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Umpqua Health Alliance List of Medication Coverage Changes

(Updated 4/1/2021)

INTRODUCTION

The Umpqua Health Alliance (UHA) Pharmacy and Therapeutics (P&T) Committee composed of pharmacists and physicians determine which drugs should be covered, the coverage restrictions, and the PA guidelines. The goal of the P&T Committee is to create a formulary (list of covered drugs) with medications that are safe and effective and that offer the best value.

Our formulary and prior authorization guidelines are usually updated quarterly. This document contains all updates made to the UHA formulary and PA guidelines since January 1, 2020. The current versions of our formulary and PA guidelines are available on the UHA Pharmacy Services webpage: https://www.umpquahealth.com/pharmacy‐services/.

LEGEND

The following are restriction and coverage abbreviations found in this document:

ABBREVIATIONS DEFINITION EXPLANATION PA Prior Authorization Required Prior authorization (e.g. prior approval) is required before filling a prescription for this drug. Without prior authorization, we may not cover this drug. The provider must submit a request for prior authorization with the appropriate documentation (including recent chart notes) before the drug is covered. A specific PA guideline policy number beginning with “RX” may be referenced in the “Description” column. Visit the UHA Pharmacy Services webpage for our PA guidelines: https://www.umpquahealth.com/pharmacy‐services/. ST Step Therapy Restriction We require trial and failure of one or more lower‐cost or preferred drug(s) (“Step 1 drug”) before using the more expensive or non‐preferred drug (“Step 2 drug”). If it is medically necessary for a member to use a Step 2 drug first, the prescriber will need to submit a request for prior authorization. AR Age Restriction Coverage of this drug is limited to a specific age range. Covered ages are listed. A prior authorization is required for members outside of the listed age range. QL Quantity Limit We will cover this drug only up to a certain quantity or limit per time or per fill. The specific quantity limit is listed. If it is medically necessary to exceed the quantity limit, the prescriber will need to submit a request for prior authorization. SPEC Specialty Drug Coverage for specialty drugs will only be provided if the drug is obtained through our contracted specialty pharmacy, MedImpact Direct Specialty Hub. MedImpact Direct Specialty Hub Telephone: (877) 391‐1103 Fax: (888) 807‐5716 Website: www.medimpactdirect.com

MEDICATION COVERAGE CHANGES

BENEFIT EFFECTIVE DRUG NAME STRENGTH ROUTE DOSAGE CHANGE DESCRIPTION DATE PHARMACY 6/1/2021 BASAGLAR 100/ML (3) SUBCUT INSULN REMOVED FROM SEMGLEE IS PREFERRED KWIKPEN ( ANE. PEN FORMULARY . GLARGINE) PHARMACY 6/1/2021 INSULINS LANTUS SOLOSTAR 100/ML (3) SUBCUT INSULN REMOVED FROM SEMGLEE IS PREFERRED (INSULIN ANE. PEN FORMULARY INSULIN GLARGINE. GLARGINE) PHARMACY 6/1/2021 INSULINS LANTUS (INSULIN 100/ML SUBCUT VIAL REMOVED FROM SEMGLEE IS PREFERRED GLARGINE) ANE. FORMULARY INSULIN GLARGINE. PHARMACY 5/1/2021 BETA‐ADRENERGIC BUDESONIDE‐ 80‐4.5 MCG INHALATI HFA AER REMOVED ST COVERED UNDER PHARMACY AND GLUCOCORTICOID FORMOTEROL ON AD RESTRICTION BENEFIT WITH NO COMBINATIONS FUMARATE RESTRICTIONS. (BUDESONIDE/FOR MOTEROL FUMARATE) PHARMACY 5/1/2021 BETA‐ADRENERGIC BUDESONIDE‐ 160‐4.5MCG INHALATI HFA AER REMOVED ST COVERED UNDER PHARMACY AND GLUCOCORTICOID FORMOTEROL ON AD RESTRICTION BENEFIT WITH NO COMBINATIONS FUMARATE RESTRICTIONS. (BUDESONIDE/FOR MOTEROL FUMARATE) PHARMACY 5/1/2021 BETA‐ADRENERGIC‐ TRELEGY ELLIPTA 200‐62.5 INHALATI BLST ADDED TO FORMULARY SEE PA GUIDELINES FOR ANTICHOLINERGIC‐ (FLUTICASONE/UM ON W/DEV WITH PA RESTRICTION DETAILS (RX041). GLUCOCORT, INHALED ECLIDIN/VILANTER) PHARMACY 5/1/2021 GLUCOCORTICOIDS, ASMANEX 110MCG INHALATI AER ADDED TO FORMULARY COVERED UNDER PHARMACY ORALLY INHALED (MOMETASONE ON POW BA BENEFIT WITH NO FUROATE) RESTRICTIONS. PHARMACY 5/1/2021 GLUCOCORTICOIDS, ASMANEX 220MCG INHALATI AER ADDED TO FORMULARY COVERED UNDER PHARMACY ORALLY INHALED (MOMETASONE ON POW BA BENEFIT WITH NO FUROATE) RESTRICTIONS. PHARMACY 5/1/2021 GLUCOCORTICOIDS, ASMANEX HFA 50 MCG INHALATI HFA AER ADDED TO FORMULARY COVERED UNDER PHARMACY ORALLY INHALED (MOMETASONE ON AD BENEFIT WITH NO FUROATE) RESTRICTIONS. PHARMACY 5/1/2021 GLUCOCORTICOIDS, ASMANEX HFA 100 MCG INHALATI HFA AER ADDED TO FORMULARY COVERED UNDER PHARMACY ORALLY INHALED (MOMETASONE ON AD BENEFIT WITH NO FUROATE) RESTRICTIONS.

PHARMACY 5/1/2021 GLUCOCORTICOIDS, ASMANEX HFA 200 MCG INHALATI HFA AER ADDED TO FORMULARY COVERED UNDER PHARMACY ORALLY INHALED (MOMETASONE ON AD BENEFIT WITH NO FUROATE) RESTRICTIONS. PHARMACY 5/1/2021 ACNE AGENTS, ISOTRETINOIN 10 MG ORAL CAPSULE ADDED TO FORMULARY SEE PA GUIDELINES FOR SYSTEMIC (MULTIPLE LABEL WITH PA RESTRICTION DETAILS (RX053). NAMES) PHARMACY 5/1/2021 ACNE AGENTS, ISOTRETINOIN 20 MG ORAL CAPSULE ADDED TO FORMULARY SEE PA GUIDELINES FOR SYSTEMIC (MULTIPLE LABEL WITH PA RESTRICTION DETAILS (RX053). NAMES) PHARMACY 5/1/2021 ACNE AGENTS, ISOTRETINOIN 30 MG ORAL CAPSULE ADDED TO FORMULARY SEE PA GUIDELINES FOR SYSTEMIC (MULTIPLE LABEL WITH PA RESTRICTION DETAILS (RX053). NAMES) PHARMACY 5/1/2021 ACNE AGENTS, ISOTRETINOIN 40 MG ORAL CAPSULE ADDED TO FORMULARY SEE PA GUIDELINES FOR SYSTEMIC (MULTIPLE LABEL WITH PA RESTRICTION DETAILS (RX053). NAMES) PHARMACY 5/1/2021 VITAMIN A ADAPALENE 0.1 % TOPICAL GEL ADDED TO FORMULARY SEE PA GUIDELINES FOR DERIVATIVES (GRAM) WITH PA RESTRICTION DETAILS (RX053). PHARMACY 5/1/2021 VITAMIN A ADAPALENE 0.3 % TOPICAL GEL ADDED TO FORMULARY SEE PA GUIDELINES FOR DERIVATIVES (GRAM) WITH PA RESTRICTION DETAILS (RX053). PHARMACY 5/1/2021 VITAMIN A TRETINOIN 0.025 % TOPICAL CREAM ADDED TO FORMULARY SEE PA GUIDELINES FOR DERIVATIVES (G) WITH PA RESTRICTION DETAILS (RX053). PHARMACY 5/1/2021 VITAMIN A TRETINOIN 0.05 % TOPICAL CREAM ADDED TO FORMULARY SEE PA GUIDELINES FOR DERIVATIVES (G) WITH PA RESTRICTION DETAILS (RX053). PHARMACY 5/1/2021 TOPICAL ANTIBIOTICS CLINDAMYCIN 1 % TOPICAL SOLUTIO ADDED TO FORMULARY SEE PA GUIDELINES FOR PHOSPHATE N WITH PA RESTRICTION DETAILS (RX053). PHARMACY 5/1/2021 KERATOLYTICS BENZOYL 10 % TOPICAL GEL ADDED TO FORMULARY SEE PA GUIDELINES FOR PEROXIDE (GRAM) WITH PA RESTRICTION DETAILS (RX053). PHARMACY 5/1/2021 KERATOLYTICS BENZOYL 10 % TOPICAL CLEANSE ADDED TO FORMULARY SEE PA GUIDELINES FOR PEROXIDE R WITH PA RESTRICTION DETAILS (RX053). PHARMACY 5/1/2021 OXAZOLIDINONES LINEZOLID 600 MG ORAL TABLET ADDED TO FORMULARY COVERED UNDER PHARMACY BENEFIT WITH NO RESTRICTIONS. PHARMACY 5/1/2021 , FENTANYL 12 MCG/HR TRANSDE PATCH ADDED QL QL (1 PATCH PER 3 DAYS). NARCOTICS RM. TD72 RESTRICTION PHARMACY 5/1/2021 ANALGESICS, FENTANYL 25 MCG/HR TRANSDE PATCH ADDED QL QL (1 PATCH PER 3 DAYS). NARCOTICS RM. TD72 RESTRICTION PHARMACY 5/1/2021 ANALGESICS, FENTANYL 50MCG/HR TRANSDE PATCH ADDED QL QL (1 PATCH PER 3 DAYS). NARCOTICS RM. TD72 RESTRICTION PHARMACY 5/1/2021 ANALGESICS, FENTANYL 75MCG/HR TRANSDE PATCH ADDED QL QL (1 PATCH PER 3 DAYS). NARCOTICS RM. TD72 RESTRICTION PHARMACY 5/1/2021 ANALGESICS, FENTANYL 100 TRANSDE PATCH ADDED QL QL (1 PATCH PER 3 DAYS). NARCOTICS MCG/HR RM. TD72 RESTRICTION

PHARMACY 5/1/2021 ANALGESICS, MORPHINE 30 MG ORAL CPMP ADDED QL QL (2 CAPSULES PER DAY). NARCOTICS SULFATE ER 24HR RESTRICTION (MORPHINE SULFATE) PHARMACY 5/1/2021 ANALGESICS, MORPHINE 45 MG ORAL CPMP ADDED QL QL (2 CAPSULES PER DAY). NARCOTICS SULFATE ER 24HR RESTRICTION (MORPHINE SULFATE) PHARMACY 5/1/2021 ANALGESICS, MORPHINE 60 MG ORAL CPMP ADDED QL QL (2 CAPSULES PER DAY). NARCOTICS SULFATE ER 24HR RESTRICTION (MORPHINE SULFATE) PHARMACY 5/1/2021 ANALGESICS, MORPHINE 75 MG ORAL CPMP ADDED QL QL (2 CAPSULES PER DAY). NARCOTICS SULFATE ER 24HR RESTRICTION (MORPHINE SULFATE) PHARMACY 5/1/2021 ANALGESICS, MORPHINE 90 MG ORAL CPMP ADDED QL QL (2 CAPSULES PER DAY). NARCOTICS SULFATE ER 24HR RESTRICTION (MORPHINE SULFATE) PHARMACY 5/1/2021 ANALGESICS, MORPHINE 120 MG ORAL CPMP ADDED QL QL (2 CAPSULES PER DAY). NARCOTICS SULFATE ER 24HR RESTRICTION (MORPHINE SULFATE) PHARMACY 5/1/2021 ANALGESICS, MORPHINE 15 MG ORAL TABLET ADDED QL QL (3 TABLETS PER DAY). NARCOTICS SULFATE ER ER RESTRICTION (MORPHINE SULFATE) PHARMACY 5/1/2021 ANALGESICS, MORPHINE 30 MG ORAL TABLET ADDED QL QL (3 TABLETS PER DAY). NARCOTICS SULFATE ER ER RESTRICTION (MORPHINE SULFATE) PHARMACY 5/1/2021 ANALGESICS, MORPHINE 60 MG ORAL TABLET ADDED QL QL (3 TABLETS PER DAY). NARCOTICS SULFATE ER ER RESTRICTION (MORPHINE SULFATE) PHARMACY 5/1/2021 ANALGESICS, MORPHINE 100 MG ORAL TABLET ADDED QL QL (3 TABLETS PER DAY). NARCOTICS SULFATE ER ER RESTRICTION (MORPHINE SULFATE) PHARMACY 5/1/2021 ANALGESICS, MORPHINE 200 MG ORAL TABLET ADDED QL QL (3 TABLETS PER DAY). NARCOTICS SULFATE ER ER RESTRICTION

(MORPHINE SULFATE) PHARMACY 2/1/2021 ANTIVIRALS, HIV‐SPEC, EMTRICITABINE‐ 200‐300 MG ORAL TABLET ADDED TO FORMULARY COVERED UNDER PHARMACY NUCLEOSIDE‐ TENOFOVIR DISOP BENEFIT WITH NO NUCLEOTIDE ANALOG RESTRICTIONS. PHARMACY 2/1/2021 PINEAL HORMONE MELATONIN 5 MG ORAL CAPSULE ADDED TO FORMULARY COVERED UNDER PHARMACY AGENTS BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 PINEAL HORMONE MELATONIN 10 MG ORAL CAPSULE ADDED TO FORMULARY COVERED UNDER PHARMACY AGENTS BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 PINEAL HORMONE MELATONIN 1 MG ORAL TABLET ADDED TO FORMULARY COVERED UNDER PHARMACY AGENTS BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 PINEAL HORMONE MELATONIN 3 MG ORAL TABLET ADDED TO FORMULARY COVERED UNDER PHARMACY AGENTS BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 PINEAL HORMONE MELATONIN 5 MG ORAL TABLET ADDED TO FORMULARY COVERED UNDER PHARMACY AGENTS BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 PINEAL HORMONE MELATONIN 10 MG ORAL TABLET ADDED TO FORMULARY COVERED UNDER PHARMACY AGENTS BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 PINEAL HORMONE MELATONIN 3 MG ORAL TAB ADDED TO FORMULARY COVERED UNDER PHARMACY AGENTS RAPDIS BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 PINEAL HORMONE MELATONIN 5 MG ORAL TAB ADDED TO FORMULARY COVERED UNDER PHARMACY AGENTS RAPDIS BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 PINEAL HORMONE MELATONIN 10 MG ORAL TAB ADDED TO FORMULARY COVERED UNDER PHARMACY AGENTS MPHASE BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 SEDATIVE‐ ZOLPIDEM 5 MG ORAL TABLET CHANGED QL QL (2 TABLETS PER DAY). HYPNOTICS,NON‐ TARTRATE RESTRICTION BARBITURATE PHARMACY 2/1/2021 SEDATIVE‐ ZOLPIDEM 10 MG ORAL TABLET CHANGED QL QL (1 TABLET PER DAY). HYPNOTICS,NON‐ TARTRATE RESTRICTION BARBITURATE PHARMACY 2/1/2021 ANGIOTENSIN RECEPT‐ ENTRESTO 24 MG‐ ORAL TABLET ADDED TO FORMULARY SEE PA GUIDELINES FOR NEPRILYSIN INHIBITOR (/VALS 26MG WITH PA AND QL DETAILS (RX052). QL (60 COMB(ARNI) ARTAN) RESTRICTIONS TABLETS PER 30 DAYS).

PHARMACY 2/1/2021 ANGIOTENSIN RECEPT‐ ENTRESTO 49 MG‐ ORAL TABLET ADDED TO FORMULARY SEE PA GUIDELINES FOR NEPRILYSIN INHIBITOR (SACUBITRIL/VALS 51MG WITH PA AND QL DETAILS (RX052). QL (60 COMB(ARNI) ARTAN) RESTRICTIONS TABLETS PER 30 DAYS). PHARMACY 2/1/2021 ANGIOTENSIN RECEPT‐ ENTRESTO 97MG‐ ORAL TABLET ADDED TO FORMULARY SEE PA GUIDELINES FOR NEPRILYSIN INHIBITOR (SACUBITRIL/VALS 103MG WITH PA AND QL DETAILS (RX052). QL (60 COMB(ARNI) ARTAN) RESTRICTIONS TABLETS PER 30 DAYS). PHARMACY 2/1/2021 TOPICAL ANTIFUNGALS MICONAZOLE 2 % TOPICAL CREAM REMOVED PA COVERED UNDER PHARMACY NITRATE (G) RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 TOPICAL ANTIFUNGALS NYSTATIN 100000/G TOPICAL CREAM REMOVED PA COVERED UNDER PHARMACY (G) RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 TOPICAL ANTIFUNGALS NYSTATIN 100000/G TOPICAL OINT. (G) REMOVED PA COVERED UNDER PHARMACY RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 TOPICAL ANTIFUNGALS NYSTATIN 100000/G TOPICAL POWDER REMOVED PA COVERED UNDER PHARMACY RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 TOPICAL ANTIFUNGALS TERBINAFINE HCL 1 % TOPICAL CREAM ADDED TO FORMULARY COVERED UNDER PHARMACY (G) BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 TOPICAL ANTI‐ BETAMETHASONE 0.05 % TOPICAL CREAM ADDED TO FORMULARY COVERED UNDER PHARMACY INFLAMMATORY DIPROP (G) BENEFIT WITH NO STEROIDAL AUGMENTED RESTRICTIONS. PHARMACY 2/1/2021 TOPICAL ANTI‐ BETAMETHASONE 0.05 % TOPICAL OINT. (G) ADDED TO FORMULARY COVERED UNDER PHARMACY INFLAMMATORY DIPROP BENEFIT WITH NO STEROIDAL AUGMENTED RESTRICTIONS. PHARMACY 2/1/2021 TOPICAL ANTI‐ BETAMETHASONE 0.1 % TOPICAL CREAM REMOVED QL COVERED UNDER PHARMACY INFLAMMATORY VALERATE (G) RESTRICTION BENEFIT WITH NO STEROIDAL RESTRICTIONS. PHARMACY 2/1/2021 TOPICAL ANTI‐ BETAMETHASONE 0.1 % TOPICAL OINT. (G) REMOVED QL COVERED UNDER PHARMACY INFLAMMATORY VALERATE RESTRICTION BENEFIT WITH NO STEROIDAL RESTRICTIONS. PHARMACY 2/1/2021 TOPICAL ANTI‐ DICLOFENAC 1 % TOPICAL GEL CHANGED QL QL (100 GRAMS PER 12 DAYS). INFLAMMATORY, SODIUM (GRAM) RESTRICTION NSAIDS PHARMACY 2/1/2021 TOPICAL LOCAL LIDOCAINE 5 % TOPICAL ADH. ADDED TO FORMULARY COVERED UNDER PHARMACY ANESTHETICS PATCH BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 TOPICAL LOCAL LIDOCAINE‐ 2.5 %‐2.5% TOPICAL CREAM ADDED TO FORMULARY COVERED UNDER PHARMACY ANESTHETICS PRILOCAINE (G) BENEFIT WITH NO RESTRICTIONS.

PHARMACY 2/1/2021 ANTIFUNGAL AGENTS TERBINAFINE HCL 250 MG ORAL TABLET REMOVED PA COVERED UNDER PHARMACY RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 NSAIDS, CELECOXIB 50 MG ORAL CAPSULE REMOVED PA COVERED UNDER PHARMACY CYCLOOXYGENASE 2 RESTRICTION BENEFIT WITH NO INHIBITOR ‐ TYPE RESTRICTIONS. PHARMACY 2/1/2021 NSAIDS, CELECOXIB 100 MG ORAL CAPSULE REMOVED PA COVERED UNDER PHARMACY CYCLOOXYGENASE 2 RESTRICTION BENEFIT WITH NO INHIBITOR ‐ TYPE RESTRICTIONS. PHARMACY 2/1/2021 NSAIDS, CELECOXIB 200 MG ORAL CAPSULE REMOVED PA COVERED UNDER PHARMACY CYCLOOXYGENASE 2 RESTRICTION BENEFIT WITH NO INHIBITOR ‐ TYPE RESTRICTIONS. PHARMACY 2/1/2021 NSAIDS, CELECOXIB 400 MG ORAL CAPSULE REMOVED PA COVERED UNDER PHARMACY CYCLOOXYGENASE 2 RESTRICTION BENEFIT WITH NO INHIBITOR ‐ TYPE RESTRICTIONS. PHARMACY 2/1/2021 LAXATIVES AND POLYETHYLENE 17G/DOSE ORAL POWDER CHANGED QL QL (510 GRAMS PER 30 DAYS). CATHARTICS GLYCOL 3350 RESTRICTION PHARMACY 2/1/2021 ANTIPARKINSONISM ROPINIROLE HCL 0.25 MG ORAL TABLET REMOVED PA COVERED UNDER PHARMACY DRUGS,OTHER RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 ANTIPARKINSONISM ROPINIROLE HCL 0.5 MG ORAL TABLET REMOVED PA COVERED UNDER PHARMACY DRUGS,OTHER RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 ANTIPARKINSONISM ROPINIROLE HCL 1 MG ORAL TABLET REMOVED PA COVERED UNDER PHARMACY DRUGS,OTHER RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 ANTIPARKINSONISM ROPINIROLE HCL 2 MG ORAL TABLET REMOVED PA COVERED UNDER PHARMACY DRUGS,OTHER RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 ANTIPARKINSONISM ROPINIROLE HCL 3 MG ORAL TABLET REMOVED PA COVERED UNDER PHARMACY DRUGS,OTHER RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 ANTIPARKINSONISM ROPINIROLE HCL 4 MG ORAL TABLET REMOVED PA COVERED UNDER PHARMACY DRUGS,OTHER RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 ANTIPARKINSONISM ROPINIROLE HCL 5 MG ORAL TABLET REMOVED PA COVERED UNDER PHARMACY DRUGS,OTHER RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 VITAMIN C ASCORBIC ACID 100 MG ORAL TABLET ADDED TO FORMULARY COVERED UNDER PHARMACY PREPARATIONS (VITAMIN C) BENEFIT WITH NO RESTRICTIONS.

PHARMACY 2/1/2021 VITAMIN C ASCORBIC ACID 250 MG ORAL TABLET ADDED TO FORMULARY COVERED UNDER PHARMACY PREPARATIONS (VITAMIN C) BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 VITAMIN C ASCORBIC ACID 500 MG ORAL TABLET ADDED TO FORMULARY COVERED UNDER PHARMACY PREPARATIONS (VITAMIN C) BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 VITAMIN C ASCORBIC ACID 1000 MG ORAL TABLET ADDED TO FORMULARY COVERED UNDER PHARMACY PREPARATIONS (VITAMIN C) BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 VITAMIN C ASCORBIC ACID 100 MG ORAL TAB ADDED TO FORMULARY COVERED UNDER PHARMACY PREPARATIONS (VITAMIN C) CHEW BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 VITAMIN C ASCORBIC ACID 125 MG ORAL TAB ADDED TO FORMULARY COVERED UNDER PHARMACY PREPARATIONS (VITAMIN C) CHEW BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 VITAMIN C ASCORBIC ACID 250 MG ORAL TAB ADDED TO FORMULARY COVERED UNDER PHARMACY PREPARATIONS (VITAMIN C) CHEW BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 VITAMIN C ASCORBIC ACID 500 MG ORAL TAB ADDED TO FORMULARY COVERED UNDER PHARMACY PREPARATIONS (VITAMIN C) CHEW BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 VITAMIN C ASCORBIC ACID 1000 MG ORAL TAB ADDED TO FORMULARY COVERED UNDER PHARMACY PREPARATIONS (VITAMIN C) CHEW BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 VITAMIN D CHOLECALCIFEROL 100 MCG ORAL CAPSULE ADDED TO FORMULARY COVERED UNDER PHARMACY PREPARATIONS (VITAMIN D3) BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 VITAMIN D CHOLECALCIFEROL 250 MCG ORAL CAPSULE ADDED TO FORMULARY COVERED UNDER PHARMACY PREPARATIONS (VITAMIN D3) BENEFIT WITH NO RESTRICTIONS. PHARMACY 2/1/2021 VITAMIN D CHOLECALCIFEROL 25 MCG ORAL TABLET ADDED TO FORMULARY COVERED UNDER PHARMACY PREPARATIONS (VITAMIN D3) BENEFIT WITH NO RESTRICTIONS. PHARMACY 11/1/2020 ANALGESICS,NARCOTIC OXYCODONE HCL 10 MG ORAL TAB ER ADDED PA SEE PA GUIDELINES FOR S ER 12H RESTRICTION DETAILS (RX005). PHARMACY 11/1/2020 ANALGESICS,NARCOTIC METHADONE HCL 10 MG ORAL TABLET ADDED PA SEE PA GUIDELINES FOR S RESTRICTION DETAILS (RX005). PHARMACY 11/1/2020 ANALGESICS,NARCOTIC METHADONE HCL 5 MG ORAL TABLET ADDED PA SEE PA GUIDELINES FOR S RESTRICTION DETAILS (RX005). PHARMACY 11/1/2020 GLUCOCORTICOIDS, ARNUITY ELLIPTA 100 MCG INHALATI BLST ADDED TO FORMULARY COVERED UNDER PHARMACY ORALLY INHALED (FLUTICASONE ON W/DEV BENEFIT WITH NO FUROATE) RESTRICTIONS.

PHARMACY 11/1/2020 GLUCOCORTICOIDS, ARNUITY ELLIPTA 200 MCG INHALATI BLST ADDED TO FORMULARY COVERED UNDER PHARMACY ORALLY INHALED (FLUTICASONE ON W/DEV BENEFIT WITH NO FUROATE) RESTRICTIONS. PHARMACY 11/1/2020 GLUCOCORTICOIDS, ARNUITY ELLIPTA 50 MCG INHALATI BLST ADDED TO FORMULARY COVERED UNDER PHARMACY ORALLY INHALED (FLUTICASONE ON W/DEV BENEFIT WITH NO FUROATE) RESTRICTIONS. PHARMACY 11/1/2020 ANTICHOLINERGICS, SPIRIVA 18 MCG INHALATI CAP CHANGED ST MUST FIRST TRY INCRUSE ORALLY INHALED LONG (TIOTROPIUM ON W/DEV RESTRICTION ELLIPTA (TUDORZA NO LONGER ACTING BROMIDE) REQUIRED). PHARMACY 11/1/2020 ANTICHOLINERGICS, SPIRIVA RESPIMAT 1.25 MCG INHALATI MIST CHANGED ST MUST FIRST TRY INCRUSE ORALLY INHALED LONG (TIOTROPIUM ON INHAL RESTRICTION ELLIPTA (TUDORZA NO LONGER ACTING BROMIDE) REQUIRED). PHARMACY 11/1/2020 ANTICHOLINERGICS, SPIRIVA RESPIMAT 2.5 MCG INHALATI MIST CHANGED ST MUST FIRST TRY INCRUSE ORALLY INHALED LONG (TIOTROPIUM ON INHAL RESTRICTION ELLIPTA (TUDORZA NO LONGER ACTING BROMIDE) REQUIRED). PHARMACY 11/1/2020 ANTICHOLINERGICS, TUDORZA 400 MCG INHALATI AER REMOVED FROM INCRUSE ELLIPTA IS PREFERRED ORALLY INHALED LONG PRESSAIR ON POW BA FORMULARY AGENT. ACTING (ACLIDINIUM BROMIDE) PHARMACY 11/1/2020 BETA‐ADRENERGIC DULERA 50MCG‐ INHALATI HFA AER ADDED TO FORMULARY MUST FIRST TRY AND GLUCOCORTICOID (MOMETASONE/F 5MCG ON AD WITH ST RESTRICTION FLUTICASONE/SALMETEROL COMBINATIONS ORMOTEROL) (GENERIC ADVAIR OR AIRDUO). PHARMACY 11/1/2020 GENE‐ AIMOVIG 70 MG/ML SUBCUT AUTO ADDED TO FORMULARY SEE PA GUIDELINES FOR RELATED AUTOINJECTOR ANE. INJCT WITH PA RESTRICTION DETAILS (RX051). (CGRP) INHIBITORS (‐ AOOE) PHARMACY 11/1/2020 CALCITONIN GENE‐ AIMOVIG 70 MG/ML SUBCUT AUTO ADDED TO FORMULARY SEE PA GUIDELINES FOR RELATED PEPTIDE AUTOINJECTOR (2 ANE. INJCT WITH PA RESTRICTION DETAILS (RX051). (CGRP) INHIBITORS PACK) (ERENUMAB‐ AOOE) PHARMACY 11/1/2020 CALCITONIN GENE‐ AIMOVIG 140 MG/ML SUBCUT AUTO ADDED TO FORMULARY SEE PA GUIDELINES FOR RELATED PEPTIDE AUTOINJECTOR ANE. INJCT WITH PA RESTRICTION DETAILS (RX051). (CGRP) INHIBITORS (ERENUMAB‐ AOOE) PHARMACY 11/1/2020 CALCITONIN GENE‐ AJOVY SYRINGE 225 MG/1.5 SUBCUT SYRINGE ADDED TO FORMULARY SEE PA GUIDELINES FOR RELATED PEPTIDE (‐ ANE. WITH PA RESTRICTION DETAILS (RX051). (CGRP) INHIBITORS VFRM) PHARMACY 11/1/2020 CALCITONIN GENE‐ AJOVY 225 MG/1.5 SUBCUT AUTO ADDED TO FORMULARY SEE PA GUIDELINES FOR RELATED PEPTIDE AUTOINJECTOR ANE. INJCT WITH PA RESTRICTION DETAILS (RX051). (CGRP) INHIBITORS (FREMANEZUMAB‐ VFRM)

PHARMACY 11/1/2020 CALCITONIN GENE‐ EMGALITY PEN 120 MG/ML SUBCUT PEN ADDED TO FORMULARY SEE PA GUIDELINES FOR RELATED PEPTIDE (‐ ANE. INJCTR WITH PA RESTRICTION DETAILS (RX051). (CGRP) INHIBITORS GNLM) PHARMACY 11/1/2020 CALCITONIN GENE‐ EMGALITY 120 MG/ML SUBCUT SYRINGE ADDED TO FORMULARY SEE PA GUIDELINES FOR RELATED PEPTIDE SYRINGE ANE. WITH PA RESTRICTION DETAILS (RX051). (CGRP) INHIBITORS (GALCANEZUMAB‐ GNLM) PHARMACY 11/1/2020 CALCITONIN GENE‐ EMGALITY 300MG/3ML SUBCUT SYRINGE ADDED TO FORMULARY SEE PA GUIDELINES FOR RELATED PEPTIDE SYRINGE ANE. WITH PA RESTRICTION DETAILS (RX051). (CGRP) INHIBITORS (GALCANEZUMAB‐ GNLM) PHARMACY 11/1/2020 CALCITONIN GENE‐ UBRELVY 50 MG ORAL TABLET ADDED TO FORMULARY SEE PA GUIDELINES FOR RELATED PEPTIDE () WITH PA RESTRICTION DETAILS (RX051). (CGRP) INHIBITORS PHARMACY 11/1/2020 CALCITONIN GENE‐ UBRELVY 100 MG ORAL TABLET ADDED TO FORMULARY SEE PA GUIDELINES FOR RELATED PEPTIDE (UBROGEPANT) WITH PA RESTRICTION DETAILS (RX051). (CGRP) INHIBITORS PHARMACY 11/1/2020 CALCITONIN GENE‐ VYEPTI 100 MG/ML INTRAVE VIAL ADDED TO FORMULARY SEE PA GUIDELINES FOR RELATED PEPTIDE (‐ N. WITH PA RESTRICTION DETAILS (RX051). (CGRP) INHIBITORS JJMR) PHARMACY 11/1/2020 CALCITONIN GENE‐ NURTEC ODT 75 MG ORAL TAB ADDED TO FORMULARY SEE PA GUIDELINES FOR RELATED PEPTIDE ( RAPDIS WITH PA RESTRICTION DETAILS (RX051). (CGRP) INHIBITORS SULFATE) PHARMACY 11/1/2020 ANTIMIGRAINE 5 MG ORAL TAB CHANGED QL QL (9 TABLETS PER 30 DAYS). PREPARATIONS ODT RAPDIS RESTRICTION PHARMACY 11/1/2020 ANTIMIGRAINE ZOMIG ZMT 5 MG ORAL TAB CHANGED QL QL (9 TABLETS PER 30 DAYS). PREPARATIONS (ZOLMITRIPTAN) RAPDIS RESTRICTION PHARMACY 11/1/2020 ANTIMIGRAINE ZOLMITRIPTAN 2.5 MG ORAL TAB CHANGED QL QL (9 TABLETS PER 30 DAYS). PREPARATIONS ODT RAPDIS RESTRICTION PHARMACY 11/1/2020 ANTIMIGRAINE ZOMIG ZMT 2.5 MG ORAL TAB CHANGED QL QL (9 TABLETS PER 30 DAYS). PREPARATIONS (ZOLMITRIPTAN) RAPDIS RESTRICTION PHARMACY 11/1/2020 ANTIMIGRAINE ZOLMITRIPTAN 2.5 MG ORAL TABLET CHANGED QL QL (9 TABLETS PER 30 DAYS). PREPARATIONS RESTRICTION PHARMACY 11/1/2020 ANTIMIGRAINE ZOMIG 2.5 MG ORAL TABLET CHANGED QL QL (9 TABLETS PER 30 DAYS). PREPARATIONS (ZOLMITRIPTAN) RESTRICTION PHARMACY 11/1/2020 ANTIMIGRAINE ZOLMITRIPTAN 5 MG ORAL TABLET CHANGED QL QL (9 TABLETS PER 30 DAYS). PREPARATIONS RESTRICTION PHARMACY 11/1/2020 ANTIMIGRAINE ZOMIG 5 MG ORAL TABLET CHANGED QL QL (9 TABLETS PER 30 DAYS). PREPARATIONS (ZOLMITRIPTAN) RESTRICTION PHARMACY 11/1/2020 ANTIMIGRAINE REYVOW 50 MG ORAL TABLET ADDED TO FORMULARY SEE PA GUIDELINES FOR PREPARATIONS ( WITH PA AND QL DETAILS (RX023). QL (4 SUCCINATE) RESTRICTIONS TABLETS PER 30 DAYS).

PHARMACY 11/1/2020 ANTIMIGRAINE REYVOW 100 MG ORAL TABLET ADDED TO FORMULARY SEE PA GUIDELINES FOR PREPARATIONS (LASMIDITAN WITH PA AND QL DETAILS (RX023). QL (4 SUCCINATE) RESTRICTIONS TABLETS PER 30 DAYS). PHARMACY 11/1/2020 ANTIMIGRAINE 6 MG/0.5ML SUBCUT SYRINGE ADDED TO FORMULARY SEE PA GUIDELINES FOR PREPARATIONS SUCCINATE ANE. WITH PA AND QL DETAILS (RX023). QL (1 RESTRICTIONS PACKAGE PER 30 DAYS). PHARMACY 10/1/2020 BETA‐ADRENERGIC PROAIR RESPICLICK 90 MCG INHALATI AER REMOVED FROM GENERIC ALBUTEROL INHALERS AGENTS, INHALED, (ALBUTEROL ON POW BA FORMULARY ARE PREFERRED AGENTS. SHORT ACTING SULFATE) PHARMACY 8/1/2020 THROMBIN PRADAXA 110 MG ORAL CAPSULE ADDED TO FORMULARY COVERED UNDER PHARMACY INHIBITORS,SELECTIVE, (DABIGATRAN WITH PA RESTRICTION BENEFIT WITH PA; SEE PA DIRECT, & REVERSIBLE ETEXILATE GUIDELINES FOR DETAILS MESYLATE) (RX014). PHARMACY 8/1/2020 TETRACYCLINES DOXYCYCLINE 50 MG ORAL CAPSULE REMOVED PA COVERED UNDER PHARMACY HYCLATE RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 8/1/2020 TETRACYCLINES DOXYCYCLINE 100 MG ORAL CAPSULE REMOVED PA COVERED UNDER PHARMACY HYCLATE RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 8/1/2020 TETRACYCLINES DOXYCYCLINE 100 MG ORAL TABLET REMOVED PA COVERED UNDER PHARMACY HYCLATE RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 8/1/2020 TETRACYCLINES DOXYCYCLINE 75 MG ORAL CAPSULE REMOVED FROM 50 MG OR 100 MG CAPSULES MONOHYDRATE FORMULARY ARE AVAILABLE. PHARMACY 8/1/2020 TETRACYCLINES DOXYCYCLINE 150 MG ORAL CAPSULE REMOVED FROM 50 MG OR 100 MG CAPSULES MONOHYDRATE FORMULARY ARE AVAILABLE. PHARMACY 8/1/2020 TETRACYCLINES DOXYCYCLINE 50 MG ORAL TABLET ADDED TO FORMULARY COVERED UNDER PHARMACY MONOHYDRATE BENEFIT WITH NO RESTRICTIONS. PHARMACY 8/1/2020 TETRACYCLINES DOXYCYCLINE 100 MG ORAL TABLET ADDED TO FORMULARY COVERED UNDER PHARMACY MONOHYDRATE BENEFIT WITH NO RESTRICTIONS. PHARMACY 8/1/2020 PEDIATRIC VITAMIN PEDI MULTIVIT 0.25‐10/ML ORAL DROPS ADDED AGE COVERED FOR AGE 1 AND PREPARATIONS 75/FLUORIDE/IRO RESTRICTION YOUNGER. N PHARMACY 8/1/2020 PEDIATRIC VITAMIN PEDI MULTIVIT 0.25‐10/ML ORAL DROPS ADDED AGE COVERED FOR AGE 1 AND PREPARATIONS 45/FLUORIDE/IRO RESTRICTION YOUNGER. N PHARMACY 8/1/2020 PEDIATRIC VITAMIN PEDI MULTIVIT 0.25 MG/ML ORAL DROPS ADDED TO FORMULARY COVERED FOR AGE 1 AND PREPARATIONS NO.2 W‐FLUORIDE WITH AR YOUNGER. PHARMACY 8/1/2020 PEDIATRIC VITAMIN PEDI MULTIVIT 0.5 MG/ML ORAL DROPS ADDED TO FORMULARY COVERED FOR AGE 1 AND PREPARATIONS NO.2 W‐FLUORIDE WITH AR YOUNGER.

PHARMACY 8/1/2020 PEDIATRIC VITAMIN PEDI MULTIVIT 0.25‐10/ML ORAL DROPS ADDED TO FORMULARY COVERED FOR AGE 1 AND PREPARATIONS 45/FLUORIDE/IRO WITH AR YOUNGER. N PHARMACY 7/1/2020 DOACS (DIRECT BEVYXXA CHANGED PA CRITERIA UPDATED PA GUIDELINES TO FACTOR XA (BETRIXABAN ALIGN WITH NATIONAL INHIBITORS; MALEATE), GUIDELINES. WARFARIN THROMBIN PRADAXA FAILURE NO LONGER INHIBITORS,SELECTIVE, (DABIGATRAN REQUIRED FOR ATRIAL DIRECT, & REVERSIBLE) ETEXILATE FIBRILLATION. SEE PA MESYLATE), GUIDELINES FOR DETAILS SAVAYSA (RX014). (EDOXABAN TOSYLATE), XARELTO (RIVAROXABAN) PHARMACY 5/1/2020 ANTIHYPERGLY,INCRETI TANZEUM CHANGED PA CRITERIA UPDATED PA GUIDELINES TO N MIMETIC(GLP‐1 (), ALIGN WITH ADA GUIDELINES. RECEP.) TRULICITY SEE PA GUIDELINES FOR (), DETAILS (RX007). BYETTA (), BYDUREON (EXENATIDE MICROSPHERES), VICTOZA (), ADLYXIN (), OZEMPIC (), RYBELSUS (SEMAGLUTIDE) PHARMACY 5/1/2020 ANTIHYPERGLY,INCRETI ADLYXIN 20 MCG/0.2 SUBCUT PEN ADDED TO FORMULARY SEE PA GUIDELINES FOR N MIMETIC(GLP‐1 (LIXISENATIDE) ANE. INJCTR WITH PA RESTRICTION DETAILS (RX007). RECEP.AGONIST) PHARMACY 5/1/2020 ANTIHYPERGLY,INCRETI ADLYXIN 10‐20 (1) SUBCUT PEN ADDED TO FORMULARY SEE PA GUIDELINES FOR N MIMETIC(GLP‐1 (LIXISENATIDE) ANE. INJCTR WITH PA RESTRICTION DETAILS (RX007). RECEP.AGONIST) PHARMACY 5/1/2020 ANTIHYPERGLY,INCRETI BYDUREON BCISE 2MG/0.85M SUBCUT AUTO ADDED TO FORMULARY SEE PA GUIDELINES FOR N MIMETIC(GLP‐1 (EXENATIDE L ANE. INJCT WITH PA RESTRICTION DETAILS (RX007). RECEP.AGONIST) MICROSPHERES)

PHARMACY 5/1/2020 ANTIHYPERGLY,INCRETI RYBELSUS 3 MG ORAL TABLET ADDED TO FORMULARY SEE PA GUIDELINES FOR N MIMETIC(GLP‐1 (SEMAGLUTIDE) WITH PA RESTRICTION DETAILS (RX007). RECEP.AGONIST) PHARMACY 5/1/2020 ANTIHYPERGLY,INCRETI RYBELSUS 7 MG ORAL TABLET ADDED TO FORMULARY SEE PA GUIDELINES FOR N MIMETIC(GLP‐1 (SEMAGLUTIDE) WITH PA RESTRICTION DETAILS (RX007). RECEP.AGONIST) PHARMACY 5/1/2020 ANTIHYPERGLY,INCRETI RYBELSUS 14 MG ORAL TABLET ADDED TO FORMULARY SEE PA GUIDELINES FOR N MIMETIC(GLP‐1 (SEMAGLUTIDE) WITH PA RESTRICTION DETAILS (RX007). RECEP.AGONIST) PHARMACY 5/1/2020 ANTIHYPERGLYCEMC‐ FARXIGA 10 MG ORAL TABLET REMOVED FROM STEGLATRO IS PREFERRED SOD/GLUC (DAPAGLIFLOZIN FORMULARY AGENT. SEE PA GUIDELINES COTRANSPORT2(SGLT2) PROPANEDIOL) FOR DETAILS (RX008). INHIB PHARMACY 5/1/2020 ANTIHYPERGLYCEMC‐ FARXIGA 5 MG ORAL TABLET REMOVED FROM STEGLATRO IS PREFERRED SOD/GLUC (DAPAGLIFLOZIN FORMULARY AGENT. SEE PA GUIDELINES COTRANSPORT2(SGLT2) PROPANEDIOL) FOR DETAILS (RX008). INHIB PHARMACY 5/1/2020 ANTIHYPERGLYCEMC‐ JARDIANCE 10 MG ORAL TABLET REMOVED FROM STEGLATRO IS PREFERRED SOD/GLUC () FORMULARY AGENT. SEE PA GUIDELINES COTRANSPORT2(SGLT2) FOR DETAILS (RX008). INHIB PHARMACY 5/1/2020 ANTIHYPERGLYCEMC‐ JARDIANCE 25 MG ORAL TABLET REMOVED FROM STEGLATRO IS PREFERRED SOD/GLUC (EMPAGLIFLOZIN) FORMULARY AGENT. SEE PA GUIDELINES COTRANSPORT2(SGLT2) FOR DETAILS (RX008). INHIB PHARMACY 5/1/2020 ANTIHYPERGLYCEMC‐ STEGLATRO 5 MG ORAL TABLET ADDED TO FORMULARY SEE PA GUIDELINES FOR SOD/GLUC (ERTUGLIFLOZIN WITH PA RESTRICTION DETAILS (RX008). COTRANSPORT2(SGLT2) PIDOLATE) INHIB PHARMACY 5/1/2020 ANTIHYPERGLYCEMC‐ STEGLATRO 15 MG ORAL TABLET ADDED TO FORMULARY SEE PA GUIDELINES FOR SOD/GLUC (ERTUGLIFLOZIN WITH PA RESTRICTION DETAILS (RX008). COTRANSPORT2(SGLT2) PIDOLATE) INHIB MEDICAL 5/1/2020 LEUKOCYTE (WBC) NEUPOGEN 480MCG/1.6 INJECTIO VIAL REMOVED FROM GRANIX, NIVESTYM, AND STIMULANTS (FILGRASTIM) N FORMULARY ZARXIO ARE PREFERRED AGENTS. SEE PA GUIDELINES FOR DETAILS (RX043). MEDICAL 5/1/2020 LEUKOCYTE (WBC) NEUPOGEN 480MCG/0.8 INJECTIO SYRINGE REMOVED FROM GRANIX, NIVESTYM, AND STIMULANTS (FILGRASTIM) N FORMULARY ZARXIO ARE PREFERRED AGENTS. SEE PA GUIDELINES FOR DETAILS (RX043).

MEDICAL 5/1/2020 LEUKOCYTE (WBC) NEUPOGEN 300MCG/0.5 INJECTIO SYRINGE REMOVED FROM GRANIX, NIVESTYM, AND STIMULANTS (FILGRASTIM) N FORMULARY ZARXIO ARE PREFERRED AGENTS. SEE PA GUIDELINES FOR DETAILS (RX043). MEDICAL 5/1/2020 LEUKOCYTE (WBC) NEUPOGEN 300 INJECTIO VIAL REMOVED FROM GRANIX, NIVESTYM, AND STIMULANTS (FILGRASTIM) MCG/ML N FORMULARY ZARXIO ARE PREFERRED AGENTS. SEE PA GUIDELINES FOR DETAILS (RX043). MEDICAL 5/1/2020 LEUKOCYTE (WBC) NIVESTYM 300 INJECTIO VIAL ADDED TO FORMULARY COVERED UNDER MEDICAL STIMULANTS (FILGRASTIM‐AAFI) MCG/ML N WITH PA RESTRICTION BENEFIT WITH PA (HCPCS = Q5110); SEE PA GUIDELINES FOR DETAILS (RX043). MEDICAL 5/1/2020 LEUKOCYTE (WBC) NIVESTYM 480MCG/1.6 INJECTIO VIAL ADDED TO FORMULARY COVERED UNDER MEDICAL STIMULANTS (FILGRASTIM‐AAFI) N WITH PA RESTRICTION BENEFIT WITH PA (HCPCS = Q5110); SEE PA GUIDELINES FOR DETAILS (RX043). PHARMACY 5/1/2020 NITROFURAN NITROFURANTOIN 25 MG/5 ML ORAL ORAL REMOVED FROM ALTERNATIVES: DERIVATIVES SUSP FORMULARY NITROFURANTOIN CAPSULES, SULFAMETHOXAZOLE/TRIMET HOPRIM ORAL SUSPENSION, CIPROFLOXACIN ORAL SUSPENSION, LEVOFLOXACIN ORAL SOLUTION. PHARMACY 5/1/2020 PREGABALIN 25 MG ORAL CAPSULE REMOVED PA COVERED UNDER PHARMACY RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 5/1/2020 ANTICONVULSANTS PREGABALIN 50 MG ORAL CAPSULE REMOVED PA COVERED UNDER PHARMACY RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 5/1/2020 ANTICONVULSANTS PREGABALIN 75 MG ORAL CAPSULE REMOVED PA COVERED UNDER PHARMACY RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 5/1/2020 ANTICONVULSANTS PREGABALIN 100 MG ORAL CAPSULE REMOVED PA COVERED UNDER PHARMACY RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 5/1/2020 ANTICONVULSANTS PREGABALIN 150 MG ORAL CAPSULE REMOVED PA COVERED UNDER PHARMACY RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 5/1/2020 ANTICONVULSANTS PREGABALIN 200 MG ORAL CAPSULE REMOVED PA COVERED UNDER PHARMACY RESTRICTION BENEFIT WITH NO RESTRICTIONS.

PHARMACY 5/1/2020 ANTICONVULSANTS PREGABALIN 300 MG ORAL CAPSULE REMOVED PA COVERED UNDER PHARMACY RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 5/1/2020 ANTICONVULSANTS PREGABALIN 225 MG ORAL CAPSULE REMOVED PA COVERED UNDER PHARMACY RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 4/10/2020 NARCOTIC NARCAN 4 MG NASAL SPRAY REMOVED QL COVERED UNDER PHARMACY ANTAGONISTS (NALOXONE HCL) RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 3/4/2020 INSULINS 100/ML SUBCUT VIAL REMOVED PA COVERED UNDER PHARMACY ANE. RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 3/4/2020 INSULINS INSULIN ASPART 100/ML (3) SUBCUT INSULN REMOVED PA COVERED UNDER PHARMACY FLEXPEN ANE. PEN RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 3/4/2020 INSULINS INSULIN ASPART 100/ML SUBCUT CARTRID REMOVED PA COVERED UNDER PHARMACY PENFILL ANE. GE RESTRICTION BENEFIT WITH NO RESTRICTIONS. PHARMACY 3/4/2020 INSULINS NOVOLOG 100/ML SUBCUT CARTRID REMOVED PA COVERED UNDER PHARMACY (INSULIN ASPART) ANE. GE RESTRICTION BENEFIT WITH NO RESTRICTIONS. MEDICAL 2/11/2020 ANTI‐INFLAMMATORY REMICADE 100 MG INTRAVE VIAL REMOVED FROM RENFLEXIS AND INFLECTRA ARE TUMOR NECROSIS (INFLIXIMAB) N. FORMULARY PREFERRED AGENTS. SEE PA FACTOR INHIBITOR GUIDELINES FOR DETAILS (RX040). PHARMACY 1/1/2020 ANTI‐ALCOHOLIC ACAMPROSATE 333 MG ORAL TABLET ADDED TO FORMULARY COVERED UNDER PHARMACY PREPARATIONS CALCIUM DR BENEFIT WITH NO RESTRICTIONS. MEDICAL 1/1/2020 ANTI‐ALCOHOLIC VIVITROL 380 MG INTRAM SUS ER REMOVED PA COVERED UNDER MEDICAL PREPARATIONS (NALTREXONE USC. REC RESTRICTION BENEFIT (HCPCS = J2315) WITH MICROSPHERES) NO RESTRICTIONS. MEDICAL 1/1/2020 HEMATINICS,OTHER EPOGEN (EPOETIN 2000/ML INJECTIO VIAL REMOVED FROM RETACRIT IS PREFERRED ALFA) N FORMULARY AGENT. SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER EPOGEN (EPOETIN 4000/ML INJECTIO VIAL REMOVED FROM RETACRIT IS PREFERRED ALFA) N FORMULARY AGENT. SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER EPOGEN (EPOETIN 10000/ML INJECTIO VIAL REMOVED FROM RETACRIT IS PREFERRED ALFA) N FORMULARY AGENT. SEE PA GUIDELINES FOR DETAILS (RX042).

MEDICAL 1/1/2020 HEMATINICS,OTHER EPOGEN (EPOETIN 20000/2ML INJECTIO VIAL REMOVED FROM RETACRIT IS PREFERRED ALFA) N FORMULARY AGENT. SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER EPOGEN (EPOETIN 3000/ML INJECTIO VIAL REMOVED FROM RETACRIT IS PREFERRED ALFA) N FORMULARY AGENT. SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER EPOGEN (EPOETIN 20000/ML INJECTIO VIAL REMOVED FROM RETACRIT IS PREFERRED ALFA) N FORMULARY AGENT. SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER PROCRIT (EPOETIN 2000/ML INJECTIO VIAL REMOVED FROM RETACRIT IS PREFERRED ALFA) N FORMULARY AGENT. SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER PROCRIT (EPOETIN 4000/ML INJECTIO VIAL REMOVED FROM RETACRIT IS PREFERRED ALFA) N FORMULARY AGENT. SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER PROCRIT (EPOETIN 10000/ML INJECTIO VIAL REMOVED FROM RETACRIT IS PREFERRED ALFA) N FORMULARY AGENT. SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER PROCRIT (EPOETIN 20000/2ML INJECTIO VIAL REMOVED FROM RETACRIT IS PREFERRED ALFA) N FORMULARY AGENT. SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER PROCRIT (EPOETIN 3000/ML INJECTIO VIAL REMOVED FROM RETACRIT IS PREFERRED ALFA) N FORMULARY AGENT. SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER PROCRIT (EPOETIN 20000/ML INJECTIO VIAL REMOVED FROM RETACRIT IS PREFERRED ALFA) N FORMULARY AGENT. SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER PROCRIT (EPOETIN 40000/ML INJECTIO VIAL REMOVED FROM RETACRIT IS PREFERRED ALFA) N FORMULARY AGENT. SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER RETACRIT 2000/ML INJECTIO VIAL ADDED TO FORMULARY COVERED UNDER MEDICAL (EPOETIN ALFA‐ N WITH PA RESTRICTION BENEFIT WITH PA (HCPCS = EPBX) Q5105, Q5106); SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER RETACRIT 3000/ML INJECTIO VIAL ADDED TO FORMULARY COVERED UNDER MEDICAL (EPOETIN ALFA‐ N WITH PA RESTRICTION BENEFIT WITH PA (HCPCS = EPBX) Q5105, Q5106); SEE PA GUIDELINES FOR DETAILS (RX042).

MEDICAL 1/1/2020 HEMATINICS,OTHER RETACRIT 4000/ML INJECTIO VIAL ADDED TO FORMULARY COVERED UNDER MEDICAL (EPOETIN ALFA‐ N WITH PA RESTRICTION BENEFIT WITH PA (HCPCS = EPBX) Q5105, Q5106); SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER RETACRIT 10000/ML INJECTIO VIAL ADDED TO FORMULARY COVERED UNDER MEDICAL (EPOETIN ALFA‐ N WITH PA RESTRICTION BENEFIT WITH PA (HCPCS = EPBX) Q5105, Q5106); SEE PA GUIDELINES FOR DETAILS (RX042). MEDICAL 1/1/2020 HEMATINICS,OTHER RETACRIT 40000/ML INJECTIO VIAL ADDED TO FORMULARY COVERED UNDER MEDICAL (EPOETIN ALFA‐ N WITH PA RESTRICTION BENEFIT WITH PA (HCPCS = EPBX) Q5105, Q5106); SEE PA GUIDELINES FOR DETAILS (RX042). PHARMACY 1/1/2020 NARCOTIC BUPRENORPHINE‐ 2 MG‐ SUBLING FILM ADDED TO FORMULARY QL (12 FILMS PER DAY). WITHDRAWAL THERAPY NALOXONE 0.5MG UAL WITH QL RESTRICTION AGENTS PHARMACY 1/1/2020 NARCOTIC BUPRENORPHINE‐ 8 MG‐2 MG SUBLING FILM ADDED TO FORMULARY QL (3 FILMS PER DAY). WITHDRAWAL THERAPY NALOXONE UAL WITH QL RESTRICTION AGENTS PHARMACY 1/1/2020 NARCOTIC BUPRENORPHINE‐ 4MG‐1MG SUBLING FILM ADDED TO FORMULARY QL (6 FILMS PER DAY). WITHDRAWAL THERAPY NALOXONE UAL WITH QL RESTRICTION AGENTS PHARMACY 1/1/2020 NARCOTIC BUPRENORPHINE‐ 12 MG‐3 SUBLING FILM ADDED TO FORMULARY QL (2 FILMS PER DAY). WITHDRAWAL THERAPY NALOXONE MG UAL WITH QL RESTRICTION AGENTS MEDICAL 1/1/2020 NARCOTIC SUBLOCADE 300 MG/1.5 SUBCUT SOLER REMOVED PA COVERED UNDER MEDICAL WITHDRAWAL THERAPY (BUPRENORPHINE) ANE. SYR RESTRICTION BENEFIT. INDUCTION THERAPY AGENTS DOES NOT REQUIRE PA (HCPCS = Q9992). MAINTENANCE THERAPY REQUIRES A PA (HCPCS = Q9991). MEDICAL 1/1/2020 NARCOTIC BUPRENORPHINE‐ MULTIPLE ORAL ORAL REMOVED PA COVERED UNDER MEDICAL WITHDRAWAL NALOXONE RESTRICTION BENEFIT WITHOUT PA (HCPCS THERAPY AGENTS = (HCPCS = J0572, J0573, J0574, J0575). MEDICAL 1/1/2020 NARCOTIC BUPRENORPHINE 1 MG ORAL ORAL REMOVED PA COVERED UNDER MEDICAL WITHDRAWAL RESTRICTION BENEFIT WITHOUT PA (HCPCS THERAPY AGENTS = J0571).