Pharmacy Benefit Coverage Updates Jan. 1, 2018

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1 Pharmacy Benefit Coverage Updates Jan. 1, 2018 UnitedHealthcare routinely evaluates prescription benefit coverage to help ensure we offer members affordable and effective medication options. Medications may change in cost or coverage. The following summary highlights Prescription Drug List (PDL) updates for UnitedHealthcare Commercial benefit plans starting Jan. 1, Medications with New Benefit Coverage The following medications were not previously covered under most UnitedHealthcare commercial benefit plans and are now eligible for coverage on or before Jan. 1, Therapeutic Use Medication Tier Constipation Trulance 1 Hepatitis C Mavyret 1 Vosevi 1 Migraines Ergomar 1 Osteoporosis Tymlos 1 Rosacea Rhofade 1 Tier Updates and Lower Cost Alternatives Some medications will change tiers on Jan. 1, Medications may move from a higher to a lower tier or from a lower to a higher tier. Therapeutic Use Cancer Hemorrhoids Hepatitis B Medication* Tier Lower-Cost Options Mekinist 1 Cotellic 1, Zelboraf 1 Tafinlar 1 Cotellic 1, Zelboraf 1 hydrocortisone suppositories (generic Anusol-HC, Proctocort) adefovir (generic Hepsera) hydrocortisone 2.5% rectal cream (generic Anusol-HC) entecavir tablet (generic Baraclude) Hepatitis C Sovaldi 1 Epclusa 1, Harvoni 1, Mavyret 1 Doc #: PCA _

2 Therapeutic Use Mental Health Migraines Medication* Tier Lower-Cost Options clomipramine capsules (generic Anafranil) fluoxetine capsules (generic Sarafem) fluoxetine delayedrelease 90mg capsule (generic Prozac weekly) fluoxetine tablet (generic Prozac) dihydroergotamine nasal spray (generic Migranal) 1 citalopram (generic Celexa), escitalopram (generic Lexapro), fluoxetine capsules (generic Prozac), fluvoxamine (generic Luvox), paroxetine (generic Paxil), sertraline (generic Zoloft) naratriptan (generic Amerge), rizatriptan (generic Maxalt/Maxalt MLT), sumatriptan (generic Imitrex), zolmitriptan (generic Zomig/Zomig-ZMT), eletriptan (generic Relpax) Osteoporosis Forteo 1 ibandronate (generic Boniva), risedronate alendronate (generic Fosamax), (generic Actonel) Pain Xtampza ER 1 levorphanol tablets (generic Levo- Dromoran) N/A Psoriasis Otezla N/A hydromorphone tablets (generic Dilaudid), morphine tablets (generic MS-IR), oxycodone tablets (generic Roxicodone) Exclusions 2, 3 The following medications will no longer be covered under our pharmacy benefit plans starting Jan. 1, Therapeutic Use Medication Lower-Cost Options ADHD Strattera (Brand 1 atomoxetine (generic Strattera) Allergies RyVent carbinoxamine tablets (generic Palgic) fluticasone/salmeterol powder for Dulera 1 inhalation (generic AirDuo Respiclick), Advair Diskus/HFA, Breo Asthma Ellipta, Symbicort fluticasone/salmeterol powder for AirDuo RespiClick (Brand inhalation (generic AirDuo RespiClick), Advair Diskus/HFA, Breo Ellipta, Symbicort Chest Pain GoNitro nitroglycerin sublingual tablet

3 Therapeutic Use Medication Lower-Cost Options (generic Nitrostat) Micort-HC 2.5% cream hydrocortisone 2.5% cream flurandrenolide 0.05% cream (generic Cordran cream), Dermatitis Cordran cream (Brand 1 hydrocortisone valerate 0.2% cream (generic Westcort), prednicarbate 0.1% cream (generic Dermatop cream) flurandrenolide 0.05% lotion (generic Cordran lotion (Brand 1 Cordran), triamcinolone acetonide 0.1% lotion (generic Kenalog lotion) Diabetes Xultophy Soliqua 1 Dry Eye Disease Restasis MultiDose 1 Restasis (single use vials) 1, Xiidra 1 Duchenne Muscular Dystrophy Emflaza 1 prednisone Endocrine Disorders Sandostatin (Brand octreotide (generic Sandostatin) Hepatitis B Hypercholesterolemia Hyperparathyroidism Baraclude tablets (Brand Livalo 1 Vytorin (Brand Rayaldee metoprolol extendedrelease/hydrochlorothiazide (Dutoprol Authorized Generic) entecavir tablet (generic Baraclude) atorvastatin (generic Lipitor), lovastatin (generic Mevacor), pravastatin (generic Pravachol), rosuvastatin (generic Crestor), simvastatin (generic Zocor) simvastatin/ezetimibe (generic Vytorin) calcitriol (generic Rocaltrol), doxercalciferol (generic Hectorol), paricalcitol (generic Zemplar) metoprolol extended-release (generic Toprol-XL) plus hydrochlorothiazide Hypertension metoprolol extended-release (generic Dutoprol Toprol-XL) plus hydrochlorothiazide Inderal LA (Brand propranolol extended-release capsule (generic Inderal LA) Infections Daxbia cephalexin (generic Keflex) Influenza Tamiflu capsules (Brand oseltamivir capsules (generic Tamiflu) Mental Health fluoxetine 60 mg tablet fluoxetine tablets (generic Sarafem) Pristiq (Brand Prozac Weekly (Brand desvenlafaxine extended-release tablet (generic Pristiq)

4 Therapeutic Use Medication Lower-Cost Options Ocular Infections Ocular Pain/Inflammation Opioid Induced Constipation Sarafem tablets Seroquel XR (Brand Trintellix 1 Vigamox (Brand BromSite Relistor tablet 1 quetiapine extended-release (generic Seroquel XR) citalopram (generic Celexa), escitalopram (generic Lexapro),, fluvoxamine (generic Luvox), paroxetine (generic Paxil), sertraline (generic Zoloft) moxifloxacin ophthalmic solution (generic Viagamox) bromfenac ophthalmic solution (generic Bromday, Xibrom), diclofenac ophthalmic solution (generic Voltaren), ketorolac ophthalmic solution (generic Acular), Nevanac Movantik Oral Steroid LoCort dexamethasone tablets ZonaCort dexamethasone tablets Otitis Media Otovel ofloxacin 0.3% solution (generic Floxin, Ocuflox), Ciprodex Pain Arymo ER 1 morphine sulfate extended-release tablet (generic MS Contin), Nucynta ER 1, Xtampza ER 1 morphine sulfate extended-release Opana ER 1 tablet (generic MS Contin), Nucynta ER 1, Xtampza ER 1 Parkinson's Disease Azilect (Brand rasagiline (generic Azilect) Stroke & Heart Attack OTC aspirin plus omeprazole Yosprala Prevention (Prilosec), pantoprazole (Protonix) Prior Authorization - Medical Necessity Changes Prior Authorization - Medical Necessity reviews evaluate the clinical appropriateness of a medication in terms of condition being treated, type of medication, frequency of use and duration of therapy. The following medications will require a medical necessity review. Therapeutic Use Rosacea Medication Rhofade

5 Prior Authorization - Medical Necessity Changes cont. 1 Step therapy or prior authorization may be required prior to coverage. 2 Exclusion includes brand, generic and authorized generic products unless otherwise noted. 3 For ben.efits that don t exclude, step therapy or prior authorization is required. Footnote All branded medications are trademarks or registered trademarks of their respective owners. Please note not all PDL updates apply to all groups depending on state regulation, riders and SPDs. Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company or their affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcare of Texas, LLC, UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc., OptumRx, OptumHealth Care Solutions, Inc. or its affiliates.

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