Formulary Updates to DHMP Commercial Plans DHHA: DMC/DMC-HP/POS DHMO/HDHP: City & County of Denver/Denver Police/DERP

Transcription

1 1 Formulary Updates to DHMP Commercial Plans DHHA: DMC/DMC-HP/POS DHMO/HDHP: City & County of Denver/Denver Police/DERP Denver Health Medical Plan (DHMP) may add or remove drugs from the formulary or make changes to restrictions on formulary drugs during the year. If DHMP removes drugs from the formulary, or adds a restriction to an existing formulary drug, such as prior authorization, quantity limits and/or step therapy, [and/or moves a drug to a higher cost-sharing tier], DHMP will notify you of the change at least 60 days before the date that the change becomes effective. If the Food and Drug Administration (FDA) deems a drug on the formulary to be unsafe, or the drug s manufacturer removes the drug from the market, DHMP will immediately remove the drug from the formulary. The table below outlines previous and/or recent changes to the formulary. The newest updates are highlighted in yellow. For questions or if you would like more information related to these changes please call the DHMP Pharmacy Services Department at or FORMULARY ABBREVIATIONS (Explanations can be found on the website in the DHMP Commercial Formulary and Pharmaceutical Management Procedures) DISC = Lowest Copay (note: DISC = 1 for the DHMO plan); LA = Limited Access (must be filled at DH Pharmacy or PA Required); PA = Prior Authorization; PREV = Preventative Medication; QL = Quantity Limit; ST = Step Therapy Atomoxetine Capsules Addition Addition N/A 2 LA, QL 07/01/2018 Fondaparinux Syringes Addition Addition N/A 4 LA, QL 07/01/2018 Sildenafil Tablets Addition Addition N/A 1 QL 07/01/2018 (Generic for Viagra Only) Levitra Tablets Added Clinical and Cost Reevaluation; Addition of Sildenafil Tablets Sildenafil (Generic for Viagra Only) N/A LA, QL, ST 07/01/2018 Buprenorphine/Naloxone Film 8 mg/2 mg Film Generic for Suboxone 8 mg/2 mg Film Generic N/A 2 LA, QL 07/01/2018 Praziquantel Tablets Generic for Biltricide Generic N/A 2 LA 07/01/2018

2 2 Atovaquone/Proguanil Tablets Change from 2 to 1; Quantity Limit Restriction Added Cost Reevaluation N/A 1 QL 07/01/2018 Ritonavir Tablets Generic for Norvir Generic N/A 2 LA 04/01/2018 Tacrolimus Capsules Addition Addition N/A 2 LA 04/01/2018 Tradjenta Tablets Addition Addition N/A 4 LA, QL 04/01/2018 Jentadueto Tablets Addition Addition N/A 4 LA, QL 04/01/2018 Narcan Nasal Spray Addition Addition N/A 3 QL 04/01/2018 Buprenorphine Addition Addition N/A 2 LA, QL 04/01/2018 Sublingual Tablets Estradiol Vaginal Cream Addition Addition N/A 1 QL 04/01/2018 Efavirenz Capsules Generic for Sustiva Generic N/A 2 LA 04/01/2018 Tenofovir Disoproxil Fumarate Tablets Generic for Viread Generic N/A 2 LA 04/01/2018 Atazanavir Capsules Generic for Reyataz Generic N/A 2 LA 04/01/2018 Aripiprazole Tablets Metformin Extended- Release Tablets (Generic for Fortamet) Change from DISC/PREV to 2; Limited Access Restriction Added Clinical and Cost Reevaluation Cost Reevaluation N/A N/A LA, QL 01/01/2018 Metformin Extended-Release (Generic for Glucophage XR) 2 LA 01/01/2018 Lyrica Capsules Addition Addition N/A 4 LA, QL, PA 01/01/2018 Oxycodone Extended- Addition Addition One Formulary 2 LA, QL, ST 01/01/2018 Release Tablets Long-Acting Opioid Victoza Pens Addition Addition One Formulary Diabetic Medication 4 LA, QL, ST 01/01/2018

3 3 Priftin Tablets Addition Addition N/A 4 LA 01/01/2018 Atorvastatin, Lovastatin, Change from 1 or 2 to Regulatory N/A PREV QL 01/01/2018 Pravastatin, Simvastatin and Rosuvastatin Tablets PREV Requirement Abacavir Oral Solution Generic Available for Ziagen Generic N/A 2 LA 10/01/2017 Eletriptan Tablets Generic Available for Relpax Generic Sumatriptan and zolmitriptan 2 LA, QL, ST 10/01/2017 Imiquimod Change from 2 to 1; Limited Access Restriction Enoxaparin Change from 4 to 3; Limited Access Restriction Clinical and Cost Reevaluation Clinical and Cost Reevaluation N/A 1 10/01/2017 N/A 3 QL 10/01/2017 Mavyret Addition Addition N/A 5 LA, QL, PA 10/01/2017 Entresto Tablets Addition Addition N/A 4 LA, QL 07/01/2017 Risperdal Consta Syringes Addition Addition Oral Risperidone 4 LA, QL, ST 07/01/2017 Jardiance Tablets Addition Addition One Formulary Diabetic Medication 4 LA, QL, ST 07/01/2017 Codeine Products Age Restriction Updated to 12 Years and Older Tramadol Tablets Age Restriction Added for 12 Years and Older Ondansetron Tablets and Oral-Disintegrating Tablets Quantity Limit Increased from 30 Tablets Per 30 Days to 90 Tablets Per 30 Days FDA Safety Warning Labeling Change FDA Safety Warning Labeling Change Clinical and Cost Reevaluation N/A N/A Age, QL 07/01/2017 N/A N/A Age, QL 07/01/2017 N/A N/A QL 07/01/2017 Norvir Change from 5 to 4 Clinical Reevaluation N/A 4 LA 07/01/2017

4 4 Vivitrol Vials Antipyrine/Benzocaine Otic Solution Atropine Ophthalmic Solution Cytra-K Crystals and Oral Solution Donnatal Elixir and Tablets Esterified Estrogens/ Methyltestosterone Tablets Hydrocortisone/ Pramoxine Rectal Cream Phenazopyridine Tablets Change from 1 to 2; Limited Access Restriction Added Clinical Reevaluation N/A 4 LA, QL 07/01/2017 Regulatory Requirement Tacrolimus Ointment Addition Addition Topical Corticosteroids Vyvanse Capsules Addition Addition Amphetamine Salts and Methylphenidate Xarelto 20 mg Tablets Venlafaxine Extended- Release Capsules Fenofibrate Tablets Quantity Limit Restriction Increased N/A 2 LA 07/01/ LA, QL, ST 04/01/ or 4 LA, QL, ST 04/01/2017 Clinical and Cost N/A N/A LA, QL 04/01/2017 Reevaluation Clinical Reevaluation N/A N/A QL 04/01/2017 Clinical and Cost Reevaluation N/A N/A QL 04/01/2017

5 5 Doxycycline Capsules and Tablets Duloxetine Capsules Moviprep Bowel Preparation Osmoprep Bowel Preparation Prepopik Bowel Preparation Suclear Bowel Preparation Suprep Bowel Preparation Aranesp Syringes and Vials Leukine Syringes and Vials Neupogen Syringes and Vials Epinephrine Auto- Injectors Quantity Limit Restriction Increased and Change from 2 to 1 Addition Addition Addition Addition Addition Generic Available for Epipen and Epipen Jr Cost Reevaluation N/A N/A QL 04/01/2017 Clinical and Cost Reevaluation N/A 1 QL 04/01/2017 Regulatory Requirement N/A PREV 04/01/2017 Regulatory N/A PREV 04/01/2017 Requirement Regulatory N/A PREV 04/01/2017 Requirement Regulatory N/A PREV 04/01/2017 Requirement Regulatory N/A PREV 04/01/2017 Requirement Clinical Reevaluation N/A N/A LA 01/01/2017 Clinical Reevaluation N/A N/A LA 01/01/2017 Clinical Reevaluation N/A N/A LA 01/01/2017 Generic N/A 1 QL 01/01/2017 Descovy Tablets Addition Addition N/A 4 LA 01/01/2017 Genvoya Tablets Addition Addition N/A 4 LA 01/01/2017 Odefsey Tablets Addition Addition N/A 4 LA 01/01/2017 Vemlidy Tablets Addition Addition N/A 4 LA 01/01/2017

6 6 Vivitrol Vials Addition Addition N/A 4 LA, QL, PA 01/01/2017 Oseltamivir Capsules Abacavir/Lamivudine Tablets Aripiprazole Tablets Generic Available for Tamiflu Generic Available for Epzicom ; Step Therapy Restriction Added Lidocaine 5% Ointment Change from 1 to 2 and Limited Access and Quantity Limit Added Generic N/A 1 QL 01/01/2017 Generic N/A 2 LA 01/01/2017 Clinical Reevaluation Clozapine, Olanzapine, Quetipaine, Risperidone, Ziprasidone Cost Reevaluation Lidocaine 4% Cream N/A LA, QL, PA 01/01/ LA, QL 01/01/2017 Sovaldi Tablets Deletion Cost Reevaluation Epclusa, Harvoni, N/A N/A 01/01/2017 Zepatier Epclusa Tablets Addition Addition N/A 4 LA, PA, QL 10/01/2016 Zepatier Tablets Addition Addition N/A 4 LA, PA, QL 10/01/2016 Mesalamine Delayed- Release Tablets Generic Available for Asacol HD Generic N/A N/A 10/01/2016 Colchicine Tablets Addition Addition N/A 2 LA, QL, ST 10/01/2016 Guanfacine Extended- Clinical Reevaluation N/A N/A LA, QL 10/01/2016 Release Tablets Acitretin Capsules Clinical Reevaluation Methotrexate N/A LA, ST 10/01/2016 ; Step Therapy Restriction Added Rosuvastatin Tablets Generic Available for Crestor Generic N/A 2 LA, QL 07/01/2016

7 7 Modafinil Tablets Addition Addition N/A 2 QL 07/01/2016 Complera Tablets Addition Addition N/A 4 LA 07/01/2016 Celecoxib Capsules Clinical Reevaluation N/A N/A QL 07/01/2016 Diclofenac Gel Generic Available for Generic N/A 1 QL 07/01/2016 Voltaren Gel Levitra Tablets Age Restriction Clinical Reevaluation N/A N/A QL 07/01/2016 Piroxicam Capsules Addition Addition N/A 1 04/01/2016 Ciprofloxacin Otic Solution Addition Addition N/A 1 04/01/2016 Cipro HC Otic Suspension Addition Addition N/A 2 04/01/2016 Ciprodex Otic Suspension Addition Addition N/A 2 04/01/2016 Phentermine Capsules Addition Addition N/A 1 QL 04/01/2016 and Tablets Raloxifene Tablets Addition Addition N/A PREV QL 04/01/2016 Clindamycin/Benzoyl Peroxide Gel Addition Addition N/A 1 QL 04/01/2016 Eszopiclone Tablets Addition Addition N/A 1 QL 04/01/2016 Sodium Fluoride Gel and Cream Dorzolamide/Timolol Ophthalmic Solution Tamoxifen Tablets Lo Norgestimate-ethinyl Estradiol Tablets Addition Addition N/A 1 04/01/2016 Addition Addition N/A 1 04/01/2016 Change from 1 to PREV Generic Available for Ortho Tri-Cyclen Lo Clinical Reevaluation N/A PREV 04/01/2016 Generic Generic PREV 04/01/2016

8 8 Xarelto Tablets Addition Addition Warfarin 3 LA, QL, ST 01/01/2016 Humalog Mix 75/25 and Addition Addition N/A 3 LA, QL 01/01/ /50 Kwikpen Insulin Pens Novolog Mix 70/30 Addition Addition N/A 3 LA, QL 01/01/2016 Flexpen insulin pens Sodium Chloride 3% Addition Addition N/A 1 01/01/2016 Nebulizer Solution Vials Ciclopirox 8% Topical Addition Addition N/A 1 01/01/2016 Solution Aluminum Chloride 20% Addition Addition N/A 1 01/01/2016 Topical Solution Triumeq Tablets Addition Addition N/A 4 LA 01/01/2016 Prezcobix Tablets Addition Addition N/A 4 LA 01/01/2016 Daraprim Tablets Change from 2 to 3; Cost Reevaluation N/A 3 LA 01/01/2016 Limited Access Restriction Added Tivicay Tablets Clinical Reevaluation N/A N/A LA, QL 01/01/2016 Stribild Tablets Clinical Reevaluation N/A N/A LA 01/01/2016 Celecoxib Capsules Clinical Reevaluation Formulary NSAIDs N/A LA, ST 01/01/2016 Changed to Step Therapy Restriction Capecitabine Tablets Clinical Reevaluation N/A N/A LA 01/01/2016 Adapalene Cream, Gel and Lotion Clinical Reevaluation N/A N/A 01/01/2016

9 9 Epinephrine and EpiPen Autoinjectors Abacavir, abacavir/ lamivudine/zidovudine, didanosine, lamivudine, lamivudine/zidovudine, nevirapine, stavudine, zidovudine Alkeran, Atripla, Fareston, Hexalen, Leukeran, Lysodren, Matulane Myleran, Neupogen, Pegasys, Prezista, Reyataz, Tabloid, Truvada, Viread, acitretin, bexarotene, capecitabine, cyclophosphamide, enoxaparin, glatiramer, lomustine, temozolomide, tretinoin, valganciclovir Aripiprazole, calcipotriene, celecoxib, desmopressin, duloxetine, esomeprazole, Quantity Limit Restriction Clinical Reevaluation N/A N/A LA, QL 01/01/2016 Increased from 2 to 4 Per Fill Change from 4 to 2 Cost Reevaluation N/A 2 LA 01/01/2016 Change from 4 to 3 Cost Reevaluation N/A 3 LA 01/01/2016 Change from 1 to 2 Cost Reevaluation N/A 2 LA 01/01/2016

10 10 isotretinoin, ivermectin, leflunomide, methylphenidate er 24h, mycophenolate, olanzapine, omega-3 acid ethyl esters, quetiapine, testosterone gel, tizanidine, ursodiol, vancomycin, ziprasidone, acetazolamide, acetic acid/hydrocortisone, atovaquone/proguanil, balsalazide, betamethasone/ propylene glycol 0.05% lot/oint, bicalutamide, bromocriptine, budesonide ampules, calcium acetate, chlorpromazine, cholestyramine, clindamycin recon soln, clobetasol 0.05% cr/gel/ lot/oint/soln, clomipramine, clozapine, cromolyn sod ampules, cyclosporine modified,

11 11 dantrolene, desonide 0.05% cr/lot/oint, desoximetasone cr/gel/ oint, dextroamphetamine sulf,dextroamphetamine/ amphetamine, divalproex, doxycycline, econazole cr, ethambutol, ethosuximide, fluocinolone cr/oil/oint/ soln, fluocinonide cr/gel/oint/soln, fluorouracil cr/soln, griseofulvin, hydrocortisone supp, hydrocortisone val cr/oint, hydroxychloroquine, hyoscyamine, imiquimod, isometh/dichlorph/apap, lidocaine patch, lidocaine/prilocaine cr, malathion, mercaptopurine, mesalamine enema, methylergonovine,

12 12 methylphenidate er, midodrine, niacin er, norethindrone acetate, nystatin/triamcinolone cr/oint, permethrin cr, perphenazine, podofilox soln, propylthiouracil, salsalate, sumatriptan nasal, tobramycin/dexameth drops, tolterodine, tretinoin cr/gel/tablet, trifluoperazine, trifluridine, zafirlukast Chantix Starting and Continuing Paks ; Limited Access Restriction Added Clinical Reevaluation N/A N/A LA, QL 10/01/2015 Lantus Solostar Pens Addition Addition N/A 2 QL 10/01/2015 Levemir Flextouch Pens Addition Addition N/A 2 QL 10/01/2015 Tizanidine Tablets Addition Addition N/A 1 LA 10/01/2015 Lidocaine Extended- Release Patches Zolpidem Extended- Release Tablets Risedronate 5 mg, 30 mg and 35 mg Tablets Generic Available for Actonel Cost Reevaluation N/A 1 QL 10/01/2015 Cost Reevaluation N/A 1 LA, QL 10/01/2015 Generic N/A 1 07/01/2015 Aripiprazole Tablets Generic Available for Abilify Generic N/A 1 LA, PA, QL 07/01/2015

13 13 PEG 3350/Bisacodyl/ Sodium Chloride/Sodium Bicarbonate/Potassium Chloride True Metrix Air Glucometer True Metrix Air Test Strips True Metrix Air Control Solution Generic Available for Halflytely-Bisacodyl Generic N/A 1 07/01/2015 Addition Addition N/A 1 QL 07/01/2015 Addition Addition N/A 1 QL 07/01/2015 Addition Addition N/A 1 QL 07/01/2015 Gynol II Spermicide Jelly Addition Addition N/A PREV 07/01/2015 FC2 Female Condom Addition Addition N/A PREV 07/01/2015 FemCap Cervical Cap Addition Addition N/A PREV 07/01/2015 Today Contraceptive Addition Addition N/A PREV 07/01/2015 Sponge Paragard IUD Addition Addition N/A PREV 07/01/2015 Nexplanon Implantable Addition Addition N/A PREV 07/01/2015 Rod Buprenorphine/Naloxone Addition Addition N/A 1 LA, QL 07/01/2015 Sublingual Tablets Guanfacine Extended- Addition Addition N/A 1 LA, QL, ST 07/01/2015 Release Tablets Xifaxan Tablets Addition Addition N/A 3 LA, QL, ST 07/01/2015 Doxycycline Capsules/Tablets ; Limited Access Restriction ; Quantity Limit Restriction Added Clinical Reevaluation N/A N/A QL 04/01/2015

14 14 Valsartan Tablets Addition Addition N/A 1 04/01/2015 Valsartan/HCTZ Tablets Addition Addition N/A 1 04/01/2015 Amlodipine/Benazepril Addition Addition N/A 1 04/01/2015 Tablets Janumet Tablets Addition Addition N/A 3 LA 04/01/2015 Omega-3 Acid Ethyl Esters Capsules Addition Addition N/A 1 LA, QL 04/01/2015 Harvoni Tablets Addition Addition N/A 4 LA, QL, PA 04/01/2015 Esomeprazole Capsules Generic Available for Nexium Incivek Tablets Deletion Manufacturer Discontinued Estradiol Twice-weekly Patches Valganciclovir Tablets Acyclovir, albuterol nebulizer soln., albuterol tablets and syrup, amoxicillin, antipyrine/benzocaine otic, atropine 1% op. soln., baclofen, benztropine, carbamazepine, cephalexin, chlorhexidine gluconate, ciprofloxacin, Generic N/A 1 LA, QL, ST 04/01/2015 Harvoni 4 LA, PA, QL 04/01/2015 Generic Available for Alora Generic N/A 1 04/01/2015 Generic Available for Valcyte Change from Discount (DISC) to 1 Generic N/A N/A LA 04/01/2015 Cost Reevaluation N/A 1 01/01/2015

15 15 cyclobenzaprine, dexamethasone, dicyclomine, digoxin, erythromycin 0.5% op. oint., fluconazole 150 mg tab, fluocinonide cream, gentamicin 0.3% op. soln., hydrocortisone cream and oint., ibuprofen, indomethacin, ipratropium bromide nebulizer soln., isoniazid, isosorbide mononitrate ER, lactulose, levobunolol 0.5% op. soln., levothyroxine, lidocaine viscous, meloxicam, metoclopramide, naproxen, neo/polymyx b/dexam op., nystatin cream, penicillin vk, polymyxin/tmp op. soln., prednisone, prochlorperazine, promethazine tabs and syrup, promethazine DM, ranitidine, SMZ/TMP,

16 16 thioridazine, timolol maleate op. soln., tobramycin 0.3% op. soln., triamcinolone cream and oint., trihexyphenidyl Levitra ; Age Restriction Added Clinical Reevaluation N/A N/A LA, QL 01/01/2015 Ventolin HFA inhaler Change from 1 to 2 Cost Reevaluation N/A 2 QL 01/01/2015 Celecoxib Capsules Generic Available for Generic N/A 1 LA, PA, QL 01/01/2015 Celebrex Halflytely-Bisacodyl Change from Preventative Cost Reevaluation N/A 2 01/01/2015 (PREV) to 2 Auvi-Q Deleted Cost Reevaluation Epinephrine Auto- N/A 01/01/2015 Injector Twinject Deleted Cost Reevaluation Epinephrine Auto- N/A 01/01/2015 Injector EpiPen Change from 2 to 3 Cost Reevaluation Epinephrine Auto- 3 LA, QL 01/01/2015 Injector EpiPen Jr Change from 2 to 3 Cost Reevaluation Epinephrine Auto- 3 LA, QL 01/01/2015 Injector Avonex Clinical Reevaluation N/A N/A LA, QL 01/01/2015 Betaseron Clinical Reevaluation N/A N/A LA, QL 01/01/2015 Leflunomide Tablets Addition Addition N/A 1 LA, QL 01/01/2015 Enbrel Addition Addition N/A 4 LA, QL, ST 01/01/2015

17 17 Humira Addition Addition N/A 4 LA, QL, ST 01/01/2015 Rebif Addition Addition N/A 4 LA, QL 01/01/2015 Duloxetine Capsules Addition Addition N/A 1 LA, QL, ST 01/01/2015 Nexium Capsules Addition Addition N/A 3 LA, QL, ST 01/01/2015 Sovaldi Tablets Addition Addition N/A 4 LA, PA, QL 01/01/2015 Doxycycline Change from Discount Cost Reevaluation Minocycline 1 LA, ST 01/01/2015 Capsules/Tablets (DISC) to 1; Step Therapy Restriction Added; Limited Access Restriction Added Ella Tablets Addition Addition N/A PREV 10/01/2014 Tivicay Tablets Addition Addition N/A 3 LA, QL, ST 10/01/2014 Stribild Tablets Addition Addition N/A 3 LA, ST 10/01/2014 Minocycline Capsules Limited Access Restriction Cost Reevaluation N/A 1 QL 10/01/2014 Fenofibrate 54 mg, 134 Addition Addition N/A 1 QL, ST 07/01/2014 mg, 160 mg Levemir Vials Addition Addition N/A 2 QL 07/01/2014 Lidocaine Extended- Addition Addition N/A 1 QL, ST 07/01/2014 Release Patches Nicotine Lozenges Addition Addition N/A 1 07/01/2014 Midazolam 1mg/ml and Addition Addition N/A 1 LA, QL 07/01/2014 5mg/ml Vials Rifabutin Capsules Generic Available for Mycobutin Generic N/A 1 07/01/2014 Budesonide 32 mcg Nasal Spray Generic Available for Rhinocort Aqua Generic N/A 1 QL 07/01/2014

18 18 Risedronate 150 mg Tablets Testosterone Gel Generic Available for Actonel Generic Available for Testim Gel Generic N/A 1 07/01/2014 Generic N/A 1 LA 07/01/2014 Glimepiride Tablets Addition Addition N/A 1 04/01/2014 Capecitabine Tablets Generic Available for Xeloda Generic N/A 1 LA, PA 04/01/2014 Abacavir/Lamivudine/ Generic Available for Trizivir Generic N/A 1 LA 04/01/2014 Zidovudine Tablets Tolterodine Extended- Release Capsules Generic Available for Detrol LA Generic N/A 1 04/01/2014 Chantix Tablets Step Therapy Changed to Clinical Reevaluation N/A N/A ST, QL 04/01/2014 Previous Failure of Bupropion or Nicotine Replacement Therapy Progesterone Capsules Addition Addition N/A 1 QL 01/01/2014 Pramipexole Tablets Addition Addition N/A 1 01/01/2014 Tobramycin 0.3% Addition Addition N/A DISC QL 01/01/2014 Ophthalmic Solution Levobunolol 0.5% Addition Addition N/A DISC QL 01/01/2014 Ophthalmic Solution Ceftibuten Suspension Generic Available for Cedax Generic N/A 1 01/01/2014 Ceftibuten Capsules Generic Available for Cedax Generic N/A 1 01/01/2014 Niacin Extended-Release Tablets Chantix Tablets Nicotine patch Generic Available for Niaspan Changed to Step Therapy Generic N/A 1 01/01/2014 Clinical Reevaluation N/A PREV ST, QL 01/01/2014 Clinical Reevaluation N/A PREV QL 01/01/2014

19 19 Nicotine gum Pulmozyme Inhalation Solution Changed to Quantity Limit and Age Clinical Reevaluation N/A PREV 01/01/2014 Clinical Reevaluation N/A 3 LA, QL 01/01/2014 Regranex Gel Deletion of Drug From Formulary Clinical Reevaluation None N/A 01/01/2014 Maxair Inhalation Aerosol Deletion of Drug From Formulary Clinical Reevaluation Ventolin HFA 1 QL 01/01/2014 Tetracycline Capsules Deletion of Drug From Formulary Clinical and Cost Doxycycline 1 01/01/2014 Reevaluation Glimepiride Tablets Change Cost Reevaluation N/A DISC 01/01/2014 Fluconazole 150 mg Change Cost Reevaluation N/A DISC QL 01/01/2014 tablets Promethazine 25 mg Change Cost Reevaluation N/A DISC 01/01/2014 tablets Promethazine 6.25 mg/5 Change Cost Reevaluation N/A DISC 01/01/2014 ml Oral Solution Gentamicin 0.3% Change Cost Reevaluation N/A DISC QL 01/01/2014 Ophthalmic Solution Polymyxin/TMP Change Cost Reevaluation N/A DISC QL 01/01/2014 Ophthalmic Solution Isosorbide Mononitrate Change Cost Reevaluation N/A DISC QL 01/01/2014 ER Tablets Prenatal Plus Tablets Change Cost Reevaluation N/A DISC QL 01/01/2014 Ventolin HFA Inhalation Change Cost Reevaluation N/A 1 QL 01/01/2014 Aerosol ProAir HFA Inhalation Aerosol Change Cost Reevaluation Ventolin HFA 2 QL 01/01/2014

20 20 Proventil HFA Inhalation Aerosol Change Cost Reevaluation Ventolin HFA 2 QL 01/01/2014 Crestor Tablets Change Clinical and Cost Reevaluation Atorvastatin 3 LA, QL 01/01/2014 Codeine Tablets Quantity Limit Restriction Added Clinical Reevaluation N/A N/A QL 01/01/2014 Hydromorphone Tablets Morphine Sulfate Extended-Release Tablets Oxycodone Tablets Venlafaxine Extended- Release Capsules/Tablets Quantity Limit Restriction Changed Quantity Limit Restriction Changed Quantity Limit Restriction Changed Clinical Reevaluation N/A N/A QL 01/01/2014 Clinical Reevaluation N/A N/A QL 01/01/2014 Clinical Reevaluation N/A N/A QL 01/01/2014 Quantity Limit Restriction Added Clinical Reevaluation N/A N/A QL 01/01/2014 Baclofen Tablets Quantity Limit Restriction Added Clinical Reevaluation N/A N/A QL 01/01/2014 Cyclobenzaprine Tablets Quantity Limit Restriction Added Clinical Reevaluation N/A N/A QL 01/01/2014 Abilify Tablets Age Restriction ; Prior Clinical Reevaluation N/A N/A QL, PA 01/01/2014 Authorization Now Required for All Ages Zostavax Injection Age Restriction Changed Clinical Reevaluation N/A N/A QL 01/01/2014 Dipyridamole Tablets Addition Addition N/A 1 10/01/2013 Eplerenone Tablets Addition Addition N/A 1 10/01/2013 Ketorolac Ophthalmic Addition Addition N/A 1 10/01/ % and 0.5% Solution Levofloxacin 0.5% Ophthalmic Solution Addition Addition N/A 1 10/01/2013 Monurol Packets Addition Addition N/A 2 QL 10/01/2013

21 21 Naphazoline Ophthalmic 0.1 % Solution Addition Addition N/A 1 10/01/2013 Terazosin Capsules Addition Addition N/A DISC 10/01/2013 Skyla Intrauterine System Addition Addition N/A PREV 10/01/2013 Midodrine Tablets Addition Addition N/A 1 10/01/2013 Ventolin HFA Inhaler Line Extension; Addition Cost Reevaluation N/A 1 QL 10/01/2013 Escitalopram Tablets Copaxone Injection Betaseron Injection Avonex Injection Regranex Gel Mycophenolate Mofetil Tablets Sumatriptan Injection DDAVP Lomustine Capsules Temozolomide Capsules Changed to Step Therapy Restriction Changed to Step Therapy ; Quantity Limit Added Changed to Step Therapy ; Generic Available Generic Available for Ceenu Generic Available for Temodar Cost Reevaluation N/A 1 QL 10/01/2013 Clinical Reevaluation N/A 3 LA 10/01/2013 Clinical Reevaluation N/A 3 LA, ST 10/01/2013 Clinical Reevaluation N/A 3 LA, ST 10/01/2013 Clinical Reevaluation N/A 3 LA, QL 10/01/2013 Clinical Reevaluation N/A 1 QL 10/01/2013 Clinical Reevaluation N/A 1 LA, QL 10/01/2013 Clinical Reevaluation N/A 1 QL 10/01/2013 Generic N/A 1 10/01/2013 Generic N/A 1 10/01/2013

22 22 Acamprosate Tablets Acitretin Capsules Generic Available for Campral Generic Available for Soriatane Generic N/A 1 LA 10/01/2013 Generic N/A 1 LA 10/01/2013 Testim Gel Addition Addition N/A 3 LA 07/01/2013 Testosterone Cypionate Vial Addition Addition N/A 1 LA 07/01/2013 Naloxone Vial Addition Addition N/A 1 LA 07/01/2013 Balsalazide Tablets Addition Addition N/A 1 05/08/2013 Asacol 400 mg Deletion of Drug From Formulary Manufacturer Asacol HD 800 mg 2 04/19/2013 Discontinuation Glipizide/Metformin Tablets Addition Addition N/A 1 04/01/2013 First-Mouthwash BLM Addition Addition N/A 2 04/01/2013 Adapalene Cream and Gel Ondansetron 4 mg and 8 mg tablets and ODT Addition Addition N/A 1 ST 04/01/2013 Limited Access Restriction Cost Reevaluation N/A 1 04/01/2013