2018 Formulary Annual Notice of Change

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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 2018 MAPD formulary. For a complete list, please refer to the 2018 MAPD Comprehensive Formulary (Drug List). Click here to view the comprehensive formulary. Please carefully review these changes. If you have any questions, please call Customer Service toll-free at (TTY/TDD relay: ) weekdays from 8 a.m. to 8 p.m. and Saturdays from 8 a.m. to noon. From October 1 to February 14, we re available seven days a week from 8 a.m. to 8 p.m. You can also visit myfhca.org for additional information. Please refer to your Evidence of Coverage for cost-share information. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You must generally use network pharmacies to use your prescription drug benefit. The formulary and pharmacy network may change at any time. You will receive notice when necessary. Y0089_MPINFO6523FH(09/2017)

2 MEDICATIONS REMOVED FROM THE 2017 MAPD FORMULARY DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING1,064 MG/3.9 ML chlorothiazide oral tablet 250 mg, 500 mg GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM HORIZANT ORAL TABLET EXTENDED RELEASE 600 MG NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % nitroglycerin translingual spray, non-aerosol 400 mcg/spray RELISTOR SUBCUTANEOUS SOLUTION12 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE12 MG/0.6 ML, 8 MG/0.4 ML SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK12.5 MG (5)- 25 MG(8)-50 MG(42) CUBICIN INTRAVENOUS RECON SOLN500 MG EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG EPZICOM ORAL TABLET MG NILANDRON ORAL TABLET 150 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG TAMIFLU ORAL CAPSULE 75 MG VALCYTE ORAL RECON SOLN 50 MG/ML ZETIA ORAL TABLET 10 MG KALETRA ORAL SOLUTION MG/5 ML Comment Other strengths available Other forms available MEDICATIONS ADDED TO THE 2018 MAPD FORMULARY AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 Benefit Tier Quantity Limit (QL) Prior Authorization (PA) or Step Therapy (ST) Requirement Part B vs D

3 MEDICATIONS ADDED TO THE 2018 MAPD FORMULARY ml Benefit Tier CORLANOR ORAL TABLET 5 MG, Tier MG COSENTYX (2 SYRINGES) Tier 5 SUBCUTANEOUS SYRINGE 150 MG/ML COSENTYX PEN (2 PENS) Tier 5 SUBCUTANEOUS PEN INJECTOR 150 MG/ML DOXY-100 INTRAVENOUS RECON Tier 4 SOLN 100 MG Fluocinonide-E topical cream 0.05 % GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN 50 MCG methylprednisolone sodium succ injection recon soln 125 mg, sodium chloride 0.45 % intravenous parenteral solution 0.45 % Tier 5 Tier 2 Tier 2 Quantity Limit (QL) Prior Authorization (PA) or Step Therapy (ST) Requirement Part B vs D Part B vs D MEDICATIONS WITH TIERING CHANGES 2017 Tier 2018 Tier desvenlafaxine oral tablet extended release 24 hr 100 Tier 4 mg, 50 mg SUBOXONE SUBLINGUAL FILM 12-3 MG Tier 4 SUBOXONE SUBLINGUAL FILM MG, 4-1 Tier 4 MG, 8-2 MG URSODIOL ORAL CAPSULE 300 MG Tier 4 COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG, 80 MG testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %) testosterone transdermal gel in packet 1 % (50 mg/5 gram) Tier 4 Tier 4 Tier 4

4 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL) nitrofurantoin monohyd/m-cryst oral capsule 100 mg QL REMOVED desvenlafaxine oral tablet extended release 24 hr 100 mg, 50 mg primaquine oral tablet 26.3 mg SELZENTRY ORAL TABLET 75 MG atomoxetine oral capsule 100 mg, 60 mg, 80 mg atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg COMPLERA ORAL TABLET MG STRIBILD ORAL TABLET MG terazosin oral capsule 1 mg, 2 mg, 5 mg QL REMOVED QL REMOVED CHANGED QL 120 EA per 30 days ADDED QL (30 EA per 30 days) ADDED QL (60 EA per 30 days) ADDED QL (30 EA per 30 days) ADDED QL (30 EA per 30 days) CHANGED QL (30 EA per 30 days) MEDICATIONS WITH PRIOR AUTHORIZATION (PA) or STEP THERAPY (ST) REQUIREMENT CHANGES Change Description PREVACID SOLUTAB ORAL TABLET,DISINTEGRAT, DELAY REL 15 MG, 30 MG PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML SUBOXONE SUBLINGUAL FILM 12-3 MG SUBOXONE SUBLINGUAL FILM MG, 4-1 MG, 8-2 MG buprenorphine HCl sublingual tablet 2 mg, 8 mg REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular oil 200 mg/ml testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %) testosterone transdermal gel in packet 1 % (25 mg/2.5gram) testosterone transdermal gel in packet 1 % (50 mg/5 gram) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 REMOVED PA REMOVED B VS D PA CHANGED B VS D PA TO PA APPLIES

5 MEDICATIONS WITH PRIOR AUTHORIZATION (PA) or STEP THERAPY (ST) REQUIREMENT CHANGES Change Description MG/2.5 GRAM) TAZORAC TOPICAL CREAM 0.05 %, 0.1 % TAZORAC TOPICAL GEL 0.05 %, 0.1 % tretinoin topical cream %, 0.05 %, 0.1 % tretinoin topical gel 0.01 %, %, 0.05 % VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML CHANGED B VS D PA TO PA APPLIES If you have any questions, please call Customer Service toll free at (TTY/TDD relay: ) weekdays from 8 a.m. to 8 p.m. and Saturdays from 8 a.m. to noon. From October 1 to February 14, we re available seven days a week from 8 a.m. to 8 p.m. 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.

6 Nondiscrimination Notice Florida Hospital Care Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Florida Hospital Care Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Florida Hospital Care Advantage: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, accessible electronic formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, please contact Doris Garcia-Durand. If you believe that Florida Hospital Care Advantage has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: Doris Garcia-Durand, ADA/Section 504 Coordinator, 6450 US Highway 1, Rockledge, FL 32955, , (TTY), Fax: , You can file a grievance in person or by mail, fax or . If you need help filing a grievance Doris Garcia-Durand, ADA/Section 504 Coordinator, is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at 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. Y0089_ MPINFO6465FH (08/17)

7 English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: ). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). Portuguese: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: ). Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: ). Y0089_ MPINFO6466FH (08/17)

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