2017 Medicare Part D Formulary Change

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1 2017 Medicare Part D Change We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorizations, quantity limits and/or step therapy restrictions on a drug (or move a drug to a higher cost-sharing tier), we will let you know of the change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and let you know. The product changes noted below will be implemented on the Medicare Part D Plan: New Added Products: Effective 11/1/2017 adapalene 0.1 %-benzoyl peroxide 2.5 % topical gel with pump BENLYSTA 200 MG/ML SUBCUTANEOUS AUTO- INJECTOR BENLYSTA 200 MG/ML SUBCUTANEOUS SYRINGE PA New Drug Tier 4 New Drug Tier 4 diazepam 2.5 mg rectal kit diazepam 5 mg-7.5 mg-10 mg rectal kit estradiol 10 mcg vaginal tablet IDHIFA 100 MG TABLET New Drug Tier 4 PA QL LA IDHIFA 50 MG TABLET New Drug Tier 4 PA QL LA ISENTRESS HD 600 MG TABLET New Drug Tier 4 LYNPARZA 100 MG TABLET New Drug Tier 4 PA LYNPARZA 150 MG TABLET New Drug Tier 4 PA NERLYNX 40 MG TABLET New Drug Tier 4 LA prasugrel 10 mg tablet prasugrel 5 mg tablet 1 "*Consult your Medical provider for changes or recommendations to your medical care and prescription therapy **Please consult the plan benefit design for copay/coinsurance amounts ***Indicates a restriction of Step Therapy, Prior Authorization or Quantity Limits may exist [LA] = Limited Access, [PA] = Prior Authorization, [QL] = Quantity Limit, [ST] = Step Therapy PRF-C4T"

2 RADICAVA 30 MG/100 ML INTRAVENOUS PIGGYBACK New Drug Tier 4 vigabatrin 500 mg oral powder packet New Drug Tier 4 LA VYXEOS 44 MG-100 MG INTRAVENOUS SOLUTION New Drug Tier 4 PA ZYTIGA 500 MG TABLET New Drug Tier 4 PA QL Future Removed Products: There were no future removed products this month. Cost Sharing Tier Changes: There were no cost sharing tier changes this month. New Added Products: Effective 10/1/2017 AMNESTEEM 10 MG CAPSULE New Drug Tier 3 AMNESTEEM 20 MG CAPSULE New Drug Tier 3 AMNESTEEM 40 MG CAPSULE desogestrel 0.15 mg-ethinyl estradiol 0.03 mg tablet eletriptan hbr 20 mg tablet eletriptan hbr 40 mg tablet ISIBLOOM 0.15 MG-0.03 MG TABLET JADENU SPRINKLE 180 MG ORAL GRANULES IN PACKET JADENU SPRINKLE 360 MG ORAL GRANULES IN PACKET JADENU SPRINKLE 90 MG ORAL GRANULES IN PACKET Tier 4 Tier 4 Tier 4 meropenem 1 gram intravenous solution mesalamine 1.2 gram tablet,delayed release moxifloxacin 0.5 % eye drops ORFADIN 20 MG CAPSULE New Drug Tier 4 LA sevelamer carbonate 800 mg tablet 2 "*Consult your Medical provider for changes or recommendations to your medical care and prescription therapy **Please consult the plan benefit design for copay/coinsurance amounts ***Indicates a restriction of Step Therapy, Prior Authorization or Quantity Limits may exist [LA] = Limited Access, [PA] = Prior Authorization, [QL] = Quantity Limit, [ST] = Step Therapy PRF-C4T"

3 testosterone 30 mg/actuation (1.5 ml) transderm solution metered pump PA XATMEP 2.5 MG/ML ORAL SOLUTION New Drug Tier 4 PA Future Removed Products: There were no future removed products this month. Cost Sharing Tier Changes: There were no cost sharing tier changes this month. New Added Products: Effective 9/1/2017 ARISTADA 1,064 MG/3.9 ML SUSPENSION, EXTEND.REL. IM SYRINGE New Drug Tier 4 atomoxetine 10 mg capsule atomoxetine 100 mg capsule atomoxetine 18 mg capsule atomoxetine 25 mg capsule atomoxetine 40 mg capsule atomoxetine 60 mg capsule atomoxetine 80 mg capsule DIASTAT 2.5 MG RECTAL KIT DIASTAT ACUDIAL 12.5 MG-15 MG-17.5 MG-20 MG RECTAL KIT DIASTAT ACUDIAL 5 MG-7.5 MG-10 MG RECTAL KIT Tier 3 Tier 3 Tier 3 lidocaine (pf) 10 mg/ml (1 %) injection solution NOLIX 0.05 % LOTION olopatadine 0.2 % eye drops ORENCIA 50 MG/0.4 ML SUBCUTANEOUS SYRINGE ORENCIA 87.5 MG/0.7 ML SUBCUTANEOUS SYRINGE New Drug Tier 4 PA New Drug Tier 4 PA 3 "*Consult your Medical provider for changes or recommendations to your medical care and prescription therapy **Please consult the plan benefit design for copay/coinsurance amounts ***Indicates a restriction of Step Therapy, Prior Authorization or Quantity Limits may exist [LA] = Limited Access, [PA] = Prior Authorization, [QL] = Quantity Limit, [ST] = Step Therapy PRF-C4T"

4 sevelamer carbonate 0.8 gram oral powder packet sevelamer carbonate 2.4 gram oral powder packet VARIZIG 125 UNIT/1.2 ML INTRAMUSCULAR SOLUTION Future Removed Products: Effective 9/1/2017 New Drug Tier 4 New Drug Tier 4 New Drug Tier 2 Drug Description of Change Reason for Change Alternative Drug Alternative Drug Tier LORTAB 10 MG-325 MG TABLET name, will no longer be covered by the Medicare Part D portion of your benefit. name, is no longer being marketed. Please contact your doctor. Will vary based on the drug prescribed. Cost Sharing Tier Changes: There were no cost sharing tier changes this month. New Added Products: Effective 8/1/2017 ALUNBRIG 30 MG TABLET New Drug Tier 4 PA QL LA clofarabine 20 mg/20 ml intravenous solution New Drug Tier 4 ezetimibe 10 mg-simvastatin 10 mg tablet QL ezetimibe 10 mg-simvastatin 20 mg tablet QL ezetimibe 10 mg-simvastatin 40 mg tablet QL ezetimibe 10 mg-simvastatin 80 mg tablet QL IMFINZI 50 MG/ML INTRAVENOUS SOLUTION New Drug Tier 4 LA IMFINZI 50 MG/ML INTRAVENOUS SOLUTION (10 ML) KISQALI FEMARA CO-PACK 200 MG/DAY(200 MG X 1)-2.5 MG TABLET New Drug Tier 4 LA New Drug Tier 4 PA 4 "*Consult your Medical provider for changes or recommendations to your medical care and prescription therapy **Please consult the plan benefit design for copay/coinsurance amounts ***Indicates a restriction of Step Therapy, Prior Authorization or Quantity Limits may exist [LA] = Limited Access, [PA] = Prior Authorization, [QL] = Quantity Limit, [ST] = Step Therapy PRF-C4T"

5 KISQALI FEMARA CO-PACK 400 MG/DAY(200 MG X 2)-2.5 MG TABLET KISQALI FEMARA CO-PACK 600 MG/DAY(200 MG X 3)-2.5 MG TABLET New Drug Tier 4 PA New Drug Tier 4 PA RYDAPT 25 MG CAPSULE New Drug Tier 4 PA TYMLOS 80 MCG/DOSE (3,120 MCG/1.56 ML) SUBCUTANEOUS PEN INJECTOR New Drug Tier 4 PA QL XATMEP 2.5 MG/ML ORAL SOLUTION New Drug Tier 4 PA ZEJULA 100 MG CAPSULE New Drug Tier 4 PA QL LA 5 "*Consult your Medical provider for changes or recommendations to your medical care and prescription therapy **Please consult the plan benefit design for copay/coinsurance amounts ***Indicates a restriction of Step Therapy, Prior Authorization or Quantity Limits may exist [LA] = Limited Access, [PA] = Prior Authorization, [QL] = Quantity Limit, [ST] = Step Therapy PRF-C4T"

6 Future Removed Products: Effective 8/1/2017 Drug Description of Change Reason for Change Alternative Drug Alternative Drug Tier DEXEDRINE 5 MG TABLET name, will no longer be covered by the Medicare Part D portion of your benefit. name, is no longer being marketed. Please contact your doctor. Will vary based on the drug prescribed. DEXEDRINE 10 MG TABLET name, will no longer be covered by the Medicare Part D portion of your benefit. name, is no longer being marketed. Please contact your doctor. Will vary based on the drug prescribed. Cost Sharing Tier Changes: There were no cost sharing tier changes this month. New Added Products: Effective 7/1/2017 BAVENCIO 20 MG/ML INTRAVENOUS SOLUTION New Drug Tier 4 LA busulfan 60 mg/10 ml intravenous solution New Drug Tier 4 DUPIXENT 300 MG/2 ML SUBCUTANEOUS SYRINGE New Drug Tier 4 PA ESBRIET 267 MG TABLET New Drug Tier 4 PA QL ESBRIET 801 MG TABLET New Drug Tier 4 PA QL FAYOSIM 0.15 MG-20 MCG/0.15 MG-25 MCG TABLETS,3 MONTH DOSE PACK INTRON A 10 MILLION UNIT/ML INJECTION SOLUTION KINRIX (PF) 25 LF-58 MCG-10 LF/0.5 ML INTRAMUSCULAR SUSPENSION levoleucovorin 50 mg intravenous powder for solution norethindrone 1 mg-e. estradiol 20 mcg (24)- iron 75 mg (4) chew tablet RIVELSA 0.15 MG-20 MCG/0.15 MG-25 MCG TABLETS,3 MONTH DOSE PACK New Drug Tier 2 New Drug Tier 2 New Drug Tier 4 6

7 ROWEEPRA 1,000 MG TABLET ROWEEPRA 750 MG TABLET tazarotene 0.1 % topical cream PA VIBATIV 750 MG INTRAVENOUS SOLUTION New Drug Tier 2 zileuton er 600 mg tablet,extended release 12hr mphase New Drug Tier 4 7

8 Future Removed Products: There were no future removed products this month. Cost Sharing Tier Changes: There were no cost sharing tier changes this month. New Added Products: Effective 6/1/2017 desvenlafaxine succinate er 100 mg tablet,extended release 24 hr desvenlafaxine succinate er 25 mg tablet,extended release 24 hr desvenlafaxine succinate er 50 mg tablet,extended release 24 hr QL QL QL KISQALI 200 MG/DAY (200 MG X 1) TABLET New Drug Tier 4 PA KISQALI 400 MG/DAY (200 MG X 2) TABLET New Drug Tier 4 PA KISQALI 600 MG/DAY (200 MG X 3) TABLET New Drug Tier 4 PA MIBELAS 24 FE 1 MG-20 MCG (24)/75 MG (4) CHEWABLE TABLET naftifine 1 % topical cream Tier 1 XERMELO 250 MG TABLET New Drug Tier 4 LA Future Removed Products: There were no future removed products this month. Cost Sharing Tier Changes: There were no cost sharing tier changes this month New Added Products: Effective 5/1/2017 calcium acetate 667 mg tablet CLINDACIN P 1 % TOPICAL SWAB epinephrine 0.3 mg/0.3 ml injection, autoinjector (manufactured by Mylan) Tier 1 New Drug Tier 2 8

9 fenofibrate 120 mg tablet fenofibrate 40 mg tablet Tier 1 Tier 1 flurandrenolide 0.05 % topical ointment KLOR-CON M10 MEQ TABLET,EXTENDED RELEASE KLOR-CON M20 MEQ TABLET,EXTENDED RELEASE LINZESS 72 MCG CAPSULE New Drug Tier 2 MENOMUNE - A/C/Y/W-135 (PF) 50 MCG SUBCUTANEOUS SOLUTION methylphenidate er 20 mg multiphase capsule 30-70,extended release methylphenidate er 40 mg multiphase capsule 30-70,extended release methylphenidate la 60 mg capsule,extended release biphasic potassium chloride er 10 meq tablet,extended release(part/cryst) potassium chloride er 20 meq tablet,extended release(part/cryst) prednisolone sodium phosphate 10 mg/5 ml oral solution prednisolone sodium phosphate 20 mg/5 ml (4 mg/ml) oral solution New Drug Tier 2 SELZENTRY 25 MG TABLET New Drug Tier 2 SELZENTRY 75 MG TABLET New Drug Tier 2 Future Removed Products: There were no future removed products this month. Cost Sharing Tier Changes: Effective 5/1/2017 9

10 Drug New Tier Old Tier Restrictions*** doxercalciferol 0.5 mcg capsule 1 3 LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK LEVETIRACETAM 1,500 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK New Added Products: Effective 4/1/2017 ADCIRCA 20 MG TABLET Tier 4 amiodarone 100 mg tablet ANDRODERM 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH ANDRODERM 4 MG/24 HR TRANSDERMAL 24 HOUR PATCH AZASITE 1 % EYE DROPS dexmethylphenidate er 25 mg capsule,extended release biphasic50-50 dexmethylphenidate er 35 mg capsule,extended release biphasic50-50 GAMASTAN S/D 15 %-18 % RANGE INTRAMUSCULAR SOLUTION (10 ML) GAMASTAN S/D 15 %-18 % RANGE INTRAMUSCULAR SOLUTION (2 ML) IMOGAM RABIES-HT (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION lopinavir-ritonavir 400 mg-100 mg/5 ml oral solution Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 PA QL PA PA 10

11 norgestimate 0.25 mg-ethinyl estradiol 35 mcg tablet ranitidine 50 mg/2 ml (25 mg/ml) injection solution RIBASPHERE RIBAPAK 200 MG (7)-400 MG (7) TABLETS IN A DOSE PACK STIOLTO RESPIMAT 2.5 MCG-2.5 MCG/ACTUATION SOLUTION FOR INHALATION Tier 2 Future Removed Products: There were no future removed products this month. Cost Sharing Tier Changes: Effective 4/1/2017 Drug New Tier Old Tier Restrictions*** doxycycline hyclate 200 mg tablet,delayed release 1 4 EDARBI 40 MG TABLET 2 3 EDARBI 80 MG TABLET 2 3 EDARBYCLOR 40 MG-12.5 MG TABLET 2 3 EDARBYCLOR 40 MG-25 MG TABLET 2 3 QL New Added Products: Effective 3/1/2017 abacavir 600 mg-lamivudine 300 mg tablet New Drug Tier 4 ADRIAMYCIN 20 MG/10 ML INTRAVENOUS SOLUTION ALA-CORT 2.5 % TOPICAL CREAM allopurinol 500 mg intravenous solution ALYACEN 1/35 (28) 1 MG-35 MCG TABLET AMABELZ 0.5 MG-0.1 MG TABLET AMABELZ 1 MG-0.5 MG TABLET 11

12 AMETHIA LO 0.10 MG-20 MCG (84)/10 MCG(7) TABLETS,3 MONTH DOSE PACK amlodipine 10 mg-olmesartan 20 mg tablet amlodipine 10 mg-olmesartan 40 mg tablet amlodipine 5 mg-olmesartan 20 mg tablet amlodipine 5 mg-olmesartan 40 mg tablet aprepitant 125 mg (1)-80 mg (2) capsules in a dose pack PA aprepitant 125 mg capsule PA aprepitant 40 mg capsule PA aprepitant 80 mg capsule PA AZACTAM 1 GRAM/50 ML IN DEXTROSE (ISO- OSMOTIC) INTRAVENOUS PIGGYBACK Tier 2 azithromycin 500 mg tablet (3 pack) BEVESPI AEROSPHERE 9 MCG-4.8 MCG HFA AEROSOL INHALER bupropion hcl 150 mg tablet,sustained release (as a smoking deterrent) New Drug Tier 2 QL BYVALSON 5 MG-80 MG TABLET New Drug Tier 2 CAMRESE LO 0.10 MG-20 MCG (84)/10 MCG(7) TABLETS,3 MONTH DOSE PACK CAZIANT (28) 0.1 MG/0.125 MG/0.15 MG-25 MCG TABLET CHOLESTYRAMINE LIGHT 4 GRAM ORAL POWDER CLEOCIN 100 MG VAGINAL SUPPOSITORY clindamycin 1.2 % (1 % base)-benzoyl peroxide 5 % topical gel Tier 2 clindamycin-tretinoin 1.2 % % topical gel PA daptomycin 500 mg intravenous solution New Drug Tier 4 drospiren-e.estrad-l.mefol 3 mg-0.02 mg mg(24)/0.451 mg(4)tablet 12

13 EMEND 125 MG (25 MG/ML FINAL CONC.) ORAL SUSPENSION New Drug Tier 2 PA EPCLUSA 400 MG-100 MG TABLET New Drug Tier 4 PA QL epinephrine 0.15 mg/0.3 ml injection,autoinjector New Drug Tier 2 epirubicin 200 mg/100 ml intravenous solution ergotamine 1 mg-caffeine 100 mg tablet erythromycin ethylsuccinate 200 mg/5 ml oral powder for suspension ethacrynic acid 25 mg tablet ethynodiol diac-eth estradiol 1 mg-50 mcg tablet ezetimibe 10 mg tablet FEMYNOR 0.25 MG-35 MCG TABLET FLOXIN 0.3 % EAR DROPS FLUOCINONIDE-E 0.05% TOPICAL CREAM flurandrenolide 0.05 % lotion GENGRAF 50 MG CAPSULE PA HUMIRA PEN PSORIASIS-UVEITIS STARTER 40 MG/0.8 ML SUBCUTANEOUS KIT New Drug Tier 4 PA QL INFLECTRA 100 MG INTRAVENOUS SOLUTION New Drug Tier 4 PA INVOKAMET XR 150 MG-1,000 MG TABLET, EXTENDED RELEASE INVOKAMET XR 150 MG-500 MG TABLET, EXTENDED RELEASE INVOKAMET XR 50 MG-1,000 MG TABLET, EXTENDED RELEASE INVOKAMET XR 50 MG-500 MG TABLET, EXTENDED RELEASE KINRIX (PF) 25 LF-58 MCG-10 LF/0.5 ML INTRAMUSCULAR SYRINGE New Drug Tier 2 QL New Drug Tier 2 QL New Drug Tier 2 QL New Drug Tier 2 QL New Drug Tier 2 KYPROLIS 30 MG INTRAVENOUS SOLUTION New Drug Tier 4 KYPROLIS 60 MG INTRAVENOUS SOLUTION New Drug Tier 4 13

14 LARISSIA 0.1 MG-20 MCG TABLET LARTRUVO 10 MG/ML INTRAVENOUS SOLUTION levalbuterol 1.25 mg/0.5 ml solution for nebulization (2.5 mg/ml) New Drug Tier 4 LA New Drug Tier 3 PA LORCET HD 10 MG-325 MG TABLET QL LOW-OGESTREL (28) 0.3 MG-30 MCG TABLET MAXIPIME 1 GRAM SOLUTION FOR INJECTION MAXIPIME 2 GRAM SOLUTION FOR INJECTION metformin er 1,000 mg 24 hr tablet,extended release metformin er 500 mg 24 hr tablet,extended release metformin er 500 mg tablet,extended release 24hr metformin er tablet,extended release 24hr (osmotic) methotrexate sodium 25 mg/ml injection solution methylphenidate er 20 mg multiphase capsule 30-70,extended release methylphenidate er 40 mg multiphase capsule 30-70,extended release Tier 3 Tier 3 New Drug Tier 3 QL New Drug Tier 3 QL New Drug Tier 3 QL New Drug Tier 3 QL PA MORGIDOX 50 MG CAPSULE mycophenolate 500 mg intravenous solution PA NAMZARIC 21 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMZARIC 7 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMZARIC 7/14/21/28 MG-10 MG CAPSULE,SPRINKLE,ER 24HR,DOSE PACK New Drug Tier 2 PA New Drug Tier 2 PA New Drug Tier 2 PA 14

15 nifedipine er 30 mg tablet,extended release 24 hr nifedipine er 60 mg tablet,extended release 24 hr nifedipine er 90 mg tablet,extended release 24 hr nilutamide 150 mg tablet New Drug Tier 4 nitroglycerin 0.3 mg sublingual tablet nitroglycerin 0.4 mg sublingual tablet nitroglycerin 0.6 mg sublingual tablet norethin-ethinyl estradiol-iron 0.4 mg-35 mcg(21)/75 mg(7) chew tablet norethindrone acetate 1 mg-ethinyl estradiol 20 mcg tablet norgestimate-ethinyl estradiol 0.18 mg/0.215mg/0.25mg-35 mcg(28)tablet NYATA 100,000 UNIT/GRAM TOPICAL POWDER OCALIVA 10 MG TABLET New Drug Tier 4 PA QL LA OCALIVA 5 MG TABLET New Drug Tier 4 PA QL LA ofloxacin 300 mg tablet olmesartan 20 mg tablet olmesartan 20 mg-amlodipine 5 mghydrochlorothiazide 12.5 mg tablet olmesartan 20 mg-hydrochlorothiazide 12.5 mg tablet olmesartan 40 mg tablet olmesartan 40 mg-amlodipine 10 mghydrochlorothiazide 12.5 mg tablet olmesartan 40 mg-amlodipine 10 mghydrochlorothiazide 25 mg tablet olmesartan 40 mg-amlodipine 5 mghydrochlorothiazide 12.5 mg tablet olmesartan 40 mg-amlodipine 5 mghydrochlorothiazide 25 mg tablet 15

16 olmesartan 40 mg-hydrochlorothiazide 12.5 mg tablet olmesartan 40 mg-hydrochlorothiazide 25 mg tablet olmesartan 5 mg tablet omeprazole 20 mg-sodium bicarbonate 1,680 mg oral packet omeprazole 40 mg-sodium bicarbonate 1,680 mg oral packet ORENCIA CLICKJECT 125 MG/ML SUBCUTANEOUS AUTO-INJECTOR QL New Drug Tier 4 PA ORKAMBI 100 MG-125 MG TABLET New Drug Tier 4 PA QL oseltamivir 30 mg capsule oseltamivir 45 mg capsule oseltamivir 75 mg capsule OTOVEL 0.3 % % (0.25 ML) EAR SOLUTION PEDIARIX (PF) 10 MCG-25 LF-25 MCG-10 LF/0.5 ML INTRAMUSCULAR SYRINGE pramipexole er 3.75 mg tablet,extended release 24 hr New Drug Tier 2 New Drug Tier 2 prednisone 10 mg tablets in a dose pack prednisone 10 mg tablets in a dose pack (48 pack) prednisone 5 mg tablets in a dose pack prednisone 5 mg tablets in a dose pack (48 pack) PRIMSOL 50 MG/5 ML ORAL SOLUTION New Drug Tier 3 quetiapine er 150 mg tablet,extended release 24 hr quetiapine er 200 mg tablet,extended release 24 hr quetiapine er 300 mg tablet,extended release 24 hr QL QL QL 16

17 quetiapine er 400 mg tablet,extended release 24 hr quetiapine er 50 mg tablet,extended release 24 hr QL QL rasagiline 0.5 mg tablet rasagiline 1 mg tablet REPATHA PUSHTRONEX 420 MG/3.5 ML SUBCUTANEOUS WEARABLE INJECTOR New Drug Tier 4 PA QL RUBRACA 200 MG TABLET New Drug Tier 4 PA QL LA RUBRACA 300 MG TABLET New Drug Tier 4 PA QL LA SPS (WITH SORBITOL) 15 GRAM-20 GRAM/60 ML ORAL SUSPENSION SULFAMYLON 50 GRAM TOPICAL PACKET sumatriptan 4 mg/0.5 ml subcutaneous pen injector triamcinolone acetonide 55 mcg nasal spray aerosol Tier 2 QL QL valganciclovir 50 mg/ml oral solution New Drug Tier 4 VASCEPA 0.5 GRAM CAPSULE New Drug Tier 2 VEMLIDY 25 MG TABLET New Drug Tier 4 VIEKIRA XR 8.33 MG-50 MG MG-200 MG TABLET, EXTENDED RELEASE New Drug Tier 4 PA QL YONDELIS 1 MG INTRAVENOUS SOLUTION New Drug Tier 4 YUVAFEM 10 MCG VAGINAL TABLET ZARAH 3 MG-0.03 MG TABLET ZERIT 1 MG/ML ORAL SOLUTION Future Removed Products: Effective 3/1/2017 Tier 3 Drug Description of Change Reason for Change Alternative Drug Alternative Drug Tier 17

18 Drug Description of Change Reason for Change Alternative Drug Alternative Drug Tier ALTABAX 1 % TOPICAL OINTMENT CERVARIX VACCINE (PF) 20 MCG-20 MCG/0.5 ML INTRAMUSCULAR SYRINGE PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS SOLUTION stavudine 1 mg/ml oral solution name, will no longer be covered by the Medicare Part D portion of your benefit. name, will no longer be covered by the Medicare Part D portion of your benefit. name, will no longer be covered by the Medicare Part D portion of your benefit. name, will no longer be covered by the Medicare Part D portion of your benefit. name, is no longer being marketed. name, is no longer being marketed. name, is no longer being marketed. name, is no longer being marketed. Please contact your physician. Please contact your physician. Please contact your physician. Please contact your physician. Will vary based on the drug prescribed. Will vary based on the drug prescribed. Will vary based on the drug prescribed. Will vary based on the drug prescribed. Cost Sharing Tier Changes: Effective 3/1/2017 Drug New Tier Old Tier Restrictions*** cefoxitin 2 gram intravenous solution 1 3 dapsone 100 mg tablet 1 2 dapsone 25 mg tablet 1 2 meropenem 500 mg intravenous solution 1 3 metformin er 500 mg tablet,extended release 24 hr morphine er 60 mg capsule,extended release 24 hr multiphase propafenone er 225 mg capsule,extended release 12 hr THEO MG CAPSULE,EXTENDED RELEASE THEO MG CAPSULE,EXTENDED RELEASE 1 3 QL 1 3 QL

19 THEO MG CAPSULE,EXTENDED RELEASE THEO MG CAPSULE,EXTENDED RELEASE Drug New Tier Old Tier Restrictions*** VARUBI 90 MG TABLET 2 3 PA 19

20 For more information about how these changes may affect your cost-sharing, such as copayments or coinsurance, or for more information about asking for an updated coverage determination or a formulary exception, please see the plan Evidence of Coverage. Alternative drugs are drugs in the same therapeutic category/class as the affected drug. Only your doctor can determine alternative drugs that are appropriate for you given the individualized nature of drug therapy. Please talk to your doctor about any changes or recommendations to your medical care and prescription drug therapy. Alternative drugs and additional information about formulary changes can be found on the plan formulary, *Consult your Medical provider for changes or recommendations to your medical care and prescription therapy **Please consult the plan benefit design for copay/coinsurance amounts ***Indicates a restriction of Step Therapy, Prior Authorization or Quantity Limits may exist [LA] = Limited Access, [PA] = Prior Authorization, [QL] = Quantity Limit, [ST] = Step Therapy ACS-O4T Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their premium and/or copayment/coinsurance may change on January 1, This document includes EmblemHealth Medicare PDP partial formulary as of November 1, For a complete, updated formulary, please visit our Web site at or call the Customer Service number below: For alternative formats or language, please call Customer Service toll free at: EmblemHealth Medicare PDP: , 24 hours a day, 7 days a week TTY/TDD users should call , 24 hours a day, 7 days a week v17 20

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