Upper Peninsula Health Plan Advantage (HMO) (H ) Updates

Transcription

1 February, /28/2017 abacavirlamivudine 02/28/2017 abacavirlamivudine 02/28/2017 rasagiline mesylate 02/28/2017 rasagiline mesylate abacavir sulfate/lamivudine ADD UM: QUANTITY 30 / 30 Days abacavir sulfate/lamivudine Specialty rasagiline mesylate rasagiline mesylate 02/28/2017 aprepitant aprepitant 02/28/2017 aprepitant aprepitant ADD UM: QUANTITY 1 / 30 Days 02/28/2017 erythromycin ethylsuccinate 02/28/2017 quetiapine fumarate er 02/28/2017 quetiapine fumarate er 02/28/2017 quetiapine fumarate er 02/28/2017 quetiapine fumarate er 02/28/2017 quetiapine fumarate er 02/28/2017 quetiapine fumarate er erythromycin ethylsuccinate Non-Preferred quetiapine fumarate ADD UM: QUANTITY 90 / 30 Days quetiapine fumarate Non-Preferred quetiapine fumarate Non-Preferred quetiapine fumarate ADD UM: QUANTITY 60 / 30 Days quetiapine fumarate ADD UM: QUANTITY 60 / 30 Days quetiapine fumarate Non-Preferred 02/28/2017 EPINEPHRINE epinephrine Preferred 02/28/2017 oseltamivir phosphate oseltamivir phosphate PAGE 1 UPDATED 11/2017

2 02/28/2017 oseltamivir phosphate 02/28/2017 oseltamivir phosphate 02/28/2017 oseltamivir phosphate 02/28/2017 levalbuterol tartrate hfa 02/28/2017 levalbuterol tartrate hfa 02/28/2017 ethynodiol-ethinyl oseltamivir phosphate ADD UM: QUANTITY 112 / 365 Days oseltamivir phosphate oseltamivir phosphate ADD UM: QUANTITY 60 / 365 Days levalbuterol tartrate ADD UM: QUANTITY 30 / 30 Days levalbuterol tartrate Non-Preferred ethynodiol diacetate-ethinyl 02/28/2017 azithromycin azithromycin 02/28/2017 norgestimateethinyl norgestimate-ethinyl 02/28/2017 fenofibrate fenofibrate 02/28/2017 fenofibrate fenofibrate 02/28/2017 low-ogestrel norgestrel-ethinyl 02/28/2017 omeprazolesodium bicarbonate 02/28/2017 omeprazolesodium bicarbonate 02/28/2017 omeprazolesodium bicarbonate 02/28/2017 omeprazolesodium bicarbonate omeprazole/sodium bicarbonate omeprazole/sodium bicarbonate omeprazole/sodium bicarbonate omeprazole/sodium bicarbonate ADD UM: QUANTITY ADD UM: QUANTITY 60 / 30 Days Non-Preferred Non-Preferred 60 / 30 Days PAGE 2 UPDATED 11/2017

3 02/28/2017 aprepitant aprepitant 02/28/2017 aprepitant aprepitant ADD UM: QUANTITY 6 / 30 Days 02/28/2017 prednisone prednisone 02/28/2017 prednisone prednisone 02/28/2017 prednisone prednisone CHANGE TIER Preferred 02/28/2017 prednisone prednisone 02/28/2017 prednisone prednisone 02/28/2017 prednisone prednisone CHANGE TIER Preferred 02/28/2017 PEDIARIX hep b virus,rcmb/dipth,pertus(acell ),tet,polio vaccine/pf 02/28/2017 KINRIX diphtheria, pertussis(acell),tetanus,polio vaccine/pf Non-Preferred Preferred 02/28/2017 caziant desogestrel-ethinyl 02/28/2017 quetiapine fumarate er 02/28/2017 quetiapine fumarate er quetiapine fumarate Non-Preferred quetiapine fumarate ADD UM: QUANTITY 60 / 30 Days 02/28/2017 COLCRYS colchicine Preferred 02/28/2017 valganciclovir hcl valganciclovir hcl Specialty 02/28/2017 clindamycin phos-tretinoin clindamycin phosphate/tretinoin Non-Preferred 02/28/2017 ADRENACLICK epinephrine Non-Preferred 02/28/2017 ADRENACLICK epinephrine Non-Preferred PAGE 3 UPDATED 11/2017

4 02/28/2017 quetiapine fumarate er 02/28/2017 quetiapine fumarate er quetiapine fumarate ADD UM: QUANTITY 60 / 30 Days quetiapine fumarate Non-Preferred 02/28/2017 nyata nystatin 02/28/2017 RUBRACA rucaparib camsylate ADD UM: QUANTITY 120 / 30 Days 02/28/2017 RUBRACA rucaparib camsylate Specialty 02/28/2017 RUBRACA rucaparib camsylate ADD UM: QUANTITY 120 / 30 Days 02/28/2017 RUBRACA rucaparib camsylate Specialty 02/28/2017 nitroglycerin nitroglycerin 02/28/2017 nitroglycerin nitroglycerin 02/28/2017 nitroglycerin nitroglycerin 02/28/2017 ofloxacin ofloxacin 02/28/2017 PRIMSOL trimethoprim Non-Preferred 02/28/2017 mycophenolate mofetil mycophenolate mofetil hcl 02/28/2017 nilutamide nilutamide Specialty 02/28/2017 oseltamivir phosphate 02/28/2017 oseltamivir phosphate oseltamivir phosphate ADD UM: QUANTITY 110 / 365 Days oseltamivir phosphate 02/28/2017 sumatriptan sumatriptan ADD UM: QUANTITY 12 / 30 Days 02/28/2017 sumatriptan sumatriptan Non-Preferred 02/28/2017 sumatriptan sumatriptan ADD UM: QUANTITY 12 / 30 Days 02/28/2017 sumatriptan sumatriptan Non-Preferred PAGE 4 UPDATED 11/2017

5 02/28/2017 olmesartan medoxomil 02/28/2017 olmesartan medoxomil 02/28/2017 olmesartan medoxomil olmesartan medoxomil olmesartan medoxomil olmesartan medoxomil 02/28/2017 ezetimibe ezetimibe Preferred 02/28/2017 aprepitant aprepitant ADD UM: QUANTITY 8 / 30 Days 02/28/2017 aprepitant aprepitant 02/28/2017 aprepitant aprepitant 02/28/2017 aprepitant aprepitant ADD UM: QUANTITY 2 / 30 Days 02/28/2017 olmesartanhydrochlorothiazi de 02/28/2017 olmesartanhydrochlorothiazi de 02/28/2017 olmesartanhydrochlorothiazi de olmesartan medoxomil/hydrochlorothiazi de olmesartan medoxomil/hydrochlorothiazi de olmesartan medoxomil/hydrochlorothiazi de 02/28/2017 daptomycin daptomycin Specialty 02/28/2017 JUBLIA efinaconazole CHANGE TIER Non-Preferred 02/28/2017 sumatriptan succinate Preferred sumatriptan succinate CHANGE UM: QUANTITY 5 / 30 days 8 / 30 Days 02/28/2017 metformin hcl er metformin hcl CHANGE UM: QUANTITY 60 / 30 DAYS 60 / 30 Days 02/28/2017 metformin hcl er metformin hcl Non-Preferred PAGE 5 UPDATED 11/2017

6 02/28/2017 metformin hcl er metformin hcl CHANGE TIER Preferred Non-Preferred 02/28/2017 metformin hcl er metformin hcl ADD UM: QUANTITY 120 / 30 Days 02/28/2017 metformin hcl er metformin hcl CHANGE UM: QUANTITY 120 / 30 days 120 / 30 Days 02/28/2017 methylphenidate hcl er 02/28/2017 methylphenidate hcl er 02/28/2017 methylphenidate hcl cd 02/28/2017 methylphenidate hcl er 02/28/2017 methylphenidate hcl er 02/28/2017 methylphenidate hcl cd 02/28/2017 zarah ethinyl /drospirenone 02/28/2017 drospirenone-eth estra-levomef methylphenidate hcl Non-Preferred methylphenidate hcl ADD UM: QUANTITY 30 / 30 Days methylphenidate hcl CHANGE UM: QUANTITY 30 / 30 DAYS 30 / 30 Days methylphenidate hcl Non-Preferred methylphenidate hcl ADD UM: QUANTITY 30 / 30 Days methylphenidate hcl CHANGE UM: QUANTITY 30 / 30 DAYS 30 / 30 Days drospirenone/ethinyl /levomefolate calcium 02/28/2017 TRIDESILON desonide 02/28/2017 norethin-eth estra-ferrous fum norethindrone-ethinyl /ferrous fumarate 02/28/2017 diphenoxylateatropine diphenoxylate hcl/atropine sulfate 02/28/2017 camrese lo levonorgestrel/ethinyl and ethinyl ADD UM: QUANTITY 91 / 91 Days PAGE 6 UPDATED 11/2017

7 02/28/2017 camrese lo levonorgestrel/ethinyl and ethinyl 02/28/2017 alyacen norethindrone-ethinyl 02/28/2017 amethia lo levonorgestrel/ethinyl and ethinyl 02/28/2017 amethia lo levonorgestrel/ethinyl and ethinyl ADD UM: QUANTITY 91 / 91 Days 02/28/2017 ethacrynic acid ethacrynic acid Specialty 02/28/2017 ergotaminecaffeine 02/28/2017 norethindronethinyl ergotamine tartrate/caffeine norethindrone acetateethinyl 02/28/2017 lorcet hd hydrocodone bitartrate/acetaminophen 02/28/2017 clindamycin phos-benzoyl perox clindamycin phosphate/benzoyl peroxide Non-Preferred 02/28/2017 RYTARY carbidopa/levodopa Non-Preferred 02/28/2017 RYTARY carbidopa/levodopa Non-Preferred 02/28/2017 RYTARY carbidopa/levodopa Non-Preferred 02/28/2017 RYTARY carbidopa/levodopa Non-Preferred 02/28/2017 methotrexate methotrexate sodium 02/28/2017 YONDELIS trabectedin Specialty PAGE 7 UPDATED 11/2017

8 02/28/2017 EMEND aprepitant Non-Preferred 02/28/2017 EMEND aprepitant ADD UM: QUANTITY 6 / 30 Days 02/28/2017 ala-cort hydrocortisone Preferred 02/28/2017 epirubicin hcl epirubicin hcl 02/28/2017 INFLECTRA infliximab-dyyb Specialty 02/28/2017 sumatriptan succinate 02/28/2017 sumatriptan succinate 02/28/2017 larissia levonorgestrel-ethinyl 02/28/2017 femynor norgestimate-ethinyl sumatriptan succinate Non-Preferred sumatriptan succinate ADD UM: QUANTITY 8 / 30 Days 02/28/2017 yuvafem Non-Preferred 02/28/2017 gengraf cyclosporine, modified 02/28/2017 triamcinolone acetonide triamcinolone acetonide 02/28/2017 morgidox doxycycline hyclate 02/28/2017 OCALIVA obeticholic acid ADD UM: QUANTITY 30 / 30 Days 02/28/2017 OCALIVA obeticholic acid Specialty 02/28/2017 OCALIVA obeticholic acid ADD UM: QUANTITY 30 / 30 Days 02/28/2017 OCALIVA obeticholic acid Specialty 02/28/2017 EPCLUSA sofosbuvir/velpatasvir Specialty 02/28/2017 EPCLUSA sofosbuvir/velpatasvir ADD UM: QUANTITY 84 / 365 Days PAGE 8 UPDATED 11/2017

9 02/28/2017 ORENCIA CLICKJECT 02/28/2017 ORENCIA CLICKJECT abatacept Specialty abatacept ADD UM: QUANTITY 4 / 28 Days 02/28/2017 adriamycin doxorubicin hcl 02/28/2017 SPS sodium polystyrene sulfonate/sorbitol solution 02/28/2017 DORYX MPC doxycycline hyclate Non-Preferred 02/28/2017 cholestyramine light cholestyramine/aspartame CHANGE TIER Non-Preferred 02/28/2017 bupropion hcl sr bupropion hcl CHANGE UM: QUANTITY 90 / 30 DAYS 60 / 30 Days 02/28/2017 REPATHA PUSHTRONEX 02/28/2017 REPATHA PUSHTRONEX evolocumab Specialty evolocumab ADD UM: QUANTITY 3.5 / 28 Days 02/28/2017 RELISTOR methylnaltrexone bromide ADD UM: QUANTITY 90 / 30 Days 02/28/2017 RELISTOR methylnaltrexone bromide Specialty 02/28/2017 VIEKIRA XR ombitasvir/paritaprevir/ritona vir/dasabuvir sodium 02/28/2017 VIEKIRA XR ombitasvir/paritaprevir/ritona vir/dasabuvir sodium ADD UM: QUANTITY 504 / 365 Days Specialty 02/28/2017 NAMZARIC memantine hcl/donepezil hcl ADD UM: QUANTITY 30 / 30 Days 02/28/2017 NAMZARIC memantine hcl/donepezil hcl Preferred 02/28/2017 NAMZARIC memantine hcl/donepezil hcl Preferred 02/28/2017 NAMZARIC memantine hcl/donepezil hcl ADD UM: QUANTITY 30 / 30 Days 02/28/2017 amabelz /norethindrone acetate Non-Preferred PAGE 9 UPDATED 11/2017

10 02/28/2017 amabelz /norethindrone acetate Non-Preferred 02/28/2017 KYPROLIS carfilzomib Specialty 02/28/2017 KYPROLIS carfilzomib Specialty 02/28/2017 GAMASTAN S-D immune globulin,gamma(igg)/glycine 02/28/2017 GAMASTAN S-D immune globulin,gamma(igg)/glycine 02/28/2017 GAMMAGARD S- D 02/28/2017 GAMMAGARD S- D immune globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml immune globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml Preferred Preferred Specialty Specialty 02/28/2017 EXONDYS 51 eteplirsen Specialty 02/28/2017 EXONDYS 51 eteplirsen Specialty 02/28/2017 INVOKAMET XR canagliflozin/metformin hcl Preferred 02/28/2017 INVOKAMET XR canagliflozin/metformin hcl ADD UM: QUANTITY 60 / 30 Days 02/28/2017 INVOKAMET XR canagliflozin/metformin hcl ADD UM: QUANTITY 60 / 30 Days 02/28/2017 INVOKAMET XR canagliflozin/metformin hcl Preferred 02/28/2017 INVOKAMET XR canagliflozin/metformin hcl Preferred 02/28/2017 INVOKAMET XR canagliflozin/metformin hcl ADD UM: QUANTITY 60 / 30 Days 02/28/2017 INVOKAMET XR canagliflozin/metformin hcl ADD UM: QUANTITY 60 / 30 Days 02/28/2017 INVOKAMET XR canagliflozin/metformin hcl Preferred 02/28/2017 VASCEPA icosapent ethyl Non-Preferred 02/28/2017 STELARA ustekinumab Specialty 02/28/2017 nifedipine er nifedipine PAGE 10 UPDATED 11/2017

11 02/28/2017 nifedipine er nifedipine 02/28/2017 ORKAMBI lumacaftor/ivacaftor Specialty 02/28/2017 ORKAMBI lumacaftor/ivacaftor ADD UM: QUANTITY 112 / 28 Days 02/28/2017 levalbuterol concentrate levalbuterol hcl CHANGE UM: QUANTITY 90 / 30 DAYS 90 / 30 Days 02/28/2017 LARTRUVO olaratumab Specialty 02/28/2017 VEMLIDY tenofovir alafenamide fumarate 02/28/2017 colchicine colchicine CHANGE TIER Non-Preferred Specialty Preferred 02/28/2017 linezolid linezolid CHANGE UM: QUANTITY 28 / 30 days 56 / 28 Days 02/28/2017 EPIPEN 2-PAK epinephrine ADD UM: QUANTITY 90 / 30 Days 02/28/2017 RENVELA sevelamer carbonate CHANGE TIER Specialty Preferred 02/28/2017 RENVELA sevelamer carbonate CHANGE TIER Specialty Preferred 02/28/2017 RENVELA sevelamer carbonate CHANGE TIER Specialty Preferred PAGE 11 UPDATED 11/2017

12 March, /30/2017 dexmethylphenid ate hcl er 03/30/2017 dexmethylphenid ate hcl er 03/30/2017 dexmethylphenid ate hcl er 03/30/2017 dexmethylphenid ate hcl er 03/30/2017 RIBASPHERE RIBAPAK dexmethylphenidate hcl Non-Preferred dexmethylphenidate hcl ADD UM: QUANTITY 30 / 30 DAYS dexmethylphenidate hcl ADD UM: QUANTITY 30 / 30 DAYS dexmethylphenidate hcl Non-Preferred ribavirin Specialty 03/30/2017 lopinavir-ritonavir lopinavir/ritonavir 03/30/2017 norgestimateethinyl norgestimate-ethinyl 03/30/2017 amiodarone hcl amiodarone hcl 03/31/2017 LARTRUVO olaratumab CHANGE TIER Specialty PAGE 12 UPDATED 11/2017

13 April, /28/2017 methylphenidate la 04/28/2017 methylphenidate la 04/28/2017 clindacin p,clindacin pac,clindacin etz 04/28/2017 butalbitalacetaminophen methylphenidate hcl methylphenidate hcl ADD UM: QUANTITY 30 / 30 DAYS clindamycin phosphate,clindamycin phosphate/skin cleanser comb no.19 butalbital/acetaminophen Non-Preferred 04/28/2017 AFREZZA insulin regular, human Non-Preferred 04/28/2017 RASUVO methotrexate/pf Preferred 04/28/2017 RASUVO methotrexate/pf Preferred 04/28/2017 RASUVO methotrexate/pf Preferred 04/28/2017 RASUVO methotrexate/pf Preferred 04/28/2017 RASUVO methotrexate/pf Preferred 04/28/2017 RASUVO methotrexate/pf Preferred 04/28/2017 RASUVO methotrexate/pf Preferred 04/28/2017 RASUVO methotrexate/pf Preferred 04/28/2017 RASUVO methotrexate/pf Preferred 04/28/2017 RASUVO methotrexate/pf Preferred 04/28/2017 AFREZZA insulin regular, human Non-Preferred 04/28/2017 AFREZZA insulin regular, human Non-Preferred PAGE 13 UPDATED 11/2017

14 04/28/2017 AFREZZA insulin regular, human Non-Preferred 04/28/2017 AFREZZA insulin regular, human Non-Preferred 04/28/2017 potassium chloride 04/28/2017 potassium chloride potassium chloride CHANGE TIER potassium chloride CHANGE TIER 04/28/2017 SELZENTRY maraviroc Non-Preferred 04/28/2017 SELZENTRY maraviroc Non-Preferred 04/28/2017 AFREZZA insulin regular, human Non-Preferred 04/28/2017 LINZESS linaclotide Preferred 04/28/2017 LINZESS linaclotide ADD UM: QUANTITY 30 / 30 DAYS 04/28/2017 EPINEPHRINE epinephrine Preferred 04/28/2017 epinephrine epinephrine CHANGE TIER Non-Preferred 04/28/2017 epinephrine epinephrine CHANGE TIER Non-Preferred 04/28/2017 EMFLAZA deflazacort Specialty 04/28/2017 EMFLAZA deflazacort Specialty 04/28/2017 EMFLAZA deflazacort Specialty 04/28/2017 EMFLAZA deflazacort Specialty 04/28/2017 EMFLAZA deflazacort Specialty 04/28/2017 calcium acetate calcium acetate PAGE 14 UPDATED 11/2017

15 04/28/2017 flurandrenolide flurandrenolide Non-Preferred 04/28/2017 prednisolone sodium phosphate 04/28/2017 prednisolone sodium phosphate 04/28/2017 SIMBRINZA brinzolamide/brimonidine tartrate 04/28/2017 buprenorphine hcl 04/28/2017 buprenorphine hcl prednisolone sod phosphate prednisolone sod phosphate CHANGE TIER Non-Preferred Preferred buprenorphine hcl CHANGE TIER buprenorphine hcl CHANGE TIER 04/28/2017 LIVALO pitavastatin calcium CHANGE TIER Non-Preferred 04/28/2017 LIVALO pitavastatin calcium CHANGE TIER Non-Preferred 04/28/2017 LIVALO pitavastatin calcium CHANGE TIER Non-Preferred 04/28/2017 EMBEDA morphine sulfate/naltrexone hcl 04/28/2017 EMBEDA morphine sulfate/naltrexone hcl Preferred Preferred Preferred CHANGE TIER Specialty Preferred CHANGE TIER Specialty Preferred PAGE 15 UPDATED 11/2017

16 May, /26/2017 clonazepam clonazepam CHANGE UM: QUANTITY 30 / 30 days 300 / 30 DAYS 05/26/2017 APOKYN apomorphine hcl CHANGE UM: QUANTITY 60 / 30 DAYS 90 / 30 DAYS 05/26/2017 desvenlafaxine succinate er 05/26/2017 desvenlafaxine succinate er 05/26/2017 mibelas 24 fe norethindrone acetateethinyl /ferrous fumarate desvenlafaxine succinate desvenlafaxine succinate ADD UM: QUANTITY 30 / 30 DAYS 05/26/2017 KISQALI ribociclib succinate Specialty 05/26/2017 KISQALI ribociclib succinate ADD UM: QUANTITY 63 / 28 OVER TIME 05/26/2017 KISQALI ribociclib succinate ADD UM: QUANTITY 63 / 28 OVER TIME 05/26/2017 KISQALI ribociclib succinate Specialty 05/26/2017 KISQALI ribociclib succinate Specialty 05/26/2017 KISQALI ribociclib succinate ADD UM: QUANTITY 63 / 28 OVER TIME 05/26/2017 desvenlafaxine succinate er 05/26/2017 desvenlafaxine succinate er 05/26/2017 desvenlafaxine succinate er 05/26/2017 desvenlafaxine succinate er desvenlafaxine succinate ADD UM: QUANTITY 120 / 30 DAYS desvenlafaxine succinate desvenlafaxine succinate desvenlafaxine succinate ADD UM: QUANTITY 30 / 30 DAYS 05/26/2017 APOKYN apomorphine hcl CHANGE UM: QUANTITY 90 / 30 DAYS 90 / 30 DAYS PAGE 16 UPDATED 11/2017

17 July, /01/2017 norethin-eth estra-ferrous fum norethindrone acetateethinyl /ferrous fumarate 07/01/2017 AKYNZEO netupitant/palonosetron hcl Non-Preferred 07/01/2017 AKYNZEO netupitant/palonosetron hcl ADD UM: QUANTITY 2 / 30 DAYS 07/01/2017 levoleucovorin calcium levoleucovorin calcium Non-Preferred 07/01/2017 ESBRIET pirfenidone Specialty 07/01/2017 ESBRIET pirfenidone Specialty 07/01/2017 XERMELO telotristat etiprate Specialty 07/01/2017 XERMELO telotristat etiprate ADD UM: QUANTITY 90 / 30 DAYS 07/01/2017 fayosim levonorgestrel/ethinyl and ethinyl 07/01/2017 fayosim levonorgestrel/ethinyl and ethinyl ADD UM: QUANTITY 91 / 91 DAYS 07/01/2017 BAVENCIO avelumab Specialty 07/01/2017 roweepra levetiracetam 07/01/2017 roweepra levetiracetam 07/01/2017 rivelsa levonorgestrel/ethinyl and ethinyl 07/01/2017 rivelsa levonorgestrel/ethinyl and ethinyl ADD UM: QUANTITY 91 / 91 DAYS PAGE 17 UPDATED 11/2017

18 07/01/2017 DUPIXENT dupilumab Specialty 07/01/2017 DUPIXENT dupilumab ADD UM: QUANTITY 8 / 28 DAYS 07/01/2017 GAMMAPLEX immune globulin,gamma (igg)/glycine/iga 0 to 50 mcg/ml 07/01/2017 GAMMAPLEX immune globulin,gamma (igg)/glycine/iga 0 to 50 mcg/ml Specialty Specialty 07/01/2017 AUSTEDO deutetrabenazine Specialty 07/01/2017 AUSTEDO deutetrabenazine ADD UM: QUANTITY 120 / 30 DAYS 07/01/2017 AUSTEDO deutetrabenazine Specialty 07/01/2017 AUSTEDO deutetrabenazine ADD UM: QUANTITY 120 / 30 DAYS PAGE 18 UPDATED 11/2017

19 August, /01/2017 INGREZZA valbenazine tosylate Specialty 08/01/2017 INGREZZA valbenazine tosylate ADD UM: QUANTITY 60 / 30 DAYS 08/01/2017 ZEJULA niraparib tosylate Specialty 08/01/2017 ZEJULA niraparib tosylate ADD UM: QUANTITY 90 / 30 DAYS 08/01/2017 RYDAPT midostaurin Specialty 08/01/2017 RYDAPT midostaurin ADD UM: QUANTITY 240 / 30 DAYS 08/01/2017 IMFINZI durvalumab Specialty 08/01/2017 IMFINZI durvalumab Specialty 08/01/2017 TYMLOS abaloparatide Specialty 08/01/2017 ALUNBRIG brigatinib Specialty 08/01/2017 ALUNBRIG brigatinib ADD UM: QUANTITY 180 / 30 DAYS 08/01/2017 XATMEP methotrexate Non-Preferred 08/01/2017 RADICAVA edaravone Specialty 08/01/2017 KISQALI FEMARA CO- PACK 08/01/2017 KISQALI FEMARA CO- PACK 08/01/2017 KISQALI FEMARA CO- PACK 08/01/2017 KISQALI FEMARA CO- PACK ribociclib succinate/letrozole Specialty ribociclib succinate/letrozole ADD UM: QUANTITY 91 / 28 DAYS ribociclib succinate/letrozole Specialty ribociclib succinate/letrozole ADD UM: QUANTITY 91 / 28 DAYS PAGE 19 UPDATED 11/2017

20 08/01/2017 KISQALI FEMARA CO- PACK 08/01/2017 KISQALI FEMARA CO- PACK ribociclib succinate/letrozole Specialty ribociclib succinate/letrozole ADD UM: QUANTITY 91 / 28 DAYS 08/01/2017 KEVZARA sarilumab Specialty 08/01/2017 KEVZARA sarilumab Specialty 08/01/2017 ezetimibesimvastatin 08/01/2017 ezetimibesimvastatin 08/01/2017 ezetimibesimvastatin 08/01/2017 ezetimibesimvastatin ezetimibe/simvastatin ezetimibe/simvastatin ezetimibe/simvastatin ezetimibe/simvastatin 08/01/2017 clofarabine clofarabine Specialty PAGE 20 UPDATED 11/2017

21 September, /01/2017 olopatadine hcl olopatadine hcl 09/01/2017 VARIZIG varicella-zoster immune globulin/maltose,varicellazoster immune globulin (human) Specialty 09/01/2017 AFREZZA insulin regular, human Non-Preferred 09/01/2017 AFREZZA insulin regular, human Non-Preferred 09/01/2017 lidocaine hcl lidocaine hcl/pf Preferred 09/01/2017 ORENITRAM ER treprostinil diolamine Specialty 09/01/2017 SILIQ brodalumab Specialty 09/01/2017 JADENU SPRINKLE 09/01/2017 JADENU SPRINKLE 09/01/2017 JADENU SPRINKLE deferasirox Specialty deferasirox Specialty deferasirox Specialty 09/01/2017 ORENCIA abatacept Specialty 09/01/2017 ORENCIA abatacept Specialty 09/01/2017 ARISTADA aripiprazole lauroxil Specialty 09/01/2017 atomoxetine hcl atomoxetine hcl ADD UM: QUANTITY 60 / 30 DAYS 09/01/2017 atomoxetine hcl atomoxetine hcl 09/01/2017 atomoxetine hcl atomoxetine hcl ADD UM: QUANTITY 30 / 30 DAYS 09/01/2017 atomoxetine hcl atomoxetine hcl PAGE 21 UPDATED 11/2017

22 09/01/2017 atomoxetine hcl atomoxetine hcl ADD UM: QUANTITY 30 / 30 DAYS 09/01/2017 atomoxetine hcl atomoxetine hcl 09/01/2017 atomoxetine hcl atomoxetine hcl ADD UM: QUANTITY 30 / 30 DAYS 09/01/2017 atomoxetine hcl atomoxetine hcl 09/01/2017 atomoxetine hcl atomoxetine hcl ADD UM: QUANTITY 30 / 30 DAYS 09/01/2017 atomoxetine hcl atomoxetine hcl 09/01/2017 tigecycline tigecycline Specialty 09/01/2017 atomoxetine hcl atomoxetine hcl 09/01/2017 atomoxetine hcl atomoxetine hcl ADD UM: QUANTITY 30 / 30 DAYS 09/01/2017 atomoxetine hcl atomoxetine hcl 09/01/2017 atomoxetine hcl atomoxetine hcl ADD UM: QUANTITY 30 / 30 DAYS 09/01/2017 DIASTAT diazepam Non-Preferred 09/01/2017 DIASTAT ACUDIAL 09/01/2017 DIASTAT ACUDIAL 09/01/2017 sevelamer carbonate 09/01/2017 sevelamer carbonate diazepam Non-Preferred diazepam Non-Preferred sevelamer carbonate Preferred sevelamer carbonate Preferred PAGE 22 UPDATED 11/2017

23 October, /01/2017 testosterone testosterone Non-Preferred 10/01/2017 meropenem,mero penem-0.9% nacl meropenem,meropenem in 0.9 % sodium chloride 10/01/2017 ORFADIN nitisinone Specialty 10/01/2017 XIIDRA lifitegrast Non-Preferred 10/01/2017 isibloom desogestrel-ethinyl 10/01/2017 RENFLEXIS infliximab-abda Specialty 10/01/2017 TREMFYA guselkumab Specialty 10/01/2017 SYNDROS dronabinol ADD UM: QUANTITY 120 / 30 DAYS 10/01/2017 SYNDROS dronabinol Specialty 10/01/2017 eletriptan hbr eletriptan hbr ADD UM: QUANTITY 12 / 30 OVER TIME 10/01/2017 eletriptan hbr eletriptan hbr Non-Preferred 10/01/2017 eletriptan hbr eletriptan hbr ADD UM: QUANTITY 12 / 30 OVER TIME 10/01/2017 eletriptan hbr eletriptan hbr Non-Preferred 10/01/2017 moxifloxacin moxifloxacin hcl 10/01/2017 amnesteem isotretinoin Non-Preferred 10/01/2017 amnesteem isotretinoin Non-Preferred PAGE 23 UPDATED 11/2017

24 10/01/2017 amnesteem isotretinoin Non-Preferred 10/01/2017 mesalamine mesalamine Preferred 10/01/2017 sevelamer carbonate 10/01/2017 desogestrelethinyl sevelamer carbonate Preferred desogestrel-ethinyl 10/01/2017 ENTRESTO sacubitril/valsartan CHANGE TIER Non-Preferred 10/01/2017 ENTRESTO sacubitril/valsartan CHANGE TIER Non-Preferred 10/01/2017 ENTRESTO sacubitril/valsartan CHANGE TIER Non-Preferred Preferred Preferred Preferred 10/30/2017 RAYALDEE calcifediol Specialty 10/30/2017 ZYTIGA abiraterone acetate Specialty 10/30/2017 ISENTRESS HD raltegravir potassium Specialty 10/30/2017 BENLYSTA belimumab Specialty 10/30/2017 VOSEVI sofosbuvir/velpatasvir/voxila previr 10/30/2017 VOSEVI sofosbuvir/velpatasvir/voxila previr ADD UM: QUANTITY Specialty 84 / 365 OVER TIME 10/30/2017 BENLYSTA belimumab Specialty 10/30/2017 IDHIFA enasidenib mesylate Specialty 10/30/2017 IDHIFA enasidenib mesylate ADD UM: QUANTITY 30 / 30 DAYS 10/30/2017 IDHIFA enasidenib mesylate ADD UM: QUANTITY 30 / 30 DAYS 10/30/2017 IDHIFA enasidenib mesylate Specialty 10/30/2017 NERLYNX neratinib maleate Specialty 10/30/2017 NERLYNX neratinib maleate ADD UM: QUANTITY 180 / 30 DAYS PAGE 24 UPDATED 11/2017

25 10/30/2017 MAVYRET glecaprevir/pibrentasvir Specialty 10/30/2017 MAVYRET glecaprevir/pibrentasvir ADD UM: QUANTITY 336 / 365 OVER TIME 10/30/2017 LYNPARZA olaparib Specialty 10/30/2017 LYNPARZA olaparib Specialty 10/30/2017 VYXEOS daunorubicin/cytarabine liposomal Specialty 10/30/2017 vigabatrin vigabatrin Specialty 10/30/2017 diazepam diazepam Non-Preferred 10/30/2017 diazepam diazepam Non-Preferred 10/30/2017 caspofungin acetate 10/30/2017 caspofungin acetate 10/30/2017 adapalenebenzoyl peroxide caspofungin acetate Specialty caspofungin acetate Specialty adapalene/benzoyl peroxide Non-Preferred 10/30/2017 prasugrel hcl prasugrel hcl 10/30/2017 prasugrel hcl prasugrel hcl 10/30/2017 Non-Preferred PAGE 25 UPDATED 11/2017