2017 Medicare Part D Formulary Change

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1 2017 Medicare Part D Formulary Change We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorizations, quantity limits and/or step therapy restrictions on a drug [or move a drug to a higher cost-sharing tier], we will let you know of the change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and let you know. The product changes noted below will be implemented on the Medicare Part D Plan formulary. To see if your drug is on this list, please refer to the tables below: New Added Products: Effective 8/1/2017 ALUNBRIG 30 MG TABLET LA CLOFARABINE 20 MG/20 ML INTRAVENOUS EZETIMIBE 10 MG-SIMVASTATIN 10 MG TABLET EZETIMIBE 10 MG-SIMVASTATIN 20 MG TABLET EZETIMIBE 10 MG-SIMVASTATIN 40 MG TABLET EZETIMIBE 10 MG-SIMVASTATIN 80 MG TABLET IMFINZI 50 MG/ML INTRAVENOUS LA IMFINZI 50 MG/ML INTRAVENOUS (10 ML) KISQALI FEMARA CO-CK 200 MG/DAY(200 MG X 1)-2.5 MG TABLET KISQALI FEMARA CO-CK 400 MG/DAY(200 MG X 2)-2.5 MG TABLET KISQALI FEMARA CO-CK 600 MG/DAY(200 MG X 3)-2.5 MG TABLET RYDAPT 25 MG CAPSULE XATMEP 2.5 MG/ML ORAL LA ZEJULA 100 MG CAPSULE LA Future Removed Products: Effective 8/1/2017 1

2 Drug AMINOSYN II 7 % INTRAVENOUS ATROPINE 0.1 MG/ML INJECTION SYRINGE GARDASIL (PF) 20MCG-40MCG-40MCG- 20MCG/0.5ML INTRAMUSCULAR SYRINGE MENOMUNE - A/C/Y/W-135 (PF) 50 MCG SUBCUTANEOUS PEGINTRON 120 MCG/0.5 ML SUBCUTANEOUS KIT PEGINTRON 150 MCG/0.5 ML SUBCUTANEOUS KIT PEGINTRON 80 MCG/0.5 ML SUBCUTANEOUS KIT PEGINTRON REDIPEN 150 MCG/0.5 ML SUBCUTANEOUS KIT PEGINTRON REDIPEN 50 MCG/0.5 ML SUBCUTANEOUS KIT PEGINTRON REDIPEN 80 MCG/0.5 ML SUBCUTANEOUS KIT Reason New Added Products: Effective 7/1/2017 BAVENCIO 20 MG/ML INTRAVENOUS LA ESBRIET 267 MG TABLET ESBRIET 801 MG TABLET INTRON A 10 MILLION UNIT/ML INJECTION KINRIX (PF) 25 LF-58 MCG-10 LF/0.5 ML INTRAMUSCULAR SUSPENSION LEVOLEUCOVORIN 50 MG INTRAVENOUS POWDER FOR Tier 3 ROWEEPRA 1,000 MG TABLET ROWEEPRA 750 MG TABLET TAZAROTENE 0.1 % TOPICAL CREAM 2

3 Future Removed Products: Effective 7/1/2017 Drug VIRAZOLE 6 GRAM FOR INHALATION Reason New Added Products: Effective 6/1/2017 DESVENLAFAXINE SUCCINATE ER 100 MG TABLET,EXTENDED DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED KISQALI 200 MG/DAY (200 MG X 1) TABLET KISQALI 400 MG/DAY (200 MG X 2) TABLET KISQALI 600 MG/DAY (200 MG X 3) TABLET XERMELO 250 MG TABLET LA Future Removed Products: Effective 6/1/2017 Drug AMETHYST 90 MCG-20 MCG TABLET OXACILLIN 2 GRAM INTRAVENOUS PRALUENT SYRINGE 75 MG/ML SUBCUTANEOUS Reason New Added Products: Effective 5/1/2017 CALCIUM ACETATE 667 MG TABLET EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO- INJECTOR (MANUFACTURED BY MYLAN) KLOR-CON M10 MEQ TABLET,EXTENDED RELEASE Tier 3 3

4 KLOR-CON M20 MEQ TABLET,EXTENDED RELEASE LINZESS 72 MCG CAPSULE Tier 3 MENOMUNE - A/C/Y/W-135 (PF) 50 MCG SUBCUTANEOUS POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(RT/CRYST) POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(RT/CRYST) PREDNISOLONE SODIUM PHOSPHATE 10 MG/5 ML ORAL PREDNISOLONE SODIUM PHOSPHATE 20 MG/5 ML (4 MG/ML) ORAL Tier 3 SELZENTRY 25 MG TABLET SELZENTRY 75 MG TABLET Future Removed Products: Effective 5/1/2017 Drug EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR KLOR-CON M20 MEQ TABLET,EXTENDED RELEASE METFORMIN ER 1,000 MG TABLET,EXTENDED RELEASE 24HR METHYLPHENIDATE LA 40 MG CAPSULE,EXTENDED RELEASE BIPHASIC Reason New Added Products: Effective 4/1/2017 AMIODARONE 100 MG TABLET LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 35 MCG TABLET 4

5 RANITIDINE 50 MG/2 ML (25 MG/ML) INJECTION RENVELA 800 MG TABLET Tier 3 Future Removed Products: Effective 4/1/2017 Drug AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR IRENKA 40 MG CAPSULE,DELAYED RELEASE MENOMUNE - A/C/Y/W-135 (PF) 50 MCG SUBCUTANEOUS METHYLPHENIDATE LA 20 MG CAPSULE,EXTENDED RELEASE BIPHASIC NECON 1/35 (28) 1 MG-35 MCG TABLET PRALUENT SYRINGE 150 MG/ML SUBCUTANEOUS Reason New Added Products: Effective 3/1/2017 ABACAVIR 600 MG-LAMIVUDINE 300 MG TABLET ADRIAMYCIN 20 MG/10 ML INTRAVENOUS ALA-CORT 2.5 % TOPICAL CREAM ALLOPURINOL 500 MG INTRAVENOUS ALYACEN 1/35 (28) 1 MG-35 MCG TABLET AMETHIA LO 0.10 MG-20 MCG (84)/10 MCG(7) TABLETS,3 MONTH DOSE CK AMLODIPINE 10 MG-OLMESARTAN 20 MG TABLET 5

6 AMLODIPINE 10 MG-OLMESARTAN 40 MG TABLET AMLODIPINE 5 MG-OLMESARTAN 20 MG TABLET AMLODIPINE 5 MG-OLMESARTAN 40 MG TABLET APREPITANT 125 MG (1)-80 MG (2) CAPSULES IN A DOSE CK APREPITANT 125 MG CAPSULE APREPITANT 40 MG CAPSULE APREPITANT 80 MG CAPSULE AZITHROMYCIN 500 MG TABLET (3 CK) BETIMOL 0.5 % EYE DROPS BUPROPION HCL 150 MG TABLET,SUSTAINED RELEASE (AS A SMOKING DETERRENT) CAMRESE LO 0.10 MG-20 MCG (84)/10 MCG(7) TABLETS,3 MONTH DOSE CK CAZIANT (28) 0.1 MG/0.125 MG/0.15 MG-25 MCG TABLET CHOLESTYRAMINE LIGHT 4 GRAM ORAL POWDER CLINDAMYCIN 1.2 % (1 % BASE)-BENZOYL PEROXIDE 5 % TOPICAL GEL DAPTOMYCIN 500 MG INTRAVENOUS DROSPIREN-E.ESTRAD-L.MEFOL 3 MG-0.02 MG MG(24)/0.451 MG(4)TABLET EMEND 125 MG (25 MG/ML FINAL CONC.) ORAL SUSPENSION EPCLUSA 400 MG-100 MG TABLET EPIRUBICIN 200 MG/100 ML INTRAVENOUS ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION EZETIMIBE 10 MG TABLET FLUOCINONIDE-E 0.05% TOPICAL CREAM 6

7 7 GAMMAGARD S-D (IGA < 1 MCG/ML) 10 GRAM INTRAVENOUS GAMMAGARD S-D (IGA < 1 MCG/ML) 5 GRAM INTRAVENOUS GENGRAF 50 MG CAPSULE HUMIRA PEN PSORIASIS-UVEITIS STARTER 40 MG/0.8 ML SUBCUTANEOUS KIT IMOGAM RABIES-HT (PF) 150 UNIT/ML INTRAMUSCULAR KINRIX (PF) 25 LF-58 MCG-10 LF/0.5 ML INTRAMUSCULAR SYRINGE Tier 3 KYPROLIS 30 MG INTRAVENOUS KYPROLIS 60 MG INTRAVENOUS LARISSIA 0.1 MG-20 MCG TABLET LARTRUVO 10 MG/ML INTRAVENOUS LEVALBUTEROL 1.25 MG/0.5 ML FOR NEBULIZATION (2.5 MG/ML) LOW-OGESTREL (28) 0.3 MG-30 MCG TABLET METHOTREXATE SODIUM 25 MG/ML INJECTION MORGIDOX 50 MG CAPSULE MYCOPHENOLATE 500 MG INTRAVENOUS NECON 1/50 (28) 1 MG-50 MCG TABLET NIFEDIPINE ER 30 MG TABLET,EXTENDED NIFEDIPINE ER 60 MG TABLET,EXTENDED NIFEDIPINE ER 90 MG TABLET,EXTENDED NILUTAMIDE 150 MG TABLET NITROGLYCERIN 0.3 MG SUBLINGUAL TABLET NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET NITROGLYCERIN 0.6 MG SUBLINGUAL TABLET NORETHIN-ETHINYL ESTRADIOL-IRON 0.4 MG- 35 MCG(21)/75 MG(7) CHEW TABLET

8 8 NORGESTIMATE 0.18 MG/0.215 MG/0.25 MG- ETHINYL ESTRADIOL 25 MCG TABLET NORGESTIMATE-ETHINYL ESTRADIOL 0.18 MG/0.215MG/0.25MG-35 MCG(28)TABLET OFLOXACIN 300 MG TABLET OLMESARTAN 20 MG TABLET OLMESARTAN 20 MG-AMLODIPINE 5 MG- HYDROCHLOROTHIAZIDE 12.5 MG TABLET OLMESARTAN 20 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET OLMESARTAN 40 MG TABLET OLMESARTAN 40 MG-AMLODIPINE 10 MG- HYDROCHLOROTHIAZIDE 12.5 MG TABLET OLMESARTAN 40 MG-AMLODIPINE 10 MG- HYDROCHLOROTHIAZIDE 25 MG TABLET OLMESARTAN 40 MG-AMLODIPINE 5 MG- HYDROCHLOROTHIAZIDE 12.5 MG TABLET OLMESARTAN 40 MG-AMLODIPINE 5 MG- HYDROCHLOROTHIAZIDE 25 MG TABLET OLMESARTAN 40 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET OLMESARTAN 40 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET OLMESARTAN 5 MG TABLET ORKAMBI 100 MG-125 MG TABLET OSELTAMIVIR 30 MG CAPSULE OSELTAMIVIR 45 MG CAPSULE OSELTAMIVIR 75 MG CAPSULE NCREAZE 2,600 UNIT-6,200 UNIT-10,850 UNIT CAPSULE,DELAYED RELEASE PEDIARIX (PF) 10 MCG-25 LF-25 MCG-10 LF/0.5 ML INTRAMUSCULAR SYRINGE PRAMIPEXOLE ER 3.75 MG TABLET,EXTENDED Tier 3 PREDNISONE 10 MG TABLETS IN A DOSE CK Tier 1 PREDNISONE 10 MG TABLETS IN A DOSE CK (48 CK) Tier 1

9 PREDNISONE 5 MG TABLETS IN A DOSE CK Tier 1 PREDNISONE 5 MG TABLETS IN A DOSE CK (48 CK) QUETIAPINE ER 150 MG TABLET,EXTENDED QUETIAPINE ER 200 MG TABLET,EXTENDED QUETIAPINE ER 300 MG TABLET,EXTENDED QUETIAPINE ER 400 MG TABLET,EXTENDED QUETIAPINE ER 50 MG TABLET,EXTENDED Tier 1 RASAGILINE 0.5 MG TABLET RASAGILINE 1 MG TABLET RETHA PUSHTRONEX 420 MG/3.5 ML SUBCUTANEOUS WEARABLE INJECTOR RUBRACA 200 MG TABLET LA RUBRACA 300 MG TABLET LA SPS (WITH SORBITOL) 15 GRAM-20 GRAM/60 ML ORAL SUSPENSION SUBOXONE 12 MG-3 MG SUBLINGUAL FILM SUBOXONE 2 MG-0.5 MG SUBLINGUAL FILM SUBOXONE 4 MG-1 MG SUBLINGUAL FILM SUBOXONE 8 MG-2 MG SUBLINGUAL FILM SUMATRIPTAN 4 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR TRIAMCINOLONE ACETONIDE 55 MCG NASAL SPRAY AEROSOL VALGANCICLOVIR 50 MG/ML ORAL VIVITROL 380 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE YONDELIS 1 MG INTRAVENOUS ZARAH 3 MG-0.03 MG TABLET ZERIT 1 MG/ML ORAL 9

10 Future Removed Products: Effective 3/1/2017 Drug A-HYDROCORT 100 MG FOR INJECTION BUPROBAN 150 MG TABLET,EXTENDED RELEASE CERVARIX VACCINE (PF) 20 MCG-20 MCG/0.5 ML INTRAMUSCULAR SYRINGE FORTICAL 200 UNIT/ACTUATION NASAL SPRAY GILDESS 1.5/30 (21) 1.5 MG-30 MCG TABLET MELOXICAM 7.5 MG/5 ML ORAL SUSPENSION METHYLERGONOVINE 0.2 MG TABLET NAPHAZOLINE 0.1 % EYE DROPS NIFEDICAL XL 30 MG TABLET,EXTENDED RELEASE NIFEDICAL XL 60 MG TABLET,EXTENDED RELEASE PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS RANITIDINE 25 MG/ML INJECTION RESERPINE 0.1 MG TABLET RESERPINE 0.25 MG TABLET STAVUDINE 1 MG/ML ORAL TRAVOPROST (BENZALKONIUM) % EYE DROPS TYVASO 1.74 MG/2.9 ML (0.6 MG/ML) FOR NEBULIZATION TYZEKA 600 MG TABLET VARIZIG 125 UNIT/1.2 ML INTRAMUSCULAR VITEKTA 150 MG TABLET VITEKTA 85 MG TABLET Reason 10

11 Cost Sharing Tier Changes: Effective 3/1/2017 Drug New Tier Old Tier Restrictions* LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET LOSARTAN 50 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET

12 For more information about how these changes may affect your cost-sharing, such as copayments or coinsurance, or for more information about asking for an updated coverage determination or a formulary exception, please see the plan Evidence of Coverage. Alternative drugs are drugs in the same therapeutic category/class as the affected drug. Only your doctor can determine alternative drugs that are appropriate for you given the individualized nature of drug therapy. Please talk to your doctor about any changes or recommendations to your medical care and prescription drug therapy. Alternative drugs and additional information about formulary changes can be found on the plan formulary, *Indicates a restriction of Step Therapy, Prior Authorization or Quantity Level Limits may exit LA = Limited Access, = Prior Authorization, = Quantity Limit, ST = Step Therapy Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayment/coinsurance may change on January 1, 2018 This document includes GuildNet Gold and GuildNet Health Advantage partial formulary as of 08/01/2017. For a complete, updated formulary, please visit our Web site at or call the Member Service number below. This information is available for free in other languages. Please contact Member Services number at for additional information. (TTY users should call ). Hours are Monday through Friday, 8am -8pm. Member Services has free language interpreter services available for non-english speakers. Esta información esta disponible en otros idiomas a gratis. Por favor llame a Servicios a los Clientes, al por información adicional. (Los usuarios de TTY deben llamar al ). Se atiende de lunes a viernes, de 8 a. m. a 8 p. m. Servicios a los Clientes tienen los servicios gratuitos de intérprete de idioma disponibles para altavoces de no-inglés. GuildNet Gold and GuildNet Health Advantage are HMO-POS SNP plans with Medicare and New York State contracts. Enrollment in GuildNet Gold and GuildNet Health Advantage depends on contract renewal. 12

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