2015 FORMULARY CHANGE NOTICE

Transcription

1 Cigna-HealthSpring Primary (HMO),, Cigna-HealthSpring TotalCare AR (HMO SNP), Cigna-HealthSpring TotalCare SMS (HMO SNP), 2015 FORMULARY CHANGE NOTICE PLEASE NOTE THESE IMPORTANT CHANGES TO YOUR 2015 FORMULARY (LIST OF COVERED DRUGS) Formulary change Reason for Formulary change alternative Effective date of change: 08/01/2015 Tier alternative alosetron tab 0.5mg Enhancement Addition N/A N/A T1; PA; QL 60 EA per 30 days alosetron hcl tab 1 mg Enhancement Addition N/A N/A T1; PA; QL 60 EA per 30 days anaspaz Enhancement Addition N/A N/A T1 atropine 1% ophth sol Enhancement Addition N/A N/A T1 AURYXIA 210MG TABS Enhancement Addition N/A N/A T1 clozapine 150 mg disintegrating oral tablet Enhancement Addition N/A N/A T1 clozapine 200 mg disintegrating oral tablet Enhancement Addition N/A N/A T1 colchicine 0.6mg caps Enhancement Addition N/A N/A T1 colchicine 0.6mg tabs Enhancement Addition N/A N/A T1 ed spaz Enhancement Addition N/A N/A T1 glatopa 20mg/ml Enhancement Addition N/A N/A T1; QL 30 ML per 30 days hyoscyamine 0.125mg Enhancement Addition N/A N/A T1 hyoscyamine 0.125mg tabs Enhancement Addition N/A N/A T1 hyoscyamine 0.125mg tabs odt Enhancement Addition N/A N/A T1 hyoscyamine 0.125mg tabs subl Enhancement Addition N/A N/A T1 hyoscyamine 0.125mg/5ml elixir Enhancement Addition N/A N/A T1 hyosyne elixir Enhancement Addition N/A N/A T1 JADENU 180MG TABS Enhancement Addition N/A N/A T1 JADENU 360MG TABS Enhancement Addition N/A N/A T1 JADENU 90MG TABS Enhancement Addition N/A N/A T1 KINRIX Enhancement Addition N/A N/A T1 KUVAN POW 500MG Enhancement Addition N/A N/A T1; PA lopreeza 0.5mg; 0.1mg Enhancement Addition N/A N/A T1; PA lopreeza 1mg; 0.5mg Enhancement Addition N/A N/A T1; PA Notes 1

2 naftifine cre hcl 1% Enhancement Addition N/A N/A T1 nulev Enhancement Addition N/A N/A T1 oscimin Enhancement Addition N/A N/A T1 oscimin Enhancement Addition N/A N/A T1 oscimin Enhancement Addition N/A N/A T1 PAZEO Enhancement Addition N/A N/A T1 phenazopyridine 100mg tabs Enhancement Addition N/A N/A T1 phenazopyridine 200mg tabs Enhancement Addition N/A N/A T1 phospha neutral 250 Enhancement Addition N/A N/A T1 risedronate sodium tab 30 mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days risedronate sodium tab 35 mg Enhancement Addition N/A N/A T1; QL 4 EA per 28 days risedronate sodium tab 5 mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days salsalate 500mg tabs Enhancement Addition N/A N/A T1 salsalate 750mg tabs Enhancement Addition N/A N/A T1 SIMBRINZA 0.2%; 1% SUSP Enhancement Addition N/A N/A T1 symax fastabs Enhancement Addition N/A N/A T1 symax-sl Enhancement Addition N/A N/A T1 virt phos 250 neutral Enhancement Addition N/A N/A T1 Effective date of change: 07/01/2015 {21 (ethinyl estradiol 0.02 mg / levonorgestrel 0.1 mg Enhancement Addition N/A N/A T1 oral tablet) / 7 (inert ingredients 1 mg oral tablet) } pack aripiprazole tab 10mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days; ST (new starts) aripiprazole tab 15mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days; ST (new starts) aripiprazole tab 20mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days; ST (new starts) aripiprazole tab 2mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days; ST (new starts) aripiprazole tab 30mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days; ST (new starts) aripiprazole tab 5mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days; ST (new starts) bimatoprost 0.3 mg/ml ophthalmic solution Enhancement Addition N/A N/A T1; QL 5 ML per 30 days cefixime 20 mg/ml oral susp Enhancement Addition N/A N/A T1 cefixime 40 mg/ml oral susp Enhancement Addition N/A N/A T1 FOSRENOL PWDER 1000MG Enhancement Addition N/A N/A T1; ST FOSRENOL PWDER 750MG Enhancement Addition N/A N/A T1; ST 2

3 LEVOLEUCOVORIN 10 MG/ML INJECT SLTN Enhancement Addition N/A N/A T1 levoleucovorin 175mg/17.5ml Enhancement Addition N/A N/A T1 potassium chloride 1.33 meq/ml oral solution Enhancement Addition N/A N/A T1 potassium chloride 2.67 meq/ml oral solution Enhancement Addition N/A N/A T1 QUADRACEL Enhancement Addition N/A N/A T1 SAPHRIS SUB 2.5MG Enhancement Addition N/A N/A T1; QL 60 EA per 30 days; ST (new starts) tolcapone tab 100mg Enhancement Addition N/A N/A T1 LYRICA 25MG Enhancement Update N/A N/A QL increased to 90 EA per 30 days Effective date of change: 06/01/2015 BEXSERO Enhancement Addition N/A N/A T1 cefixime 100/5ml Enhancement Addition N/A N/A T1 cefixime 200/5ml Enhancement Addition N/A N/A T1 FARYDAK CAP 10MG Enhancement Addition N/A N/A T1; PA (new starts); QL 9 EA per 28 days FARYDAK CAP 15MG Enhancement Addition N/A N/A T1; PA (new starts); QL 9 EA per 28 days FARYDAK CAP 20MG Enhancement Addition N/A N/A T1; PA (new starts); QL 9 EA per 28 days fluoxetine 10mg cap Enhancement Addition N/A N/A T1 k-sol 10% Enhancement Addition N/A N/A T1 k-sol 20% Enhancement Addition N/A N/A T1 LENVIMA CAP 10MG Enhancement Addition N/A N/A T1; PA (new starts) LENVIMA CAP 14MG Enhancement Addition N/A N/A T1; PA (new starts) LENVIMA CAP 20MG Enhancement Addition N/A N/A T1; PA (new starts) LENVIMA CAP 24MG Enhancement Addition N/A N/A T1; PA (new starts) LEVEMIR FLEXPEN Enhancement Addition N/A N/A T1 levetiracetam 10 mg/ml sltn Enhancement Addition N/A N/A T1 levetiracetam 15 mg/ml sltn Enhancement Addition N/A N/A T1 levetiracetam 5 mg/ml sltn Enhancement Addition N/A N/A T1 omega-3 acid 900 mg cap Enhancement Addition N/A N/A T1; QL 120 EA per 30 days ondansetron 2 mg/ml prefilled syr Enhancement Addition N/A N/A T1 pramipexole mg er tab Enhancement Addition N/A N/A T1; QL 90 EA per 30 days pramipexole 0.75 mg er tab Enhancement Addition N/A N/A T1; QL 90 EA per 30 days pramipexole 1.5 mg er tab Enhancement Addition N/A N/A T1; QL 90 EA per 30 days PRISTIQ 25MG Enhancement Addition N/A N/A T1; QL 30 EA per 30 days ST (new starts) PROAIR RESPICLICK Enhancement Addition N/A N/A T1; QL 2 EA per 30 days 3

4 RELISTOR 0.4ML Enhancement Addition N/A N/A T1; PA; QL 12 ML per 30 days RELISTOR 0.6ML Enhancement Addition N/A N/A T1; PA; QL 28 ML per 28 days STRIVERDI RESPIMAT Enhancement Addition N/A N/A T1; QL 4 GM per 30 days tazicef 200 mg/ml (6gm) Enhancement Addition N/A N/A T1 testosterone cyp 200 mg/ml sltn Enhancement Addition N/A N/A T1; PA TOUJEO SOLO INJ 300IU/ML Enhancement Addition N/A N/A T1 tramadol er 100mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days tramadol er 200mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days tramadol er 300mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days zenatane 30mg Enhancement Addition N/A N/A T1 Effective date of change: 05/01/2015 ABILIFY MAINTENA 300MG SUSR Enhancement Addition N/A N/A T1; QL 1.5 EA per 30 days ARANESP INJ 10MCG Enhancement Addition N/A N/A T1; PA docetaxel 200mg/20ml vial Enhancement Addition N/A N/A T1; PA (Part B) famotidine 10mg/ml Enhancement Addition N/A N/A T1 fentanyl td patch 72hr 37.5 mcg/hr Enhancement Addition N/A N/A T1; QL 15 EA per 30 days fentanyl td patch 72hr 62.5 mcg/hr Enhancement Addition N/A N/A T1; QL 15 EA per 30 days fentanyl td patch 72hr 87.5 mcg/hr Enhancement Addition N/A N/A T1; QL 15 EA per 30 days GLEOSTINE 100MG CAP Enhancement Addition N/A N/A T1 GLEOSTINE 10MG CAP Enhancement Addition N/A N/A T1 GLEOSTINE 40MG CAP Enhancement Addition N/A N/A T1 IBRANCE 100MG CAP Enhancement Addition N/A N/A T1; PA (new starts); QL 21 EA per 28 days IBRANCE 125MG CAP Enhancement Addition N/A N/A T1; PA (new starts); QL 21 EA per 28 days IBRANCE 75MG CAP Enhancement Addition N/A N/A T1; PA (new starts); QL 21 EA per 28 days klor-con 8 tab Enhancement Addition N/A N/A T1 lamotrigine 100mg odt Enhancement Addition N/A N/A T1 lamotrigine 200mg odt Enhancement Addition N/A N/A T1 lamotrigine 25mg odt Enhancement Addition N/A N/A T1 lamotrigine 50mg odt Enhancement Addition N/A N/A T1 morphine sulf 4mg/ml Enhancement Addition N/A N/A T1 NORMOSOL-R Enhancement Addition N/A N/A T1; PA (Part B) potassium chloride er tab 20 meq Enhancement Addition N/A N/A T1 PREZCOBIX 150/800MG TAB Enhancement Addition N/A N/A T1 4

5 trezix 320.5mg; 30mg; 16mg cap Enhancement Addition N/A N/A T1; QL 360 EA per 30 days VITEKTA 150MG TAB Enhancement Addition N/A N/A T1 VITEKTA 85MG TAB Enhancement Addition N/A N/A T1 celecoxib 50mg tab Enhancement Update N/A N/A Step Therapy removed celecoxib 100mg tab Enhancement Update N/A N/A Step Therapy removed celecoxib 200mg tab Enhancement Update N/A N/A Step Therapy removed celecoxib 400mg tab Enhancement Update N/A N/A Step Therapy removed Effective date of change: 04/01/2015 BEXSERO VACCINE Enhancement Addition N/A N/A T1 esomeprazole 20mg dr cap Enhancement Addition N/A N/A T1; QL 60 EA per 30 days esomeprazole 40mg dr cap Enhancement Addition N/A N/A T1; QL 60 EA per 30 days EVOTAZ TAB Enhancement Addition N/A N/A T1 fenoprofen 400mg capsule Enhancement Addition N/A N/A T1 HARVONI 90MG; 400MG TAB Enhancement Addition N/A N/A T1; PA; QL 28 EA per 28 days ILEVRO 0.3% OPHTHALMIC SUSP Enhancement Addition N/A N/A T1 INTRALIPID Enhancement Addition N/A N/A T1; PA (Part B) KABIVEN EMULSION Enhancement Addition N/A N/A T1; PA (Part B) LIPOSYN II Enhancement Addition N/A N/A T1; PA (Part B) LIPOSYN III Enhancement Addition N/A N/A T1; PA (Part B) LYNPARZA 50 MG CAPSULE Enhancement Addition N/A N/A T1; PA (new starts); QL 480 EA per 30 days LYNPARZA 50MG CAPS Enhancement Addition N/A N/A T1; PA (new starts); QL 480 EA per 30 days OPDIVO INJ 100MG/10 SOLN Enhancement Addition N/A N/A T1; PA (new starts) OPDIVO INJ 40MG/4ML SOLN Enhancement Addition N/A N/A T1; PA (new starts) OPDIVO 40 MG/4 ML VIAL Enhancement Addition N/A N/A T1; PA (new starts) PERIKABIVEN EMULSION Enhancement Addition N/A N/A T1; PA (Part B) REYATAZ 100MG CAP Enhancement Addition N/A N/A T1 REYATAZ 50 MG POWDER PACKET Enhancement Addition N/A N/A T1 REYATAZ 50MG POWDER PACK Enhancement Addition N/A N/A T1 SANDIMMUNE ORAL SOLN 100MG/ML Enhancement Addition N/A N/A T1; PA (Part B) LUFYLLIN-400 TABLET Deletion No longer available theophylline T1 No longer available on market on market klor-con 8 tab Enhancement Addition N/A N/A T1 Effective date of change: 03/01/2015 5

6 ANDROGEL 1% GEL PUMP Enhancement Addition N/A N/A T1; PA ANDROGEL 1%(2.5G) GEL PACKET Enhancement Addition N/A N/A T1; PA ANDROGEL 1.62%(1.25G) GEL PCKT Enhancement Addition N/A N/A T1; PA ANDROGEL 1.62%(2.5G) GEL PCKT Enhancement Addition N/A N/A T1; PA AMINOSYN 7%-ELECTROLYTE SOL Enhancement Addition N/A N/A T1; PA (Part B) AMINOSYN-RF 5.2% IV SOLUTION Enhancement Addition N/A N/A T1; PA (Part B) CLINIMIX-E 4.25% Enhancement Addition N/A N/A T1; PA (Part B) CLINIMIX-E 5% Enhancement Addition N/A N/A T1; PA (Part B) deblitane 0.35 mg tablet Enhancement Addition N/A N/A T1 delyla-28 tablet Enhancement Addition N/A N/A T1 desogestr-eth estrad eth estra Enhancement Addition N/A N/A T1 diazepam 5 mg/ml Enhancement Addition N/A N/A QL 240 ML per 30 days docetaxel 20mg/ml Enhancement Addition N/A N/A T1; PA (Part B) docetaxel 80mg/4ml Enhancement Addition N/A N/A T1; PA (Part B) epinephrine 0.15 mg auto-injct Enhancement Addition N/A N/A QL 2 EA per 30 days estradiol dis 0.025mg Enhancement Addition N/A N/A T1; PA estradiol dis mg Enhancement Addition N/A N/A T1; PA estradiol dis 0.05mg Enhancement Addition N/A N/A T1; PA estradiol dis 0.1mg Enhancement Addition N/A N/A T1; PA falmina-28 tablet Enhancement Addition N/A N/A T1 FREAMINE HBC 6.9% IV SOLN Enhancement Addition N/A N/A T1; PA (Part B) furosemide 10 mg/ml syringe Enhancement Addition N/A N/A T1 GARDASIL 9 SYRINGE Enhancement Addition N/A N/A T1 GARDASIL 9 VIAL Enhancement Addition N/A N/A T1 GARDASIL SYRINGE Enhancement Addition N/A N/A T1 gildess 1.5mg Enhancement Addition N/A N/A T1 HUMIRA 10 MG/0.2 ML SYRINGE Enhancement Addition N/A N/A QL increased to 2 EA per 28 days INTRON A 18 MILLION UNITS VIAL Enhancement Addition N/A N/A T1 INTRON A 50 MILLION UNITS VIAL Enhancement Addition N/A N/A T1 ivermectin 3 mg tablet Enhancement Addition N/A N/A T1 KEYTRUDA 100MG/4ML Enhancement Addition N/A N/A T1; PA (new starts) lamivudine sol 10mg/ml Enhancement Addition N/A N/A T1 linezolid inj 2mg/ml Enhancement Addition N/A N/A T1; PA 6

7 MINIVELLE 0.025MG PATCH/24 HR Enhancement Addition N/A N/A T1; PA; QL 8 EA per 28 days NUTRILIPID 20% IV FAT EMULSION Enhancement Addition N/A N/A T1; PA (Part B) sharobel 0.35 mg tablet Enhancement Addition N/A N/A T1 TRUMENBA 120 MCG/0.5 ML VACCIN Enhancement Addition N/A N/A T1 DULERA 5MCG/100MCG Enhancement Update N/A N/A QL increased to 18 EA per 30 days DULERA 5MCG/200MCG Enhancement Update N/A N/A QL increased to 18 EA per 30 days SYMBICORT 160MCG/4.5MCG Enhancement Update N/A N/A QL increased to 12 EA per 30 days Effective date of change: 02/09/2015 clonazepam 0.5mg tabs Enhancement Update N/A N/A QL increased to 300 EA per 30 days clonazepam 1mg tabs Enhancement Update N/A N/A QL increased to 300 EA per 30 days clonazepam odt 0.125mg tbdp Enhancement Update N/A N/A QL increased to 300 EA per 30 days clonazepam odt 0.25mg tbdp Enhancement Update N/A N/A QL increased to 300 EA per 30 days clonazepam odt 0.5mg tbdp Enhancement Update N/A N/A QL increased to 300 EA per 30 days clonazepam odt 1mg tbdp Enhancement Update N/A N/A QL increased to 300 EA per 30 days escitalopram oxalate 10mg tabs Enhancement Update N/A N/A QL removed escitalopram oxalate 20mg tabs Enhancement Update N/A N/A QL removed escitalopram oxalate 5mg tabs Enhancement Update N/A N/A QL removed escitalopram oxalate 5mg/5ml soln Enhancement Update N/A N/A QL removed lansoprazole 15 mg cap Enhancement Update N/A N/A QL removed lansoprazole 30 mg cap Enhancement Update N/A N/A QL removed NEXIUM 10 MG PACK Enhancement Update N/A N/A QL increased to 60 EA per 30 days NEXIUM 2.5 MG PACK Enhancement Update N/A N/A QL increased to 60 EA per 30 days NEXIUM 20 MG CAP Enhancement Update N/A N/A QL increased to 60 EA per 30 days NEXIUM 20 MG PACK Enhancement Update N/A N/A QL increased to 60 EA per 30 days NEXIUM 40 MG CAP Enhancement Update N/A N/A QL increased to 60 EA per 30 days NEXIUM 40 MG PACK Enhancement Update N/A N/A QL increased to 60 EA per 30 days NEXIUM 5 MG PACK Enhancement Update N/A N/A QL increased to 60 EA per 30 days omeprazole 10 mg cap Enhancement Update N/A N/A QL removed omeprazole 20 mg cap Enhancement Update N/A N/A QL removed omeprazole 40 mg cap Enhancement Update N/A N/A QL removed pantoprazole 20 mg tab Enhancement Update N/A N/A QL removed pantoprazole 40 mg tab Enhancement Update N/A N/A QL removed venlafaxine hcl 100mg tabs Enhancement Update N/A N/A QL removed 7

8 venlafaxine hcl 25mg tabs Enhancement Update N/A N/A QL removed venlafaxine hcl 37.5mg tabs Enhancement Update N/A N/A QL removed venlafaxine hcl 50mg tabs Enhancement Update N/A N/A QL removed venlafaxine hcl 75mg tabs Enhancement Update N/A N/A QL removed venlafaxine hcl er 150mg cp24 Enhancement Update N/A N/A QL removed venlafaxine hcl er 150mg tb24 Enhancement Update N/A N/A QL removed venlafaxine hcl er 37.5mg cp24 Enhancement Update N/A N/A QL removed venlafaxine hcl er 37.5mg tb24 Enhancement Update N/A N/A QL removed venlafaxine hcl er 75mg cp24 Enhancement Update N/A N/A QL removed venlafaxine hcl er 75mg tb24 Enhancement Update N/A N/A QL removed Effective date of change: 01/01/2015 ace acd/alum sol 2% otic Enhancement Addition N/A N/A T1 adrucil inj 500/10ml Enhancement Addition N/A N/A T1; PA (Part B) adrucil inj 5gm/100m Enhancement Addition N/A N/A T1; PA (Part B) ALOPRIM 500MG Enhancement Addition N/A N/A T1 amikacin inj 1gm/4ml Enhancement Addition N/A N/A T1 amiodarone inj 50mg/ml Enhancement Addition N/A N/A T1 amiodarone inj 50mg/ml Enhancement Addition N/A N/A T1 amlod/valsar tab mg Enhancement Addition N/A N/A T1 amlod/valsar tab 5-160mg Enhancement Addition N/A N/A T1 amlod/valsar tab 5-320mg Enhancement Addition N/A N/A T1 amlod/valsartan/hctz 10mg; 12.5mg; 160mg Enhancement Addition N/A N/A T1 amlod/valsartan/hctz 10mg; 25mg; 160mg Enhancement Addition N/A N/A T1 amlod/valsartan/hctz 10mg; 25mg; 320mg Enhancement Addition N/A N/A T1 amlod/valsartan/hctz 5mg; 12.5mg; 160mg Enhancement Addition N/A N/A T1 amlod/valsartan/hctz 5mg; 25mg; 160mg Enhancement Addition N/A N/A T1 amlod-valsar tab mg Enhancement Addition N/A N/A T1 ampicillin inj 2gm Enhancement Addition N/A N/A T1 amp-sulbacta inj 1.5gm Enhancement Addition N/A N/A T1 BELEODAQ Enhancement Addition N/A N/A T1; PA (new starts) bromfenac 0.09% 1.7ml bottle Enhancement Addition N/A N/A T1 butalbital/apap/caffeine 500/50/40 Enhancement Addition N/A N/A T1; PA; QL 180 EA per 30 days 8

9 butalbital/apap/caffeine; butalbital compound products Enhancement Addition N/A N/A T1; PA; QL 180 EA per 30 days butalbital/aspirin/caffeine 325/50/40 Enhancement Addition N/A N/A T1; PA; QL 180 EA per 30 days BYDUREON INJ PEN Enhancement Addition N/A N/A T1; QL 4 EA per 28 days cefaclor 125mg/5ml susr Enhancement Addition N/A N/A T1 cefaclor 250mg/5ml susr Enhancement Addition N/A N/A T1 cefaclor 375mg/5ml susr Enhancement Addition N/A N/A T1 ceftriaxone inj 2gm Enhancement Addition N/A N/A T1 cefuroxime inj 7.5gm Enhancement Addition N/A N/A T1 celecoxib 100mg cap Enhancement Addition N/A N/A T1; ST; QL 60 EA per 30 days celecoxib 200mg cap Enhancement Addition N/A N/A T1; ST; QL 60 EA per 30 days celecoxib 400mg cap Enhancement Addition N/A N/A T1; ST; QL 60 EA per 30 days celecoxib 50mg cap Enhancement Addition N/A N/A T1; ST; QL 60 EA per 30 days ciclodan cre 0.77% Enhancement Addition N/A N/A T1 ciclodan sol 8% Enhancement Addition N/A N/A T1 ciprofloxacin 50 mg/ml Enhancement Addition N/A N/A T1 cisplatin inj 200mg Enhancement Addition N/A N/A T1; PA (Part B) cisplatin inj 50/50ml Enhancement Addition N/A N/A T1; PA (Part B) clobetasol aer 0.05% Enhancement Addition N/A N/A T1 clobetasol propionate Enhancement Addition N/A N/A T1 clobetasol propionate 0.05% foam Enhancement Addition N/A N/A T1 clobetasol shampoo 0.05% Enhancement Addition N/A N/A T1 clodan shampoo Enhancement Addition N/A N/A T1 CYRAMZA 100MG/10ML INJ Enhancement Addition N/A N/A T1; PA (new starts) CYRAMZA 500MG/50ML INJ Enhancement Addition N/A N/A T1; PA (new starts) DELESTROGEN 10MG/ML OIL Enhancement Addition N/A N/A T1 DELESTROGEN 20MG/ML OIL Enhancement Addition N/A N/A T1 DELESTROGEN 40MG/ML OIL Enhancement Addition N/A N/A T1 dexamethason sol 0.5/5ml Enhancement Addition N/A N/A T1 dexamethasone sodium phosphate 10mg/ml Enhancement Addition N/A N/A T1 dexrazoxone 500mg Enhancement Addition N/A N/A T1; PA (Part B) dextrose 5%/lactated ringers Enhancement Addition N/A N/A T1 diclofenac sod 1.5% Enhancement Addition N/A N/A T1 9

10 digitek 0.125mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days digitek 0.250mg Enhancement Addition N/A N/A T1; PA diltiazem cd 360mg Enhancement Addition N/A N/A T1 diltiazem hcl er 180mg tb24 Enhancement Addition N/A N/A T1 diltiazem hcl er 240mg tb24 Enhancement Addition N/A N/A T1 diltiazem hcl er 300mg tb24 Enhancement Addition N/A N/A T1 diltiazem hcl er 360mg tb24 Enhancement Addition N/A N/A T1 diltiazem hcl er 420mg tb24 Enhancement Addition N/A N/A T1 docetaxel 20mg/ml Enhancement Addition N/A N/A T1; PA (Part B) doxy 100mg Enhancement Addition N/A N/A T1 entecavir 0.5mg Enhancement Addition N/A N/A T1 entecavir 1mg Enhancement Addition N/A N/A T1 esgic 325mg; 50mg; 40mg Enhancement Addition N/A N/A T1; PA; QL 180 EA per 30 days famotidine inj 200/20ml Enhancement Addition N/A N/A T1 famotidine inj 40mg/4ml Enhancement Addition N/A N/A T1 fluocinolone acetonide body 0.1% Enhancement Addition N/A N/A T1 fluocinolone acetonide scalp 0.1% Enhancement Addition N/A N/A T1 FLUOROURACIL CREAM 0.5% Enhancement Addition N/A N/A T1 fluorouracil inj 1gm/20ml Enhancement Addition N/A N/A T1; PA (Part B) fluorouracil inj 500/10ml Enhancement Addition N/A N/A T1; PA (Part B) fluorouracil inj 5gm/100m Enhancement Addition N/A N/A T1; PA (Part B) fluoxetine 20mg Enhancement Addition N/A N/A T1 gamunex-c 40gm/400mls Enhancement Addition N/A N/A T1; PA (Part B) GARDASIL SUSP Enhancement Addition N/A N/A T1 gentam/nacl inj 100mg pb Enhancement Addition N/A N/A T1 glipizide xl 10 tb24 Enhancement Addition N/A N/A T1 glipizide xl 10mg Enhancement Addition N/A N/A T1 glipizide xl 2.5 tb24 Enhancement Addition N/A N/A T1 glipizide xl 2.5mg Enhancement Addition N/A N/A T1 glipizide xl 5 tb24 Enhancement Addition N/A N/A T1 glipizide xl 5mg Enhancement Addition N/A N/A T1 glycopyrrol inj 0.2mg/ml Enhancement Addition N/A N/A T1 glycopyrrol inj 0.2mg/ml Enhancement Addition N/A N/A T1 10

11 glycopyrrol inj 0.2mg/ml Enhancement Addition N/A N/A T1 heparin sodium/sodium chloride 0.9% premix Enhancement Addition N/A N/A T1 HUMIRA INJ 10MG/0.2 Enhancement Addition N/A N/A T1; PA; QL 0.4 EA per 28 days HUMIRA PEDIATRIC KIT CROHNS STARTER Enhancement Addition N/A N/A T1; PA; QL 6 EA per 28 days HUMIRA PSORIASIS STARTER KIT Enhancement Addition N/A N/A T1; PA; QL 4 EA per 28 days ifosfamide inj 1gm/20ml Enhancement Addition N/A N/A T1; PA (Part B) ifosfamide inj 3gm/60ml Enhancement Addition N/A N/A T1; PA (Part B) INTRON A INJ 10MU Enhancement Addition N/A N/A T1 INTRON A INJ 18MU Enhancement Addition N/A N/A T1 INTRON A INJ 50MU Enhancement Addition N/A N/A T1 INVOKAMET 150/1000MG TAB Enhancement Addition N/A N/A T1; QL 60 EA per 30 days INVOKAMET 150/500MG TAB Enhancement Addition N/A N/A T1; QL 60 EA per 30 days INVOKAMET 50/1000MG TAB Enhancement Addition N/A N/A T1; QL 60 EA per 30 days INVOKAMET 50/500MG TAB Enhancement Addition N/A N/A T1; QL 60 EA per 30 days INVOKANA 100MG Enhancement Addition N/A N/A T1; QL 30 EA per 30 days INVOKANA 300MG Enhancement Addition N/A N/A T1; QL 30 EA per 30 days irinotecan inj 40mg/2ml Enhancement Addition N/A N/A T1; PA (Part B) irinotecan inj 500mg/25 Enhancement Addition N/A N/A T1; PA (Part B) ISENTRESS 100MG POWDER PACK Enhancement Addition N/A N/A T1 ivermectin tab 3mg Enhancement Addition N/A N/A T1 KEYTRUDA 50MG SOLR Enhancement Addition N/A N/A T1; PA (new starts) LEVEMIR FLEXTOUCH Enhancement Addition N/A N/A T1 levonor/ethi tab estradio Enhancement Addition N/A N/A T1 lidocaine hcl jelly * gel 2% Enhancement Addition N/A N/A T1 lidocaine hcl jelly * gel 2% Enhancement Addition N/A N/A T1 lorazepam intensol Enhancement Addition N/A N/A T1; QL 120 ML per 30 days lorazepam intensol 2mg/ml conc Enhancement Addition N/A N/A T1; QL 120 ML per 30 days LUPRON DEPOT-PED Enhancement Addition N/A N/A T1; PA (new starts); QL 1 EA per 30 days magnesium sulfate soln Enhancement Addition N/A N/A T1; PA (Part B) methadone intensol Enhancement Addition N/A N/A T1; QL 500 ML per 30 days MINIVELLE PATCH MG/24 HR Enhancement Addition N/A N/A T1; PA; QL 8 EA per 28 days MINIVELLE PATCH 0.05MG/24 HR Enhancement Addition N/A N/A T1; PA; QL 8 EA per 28 days MINIVELLE PATCH 0.075MG/24 HR Enhancement Addition N/A N/A T1; PA; QL 8 EA per 28 days 11

12 mitoxantrone inj 2mg/ml Enhancement Addition N/A N/A T1; PA (Part B) mitoxantrone inj 2mg/ml Enhancement Addition N/A N/A T1; PA (Part B) morphine sulfate add-vantage Enhancement Addition N/A N/A T1 mycophenolate mofetil for oral susp 200 mg/ml Enhancement Addition N/A N/A T1; PA (Part B) nafcillin inj 1gm Enhancement Addition N/A N/A T1 NAMENDA 10MG Enhancement Addition N/A N/A T1; QL 60 EA per 30 days NAMENDA 5MG Enhancement Addition N/A N/A T1; QL 90 EA per 30 days NAMENDA TITRATION PACK Enhancement Addition N/A N/A T1; QL 49 EA per 28 days neo-polycin oin hc 1%op Enhancement Addition N/A N/A T1 NEUPOGEN 300MCG/ML VIAL Enhancement Addition N/A N/A T1; PA NEXIUM 10MG PACK Enhancement Addition N/A N/A T1; QL 30 EA per 30 days NEXIUM 2.5MG PACK Enhancement Addition N/A N/A T1; QL 30 EA per 30 days NEXIUM 20MG DR CAPSULE Enhancement Addition N/A N/A T1; QL 30 EA per 30 days NEXIUM 20MG PACK Enhancement Addition N/A N/A T1; QL 30 EA per 30 days NEXIUM 40MG DR CAPSULE Enhancement Addition N/A N/A T1; QL 30 EA per 30 days NEXIUM 40MG PACK Enhancement Addition N/A N/A T1; QL 30 EA per 30 days NEXIUM 5MG PACK Enhancement Addition N/A N/A T1; QL 30 EA per 30 days NIPENT Enhancement Addition N/A N/A T1; PA (Part B) norlyroc Enhancement Addition N/A N/A T1 ondansetron inj 40/20ml Enhancement Addition N/A N/A T1 oxacillin sodium 1g solr Enhancement Addition N/A N/A T1 oxaliplatin inj 100mg Enhancement Addition N/A N/A T1; PA (Part B) oxaliplatin inj 50mg Enhancement Addition N/A N/A T1; PA (Part B) oxycodone 2.5mg/325 mg tab Enhancement Addition N/A N/A T1; QL 360 EA per 30 days paclitaxel inj 100mg Enhancement Addition N/A N/A T1; PA (Part B) paclitaxel inj 150/25ml Enhancement Addition N/A N/A T1; PA (Part B) paclitaxel inj 30mg/5ml Enhancement Addition N/A N/A T1; PA (Part B) pamidronate inj 30mg Enhancement Addition N/A N/A T1; PA (Part B) pamidronate inj 90mg Enhancement Addition N/A N/A T1; PA (Part B) paroex soln Enhancement Addition N/A N/A T1 PEGINTRON KIT 120MCG Enhancement Addition N/A N/A T1; PA PEGINTRON KIT 150MCG Enhancement Addition N/A N/A T1; PA PEGINTRON KIT 50MCG Enhancement Addition N/A N/A T1; PA 12

13 PEGINTRON KIT 80MCG Enhancement Addition N/A N/A T1; PA pot chloride tab 8meq er Enhancement Addition N/A N/A T1 potassium chloride 0.15% d5w/ nacl 0.45% viaflex Enhancement Addition N/A N/A T1; PA (Part B) potassium chloride 0.15% d5w/ nacl 0.9% viaflex Enhancement Addition N/A N/A T1; PA (Part B) potassium citrate cr 15meq Enhancement Addition N/A N/A T1 prednisolone sol 15mg/5ml Enhancement Addition N/A N/A T1 prednisone pak 5mg Enhancement Addition N/A N/A T1 PURIXAN SUS 20MG/ML Enhancement Addition N/A N/A T1; PA (new starts) RECOMBIVA HB INJ 5MCG/0.5 Enhancement Addition N/A N/A T1; PA (Part B) rosadan cre 0.75% Enhancement Addition N/A N/A T1 SILVER SULFADIAZINE CREAM 1% Enhancement Addition N/A N/A T1 sirolimus 1mg tab Enhancement Addition N/A N/A T1; PA (Part B) sirolimus 2mg tab Enhancement Addition N/A N/A T1; PA (Part B) sod poly sul sus 30/120ml Enhancement Addition N/A N/A T1 sodium bicarbonate Enhancement Addition N/A N/A T1 SOMAVERT 25MG Enhancement Addition N/A N/A T1; PA; QL 30 EA per 30 days SOMAVERT 30MG Enhancement Addition N/A N/A T1; PA; QL 30 EA per 30 days SPIRIVA RESPIMAT Enhancement Addition N/A N/A T1; QL 4 EA per 30 days sulfasalazine Enhancement Addition N/A N/A T1 sulfasalazine 500mg tbec Enhancement Addition N/A N/A T1 sulfatrim pediatric Enhancement Addition N/A N/A T1 sulfatrim pediatric 200mg/5ml; 40mg/5ml susp Enhancement Addition N/A N/A T1 sumatriptan inj 6mg/0.5 Enhancement Addition N/A N/A T1; QL 8 EA per 30 days SUTENT 37.5MG Enhancement Addition N/A N/A T1; PA (new starts) tacrolimus ointment 0.1% Enhancement Addition N/A N/A T1 tacrolimus ointment 0.3% Enhancement Addition N/A N/A T1 tarina fe Enhancement Addition N/A N/A T1 theophylline tab 100mg er Enhancement Addition N/A N/A T1 tobramycin inj 1.2/30ml Enhancement Addition N/A N/A T1 tobramycin inj 40mg/ml Enhancement Addition N/A N/A T1 TREANDA INJECTION 180 MG/2 ML VIAL Enhancement Addition N/A N/A T1; PA (Part B) 13

14 TREANDA INJECTION 45 MG/0.5 ML VIAL Enhancement Addition N/A N/A T1; PA (Part B) tretinoin microsphere pump Enhancement Addition N/A N/A T1; PA; QL 50 GM per 30 days TRIUMEQ 600/50/300MG Enhancement Addition N/A N/A T1; QL 30 EA per 30 days TYBOST 150MG TAB Enhancement Addition N/A N/A T1 valganciclovir hcl tab 450 mg Enhancement Addition N/A N/A T1 valsartan 160mg Enhancement Addition N/A N/A T1 valsartan 320mg Enhancement Addition N/A N/A T1 valsartan 40mg Enhancement Addition N/A N/A T1 valsartan 80mg Enhancement Addition N/A N/A T1 XARELTO STAR TAB 15/20MG Enhancement Addition N/A N/A T1; QL 102 EA per 365 days zebutal 325mg; 50mg; 40mg Enhancement Addition N/A N/A T1; PA; QL 180 EA per 30 days ZENPEP UNIT; 40000UNIT; UNIT Enhancement Addition N/A N/A T1 CPEP zinecard 500mg Enhancement Addition N/A N/A T1; PA (Part B) zoledronic inj 4mg Enhancement Addition N/A N/A T1; PA (Part B) ZYDELIG 100MG Enhancement Addition N/A N/A T1; PA (new starts); QL 60 EA per 30 days ZYDELIG 150MG Enhancement Addition N/A N/A T1; PA (new starts); QL 60 EA per 30 days SEROQUEL XR 150MG Enhancement Update N/A N/A Step Therapy removed SEROQUEL XR 200MG Enhancement Update N/A N/A Step Therapy removed SEROQUEL XR 300MG Enhancement Update N/A N/A Step Therapy removed SEROQUEL XR 400MG Enhancement Update N/A N/A Step Therapy removed SEROQUEL XR 50MG Enhancement Update N/A N/A Step Therapy removed buprenorphine 0.3mg/ml inj Enhancement Update N/A N/A PA removed BYDUREON INJ PEN Enhancement Update N/A N/A QL increased to 4 EA per 28 days ELIQUIS 2.5MG TAB Enhancement Update N/A N/A PA removed ELIQUIS 5MG TAB Enhancement Update N/A N/A PA removed ELIQUIS 5MG TAB Enhancement Update N/A N/A PA removed HUMIRA PEN-PSORIASIS STARTER Enhancement Update N/A N/A QL increased to 6 EA per 28 days PRADAXA 150MG TAB Enhancement Update N/A N/A PA removed PRADAXA 75MG TAB Enhancement Update N/A N/A PA removed SYMLIN PEN 120 Enhancement Update N/A N/A QL increased to 11 EA per 28 days XARELTO 10 MG TAB Enhancement Update N/A N/A PA removed XARELTO 15 MG TAB Enhancement Update N/A N/A PA removed 14

15 XARELTO 20 MG TAB Enhancement Update N/A N/A PA removed 15

16 Formulary change Reason for change Formulary alternative Tier alternative Notes Cost-sharing tier description key Utilization management requirements/limits key Tier 1: Preferred drugs. PA: Prior authorization is required QL: Quantity limits apply RA: Restricted access. This prescription may be available only at certain pharmacies. MO: Mail order ST: Step therapy is required B vs. D: Coverage determination for Part B or Part D required. Note: Inhalant solutions used in a nebulizer are only covered under Part D when the member is located in a long term care (LTC) setting. You have a right to ask us to make a coverage determination, including an exception to this change. You can ask us to make a coverage determination about the drug(s) or payment you need, including an exception. Look in your Evidence of Coverage for information about how to ask for a coverage decision, including an exception. If you have any questions, please contact Cigna-HealthSpring at , 8 am 8 pm, 7 days a week. TTY/TDD users should call 711. This information is available for free in other languages. Please call our customer service number at (TTY 711), 8 am 8 pm, 7 days a week. Esta información está disponible de forma gratuita en otros idiomas. Por favor, llame a nuestro servicio al cliente al (TTY 711), 8 a.m. a 8 p.m., 7 días de la semana, Los usuarios de TTY deben llamar al TTY number. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal. 16