pros) oral granules packet 50 mg 6 • VIJOICE alpelisib (pros) pak 250 mg daily dose (200 mg & 50 mg tabs) 6 • VIJOICE alpelisib (pros) tab therapy pack 50 mg daily dose, 125 mg daily dose 6 • VYVGART HYTRULO efgartigimod alf-hyalur-qvfc pref syr 1000-10000 mg-unit/5ml 6 • • • • ZOKINVY lonafarnib cap 50 mg, 75 mg 5 • • • •

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 79 INDEX A abacavir sulfate-lamivudine tab 600-300 mg (Epzicom)......................................................................... 3 abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen).............................................................................3 abacavir sulfate tab 300 mg (base equiv) (Ziagen)........3 abiraterone acetate tab 250 mg, 500 mg (Zytiga).........11 ABRYSVO.............................................................................8 acamprosate calcium tab delayed release 333 mg......48 acarbose tab 25 mg, 50 mg, 100 mg (Precose)............21 acebutolol hcl cap 200 mg, 400 mg...............................27 ACETAMINOPHEN/CODEINE.......................................... 51 acetaminophen w/ codeine tab 300-30 mg................... 51 acetaminophen w/ codeine tab 300-60 mg................... 51 acetaminophen w/ codeine tab 300-15 mg (Tylenol/ codeine)..........................................................................51 acetazolamide cap er 12hr 500 mg................................31 acetazolamide tab 125 mg..............................................31 acetazolamide tab 250 mg..............................................31 acetic acid otic soln 2%..................................................68 acetylcysteine inhal soln 10%, 20%.............................. 34 acitretin cap 17.5 mg.......................................................70 acitretin cap 10 mg, 25 mg (Soriatane).........................70 ACTHAR............................................................................. 25 ACTHIB.................................................................................8 ACTIMMUNE......................................................................11 acyclovir cap 200 mg........................................................ 3 acyclovir oint 5% (Zovirax).............................................70 acyclovir susp 200 mg/5ml (Zovirax).............................. 3 acyclovir tab 400 mg, 800 mg.......................................... 3 ADACEL..............................................................................10 ADALIMUMAB-AATY CD/UC/HS...................................... 53 ADALIMUMAB-AATY 1-PEN KIT...................................... 53 ADALIMUMAB-AATY 2-PEN KIT...................................... 53 ADALIMUMAB-AATY 2-SYRINGE.................................... 53 ADALIMUMAB-ADAZ.........................................................53 ADBRY................................................................................70 adefovir dipivoxil tab 10 mg (Hepsera)...........................3 ADEMPAS.......................................................................... 33 ADVAIR HFA...................................................................... 35 ADVATE.............................................................................. 63 ADYNOVATE......................................................................63 AFLURIA 2025-2026............................................................8 AFSTYLA............................................................................63 AIMOVIG............................................................................ 55 AJOVY................................................................................ 55 AKEEGA............................................................................. 11 albendazole tab 200 mg (Albenza).................................. 7 albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) (Proventil hfa)....................................................35 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).........35 albuterol sulfate soln nebu 0.5% (5 mg/ml), 0.63 mg/3ml (base equiv), 1.25 mg/3ml (base equiv)........35 albuterol sulfate syrup 2 mg/5ml...................................35 albuterol sulfate tab 2 mg, 4 mg....................................35 ALCLOMETASONE DIPROPIONAT................................. 70 alclometasone dipropionate cream 0.05%....................70 ALECENSA.........................................................................11 alendronate sodium tab 10 mg, 35 mg......................... 25 alendronate sodium tab 70 mg (Fosamax)...................25 alfuzosin hcl tab er 24hr 10 mg (Uroxatral)..................41 allopurinol tab 100 mg, 300 mg (Zyloprim)...................56 ALOCRIL............................................................................ 66 alosetron hcl tab 0.5 mg (base equiv), 1 mg (base equiv) (Lotronex)...........................................................39 ALPHANATE.......................................................................64 ALPHANINE SD.................................................................64 alprazolam tab er 24hr 0.5 mg, 1 mg, 3 mg (Xanax xr).................................................................................... 42 alprazolam tab er 24hr 2 mg (Xanax xr)........................42 alprazolam tab 0.25 mg, 0.5 mg, 1 mg, 2 mg (Xanax)............................................................................42 ALPROLIX.......................................................................... 64 ALTUVIIIO...........................................................................64 ALUNBRIG......................................................................... 11 ALYFTREK......................................................................... 37 amantadine hcl cap 100 mg........................................... 59 amantadine hcl soln 50 mg/5ml.....................................59 ambrisentan tab 5 mg, 10 mg (Letairis)........................33 AMILORIDE/HYDROCHLOROTHIA................................. 31 amiloride hcl tab 5 mg.................................................... 31 amiodarone hcl tab 100 mg............................................29 amiodarone hcl tab 200 mg............................................29 amitriptyline hcl tab 150 mg...........................................42 amitriptyline hcl tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg................................................................................... 42 amlodipine besylate-benazepril hcl cap 2.5-10 mg, 5-40 mg...........................................................................29 amlodipine besylate-benazepril hcl cap 5-10 mg, 5-20 mg, 10-20 mg, 10-40 mg (Lotrel).................................29 amlodipine besylate-olmesartan medoxomil tab 5-20 mg, 5-40 mg, 10-20 mg, 10-40 mg (Azor)...................29 amlodipine besylate tab 2.5 mg (base equivalent), 5 mg (base equivalent), 10 mg (base equivalent) (Norvasc)........................................................................28 amlodipine besylate-valsartan tab 5-160 mg, 5-320 mg, 10-160 mg, 10-320 mg (Exforge)......................... 29 amoxapine tab 25 mg......................................................42 amoxapine tab 50 mg, 100 mg, 150 mg........................ 42 AMOXICILLIN.......................................................................1 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml.............................................................................. 1 amoxicillin & k clavulanate for susp 400-57 mg/5ml..... 1 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin)..................................................................... 1

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 80 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)........................................................ 1 amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg......................................................................................1 amoxicillin & k clavulanate tab 250-125 mg...................1 amoxicillin & k clavulanate tab 875-125 mg...................1 amoxicillin & k clavulanate tab 500-125 mg (Augmentin)..................................................................... 1 amoxicillin (trihydrate) cap 250 mg, 500 mg.................. 1 amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml................................. 1 amoxicillin (trihydrate) tab 500 mg, 875 mg................... 1 amphetamine-dextroamphetamine cap er 24hr 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg (Adderall xr).................................................................................... 46 amphetamine-dextroamphetamine tab 7.5 mg, 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg (Adderall).................. 46 amphetamine-dextroamphetamine tab 5 mg (Adderall)........................................................................46 ampicillin cap 500 mg....................................................... 1 anagrelide hcl cap 1 mg................................................. 64 anagrelide hcl cap 0.5 mg (Agrylin).............................. 64 ANALPRAM HC................................................................. 70 anastrozole tab 1 mg (Arimidex)................................... 11 ANDEMBRY....................................................................... 64 ANGELIQ............................................................................18 ANORO ELLIPTA...............................................................35 ANUCORT-HC....................................................................70 ANUSOL-HC.......................................................................70 APOKYN.............................................................................59 apomorphine hcl soln cartridge 30 mg/3ml (Apokyn).........................................................................59 APRACLONIDINE.............................................................. 66 aprepitant capsule 40 mg, 125 mg................................ 38 aprepitant capsule 80 mg (Emend)............................... 38 aprepitant capsule therapy pack 80 & 125 mg (Emend tripack)............................................................................38 APRETUDE.......................................................................... 3 APTIOM.............................................................................. 56 APTIVUS...............................................................................3 AQNEURSA........................................................................48 ARANELLE.........................................................................19 ARANESP ALBUMIN FREE..............................................62 ARCALYST.........................................................................53 AREXVY............................................................................... 8 arformoterol tartrate soln nebu 15 mcg/2ml (base equiv) (Brovana)............................................................35 aripiprazole orally disintegrating tab 10 mg, 15 mg................................................................................... 44 aripiprazole oral solution 1 mg/ml.................................44 aripiprazole tab 2 mg, 5 mg, 10 mg, 15 mg, 20 mg (Abilify)........................................................................... 44 aripiprazole tab 30 mg (Abilify)......................................44 armodafinil tab 150 mg, 200 mg, 250 mg (Nuvigil).......46 armodafinil tab 50 mg (Nuvigil)......................................46 ARMOUR THYROID..........................................................24 ARNUITY ELLIPTA............................................................ 35 asenapine maleate sl tab 2.5 mg (base equiv), 5 mg (base equiv), 10 mg (base equiv) (Saphris)...............44 ASMANEX HFA..................................................................35 ASMANEX TWISTHALER 120 ME................................... 35 ASMANEX TWISTHALER 30 MET...................................35 ASMANEX TWISTHALER 60 MET...................................35 aspirin chew tab 81 mg...................................................51 aspirin-dipyridamole cap er 12hr 25-200 mg................64 aspirin tab delayed release 81 mg.................................51 ASTAGRAF XL...................................................................77 atazanavir sulfate cap 150 mg (base equiv), 200 mg (base equiv), 300 mg (base equiv) (Reyataz).............. 4 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)....................................................................................29 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100)..................................................................................29 atenolol tab 25 mg, 50 mg, 100 mg (Tenormin)............27 atomoxetine hcl cap 10 mg (base equiv), 18 mg (base equiv), 25 mg (base equiv), 40 mg (base equiv), 60 mg (base equiv), 80 mg (base equiv), 100 mg (base equiv) (Strattera)........................................................... 47 atorvastatin calcium tab 10 mg (base equivalent), 20 mg (base equivalent), 40 mg (base equivalent), 80 mg (base equivalent) (Lipitor).....................................32 atovaquone-proguanil hcl tab 62.5-25 mg, 250-100 mg (Malarone)........................................................................ 7 atovaquone susp 750 mg/5ml (Mepron)......................... 7 ATROPINE SULFATE........................................................ 66 atropine sulfate ophth soln 1% (Atropine sulfate).......66 ATROVENT HFA................................................................35 ATTRUBY........................................................................... 33 AUGMENTIN........................................................................ 1 AUGTYRO..........................................................................11 AURANOFIN.......................................................................53 AURYXIA............................................................................ 39 AUSTEDO.......................................................................... 48 AUSTEDO XR....................................................................48 AUSTEDO XR PATIENT TITRAT......................................48 AUVI-Q................................................................................32 AVMAPKI FAKZYNJA CO-PACK...................................... 11 AVONEX............................................................................. 48 AVONEX PEN.................................................................... 48 AYVAKIT............................................................................. 11 AZASITE.............................................................................66 azathioprine tab 75 mg, 100 mg.....................................77 azathioprine tab 50 mg (Imuran)....................................77 azelaic acid gel 15% (Finacea).......................................70 azelastine hcl nasal spray 0.1% (137 mcg/spray)........ 34 azelastine hcl ophth soln 0.05%.................................... 66 azithromycin for susp 100 mg/5ml (Zithromax)............. 1 azithromycin for susp 200 mg/5ml (Zithromax)............. 2 azithromycin tab 600 mg.................................................. 2 azithromycin tab 250 mg, 500 mg (Zithromax)...............2

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 81 B BACITRACIN/POLYMYXIN B............................................66 baclofen tab 10 mg, 20 mg.............................................60 balsalazide disodium cap 750 mg (Colazal)................. 39 BALVERSA.........................................................................11 BAQSIMI ONE PACK........................................................ 21 BAQSIMI TWO PACK........................................................21 BARACLUDE........................................................................4 BAXDELA............................................................................. 2 BELBUCA...........................................................................51 BELSOMRA........................................................................46 benazepril & hydrochlorothiazide tab 5-6.25 mg......... 29 benazepril & hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg, 20-25 mg (Lotensin hct)..........................29 benazepril hcl tab 5 mg.................................................. 29 benazepril hcl tab 10 mg, 20 mg, 40 mg (Lotensin).....29 BENEFIX............................................................................ 64 BENLYSTA..........................................................................77 BENZNIDAZOLE..................................................................7 benztropine mesylate tab 0.5 mg, 1 mg, 2 mg............. 59 bepotastine besilate ophth soln 1.5% (Bepreve)......... 66 BESIVANCE....................................................................... 67 BESREMI............................................................................11 betaine powder for oral solution (Cystadane)..............25 BETAMETHASONE DIPROPIONAT................................. 70 betamethasone dipropionate augmented cream 0.05% (Diprolene af).................................................................71 betamethasone dipropionate augmented lotion 0.05%...............................................................................71 betamethasone dipropionate augmented oint 0.05% (Diprolene)......................................................................71 betamethasone dipropionate cream 0.05%.................. 71 betamethasone dipropionate lotion 0.05%...................71 betamethasone dipropionate oint 0.05%...................... 71 BETAMETHASONE VALERATE........................................71 betamethasone valerate cream 0.1% (base equivalent)......................................................................71 betamethasone valerate oint 0.1% (base equivalent)......................................................................71 BETASERON......................................................................48 BETAXOLOL HCL..............................................................67 betaxolol hcl tab 10 mg, 20 mg......................................28 bethanechol chloride tab 5 mg, 10 mg, 25 mg, 50 mg................................................................................... 40 bexarotene cap 75 mg (Targretin)..................................11 BEXSERO............................................................................ 8 bicalutamide tab 50 mg (Casodex)................................11 BIJUVA................................................................................18 BIKTARVY............................................................................ 4 bimatoprost ophth soln 0.01% (Lumigan).................... 67 BIMZELX............................................................................ 71 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg, 5-6.25 mg, 10-6.25 mg (Ziac)....................................... 30 bisoprolol fumarate tab 5 mg.........................................28 bisoprolol fumarate tab 10 mg.......................................28 BOOSTRIX......................................................................... 10 bosentan tab for oral susp 32 mg (Tracleer)................33 bosentan tab 62.5 mg, 125 mg (Tracleer)..................... 33 BOSULIF............................................................................ 11 BRAFTOVI..........................................................................11 BRAND PRENATAL VITAMINS - VARIOUS..................... 61 BREO ELLIPTA..................................................................35 BREZTRI AEROSPHERE..................................................35 brimonidine tartrate gel 0.33% (base equivalent) (Mirvaso).........................................................................71 brimonidine tartrate ophth soln 0.2%........................... 67 brimonidine tartrate-timolol maleate ophth soln 0.2-0.5% (Combigan).................................................... 67 BRINSUPRI........................................................................ 37 brinzolamide ophth susp 1% (Azopt)............................67 brivaracetam oral soln 10 mg/ml (Briviact).................. 56 brivaracetam tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg (Briviact).........................................................................56 BRIVIACT........................................................................... 56 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily).................................................................... 67 bromocriptine mesylate cap 5 mg (base equivalent) (Parlodel)........................................................................59 bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel)........................................................................59 BRUKINSA......................................................................... 11 budesonide delayed release particles cap 3 mg (Entocort ec)..................................................................17 budesonide inhalation susp 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml (Pulmicort)....................................................35 bumetanide tab 1 mg...................................................... 31 bumetanide tab 2 mg...................................................... 31 bumetanide tab 0.5 mg (Bumex)....................................31 buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv), 4-1 mg (base equiv), 8-2 mg (base equiv), 12-3 mg (base equiv) (Suboxone)...............................51 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv), 8-2 mg (base equiv).........................................51 buprenorphine hcl sl tab 2 mg (base equiv), 8 mg (base equiv)................................................................... 51 buprenorphine td patch weekly 5 mcg/hr, 7.5 mcg/hr, 10 mcg/hr, 15 mcg/hr, 20 mcg/hr (Butrans)............... 51 bupropion hcl (smoking deterrent) tab er 12hr 150 mg................................................................................... 48 bupropion hcl tab er 12hr 100 mg, 150 mg, 200 mg (Wellbutrin sr)................................................................42 bupropion hcl tab er 24hr 150 mg, 300 mg (Wellbutrin xl).....................................................................................42 bupropion hcl tab 75 mg, 100 mg..................................43 buspirone hcl tab 5 mg, 10 mg, 15 mg, 30 mg............. 42 butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic).............................................................................51 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg............................................................51 butalbital-acetaminophen tab 50-325 mg......................51

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 82 butalbital-aspirin-caffeine cap 50-325-40 mg............... 51 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg................................................................................... 51 butorphanol tartrate nasal soln 10 mg/ml.................... 51 BUTRANS...........................................................................51 BYLVAY...............................................................................39 BYLVAY (PELLETS)...........................................................39 C cabergoline tab 0.5 mg................................................... 25 CABLIVI.............................................................................. 64 CABOMETYX..................................................................... 11 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv).............................................................................. 47 CALCIPOTRIENE...............................................................71 calcipotriene cream 0.005% (Dovonex).........................71 calcitonin (salmon) nasal soln 200 unit/act..................25 CALCITRIOL.......................................................................71 calcitriol cap 0.25 mcg (Rocaltrol).................................25 calcitriol cap 0.5 mcg (Rocaltrol)...................................25 calcium acetate (phosphate binder) cap 667 mg (169 mg ca).............................................................................39 calcium acetate (phosphate binder) tab 667 mg..........39 CALQUENCE..................................................................... 11 CAMZYOS..........................................................................33 candesartan cilexetil tab 4 mg, 8 mg, 16 mg, 32 mg (Atacand)........................................................................30 capecitabine tab 150 mg, 500 mg (Xeloda)...................11 CAPLYTA............................................................................44 CAPRELSA.........................................................................12 captopril tab 12.5 mg, 25 mg, 50 mg, 100 mg...............30 CAPVAXIVE..........................................................................8 CARBAMAZEPINE.............................................................56 carbamazepine cap er 12hr 100 mg, 200 mg, 300 mg (Carbatrol)...................................................................... 56 carbamazepine chew tab 100 mg.................................. 56 carbamazepine susp 100 mg/5ml (Tegretol).................56 carbamazepine tab er 12hr 100 mg, 200 mg, 400 mg (Tegretol-xr)....................................................................56 carbamazepine tab 200 mg (Tegretol)...........................56 CARBATROL......................................................................56 carbidopa & levodopa orally disintegrating tab 10-100 mg, 25-100 mg, 25-250 mg.......................................... 59 carbidopa & levodopa tab er 25-100 mg, 50-200 mg................................................................................... 59 carbidopa & levodopa tab 25-250 mg........................... 59 carbidopa & levodopa tab 10-100 mg (Sinemet)..........59 carbidopa & levodopa tab 25-100 mg (Sinemet)..........59 carbidopa-levodopa-entacapone tabs 12.5-50-200 mg (Stalevo 50)....................................................................59 carbidopa-levodopa-entacapone tabs 18.75-75-200 mg (Stalevo 75).............................................................59 carbidopa-levodopa-entacapone tabs 25-100-200 mg (Stalevo 100)..................................................................59 carbidopa-levodopa-entacapone tabs 31.25-125-200 mg (Stalevo 125)...........................................................59 carbidopa-levodopa-entacapone tabs 37.5-150-200 mg (Stalevo 150)...........................................................59 carbidopa-levodopa-entacapone tabs 50-200-200 mg (Stalevo 200)..................................................................59 carbidopa tab 25 mg (Lodosyn).....................................59 carbinoxamine maleate tab 4 mg.................................. 34 carbonyl iron susp 15 mg/1.25ml (elemental iron)...... 62 carglumic acid soluble tab 200 mg (Carbaglu)............ 25 carisoprodol tab 250 mg (Soma)................................... 60 carisoprodol tab 350 mg (Soma)................................... 60 CARTEOLOL HCL............................................................. 67 carvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25 mg (Coreg)............................................................................28 CAYA...................................................................................75 CAYSTON.............................................................................7 CEFACLOR.......................................................................... 1 cefadroxil cap 500 mg.......................................................1 cefadroxil for susp 250 mg/5ml, 500 mg/5ml................. 1 cefdinir cap 300 mg...........................................................1 cefdinir for susp 125 mg/5ml, 250 mg/5ml..................... 1 CEFIXIME.............................................................................1 cefixime for susp 200 mg/5ml (Suprax).......................... 1 CEFPODOXIME PROXETIL............................................... 1 cefpodoxime proxetil tab 100 mg, 200 mg..................... 1 cefprozil for susp 125 mg/5ml, 250 mg/5ml....................1 cefprozil tab 250 mg, 500 mg...........................................1 cefuroxime axetil tab 250 mg...........................................1 cefuroxime axetil tab 500 mg...........................................1 celecoxib cap 50 mg, 100 mg, 200 mg (Celebrex)........53 celecoxib cap 400 mg (Celebrex).................................. 53 CELONTIN..........................................................................56 cephalexin cap 250 mg, 500 mg...................................... 1 cephalexin cap 750 mg (Keflex).......................................1 cephalexin for susp 125 mg/5ml, 250 mg/5ml................1 CERDELGA........................................................................62 CERVIDIL........................................................................... 25 cevimeline hcl cap 30 mg (Evoxac)...............................69 CHEMET.............................................................................75 CHLORDIAZEPOXIDE/AMITRIPT.................................... 48 chlordiazepoxide hcl cap 5 mg, 10 mg, 25 mg.............42 chlorhexidine gluconate soln 0.12% (Peridex).............69 CHLOROQUINE PHOSPHATE...........................................7 chloroquine phosphate tab 500 mg................................ 7 chlorpromazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg, 200 mg............................................................................44 chlorthalidone tab 25 mg, 50 mg...................................31 chlorzoxazone tab 500 mg..............................................60 cholecalciferol cap 1.25 mg (50000 unit)...................... 61 cholestyramine light powder 4 gm/dose (Questran light)................................................................................32 cholestyramine powder 4 gm/dose (Questran)............32 CIBINQO.............................................................................71 ciclopirox gel 0.77%........................................................ 71 ciclopirox olamine cream 0.77% (base equiv) (Loprox).......................................................................... 71

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 83 ciclopirox olamine susp 0.77% (base equiv)................71 ciclopirox shampoo 1% (Loprox shampoo)................. 71 ciclopirox solution 8% (Penlac Nail Lacquer).............. 71 cilostazol tab 50 mg, 100 mg......................................... 64 CIMDUO............................................................................... 4 cimetidine hcl soln 300 mg/5ml..................................... 38 CIMZIA................................................................................39 CIMZIA STARTER KIT...................................................... 39 cinacalcet hcl tab 30 mg (base equiv), 60 mg (base equiv), 90 mg (base equiv) (Sensipar)....................... 25 CIPRO...................................................................................2 ciprofloxacin-dexamethasone otic susp 0.3-0.1% (Ciprodex).......................................................................69 ciprofloxacin hcl ophth soln 0.3% (base equivalent) (Ciloxan)......................................................................... 67 ciprofloxacin hcl otic soln 0.2% (base equivalent) (Cetraxal)........................................................................69 ciprofloxacin hcl tab 750 mg (base equiv)..................... 2 ciprofloxacin hcl tab 250 mg (base equiv), 500 mg (base equiv) (Cipro)........................................................2 citalopram hydrobromide oral soln 10 mg/5ml............43 citalopram hydrobromide tab 10 mg (base equiv), 20 mg (base equiv), 40 mg (base equiv) (Celexa)..........43 cladribine tab therapy pack 10 mg (4 tabs), 10 mg (5 tabs), 10 mg (6 tabs), 10 mg (7 tabs), 10 mg (8 tabs), 10 mg (9 tabs), 10 mg (10 tabs) (Mavenclad)............ 48 CLARITHROMYCIN............................................................. 2 clarithromycin tab er 24hr 500 mg.................................. 2 clarithromycin tab 250 mg, 500 mg.................................2 CLEMASTINE FUMARATE............................................... 34 CLIMARA PRO.................................................................. 18 clindamycin hcl cap 75 mg, 150 mg, 300 mg (Cleocin)........................................................................... 7 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr)..........................................7 clindamycin phosphate gel 1% (twice-daily)................71 clindamycin phosphate lotion 1% (Cleocin-t).............. 71 clindamycin phosphate soln 1%....................................71 clindamycin phosphate swab 1%..................................71 clindamycin phosphate vaginal cream 2% (Cleocin)......................................................................... 41 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5%..............................................................................71 CLINPRO 5000.................................................................. 69 clobazam suspension 2.5 mg/ml (Onfi)........................ 56 clobazam tab 10 mg, 20 mg (Onfi).................................56 clobetasol propionate cream 0.05% (Temovate)..........71 clobetasol propionate emollient base cream 0.05%...............................................................................71 clobetasol propionate foam 0.05%................................71 clobetasol propionate gel 0.05%................................... 71 clobetasol propionate oint 0.05% (Temovate)..............71 clobetasol propionate soln 0.05%................................. 71 CLOCORTOLONE PIVALATE...........................................71 clomipramine hcl cap 25 mg, 50 mg, 75 mg (Anafranil).......................................................................43 clonazepam orally disintegrating tab 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg...............................................56 clonazepam tab 0.5 mg, 1 mg, 2 mg (Klonopin)...........56 clonidine hcl tab er 12hr 0.1 mg (Kapvay)....................47 clonidine hcl tab 0.1 mg, 0.2 mg, 0.3 mg...................... 30 clonidine td patch weekly 0.1 mg/24hr (Catapres- tts-1)................................................................................30 clonidine td patch weekly 0.2 mg/24hr (Catapres- tts-2)................................................................................30 clonidine td patch weekly 0.3 mg/24hr (Catapres- tts-3)................................................................................30 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)............................................................................64 clorazepate dipotassium tab 3.75 mg, 15 mg...............42 clorazepate dipotassium tab 7.5 mg (Tranxene t)........42 clotrimazole troche 10 mg..............................................69 clotrimazole w/ betamethasone cream 1-0.05%...........71 clozapine orally disintegrating tab 12.5 mg, 25 mg, 100 mg, 150 mg, 200 mg..............................................44 clozapine tab 50 mg, 100 mg, 200 mg (Clozaril).......... 44 clozapine tab 25 mg (Clozaril)........................................44 COAGADEX....................................................................... 64 COARTEM............................................................................7 codeine sulfate tab 30 mg (Codeine sulfate)................51 colchicine tab 0.6 mg (Colcrys)..................................... 56 colchicine w/ probenecid tab 0.5-500 mg..................... 56 colesevelam hcl tab 625 mg (Welchol)......................... 32 colestipol hcl granule packets 5 gm (Colestid flavored)......................................................................... 32 colestipol hcl granules 5 gm (Colestid flavored).........32 colestipol hcl tab 1 gm (Colestid)..................................32 COMBIPATCH.................................................................... 18 COMBIVENT RESPIMAT.................................................. 35 COMETRIQ........................................................................ 12 COMIRNATY 2025-26..........................................................8 COMIRNATY/5-11Y/2025-26............................................... 8 COMPLERA..........................................................................4 CONDOMS.........................................................................75 CONTOUR BLOOD GLUCOSE MON.............................. 75 CONTOUR BLOOD GLUCOSE TES................................75 CONTOUR NEXT BLOOD GLUCOS................................75 CONTOUR NEXT EZ BLOOD GLU..................................75 CONTOUR NEXT GEN BLOOD GL................................. 75 CONTOUR NEXT LINK BLOOD G...................................75 CONTOUR NEXT LINK WIRELES................................... 75 CONTOUR NEXT ONE BLOOD GL................................. 75 CONTOUR PLUS BLOOD GLUCOS................................75 CONTOUR PLUS BLUE BLOOD G..................................76 COPIKTRA......................................................................... 12 CORIFACT..........................................................................64 CORLANOR....................................................................... 33 CORTIFOAM...................................................................... 70 CORTISPORIN-TC.............................................................69

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 84 COSENTYX........................................................................72 COSENTYX SENSOREADY PEN.................................... 72 COSENTYX UNOREADY..................................................72 COTELLIC.......................................................................... 12 CRENESSITY.....................................................................25 CREON...............................................................................39 CRESEMBA..........................................................................3 CROMOLYN SODIUM....................................................... 67 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom)..................................................................39 cromolyn sodium soln nebu 20 mg/2ml....................... 35 CROTAN.............................................................................72 CTEXLI............................................................................... 39 cyanocobalamin inj 1000 mcg/ml.................................. 62 cyclobenzaprine hcl tab 5 mg, 10 mg........................... 60 CYCLOMYDRIL..................................................................67 cyclopentolate hcl ophth soln 1% (Cyclogyl)...............67 CYCLOPHOSPHAMIDE.................................................... 12 cyclophosphamide cap 25 mg, 50 mg (Cyclophosphamide).................................................... 12 CYCLOSERINE....................................................................3 cyclosporine cap 25 mg, 100 mg (Sandimmune).........77 cyclosporine modified cap 50 mg................................. 77 cyclosporine modified cap 25 mg, 100 mg (Neoral)........................................................................... 77 cyclosporine modified oral soln 100 mg/ml (Neoral)........................................................................... 77 cyproheptadine hcl syrup 2 mg/5ml..............................34 cyproheptadine hcl tab 4 mg......................................... 34 CYSTADROPS................................................................... 67 CYSTAGON........................................................................41 CYSTARAN........................................................................ 67 D dabigatran etexilate mesylate cap 75 mg (etexilate base eq), 110 mg (etexilate base eq), 150 mg (etexilate base eq) (Pradaxa).......................................62 dalfampridine tab er 12hr 10 mg (Ampyra)...................48 danazol cap 50 mg, 100 mg, 200 mg.............................18 dantrolene sodium cap 100 mg..................................... 60 dantrolene sodium cap 25 mg, 50 mg (Dantrium)........60 dapsone tab 25 mg, 100 mg.............................................7 DAPTACEL.........................................................................10 darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv), 15 mg (base equiv)..........................................40 darunavir tab 600 mg, 800 mg (Prezista)........................4 dasatinib tab 20 mg, 50 mg, 70 mg, 80 mg, 100 mg, 140 mg (Sprycel)...........................................................12 DAURISMO........................................................................ 12 DAWNZERA....................................................................... 64 DAYBUE............................................................................. 60 DAYBUE STIX....................................................................60 deferiprone tab 500 mg, 1000 mg (Ferriprox)...............75 DELSTRIGO.........................................................................4 demeclocycline hcl tab 150 mg, 300 mg.........................2 DENTAGEL.........................................................................69 DENTA 5000 PLUS........................................................... 69 DEPO-ESTRADIOL............................................................18 DEPO-SUBQ PROVERA 104........................................... 19 DESCOVY............................................................................ 4 desipramine hcl tab 50 mg, 75 mg, 100 mg, 150 mg................................................................................... 43 desipramine hcl tab 10 mg (Norpramin)....................... 43 desipramine hcl tab 25 mg (Norpramin)....................... 43 DESMOPRESSIN ACETATE.............................................25 desmopressin acetate inj 4 mcg/ml (Ddavp)................25 desmopressin acetate nasal spray soln 0.01% (refrigerated)..................................................................25 desmopressin acetate preservative free (pf) inj 4 mcg/ ml (Ddavp)......................................................................25 desmopressin acetate tab 0.1 mg, 0.2 mg (Ddavp)......25 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette)........................................................19 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg................................................................................. 19 desonide cream 0.05% (Desowen)................................ 72 desonide oint 0.05%........................................................ 72 desoximetasone cream 0.25% (Topicort)......................72 desoximetasone oint 0.25% (Topicort)..........................72 desvenlafaxine succinate tab er 24hr 25 mg (base equiv), 50 mg (base equiv), 100 mg (base equiv) (Pristiq)........................................................................... 43 DEXAMETHASONE...........................................................17 dexamethasone elixir 0.5 mg/5ml..................................17 DEXAMETHASONE INTENSOL....................................... 17 DEXAMETHASONE SODIUM PHOS............................... 67 dexamethasone tab 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg.............................................................17 DEXCOM G7 15 DAY SENSOR....................................... 76 DEXCOM G6 RECEIVER..................................................76 DEXCOM G7 RECEIVER..................................................76 DEXCOM G6 SENSOR.....................................................76 DEXCOM G7 SENSOR.....................................................76 DEXCOM G6 TRANSMITTER.......................................... 76 dexlansoprazole cap delayed release 30 mg, 60 mg (Dexilant)........................................................................ 38 dexmethylphenidate hcl cap er 24 hr 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg (Focalin xr).................................................................................... 47 dexmethylphenidate hcl tab 2.5 mg, 5 mg (Focalin)..........................................................................47 dexmethylphenidate hcl tab 10 mg (Focalin)............... 47 dextroamphetamine sulfate cap er 24hr 5 mg, 10 mg, 15 mg (Dexedrine)........................................................ 47 dextroamphetamine sulfate oral solution 5 mg/5ml............................................................................ 47 dextroamphetamine sulfate tab 5 mg, 10 mg...............47 DIACOMIT.......................................................................... 56 diazepam conc 5 mg/ml..................................................42 diazepam oral soln 1 mg/ml........................................... 42 diazepam rectal gel delivery system 2.5 mg................ 56

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 85 diazepam rectal gel delivery system 10 mg, 20 mg (Diastat acudial)............................................................ 56 diazepam tab 2 mg, 5 mg, 10 mg (Valium)....................42 diazoxide susp 50 mg/ml (Proglycem)..........................21 diclofenac potassium tab 50 mg................................... 53 diclofenac sodium ophth soln 0.1%..............................67 diclofenac sodium soln 1.5%......................................... 72 diclofenac sodium tab delayed release 25 mg.............53 diclofenac sodium tab delayed release 50 mg, 75 mg................................................................................... 53 diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50)..........................................................53 diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75)..........................................................53 dicloxacillin sodium cap 250 mg, 500 mg...................... 1 dicyclomine hcl cap 10 mg.............................................38 dicyclomine hcl oral soln 10 mg/5ml............................ 38 dicyclomine hcl tab 20 mg............................................. 38 DIFICID.................................................................................2 DIFLORASONE DIACETATE............................................ 72 diflunisal tab 500 mg.......................................................51 difluprednate ophth emulsion 0.05% (Durezol)............67 DIGOXIN.............................................................................27 digoxin oral soln 0.05 mg/ml (Digoxin).........................27 digoxin tab 125 mcg (0.125 mg), 250 mcg (0.25 mg) (Lanoxin)........................................................................ 27 digoxin tab 62.5 mcg (0.0625 mg) (Lanoxin)................ 27 dihydroergotamine mesylate inj 1 mg/ml (D.h.e. 45)....................................................................................55 DILANTIN........................................................................... 57 DILANTIN-125....................................................................57 DILANTIN INFATABS.........................................................57 diltiazem hcl cap er 24hr 120 mg...................................28 diltiazem hcl cap er 12hr 60 mg, 90 mg........................28 diltiazem hcl cap er 24hr 180 mg, 240 mg.................... 28 diltiazem hcl coated beads cap er 24hr 120 mg, 180 mg, 240 mg (Cardizem cd).......................................... 28 diltiazem hcl coated beads cap er 24hr 300 mg (Cardizem cd)................................................................ 28 diltiazem hcl extended release beads cap er 24hr 240 mg, 300 mg, 360 mg, 420 mg (Tiazac)........................28 diltiazem hcl extended release beads cap er 24hr 120 mg, 180 mg (Tiazac)..................................................... 28 diltiazem hcl tab er 24hr 120 mg (Cardizem la)............28 diltiazem hcl tab 90 mg...................................................29 diltiazem hcl tab 30 mg, 60 mg, 120 mg (Cardizem)......................................................................29 dimethyl fumarate capsule delayed release 120 mg, 240 mg (Tecfidera)........................................................48 dimethyl fumarate capsule dr starter pack 120 mg & 240 mg (Tecfidera starter pa)......................................48 DIPENTUM.........................................................................39 diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)......................................................................... 38 dipyridamole tab 25 mg, 50 mg, 75 mg.........................64 DISKETS............................................................................ 51 disopyramide phosphate cap 100 mg, 150 mg (Norpace)........................................................................29 disulfiram tab 250 mg, 500 mg...................................... 49 DIURIL................................................................................ 31 divalproex sodium cap delayed release sprinkle 125 mg (Depakote sprinkles)..............................................57 divalproex sodium tab delayed release 125 mg, 250 mg, 500 mg (Depakote)................................................57 divalproex sodium tab er 24 hr 250 mg, 500 mg (Depakote er)................................................................. 57 dofetilide cap 125 mcg (0.125 mg), 250 mcg (0.25 mg), 500 mcg (0.5 mg) (Tikosyn).........................................29 donepezil hydrochloride orally disintegrating tab 5 mg, 10 mg......................................................................49 donepezil hydrochloride tab 5 mg, 10 mg (Aricept)..........................................................................49 donepezil hydrochloride tab 23 mg (Aricept)...............49 dorzolamide hcl ophth soln 2% (Trusopt).................... 67 dorzolamide hcl-timolol maleate ophth soln 2-0.5% (Cosopt)..........................................................................67 DOVATO............................................................................... 4 doxazosin mesylate tab 1 mg, 2 mg, 4 mg, 8 mg (Cardura)........................................................................ 30 DOXEPIN HCL...................................................................43 doxepin hcl cap 10 mg, 25 mg, 50 mg.......................... 43 doxepin hcl cap 75 mg, 100 mg, 150 mg...................... 43 doxycycline hyclate cap 50 mg....................................... 2 doxycycline hyclate cap 100 mg (Vibramycin)...............2 doxycycline hyclate tab 20 mg, 100 mg..........................2 doxycycline monohydrate cap 50 mg, 100 mg.............. 2 doxycycline monohydrate for susp 25 mg/5ml (Vibramycin).....................................................................2 doxycycline monohydrate tab 50 mg, 100 mg............... 2 doxycycline monohydrate tab 75 mg, 150 mg............... 2 dronabinol cap 2.5 mg, 5 mg, 10 mg (Marinol).............38 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28)....................................................................................19 drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz).....19 drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg (Beyaz)...............................................19 drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg (Safyral)............................................. 19 DUAVEE............................................................................. 18 DULERA............................................................................. 35 duloxetine hcl enteric coated pellets cap 20 mg (base eq), 30 mg (base eq), 60 mg (base eq) (Cymbalta)......................................................................43 DUOPA............................................................................... 59 DUPIXENT..........................................................................72 dutasteride cap 0.5 mg (Avodart).................................. 41 DUVYZAT........................................................................... 60 E EASYGEL...........................................................................69 EBGLYSS........................................................................... 72

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 86 econazole nitrate cream 1%........................................... 72 EDURANT............................................................................ 4 EDURANT PED................................................................... 4 E.E.S. 400............................................................................ 2 EFAVIRENZ/LAMIVUDINE/TENO....................................... 4 efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg (Atripla)......................................................................4 efavirenz-lamivudine-tenofovir df tab 600-300-300 mg (Symfi)...............................................................................4 efavirenz tab 600 mg (Sustiva)........................................ 4 eletriptan hydrobromide tab 20 mg (base equivalent), 40 mg (base equivalent) (Relpax)...............................55 ELIQUIS..............................................................................63 ELIQUIS STARTER PACK................................................ 63 ELLA................................................................................... 19 ELMIRON........................................................................... 41 ELOCTATE......................................................................... 64 eltrombopag olamine powder pack for susp 25 mg (base equiv), 12.5 mg (base eq) (Promacta)..............62 eltrombopag olamine tab 12.5 mg (base equiv), 25 mg (base equiv), 50 mg (base equiv), 75 mg (base equiv) (Promacta)..........................................................62 EMEND...............................................................................38 EMGALITY..........................................................................55 EMPAVELI.......................................................................... 64 EMSAM...............................................................................43 emtricitabine caps 200 mg (Emtriva).............................. 4 emtricitabine-rilpivirine-tenofovir df tab 200-25-300 mg (Complera).................................................................4 emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg, 133-200 mg, 167-250 mg (Truvada).........4 emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg (Truvada).....................................................4 EMTRIVA.............................................................................. 4 EMVERM.............................................................................. 7 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg................................................................................... 30 enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic)...................................................................... 30 enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20 mg (Vasotec).........................................................................30 ENBREL..............................................................................53 ENBREL MINI.................................................................... 53 ENBREL SURECLICK.......................................................54 ENCARE.............................................................................41 ENGERIX-B..........................................................................8 enoxaparin sodium inj 300 mg/3ml (Lovenox).............63 enoxaparin sodium inj soln pref syr 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml, 100 mg/ml, 120 mg/0.8ml, 150 mg/ml (Lovenox)..................................63 ENSACOVE........................................................................12 ENSPRYNG........................................................................77 ENSTILAR.......................................................................... 72 entacapone tab 200 mg (Comtan)................................. 60 entecavir tab 0.5 mg, 1 mg (Baraclude)..........................4 ENTRESTO........................................................................ 33 ENTYVIO PEN................................................................... 39 ENVARSUS XR..................................................................77 EPCLUSA............................................................................. 4 EPIDIOLEX.........................................................................57 epinastine hcl ophth soln 0.05%....................................67 epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) (Epipen-jr 2-pak)............................................ 32 epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) (Epipen 2-pak)................................................ 32 eplerenone tab 25 mg, 50 mg (Inspra).......................... 30 EQUETRO..........................................................................44 ergocalciferol cap 1.25 mg (50000 unit) (Drisdol)........61 ERGOMAR......................................................................... 55 ERGOTAMINE TARTRATE/CAFFE.................................. 55 ERIVEDGE......................................................................... 12 ERLEADA...........................................................................12 erlotinib hcl tab 25 mg (base equivalent), 100 mg (base equivalent), 150 mg (base equivalent) (Tarceva).........................................................................12 ERY.....................................................................................72 ERYTHROMYCIN.............................................................. 72 ERYTHROMYCIN DR..........................................................2 erythromycin ethylsuccinate for susp 200 mg/5ml (E.e.s. granules).............................................................. 2 erythromycin ethylsuccinate for susp 400 mg/5ml (Eryped 400).....................................................................2 erythromycin ophth oint 5 mg/gm.................................67 erythromycin soln 2%..................................................... 72 erythromycin tab delayed release 250 mg, 333 mg, 500 mg..............................................................................2 erythromycin tab 250 mg, 500 mg...................................2 escitalopram oxalate soln 5 mg/5ml (base equiv)....... 43 escitalopram oxalate tab 5 mg (base equiv), 10 mg (base equiv), 20 mg (base equiv) (Lexapro)..............43 eslicarbazepine acetate tab 200 mg, 400 mg, 600 mg, 800 mg (Aptiom)........................................................... 57 esomeprazole magnesium cap delayed release 20 mg (base eq), 40 mg (base eq) (Nexium)......................... 38 esomeprazole magnesium for delayed release susp packet 5 mg, 10 mg, 20 mg, 40 mg (Nexium)............ 38 esomeprazole magnesium for delayed release susp pack 2.5 mg (Nexium).................................................. 38 ESPEROCT........................................................................64 estazolam tab 1 mg, 2 mg.............................................. 46 estradiol & norethindrone acetate tab 0.5-0.1 mg........18 estradiol & norethindrone acetate tab 1-0.5 mg (Activella)....................................................................... 18 estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump) (Estrogel)........................................................... 18 estradiol tab 0.5 mg, 1 mg, 2 mg (Estrace)...................18 estradiol td gel 0.25 mg/0.25gm (0.1%), 0.5 mg/0.5gm (0.1%), 0.75 mg/0.75gm (0.1%), 1 mg/gm (0.1%), 1.25 mg/1.25gm (0.1%) (Divigel)..........................................18

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 87 estradiol td patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr (Vivelle-dot)....................................................................18 estradiol td patch weekly 0.025 mg/24hr, 0.0375 mg/24hr (37.5 mcg/24hr), 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr (Climara).........18 estradiol vaginal cream 0.01%....................................... 41 estradiol vaginal tab 10 mcg (Vagifem).........................41 estradiol valerate im in oil 10 mg/ml, 20 mg/ml, 40 mg/ ml (Delestrogen)............................................................18 ESTRING............................................................................41 estrogens, conjugated tab 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, 1.25 mg (Premarin)......................................... 18 eszopiclone tab 1 mg, 2 mg, 3 mg (Lunesta)............... 46 ethacrynic acid tab 25 mg (Edecrin)............................. 31 ethambutol hcl tab 100 mg...............................................3 ethambutol hcl tab 400 mg (Myambutol)........................ 3 ethosuximide cap 250 mg (Zarontin)............................ 57 ethosuximide soln 250 mg/5ml (Zarontin)....................57 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg................................................................................. 19 ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg................................................................................. 19 etodolac cap 200 mg, 300 mg........................................ 54 etodolac tab 500 mg........................................................54 etodolac tab 400 mg (Lodine)........................................ 54 ETOPOSIDE.......................................................................12 etravirine tab 100 mg, 200 mg (Intelence)...................... 4 EVAMIST............................................................................ 18 everolimus tab for oral susp 2 mg, 3 mg, 5 mg (Afinitor disperz)........................................................... 12 everolimus tab 2.5 mg, 5 mg, 7.5 mg, 10 mg (Afinitor)......................................................................... 12 everolimus tab 0.25 mg, 0.5 mg, 0.75 mg, 1 mg (Zortress)........................................................................77 EVOTAZ................................................................................4 EVRYSDI............................................................................ 60 EXELDERM........................................................................72 exemestane tab 25 mg (Aromasin)................................12 ezetimibe-simvastatin tab 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg (Vytorin).................................................32 ezetimibe tab 10 mg (Zetia)............................................ 32 F FABHALTA..........................................................................64 famciclovir tab 125 mg, 250 mg, 500 mg........................ 4 famotidine for susp 40 mg/5ml...................................... 38 famotidine tab 40 mg (Pepcid).......................................38 FANAPT..............................................................................44 FANAPT TITRATION PACK A...........................................44 FANAPT TITRATION PACK B...........................................45 FANAPT TITRATION PACK C.......................................... 45 FARXIGA............................................................................ 21 FASENRA PEN..................................................................35 FC2 FEMALE CONDOM................................................... 76 febuxostat tab 40 mg, 80 mg (Uloric)............................56 FEIBA..................................................................................64 felbamate susp 600 mg/5ml (Felbatol)..........................57 felbamate tab 400 mg, 600 mg (Felbatol)......................57 felodipine tab er 24hr 2.5 mg, 5 mg, 10 mg..................29 FEMCAP.............................................................................76 FEMRING........................................................................... 41 fenofibrate micronized cap 67 mg, 134 mg, 200 mg................................................................................... 32 fenofibrate tab 54 mg, 160 mg....................................... 32 fenofibrate tab 48 mg, 145 mg (Tricor)..........................32 fentanyl td patch 72hr 12 mcg/hr, 25 mcg/hr, 50 mcg/ hr, 75 mcg/hr, 100 mcg/hr (Duragesic).......................52 FERRETTS CHEWABLE IRON........................................ 62 ferric citrate tab 1 gm (210 mg ferric iron) (Auryxia).........................................................................39 ferrous sulfate soln 300 mg/5ml (60 mg/5ml elemental fe).....................................................................................62 ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe), 220 mg/5ml (44 mg/5ml elemental fe)........................ 62 FETZIMA............................................................................ 43 FETZIMA TITRATION PACK.............................................43 FIASP..................................................................................22 FIASP FLEXTOUCH..........................................................22 FIASP PENFILL................................................................. 22 FIBRYGA............................................................................ 64 fidaxomicin tab 200 mg (Dificid)......................................2 FILSPARI............................................................................ 42 FILSUVEZ...........................................................................72 finasteride tab 5 mg (Proscar)....................................... 42 fingolimod hcl cap 0.5 mg (base equiv) (Gilenya)....... 49 FINTEPLA...........................................................................57 flavoxate hcl tab 100 mg.................................................41 flecainide acetate tab 50 mg.......................................... 29 flecainide acetate tab 100 mg, 150 mg..........................29 FLORICAL.......................................................................... 61 FLORIVA.............................................................................61 FLUAD 2025-2026............................................................... 8 FLUARIX 2025-2026............................................................8 FLUBLOK 2025-2026.......................................................... 9 FLUCELVAX 2025-2026...................................................... 9 fluconazole for susp 10 mg/ml, 40 mg/ml (Diflucan)..... 3 fluconazole tab 50 mg, 100 mg, 150 mg, 200 mg (Diflucan).......................................................................... 3 flucytosine cap 250 mg, 500 mg (Ancobon)...................3 fludrocortisone acetate tab 0.1 mg............................... 17 FLULAVAL 2025-2026......................................................... 9 FLUMIST NASAL VACCINE 202........................................ 9 fluocinolone acetonide cream 0.01%............................ 72 fluocinolone acetonide oil 0.01% (body oil) (Derma- smoothe/fs bod)............................................................72 fluocinolone acetonide oil 0.01% (scalp oil) (Derma- smoothe/fs sca).............................................................72 fluocinolone acetonide oint 0.025% (Synalar)..............72 fluocinolone acetonide (otic) oil 0.01% (Dermotic)......69 fluocinolone acetonide soln 0.01% (Synalar)...............72

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 88 fluocinonide cream 0.05%.............................................. 72 fluocinonide cream 0.1% (Vanos)..................................72 fluocinonide emulsified base cream 0.05%..................72 fluocinonide oint 0.05%.................................................. 72 fluocinonide soln 0.05%..................................................72 FLUORIDE..........................................................................61 FLUORIDEX DAILY DEFENSE.........................................69 FLUORIDEX DAILY RENEWAL........................................ 69 FLUORIDEX ENHANCED WHITEN................................. 69 FLUORIDEX SENSITIVITY REL.......................................69 FLUORIMAX 5000............................................................. 69 fluorometholone ophth susp 0.1% (Fml liquifilm)....... 67 FLUOROURACIL............................................................... 73 fluorouracil cream 5% (Efudex)..................................... 73 fluorouracil soln 5%........................................................ 73 FLUOXETINE DR.............................................................. 43 fluoxetine hcl cap 10 mg, 20 mg, 40 mg (Prozac)........ 43 fluoxetine hcl solution 20 mg/5ml................................. 43 fluoxetine hcl tab 10 mg................................................. 43 fluoxetine hcl tab 20 mg................................................. 43 FLUPHENAZINE HCL....................................................... 45 fluphenazine hcl tab 1 mg, 2.5 mg, 5 mg, 10 mg..........45 FLUPHENAZINE HYDROCHLORID.................................45 FLURBIPROFEN................................................................54 FLURBIPROFEN SODIUM................................................67 FLUTICASONE PROPIONATE/SA................................... 35 fluticasone propionate cream 0.05%.............................73 fluticasone propionate nasal susp 50 mcg/act............ 34 fluticasone propionate oint 0.005%...............................73 fluticasone-salmeterol aer powder ba 100-50 mcg/act, 250-50 mcg/act, 500-50 mcg/act (Advair diskus)...... 36 fluvastatin sodium cap 20 mg (base equivalent), 40 mg (base equivalent)....................................................32 fluvoxamine maleate tab 100 mg...................................43 fluvoxamine maleate tab 25 mg, 50 mg........................ 43 FLUZONE 2025-2026.......................................................... 9 FLUZONE HIGH-DOSE 2025-20........................................ 9 folic acid cap 0.8 mg.......................................................62 folic acid tab 400 mcg, 800 mcg....................................62 folic acid tab 1 mg...........................................................62 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml, 10 mg/0.8ml (Arixtra).......63 fosamprenavir calcium tab 700 mg (base equiv) (Lexiva)............................................................................. 4 fosfomycin tromethamine powd pack 3 gm (base equivalent) (Monurol)..................................................... 7 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg..............................................................30 fosinopril sodium tab 10 mg, 20 mg, 40 mg.................30 FOTIVDA............................................................................ 12 FRAGMIN........................................................................... 63 FREESTYLE LIBRE 2/READER/...................................... 76 FREESTYLE LIBRE 3/READER/...................................... 76 FREESTYLE LIBRE/READER/FL..................................... 76 FREESTYLE LIBRE 2/SENSOR/......................................76 FREESTYLE LIBRE 3/SENSOR/......................................76 FREESTYLE LIBRE 14 DAY/RE.......................................76 FREESTYLE LIBRE 14 DAY/SE.......................................76 FREESTYLE LIBRE 2 PLUS/SE.......................................76 FREESTYLE LIBRE 3 PLUS/SE.......................................76 FREESTYLE PRECISION NEO B.................................... 75 frovatriptan succinate tab 2.5 mg (base equivalent) (Frova).............................................................................55 FRUZAQLA.........................................................................12 FUROSCIX......................................................................... 31 FUROSEMIDE....................................................................31 furosemide tab 20 mg, 40 mg, 80 mg (Lasix)............... 31 FYCOMPA.......................................................................... 57 G gabapentin cap 100 mg, 300 mg, 400 mg (Neurontin)..................................................................... 57 gabapentin oral soln 250 mg/5ml (Neurontin)..............57 gabapentin tab 600 mg, 800 mg (Neurontin)................ 57 GALAFOLD.........................................................................25 GALANTAMINE HYDROBROMIDE.................................. 49 galantamine hydrobromide cap er 24hr 8 mg, 16 mg, 24 mg (Razadyne er).................................................... 49 galantamine hydrobromide tab 4 mg, 8 mg, 12 mg..... 49 GARDASIL 9........................................................................ 9 gatifloxacin ophth soln 0.5% (Zymaxid)....................... 67 GAVILYTE-C.......................................................................37 GAVRETO...........................................................................12 gefitinib tab 250 mg (Iressa)...........................................12 gemfibrozil tab 600 mg (Lopid)......................................32 GENOTROPIN................................................................... 25 GENOTROPIN MINIQUICK...............................................25 gentamicin sulfate cream 0.1%......................................73 gentamicin sulfate oint 0.1%..........................................73 gentamicin sulfate ophth soln 0.3%..............................67 GENVOYA............................................................................ 4 GILENYA.............................................................................49 GILOTRIF........................................................................... 12 glatiramer acetate soln prefilled syringe 20 mg/ml, 40 mg/ml (Copaxone)........................................................ 49 GLEOSTINE....................................................................... 12 glimepiride tab 1 mg, 2 mg, 4 mg (Amaryl).................. 21 GLIPIZIDE.......................................................................... 21 glipizide-metformin hcl tab 2.5-250 mg, 2.5-500 mg, 5-500 mg.........................................................................21 glipizide tab er 24hr 2.5 mg, 5 mg, 10 mg (Glucotrol xl).....................................................................................21 glipizide tab 5 mg............................................................ 21 glipizide tab 10 mg (Glucotrol).......................................21 GLUCAGON EMERGENCY KIT FO.................................21 glucagon for inj 1 mg......................................................21 glutamine (sickle cell) powd pack 5 gm (Endari).........62 glyburide-metformin tab 1.25-250 mg, 2.5-500 mg, 5-500 mg.........................................................................21 glyburide tab 1.25 mg, 2.5 mg, 5 mg.............................21 glycerol phenylbutyrate liquid 1.1 gm/ml (Ravicti)......26

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 89 glycopyrrolate oral soln 1 mg/5ml (Cuvposa)..............38 glycopyrrolate tab 1 mg, 2 mg.......................................38 GLYXAMBI..........................................................................21 GOMEKLI........................................................................... 12 granisetron hcl tab 1 mg................................................ 38 GRASTEK...........................................................................11 griseofulvin microsize susp 125 mg/5ml........................3 griseofulvin microsize tab 500 mg.................................. 3 griseofulvin ultramicrosize tab 125 mg, 250 mg............3 guaifenesin-codeine soln 100-10 mg/5ml..................... 34 guanfacine hcl tab er 24hr 1 mg (base equiv), 2 mg (base equiv), 3 mg (base equiv), 4 mg (base equiv) (Intuniv).......................................................................... 47 guanfacine hcl tab 1 mg, 2 mg...................................... 30 GVOKE HYPOPEN 1-PACK............................................. 21 GVOKE HYPOPEN 2-PACK............................................. 21 GVOKE KIT........................................................................21 GVOKE PFS.......................................................................21 GYNAZOLE-1.....................................................................41 H HADLIMA............................................................................54 HADLIMA PUSHTOUCH................................................... 54 HAEGARDA........................................................................64 halobetasol propionate cream 0.05%............................73 haloperidol lactate oral conc 2 mg/ml...........................45 haloperidol tab 0.5 mg, 1 mg......................................... 45 haloperidol tab 2 mg, 5 mg, 10 mg, 20 mg................... 45 HARVONI..............................................................................5 HAVRIX.................................................................................9 HEMLIBRA......................................................................... 64 HEMMOREX-HC................................................................70 HEMOFIL M....................................................................... 65 HEPARIN SODIUM............................................................63 heparin sodium (porcine) inj 1000 unit/ml, 5000 unit/ ml, 10000 unit/ml, 20000 unit/ml................................. 63 heparin sodium (porcine) pf inj 1000 unit/ml, 5000 unit/0.5ml........................................................................63 HEPLISAV-B.........................................................................9 HERNEXEOS..................................................................... 12 HETLIOZ LQ...................................................................... 46 HIBERIX................................................................................9 HUMALOG..........................................................................22 HUMALOG JUNIOR KWIKPEN........................................ 22 HUMALOG KWIKPEN....................................................... 22 HUMALOG MIX 75/25....................................................... 23 HUMALOG MIX 50/50 KWIKPEN..................................... 23 HUMALOG MIX 75/25 KWIKPEN..................................... 23 HUMALOG TEMPO PEN.................................................. 22 HUMATE-P......................................................................... 65 HUMATIN..............................................................................2 HUMULIN 70/30.................................................................23 HUMULIN 70/30 KWIKPEN...............................................23 HUMULIN N....................................................................... 23 HUMULIN N KWIKPEN..................................................... 23 HUMULIN R....................................................................... 23 HUMULIN R U-500 KWIKPEN..........................................23 HYCAMTIN.........................................................................12 hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg.......30 hydrochlorothiazide cap 12.5 mg.................................. 31 hydrochlorothiazide tab 12.5 mg, 25 mg, 50 mg..........32 hydrocodone-acetaminophen soln 7.5-325 mg/15ml..........................................................................52 hydrocodone-acetaminophen tab 10-325 mg, 5-325 mg, 7.5-325 mg..............................................................52 HYDROCODONE BITARTRATE/AC.................................52 HYDROCODONE BITARTRATE ER.................................52 hydrocodone-ibuprofen tab 7.5-200 mg........................52 HYDROCORTISONE.........................................................70 HYDROCORTISONE ACETATE....................................... 70 HYDROCORTISONE BUTYRATE.................................... 73 hydrocortisone cream 2.5%............................................73 hydrocortisone enema 100 mg/60ml (Cortenema).......70 hydrocortisone oint 2.5%................................................73 hydrocortisone perianal cream 2.5% (Anusol-hc)....... 70 hydrocortisone tab 5 mg, 10 mg, 20 mg (Cortef)......... 17 hydrocortisone valerate cream 0.2%.............................73 hydrocortisone w/ acetic acid otic soln 1-2%.............. 69 hydromorphone hcl liqd 1 mg/ml (Dilaudid).................52 hydromorphone hcl tab er 24hr 8 mg, 12 mg, 16 mg, 32 mg..............................................................................52 hydromorphone hcl tab 2 mg, 4 mg (Dilaudid)............ 52 hydromorphone hcl tab 8 mg (Dilaudid).......................52 HYDROXOCOBALAMIN....................................................62 hydroxychloroquine sulfate tab 400 mg......................... 7 hydroxychloroquine sulfate tab 100 mg, 300 mg...........7 hydroxychloroquine sulfate tab 200 mg (Plaquenil)......7 hydroxyurea cap 500 mg (Hydrea)................................ 12 hydroxyzine hcl syrup 10 mg/5ml................................. 42 hydroxyzine hcl tab 10 mg, 25 mg, 50 mg....................42 hydroxyzine pamoate cap 25 mg, 50 mg (Vistaril).......42 HYFTOR............................................................................. 73 HYMPAVZI..........................................................................65 I ibandronate sodium tab 150 mg (base equivalent) (Boniva).......................................................................... 26 IBRANCE............................................................................12 IBTROZI..............................................................................12 ibuprofen tab 400 mg, 600 mg, 800 mg.........................54 icatibant acetate subcutaneous soln pref syr 30 mg/3ml (Firazyr)............................................................ 65 ICLUSIG..............................................................................13 icosapent ethyl cap 0.5 gm, 1 gm (Vascepa)................32 IDELVION........................................................................... 65 IDHIFA................................................................................ 13 imatinib mesylate tab 100 mg (base equivalent), 400 mg (base equivalent) (Gleevec).................................. 13 IMBRUVICA........................................................................13 IMCIVREE.......................................................................... 26 imipramine hcl tab 10 mg, 25 mg, 50 mg......................43 imiquimod cream 5% (Aldara)........................................73

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 90 IMOVAX RABIES (H.D.C.V.)............................................... 9 IMPAVIDO.............................................................................7 INBRIJA.............................................................................. 60 INCRELEX..........................................................................26 INCRUSE ELLIPTA............................................................36 indapamide tab 1.25 mg, 2.5 mg....................................32 indomethacin cap er 75 mg............................................54 indomethacin cap 25 mg, 50 mg....................................54 INFANRIX........................................................................... 10 INGREZZA..........................................................................49 INLYTA................................................................................13 INQOVI............................................................................... 13 INREBIC............................................................................. 13 INSULIN GLARGINE-YFGN..............................................24 INSULIN PEN NEEDLES - VARIOUS...............................76 INSULIN SYRINGES - VARIOUS..................................... 76 INTELENCE..........................................................................5 IPOL INACTIVATED IPV..................................................... 9 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 36 ipratropium bromide hfa inhal aerosol 17 mcg/act (Atrovent hfa)................................................................ 36 ipratropium bromide inhal soln 0.02%..........................36 ipratropium bromide nasal soln 0.03% (21 mcg/spray), 0.06% (42 mcg/spray)...................................................34 IQIRVO............................................................................... 39 irbesartan-hydrochlorothiazide tab 150-12.5 mg, 300-12.5 mg (Avalide)...................................................30 irbesartan tab 75 mg, 150 mg, 300 mg (Avapro).......... 30 IRESSA...............................................................................13 IRON CHEWS PEDIATRIC............................................... 62 IRON UP............................................................................ 62 ISENTRESS......................................................................... 5 ISENTRESS HD...................................................................5 isoniazid syrup 50 mg/5ml................................................3 isoniazid tab 100 mg, 300 mg.......................................... 3 isosorbide dinitrate-hydralazine hcl tab 20-37.5 mg (Bidil)...............................................................................33 isosorbide dinitrate tab 10 mg, 20 mg, 30 mg..............27 isosorbide dinitrate tab 5 mg (Isordil titradose).......... 27 isosorbide mononitrate tab er 24hr 30 mg, 60 mg, 120 mg................................................................................... 27 isosorbide mononitrate tab 10 mg, 20 mg....................27 isotretinoin cap 10 mg, 20 mg, 30 mg, 40 mg (Absorica).......................................................................73 ISTURISA........................................................................... 26 ITOVEBI..............................................................................13 itraconazole cap 100 mg (Sporanox).............................. 3 itraconazole oral soln 10 mg/ml (Sporanox).................. 3 ivabradine hcl tab 5 mg (base equiv), 7.5 mg (base equiv) (Corlanor)...........................................................33 ivermectin cream 1% (Soolantra).................................. 73 ivermectin tab 3 mg (Stromectol).................................... 7 IWILFIN...............................................................................13 IXINITY............................................................................... 65 J JAKAFI................................................................................13 JANUMET...........................................................................21 JANUMET XR.................................................................... 21 JANUVIA.............................................................................21 JARDIANCE....................................................................... 21 JAYPIRCA.......................................................................... 13 JIVI......................................................................................65 JOENJA.............................................................................. 77 JOURNAVX........................................................................ 51 JULUCA................................................................................5 JUST RIGHT 5000.............................................................69 JUXTAPID...........................................................................32 JYNARQUE........................................................................ 26 JYNNEOS.............................................................................9 K KALYDECO........................................................................ 37 KERENDIA......................................................................... 26 KESIMPTA..........................................................................49 ketoconazole cream 2%..................................................73 ketoconazole shampoo 2%.............................................73 ketoconazole tab 200 mg..................................................3 KETONE BLOOD TEST STRIPS - VARIOUS.................. 75 ketorolac tromethamine ophth soln 0.5% (Acular)......67 ketorolac tromethamine ophth soln 0.4% (Acular ls).....................................................................................67 ketorolac tromethamine tab 10 mg............................... 54 KEVZARA...........................................................................54 KINRIX................................................................................10 KISQALI..............................................................................13 KLOXXADO........................................................................75 KOATE................................................................................65 KOATE-DVI.........................................................................65 KOSELUGO........................................................................13 KOVALTRY......................................................................... 65 K-PHOS NO 2....................................................................42 KRAZATI.............................................................................13 L labetalol hcl tab 100 mg..................................................28 labetalol hcl tab 200 mg, 300 mg...................................28 lacosamide oral solution 10 mg/ml (Vimpat)................57 lacosamide tab 50 mg, 100 mg, 150 mg, 200 mg (Vimpat).......................................................................... 57 lactic acid (ammonium lactate) cream 12%..................73 lactic acid (ammonium lactate) lotion 12%...................73 lactulose (encephalopathy) solution 10 gm/15ml........39 lactulose solution 10 gm/15ml....................................... 37 LAGEVRIO........................................................................... 5 lamivudine oral soln 10 mg/ml (Epivir)........................... 5 lamivudine tab 150 mg, 300 mg (Epivir)......................... 5 lamivudine tab 100 mg (hbv) (Epivir hbv).......................5 lamivudine-zidovudine tab 150-300 mg (Combivir)....... 5

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 91 lamotrigine orally disintegrating tab 25 mg, 50 mg, 100 mg, 200 mg (Lamictal odt)................................... 57 lamotrigine tab chewable dispersible 5 mg, 25 mg (Lamictal chewable di)................................................. 57 lamotrigine tab er 24hr 25 mg, 50 mg, 100 mg, 200 mg, 250 mg, 300 mg (Lamictal xr)......................................57 lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg (Lamictal)........................................................................57 LAMPIT.................................................................................7 LANCETS - VARIOUS.......................................................76 LANOXIN............................................................................ 27 lansoprazole cap delayed release 30 mg (Prevacid)....................................................................... 38 lanthanum carbonate chew tab 500 mg (elemental), 750 mg (elemental), 1000 mg (elemental) (Fosrenol).......................................................................39 lapatinib ditosylate tab 250 mg (base equiv) (Tykerb)...........................................................................13 latanoprost ophth soln 0.005% (Xalatan)......................67 LAZCLUZE......................................................................... 13 LEDIPASVIR/SOFOSBUVIR................................................5 leflunomide tab 10 mg, 20 mg (Arava)..........................54 lenalidomide cap 5 mg, 10 mg, 15 mg, 20 mg, 25 mg (Revlimid)....................................................................... 77 lenalidomide caps 2.5 mg (Revlimid)............................ 77 LENVIMA 4 MG DAILY DOSE.......................................... 13 LENVIMA 8 MG DAILY DOSE.......................................... 13 LENVIMA 10 MG DAILY DOSE........................................ 13 LENVIMA 12MG DAILY DOSE......................................... 13 LENVIMA 14 MG DAILY DOSE........................................ 13 LENVIMA 18 MG DAILY DOSE........................................ 13 LENVIMA 20 MG DAILY DOSE........................................ 13 LENVIMA 24 MG DAILY DOSE........................................ 13 letrozole tab 2.5 mg (Femara)........................................ 14 leucovorin calcium tab 5 mg, 15 mg, 25 mg.................14 LEUKERAN........................................................................ 14 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) (Xopenex concentrate).....................................36 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv), 0.63 mg/3ml (base equiv), 1.25 mg/3ml (base equiv) (Xopenex)....................................................................... 36 levetiracetam oral soln 100 mg/ml (Keppra).................57 levetiracetam tab er 24hr 500 mg, 750 mg (Keppra xr).................................................................................... 57 levetiracetam tab 250 mg, 500 mg (Keppra).................57 levetiracetam tab 750 mg, 1000 mg (Keppra)...............57 LEVOBUNOLOL HCL........................................................67 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 26 levocarnitine tab 330 mg (Carnitor)...............................26 levofloxacin oral soln 25 mg/ml.......................................2 levofloxacin tab 250 mg, 500 mg, 750 mg...................... 2 levonor-eth est tab 0.15-0.02/0.025/0.03 mg &eth est 0.01 mg (Quartette).......................................................19 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg.................................................................. 19 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg, 0.15 mg-30 mcg.............................................................19 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg...............................19 levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg.......................................................................19 levonorgestrel tab 1.5 mg...............................................19 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique)........................................... 19 levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique)............................................... 19 LEVOTHYROXINE SODIUM.............................................24 levothyroxine sodium tab 25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg (Synthroid)..........24 lidocaine hcl soln 4%......................................................73 lidocaine hcl viscous soln 2%....................................... 69 LIDOCAINE HYDROCHLORIDE J....................................73 lidocaine oint 5%............................................................. 73 lidocaine patch 5% (Lidoderm)...................................... 73 lidocaine-prilocaine cream 2.5-2.5%..............................73 linezolid for susp 100 mg/5ml (Zyvox)............................7 linezolid tab 600 mg (Zyvox)............................................ 7 liothyronine sodium tab 25 mcg, 50 mcg (Cytomel)........................................................................24 liothyronine sodium tab 5 mcg (Cytomel).................... 24 liraglutide (weight mngmt) soln pen-inj 18 mg/3ml (6 mg/ml) (Saxenda)..........................................................47 lisdexamfetamine dimesylate cap 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg (Vyvanse)..............47 lisdexamfetamine dimesylate chew tab 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg (Vyvanse).....................47 lisinopril & hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg, 20-25 mg (Zestoretic).............................. 30 lisinopril tab 2.5 mg, 5 mg, 10 mg, 30 mg, 40 mg (Zestril)........................................................................... 30 lisinopril tab 20 mg (Prinivil)..........................................30 LITHIUM CARBONATE..................................................... 45 lithium carbonate cap 300 mg....................................... 45 lithium carbonate cap 150 mg, 600 mg (Lithium carbonate)...................................................................... 45 lithium carbonate tab er 450 mg....................................45 lithium carbonate tab er 300 mg (Lithobid).................. 45 lithium carbonate tab 300 mg........................................ 45 LITHOBID........................................................................... 45 LITHOSTAT.........................................................................42 LIVDELZI............................................................................ 39 LIVMARLI........................................................................... 39 LIVTENCITY.........................................................................5 lofexidine hcl tab 0.18 mg (base equivalent) (Lucemyra)..................................................................... 49 LOKELMA...........................................................................77 LO LOESTRIN FE............................................................. 19 lomustine cap 10 mg, 40 mg, 100 mg (Gleostine)........14 LONSURF...........................................................................14

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 92 lopinavir-ritonavir tab 100-25 mg, 200-50 mg (Kaletra)............................................................................ 5 lorazepam conc 2 mg/ml.................................................42 lorazepam tab 0.5 mg, 1 mg, 2 mg (Ativan)..................42 LORBRENA........................................................................14 losartan potassium & hydrochlorothiazide tab 50-12.5 mg, 100-12.5 mg, 100-25 mg (Hyzaar)........................30 losartan potassium tab 25 mg, 50 mg, 100 mg (Cozaar).......................................................................... 30 LOTEMAX...........................................................................67 LOTEMAX SM....................................................................67 loteprednol etabonate ophth gel 0.5% (Lotemax)........67 loteprednol etabonate ophth susp 0.5% (Lotemax)....................................................................... 67 lovastatin tab 10 mg........................................................33 lovastatin tab 20 mg, 40 mg...........................................33 loxapine succinate cap 5 mg, 10 mg, 25 mg, 50 mg................................................................................... 45 lubiprostone cap 8 mcg, 24 mcg (Amitiza)...................39 LUMAKRAS........................................................................14 LUMIGAN........................................................................... 67 LUMRYZ............................................................................. 49 LUMRYZ STARTER PACK................................................49 LUPKYNIS..........................................................................77 lurasidone hcl tab 20 mg, 40 mg, 60 mg, 80 mg, 120 mg (Latuda)....................................................................45 LYNPARZA......................................................................... 14 LYSODREN........................................................................ 14 LYTGOBI.............................................................................14 LYUMJEV............................................................................22 LYUMJEV KWIKPEN......................................................... 22 LYUMJEV TEMPO PEN.................................................... 22 M malathion lotion 0.5% (Ovide)........................................73 maraviroc tab 150 mg, 300 mg (Selzentry).....................5 MARPLAN.......................................................................... 43 MATULANE........................................................................ 14 MAVENCLAD......................................................................49 MAVYRET.............................................................................5 MAYZENT...........................................................................49 MAYZENT STARTER PACK..............................................49 MECLOFENAMATE SODIUM........................................... 54 medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac)................................................20 medroxyprogesterone acetate im susp prefilled syr 150 mg/ml (Depo-provera contrac).............................20 medroxyprogesterone acetate tab 2.5 mg, 5 mg, 10 mg (Provera)..................................................................20 mefenamic acid cap 250 mg.......................................... 54 mefloquine hcl tab 250 mg...............................................7 megestrol acetate susp 40 mg/ml................................. 14 megestrol acetate tab 20 mg..........................................14 megestrol acetate tab 40 mg..........................................14 MEKINIST...........................................................................14 MEKTOVI............................................................................14 meloxicam tab 7.5 mg, 15 mg (Mobic).......................... 54 memantine hcl oral solution 2 mg/ml............................49 memantine hcl tab 5 mg, 10 mg (Namenda).................49 MEMANTINE HCL TITRATION P..................................... 49 MENQUADFI........................................................................ 9 MENVEO.............................................................................. 9 meprobamate tab 200 mg, 400 mg................................ 42 mercaptopurine susp 2000 mg/100ml (20 mg/ml) (Purixan).........................................................................14 mercaptopurine tab 50 mg............................................. 14 mesalamine cap er 24hr 0.375 gm (Apriso)..................39 MESALAMINE DR............................................................. 39 mesalamine enema 4 gm................................................39 mesalamine suppos 1000 mg (Canasa)........................39 mesalamine tab delayed release 1.2 gm (Lialda).........40 mesalamine tab delayed release 800 mg......................40 mesna tab 400 mg (Mesnex).......................................... 14 MESNEX.............................................................................14 metaxalone tab 400 mg...................................................60 metaxalone tab 800 mg (Skelaxin)................................ 60 metformin hcl tab er 24hr 500 mg, 750 mg...................21 metformin hcl tab 500 mg, 850 mg, 1000 mg............... 21 methadone hcl conc 10 mg/ml (Methadose)................ 52 methadone hcl soln 5 mg/5ml, 10 mg/5ml (Methadone hcl).................................................................................. 52 methadone hcl tab for oral susp 40 mg........................52 methadone hcl tab 5 mg.................................................52 methadone hcl tab 10 mg...............................................52 methamphetamine hcl tab 5 mg.................................... 47 methazolamide tab 25 mg, 50 mg..................................32 methenamine hippurate tab 1 gm (Hiprex).....................7 methimazole tab 5 mg, 10 mg (Tapazole)..................... 24 METHITEST....................................................................... 18 methocarbamol tab 500 mg, 750 mg.............................60 METHOTREXATE SODIUM.............................................. 14 methotrexate sodium for inj 1 gm................................. 14 methotrexate sodium inj pf 1000 mg/40ml (25 mg/ ml)................................................................................... 14 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml), 250 mg/10ml (25 mg/ml)......................................................14 methotrexate sodium tab 2.5 mg (base equiv).............14 METHOXSALEN................................................................ 73 methscopolamine bromide tab 2.5 mg, 5 mg...............38 methsuximide cap 300 mg (Celontin)........................... 57 METHYLDOPA................................................................... 30 methyldopa tab 250 mg.................................................. 30 methylergonovine maleate tab 0.2 mg..........................25 methylphenidate hcl cap er 24hr 60 mg (la).................47 methylphenidate hcl cap er 24hr 10 mg (la), 20 mg (la), 30 mg (la), 40 mg (la) (Ritalin la).........................47 methylphenidate hcl cap er 10 mg (cd), 20 mg (cd), 30 mg (cd), 40 mg (cd), 50 mg (cd), 60 mg (cd)..............47 methylphenidate hcl chew tab 2.5 mg, 5 mg, 10 mg................................................................................... 47

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 93 methylphenidate hcl soln 5 mg/5ml, 10 mg/5ml (Methylin)........................................................................47 methylphenidate hcl tab er 10 mg, 20 mg.................... 47 methylphenidate hcl tab er osmotic release (osm) 72 mg................................................................................... 47 methylphenidate hcl tab er osmotic release (osm) 18 mg, 27 mg, 36 mg, 54 mg (Concerta).........................47 methylphenidate hcl tab 5 mg, 10 mg (Ritalin)............ 47 methylphenidate hcl tab 20 mg (Ritalin).......................47 METHYLPHENIDATE HYDROCHLO................................47 methylprednisolone tab 4 mg, 16 mg, 32 mg (Medrol).......................................................................... 17 methylprednisolone tab 8 mg (Medrol).........................17 methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak).......................................................... 17 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv).............................................................................. 40 metoclopramide hcl tab 5 mg (base equivalent), 10 mg (base equivalent) (Reglan)....................................40 METOCLOPRAMIDE ODT................................................ 40 metolazone tab 2.5 mg....................................................32 metolazone tab 5 mg, 10 mg..........................................32 metoprolol & hydrochlorothiazide tab 50-25 mg, 100-25 mg, 100-50 mg..................................................30 metoprolol succinate tab er 24hr 25 mg (tartrate equiv), 50 mg (tartrate equiv), 100 mg (tartrate equiv), 200 mg (tartrate equiv) (Toprol xl)................. 28 metoprolol tartrate tab 25 mg........................................ 28 metoprolol tartrate tab 50 mg, 100 mg (Lopressor).....28 metronidazole cream 0.75% (Metrocream)................... 73 metronidazole gel 0.75%.................................................73 metronidazole gel 1% (Metrogel)................................... 73 metronidazole tab 250 mg................................................ 7 metronidazole tab 500 mg (Flagyl).................................. 7 metronidazole vaginal gel 0.75%................................... 41 mexiletine hcl cap 150 mg, 200 mg, 250 mg.................29 MICONAZOLE 3................................................................ 41 midodrine hcl tab 2.5 mg, 5 mg, 10 mg........................ 32 mifepristone tab 300 mg (Korlym).................................21 milnacipran hcl tab 12.5 mg, 25 mg, 50 mg, 100 mg (Savella)..........................................................................49 milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & 50 mg (42) pak (Savella titration pa)......................................49 minocycline hcl cap 50 mg...............................................2 minocycline hcl cap 75 mg, 100 mg................................2 minoxidil tab 2.5 mg, 10 mg...........................................30 mirabegron tab er 24 hr 25 mg, 50 mg (Myrbetriq)...... 41 mirtazapine orally disintegrating tab 30 mg, 45 mg (Remeron soltab).......................................................... 43 mirtazapine orally disintegrating tab 15 mg (Remeron soltab).............................................................................43 mirtazapine tab 7.5 mg....................................................43 mirtazapine tab 45 mg.....................................................43 mirtazapine tab 15 mg, 30 mg (Remeron).....................43 misoprostol tab 100 mcg, 200 mcg (Cytotec).............. 38 M-M-R II................................................................................9 MNEXSPIKE COVID-19 VACCIN........................................9 modafinil tab 100 mg, 200 mg (Provigil).......................48 MODEYSO......................................................................... 14 moexipril hcl tab 7.5 mg, 15 mg.................................... 30 MOLINDONE HYDROCHLORIDE.................................... 45 mometasone furoate cream 0.1%..................................73 mometasone furoate oint 0.1%...................................... 73 mometasone furoate solution 0.1% (lotion)................. 73 MONOCAL..........................................................................61 montelukast sodium chew tab 4 mg (base equiv), 5 mg (base equiv) (Singulair).........................................36 montelukast sodium tab 10 mg (base equiv) (Singulair).......................................................................36 morphine sulfate oral soln 10 mg/5ml.......................... 52 morphine sulfate oral soln 100 mg/5ml (20 mg/ml)..... 52 morphine sulfate oral soln 20 mg/5ml (Morphine sulfate)............................................................................52 morphine sulfate tab er 30 mg, 60 mg, 100 mg, 200 mg (Ms contin).....................................................................52 morphine sulfate tab er 15 mg (Ms contin).................. 52 morphine sulfate tab 15 mg (Morphine sulfate)...........52 morphine sulfate tab 30 mg (Morphine sulfate)...........52 MOUNJARO....................................................................... 21 moxifloxacin hcl ophth soln 0.5% (base equiv) (Vigamox)....................................................................... 68 moxifloxacin hcl tab 400 mg (base equiv)......................2 MRESVIA..............................................................................9 MULPLETA.........................................................................62 MULTAQ............................................................................. 29 mupirocin oint 2%............................................................73 MYALEPT........................................................................... 26 MYCAPSSA........................................................................26 mycophenolate mofetil cap 250 mg (Cellcept).............77 mycophenolate mofetil for oral susp 200 mg/ml (Cellcept)........................................................................ 77 mycophenolate mofetil tab 500 mg (Cellcept)..............77 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv), 360 mg (mycophenolic acid equiv) (Myfortic)........................................................................ 77 MYFEMBREE.....................................................................18 MYHIBBIN.......................................................................... 77 MYLERAN.......................................................................... 14 MYRBETRIQ...................................................................... 41 MYSOLINE......................................................................... 57 N nabumetone tab 500 mg, 750 mg.................................. 54 nadolol tab 20 mg, 40 mg, 80 mg (Corgard).................28 naftifine hcl cream 2% (Naftifine hydrochlor).............. 73 NAFTIFINE HYDROCHLORIDE........................................73 naloxone hcl inj 0.4 mg/ml............................................. 75 naloxone hcl inj 4 mg/10ml............................................ 75 naloxone hcl nasal spray 4 mg/0.1ml (Narcan)............75 naloxone hcl soln prefilled syringe 0.4 mg/ml, 2 mg/2ml............................................................................ 75

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 94 NALOXONE HYDROCHLORIDE...................................... 75 naltrexone hcl tab 50 mg................................................75 naproxen sodium tab 275 mg, 550 mg..........................54 naproxen tab 250 mg, 375 mg....................................... 54 naproxen tab 500 mg (Naprosyn).................................. 54 naratriptan hcl tab 1 mg (base equiv), 2.5 mg (base equiv) (Amerge).............................................................55 NATACYN........................................................................... 68 NATAZIA............................................................................. 20 NATROBA...........................................................................73 NAYZILAM.......................................................................... 57 nebivolol hcl tab 2.5 mg (base equivalent), 5 mg (base equivalent), 10 mg (base equivalent), 20 mg (base equivalent) (Bystolic)................................................... 28 NEBUSAL...........................................................................34 NEFAZODONE HYDROCHLORIDE................................. 43 NEMLUVIO.........................................................................73 NEOMYCIN/POLYMYXIN/BACITR................................... 68 NEOMYCIN/POLYMYXIN/GRAMIC.................................. 68 neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol)........................................................................ 68 neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol)...............................................................68 neomycin-polymyxin-hc otic soln 1%...........................69 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%...................................................................... 69 neomycin sulfate tab 500 mg...........................................3 NEORAL............................................................................. 77 NERLYNX........................................................................... 14 NEUPRO............................................................................ 60 NEVIRAPINE........................................................................5 nevirapine tab er 24hr 400 mg (Viramune xr).................5 nevirapine tab 200 mg.......................................................5 NEXLETOL.........................................................................33 NEXLIZET...........................................................................33 niacin tab er 500 mg (antihyperlipidemic), 750 mg (antihyperlipidemic), 1000 mg (antihyperlipidemic) (Niaspan)........................................................................ 33 nicotine polacrilex gum 2 mg, 4 mg..............................49 nicotine polacrilex lozenge 2 mg, 4 mg........................49 nicotine td patch 24hr 7 mg/24hr, 14 mg/24hr, 21 mg/24hr...........................................................................50 NICOTINE TRANSDERMAL SYST...................................50 NICOTROL NS...................................................................50 nifedipine cap 10 mg, 20 mg..........................................29 nifedipine tab er 24hr 30 mg, 60 mg, 90 mg................. 29 nifedipine tab er 24hr osmotic release 30 mg, 60 mg (Procardia xl)................................................................. 29 nifedipine tab er 24hr osmotic release 90 mg (Procardia xl)................................................................. 29 nilotinib hcl cap 50 mg (base equivalent), 150 mg (base equivalent), 200 mg (base equivalent) (Tasigna).........................................................................14 NILUTAMIDE...................................................................... 14 nimodipine cap 30 mg.....................................................29 NINLARO............................................................................14 nitazoxanide tab 500 mg...................................................8 nitisinone cap 2 mg, 5 mg, 10 mg, 20 mg (Orfadin).....26 NITRO-BID......................................................................... 27 NITRO-DUR........................................................................27 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin)...................................................................8 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin)...................................................................8 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)................................................................. 8 nitrofurantoin susp 25 mg/5ml.........................................8 nitroglycerin oint 0.4% (Rectiv)..................................... 70 nitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6 mg (Nitrostat)....................................................................... 27 nitroglycerin td patch 24hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr (Nitro-dur).........................................27 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) (Nitrolingual pumpspr).................................................27 NITRO-TIME.......................................................................27 NIVA THYROID..................................................................24 NIZATIDINE........................................................................38 nizatidine cap 150 mg..................................................... 38 norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr.........................................................................20 norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg..................................................................... 20 norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg (Generess fe)............................................ 20 norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg................................................................................. 20 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg, 1 mg-35 mcg..................................................................20 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg, 1.5 mg-30 mcg.....................................................20 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg, 1.5 mg-30 mcg.....................................................20 norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24) (Minastrin 24 fe)............................................20 norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)......................................................................... 20 norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg................................................................................. 19 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt)................................................................. 19 norethindrone acetate tab 5 mg (Aygestin)..................20 norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe)................................................. 20 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg...........................................................................20 norethindrone tab 0.35 mg............................................. 20 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg................................................................................. 20 norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg, 0.18-35/0.215-35/0.25-35 mg-mcg............... 20

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 95 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........20 NORPACE CR....................................................................29 nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75 mg (Pamelor)........................................................................44 nortriptyline hcl soln 10 mg/5ml....................................44 NORVIR................................................................................5 NOVAFERRUM PEDIATRIC DROP..................................62 NOVOEIGHT...................................................................... 65 NOVOLIN 70/30.................................................................23 NOVOLIN 70/30 FLEXPEN...............................................23 NOVOLIN 70/30 FLEXPEN REL.......................................23 NOVOLIN 70/30 RELION..................................................23 NOVOLIN N........................................................................23 NOVOLIN N FLEXPEN......................................................23 NOVOLIN N FLEXPEN RELION.......................................23 NOVOLIN N RELION.........................................................23 NOVOLIN R........................................................................23 NOVOLIN R FLEXPEN......................................................23 NOVOLIN R FLEXPEN RELION.......................................23 NOVOLIN R RELION.........................................................23 NOVOLOG..........................................................................22 NOVOLOG FLEXPEN....................................................... 22 NOVOLOG FLEXPEN RELION.........................................23 NOVOLOG MIX 70/30....................................................... 23 NOVOLOG MIX 70/30 PREFILL....................................... 24 NOVOLOG MIX 70/30 RELION........................................ 24 NOVOLOG PENFILL......................................................... 23 NOVOLOG RELION.......................................................... 23 NOVOSEVEN RT...............................................................65 NOXAFIL...............................................................................3 NP THYROID 15................................................................24 NP THYROID 30................................................................24 NP THYROID 60................................................................24 NP THYROID 90................................................................24 NP THYROID 120..............................................................24 NUBEQA.............................................................................14 NUCALA............................................................................. 36 NUCYNTA ER.................................................................... 52 NULIBRY............................................................................ 26 NURTEC.............................................................................55 NUVARING.........................................................................20 NUVAXOVID COVID-19 VACCIN........................................9 NUWIQ................................................................................65 NUZYRA............................................................................... 2 nystatin cream 100000 unit/gm......................................73 nystatin oint 100000 unit/gm..........................................73 nystatin susp 100000 unit/ml......................................... 69 nystatin tab 500000 unit....................................................3 nystatin topical powder 100000 unit/gm.......................73 nystatin-triamcinolone cream 100000-0.1 unit/gm- %......................................................................................74 nystatin-triamcinolone oint 100000-0.1 unit/gm-%...... 74 O OBIZUR.............................................................................. 65 ODACTRA.......................................................................... 11 ODEFSEY.............................................................................5 ODOMZO............................................................................14 OFEV.................................................................................. 37 OFLOXACIN.........................................................................2 ofloxacin ophth soln 0.3% (Ocuflox).............................68 ofloxacin otic soln 0.3%..................................................69 OGSIVEO........................................................................... 14 OJEMDA.............................................................................14 OJJAARA............................................................................15 olanzapine orally disintegrating tab 5 mg, 10 mg, 15 mg, 20 mg (Zyprexa zydis)..........................................45 olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg (Zyprexa)........................................................................ 45 olanzapine tab 20 mg (Zyprexa).................................... 45 olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg, 40-5-12.5 mg, 40-5-25 mg, 40-10-12.5 mg, 40-10-25 mg (Tribenzor)....................................... 31 olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg, 40-12.5 mg, 40-25 mg (Benicar hct).......30 olmesartan medoxomil tab 5 mg, 20 mg, 40 mg (Benicar).........................................................................30 olopatadine hcl nasal soln 0.6% (Patanase).................34 OLUMIANT......................................................................... 54 omeprazole cap delayed release 10 mg, 20 mg, 40 mg................................................................................... 38 OMNIFLEX DIAPHRAGM..................................................76 OMNIPOD DASH PODS (GEN 4).................................... 76 OMNIPOD 5 DEXCOM G7G6 INT....................................76 OMNIPOD 5 DEXCOM G7G6 POD..................................76 OMNIPOD 5 LIBRE2 PLUS G6........................................ 76 OMNITROPE......................................................................26 OMVOH.............................................................................. 40 ONAPGO............................................................................ 60 ondansetron hcl oral soln 4 mg/5ml............................. 38 ondansetron hcl tab 8 mg.............................................. 38 ondansetron hcl tab 4 mg (Zofran)................................38 ondansetron orally disintegrating tab 4 mg, 8 mg.......38 ONFI................................................................................... 57 ONUREG............................................................................ 15 OPFOLDA...........................................................................26 OPILL..................................................................................20 OPSUMIT........................................................................... 33 OPTIONS GYNOL II VAGINAL......................................... 41 OPTIUMEZ TEST STRIPS................................................75 OPVEE................................................................................75 ORAVIG.............................................................................. 69 ORENCIA........................................................................... 54 ORENCIA CLICKJECT......................................................54 ORENITRAM...................................................................... 33 ORENITRAM TITRATION KIT M...................................... 33 ORFADIN............................................................................26 ORGOVYX..........................................................................15 ORIAHNN........................................................................... 19 ORILISSA........................................................................... 26 ORKAMBI........................................................................... 37

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 96 ORLADEYO........................................................................65 ORLISTAT...........................................................................48 orphenadrine citrate tab er 12hr 100 mg...................... 60 ORSERDU..........................................................................15 oseltamivir phosphate cap 30 mg (base equiv), 45 mg (base equiv), 75 mg (base equiv) (Tamiflu)................. 5 oseltamivir phosphate for susp 6 mg/ml (base equiv) (Tamiflu)............................................................................5 OTEZLA..............................................................................54 OTEZLA/OTEZLA XR 28 DAY T.......................................54 OTEZLA XR....................................................................... 54 oxaprozin tab 600 mg (Daypro)..................................... 54 oxazepam cap 10 mg, 15 mg, 30 mg.............................42 oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal)........................................................................ 58 oxcarbazepine tab er 24hr 150 mg, 300 mg, 600 mg (Oxtellar xr)....................................................................58 oxcarbazepine tab 300 mg, 600 mg (Trileptal)............. 58 oxcarbazepine tab 150 mg (Trileptal)............................58 OXERVATE.........................................................................68 oxiconazole nitrate cream 1% (Oxistat)........................74 oxybutynin chloride solution 5 mg/5ml........................ 41 oxybutynin chloride tab er 24hr 15 mg.........................41 oxybutynin chloride tab er 24hr 5 mg, 10 mg (Ditropan xl).....................................................................................41 oxybutynin chloride tab 5 mg........................................ 41 oxycodone hcl conc 100 mg/5ml (20 mg/ml)................52 oxycodone hcl soln 5 mg/5ml........................................52 oxycodone hcl tab 10 mg............................................... 52 oxycodone hcl tab 20 mg............................................... 52 oxycodone hcl tab 15 mg, 30 mg (Roxicodone)...........52 oxycodone hcl tab 5 mg (Roxicodone).........................52 oxycodone w/ acetaminophen tab 2.5-325 mg, 7.5-325 mg, 10-325 mg (Percocet)............................................52 oxycodone w/ acetaminophen tab 5-325 mg (Percocet).......................................................................52 OXYCONTIN...................................................................... 52 oxymorphone hcl tab 5 mg, 10 mg................................53 OXYMORPHONE HYDROCHLORIDE............................. 53 OZEMPIC........................................................................... 21 P paliperidone tab er 24hr 1.5 mg, 3 mg, 6 mg, 9 mg (Invega)...........................................................................45 PALYNZIQ...........................................................................26 pantoprazole sodium ec tab 20 mg (base equiv), 40 mg (base equiv) (Protonix)..........................................38 PARODONTAX...................................................................69 paroxetine hcl tab 10 mg, 20 mg, 30 mg, 40 mg (Paxil)..............................................................................44 PAXLOVID............................................................................ 5 pazopanib hcl tab 200 mg (base equiv) (Votrient)....... 15 PEDIARIX...........................................................................10 PEDVAX HIB........................................................................9 PEGASYS.............................................................................5 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely)................................................................. 37 peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln 100 gm (Moviprep)........................................................37 peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely)........................................................................ 37 PEG-PREP......................................................................... 37 PEMAZYRE........................................................................15 PENBRAYA...........................................................................9 penicillamine tab 250 mg (Depen titratabs)..................77 PENICILLIN V POTASSIUM................................................1 penicillin v potassium tab 250 mg, 500 mg....................1 PENMENVY..........................................................................9 PENTACEL.........................................................................11 pentamidine isethionate for nebulization soln 300 mg (Nebupent)........................................................................8 pentoxifylline tab er 400 mg...........................................65 perampanel susp 0.5 mg/ml (Fycompa)........................58 perampanel tab 2 mg, 4 mg, 6 mg, 8 mg, 10 mg, 12 mg (Fycompa)...................................................................... 58 PERINDOPRIL ERBUMINE.............................................. 31 perindopril erbumine tab 4 mg...................................... 31 PERIOMED.........................................................................69 permethrin cream 5% (Elimite)...................................... 74 PERPHENAZINE/AMITRIPTYLIN.....................................50 perphenazine tab 2 mg, 4 mg, 8 mg, 16 mg................. 45 PHEBURANE..................................................................... 26 PHENELZINE SULFATE....................................................44 PHENOBARBITAL..............................................................46 phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 31 phentermine hcl cap 15 mg, 30 mg, 37.5 mg................48 phentermine hcl tab 8 mg...............................................48 phentermine hcl tab 37.5 mg (Adipex-p).......................48 phentermine hcl-topiramate cap er 24hr 3.75-23 mg, 7.5-46 mg, 11.25-69 mg, 15-92 mg (Qsymia)..............48 phenylephrine hcl ophth soln 2.5%, 10%..................... 68 phenytoin chew tab 50 mg (Dilantin infatabs)..............58 phenytoin sodium extended cap 200 mg, 300 mg (Phenytek)...................................................................... 58 phenytoin sodium extended cap 100 mg (Dilantin).....58 phenytoin susp 125 mg/5ml (Dilantin-125)...................58 PHEXX................................................................................41 PHOSPHA 250 NEUTRAL................................................ 61 PHOSPHOROUS............................................................... 61 PHOSPHO-TRIN K500......................................................61 PHOSPHO-TRIN 250 NEUTRAL...................................... 61 phytonadione tab 5 mg (Mephyton).............................. 61 pilocarpine hcl ophth soln 1%, 2%, 4% (Isopto carpine)...........................................................................68 pilocarpine hcl tab 5 mg, 7.5 mg (Salagen)..................69 pimecrolimus cream 1% (Elidel).................................... 74 PIMOZIDE.......................................................................... 50 pindolol tab 5 mg, 10 mg................................................28 pioglitazone hcl-metformin hcl tab 15-500 mg, 15-850 mg (Actoplus met)........................................................22

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 97 pioglitazone hcl tab 15 mg (base equiv), 30 mg (base equiv), 45 mg (base equiv) (Actos)............................ 22 PIQRAY 200MG DAILY DOSE..........................................15 PIQRAY 250MG DAILY DOSE..........................................15 PIQRAY 300MG DAILY DOSE..........................................15 PIRFENIDONE...................................................................37 pirfenidone cap 267 mg (Esbriet).................................. 37 pirfenidone tab 267 mg, 801 mg (Esbriet).................... 37 piroxicam cap 10 mg, 20 mg (Feldene).........................54 PLEGRIDY..........................................................................50 PLEGRIDY STARTER PACK............................................ 50 PNEUMOVAX 23............................................................... 10 PODOFILOX.......................................................................74 polymyxin b-trimethoprim ophth soln 10000 unit/ ml-0.1% (Polytrim)........................................................ 68 pomalidomide cap 1 mg, 2 mg, 3 mg, 4 mg (Pomalyst)...................................................................... 15 POMALYST........................................................................ 15 posaconazole susp 40 mg/ml (Noxafil)...........................3 posaconazole tab delayed release 100 mg (Noxafil)..... 3 potassium chloride cap er 8 meq, 10 meq................... 61 potassium chloride microencapsulated crys er tab 15 meq................................................................................. 61 potassium chloride microencapsulated crys er tab 10 meq, 20 meq..................................................................61 potassium chloride oral soln 10% (20 meq/15ml), 20% (40 meq/15ml)................................................................61 potassium chloride powder packet 20 meq................. 61 potassium chloride tab er 10 meq, 20 meq (1500 mg) (K-tab)............................................................................. 61 potassium chloride tab er 8 meq (600 mg)...................61 potassium citrate tab er 5 meq (540 mg) (Urocit-k 5)......................................................................................42 potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10)....................................................................................42 potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15)....................................................................................42 PRADAXA...........................................................................63 pramipexole dihydrochloride tab 0.25 mg, 1.5 mg...... 60 pramipexole dihydrochloride tab 0.125 mg, 0.5 mg, 0.75 mg, 1 mg (Mirapex).............................................. 60 prasugrel hcl tab 5 mg (base equiv), 10 mg (base equiv) (Effient)...............................................................65 pravastatin sodium tab 10 mg, 20 mg, 40 mg, 80 mg................................................................................... 33 praziquantel tab 600 mg (Biltricide)................................ 7 prazosin hcl cap 1 mg, 2 mg (Minipress)......................31 prazosin hcl cap 5 mg (Minipress)................................ 31 PRECISION XTRA BLOOD GLUC................................... 75 prednisolone acetate ophth susp 1% (Pred forte).......68 prednisolone sodium phosphate oral soln 25 mg/5ml (base eq)........................................................................ 17 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)................................................................... 17 prednisolone sod phosphate oral soln 5 mg/5ml (base equiv) (Pediapred)........................................................ 17 prednisolone soln 15 mg/5ml.........................................17 PREDNISONE....................................................................17 prednisone tab 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50 mg................................................................................... 17 prednisone tab therapy pack 10 mg (48)......................17 prednisone tab therapy pack 5 mg (21), 5 mg (48), 10 mg (21)........................................................................... 17 pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg, 225 mg, 300 mg (Lyrica)................................58 pregabalin soln 20 mg/ml (Lyrica).................................58 PREMARIN.........................................................................19 PREMPHASE..................................................................... 19 PREMPRO..........................................................................19 PREPIDIL........................................................................... 25 PRETOMANID......................................................................3 PREVNAR 20.....................................................................10 PREVYMIS........................................................................... 5 PREZCOBIX.........................................................................6 PREZISTA.............................................................................6 PRIFTIN................................................................................3 primaquine phosphate tab 26.3 mg (15 mg base) (Primaquine phosphate).................................................7 PRIMIDONE....................................................................... 58 primidone tab 50 mg (Mysoline).................................... 58 primidone tab 250 mg (Mysoline).................................. 58 PRIORIX............................................................................. 10 probenecid tab 500 mg................................................... 56 prochlorperazine maleate tab 5 mg (base equivalent), 10 mg (base equivalent).............................................. 45 prochlorperazine suppos 25 mg....................................45 PROCTOCORT.................................................................. 70 PROCTOFOAM HC........................................................... 70 PROFILNINE...................................................................... 65 progesterone cap 100 mg (Prometrium).......................20 progesterone cap 200 mg (Prometrium).......................20 progesterone im in oil 50 mg/ml....................................20 PROGRAF..........................................................................77 promethazine-dm syrup 6.25-15 mg/5ml.......................34 promethazine hcl oral soln 6.25 mg/5ml.......................34 promethazine hcl suppos 12.5 mg, 25 mg....................34 promethazine hcl tab 12.5 mg, 25 mg, 50 mg...............34 promethazine w/ codeine syrup 6.25-10 mg/5ml..........34 PROMETHEGAN............................................................... 34 propafenone hcl cap er 12hr 225 mg, 325 mg, 425 mg (Rythmol sr)...................................................................29 propafenone hcl tab 150 mg.......................................... 29 propafenone hcl tab 225 mg, 300 mg............................29 PROPRANOLOL HCL....................................................... 28 propranolol hcl cap er 24hr 60 mg, 80 mg (Inderal la).....................................................................................28 propranolol hcl cap er 24hr 120 mg, 160 mg (Inderal la).....................................................................................28 propranolol hcl tab 60 mg.............................................. 28

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 98 propranolol hcl tab 10 mg, 20 mg, 40 mg, 80 mg.........28 PROPRANOLOL HYDROCHLORIDE...............................28 propylthiouracil tab 50 mg............................................. 24 PROQUAD..........................................................................10 protriptyline hcl tab 5 mg, 10 mg.................................. 44 PULMOSAL........................................................................ 34 PULMOZYME.....................................................................37 PURIXAN............................................................................15 pyrazinamide tab 500 mg..................................................3 pyridostigmine bromide oral soln 60 mg/5ml (Mestinon)...................................................................... 61 pyridostigmine bromide tab 60 mg (Mestinon)............61 pyrimethamine tab 25 mg (Daraprim)............................. 7 PYRUKYND........................................................................65 PYRUKYND TAPER PACK............................................... 66 Q QINLOCK............................................................................15 QUADRACEL..................................................................... 11 quetiapine fumarate tab er 24hr 50 mg, 150 mg, 200 mg (Seroquel xr)...........................................................45 quetiapine fumarate tab er 24hr 300 mg, 400 mg (Seroquel xr)..................................................................45 quetiapine fumarate tab 25 mg, 50 mg, 100 mg, 200 mg, 300 mg, 400 mg (Seroquel)..................................45 QUINAPRIL/HYDROCHLOROTHIA..................................31 quinapril hcl tab 5 mg, 10 mg, 20 mg, 40 mg (Accupril)........................................................................31 quinidine gluconate tab er 324 mg................................29 QUINIDINE SULFATE........................................................29 quinine sulfate cap 324 mg (Qualaquin).........................7 QULIPTA.............................................................................55 QVAR REDIHALER............................................................36 R RABAVERT.........................................................................10 rabeprazole sodium ec tab 20 mg (Aciphex)................38 RADICAVA ORS.................................................................60 RADICAVA ORS STARTER KIT........................................60 RAGWITEK.........................................................................11 raloxifene hcl tab 60 mg (Evista)...................................26 ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10 mg (Altace).....31 ranolazine tab er 12hr 500 mg, 1000 mg (Ranexa).......27 rasagiline mesylate tab 0.5 mg (base equiv), 1 mg (base equiv) (Azilect)....................................................60 RASUVO.............................................................................54 REBIF................................................................................. 50 REBIF REBIDOSE.............................................................50 REBIF REBIDOSE TITRATION.........................................50 REBIF TITRATION PACK..................................................50 REBINYN............................................................................66 RECOMBINATE................................................................. 66 RECOMBIVAX HB............................................................. 10 RELENZA DISKHALER.......................................................6 repaglinide tab 2 mg....................................................... 22 repaglinide tab 0.5 mg, 1 mg..........................................22 REPATHA........................................................................... 33 REPATHA SURECLICK.....................................................33 RESTASIS.......................................................................... 68 RETACRIT.......................................................................... 62 RETEVMO..........................................................................15 REVUFORJ........................................................................ 15 REXTOVY...........................................................................75 REXULTI.............................................................................45 REYATAZ.............................................................................. 6 REYVOW............................................................................55 REZLIDHIA.........................................................................15 REZUROCK........................................................................77 RHAPSIDO.........................................................................77 RHOPRESSA..................................................................... 68 RIASTAP.............................................................................66 RIBAVIRIN............................................................................ 6 RIDAURA............................................................................54 rifabutin cap 150 mg (Mycobutin)....................................3 rifampin cap 150 mg, 300 mg...........................................3 rilpivirine hcl tab 25 mg (base equivalent) (Edurant)...........................................................................6 riluzole tab 50 mg (Rilutek)............................................ 60 RINVOQ..............................................................................54 RINVOQ LQ....................................................................... 55 risedronate sodium tab 35 mg, 150 mg (Actonel)........26 RISPERIDONE ODT..........................................................45 risperidone orally disintegrating tab 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg.............................................................45 risperidone soln 1 mg/ml (Risperdal)............................46 risperidone tab 0.25 mg..................................................46 risperidone tab 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg (Risperdal)......................................................................46 ritonavir tab 100 mg (Norvir)............................................6 rivaroxaban for susp 1 mg/ml (Xarelto)........................ 63 rivaroxaban tab 2.5 mg (Xarelto)................................... 63 rivastigmine tartrate cap 1.5 mg (base equivalent), 3 mg (base equivalent), 4.5 mg (base equivalent), 6 mg (base equivalent)....................................................50 rivastigmine td patch 24hr 4.6 mg/24hr, 9.5 mg/24hr, 13.3 mg/24hr (Exelon).................................................. 50 RIVIVE................................................................................ 75 RIXUBIS..............................................................................66 rizatriptan benzoate oral disintegrating tab 5 mg (base eq)................................................................................... 55 rizatriptan benzoate oral disintegrating tab 10 mg (base eq) (Maxalt-mlt).................................................. 55 rizatriptan benzoate tab 5 mg (base equivalent)..........55 rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt)........................................................................... 56 roflumilast tab 250 mcg, 500 mcg (Daliresp)................36 ROMVIMZA........................................................................ 15 ropinirole hydrochloride tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg..................................................60 rosuvastatin calcium tab 5 mg, 10 mg, 20 mg, 40 mg (Crestor)......................................................................... 33

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 99 ROTARIX............................................................................ 10 ROTATEQ...........................................................................10 ROZLYTREK...................................................................... 15 RUBRACA.......................................................................... 15 RUKOBIA..............................................................................6 RYBELSUS.........................................................................22 RYCLORA.......................................................................... 34 RYDAPT............................................................................. 15 RYTARY..............................................................................60 S sacubitril-valsartan tab 24-26 mg, 49-51 mg, 97-103 mg (Entresto).................................................................33 SANDIMMUNE...................................................................77 SANTYL..............................................................................74 sapropterin dihydrochloride powder packet 100 mg, 500 mg (Kuvan).............................................................26 sapropterin dihydrochloride tab 100 mg (Kuvan)........26 SAVELLA............................................................................ 50 SAVELLA TITRATION PACK.............................................50 SCEMBLIX..........................................................................15 scopolamine td patch 72hr 1 mg/3days (Transderm- scop)............................................................................... 38 SECUADO..........................................................................46 SELARSDI..........................................................................74 selegiline hcl cap 5 mg...................................................60 selegiline hcl tab 5 mg....................................................60 SELENIUM SULFIDE........................................................ 74 SELZENTRY.........................................................................6 SEMGLEE.......................................................................... 24 SENSODYNE COMPLETE PROTEC...............................69 SENSODYNE RAPID RELIEF.......................................... 69 SENSODYNE REPAIR & PROTEC.................................. 69 SENSODYNE SENSITIVITY & G......................................69 SENSODYNE SENSITIVITY GUM................................... 69 SEPHIENCE.......................................................................26 SEREVENT DISKUS......................................................... 36 sertraline hcl oral concentrate for solution 20 mg/ml (Zoloft)............................................................................ 44 sertraline hcl tab 25 mg, 50 mg, 100 mg (Zoloft)......... 44 sevelamer carbonate packet 0.8 gm, 2.4 gm (Renvela)........................................................................ 40 sevelamer carbonate tab 800 mg (Renvela)................. 40 sevelamer hcl tab 400 mg...............................................40 SEVENFACT...................................................................... 66 SF........................................................................................69 SF 5000 PLUS...................................................................69 SHINGRIX.......................................................................... 10 SIGNIFOR.......................................................................... 26 SIKLOS...............................................................................62 sildenafil citrate tab 20 mg (Revatio)............................ 33 silodosin cap 4 mg, 8 mg (Rapaflo).............................. 42 silver sulfadiazine cream 1% (Silvadene).....................74 SIMBRINZA........................................................................ 68 SIMLANDI...........................................................................55 SIMLANDI 1-PEN KIT........................................................55 SIMLANDI 2-PEN KIT........................................................55 SIMPONI.............................................................................55 simvastatin tab 5 mg.......................................................33 simvastatin tab 10 mg, 20 mg, 40 mg (Zocor)..............33 simvastatin tab 80 mg (Zocor)....................................... 33 sirolimus oral soln 1 mg/ml (Rapamune)......................77 sirolimus tab 0.5 mg, 1 mg, 2 mg (Rapamune)............ 77 SIRTURO..............................................................................3 SIVEXTRO............................................................................8 SKYCLARYS...................................................................... 60 SKYRIZI..............................................................................40 SKYRIZI PEN.....................................................................74 SKYTROFA.........................................................................26 SODIUM CHLORIDE......................................................... 35 SODIUM CITRATE/CITRIC ACI........................................42 SODIUM CITRATE AND CITRIC...................................... 42 SODIUM FLUORIDE......................................................... 61 SODIUM FLUORIDE/POTASSIUM................................... 70 SODIUM FLUORIDE 5000 PLUS..................................... 70 SODIUM FLUORIDE 5000 PPM.......................................70 sodium oxybate oral solution 500 mg/ml (Xyrem).......50 sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl)......................................................................26 sodium phenylbutyrate tab 500 mg (Buphenyl)...........26 sodium polystyrene sulfonate powder......................... 77 sodium polystyrene sulfonate susp 15 gm/60ml.........78 sod sulfate-pot sulf-mg sulf oral sol 17.5-3.13-1.6 gm/177ml (Suprep bowel prep ki)...............................37 SOFOSBUVIR/VELPATASVIR.............................................6 SOHONOS......................................................................... 60 solifenacin succinate tab 5 mg, 10 mg (Vesicare)....... 41 SOLIQUA 100/33............................................................... 22 SOLTAMOX........................................................................ 15 SOMAVERT........................................................................27 sorafenib tosylate tab 200 mg (base equivalent) (Nexavar)........................................................................ 15 sotalol hcl (afib/afl) tab 80 mg, 120 mg (Betapace af).....................................................................................28 sotalol hcl (afib/afl) tab 160 mg (Betapace af)..............28 sotalol hcl tab 240 mg.....................................................28 sotalol hcl tab 80 mg, 120 mg (Betapace).................... 28 sotalol hcl tab 160 mg (Betapace).................................28 SOTYKTU...........................................................................74 SOVALDI...............................................................................6 SPEVIGO............................................................................74 SPIKEVAX COVID-19 VACCINE.......................................10 SPINOSAD......................................................................... 74 SPIRIVA RESPIMAT..........................................................36 spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide)..................................................................32 spironolactone tab 25 mg, 50 mg, 100 mg (Aldactone).....................................................................32 SPS.....................................................................................78 stannous fluoride gel 0.4%.............................................70 STEQEYMA........................................................................74

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 100 STIOLTO RESPIMAT.........................................................36 STIVARGA..........................................................................15 STRENSIQ......................................................................... 27 STRIBILD..............................................................................6 STRIVERDI RESPIMAT.....................................................36 SUBOXONE....................................................................... 53 sucralfate tab 1 gm (Carafate)....................................... 38 SULCONAZOLE NITRATE................................................74 SULFACETAMIDE SODIUM..............................................68 SULFACETAMIDE SODIUM/PRED.................................. 68 sulfacetamide sodium lotion 10% (acne) (Klaron).......74 sulfadiazine tab 500 mg....................................................3 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml.............................................................................. 8 sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim)...........................................................................8 sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds)..................................................................... 8 SULFAMYLON................................................................... 74 sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)...........................................................................40 sulfasalazine tab 500 mg (Azulfidine)........................... 40 sulindac tab 150 mg, 200 mg......................................... 55 sumatriptan nasal spray 5 mg/act, 20 mg/act (Imitrex).......................................................................... 56 sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............56 sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys)................................. 56 sumatriptan succinate tab 25 mg, 50 mg, 100 mg (Imitrex).......................................................................... 56 sunitinib malate cap 12.5 mg (base equivalent), 25 mg (base equivalent), 37.5 mg (base equivalent), 50 mg (base equivalent) (Sutent)........................................... 15 SUNLENCA.......................................................................... 6 SUNOSI.............................................................................. 48 SUTAB................................................................................ 38 SYMBICORT...................................................................... 36 SYMDEKO..........................................................................37 SYMPROIC.........................................................................40 SYMTUZA.............................................................................6 SYNAREL...........................................................................27 SYNJARDY.........................................................................22 SYNJARDY XR..................................................................22 SYNTHROID.......................................................................24 T TABLOID.............................................................................15 TABRECTA......................................................................... 15 tacrolimus cap 0.5 mg, 1 mg, 5 mg (Prograf)...............78 tacrolimus oint 0.03%, 0.1% (Protopic).........................74 tadalafil tab 20 mg (pah) (Adcirca)................................ 33 TAFINLAR...........................................................................15 tafluprost preservative free (pf) ophth soln 0.0015% (Zioptan)......................................................................... 68 TAGRISSO......................................................................... 16 TAKHZYRO........................................................................ 66 TALZENNA......................................................................... 16 tamoxifen citrate tab 10 mg (base equivalent), 20 mg (base equivalent)...........................................................16 tamsulosin hcl cap 0.4 mg (Flomax)............................. 42 TASIGNA............................................................................ 16 tasimelteon capsule 20 mg (Hetlioz)............................. 46 TAVALISSE.........................................................................66 tazarotene cream 0.1% (Tazorac)...................................74 tazarotene gel 0.05% (Tazorac)...................................... 74 TEGRETOL........................................................................ 58 TEGRETOL-XR.................................................................. 58 telmisartan tab 20 mg, 80 mg (Micardis)...................... 31 telmisartan tab 40 mg (Micardis)................................... 31 temazepam cap 15 mg, 30 mg (Restoril)...................... 46 temozolomide cap 5 mg, 20 mg.....................................16 temozolomide cap 100 mg, 140 mg, 180 mg, 250 mg (Temodar)....................................................................... 16 TENCON.............................................................................51 TENIVAC.............................................................................11 tenofovir disoproxil fumarate tab 300 mg (Viread)........6 TEPMETKO........................................................................16 terazosin hcl cap 1 mg (base equivalent), 2 mg (base equivalent), 5 mg (base equivalent), 10 mg (base equivalent)......................................................................31 terbinafine hcl tab 250 mg................................................3 terbutaline sulfate tab 2.5 mg, 5 mg..............................36 terconazole vaginal cream 0.4%, 0.8%..........................41 terconazole vaginal suppos 80 mg............................... 41 teriflunomide tab 7 mg, 14 mg (Aubagio)..................... 50 teriparatide soln pen-inj 560 mcg/2.24ml (Forteo).......27 testosterone cypionate im inj in oil 100 mg/ml, 200 mg/ml (Depo-testosterone)..........................................18 TESTOSTERONE ENANTHATE.......................................18 testosterone td gel 12.5 mg/act (1%).............................18 testosterone td gel 20.25 mg/act (1.62%) (Androgel pump)..............................................................................18 testosterone td gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) (Androgel)............................................................. 18 testosterone td soln 30 mg/act...................................... 18 tetrabenazine tab 12.5 mg, 25 mg (Xenazine).............. 50 TETRACAINE HCL............................................................ 68 tetracaine hcl ophth soln 0.5%...................................... 68 tetracycline hcl cap 250 mg, 500 mg...............................2 TEZSPIRE.......................................................................... 36 THALOMID......................................................................... 78 THEO-24.............................................................................36 theophylline elixir 80 mg/15ml....................................... 36 theophylline soln 80 mg/15ml........................................ 36 theophylline tab er 12hr 300 mg, 450 mg..................... 36 theophylline tab er 24hr 400 mg, 600 mg..................... 36 thioridazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg.......46 thiothixene cap 1 mg, 2 mg, 5 mg, 10 mg.....................46 THYQUIDITY......................................................................25 THYROID............................................................................25 tiagabine hcl tab 2 mg, 4 mg (Gabitril)..........................58

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 101 TIAGABINE HYDROCHLORIDE.......................................58 TIBSOVO............................................................................16 ticagrelor tab 60 mg, 90 mg (Brilinta)........................... 66 timolol maleate ophth soln 0.25%, 0.5% (Timoptic).....68 tinidazole tab 250 mg, 500 mg......................................... 8 tiopronin tab delayed release 100 mg, 300 mg (Thiola ec)....................................................................................42 tiopronin tab 100 mg (Thiola).........................................42 TIROSINT...........................................................................25 TIROSINT-SOL.................................................................. 25 TIVICAY................................................................................ 6 TIVICAY PD..........................................................................6 tizanidine hcl tab 2 mg (base equivalent).....................61 tizanidine hcl tab 4 mg (base equivalent) (Zanaflex)........................................................................61 TOBRADEX........................................................................68 tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex)...................................................................... 68 tobramycin nebu soln 300 mg/5ml (Tobi)....................... 3 tobramycin ophth soln 0.3% (Tobrex)...........................68 TODAY SPONGE...............................................................41 tolcapone tab 100 mg (Tasmar)..................................... 60 tolterodine tartrate cap er 24hr 2 mg, 4 mg (Detrol la).....................................................................................41 tolterodine tartrate tab 1 mg, 2 mg (Detrol)..................41 tolvaptan (hyponatremia) tab 15 mg, 30 mg (Samsca).........................................................................27 topiramate cap er 24hr sprinkle 25 mg, 50 mg, 100 mg, 150 mg, 200 mg (Qudexy xr)............................... 58 topiramate sprinkle cap 15 mg, 25 mg (Topamax sprinkle)..........................................................................58 topiramate tab 25 mg, 50 mg, 100 mg, 200 mg (Topamax).......................................................................58 toremifene citrate tab 60 mg (base equivalent) (Fareston).......................................................................16 torsemide tab 5 mg, 10 mg, 20 mg, 100 mg................. 32 TOUJEO MAX SOLOSTAR...............................................24 TOUJEO SOLOSTAR........................................................ 24 tramadol-acetaminophen tab 37.5-325 mg (Ultracet).........................................................................53 tramadol hcl tab er 24hr 100 mg, 200 mg, 300 mg.......53 tramadol hcl tab 50 mg (Ultram)....................................53 trandolapril tab 1 mg, 2 mg, 4 mg................................. 31 tranexamic acid tab 650 mg (Lysteda)..........................63 tranylcypromine sulfate tab 10 mg (Parnate)...............44 travoprost ophth soln 0.004% (benzalkonium free) (bak free) (Travatan z)..................................................68 trazodone hcl tab 50 mg, 100 mg, 150 mg....................44 TRELEGY ELLIPTA........................................................... 36 TREMFYA...........................................................................40 TREMFYA INDUCTION PACK FO....................................40 TREMFYA PEN..................................................................74 TRESIBA............................................................................ 24 TRESIBA FLEXTOUCH.....................................................24 tretinoin cap 10 mg......................................................... 16 tretinoin cream 0.025%, 0.05%, 0.1% (Retin-a).............74 tretinoin gel 0.01% (Retin-a)...........................................74 TRETTEN........................................................................... 66 TRIAMCINOLONE ACETONIDE.......................................74 triamcinolone acetonide cream 0.025%, 0.1%, 0.5%.................................................................................74 triamcinolone acetonide dental paste 0.1%................. 70 triamcinolone acetonide lotion 0.1%.............................74 triamcinolone acetonide oint 0.025%, 0.1%, 0.5%....... 74 triamterene & hydrochlorothiazide cap 37.5-25 mg................................................................................... 32 triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25)...................................................................32 triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide)........................................................................ 32 trientine hcl cap 250 mg (Syprine)................................ 78 trifluoperazine hcl tab 1 mg (base equivalent), 2 mg (base equivalent), 5 mg (base equivalent), 10 mg (base equivalent)...........................................................46 TRIFLURIDINE...................................................................68 TRIHEXYPHENIDYL HCL................................................. 60 trihexyphenidyl hcl tab 2 mg, 5 mg...............................60 TRIJARDY XR....................................................................22 TRIKAFTA...........................................................................37 trimethobenzamide hcl cap 300 mg.............................. 38 trimethoprim tab 100 mg.................................................. 8 trimipramine maleate cap 25 mg, 50 mg, 100 mg........ 44 TRINTELLIX....................................................................... 44 TRIUMEQ............................................................................. 6 TRIUMEQ PD.......................................................................6 trospium chloride cap er 24hr 60 mg............................41 trospium chloride tab 20 mg..........................................41 TRULANCE........................................................................ 40 TRULICITY......................................................................... 22 TRUMENBA........................................................................10 TRUQAP.............................................................................16 TRYNGOLZA......................................................................27 TUKYSA..............................................................................16 TURALIO............................................................................ 16 TWINRIX.............................................................................10 TYBLUME...........................................................................20 TYENNE............................................................................. 55 TYMLOS............................................................................. 27 TYVASO..............................................................................34 TYVASO DPI MAINTENANCE KI..................................... 34 TYVASO DPI TITRATION KIT...........................................34 TYVASO REFILL KIT.........................................................34 TYVASO STARTER KIT.................................................... 34 U UBRELVY........................................................................... 56 UPTRAVI.............................................................................34 UPTRAVI TITRATION PACK.............................................34 URINE TEST STRIPS - VARIOUS....................................75 ursodiol cap 300 mg........................................................40 ursodiol tab 250 mg (Urso 250)..................................... 40

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 102 ursodiol tab 500 mg (Urso forte)................................... 40 V valacyclovir hcl tab 1 gm (Valtrex).................................. 6 valacyclovir hcl tab 500 mg (Valtrex).............................. 6 VALCHLOR.........................................................................74 valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte)............................................................................6 valganciclovir hcl tab 450 mg (base equivalent) (Valcyte)............................................................................6 valproate sodium oral soln 250 mg/5ml (base equiv).............................................................................. 58 valproic acid cap 250 mg................................................58 valsartan-hydrochlorothiazide tab 80-12.5 mg, 160-12.5 mg, 160-25 mg (Diovan hct).........................31 valsartan-hydrochlorothiazide tab 320-12.5 mg, 320-25 mg (Diovan hct)................................................31 valsartan tab 40 mg, 80 mg, 160 mg, 320 mg (Diovan).......................................................................... 31 VALTOCO 5 MG DOSE.....................................................58 VALTOCO 10 MG DOSE...................................................58 VALTOCO 15 MG DOSE...................................................58 VALTOCO 20 MG DOSE...................................................58 vancomycin hcl cap 250 mg (base equivalent) (Vancocin)........................................................................ 8 vancomycin hcl cap 125 mg (base equivalent) (Vancocin hcl)..................................................................8 vancomycin hcl for oral soln 25 mg/ml (base equivalent), 50 mg/ml (base equivalent) (Firvanq)..... 8 VANFLYTA..........................................................................16 VANRAFIA.......................................................................... 42 VAQTA................................................................................ 10 varenicline tartrate tab 0.5 mg (base equiv), 1 mg (base equiv)................................................................... 50 varenicline tartrate tab 11 x 0.5 mg & 42 x 1 mg start pack.................................................................................50 VARIVAX.............................................................................10 VARUBI...............................................................................39 VASCEPA........................................................................... 33 VAXELIS............................................................................. 11 VAXNEUVANCE.................................................................10 VCF VAGINAL CONTRACEPTIVE................................... 41 VECAMYL...........................................................................31 VELIVET............................................................................. 20 VEMLIDY.............................................................................. 6 VENCLEXTA.......................................................................16 VENCLEXTA STARTING PACK........................................16 venlafaxine hcl cap er 24hr 37.5 mg (base equivalent), 75 mg (base equivalent), 150 mg (base equivalent) (Effexor xr).....................................................................44 venlafaxine hcl tab 25 mg (base equivalent), 37.5 mg (base equivalent), 50 mg (base equivalent), 75 mg (base equivalent), 100 mg (base equivalent).............44 VENTOLIN HFA................................................................. 37 verapamil hcl tab er 120 mg, 180 mg, 240 mg (Calan sr).................................................................................... 29 verapamil hcl tab 40 mg, 80 mg, 120 mg......................29 VERSACLOZ......................................................................46 VERZENIO......................................................................... 16 VIBERZI..............................................................................40 vigabatrin powd pack 500 mg (Sabril).......................... 58 vigabatrin tab 500 mg (Sabril)........................................58 VIJOICE..............................................................................78 vilazodone hcl tab 10 mg, 20 mg, 40 mg (Viibryd).......44 VIMPAT............................................................................... 58 VIRACEPT............................................................................6 VIREAD.................................................................................6 VITRAKVI........................................................................... 16 VIVOTIF..............................................................................10 VIZIMPRO.......................................................................... 16 VONJO................................................................................16 VONVENDI.........................................................................66 VORANIGO........................................................................ 16 voriconazole for susp 40 mg/ml (Vfend).........................3 voriconazole tab 50 mg, 200 mg (Vfend)........................ 3 VOSEVI.................................................................................7 VOTRIENT..........................................................................16 VOWST...............................................................................40 VOXZOGO..........................................................................27 VRAYLAR........................................................................... 46 VUMERITY......................................................................... 50 VYALEV.............................................................................. 60 VYKAT XR..........................................................................27 VYNDAMAX........................................................................34 VYVGART HYTRULO........................................................78 W WAINUA..............................................................................50 WAKIX.................................................................................48 warfarin sodium tab 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg, 10 mg.............................................63 WEGOVY............................................................................48 WELIREG........................................................................... 16 WES-PHOS 250 NEUTRAL.............................................. 62 WIDE-SEAL SILICONE DIAPHR...................................... 77 WILATE...............................................................................66 WINREVAIR........................................................................34 X XALKORI............................................................................ 16 XARELTO........................................................................... 63 XARELTO STARTER PACK.............................................. 63 XCOPRI.............................................................................. 59 XELJANZ............................................................................ 55 XELJANZ XR......................................................................55 XENICAL............................................................................ 48 XERMELO.......................................................................... 40 XIFAXAN...............................................................................8 XIGDUO XR....................................................................... 22 XIIDRA................................................................................68 XOFLUZA............................................................................. 7 XOLAIR...............................................................................37

2026 ND Health Insurance Market Individual, Small Group Formulary May 2026 103 XOLREMDI.........................................................................62 XOSPATA............................................................................16 XPOVIO.............................................................................. 17 XPOVIO 60 MG TWICE WEEKLY.................................... 17 XPOVIO 80 MG TWICE WEEKLY.................................... 17 XTANDI...............................................................................17 XULTOPHY 100/3.6...........................................................22 XYNTHA............................................................................. 66 XYNTHA SOLOFUSE........................................................66 XYWAV............................................................................... 51 Y YESINTEK..........................................................................74 YEZTUGO............................................................................ 7 YONSA............................................................................... 17 YORVIPATH........................................................................27 YUTREPIA..........................................................................34 Z zafirlukast tab 10 mg, 20 mg (Accolate)....................... 37 zaleplon cap 5 mg, 10 mg.............................................. 46 ZARONTIN......................................................................... 59 ZEJULA...............................................................................17 ZELBORAF.........................................................................17 ZELSUVMI..........................................................................75 ZENPEP..............................................................................39 ZEPBOUND........................................................................48 ZEPOSIA............................................................................ 51 ZEPOSIA 7-DAY STARTER PAC......................................51 ZEPOSIA STARTER KIT...................................................51 ZERVIATE...........................................................................68 zidovudine cap 100 mg (Retrovir)................................... 7 zidovudine syrup 10 mg/ml (Retrovir).............................7 zidovudine tab 300 mg......................................................7 zileuton tab er 12hr 600 mg........................................... 37 ziprasidone hcl cap 20 mg, 40 mg, 60 mg, 80 mg (Geodon).........................................................................46 ZOKINVY............................................................................ 78 ZOLINZA.............................................................................17 zolmitriptan tab 2.5 mg, 5 mg (Zomig)..........................56 zolpidem tartrate tab er 6.25 mg (Ambien cr)...............46 zolpidem tartrate tab er 12.5 mg (Ambien cr)...............46 zolpidem tartrate tab 5 mg, 10 mg (Ambien)................46 zonisamide cap 50 mg.................................................... 59 zonisamide cap 25 mg (Zonegran)................................ 59 zonisamide cap 100 mg (Zonegran).............................. 59 ZONTIVITY.........................................................................66 ZTALMY..............................................................................59 ZUBSOLV........................................................................... 53 ZURNAI...............................................................................75 ZURZUVAE.........................................................................44 ZYDELIG............................................................................ 17 ZYKADIA............................................................................ 17 ZYMFENTRA 1-PEN......................................................... 40 ZYMFENTRA 2-PEN......................................................... 40 ZYMFENTRA 2-SYRINGE................................................ 40

Book a walkthrough

Walk through this policy with us

Review how this policy can be converted into cited criteria, prior authorization checks, and operational automation.