Commercial Changes Starting December 1, 2016 A reference for providers Changes for your patients on insulin We carefully monitor our members’ benefits to make sure they have access to the they need. Medications such as insulin are becoming more expensive due to the rising prices charged by the drug manufacturers. To make sure that insulin stays affordable for our members, we’re changing the brands we cover and ask that you move your patients to a preferred rapid-acting and/or long-acting/basal insulin. We’ll cover alternatives that meet our quality standards and provide the same therapeutic outcome as your patients’ current . There’s also an exception process if it’s medically necessary for your patients to remain on their current medication. We’re providing a transition period from December 1, 2016, to February 28, 2017, to give you time to switch your patients to preferred products. Essential Prescription Formulary NON-FORMULARY MEDICATIONS ALTERNATIVE COVERED MEDICATIONS Afrezza® (inhaled ) Rapid-acting Apidra® () NovoLog® products () Humalog® products () Short- and Humulin® products* (regular insulin, insulin NPH) Novolin products Intermediate-acting ReliOn® Novolin® (regular insulin, insulin NPH) Basaglar® () Lantus® (insulin glargine) Levemir® () Long-acting/basal (>200 units of insulin per day, consider Toujeo® (insulin glargine) endocrinology consultation) Tresiba® () Humulin Mix (insulin NPH/regular insulin) Novolin Mix (isophane (NPH)/regular) ReliOn Novolin Mix Mix Insulin Humalog Mix (lispro protamine/lispro) NovoLog Mix (aspart protamine/aspart) NovoLog (insulin aspart) Ryzodeg® (insulin degludec/insulin aspart) + Lantus (insulin glargine) Select, Choice, and Metallic Formularies MEDICATIONS THAT REQUIRE A MEDICAL ALTERNATIVE COVERED MEDICATIONS NECESSITY PRIOR AUTHORIZATION (MNPA) Afrezza (inhaled regular insulin) Rapid-acting Apidra (insulin glulisine) NovoLog products (insulin aspart) Humalog products (insulin lispro) Short- and Humulin products* (regular insulin, insulin NPH) Novolin products Intermediate-acting ReliOn Novolin (regular insulin, insulin NPH) Basaglar (insulin glargine) Lantus (insulin glargine)-tier 1 Long-acting/basal Levemir (insulin detemir) Toujeo (insulin glargine)-tier 3 Tresiba (insulin degludec) Humulin Mix (insulin NPH/regular insulin) Novolin Mix (isophane (NPH)/regular) ReliOn Novolin Mix Mix Insulin Humalog Mix (lispro protamine/lispro) NovoLog Mix (aspart protamine/aspart) NovoLog (insulin aspart) Ryzodeg (insulin degludec/insulin aspart) + insulin glargine (Lantus-tier 1 or Toujeo-tier 3) *Except Humulin R U-500®.

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