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 to a drug and/or move a drug to a higher cost-sharing tier, we will notify you of the change at least 60 days before the date that the change becomes effective.

There are two exceptions to the 60-day advance member notification requirement:

1. If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary. 2. When the FDA approves a first time generic for a brand name drug, we may immediately allow a brand to generic substitution. Notification to the member will be made but can occur after the substitution is made.

FORMULARY CHANGES EFFECTIVE 03/01/2021 Medication Name Change Description BAVENCIO 200 MG/10 ML VIAL - Added to Tier 5 avelumab - PA Added: BAVENCIO (s)

BRONCHITOL 40 MG INHALE CAP - Added to Tier 5 mannitol - QL Added: 560 / 28 DAYS - PA Added: Bronchitol (s)

CABENUVA 400 MG-600 MG ER SUSP - Added to Tier 5 cabotegravir/rilpivirine

CABENUVA 600 MG-900 MG ER SUSP - Added to Tier 5 cabotegravir/rilpivirine

DYSPORT 300 UNIT VIAL - Added to Tier 5 abobotulinumtoxina - PA Added: Dysport (s)

DYSPORT 500 UNITS VIAL - Added to Tier 5 abobotulinumtoxina - PA Added: Dysport (s)

emtricitabine/tenofovir (tdf) 100-150 mg - Added to Tier 5 tablet - QL Added: 30 / 30 DAYS

emtricitabine/tenofovir (tdf) 133-200 mg - Added to Tier 5 tablet - QL Added: 30 / 30 DAYS

emtricitabine/tenofovir (tdf) 167-250 mg - Added to Tier 5 tablet - QL Added: 30 / 30 DAYS

epinephrine 0.1 mg/ml syringe - Added to Tier 2

glucagon,human recombinant 1 mg vial - Added to Tier 3

ICLUSIG 10 MG TABLET - Added to Tier 5 ponatinib hcl - QL Added: 30 / 30 DAYS - PA Added: ICLUSIG (s) ICLUSIG 30 MG TABLET - Added to Tier 5 ponatinib hcl - PA Added: ICLUSIG (s)

IMFINZI 120 MG/2.4 ML VIAL - Added to Tier 5 durvalumab - PA Added: IMFINZI (s)

IMFINZI 500 MG/10 ML VIAL - Added to Tier 5 durvalumab - PA Added: IMFINZI (s) imiquimod 3.75 % cream pack - Added to Tier 5 isotretinoin 10 mg capsule - Added to Tier 4 - PA Added: ISOTRETINOIN (s) isotretinoin 20 mg capsule - Added to Tier 4 - PA Added: ISOTRETINOIN (s) isotretinoin 30 mg capsule - Added to Tier 4 - PA Added: ISOTRETINOIN (s) isotretinoin 40 mg capsule - Added to Tier 4 - PA Added: ISOTRETINOIN (s)

KEYTRUDA 100 MG/4 ML VIAL - Added to Tier 5 pembrolizumab - PA Added: KEYTRUDA (s)

KLISYRI 1% OINTMENT PACKET - Added to Tier 5 tirbanibulin

LIBTAYO 350 MG/7 ML VIAL - Added to Tier 5 cemiplimab-rwlc - PA Added: LIBTAYO (s)

LUPKYNIS 7.9 MG CAPSULE - Added to Tier 5 voclosporin - QL Added: 180 / 30 DAYS - PA Added: Lupkynis (s)

MAYZENT 0.25 MG STARTER PACK - Added to Tier 5 siponimod - QL Added: 24 / 365 OVER TIME - PA Added: MAYZENT (s) norethindrone-e.estradiol-iron 1mg-20(24) - Added to Tier 2 capsule

OPDIVO 100 MG/10 ML VIAL - Added to Tier 5 nivolumab - PA Added: OPDIVO (s)

OPDIVO 240 MG/24 ML VIAL - Added to Tier 5 nivolumab - PA Added: OPDIVO (s)

OPDIVO 40 MG/4 ML VIAL - Added to Tier 5 nivolumab - PA Added: OPDIVO (s) TECENTRIQ 1,200 MG/20 ML VIAL - Added to Tier 5 atezolizumab - PA Added: TECENTRIQ (s)

TECENTRIQ 840 MG/14 ML VIAL - Added to Tier 5 atezolizumab - PA Added: TECENTRIQ (s)

TOTECT 500 MG VIAL - Added to Tier 5 dexrazoxane hcl

YERVOY 200 MG/40 ML VIAL - Added to Tier 5 ipilimumab - PA Added: YERVOY (s)

YERVOY 50 MG/10 ML VIAL - Added to Tier 5 ipilimumab - PA Added: YERVOY (s) FORMULARY CHANGES EFFECTIVE 02/01/2021 Medication Name Change Description GAMIFANT 10 MG/2 ML VIAL - Added to Tier 5 emapalumab-lzsg - PA Added: Gamifant (s) GAMIFANT 50 MG/10 ML VIAL - Added to Tier 5 emapalumab-lzsg - PA Added: Gamifant (s) loperamide hcl 1mg/7.5ml liquid - Removed From Coverage ORGOVYX 120 MG TABLET - Added to Tier 5 relugolix - PA Added: Orgovyx (s)

RIABNI 100 MG/10 ML VIAL - Added to Tier 5 rituximab-arrx - PA Added: Riabni (s)

RIABNI 500 MG/50 ML VIAL - Added to Tier 5 rituximab-arrx - PA Added: Riabni (s)

ZOKINVY 50 MG CAPSULE - Added to Tier 5 lonafarnib - QL Added: 120 / 30 DAYS - PA Added: Zokinvy (s) ZOKINVY 75 MG CAPSULE - Added to Tier 5 lonafarnib - QL Added: 120 / 30 DAYS - PA Added: Zokinvy (s)

QL = Quantity Limit, PA = Prior Authorization, B/D = Medicare Part B versus Part D determination

AER = Aerosol, CAP = Capsule, CON = Concentrate, CRE = Cream, DRO = Drops, ER = Extended Release, ENE = Enema, GRA = Granules, INH = Inhalation, INJ = Injection, LOT = Lotion, NEB = Nebulizer, ODT = Orally Disintegrating, OIN = Ointment, OP = Ophthalmic, POW = Powder, SHA = Shampoo, SOL = Solution, SPR = Spray, SUB = Sublingual, SUP = Suppository, SUS = Suspension, TAB = Tablet, CHW = Chewable

Formulary ID#: 21310 Last Update: 2/2021