Changes to the 2018 University of Utah Exchange Formulary

Transcription

1 May 2, 2018 Changes to the 2018 University of Utah Exchange Formulary University of Utah Health Plan Exchange may add or remove drugs from the formulary during the year. If a drug is scheduled to be removed from the formulary, you will be notified at least 60 days before the change becomes effective. In cases where the U.S. Food and Drug Administration (FDA) deems a drug unsafe, or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from the formulary and notify you afterward. PA indicates Prior Authorization is required. Upcoming Changes 7/1/2018 ACETASOL HC EAR DROPS Not Covered 7/1/2018 ADDERALL 10 MG TABLET Not Covered 7/1/2018 ADDERALL 12.5 MG TABLET Not Covered 7/1/2018 ADDERALL 15 MG TABLET Not Covered 7/1/2018 ADDERALL 20 MG TABLET Not Covered 7/1/2018 ADDERALL 30 MG TABLET Not Covered 7/1/2018 ADDERALL 5 MG TABLET Not Covered 7/1/2018 AFEDITAB CR 30 MG TABLET Not Covered 7/1/2018 AFEDITAB CR 60 MG TABLET Not Covered 5/1/2018 AGONEAZE 2.5%-2.5% CREAM Move to Tier 3 5/1/2018 AMABELZ 0.5 MG-0.1 MG TAB Move to Tier 3 5/1/2018 AMABELZ 1 MG-0.5 MG TABLET Move to Tier 3 7/1/2018 AMETHYST MCG TABLET Not Covered 7/1/2018 AMNESTEEM 10 MG CAPSULE Not Covered 7/1/2018 AMNESTEEM 20 MG CAPSULE Not Covered 7/1/2018 AMNESTEEM 40 MG CAPSULE Not Covered 5/1/2018 ANDROGEL 1.62% GEL PUMP Not Covered 5/1/2018 ANDROGEL 1.62%(1.25G) GEL Not Covered 5/1/2018 ANDROGEL 1.62%(2.5G) GEL Not Covered 5/1/2018 ANODYNE LPT % CRM Move to Tier 3 7/1/2018 ANUCORT-HC 25 MG SUPP Not Covered 5/1/2018 APREPITANT 125 MG CAPSULE Move to Tier 4 5/1/2018 APREPITANT MG Move to Tier 4 5/1/2018 APREPITANT 40 MG CAPSULE Move to Tier 4 5/1/2018 APREPITANT 80 MG CAPSULE Move to Tier 4 5/1/2018 ARBINOXA 4 MG TABLET Move to Tier 3 7/1/2018 ARYMO ER Not Covered 7/1/2018 atazanavir Move to Tier 4, PA 7/1/2018 AUGMENTIN TABLET Not Covered 7/1/2018 AVIDOXY 100 MG TABLET Not Covered 7/1/2018 AVITA 0.025% CREAM Not Covered

2 7/1/2018 AVITA 0.025% GEL Not Covered 5/1/2018 AXERT 12.5 MG TABLET Not Covered 5/1/2018 AXERT 6.25 MG TABLET Not Covered 7/1/2018 AYGESTIN 5 MG TABLET Not Covered 7/1/2018 BELBUCA Not Covered 7/1/2018 BIAXIN 250 MG TABLET Not Covered 7/1/2018 BILTRICIDE 600 MG TABLET Not Covered 5/1/2018 BUPRENORPHINE 15 MCG/HR Move to Tier 2, PA 5/1/2018 BUPRENORPHINE PATCHES Add PA to all 5/1/2018 BUTRANS 10 MCG/HR PATCH Not Covered 5/1/2018 BUTRANS 10 MCG/HR PATCH Not Covered 5/1/2018 BUTRANS 15 MCG/HR PATCH Not Covered 5/1/2018 BUTRANS 15 MCG/HR PATCH Not Covered 5/1/2018 BUTRANS 20 MCG/HR PATCH Not Covered 5/1/2018 BUTRANS 20 MCG/HR PATCH Not Covered 5/1/2018 BUTRANS 5 MCG/HR PATCH Not Covered 5/1/2018 BUTRANS 5 MCG/HR PATCH Not Covered 5/1/2018 BUTRANS 7.5 MCG/HR PATCH Not Covered 5/1/2018 BUTRANS 7.5 MCG/HR PATCH Not Covered 5/1/2018 BYETTA Move to Tier 3 7/1/2018 BYETTA Not Covered 7/1/2018 CAPACET Not Covered 7/1/2018 CAMRESE MG Not Covered 7/1/2018 CARAFATE 1 GM/10 ML SUSP Not Covered 5/1/2018 CARTIA XT 120 MG CAPSULE Move to Tier 2 7/1/2018 CARTIA XT 120 MG CAPSULE Not Covered 5/1/2018 CARTIA XT 180 MG CAPSULE Move to Tier 2 7/1/2018 CARTIA XT 180 MG CAPSULE Not Covered 5/1/2018 CARTIA XT 240 MG CAPSULE Move to Tier 2 7/1/2018 CARTIA XT 240 MG CAPSULE Not Covered 5/1/2018 CARTIA XT 300 MG CAPSULE Move to Tier 2 7/1/2018 CARTIA XT 300 MG CAPSULE Not Covered 7/1/2018 CEDAX 400 MG CAPSULE Not Covered 7/1/2018 CELEBREX 100 MG CAPSULE Not Covered 7/1/2018 CELEBREX 200 MG CAPSULE Not Covered 7/1/2018 CELEBREX 400 MG CAPSULE Not Covered 7/1/2018 CELEBREX 50 MG CAPSULE Not Covered 5/1/2018 CELEXA 40 MG TABLET Move to Tier 3 7/1/2018 CELEXA 40 MG TABLET Not Covered 7/1/2018 chlorpropamide Not Covered 7/1/2018 CICLODAN 0.77% CREAM Not Covered 7/1/2018 CICLODAN 8% KIT Not Covered 7/1/2018 CICLODAN 8% SOLUTION Not Covered 5/1/2018 CIMZIA Not Covered

3 7/1/2018 CLARAVIS 30 MG CAPSULE Not Covered 5/1/2018 CLINDACIN ETZ 1% PLEDGET Move to Tier 3 5/1/2018 CLINDACIN P 1% PLEDGETS Move to Tier 3 7/1/2018 CLINDACIN P 1% PLEDGETS Not Covered 5/1/2018 CLINDACIN PAC KIT Move to Tier 3, PA 7/1/2018 CLODAN 0.05% SHAMPOO Not Covered 7/1/2018 COLCRYS 0.6 MG TABLET Not Covered 7/1/2018 COLOCORT 100 MG ENEMA Not Covered 5/1/2018 COMFORT PAC-IBUPROFEN KIT Not Covered 5/1/2018 COMFORT PAC-MELOXICAM KIT Not Covered 5/1/2018 COMFORT PAC-NAPROXEN KIT Not Covered 7/1/2018 COMTAN 200 MG TABLET Not Covered 7/1/2018 CORDRAN 0.05% LOTION Not Covered 7/1/2018 COREG MG TABLET Not Covered 7/1/2018 COREG CR 20 MG CAPSULE Not Covered 7/1/2018 CORMAX 0.05% SOLUTION Not Covered 5/1/2018 COUMADIN 5 MG TABLET Not Covered 7/1/2018 COUMADIN 5 MG TABLET Not Covered 5/1/2018 CRESTOR 10 MG Not Covered 5/1/2018 CRESTOR 20 MG Not Covered 5/1/2018 CRESTOR 40 MG Not Covered 5/1/2018 CRESTOR 5 MG Not Covered 7/1/2018 CYTOTEC 200 MCG TABLET Not Covered 7/1/2018 DEPO-PROVER 150 MG/ML VIAL Not Covered 7/1/2018 DEPO-TESTOSTE 100 MG/ML VL Not Covered 7/1/2018 DEPO-TESTOSTE 200 MG/ML VL Not Covered 5/1/2018 DERMACINRX EMPRICAINE KIT Move to Tier 3 5/1/2018 DEXAMETHASONE INTENSOL Move to Tier 2 1MG/1ML 7/1/2018 didanosine Move to Tier 4, PA 5/1/2018 DIFLORASONE 0.05% OINT Move to Tier 2 5/1/2018 DIGOX 125 MCG TABLET Move to Tier 3 5/1/2018 DIGOX 250 MCG TABLET Move to Tier 3 5/1/2018 DILANTIN 100 MG CAPSULE Move to Tier 3 7/1/2018 DILANTIN 100 MG CAPSULE Not Covered 5/1/2018 DILANTIN 100 MG KAPSEAL Move to Tier 3 5/1/2018 DILATRATE-SR 40 MG CAPSULE Move to Tier 3, PA 5/1/2018 DILT XR 120 MG CAPSULE Move to Tier 2 7/1/2018 DILT XR 120 MG CAPSULE Not Covered 5/1/2018 DILT XR 180 MG CAPSULE Move to Tier 2 7/1/2018 DILT XR 180 MG CAPSULE Not Covered 5/1/2018 DILT XR 240 MG CAPSULE Move to Tier 2 7/1/2018 DILT XR 240 MG CAPSULE Not Covered 5/1/2018 DM2 KIT Move to Tier 3, PA

4 7/1/2018 DURAGESIC Not Covered 7/1/2018 E.E.S. 400 FILMTAB Not Covered 7/1/2018 ECONTRA EZ 1.5 MG TABLET Not Covered 7/1/2018 EDECRIN 25 MG TABLET Not Covered 7/1/2018 EFFEXOR XR 37.5 MG CAPSULE Not Covered 7/1/2018 EFFIENT 10 MG TABLET Not Covered 7/1/2018 EFFIENT 5 MG TABLET Not Covered 5/1/2018 ELIMITE 5% CREAM Move to Tier 3 7/1/2018 ELIMITE 5% CREAM Not Covered 7/1/2018 ELIPHOS 667 MG TABLET Not Covered 7/1/2018 EMBEDA Not Covered 7/1/2018 ENABLEX 15 MG TABLET Not Covered 7/1/2018 ENABLEX 7.5 MG TABLET Not Covered 5/1/2018 ENDOCET MG TABLET Move to Tier 3 7/1/2018 ENDOCET MG TABLET Not Covered 7/1/2018 ENPRESSE-28 TABLET Not Covered 7/1/2018 ENTOCORT EC 3 MG CAPSULE Not Covered 7/1/2018 EPIDUO % GEL PUMP Not Covered 5/1/2018 EPINEPHRIN 0.15 MG AUTO-INJ Move to Tier 2 5/1/2018 EPITOL 200 MG TABLET Move to Tier 2 7/1/2018 EPZICOM TABLET Not Covered 5/1/2018 ERY 2% PADS Move to Tier 3 7/1/2018 ERY 2% PADS Not Covered 7/1/2018 ERYPED 200 MG/5 ML SUSP Not Covered 5/1/2018 ERY-TAB EC 250 MG TABLET Move to Tier 3, PA 5/1/2018 ERY-TAB EC 333 MG TABLET Move to Tier 3, PA 5/1/2018 ERY-TAB EC 500 MG TABLET Move to Tier 3, PA 5/1/2018 ERYTHROCIN 250 MG FILMTAB Move to Tier 3, PA 5/1/2018 ERYTHROCIN STEARATE Move to Tier 3 5/1/2018 ERYTHROMYCIN 200 MG/5 ML Move to Tier 2 5/1/2018 ERYTHROMYCIN-BENZOYL GEL Move to Tier 2 7/1/2018 ESTRACE 0.01% CREAM Not Covered 7/1/2018 EVOCLIN 1% FOAM Not Covered 5/1/2018 FARXIGA 10 MG TABLET Move to Tier 3 7/1/2018 FARXIGA 10 MG TABLET Not Covered 5/1/2018 FARXIGA 5 MG TABLET Move to Tier 3 7/1/2018 FARXIGA 5 MG TABLET Not Covered 5/1/2018 FELDENE 20 MG CAPSULE Move to Tier 3, PA 7/1/2018 FELDENE 20 MG CAPSULE Not Covered 5/1/2018 FENOPROFEN Move to Tier 2 5/1/2018 FENTANYL CITR OTF 1600 MCG Move to Tier 2 5/1/2018 FENTANYL CITR OTFC 200 MCG Move to Tier 2 5/1/2018 FENTANYL CITR OTFC 400 MCG Move to Tier 2 5/1/2018 FENTANYL CITR OTFC 600 MCG Move to Tier 2

5 5/1/2018 FENTANYL CITR OTFC 800 MCG Move to Tier 2 7/1/2018 FENTORA Not Covered 5/1/2018 FIRST AID BACITRACIN OINT Not Covered 7/1/2018 FLOMAX 0.4 MG CAPSULE Not Covered 7/1/2018 FOSRENOL 1,000 MG TAB CHW Not Covered 7/1/2018 FOSRENOL 500 MG TAB CHEW Not Covered 7/1/2018 FOSRENOL 750 MG TAB CHEW Not Covered 7/1/2018 GAVILYTE-G SOLUTION Not Covered 7/1/2018 GAVILYTE-N SOLUTION Not Covered 5/1/2018 GENGRAF 100 MG CAPSULE Move to Tier 3 7/1/2018 GENGRAF 100 MG CAPSULE Not Covered 7/1/2018 GENGRAF 100 MG/ML SOLUT Not Covered 5/1/2018 GENGRAF 25 MG CAPSULE Move to Tier 3 7/1/2018 GENGRAF 25 MG CAPSULE Not Covered 5/1/2018 GENGRAF 50 MG CAPSULE Move to Tier 3 7/1/2018 GENGRAF 50 MG CAPSULE Not Covered 7/1/2018 GENTAK 0.3 % EYE OINTMENT Not Covered 7/1/2018 GIANVI 3 MG-0.02 MG TABLET Not Covered 7/1/2018 GLEEVEC 100 MG TABLET Not Covered 7/1/2018 GLEEVEC 400 MG TABLET Not Covered 7/1/2018 GLUCOTROL 5 MG TABLET Not Covered 7/1/2018 GLYDO 2% JELLY SYRINGE Not Covered 7/1/2018 GLYSET 100 MG TABLET Not Covered 7/1/2018 GLYSET 25 MG TABLET Not Covered 7/1/2018 GLYSET 50 MG TABLET Not Covered 5/1/2018 HEPARIN 50 UNT/5 ML (10/ML) Move to Tier 3 7/1/2018 HEPSERA 10 MG TABLET Not Covered 5/1/2018 HYDROCORTISO AC 30 MG SUP Move to Tier 2 5/1/2018 HYDROMORPHO 1 MG/ML SOL Move to Tier 2 7/1/2018 HYSINGLA Not Covered 7/1/2018 IBU 400 MG TABLET Not Covered 7/1/2018 IBU 600 MG TABLET Not Covered 7/1/2018 IBU 800 MG TABLET Not Covered 5/1/2018 INDERAL LA 120 MG CAPSULE Move to Tier 3 7/1/2018 INDERAL LA 120 MG CAPSULE Not Covered 5/1/2018 INDERAL LA 80 MG CAPSULE Move to Tier 3 7/1/2018 INDERAL LA 80 MG CAPSULE Not Covered 5/1/2018 INDERAL XL 120 MG CAPSULE Move to Tier 3 7/1/2018 INVEGA ER 1.5 MG TABLET Not Covered 7/1/2018 INVEGA ER 3 MG TABLET Not Covered 7/1/2018 INVEGA ER 6 MG TABLET Not Covered 7/1/2018 INVEGA ER 9 MG TABLET Not Covered 5/1/2018 INVOKANA 100 MG TABLET Move to Tier 2 5/1/2018 INVOKANA 300 MG TABLET Move to Tier 2

6 5/1/2018 ISOCHRON 40 MG TABLET SA Move to Tier 3 7/1/2018 ISOCHRON 40 MG TABLET SA Not Covered 5/1/2018 ISOPROPYL ALCOHOL Not Covered 5/1/2018 ISORDIL 40 MG TABLET Move to Tier 3, PA 7/1/2018 ISTALOL 0.5% EYE DROPS Not Covered 5/1/2018 JANTOVEN 1 MG TABLET Move to Tier 2 7/1/2018 JANTOVEN 1 MG TABLET Not Covered 5/1/2018 JANTOVEN 10 MG TABLET Move to Tier 2 7/1/2018 JANTOVEN 10 MG TABLET Not Covered 5/1/2018 JANTOVEN 2 MG TABLET Move to Tier 2 7/1/2018 JANTOVEN 2 MG TABLET Not Covered 5/1/2018 JANTOVEN 2.5 MG TABLET Move to Tier 2 7/1/2018 JANTOVEN 2.5 MG TABLET Not Covered 5/1/2018 JANTOVEN 3 MG TABLET Move to Tier 2 7/1/2018 JANTOVEN 3 MG TABLET Not Covered 5/1/2018 JANTOVEN 4 MG TABLET Move to Tier 2 7/1/2018 JANTOVEN 4 MG TABLET Not Covered 5/1/2018 JANTOVEN 5 MG TABLET Move to Tier 2 5/1/2018 JANTOVEN 6 MG TABLET Move to Tier 2 7/1/2018 JANTOVEN 6 MG TABLET Not Covered 5/1/2018 JANTOVEN 7.5 MG TABLET Move to Tier 2 7/1/2018 JANTOVEN 7.5 MG TABLET Not Covered 7/1/2018 JINTELI 1 MG-5 MCG TABLET Not Covered 7/1/2018 JUNEL FE 24 TABLET Not Covered 7/1/2018 K EFFERVESCENT 25 MEQ TAB Not Covered 5/1/2018 K EFFERVESCENT 25 MEQ TAB Move to Tier 3 7/1/2018 KADIAN Not Covered 5/1/2018 KALEXATE 15 GRAM POWDER Move to Tier 3 7/1/2018 KARIVA 28 DAY TABLET Not Covered 5/1/2018 KIONEX 15 GM/60 ML SUSPENS Move to Tier 2 5/1/2018 KIONEX POWDER Move to Tier 3 7/1/2018 KIONEX POWDER Not Covered 7/1/2018 KLOFENSAID II 1.5% TOPIC SOL Not Covered 5/1/2018 KLOR-CON 10 MEQ TABLET Move to Tier 2 5/1/2018 KLOR-CON 8 MEQ TABLET Move to Tier 2 5/1/2018 KLOR-CON M10 TABLET Move to Tier 2 7/1/2018 KLOR-CON M10 TABLET Not Covered 5/1/2018 KLOR-CON M15 TABLET Move to Tier 2 5/1/2018 KLOR-CON M20 TABLET Move to Tier 2 7/1/2018 KLOR-CON M20 TABLET Not Covered 5/1/2018 KLOR-CON SPRINK ER 10 MQ CP Move to Tier 2 5/1/2018 KLOR-CON SPRINK ER 8 MQ CP Move to Tier 2 7/1/2018 KLOR-CON SPRK ER 10 MEQ CP Not Covered 7/1/2018 KLOR-CON SPRK ER 8 MEQ CAP Not Covered

7 5/1/2018 K-TAB ER 10 MEQ TABLET Move to Tier 3 7/1/2018 K-TAB ER 10 MEQ TABLET Not Covered 5/1/2018 K-TAB ER 20 MEQ TABLET Move to Tier 3 7/1/2018 K-TAB ER 20 MEQ TABLET Not Covered 5/1/2018 K-TAB ER 8 MEQ TABLET Move to Tier 3 7/1/2018 K-TAB ER 8 MEQ TABLET Not Covered 7/1/2018 lamivudine-zidovudine Move to Tier 4, PA 5/1/2018 LANOXIN 125 MCG TABLET Move to Tier 3 5/1/2018 LANOXIN 250 MCG TABLET Move to Tier 3 5/1/2018 LANTUS Add PA 7/1/2018 LASIX 20 MG TABLET Not Covered 5/1/2018 LASIX 40 MG TABLET Move to Tier 2 7/1/2018 LASIX 40 MG TABLET Not Covered 7/1/2018 LAYOLIS FE CHEWABLE TABLET Not Covered 5/1/2018 LEFLUNOMIDE 20 MG TABLET Move to Tier 2 7/1/2018 leuprolide Move to Tier 4, PA 5/1/2018 LEVA SET 2.5%-2.5% CREAM-DR Move to Tier 3 7/1/2018 LEVAQUIN 250 MG TABLET Not Covered 7/1/2018 LEVAQUIN 500 MG TABLET Not Covered 5/1/2018 LEVEMIR Add PA 7/1/2018 LEVORPHANOL Not Covered 7/1/2018 LEXIVA 700 MG TABLET Not Covered 7/1/2018 LIALDA DR 1.2 GM TABLET Not Covered 7/1/2018 LIDODERM 5% PATCH Not Covered 5/1/2018 LIDOPRIL 2.5%-2.5% CREAM-DR Move to Tier 3 5/1/2018 LIDOPRIL XR % CRM-DRE Move to Tier 3 5/1/2018 LIDO-PRILO CAINE PACK Move to Tier 3 5/1/2018 LIPROZONEPAK % CRM- Move to Tier 3 5/1/2018 LIVIXIL PAK % CRM-DRES Move to Tier 3 7/1/2018 LIVIXIL PAK % CRM-DRSS Not Covered 7/1/2018 LODOSYN 25 MG TABLET Not Covered 5/1/2018 LOPROX 0.77% CREAM Move to Tier 3 5/1/2018 LOPROX 0.77% CREAM KIT Move to Tier 3 7/1/2018 LORAZEPAM INTENS 2 MG/ML Not Covered 5/1/2018 LORCET MG TABLET Move to Tier 3 7/1/2018 LORCET MG TABLET Not Covered 5/1/2018 LORCET HD MG TABLET Move to Tier 3 7/1/2018 LORCET HD MG TABLET Not Covered 7/1/2018 LORCET PLUS MG TAB Not Covered 5/1/2018 LORCET PLUS MG TAB Move to Tier 3 5/1/2018 LORZONE 375 MG TABLET Move to Tier 3 5/1/2018 LORZONE 750 MG TABLET Move to Tier 3, PA 7/1/2018 LOTENSIN 40 MG TABLET Not Covered 5/1/2018 LOTRISONE CREAM Not Covered

8 5/1/2018 LOTRONEX 0.5 MG TABLET Not Covered 5/1/2018 LOTRONEX 1 MG TABLET Not Covered 5/1/2018 LP LITE PAK % CRM-DRES Move to Tier 3 7/1/2018 LUDENT FLUO 0.25 MG TB CHW Not Covered 7/1/2018 LUDENT FLUO 0.5 MG TB CHEW Not Covered 7/1/2018 LUDENT FLUO 1 MG TAB CHEW Not Covered 7/1/2018 MARTEN-TAB Not Covered 5/1/2018 MATZIM LA 180 MG TABLET Move to Tier 3 7/1/2018 MATZIM LA 180 MG TABLET Not Covered 5/1/2018 MATZIM LA 240 MG TABLET Move to Tier 3 7/1/2018 MATZIM LA 240 MG TABLET Not Covered 5/1/2018 MATZIM LA 300 MG TABLET Move to Tier 3 7/1/2018 MATZIM LA 300 MG TABLET Not Covered 5/1/2018 MATZIM LA 360 MG TABLET Move to Tier 3 7/1/2018 MATZIM LA 360 MG TABLET Not Covered 5/1/2018 MATZIM LA 420 MG TABLET Move to Tier 3 7/1/2018 MATZIM LA 420 MG TABLET Not Covered 7/1/2018 MEDI-MECLIZINE 25 MG TAB Not Covered 5/1/2018 MEDOLOR PK % CRM-DR Move to Tier 3 5/1/2018 MEMANTINE HCL 5 MG TABLET Move to Tier 2 7/1/2018 MENTAX 1% CREAM Not Covered 5/1/2018 MESALAMINE DR 1.2 GM TAB Move to Tier 2 7/1/2018 METADATE ER 20 MG TABLET Not Covered 5/1/2018 METHAMPHETAMIN 5 MG TAB Not Covered 7/1/2018 METROGEL TOPICAL 1% GEL Not Covered 7/1/2018 METROGEL TOPICAL 1% PUMP Not Covered 7/1/2018 MICARDIS 80 MG TABLET Not Covered 5/1/2018 MIGRANAL NASAL SPRAY Not Covered 7/1/2018 MILLIPRED 10 MG/5 ML SOLUT Not Covered 5/1/2018 MIMVEY MG TABLET Move to Tier 2 7/1/2018 MIMVEY MG TABLET Not Covered 5/1/2018 MIMVEY LO MG TABLET Move to Tier 2 7/1/2018 MIMVEY LO MG TABLET Not Covered 7/1/2018 MINASTRIN 24 FE CHEW TAB Not Covered 5/1/2018 MINITRAN 0.1 MG/HR PATCH Move to Tier 3 7/1/2018 MINITRAN 0.1 MG/HR PATCH Not Covered 5/1/2018 MINITRAN 0.2 MG/HR PATCH Move to Tier 3 7/1/2018 MINITRAN 0.2 MG/HR PATCH Not Covered 5/1/2018 MINITRAN 0.4 MG/HR PATCH Move to Tier 3 7/1/2018 MINITRAN 0.4 MG/HR PATCH Not Covered 5/1/2018 MINITRAN 0.6 MG/HR PATCH Move to Tier 3 7/1/2018 MINITRAN 0.6 MG/HR PATCH Not Covered 7/1/2018 MITIGARE 0.6 MG CAPSULE Not Covered 5/1/2018 MOBIC 15 MG TABLET Move to Tier 3

9 7/1/2018 MOBIC 15 MG TABLET Not Covered 5/1/2018 MOBIK Add PA 7/1/2018 MONDOXYNE NL 100 MG CAP Not Covered 7/1/2018 MONDOXYNE NL 50 MG CAP Not Covered 5/1/2018 MONDOXYNE NL 50 MG CAP Move to Tier 3 7/1/2018 MONDOXYNE NL 75 MG CAP Not Covered 5/1/2018 MORGIDOX 100 MG CAPSULE Move to Tier 3 5/1/2018 MORGIDOX 1X100 MG KIT Move to Tier 3, PA 5/1/2018 MORGIDOX 2X100 MG KIT Move to Tier 3, PA 7/1/2018 Morphine sulfate CR Not Covered 5/1/2018 MOVANTIK Move to Tier 3, PA 5/1/2018 MOVIPREP POWDER PACKET Move to Tier 3 5/1/2018 NALFON 200 mg Not Covered 5/1/2018 NALFON 400 mg Not Covered 7/1/2018 NAMENDA XR 14 MG CAPSULE Not Covered 7/1/2018 NAMENDA XR 21 MG CAPSULE Not Covered 7/1/2018 NAMENDA XR 28 MG CAPSULE Not Covered 7/1/2018 NAMENDA XR 7 MG CAPSULE Not Covered 5/1/2018 NAPROXEN SOD ER 500 MGTAB Move to Tier 2 7/1/2018 NEO-POLYCIN EYE OINTMENT Not Covered 7/1/2018 NESINA 12.5 MG TABLET Not Covered 7/1/2018 NESINA 25 MG TABLET Not Covered 7/1/2018 NESINA 6.25 MG TABLET Not Covered 7/1/2018 NEURONTIN 100 MG CAPSULE Not Covered 7/1/2018 NEURONTIN 800 MG TABLET Not Covered 7/1/2018 nevirapine Move to Tier 4, PA 7/1/2018 NEXIUM DR 20 MG CAPSULE Move to Tier 3, PA 7/1/2018 NEXIUM DR 40 MG CAPSULE Move to Tier 3, PA 5/1/2018 NIACOR 500 MG TABLET Move to Tier 3 7/1/2018 NICODERM CQ 21MG/24HR PC Not Covered 7/1/2018 NICORELIEF 2 MG GUM Not Covered 7/1/2018 NICORETTE 4 MG LOZENGE Not Covered 5/1/2018 NIFEDICAL XL 30 MG TABLET Move to Tier 3 5/1/2018 NIFEDICAL XL 60 MG TABLET Move to Tier 3 5/1/2018 NILANDRON Move to Tier 4, PA 7/1/2018 NILANDRON 150 MG TABLET Not Covered 5/1/2018 NITRO-BID 2% OINTMENT Move to Tier 2 7/1/2018 NITROLINGUAL 0.4 MG SPRAY Not Covered 7/1/2018 NITROMIST 400 MCG SPRAY Not Covered 7/1/2018 NITROSTAT 0.3 MG TABLET SL Not Covered 7/1/2018 NITROSTAT 0.4 MG TABLET SL Not Covered 7/1/2018 NITROSTAT 0.6 MG TABLET SL Not Covered 7/1/2018 NORVIR 100 MG TABLET Not Covered 5/1/2018 NOVOFINE 30G X 1/3 NEEDLES Move to Tier 2

10 7/1/2018 NUCYNTA IR Not Covered 5/1/2018 NYAMYC UNT/GM PWD Move to Tier 3 5/1/2018 NYSTOP UNIT/GM PWD Move to Tier 3 7/1/2018 NYSTOP UNIT/GM PWD Not Covered 7/1/2018 OCELLA 3 MG-0.03 MG TABLET Not Covered 7/1/2018 OGESTREL TABLET Not Covered 5/1/2018 OLOPATADINE HCL 0.2% EYE DR Move to Tier 2 7/1/2018 ONGLYZA Not Covered 5/1/2018 ORALONE 0.1% PASTE Move to Tier 3 7/1/2018 ORALONE 0.1% PASTE Not Covered 5/1/2018 ORAP 1 MG TABLET Not Covered 5/1/2018 ORAP 2 MG TABLET Not Covered 5/1/2018 ORTHO TRI-CYCLEN LO TABLET Move to Tier 3 5/1/2018 OXYCONTIN, ALL Move to Tier 3, PA 7/1/2018 OXYCONTIN 10 MG TABLET Not Covered 7/1/2018 OXYCONTIN 15 MG TABLET Not Covered 7/1/2018 OXYCONTIN 20 MG TABLET Not Covered 7/1/2018 OXYCONTIN 30 MG TABLET Not Covered 7/1/2018 OXYCONTIN 40 MG TABLET Not Covered 7/1/2018 OXYCONTIN 60 MG TABLET Not Covered 7/1/2018 OXYCONTIN 80 MG TABLET Not Covered 5/1/2018 PACERONE 100 MG TABLET Move to Tier 3 5/1/2018 PACERONE 100 MG TABLET Not Covered 5/1/2018 PACERONE 200 MG TABLET Move to Tier 3 5/1/2018 PACERONE 200 MG TABLET Not Covered 5/1/2018 PACERONE 400 MG TABLET Move to Tier 3 5/1/2018 PACERONE 400 MG TABLET Not Covered 5/1/2018 PAROEX 0.12% ORAL RINSE Move to Tier 2 5/1/2018 PATADAY 0.2% EYE DROPS Not Covered 5/1/2018 PATANOL 0.1% EYE DROPS Not Covered 5/1/2018 PEDIAPRED 5 MG/5 ML SOLN Move to Tier 3 5/1/2018 PEDIAPRED 5 MG/5 ML SOLN Not Covered 7/1/2018 pentazocine naloxone Not Covered 5/1/2018 PERIOGARD 0.12% ORAL RINSE Move to Tier 3 7/1/2018 PERIOGARD 0.12% ORAL RINSE Not Covered 7/1/2018 PHENADOZ 12.5 MG SUPPOSIT Not Covered 5/1/2018 PHENADOZ 12.5 MG SUPPOSIT Move to Tier 3 7/1/2018 PHENADOZ 25 MG SUPPOSIT Not Covered 5/1/2018 PHENADOZ 25 MG SUPPOSIT Move to Tier 3 5/1/2018 PHENERGAN 12.5 MG SUPPOS Move to Tier 3 5/1/2018 PHENERGAN 25 MG SUPPOSIT Move to Tier 3 7/1/2018 PHENYTEK 300 MG CAPSULE Not Covered 7/1/2018 PLAQUENIL 200 MG TABLET Not Covered 5/1/2018 PLAVIX 75 MG TABLET Move to Tier 3

11 7/1/2018 PLAVIX 75 MG TABLET Not Covered 7/1/2018 POLYCIN EYE OINTMENT Not Covered 5/1/2018 PRANDIN 1 MG TABLET Not Covered 7/1/2018 PRANDIN 1 MG TABLET Not Covered 5/1/2018 PRANDIN 2 MG TABLET Not Covered 7/1/2018 PRANDIN 2 MG TABLET Not Covered 5/1/2018 PRASUGREL 10 MG TABLET Move to Tier 2 5/1/2018 PRAVACHOL 40 MG TABLET Move to Tier 3 5/1/2018 PRAVACHOL 40 MG TABLET Move to Tier 3 7/1/2018 PRAVACHOL 40 MG TABLET Not Covered 5/1/2018 PREDNISONE 5 MG/ML SOLUT Move to Tier 2 7/1/2018 PREPLUS CA-FE 27 MG-FA 1 MG Not Covered 5/1/2018 PREPOPIK POWDER PACKET Move to Tier 2 5/1/2018 PREVALITE PACKET Move to Tier 3 7/1/2018 PREVALITE PACKET Not Covered 5/1/2018 PREVALITE POWDER Move to Tier 3 7/1/2018 PREVALITE POWDER Not Covered 5/1/2018 PRILOLID % CRM-DRESS Move to Tier 3 7/1/2018 PRISTIQ ER 100 MG TABLET Not Covered 7/1/2018 PRISTIQ ER 50 MG TABLET Not Covered 5/1/2018 PROCTOSOL-HC 2.5% CREAM Move to Tier 2 7/1/2018 PROCTOSOL-HC 2.5% CREAM Not Covered 5/1/2018 PROCTOZONE-HC 2.5% CREAM Move to Tier 2 5/1/2018 PROMETHEGAN 12.5 MG SUPP Move to Tier 3 5/1/2018 PROMETHEGAN 25 MG SUPPOS Move to Tier 3 7/1/2018 PROMETHEGAN 50 MG SUPPOS Not Covered 5/1/2018 PROMETHEGAN 50 MG SUPPOS Move to Tier 3 7/1/2018 PROTONIX DR 40 MG TABLET Not Covered 7/1/2018 PROZAC WEEKLY 90 MG CAP Not Covered 5/1/2018 PRUDOXIN Move to Tier 3, PA 7/1/2018 PRUDOXIN 5% CREAM Not Covered 7/1/2018 PULMICORT 0.5 MG/2 ML RESP Not Covered 5/1/2018 QC BACITRACIN 500 UNIT/GM Not Covered OINT 5/1/2018 QUESTRAN PACKET Move to Tier 3 7/1/2018 QUESTRAN PACKET Not Covered 5/1/2018 QUESTRAN POWDER Move to Tier 3 7/1/2018 QUESTRAN POWDER Not Covered 5/1/2018 QUETIAPINE FUMARATE 400 Move to Tier 2 MG TAB 7/1/2018 RAJANI 28 TABLET Not Covered 7/1/2018 REFISSA 0.05% CREAM Not Covered 7/1/2018 REGLAN 10 MG TABLET Not Covered 7/1/2018 RELPAX 20 MG TABLET Not Covered

12 7/1/2018 RELPAX 40 MG TABLET Not Covered 7/1/2018 RENVELA 0.8 GM POWDER PCK Not Covered 7/1/2018 RENVELA 2.4 GM POWDER PCK Not Covered 5/1/2018 RENVELA 800 MG TABLET Not Covered 7/1/2018 REYATAZ 150 MG CAPSULE Not Covered 7/1/2018 REYATAZ 200 MG CAPSULE Not Covered 7/1/2018 REYATAZ 300 MG CAPSULE Not Covered 7/1/2018 RIBASPHERE 200 MG CAPSULE Not Covered 7/1/2018 RIBASPHERE 200 MG TABLET Not Covered 5/1/2018 RILUTEK 50 MG TABLET Not Covered 5/1/2018 ROCALTROL 0.25 MCG CAPSULE Move to T3 7/1/2018 ROCALTROL 0.25 MCG CAPSULE Not Covered 7/1/2018 ROSADAN 0.75% CREAM Not Covered 7/1/2018 ROSADAN 0.75% GEL Not Covered 7/1/2018 ROXICODONE 15 MG TABLET Not Covered 7/1/2018 ROXICODONE 30 MG TABLET Not Covered 7/1/2018 ROXICODONE 5 MG TABLET Not Covered 7/1/2018 SABRIL 500 MG POWDER PCKET Not Covered 7/1/2018 SAFYRAL TABLET Not Covered 7/1/2018 SE-NATAL 19 CHEWABLE TAB Not Covered 7/1/2018 SE-NATAL 19 TABLET Not Covered 5/1/2018 SENSIPAR Move to Tier 4, PA 7/1/2018 SEROQUEL 300 MG TABLET Not Covered 7/1/2018 SEROQUEL XR 300 MG TABLET Not Covered 7/1/2018 SEROQUEL XR 50 MG TABLET Not Covered 7/1/2018 SORIATANE 10 MG CAPSULE Not Covered 7/1/2018 SORIATANE 17.5 MG CAPSULE Not Covered 7/1/2018 SORIATANE 25 MG CAPSULE Not Covered 5/1/2018 SORINE 120 MG TABLET Move to Tier 3 7/1/2018 SORINE 120 MG TABLET Not Covered 5/1/2018 SORINE 160 MG TABLET Move to Tier 3 7/1/2018 SORINE 160 MG TABLET Not Covered 5/1/2018 SORINE 240 MG TABLET Move to Tier 3 7/1/2018 SORINE 240 MG TABLET Not Covered 5/1/2018 SORINE 80 MG TABLET Move to Tier 3 7/1/2018 SORINE 80 MG TABLET Not Covered 5/1/2018 SPS 15 GM/60 ML SUSPENSION Move to Tier 2 5/1/2018 SPS 30 GM/120 ML ENEMA Move to Tier 2 5/1/2018 SSD 1% CREAM Move to Tier 2 7/1/2018 SSD 1% CREAM Not Covered 7/1/2018 STRATTERA 10 MG CAPSULE Not Covered 7/1/2018 STRATTERA 100 MG CAPSULE Not Covered 7/1/2018 STRATTERA 18 MG CAPSULE Not Covered 7/1/2018 STRATTERA 25 MG CAPSULE Not Covered

13 7/1/2018 STRATTERA 40 MG CAPSULE Not Covered 7/1/2018 STRATTERA 60 MG CAPSULE Not Covered 7/1/2018 STRATTERA 80 MG CAPSULE Not Covered 7/1/2018 STROMECTOL 3 MG TABLET Not Covered 7/1/2018 SULFAMYLON POWDER PACKET Not Covered 7/1/2018 SULFATRIM MG/20 ML Not Covered 7/1/2018 SULFATRIM PEDIATRIC SUSP Not Covered 5/1/2018 SULFATRIM PEDIATRIC SUSP Move to Tier 2 5/1/2018 SUMATRIPTAN Move to Tier 2 7/1/2018 SUPRAX 100 MG/5 ML SUSPEN Not Covered 5/1/2018 SUPREP BOWEL PREP KIT Move to Tier 2 7/1/2018 SYNALOGOS-DC Not Covered 7/1/2018 SYPRINE 250 MG CAPSULE Not Covered 5/1/2018 TAMIFLU Move to Tier 3, PA 7/1/2018 TAMIFLU 30 MG CAPSULE Not Covered 7/1/2018 TAMIFLU 45 MG CAPSULE Not Covered 7/1/2018 TAMIFLU 6 MG/ML SUSPENS Not Covered 7/1/2018 TAMIFLU 75 MG CAPSULE Not Covered 7/1/2018 TANZEUM Not Covered 5/1/2018 TARGRETIN 75 MG CAPSULE Not Covered 5/1/2018 TASMAR 100 MG TABLET Not Covered 7/1/2018 TAZORAC 0.1% CREAM Not Covered 5/1/2018 TAZTIA XT 120 MG CAPSULE Move to Tier 2 7/1/2018 TAZTIA XT 120 MG CAPSULE Not Covered 5/1/2018 TAZTIA XT 180 MG CAPSULE Move to Tier 2 7/1/2018 TAZTIA XT 180 MG CAPSULE Not Covered 5/1/2018 TAZTIA XT 240 MG CAPSULE Move to Tier 2 7/1/2018 TAZTIA XT 240 MG CAPSULE Not Covered 5/1/2018 TAZTIA XT 300 MG CAPSULE Move to Tier 2 5/1/2018 TAZTIA XT 360 MG CAPSULE Move to Tier 2 7/1/2018 TAZTIA XT 360 MG CAPSULE Not Covered 5/1/2018 TERBUTALINE SULF 2.5 MG TAB Move to Tier 2 7/1/2018 TESSALON PERLE 100 MG CAP Not Covered 5/1/2018 TESTOSTER 30 MG/1.5 ML PMP Move to Tier 2 7/1/2018 THEOCHRON ER 100 MG TAB Not Covered 5/1/2018 THEOCHRON ER 100 MG TAB Move to Tier 2 7/1/2018 THEOCHRON ER 200 MG TAB Not Covered 5/1/2018 THEOCHRON ER 200 MG TAB Move to Tier 2 7/1/2018 THEOCHRON ER 300 MG TAB Not Covered 5/1/2018 THEOCHRON ER 300 MG TAB Move to Tier 2 5/1/2018 THERMAZENE 1% CREAM Move to Tier 2 7/1/2018 TIAZAC ER 300 MG CAPSULE Not Covered 7/1/2018 TIKOSYN 125 MCG CAPSULE Not Covered 7/1/2018 TIKOSYN 250 MCG CAPSULE Not Covered

14 7/1/2018 TIKOSYN 500 MCG CAPSULE Not Covered 7/1/2018 TIMOPTIC 0.25% EYE DROP Not Covered 7/1/2018 TIMOPTIC 0.5% EYE DROP Not Covered 7/1/2018 tolazamide Not Covered 7/1/2018 tolbutamide Not Covered 7/1/2018 TOPICORT 0.25% OINTMENT Not Covered 5/1/2018 TOPROL XL 100 MG TABLET Not Covered 5/1/2018 TOPROL XL 200 MG TABLET Not Covered 5/1/2018 TOPROL XL 25 MG TABLET Not Covered 5/1/2018 TOPROL XL 50 MG TABLET Not Covered 6/1/2018 TOUJEO Add PA 7/1/2018 TOUJEO Not Covered 5/1/2018 TRESIBA Add Tier 3, PA 5/1/2018 TREXALL Move to Tier 3, PA 7/1/2018 TRICOR 48 MG TABLET Not Covered 7/1/2018 TRIDERM 0.1% CREAM Not Covered 7/1/2018 TRI-LO-SPRINTEC TABLET Not Covered 7/1/2018 TRNSDRM-SCOP 1.5 MG/3 DAY Not Covered 5/1/2018 TRUVADA MG Add PA 5/1/2018 UNITHROID 100 MCG TABLET Move to Tier 3 5/1/2018 UNITHROID 112 MCG TABLET Move to Tier 3 5/1/2018 UNITHROID 125 MCG TABLET Move to Tier 3 5/1/2018 UNITHROID 137 MCG TABLET Move to Tier 3 5/1/2018 UNITHROID 150 MCG TABLET Move to Tier 3 5/1/2018 UNITHROID 175 MCG TABLET Move to Tier 3 5/1/2018 UNITHROID 200 MCG TABLET Move to Tier 3 5/1/2018 UNITHROID 25 MCG TABLET Move to Tier 3 5/1/2018 UNITHROID 300 MCG TABLET Move to Tier 3 5/1/2018 UNITHROID 50 MCG TABLET Move to Tier 3 5/1/2018 UNITHROID 75 MCG TABLET Move to Tier 3 5/1/2018 UNITHROID 88 MCG TABLET Move to Tier 3 7/1/2018 VAGIFEM 10 MCG VAGIN TAB Not Covered 5/1/2018 VALCYTE 450 MG TABLET Not Covered 7/1/2018 VANDAZOLE VAGIN 0.75% GEL Not Covered 5/1/2018 VENLAFAXIN HCL ER 150 MG TA Move to Tier 2 7/1/2018 VERDROCET Not Covered 7/1/2018 VIBRAMYCIN 100 MG CAPSULE Not Covered 5/1/2018 VIGAMOX 0.5 % Not Covered 7/1/2018 VIREAD 300 MG TABLET Not Covered 7/1/2018 VIVELLE-DOT MG PATCH Not Covered 7/1/2018 VIVELLE-DOT 0.1 MG PATCH Not Covered 7/1/2018 VOL-PLUS TABLET Not Covered 7/1/2018 WELLBUTRIN SR 100 MG TAB Not Covered 5/1/2018 WELLBUTRIN SR 100 MG TAB Move to Tier 3

15 7/1/2018 WELLBUTRIN SR 150 MG TAB Not Covered 5/1/2018 WELLBUTRIN SR 150 MG TAB Move to Tier 3 7/1/2018 XARTAMIS XR Not Covered 5/1/2018 XENAZINE 12.5 MG TABLET Not Covered 5/1/2018 XENAZINE 25 MG TABLET Not Covered 7/1/2018 XOPENEX HFA 45 MCG INHALER Not Covered 5/1/2018 YUVAFEM 10 MCG VAG INSERT Move to Tier 3 7/1/2018 ZAMICET Not Covered 7/1/2018 ZANAFLEX 4 MG TABLET Not Covered 7/1/2018 ZOHYDRO ER Not Covered 7/1/2018 ZEBUTAL MG CAPS Not Covered 5/1/2018 ZEBUTAL MG CAPS Move to Tier 3 5/1/2018 ZEMPLAR 1 MCG CAPSULE Not Covered 5/1/2018 ZEMPLAR 2 MCG CAPSULE Not Covered 7/1/2018 ZENCHENT FE TABLET CHEW Not Covered 7/1/2018 ZENZEDI 10 MG TABLET Not Covered 7/1/2018 ZENZEDI 5 MG TABLET Not Covered 5/1/2018 ZEPATIER Not Covered 7/1/2018 ZETIA 10 MG TABLET Not Covered 7/1/2018 ZITHROMAX 1 GM POWD PCK Not Covered 5/1/2018 ZITHROMAX 250 MG TABLET Move to Tier 3 7/1/2018 ZITHROMAX 250 MG TABLET Not Covered 7/1/2018 ZITHROMAX 600 MG TABLET Not Covered 5/1/2018 ZOLOFT 100 MG TABLET Move to Tier 3 7/1/2018 ZOLOFT 100 MG TABLET Not Covered 5/1/2018 ZOMIG 2.5 MG TABLET Not Covered 5/1/2018 ZOMIG 5 MG Not Covered 5/1/2018 ZOMIG ZMT 2.5 MG TABLET Not Covered 5/1/2018 ZOMIG ZMT 5 MG TABLET Not Covered 7/1/2018 ZOSTAVAX Not Covered 7/1/2018 ZYFLO CR 600 MG TABLET Not Covered 7/1/2018 ZYVOX 100 MG/5 ML SUSPENS Not Covered 5/1/2018 ZYVOX 600 MG TABLET Not Covered