Upcoming Changes to Retiree RxCare s 5 Tier Formulary Retiree RxCare may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, [or] add prior authorization, quantity limits and/or step therapy restrictions on a drug [and/or move a drug at a higher cost-sharing tier], we will notify you 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, in which case we will immediately remove the drug from our formulary. The table below outlines upcoming changes to our formulary that may impact you. ADACEL Name of Affected Drug Description of Change Reason for Change * INJ ADAPAL/BEN P GEL 0.1%-2.5% ALIQOPA INJ 60MG AMNESTEEM CAP 10MG AMNESTEEM CAP 20MG AMNESTEEM CAP 40MG ARIPIPRAZOLE SOL 1MG/ML BAXDELA BAXDELA INJ 300MG TAB 450MG Last Updated 4/1/2018 1 Formulary ID# 18402
Name of Affected Drug Description of Change Reason for Change * BENLYSTA INJ 200MG/ML BORTEZOMIB INJ 3.5MG BOSULIF TAB 400MG BUPRENORPHIN INJ 0.3MG/ML Tier Decrease N/A N/A N/A 3/1/2018 BYDUREON INJ BCISE CALQUENCE CAP 100MG CARVEDILOL CAP 80MG ER CASPOFUNGIN INJ 50MG CASPOFUNGIN INJ 70MG CLINDACIN-P PAD 1% CLINISOL SF INJ 15% with B vs D Prior Authorization DACTINOMYCIN INJ 0.5MG Last Updated 4/1/2018 2 Formulary ID# 18402
Name of Affected Drug Description of Change Reason for Change * DAPSONE GEL 5% DESO/ETHINYL ESTRADIO TAB 0.15MG/30MCG DOXYCYCLINE TAB 150MG DOXYCYCLINE TAB 75MG EFAVIRENZ CAP 50MG ELETRIPTAN TAB 20MG ELETRIPTAN TAB 40MG EMBEDA CAP 100MG-4MG Tier Decrease N/A N/A N/A 3/1/2018 EMBEDA CAP 80MG-3.2MG Tier Decrease N/A N/A N/A 3/1/2018 ENTRESTO TAB 24MG-26MG Prior Aurthorization Removed and Tier Decrease N/A N/A N/A 3/1/2018 ENTRESTO TAB 49MG-51MG Prior Aurthorization Removed and Tier Decrease N/A N/A N/A 3/1/2018 ENTRESTO TAB 97MG-103MG Prior Aurthorization Removed and Tier Decrease N/A N/A N/A 3/1/2018 ESTRADIOL TAB 10MCG Last Updated 4/1/2018 3 Formulary ID# 18402
Name of Affected Drug Description of Change Reason for Change * ETHY ETH EST TAB 1MG-35MCG FASENRA INJ 30MG/ML FOSAMPRENAVI TAB 700MG FYCOMPA TAB 10MG Tier Decrease N/A N/A N/A 3/1/2018 FYCOMPA TAB 12MG Tier Decrease N/A N/A N/A 3/1/2018 FYCOMPA TAB 4MG Tier Decrease N/A N/A N/A 3/1/2018 FYCOMPA TAB 6MG Tier Decrease N/A N/A N/A 3/1/2018 GLATIRAMER INJ 20MG/ML GLATIRAMER INJ 40MG/ML GLYXAMBI TAB 10MG-5MG GLYXAMBI TAB 25MG-5MG GOCOVRI CAP 137MG Last Updated 4/1/2018 4 Formulary ID# 18402
Name of Affected Drug Description of Change Reason for Change * GOCOVRI CAP 68.5MG HALOPER DEC INJ 100MG/ML HAVRIX INJ 1440UNIT HAVRIX INJ 720UNIT HUMALOG JR INJ 100UNIT/ML HUMULIN R INJ U-500 Tier Decrease N/A N/A N/A 3/1/2018 IDHIFA TAB 100MG IDHIFA TAB 50MG INGREZZA CAP 80MG ISIBLOOM TAB 0.15MG-30MCG JULUCA TAB 50MG-25MG Last Updated 4/1/2018 5 Formulary ID# 18402
KADCYLA KLOR-CON Name of Affected Drug Description of Change Reason for Change * LANTHANUM LANTHANUM LANTHANUM LARTRUVO INJ 160MG PAK 20MEQ CHW 1000MG CHW 500MG CHW 750MG INJ 190MG/19ML LEVONOR/ETHI TAB ESTRADIO TAB 100MCG TAB 112MCG TAB 125MCG TAB 137MCG TAB 150MCG TAB 175MCG Last Updated 4/1/2018 6 Formulary ID# 18402
Name of Affected Drug Description of Change Reason for Change * TAB 200 MCG TAB 25MCG TAB 300 MCG TAB 50MCG TAB 75MCG TAB 88MCG LUPR DEP-PED INJ 3M 30MG LYNPARZA LYNPARZA MAVYRET TAB 100MG TAB 150MG TAB 100MG-40MG MEROPENEM INJ 1GM MESALAMINE TAB 1.2GM Last Updated 4/1/2018 7 Formulary ID# 18402
Name of Affected Drug Description of Change Reason for Change * METHOTREXATE INJ 250MG/10ML METHYLPHENID CAP 30MG ER MORPHINE SUL INJ 5MG/ML MOXIFLOXACIN SOL 0.5% MYLOTARG INJ 4.5MG NERLYNX TAB 40MG NORGEST/ETHI TAB 0.25MG/35MCG NOVAREL INJ 5000UNIT NYMALIZE SOL 30MG/10ML OPDIVO INJ 100MG/10ML OSELTAMIVIR SUS 6MG/ML Last Updated 4/1/2018 8 Formulary ID# 18402
Name of Affected Drug Description of Change Reason for Change * OXALIPLATIN INJ 100MG PAROXETINE CAP 7.5MG PEG 3350 SOL ELECTROL PHRENILIN CAP FORTE PIPER/TAZOBA INJ 2GM-0.25GM POT CHLORIDE INJ 2MEQ/ML PRASUGREL TAB 10MG PRASUGREL TAB 5MG PREVYMIS PREVYMIS PREVYMIS PREVYMIS PROFENO INJ 240MG/12ML INJ 480MG/24ML TAB 240MG TAB 480MG TAB 600MG Last Updated 4/1/2018 9 Formulary ID# 18402
Name of Affected Drug Description of Change Reason for Change * RADICAVA INJ 30MG RAYALDEE CAP 30MCG RENFLEXIS INJ 100MG RENVELA PAK 0.8GM Tier Decrease N/A N/A N/A 3/1/2018 RENVELA PAK 2.4GM Tier Decrease N/A N/A N/A 3/1/2018 RENVELA TAB 800MG Tier Decrease N/A N/A N/A 3/1/2018 RISEDRONATE TAB 35MG RITUXAN INJ 100MG SCOPOLAMINE DIS 1MG/3DAY SEVELAMER POW 0.8GM Tier Decrease N/A N/A N/A 3/1/2018 SEVELAMER POW 2.4GM Tier Decrease N/A N/A N/A 3/1/2018 SEVELAMER TAB 800MG STELARA INJ 45MG/0.5ML SUPRAX SUS 500MG/5ML Tier Decrease N/A N/A N/A 3/1/2018 Last Updated 4/1/2018 10 Formulary ID# 18402
SYNDROS TAMIFLU TAMIFLU TAMIFLU Name of Affected Drug Description of Change Reason for Change * SOL 5MG/ML CAP 30MG CAP 45MG CAP 75MG TESTOSTERONE SOL 30MG/ACT TIMOLOL MALE SOL 0.5% TRAMADOL HCL TAB 100MG ER TRAMADOL HCL TAB 200MG ER TRAMADOL HCL TAB 300MG ER TREANDA TREMFYA TRISENOX INJ 25MG INJ 100MG/ML INJ 12MG/6ML Last Updated 4/1/2018 11 Formulary ID# 18402
TWINRIX VABOMERE VAQTA VAQTA Name of Affected Drug Description of Change Reason for Change * INJ INJ 2GM(1GM-1GM) INJ 25UNIT/0.5ML INJ 50UNIT/ML VENTOLIN HFA AER VERZENIO VERZENIO VERZENIO VERZENIO TAB 100MG TAB 150MG TAB 200MG TAB 50MG VIGABATRIN PAK 500MG Last Updated 4/1/2018 12 Formulary ID# 18402
VIVITROL VOSEVI VYXEOS XATMEP Name of Affected Drug Description of Change Reason for Change * INJ 380MG TAB XIIDRA DRO 5% XURIDEN ZENPEP ALTAVERA ALUNBRIG ALUNBRIG INJ 44MG-100MG SOL 2.5MG/ML POW 2GM CAP 20000UNIT TAB PAK TAB 180MG Prior Aurthorization Removed N/A N/A N/A 3/1/2018 and Quantity Limits N/A N/A N/A 4/1/2018 and Quantity Limits N/A N/A N/A 4/1/2018 Last Updated 4/1/2018 13 Formulary ID# 18402
Name of Affected Drug Description of Change Reason for Change * ALUNBRIG TAB 90MG ATAZANAVIR CAP 150MG ATAZANAVIR CAP 200MG ATAZANAVIR CAP 300MG CARVEDILOL CAP 10MG ER CARVEDILOL CAP 20MG ER CARVEDILOL CAP 40MG ER CINVANTI INJ 130MG/18ML DORIPENEM INJ 500MG ELIQUIS ST P TAB 5MG EMFLAZA EMFLAZA SUS 22.75MG/ML TAB 18MG and Quantity Limits N/A N/A N/A 4/1/2018 Limits N/A N/A N/A 4/1/2018 Required N/A N/A N/A 4/1/2018 Required N/A N/A N/A 4/1/2018 Last Updated 4/1/2018 14 Formulary ID# 18402
Name of Affected Drug Description of Change Reason for Change * EMFLAZA EMFLAZA EMFLAZA ENSKYCE TAB 30MG TAB 36MG TAB 6MG TAB ESTRADIOL CRE 0.01% HERCEPTIN INJ 150MG KURVELO TAB 0.15MG/30MG LEVONOR/ETHI TAB ESTRADIO MEDROXYPR AC INJ 150MG/ML ROWEEPRA XR TAB 500MG XR ROWEEPRA XR TAB 750MG XR SELZENTRY SOL 20MG/ML Required N/A N/A N/A 4/1/2018 Required N/A N/A N/A 4/1/2018 Required N/A N/A N/A 4/1/2018 Required N/A N/A N/A 4/1/2018 Limits N/A N/A N/A 4/1/2018 Last Updated 4/1/2018 15 Formulary ID# 18402
Name of Affected Drug Description of Change Reason for Change * SHINGRIX INJ 50MCG TENOFOVIR TAB 300MG ZENPEP CAP ZENPEP CAP 40000UNIT Tier Decrease N/A N/A N/A 4/1/2018 BIKTARVY TAB 200MG Formulary Addition N/A CREON CAP 36000UNIT Reduction in Preferred or Tiered Cost-Sharing QL Status DIGOX TAB 0.125MG Formulary Addition DIGOX TAB 0.25MG Formulary Addition QL EFAVIRENZ CAP 200MG Formulary Addition PA EFAVIRENZ TAB 600MG Formulary Addition ENDARI POW 5GM Formulary Addition ERLEADA TAB 60MG Formulary Addition PA HALOPERIDOL INJ 5MG/ML Formulary Addition QL,PA ISOTRETINOIN CAP 10MG Formulary Addition ISOTRETINOIN CAP 20MG Formulary Addition PA ISOTRETINOIN CAP 30MG Formulary Addition PA ISOTRETINOIN CAP 40MG Formulary Addition PA LEVONOR/ETHI TAB ESTRADIO Formulary Addition PA MEMANTINE HC CAP 14MG ER Formulary Addition QL MEMANTINE HC CAP 21MG ER Formulary Addition QL MEMANTINE HC CAP 28MG ER Formulary Addition QL MEMANTINE HC CAP 7MG ER Formulary Addition QL METHOTREXATE INJ 25MG/ML Formulary Addition QL MINOCYCLINE TAB 115MG ER Formulary Addition MINOCYCLINE TAB 65MG ER Formulary Addition Last Updated 4/1/2018 16 Formulary ID# 18402
Name of Affected Drug Description of Change Reason for Change * NALOXONE INJ 0.4MG/ML Formulary Addition NOLIX CRE 0.05% Formulary Addition Reduction in Preferred or PREDNISOLONE SOL 15MG/5ML Tiered Cost-Sharing Status QVAR REDIHA AER 80MCG Formulary Addition QVAR REDIHAL AER 40MCG Formulary Addition QL SODIUM PHENY TAB 500MG Formulary Addition QL SUMAT-NAPROX TAB 85MG- 500MG Formulary Addition SYMDEKO TAB 100MG-150MG Formulary Addition QL TRIENTINE CAP 250MG Formulary Addition QL,PA VIDEX EC CAP 125MG Formulary Addition XTAMPZA ER CAP 13.5MG Formulary Addition XTAMPZA ER CAP 18MG Formulary Addition XTAMPZA ER CAP 27MG Formulary Addition XTAMPZA ER CAP 36MG Formulary Addition XTAMPZA ER CAP 9MG Formulary Addition ZENPEP CAP 25000UNIT Formulary Addition ZENPEP CAP 5000UNIT Formulary Addition Last Updated 4/1/2018 17 Formulary ID# 18402
Name of Affected Drug Description of Change Reason for Change * * Alternative drugs are drugs in the same therapeutic category/class or cost-sharing tier as the affected drug. Only your physician can determine if the alternate here is appropriate for you given the individualized nature of the drug therapy. Please consult your physician as to whether this is an appropriate drug for you. Last Updated 4/1/2018 18 Formulary ID# 18402