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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 EFFECTIVE 05/01/2020 Name Change Description albuterol sulfate 90 mcg hfa aer ad - Added to Tier 2 - QL Added: 48 / 30 DAYS

diazoxide 50 mg/ml oral susp - Added to Tier 5

esomeprazole magnesium 10 mg suspdr - Added to Tier 2 pkt - QL Added: 60 / 30 DAYS

esomeprazole magnesium 20 mg suspdr - Added to Tier 2 pkt - QL Added: 60 / 30 DAYS

esomeprazole magnesium 40 mg suspdr - Added to Tier 2 pkt - QL Added: 60 / 30 DAYS

HIZENTRA 1 GRAM/5 ML SYRINGE - Added to Tier 5 immune globulin,gamma (igg)/proline/iga 0 to 50 - PA Added: HIZENTRA (s) mcg/ml

HIZENTRA 2 GRAM/10 ML SYRINGE - Added to Tier 5 immune globulin,gamma (igg)/proline/iga 0 to 50 - PA Added: HIZENTRA (s) mcg/ml

HIZENTRA 4 GRAM/20 ML SYRINGE - Added to Tier 5 immune globulin,gamma (igg)/proline/iga 0 to 50 - PA Added: HIZENTRA (s) mcg/ml

INSULIN LISPRO JR 100 UNIT/ML - Added to Tier 3 lispro

INSULIN LISPRO MIX 75-25 KWKPN - Added to Tier 3 insulin lispro protamine and insulin lispro

PENTACEL VIAL KIT - Added to Tier 3 diphtheria,pertussis(acell),tetanus,polio/haemophil us b/pf PROMACTA 25 MG SUSPENSION PCKT - Added to Tier 5 eltrombopag olamine - PA Added: Promacta (s)

PROVENTIL HFA 90 MCG INHALER - Added to Tier 4 albuterol sulfate - QL Added: 13.4 / 30 DAYS

TERIPARATIDE 620 MCG/2.48 ML - Added to Tier 5 - PA Added: Teriparatide (s)

ULTRA FLO PEN NEEDLES 12MM 29G - Added to Tier 3 pen needle, diabetic - QL Added: 200 / 30 DAYS

ULTRA FLO SYR 0.3 ML 29GX1/2" - Added to Tier 3 syringe with needle,insulin,0.3 ml - QL Added: 200 / 30 DAYS

UNIFINE SAFECONTROL 30GX5/16" - Added to Tier 3 pen needle, diabetic disposable, safety - QL Added: 200 / 30 DAYS

VENTOLIN HFA 90 MCG INHALER - Added to Tier 3 albuterol sulfate - QL Added: 48 / 30 DAYS

XCOPRI 100 MG TABLET - Added to Tier 5 cenobamate - PA Added: Xcopri (s)

XCOPRI 12.5-25 MG TITRATION PK - Added to Tier 4 cenobamate - PA Added: Xcopri (s)

XCOPRI 150 MG TABLET - Added to Tier 5 cenobamate - PA Added: Xcopri (s)

XCOPRI 150-200 MG TITRATION PK - Added to Tier 5 cenobamate - PA Added: Xcopri (s)

XCOPRI 200 MG TABLET - Added to Tier 5 cenobamate - PA Added: Xcopri (s)

XCOPRI 250 MG DAILY DOSE PACK - Added to Tier 5 cenobamate - PA Added: Xcopri (s)

XCOPRI 350 MG DAILY DOSE PACK - Added to Tier 5 cenobamate - PA Added: Xcopri (s)

XCOPRI 50 MG TABLET - Added to Tier 5 cenobamate - PA Added: Xcopri (s)

XCOPRI 50-100 MG TITRATION PAK - Added to Tier 5 cenobamate - PA Added: Xcopri (s)

XOPENEX 0.31 MG/3 ML SOLUTION - Added to Tier 4 levalbuterol hcl - PA Added: Part D vs Part B - QL Added: 540 / 30 DAYS XOPENEX 0.63 MG/3 ML SOLUTION - Added to Tier 4 levalbuterol hcl - PA Added: Part D vs Part B - QL Added: 540 / 30 DAYS

XOPENEX 1.25 MG/3 ML SOLUTION - Added to Tier 4 levalbuterol hcl - QL Added: 270 / 30 DAYS - PA Added: Part D vs Part B

XOPENEX CONC 1.25 MG/0.5 ML - Added to Tier 4 levalbuterol hcl - PA Added: Part D vs Part B - QL Added: 90 / 30 DAYS

XOPENEX HFA 45 MCG INHALER - Added to Tier 4 levalbuterol tartrate - QL Added: 30 / 30 DAYS FORMULARY CHANGES EFFECTIVE 04/01/2020 Medication Name Change Description ABOUTTIME PEN NEEDLE 30G X 8MM - Added to Tier 3 pen needle, diabetic - QL Added: 200 / 30 DAYS

ABOUTTIME PEN NEEDLE 31G X 5MM - Added to Tier 3 pen needle, diabetic - QL Added: 200 / 30 DAYS

ABOUTTIME PEN NEEDLE 31G X 8MM - Added to Tier 3 pen needle, diabetic - QL Added: 200 / 30 DAYS

ABOUTTIME PEN NEEDLE 32G X 4MM - Added to Tier 3 pen needle, diabetic - QL Added: 200 / 30 DAYS azelastine/fluticasone 137-50 mcg - Added to Tier 4 spray/pump - QL Added: 23 / 30 DAYS

BAQSIMI 3 MG SPRAY ONE PACK - Added to Tier 3

BAQSIMI 3 MG SPRAY TWO PACK - Added to Tier 3 glucagon butalbital/acetaminophen 25mg-325mg - Added to Tier 5 tablet - PA Added: HRM - Butalbital carboplatin 10 mg/ml vial - Added to Tier 2 dapsone 7.5 % gel w/pump - Added to Tier 4 desog-e./e.estradiol 21-5 (28) - Added to Tier 2 tablet

EUTHYROX 100 MCG TABLET - Added to Tier 4 levothyroxine sodium EUTHYROX 112 MCG TABLET - Added to Tier 4 levothyroxine sodium

EUTHYROX 125 MCG TABLET - Added to Tier 4 levothyroxine sodium

EUTHYROX 137 MCG TABLET - Added to Tier 4 levothyroxine sodium

EUTHYROX 150 MCG TABLET - Added to Tier 4 levothyroxine sodium

EUTHYROX 175 MCG TABLET - Added to Tier 4 levothyroxine sodium

EUTHYROX 200 MCG TABLET - Added to Tier 4 levothyroxine sodium

EUTHYROX 25 MCG TABLET - Added to Tier 4 levothyroxine sodium

EUTHYROX 50 MCG TABLET - Added to Tier 4 levothyroxine sodium

EUTHYROX 75 MCG TABLET - Added to Tier 4 levothyroxine sodium

EUTHYROX 88 MCG TABLET - Added to Tier 4 levothyroxine sodium 0.25 mg tablet - Added to Tier 5 - PA Added: Zortress (s) everolimus 0.5 mg tablet - Added to Tier 5 - PA Added: Zortress (s) everolimus 0.75 mg tablet - Added to Tier 5 - PA Added: Zortress (s)

FLUOROPLEX 1% CREAM - Added to Tier 5 fluorouracil

GVOKE 0.5 MG/0.1 ML SYRINGE - Added to Tier 3 glucagon

GVOKE 1 MG/0.2 ML SYRINGE - Added to Tier 3 glucagon

IBRANCE 100 MG TABLET - Added to Tier 5 palbociclib - PA Added: Ibrance (s)

IBRANCE 125 MG TABLET - Added to Tier 5 palbociclib - PA Added: Ibrance (s) IBRANCE 75 MG TABLET - Added to Tier 5 palbociclib - PA Added: Ibrance (s) irinotecan hcl 300mg/15ml vial - Added to Tier 2 l-norgest/e.estradiol-e.estrad 100-20(84) - Added to Tier 2 tbdspk 3mo - QL Added: 91 / 91 DAYS l-norgest/e.estradiol-e.estrad 150-30(84) - Added to Tier 2 tbdspk 3mo - QL Added: 91 / 91 DAYS naproxen/esomeprazole mag 375mg- - Added to Tier 5 20mg tab ir dr - QL Added: 60 / 30 DAYS - PA Added: VIMOVO (s) naproxen/esomeprazole mag 500mg- - Added to Tier 5 20mg tab ir dr - QL Added: 60 / 30 DAYS - PA Added: VIMOVO (s)

NURTEC ODT 75 MG TABLET - Added to Tier 5 sulfate - PA Added: Nurtec (s) - QL Added: 8 / 30 OVER TIME oxycodone hcl/acetaminophen 2.5-300 - Added to Tier 5 mg tablet potassium phos,m-basic-d-basic - Added to Tier 2 3mmol/ml vial

PROCYSBI DR 300 MG GRANULE PKT - Added to Tier 5 cysteamine bitartrate - PA Added: Procysbi (s)

PROCYSBI DR 75 MG GRANULE PKT - Added to Tier 5 cysteamine bitartrate - PA Added: Procysbi (s) pyrimethamine 25 mg tablet - Added to Tier 5 - PA Added: DARAPRIM (s)

REYVOW 100 MG TABLET - Added to Tier 4 succinate - PA Added: Reyvow (s) - QL Added: 4 / 30 OVER TIME

REYVOW 50 MG TABLET - Added to Tier 4 lasmiditan succinate - PA Added: Reyvow (s) - QL Added: 4 / 30 OVER TIME

SARCLISA 100 MG/5 ML VIAL - Added to Tier 5 isatuximab-irfc - PA Added: Sarclisa (s)

SARCLISA 500 MG/25 ML VIAL - Added to Tier 5 isatuximab-irfc - PA Added: Sarclisa (s) triamcinolone acetonide 0.05 % oint. (g) - Added to Tier 4

UNIFINE SAFECONTROL 30GX3/16" - Added to Tier 3 pen needle, diabetic disposable, safety - QL Added: 200 / 30 DAYS

VANISHPOINT INS 1 ML 30GX3/16" - Added to Tier 3 syringe with needle, insulin, safety, 1 ml - QL Added: 200 / 30 DAYS ziprasidone mesylate fnl 20mg/1 vial - Added to Tier 2 - QL Added: 60 / 30 DAYS FORMULARY CHANGES EFFECTIVE 03/01/2020 Medication Name Change Description ASMANEX HFA 50 MCG INHALER - Added to Tier 4 mometasone furoate - QL Added: 13 / 30 DAYS

AYVAKIT 100 MG TABLET - Added to Tier 5 avapritinib

AYVAKIT 200 MG TABLET - Added to Tier 5 avapritinib

AYVAKIT 300 MG TABLET - Added to Tier 5 avapritinib butalb/acetaminophen/caffeine 50-325/15 - Added to Tier 5 solution - PA Added: HRM - Butalbital calcipotriene/betamethasone 0.005-.064 - Added to Tier 5 suspension

CAPLYTA 42 MG CAPSULE - Added to Tier 5 lumateperone tosylate - QL Added: 30 / 30 DAYS - ST Added: ATYPICAL ANTIPSYCHOTICS - SCORE diltiazem hcl 120 mg cap sa 24h - Added to Tier 2 diltiazem hcl 180 mg cap sa 24h - Added to Tier 2 diltiazem hcl 240 mg cap sa 24h - Added to Tier 2 diltiazem hcl 300 mg cap sa 24h - Added to Tier 2 diltiazem hcl 420 mg cap sa 24h - Added to Tier 2

DULERA 50 MCG-5 MCG INHALER - Added to Tier 4 mometasone furoate/formoterol fumarate - QL Added: 13 / 30 DAYS EASY TOUCH SAF PEN NDL 30G 5MM - Added to Tier 3 pen needle, diabetic, safety - QL Added: 200 / 30 DAYS ketorolac tromethamine 15.75 mg spray - Added to Tier 5 - QL Added: 5 / 30 OVER TIME

RIOMET ER 500 MG/5 ML SUSP - Added to Tier 4 metformin hcl

RYBELSUS 14 MG TABLET - Added to Tier 3 - QL Added: 30 / 30 DAYS

RYBELSUS 3 MG TABLET - Added to Tier 3 semaglutide - QL Added: 60 / 365 OVER TIME

RYBELSUS 7 MG TABLET - Added to Tier 3 semaglutide - QL Added: 30 / 30 DAYS

TAZVERIK 200 MG TABLET - Added to Tier 5 tazemetostat hydrobromide - PA Added: Tazverik (s)

TEPEZZA 500 MG VIAL - Added to Tier 5 teprotumumab-trbw - PA Added: Tepezza (s) tramadol hcl 100 mg tablet - Added to Tier 2 trientine hcl 250 mg capsule - Added to Tier 5 - PA Added: SYPRINE (s)

TRIKAFTA 100/50/75 MG-150 MG - Added to Tier 5 elexacaftor/tezacaftor/ivacaftor - QL Added: 84 / 28 DAYS - PA Added: Trikafta (s)

UBRELVY 100 MG TABLET - Added to Tier 5 ubrogepant

UBRELVY 50 MG TABLET - Added to Tier 5 ubrogepant

VALTOCO 10 MG NASAL SPRAY - Added to Tier 5 diazepam

VALTOCO 15 MG NASAL SPRAY - Added to Tier 5 diazepam

VALTOCO 20 MG NASAL SPRAY - Added to Tier 5 diazepam

VALTOCO 5 MG NASAL SPRAY - Added to Tier 5 diazepam XELJANZ XR 22 MG TABLET - Added to Tier 5 tofacitinib citrate - PA Added: XELJANZ (s) FORMULARY CHANGES EFFECTIVE 02/01/2020 Medication Name Change Description ADCETRIS 50 MG VIAL - Added to Tier 5 brentuximab vedotin - PA Added: Adcetris (s)

BRUKINSA 80 MG CAPSULE - Added to Tier 5 zanubrutinib - PA Added: Brukinsa (s) bupivacaine hcl/pf 2.5 mg/ml ampul - Added to Tier 4

DIVIGEL 1.25 MG GEL PACKET - Added to Tier 4 estradiol

ENHERTU 100 MG VIAL - Added to Tier 5 fam-trastuzumab deruxtecan-nxki - PA Added: Enhertu (s)

ESTROGEL 0.06% GEL - Added to Tier 4 estradiol

KRO PEN NEEDLE 4MM X 33G - Added to Tier 3 pen needle, diabetic - QL Added: 200 / 30 DAYS

NOVOLIN N 100 UNIT/ML FLEXPEN - Added to Tier 3 insulin nph human isophane

PADCEV 20 MG VIAL - Added to Tier 5 enfortumab vedotin-ejfv - PA Added: Padcev (s)

PADCEV 30 MG VIAL - Added to Tier 5 enfortumab vedotin-ejfv - PA Added: Padcev (s) penicillamine 250 mg tablet - Added to Tier 5 pentamidine isethionate 300 mg vial-neb - Added to Tier 2 - PA Added: Part D vs Part B prednisolone sodium phosphate 15 mg/5 - Added to Tier 2 ml solution

PURE COMFORT ALCOHOL 70% PADS - Added to Tier 3 alcohol antiseptic pads

PURE COMFORT PEN NDL 32G 4MM - Added to Tier 3 pen needle, diabetic - QL Added: 200 / 30 DAYS

PURE COMFORT PEN NDL 32G 5MM - Added to Tier 3 pen needle, diabetic - QL Added: 200 / 30 DAYS PURE COMFORT PEN NDL 32G 6MM - Added to Tier 3 pen needle, diabetic - QL Added: 200 / 30 DAYS

PURE COMFORT PEN NDL 32G 8MM - Added to Tier 3 pen needle, diabetic - QL Added: 200 / 30 DAYS

RELION NOVOLIN N U-100 FLEXPEN - Added to Tier 3 insulin nph human isophane

ULTIGUARD SAFE PACK 31GX1/4" - Added to Tier 3 pen needle, diabetic, remover and disposal unit - QL Added: 200 / 30 DAYS

ULTIGUARD SAFE PACK 31GX5/16" - Added to Tier 3 pen needle, diabetic, remover and disposal unit - QL Added: 200 / 30 DAYS

ULTIGUARD SAFE PACK 32GX1/4" - Added to Tier 3 pen needle, diabetic, remover and disposal unit - QL Added: 200 / 30 DAYS

QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, 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#: 20402 Last Update: 4/24/2020