2017 Formulary Annual Notice of Change

Transcription

1 Updated: October 10, Formulary Annual Notice of Change Commercial 5 Tier - Qualified Health Plans (QHP) This is a listing of the changes that have occurred to the 2017 Commercial Qualified Health Plans 5 Tier formulary. For a complete list, please refer to our website and review the 2017 QHP 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 call Customer Service toll-free at (TTY/TDD relay: ) Monday through Friday from 8 a.m. to 5 p.m. or visit myfhca.org. 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, 2018, and from time to time during the year. The Formulary and pharmacy network may change at any time. You will receive notice when necessary. Health First Commercial Plans, Inc. is doing business under the name of Florida Hospital Care Advantage. Florida Hospital Care Advantage does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations _MPINFO165FH (11/2016)

2 MEDICATIONS REMOVED FROM THE 2016 QHP FORMULARY Medication Name Medication Name Abilify Discmelt 10mg tablet,disintegrating donepezil 10mg tablet,disintegrating Aggrenox mg capsule, ER multiphase 12 hr donepezil 5mg tablet,disintegrating amiodarone 400mg tablet Edarbi 40mg tablet AndroGel 1 %(25 mg/2.5gram) gel in packet Edarbi 80mg tablet AndroGel 1 %(50 mg/5 gram) gel in packet AndroGel 1.25 gram/actuation (1 %) gel in metereddose pump Atralin 0.05% gel Avodart 0.5mg capsule Axert 12.5mg tablet Axert 6.25mg tablet betamethasone valerate 0.12% foam Carac 0.5% cream Cardizem LA 120mg tablet extended release 24 hr cefaclor 500mg tablet extended release 12 hr Celebrex 100mg capsule Celebrex 200mg capsule Celebrex 400mg capsule Celebrex 50mg capsule ClindaMax 1% gel clindamycin HCl 75mg capsule clindamycin phosphate 1% foam clobetasol 0.05% foam clobetasol-emollient 0.05% foam Cloderm 0.1% cream Colcrys 0.6mg tablet Cormax 0.05% solution Crestor 10mg tablet Crestor 20mg tablet Crestor 40mg tablet Crestor 5mg tablet cyclobenzaprine 7.5mg tablet Dibenzyline 10mg capsule diltiazem HCl 360mg capsule,extended release 24hr EEMT HS mg tablet Enablex 15mg tablet extended release 24 hr Enablex 7.5mg tablet extended release 24 hr eprosartan 600mg tablet FazaClo 100mg tablet,disintegrating FazaClo 12.5mg tablet,disintegrating FazaClo 150mg tablet,disintegrating FazaClo 200mg tablet,disintegrating FazaClo 25mg tablet,disintegrating Fluoroplex 1% cream fluorouracil 0.5% cream Frova 2.5mg tablet Gleevec 100mg tablet Gleevec 400mg tablet Glyset 100mg tablet Glyset 25mg tablet Glyset 50mg tablet Gralise 30-Day Starter Pack 300 mg (9)-600 mg (69) tablet extended release 24 hr Ibudone 5-200mg tablet Jalyn mg capsule, ER multiphase 24 hr Januvia 100mg tablet Januvia 25mg tablet Januvia 50mg tablet Lamictal ODT 100mg tablet,disintegrating Lamictal ODT 200mg tablet,disintegrating Lamictal ODT 25mg tablet,disintegrating Lamictal ODT 50mg tablet,disintegrating Lamictal ODT Starter (Blue) 25 mg (21)-50 mg (7) tablet disintegrating, dose pk Lamictal ODT Starter (Green) 50 mg (42)-100 mg (14) tablet disintegrating, dose pk

3 MEDICATIONS REMOVED FROM THE 2016 QHP FORMULARY Medication Name Lamictal ODT Starter (Orange) 25 mg(14)-50 mg(14)-100 mg (7) tablet disintegrating, dose pk Liptruzet 10-10mg tablet Liptruzet 10-20mg tablet Liptruzet 10-40mg tablet Liptruzet 10-80mg tablet Lodosyn 25mg tablet Lotronex 0.5mg tablet Lotronex 1mg tablet Luxiq 0.12% foam Mestinon Timespan 180mg tablet extended release metformin 1,000mg tablet extended release 24hr metformin 500mg tablet extended release 24hr methylphenidate 10mg tablet,chewable methylphenidate 2.5mg tablet,chewable methylphenidate 5mg tablet,chewable Migranol Minivelle 0.025mg/24 hr patch semiweekly Minivelle mg/24 hr patch semiweekly Minivelle 0.05mg/24 hr patch semiweekly Minivelle 0.075mg/24 hr patch semiweekly Minivelle 0.1mg/24 hr patch semiweekly minocycline 100mg tablet minocycline 50mg tablet minocycline 75mg tablet Naftin 2% cream Namenda 10mg tablet Namenda 2mg/mL solution Namenda 5mg tablet Namenda Titration Pak 5-10mg tablets,dose pack naproxen sodium 275mg tablet naproxen sodium 550mg tablet Nasonex 50mcg/actuation spray,non-aerosol Niaspan Extended-Release 1,000mg tablet extended release 24 hr Medication Name Niaspan Extended-Release 500mg tablet extended release 24 hr Niaspan Extended-Release 750mg tablet extended release 24 hr Nuvigil 150mg tablet Nuvigil 200mg tablet Nuvigil 250mg tablet Nuvigil 50mg tablet Onglyza 2.5mg tablet Onglyza 5mg tablet Orap 1mg tablet Orap 2mg tablet Orapred ODT 10mg tablet,disintegrating Orapred ODT 15mg tablet,disintegrating Orapred ODT 30mg tablet,disintegrating Ovace Plus Shampoo 10% shampoo Ovace Plus Wash 10% cleanser,gel extended release Oxistat 1% cream OxyContin 10mg tablet extended release 12 hr OxyContin 10mg tablet,oral only,ext.rel.12 hr OxyContin 15mg tablet extended release 12 hr OxyContin 15mg tablet,oral only,ext.rel.12 hr OxyContin 160mg tablet extended release 12 hr OxyContin 20mg tablet extended release 12 hr OxyContin 20mg tablet,oral only,ext.rel.12 hr OxyContin 30mg tablet extended release 12 hr OxyContin 30mg tablet,oral only,ext.rel.12 hr OxyContin 40mg tablet extended release 12 hr OxyContin 40mg tablet,oral only,ext.rel.12 hr OxyContin 60mg tablet extended release 12 hr OxyContin 60mg tablet,oral only,ext.rel.12 hr OxyContin 80mg tablet extended release 12 hr OxyContin 80mg tablet,oral only,ext.rel.12 hr Patanol 0.1% drops Proventil HFA 90mcg/actuation HFA aerosol inhaler

4 MEDICATIONS REMOVED FROM THE 2016 QHP FORMULARY Medication Name ranitidine HCl 150mg capsule ranitidine HCl 300mg capsule Rapamune 0.5mg tablet Rapamune 1mg tablet Rapamune 2mg tablet Rea Lo 39 39% cream Rea Lo 40 40% cream Reclast 5mg/100 ml solution Remicade 100mg recon soln Rosadan 0.75% cream Rosadan 0.75% gel Soriatane 10mg capsule Soriatane 17.5mg capsule Soriatane 25mg capsule Stromectol 3mg tablet Suprax 100mg/5 ml suspension for reconstitution Suprax 200mg/5 ml suspension for reconstitution Sure-Touch Lancet misc Surmontil 100mg capsule Surmontil 25mg capsule Surmontil 50mg capsule Taclonex % ointment Targretin 75mg capsule Medication Name Tasmar 100mg tablet temazepam 22.5mg capsule temazepam 7.5mg capsule Testim 50mg/5 gram (1 %) gel Tikosyn 125mcg capsule Tikosyn 250mcg capsule Tikosyn 500mcg capsule timolol maleate 0.25% gel forming solution timolol maleate 0.5% gel forming solution tizanidine 2mg capsule tizanidine 4mg capsule tizanidine 6mg capsule Treximet mg tablet Valcyte 450mg tablet Vandazole 0.75% gel Vectical 3mcg/gram ointment Voltaren 1% gel Xenazine 12.5mg tablet Xenazine 25mg tablet Zovirax 5% cream Zymaxid 0.5% drops Zyvox 100mg/5 ml suspension for reconstitution Zyvox 600mg tablet MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name acetaminophen-codeine 120 mg-12 mg/5 ml (5 ml) solution Benefit Tier Tier 3 Quantity Limit (QL) QL(2700 ML per 30 Prior Authorization () or Step Therapy (ST) Requirement acetaminophen-codeine 240 mg-24 mg/10 ml (10 ml) solution acetaminophen-codeine 300 mg-30 mg/12.5 ml solution Tier 3 Tier 3 QL(2700 ML per 30 QL(2700 ML per 30 acetic acid-aluminum acetate 2% drops Tier 2

5 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Addyi 100mg tablet Tier 5 Adempas 0.5mg tablet Tier 5 Adempas 1.5mg tablet Tier 5 Adempas 1mg tablet Tier 5 Adempas 2.5mg tablet Tier 5 Adempas 2mg tablet Tier 5 Adrucil 500mg/10 ml solution Tier 3 Afeditab CR 30mg tablet extended release Tier 2 Afeditab CR 60mg tablet extended release Tier 2 AK-Poly-Bac ,000unit/gram ointment Tier 2 albuterol sulfate 5mg/mL solution for nebulization Tier 2 aluminum chloride 20% solution Tier 2 aminophylline 100mg tablet Tier 2 aminophylline 200mg tablet Tier 2 Ampyra 10mg tablet extended release 12 hr Tier 5 Amturnide mg tablet Tier 3 Amturnide mg tablet Tier 3 Amturnide mg tablet Tier 3

6 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Amturnide mg tablet Tier 3 Amturnide mg tablet Tier 3 antipyrine-benzocaine % drops Tier 2 Aptiom 200mg tablet Tier 4 Aptiom 400mg tablet Tier 4 Aptiom 600mg tablet Tier 4 Aptiom 800mg tablet Tier 4 Aranesp (in albumin) 100mcg/0.5 ml syringe Tier 5 Aranesp (in albumin) 100mcg/mL solution Tier 5 Aranesp (in albumin) 150mcg/0.3 ml syringe Tier 5 Aranesp (in albumin) 150mcg/0.75 ml solution Tier 5 Aranesp (in albumin) 200mcg/0.4 ml syringe Tier 5 Aranesp (in albumin) 200mcg/mL solution Tier 5 Aranesp (in albumin) 25mcg/0.42 ml syringe Tier 5 Aranesp (in albumin) 25mcg/mL solution Tier 5 Aranesp (in albumin) 300mcg/0.6 ml syringe Tier 5 Aranesp (in albumin) 300mcg/mL solution Tier 5

7 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Aranesp (in albumin) 40mcg/0.4 ml syringe Tier 5 Aranesp (in albumin) 40mcg/mL solution Tier 5 Aranesp (in albumin) 500mcg/mL syringe Tier 5 Aranesp (in albumin) 60mcg/0.3 ml syringe Tier 5 Aranesp (in albumin) 60mcg/mL solution Tier 5 Aranesp (in polysorbate) 100mcg/0.5 ml syringe Tier 5 Aranesp (in polysorbate) 100mcg/mL solution Tier 5 Aranesp (in polysorbate) 10mcg/0.4 ml syringe Aranesp (in polysorbate) 150mcg/0.3 ml syringe Aranesp (in polysorbate) 150mcg/0.75 ml solution Aranesp (in polysorbate) 200mcg/0.4 ml syringe Tier 5 Tier 5 Tier 5 Tier 5 Aranesp (in polysorbate) 200mcg/mL solution Tier 5 Aranesp (in polysorbate) 25mcg/0.42 ml syringe Tier 5 Aranesp (in polysorbate) 25mcg/mL solution Tier 5 Aranesp (in polysorbate) 300mcg/0.6 ml syringe Tier 5 Aranesp (in polysorbate) 300mcg/mL solution Tier 5 Aranesp (in polysorbate) 40mcg/0.4 ml syringe Tier 5

8 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Aranesp (in polysorbate) 40mcg/mL solution Tier 5 Aranesp (in polysorbate) 500mcg/mL syringe Tier 5 Aranesp (in polysorbate) 60mcg/0.3 ml syringe Tier 5 Aranesp (in polysorbate) 60mcg/mL solution Tier 5 Aranesp SureClick (polysorbat) 100mcg/0.5 ml pen injector Aranesp SureClick (polysorbat) 150mcg/0.3 ml pen injector Aranesp SureClick (polysorbat) 200mcg/0.4 ml pen injector Aranesp SureClick (polysorbat) 25mcg/0.42 ml pen injector Aranesp SureClick (polysorbat) 300mcg/0.6 ml pen injector Aranesp SureClick (polysorbat) 40mcg/0.4 ml pen injector Aranesp SureClick (polysorbat) 500mcg/mL pen injector Aranesp SureClick (polysorbat) 60mcg/0.3 ml pen injector Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 aripiprazole 10mg tablet,disintegrating Tier 5 aripiprazole 15mg tablet,disintegrating Tier 5 armodafinil 150mg tablet Tier 4 armodafinil 200mg tablet Tier 4 armodafinil 250mg tablet Tier 4 QL(60 EA per 30 QL(60 EA per 30 QL (30 EA per 30 QL (30 EA per 30 QL (30 EA per 30

9 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier armodafinil 50mg tablet Tier 4 Quantity Limit (QL) QL (30 EA per 30 Prior Authorization () or Step Therapy (ST) Requirement atropine in 0.9 % sod chloride 0.25 mg/5 ml(0.05 mg/ml) syringe Tier 4 atropine sulfate (PF) 1% drops Tier 2 Aubagio 14mg tablet Tier 5 Aubagio 7mg tablet Tier 5 Avandia 8mg tablet Tier 4 BD Lancet Device misc Tier 3 bimatoprost 0.03% drops Tier 4 QL(5 ML per 31 0 Butalbital Compound-Codeine mg capsule Tier 4 QL(180 EA per 30 butalbital-acetaminop-caf-cod mg capsule Tier 4 QL(180 EA per 30 calcitriol 3mcg/gram ointment Tier 5 carbamazepine 100mg tablet extended release 12 hr carbamazepine 100mg/5 ml (5 ml) suspension Tier 3 Tier 3 carbamazepine 200mg/10 ml suspension Tier 3 Cayston 75mg/mL solution for nebulization Tier 5 Cedax 400mg capsule Tier 4 cefazolin 10gram recon soln Tier 3

10 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement cefazolin 1gram recon soln Tier 2 cefazolin 500mg recon soln Tier 2 cefazolin in dextrose (iso-os) 1gram/50 ml piggyback Tier 3 cefditoren pivoxil 200mg tablet Tier 2 cefditoren pivoxil 400mg tablet Tier 2 cefpodoxime 100mg/5 ml suspension for reconstitution cefpodoxime 50mg/5 ml suspension for reconstitution Tier 3 Tier 3 ceftriaxone 100gram recon soln Tier 2 cefuroxime sodium 1.5gram recon soln Tier 2 cefuroxime sodium 7.5gram recon soln Tier 2 cefuroxime sodium 750mg recon soln Tier 2 cevimeline 30mg capsule Tier 2 Chantix Starting Month Pak 0.5 mg (11)-1 mg (42) tablets,dose pack Tie 6 QL(106 EA per 365 Cialis 2.5mg tablet Tier 4 Cialis 5mg tablet Tier 4 ciclopirox-ure-camph-menth-euc 8% solution Tier 3 ciclopirox-vite-nail lacq remo 8-5% kit Tier 3

11 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Cinryze 500unit (5 ml) recon soln Tier 5 Clindacin Pac 1% kit Tier 2 clotrimazole 10mg troche Tier 2 clozapine 100mg tablet,disintegrating Tier 4 clozapine 12.5mg tablet,disintegrating Tier 4 clozapine 150mg tablet,disintegrating Tier 4 clozapine 200mg tablet,disintegrating Tier 4 clozapine 25mg tablet,disintegrating Tier 4 codeine-butalbital-asa-caff mg capsule Tier 4 QL(180 EA per 30 Cometriq 100 mg/day(80mg x1-20 mg x1) capsule Cometriq 140 mg/day(80mg x1-20 mg x3) capsule Tier 5 Tier 5 Cometriq 60 mg/day(20 mg x 3/day) capsule Tier 5 Copaxone 20mg/mL syringe Tier 5 Cordran Tape Large Roll 4mcg/cm2 tape Tier 4 Cresemba 186mg capsule Tier 5 Cresemba 372mg recon soln Tier 5 cyclosporine 250mg/5 ml solution Tier 3

12 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Cystaran 0.44% drops Tier 4 Daklinza 30mg tablet Tier 5 Daklinza 60mg tablet Tier 5 Daliresp 500mcg tablet Tier 4 darifenacin 15mg tablet extended release 24 hr darifenacin 7.5mg tablet extended release 24 hr Tier 4 Tier 4 Decara 50,000unit capsule Tier 3 Descovy mg tablet Tier 3 desloratadine 5mg tablet Tier 2 desmopressin 10 mcg/spray(0.1 ml) aerosol,spray Tier 3 desoximetasone 0.05% ointment Tier 3 dexamethasone sodium phosphate 4mg/mL solution dexamethasone sodium phosphate 4mg/mL syringe Tier 2 Tier 3 dexchlorpheniramine maleate 2mg/5 ml syrup Tier 4 dextroamphetamine-amphetamine 10mg capsule,extended release 24hr Tier 2 dextroamphetamine-amphetamine 10mg tablet Tier 2 QL(90 EA per 30 dextroamphetamine-amphetamine 15mg capsule,extended release 24hr Tier 2

13 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name dextroamphetamine-amphetamine 20mg capsule,extended release 24hr Benefit Tier Tier 2 Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement dextroamphetamine-amphetamine 20mg tablet Tier 2 QL(90 EA per 30 dextroamphetamine-amphetamine 25mg capsule,extended release 24hr Tier 2 dextroamphetamine-amphetamine 30mg capsule,extended release 24hr Tier 2 dextroamphetamine-amphetamine 30mg tablet Tier 2 QL(60 EA per 30 dextroamphetamine-amphetamine 5mg capsule,extended release 24hr Tier 2 dextroamphetamine-amphetamine 5mg tablet Tier 2 QL(90 EA per 30 diclofenac sodium 1% gel Tier 3 dicyclomine 10mg/5 ml syrup Tier 2 digoxin 0.25 mg/5 ml(5 ml) solution Tier 3 dihydrocode-acetaminophen-caff mg capsule dihydroergotamine 0.5 mg/pumpact. (4 mg/ml) spray,non-aerosol DILT-CD 120mg capsule,extended release 24hr DILT-CD 180mg capsule,extended release 24hr DILT-CD 240mg capsule,extended release 24hr Tier 4 Tier 4 Tier 2 Tier 2 Tier 2 diphenhydramine HCl 50mg/mL solution Tier 2 diphenoxylate-atropine mg tablet Tier 2

14 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement dipivefrin 0.1% drops Tier 4 dofetilide 125mcg capsule Tier 4 dofetilide 250mcg capsule Tier 4 dofetilide 500mcg capsule Tier 4 Donnatal mg/5 ml elixir Tier 4 E.E.S mg/5 ml suspension for reconstitution Tier 4 Eliquis 2.5mg tablet Tier 4 Eliquis 5mg tablet Tier 4 Epiduo % gel Tier 4 EpiPen 0.3mg/0.3 ml auto-injector Tier 3 EpiPen Jr 0.15mg/0.3 ml auto-injector Tier 3 QL(4 EA per 30 QL(4 EA per 30 erythromycin 2% solution Tier 2 erythromycin 250mg capsule,delayed release(dr/ec) Tier 4 Evotaz mg tablet Tier 3 Farydak 10mg capsule Tier 5 Farydak 15mg capsule Tier 5 Farydak 20mg capsule Tier 5 QL(6 EA per 21 QL(6 EA per 21 QL(6 EA per 21

15 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Fetzima 120mg capsule,extended release 24 hr Benefit Tier Tier 4 Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Fetzima 20 mg (2)-40 mg (26) capsule,ext Rel 24hr dose pack Tier 4 Fetzima 20mg capsule,extended release 24 hr Tier 4 Fetzima 40mg capsule,extended release 24 hr Tier 4 Fetzima 80mg capsule,extended release 24 hr Tier 4 fexofenadine 30mg/5 ml suspension Tier 2 fexofenadine-pseudoephedrine mg tablet extended release 12 hr Tier 3 Finacea Plus 15% kit Tier 4 fluocinolone 0.025% cream Tier 3 fluocinolone 0.025% ointment Tier 3 fluorouracil 50mg/mL solution Tier 3 fluoxetine 10mg capsule Tier 2 fluoxetine 10mg tablet Tier 3 fluoxetine 20mg capsule Tier 2 fluoxetine 20mg tablet Tier 3 frovatriptan 2.5mg tablet Tier 4 QL(240 EA per 30 QL(90 EA per 30 QL(120 EA per 30 QL(18 EA per 30 ST Applies furosemide 40mg/4 ml solution Tier 1

16 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Fycompa 0.5mg/mL suspension Tier 4 Fycompa 10mg tablet Tier 4 Fycompa 12mg tablet Tier 4 Fycompa 2 mg (7)-4 mg (7) tablets,dose pack Tier 4 Fycompa 2mg tablet Tier 4 Fycompa 4mg tablet Tier 4 Fycompa 6mg tablet Tier 4 Fycompa 8mg tablet Tier 4 gabapentin 250mg/5 ml (5 ml) solution Tier 2 gabapentin 300mg/6 ml (6 ml) solution Tier 2 QL(60 EA per 30 QL(2160 ML per 30 QL(2160 ML per 30 Gammagard Liquid 10% solution Tier 5 Gammagard S-D (IgA < 1 mcg/ml) 10gram recon soln Gammagard S-D (IgA < 1 mcg/ml) 5gram recon soln Tier 5 Tier 5 Gengraf 100mg capsule Tier 3 Gengraf 25mg capsule Tier 3 Gengraf 50mg capsule Tier 3 Genvoya mg tablet Tier 3

17 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Gilotrif 20mg tablet Tier 5 Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Gilotrif 30mg tablet Tier 5 Gilotrif 40mg tablet Tier 5 GlucaGen 1mg recon soln Tier 3 heparin (porcine) 20,000unit/mL syringe Tier 2 hydrocodone-acetaminophen mg tablet Tier 3 QL(240 EA per 30 hydrocodone-acetaminophen 5-300mg tablet Tier 3 hydrocodone-ibuprofen mg tablet Tier 3 QL(240 EA per 30 QL(50 EA per 30 hydrocortisone 1% cream Tier 2 hydrocortisone 1% packet Tier 2 hydrocortisone 2.5% cream Tier 2 hydrocortisone-aloe vera 1% cream Tier 2 hydrocortisone-aloe vera 1% ointment Tier 2 hydrocortisone-min oil-wht pet 1% ointment Tier 2 hydrocortisone-oatmeal-aloe-e 1% cream Tier 2 hydroxyzine HCl 10mg/5 ml (5 ml) solution Tier 2 HyQvia 10 gram/100 ml (10 %) solution Tier 5 HyQvia 2.5 gram/25 ml (10 %) solution Tier 5

18 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement HyQvia 20 gram/200 ml (10 %) solution Tier 5 HyQvia 30 gram/300 ml (10 %) solution Tier 5 HyQvia 5 gram/50 ml (10 %) solution Tier 5 Ibrance 100mg capsule Tier 5 Ibrance 125mg capsule Tier 5 Ibrance 75mg capsule Tier 5 Iclusig 15mg tablet Tier 5 Iclusig 45mg tablet Tier 5 imatinib 100mg tablet Tier 5 imatinib 400mg tablet Tier 5 Imbruvica 140mg capsule Tier 5 QL(21 EA per 28 QL(21 EA per 28 QL(21 EA per 28 QL(60 EA per 30 QL(180 EA per 30 QL(60 EA per 30 QL(120 EA per 30 Incruse Ellipta 62.5mcg/actuation blister with device Tier 3 Kalydeco 150mg tablet Tier 5 Kalydeco 50mg granules in packet Tier 5 Kalydeco 75mg granules in packet Tier 5 QL(60 EA per 30 QL(56 EA per 28 QL(56 EA per 28 Kapidex 30mg capsule,biphase delayed releas Tier 3 Ketek Pak 400mg tablet Tier 5

19 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Klor-Con Sprinkle 10mEq capsule, extended release Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Tier 2 Klor-Con Sprinkle 8mEq capsule, extended release Tier 2 Lacrisert 5mg insert Tier 5 lactulose 10 gram/15 ml(15 ml) solution Tier 2 lamotrigine 25 mg (21)-50 mg (7) tablet disintegrating, dose pk lamotrigine 25 mg (42)-100 mg (7) tablets,dose pack lamotrigine 25 mg (84)-100 mg (14) tablets,dose pack lamotrigine 25 mg(14)-50 mg(14)-100 mg (7) tablet disintegrating, dose pk Tier 3 Tier 3 Tier 3 Tier 3 lamotrigine 25mg (35) tablets,dose pack Tier 3 lamotrigine 50 mg (42)-100 mg (14) tablet disintegrating, dose pk Tier 3 lancets misc Tier 3 Lenvima 10 mg/day (10mg x 1/day) capsule Tier 5 QL(200 EA per 30 Lenvima 14 mg/day(10 mgx 1-4 mg x 1) capsule Tier 5 Lenvima 18 mg/day (10mg x 1-4 mg x2) capsule Tier 5 Lenvima 20 mg/day(10 mg x 2) capsule Tier 5 Lenvima 24 mg/day(10 mgx 2-4 mg x 1) capsule Tier 5 Lenvima 8 mg/day(4 mg x 2) capsule Tier 5

20 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement leuprolide 1mg/0.2 ml solution Tier 5 levetiracetam 500mg/5 ml (5 ml) solution Tier 2 Levoxyl 100mcg tablet Tier 2 Levoxyl 112mcg tablet Tier 2 Levoxyl 125mcg tablet Tier 2 Levoxyl 137mcg tablet Tier 2 Levoxyl 150mcg tablet Tier 2 Levoxyl 175mcg tablet Tier 2 Levoxyl 200mcg tablet Tier 2 Levoxyl 25mcg tablet Tier 2 Levoxyl 50mcg tablet Tier 2 Levoxyl 75mcg tablet Tier 2 Levoxyl 88mcg tablet Tier 2 lidocaine HCl 2% solution Tier 2 Lipofen 150mg capsule Tier 3 Lipofen 50mg capsule Tier 3 lithium citrate 8mEq/5 ml (5 ml) solution Tier 2

21 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement lomustine 100mg capsule Tier 4 lomustine 10mg capsule Tier 4 lomustine 40mg capsule Tier 4 Lotemax 0.5% drops,gel Tier 4 Lupaneta Pack (1 month) 3.75 mg-5 mg (30) kit. syringe and tablet Lupaneta Pack (3 month) mg-5 mg (90) kit. syringe and tablet Tier 5 Tier 5 Lynparza 50mg capsule Tier 5 Mekinist 0.5mg tablet Tier 5 Mekinist 2mg tablet Tier 5 QL(480 EA per 30 QL(120 EA per 30 methenamine mandelate 1gram tablet Tier 3 metronidazole 1% gel with pump Tier 4 mexiletine 150mg capsule Tier 2 mexiletine 200mg capsule Tier 2 mexiletine 250mg capsule Tier 2 miglitol 100mg tablet Tier 4 miglitol 25mg tablet Tier 4 miglitol 50mg tablet Tier 4 QL(90 EA per 30 QL(90 EA per 30 QL(90 EA per 30

22 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement misoprostol 100mcg tablet Tier 2 Moderiba 200mg tablet Tier 4 mometasone 50mcg/actuation spray,nonaerosol Tier 4 morphine concentrate 20mg/mL syringe Tier 3 QL(600 EA per 30 Movantik 12.5mg tablet Tier 4 Movantik 25mg tablet Tier 4 mycophenolate mofetil 200mg/mL suspension for reconstitution Tier 4 Myrbetriq 25mg tablet extended release 24 hr Tier 3 Myrbetriq 50mg tablet extended release 24 hr Tier 3 naftifine 2% cream Tier 4 naloxone 1mg/mL syringe Tier 2 Namenda XR 14mg capsule,sprinkle,er 24hr Tier 3 Namenda XR 21mg capsule,sprinkle,er 24hr Tier 3 Namenda XR 28mg capsule,sprinkle,er 24hr Tier 3 Namenda XR mg cap,sprinkle,er 24hr dose pack Tier 3 Namenda XR 7mg capsule,sprinkle,er 24hr Tier 3 Natpara 100mcg/dose cartridge Tier 5

23 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Natpara 25mcg/dose cartridge Tier 5 Natpara 50mcg/dose cartridge Tier 5 Natpara 75mcg/dose cartridge Tier 5 Neulasta 6mg/0.6 ml syringe, w/ wearable injector Tier 5 Neupogen 300mcg/0.5 ml syringe Tier 5 Neupogen 480mcg/0.8 ml syringe Tier 5 niacin 500mg tablet Tier 2 Northera 100mg capsule Tier 5 Northera 200mg capsule Tier 5 Northera 300mg capsule Tier 5 Norvir Soft Gelatin 100mg capsule Tier 3 Noxafil 100mg tablet,delayed release (DR/EC) Tier 5 Noxafil 300mg/16.7 ml solution Tier 5 Nuedexta 20-10mg capsule Tier 5 QL QL(60 EA per 30 nystatin 150 millionunit powder Tier 2 nystatin 2 billionunit powder Tier 2 nystatin 50 millionunit powder Tier 2

24 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement nystatin 500 millionunit powder Tier 2 Odefsey mg tablet Tier 3 Odomzo 200mg capsule Tier 5 omega 3-dha-epa-fish oil 1,000 mg (120mg- 180 mg) capsule omeprazole magnesium 20mg capsule,delayed release(dr/ec) Tier 4 Tier 2 Onfi 10mg tablet Tier 5 Onfi 2.5mg/mL suspension Tier 5 Onfi 20mg tablet Tier 5 Opsumit 10mg tablet Tier 5 Orencia ClickJect 125mg/mL auto-injector Tier 5 Orenitram 0.125mg tablet extended release Tier 5 Orenitram 0.25mg tablet extended release Tier 5 Orenitram 1mg tablet extended release Tier 5 Orenitram 2.5mg tablet extended release Tier 5 Osphena 60mg tablet Tier 4 oxiconazole 1% cream Tier 4 oxycodone 10mg tablet,oral only,ext.rel.12 hr Tier 4 QL (60 EA per 30

25 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier oxycodone 15mg tablet,oral only,ext.rel.12 hr Tier 4 Quantity Limit (QL) QL (60 EA per 30 Prior Authorization () or Step Therapy (ST) Requirement oxycodone 20mg tablet,oral only,ext.rel.12 hr Tier 4 oxycodone 30mg tablet,oral only,ext.rel.12 hr Tier 4 oxycodone 40mg tablet,oral only,ext.rel.12 hr Tier 4 oxycodone 60mg tablet,oral only,ext.rel.12 hr Tier 4 oxycodone 80mg tablet,oral only,ext.rel.12 hr Tier 4 QL (60 EA per 30 QL (60 EA per 30 QL (60 EA per 30 QL (60 EA per 30 QL (60 EA per 30 paliperidone 1.5mg tablet extended release 24hr Tier 5 paliperidone 3mg tablet extended release 24hr Tier 5 paliperidone 6mg tablet extended release 24hr Tier 5 QL(60 EA per 30 paliperidone 9mg tablet extended release 24hr Tier 5 Pazeo 0.7% drops Tier 3 PegIntron 120mcg/0.5 ml kit Tier 5 PegIntron 150mcg/0.5 ml kit Tier 5 PegIntron 50mcg/0.5 ml kit Tier 5 PegIntron 80mcg/0.5 ml kit Tier 5 Pentasa 250mg capsule, extended release Tier 3 Pentasa 500mg capsule, extended release Tier 3 QL(240 EA per 30 QL(240 EA per 30

26 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Phenergan 12.5mg suppository Tier 3 Phenergan 25mg suppository Tier 3 Phenergan 50mg suppository Tier 3 phenobarb-hyoscy-atropine-scop mg tablet Tier 4 phenoxybenzamine 10mg capsule Tier 3 phenytoin 100mg/4 ml suspension Tier 2 phenytoin 100mg/4 ml syringe Tier 2 pilocarpine HCl 1% drops Tier 3 pilocarpine HCl 2% drops Tier 3 pilocarpine HCl 4% drops Tier 3 pioglitazone-metformin mg tablet Tier 3 pioglitazone-metformin mg tablet Tier 3 QL(90 EA per 30 QL(90 EA per 30 Pomalyst 1mg capsule Tier 5 Pomalyst 2mg capsule Tier 5 Pomalyst 3mg capsule Tier 5 Pomalyst 4mg capsule Tier 5 prednisolone 15mg/5 ml solution Tier 2

27 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name prednisolone sodium phosphate 15mg/5 ml (5 ml) solution Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Tier 2 Prepopik 10 mg-3.5gram-12 gram powder in packet Tier 4 Prezcobix mg-mg tablet Tier 3 Prezista 300mg tablet Tier 3 prochlorperazine Edisylate 5mg/mL solution Tier 2 Prolensa 0.07% drops Tier 3 promethazine 25mg/mL syringe Tier 3 rabeprazole 20mg tablet,delayed release (DR/EC) Tier 4 Renvela 0.8gram powder in packet Tier 5 Renvela 2.4gram powder in packet Tier 5 Retrovir 300mg tablet Tier 4 Reyataz 100mg capsule Tier 3 Ribasphere 200mg capsule Tier 4 Ribasphere 200mg tablet Tier 4 Rifamate mg capsule Tier 4 ringers solution Tier 2 risperidone 0.5mg tablet,disintegrating Tier 3 QL(120 EA per 30

28 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier risperidone 1mg tablet,disintegrating Tier 3 Quantity Limit (QL) QL(120 EA per 30 Prior Authorization () or Step Therapy (ST) Requirement risperidone 1mg/mL syringe Tier 2 risperidone 2mg tablet,disintegrating Tier 3 risperidone 3mg tablet,disintegrating Tier 3 risperidone 4mg tablet,disintegrating Tier 3 rosuvastatin 10mg tablet Tier 4 rosuvastatin 20mg tablet Tier 4 rosuvastatin 40mg tablet Tier 4 rosuvastatin 5mg tablet Tier 4 QL(120 EA per 30 QL(120 EA per 30 QL(120 EA per 30 Sandostatin LAR Depot 10mg kit Tier 5 Sandostatin LAR Depot 20mg kit Tier 5 Sandostatin LAR Depot 30mg kit Tier 5 Saphris 10mg tablet Tier 4 Saphris 5mg tablet Tier 4 selenium sulfide 2.5% shampoo Tier 2 Signifor 0.3mg/mL (1 ml) solution Tier 5 Signifor 0.6mg/mL (1 ml) solution Tier 5

29 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Signifor 0.9mg/mL (1 ml) solution Tier 5 Signifor LAR 20mg suspension for reconstitution Signifor LAR 40mg suspension for reconstitution Signifor LAR 60mg suspension for reconstitution Tier 5 Tier 5 Tier 5 Silenor 3mg tablet Tier 4 sodium chloride 0.9 % 0.9% solution Tier 2 sodium fluoride 1 mg fluoride(2.2 mg) tablet Tie 6 sodium polystyrene (sorb free) 15gram/60 ml suspension Tier 3 Sorine 120mg tablet Tier 2 Sorine 160mg tablet Tier 2 Sorine 240mg tablet Tier 2 Sorine 80mg tablet Tier 2 Stiolto Respimat mcg/actuation mist Tier 3 Stivarga 40mg tablet Tier 5 QL(4 GM per 30 QL(84 EA per 28 sulfacetamide sodium 10% cleanser,gel extended release Tier 4 sulfacetamide sodium-urea 10-10% lotion Tier 2 sulfasalazine 500mg tablet,delayed release (DR/EC) Tier 2

30 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Suprax 100mg tablet,chewable Tier 4 Suprax 200mg tablet,chewable Tier 4 Suprax 400mg capsule Tier 4 Synjardy ,000mg tablet Tier 3 Synjardy mg tablet Tier 3 Synjardy 5-1,000mg tablet Tier 3 Synjardy 5-500mg tablet Tier 3 Tafinlar 50mg capsule Tier 5 Tafinlar 75mg capsule Tier 5 tetrabenazine 25mg tablet Tier 5 Tis-U-Sol solution Tier 3 Tivicay 10mg tablet Tier 3 Tivicay 25mg tablet Tier 3 tobramycin in % NaCl 300mg/5 ml solution for nebulization Transderm-Scop 1.5 mg (1 mgover 3 patch 3 day travoprost (benzalkonium) 0.004% drops Tier 3 Tier 5 Tier 4 QL(5 ML per 31 tretinoin (emollient) 0.05% cream Tier 3 triamcinolone acetonide 55mcg aerosol,spray Tier 2 Trintellix 10mg tablet Tier 3 Trintellix 20mg tablet Tier 3

31 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Benefit Tier Trintellix 5mg tablet Tier 3 Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Triumeq mg tablet Tier 3 Truvada mg tablet Tier 3 Truvada mg tablet Tier 3 Truvada mg tablet Tier 3 Tudorza Pressair 400mcg/actuation aerosol powdr breath activated Tybost 150mg tablet Tier 3 valproic acid (as sodium salt) 250mg/5 ml (5 ml) solution valproic acid (as sodium salt) 250mg/5 ml syringe valproic acid (as sodium salt) 500 mg/10 ml(10 ml) solution Tier 4 Tier 2 Tier 2 Tier 2 vancomycin 1,000mg recon soln Tier 2 vancomycin 500mg recon soln Tier 2 Varubi 90mg tablet Tier 5 Victoza 3-Pak 0.6 mg/0.1 ml(18 mg/3 ml) pen injector Viibryd 10 mg (7)-20 mg(7)-40 mg (16) tablets,dose pack Vimpat 50 mg (14)-100 mg (14) tablets,dose pack Tier 4 Tier 4 ST Tier 5 Visicol 1.5gram tablet Tier 2 Vitekta 150mg tablet Tier 3 Vitekta 85mg tablet Tier 3 voriconazole 200 mg/5 ml(40 mg/ml) suspension for reconstitution Tier 5

32 MEDICATIONS ADDED TO THE 2017 QHP FORMULARY Medication Name Vraylar 1.5 mg (1)-3 mg (6) capsule,dose pack Benefit Tier Quantity Limit (QL) Prior Authorization () or Step Therapy (ST) Requirement Tier 5 Vraylar 1.5mg capsule Tier 5 Vraylar 3mg capsule Tier 5 Vraylar 4.5mg capsule Tier 5 Vraylar 6mg capsule Tier 5 WelChol 3.75gram powder in packet Tier 4 Xarelto 15 mg (42)-20 mg (9) tablets,dose pack Tier 4 Xeljanz 5mg tablet Tier 5 Xeljanz XR 11mg tablet extended release 24 hr Tier 5 Xgeva 120 mg/1.7 ml(70 mg/ml) solution Tier 5 zoledronic acid-mannitol-water 5mg/100 ml piggyback Zydelig 100mg tablet Tier 5 Zydelig 150mg tablet Tier 5 Zyflo 600mg tablet Tier 5 Zykadia 150mg capsule Tier 5 Tier 5 QL(60 EA per 30 QL(60 EA per 30 QL(120 EA per 30 QL(150 EA per 30 MEDICATIONS WITH TIERING CHANGES Medication Name 2016 Tier 2017 Tier acamprosate 333mg tablet,delayed release (DR/EC) Tier 2 Tier 4 acetaminophen-codeine mg/5 ml solution Tier 2 Tier 3 acetaminophen-codeine mg tablet Tier 2 Tier 3 acetaminophen-codeine mg tablet Tier 2 Tier 3 acetaminophen-codeine mg tablet Tier 2 Tier 3

33 MEDICATIONS WITH TIERING CHANGES Medication Name 2016 Tier 2017 Tier Acetasol HC 1-2% drops Tier 2 Tier 3 acetazolamide 125mg tablet Tier 2 Tier 3 acetazolamide 250mg tablet Tier 2 Tier 3 acyclovir 200mg/5 ml suspension Tier 2 Tier 3 adapalene 0.1% cream Tier 2 Tier 3 adapalene 0.1% gel Tier 2 Tier 3 Adderall XR 10mg capsule,extended release 24hr Tier 3 Tier 4 Adderall XR 15mg capsule,extended release 24hr Tier 3 Tier 4 Adderall XR 20mg capsule,extended release 24hr Tier 3 Tier 4 Adderall XR 25mg capsule,extended release 24hr Tier 3 Tier 4 Adderall XR 30mg capsule,extended release 24hr Tier 3 Tier 4 Adderall XR 5mg capsule,extended release 24hr Tier 3 Tier 4 Albenza 200mg tablet Tier 3 Tier 5 albuterol sulfate 2mg tablet Tier 2 Tier 4 albuterol sulfate 4mg tablet Tier 2 Tier 4 alendronate 35mg tablet Tier 2 Tier 1 alendronate 70mg tablet Tier 2 Tier 1 alfuzosin 10mg tablet extended release 24 hr Tier 3 Tier 2 Alphagan P 0.1% drops Tier 3 Tier 4 alprazolam 0.5mg tablet extended release 24 hr Tier 2 Tier 3 alprazolam 1mg tablet extended release 24 hr Tier 2 Tier 3 alprazolam 2mg tablet extended release 24 hr Tier 2 Tier 3 alprazolam 3mg tablet extended release 24 hr Tier 2 Tier 3 Altabax 1% ointment Tier 3 Tier 4 amantadine HCl 100mg capsule Tier 2 Tier 3 amantadine HCl 100mg tablet Tier 2 Tier 3 amcinonide 0.1% cream Tier 2 Tier 4 amlodipine 10mg tablet Tier 2 Tier 1

34 MEDICATIONS WITH TIERING CHANGES Medication Name 2016 Tier 2017 Tier amlodipine 2.5mg tablet Tier 2 Tier 1 amlodipine 5mg tablet Tier 2 Tier 1 amlodipine-benazepril 10-20mg capsule Tier 4 Tier 2 amlodipine-benazepril 10-40mg capsule Tier 4 Tier 2 amlodipine-benazepril mg capsule Tier 4 Tier 2 amlodipine-benazepril 5-10mg capsule Tier 4 Tier 2 amlodipine-benazepril 5-20mg capsule Tier 4 Tier 2 amlodipine-benazepril 5-40mg capsule Tier 4 Tier 2 amlodipine-valsartan mg tablet Tier 3 Tier 2 amlodipine-valsartan mg tablet Tier 3 Tier 2 amlodipine-valsartan 5-160mg tablet Tier 3 Tier 2 amlodipine-valsartan 5-320mg tablet Tier 3 Tier 2 amoxapine 100mg tablet Tier 3 Tier 2 amoxapine 150mg tablet Tier 3 Tier 2 amoxapine 25mg tablet Tier 3 Tier 2 amoxapine 50mg tablet Tier 3 Tier 2 amoxicillin 125mg tablet,chewable Tier 1 Tier 2 amoxicillin-pot clavulanate 1, mg tablet extended release 12 hr Tier 2 Tier 3 amoxicillin-pot clavulanate mg tablet Tier 2 Tier 3 amoxicillin-pot clavulanate mg/5 ml suspension for reconstitution Tier 2 Tier 3 anagrelide 0.5mg capsule Tier 2 Tier 3 anagrelide 1mg capsule Tier 2 Tier 3 Anucort-HC 25mg suppository Tier 2 Tier 3 Ascomp with Codeine mg capsule Tier 2 Tier 3 aspirin-dipyridamole mg capsule, ER multiphase 12 hr Tier 3 Tier 4 atenolol-chlorthalidone mg tablet Tier 1 Tier 2 atenolol-chlorthalidone 50-25mg tablet Tier 1 Tier 2

35 MEDICATIONS WITH TIERING CHANGES Medication Name 2016 Tier 2017 Tier atovaquone 750mg/5 ml suspension Tier 4 Tier 5 atovaquone-proguanil mg tablet Tier 2 Tier 4 atovaquone-proguanil mg tablet Tier 2 Tier 4 Avar 10-5% (w/w) cleanser Tier 2 Tier 4 Avar-E 10-5% (w/w) cream Tier 2 Tier 4 Avar-E Green 10-5% (w/w) cream Tier 2 Tier 4 azelastine 0.15 %(205.5 mcg) spray,non-aerosol Tier 2 Tier 3 azelastine 137 mcg(0.1 %) aerosol,spray Tier 2 Tier 3 azithromycin 250mg tablet Tier 2 Tier 1 azithromycin 500mg tablet Tier 2 Tier 1 azithromycin 600mg tablet Tier 2 Tier 1 bacitracin 500unit/gram ointment Tier 2 Tier 3 Bactroban Nasal 2% ointment Tier 3 Tier 4 balsalazide 750mg capsule Tier 2 Tier 3 betamethasone dipropionate 0.05% cream Tier 2 Tier 3 betamethasone dipropionate 0.05% ointment Tier 2 Tier 3 betamethasone valerate 0.1% lotion Tier 2 Tier 3 betamethasone, augmented 0.05% lotion Tier 2 Tier 3 bethanechol chloride 10mg tablet Tier 2 Tier 3 bethanechol chloride 25mg tablet Tier 2 Tier 3 bethanechol chloride 50mg tablet Tier 2 Tier 3 bethanechol chloride 5mg tablet Tier 2 Tier 3 Betoptic S 0.25% drops,suspension Tier 3 Tier 4 Beyaz mg (24) tablet Tier 3 Tier 4 brimonidine 0.15% drops Tier 2 Tier 3 brimonidine 0.2% drops Tier 2 Tier 1 Bromfed DM mg/5 ml syrup Tier 2 Tier 3

36 MEDICATIONS WITH TIERING CHANGES Medication Name 2016 Tier 2017 Tier bromocriptine 2.5mg tablet Tier 2 Tier 4 bromocriptine 5mg capsule Tier 2 Tier 4 brompheniramine-pseudoeph-dm mg/5 ml syrup Tier 2 Tier 3 Brovana 15mcg/2 ml solution for nebulization Tier 5 Tier 4 budesonide 0.25mg/2 ml suspension for nebulization Tier 2 Tier 4 budesonide 0.5mg/2 ml suspension for nebulization Tier 2 Tier 4 budesonide 1mg/2 ml suspension for nebulization Tier 2 Tier 4 buprenorphine HCl 2mg tablet Tier 2 Tier 3 buprenorphine HCl 8mg tablet Tier 2 Tier 3 Butalbital Compound W/Codeine mg capsule butalbital-acetaminop-caf-cod mg capsule Tier 2 Tier 4 Tier 2 Tier 4 butalbital-acetaminophen mg tablet Tier 2 Tier 4 butalbital-acetaminophen-caff mg capsule Tier 2 Tier 4 butalbital-acetaminophen-caff mg capsule Tier 2 Tier 4 butalbital-acetaminophen-caff mg tablet Tier 2 Tier 4 butalbital-aspirin-caffeine mg capsule Tier 2 Tier 4 butorphanol tartrate 1mg/mL solution Tier 2 Tier 3 butorphanol tartrate 2mg/mL solution Tier 2 Tier 3 cabergoline 0.5mg tablet Tier 2 Tier 3 calcipotriene 0.005% cream Tier 2 Tier 4 calcipotriene 0.005% ointment Tier 2 Tier 4 calcipotriene 0.005% solution Tier 2 Tier 4 calcitonin (salmon) 200unit/actuation spray,nonaerosol Tier 4 Tier 3 Canasa 1,000mg suppository Tier 4 Tier 5 captopril 100mg tablet Tier 1 Tier 2 captopril 12.5mg tablet Tier 1 Tier 2 captopril 25mg tablet Tier 1 Tier 2

37 MEDICATIONS WITH TIERING CHANGES Medication Name 2016 Tier 2017 Tier captopril 50mg tablet Tier 1 Tier 2 captopril-hydrochlorothiazide 25-15mg tablet Tier 1 Tier 2 captopril-hydrochlorothiazide 25-25mg tablet Tier 1 Tier 2 captopril-hydrochlorothiazide 50-15mg tablet Tier 1 Tier 2 captopril-hydrochlorothiazide 50-25mg tablet Tier 1 Tier 2 Carafate 100mg/mL suspension Tier 3 Tier 4 carbamazepine 100mg capsule, ER multiphase 12 hr Tier 2 Tier 3 carbamazepine 100mg/5 ml suspension Tier 2 Tier 3 carbamazepine 200mg capsule, ER multiphase 12 hr Tier 2 Tier 3 carbamazepine 200mg tablet extended release 12 hr Tier 2 Tier 3 carbamazepine 300mg capsule, ER multiphase 12 hr Tier 2 Tier 3 carbamazepine 400mg tablet extended release 12 hr Tier 2 Tier 3 carbidopa 25mg tablet Tier 3 Tier 4 carvedilol 12.5mg tablet Tier 2 Tier 1 carvedilol 25mg tablet Tier 2 Tier 1 carvedilol 3.125mg tablet Tier 2 Tier 1 carvedilol 6.25mg tablet Tier 2 Tier 1 cefaclor 250mg capsule Tier 2 Tier 3 cefaclor 500mg capsule Tier 2 Tier 3 cefadroxil 1gram tablet Tier 2 Tier 3 cefadroxil 250mg/5 ml suspension for reconstitution Tier 2 Tier 3 cefadroxil 500mg/5 ml suspension for reconstitution Tier 2 Tier 3 cefdinir 125mg/5 ml suspension for reconstitution Tier 2 Tier 3 cefdinir 250mg/5 ml suspension for reconstitution Tier 2 Tier 3 cefpodoxime 100mg tablet Tier 2 Tier 3 cefpodoxime 200mg tablet Tier 2 Tier 3 cefprozil 125mg/5 ml suspension for reconstitution Tier 2 Tier 3

38 MEDICATIONS WITH TIERING CHANGES Medication Name 2016 Tier 2017 Tier cefprozil 250mg/5 ml suspension for reconstitution Tier 2 Tier 3 cefuroxime axetil 250mg tablet Tier 2 Tier 3 cefuroxime axetil 500mg tablet Tier 2 Tier 3 cephalexin 125mg/5 ml suspension for reconstitution Tier 1 Tier 2 cephalexin 250mg/5 ml suspension for reconstitution Tier 1 Tier 2 chlordiazepoxide-clidinium 5-2.5mg capsule Tier 2 Tier 3 chlorpromazine 100mg tablet Tier 2 Tier 3 chlorpromazine 10mg tablet Tier 2 Tier 3 chlorpromazine 200mg tablet Tier 2 Tier 3 chlorpromazine 25mg tablet Tier 2 Tier 3 chlorpromazine 50mg tablet Tier 2 Tier 3 cholestyramine (with sugar) 4gram powder Tier 2 Tier 3 cholestyramine (with sugar) 4gram powder in packet Tier 2 Tier 3 Cholestyramine Light 4gram powder Tier 1 Tier 3 Cholestyramine Light 4gram powder in packet Tier 1 Tier 3 ciclopirox 0.77% cream Tier 2 Tier 3 ciclopirox 0.77% gel Tier 2 Tier 3 ciclopirox 0.77% suspension Tier 2 Tier 3 ciclopirox 1% shampoo Tier 2 Tier 3 Cipro HC 0.2-1% drops,suspension Tier 3 Tier 4 ciprofloxacin (mixture) 1,000mg tablet, ER multiphase 24 hr ciprofloxacin (mixture) 500mg tablet, ER multiphase 24 hr Tier 2 Tier 3 Tier 2 Tier 3 ciprofloxacin HCl 0.3% drops Tier 2 Tier 1 ciprofloxacin HCl 100mg tablet Tier 2 Tier 4 ciprofloxacin HCl 250mg tablet Tier 2 Tier 1 ciprofloxacin HCl 500mg tablet Tier 2 Tier 1 ciprofloxacin HCl 750mg tablet Tier 2 Tier 1

39 MEDICATIONS WITH TIERING CHANGES Medication Name 2016 Tier 2017 Tier citalopram 10mg tablet Tier 2 Tier 1 citalopram 20mg tablet Tier 2 Tier 1 citalopram 40mg tablet Tier 2 Tier 1 Claravis 10mg capsule Tier 5 Tier 4 Claravis 20mg capsule Tier 5 Tier 4 Claravis 30mg capsule Tier 5 Tier 4 Claravis 40mg capsule Tier 5 Tier 4 clemastine 2.68mg tablet Tier 2 Tier 3 Cleocin 100mg suppository Tier 3 Tier 4 clindamycin HCl 150mg capsule Tier 2 Tier 1 clindamycin HCl 300mg capsule Tier 2 Tier 1 clindamycin palmitate HCl 75mg/5 ml recon soln Tier 2 Tier 3 clindamycin phosphate 1% gel Tier 2 Tier 3 clindamycin phosphate 1% lotion Tier 2 Tier 3 clindamycin phosphate 1% solution Tier 2 Tier 3 clindamycin phosphate 2% cream Tier 2 Tier 3 clindamycin-benzoyl peroxide 1.2 %(1 % base)-5 % gel Tier 2 Tier 4 clindamycin-benzoyl peroxide 1-5% gel Tier 2 Tier 4 clobetasol 0.05% cream Tier 2 Tier 4 clobetasol 0.05% gel Tier 2 Tier 4 clobetasol 0.05% lotion Tier 2 Tier 4 clobetasol 0.05% ointment Tier 2 Tier 4 clobetasol 0.05% shampoo Tier 2 Tier 4 clobetasol 0.05% solution Tier 2 Tier 3 clobetasol-emollient 0.05% cream Tier 2 Tier 4 clocortolone pivalate 0.1% cream Tier 2 Tier 4 Clodan 0.05% shampoo Tier 2 Tier 4 clomipramine 25mg capsule Tier 2 Tier 4 clomipramine 50mg capsule Tier 2 Tier 4

40 MEDICATIONS WITH TIERING CHANGES Medication Name 2016 Tier 2017 Tier clomipramine 75mg capsule Tier 2 Tier 4 clonidine 0.1mg/24 hr patch weekly Tier 2 Tier 3 clonidine 0.2mg/24 hr patch weekly Tier 2 Tier 3 clonidine 0.3mg/24 hr patch weekly Tier 2 Tier 3 clonidine HCl 0.1mg tablet Tier 2 Tier 1 clonidine HCl 0.2mg tablet Tier 2 Tier 1 clonidine HCl 0.3mg tablet Tier 2 Tier 1 clotrimazole-betamethasone % lotion Tier 2 Tier 3 codeine sulfate 15mg tablet Tier 2 Tier 3 codeine sulfate 30mg tablet Tier 2 Tier 3 codeine sulfate 60mg tablet Tier 2 Tier 3 colestipol 1gram tablet Tier 2 Tier 3 colestipol 5gram granules Tier 2 Tier 3 Compro 25mg suppository Tier 2 Tier 4 cyclosporine 100mg capsule Tier 2 Tier 3 cyclosporine 25mg capsule Tier 2 Tier 3 cyclosporine modified 100mg capsule Tier 2 Tier 3 cyclosporine modified 100mg/mL solution Tier 2 Tier 3 cyclosporine modified 25mg capsule Tier 2 Tier 3 cyclosporine modified 50mg capsule Tier 2 Tier 3 Cystaran 0.44% drops Tier 4 Tier 5 danazol 100mg capsule Tier 2 Tier 4 danazol 200mg capsule Tier 2 Tier 4 danazol 50mg capsule Tier 2 Tier 4 dantrolene 100mg capsule Tier 2 Tier 3 dantrolene 25mg capsule Tier 2 Tier 3 dantrolene 50mg capsule Tier 2 Tier 3 Denavir 1% cream Tier 3 Tier 4 Depen Titratabs 250mg tablet Tier 4 Tier 5 Dermazene 1-1% cream Tier 2 Tier 3 desmopressin 0.1mg tablet Tier 2 Tier 3 desmopressin 0.2mg tablet Tier 2 Tier 3 desmopressin 10 mcg/spray(0.1 ml) spray,nonaerosol Tier 2 Tier 3 desonide 0.05% cream Tier 2 Tier 4

41 MEDICATIONS WITH TIERING CHANGES Medication Name 2016 Tier 2017 Tier desonide 0.05% lotion Tier 2 Tier 4 desonide 0.05% ointment Tier 2 Tier 4 desoximetasone 0.05% cream Tier 2 Tier 3 desoximetasone 0.05% gel Tier 2 Tier 3 desoximetasone 0.25% cream Tier 2 Tier 3 desoximetasone 0.25% ointment Tier 2 Tier 3 dexmethylphenidate 10mg tablet Tier 2 Tier 3 dexmethylphenidate 2.5mg tablet Tier 2 Tier 3 dexmethylphenidate 5mg tablet Tier 2 Tier 3 dextroamphetamine 10mg capsule, extended release Tier 2 Tier 4 dextroamphetamine 10mg tablet Tier 2 Tier 3 dextroamphetamine 15mg capsule, extended release Tier 2 Tier 4 dextroamphetamine 5mg capsule, extended release Tier 2 Tier 4 dextroamphetamine 5mg tablet Tier 2 Tier 3 diazepam 5 mg/5 ml(1 mg/ml) solution Tier 2 Tier 4 diclofenac potassium 50mg tablet Tier 1 Tier 2 dicyclomine 10mg capsule Tier 2 Tier 1 dicyclomine 20mg tablet Tier 2 Tier 1 Dipentum 250mg capsule Tier 4 Tier 5 doxycycline hyclate 100mg capsule Tier 2 Tier 3 doxycycline hyclate 100mg tablet Tier 2 Tier 3 doxycycline hyclate 50mg capsule Tier 2 Tier 3 doxycycline monohydrate 100mg tablet Tier 2 Tier 3 doxycycline monohydrate 50mg tablet Tier 2 Tier 3 doxycycline monohydrate 75mg tablet Tier 2 Tier 3 dronabinol 2.5mg capsule Tier 5 Tier 4 dronabinol 5mg capsule Tier 5 Tier 4 Droxia 200mg capsule Tier 3 Tier 4 Droxia 300mg capsule Tier 3 Tier 4 Droxia 400mg capsule Tier 3 Tier 4 Durezol 0.05% drops Tier 3 Tier 4 econazole 1% cream Tier 2 Tier 4 Elidel 1% cream Tier 3 Tier 4

42 MEDICATIONS WITH TIERING CHANGES Medication Name 2016 Tier 2017 Tier Elmiron 100mg capsule Tier 3 Tier 4 enalapril-hydrochlorothiazide 10-25mg tablet Tier 2 Tier 1 enalapril-hydrochlorothiazide mg tablet Tier 2 Tier 1 Endocet mg tablet Tier 2 Tier 3 Endocet mg tablet Tier 2 Tier 3 Endocet 5-325mg tablet Tier 2 Tier 3 Endocet mg tablet Tier 2 Tier 3 enoxaparin 100mg/mL syringe Tier 5 Tier 4 enoxaparin 120mg/0.8 ml syringe Tier 5 Tier 4 enoxaparin 150mg/mL syringe Tier 5 Tier 4 enoxaparin 300mg/3 ml solution Tier 5 Tier 4 enoxaparin 30mg/0.3 ml syringe Tier 5 Tier 4 enoxaparin 40mg/0.4 ml syringe Tier 5 Tier 4 enoxaparin 60mg/0.6 ml syringe Tier 5 Tier 4 enoxaparin 80mg/0.8 ml syringe Tier 5 Tier 4 entacapone 200mg tablet Tier 3 Tier 4 eplerenone 25mg tablet Tier 2 Tier 3 eplerenone 50mg tablet Tier 2 Tier 3 ergoloid 1mg tablet Tier 2 Tier 3 Ery Pads 2% swab Tier 2 Tier 3 erythromycin 250mg tablet Tier 2 Tier 4 erythromycin 500mg tablet Tier 2 Tier 4 erythromycin ethylsuccinate 400mg tablet Tier 2 Tier 4 erythromycin-benzoyl peroxide 3-5% gel Tier 2 Tier 4 escitalopram oxalate 5mg/5 ml solution Tier 2 Tier 3 estradiol 0.025mg/24 hr patch semiweekly Tier 3 Tier 4 estradiol 0.025mg/24 hr patch weekly Tier 2 Tier 3 estradiol mg/24 hr patch semiweekly Tier 3 Tier 4 estradiol mg/24 hr patch weekly Tier 2 Tier 3 estradiol 0.05mg/24 hr patch semiweekly Tier 3 Tier 4 estradiol 0.05mg/24 hr patch weekly Tier 2 Tier 3 estradiol 0.06mg/24 hr patch weekly Tier 2 Tier 3 estradiol 0.075mg/24 hr patch semiweekly Tier 2 Tier 4

43 MEDICATIONS WITH TIERING CHANGES Medication Name 2016 Tier 2017 Tier estradiol 0.075mg/24 hr patch weekly Tier 2 Tier 3 estradiol 0.1mg/24 hr patch semiweekly Tier 3 Tier 4 estradiol 0.1mg/24 hr patch weekly Tier 2 Tier 3 estrogens-methyltestosterone mg tablet Tier 2 Tier 3 estrogens-methyltestosterone mg tablet Tier 2 Tier 3 eszopiclone 1mg tablet Tier 3 Tier 2 eszopiclone 2mg tablet Tier 3 Tier 2 eszopiclone 3mg tablet Tier 3 Tier 2 ethambutol 100mg tablet Tier 2 Tier 3 ethambutol 400mg tablet Tier 2 Tier 3 ethosuximide 250mg capsule Tier 2 Tier 3 ethosuximide 250mg/5 ml solution Tier 2 Tier 3 etodolac 200mg capsule Tier 2 Tier 3 etodolac 300mg capsule Tier 2 Tier 3 etodolac 400mg tablet Tier 2 Tier 3 etodolac 400mg tablet extended release 24 hr Tier 2 Tier 4 etodolac 500mg tablet Tier 2 Tier 3 etodolac 500mg tablet extended release 24 hr Tier 2 Tier 4 etodolac 600mg tablet extended release 24 hr Tier 2 Tier 4 exemestane 25mg tablet Tier 2 Tier 4 famciclovir 125mg tablet Tier 4 Tier 3 famciclovir 250mg tablet Tier 4 Tier 3 famciclovir 500mg tablet Tier 4 Tier 3 famotidine 40 mg/5 ml(8 mg/ml) suspension Tier 2 Tier 4 fenofibrate nanocrystallized 145mg tablet Tier 3 Tier 2 fenofibrate nanocrystallized 48mg tablet Tier 3 Tier 2 fenofibric acid (choline) 45mg capsule,delayed release(dr/ec) Tier 3 Tier 2 fentanyl 100mcg/hr patch 72 hour Tier 2 Tier 3 fentanyl 12mcg/hr patch 72 hour Tier 2 Tier 3 fentanyl 25mcg/hr patch 72 hour Tier 2 Tier 3 fentanyl 50mcg/hr patch 72 hour Tier 2 Tier 3 fentanyl 75mcg/hr patch 72 hour Tier 2 Tier 3 flunisolide 25mcg (0.025 %) spray,non-aerosol Tier 2 Tier 3

44 MEDICATIONS WITH TIERING CHANGES Medication Name 2016 Tier 2017 Tier fluocinolone 0.01% cream Tier 2 Tier 3 fluocinolone 0.01% oil Tier 2 Tier 3 fluocinolone 0.01% solution Tier 2 Tier 3 fluocinolone acetonide oil 0.01% drops Tier 2 Tier 3 fluocinolone and shower cap 0.01% oil Tier 2 Tier 3 fluocinonide 0.05% cream Tier 2 Tier 3 fluocinonide 0.05% gel Tier 2 Tier 3 fluocinonide 0.05% ointment Tier 2 Tier 3 fluocinonide 0.05% solution Tier 2 Tier 3 Fluocinonide-E 0.05% cream Tier 2 Tier 3 fluorouracil 2% solution Tier 2 Tier 3 fluorouracil 5% cream Tier 2 Tier 3 fluorouracil 5% solution Tier 2 Tier 3 flutamide 125mg capsule Tier 2 Tier 3 fluvastatin 20mg capsule Tier 2 Tier 3 fluvastatin 40mg capsule Tier 2 Tier 3 Focalin XR 25mg capsule,er biphasic Tier 3 Tier 4 Focalin XR 35mg capsule,er biphasic Tier 3 Tier 4 furosemide 10mg/mL solution Tier 1 Tier 2 galantamine 12mg tablet Tier 2 Tier 3 galantamine 16mg capsule,ext rel. pellets 24 hr Tier 2 Tier 3 galantamine 24mg capsule,ext rel. pellets 24 hr Tier 2 Tier 3 galantamine 4mg tablet Tier 2 Tier 3 galantamine 4mg/mL solution Tier 2 Tier 4 galantamine 8mg capsule,ext rel. pellets 24 hr Tier 2 Tier 3 galantamine 8mg tablet Tier 2 Tier 3 Gavilyte-C gram recon soln Tier 2 Tier 6 ($0) GaviLyte-G gram recon soln Tier 2 Tier 6 ($0) GaviLyte-N 420gram recon soln Tier 2 Tier 6 ($0) Gengraf 100mg/mL solution Tier 2 Tier 3 glimepiride 1mg tablet Tier 2 Tier 1 glimepiride 2mg tablet Tier 2 Tier 1 glimepiride 4mg tablet Tier 2 Tier 1