Drug Formulary Update, April 2017 Commercial and State Programs

Drug Formulary Update, April 2017 Commercial and State Programs Updates to the HealthPartners Commercial and State Program Drug Formularies are listed below. Updates apply to all Commercial groups (PreferredRx, GenericsPlusRx, EnhancedRx, and GenericsAdvantageRx) and to HealthPartners Minnesota Health Care Programs (Medicaid and Minnesota Care State Programs ) Drug Formulary. Please see www.healthpartners.com/formularies for details. Positive changes (additions) are generally effective April 1, and negative changes (deletions) are generally effective July 1. Additional communications are sent to members and providers affected by negative changes. Adapalene 0.1 % gel F NF 7/1/17 Adapalene 0.1% gel as a prescription medication is being removed from the Differin OTC is being added to the formulary as a replacement, and will be covered for a generic co pay. Arformoterol nebulization (Brovana) NF NF PA 7/1/17 Brovana will be reserved for patients with an inadequate response to a preferred product, with significant Azilsartan (Edarbi and Edarbyclor) NF PA Update 4/1/17 Azilsartan is reserved for patients with an inadequate response to two or more preferred products (losartan, irbesartan, and valsartan), with improved Balsalazide (Colazal), Brandonly NF NF PA 7/1/17 Colazal Brand will be reserved for

HealthPartners Formulary Update, page 2 of 9 Benzoyl peroxide NF NF PA 7/1/17 Several strengths will be reserved for to preferred products (benzoyl peroxide OTC), with significant clinical rationale suggesting improved This change applies to the 8% gel, 6% towelette, 4% gel, 7% cleanser, 9.8% foam, 5.3% foam, 9.8 % foam, and 5.3% foam. Budesonide nebulization suspension F AE F AE PA 4/1/17 Coverage criteria have been added for eosinophilic esophagitis. For eosinophilic esophagitis, budesonide nebulization is reserved for to swallowed fluticasone. Budesonide nebulization continues to be available for children <= age 8 (no restrictions). Inhaled steroids are preferred for asthma for older children and adults. Clindamycin 1%/ benzoyl peroxide 5% gel pump Clindamycin/ tretinoin Brands NF NF PA 7/1/17 Clindamycin 1%/ benzoyl peroxide 5% gel will be reserved for patients who have tried preferred products, with improved Clindamycin gel remains on formulary, and benzoyl peroxide is available OTC. NF NF PA 7/1/17 Clindamycin/ tretinoin Brands will be reserved for patients with an inadequate response to generic clindamycin/ tretinoin, with significant Note: Generic clindamycin/ tretinoin is non Individual products given separately are preferred. This change applies to Veltin and Ziana.

HealthPartners Formulary Update, page 3 of 9 Desloratadine (Clarinex), NF NF PA* 7/1/17 Clarinex Brand will be reserved for * Clarinex remains excluded for the Desonide, NF NF PA 7/1/17 Desonide Brands will be reserved for to two or more preferred products, with significant clinical rationale suggesting improved This change applies to Desonate gel and Verdeso foam. Desoximetasone (Topicort) spray NF NF PA 7/1/17 Topicort spray will be reserved for to two or more preferred products, with significant clinical rationale suggesting improved Dexlansoprazole (Dexilant) NF NF PA* 7/1/17 Dexilant will be reserved for patients improved * Dexilant remains excluded for the Diflorasone NF NF PA 7/1/17 Diflorasone will be reserved for patients improved Diltiazem (Cardizem CD) 120mg NF NF PA 7/1/17 Cardizem CD (all strengths) will be reserved for patients with an inadequate response to the equivalent generic due to a documented allergic reaction. Econazole F NF 7/1/17 Econazole will be removed from the

HealthPartners Formulary Update, page 4 of 9 Escitalopram (Lexapro), NF NF PA 7/1/17 Lexapro Brands will be reserved for to the equivalent generic due to a documented allergic reaction. Fenofibrate NF NF PA 7/1/17 Several forms of fenofibrate will be reserved for patients with an inadequate response to preferred products, with significant clinical rationale suggesting improved This change applies to Fenoglide, Antara, and fenofibrate 120mg tablet. Most fenofibrate generics remain on Fioricet Brands NF QL NF QL PA 7/1/17 Fioricet Brands will be reserved for This change applies to Fioricet (butalbital/ acetaminophen/ caffeine) and Fioricet with codeine (codeine/ butalbital/ acetaminophen/ caffeine). Fluocinolone shampoo (Capex) NF NF PA 7/1/17 Capex will be reserved for patients with an inadequate response to two or more Flurandrenolide NF NF PA 7/1/17 Most forms of flurandrenolide will be reserved for patients with an inadequate response to two or more This change applies to flurandrenolide cream, lotion, and ointment. Cordran tape remains on formulary with prior authorization.

HealthPartners Formulary Update, page 5 of 9 Formoterol (Foradil) F NF 4/1/17 Foradil has been removed from the Formoterol nebulization (Perforomist) Glycopyrrolate (Robinul), NF NF PA 7/1/17 Perforomist will be reserved for to a preferred product, with significant NF NF PA 7/1/17 Robinul Brands will be reserved for Halcinonide (Halog) NF NF PA 7/1/17 Halog will be reserved for patients with an inadequate response to two or more Hydrocortisone rectal foam (Cortifoam) NF NF PA 7/1/17 Cortifoam will be reserved for patients with an inadequate response to a preferred product, with significant Hydrocortisone suppositories remain on Insulin inhaled (Afrezza) NF NF PA 7/1/17 Afrezza will be reserved for patients with an inadequate response to preferred products. Isotretinoin (Absorica) NF QL NF PA QL 7/1/17 Absorica will be reserved for patients with a documented allergic reaction to the equivalent generic. Ivermectin (Soolantra) cream NF PA Update 4/1/17 Soolantra is reserved for patients with an inadequate response to two or more preferred products (metronidazole, sulfacetamide sulfur, doxycycline or minocycline, tretinoin, or adapalene).

HealthPartners Formulary Update, page 6 of 9 Lactulose (Kristalose) packet NF NF PA 7/1/17 Kristalose packet will be reserved for to lactulose solution, with significant Lactulose solution remains on Lamotrigine (Lamictal and Lamictal XR), NF NF PA 7/1/17 Lamictal Brands will be reserved for to the equivalent generic due to a documented allergic reaction. Lesinurad (Zurampic) NF NF PA 7/1/17 Zurampic will require prior authorization. Levocetirizine (Xyzal), Brandonly NF NF PA* 7/1/17 Xyzal Brand will be reserved for patients with a documented allergic reaction to the equivalent generic. * Xyzal remains excluded for the Lomotil (diphenoxylate/ atropine), NF QL NF QL PA 7/1/17 Lomotil Brands will be reserved for Miconazole (Vusion) ointment NF NF PA 7/1/17 Vusion will be reserved for patients improved Naftifine (Naftin) gel NF NF PA 7/1/17 Naftin gel will be reserved for patients improved

HealthPartners Formulary Update, page 7 of 9 Olmesartan NF PA NF 4/1/17 Olmesartan is non This applies to olmesartan, olmesartan/ HCTZ, olmesartan amlodipine, and olmesartan/ amlodipine/ HCTZ. Benicar, Benicar HCT, Azor, and Tribenzor Brands remain non formulary with prior authorization. Olsalazine (Dipentum) NF NF PA 7/1/17 Dipentum will be reserved for patients improved Oxiconazole (Oxistat) NF NF PA 7/1/17 Oxistat will be reserved for patients improved Pantoprazole (Protonix) granules NF PA NF* 4/1/17 Protonix is non Protonix remains excluded for the Pramipexole ER F PA Update 4/1/17 Pramipexole ER is reserved for patients with Parkinson s disease who have significant side effects, loss of effectiveness or compliance concerns with regular release pramipexole. Propranolol Brands NF NF PA 7/1/17 Propranolol Brands will be reserved for to This applies to Inderal XL, InnoPran XL, and Inderal LA.

HealthPartners Formulary Update, page 8 of 9 Quetiapine ER F PA Update 4/1/17 Quetiapine ER is reserved for patients with documented compliance concerns with quetiapine regular release; or for patients previously stable on this medication. Approvals are given for five years. Reauthorizations are given to patients who have been seen within the previous 14 months, and who continue to need this medication. Quetiapine XR (Seroquel XR), NF PA Update 4/1/17 Seroquel XR Brand is reserved for reaction to the generic equivalent. Approvals are given for one year. Reauthorizations are given to patients who have been seen within the previous 14 months, and who continue to need this medication, and can t use the generic equivalent. Rabeprazole (Aciphex Sprinkle) NF NF PA* 7/1/17 Aciphex Sprinkle will be reserved for to two or more preferred products, with significant clinical rationale suggesting improved Rabeprazole tablets remain on * Aciphex remains excluded for the Ranitidine syrup F AE F 4/1/17 Ranitidine syrup is on Rosuvastatin (Crestor), NF NF PA 7/1/17 Crestor Brand will be reserved for to the equivalent generic due to a documented allergic reaction.

HealthPartners Formulary Update, page 9 of 9 Sulconazole (Exelderm) F NF 7/1/17 Exelderm will be removed from PreferredRx and EnhancedRx formularies, and is non formulary for all formularies. Sulfacetamide/ sulfur (BP 10 1) Tacrolimus (Protopic), F NF PA 7/1/17 BP 10 1 will be reserved for patients with an inadequate response to preferred sulfacetamide/ sulfur products, with significant clinical rationale suggesting improved NF NF PA 7/1/17 Protopic Brand will be reserved for Ursodiol (Actigall) Brand NF NF PA 7/1/17 Actigall Brand will be reserved for to the equivalent generic due to a documented allergic reaction. Vanatol (butalbital/ acetaminophen/ caffeine) NF NF PA 7/1/17 Vanatol will be reserved for patients with an inadequate response to two Zubsolv (buprenorphine/ naloxone) NF QL NF QL PA 7/1/17 Zubsolv will be reserved for patients with an inadequate response to Suboxone film and buprenorphine/ naloxone tablets remain on