PRESCRIPTION DRUG LIST CHANGES

Transcription

1 PRESCRIPTION DRUG LIST CHANGES For Providers 2018 Changes are being made to Cigna s Prescription Drug List that may affect some of your patients. These changes are listed by drug list name and by effective date. Below is the list of medications that are changing coverage levels. Please note that the coverage status of medications under our Prescription Drug Lists are always subject to the cost-share requirements, exclusions and coverage limitations of particular benefit plans. STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST Medication not covered^ July 1, 2018 GASTROINTESTINAL/HEARTBURN OmePPI omeprazole INFECTIONS Mycobutin rifabutin MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil, imiquimod, Picato April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, Uloric March 1, 2018 DIABETES Fiasp Humalog PARKINSON S DISEASE Gocovri amantadine February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort Flexhaler January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor nortriptyline Parnate tranylcypromine Tofranil imipramine ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER Zyflo CR zileuton ER ATTENTION DEFICIT HYPERACTIVITY DISORDER Desoxyn Dexedrine methamphetamine dextroamphetamine, dextroamphetamine ER BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablets CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba Novolin, Novolog Humalog, Humulin UPDATED_3/13/2018

2 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Medication not covered^ January 1, 2018 GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Anucort-HC, Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto- Pak, Proctosol-HC, Proctozone-HC Lotronex alosetron Marinol dronabinol omeprazole bicarbonate packets, omeprazole mg capsules Rowasa mesalamine enema Uceris tablet budesonide EC capsule Zegerid omeprazole Zofran ondansetron Zofran ODT ondansetron ODT HORMONAL AGENTS DDAVP desmopressin Hectorol doxercalciferol capsule INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillinclavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 erythromycin ethylsuccinate Mepron atovaquone Sporanox itraconazole Targadox Valcyte Vancocin Zovirax Avidoxy tablet, doxycycline hyclate, Morgidox capsule valganciclovir vancomycin capsule acyclovir MISCELLANEOUS Gralise, Horizant gabapentin PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone D.H.E. 45, Migranal dihydroergotamine Imitrex, Sumavel DosePro Lorzone OxyContin Roxicodone Tivorbex Vanatol LQ Vivlodex Zomig Zorvolex sumatriptan chlorzoxazone Embeda, Hysingla ER, Xtampza ER oxycodone indomethacin butalbital/acetaminophen/caffeine tabs or caps meloxicam sumatriptan, zolmitriptan diclofenac, diclofenac ER

3 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Medication not covered^ January 1, 2018 PARKINSON'S DISEASE Lodosyn carbidopa Requip XL ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone Zyprexa olanzapine Zyprexa Zydis olanzapine ODT SKIN CONDITIONS Cutivate fluticasone cream Kenalog triamcinolone spray Locoid lotion hydrocortisone butyrate Luzu ketoconazole cream Soriatane acitretin Ziana clindamycin-tretinoin SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil modafinil Restoril temazepam URINARY TRACT CONDITIONS Detrol tolterodine Detrol LA tolterodine ER Ditropan XL oxybutynin ER Enablex darifenacin ER Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER April 1, 2018 DIABETES QTERN January 1, 2018 MISCELLANEOUS Nityr + Non-preferred brand medication July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Arixtra + fondaparinux Lovenox + enoxaparin Reopro + CANCER dexrazoxane +, Evomela +, Hycamtin capsule +, Nilandron +, nilutamide +, Zinecard CONTRACEPTION PRODUCTS Depo-Provera 150mg/ml medroxyprogesterone LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg Nexplanon +, Paragard T 380-a + Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg DENTAL PRODUCTS Arestin + DIABETES Korlym + Preferred brand medication

4 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication July 1, 2018 EYE CONDITIONS Cystaran +, Ozurdex +, Retisert + GASTROINTESTINAL/HEARTBURN alosetron +, Buphenyl +, Chenodal +, Ravicti +, sodium phenylbutyrate HORMONAL AGENTS Aveed +, hydroxyprogesterone caproate + Depo-Provera 400mg/ml medroxyprogesterone INFECTIONS Daraprim +, Sirturo + INFERTILITY Makena + MISCELLANEOUS Asclera +, Carbaglu +, Ferriprox +, Flebogamma DIF +, Keveyis +, Varithena + Orfadin + Nityr PAIN RELIEF AND INFLAMMATORY DISEASE Colcrys colchicine (NON-NARCOTIC) PARKINSON S DISEASE Azilect rasagiline SEIZURE DISORDERS Lamictal ODT lamotrigine ODT SKIN CONDITIONS Ameluz +, Levulan + Tazorac 0.1% cream tazarotene SLEEP DISORDERS/SEDATIVES Hetlioz + TRANSPLANT MEDICATIONS Cellcept + mycophenolate Neoral 25mg capsule, solution + Sandimmune 100mg capsule + cyclosporine modified, Gengraf cyclosporine URINARY TRACT CONDITIONS Thiola + March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic HORMONAL AGENTS Depo-Testosterone testosterone cypionate February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR Focalin XR dextroamphetamine-amphetamine ER dexmethylphenidate ER SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC lotion Capex shampoo Cordran Differin hydrocortisone-pramoxine fluocinolone flurandrenolide adapalene

5 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication January 1, 2018 SKIN CONDITIONS (cont) Metrogel metronidazole gel Naftin Nucort, Texacort naftifine hydrocortisone Medication requiring prior authorization^^ July 1, 2018 CANCER Hycamtin ++, Targretin ++, tretinoin capsule ++, Xeloda ++ MISCELLANEOUS Nityr, Orfadin ++ PAIN RELIEF AND INFLAMMATORY Diskets, Dolophine, methadone ++, Methadose DISEASE (NARCOTIC) March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Striant, testosterone MISCELLANEOUS Nityr Medication with quantity limits^^ July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER #, Celexa #, citalopram #, desvenlafaxiner ER #, duloxetine #, Effexor XR #, Effexor #, Emsam #, escitalopram #, Fetzima #, fluoxetine #, fluvoxamine ER #, fluvoxamine #, Forfivo XL #, Khedezla, paroxetine CR #, paroxetine #, Paxil CR #, Pexeva #, Prozac, sertraline #, venlafaxine ER #, Wellbutrin SR, Wellbutrin XL, Zoloft BLOOD PRESSURE/HEART MEDICATIONS CHOLESTEROL MEDICATIONS GASTROINTESTINAL/HEARTBURN NUTRITIONAL/DIETARY PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC) PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC) SEIZURE DISORDERS Banzel # SKIN CONDITIONS calcitriol, Vectical SLEEP DISORDERS/SEDATIVES Rozerem BiDil mg #, captopril-hctz, dofetilide #, Tikosyn simvastatin, Zocor Aciphex, Dexilant, esomeprazole, lansoprazole DR, Nexium DR, Nexium, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole Auryxia Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asabutalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodoneacetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro

6 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Medication with quantity limits^^ February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone ALZHEIMER'S DISEASE Namenda XR, Namzaric ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, Pristiq ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, nilutamide EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medication^^ April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta ## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY Focalin XR ## dexmethylphenidate ER DISORDER SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap ## pimozide SKIN CONDITIONS Ala-Scalp ## hydrocortisone Capex shampoo ## fluocinolone Cordran ## flurandrenolide Nucort, Texacort ## hydrocortisone Medication strength with limitations** (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT mg Tekturna HCT mg

7 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Medication strength with limitations** (Your plan doesn t cover 2 capsules/tablets per day of this strength) January 1, 2018 CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 6mg Trokendi XR 25mg Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength) Fycompa 8mg Fycompa 12mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST April 1, 2018 DIABETES QTERN March 1, 2018 DIABETES Fiasp January 1, 2018 MISCELLANEOUS Nityr + Preferred brand medication Non-preferred brand medication July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Reopro + CANCER dexrazoxane +, Evomela +, Hycamtin capsule +, Nilandron +, nilutamide +, Zinecard Fusilev + leucovorin CONTRACEPTION PRODUCTS LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg Nexplanon +, Paragard T 380-a + Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg DENTAL PRODUCTS Arestin + DIABETES Korlym + EYE CONDITIONS Cystaran +, Ozurdex +, Retisert +

8 LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication July 1, 2018 GASTROINTESTINAL/HEARTBURN alosetron +, Buphenyl +, Chenodal +, Ravicti +, sodium phenylbutyrate HORMONAL AGENTS Aveed +, hydroxyprogesterone caproate + Saizen + Humatrope INFECTIONS Daraprim +, Sirturo + INFERTILITY Makena + MISCELLANEOUS Asclera +, Carbaglu +, Ferriprox +, Flebogamma DIF +, Keveyis +, Varithena + Orfadin + Nityr MULTIPLE SCLEROSIS Copaxone + Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera PAIN RELIEF AND INFLAMMATORY DISEASE Colcrys colchicine (NON-NARCOTIC) PARKINSON S DISEASE Azilect rasagiline SEIZURE DISORDERS Lamictal ODT lamotrigine ODT SKIN CONDITIONS Ameluz +, Levulan + Tazorac 0.1% cream tazarotene SLEEP DISORDERS/SEDATIVES Hetlioz + July 1, 2018 TRANSPLANT MEDICATIONS Cellcept tablet, capsule, suspension + mycophenolate tablet, capsule, suspension Neoral 25mg capsule, solution + cyclosporine modified, Gengraf Sandimmune 100mg capsule + cyclosporine URINARY TRACT CONDITIONS Thiola + April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, Uloric March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic PARKINSON S DISEASE Gocovri amantadine February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort Flexhaler BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Tresiba, Levemir GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, omeprazole 40mg-1100mg capsule, 20mg-1100mg

9 LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication January 1, 2018 INFECTIONS Eryped 400 erythromycin PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps SKIN CONDITIONS Ala-Scalp hydrocortisone topical Capex shampoo fluocinolone scalp Cordran flurandrenolide topical Differin adapalene Kenalog spray triamcinolone spray Locoid lotion hydrocortisone butyrate Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone Medication requiring prior authorization^^ July 1, 2018 CANCER Hycamtin ++, Targretin ++, tretinoin capsule ++, Xeloda ++ MISCELLANEOUS Nityr, Orfadin ++ MULTIPLE SCLEROSIS Copaxone PAIN RELIEF AND INFLAMMATORY DISEASE Diskets, Dolophine, methadone tablet, solution ++, methadone intensol ++, Methadose (NARCOTIC) April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, testosterone, Vogelxo MISCELLANEOUS Nityr PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone Medication with quantity limits^^ July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Aplenzin #, bupropion ER #, Celexa #, citalopram #, Cymbalta #, desvenlafaxiner ER #, duloxetine #, Effexor XR #, Effexor #, Emsam #, escitalopram #, Fetzima #, fluoxetine #, fluvoxamine ER #, fluvoxamine #, Forfivo XL #, Khedezla, Lexapro, paroxetine CR #, paroxetine #, Paxil CR #, Pexeva #, Prozac, sertraline #, venlafaxine ER #, Wellbutrin SR, Wellbutrin XL, Zoloft BLOOD PRESSURE/HEART MEDICATIONS BiDil mg #, captopril-hctz, dofetilide #, Tikosyn CHOLESTEROL MEDICATIONS simvastatin, Zocor DIABETES Jentadueto XR

10 LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont) Medication with quantity limits^^ July 1, 2018 GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, OmePPI, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid Solutab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole, Zegerid NUTRITIONAL/DIETARY Auryxia PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC) Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC) SCHIZOPHRENIA/ANTI-PSYCHOTICS Invega Sustenna # SEIZURE DISORDERS Banzel # SKIN CONDITIONS calcitriol, Vectical SLEEP DISORDERS/SEDATIVES Rozerem February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone, Nasonex ALZHEIMER'S DISEASE ANXIETY/DEPRESSION/BIPOLAR DISORDER ASTHMA/COPD/RESPIRATORY BLOOD PRESSURE/HEART MEDICATIONS CANCER DIABETES EYE CONDITIONS HORMONAL AGENTS INFECTIONS MISCELLANEOUS OSTEOPOROSIS PRODUCTS PAIN RELIEF AND INFLAMMATORY DISEASE SCHIZOPHRENIA/ANTI-PSYCHOTICS SEIZURE DISORDERS SKIN CONDITIONS SLEEP DISORDERS/SEDATIVES acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asabutalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodoneacetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro Namenda XR, Namzaric desvenlafaxine 25mg, 100mg, Marplan, Pristiq Perforomist Ranexa Fareston, Nilandron, nilutamide Jentadueto, Tradjenta bimatoprost eye drops, Cystaran, Zioptan Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle Dot, yuvafem Zovirax Nuedexta alendronate Daliresp, Mitigare Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv Gabitril, Potiga Denavir, Regranex, Santyl, Vectical, Zyclara Hetlioz

11 LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont) Medication strength with limitations** (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Trintellix 5mg Trintellix 10mg Fetzima ER 80mg Trintellix 10mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar HCT mg Bystolic 10mg Tekturna 150mg Tekturna HCT mg Benicar 40mg Benicar HCT 40-25mg Bystolic 20mg Tekturna 300mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Tekturna HCT mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Fycompa 4mg Fycompa 6mg Trokendi XR 25mg Trokendi XR 100mg Aptiom 800mg Fycompa 8mg Fycompa 12mg Trokendi XR 50mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg Step Therapy medication^^ Generic and/or Preferred Brand Alternatives July 1, 2018 ERECTILE DYSFUNCTION Cialis ## Viagra ## sildenafil, Cialis April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta ## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir ## QVAR, Pulmicort Flexhaler January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR ## dextroamphetamine-amphetamine ER Focalin XR ## SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify ## aripiprazole Orap ## dexmethylphenidate ER pimozide SKIN CONDITIONS Locoid lotion ## hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor ## eszopiclone, zolpidem

12 LEGACY (STANDARD) PRESCRIPTION DRUG LIST April 1, 2018 DIABETES QTERN March 1, 2018 DIABETES Fiasp January 1, 2018 MISCELLANEOUS Nityr + Preferred brand medication Non-preferred brand medication July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Arixtra + fondaparinux Lovenox + enoxaparin Reopro + CANCER dexrazoxane +, Evomela +, Hycamtin capsule +, Nilandron +, nilutamide +, Zinecard CONTRACEPTION PRODUCTS Depo-Provera 150mg/ml medroxyprogesterone LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg Nexplanon +, Paragard T 380-a + Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg DENTAL PRODUCTS Arestin + DIABETES Korlym + EYE CONDITIONS Cystaran +, Ozurdex +, Retisert + GASTROINTESTINAL/HEARTBURN alosetron +, Buphenyl +, Chenodal +, Lotronex +, Ravicti +, sodium phenylbutyrate HORMONAL AGENTS Aveed +, hydroxyprogesterone caproate + Depo-Provera 400mg/ml medroxyprogesterone Saizen Humatrope INFECTIONS Daraprim +, Sirturo + INFERTILITY Makena + MISCELLANEOUS Asclera +, Carbaglu +, Ferriprox +, Flebogamma DIF +, Keveyis +, Varithena + Orfadin + Nityr MULTIPLE SCLEROSIS Copaxone + Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera PAIN RELIEF AND INFLAMMATORY DISEASE Colcrys colchicine (NON-NARCOTIC) PARKINSON S DISEASE Azilect rasagiline SEIZURE DISORDERS Lamictal ODT lamotrigine ODT

13 LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication July 1, 2018 SKIN CONDITIONS Ameluz +, Levulan + Tazorac 0.1% cream tazarotene SLEEP DISORDERS/SEDATIVES Hetlioz + TRANSPLANT MEDICATIONS Cellcept capsule, tablet, suspension + mycophenolate Neoral 25mg capsule, solution + cyclosporine modified, Gengraf Sandimmune 100mg capsule + cyclosporine URINARY TRACT CONDITIONS Thiola + April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, Uloric March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic HORMONAL AGENTS Depo-Testosterone testosterone cypionate PARKINSON S DISEASE Gocovri amantadine February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort Flexhaler BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER CANCER Nilandron nilutamide DIABETES Apidra Humalog, Novolog Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, 40mg- omeprazole 1100mg capsule, 20mg-1100 mg capsule INFECTIONS Eryped 400 erythromycin PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45 dihydroergotamine Imitrex sumatriptan OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC hydrocortisone-pramoxine Capex shampoo fluocinolone Cordran flurandrenolide Differin adapalene Kenalog triamcinolone spray Locoid lotion hydrocortisone butyrate Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone

14 LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont) Medication requiring prior authorization^^ July 1, 2018 CANCER Hycamtin ++, Targretin ++, tretinoin capsule ++, Xeloda ++ MISCELLANEOUS Nityr, Orfadin ++ MULTIPLE SCLEROSIS Copaxone PAIN RELIEF AND INFLAMMATORY DISEASE Diskets, Dolophine, methadone ++, Methadose (NARCOTIC) April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi HORMONAL AGENTS MISCELLANEOUS PAIN RELIEF AND INFLAMMATORY DISEASE Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, testosterone, Vogelxo Nityr Roxicodone Medication with quantity limits^^ July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Aplenzin #, bupropion ER #, Celexa #, citalopram #, Cymbalta #, desvenlafaxiner ER #, duloxetine #, Effexor XR #, Effexor #, Emsam #, escitalopram #, Fetzima #, fluoxetine #, fluvoxamine ER #, fluvoxamine #, Forfivo XL #, Khedezla, Lexapro, paroxetine CR #, paroxetine #, Paxil CR #, Pexeva #, Prozac, sertraline #, venlafaxine ER #, Wellbutrin SR, Wellbutrin XL, Zoloft BLOOD PRESSURE/HEART MEDICATIONS BiDil mg #, captopril-hctz, dofetilide #, Tikosyn CHOLESTEROL MEDICATIONS simvastatin, Zocor DIABETES Jentadueto XR GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, OmePPI, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole, Zegerid NUTRITIONAL/DIETARY Auryxia PAIN RELIEF AND INFLAMMATORY DISEASE Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren (NON-NARCOTIC) PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC) SEIZURE DISORDERS Banzel # SKIN CONDITIONS calcitriol, Vectical SLEEP DISORDERS/SEDATIVES Rozerem February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caffcodeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminophcaff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodoneibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadolacetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro

15 LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont) Medication with quantity limits^^ January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone ALZHEIMER'S DISEASE Namenda XR, Namzaric ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, Pristiq ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, Nilandron, nilutamide DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem INFECTIONS Zovirax MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medication^^ April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta ## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir ## QVAR, Pulmicort Flexhaler January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR ## dextroamphetamine-amphetamine ER Focalin XR ## dexmethylphenidate ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify ## aripiprazole Orap ## pimozide SKIN CONDITIONS Locoid lotion ## hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor ## eszopiclone, zolpidem Medication strength with limitations** (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg

16 LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont) January 1, 2018 Medication strength with limitations** (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength) BLOOD PRESSURE/HEART MEDICATIONS Tekturna 150mg Tekturna 300mg (cont) Tekturna HCT mg Tekturna HCT mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg PERFORMANCE PRESCRIPTION DRUG LIST Medication not covered^ July 1, 2018 GASTROINTESTINAL/HEARTBURN OmePPI omeprazole INFECTIONS Mycobutin rifabutin MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil topical, imiquimod cream, Picato April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, Uloric March 1, 2018 DIABETES Fiasp Humalog PARKINSON S DISEASE Gocovri amantadine February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort Flexhaler January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor nortriptyline Parnate tranylcypromine Tofranil imipramine ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER Zyflo CR zileuton ER ATTENTION DEFICIT HYPERACTIVITY Desoxyn methamphetamine DISORDER Dexedrine dextroamphetamine, dextroamphetamine ER

17 PERFORMANCE PRESCRIPTION DRUG LIST (cont) Medication not covered^ January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba Novolin, Novolog Humalog, Humulin GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC Marinol dronabinol omeprazole bicarbonate packet, 40mg- omeprazole 1100mg capsule, 20mg-1100mg OmePPI omeprazole Rowasa mesalamine enema Uceris tablet budesonide EC capsule Zegerid omeprazole Zofran ondansetron Zofran ODT ondansetron ODT HORMONAL AGENTS Cortrosyn cosyntropin DDAVP desmopressin Hectorol doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillinclavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 erythromycin Mepron atovaquone Sporanox itraconazole Targadox Avidoxy, demeclocycline, doxycycline, doxycycline IR-DR, minocycline, minocycline ER, mondoxyne NL, Morgidox capsule, tetracycline Valcyte valganciclovir Vancocin vancomycin capsule Zovirax acyclovir PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone D.H.E. 45, Migranal dihydroergotamine Gralise, Horizant gabapentin Imitrex, Sumavel DosePro sumatriptan Lorzone chlorzoxazone

18 PERFORMANCE PRESCRIPTION DRUG LIST (cont) January 1, 2018 Medication not covered^ PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER (cont) Roxicodone oxycodone Tivorbex indomethacin Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps Vivlodex meloxicam Zomig sumatriptan, zolmitriptan Zorvolex diclofenac, diclofenac ER PARKINSON'S DISEASE Lodosyn carbidopa Requip XL ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon capsule ziprasidone Zyprexa tablet olanzapine Zyprexa Zydis olanzapine ODT SKIN CONDITIONS Cutivate fluticasone Kenalog topical spray triamcinolone Locoid hydrocortisone Luzu ketoconazole Soriatane acitretin Ziana clindamycin-tretinoin SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil modafinil Restoril temazepam URINARY TRACT CONDITIONS Detrol tolterodine Detrol LA tolterodine ER Ditropan XL oxybutynin ER Enablex darifenacin ER Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER April 1, 2018 DIABETES QTERN January 1, 2018 MISCELLANEOUS Nityr + Preferred brand medication Non-preferred brand medication July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Reopro + a lower-cost option, if appropriate. CANCER dexrazoxane +, Evomela +, Hycamtin capsule +, Nilandron +, nilutamide +, Zinecard Fusilev + a lower-cost option, if appropriate. leucovorin

19 PERFORMANCE PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication July 1, 2018 CONTRACEPTION PRODUCTS LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg Nexplanon +, Paragard T 380-a + a lower-cost option, if appropriate. Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg DENTAL PRODUCTS Arestin + a lower-cost option, if appropriate. DIABETES Korlym + a lower-cost option, if appropriate. EYE CONDITIONS Cystaran +, Ozurdex +, Retisert + a lower-cost option, if appropriate. GASTROINTESTINAL/HEARTBURN alosetron +, Buphenyl, Chenodal +, Ravicti +, sodium phenylbutyrate a lower-cost option, if appropriate. HORMONAL AGENTS Aveed +, hydroxyprogesterone caproate + a lower-cost option, if appropriate. INFECTIONS Daraprim +, Sirturo + a lower-cost option, if appropriate. INFERTILITY Makena + a lower-cost option, if appropriate. MISCELLANEOUS Asclera +, Carbaglu +, Ferriprox +, Flebogamma DIF +, Keveyis +, Varithena + a lower-cost option, if appropriate. Orfadin + Nityr PAIN RELIEF AND INFLAMMATORY DISEASE Colcrys colchicine (NON-NARCOTIC) PARKINSON S DISEASE Azilect rasagiline SEIZURE DISORDERS Lamictal ODT lamotrigine ODT SKIN CONDITIONS Ameluz +, Levulan + a lower-cost option, if appropriate. Tazorac 0.1% cream tazarotene SLEEP DISORDERS/SEDATIVES Hetlioz + a lower-cost option, if appropriate. TRANSPLANT MEDICATIONS Cellcept + mycophenolate Neoral 25mg capsule, solution + cyclosporine modified, Gengraf Sandimmune 100mg capsule + cyclosporine URINARY TRACT CONDITIONS Thiola + a lower-cost option, if appropriate. March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

20 PERFORMANCE PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication January 1, 2018 SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC lotion hydrocortisone-pramoxine Capex shampoo fluocinolone Cordran flurandrenolide Differin adapalene Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone Medication requiring prior authorization^^ July 1, 2018 CANCER Hycamtin ++, Targretin ++, tretinoin capsule ++, Xeloda ++ MISCELLANEOUS Nityr, Orfadin ++ PAIN RELIEF AND INFLAMMATORY DISEASE Diskets, Dolophine, methadone ++, Methadose (NARCOTIC) March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, testosterone MISCELLANEOUS Nityr Medication with quantity limits^^ July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER #, Celexa #, citalopram #, desvenlafaxine ER #, duloxetine #, Effexor XR #, Effexor #, Emsam #, escitalopram #, Fetzima #, fluoxetine #, fluvoxamine ER #, fluvoxamine #, Forfivo XL #, Khedezla, paroxetine CR #, paroxetine #, Paxil CR #, Pexeva #, Prozac, sertraline #, venlafaxine ER #, Wellbutrin SR, Wellbutrin XL, Zoloft BLOOD PRESSURE/HEART MEDICATIONS CHOLESTEROL MEDICATIONS GASTROINTESTINAL/HEARTBURN NUTRITIONAL/DIETARY PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC) PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC) BiDil mg #, captopril-hctz, dofetilide #, Tikosyn simvastatin, Zocor Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole Auryxia Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asabutalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodoneibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadolacetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro

21 PERFORMANCE PRESCRIPTION DRUG LIST (cont) Medication with quantity limits^^ July 1, 2018 SCHIZOPHRENIA/ANTI-PSYCHOTICS Invega Sustenna # SEIZURE DISORDERS Banzel # SKIN CONDITIONS calcitriol, Vectical SLEEP DISORDERS/SEDATIVES Rozerem February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone ALZHEIMER'S DISEASE Namenda XR, Namzaric ANXIETY/DEPRESSION/BIPOLAR DISORDER desvanlafaxine 25mg, 100mg, Marplan, Pristiq ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, nilutamide EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medication^^ July 1, 2018 ERECTILE DYSFUNCTION Cialis ## Viagra ## sildenafil, Cialis April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta ## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR ## dextroamphetamine-amphetamine ER Focalin XR ## SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap ## pimozide dexmethylphenidate ER SLEEP DISORDERS/SEDATIVES Silenor ## eszopiclone, zolpidem Medication strength with limitations** (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Trintellix 5mg Trintellix 10mg Fetzima ER 80mg Trintellix 10mg Trintellix 20mg

22 PERFORMANCE PRESCRIPTION DRUG LIST (cont) Medication strength with limitations** (Your plan doesn t cover 2 capsules/tablets per day of this strength) January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar HCT mg Bystolic 10mg Tekturna 150mg Tekturna HCT mg Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength) Benicar 40mg Benicar HCT 40-25mg Bystolic 20mg Tekturna 300mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Tekturna HCT mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Fycompa 4mg Fycompa 6mg Trokendi XR 25mg Trokendi XR 100mg Aptiom 800mg Fycompa 8mg Fycompa 12mg Trokendi XR 50mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg VALUE PRESCRIPTION DRUG LIST Medication not covered^ July 1, 2018 INFECTIONS Mycobutin rifabutin MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil topical, imiquimod cream, Picato April 1, 2018 DIABETES QTERN Glyxambi PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid March 1, 2018 DIABETES Fiasp Humalog PARKINSON S DISEASE Gocovri amantadine February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor nortriptyline Parnate tranylcypromine Tofranil imipramine

23 VALUE PRESCRIPTION DRUG LIST (cont) Medication not covered^ January 1, 2018 ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta ATTENTION DEFICIT HYPERACTIVITY DISORDER Stiolto Respimat Zyflo Zyflo CR Desoxyn Dexedrine Anoro Ellipta montelukast, zafirlukast, zileuton ER zileuton ER methamphetamine dextroamphetamine, dextroamphetamine ER BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablet CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Kombiglyze XR, Onglyza Lantus, Lantus SoloStar, Toujeo SoloStar Farxiga, Jardiance alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Basaglar, Levemir, Tresiba EYE CONDITIONS Alocril, Alomide cromolyn eye drops Bepreve, Emadine, Lastacaft, Pataday, Patanol, Pazeo Elestat azelastine, epinastine, olopatadine epinastine GASTROINTESTINAL/HEARTBURN Marinol dronabinol Rowasa Zofran Zofran ODT mesalamine enema ondansetron ondansetron ODT HORMONAL AGENTS DDAVP nasal spray, tablet desmopressin nasal spray, tablets Hectorol doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate Diflucan E.E.S. 200, Eryped 400 Mepron Sporanox Targadox Valcyte Vancocin Zovirax fluconazole erythromycin atovaquone itraconazole doxycycline valganciclovir vancomycin capsule acyclovir PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine Imitrex sumatriptan OxyContin Embeda, Hysingla ER, Xtampza ER Roxicodone oxycodone

24 VALUE PRESCRIPTION DRUG LIST (cont) January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (cont) Medication not covered^ Vanatol LQ Zomig PARKINSON'S DISEASE Lodosyn carbidopa Requip XL ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone Zyprexa tablet olanzapine tablet Zyprexa Zydis olanzapine ODT SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin Cutivate Dovonex, Sorilux Enstilar, Taclonex Soriatane Tazorac Vectical butalbital/acetaminophen/caffeine tabs or caps sumatriptan, zolmitriptan Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycin-benzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm fluticasone calcipotriene calcipotriene-betamethasone DP acitretin adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm calcitriol ointment SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil modafinil Restoril temazepam URINARY TRACT CONDITIONS Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique darifenacin ER, oxybutynin ER, tolterodine, tolterodine ER, trospium ER January 1, 2018 MISCELLANEOUS Nityr + Preferred brand medication

25 VALUE PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Arixtra + fondaparinux Lovenox + enoxaparin Reopro + CANCER dexrazoxane +, Evomela +, Nilandron +, nilutamide +, Zinecard Targretin capsule + bexarotene CONTRACEPTION PRODUCTS Depo-Provera 150mg/ml medroxyprogesterone LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg Nexplanon +, Paragard T 380-a + Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg DENTAL PRODUCTS Arestin + DIABETES Korlym + EYE CONDITIONS Cystaran +, Ozurdex +, Retisert + GASTROINTESTINAL/HEARTBURN alosetron +, Buphenyl +, Chenodal +, Ravicti +, sodium phenylbutyrate, HORMONAL AGENTS Aveed +, hydroxyprogesterone caproate + Depo-Provera 400mg/ml medroxyprogesterone INFECTIONS Daraprim +, Sirturo + INFERTILITY Makena + MISCELLANEOUS Asclera +, Carbaglu +, Ferriprox +, Flebogamma DIF +, Keveyis +, Varithena + PARKINSON'S DISEASE Azilect rasagiline SEIZURE DISORDERS Lamictal ODT lamotrigine ODT SKIN CONDITIONS Ameluz +, Levulan + SLEEP DISORDERS/SEDATIVES Hetlioz + TRANSPLANT MEDICATIONS Cellcept + mycophenolate Neoral 25mg capsule, solution + cyclosporine modified, Gengraf URINARY TRACT CONDITIONS Thiola + March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic HORMONAL AGENTS Depo-Testosterone testosterone cypionate

26 VALUE PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Medication requiring prior authorization^^ July 1, 2018 CANCER Hycamtin ++, Targretin ++, tretinoin capsule ++, Xeloda ++ MISCELLANEOUS Nityr, Orfadin ++ PAIN RELIEF AND INFLAMMATORY DISEASE Diskets, Dolophine, methadone ++, Methadose (NARCOTIC) March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi HORMONAL AGENTS MISCELLANEOUS Androderm, Androgel, Striant testosterone Nityr Medication with quantity limits^^ July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER #, Celexa #, citalopram #, desvenlafaxine ER #, duloxetine #, Effexor XR #, Effexor #, Emsam #, escitalopram #, Fetzima #, fluoxetine #, fluvoxamine ER #, fluvoxamine #, Forfivo XL #, Khedezla, paroxetine CR #, paroxetine #, Paxil CR #, Pexeva #, Prozac, sertraline #, venlafaxine ER #, Wellbutrin SR, Wellbutrin XL, Zoloft BLOOD PRESSURE/HEART MEDICATIONS BiDil mg #, captopril-hctz, dofetilide #, Tikosyn CHOLESTEROL MEDICATIONS NUTRITIONAL/DIETARY PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC) PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC) simvastatin Auryxia SEIZURE DISORDERS Banzel # SKIN CONDITIONS SLEEP DISORDERS/SEDATIVES Cafergot, ergotamine-caffeine diclofenac 1% gel, Voltaren acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asabutalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodoneacetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro calcitriol Rozerem February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone ALZHEIMER'S DISEASE ANXIETY/DEPRESSION/BIPOLAR DISORDER ASTHMA/COPD/RESPIRATORY Namenda XR, Namzaric desvenlafaxine ER, Marplan Perforomist

27 VALUE PRESCRIPTION DRUG LIST (cont) January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER EYE CONDITIONS HORMONAL AGENTS MISCELLANEOUS OSTEOPOROSIS PRODUCTS PAIN RELIEF AND INFLAMMATORY DISEASE SCHIZOPHRENIA/ANTI-PSYCHOTICS SEIZURE DISORDERS SKIN CONDITIONS SLEEP DISORDERS/SEDATIVES Medication with quantity limits^^ Fareston, nilutamide bimatoprost eye drops, Cystaran, Zioptan Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem Nuedexta alendronate Daliresp, Mitigare Fanapt Gabitril, Potiga Denavir, Regranex, Santyl Hetlioz Step Therapy medication^^ April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta ## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR ## dextroamphetamine-amphetamine ER Focalin XR ## SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap ## pimozide dexmethylphenidate ER SLEEP DISORDERS/SEDATIVES Silenor ## zolpidem, eszopiclone Medication strength with limitations** (Your plan doesn t cover 2 capsules/tablets per day of this strength) January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Trintellix 5mg Trintellix 10mg Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength) Fetzima ER 80mg Trintellix 10mg Trintellix 20mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Fycompa 4mg Fycompa 6mg Trokendi XR 25mg Trokendi XR 100mg Aptiom 800mg Fycompa 8mg Fycompa 12mg Trokendi XR 50mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg