Current as of November 1, 2017

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1 Current as of November 1, 2017 ZYTIGA 500 MG ORAL TABLETS Formulary Addition TIER 5 QL = 2 PER DAY BENLYSTA 200 MG/ML AUTO- INJECTOR Formulary Addition TIER 5 BENLYSTA 200 MG/ML PREFILLED SYRINGE Formulary Addition TIER 5 RAYALDEE 0.03 MG EXTENDED ORAL RELEASE CAPSULE Formulary Addition TIER 5 caspogungin acetate 50 mg injection Formulary Addition TIER 5 caspogungin acetate 70 mg injection Formulary Addition TIER 5 VYXEOS 100 MG/44 MG INJECTION Formulary Addition TIER 5 PA/ B VS D DETERMINATION diazepam 5 mg/ml prefilled applicator Formulary Addition TIER 3 diazepam 5 mg/ml prefilled applicator Formulary Addition TIER 3 IDHIFA 100 MG ORAL TABLETS Formulary Addition TIER 5 QL = 1 PER DAY IDHIFA 50 MG ORAL TABLETS Formulary Addition TIER 5 QL = 1 PER DAY

2 estradiol 0.01 mg vaginal tablets Formulary Addition TIER 2 ARMONAIR MG DRY POWDER INHALER Formulary Addition TIER 4 ARMONAIR MG DRY POWDER INHALER Formulary Addition TIER 4 ARMONAIR MG DRY POWDER INHALER Formulary Addition TIER 4 MAVYRET 100 MG/40 MG ORAL TABLETS Formulary Addition TIER 5 PA REQUIRED QL=3 PER DAY NERLYNX 40 MG ORAL TABLETS Formulary Addition TIER 5 LYNPARZA 100 MG ORAL TABLETS Formulary Addition TIER 5 QL=4 PER DAY LYNPARZA 150 MG ORAL TABLETS Formulary Addition TIER 5 QL= 4 PER DAY prasugrel 10 mg oral tablets Formulary Addition TIER 3 prasugrel 5 mg oral tablets Formulary Addition TIER 3 ISENTRESS 600 MG ORAL TABLETS Formulary Addition TIER 3 VOSEVI 400 MG/100 MG/100 MG ORAL TABLETS Formulary Addition TIER 5 PA REQUIRED QL=1 PER DAY vigabatrin 50 mg/ml oral solution Formulary Addition TIER 5 bupremorphine mg/hr transdermal system Formulary Addition Tier 4 desogestrel 0.15 mg/ ethinyl estradil 0.03 mg/inert ingredients 1 mg pack Formulary Addition Tier 3 ISIBLOOM 28 DAY PACK Formulary Addition Tier 3

3 eletriptan 20 mg oral tablet Formulary Addition Tier 4 QL 12 per 30 days eletriptan 40 mg oral tablet Formulary Addition Tier 4 QL 12 per 30 days RENFLEXIS 100 MG INJECTION Formulary Addition Tier 5 AMNESTEEM 10 MG ORAL CAPSULE Formulary Addition Tier 4 AMNESTEEM 20 MG ORAL CAPSULE Formulary Addition Tier 4 AMNESTEEM 40 MG ORAL CAPSULE Formulary Addition Tier 4 meropenem 1000 mg injection Formulary Addition Tier 3 HI DRUG mesalamine 1200 mg delayed release oral tablet Formulary Addition Tier 3 XATMEP 2.5 MG/ML ORAL SOLUTION Formulary Addition Tier 4 PA/B VS. D DETERMINATION moxifloxacin 5 mg/ml ophthalmic solution Formulary Addition Tier 2 sevelamer carbonate 800 mg oral tablet Formulary Addition Tier 2 ALUNBRIG 30 MG TABLET Formulary addition T/5 PA Required IMFINZI 50 MG INJECTION Formulary addition T/5 PA/B vs. D Determination ezetimibe 10mg/simvastatin 10 mg tablets Formulary addition T/2 ezetimibe 10mg/simvastatin 20 mg tablets Formulary addition T/2 ezetimibe 10mg/simvastatin 40 mg tablets Formulary addition T/2 ezetimibe 10mg/simvastatin 80 mg tablets Formulary addition T/2 fluticasone propionate 0.055mg/actuat/salmeterol Formulary addition T/2

4 xinafoate mg/actuat inhaler fluticasone propionate 0.113mg/actuat/salmeterol xinafoate mg/actuat inhaler Formulary addition T/2 fluticasone propionate 0.232mg/actuat/salmeterol xinafoate mg/actuat inhaler Formulary addition T/2 KISQALI FEMARA CO-PACK MG /200 MG PACK Formulary addition T/5 PA Required KISQALI FEMARA CO-PACK MG/200 MG PACK Formulary addition T/5 PA Required KISQUALI FEMARA CO-PACK MG/200 MG PACK Formulary addition T/5 PA Required XATMEP 2.5 MG/ML ORAL SOLUTION Formulary addition T/4 PA/B vs. D Determination RYDAPT 25 MG CAPSULE Formulary addition T/5 PA Required ZEJULA 100 MG CAPSULE Formulary addition T/5 PA Required XADAGO 100 MG CAPSULE Formulary addition T/4 XADAGO 50 MG CAPSULE Formulary addition T/4 ORENCIA Formulary addition T/5 PA Required ARISTADA 273 MG/ML PREFILLED SYRINGE Formulary addition T/5 atomoxetine 10 mg capsule Formulary addition T/3 atomoxetine 100 mg capsule Formulary addition T/3 atomoxetine 18 mg capsule Formulary addition T/3 atomoxetine 25 mg capsule Formulary addition T/3 atomoxetine 40 mg capsule Formulary addition T/3

5 atomoxetine 60 mg capsule Formulary addition T/3 atomoxetine 80 mg capsule Formulary addition T/3 SILIQ 140 MG/ML PREFILLED SYRINGE Formulary addition T/5 buprenorphine mg/hr transdermal system Formulary addition T/4 buprenorphine 0.01 mg/hr transdermal system Formulary addition T/4 buprenorphine mg/hr transdermal system Formulary addition T/4 buprenorphine 0.02 mg/hr transdermal system Formulary addition T/4 JADENU 180 MG ORAL GRANULES Formulary addition T/5 PA Required JADENU 360 MG ORAL GRANULES Formulary addition T/5 PA Required JADENU 90 MG ORAL GRANULES Formulary addition T/5 PA Required lidocaine hydrochloride 10 mg/ml injection Formulary addition T/4 VYVANSE 10 MG CHEWABLE TABLETS Formulary addition T/4 VYVANSE 20 MG CHEWABLE TABLETS Formulary addition T/4 VYVANSE 30 MG CHEWABLE TABLETS Formulary addition T/4 VYVANSE 40 MG CHEWABLE TABLETS Formulary addition T/4 VYVANSE 50 MG CHEWBLE TABLETS Formulary addition T/4 VYVANSE 60 MG CHEWABLE Formulary addition T/4

6 TABLETS olopatadine 2 mg/ml ophthalmic solution Formulary addition T/3 sevelamer carbonate 2400 mg oral suspension Formulary addition T/3 sevelamer carbonate 800 mg oral suspension Formulary addition T/3 ORENITRAM 5 MG ER TABLETS Formulary addition T/5 PA Required gavilyte oral package kit Reduction in Tiered Cost-Sharing Status T/2 7/1/2017 BAVENCIO 20 MG/ML Formulary Addition TIER 5 PA/B VS. D DETERMINATION INJECTION 7/1/2017 FAYOSIM 91 DAY PACK Formulary Addition TIER 4 7/1/2017 GAMMAPLEX 100 MG/ML Formulary Addition TIER 5 PA/B VS. D DETERMINATION INJECTION 7/1/2017 INTRON A 2B 10 MILLION UNIT/ML INJECTABLE SOLUTION Formulary Addition TIER 5 7/1/2017 ROWEEPRA 1000 MG TABLET Formulary Addition TIER 2 7/1/2017 ROWEEPRA 750 MG TABLET Formulary Addition TIER 2 7/1/2017 ESBRIET 267 MG TABLET Formulary Addition TIER 5 PA REQUIRED 7/1/2017 ESBRIET 801 MG TABLET Formulary Addition TIER 5 PA REQUIRED 7/1/2017 tazarotene 1 mg/ml topical Formulary Addition TIER 3 cream 7/1/2017 zileuton 600 mg er tablet Formulary Addition TIER 5 6/1/2017 desvenlafaxine succ 100 mg er tablet Formulary Addition TIER 3 6/1/2017 desvenlafaxine succ 25 mg er tablet Formulary Addition TIER 3 6/1/2017 desvenlafaxine succ 50 mg er tablet Formulary Addition TIER 3 6/1/2017 KISQALI 200 MG DAILY DOSE Formulary Addition TIER 5

7 CARTON KISQALI 400 MG DAILY DOSE 6/1/2017 CARTON Formulary Addition TIER 5 KISQALI 600 MG DAILY DOSE 6/1/2017 CARTON Formulary Addition TIER 5 5/1/2017 calcium acetat 667 mg tablet Formulary Addition TIER 3 5/1/2017 EMFLAZA 18 MG TABLET Formulary Addition TIER 5 PA REQUIRED 5/1/2017 EMFLAZA MG/ ML Formulary Addition TIER 5 PA REQUIRED SUSPENION 5/1/2017 EMFLAZA 30 MG TABLET Formulary Addition TIER 5 PA REQUIRED 5/1/2017 EMFLAZA 36 MG TABLET Formulary Addition TIER 5 PA REQUIRED 5/1/2017 EMFLAZA 6 MG TALBET Formulary Addition TIER 5 PA REQUIRED 5/1/2017 epinephrine 1 mg/ml autoinjector Formulary Addition TIER 3 5/1/2017 LINZESS MG CAPSULE Formulary Addition TIER 4 5/1/2017 SELZENTRY 25 MG TABLET Formulary Addition TIER 4 5/1/2017 SELZENTRY 75 MG TABLET Formulary Addition TIER 5 5/1/2017 MENOMUNE A/C/Y/W-135 Formulary Addition TIER 3 INJECTION 5/1/2017 methylphenicate 20 mg er Formulary Addition TIER 4 capsule 5/1/2017 methylphenicate 40 mg er Formulary Addition TIER 4 capsule 5/1/2017 methylphenicate 60 mg er Formulary Addition TIER 4 capsule 5/1/2017 potassium 10 meq er tablet Formulary Addition TIER 2 5/1/2017 KLOR-CON 10 MEQ ER TABLET Formulary Addition TIER 2 5/1/2017 potassium 20 meq er tablet Formulary Addition TIER 2 5/1/2017 KLOR-CON 20 MEQ ER TABLET Formulary Addition TIER 2

8 5/1/2017 CLINDAMYCIN 15 MG/ML Formulary Addition TIER 4 HI Drug INJECTION SOLUTION 5/1/2017 CLINDAMYCIN 15 MG/ML Formulary Addition TIER 4 HI Drug INJECTION SOLUTION 6 ML 5/1/2017 furosemide 10 mg/ml injection Formulary Addition TIER 1 HI Drug solution 5/1/2017 chlorothiazide sod 500 mg vial Formulary Addition TIER 4 HI Drug dexmethylphenidate 25 mg er capsule Formulary Addition Tier 4 dexmethylphenidate 35 mg er capsule Formulary Addition Tier 4 ethinyl estradiol mg/ inert ingredients 1 mg/ norgestimate 0.25 mg pack Formulary Addition Tier 3 lopinavir 80 mg/ ml / ritonavir 20 mg/ml oral solution Formulary Addition Tier 4 ranitidine 25 mg/ml injection Formulary Addition Tier 4 cartia xt 120 mg capsule Reduction in Tiered Cost-Sharing Status Tier 2 cartia xt 180 mg capsule Reduction in Tiered Cost-Sharing Status Tier 2 cartia xt 240 mg capsule Reduction in Tiered Cost-Sharing Status Tier 2 cartia xt 300 mg capsule Reduction in Tiered Cost-Sharing Status Tier 2 GLYXAMBI 10 MG/5 MG Formulary Addition Tier 4 GLYXAMBI 25 MG/5 MG Formulary Addition Tier 4 RIVASTIGMINE 13.3 MG/24 PATCH Formulary Addition Tier 3 RIVASTIGMINE 4.6 MG/24 PATCH Formulary Addition Tier 3 RIVASTIGMINE 9.5 MG/24 PATCH Formulary Addition Tier 3 metadate er 200 mg tablet Formulary Addition Tier 4

9 erythromycin ethylsuccinate 200 mg/ 5ml oral susp Formulary Addition Tier 3 mimvey 1 mg-0.5 mg tablet Formulary Addition Tier 3 mimvey lo 0.5 mg-0.1 mg tablet Formulary Addition Tier 3 estradiol-norethindrone 0.5 mg-0.1 mg tablet Formulary Addition Tier 3 estradiol-norethindrone 1 mg- 0.5 mg tablet Formulary Addition Tier 3 ANORO ELLIPA INHALATION Reduction in Tiered Cost-Sharing Status Tier 3 PROAIR HFA 90 MCG INHALER Reduction in Tiered Cost-Sharing Status Tier 3 GILENYA 0.5 MG CAPSULE Change in Utilization Management Tier 5 abacavir 600 mg/ lamivudine 300 mg tablet Formulary Addition TIER 3 ORENCIA AUTO-INJECTOR Formulary Addition TIER 5 PA REQUIRED HUMIRA PEN - PSORIASIS STARTER PACK Formulary Addition TIER 5 PA REQUIRED/QL = 6 PER 28 DAYS amlopidine 10 mg/ hctz 12.5 mg/ olmesartan 40 mg tablet Formulary Addition TIER 3 amlopidine 10 mg/ hctz 25 mg/ olmesartan 40 mg tablet Formulary Addition TIER 3 amlopidine 10 mg/ olmesartan 20 mg tablet Formulary Addition TIER 2 amlopidine 10 mg/ olmesartan 40 mg tablet Formulary Addition TIER 2 amlopidine 5 mg/ hctz 12.5 mg/ olmesartan 20 mg tablet Formulary Addition TIER 3 amlopidine 5 mg/ hctz 12.5 mg/ olmesartan 40 mg tablet Formulary Addition TIER 3 amlopidine 5 mg/ hctz 25 mg/ Formulary Addition TIER 3

10 olmesartan 40 mg tablet amlopidine 5 mg/ olmesartan 20 mg tablet Formulary Addition TIER 2 amlopidine 5 mg/ olmesartan 40 mg tablet Formulary Addition TIER 2 PANCREAZE UNT/ ENDOPEPTIDASES 6200 UNT/ LIPASE 2600 UNT CAPSULE Formulary Addition TIER 3 EMEND 125 MG POWDER FOR ORAL SUSPENSION Formulary Addition TIER 4 PA/B VS. D DETERMINATION aprepitant 125 mg capsule Formulary Addition TIER 2 PA/B VS. D DETERMINATION aprepitant 125 mg/ aprepitant 80 mg pack Formulary Addition TIER 2 PA/B VS. D DETERMINATION aprepitant 40 mg capsule Formulary Addition TIER 2 PA/B VS. D DETERMINATION aprepitant 80 mg capsule Formulary Addition TIER 2 PA/B VS. D DETERMINATION azithromycin 500 mg pack Formulary Addition TIER 1 BENZOYL PEROXIDE 0.05 MG/MG / CLINDAMYCIN PHOSPHATE MG/MG TOPICAL GEL Formulary Addition TIER 4 bupropion 150 mg er tablet Formulary Addition TIER 1 QL = 2 TABLETS DAILY INVOKAMET 150 MG/ 1000 MG ER TABLET Formulary Addition TIER 3 INVOKAMET 150 MG/ 500 MG ER TABLET Formulary Addition TIER 3 INVOKAMET 50 MG/ 1000 MG ER TABLET Formulary Addition TIER 3 INVOKAMET 50 MG/ 500 MG ER TABLET Formulary Addition TIER 3 cholestyramine 4000 mg Formulary Addition TIER 2

11 powder for oral suspension gengraf 50 mg capsule Formulary Addition TIER 3 PA/B VS. D DETERMINATION daptomycin 500 mg injection Formulary Addition TIER 4 HI DRUG VIEKIRA XR PAK Formulary Addition TIER 5 PA REQUIRED CAZIANT 28 DAY PACK Formulary Addition TIER 3 drospirenone 3 mg/ ethinyl estradiol 0.02 mg/ levomefolate mg pack Formulary Addition TIER 3 zarah pack Formulary Addition TIER 3 epinephrine 0.5 mg/ ml autoinjector Formulary Addition TIER 2 epirubicin 2 mg/ ml injection Formulary Addition TIER 4 yuvafem vaginal tablet Formulary Addition TIER 2 AMABELZ 0.5/ DAY Formulary Addition TIER 3 AMABELZ 1/ DAY Formulary Addition TIER 3 ethacrynic 25 mg tablet Formulary Addition TIER 3 AMETHIA LO 91 DAY Formulary Addition TIER 3 CAMRESELO 91 DAY Formulary Addition TIER 3 LARISSIA 28 DAY PACK Formulary Addition TIER 3 ethinyl estradiol 0.02 mg/ norethindrone 1 mg Formulary Addition TIER 3 LOW-OGESTREL 28 DAY Formulary Addition TIER 3 ethinyl estradiol mg/ ferrous fumarate 75 mg/ norethindrone 0.4 mg pack Formulary Addition TIER 3 ALYACEN 1/35 Formulary Addition TIER 3 ethinyl estradiol mg/ inert 1 mg/ norgestimate 0.18 mg/ norgestimate mg/ Formulary Addition TIER 3

12 norgestimate 0.25 mg pack FEMYNOR 28 DAY Formulary Addition TIER 3 ethinyl estradiol 0.05 mg/ ethynodiol 1 mg/ inert 1 mg Formulary Addition TIER 3 REPATHA 120 MG/ ML CARTIRIDGE Formulary Addition TIER 5 PA REQUIRED ezetimibe 10 mg tablet Formulary Addition TIER 2 fluocinonide 0.5 mg/ml topical cream Formulary Addition TIER 3 BEVESPI METERED DOSE INHALER Formulary Addition TIER 4 olmesartan 20 mg/ hctz 12.5 tablet Formulary Addition TIER 2 olmesartan 40 mg/ hctz 12.5 tablet Formulary Addition TIER 2 olmesartan 40 mg/ hctz 25 tablet Formulary Addition TIER 2 VASCEPA 500 MG CAPSULE Formulary Addition TIER 4 GAMMAGARD MG INJECTION Formulary Addition TIER 5 PA/B VS. D DETERMINATION GAMASTAN 180 UNT/ML INJECTION Formulary Addition TIER 3 PA/B VS. D DETERMINATION GAMMAGARD 5000 MG INJECTION Formulary Addition TIER 5 PA/B VS. D DETERMINATION BASAGLAR PEN INJECTOR Formulary Addition TIER 3 ORKAMBI 125 MG/ 100 MG TABLET Formulary Addition TIER 5 PA REQUIRED levalbuterol mg/actuat metered dose inhaler Formulary Addition TIER 3 levalbuterol 2.5 mg/ml Formulary Addition TIER 4 PA/B VS. D DETERMINATION

13 inhalant solution XIIDRA OPHTHAL SOLUTION Formulary Addition TIER 4 ADLYXIN STARTER KIT PACK Formulary Addition TIER 4 ADLYXIN 0.1 MG/ML PEN INJECTOR Formulary Addition TIER 4 mesalamine 800 mg er tablet Formulary Addition TIER 3 methotrexate 25 mg/ ml injection Formulary Addition TIER 4 methylphenidate 20 mg er capsule Formulary Addition TIER 4 methylphenidate 40 mg er capsule Formulary Addition TIER 4 mycophenolate 500 mg injection Formulary Addition TIER 4 PA/B VS. D DETERMINATION nifedipine 30 mg er tablet Formulary Addition TIER 2 nifedipine 60 mg er tablet Formulary Addition TIER 2 nifedipine 90 mg er tablet Formulary Addition TIER 2 nilutamide 150 mg tablet Formulary Addition TIER 5 nitroglycerin 0.3 mg sublingual tablet Formulary Addition TIER 2 nitroglycerin 0.4 mg sublingual tablet Formulary Addition TIER 2 nitroglycerin 0.6 mg sublingual tablet Formulary Addition TIER 2 ofloxacin 300 mg tablet Formulary Addition TIER 3 LARTRUVO 10 MG/ML INJECTION Formulary Addition TIER 5 olmesartan 20 mg tablet Formulary Addition TIER 2 olmesartan 40 mg tablet Formulary Addition TIER 2

14 olmesartan 5 mg tablet Formulary Addition TIER 2 oseltamivir 30 mg capsule Formulary Addition TIER 2 oseltamivir 45 mg capsule Formulary Addition TIER 2 oseltamivir 75 mg capsule Formulary Addition TIER 2 quetiapine 150 mg er tablet Formulary Addition TIER 3 quetiapine 200 mg er tablet Formulary Addition TIER 3 quetiapine 300 mg er tablet Formulary Addition TIER 3 quetiapine 400 mg er tablet Formulary Addition TIER 3 quetiapine 50 mg er tablet Formulary Addition TIER 3 rasagiline 0.5 mg tablet Formulary Addition TIER 3 rasagiline 1 mg tablet Formulary Addition TIER 3 RUBRACA 200 MG TABLET Formulary Addition TIER 5 RUBRACA 300 MG TABLET Formulary Addition TIER 5 SPS 250 MG/ ML ORAL SUSPENSION Formulary Addition TIER 3 EPCLUSA 400 MG/ 100 MG TABLET Formulary Addition TIER 5 PA REQUIRED sumatriptan 8 mg/ml autoinjector Formulary Addition TIER 4 QL = 8 MLS IN 30 DAYS VEMLIDY 25 MG TABLET Formulary Addition TIER 5 YONDELIS 1 MG INJECTION Formulary Addition TIER 5 triamcinolone mg/actuat metered dose nasal spray Formulary Addition TIER 3 valganciclovir 50 mg/ml oral solution Formulary Addition TIER 4

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