2016 Formulary Annual Notice of Change. Medicare Advantage Plans (MAPD)

Transcription

1 2016 Formulary Annual Notice of Change Updated: October 1, 2015 Medicare Advantage Plans (MAPD) This is a listing of the changes that have occurred to the 2016 MAPD formulary. For a complete list, please refer to our website and review the 2016 MAPD Comprehensive Formulary (Drug List). Click here to view the comprehensive formulary. Please carefully review these changes. If you have any questions or need to obtain updated coverage determination and exception information, please contact Customer Service at or, for TTY users, , weekdays from 8 a.m. to 8 p.m. and Saturdays from 8 a.m. to noon. From October 1 through February 15, we are available seven days a week from 8 a.m. to 8 p.m. or you may visit myfhca.org. Please refer to your Evidence of Coverage for cost-sharing information. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and copayments/co-insurance may change on January 1 of each year. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. 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. The Formulary and pharmacy network may change at any time. You will receive notice when necessary. Y0089_MPINFO4355FH (09/15) MEDICATIONS DELETED FROM THE 2016 MAPD

2 ABILIFY 10 MG TABLET (BRAND) ABILIFY 15 MG TABLET (BRAND) ABILIFY 2 MG TABLET (BRAND) ABILIFY 20 MG TABLET (BRAND) ABILIFY 30 MG TABLET (BRAND) ABILIFY 5 MG TABLET (BRAND) Abilify Discmelt TABLET DISPERSIBLE 10 MG Actiq LOLLIPOP 1200 MCG BUCCAL (BRAND) Actiq LOLLIPOP 1600 MCG BUCCAL (BRAND) Intuniv TABLET EXTENDED RELEASE 24 HR* 3 MG (BRAND) Intuniv TABLET EXTENDED RELEASE 24 HR* 4 MG (BRAND) LaMICtal ODT TABLET DISPERSIBLE 100 MG (BRAND) LaMICtal ODT TABLET DISPERSIBLE 200 MG (BRAND) LaMICtal ODT TABLET DISPERSIBLE 25 MG (BRAND) LaMICtal ODT TABLET DISPERSIBLE 50 MG (BRAND) Lodosyn TABLET 25 MG (BRAND) LOTRONEX 0.5 MG TABLET (BRAND) LOTRONEX 1 MG TABLET (BRAND) Actiq LOLLIPOP 400 MCG BUCCAL (BRAND) Lovaza CAPSULE 1 GM (BRAND) Actiq LOLLIPOP 600 MCG BUCCAL (BRAND) Malarone TABLET MG (BRAND) Actiq LOLLIPOP 800 MCG BUCCAL (BRAND) ACTONEL {12 (RISEDRONATE SODIUM 35 MG TABLET) } PACK (BRAND) ACTONEL {4 (RISEDRONATE SODIUM 35 MG TABLET) } PACK (BRAND) ACTONEL 30 MG TABLET (BRAND) ACTONEL RISEDRONATE SODIUM 5 MG TABLET (BRAND) Actonel TABLET 150 MG (BRAND) Aldara CREAM 5 % EXTERNAL (BRAND) Alphagan P SOLUTION 0.15 % OPHTHALMIC (BRAND) Alvesco Androxy TABLET 10 MG Antabuse TABLET 250 MG (BRAND) Antabuse TABLET 500 MG (BRAND) Aricept TABLET 23 MG (BRAND) Mepron SUSPENSION 750 MG/5ML (BRAND) Mestinon TABLET 60 MG (BRAND) Mycobutin CAPSULE 150 MG (BRAND) NAFTIN 10 MG/ML TOPICAL CREAM (BRAND) Nardil TABLET 15 MG (BRAND) Niaspan TABLET EXTENDEDRELEASE* 1000 MG (BRAND) Niaspan TABLET EXTENDEDRELEASE* 500 MG (BRAND) Niaspan TABLET EXTENDEDRELEASE* 750 MG (BRAND) Ofloxacin TABLET 300 MG Olysio Omaris Opana ER Orapred ODT TABLET DISPERSIBLE 15 MG (BRAND)

3 MEDICATIONS DELETED FROM THE 2016 MAPD Arixtra SOLUTION 10 MG/0.8ML SUBCUTANEOUS * (BRAND) Arixtra SOLUTION 2.5 MG/0.5ML SUBCUTANEOUS* (BRAND) Arixtra SOLUTION 5 MG/0.4ML SUBCUTANEOUS* (BRAND) Arixtra SOLUTION 7.5 MG/0.6ML SUBCUTANEOUS*(BRAND) Atrovent SOLUTION 0.03 % NASAL (BRAND) Atrovent SOLUTION 0.06 % NASAL (BRAND) Avandamet TABLET MG Avandamet TABLET MG Avandaryl TABLET 4-1 MG Avandaryl TABLET 4-2 MG Avandaryl TABLET 8-4 MG Avandia TABLET 2 MG Avandia TABLET 4 MG Avandia TABLET 8 MG Baraclude TABLET 0.5 MG (BRAND) Baraclude TABLET 1 MG (BRAND) Campral TABLET DELAYED RELEASE 333 MG CeleBREX CAPSULE 100 MG (BRAND) CeleBREX CAPSULE 200 MG (BRAND) CeleBREX CAPSULE 400 MG (BRAND) CeleBREX CAPSULE 50 MG (BRAND) CellCept SUSPENSION RECONSTITUTED 200 MG/ML (BRAND) Cleocin CREAM 2 % VAGINAL (BRAND) Cleocin in D5W SOLUTION 300 MG/50ML INTRAVENOUS* (BRAND) Cleocin in D5W SOLUTION 600 MG/50ML INTRAVENOUS* (BRAND) Cleocin in D5W SOLUTION 900 MG/50ML INTRAVENOUS* (BRAND) Cyklokapron SOLUTION 100 MG/ML INTRAVENOUS* (BRAND) Dilantin Infatabs TABLET CHEWABLE 50 MG (BRAND) Oxsoralen Ultra CAPSULE 10 MG (BRAND) Phenytek CAPSULE 200 MG (BRAND) Phenytek CAPSULE 300 MG (BRAND) Prandin TABLET 0.5 MG (BRAND) Prandin TABLET 1 MG (BRAND) Prandin TABLET 2 MG (BRAND) Pred Forte SUSPENSION 1 % OPHTHALMIC (BRAND) Protopic OINTMENT 0.03 % EXTERNAL (BRAND) Protopic OINTMENT 0.1 % EXTERNAL (BRAND) Proventil Reserpine TABLET 0.25 MG Rilutek TABLET 50 MG (BRAND) Scopolamine TD Patch 72HR 1 MG/3DAYS Silvadene CREAM 1 % EXTERNAL Sodium Fluoride TABLET 2.2 (1 F) MG Solaraze 3 % TRANSDERMAL (BRAND) Soriatane CAPSULE 10 MG (BRAND) Soriatane CAPSULE 17.5 MG (BRAND) Soriatane CAPSULE 25 MG (BRAND) Stromectol TABLET 3 MG (BRAND) TASMAR 100 MG TABLET (BRAND) Tekamlo TABLET MG Tekamlo TABLET MG Tekamlo TABLET MG Tekamlo TABLET MG Tetanus Toxoid Adsorbed SOLUTION 5 LFU INTRAMUSCULAR* Tobi NEBULIZATION SOLUTION 300 MG/5ML INHALATION (BRAND) TobraDex SUSPENSION % OPHTHALMIC (BRAND)

4 MEDICATIONS DELETED FROM THE 2016 MAPD Dilt-XR CAPSULE EXTENDED RELEASE 24 HOUR 120 MG Dilt-XR CAPSULE EXTENDED RELEASE 24 HOUR 180 MG Dilt-XR CAPSULE EXTENDED RELEASE 24 HOUR 240 MG Diovan TABLET 160 MG (BRAND) Diovan TABLET 320 MG (BRAND) Diovan TABLET 40 MG (BRAND) Diovan TABLET 80 MG (BRAND) Doxycycline Monohydrate CAPSULE 50 MG Dyrenium CAPSULE 100 MG Dyrenium CAPSULE 50 MG Ella TABLET 30 MG Epivir HBV TABLET 100 MG (BRAND) Epivir SOLUTION 10 MG/ML (BRAND) FAZACLO 150 MG DISINTEGRATING TABLET (BRAND) FAZACLO 200 MG DISINTEGRATING TABLET (BRAND) Fortaz SOLUTION RECONSTITUTED 2 GM INJECTION (BRAND) Fortaz SOLUTION RECONSTITUTED 6 GM INJECTION (BRAND) Golytely SOLUTION RECONSTITUTED 236 GM (BRAND) Hepsera TABLET 10 MG (BRAND) Intuniv TABLET EXTENDED RELEASE 24 HR* 1 MG (BRAND) Intuniv TABLET EXTENDED RELEASE 24 HR* 2 MG (BRAND) Toviaz Treximet Trizivir TABLET MG (BRAND) Valcyte TABLET 450 MG (BRAND) Victrelis Vidaza SUSPENSION RECONSTITUTED 100 MG INJECTION (BRAND) Viramune XR TABLET EXTENDED RELEASE 24 HR* 400 MG (BRAND) Xopenex HFA Zerit SOLUTION RECONSTITUTED 1 MG/ML (BRAND) Zetonna Ziagen TABLET 300 MG (BRAND) Zometa CONCENTRATE 4 MG/5ML INTRAVENOUS* (BRAND) Zomig TABLET 2.5 MG (BRAND) Zomig TABLET 5 MG (BRAND) Zomig ZMT TABLET DISPERSIBLE 2.5 MG (BRAND) Zomig ZMT TABLET DISPERSIBLE 5 MG (BRAND) Zosyn SOLUTION RECONSTITUTED GM (BRAND)INTRAVENOUS* Zovirax OINTMENT 5 % EXTERNAL (BRAND) Zymaxid SOLUTION 0.5 % OPHTHALMIC (BRAND) ZYVOX 600 MG TABLET (BRAND) Zyvox SOLUTION 2 MG/ML INTRAVENOUS* (BRAND) MEDICATIONS ADDED TO THE 2016 MAPD Benefit Tier Quantity Limit Prior Authorization Requirement Step Therapy

5 MEDICATIONS ADDED TO THE 2016 MAPD Benefit Tier Quantity Limit Prior Authorization Requirement Abraxane SUSPENSION RECONSTITUTED 100 MG INTRAVENOUS* Tier 5 B/D PA Acitretin CAPSULE 10 MG Tier 5 Acitretin CAPSULE 17.5 MG Tier 5 Acitretin CAPSULE 25 MG Tier 5 Adempas TABLET 0.5 MG Tier 5 Adempas TABLET 1 MG Tier 5 Adempas TABLET 1.5 MG Tier 5 (SORIATANE) (SORIATANE) (SORIATANE) (ADEMPAS) (ADEMPAS) (ADEMPAS) Step Therapy Adempas TABLET 2 MG Tier 5 (ADEMPAS) Adempas TABLET 2.5 MG Tier 5 Alclometasone Dipropionate OINTMENT 0.05 % EXTERNAL Tier 4 Alcohol Prep with Benzocaine PAD 6-70 % EXTERNAL Tier 2 Amantadine HCl CAPSULE 100 MG Tier 3 Aminosyn II SOLUTION 10 % INTRAVENOUS* Tier 4 (ADEMPAS) Aminosyn II SOLUTION 15 % INTRAVENOUS* Tier 3 Aminosyn II SOLUTION 7 % INTRAVENOUS* Tier 3 Aminosyn II SOLUTION 8.5 % INTRAVENOUS* Tier 4 Aminosyn II/Electrolytes SOLUTION 8.5 % INTRAVENOUS* Tier 3 Aminosyn M SOLUTION 3.5 % INTRAVENOUS* Tier 3

6 MEDICATIONS ADDED TO THE 2016 MAPD Benefit Tier Quantity Limit Aminosyn-HBC SOLUTION 7 % INTRAVENOUS* Tier 3 Aminosyn-PF SOLUTION 10 % INTRAVENOUS* Tier 4 Aminosyn-PF SOLUTION 7 % INTRAVENOUS* Tier 4 Amoxicillin-Pot Clavulanate ER TABLET EXTENDED RELEASE 12 HR* MG Tier 3 Anadrol-50 TABLET 50 MG Tier 5 AndroGel MG/1.25GM (1.62%) TRANSDERMAL Tier 3 AndroGel 25 MG/2.5GM (1%) TRANSDERMAL Tier 3 AndroGel 40.5 MG/2.5GM (1.62%) TRANSDERMAL Tier 3 AndroGel Pump 12.5 MG/ACT (1%) TRANSDERMAL Tier 3 Azelastine HCl SOLUTION 0.15 % NASAL Tier 3 Prior Authorization Requirement (ANADROL-5) (Testosterone replacement topical) (Testosterone replacement topical) (Testosterone replacement topical) (Testosterone replacement topical) Step Therapy BCG Vaccine Inj Tier 3 QL(100 EA BD Eclipse Shielded Needle 18G X 1-1/2" Tier 2 per 30 Benlysta SOLUTION RECONSTITUTED 120 MG INTRAVENOUS* Tier 5 PA (BENLYSTA) Betamethasone Dipropionate Aug 0.05 % EXTERNAL Tier 3 Betamethasone Dipropionate Aug OINTMENT 0.05 % EXTERNAL Tier 3 Betamethasone Valerate LOTION 0.1 % EXTERNAL Tier 3 Bexsero INTRAMUSCULAR* Tier 4

7 MEDICATIONS ADDED TO THE 2016 MAPD Benefit Tier Quantity Limit Butalbital-Acetaminophen TABLET MG Tier 2 Butalbital-APAP-Caffeine CAPSULE MG Tier 2 Butalbital-APAP-Caffeine CAPSULE MG Tier 2 Butalbital-APAP-Caffeine TABLET MG Tier 2 Butalbital-Aspirin-Caffeine CAPSULE MG Tier 3 Carbaglu TABLET 200 MG Tier 5 QL186 EA per 31 ; QL(186 EA per 31 QL(186 EA per 31 QL(186 EA per 31 QL(186 EA per 31 Prior Authorization Requirement (BUTALBITAL CONTAINING PRODUCTS) (BUTALBITAL CONTAINING PRODUCTS) (BUTALBITAL CONTAINING PRODUCTS) (BUTALBITAL CONTAINING PRODUCTS) (BUTALBITAL CONTAINING PRODUCTS) (CARBAGLU) Cayston SOLUTION RECONSTITUTED 75 MG INHALATION Tier 5 (CAYSTON) CefOXitin Sodium SOLUTION RECONSTITUTED 1 GM INTRAVENOUS* Tier 3 CefOXitin Sodium SOLUTION RECONSTITUTED 10 GM INJECTION Tier 3 CefOXitin Sodium SOLUTION RECONSTITUTED 2 GM INTRAVENOUS* Tier 3 CefOXitin Sodium-Dextrose SOLUTION RECONSTITUTED 1-4 GM-% INTRAVENOUS* Tier 3 CefOXitin Sodium-Dextrose SOLUTION RECONSTITUTED GM-% INTRAVENOUS* Tier 3 Step Therapy Cefprozil TABLET 250 MG Tier 3 Clinimix E/Dextrose (2.75/10) SOLUTION 2.75 % INTRAVENOUS* Tier 4

8 MEDICATIONS ADDED TO THE 2016 MAPD Benefit Tier Quantity Limit Clinimix E/Dextrose (2.75/5) SOLUTION 2.75 % INTRAVENOUS* Tier 4 Clinimix E/Dextrose (4.25/10) SOLUTION 4.25 % INTRAVENOUS* Tier 4 Clinimix E/Dextrose (4.25/25) SOLUTION 4.25 % INTRAVENOUS* Tier 4 Clinimix E/Dextrose (4.25/5) SOLUTION 4.25 % INTRAVENOUS* Tier 4 Clinimix E/Dextrose (5/15) SOLUTION 5 % INTRAVENOUS* Tier 4 Clinimix E/Dextrose (5/20) SOLUTION 5 % INTRAVENOUS* Tier 4 Clinimix E/Dextrose (5/25) SOLUTION 5 % INTRAVENOUS* Tier 4 Clinimix/Dextrose (2.75/5) SOLUTION 2.75 % INTRAVENOUS* Tier 4 Clinimix/Dextrose (4.25/10) SOLUTION 4.25 % INTRAVENOUS* Tier 4 Clinimix/Dextrose (4.25/20) SOLUTION 4.25 % INTRAVENOUS* Tier 4 Clinimix/Dextrose (4.25/25) SOLUTION 4.25 % INTRAVENOUS* Tier 4 Clinimix/Dextrose (4.25/5) SOLUTION 4.25 % INTRAVENOUS* Tier 4 Clinimix/Dextrose (5/15) SOLUTION 5 % INTRAVENOUS* Tier 4 Clinimix/Dextrose (5/20) SOLUTION 5 % INTRAVENOUS* Tier 4 Clinimix/Dextrose (5/25) SOLUTION 5 % INTRAVENOUS* Tier 4 Clinisol SF SOLUTION 15 % INTRAVENOUS* Tier 3 Dextrose-NaCl SOLUTION % INTRAVENOUS* Tier 2 Prior Authorization Requirement Step Therapy

9 MEDICATIONS ADDED TO THE 2016 MAPD Benefit Tier Quantity Limit Dextrose-NaCl SOLUTION % INTRAVENOUS* Tier 2 Doxycycline Hyclate CAPSULE 100 MG Tier 4 Doxycycline Hyclate CAPSULE 50 MG Tier 3 Doxycycline Hyclate SOLUTION RECONSTITUTED 100 MG INTRAVENOUS* Tier 3 DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE Tier 2 Entecavir TABLET 0.5 MG Tier 5 Entecavir TABLET 1 MG Tier 5 QL(31 EA per 31 QL(31 EA per 31 Prior Authorization Requirement Step Therapy Esbriet CAPSULE 267 MG Tier 5 (ESBRIET) Estradiol PATCH BIWEEKLY MG/24HR TRANSDERMAL Tier 4 (HRM AND TRANSDERMAL ESTROGENS AND PROGESTINS) Estradiol PATCH BIWEEKLY MG/24HR TRANSDERMAL Tier 4 Estradiol PATCH BIWEEKLY 0.05 MG/24HR TRANSDERMAL Tier 4 Estradiol PATCH BIWEEKLY MG/24HR TRANSDERMAL Tier 4 Estradiol PATCH BIWEEKLY 0.1 MG/24HR TRANSDERMAL Tier 4 (HRM AND TRANSDERMAL ESTROGENS AND PROGESTINS) (HRM AND TRANSDERMAL ESTROGENS AND PROGESTINS) (HRM AND TRANSDERMAL ESTROGENS AND PROGESTINS) (HRM AND TRANSDERMAL ESTROGENS AND

10 MEDICATIONS ADDED TO THE 2016 MAPD Benefit Tier Quantity Limit Prior Authorization Requirement PROGESTINS) Step Therapy Etodolac CAPSULE Tier 2 Etodolac ER TABLET EXTENDED RELEASE 24 HR Tier 3 Exel Pen Needles 1/2" 29G X 12MM Tier 2 Ferriprox TABLET 500 MG Tier 5 Fluorometholone SUSPENSION 0.1 % OPHTHALMIC Tier 4 Gardasil 9 INTRAMUSCULAR* Tier 3 Gardasil 9 SUSPENSION INTRAMUSCULAR* Tier 3 (FERRIPROX) (GARDASIL) (GARDASIL) Gattex KIT 5 MG SUBCUTANEOUS* Tier 5 (GATTEX) Halobetasol Propionate CREAM 0.05 % EXTERNAL Tier 4 Halobetasol Propionate OINTMENT 0.05 % EXTERNAL Tier 4 Hepatamine SOLUTION 8 % INTRAVENOUS* Tier 4 Herceptin SOLUTION RECONSTITUTED 440 MG INTRAVENOUS* Tier 5 B/D PA Hetlioz CAPSULE 20 MG Tier 5 (HETLIOZ) QL (2 EA Humira 10 MG/0.2ML SUBCUTANEOUS* Tier 5 per 28 (HUMIRA) Hydrocortisone Butyrate OINTMENT 0.1 % EXTERNAL Tier 4 Hydrocortisone Butyrate SOLUTION 0.1 % EXTERNAL Tier 4

11 MEDICATIONS ADDED TO THE 2016 MAPD Benefit Tier Quantity Limit Hydrocortisone Valerate CREAM 0.2 % EXTERNAL Tier 4 HYDROmorphone HCl PF SOLUTION 500 MG/50ML INJECTION Tier 4 Juxtapid CAPSULE 10 MG Tier 5 Juxtapid CAPSULE 20 MG Tier 5 Juxtapid CAPSULE 5 MG Tier 5 JUXTAPID LOMITAPIDE 30 MG CAPSULE [JUXTAPID] Tier 5 Prior Authorization Requirement (JUXTAPID) (JUXTAPID) (JUXTAPID) (JUXTAPID) Step Therapy JUXTAPID LOMITAPIDE 40 MG CAPSULE [JUXTAPID] Tier 5 JUXTAPID LOMITAPIDE 60 MG CAPSULE [JUXTAPID] Tier 5 Korlym TABLET 300 MG Tier 5 Kynamro 200 MG/ML SUBCUTANEOUS* Tier 5 QL (120 EA per 30 (JUXTAPID) (JUXTAPID) (KYNAMRO) Levoleucovorin Calcium SOLUTION 175 MG/17.5ML INTRAVENOUS* Tier 4 B/D PA Lidocaine HCl 2 % EXTERNAL Tier 2 Lidocaine HCl 2 % EXTERNAL Tier 2 Lidocaine HCl 2 % EXTERNAL Tier 2 Linezolid SOLUTION 2 MG/ML INTRAVENOUS* Tier 5 Lithium Carbonate TABLET 300 MG Tier 2 Methoxsalen Rapid CAPSULE 10 MG Tier 5

12 MEDICATIONS ADDED TO THE 2016 MAPD Benefit Tier Quantity Limit MethylPREDNISolone TABLET 16 MG Tier 2 MethylPREDNISolone TABLET 32 MG Tier 2 Minocycline HCl TABLET 100 MG Tier 4 Minocycline HCl TABLET 50 MG Tier 4 Minocycline HCl TABLET 75 MG Tier 4 Mometasone Furoate SOLUTION 0.1 % EXTERNAL Tier 2 Morphine Sulfate (PF) SOLUTION 10 MG/ML INTRAVENOUS* Tier 3 Morphine Sulfate (PF) SOLUTION 2 MG/ML INTRAVENOUS* Tier 3 Morphine Sulfate (PF) SOLUTION 4 MG/ML INTRAVENOUS* Tier 3 Prior Authorization Requirement Step Therapy Morphine Sulfate (PF) SOLUTION 8 MG/ML INTRAVENOUS* Tier 3 Nalbuphine HCl SOLUTION 10 MG/ML INJECTION Tier 4 Nalbuphine HCl SOLUTION 20 MG/ML INJECTION Tier 4 QL (240 ML per 30 QL (120 ML per 30 Natpara 100 MCG SUBCUTANEOUS* Tier 5 (NATPARA) Natpara 25 MCG SUBCUTANEOUS* Tier 5 (NATPARA) Natpara 50 MCG SUBCUTANEOUS* Tier 5 (NATPARA) Natpara 75 MCG SUBCUTANEOUS* Tier 5 (NATPARA) NephrAmine SOLUTION 5.4 % INTRAVENOUS* Tier 4

13 MEDICATIONS ADDED TO THE 2016 MAPD Benefit Tier Quantity Limit Northera CAPSULE 100 MG Tier 5 Northera CAPSULE 200 MG Tier 5 Northera CAPSULE 300 MG Tier 5 Prior Authorization Requirement (NORTHERA) (NORTHERA) (NORTHERA) Step Therapy Ofev CAPSULE 100 MG Tier 5 (OFEV) Ofev CAPSULE 150 MG Tier 5 (OFEV) ondansetron 24 mg Tier 2 B/D PA Opsumit TABLET 10 MG Tier 5 (OPSUMIT) Orencia 125 MG/ML SUBCUTANEOUS* Tier 5 (ORENCIA) Orencia SOLUTION RECONSTITUTED 250 MG INTRAVENOUS* Tier 5 (ORENCIA) QL(248 EA OxyCODONE HCl TABLET 20 MG Tier 2 per 31 Oxymorphone HCl ER TABLET EXTENDED RELEASE 12 HR Tier 4 QL (62 EA per 31 PACLitaxel CONCENTRATE 300 MG/50ML INTRAVENOUS* Tier 4 B/D PA PEG-3350/Electrolytes SOLUTION RECONSTITUTED 236 GM Tier 2 Phenadoz SUPPOSITORY 12.5 MG Tier 3 Phenergan SUPPOSITORY 12.5 MG Tier 3 Phenergan SUPPOSITORY 25 MG Tier 3 Phenergan SUPPOSITORY 50 MG Tier 3 (HRM (HRM (HRM (HRM

14 MEDICATIONS ADDED TO THE 2016 MAPD Benefit Tier Quantity Limit Prior Authorization Requirement Step Therapy Pilocarpine HCl SOLUTION 1 % OPHTHALMIC Tier 4 Pilocarpine HCl SOLUTION 2 % OPHTHALMIC Tier 4 Pilocarpine HCl SOLUTION 4 % OPHTHALMIC Tier 4 Preferred Plus Insulin Syringe 28G X 1/2" 0.5 ML Tier 3 Premasol SOLUTION 10 % INTRAVENOUS* Tier 4 QL(100 EA per 30 Premasol SOLUTION 6 % INTRAVENOUS* Tier 4 Procalamine SOLUTION 3 % INTRAVENOUS* Tier 4 Promacta TABLET 12.5mg Tier 5 Promethazine HCl SOLUTION 25 MG/ML INJECTION Tier 3 Promethazine HCl SOLUTION 50 MG/ML INJECTION Tier 3 Promethazine HCl SUPPOSITORY 12.5 MG Tier 3 Promethazine HCl SUPPOSITORY 25 MG Tier 3 Promethazine HCl SUPPOSITORY 50 MG Tier 3 Promethazine HCl SYRUP 6.25 MG/5ML Tier 2 Promethazine HCl TABLET 12.5 MG Tier 2 QL (62 EA per 31 (PROMACTA) (HRM (HRM (HRM (HRM (HRM (HRM (HRM

15 MEDICATIONS ADDED TO THE 2016 MAPD Benefit Tier Quantity Limit Promethazine HCl TABLET 25 MG Tier 2 Promethazine HCl TABLET 50 MG Tier 2 Promethazine VC Plain SYRUP MG/5ML Tier 3 Promethegan SUPPOSITORY 25 MG Tier 3 Promethegan SUPPOSITORY 50 MG Tier 3 Prosol SOLUTION 20 % INTRAVENOUS* Tier 4 Quadracel SUSPENSION INTRAMUSCULAR* Tier 3 Prior Authorization Requirement (HRM (HRM (HRM (HRM (HRM Step Therapy Ravicti LIQUID 1.1 GM/ML Tier 5 (RAVICTI) Recombivax HB SUSPENSION 5 MCG/0.5ML INJECTION Tier 3 B/D PA Riluzole TABLET 50 MG Tier 5 SAPHRIS 2.5 MG SUBLINGUAL TABLET [SAPHRIS] Tier 4 ST New Starts Signifor LAR SUSPENSION RECONSTITUTED 20 MG INTRAMUSCULAR* Tier 5 Signifor LAR SUSPENSION RECONSTITUTED 40 MG INTRAMUSCULAR* Tier 5 Signifor LAR SUSPENSION RECONSTITUTED 60 MG INTRAMUSCULAR* Tier 5 (SIGNIFOR LAR) (SIGNIFOR LAR) (SIGNIFOR LAR) Signifor SOLUTION 0.3 MG/ML SUBCUTANEOUS* Tier 5 (SIGNIFOR) Signifor SOLUTION 0.6 MG/ML SUBCUTANEOUS* Tier 5 (SIGNIFOR) Signifor SOLUTION 0.9 MG/ML SUBCUTANEOUS* Tier 5 (SIGNIFOR)

16 MEDICATIONS ADDED TO THE 2016 MAPD Benefit Tier Quantity Limit Prior Authorization Requirement Step Therapy Sirturo TABLET 100 MG Tier 5 (SIRTURO) Sodium Fluoride TABLET CHEWABLE 1.1 (0.5 F) MG Tier 2 Telmisartan TABLET 20 MG Tier 4 Telmisartan TABLET 40 MG Tier 4 Telmisartan TABLET 80 MG Tier 4 Tenivac INJECTABLE 5-2 LFU INTRAMUSCULAR* Tier 3 Theophylline ER TABLET EXTENDED RELEASE 24 HR* 400 MG Tier 3 Theophylline ER TABLET EXTENDED RELEASE 24 HR* 600 MG Tier 3 TOLCAPONE 100 MG TABLET Tier 5 Travasol SOLUTION 10 % INTRAVENOUS* Tier 4 TrophAmine SOLUTION 10 % INTRAVENOUS* Tier 4 Trophamine SOLUTION 6 % INTRAVENOUS* Tier 4 Trumenba INTRAMUSCULAR* Tier 4 Typhim VI SOLUTION 25 MCG/0.5ML INTRAMUSCULAR* Tier 3 ValGANciclovir HCl TABLET 450 MG Tier 5 Vaqta SUSPENSION 25 UNIT/0.5ML INTRAMUSCULAR* Tier 3 Vaqta SUSPENSION 50 UNIT/ML INTRAMUSCULAR* Tier 3 Verapamil HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 360 MG Tier 2 Voriconazole SUSPENSION RECONSTITUTED 40 MG/ML Tier 5 (VORICONAZOLE) Yervoy SOLUTION 50 MG/10ML INTRAVENOUS* Tier 5 (YERVOY) Zoledronic Acid CONCENTRATE 4 MG/5ML INTRAVENOUS* Tier 4 (ZOMETA)

17 MEDICATIONS WITH TIERING CHANGES 2015 Tier 2016 Tier Acebutolol HCl CAPSULE 200 MG Tier 2 Tier 3 Acebutolol HCl CAPSULE 400 MG Tier 2 Tier 3 Albuterol Sulfate TABLET 2 MG Tier 2 Tier 4 Albuterol Sulfate TABLET 4 MG Tier 2 Tier 4 Alosetron HCl TABLET 0.5 MG Tier 3 Tier 5 Amcinonide CREAM 0.1 % EXTERNAL Tier 2 Tier 4 Amifostine SOLUTION RECONSTITUTED 500 MG INTRAVENOUS* Tier 4 Tier 5 Amitiza Tier 4 Tier 3 Atovaquone SUSPENSION 750 MG/5ML Tier 4 Tier 5 AzaCITIDine SUSPENSION RECONSTITUTED 100 MG INJECTION Tier 4 Tier 5 Azithromycin SUSPENSION RECONSTITUTED 100 MG/5ML Tier 2 Tier 3 Azithromycin SUSPENSION RECONSTITUTED 200 MG/5ML Tier 2 Tier 3 Bacitracin OINTMENT 500 UNIT/GM OPHTHALMIC Tier 2 Tier 3 Banzel TABLET 400 MG Tier 4 Tier 5 Betamethasone Dipropionate CREAM 0.05 % EXTERNAL Tier 2 Tier 4 Betamethasone Dipropionate OINTMENT 0.05 % EXTERNAL Tier 2 Tier 4 Cefaclor ER TABLET EXTENDED RELEASE 12 HR* 500 MG Tier 2 Tier 4 Cefdinir CAPSULE 300 MG Tier 2 Tier 3 Cefdinir SUSPENSION RECONSTITUTED 125 MG/5ML Tier 2 Tier 4 Cefdinir SUSPENSION RECONSTITUTED 250 MG/5ML Tier 2 Tier 4 Cefuroxime Axetil TABLET 250 MG Tier 2 Tier 3

18 MEDICATIONS WITH TIERING CHANGES 2015 Tier 2016 Tier Cefuroxime Axetil TABLET 500 MG Tier 2 Tier 3 ChlorproMAZINE HCl TABLET 10 MG Tier 2 Tier 3 ChlorproMAZINE HCl TABLET 100 MG Tier 2 Tier 3 ChlorproMAZINE HCl TABLET 200 MG Tier 2 Tier 3 ChlorproMAZINE HCl TABLET 25 MG Tier 2 Tier 3 ChlorproMAZINE HCl TABLET 50 MG Tier 2 Tier 3 Ciclopirox Olamine CREAM 0.77 % EXTERNAL Tier 3 Tier 2 Ciclopirox Olamine SUSPENSION 0.77 % EXTERNAL Tier 3 Tier 2 Ciprofloxacin HCl TABLET 100 MG Tier 2 Tier 4 Citalopram Hydrobromide SOLUTION 10 MG/5ML Tier 1 Tier 2 Clarithromycin TABLET 250 MG Tier 2 Tier 3 Clarithromycin TABLET 500 MG Tier 2 Tier 3 Clindamycin Phosphate 1 % EXTERNAL Tier 2 Tier 3 Clindamycin Phosphate LOTION 1 % EXTERNAL Tier 2 Tier 3 Clobetasol Propionate E CREAM 0.05 % EXTERNAL Tier 2 Tier 4 Clobetasol Propionate OINTMENT 0.05 % EXTERNAL Tier 2 Tier 4 Clobetasol Propionate SOLUTION 0.05 % EXTERNAL Tier 2 Tier 3 Clotrimazole-Betamethasone LOTION % EXTERNAL Tier 2 Tier 4 Creon CAPSULE DELAYED RELEASE PARTICLES UNIT Tier 3 Tier 5 Creon CAPSULE DELAYED RELEASE PARTICLES UNIT Tier 3 Tier 4 Creon CAPSULE DELAYED RELEASE PARTICLES UNIT Tier 3 Tier 4 Creon CAPSULE DELAYED RELEASE PARTICLES UNIT Tier 3 Tier 4 Creon CAPSULE DELAYED RELEASE PARTICLES 6000 UNIT Tier 3 Tier 4

19 MEDICATIONS WITH TIERING CHANGES 2015 Tier 2016 Tier Cyclophosphamide CAPSULE 25 MG Tier 4 Tier 2 Cyclophosphamide CAPSULE 50 MG Tier 4 Tier 2 Desonide CREAM 0.05 % EXTERNAL Tier 2 Tier 4 Desonide LOTION 0.05 % EXTERNAL Tier 2 Tier 4 Desonide OINTMENT 0.05 % EXTERNAL Tier 2 Tier 4 Diclofenac Sodium 3 % TRANSDERMAL Tier 4 Tier 5 Dipyridamole TABLET 25 MG Tier 2 Tier 3 Dipyridamole TABLET 50 MG Tier 2 Tier 3 Dipyridamole TABLET 75 MG Tier 2 Tier 3 Doxycycline Hyclate TABLET 100 MG Tier 2 Tier 4 Doxycycline Hyclate TABLET 100 MG Tier 2 Tier 4 Doxycycline Monohydrate TABLET 50 MG Tier 2 Tier 3 Doxycycline Monohydrate TABLET 50 MG Tier 2 Tier 3 Edurant TABLET 25 MG Tier 4 Tier 5 Emsam PATCH 24 HR 12 MG/24HR TRANSDERMAL Tier 4 Tier 5 Emsam PATCH 24 HR 6 MG/24HR TRANSDERMAL Tier 4 Tier 5 Emsam PATCH 24 HR 9 MG/24HR TRANSDERMAL Tier 4 Tier 5 Epogen SOLUTION UNIT/ML INJECTION Tier 4 Tier 5 Ery PAD 2 % EXTERNAL Tier 2 Tier 3 Erythromycin Base TABLET 250 MG Tier 2 Tier 4 Erythromycin Base TABLET 500 MG Tier 2 Tier 4 Fanapt TABLET 10 MG Tier 4 Tier 5 Fanapt TABLET 12 MG Tier 4 Tier 5 Fanapt TABLET 6 MG Tier 4 Tier 5 Fanapt TABLET 8 MG Tier 4 Tier 5 Faslodex SOLUTION 250 MG/5ML INTRAMUSCULAR* Tier 4 Tier 5

20 MEDICATIONS WITH TIERING CHANGES 2015 Tier 2016 Tier FentaNYL PATCH 72 HR 100 MCG/HR TRANSDERMAL Tier 2 Tier 3 FentaNYL PATCH 72 HR 12 MCG/HR TRANSDERMAL Tier 2 Tier 3 FentaNYL PATCH 72 HR 25 MCG/HR TRANSDERMAL Tier 2 Tier 3 FentaNYL PATCH 72 HR 50 MCG/HR TRANSDERMAL Tier 2 Tier 3 FentaNYL PATCH 72 HR 75 MCG/HR TRANSDERMAL Tier 2 Tier 3 Fluocinolone Acetonide CREAM 0.01 % EXTERNAL Tier 2 Tier 4 FluPHENAZine Decanoate SOLUTION 25 MG/ML INJECTION Tier 2 Tier 4 Hydrochlorothiazide TABLET 12.5 MG Tier 3 Tier 2 Hydrocodone-Acetaminophen SOLUTION MG/15ML Tier 2 Tier 4 Invega Sustenna SUSPENSION 78 MG/0.5ML INTRAMUSCULAR* Tier 4 Tier 5 Invega TABLET EXTENDED RELEASE 24 HR* 1.5 MG Tier 4 Tier 5 Invega TABLET EXTENDED RELEASE 24 HR* 3 MG Tier 4 Tier 5 Invega TABLET EXTENDED RELEASE 24 HR* 6 MG Tier 4 Tier 5 Invega TABLET EXTENDED RELEASE 24 HR* 9 MG Tier 4 Tier 5 Invirase CAPSULE 200 MG Tier 4 Tier 5 Invirase TABLET 500 MG Tier 4 Tier 5 Kaletra TABLET MG Tier 4 Tier 5 Ketorolac Tromethamine SOLUTION 0.4 % OPHTHALMIC Tier 3 Tier 2 Ketorolac Tromethamine SOLUTION 0.5 % OPHTHALMIC Tier 3 Tier 2 Levofloxacin SOLUTION 25 MG/ML INTRAVENOUS* Tier 2 Tier 4 Levofloxacin SOLUTION 25 MG/ML Tier 2 Tier 4 Lexiva TABLET 700 MG Tier 4 Tier 5 Lidocaine OINTMENT 5 % EXTERNAL Tier 2 Tier 4 Lomustine CAPSULE 10 MG Tier 4 Tier 2

21 MEDICATIONS WITH TIERING CHANGES 2015 Tier 2016 Tier Lomustine CAPSULE 100 MG Tier 4 Tier 2 Lomustine CAPSULE 40 MG Tier 4 Tier 2 Lotronex TABLET 0.5 MG Tier 3 Tier 5 Mesnex TABLET 400 MG Tier 4 Tier 5 Methenamine Hippurate TABLET 1 GM Tier 2 Tier 3 Midodrine HCl TABLET 10 MG Tier 2 Tier 3 Midodrine HCl TABLET 2.5 MG Tier 2 Tier 3 Midodrine HCl TABLET 5 MG Tier 2 Tier 3 Nilandron TABLET 150 MG Tier 4 Tier 5 Ondansetron TABLET DISPERSIBLE 4 MG Tier 2 Tier 3 Ondansetron TABLET DISPERSIBLE 8 MG Tier 2 Tier 3 Permethrin CREAM 5 % EXTERNAL Tier 2 Tier 4 Perphenazine TABLET 16 MG Tier 2 Tier 4 Perphenazine TABLET 16 MG Tier 2 Tier 4 Perphenazine TABLET 2 MG Tier 2 Tier 4 Perphenazine TABLET 2 MG Tier 2 Tier 4 Perphenazine TABLET 4 MG Tier 2 Tier 4 Perphenazine TABLET 4 MG Tier 2 Tier 4 Perphenazine TABLET 8 MG Tier 2 Tier 4 Perphenazine TABLET 8 MG Tier 2 Tier 4 Pioglitazone HCl TABLET 15 MG Tier 2 Tier 3 Pioglitazone HCl TABLET 30 MG Tier 2 Tier 3 Pioglitazone HCl TABLET 45 MG Tier 2 Tier 3 Potiga TABLET 300 MG Tier 4 Tier 5 Potiga TABLET 400 MG Tier 4 Tier 5 Progesterone Micronized CAPSULE 200 MG Tier 2 Tier 3 Propranolol HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 120 MG Tier 2 Tier 3

22 MEDICATIONS WITH TIERING CHANGES 2015 Tier 2016 Tier Propranolol HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 160 MG Tier 2 Tier 3 Propranolol HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 60 MG Tier 2 Tier 3 Propranolol HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 80 MG Tier 2 Tier 3 Propylthiouracil TABLET 50 MG Tier 2 Tier 3 QUEtiapine Fumarate TABLET 100 MG Tier 2 Tier 3 QUEtiapine Fumarate TABLET 200 MG Tier 2 Tier 3 QUEtiapine Fumarate TABLET 25 MG Tier 2 Tier 3 QUEtiapine Fumarate TABLET 300 MG Tier 2 Tier 3 QUEtiapine Fumarate TABLET 400 MG Tier 2 Tier 3 QUEtiapine Fumarate TABLET 50 MG Tier 2 Tier 3 Rapamune SOLUTION 1 MG/ML Tier 4 Tier 5 Reyataz CAPSULE 150 MG Tier 3 Tier 5 Reyataz CAPSULE 200 MG Tier 3 Tier 5 Reyataz CAPSULE 300 MG Tier 3 Tier 5 Reyataz PACKET 50 MG Tier 3 Tier 5 Ridaura CAPSULE 3 MG Tier 3 Tier 5 Riluzole TABLET 50 MG Tier 5 Tier 4 Sulfamethoxazole-Trimethoprim SUSPENSION MG/5ML Tier 2 Tier 3 Syprine CAPSULE 250 MG Tier 4 Tier 5 Targretin 1 % EXTERNAL Tier 3 Tier 5 Targretin CAPSULE 75 MG Tier 3 Tier 5 Tekturna Tier 4 Tier 3 Testosterone Cypionate SOLUTION 100 MG/ML INTRAMUSCULAR* Tier 2 Tier 3 Testosterone Cypionate SOLUTION 200 MG/ML INTRAMUSCULAR* Tier 2 Tier 3 Testosterone Enanthate SOLUTION 200 MG/ML INTRAMUSCULAR* Tier 2 Tier 3 Thiothixene CAPSULE 1 MG Tier 2 Tier 3 Thiothixene CAPSULE 10 MG Tier 2 Tier 3

23 MEDICATIONS WITH TIERING CHANGES 2015 Tier 2016 Tier Thiothixene CAPSULE 2 MG Tier 2 Tier 3 Thiothixene CAPSULE 5 MG Tier 2 Tier 3 Triamcinolone Acetonide LOTION 0.1 % EXTERNAL Tier 2 Tier 4 Triamcinolone Acetonide PASTE 0.1 % MOUTH/THROAT Tier 2 Tier 3 Tybost TABLET 150 MG Tier 4 Tier 3 Tyzeka TABLET 600 MG Tier 4 Tier 5 Ursodiol CAPSULE 300 MG Tier 2 Tier 4 Venlafaxine HCl TABLET 100 MG Tier 3 Tier 2 Venlafaxine HCl TABLET 25 MG Tier 3 Tier 2 Venlafaxine HCl TABLET 37.5 MG Tier 3 Tier 2 Venlafaxine HCl TABLET 50 MG Tier 3 Tier 2 Venlafaxine HCl TABLET 75 MG Tier 3 Tier 2 Xarelto TABLET Tier 3 Tier 4 Xifaxan TABLET 550 MG Tier 4 Tier 5 Zortress TABLET 0.5 MG Tier 4 Tier 5 Zortress TABLET 0.75 MG Tier 4 Tier 5 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES Drug Description 2016 Quantity Limit Acamprosate Calcium TABLET DELAYED RELEASE 333 MG Alinia TABLET 500 MG AmLODIPine Besylate TABLET 2.5 MG Asmanex Aerosol Powder Atrovent HFA AEROSOL, SOLUTION 17 MCG/ACT INHALATION Calcitonin (Salmon) SOLUTION 200 UNIT/ACT NASAL Dexilant CAPSULE DELAYED RELEASE 30 MG Dexilant CAPSULE DELAYED RELEASE 60 MG Emend caps Emend titration Added QL 31 EA per 31 days Changed QL 1.00 EA per 30 days Changed QL 25.8 GM per 30 days Changed QL to 3.7 ML per 30 days Changed QL 62 EA per 31 days Changed QL 31 EA per 31 days

24 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES Drug Description 2016 Quantity Limit Enbrel SureClick 50 MG/ML SUBCUTANEOUS* Famciclovir Tab 250 MG Flovent Diskus AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST INHALATION Flovent Diskus AEROSOL POWDER, BREATH ACTIVATED 250 MCG/BLIST INHALATION Flovent Diskus AEROSOL POWDER, BREATH ACTIVATED 50 MCG/BLIST INHALATION Flovent HFA AEROSOL 110 MCG/ACT INHALATION Flovent HFA AEROSOL 220 MCG/ACT INHALATION Flovent HFA AEROSOL 44 MCG/ACT INHALATION GlipiZIDE ER TABLET EXTENDED RELEASE 24 HR* 2.5 MG GlipiZIDE ER TABLET EXTENDED RELEASE 24 HR* 5 MG Humira 20 MG/0.4ML SUBCUTANEOUS* Humira 40 MG/0.8ML SUBCUTANEOUS* Leflunomide TABLET 10 MG Leflunomide TABLET 20 MG Lenvima 14 MG Daily Dose 10 & 4 MG Lenvima 24 MG Daily Dose 10 (2) & 4 MG LevETIRAcetam TABLET 1000 MG LevETIRAcetam TABLET 250 MG LevETIRAcetam TABLET 500 MG LevETIRAcetam TABLET 750 MG Losartan Potassium TABLET 100 MG Losartan Potassium TABLET 25 MG Losartan Potassium TABLET 50 MG Losartan Potassium-HCTZ TABLET MG Losartan Potassium-HCTZ TABLET MG Changed QL 8 ML per 31 days Changed QL 60 per 30 days Changed QL 240 EA per 30 days Changed QL 60 EA per 30 days Changed QL 12 GM per 30 days Changed QL 24 GM per 30 days Changed QL 10.6 GM per 30 days Changed QL 62 EA per 31 days Changed QL 62 EA per 31 days Changed QL to 2 EA per 28 days Changed QL to 6 EA per 28 days Added QL 31 EA per 31 days Added QL 62 EA per 31 days Added QL 62 EA per 31 days Added QL 31 EA per 31 days Added QL 31 EA per 31 days

25 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES Drug Description 2016 Quantity Limit Losartan Potassium-HCTZ TABLET MG Added QL 62 EA per 31 days Naratriptan HCl TABLET 1 MG Naratriptan HCl TABLET 2.5 MG Nitrofurantoin Macrocrystal CAPSULE 50 MG Nitrofurantoin Monohyd Macro CAPSULE 100 MG Oxandrolone Tab 2.5 MG Changed QL 9 EA per 31 days Changed QL 9 EA per 31 days Added QL 90 EA per 365 days Added QL 90 EA per 365 days Changed QL to 124 EA per 31 days Promacta TABLET 25 MG Changed QL to 62 EA per 31 Promacta TABLET 50 MG Changed QL to 62 EA per 31 Promacta TABLET 75 MG Changed QL to 62 EA per 31 Relenza Diskhaler AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER INHALATION Changed QL 60 EA per 180 days risperidone oral tablet risperidone oral tablet dispersible Sensipar TABLET 30 MG Strattera CAPSULE 10 MG Strattera CAPSULE 18 MG Strattera CAPSULE 25 MG Strattera CAPSULE 40 MG Suboxone FILM MG SUBLINGUAL Suboxone FILM 4-1 MG SUBLINGUAL Suboxone FILM 8-2 MG SUBLINGUAL Symbicort Changed QL 124 EA per 31 days Changed QL 124 EA per 31 days Changed QL 62 EA per 31 days Changed QL 62 EA per 31 days Changed QL 62 EA per 31 days Changed QL 62 EA per 31 days Changed QL 62 EA per 31 days Changed QL 93 EA per 31 days Changed QL 93 EA per 31 days Changed QL 93 EA per 31 days Changed QL GM per 30 days Tecfidera 120 & 240 MG Tecfidera CAPSULE DELAYED RELEASE 120 MG Change QL to 62 EA per 31 ValACYclovir HCl TABLET 1 GM ValACYclovir HCl TABLET 500 MG Xifaxan TABLET 200 MG

26 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES Drug Description 2016 Quantity Limit Zortress TABLET 0.25 MG Zortress TABLET 0.5 MG Zortress TABLET 0.75 MG MEDICATIONS WITH PRIOR AUTHORIZATION REQUIREMENT CHANGES Change Description Amphetamine-Dextroamphetamine TABLET 10 MG Amphetamine-Dextroamphetamine TABLET 12.5 MG Amphetamine-Dextroamphetamine TABLET 15 MG Amphetamine-Dextroamphetamine TABLET 20 MG Amphetamine-Dextroamphetamine TABLET 30 MG Amphetamine-Dextroamphetamine TABLET 5 MG Amphetamine-Dextroamphetamine TABLET 7.5 MG Butalbital-APAP-Caff-Cod CAPSULE MG Butalbital-APAP-Caffeine CAPSULE MG Dextroamphetamine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 10 MG Dextroamphetamine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 15 MG Dextroamphetamine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 5 MG Dextroamphetamine Sulfate TABLET 10 MG Dextroamphetamine Sulfate TABLET 5 MG Digoxin mg Nitrofurantoin Macrocrystal CAPSULE 50 MG Nitrofurantoin Monohyd Macro CAPSULE 100 MG ondansetron ODT ondansetron tabs Oxandrolone Tab 10 MG Oxandrolone Tab 2.5 MG Rozerem TABLET 8 MG Added PA requirement Added PA requirement Added PA requirement Add B/D PA Add B/D PA Added PA requirement Added PA requirement

27 MEDICATIONS WITH PRIOR AUTHORIZATION REQUIREMENT CHANGES Change Description Testosterone Cypionate SOLUTION 100 MG/ML INTRAMUSCULAR* Testosterone Cypionate SOLUTION 200 MG/ML INTRAMUSCULAR* Testosterone Enanthate SOLUTION 200 MG/ML INTRAMUSCULAR* Xarelto Starter Pack 15 & 20 MG Xarelto TABLET 10 MG Xarelto TABLET 15 MG Xarelto TABLET 20 MG Added PA requirement Added PA requirement Added PA requirement