ate Formulary Upda ). We are open: October 1 February 8 a.m. 8 a.m. February drugs: You ask us to pay Formulary attached If you

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1 MEDICARE ADVANTAGE HealthNow New York Formulary Upda ate Please note, the HealthNow New York Formulary has been updated since its original printing in September, This insert outlines all of the updates to the Formulary as of November 1,. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/ /coinsurance may change on January 1, If you would like to receive this material in an alternate format or language, or have questions about this Formulary, please call customer service at (TTY users call ) ). We are open: October 1 February 14 February 15 September 30 8 a.m. 8 a.m. to 8 p.m., 7 days a week to 8 p.m., Monday Friday During non-business hours, your call will be answered by our automated phone system. A representative will return your call the next business day. Part D Coverage Decisions and Appeals A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. Here are examples of coverage decisions you ask us to make about your Part D drugs: You ask us to make an exception, including Asking us to cover a Part D drug that is not on the plan s List of Covered Drugs i.e. The Formulary attached Asking us to waive a restriction on the plan s coverage for a drug (such as limits on the amount of the drug you can get) Asking to pay a lower cost-sharing amount for a covered non-preferred drug You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the plan s List of Covered Drugs but we require you to get approval from us before we will cover it for you.) You ask us to pay for a prescription drug you alreadyy bought. This is a request for a coverage decision about payment. If you disagree with a coverage decision we have made, you can appeal our decision. Y0086_PTD203 CMS Approved HNNY_R3340_ HPMS Approved Formulary File Submission ID , Version #17

2 If you would like file an appeal or request an exception to a recent coverage determination, see Chapter 9, Section 6 of your Evidence of Coverage for detailed instructions. If you disagree with our decision to remove or change the tiering structure of the drugs on our List of Covered Drugs, i.e., The Formulary, you may also file a grievance with us. Please call us at if you want to file a grievance. TTY users call You may also send your grievance to us in writing by sending it to: HealthNow New York PO Box 5204 Binghamton, NY Whether you call or write, you should contact Customer Service right away. The grievance must be made within 60 calendar days after you had the problem you want to complain about. See Chapter 9, Section 10 of your Evidence of Coverage for detailed instructions. Cosmegen recon soln 0.5mg T5 March 1, olopatadine drops 0.1% March 1, levoleucovorin solution 10mg/mL T5 calcium March 1, pramipexole tablet 2.25mg March 1, naproxen sodium tablet, ER multiphase 375mg T1 Zyclara 24 hr cream in metereddose pump March 1, 2.5% T5 ST (TOPICAL ACTINIC KERATOSIS-PST) March 1, molindone tablet 10mg March 1, molindone tablet 25mg March 1, molindone tablet 5mg March 1, rivastigmine patch 24 hour 13.3mg/24 hour March 1, nevirapine tablet 100mg March 1, Olysio capsule 150mg T5 QL (20 PER 28 (olysio) March 1, Jardiance tablet 10mg T3 QL (30 PER 30 DAYS) March 1, Jardiance tablet 25mg T3 QL (30 PER 30 DAYS) March 1, Gleostine capsule 10mg T3 March 1, 2

3 Gleostine capsule 100mg T3 March 1, Gleostine capsule 40mg T3 March 1, testosterone gel in packet 1 % (25PA mg/2.5gram) 3 PA (topical testosterone products) March 1, amino acids 15 % parenteral solution 15% PA (B VS D) March 1, Namzaric capsule, sprinkle, ER 14-10mg T3 PA (namenda) 24hr March 1, Namzaric capsule, sprinkle, ER 28-10mg T3 PA (namenda) 24hr March 1, Zarxio syringe 300mcg/0.5 ml T5 PA (ZARXIO) March 1, Zarxio syringe 480mcg/0.8 ml T5 PA (ZARXIO) March 1, Juleber tablet mg March 1, nitrofurantoin capsule 100mg (75/25) monohyd/m-cryst March 1, Layolis Fe tablet, chewable 0.8mg- 25mcg(24)and 75 mg (4) March 1, Kimidess (28) tablet mgx21/0.01 mg x 5 March 1, Orkambi tablet mg T5 QL (112 PER 28 (ORKAMBI) March 1, Entresto tablet 24-26mg T3 QL (60 PER 30 (ENTRESTO) March 1, Entresto tablet 49-51mg T3 QL (60 PER 30 (ENTRESTO) March 1, Entresto tablet mg T3 QL (60 PER 30 (ENTRESTO) March 1, Avastin solution 25mg/mL (16 ml) T3 March 1, sumatriptan succinate pen injector 6mg/0.5 ml (auto- Injector) QL (16 PER 28 DAYS) March 1, sumatriptan succinate cartridge 6mg/0.5 ml QL (16 PER 28 DAYS) March 1, sumatriptan succinate cartridge 4mg/0.5 ml QL (16 PER 28 DAYS) March 1, Keytruda solution 100 mg/4 ml(25 T5 mg/ml) March 1,

4 Cyramza solution 10mg/mL T5 PA (B VS D) March 1, Cyramza solution 10mg/mL (50 ml) T5 PA (B VS D) March 1, Actemra solution 80 mg/4 ml(20 T5 PA (actemra) mg/ml) March 1, Actemra solution 400 mg/20 ml(20 T5 PA (actemra) mg/ml) March 1, Klor-Con Sprinkle capsule, 8mEq release March 1, Klor-Con Sprinkle capsule, 10mEq release March 1, Rexulti tablet 0.25mg T5 QL (480 PER 30 DAYS) March 1, Rexulti tablet 0.5mg T5 QL (240 PER 30 DAYS) March 1, Rexulti tablet 1mg T5 QL (120 PER 30 DAYS) March 1, Rexulti tablet 2mg T5 QL (60 PER 30 DAYS) March 1, Rexulti tablet 3mg T5 QL (40 PER 30 DAYS) March 1, Rexulti tablet 4mg T5 QL (30 PER 30 DAYS) March 1, Praluent Pen pen injector 150mg/mL T5 QL (2 PER 28 (PRALUENT) March 1, Praluent Syringe syringe 150mg/mL T5 QL (2 PER 28 (PRALUENT) March 1, Praluent Syringe syringe 75mg/mL T5 QL (4 PER 28 (PRALUENT) March 1, Praluent Pen pen injector 75mg/mL T5 QL (4 PER 28 (PRALUENT) March 1, Technivie tablet mg T5 QL (56 PER 28 (TECHNIVIE) March 1, Odomzo capsule 200mg T5 QL (30 PER 30 Only PA (ODOMZO); LA March 1, thiotepa recon soln 15mg T5 March 1, 4

5 Daklinza tablet 30mg T5 QL (84 PER 28 (DAKLINZA) March 1, Daklinza tablet 60mg T5 QL (84 PER 28 (DAKLINZA) March 1, Setlakin tablets, dose pack, mg-mcg month March 1, Myorisan capsule 30mg March 1, Synjardy tablet 5-500mg T3 QL (120 PER 30 DAYS) March 1, Synjardy tablet mg T3 QL (60 PER 30 DAYS) March 1, Synjardy tablet 5-1,000mg T3 QL (60 PER 30 DAYS) March 1, Synjardy tablet ,000mg T3 QL (60 PER 30 DAYS) March 1, levofloxacin in piggyback 750mg/150 ml D5W March 1, Repatha SureClick pen injector 140mg/mL T5 QL (3 PER 30 (REPATHA) March 1, Repatha Syringe syringe 140mg/mL T5 QL (3 PER 30 (REPATHA) March 1, BRILINTA tablet 60mg T3 March 1, Spiriva Respimat mist 1.25mcg/actuation T3 QL (60 PER 30 DAYS) March 1, Tolak cream 4% T4 March 1, Lonsurf tablet mg T5 New Starts Only PA (LONSURF) March 1, Lonsurf tablet mg T5 New Starts Only PA (LONSURF) March 1, Varubi tablet 90mg T5 PA (B VS D) March 1, Bekyree (28) tablet mgx21/0.01 mg x 5 March 1, Veltassa powder in packet 8.4gram T3 March 1, Veltassa powder in packet 16.8gram T3 March 1, Veltassa powder in packet 25.2gram T3 March 1, Ferriprox solution 100mg/mL T5 March 1, 5

6 GaviLyte-H and kit 5-210mg-gram Bisacodyl March 1, Strensiq solution 40mg/mL T5 LA March 1, Strensiq solution 80mg/0.8 ml T5 LA March 1, Nucala recon soln 100mg T5 QL (1 PER 28 (NUCALA)LA March 1, Gleostine capsule 5mg T3 March 1, Tagrisso tablet 40mg T5 QL (60 PER 30 Only PA (TAGRISSO): LA March 1, Tagrisso tablet 80mg T5 QL (30 PER 30 Only PA (TAGRISSO): LA March 1, Genvoya tablet mg T5 March 1, Darzalex solution 20mg/mL T5 LA March 1, Cotellic tablet 20mg T5 QL (63 PER 28 Only PA (COTELLIC): LA March 1, Blisovi 24 Fe tablet 1 mg-20 mcg(24)/75 mg (4) March 1, Pradaxa capsule 110mg T3 March 1, Ninlaro capsule 2.3mg T5 QL (6 PER 28 Only PA (NINLARO) March 1, Ninlaro capsule 3mg T5 QL (4 PER 28 Only PA (NINLARO) March 1, Ninlaro capsule 4mg T5 QL (3 PER 28 Only PA (NINLARO) March 1, Blisovi Fe 1/20 (28) tablet 1 mg-20 mcg(21)/75 mg (7) March 1, Empliciti recon soln 300mg T5 PA (B VS D) March 1, Kanuma solution 2mg/mL T5 March 1, 6

7 Alecensa capsule 150mg T5 QL (240 PER 30 Only PA (ALECENSA) March 1, methyltestosterone capsule 10mg March 1, pimozide tablet 2mg March 1, tetrabenazine tablet 25mg T5 PA (xenazine) March 1, tretinoin gel 0.05% PA (topical retinoid products) March 1, budesonide suspension for 1mg/2 ml PA (B VS D) nebulization March 1, aspirindipyridamole capsule, ER mg multiphase 12 hr March 1, almotriptan tablet 6.25mg QL (18 PER 28 malate almotriptan malate bexarotene capsule 75mg T5 DAYS) March 1, tablet 12.5mg QL (24 PER 28 DAYS) March 1, 7 March 1, erythromycin capsule, delayed 250mg release (DR/EC) March 1, linezolid suspension for 100mg/5 ml T5 reconstitution March 1, nitrofurantoin capsule 25mg macrocrystal March 1, pimozide tablet 1mg March 1, trimipramine capsule 100mg New Starts Only PA (high risk medications - tertiary tricyclic antidepressants) March 1, trimipramine capsule 25mg New Starts Only PA (high risk medications - tertiary tricyclic antidepressants) March 1, trimipramine capsule 50mg New Starts Only PA (high risk medications - tertiary tricyclic antidepressants) March 1, dutasteride capsule 0.5mg March 1, Rapamune tablet 1mg T4 PA (B VS D) March 1,

8 fluvastatin tablet 80mg QL (30 PER 30 DAYS) March 1, Iressa tablet 250mg T5 QL (30 PER 30 Only PA (IRESSA) March 1, Rapamune tablet 2mg T5 PA (B VS D) March 1, megestrol suspension 625mg/5 ml March 1, esomeprazole capsule, delayed 40mg magnesium release (DR/EC) March 1, metoclopramide tablet, disintegrating 10mg HCl March 1, ethacrynate recon soln 50mg T5 sodium March 1, aripiprazole tablet, disintegrating 10mg QL (90 PER 30 DAYS) March 1, aripiprazole tablet, disintegrating 15mg QL (60 PER 30 DAYS) March 1, paliperidone tablet release 24hr 3mg QL (120 PER 30 DAYS) March 1, paliperidone tablet release 24hr 6mg QL (60 PER 30 DAYS) March 1, paliperidone tablet release 24hr 9mg QL (41 PER 30 DAYS) March 1, rivastigmine patch 24 hour 4.6mg/24 hr March 1, rivastigmine patch 24 hour 9.5mg/24 hr March 1, ketoconazole foam 2% March 1, drospirenoneethinyl tablet mg estradiol March 1, levonorg-eth tablet (6)/75- estrad triphasic 40(5)/125-30(10) March 1, azithromycin tablet 250mg (6 pack) March 1, peg-electrolyte recon soln 420gram soln March 1, tetrabenazine tablet 12.5mg T5 PA (xenazine) March 1, hydrocodoneibuprofen tablet 5-200mg QL (50 PER 30 DAYS) March 1, hydrocodoneibuprofen tablet mg QL (50 PER 30 DAYS) March 1, fenofibric acid tablet 105mg March 1, phenoxybenzamine capsule 10mg T5 March 1, 8

9 repaglinidemetformin tablet 1-500mg QL (150 PER 30 DAYS) March 1, repaglinidemetformin tablet 2-500mg QL (150 PER 30 DAYS) March 1, Zenpep capsule, delayed 5,000-17,000- T3 release(dr/ec) 27,000 unit March 1, paliperidone tablet 1.5mg QL (240 PER 30 DAYS) March 1, verapamil tablet 120mg T1 release March 1, pramipexole tablet 4.5mg March 1, pramipexole tablet 0.375mg March 1, pramipexole tablet 3mg March 1, pyridostigmine tablet 180mg bromide release March 1, risedronate tablet 35mg QL (4 PER 28 DAYS) March 1, Synthroid tablet 25mcg T3 March 1, Synthroid tablet 75mcg T3 March 1, Synthroid tablet 112mcg T3 March 1, Synthroid tablet 125mcg T3 March 1, Synthroid tablet 150mcg T3 March 1, Synthroid tablet 175mcg T3 March 1, Synthroid tablet 300mcg T3 March 1, Synthroid tablet 50mcg T3 March 1, Synthroid tablet 100mcg T3 March 1, Synthroid tablet 200mcg T3 March 1, Synthroid tablet 137mcg T3 March 1, Synthroid tablet 88mcg T3 March 1, Zyclara cream in packet 3.75% T5 ST (TOPICAL ACTINIC KERATOSIS-PST) March 1, dutasteridetamsulosin capsule, ER mg multiphase 24 hr March 1, memantine tablet 10mg PA (namenda) March 1, 9

10 memantine tablet 5mg PA (namenda) March 1, memantine solution 2mg/mL PA (namenda) March 1, Oravig muco-adhesive buccal 50mg T3 tablet March 1, Prepopik powder in packet 10 mg-3.5gram-12 Humira Pediatric Crohn's Start syringe kit 40mg/0.8 ml (6 pack) gram T3 April 1, QL (4.8 PER 180 T5 Only PA (humira) April 1, Humira Pediatric syringe kit 40mg/0.8 ml QL (2.4 PER 180 Crohn's Start T5 Only PA (humira) April 1, Invega Trinza syringe 273mg/0.875 ml T5 April 1, Invega Trinza syringe 410mg/1.315 ml T5 April 1, Invega Trinza syringe 546mg/1.75 ml T5 April 1, Invega Trinza syringe 819mg/2.625 ml T5 April 1, Viibryd tablets, dose pack 10 mg (7)-20 mg QL (30 PER 30 (23) T3 DAYS); April 1, Humira Pen pen injector kit 40mg/0.8 ml QL (3.2 PER 28 T5 Only PA (humira) April 1, Vienva tablet mg-mcg April 1, Tri-Lo-Estarylla tablet 0.18/0.215/0.25mg -25 mcg April 1, Empliciti recon soln 400mg T5 PA (B VS D) April 1, Kaitlib Fe tablet, chewable 0.8mg- 25mcg(24)and 75 mg (4) April 1, Uptravi tablet 1,000mcg T5 PA (UPTRAVI); LA April 1, Uptravi tablet 1,200mcg T5 PA (UPTRAVI); LA April 1, Uptravi tablet 1,400mcg T5 PA (UPTRAVI); LA April 1, Uptravi tablet 1,600mcg T5 PA (UPTRAVI); LA April 1, Uptravi tablet 200mcg T5 PA (UPTRAVI); LA April 1, Uptravi tablet 400mcg T5 PA (UPTRAVI); LA April 1, Uptravi tablet 600mcg T5 PA (UPTRAVI); LA April 1, Uptravi tablet 800mcg T5 PA (UPTRAVI); LA April 1, 10

11 Uptravi tablets, dose pack 200 mcg (140)-800 mcg (60) T5 PA (UPTRAVI); LA April 1, Blisovi Fe 1.5/30 (28) tablet 1.5 mg-30 mcg(21)/75 mg (7) April 1, Emend recon soln 150mg T3 April 1, lincomycin solution 300mg/mL April 1, norgestimateethinyl estradiol tablet 0.18/0.215/0.25mg -25 mcg April 1, phenytoin sodium capsule 200mg April 1, phenytoin sodium capsule 300mg April 1, Tri-Lo-Sprintec tablet 0.18/0.215/0.25mg -25 mcg April 1, fenofibric acid tablet 35mg April 1, naftifine cream 2% May 1, Plegridy pen injector 125mcg/0.5 ml T5 QL (1 PER 28 (PLEGRIDY) May 1, Plegridy pen injector 63 mcg/0.5 ml-94 mcg/0.5 ml 11 T5 QL (1 PER 180 (PLEGRIDY) May 1, Vraylar capsule 1.5mg T5 QL (120 PER 30 DAYS) May 1, Vraylar capsule 3mg T5 QL (60 PER 30 DAYS) May 1, Vraylar capsule 4.5mg T5 QL (40 PER 30 DAYS) May 1, Vraylar capsule 6mg T5 QL (30 PER 30 DAYS) May 1, fluconazole in piggyback 400mg/200 ml dextrose(iso-o) May 1, Fyavolv tablet mg-mcg May 1, Fyavolv tablet 1-5mg-mcg May 1, imatinib tablet 100mg T5 New Starts Only PA (gleevec) May 1, imatinib tablet 400mg T5 QL (60 PER 30 Only PA (gleevec) May 1, doxepin cream 5% June 1, Makena oil 250mg/mL (1 ml) T5 June 1,

12 zolpidem tablet 1.75mg June 1, zolpidem tablet 3.5mg June 1, Mitigare capsule 0.6mg T3 June 1, Benlysta recon soln 400mg T5 June 1, cefazolin recon soln 1gram June 1, fluconazole in NaCl piggyback 200mg/100 ml (iso-osm) June 1, Narcan spray, non-aerosol 4mg/actuation T3 QL (2 PER 28 DAYS) June 1, Humulin R U-500 insulin pen 500 unit/ml (3 ml) T3 (Conc) Kwikpen June 1, Spritam tablet for suspension 1,000mg T4 June 1, Spritam tablet for suspension 250mg T4 June 1, Spritam tablet for suspension 500mg T4 June 1, Spritam tablet for suspension 750mg T4 June 1, Emverm tablet, chewable 100mg T5 June 1, Xeljanz XR tablet 11mg T5 PA (xeljanz) June 1, Odefsey tablet mg T5 June 1, Vraylar capsule, dose pack 1.5 mg (1)-3 mg (6) T4 QL (7 PER 30 DAYS) June 1, metoprolol syringe 5mg/5 ml tartrate June 1, carbamazepine tablet 100mg release 12 hr June 1, Erygel gel 2% June 1, oxiconazole cream 1% June 1, frovatriptan tablet 2.5mg June 1, darifenacin tablet 15mg June 1, darifenacin tablet 7.5mg June 1, mometasone spray, non-aerosol 50mcg/actuation QL (34 PER 30 DAYS) June 1, diclofenac sodium gel 1% June 1, Kuvan powder in packet 100mg T5 July 1, Menhibrix (PF) recon soln 5-2.5mcg/0.5 ml T3 July 1, 12

13 Cholbam capsule 250mg T5 PA (CHOLBAM) July 1, Cholbam capsule 50mg T5 QL (120 PER 30 (CHOLBAM) July 1, Roweepra tablet 500mg July 1, Zepatier tablet mg T5 QL (28 PER 28 (ZEPATIER) July 1, Venclexta tablet 100mg T5 New Starts Only PA (VENCLEXTA); LA July 1, Venclexta tablet 10mg T3 New Starts Only PA (VENCLEXTA); LA July 1, Venclexta tablet 50mg T3 New Starts Only PA (VENCLEXTA); LA July 1, Venclexta Starting Pack tablets, dose pack 10 mg-50 mg-100 mg Descovy tablet mg T5 flurandrenolide cream 0.05% azathioprine recon soln 100mg sodium pantoprazole recon soln 40mg Coly-Mycin S drops, suspension mg/mL T3 WelChol powder in packet 3.75gram T3 WelChol Tablet 625mg T3 doxycycline tablet, delayed 50mg hyclate release (DR/EC) naloxone solution 0.4mg/mL Briviact solution 50mg/5 ml T4 Briviact tablet 10mg T5 Briviact tablet 100mg T5 Briviact tablet 25mg T5 Briviact tablet 50mg T5 Briviact tablet 75mg T5 13 T5 QL (42 PER 28 Only PA (VENCLEXTA); LA July 1, July 1, July 1, PA (B VS D) July 1, July 1, July 1, July 1, July 1, August 1, August 1, August 1, August 1, August 1, August 1, August 1, August 1,

14 Briviact solution 10mg/mL T5 August 1, Truvada tablet mg T5 August 1, Truvada tablet mg T5 August 1, Truvada tablet mg T5 August 1, Cabometyx tablet 20mg T5 New Starts Only PA (CABOMETYX) August 1, Cabometyx tablet 40mg T5 New Starts Only PA (CABOMETYX) August 1, Cabometyx tablet 60mg T5 New Starts Only PA (CABOMETYX) August 1, Elitek recon soln 7.5mg T5 August 1, Procto-Med HC cream 2.5% August 1, Trintellix tablet 10mg T3 QL (60 PER 30 DAYS) August 1, Trintellix tablet 20mg T3 QL (30 PER 30 DAYS) August 1, Trintellix tablet 5mg T3 QL (120 PER 30 DAYS) August 1, Nuplazid tablet 17mg T5 August 1, Lenvima capsule 8 mg/day(4 mg x 2) T5 New Starts Only PA (LENVIMA) August 1, Lenvima capsule 18 mg/day (10mg x 1-4 mg x2) T5 New Starts Only PA (LENVIMA) August 1, Tecentriq solution 1,200 mg/20 ml T5 (60 mg/ml) August 1, miglitol tablet 25mg QL (360 PER 30 DAYS) August 1, miglitol tablet 50mg QL (180 PER 30 DAYS) August 1, miglitol tablet 100mg QL (90 PER 30 DAYS) August 1, Buphenyl tablet 500mg T5 August 1, rosuvastatin tablet 40mg QL (30 PER 30 DAYS) August 1, rosuvastatin tablet 5mg QL (30 PER 30 DAYS) August 1, rosuvastatin tablet 10mg QL (30 PER 30 DAYS) August 1, rosuvastatin tablet 20mg QL (30 PER 30 DAYS) August 1, 14

15 oxycodoneacetaminophen solution 5-325mg/5 ml QL (800 PER 30 DAYS) September 1, hydroxyprogestero ne caproate oil 250mg/mL T5 September 1, Hiberix (PF) recon soln 10mcg/0.5 ml T3 September 1, doxycycline hyclate tablet,delayed release (DR/EC) 200mg September 1, Aristada suspension, rel syring 441mg/1.6 ml T3 September 1, Aristada suspension, rel syring 662mg/2.4 ml T3 September 1, Aristada suspension, rel syring 882mg/3.2 ml T3 September 1, doxorubicin, pegliposomal suspension 2mg/mL T5 September 1, Fycompa suspension 0.5mg/mL T5 September 1, Orfadin suspension 4mg/mL T5 LA September 1, Daklinza tablet 90mg T5 QL (28 PER 28 (DAKLINZA) 15 September 1, Tivicay tablet 10mg T3 September 1, Tivicay tablet 25mg T5 September 1, Jentadueto XR tablet, IR - ER, biphasic 24hr 2.5-1,000mg T4 QL (60 PER 30 DAYS) September 1, Jentadueto XR tablet, IR - ER, biphasic 24hr 5-1,000mg T4 QL (30 PER 30 DAYS) September 1, Lenvima capsule 8 mg/day(4 mg x 2) (60 pack) T5 New Starts Only PA (LENVIMA) September 1, dofetilide capsule 125mcg September 1, dofetilide capsule 250mcg September 1, dofetilide capsule 500mcg September 1, armodafinil tablet 150mg September 1, armodafinil tablet 250mg September 1, armodafinil tablet 50mg September 1,

16 armodafinil tablet 200mg September 1, hydromorphone syringe 2mg/mL QL (1200 PER 30 DAYS) September 1, pramipexole tablet 3.75mg Gralise tablet 300mg T3 PA (GRALISE/ HORIZANT) Gralise tablet 600mg T3 PA (GRALISE/ HORIZANT) Gralise 30-Day Starter Pack tablet 300 mg (9)-600 mg (69) T3 PA (GRALISE/ HORIZANT) Cosentyx syringe 150mg/mL T5 PA (COSENTYX) Cosentyx Pen pen injector 150mg/mL T5 PA (COSENTYX) ampicillinsulbactam recon soln 1.5gram sumatriptan succinate pen injector 4mg/0.5 ml QL (16 PER 28 DAYS) Gengraf capsule 50mg PA (B VS D) Morgidox capsule 50mg Ocaliva tablet 5mg T5 PA (ocaliva); LA Ocaliva tablet 10mg T5 PA (ocaliva); LA Epclusa tablet mg T5 QL (28 PER 28 (epclusa) Orencia ClickJect auto-injector 125mg/mL T5 New Starts Only PA (orencia) SPS suspension 15gram/60 ml Humira Pen Psoriasis-Uveitis pen injector kit 40mg/0.8 ml T5 QL (3.2 PER 180 Only PA (humira) Cholestyramine Light powder 4gram Fluocinonide-E cream 0.05% bupropion HCl (smoking deter) tablet release 150mg 16

17 nilutamide tablet 150mg norgestimate- tablet 0.18/0.215/0.25mg -35 mcg (28) packet 40-1,680mg packet 20-1,680mg prednisone tablets,dose pack 5mg (48 pack) T1 prednisone tablets,dose pack 5mg T1 prednisone tablets,dose pack 10mg (48 pack) T1 prednisone tablets,dose pack 10mg T1 ethinyl estradiol omeprazolesodium bicarbonate omeprazolesodium bicarbonate Stelara syringe 45mg/0.5 ml T5 New Starts Only PA (STELARA) Stelara syringe 90mg/mL T5 New Starts Only PA (STELARA) clindamycintretinoin gel % PA (topical retinoid products) Clindacin P swab 1% November 1, Prolastin-C recon soln 1mg T5 November 1, LA Yondelis recon soln 1mg T5 November 1, Emend suspension for 125 mg (25 mg/ml T3 November 1, reconstitution final conc.) PA (B VS D) Otovel solution % (0.25 ml) T3 November 1, Larissia tablet mg-mcg November 1, Byvalson tablet 5-80mg T3 November 1, Repatha Pushtronex Viekira XR wearable injector 420mg/3.5 ml T5 QL (3.5 PER 28 (REPATHA) tablet, IR - ER, biphasic 24hr 8.33 mg-50 mg mg-200 mg T5 QL (84 PER 28 (viekira) November 1, November 1, 17

18 Eraxis(Water Diluent) recon soln 50mg T3 November 1, Low-Ogestrel (28) tablet mg-mcg November 1, Caziant (28) tablet 0.1/.125/.15-25mgmcg November 1, Floxin drops 0.3% November 1, Drug Name Dosage Dosage Form Reason for Change Deletions Alternative Drug Alternative Drug Tier Effective Date No deletions March 1, No deletions April 1, No deletions May 1, No deletions June 1, No deletions July 1, No deletions August 1, September 1, No deletions No deletions November 1, No deletions Please consult with your physician to determine if the alternative drug listed here is appropriate for you. If you have any questions regarding the HealthNow New York Medicare Part D formulary, please contact the Customer Service phone number listed on the back of your insurance card. Changes from Previous Month s Formulary Drug Name Dosage Form Strength Previous Tier & Limitations Current Tier & Limitations Brintellix tablet 5mg T4; QL (120 PER 30 DAYS) T3; QL (120 PER 30 DAYS) Brintellix tablet 20mg T4; QL (30 PER 30 DAYS) T3; QL (30 PER 30 DAYS) Brintellix tablet 10mg T4; QL (60 PER 30 DAYS) T3; QL (60 PER 30 DAYS) Effective Date March 1, March 1, March 1, 18

19 Changes from Previous Month s Formulary Drug Name Dosage Form Strength Previous Tier & Limitations Current Tier & Limitations Fetzima capsule, 120mg T3; QL (30 PER 30 DAYS); ST (antidepressants - snri) Fetzima Fetzima Fetzima capsule, capsule, capsule, 20mg 40mg 80mg T3; QL (180 PER 30 DAYS); ST (antidepressants - snri) T3; QL (90 PER 30 DAYS); ST (antidepressants - snri) T3; QL (45 PER 30 DAYS); ST (antidepressants - snri) Effective Date T3; QL (30 PER 30 DAYS) March 1, T3; QL (180 PER 30 DAYS) March 1, T3; QL (90 PER 30 DAYS) March 1, T3; QL (45 PER 30 DAYS) March 1, Fetzima capsule, Ext 20 mg (2)-40 T3; QL (28 PER 28 DAYS); T3; QL (28 Rel 24hr dose pack mg (26) ST (antidepressants - snri) PER 28 DAYS) March 1, Kuvan tablet, soluble 100mg T5; LA T5 March 1, OxyContin tablet, oral only,ext.rel.12 hr Pristiq tablet Pristiq tablet Pristiq tablet 80mg T5; QL (50 PER 30 DAYS) T5; QL (60 PER 30 DAYS) March 1, 25mg 100mg 50mg T3; QL (480 PER 30 DAYS); ST (antidepressants - snri) T3; QL (120 PER 30 DAYS); ST (antidepressants - snri) T3; QL (240 PER 30 DAYS); ST (antidepressants - snri) T3; QL (480 PER 30 DAYS) March 1, T3; QL (120 PER 30 DAYS) March 1, T3; QL (240 PER 30 DAYS) March 1, Invokana tablet 100mg T3: QL (30 PER 90 DAYS) T3: QL (90 PER 90 DAYS) Olysio capsule 150mg T5: QL (20 PER 28 DAYS); T5: QL (28 PA (olysio) PER 28 DAYS); PA (olysio) Invokamet tablet mg T3: QL (60 PER 120 DAYS) T3: QL (120 PER 120 DAYS) April 1, April 1, April 1, Menest tablet 0.3mg T4 T3 April 1, Menest tablet 0.625mg T4 T3 April 1, Menest tablet 1.25mg T4 T3 April 1, 19

20 Changes from Previous Month s Formulary Previous Tier & Current Tier Effective Drug Name Dosage Form Strength Limitations & Limitations Date Menest tablet 2.5mg T4 T3 April 1, Versacloz suspension 50mg/mL T5; LA T5 June 1, Zyprexa Relprevv suspension for reconstitution 210mg T5; LA T5 Suboxone film 8-2mg T3; QL (90 PER 30 DAYS); PA (buprenorphine/naloxone) June 1, 4mg/actuation T3; QL (2 PER 28 DAYS) T3 July 1, T3; QL (360 PER 30 DAYS) September 1, (buprenorphine/naloxone) T3; QL (90 PER 30 DAYS) September 1, Suboxone film 4-1mg T3; QL (90 PER 30 DAYS); PA (buprenorphine/naloxone) Suboxone film 12-3mg T3; QL (60 PER 30 DAYS); PA (buprenorphine/naloxone) Narcan Spray, nonaerosol Suboxone film 2-0.5mg T3; QL (360 PER 30 DAYS); PA buprenorphinenaloxone buprenorphinenaloxone oxycodoneacetaminophen Theo-24 Theo-24 Theo-24 Theo-24 tablet 2-0.5mg ; QL (360 PER 30 DAYS); PA (buprenorphine/naloxone) tablet 8-2mg ; QL (90 PER 30 DAYS); PA (buprenorphine/naloxone) solution 5-325mg/5 ml ; QL (800 PER 30 DAYS) ; QL (1846 PER 30 DAYS) capsule, 100mg T4 T3 release 24hr capsule, release 24hr capsule, release 24hr capsule, release 24hr 300mg T4 T3 200mg T4 T3 400mg T4 T3 Varubi tablet 90mg T5; PA (B VS D) T3; PA (B VS D) T3; QL (90 PER 30 DAYS) September 1, T3; QL (60 PER 30 DAYS) September 1, ; QL (360 PER 30 DAYS) September 1, ; QL (90 PER 30 DAYS) September 1, November 1, 20

21 HealthNow New York Inc. is a Medicare Advantage and PDP plan with a Medicare contract and enrollment depends on contract renewal. 21

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