2014 Medicare Part D Formulary Change

Transcription

1 2014 Medicare Part D Formulary Change We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorizations, quantity limits and/or step therapy restrictions on a drug [or move a drug to a higher cost-sharing tier], we will let you know of the change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and let you know. The product changes noted below will be implemented on the Medicare Part D Plan formulary. To see if your drug is on this list, please refer to the tables below: New Added Products: Effective 11/01/2014 Drug Cost sharing Restrictions* HYDROCODONE BITARTRATE/ACETAMINOPHEN 325MG; 2.5MG TABS Tier 2 CLINIMIX E 4.25%/DEXTROSE 10% 880MG/100ML; 489MG/100ML; 33MG/100ML; 10GM/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 51MG/100ML; 170MG/100ML; 702MG/100ML; 238MG/100ML; 261MG/100ML; 289MG/100ML; 213MG/100ML; 297MG/100ML; 77MG/100ML; 179MG/10 Tier 3 PA B/D AMINOSYN 7%/ELECTROLYTES 124MEQ/L; 900MG/100ML; 690MG/100ML; 96MEQ/L; 900MG/100ML; 210MG/100ML; 510MG/100ML; 660MG/100ML; 510MG/100ML; 10MEQ/L; 280MG/100ML; 310MG/100ML; 30MMOLE/L; 65MEQ/L; 610MG/100ML; 300MG/100ML; 65MEQ/L; 370MG/100ML; 120MG/100ML; 44MG Tier 3 PA B/D AMINOSYN-RF 113MEQ/L; 600MG/100ML; 429MG/100ML; 462MG/100ML; 726MG/100ML; 535MG/100ML; 726MG/100ML; 726MG/100ML; 330MG/100ML; 165MG/100ML; 528MG/100ML SOLN Tier 3 PA B/D FLUOROMETHOLONE 0.1% SUSP Tier 2 FUROSEMIDE 10MG/ML SOLN Tier 1 PA B/D ZYDELIG 100MG TABS Tier 5 PA LA ZYDELIG 150MG TABS Tier 5 PA LA MAGNESIUM SULFATE 50% SOLN Tier 2 PA B/D POTASSIUM CITRATE ER 15MEQ TBCR Tier 2 ELIQUIS 2.5MG TABS Tier 4 Updated: 11/2014 H6864_MGM14_35 Formulary Change Web Posting_Approved

2 ELIQUIS 5MG TABS Tier 4 Formulary Removals: Effective 11/01/2014 Drug HEPATASOL 0.77GM/100ML; 0.6GM/100ML; 0.02GM/100ML; 0.9GM/100ML; 0.24GM/100ML; 0.9GM/100ML; 1.1GM/100ML; 0.61GM/100ML; 0.1GM/100ML; 0.1GM/100ML; 0.115GM/100ML; 0.8GM/100ML; 0.5GM/100ML; 0.45GM/100ML; 0.065GM/100ML; 0.84GM/100ML SOLN BUDEPRION SR 100MG TB12 MICROGESTIN FE 20MCG; 75MG; 1MG TABS MICROGESTIN 1/20 20MCG; 1MG TABS MICROGESTIN FE 1.5/30 30MCG; 75MG; 1.5MG TABS MICROGESTIN 1.5/30 30MCG; 1.5MG TABS GRANISOL 2MG/10ML SOLN INFERGEN 15MCG/0.5ML INJ DETROL LA 2MG CP24 DETROL LA 4MG CP24 Reason Cost Sharing Tier Updates: There were no cost sharing tier updates this month. New Added Products: Effective 10/01/2014 Drug Cost sharing Restrictions* BELEODAQ 500MG SOLR Tier 5 PA B/D AUBRA 20MCG; 0.1MG TABS Tier 2 FALMINA 20MCG; 0.1MG TABS Tier 2 GILDESS 1.5/30 30MCG; 1.5MG TABS Tier 2 GARAMYCIN 0.3% SOLN Tier 1 VAQTA 25UNIT/0.5ML SUSP Syringe Tier 3 VAQTA 50UNIT/ML SUSP Syringe Tier 3 RECOMBIVAX HB 5MCG/0.5ML SUSP Tier 3 PA B/D RECOMBIVAX HB 10MCG/ML SUSP Tier 3 PA B/D PROCTOSOL HC 2.5% CREA Tier 2 GARDASIL 0 SUSP Tier 3 KADIAN 40MG CP24 Tier 4 QL SUTENT 37.5MG CAPS Tier 5 PA

3 THEOPHYLLINE 80MG/15ML SOLN Tier 2 VALSARTAN 160MG TABS Tier 2 VALSARTAN 320MG TABS Tier 2 VALSARTAN 40MG TABS Tier 2 VALSARTAN 80MG TABS Tier 2 Formulary Removals: Effective 10/01/2014 NIFEDIAC CC 90MG TB24 Drug Reason Cost Sharing Tier Updates: There were no cost sharing tier updates this month. New Added Products: Effective 09/01/2014 Drug Cost sharing Restrictions* ATOVAQUONE/PROGUANIL HCL 62.5MG; 25MG TABS Tier 2 BUDESONIDE 32MCG/ACT SUSP Tier 2 CARBIDOPA/LEVODOPA/ENTACAPONE 12.5MG; 200MG; 50MG TABS Tier 2 CARBIDOPA/LEVODOPA/ENTACAPONE 18.75MG; 200MG; 75MG TABS Tier 2 CARBIDOPA/LEVODOPA/ENTACAPONE 25MG; 200MG; 100MG TABS Tier 2 CARBIDOPA/LEVODOPA/ENTACAPONE 31.25MG; 200MG; 125MG TABS Tier 2 CARBIDOPA/LEVODOPA/ENTACAPONE 37.5MG; 200MG; 150MG TABS Tier 2 CARBIDOPA/LEVODOPA/ENTACAPONE 50MG; 200MG; 200MG TABS Tier 2 CEFDITOREN PIVOXIL 200MG TABS Tier 2 CIPROFLOXACIN 500MG/5ML SUSR Tier 2 CIPROFLOXACIN 250GM/5ML SUSR Tier 2 CYCLOPHOSPHAMIDE 25MG CAPS Tier 4 PA B/D CYCLOPHOSPHAMIDE 50MG CAPS Tier 4 PA B/D DICLOFENAC SODIUM 1.5% SOLN Tier 2

4 METHOXSALEN 10MG CAPS Tier 2 NEVIRAPINE 50MG/5ML SUSP Tier 2 OMEGA-3-ACID ETHYL ESTERS 375MG; 465MG; 1GM CAPS Tier 2 OMEPRAZOLE/SODIUM BICARBONATE 20MG; 1100MG CAPS Tier 2 OMEPRAZOLE/SODIUM BICARBONATE 40MG; 1100MG CAPS Tier 2 ISENTRESS 100MG PACK Tier 4 RISEDRONATE SODIUM 150MG TABS Tier 2 QUDEXY XR 100MG CS24 Tier 4 PA QUDEXY XR 150MG CS24 Tier 4 PA QUDEXY XR 200MG CS24 Tier 4 PA QUDEXY XR 25MG CS24 Tier 4 PA QUDEXY XR 50MG CS24 Tier 4 PA Formulary Removals: Effective 09/01/2014 Drug AMIKACIN SULFATE 50MG/ML SOLN CYTARABINE 500MG SOLR Reason Cost Sharing Tier Updates: There were no cost sharing tier updates this month. New Added Products: Effective 08/01/2014 Drug Cost sharing Restrictions* AZELASTINE HCL 0.15% SOLN Tier 2 QL AZITHROMYCIN 1GM PACK Tier 2 CALCITRIOL 3MCG/GM OINT Tier 2 ZYKADIA 150MG CAPS Tier 5 QL PA DOXYCYCLINE HYCLATE 100MG SOLR Tier 2 PA B/D HYDROMORPHONE HCL 1MG/ML LIQD Tier 2 NITROGLYCERIN LINGUAL 0.4MG/SPRAY SOLN Tier 2 PILOCARPINE HCL 1% SOLN Tier 2 PILOCARPINE HCL 2% SOLN Tier 2 PILOCARPINE HCL 4% SOLN Tier 2

5 SUMATRIPTAN 20MG/ACT SOLN Tier 2 SUMATRIPTAN 5MG/ACT SOLN Tier 2 TRIAMCINOLONE ACETONIDE 10MG/ML SUSP Tier 2 PA B/D KENALOG-10 10MG/ML SUSP Tier 4 PA B/D TRIAMCINOLONE ACETONIDE 40MG/ML SUSP Tier 2 PA B/D KENALOG-40 40MG/ML SUSP Tier 4 PA B/D Formulary Removals: Effective 08/01/2014 Drug HYDROCODONE/ACETAMINOPHEN 500MG; 10MG TABS HYDROCODONE/ACETAMINOPHEN 500MG; 5MG TABS STAGESIC 500MG; 5MG CAPS HYDROCODONE/ACETAMINOPHEN 500MG; 7.5MG TABS OXYCODONE/ACETAMINOPHEN 500MG; 5MG CAPS OXYCODONE/ACETAMINOPHEN 500MG; 7.5MG TABS HYDROCODONE/ACETAMINOPHEN 650MG; 10MG TABS HYDROCODONE/ACETAMINOPHEN 650MG; 7.5MG TABS OXYCODONE/ACETAMINOPHEN 650MG; 10MG TABS HYDROCODONE/ACETAMINOPHEN 660MG; 10MG TABS HYDROCODONE BITARTRATE/ACETAMINOPHEN 750MG; 10MG TABS HYDROCODONE/ACETAMINOPHEN 750MG; 7.5MG TABS ONFI 5MG TABS Reason Cost Sharing Tier Updates: There were no cost sharing tier updates this month. New Added Products: Effective 07/01/2014 Drug Cost sharing Restrictions* ADAPALENE 0.3% GEL Tier 2 AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM 10MG; 10MG TABS Tier 2

6 AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM 10MG; 80MG TABS Tier 2 AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM 2.5MG; 10MG TABS Tier 2 AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM 2.5MG; 20MG TABS Tier 2 AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM 2.5MG; 40MG TABS Tier 2 AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM 5MG; 10MG TABS Tier 2 AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM 5MG; 20MG TABS Tier 2 AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM 5MG; 40MG TABS Tier 2 AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM 5MG; 80MG TABS Tier 2 ESZOPICLONE 1MG TABS Tier 2 PA ESZOPICLONE 2MG TABS Tier 2 PA ESZOPICLONE 3MG TABS Tier 2 PA XULANE 35MCG/24HR; 150MCG/24HR PTWK Tier 2 NEVIRAPINE ER 400MG TB24 Tier 2 PEG-INTRON 80MCG/0.5ML KIT Tier 5 PA PEG-INTRON 120MCG/0.5ML KIT Tier 5 PA PEG-INTRON 150MCG/0.5ML KIT Tier 5 PA RALOXIFENE HYDROCHLORIDE 60MG TABS Tier 2 RIFABUTIN 150MG CAPS Tier 2 Formulary Removals: Effective 07/01/2014 Drug HYDROCODONE/ACETAMINOPHEN 500MG/15ML; 7.5MG/15ML SOLN CO-GESIC 500MG; 5MG TABS ADRIAMYCIN 2MG/ML SOLN PENTOSTATIN 10MG SOLR PILOPINE HS 4% GEL EXELON 2MG/ML SOLN Reason

7 Cost Sharing Tier Updates: There were no cost sharing tier updates this month. New Added Products: Effective 06/01/2014 Drug Cost sharing Restrictions* AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM 10MG; 20MG TABS Tier 2 AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM 10MG; 40MG TABS Tier 2 ATOVAQUONE 750MG/5ML SUSP Tier 2 CARBIDOPA 25MG TABS Tier 2 DIASTAT ACUDIAL 10MG GEL Tier 4 DIASTAT ACUDIAL 20MG GEL Tier 4 DIASTAT PEDIATRIC 2.5MG GEL Tier 4 APTIOM 200MG TABS Tier 4 APTIOM 400MG TABS Tier 4 APTIOM 600MG TABS Tier 4 APTIOM 800MG TABS Tier 4 TELMISARTAN/HYDROCHLOROTHIAZIDE 12.5MG; 40MG TABS Tier 2 TELMISARTAN/HYDROCHLOROTHIAZIDE 12.5MG; 80MG TABS Tier 2 TELMISARTAN/HYDROCHLOROTH 25MG; 80MG TABS Tier 2 MOXIFLOXACIN HCL 400MG TABS Tier 2 VICODIN 300MG; 5MG TABS Tier 2 QL VICODIN ES 300MG; 7.5MG TABS Tier 2 QL VICODIN HP 300MG; 10MG TABS Tier 2 QL Formulary Removals: Effective 06/01/2014 Drug ISOLYTE-M/DEXTROSE 5% 20MEQ/L; 44MEQ/L; 5%; 15MEQ/L; 35MEQ/L; 38MEQ/L SOLN DOXYCYCLINE HYCLATE 100MG SOLR METHADONE HCL 10MG/ML CONC REGONOL 5MG/ML SOLN Reason

8 LIDODERM 5% PTCH Cost Sharing Tier Updates: There were no cost sharing tier updates this month. New Added Products: Effective 05/01/2014 Drug Cost sharing Restrictions* ZOLMITRIPTAN 2.5MG TABS Tier 2 QL ZOLMITRIPTAN 5MG TABS Tier 2 QL ZOLMITRIPTAN ODT 2.5MG TBDP Tier 2 QL DEXAMETHASONE SODIUM PHOSPHATE 10MG/ML SOLN Tier 2 PA B/D ZOLMITRIPTAN ODT 5MG TBDP Tier 2 QL MORPHINE SULFATE ER 120MG CP24 Tier 2 QL MORPHINE SULFATE ER 30MG CP24 Tier 2 QL MORPHINE SULFATE ER 60MG CP24 Tier 2 QL MORPHINE SULFATE ER 90MG CP24 Tier 2 QL MORPHINE SULFATE ER 45MG CP24 Tier 2 QL MORPHINE SULFATE ER 75MG CP24 Tier 2 QL LANOXIN 62.5MCG TABS Tier 3 PA LEVOTHYROXINE SODIUM 100MCG SOLR Tier 2 PA B/D FYCOMPA 10MG TABS Tier 4 FYCOMPA 12MG TABS Tier 4 LANOXIN 187.5MCG TABS Tier 3 PA COPAXONE 40MG/ML SOSY Tier 5 PA ZOLMITRIPTAN 2.5MG TABS Tier 2 QL ZOLMITRIPTAN 5MG TABS Tier 2 QL ZOLMITRIPTAN ODT 2.5MG TBDP Tier 2 QL DEXAMETHASONE SODIUM PHOSPHATE 10MG/ML SOLN Tier 2 PA B/D ZOLMITRIPTAN ODT 5MG TBDP Tier 2 QL MORPHINE SULFATE ER 120MG CP24 Tier 2 QL MORPHINE SULFATE ER 30MG CP24 Tier 2 QL MORPHINE SULFATE ER 60MG CP24 Tier 2 QL MORPHINE SULFATE ER 90MG CP24 Tier 2 QL

9 MORPHINE SULFATE ER 45MG CP24 Tier 2 QL MORPHINE SULFATE ER 75MG CP24 Tier 2 QL LANOXIN 62.5MCG TABS Tier 3 PA LEVOTHYROXINE SODIUM 100MCG SOLR Tier 2 PA B/D FYCOMPA 10MG TABS Tier 4 FYCOMPA 12MG TABS Tier 4 LANOXIN 187.5MCG TABS Tier 3 PA COPAXONE 40MG/ML SOSY Tier 5 PA Formulary Removals: Effective 05/01/2014 Drug AZATHIOPRINE SODIUM 100MG SOLR ALLOPURINOL SODIUM 500MG SOLR AZATHIOPRINE SODIUM 100MG SOLR ALLOPURINOL SODIUM 500MG SOLR Reason Cost Sharing Tier Updates: There were no cost sharing tier updates this month. New Added Products: Effective 04/01/2014 Drug Cost sharing Restrictions* NIACIN ER 1000MG TBCR Tier 2 NIACIN ER 500MG TBCR Tier 2 NIACIN ER 750MG TBCR Tier 2 ERWINAZE 10000UNIT SOLR Tier 5 PA ZYCLARA PUMP 2.5% CREA Tier 3 HORIZANT 300MG TB24 Tier 4 METRONIDAZOLE 375MG CAPS Tier 2 TELMISARTAN 40MG TABS Tier 2 TELMISARTAN 80MG TABS Tier 2 LAMIVUDINE 100MG TABS Tier 2

10 ONCASPAR 750UNIT/ML SOLN Tier 5 PA TELMISARTAN 20MG TABS Tier 2 MYCOPHENOLIC ACID DR 180MG TBEC Tier 2 PA B/D MYCOPHENOLIC ACID DR 360MG TBEC Tier 2 PA B/D FLUOCINONIDE 0.1% CREA Tier 2 ESOMEPRAZOLE SODIUM 20MG SOLR Tier 2 PA B/D ESOMEPRAZOLE SODIUM 40MG SOLR Tier 2 PA B/D ZENCHENT 35MCG; 0.4MG TABS Tier 2 TOLTERODINE TARTRATE ER 2MG CP24 Tier 2 TOLTERODINE TARTRATE ER 4MG CP24 Tier 2 SIROLIMUS 0.5MG TABS Tier 2 PA B/D LIDOCAINE 5% PTCH Tier 2 CLONIDINE HCL ER 0.1MG TB12 Tier 2 HYDROCORTISONE BUTYRATE (LIPOPHILIC) 0.1% CREA Tier 2 EGRIFTA 2MG SOLR Tier 5 OXYCODONE HCL 5MG/5ML SOLN Tier 2 METHYLPHENIDATE HCL ER 18MG TBCR Tier 2 DONEPEZIL HCL 23MG TABS Tier 2 QL HORIZANT 600MG TB24 Tier 4 VESTURA 3MG; 0.02MG TABS Tier 2 REVLIMID 2.5MG CAPS Tier 5 PA INTELENCE 25MG TABS Tier 3 MYRBETRIQ 25MG TB24 Tier 3 MYRBETRIQ 50MG TB24 Tier 3 AFINITOR DISPERZ 2MG TBSO Tier 5 PA AFINITOR DISPERZ 3MG TBSO Tier 5 PA AFINITOR DISPERZ 5MG TBSO Tier 5 PA FYCOMPA 2MG TABS Tier 4 FYCOMPA 4MG TABS Tier 4 FYCOMPA 6MG TABS Tier 4 FYCOMPA 8MG TABS Tier 4

11 OXTELLAR XR 150MG TB24 Tier 4 OXTELLAR XR 300MG TB24 Tier 4 OXTELLAR XR 600MG TB24 Tier 4 ONFI 2.5MG/ML SUSP Tier 5 PA VERSACLOZ 50MG/ML SUSP Tier 5 INVOKANA 100MG TABS Tier 3 INVOKANA 300MG TABS Tier 3 TECFIDERA 120MG CPDR Tier 5 TECFIDERA 240MG CPDR Tier 5 TECFIDERA STARTER PACK 0 MISC Tier 5 PIRMELLA 1/35 35MCG; 1MG TABS Tier 2 REVLIMID 20MG CAPS Tier 5 PA BRISDELLE 7.5MG CAPS Tier 4 LYZA 0.35MG TABS Tier 2 GILOTRIF 20MG TABS Tier 5 PA GILOTRIF 30MG TABS Tier 5 PA GILOTRIF 40MG TABS Tier 5 PA LATUDA 60MG TABS Tier 4 ASTAGRAF XL 0.5MG CP24 Tier 4 PA B/D ASTAGRAF XL 1MG CP24 Tier 4 PA B/D ASTAGRAF XL 5MG CP24 Tier 4 PA B/D FETZIMA 120MG CP24 Tier 4 FETZIMA 20MG CP24 Tier 4 FETZIMA 40MG CP24 Tier 4 FETZIMA 80MG CP24 Tier 4 FETZIMA TITRATION PACK 0 C4PK Tier 4 TIVICAY 50MG TABS Tier 5 KHEDEZLA 100MG TB24 Tier 4 KHEDEZLA 50MG TB24 Tier 4 EPANED 1MG/ML SOLR Tier 5 TROKENDI XR 50MG CP24 Tier 4

12 TROKENDI XR 25MG CP24 Tier 4 TROKENDI XR 100MG CP24 Tier 4 TROKENDI XR 200MG CP24 Tier 5 BRINTELLIX 5MG TABS Tier 4 BRINTELLIX 20MG TABS Tier 4 BRINTELLIX 10MG TABS Tier 4 ANTARA 30MG CAPS Tier 3 ANTARA 90MG CAPS Tier 3 IMBRUVICA 140MG CAPS Tier 5 PA CANDESARTAN CILEXETIL 4MG TABS Tier 2 CANDESARTAN CILEXETIL 8MG TABS Tier 2 LOMUSTINE 10MG CAPS Tier 3 LOMUSTINE 100MG CAPS Tier 3 LOMUSTINE 40MG CAPS Tier 3 TRIAMTERENE/HYDROCHLOROTHIAZIDE 25MG; 50MG CAPS Tier 2 ACITRETIN 10MG CAPS Tier 2 ACITRETIN 25MG CAPS Tier 5 REPAGLINIDE 1MG TABS Tier 2 REPAGLINIDE 0.5MG TABS Tier 2 REPAGLINIDE 2MG TABS Tier 2 BCG VACCINE 0 INJ Tier 4 PA B/D REGRANEX 0.01% GEL Tier 5 QL ESTRADIOL 0.05MG/24HR PTWK Tier 2 ESTRADIOL 0.1MG/24HR PTWK Tier 2 ESTRADIOL 0.075MG/24HR PTWK Tier 2 ESTRADIOL 0.025MG/24HR PTWK Tier 2 ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE 300MG; 150MG; 300MG TABS Tier 2 CEFOTAXIME SODIUM 1GM SOLR Tier 2 PA B/D CEFOTAXIME SODIUM 2GM SOLR Tier 2 PA B/D CEFOTAXIME SODIUM 500MG SOLR Tier 2 PA B/D

13 GENTAMICIN SULFATE 0.3% OINT Tier 2 NORTRIPTYLINE HCL 10MG/5ML SOLN Tier 2 TOBRAMYCIN 300MG/5ML NEBU Tier 5 METAXALONE 800MG TABS Tier 2 PA ESTRADIOL 37.5MCG/24HR PTWK Tier 2 ESTRADIOL 0.06MG/24HR PTWK Tier 2 VORICONAZOLE 40MG/ML SUSR Tier 5 FENOFIBRATE 130MG CAPS Tier 2 FENOFIBRATE 43MG CAPS Tier 2 AZACITIDINE 100MG SUSR Tier 5 CLINDAMYCIN PALMITATE HCL 75MG/5ML SOLR Tier 2 METRONIDAZOLE 1% GEL Tier 2 PARICALCITOL 1MCG CAPS Tier 2 PA B/D PARICALCITOL 2MCG CAPS Tier 2 PA B/D PARICALCITOL 4MCG CAPS Tier 2 PA B/D CANDESARTAN CILEXETIL 16MG TABS Tier 2 DULOXETINE HCL 20MG CPEP Tier 2 DULOXETINE HCL 30MG CPEP Tier 2 DULOXETINE HCL 60MG CPEP Tier 2 DECITABINE 50MG SOLR Tier 5 PA B/D CANDESARTAN CILEXETIL 32MG TABS Tier 2 NORETHINDRONE 0.35MG TABS Tier 2 LANSOPRAZOLE/AMOXICILLIN/CLARITHROMYCIN 500MG; 500MG; 30MG MISC Tier 2 NUVIGIL 150MG TABS Tier 3 FENOFIBRIC ACID DR 135MG CPDR Tier 2 FENOFIBRIC ACID DR 45MG CPDR Tier 2 ACAMPROSATE CALCIUM DR 333MG TBEC Tier 2 RABEPRAZOLE SODIUM 20MG TBEC Tier 2 CLEMASTINE FUMARATE 0.67MG/5ML SYRP Tier 2 ADEFOVIR DIPIVOXIL 10MG TABS Tier 5

14 MORPHINE SULFATE ER 10MG CP24 Tier 2 QL ACITRETIN 17.5MG CAPS Tier 5 GATIFLOXACIN 0.5% SOLN Tier 2 Formulary Removals: Effective 04/01/2014 Drug ONTAK 150MCG/ML SOLN ENDOCET 500MG; 7.5MG TABS ENDOCET 650MG; 10MG TABS ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE BITARTRATE 712.8MG; 60MG; 32MG TABS ICLUSIG 15MG TABS ICLUSIG 45MG TABS LEUKINE 500MCG/ML SOLN CIMETIDINE HCL 150MG/ML SOLN TOBRAMYCIN SULFATE/SODIUM CHLORIDE 0.9%; 1.2MG/ML SOLN CLARINEX REDITABS 2.5MG TBDP CLARINEX REDITABS 5MG TBDP FREAMINE III 72MEQ/L; 600MG/100ML; 810MG/100ML; 3MEQ/L; 14MG/100ML; 1190MG/100ML; 240MG/100ML; 590MG/100ML; 770MG/100ML; 620MG/100ML; 450MG/100ML; 480MG/100ML; 10MMOLE/L; 115MG/100ML; 950MG/100ML; 500MG/100ML; 10MEQ/L; 340MG/100ML; 130MG/100ML; 560MG/100M PREZISTA 400MG TABS COMBIVENT 103MCG/ACT; 18MCG/ACT AERO HYDROCODONE/ACETAMINOPHEN 500MG; 2.5MG TABS ELSPAR 10000UNIT SOLR ASTRAMORPH 0.5MG/ML SOLN ASTRAMORPH 1MG/ML SOLN LEVOTHROID 25MCG TABS LEVOTHROID 50MCG TABS LEVOTHROID 75MCG TABS LEVOTHROID 88MCG TABS Reason

15 LEVOTHROID 100MCG TABS LEVOTHROID 112MCG TABS LEVOTHROID 137MCG TABS LEVOTHROID 150MCG TABS LEVOTHROID 175MCG TABS LEVOTHROID 200MCG TABS LEVOTHROID 300MCG TABS LEVOTHROID 125MCG TABS Cost Sharing Tier Updates: There were no cost sharing tier updates this month.

16 For more information about how these changes may affect your cost-sharing, such as copayments or coinsurance, or for more information about asking for an updated coverage determination or a formulary exception, please see the plan Evidence of Coverage. Alternative drugs are drugs in the same therapeutic category/class as the affected drug. Only your doctor can determine alternative drugs that are appropriate for you given the individualized nature of drug therapy. Please talk to your doctor about any changes or recommendations to your medical care and prescription drug therapy. Alternative drugs and additional information about formulary changes can be found on the plan formulary, *Indicates a restriction of Step Therapy, Prior Authorization or Quantity Level Limits may exist. LA = Limited Access, PA = Prior Authorization, QL = Quantity Limit, ST = Step Therapy Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayment/coinsurance may change on January 1, This document includes GuildNet Gold and GuildNet Health Advantage partial formulary as of 11/01/2014. For a complete, updated formulary, please visit our Web site at or call the Member Service number below. This information is available for free in other languages. Please contact Member Services number at for additional information. (TTY users should call ). Hours are Monday through Friday, 8am -8pm. Member Services has free language interpreter services available for non-english speakers. Esta información esta disponible en otros idiomas a gratis. Por favor llame a Servicios a los Clientes, al por información adicional. (Los usuarios de TTY deben llamar al ). Se atiende de lunes a viernes, de 8 a. m. a 8 p. m. Servicios a los Clientes tienen los servicios gratuitos de intérprete de idioma disponibles para altavoces de no-inglés. GuildNet Gold and GuildNet Health Advantage are HMO-POS SNP plans with Medicare and New York State contracts. Enrollment in GuildNet Gold and GuildNet Health Advantage depends on contract renewal.