2019 Drug List Negative Changes

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1 2019 Drug List Negative Changes Updated 02/26/2019 If you are taking a drug that is removed from the formulary (also known as the Drug List), we will tell you. We will also tell you if we add any restrictions on a drug. We will tell you at least 60 days before we make these changes. This gives you time to talk to your doctor about what to do next. If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the formulary right away. We will also send you a letter telling you that. The table below shows changes made to our 2019 formulary. Your cost share depends on your coverage stage. Your formulary tells you the tier that applies to each covered drug. Date of Change Drug Name Type of Change Possible Alternative Drug(s) 1/1/2019 GLEOSTINE CAPS 5 MG 1/1/2019 HYDROMORPHONE HYDROCHLORIDE Removed non-part D eligible drug (not on hydromorphone hcl soln ij SOLN 110 MG/55ML NSDE) 2 mg/ml Comments 1/1/2019 IPRIVASK SOLR 1/1/2019 ISTODAX SOLR This drug was removed from the market. 1/1/2019 METFORMIN HYDROCHLORIDE SOLN Removed non-medicaid and non-part D eligible drug. RIOMET 1/1/2019 PCE TBEC 333 MG 1/1/2019 PCE TBEC 500 MG 1/1/2019 PEG-INTRON REDIPEN PAK 4 KIT Y0020_DrugLstNegChngWebNtc17_NM This drug was removed from the market.

2 Date of Change Drug Name Type of Change Possible Alternative Drug(s) 1/1/2019 POTIGA TABS 300 MG 1/1/2019 This drug was removed from the market. VEXOL SUSP AMICAR TAB aminocaproic acid tabs or 1000MG 1000 mg AMICAR TAB 500MG ADDYI TABS AFREZZA DEXTROSE DEXTROSE 50% FINACEA GEL 15% FLUCONAZOLE IN DEXTROSE SOLN 200MG/100ML- 56MG/ML, 400MG/200ML- 56MG/ML GRASTEK SUBL Removed non-medicaid and non-part D eligible drug. Removed non-part D eligible drug (not on NSDE) Removed non-part D eligible drug (not on NSDE) This drug was removed from the market. aminocaproic acid tabs or 500 mg Dextrose Inj 50% Dextrose Inj 50% azelaic acid gel 15% fluconazole in dextrose SOLN Comments

3 Date of Change Drug Name Type of Change Possible Alternative Drug(s) Removed non-part D eligible drug (not on HYDROMORPHONE NSDE) HYDROCHLORIDE SOLN 1 MG/ML MAGNESIUM SULFATE SOLN IJ 50 % MENOMUNE- A/C/Y/W-135 INJ POTASSIUM CHLORIDE SOLN IV 2 MEQ/ML PRALUENT SOSY 150 MG/ML STAXYN TAB 10MG TESTOSTERONE CYPIONATE SOLN 200 MG/ML Removed non-part D eligible drug (not on NSDE) Removed non-part D eligible drug (not on NSDE) This drug was removed from the market. Removed non-part D eligible drug (Unapproved drug other) TRELSTAR SUSR VANCOMYCIN Removed non-part D eligible drug (not on HYDROCHLORIDE/D NSDE) EXT ROSE SOLN 5%- 750MG/150ML This drug was removed from the market. VERAMYST Hydromorphone HCl Inj 1 MG/ML magnesium sulfate SOLN IJ 50 % potassium chloride SOLN IV 2 MEQ/ML vardenafil hcl tbdp testosterone cypionate soln 200 mg/ml TRELSTAR MIXJECT VANCOMYCIN HCL IN DEXTROSE FLONASE SENSIMIST Comments

4 Date of Change Drug Name Type of Change Possible Alternative Drug(s) ZYTIGA TAB 250MG abiraterone acetate tabs NORVIR NORVIR tabs PEGASYS PROCLICK PEGASYS triamcinolone mometasone furoate acetonide Nasal Susp 50 MCG/ACT CLINIMIX CLINIMIX 2.75%/DEXTROSE 5% 4.25%/DEXTROSE 5% pramoxine-hc crea Removal of non-part D eligible drug (DESI 5 LTE) amifostine SOLR This drug was removed from the market. TETANUS/DIPHTHERIA TOXOIDS-ADSORBED TDVAX SUSP SUSP This drug was removed from the market. ketoprofen CAPS 50 MG triamterene & hydrochlorothiazide CAPS 50MG-25MG This drug was removed from the market. Codeine Sulfate Tab 15 MG This drug was removed from the market. CANASA SUP Mesalamine Suppos MG MG RAPAFLO CAP 8MG silodosin Cap 8 MG RAPAFLO CAP 4MG silodosin Cap 4 MG Fluticasone-Salmeterol ADVAIR DISKU AER Aer Powder BA /50 ADVAIR DISKU AER 250/50 MCG/DOSE Fluticasone-Salmeterol Aer Powder BA MCG/DOSE Comments

5 Date of Change Drug Name Type of Change Possible Alternative Drug(s) Fluticasone-Salmeterol ADVAIR DISKU AER Aer Powder BA /50 MCG/DOSE Comments If you or your doctor disagrees with the change to your drug, you may request an exception. To request an exception, call us at: State California (HMO Plans) Health Net Seniority Plus Employer (HMO) California (All Other HMO SNP Plans) Health Net Seniority Plus Sapphire (HMO) Health Net Seniority Plus Sapphire Premier (HMO) Health Net Seniority Plus Sapphire Premier II (HMO) Oregon/Washington Phone Number , TTY: , TTY: ; TTY:711 Health Net Seniority Plus Employer (HMO) UC Employees ; TTY: 711 From October 1 March 31, seven days a week, 8 a.m. to 8 p.m. From April 1 - September 30, Monday through Friday, 8 a.m. to 8 p.m. On weekends and holidays, an automated system will handle your call. Your doctor must provide a statement to support your request. For details on asking for an exception, check your Evidence of Coverage. If you don t agree with our decision, you may file a complaint with us. To file a complaint, call us at:

6 State California (HMO Plans) Health Net Seniority Plus Employer (HMO) California (All Other HMO SNP Plans) Health Net Seniority Plus Sapphire (HMO) Health Net Seniority Plus Sapphire Premier (HMO) Health Net Seniority Plus Sapphire Premier II (HMO) Phone Number , TTY: , TTY:711 Oregon/Washington ; TTY:711 Health Net Seniority Plus Employer (HMO) UC Employees ; TTY: 711 From October 1 March 31, seven days a week, 8 a.m. to 8 p.m. From April 1 - September 30, Monday through Friday, 8 a.m. to 8 p.m. On weekends and holidays, an automated system will handle your call. Your doctor must provide a statement to support your request. You may also send your complaint to us in writing at the following address. Health Net Attention: Appeals & Grievances Dept. PO Box Van Nuys, CA The Formulary may change at any time. You will receive notice when necessary.

7 d' Health Net Section 1557 Non-Discrimination Language Notice of Non-Discrimination Health rjet complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently because of race, color, national origin, age, disabiiity, or sex. HeaI th ~Jet: Provices free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provices free language services to people whose primary language is not English, such as qualified interpreters and information writte, in other I anguage s. If you need these services, contact Health Net's Customer Contact Center at California: (Jade, Sapphire, Amber, and HMO S~JP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711). From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p:n. From April 1 to September 30, you can call us Monday througr Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. Ifyou believe that Health Nethas failed to provide these services or discriminated in another way on the basis of race, col or, national origin, sge, disabiiity, or sex, you can fi I e a grievance by caiii ng the number above and te 11 i ng them you need he Ip fiiing a grievance; Health rjet's Customer Contact Center is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, eleclrunically Lhruu~h the Office rur Civil Ri~hl~ Corri[Jlainl Pur Lal, availal>le al 1LL[J~://ucr[Jor Lal.hh~-~uv/ucr/[Jur Lal/lul>l>y.j~r or l.,y mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, (TDD: ). Compl a ntforms are available at /office/file/index.html.

8 Health Net is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Health Net depends on contract renewal. CA - OR MLI - C

9 Section 1557 Non-Discrimination Language Multi-Language Interpreter Services ARABIC ARMENIAN!"')'-! JL.,:i':11 '-5'!'-J,.cell ;;..,.t:i.. :\.,J~I :\.,y.lll ;;.i.cwi wt...l.i. u)-i,ti,y.11 c'.jh.:i:i c::.us 1:iJ :":!,W California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO);.(711 :r5-,tji_., ~I c..ij'\.,,) Oregon: (HMO and PPO) JlJ.t;U'1f'JlJ.[cl-8JlI 'l,' bpth ]ununu.f hp hrujhphu, U1UJ.U1 ii.hq ruutl_~rup qrupn11 hu mprutfru11phl lhqtl_ruqruu ru2rulj.gmptju1u orunrujmptjm'i.iuhp: Qruuqruhruphp: California: Gade, Sapphire, Amber, and HMO SNP), (all other HMO) (TTY: 711). CHINESE CUSHITE FRENCH GERMAN HINDI O 51:~ : 3105"':fGS }lt:px: ' JGSBJJ;).92,J 'JJH~~t';"~Jl.jJ~1 tt ill'r 5<'.JI California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa Oregon: {HMO and PPO} {TIY: 711}. ATTENTION : Si vous parlez fran~ais, des services d'aide linguistique vous sont proposes gratuitement. Appelez le Oregon: {HMO and PPO} {TTY: 711}. ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfugung. Rufnummer Oregon: {HMO and PPO} {TTY: 711}. California:.:, ( (Jade, Sapphire, Amber, and HMO SNP}, )all other HMO} {TTY: 711). ~ m t.<no, ~: <rfu JITCl" ~ ~ i, 3ff11'ITT 3lf\TI *1$1<:Jc''II ~ f.:t:~~ 3q(>\.stf i ill m <RI 0

10 HMONG LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau California: {Jade, Sapphire, Amber, and HMO SNP}, {all other HMO} {TTY: 711}. ;i~$:j.i'l:: E3*B!~~!~n0~i., 1!!U40)~B!3zt.i-+t-t::';z.,~,.._-f1Jfflt,,f.=t::1tac:"'ta California: JAPANESE (Jade, Sapphire Amber, and HMO SNP), (al I other HMO); Oregon: (HMO and PPO) (TTY:711)!=~~~!< t::~t,,o KOREAN MON-KHMER CAMBODIAN PERSIAN PUNJABI "?~I: 21~0,~ /J~ofAI::::: ~Si2-. '2:iO, J:I~ A1i::JIA~ ~fi~ Ol~of~,4,. v;;;;;uo. California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711) \!:! 0 ~ ~ ~.foh "?~ Al 2.. dittnuhln:::nm, iuwshnsrn1wn1mtb1 iwnlils wn1 Mtt':fl wf'lnfintel Fil:::llswriuHni w1:1mwni'i:rl..., c:t..., t-1 ru c:t ~~d HUB California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711) (all other HMO); Oregon: (HMO and PPO) (TTY: 711) i.~'-! cs-' w _)L/ii,.I _J.l uk.1_) _JJh ""i i..'"-ij.i1.,_,1 wt...l.i.,w..l i.rj-' w u'-!j _;1 :-4-Ji California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); _!W '-! \.ibl..i,~ ly'w Oregon: (HMO and PPO) (TTY: 711) ftrwo ft; ': rl ~ ~ ~ ~ 3' ~ ~ ~ Hcl 1 IE3 1 ~ 1~M'3M ~~ I fc@l..ft ~ California: {Jade, Sapphire, Amber, and HMO SNP}, {all other HMO} {TTY: 711} ' d ~~I ROMANIAN ATENTIE: Daca vorbiti limba romana, va stau la dispozitie servicii de asistenta lingvistica, gratuit. Sunati la Oregon: {HMO and PPO} {TTY: 711}.

11

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