Health Partners Medicare Special 2018 Formulary Changes

Health Partners Medicare Special 2018 Changes Changes occur, for example, because new drugs come on the market, a drug is moved to a different cost-sharing level (tier), or a generic version becomes available. Requirements/ Key: NEDS QL LA PA ST Non-Extended Day Supply Quantity Limit Limited Access Prior Authorization Step Therapy ALIQOPA 60 MG VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 aripiprazole 1 mg/ml solution SOLUTION 1 - Covered Addition 03/01/2018 atazanavir sulfate 150 mg cap CAPSULE 1 - Covered QL: 60/30 DAYS Addition 03/01/2018 atazanavir sulfate 200 mg cap CAPSULE 1 - Covered QL: 60/30 DAYS Addition 03/01/2018 atazanavir sulfate 300 mg cap CAPSULE 1 - Covered QL: 30/30 DAYS Addition 03/01/2018 BENLYSTA 200 MG/ML AUTOINJECT AUTO INJCT 1 - Covered NEDS Addition 03/01/2018 BENLYSTA 200 MG/ML SYRINGE SYRINGE 1 - Covered NEDS Addition 03/01/2018 bortezomib 3.5 mg vial VIAL 1 - Covered PA, NEDS Addition 03/01/2018 BOSULIF 400 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 BYDUREON BCISE 2 MG AUTOINJECT AUTO INJCT 1 - Covered Addition 03/01/2018 CALQUENCE 100 MG CAPSULE CAPSULE 1 - Covered NEDS Addition 03/01/2018 carvedilol ER 10 mg capsule CPMP 24HR 1 - Covered QL: 30/30 DAYS Addition 03/01/2018 1 Updated 10/2018

carvedilol ER 20 mg capsule CPMP 24HR 1 - Covered QL: 30/30 DAYS Addition 03/01/2018 carvedilol ER 40 mg capsule CPMP 24HR 1 - Covered QL: 30/30 DAYS Addition 03/01/2018 carvedilol ER 80 mg capsule CPMP 24HR 1 - Covered QL: 30/30 DAYS Addition 03/01/2018 caspofungin acetate 50 mg vial VIAL 1 - Covered Addition 03/01/2018 caspofungin acetate 70 mg vial VIAL 1 - Covered Addition 03/01/2018 cholestyramine packet POWD PACK 1 - Covered Addition 03/01/2018 cholestyramine powder POWDER 1 - Covered Addition 03/01/2018 clobetasol emollnt 0.05% foam FOAM 1 - Covered Addition 03/01/2018 clobetasol emulsion 0.05% foam FOAM 1 - Covered Addition 03/01/2018 clobetasol 0.05% cream CREAM (G) 1 - Covered Addition 03/01/2018 dactinomycin 0.5 mg vial VIAL 1 - Covered PA, NEDS Addition 03/01/2018 desogest-eth estra 0.15-0.03mg TABLET 1 - Covered Addition 03/01/2018 desogestrel-ethinyl estradiol tab TABLET 1 - Covered Addition 03/01/2018 doxycycline hyclate 150 mg tab TABLET 1 - Covered Addition 03/01/2018 doxycycline hyclate 75 mg tab TABLET 1 - Covered Addition 03/01/2018 efavirenz 200 mg capsule CAPSULE 1 - Covered QL: 90/30 DAYS Addition 03/01/2018 efavirenz 50 mg capsule CAPSULE 1 - Covered QL: 240/30 DAYS Addition 03/01/2018 estradiol 10 mcg vaginal insert TABLET 1 - Covered Addition 03/01/2018 ethynodiol-eth estra 1mg-35 mcg TABLET 1 - Covered Addition 03/01/2018 fluocinolone 0.01% scalp oil OIL 1 - Covered Addition 03/01/2018 fluocinolone 0.01% body oil OIL 1 - Covered Addition 03/01/2018 fluocinonide 0.05% cream CREAM (G) 1 - Covered Addition 03/01/2018 2 Updated 10/2018

fosamprenavir 700 mg tablet TABLET 1 - Covered Addition 03/01/2018 GLATIRAMER 20 MG/ML SYRINGE SYRINGE 1 - Covered NEDS Addition 03/01/2018 GLATIRAMER 40 MG/ML SYRINGE SYRINGE 1 - Covered NEDS Addition 03/01/2018 HAVRIX 1,440 UNITS/ML SYRINGE SYRINGE 1 - Covered Addition 03/01/2018 HAVRIX 720 UNITS/0.5 ML VIAL VIAL 1 - Covered Addition 03/01/2018 HUMALOG JR 100 UNIT/ML KWIKPEN INS PEN HF 1 - Covered QL: 45/30 DAYS Addition 03/01/2018 IDHIFA 100 MG TABLET TABLET 1 - Covered Addition 03/01/2018 IDHIFA 50 MG TABLET TABLET 1 - Covered Addition 03/01/2018 INGREZZA 80 MG CAPSULE CAPSULE 1 - Covered QL: 30/30 DAYS, PA, NEDS Addition 03/01/2018 JULUCA 50-25 MG TABLET TABLET 1 - Covered Addition 03/01/2018 KADCYLA 160 MG VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 lanthanum carb 1,000 mg tab chew TAB CHEW 1 - Covered Addition 03/01/2018 lanthanum carb 500 mg tab chew TAB CHEW 1 - Covered Addition 03/01/2018 lanthanum carb 750 mg tab chew TAB CHEW 1 - Covered Addition 03/01/2018 LYNPARZA 100 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 LYNPARZA 150 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 meropenem IV 1 gm vial VIAL 1 - Covered Addition 03/01/2018 mesalamine DR 1.2 gm tablet TABLET DR 1 - Covered Addition 03/01/2018 moxifloxacin 0.5% eye drops DROPS 1 - Covered Addition 03/01/2018 MYLOTARG 4.5 MG VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 NERLYNX 40 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 OPDIVO 100 MG/10 ML VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 3 Updated 10/2018

oseltamivir 6 mg/ml suspension SUSP RECON 1 - Covered Addition 03/01/2018 oxaliplatin 100 mg vial VIAL 1 - Covered Addition 03/01/2018 paroxetine mesylate 7.5 mg cap CAPSULE 1 - Covered Addition 03/01/2018 piperacil-tazo 2.25 gm add vial VIAL PORT 1 - Covered Addition 03/01/2018 piperacil-tazobact 2.25 gm vial VIAL 1 - Covered Addition 03/01/2018 KLOR-CON 20 MEQ PACKET PACKET 1 - Covered Addition 03/01/2018 prasugrel 10 mg tablet TABLET 1 - Covered Addition 03/01/2018 prasugrel 5 mg tablet TABLET 1 - Covered Addition 03/01/2018 RADICAVA 30 MG/100 ML BAG PIGGYBACK 1 - Covered PA, NEDS Addition 03/01/2018 RENFLEXIS 100 MG VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 sevelamer carbonate 800 mg tab TABLET 1 - Covered Addition 03/01/2018 tenofovir disop fum 300 mg tab TABLET 1 - Covered QL: 30/30 DAYS Addition 03/01/2018 TRACLEER 32 MG TABLET FOR SUSP TAB SUSP 1 - Covered PA, LA, NEDS Addition 03/01/2018 TREANDA 25 MG VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 TRISENOX 12 MG/6 ML VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 TWINRIX VACCINE SYRINGE SYRINGE 1 - Covered Addition 03/01/2018 VAQTA 25 UNITS/0.5 ML VIAL VIAL 1 - Covered Addition 03/01/2018 VAQTA 50 UNITS/ML VIAL VIAL 1 - Covered Addition 03/01/2018 VERZENIO 100 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 VERZENIO 150 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 VERZENIO 200 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 VERZENIO 50 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 4 Updated 10/2018

vigabatrin 500 mg powder packet POWD PACK 1 - Covered LA, NEDS Addition 03/01/2018 VYXEOS 44 MG-100 MG VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 XATMEP 2.5 MG/ML ORAL SOLUTION SOLUTION 1 - Covered Addition 03/01/2018 ALUNBRIG 180 MG TABLET TABLET 1 - Covered NEDS Addition 04/01/2018 ALUNBRIG 90 MG TABLET TABLET 1 - Covered NEDS Addition 04/01/2018 ALUNBRIG 90 MG-180 MG TAB PACK TAB DS PK 1 - Covered NEDS Addition 04/01/2018 doripenem 500 mg vial VIAL 1 - Covered Addition 04/01/2018 ELIQUIS 5 MG STARTER PACK TAB DS PK 1 - Covered QL: 74/30 DAYS Addition 04/01/2018 EMFLAZA 18 MG TABLET TABLET 1 - Covered PA, NEDS Addition 04/01/2018 EMFLAZA 22.75 MG/ML ORAL SUSP ORAL SUSP 1 - Covered PA, NEDS Addition 04/01/2018 EMFLAZA 30 MG TABLET TABLET 1 - Covered PA, NEDS Addition 04/01/2018 EMFLAZA 36 MG TABLET TABLET 1 - Covered PA, NEDS Addition 04/01/2018 EMFLAZA 6 MG TABLET TABLET 1 - Covered PA, NEDS Addition 04/01/2018 estradiol 0.01% cream CREAM/APPL 1 - Covered Addition 04/01/2018 HERCEPTIN 150 MG VIAL VIAL 1 - Covered PA, NEDS Addition 04/01/2018 ROWEEPRA XR 500 MG TABLET TAB ER 24H 1 - Covered QL: 240/30 DAYS Addition 04/01/2018 ROWEEPRA XR 750 MG TABLET TAB ER 24H 1 - Covered QL: 150/30 DAYS Addition 04/01/2018 levonor-eth estrad 0.15-0.03 TABLET 1 - Covered Addition 04/01/2018 LYRICA CR 82.5 MG TABLET TAB ER 24H 1 - Covered QL: 90/30 DAYS, PA Addition 04/01/2018 LYRICA CR 165 MG TABLET TAB ER 24H 1 - Covered QL: 90/30 DAYS, PA Addition 04/01/2018 LYRICA CR 330 MG TABLET TAB ER 24H 1 - Covered QL: 60/30 DAYS, PA Addition 04/01/2018 5 Updated 10/2018

QVAR REDIHALER 40 MCG HFA AEROBA 1 - Covered QL: 21.2/30 DAYS Addition 04/01/2018 QVAR REDIHALER 80 MCG HFA AEROBA 1 - Covered QL: 21.2/30 DAYS Addition 04/01/2018 RESTASIS MULTIDOSE 0.05% EYE DROPS 1 - Covered QL: 5.5/28 DAYS Addition 04/01/2018 SELZENTRY 20 MG/ML ORAL SOLN SOLUTION 1 - Covered Addition 04/01/2018 SHINGRIX VIAL KIT KIT 1 - Covered Addition 04/01/2018 abacavir 20 mg/ml solution SOLUTION 1 - Covered Addition 05/01/2018 BIKTARVY 50-200-25 MG TABLET TABLET 1 - Covered QL: 30/30 DAYS Addition 05/01/2018 efavirenz 600 mg tablet TABLET 1 - Covered QL: 30/30 DAYS Addition 05/01/2018 ENDARI 5 GRAM POWDER PACKET POWD PACK 1 - Covered QL: 180/30 DAYS, PA, LA, NEDS Addition 05/01/2018 ERLEADA 60 MG TABLET TABLET 1 - Covered NEDS Addition 05/01/2018 haloperidol lac 5 mg/ml syringe SYRINGE 1 - Covered Addition 05/01/2018 isotretinoin 10 mg capsule CAPSULE 1 - Covered Addition 05/01/2018 isotretinoin 20 mg capsule CAPSULE 1 - Covered Addition 05/01/2018 isotretinoin 30 mg capsule CAPSULE 1 - Covered Addition 05/01/2018 isotretinoin 40 mg capsule CAPSULE 1 - Covered Addition 05/01/2018 levono-e estrad 0.10-0.02-0.01 TBDSPK 3MO 1 - Covered Addition 05/01/2018 memantine ER 14 mg capsule CAP SPR 24 1 - Covered QL: 30/30 DAYS Addition 05/01/2018 memantine ER 21 mg capsule CAP SPR 24 1 - Covered QL: 30/30 DAYS Addition 05/01/2018 memantine ER 28 mg capsule CAP SPR 24 1 - Covered QL: 30/30 DAYS Addition 05/01/2018 memantine ER 7 mg capsule CAP SPR 24 1 - Covered QL: 30/30 DAYS Addition 05/01/2018 naloxone 0.4 mg/ml carpuject SYRINGE 1 - Covered Addition 05/01/2018 6 Updated 10/2018

trientine hcl 250 mg capsule CAPSULE 1 - Covered QL: 240/30 DAYS Addition 05/01/2018 VIDEX EC 125 MG CAPSULE CAPSULE DR 1 - Covered QL: 60/30 DAYS Addition 05/01/2018 ADMELOG 100 UNIT/ML VIAL VIAL 1 - Covered QL: 40/30 DAYS Addition 06/01/2018 ADMELOG SOLOSTAR 100 UNIT/ML INSULIN PEN 1 - Covered QL: 45/30 DAYS Addition 06/01/2018 ALIMTA 100 MG VIAL VIAL 1 - Covered PA, NEDS Addition 06/01/2018 DALIRESP 250 MCG TABLET TABLET 1 - Covered Addition 06/01/2018 DEPO-MEDROL 20 MG/ML VIAL VIAL 1 - Covered Addition 06/01/2018 DEPO-MEDROL 40 MG/ML VIAL VIAL 1 - Covered Addition 06/01/2018 DEPO-MEDROL 80 MG/ML VIAL VIAL 1 - Covered Addition 06/01/2018 FABRAZYME 5 MG VIAL VIAL 1 - Covered NEDS Addition 06/01/2018 FIASP 100 UNIT/ML VIAL VIAL 1 - Covered QL: 40/30 DAYS Addition 06/01/2018 flunisolide 0.025% spray SPRAY 1 - Covered Addition 06/01/2018 GLATOPA 40 MG/ML SYRINGE SYRINGE 1 - Covered NEDS Addition 06/01/2018 ILARIS 150 MG/ML VIAL VIAL 1 - Covered NEDS Addition 06/01/2018 IMBRUVICA 140 MG TABLET TABLET 1 - Covered NEDS Addition 06/01/2018 IMBRUVICA 280 MG TABLET TABLET 1 - Covered NEDS Addition 06/01/2018 IMBRUVICA 420 MG TABLET TABLET 1 - Covered NEDS Addition 06/01/2018 IMBRUVICA 560 MG TABLET TABLET 1 - Covered NEDS Addition 06/01/2018 IMBRUVICA 70 MG CAPSULE CAPSULE 1 - Covered NEDS Addition 06/01/2018 INTRON A 25 MILLION UNIT/2.5ML VIAL 1 - Covered NEDS Addition 06/01/2018 ISENTRESS HD 600 MG TABLET TABLET 1 - Covered QL: 60/30 DAYS Addition 06/01/2018 7 Updated 10/2018

KELNOR 1-50 TABLET TABLET 1 - Covered Addition 06/01/2018 lamotrigine 25 mg tab start kit TAB DS PK 1 - Covered Addition 06/01/2018 lamotrigine tab start kit-blue TAB DS PK 1 - Covered Addition 06/01/2018 lamotrigine tab start kit-green TAB DS PK 1 - Covered Addition 06/01/2018 lamotrigine tab start kit-orang TAB DS PK 1 - Covered Addition 06/01/2018 levoleucovorin 50 mg vial VIAL 1 - Covered PA Addition 06/01/2018 levonor-eth estrad 0.15-0.03 TBDSPK 3MO 1 - Covered Addition 06/01/2018 ORFADIN 20 MG CAPSULE CAPSULE 1 - Covered NEDS Addition 06/01/2018 PLEGRIDY SYRINGE STARTER PACK SYRINGE 1 - Covered NEDS Addition 06/01/2018 ritonavir 100 mg tablet TABLET 1 - Covered QL: 360/30 DAYS Addition 06/01/2018 RUBRACA 250 MG TABLET TABLET 1 - Covered NEDS Addition 06/01/2018 SYLVANT 400 MG VIAL VIAL 1 - Covered PA, NEDS Addition 06/01/2018 SYMFI LO 400-300-300 MG TABLET TABLET 1 - Covered QL: 30/30 DAYS Addition 06/01/2018 tiagabine hcl 12 mg tablet TABLET 1 - Covered QL: 120/30 DAYS Addition 06/01/2018 tiagabine hcl 16 mg tablet TABLET 1 - Covered QL: 90/30 DAYS Addition 06/01/2018 triamcinolone 200 mg/5 ml vial VIAL 1 - Covered Addition 06/01/2018 triamcinolone 400 mg/10 ml VIAL 1 - Covered Addition 06/01/2018 triamcinolone acet 40 mg/ml VIAL 1 - Covered Addition 06/01/2018 VIRAMUNE 50 MG/5 ML SUSP ORAL SUSPENSION 1 - Covered Addition 06/01/2018 ZYTIGA 500 MG TABLET TABLET 1 - Covered NEDS Addition 06/01/2018 benznidazole 100 mg tablet TABLET 1 - Covered Addition 07/01/2018 8 Updated 10/2018

benznidazole 12.5 mg tablet TABLET 1 - Covered Addition 07/01/2018 OCELLA 3 MG-0.03 MG TABLET TABLET 1 - Covered Addition 07/01/2018 SYEDA 28 TABLET TABLET 1 - Covered Addition 07/01/2018 FIASP 100 UNIT/ML FLEXTOUCH INSULIN PEN 1 - Covered QL: 45/30 DAYS Addition 07/01/2018 GLYXAMBI 10 MG-5 MG TABLET TABLET 1 - Covered Addition 07/01/2018 GLYXAMBI 25 MG-5 MG TABLET TABLET 1 - Covered Addition 07/01/2018 HUMIRA 10 MG/0.1 ML SYRINGE SYRINGEKIT 1 - Covered PA, NEDS Addition 07/01/2018 HUMIRA 40 MG/0.4 ML SYRINGE SYRINGEKIT 1 - Covered PA, NEDS Addition 07/01/2018 HUMIRA PED CROHNS 80 MG/0.8 ML SYRINGEKIT 1 - Covered PA, NEDS Addition 07/01/2018 HUMIRA PEDIATR CROHN'S 80-40MG SYRINGEKIT 1 - Covered PA, NEDS Addition 07/01/2018 HUMIRA 40 MG/0.4 ML PEN PEN IJ KIT 1 - Covered PA, NEDS Addition 07/01/2018 levonor-eth estrad 0.1-0.02 mg TABLET 1 - Covered Addition 07/01/2018 TRI-VYLIBRA 28 TABLET TABLET 1 - Covered Addition 07/01/2018 VYLIBRA 28 TABLET TABLET 1 - Covered Addition 07/01/2018 TASIGNA 50 MG CAPSULE CAPSULE 1 - Covered NEDS Addition 07/01/2018 TOUJEO MAX SOLOSTAR 300 UNIT/ML INSULIN PEN 1 - Covered QL: 18/30 DAYS Addition 07/01/2018 AIMOVIG 140 MG DOSE-2 AUTOINJ AUTO INJCT 1 - Covered QL: 2/28 DAYS, PA Addition 08/01/2018 AIMOVIG 70 MG/ML AUTOINJECTOR AUTO INJCT 1 - Covered QL: 2/28 DAYS, PA Addition 08/01/2018 baclofen 5 mg tablet TABLET 1 - Covered Addition 08/01/2018 buprenorp-nalox 8-2 mg SL film FILM 1 - Covered QL: 60/30 DAYS Addition 08/01/2018 colesevelam 625 mg tablet TABLET 1 - Covered Addition 08/01/2018 9 Updated 10/2018

HUMIRA 20 MG/0.2 ML SYRINGE SYRINGEKIT 1 - Covered PA, NEDS Addition 08/01/2018 ESTARYLLA 0.25-0.035 MG TABLET TABLET 1 - Covered Addition 08/01/2018 MILI 0.25-0.035 MG TABLET TABLET 1 - Covered Addition 08/01/2018 TRI-MILI 28 TABLET TABLET 1 - Covered Addition 08/01/2018 NORVIR 100 MG POWDER PACKET POWD PACK 1 - Covered QL: 360/30 DAYS Addition 08/01/2018 SYMFI 600-300-300 MG TABLET TABLET 1 - Covered QL: 30/30 DAYS Addition 08/01/2018 SYNJARDY XR 10-1,000 MG TABLET TAB BP 24H 1 - Covered QL: 60/30 DAYS Addition 08/01/2018 SYNJARDY XR 12.5-1,000 MG TABLET TAB BP 24H 1 - Covered QL: 60/30 DAYS Addition 08/01/2018 SYNJARDY XR 25-1,000 MG TABLET TAB BP 24H 1 - Covered QL: 30/30 DAYS Addition 08/01/2018 SYNJARDY XR 5-1,000 MG TABLET TAB BP 24H 1 - Covered QL: 60/30 DAYS Addition 08/01/2018 ARNUITY ELLIPTA 50 MCG INH BLST W/DEV 1 - Covered QL: 30/30 DAYS Addition 09/01/2018 budesonide er 9 mg tablet TABDR - ER 1 - Covered Addition 09/01/2018 estradiol-noreth 0.5-0.1 mg tab TABLET 1 - Covered Addition 09/01/2018 estradiol-noreth 1-0.5 mg tab TABLET 1 - Covered Addition 09/01/2018 KUVAN 500 MG POWDER PACKET POWD PACK 1 - Covered NEDS Addition 09/01/2018 LUCEMYRA 0.18 MG TABLET TABLET 1 - Covered QL: 16/1 DAY, PA Addition 09/01/2018 miglustat 100 mg capsule CAPSULE 1 - Covered NEDS Addition 09/01/2018 MONO-LINYAH 28 TABLET TABLET 1 - Covered Addition 09/01/2018 oxacillin 1 gm add-vantage vial VIAL PORT 1 - Covered Addition 09/01/2018 oxacillin 1 gm vial VIAL 1 - Covered Addition 09/01/2018 YONSA 125 MG TABLET TABLET 1 - Covered NEDS Addition 09/01/2018 10 Updated 10/2018

CIMDUO 300-300 MG TABLET TABLET 1 - Covered QL: 30/30 DAYS Addition 10/01/2018 MYORISAN 10 MG CAPSULE CAPSULE 1 - Covered Addition 10/01/2018 MYORISAN 20 MG CAPSULE CAPSULE 1 - Covered Addition 10/01/2018 MYORISAN 30 MG CAPSULE CAPSULE 1 - Covered Addition 10/01/2018 MYORISAN 40 MG CAPSULE CAPSULE 1 - Covered Addition 10/01/2018 ORKAMBI 100-125 MG GRANULE PKT GRAN PACK 1 - Covered PA, NEDS Addition 10/01/2018 ORKAMBI 150-188 MG GRANULE PKT GRAN PACK 1 - Covered PA, NEDS Addition 10/01/2018 clobazam 10 mg tablet TABLET 1 - Covered QL: 60/30 DAYS Addition 11/01/2018 clobazam 2.5 mg/ml suspension ORAL SUSP 1 - Covered QL: 480/30 DAYS Addition 11/01/2018 clobazam 20 mg tablet TABLET 1 - Covered QL: 60/30 DAYS Addition 11/01/2018 dalfampridine er 10 mg TAB ER 12H 1 - Covered NEDS Addition 11/01/2018 ertapenem 1 gram vial VIAL 1 - Covered Addition 11/01/2018 HUMIRA PEN CROHN-UC-HS 80 MG PEN IJ KIT 1 - Covered PA, NEDS Addition 11/01/2018 HUMIRA PEN PSOR-UVEI 80 MG-40 MG PEN IJ KIT 1 - Covered PA, NEDS Addition 11/01/2018 itraconazole 10 mg/ml solution SOLUTION 1 - Covered Addition 11/01/2018 SYMTUZA 800-150-200-10 MG TAB TABLET 1 - Covered QL: 30/30 DAYS Addition 11/01/2018 tadalafil 20 mg tablet TABLET 1 - Covered PA Addition 11/01/2018 11 Updated 10/2018