2019 Formulary Annual Notice of Change

Transcription

1 Updated: October 1, Formulary Annual Notice of Change Medicare Advantage Plans (MAPD) This is a listing of the changes that have occurred to the 2019 MAPD formulary. For a complete list, please refer to the 2019 MAPD Comprehensive Formulary (Drug List). Click here to view the comprehensive formulary. Please carefully review these changes. If you have any questions, please call Customer Service toll-free at (TTY/TDD relay: ) weekdays from 8 a.m. to 8 p.m. and Saturdays from 8 a.m. to noon. From October 1 to March 31, we re available seven days a week from 8 a.m. to 8 p.m. You can also visit myfhca.org for additional information. Please refer to your Evidence of Coverage for cost-share information. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You must generally use network pharmacies to use your prescription drug benefit. The formulary and pharmacy network may change at any time. You will receive notice when necessary. Y0089_MPINFO6523FH(09/2017)

2 MEDICATIONS REMOVED FROM THE 2018 MAPD FORMULARY ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG acetazolamide sodium injection recon soln 500 mg ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML Adrucil intravenous solution 500 mg/10 ml ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML ALIMTA INTRAVENOUS RECON SOLN 100 MG ALIMTA INTRAVENOUS RECON SOLN 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG AVASTIN INTRAVENOUS SOLUTION 25 MG/ML azacitidine injection recon soln 100 mg AZILECT ORAL TABLET 0.5 MG, 1 MG AZOR ORAL TABLET MG, MG, 5-20 MG, 5-40 MG bacitracin intramuscular recon soln 50,000 unit BAVENCIO INTRAVENOUS SOLUTION 20 MG/ML Bekyree (28) oral tablet mgx21 /0.01 mg x 5 BELEODAQ INTRAVENOUS RECON SOLN 500 MG BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG BENICAR HCT ORAL TABLET MG, MG, MG BENLYSTA INTRAVENOUS RECON SOLN 120 MG, 400 MG betaxolol ophthalmic (eye) drops 0.5 % bleomycin injection recon soln 30 unit BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML buprenorphine HCl injection syringe 0.3 mg/ml butalbital-acetaminophen-caff oral capsule mg Comment

3 MEDICATIONS REMOVED FROM THE 2018 MAPD FORMULARY BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR CAPASTAT INJECTION RECON SOLN 1 GRAM CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN 500 MG CEREBYX INJECTION SOLUTION 500 MG PE/10 ML CEREZYME INTRAVENOUS RECON SOLN 400 UNIT chloramphenicol sod succinate intravenous recon soln 1 gram chlorpromazine injection solution 25 mg/ml chorionic gonadotropin, human intramuscular recon soln 10,000 unit COLCRYS ORAL TABLET 0.6 MG COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG, 80 MG CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML dactinomycin intravenous recon soln 0.5 mg DARZALEX INTRAVENOUS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 mg desmopressin injection solution 4 mcg/ml dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml diltiazem HCl intravenous recon soln 100 mg diphenhydramine HCl injection solution 50 mg/ml ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON SOLN 1.5 MG, 7.5 MG EMEND ORAL CAPSULE,DOSE PACK 125 MG (1)- 80 MG (2) EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG Enpresse oral tablet (6)/75-40 (5)/125-30(10) Comment

4 MEDICATIONS REMOVED FROM THE 2018 MAPD FORMULARY EPCLUSA ORAL TABLET MG ERWINAZE INJECTION RECON SOLN 10,000 UNIT etoposide intravenous solution 20 mg/ml FABRAZYME INTRAVENOUS RECON SOLN 35 MG FABRAZYME INTRAVENOUS RECON SOLN 5 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML ganciclovir sodium intravenous recon soln 500 mg glycopyrrolate injection solution 0.2 mg/ml granisetron HCl intravenous solution 1 mg/ml (1 ml) HARVONI ORAL TABLET MG ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MG/ML IMFINZI INTRAVENOUS SOLUTION 50 MG/ML, 50 MG/ML (10 ML) IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML KADCYLA INTRAVENOUS RECON SOLN 100 MG, 160 MG Kariva (28) oral tablet mgx21 /0.01 mg x 5 KENALOG INJECTION SUSPENSION 10 MG/ML, 40 MG/ML ketorolac injection solution 15 mg/ml, 30 mg/ml (1 ml) KEYTRUDA INTRAVENOUS SOLUTION 25 MG/ML Kimidess (28) oral tablet mgx21 /0.01 mg x 5 KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML KYPROLIS INTRAVENOUS RECON SOLN 30 MG, 60 MG labetalol intravenous solution 5 mg/ml LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML (19 ML) LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML leucovorin calcium injection recon soln 100 mg, 350 mg Comment

5 MEDICATIONS REMOVED FROM THE 2018 MAPD FORMULARY LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) 1.2 GRAM lincomycin injection solution 300 mg/ml methadone injection solution 10 mg/ml methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous recon soln 1,000 mg metoclopramide HCl injection solution 5 mg/ml MIACALCIN INJECTION SOLUTION 200 UNIT/ML MITOMYCIN INTRAVENOUS RECON SOLN 20 MG, 40 MG, 5 MG mitoxantrone intravenous concentrate 2 mg/ml MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML) mycophenolate mofetil HCl intravenous recon soln 500 mg MYLOTARG INTRAVENOUS RECON SOLN 4.5 MG (1 MG/ML INITIAL CONC) NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML nalbuphine injection solution 10 mg/ml nalbuphine injection solution 20 mg/ml NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML ORENCIA CLICKJECT SUBCUTANEOUS AUTO- INJECTOR 125 MG/ML ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG ORENCIA CLICKJECT SUBCUTANEOUS AUTO- INJECTOR 125 MG/ML Comment

6 MEDICATIONS REMOVED FROM THE 2018 MAPD FORMULARY oxaliplatin intravenous recon soln 100 mg paclitaxel intravenous concentrate 6 mg/ml pantoprazole intravenous recon soln 40 mg paroxetine HCl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg PERJETA INTRAVENOUS SOLUTION 420 MG/14 ML (30 MG/ML) Pimtrea (28) oral tablet mgx21 /0.01 mg x 5 PREMARIN INJECTION RECON SOLN 25 MG procainamide injection solution 100 mg/ml procainamide injection solution 500 mg/ml prochlorperazine Edisylate injection solution 10 mg/2 ml (5 mg/ml) Prograf intravenous solution 5 mg/ml PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT promethazine injection solution 25 mg/ml, 50 mg/ml RADICAVA INTRAVENOUS PIGGYBACK 30 MG/100 ML RENVELA ORAL TABLET 800 MG RETROVIR INTRAVENOUS SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG Ribasphere oral capsule 200 mg Ribasphere oral tablet 200 mg RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML (10 ML) RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 MG, 40 MG, 60 MG Comment

7 MEDICATIONS REMOVED FROM THE 2018 MAPD FORMULARY Comment SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML, 250 MG/2 ML STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG sulfamethoxazole-trimethoprim intravenous solution mg/5 ml SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML TAMIFLU ORAL CAPSULE 30 MG, 75 MG TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) THIOTEPA INJECTION RECON SOLN 15 MG THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG Transderm-Scop transdermal patch 3 day 1 mg over 3 days TREANDA INTRAVENOUS RECON SOLN 100 MG TREANDA INTRAVENOUS RECON SOLN 25 MG triamcinolone acetonide injection suspension 40 mg/ml TRIBENZOR ORAL TABLET MG, MG, MG, MG, MG TriNessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) TRISENOX INTRAVENOUS SOLUTION 2 MG/ML TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIREAD ORAL TABLET 300 MG VPRIV INTRAVENOUS RECON SOLN 400 UNIT VYTORIN ORAL TABLET MG VYTORIN ORAL TABLET MG VYTORIN ORAL TABLET MG VYTORIN ORAL TABLET MG VYXEOS INTRAVENOUS RECON SOLN MG

8 MEDICATIONS REMOVED FROM THE 2018 MAPD FORMULARY Comment YONDELIS INTRAVENOUS RECON SOLN 1 MG ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) ZEBUTAL ORAL CAPSULE MG Zovia 1/35E (28) oral tablet 1-35 mg-mcg MEDICATIONS ADDED TO THE 2019 MAPD FORMULARY Benefit Tier carbidopa oral tablet 25 mg Tier 4 Quantity Limit (QL) Prior Authorization (PA) or Step Therapy (ST) Requirement carbidopa-levodopa-entacapone oral tablet Tier mg carbidopa-levodopa-entacapone oral tablet Tier mg carbidopa-levodopa-entacapone oral tablet Tier mg carbidopa-levodopa-entacapone oral tablet Tier mg carbidopa-levodopa-entacapone oral tablet Tier mg carbidopa-levodopa-entacapone oral tablet Tier mg carvedilol phosphate oral capsule, ER Tier 3 QL (30 EA per 30 days) PA Applies multiphase 24 hr 10 mg carvedilol phosphate oral capsule, ER Tier 3 QL (30 EA per 30 days) multiphase 24 hr 20 mg carvedilol phosphate oral capsule, ER Tier 3 QL (30 EA per 30 days) multiphase 24 hr 40 mg carvedilol phosphate oral capsule, ER Tier 3 QL (30 EA per 30 days) Part B vs D PA Applies multiphase 24 hr 80 mg colistin (colistimethate Na) injection recon Tier 4 soln 150 mg DIASTAT RECTAL KIT 2.5 MG Tier 4 DIASTAT ACUDIAL RECTAL KIT MG DIASTAT ACUDIAL RECTAL KIT MG Tier 4 Tier 4

9 MEDICATIONS ADDED TO THE 2019 MAPD FORMULARY Benefit Tier Quantity Limit (QL) Prior Authorization (PA) or Step Therapy (ST) Requirement DUAVEE ORAL TABLET MG Tier 3 PA ESBRIET ORAL CAPSULE 267 MG Tier 5 QL (270 EA per 30 days) PA ESBRIET ORAL TABLET 267 MG Tier 5 QL (270 EA per 30 days) PA ESBRIET ORAL TABLET 801 MG Tier 5 QL (90 EA per 30 days) PA EVZIO INJECTION AUTO- Tier 5 PA INJECTOR 2 MG/0.4 ML glatiramer subcutaneous syringe 20 mg/ml Tier 5 QL (30 ML per 30 days) PA glatiramer subcutaneous syringe 40 mg/ml Tier 5 QL (12 ML per 28 days) PA GLATOPA SUBCUTANEOUS Tier 5 QL (30 ML per 30 days) PA SYRINGE 20 MG/ML GLATOPA SUBCUTANEOUS Tier 5 QL (12 ML per 28 days) PA SYRINGE 40 MG/ML HAVRIX (PF) INTRAMUSCULAR Tier 3 SUSPENSION 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR Tier 3 SYRINGE 1,440 ELISA UNIT/ML KLOR-CON M10 ORAL TABLET,ER Tier 2 PARTICLES/CRYSTALS 10 MEQ leucovorin calcium oral tablet 5 mg Tier 3 leucovorin calcium oral tablet 10 mg Tier 3 leucovorin calcium oral tablet 15 mg Tier 3 leucovorin calcium oral tablet 25 mg Tier 3 memantine oral capsule,sprinkle,er 24hr Tier 3 7 mg memantine oral capsule,sprinkle,er 24hr Tier 3 14 mg memantine oral capsule,sprinkle,er 24hr Tier 3 21 mg memantine oral capsule,sprinkle,er 24hr Tier 3 28 mg PENNSAID TOPICAL SOLUTION IN Tier 5 METERED-DOSE PUMP 20 MG/GRAM /ACTUATION(2 %) perphenazine-amitriptyline oral tablet 2-10 Tier 3 mg perphenazine-amitriptyline oral tablet 2-25 Tier 3 mg perphenazine-amitriptyline oral tablet 4-10 Tier 3 mg QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) PA PA PA PA

10 MEDICATIONS ADDED TO THE 2019 MAPD FORMULARY Benefit Tier perphenazine-amitriptyline oral tablet 4-25 Tier 3 mg perphenazine-amitriptyline oral tablet 4-50 Tier 3 mg prasugrel oral tablet 5 mg Tier 3 prasugrel oral tablet 10 mg Tier 3 Quantity Limit (QL) rasagiline oral tablet 0.5 mg Tier 4 QL (30 EA per 30 days) rasagiline oral tablet 1 mg Tier 4 QL (30 EA per 30 days) RECTIV RECTAL OINTMENT 0.4 % Tier 4 (W/W) tenofovir disoproxil fumarate oral tablet Tier mg tizanidine oral tablet 2 mg Tier 2 Prior Authorization (PA) or Step Therapy (ST) Requirement tizanidine oral tablet 4 mg Tier 2 TWINRIX (PF) INTRAMUSCULAR Tier 3 SYRINGE 720 ELISA UNIT- 20 MCG/ML VAQTA (PF) INTRAMUSCULAR Tier 3 SUSPENSION 25 UNIT/0.5 ML VAQTA (PF) INTRAMUSCULAR Tier 3 SUSPENSION 50 UNIT/ML VIBERZI ORAL TABLET 75 MG Tier 5 PA VIBERZI ORAL TABLET 100 MG Tier 5 PA PA PA MEDICATIONS WITH TIERING CHANGES 2018 Tier 2019 Tier ezetimibe-simvastatin oral tablet mg Tier 4 Tier 3 ezetimibe-simvastatin oral tablet mg Tier 4 Tier 3 ezetimibe-simvastatin oral tablet mg Tier 4 Tier 3 ezetimibe-simvastatin oral tablet mg Tier 4 Tier 3 fenofibric acid (choline) oral capsule,delayed Tier 3 Tier 4 release(dr/ec) 135 mg isoniazid oral tablet 100 mg Tier 3 Tier 2 isoniazid oral tablet 300 mg Tier 3 Tier 2

11 MEDICATIONS WITH TIERING CHANGES 2018 Tier 2019 Tier JULUCA ORAL TABLET MG Tier 4 Tier 5 naratriptan oral tablet 1 mg Tier 3 Tier 2 naratriptan oral tablet 2.5 mg Tier 3 Tier 2 PENTASA ORAL CAPSULE, EXTENDED Tier 3 Tier 4 RELEASE 250 MG PENTASA ORAL CAPSULE, EXTENDED Tier 3 Tier 5 RELEASE 500 MG sevelamer carbonate oral tablet 800 mg Tier 5 Tier 4 TABLOID ORAL TABLET 40 MG Tier 4 Tier 5 valganciclovir oral tablet 450 mg Tier 4 Tier 5 vancomycin oral capsule 125 mg Tier 5 Tier 4 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION Updated Quantity Limit (QL) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG acetaminophen-codeine oral solution mg/5 ml AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ADDED QL (1 EA per 28 days) ADDED QL (1 EA per 28 days) QL(60 EA per 30days) AFINITOR ORAL TABLET 10 MG ALUNBRIG ORAL TABLET 30 MG ALUNBRIG ORAL TABLET 180 MG, 90 MG ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (23) amlodipine-olmesartan oral tablet mg, mg, 5-20 mg, 5-40 mg AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) CHANGED QL (30 EA per 30 days) ADDED QL (180 EA per 30 days) ADDED QL (150 GM per 30 days) ADDED QL (150 GM per 30 days)

12 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION Updated Quantity Limit (QL) ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML BOSULIF ORAL TABLET 400 MG CALQUENCE ORAL CAPSULE 100 MG celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg chlordiazepoxide HCl oral capsule 10 mg, 25 mg, 5 mg ciprofloxacin HCl otic (ear) dropperette 0.2 % clonazepam oral tablet,disintegrating 0.5 mg, 1 mg clonazepam oral tablet,disintegrating 2 mg COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML donepezil oral tablet 5 mg donepezil oral tablet,disintegrating 10 mg, 5 mg DOPTELET ORAL TABLET 20 MG, 20 MG (15 PACK) dronabinol oral capsule 2.5 mg, 5 mg, 10 mg fenofibric acid oral tablet 105 mg fenofibric acid (choline) oral capsule,delayed release(dr/ec) 45 mg fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML galantamine oral solution 4 mg/ml ADDED QL (1.6 ML per 30 days) ADDED QL (2.4 ML per 30 days) ADDED QL (3.2 ML per 30 days) ADDED QL (120 EA per 30 days) CHANGED QL (60 EA per 30 days) ADDED QL (90 EA per 30 days) ADDED QL (300 EA per 30 days) ADDED QL (112 EA per 30 days) ADDED QL (56 EA per 30 days) ADDED QL (84 EA per 30 days) ADDED QL over time (32 ML per 365 days) ADDED QL over time (32 ML per 365 days) CHANGED QL over time (15 EA per 30 days) ADDED QL (120 EA per 30 days) ADDED QL (720 ML per 30 days) CHANGED QL (200 ML per 30 days)

13 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION Updated Quantity Limit (QL) hydrocodone-ibuprofen oral tablet mg IDHIFA ORAL TABLET 100 MG, 50 MG INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 234 MG/1.5 ML, 78 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG JYNARQUE ORAL TABLETS, SEQUENTIAL 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM) KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1) KISQALI ORAL TABLET 400 MG/DAY (200 MG X 2) KISQALI ORAL TABLET 600 MG/DAY (200 MG X 3) KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(200 MG X 2)-2.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(200 MG X 3)-2.5 MG LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY) LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1) LONSURF ORAL TABLET MG LONSURF ORAL TABLET MG LYNPARZA ORAL TABLET 100 MG, 150 MG MAVYRET ORAL TABLET MG MULTAQ ORAL TABLET 400 MG NERLYNX ORAL TABLET 40 MG olmesartan-amlodipin-hcthiazid oral tablet mg, mg, mg, mg, mg CHANGED QL (90 EA per 30 days) ADDED QL (1.5 ML per 28 days) ADDED QL (1 ML per 28 days) ADDED QL (1.5 ML per 28 days) QL Removed ADDED QL (21 EA per 30 days) ADDED QL (42 EA per 30 days) ADDED QL (63 EA per 30 days) ADDED QL (49 EA per 30 days) ADDED QL (70 EA per 30 days) ADDED QL (91 EA per 30 days) ADDED QL (90 EA per 30 days) ADDED QL (100 EA per 30 days) ADDED QL (80 EA per 30 days) ADDED QL (120 EA per 30 days) ADDED QL (84 EA per 30 days) ADDED QL (180 EA per 30 days)

14 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION Updated Quantity Limit (QL) PURIXAN ORAL SUSPENSION 20 MG/ML quetiapine oral tablet extended release 24 hr 200 mg, 300 mg, 400 mg, 50 mg quetiapine oral tablet extended release 24 hr 150 mg RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML RUBRACA ORAL TABLET 200 MG, 300 MG RUBRACA ORAL TABLET 250 MG RYDAPT ORAL CAPSULE 25 MG SELZENTRY ORAL SOLUTION 20 MG/ML TAFINLAR ORAL CAPSULE 50 MG TAFINLAR ORAL CAPSULE 75 MG testosterone transdermal gel in packet 1 % (25 mg/2.5gram) testosterone transdermal gel in packet 1 % (50 mg/5 gram) testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %) testosterone enanthate intramuscular oil 200 mg/ml topiramate oral tablet 200 mg TOUJEO MAX SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG XELJANZ ORAL TABLET 5 MG XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG zolpidem oral tablet 10 mg, 5 mg ADDED QL (300 ML per 30 days) ADDED QL (90 EA per 30 days) CHANGED QL (2 EA per 30 days) ADDED QL (120 EA per 30 days) ADDED QL (120 EA per 30 days) ADDED QL (224 EA per 30 days) CHANGED QL (1840 ML per 30 days) ADDED QL (180 EA per 30 days) ADDED QL (120 EA per 30 days) ADDED QL (300 GM per 30 days) ADDED QL (300 GM per 30 days) ADDED QL (300 GM per 30 days) ADDED QL (5 ML per 30 days) ADDED QL (21 ML per 30 days) ADDED QL (28 EA per 30 days) ADDED QL (14 EA per 30 days) ADDED QL (120 EA per 30 days) ADDED QL (48 EA per 28 days) ADDED QL (600 EA per 30 days) ADDED QL (600 EA per 30 days) CHANGED QL (30 EA per 30 days)

15 MEDICATIONS WITH PRIOR AUTHORIZATION (PA) or STEP THERAPY (ST) REQUIREMENT CHANGES Change Description ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML buprenorphine HCl sublingual tablet 2 mg, 8 mg diclofenac sodium topical gel 3 % EMCYT ORAL CAPSULE 140 MG GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) SUBOXONE SUBLINGUAL FILM 12-3 MG SUBOXONE SUBLINGUAL FILM MG, 4-1 MG, 8-2 MG XATMEP ORAL SOLUTION 2.5 MG/ML zolpidem oral tablet 10 mg, 5 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG ADDED PA ADDED PA ADDED PA REMOVED PA ADDED PA REMOVED PA ADDED PA REMOVED PA REMOVED PA CHANGED PA TYPE ADDED PA ADDED PA If you have any questions, please call Customer Service toll free at (TTY/TDD relay: ) weekdays from 8 a.m. to 8 p.m. and Saturdays from 8 a.m. to noon. From October 1 to March 31, we re available seven days a week from 8 a.m. to 8 p.m. Florida Hospital Care Advantage is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal.

16 Nondiscrimination Notice Florida Hospital Care Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Florida Hospital Care Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Florida Hospital Care Advantage: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, accessible electronic formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, please contact Doris Garcia-Durand. If you believe that Florida Hospital Care Advantage has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: Doris Garcia-Durand, ADA/Section 504 Coordinator, 6450 US Highway 1, Rockledge, FL 32955, , (TTY), Fax: , doris.garciadurand@health-first.org. You can file a grievance in person or by mail, fax or . If you need help filing a grievance Doris Garcia-Durand, ADA/Section 504 Coordinator, is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at Florida Hospital Care Advantage is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal. Y0089_ MPINFO6465FH (08/17)

17 English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: ). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). Portuguese: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: ). Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: ). Thai: เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: ). Y0089_ MPINFO6466FH (08/17)