Updates to your prescription benefits Effective January 1, 2015

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1 Updates to your prescription benefits Effective January 1, 2015 Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount your covered employees pay when they fill a prescription. Please reference this chart to review the following updates. Most options listed are available in Tier 1, the lowest-cost option. Medications moving to a lower tier The following medications are moving to a lower tier, making them more affordable. Therapeutic Use Medication Name Tier Placement Cystinosis Cystagon Tier 3 to Tier 2 Diabetes Invokana 1 Tier 3 to Tier 2 Tanzeum 1 Tier 3 to Tier 2 Hereditary Angioedema Berinert Tier 3 to Tier 2 Inflammatory Conditions Humira Tier 3 to Tier 2 1. Diabetic supplies and prescription medications may be subject to different cost share arrangements. Confirm these state mandates with your Oxford Account Manager. Medications moving to a higher tier Medications may move from a lower tier to a higher tier when they are more costly and have available lower-cost options. Therapeutic Use Medication Name Tier Placement Lower-Cost Options ADHD Intuniv 2 Tier 2 to Tier 3 guanfacine (generic Tenex) Allergies Omnaris 2 Tier 2 to Tier 3 flunisolide (generic Nasarel), fluticasone (generic Flonase) Zetonna Tier 2 to Tier 3 fluticasone (generic Flonase) Diabetes Lantus Vials 1 Tier 2 to Tier 3 Levemir Pens, Levemir Vials Hormone Replacement Inflammatory Conditions Opioid Dependence Enjuvia Tier 2 to Tier 3 estradiol tablet (generic Estrace) Estrace cream Tier 2 to Tier 3 Vagifem, Estring Enbrel Tier 2 to Tier 3 Cimzia, Simponi, Stelara, Humira Suboxone Film 2 Tier 2 to Tier 3 Zubsolv 1. Diabetic supplies and prescription medications may be subject to different cost share arrangements. Confirm these state mandates with your Oxford Account Manager. 2. Precertification (sometimes referred to as preauthorization) is already required.

2 Medications with new benefit coverage The following medications were previously not covered under most benefit plans and are now eligible for coverage. Therapeutic Use Medication Name Tier Placement Acne clindamycin 1.2%/benzoyl peroxide 5% gel (generic Duac) 2 Tier 1 Alzheimer's Disease Namenda XR 2 Tier 3 Ulcers, Heartburn, and Reflux Prevacid Solutab 2, * Tier 3 2. Precertification (sometimes referred to as preauthorization) is already required. Medications no longer covered under most of our benefit plans 3 When several medications work in the same way, we may choose to not cover the higher-cost option. The medications listed below will no longer be covered under many of our pharmacy benefit plans. Skin Conditions SelRx Excluded 3 selenium sulfide shampoo Ulcers, Heartburn, and Reflux Nexium capsules Excluded 3 (generic Protonix), rabeprazole (generic Aciphex), Dexilant, Nexium Suspension*, omeprazole (generic Prilosec), pantoprazole Prevacid SoluTab* Prevacid capsules Excluded 3 (generic Protonix), rabeprazole (generic Aciphex), Dexilant, Nexium Suspension*, omeprazole (generic Prilosec), pantoprazole Prevacid SoluTab* 3. In New Jersey, prescription drug products that include components available in over-the-counter form or equivalent are not covered under the pharmacy benefit plans; in New York, this includes non-fda approved legend drugs, non-legend drugs and drugs available over-the-counter that do not require a prescription order or refill by federal or state law before being dispensed. Any prescription drug product that is therapeutically equivalent to an over-the-counter drug is not covered unless it is determined to be medically necessary. Medications that require precertification (New York only) The medications listed below require your physician to provide additional prescribing information to determine if coverage is available. Sometimes this may mean that another medication will need to be tried first before a medication will be covered under your benefit. Acne Atralin tretinoin (generic Retin-A) clindamycin 1%/benzoyl peroxide 5% (generic BenzaClin) clindamycin solution (generic Cleocin T) plus OTC benzoyl peroxide, clindamycin 1.2%/benzoyl peroxide 5% (generic Duac) Fabior Precertification 5 tretinoin (generic Retin-A), Tazorac gel Neuac 1.2%-5% Kit Precertification 5 OTC benzoyl peroxide, clindamycin clindamycin solution (generic Cleocin T) plus 1.2%/benzoyl peroxide 5% (generic Duac) Tretin-X cream tretinoin (generic Retin-A) Tretin-X cream Precertification 5 tretinoin (generic Retin-A) Tretin-X Kit tretinoin (generic Retin-A)

3 5 Aubra, Aviane, Delyla, Falmina Lessina, Lutera, Falessa Kit Precertification Orsythia, Sronyx, (generics Alesse, Levlite) 5 Gildess Fe, Junel Fe, Larin Fe, Microgestin Fe Lo Minastrin FE Precertification (branded generics for Loestrin Fe) Contraceptive Ortho Evra (Brand norelgestromin/ethinyl estradiol topical patch, Xulane (generic Ortho Evra) Quartette Precertification 5 Seasonale); Amethia, Camrese, Daysee (generic for Seasonique); Amethia Lo, Camrese Lo Introvale, Jolessa, Quasense (generics for (generic for LoSeasonique) Cough and Cold Zutripro (Brand chlorpheniramine/hydrocodone/pseudoephedrine (generic Zutripro) Desvenlafaxine Precertification 5 venlafaxine extended-release capsule (generic (fumarate) Effexor XR), Pristiq Depression Khedezla 5 venlafaxine extended-release capsule (generic Precertification Effexor XR), Pristiq 4 paroxetine (generic Paxil), paroxetine extendedrelease (generic Paxil CR) Pexeva Precertification Excessive Secretions Glycate Precertification 5 glycopyrrolate (generic Robinul) Ertaczo Spectazole), ketoconazole (generic Nizoral), Luzu Spectazole), ketoconazole (generic Nizoral), Naftin 1% cream and Spectazole), ketoconazole (generic Nizoral), gel Fungal Infections High Blood Pressure High Cholesterol Naftin 2% cream Spectazole), ketoconazole (generic Nizoral), Naftin 2% gel Precertification 5 Spectazole), ketoconazole (generic Nizoral), nystatin/triamcinolone (generic Mycolog II) cream & ointment nystatin cream (generic Mycostatin) + triamcinolone 0.1% cream or ointment (generic Kenalog) Oxistat Lotion Spectazole), ketoconazole (generic Nizoral), OTC Lamisil AT, Lotrimin, Lotrimin 4 nystatin cream (generic Mycostatin), OTC Vusion Precertification miconazole cream 4 losartan (generic Cozaar), telmisartan (generic Micardis (Brand Precertification Micardis) losartan/hydrochlorothiazide (generic Hyzaar), Micardis HCT (Brand telmisartan/hydrochlorothiazide (generic Micardis HCT) Antara 43 mg, 130 mg fenofibrate 54 mg, 160 mg (generic Lofibra) Antara 30 mg, 90 mg, Precertification 5 fenofibrate 54 mg, 160 mg (generic Lofibra) Fenoglide fenofibrate 54 mg, 160 mg (generic Lofibra) Fibricor 35 mg, 105 mg (brand and fenofibrate 54 mg, 160 mg (generic Lofibra) Lipofen (brand and fenofibrate 54 mg, 160 mg (generic Lofibra) Lofibra 67 mg, 134 mg, 200 mg capsule fenofibrate 54 mg, 160 mg (generic Lofibra)

4 Lofibra 54 mg, 160 mg (Brand only) fenofibrate 54 mg, 160 mg (generic Lofibra) High Cholesterol 4 omega-3-acid ethyl esters (generic Lovaza), Lovaza (Brand Precertification Vascepa Triglide fenofibrate 54 mg, 160 mg (generic Lofibra) HIV Viramune XR (Brand nevirapine extended-release (generic Viramune XR) Hormone 4 estradiol tablet (generic Estrace), Enjuvia, Cenestin Precertification Replacement Premarin Avelox Tablet (Brand moxifloxacin tablets (generic Avelox) Cipro Suspension ciprofloxacin oral suspension (generic Cipro (Brand Suspension) Infections doxycycline 75 mg capsule (generic Monodox) Mepron Suspension (Brand doxycycline hyclate (generic Morgidox, Vibramycin), doxycycline monohydrate 50 mg or 100 mg (generic Monodox) atovaquone suspension (generic Mepron) Osteoporosis Evista (Brand raloxifene (generic Evista) Pain Phosphate Binder Skin Conditions Active-Pac with Gabapentin 300 Precertification 5 gabapentin (generic Neurontin) Avinza (Brand (generic MS Contin), morphine sulfate extendedrelease capsule (generic Avinza), Nucynta ER, morphine sulfate extended-release tablet Opana ER, Oxycontin Duragesic fentanyl transdermal patch (generic Duragesic) Fioricet with Codeine 50 mg/325 mg/40 mg/30 mg (Brand Fioricet with Codeine 50 mg/300 mg/40 mg/30 mg (brand and Precertification 5 butalbital/acetaminophen/caffeine/codeine phosphate 50 mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine) butalbital/acetaminophen/caffeine/codeine phosphate 50 mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine) Zorvolex Precertification 5 diclofenac sodium (generic Voltaren), ibuprofen (generic Motrin), naproxen (generic Anaprox, diclofenac potassium (generic Cataflam), Anaprox DS, Naprosyn) Renvela tablets (Brand sevelamer carbonate (generic Renvela) Clobex Lotion Diprolene), clobetasol 0.05% gel (generic Temovate), betamethasone 0.05% augmented gel (generic clobetasol 0.05% solution (generic Temovate) 5 clobetasol 0.05% gel (generic Temovate), Clodan Kit Precertification clobetasol 0.05% lotion (generic Temovate) Cloderm (Brand mometasone furoate cream 0.1 % (generic clocortolone 0.1% cream (generic Cloderm), Elocon) 5 fluocinolone cream (generic Lidex) plus OTC Neo-Synalar Kit Precertification Neosporin 4 metronidazole 0.75% cream (generic Noritate Precertification Metrocream) betamethasone 0.05% augmented gel (generic Diprolene), Olux foam (brand and clobetasol propionate 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic Temovate)

5 Therapeutic Use Skin Conditions Medication Name Olux-E foam (brand and Taclonex Ointment (Brand New Benefit Coverage Lower Cost Options betamethasone 0.05% augmented gel (generic Diprolene), clobetasol propionate 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic Temovate) betamethasone/calcipotriene ointment (generic Taclonex) 5 desoximetasone 0.05% gel (generic Topicort), fluocinolone Topicort spray Precertification 0.05% solution (generic Lidex) Utopic Precertification 5 urea 40% 4 eszopiclone (generic Lunesta), zaleplon (generic Sonata), Sleep Lunesta (Brand Precertification zolpidem (generic Ambien) Symptoms associated with menopause 5 paroxetine (generic Paxil), paroxetine extended-release Brisdelle Precertification (generic Paxil CR) Transplant Astagraf XL Precertification 5 tacrolimus (generic Prograf) Ulcers, Heartburn, and Reflux Viral Infections Aciphex Sprinkle Precertification 5 Protonix), rabeprazole (generic Aciphex), Dexilant, Nexium Prilosec Suspension Protonix), rabeprazole (generic Aciphex), Dexilant, Nexium Protonix Granules for Suspension Protonix), rabeprazole (generic Aciphex), Dexilant, Nexium 4 acyclovir capsule or tablet (generic Zovirax), famciclovir tablet Denavir Precertification (generic Famvir), valacyclovir tablet (generic Valtrex) 4 acyclovir capsule or tablet (generic Zovirax), famciclovir tablet Zovirax cream Precertification (generic Famvir), valacyclovir tablet (generic Valtrex) 4. For impacted plans, these medications may also move to the highest tier (Tier 3). Please refer to additional coverage language to determine exclusion status. For New York, medications may be excluded unless medically necessary. 5. These medications were excluded at launch in New York (unless medically necessary) precertification may already be in place. They are covered in New Jersey. For more information Please contact your Oxford representative for more information or visit oxfordhealth.com Oxford Health Plans LLC. All rights reserved. UnitedHealthcare and the dimensional U logo are registered marks owned by UnitedHealth Group, Inc. All branded medications are trademarks or registered trademarks of their respective owners. Applies to Traditional PDL. NY and NJ Member 1/15 C MS Rev.1 Please note that not all PDL updates apply to all groups depending on state regulations, additional coverage and Summary Plan Descriptions (SPDs). Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc. and Oxford Health Plans (NJ), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc.