Network Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary

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1 Requesting an Exception to the Formulary You can ask Network Health Insurance Corporation to make an exception to our coverage rules. Generally, we will only approve your request for an exception if alternative formulary drugs would not be as effective in treating your condition and would have a negative effect on your health. Contact us to ask for an initial coverage decision for a formulary, tier or utilization restriction (specific criteria) exception. When you re requesting an exception, please submit a statement from your physician supporting your request. For more detailed information about your Network Health Insurance Corporation prescription drug coverage, please review your Evidence of Coverage and other plan materials. The following brand name drugs will have a tier increase, with an increase in the member s share of the cost. For each drug, a generic alternative is now available. Drug Name Effective Date New Tier Alternative Drug Alternative Drug Tier INTUNIV ER 1 MG TABLET 7/1/15 4 Guanfacine ER 1mg tablet Tier 2: Non-Preferred Generic INTUNIV ER 2 MG TABLET 7/1/15 4 Guanfacine ER 2mg tablet Tier 2: Non-Preferred Generic INTUNIV ER 3 MG TABLET 7/1/15 4 Guanfacine ER 3mg tablet Tier 2: Non-Preferred Generic INTUNIV ER 4 MG TABLET 7/1/15 4 Guanfacine ER 4mg tablet Tier 2: Non-Preferred Generic CELEBREX 50 MG CAPSULE 7/1/15 4 Celecoxib 50mg capsule Tier 2: Non-Preferred Generic CELEBREX 100 MG CAPSULE 7/1/15 4 Celecoxib 100mg capsule Tier 2: Non-Preferred Generic CELEBREX 200 MG CAPSULE 7/1/15 4 Celecoxib 200mg capsule Tier 2: Non-Preferred Generic CELEBREX 400 MG CAPSULE 7/1/15 4 Celecoxib 400mg capsule Tier 2: Non-Preferred Generic STROMECTOL 3 MG TABLET 7/1/15 4 Ivermectin 3mg tablet Tier 2: Non-Preferred Generic EPIVIR 10 MG/ML ORAL SOLN 8/1/15 4 Lamivudine 10mg/ml oral soln Tier 2: Non-Preferred Generic MIGRANAL NASAL SPRAY 10/1/15 4 Dihydroergotamine Nasal Spray Tier 2: Non-Preferred Generic ABILIFY 1 MG/ML SOLUTION Abilify discmelt 10 mg tablet Tier 4: AKNE-MYCIN 2% OINTMENT erythromycin 2% gel Tier 2: Non-Preferred Generic ALAGESIC LQ ORAL SOLUTION acetaminophen-butalbital-caffeine tablets Tier 2: Non-Preferred Generic 1

2 AMTURNIDE MG TAB Tekturna hct mg tab; Tekamlo 150 Tier 4: ; Tier 4: mg-5 mg tablet AMTURNIDE MG TAB Tekturna hct mg tab; Tekamlo 300 Tier 4: ; Tier 4: mg-10 mg tablet AMTURNIDE MG TAB Tekturna hct mg tab; Tekamlo 300 mg Tier 4: ; Tier 4: 10 mg tablet AMTURNIDE MG TAB Tekturna hct mg tab; Tekamlo 300 Tier 4: ; Tier 4: mg-5 mg tablet AMTURNIDE MG TAB Tekturna hct mg tab; Tekamlo 300 mg Tier 4: ; Tier 4: 5 mg tablet ANDROXY 10 MG TABLET n/a N/A ANTARA 130 MG CAPSULE fenofibrate 130 mg capsule Tier 2: Non-Preferred Generic ANTARA 43 MG CAPSULE fenofibrate 43 mg capsule Tier 2: Non-Preferred Generic ARICEPT ODT 10 MG TABLET donepezil hcl odt 10 mg tablet Tier 2: Non-Preferred Generic ARICEPT ODT 5 MG TABLET donepezil hcl odt 5 mg tablet Tier 2: Non-Preferred Generic ASTELIN 137 MCG NASAL SPRAY azelastine 137 mcg nasal spray Tier 2: Non-Preferred Generic AVANDAMET 4 MG-1,000 MG TABLET Avandamet 2 mg-500 mg tablet Tier 4: AVANDARYL 4 MG-4 MG TABLET glimepiride 4 mg tablet; avandia 4 mg tablet Tier 1: Preferred Generic; Tier 4: Non- Preferred Brand AVANDARYL 8 MG-2 MG TABLET Avandaryl 4 mg-2 mg tablet Tier 4: AXID 15MG/ML ORAL SOLUTION nizatidine 15mg/ml solution Tier 2: Non-Preferred Generic BIAXIN XL 500 MG TABLET clarithromycin er 500mg tab Tier 2: Non-Preferred Generic BUTISOL SODIUM 30 MG/5 ML ELX Butisol sodium 30 mg tablet Tier 4: BUTISOL SODIUM 50MG TABLET Butisol sodium 30mg tablet Tier 4: CAMPRAL DR 333 MG TABLET acamprosate calc dr 333 mg tab Tier 2: Non-Preferred Generic CARDENE SR 30 MG CAPSULE nicardipine 30mg capsule Tier 2: Non-Preferred Generic CARDENE SR 60 MG CAPSULE nicardipine 30mg capsule Tier 2: Non-Preferred Generic CATAFLAM 50MG TABLET diclofenac potassium 50mg tablet Tier 2: Non-Preferred Generic 2

3 CEDAX 90 MG/5 ML SUSPENSION Cedax 180 mg/5 ml suspension Tier 4: CEFOTAXIME SODIUM 10 GM VIAL cefotaxime sodium 2gm vial Tier 2: Non-Preferred Generic CENESTIN 0.3 MG TABLET Enjuvia 0.3 mg tablet Tier 4: CENESTIN 0.45 MG TABLET Enjuvia 0.45 mg tablet Tier 4: CENESTIN MG TABLET Enjuvia mg tablet Tier 4: CENESTIN 0.9 MG TABLET Enjuvia 0.9 mg tablet Tier 4: CLARINEX-D 24 HOUR TABLET Clarinex-d 12 hour tablet Tier 4: COLY-MYCIN M 150 MG VIAL colistimethate 150mg vial Tier 2: Non-Preferred Generic COUMADIN 5MG VIAL heparin vial Tier 2: Non-Preferred Generic CYCLOPHOSPHAMIDE 25 MG TAB Cyclophosphamide 25mg capsule Tier 4: CYCLOPHOSPHAMIDE 50 MG TAB Cyclophosphamide 50mg capsule Tier 4: DANTRIUM 100 MG CAPSULE dantrolene sodium 100 mg cap Tier 2: Non-Preferred Generic DDAVP 10 MCG/0.1 ML SOLUTION desmopressin 0.1 mg/ml sol Tier 2: Non-Preferred Generic DILACOR XR 240 MG CAPSULE diltiazem 24hr er 240 mg cap Tier 2: Non-Preferred Generic DOCEFREZ 80 MG VIAL Docefrez 20 mg vial Tier 4: ENDOMETRIN 100 MG SUPPOSITORY N/A N/A ERYTHROMYCIN-SULFISOX SUSP e.e.s. 400mg filmtab Tier 2: Non-Preferred Generic ESTRASORB PACKET Evamist 1.53 mg/spray Tier 4: FLONASE 0.05% NASAL SPRAY fluticasone prop 50 mcg spray Tier 2: Non-Preferred Generic FRAGMIN 25,000 U/ML VIAL Fragmin 12,500 unit syringe Tier 5: Specialty Drugs FRAGMIN 7,500 UNITS SYRINGE Fragmin 7,500 units/0.3 ml syr Tier 5: Specialty Drugs GLYCATE 1.5 MG TABLET glycopyrrolate 1 mg oral tablet Tier 2: Non-Preferred Generic GRANISOL 2 MG/10 ML SOLUTION ondansetron 4 mg/5 ml solution Tier 2: Non-Preferred Generic HEPARIN-NS 1,000 UNITS/500 ML heparin-d5w 20,000 unit/500ml Tier 2: Non-Preferred Generic HEPATASOL 8% IV SOLUTION Hepatamine 8% iv solution Tier 3: Preferred Brand INCIVEK 375 MG TABLET Victrelis 200 mg capsule Tier 5: Specialty Drugs KADIAN ER 130 MG CAPSULE Kadian er 60 mg capsule Tier 4: KADIAN ER 150 MG CAPSULE Kadian er 80 mg capsule Tier 4: 3

4 KADIAN ER 70 MG CAPSULE Kadian er 60 mg capsule Tier 4: KAPVAY ER 0.1 MG TABLET clonidine hcl er 0.1 mg tablet Tier 2: Non-Preferred Generic LIDOCAINE HCL 1% VIAL lidocaine hcl 2% vial Tier 2: Non-Preferred Generic LO MINASTRIN FE TABLET CHEW Lo loestrin fe 1-10 tablet Tier 4: LOXITANE 5 MG CAPSULE loxapine 5 mg capsule Tier 2: Non-Preferred Generic LUFYLLIN-400 TABLET Lufyllin 200 mg tablet Tier 4: LUVOX CR 100 MG CAPSULE fluvoxamine er 100 mg capsule Tier 2: Non-Preferred Generic LUVOX CR 150 MG CAPSULE fluvoxamine er 150 mg capsule Tier 2: Non-Preferred Generic MAFENIDE ACETATE 50 GM POWD PK Sulfamylon powder packet Tier 4: MOXATAG ER 775 MG TABLET amoxicillin 875 mg tablet Tier 2: Non-Preferred Generic NASACORT AQ NASAL SPRAY triamcinolone 55mcg nasal spray Tier 2: Non-Preferred Generic OFLOXACIN 200 MG TABLET ofloxacin 400 mg tablet Tier 2: Non-Preferred Generic OMEGA-3 ETHYL ESTERS 1 GM CAP omega-3 ethyl esters 1 gm cap Tier 2: Non-Preferred Generic OPTIVAR 0.05% DROPS azelastine hcl 0.05% drops Tier 2: Non-Preferred Generic ORAPRED 15 MG/5 ML SOLUTION prednisolone 15 mg/5 ml soln Tier 2: Non-Preferred Generic ORTHO EVRA PATCH xulane patch Tier 2: Non-Preferred Generic PALGIC 4 MG TABLET carbinoxamine maleate 4 mg tablet Tier 2: Non-Preferred Generic PALGIC 4 MG/5 ML LIQUID carbinoxamine 4mg/5ml liquid Tier 2: Non-Preferred Generic PANTOPRAZOLE SODIUM 40 MG VIAL pantoprazole sod dr 40 mg tab Tier 2: Non-Preferred Generic PARCOPA 10MG-100MG ODT carbidopa-levodopa 10mg-100mg odt Tier 2: Non-Preferred Generic PARCOPA 25MG-100MG ODT carbidopa-levodopa 25mg-100mg odt Tier 2: Non-Preferred Generic PARCOPA 25MG-250MG ODT carbidopa-levodopa 25mg-250mg odt Tier 2: Non-Preferred Generic PEDI-DRI TOPICAL POWDER nystatin 100,000 unit/gm powd Tier 2: Non-Preferred Generic PEPCID 40 MG TABLET famotidine 40 mg tablet Tier 2: Non-Preferred Generic PHENADOZ 25 MG SUPPOSITORY promethazine 25 mg suppository Tier 2: Non-Preferred Generic PURINETHOL 50 MG TABLET mercaptopurine 50 mg tablet Tier 2: Non-Preferred Generic QVAR 80 MCG ORAL INHALER (100 actuation pack) Qvar 80 mcg oral inhaler (120 actuation pack) Tier 4: 4

5 RAZADYNE 4 MG/ML ORAL SOLUTION galantamine 4 mg/ml oral soln Tier 2: Non-Preferred Generic REVIA 50 MG TABLET naltrexone 50 mg tablet Tier 2: Non-Preferred Generic RITALIN SR 20MG TABLET methylphenidate er 20mg tablet Tier 2: Non-Preferred Generic SANCTURA 20 MG TABLET trospium chloride 20 mg tablet Tier 2: Non-Preferred Generic SANCTURA XR 60 MG CAPSULE trospium chloride er 60 mg cap Tier 2: Non-Preferred Generic SUPRAX 400 MG TABLET Suprax 400 mg capsule Tier 4: SYMBICORT MCG INHALER (60 Symbicort mcg inhaler (120 actuation actuation pack) pack) Tier 3: Preferred Brand TARGRETIN 1% GEL N/A N/A TERAZOL 3 80MG SUPPOSITORY terconazole 80mg suppository Tier 2: Non-Preferred Generic TESTOSTERONE CYP 100MG/ML Depo-testosterone 100mg/ml Tier 4: TESTOSTERONE CYP 200MG/ML Depo-testosterone 200mg/ml Tier 4: TIGAN 100 MG/ML VIAL ondansetron 4 mg/2 ml vial Tier 2: Non-Preferred Generic TIMENTIN 3.1 GM VIAL piperacilllin/tazobactam 3.375gm vial Tier 2: Non-Preferred Generic ULESFIA 5% LOTION N/A N/A UNIRETIC TABLET moexipril-hctz mg tab Tier 2: Non-Preferred Generic UNIRETIC MG TABLET moexipril-hctz mg tab Tier 2: Non-Preferred Generic UNIVASC 15 MG TABLET moexipril hcl 15 mg tablet Tier 2: Non-Preferred Generic UNIVASC 7.5 MG TABLET moexipril hcl 7.5 mg tablet Tier 2: Non-Preferred Generic VIVACTIL 10 MG TABLET protriptyline hcl 10 mg tablet Tier 2: Non-Preferred Generic VIVACTIL 5 MG TABLET protriptyline hcl 5 mg tablet Tier 2: Non-Preferred Generic VOSOL HC EAR DROPS hydrocortison-acetic acid soln Tier 2: Non-Preferred Generic XYLOCAINE-MPF 1% AMPUL lidocaine hcl 2% vial Tier 2: Non-Preferred Generic ZAMICET MG/15 ML SOLN hydrocodone-acetaminophen /15ml soln Tier 2: Non-Preferred Generic ZAROXOLYN 2.5 MG TABLET metolazone 2.5 mg tablet Tier 2: Non-Preferred Generic ZAROXOLYN 5 MG TABLET metolazone 5 mg tablet Tier 2: Non-Preferred Generic 5

6 ZEMPLAR 4 MCG CAPSULE paricalcitol 4 mcg capsule Tier 2: Non-Preferred Generic 6

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