2015 Formulary Annual Notice of Change

Transcription

1 Updated: October 1, Formulary Annual Notice of Change Medicare Advantage Plans (MAPD) This is a listing of the changes that have occurred to the 2015 MAPD formulary. For a complete list, please refer to the 2015 MAPD Comprehensive Formulary (Drug List). Please carefully review these changes and call Customer Service at the telephone number listed in your Comprehensive Formulary if you have any questions. You can obtain an updated coverage determination or an exception to a coverage determination by visiting our website at or by calling the telephone number listed in your Comprehensive Formulary. Please refer to your Evidence of Coverage for cost-sharing information. Florida Hospital Care Advantage is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal.

2 MEDICATIONS DELETED FROM THE 2015 MAPD Actiq LOLLIPOP 200 MCG BUCCAL Alcohol Preps PAD Avandamet TABLET MG Avandaryl TABLET 8-2 MG Buphenyl POWDER 3 GM/TSP Buphenyl TABLET 500 MG Carimune NF SOLUTION RECONSTITUTED 3 GM CeeNU CAPSULE 10 MG CeeNU CAPSULE 40 MG Cerezyme SOLUTION RECONSTITUTED 200 UNIT Cymbalta CAPSULE DELAYED RELEASE PARTICLES 20 MG Cymbalta CAPSULE DELAYED RELEASE PARTICLES 30 MG Cymbalta CAPSULE DELAYED RELEASE PARTICLES 60 MG Dexamethasone Sodium Phosphate SOLUTION 120 MG/30ML Evista TABLET 60 MG Fortaz in D5W SOLUTION 1-5 GM/50ML-% Fortaz in D5W SOLUTION 2-5 GM/50ML-% Forteo SOLUTION 600 MCG/2.4ML Horizant TABLET EXTENDED RELEASE 24 HR* 600 MG Isosorbide Dinitrate TABLET SUBLINGUAL 2.5 MG SUBLINGUAL Kuvan TABLET SOLUBLE 100 MG Nevirapine ER TABLET EXTENDED RELEASE 24 HR* 400 MG NovoLOG FlexPen 100 UNIT/ML Ofloxacin TABLET 200 MG Ofloxacin TABLET 300 MG Opana ER 10 MG Opana ER 15 MG Opana ER 20 MG Opana ER 30 MG Opana ER 40 MG Opana ER 5 MG Opana ER 7.5 MG Orfadin CAPSULE 10 MG Orfadin CAPSULE 2 MG Orfadin CAPSULE 5 MG Peg-Intron KIT 120 MCG/0.5ML Peg-Intron KIT 150 MCG/0.5ML Peg-Intron KIT 80 MCG/0.5ML Potassium Chloride SOLUTION 30 MEQ/100ML PrednisoLONE Acetate SUSPENSION 1 % OPHTHALMIC Proctocream HC CREAM 2.5 % Proctozone-HC CREAM 2.5 %

3 MEDICATIONS DELETED FROM THE 2015 MAPD LaMICtal ODT TABLET DISPERSIBLE 100 MG LaMICtal ODT TABLET DISPERSIBLE 200 MG LaMICtal ODT TABLET DISPERSIBLE 25 MG LaMICtal ODT TABLET DISPERSIBLE 50 MG Lazanda SOLUTION 100 MCG/ACT NASAL Lazanda SOLUTION 400 MCG/ACT NASAL Lidoderm PATCH 5 % EXTERNAL Lithium Citrate SOLUTION 8 MEQ/5ML Lupron Depot-Ped KIT MG (Ped) Lupron Depot-Ped KIT 7.5 MG Meloxicam SUSPENSION 7.5 MG/5ML Methotrexate Sodium (PF) SOLUTION 50 MG/2ML Naltrexone HCl TABLET 50 MG Namenda TABLET 10 MG Namenda TABLET 5 MG Namenda Titration Pak TABLET 5 (28)-10 (21) MG Proventil HFA AEROSOL, SOLUTION 108 (90 Base) MCG/ACT INHALATION Reyataz CAPSULE 100 MG Seromycin CAPSULE 250 MG Silver Sulfadiazine CREAM 1 % EXTERNAL Sodium Fluoride TABLET 2.2 (1 F) MG Stavzor CAPSULE DELAYED RELEASE 125 MG Stavzor CAPSULE DELAYED RELEASE 250 MG Stavzor CAPSULE DELAYED RELEASE 500 MG Sylvant SOLUTION RECONSTITUTED 100 MG Treximet TABLET MG Valproate Sodium SOLUTION 100 MG/ML Vascepa CAPSULE 1 GM Vectical OINTMENT 3 MCG/GM EXTERNAL Vibativ SOLUTION RECONSTITUTED 250 MG Viramune SUSPENSION 50 MG/5ML MEDICATIONS ADDED TO THE 2015 MAPD Benefit Quantity Prior Authorization Step Tier Limit Requirement Therapy Tier 3 Part D Vs. Part B PA A-Hydrocort SOLUTION RECONSTITUTED 100 MG Abelcet SUSPENSION 5 MG/ML Tier 5 Part D Vs. Part B PA

4 MEDICATIONS ADDED TO THE 2015 MAPD Benefit Quantity Prior Authorization Step Tier Limit Requirement Therapy Alcohol Swabs PAD Tier 2 Amnesteem CAPSULE 10 MG Amnesteem CAPSULE 20 MG Amnesteem CAPSULE 40 MG Amoxicill-Clarithro-Lansopraz Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 15 (10-5) GM Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 3 (2-1) GM Aztreonam SOLUTION RECONSTITUTED 1 GM Betamethasone Dipropionate Aug CREAM 0.05 % EXTERNAL Betamethasone Dipropionate LOTION 0.05 % EXTERNAL Betamethasone Valerate CREAM 0.1 % EXTERNAL Betamethasone Valerate OINTMENT 0.1 % EXTERNAL Betaxolol HCl TABLET 10 MG Bicillin C-R 900/300 SUSPENSION UNIT/2ML Bicillin C-R SUSPENSION UNIT/2ML Bicillin L-A SUSPENSION UNIT/2ML Tier 3 Tier 3 Tier 3 Tier 4 Tier 2 Part D Vs. Part B PA Tier 2 Part D Vs. Part B PA Tier 3 Part D Vs. Part B PA Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 4 Tier 4 Tier 4

5 MEDICATIONS ADDED TO THE 2015 MAPD Benefit Quantity Prior Authorization Step Tier Limit Requirement Therapy Tier 4 Bicillin L-A SUSPENSION UNIT/4ML Bicillin L-A SUSPENSION UNIT/ML Buprenorphine HCl TABLET SUBLINGUAL 2 MG SUBLINGUAL Buprenorphine HCl TABLET SUBLINGUAL 8 MG SUBLINGUAL Calcitriol OINTMENT 3 MCG/GM EXTERNAL Candesartan Cilexetil TABLET 16 MG Candesartan Cilexetil TABLET 32 MG Candesartan Cilexetil TABLET 4 MG Candesartan Cilexetil TABLET 8 MG Candesartan Cilexetil-HCTZ TABLET MG Candesartan Cilexetil-HCTZ TABLET MG Candesartan Cilexetil-HCTZ TABLET MG Cerezyme SOLUTION RECONSTITUTED 400 UNIT Cinryze SOLUTION RECONSTITUTED 500 UNIT Tier 4 Tier 4 93 EA per 31 days Tier 4 93 EA per 31 days Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 5 Part D Vs. Part B PA Tier 5 PA Applies (CINRYZE) Claravis CAPSULE 10 MG Tier 3 Claravis CAPSULE 20 MG Tier 3 Claravis CAPSULE 30 MG Tier 3 Claravis CAPSULE 40 MG Tier 3

6 MEDICATIONS ADDED TO THE 2015 MAPD Benefit Quantity Prior Authorization Step Tier Limit Requirement Therapy Coartem TABLET MG Tier 4 Cuprimine CAPSULE 250 MG Tier 3 CycloSPORINE Modified Tier 3 CAPSULE 25 MG Demser CAPSULE 250 MG Tier 5 PA Applies (DEMSER) Depen Titratabs TABLET 250 MG Tier 3 Depo-SubQ Provera 104 SUSPENSION 104 MG/0.65ML Tier 3 Dexamethasone Sodium Phosphate SOLUTION 120 MG/30ML Diphtheria-Tetanus Toxoids DT SUSPENSION 25-5 LFU/0.5ML Tier 2 Part D Vs. Part B PA Tier 3 Errin TABLET 0.35 MG Tier 2 Firazyr SOLUTION 30 MG/3ML Flunisolide SOLUTION 25 MCG/ACT (0.025%) NASAL Fortaz SOLUTION RECONSTITUTED 1 GM Fortaz SOLUTION RECONSTITUTED 2 GM Forteo SOLUTION 600 MCG/2.4ML Horizant TABLET EXTENDED RELEASE 24 HR* 600 MG Tier 5 PA Applies (FIRAZYR) Tier 3 Tier 4 Part D Vs. Part B PA Tier 4 Part D Vs. Part B PA Tier 5 Tier ML per 28 Days 62 EA per 31 PA Applies (FORTEO) days Iclusig TABLET 15 MG Tier 5 PA for New Starts Only (ICLUSIG)

7 MEDICATIONS ADDED TO THE 2015 MAPD Benefit Quantity Prior Authorization Step Tier Limit Requirement Therapy Iclusig TABLET 45 MG Tier 5 PA for New Starts Only (ICLUSIG) Ilaris SOLUTION RECONSTITUTED 180 MG Tier 5 PA Applies (ILARIS) InnoPran XL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG InnoPran XL CAPSULE EXTENDED RELEASE 24 HOUR 80 MG INVanz SOLUTION RECONSTITUTED 1 GM Tier 4 Tier 4 Tier 4 Part D Vs. Part B PA Jolivette TABLET 0.35 MG Tier 2 Kalydeco TABLET 150 MG Tier 5 PA Applies (KALYDECO) Kineret SOLUTION 100 Tier 5 PA Applies MG/0.67ML (KINERET) Kuvan TABLET SOLUBLE 100 Tier 5 PA Applies MG Lansoprazole CAPSULE DELAYED RELEASE 15 MG Lansoprazole CAPSULE DELAYED RELEASE 30 MG Lidocaine PATCH 5 % EXTERNAL Tier 4 Tier 4 Tier 4 31 EA per 31 days 31 EA per 31 days 93 EA per 31 days (KUVAN) PA Applies (Lidoderm) Lithium Citrate SOLUTION 8 Tier 2 MEQ/5ML Lupron Depot KIT MG Tier 5 1 EA per PA Applies 84 Days (LUPRON) Lupron Depot KIT 7.5 MG Tier 5 1 EA per PA Applies 28 Days (LUPRON) Lyza TABLET 0.35 MG Tier 2

8 MEDICATIONS ADDED TO THE 2015 MAPD Benefit Quantity Prior Authorization Step Tier Limit Requirement Therapy Tier 2 Methadone HCl CONCENTRATE 10 MG/ML Methotrexate Sodium (PF) SOLUTION 1 GM/40ML MethylPREDNISolone Sodium Succ SOLUTION RECONSTITUTED 125 MG MethylPREDNISolone Sodium Succ SOLUTION RECONSTITUTED 40 MG Mexiletine HCl CAPSULE 150 MG Mexiletine HCl CAPSULE 200 MG Mexiletine HCl CAPSULE 250 MG Modafinil TABLET 100 MG Modafinil TABLET 200 MG Mozobil SOLUTION 24 MG/1.2ML Tier 2 Part D Vs. Part B PA Tier 2 Part D Vs. Part B PA Tier 2 Part D Vs. Part B PA Tier 2 Tier 2 Tier 2 Tier 4 Tier 4 31 EA per 31 days 31 EA per 31 PA Applies (Modafinil) PA Applies (Modafinil) days Tier 5 Part D Vs. Part B PA Myorisan CAPSULE 10 MG Tier 3 Myorisan CAPSULE 20 MG Tier 3 Myorisan CAPSULE 40 MG Tier 3 Naltrexone HCl TABLET 50 MG Naltrexone HCl TABLET 50 MG Neupro PATCH 24 HR 1 MG/24HR Neupro PATCH 24 HR 2 MG/24HR Tier 3 Tier 3 Tier 4 PA Applies (NEUPRO) Tier 4 PA Applies (NEUPRO)

9 MEDICATIONS ADDED TO THE 2015 MAPD Benefit Quantity Prior Authorization Step Tier Limit Requirement Therapy Neupro PATCH 24 HR 3 Tier 4 PA Applies MG/24HR (NEUPRO) Neupro PATCH 24 HR 4 Tier 4 PA Applies MG/24HR (NEUPRO) Neupro PATCH 24 HR 6 Tier 4 PA Applies MG/24HR (NEUPRO) Neupro PATCH 24 HR 8 Tier 4 PA Applies MG/24HR (NEUPRO) NiCARdipine HCl CAPSULE 20 Tier 2 MG NiCARdipine HCl CAPSULE 30 Tier 2 MG NovoLOG PenFill 100 UNIT/ML Tier 3 60 ML per 31 Days Olysio CAPSULE 150 MG Tier 5 PA Applies (OLYSIO (simeprevir)) Pindolol TABLET 10 MG Tier 2 Pindolol TABLET 5 MG Tier 2 Proctozone-HC CREAM 2.5 % Tier 2 Progesterone Micronized Tier 2 CAPSULE 100 MG Progesterone Micronized Tier 2 CAPSULE 200 MG Pyrazinamide TABLET 500 MG Tier 2 QuiNINE Sulfate CAPSULE 324 Tier 2 PA Applies MG (QUNINE) RABEprazole Sodium TABLET Tier 4 31 EA DELAYED RELEASE 20 MG per 31 days Rotarix SUSPENSION Tier 3 RECONSTITUTED Rozerem TABLET 8 MG Tier 3 PA Applies (ROZEREM) SODIUM FLUORIDE 2.2 MG (FLUORIDE ION 1 MG) Tier 2

10 MEDICATIONS ADDED TO THE 2015 MAPD Benefit Quantity Prior Authorization Step Tier Limit Requirement Therapy TABLET Solu-CORTEF SOLUTION RECONSTITUTED 100 MG Solu-CORTEF SOLUTION RECONSTITUTED 250 MG Tier 3 Part D Vs. Part B PA Tier 3 Part D Vs. Part B PA Sovaldi TABLET 400 MG Tier 5 PA Applies (SOVALDI (sofosbuvir)) Suprax CAPSULE 400 MG Tier 4 Suprax SUSPENSION RECONSTITUTED 200 MG/5ML Suprax SUSPENSION RECONSTITUTED 500 MG/5ML Suprax TABLET CHEWABLE 100 MG Suprax TABLET CHEWABLE 200 MG Synagis SOLUTION 50 MG/0.5ML Synercid SOLUTION RECONSTITUTED MG Teflaro SOLUTION RECONSTITUTED 400 MG Teflaro SOLUTION RECONSTITUTED 600 MG Tranexamic Acid SOLUTION 100 MG/ML Tranexamic Acid TABLET 650 MG Tier 4 Tier 4 Tier 4 Tier 4 Tier 5 PA Applies (SYNAGIS) Tier 5 Part D Vs. Part B PA Tier 4 Part D Vs. Part B PA Tier 4 Part D Vs. Part B PA Tier 2 Tier 2

11 MEDICATIONS ADDED TO THE 2015 MAPD Benefit Quantity Prior Authorization Step Tier Limit Requirement Therapy Tier 4 PA Applies (HRM - ANTIHISTAMINES) Transderm-Scop PATCH 72 HR 1.5 MG Tyzine SOLUTION 0.1 % NASAL Tier 3 Valproate Sodium SOLUTION 500 MG/5ML Virazole SOLUTION RECONSTITUTED 6 GM INHALATION Vivitrol SUSPENSION RECONSTITUTED 380 MG Voriconazole SOLUTION RECONSTITUTED 200 MG Tier 2 Part D Vs. Part B PA Tier 5 Part D Vs. Part B PA Tier 5 Part D Vs. Part B PA Tier 2 Zenatane CAPSULE 10 MG Tier 3 Zenatane CAPSULE 20 MG Tier 3 Zenatane CAPSULE 40 MG Tier 3 MEDICATIONS WITH TIERING CHANGES Aggrenox CAPSULE EXTENDED RELEASE 12 HOUR MG Citalopram Hydrobromide TABLET 10 MG Citalopram Hydrobromide TABLET 20 MG Citalopram Hydrobromide TABLET 40 MG ClomiPRAMINE HCl CAPSULE 25 MG ClomiPRAMINE HCl CAPSULE 50 MG ClomiPRAMINE HCl CAPSULE 75 MG Changed from Tier 3 to Tier 4 Changed from Tier 1 to Tier 2 Changed from Tier 1 to Tier 2 Changed from Tier 1 to Tier 2 Changed from Tier 2 to Tier 4 Changed from Tier 2 to Tier 4 Changed from Tier 2 to Tier 4

12 MEDICATIONS WITH TIERING CHANGES Coreg CR CAPSULE EXTENDED RELEASE 24 HOUR 10 MG Changed from Tier 3 to Tier 4 Coreg CR CAPSULE EXTENDED RELEASE Changed from Tier 3 to Tier 4 24 HOUR 20 MG Coreg CR CAPSULE EXTENDED RELEASE Changed from Tier 3 to Tier 4 24 HOUR 40 MG Coreg CR CAPSULE EXTENDED RELEASE Changed from Tier 3 to Tier 4 24 HOUR 80 MG Crixivan CAPSULE 200 MG Changed from Tier 4 to Tier 3 Crixivan CAPSULE 400 MG Changed from Tier 4 to Tier 3 Depo-Provera SUSPENSION 400 MG/ML Changed from Tier 4 to Tier 3 Dexamethasone TABLET 6 MG Changed from Tier 3 to Tier 2 Ella TABLET 30 MG Changed from Tier 4 to Tier 3 Emtriva CAPSULE 200 MG Changed from Tier 4 to Tier 3 Emtriva SOLUTION 10 MG/ML Changed from Tier 4 to Tier 3 Epivir SOLUTION 10 MG/ML Changed from Tier 4 to Tier 3 Estradiol PATCH WEEKLY MG/24HR Changed from Tier 2 to Tier 3 Estradiol PATCH WEEKLY MG/24HR Changed from Tier 2 to Tier 3 Estradiol PATCH WEEKLY 0.05 MG/24HR Changed from Tier 2 to Tier 3 Estradiol PATCH WEEKLY 0.06 MG/24HR Changed from Tier 2 to Tier 3 Estradiol PATCH WEEKLY MG/24HR Changed from Tier 2 to Tier 3 Estradiol PATCH WEEKLY 0.1 MG/24HR Changed from Tier 2 to Tier 3 Furosemide SOLUTION 10 MG/ML Changed from Tier 2 to Tier 3 Furosemide SOLUTION 10 MG/ML Changed from Tier 3 to Tier 2 Leflunomide TABLET 10 MG Changed from Tier 2 to Tier 3

13 MEDICATIONS WITH TIERING CHANGES Leflunomide TABLET 20 MG Changed from Tier 2 to Tier 3 Letrozole TABLET 2.5 MG Changed from Tier 4 to Tier 2 Lovaza CAPSULE 1 GM Changed from Tier 3 to Tier 4 Methazolamide TABLET 25 MG Changed from Tier 2 to Tier 3 Methazolamide TABLET 25 MG Changed from Tier 2 to Tier 3 Methazolamide TABLET 50 MG Changed from Tier 2 to Tier 3 Methazolamide TABLET 50 MG Changed from Tier 2 to Tier 3 Nabumetone TABLET 500 MG Changed from Tier 3 to Tier 2 Nabumetone TABLET 500 MG Changed from Tier 3 to Tier 2 Nabumetone TABLET 750 MG Changed from Tier 3 to Tier 2 Nabumetone TABLET 750 MG Changed from Tier 3 to Tier 2 Nisoldipine ER TABLET EXTENDED Changed from Tier 3 to Tier 4 RELEASE 24 HR* 17 MG Nisoldipine ER TABLET EXTENDED Changed from Tier 3 to Tier 4 RELEASE 24 HR* 20 MG Nisoldipine ER TABLET EXTENDED Changed from Tier 3 to Tier 4 RELEASE 24 HR* 25.5 MG Nisoldipine ER TABLET EXTENDED Changed from Tier 3 to Tier 4 RELEASE 24 HR* 30 MG Nisoldipine ER TABLET EXTENDED Changed from Tier 3 to Tier 4 RELEASE 24 HR* 34 MG Nisoldipine ER TABLET EXTENDED Changed from Tier 3 to Tier 4 RELEASE 24 HR* 40 MG Nisoldipine ER TABLET EXTENDED Changed from Tier 3 to Tier 4 RELEASE 24 HR* 8.5 MG Nystatin-Triamcinolone CREAM Changed from Tier 1 to Tier 2 UNIT/GM-% EXTERNAL Nystatin-Triamcinolone OINTMENT Changed from Tier 1 to Tier UNIT/GM-% EXTERNAL Onfi TABLET 20 MG Changed from Tier 4 to Tier 5 Oxybutynin Chloride TABLET 5 MG Changed from Tier 1 to Tier 2 PredniSONE TABLET 1 MG Changed from Tier 1 to Tier 2

14 MEDICATIONS WITH TIERING CHANGES PredniSONE TABLET 10 MG Changed from Tier 1 to Tier 2 PredniSONE TABLET 2.5 MG Changed from Tier 1 to Tier 2 PredniSONE TABLET 20 MG Changed from Tier 1 to Tier 2 PredniSONE TABLET 5 MG Changed from Tier 1 to Tier 2 Prezista TABLET 75 MG Changed from Tier 4 to Tier 3 Rescriptor TABLET 100 MG Changed from Tier 4 to Tier 3 Rescriptor TABLET 200 MG Changed from Tier 4 to Tier 3 Reyataz CAPSULE 150 MG Changed from Tier 4 to Tier 3 Reyataz CAPSULE 200 MG Changed from Tier 4 to Tier 3 Reyataz CAPSULE 300 MG Changed from Tier 4 to Tier 3 Rizatriptan Benzoate TABLET 10 MG Changed from Tier 3 to Tier 4 Rizatriptan Benzoate TABLET 5 MG Changed from Tier 3 to Tier 4 Rizatriptan Benzoate TABLET DISPERSIBLE Changed from Tier 3 to Tier 4 10 MG Rizatriptan Benzoate TABLET DISPERSIBLE Changed from Tier 3 to Tier 4 5 MG Sertraline HCl TABLET 100 MG Changed from Tier 1 to Tier 2 Sertraline HCl TABLET 25 MG Changed from Tier 1 to Tier 2 Sertraline HCl TABLET 50 MG Changed from Tier 1 to Tier 2 Suboxone FILM MG SUBLINGUAL Changed from Tier 3 to Tier 4 Suboxone FILM 8-2 MG SUBLINGUAL Changed from Tier 3 to Tier 4 Targretin 1 % EXTERNAL Changed from Tier 4 to Tier 3 Targretin CAPSULE 75 MG Changed from Tier 4 to Tier 3 Timolol Maleate SOLUTION 0.25 % Changed from Tier 1 to Tier 2 OPHTHALMIC Timolol Maleate SOLUTION 0.5 % Changed from Tier 1 to Tier 2 OPHTHALMIC Versacloz SUSPENSION 50 MG/ML Changed from Tier 5 to Tier 4 Xarelto TABLET 10 MG Changed from Tier 3 to Tier 4

15 MEDICATIONS WITH TIERING CHANGES Xarelto TABLET 15 MG Changed from Tier 3 to Tier 4 Xarelto TABLET 20 MG Changed from Tier 3 to Tier 4 Ziagen SOLUTION 20 MG/ML Changed from Tier 4 to Tier 3 Ziagen TABLET 300 MG Changed from Tier 4 to Tier 3 Zovirax CREAM 5 % EXTERNAL Changed from Tier 3 to Tier 4 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES Drug Description Afinitor Disperz TABLET SOLUBLE 2 MG Afinitor Disperz TABLET SOLUBLE 3 MG Afinitor Disperz TABLET SOLUBLE 5 MG Alphagan P SOLUTION 0.1 % OPHTHALMIC ALPRAZolam TABLET 0.25 MG ALPRAZolam TABLET 0.5 MG ALPRAZolam TABLET 1 MG ALPRAZolam TABLET 2 MG Aptiom TABLET 200 MG Aptiom TABLET 400 MG Aptiom TABLET 600 MG Aptiom TABLET 800 MG Chantix Starting Month Pak TABLET 0.5 MG X 11 & 1 MG X 42 Combigan SOLUTION % OPHTHALMIC Fetzima Titration 20 & 40 MG Humira KIT 40 MG/0.8ML Ilevro SUSPENSION 0.3 % OPHTHALMIC Quantity Limit Changed QL to 124 EA per 31 days Changed QL to 124 EA per 31 days Changed QL to 248 EA per 31 days Changed QL to 155 EA per 31 days Changed QL to 53 EA per 28 days Changed QL to 31 EA per 31 days Changed QL to 4.8 EA per 28 days

16 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES Drug Description Lastacaft SOLUTION 0.25 % OPHTHALMIC Quantity Limit Nevanac SUSPENSION 0.1 % OPHTHALMIC Nuvigil TABLET 150 MG Changed QL to 31 EA per 31 days Nuvigil TABLET 250 MG Changed QL to 31 EA per 31 days Nuvigil TABLET 50 MG Changed QL to 31 EA per 31 days Pataday SOLUTION 0.2 % OPHTHALMIC Suboxone FILM 12-3 MG SUBLINGUAL Add QL 62 EA per 31 days Suboxone FILM 4-1 MG SUBLINGUAL ValACYclovir HCl TABLET 1 GM Veramyst SUSPENSION 27.5 MCG/SPRAY NASAL Xopenex HFA AEROSOL 45 MCG/ACT INHALATION Add QL 62 EA per 31 days Changed QL to 62 EA per 31 days Changed QL to 10 GM per 30 days Changed QL to 30 GM per 30 days MEDICATIONS WITH PRIOR AUTHORIZATION REQUIREMENT CHANGES Acetylcysteine SOLUTION 10 % INHALATION Acetylcysteine SOLUTION 20 % INHALATION Engerix-B SUSPENSION 10 MCG/0.5ML Engerix-B SUSPENSION 10 MCG/0.5ML Engerix-B SUSPENSION 20 MCG/ML Ipratropium Bromide SOLUTION 0.02 % INHALATION Mycophenolic Acid TABLET DELAYED RELEASE 180 MG Mycophenolic Acid TABLET DELAYED RELEASE 360 MG Ondansetron HCl SOLUTION 4 MG/5ML

17 MEDICATIONS WITH PRIOR AUTHORIZATION REQUIREMENT CHANGES Recombivax HB SUSPENSION 10 MCG/ML Recombivax HB SUSPENSION 40 MCG/ML Sirolimus TABLET 0.5 MG Benztropine Mesylate TABLET 0.5 MG Benztropine Mesylate TABLET 1 MG Benztropine Mesylate TABLET 2 MG Butalbital-APAP-Caff-Cod CAPSULE MG Estradiol PATCH WEEKLY MG/24HR Estradiol PATCH WEEKLY MG/24HR Estradiol PATCH WEEKLY 0.05 MG/24HR Estradiol PATCH WEEKLY 0.06 MG/24HR Estradiol PATCH WEEKLY MG/24HR Estradiol PATCH WEEKLY 0.1 MG/24HR Indomethacin CAPSULE 25 MG Indomethacin CAPSULE 25 MG Indomethacin CAPSULE 50 MG Indomethacin CAPSULE 50 MG Sildenafil Citrate TABLET 20 MG Ticlopidine HCl TABLET 250 MG Tretinoin 0.01 % EXTERNAL Tretinoin % EXTERNAL Tretinoin CREAM % EXTERNAL Tretinoin CREAM 0.05 % EXTERNAL Tretinoin CREAM 0.1 % EXTERNAL Tysabri CONCENTRATE 300 MG/15ML Zaleplon CAPSULE 10 MG Zaleplon CAPSULE 5 MG

18 MEDICATIONS WITH PRIOR AUTHORIZATION REQUIREMENT CHANGES Zolpidem Tartrate TABLET 10 MG Zolpidem Tartrate TABLET 5 MG Avonex KIT 30 MCG for New Starts Avonex Prefilled KIT 30 MCG/0.5ML for New Starts Betaseron KIT 0.3 MG for New Starts Copaxone 40 MG/ML for New Starts Copaxone KIT 20 MG/ML for New Starts FazaClo TABLET DISPERSIBLE 100 MG for New Starts FazaClo TABLET DISPERSIBLE 12.5 MG for New Starts FazaClo TABLET DISPERSIBLE 150 MG for New Starts FazaClo TABLET DISPERSIBLE 200 MG for New Starts FazaClo TABLET DISPERSIBLE 25 MG for New Starts Gilenya CAPSULE 0.5 MG for New Starts Megestrol Acetate SUSPENSION 40 MG/ML for New Starts Megestrol Acetate TABLET 20 MG for New Starts Megestrol Acetate TABLET 40 MG for New Starts PHENobarbital ELIXIR 20 MG/5ML for New Starts PHENobarbital TABLET 100 MG for New Starts PHENobarbital TABLET 15 MG for New Starts PHENobarbital TABLET 16.2 MG for New Starts PHENobarbital TABLET 30 MG for New Starts PHENobarbital TABLET 32.4 MG for New Starts PHENobarbital TABLET 60 MG for New Starts PHENobarbital TABLET 64.8 MG for New Starts PHENobarbital TABLET 97.2 MG for New Starts Tecfidera 120 & 240 MG for New Starts Tecfidera CAPSULE DELAYED RELEASE for New Starts 120 MG Tecfidera CAPSULE DELAYED RELEASE for New Starts 240 MG Alinia SUSPENSION RECONSTITUTED 100

19 MEDICATIONS WITH PRIOR AUTHORIZATION REQUIREMENT CHANGES MG/5ML Alinia TABLET 500 MG Clorazepate Dipotassium TABLET 15 MG Clorazepate Dipotassium TABLET 3.75 MG Clorazepate Dipotassium TABLET 7.5 MG Diazepam 10 MG Diazepam 2.5 MG Diazepam 20 MG Diazepam Intensol CONCENTRATE 5 MG/ML Diazepam SOLUTION 1 MG/ML Ergoloid Mesylates TABLET 1 MG Etoposide SOLUTION 500 MG/25ML Kenalog SUSPENSION 10 MG/ML Kenalog SUSPENSION 40 MG/ML Lyrica SOLUTION 20 MG/ML Mitoxantrone HCl CONCENTRATE 25 MG/12.5ML Mitoxantrone HCl CONCENTRATE 25 MG/12.5ML Naloxone HCl SOLUTION 1 MG/ML MEDICATIONS STEP THERAPY CRITERIA CHANGES Drug Description CeleBREX CAPSULE 100 MG CeleBREX CAPSULE 200 MG CeleBREX CAPSULE 400 MG CeleBREX CAPSULE 50 MG Trial of meloxicam is required prior to Celebrex coverage Trial of meloxicam is required prior to Celebrex coverage Trial of meloxicam is required prior to Celebrex coverage Trial of meloxicam is required prior to Celebrex coverage

20 MEDICATIONS STEP THERAPY CRITERIA CHANGES Drug Description Meloxicam TABLET 15 MG Meloxicam TABLET 7.5 MG FazaClo TABLET DISPERSIBLE 100 MG FazaClo TABLET DISPERSIBLE 12.5 MG FazaClo TABLET DISPERSIBLE 150 MG FazaClo TABLET DISPERSIBLE 200 MG FazaClo TABLET DISPERSIBLE 25 MG Trial of meloxicam is required prior to Celebrex coverage Trial of meloxicam is required prior to Celebrex coverage Step therapy requirement removed Step therapy requirement removed Step therapy requirement removed Step therapy requirement removed Step therapy requirement removed