Updates to your prescription benefits Effective January 1, 2015

Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount your covered employees pay when they fill a prescription. Please reference this chart to review the following updates. Most options listed are available in Tier 1, the lowest-cost option.

Medications moving to a lower-tier The following medications are moving to a lower tier, making them more affordable.

Therapeutic Use Medication Name Tier Placement

Cystinosis Cystagon Tier 3 to Tier 2

Invokana1 Tier 3 to Tier 2 Diabetes Tanzeum1 Tier 3 to Tier 2

Hereditary Angioedema Berinert Tier 3 to Tier 2

Inflammatory Humira Tier 3 to Tier 2 Conditions

Pain fentanyl patch (generic Duragesic) Tier 3 to Tier 2

1. Diabetic supplies and prescription medications may be subject to different cost share arrangements. Confirm these state mandates with your Oxford Account Manager.

Medications moving to a higher tier Medications may move from a lower tier to a higher tier when they are more costly and have available lower-cost options.

Therapeutic Use Medication Name Tier Placement Lower-Cost Options clindamycin phosphate clindamycin 1% solution (generic Cleocin Acne 1% (generic Cleocin T) Tier 1 to Tier 3 T), erythromycin 2% gel (generic Emgel, gel, lotion Erygel) Enjuvia Tier 2 to Tier 3 estradiol tablet (generic Estrace) Hormone Replacement Estrace cream Tier 2 to Tier 3 Vagifem, Estring doxycycline hyclate doxycycline monohydrate 50 mg or 100 capsule (generic Tier 1 to Tier 2 mg (generic Monodox) Morgidox) doxycycline hyclate doxycycline monohydrate 50 mg or 100 tablet (generic Tier 1 to Tier 2 Infections mg (generic Monodox) Vibramycin) doxycycline monohydrate 50 mg or 100 minocycline tablet mg (generic Monodox), doxycycline Tier 1 to Tier 3 (generic Dynacin) hyclate (generic Morgidox, Vibramycin), minocycline capsule (generic Minocin)

Medications moving to a higher tier – continued

Tier Therapeutic Use Medication Name Lower-Cost Options Placement doxycycline monohydrate 50 mg or 100 mg (generic tetracycline capsule Infections Tier 1 to Tier 3 Monodox), doxycycline hyclate (generic Morgidox, (generic Sumycin) Vibramycin), minocycline capsule (generic Minocin) Inflammatory Enbrel Tier 2 to Tier 3 Cimzia, Simponi, Stelara, Humira Conditions amcinonide 0.1% cream Tier 1 to Tier 3 triamcinolone 0.5% cream (generic Aristocort) (generic Cyclocort) amcinonide 0.1% lotion Tier 1 to Tier 3 betamethasone 0.05% lotion (generic Alphatrex) (generic Cyclocort) betamethasone dipropionate 0.05% Tier 1 to Tier 2 triamcinolone 0.5% cream (generic Aristocort) cream (generic Diprosone) betamethasone dipropionate 0.05% Tier 1 to Tier 2 fluocinonide 0.05% ointment (generic Lidex) ointment (generic Diprosone) bethamethasone dipropionate 0.05% betamethasone 0.05% augmented gel (generic Alphatrex), Tier 1 to Tier 3 augmented lotion clobetasol propionate 0.05% gel (generic Temovate) (generic Diprolene) bethamethasone dipropionate 0.05% clobetasol propionate 0.05% emollient ointment (generic Tier 1 to Tier 3 augmented ointment Temovate E) (generic Diprolene) desonide 0.05% cream alclometasone 0.05% cream (generic Aclovate), Tier 1 to Tier 3 (generic Desowen) triamcinolone 0.025% cream (generic Kenalog) desonide 0.05% lotion betamethasone valerate 0.1% lotion (generic Valisone), Tier 1 to Tier 3 (generic Desowen) triamcinolone 0.025% lotion (generic Kenalog) Skin Conditions desonide 0.05% prednicarbate 0.1% ointment (generic Dermatop), ointment (generic Tier 1 to Tier 3 triamcinolone 0.025% ointment (generic Kenalog) Desowen) desoximetasone gel Tier 1 to Tier 3 fluocinonide 0.05% solution (generic Lidex) (generic Topicort) desoximetasone ointment (generic Tier 1 to Tier 3 fluocinonide 0.05% ointment (generic Lidex) Topicort) diflorasone diacetate 0.05% ointment clobetasol propionate 0.05% emollient ointment (generic Tier 1 to Tier 3 (generic Apexicon, Temovate E) Florone) diflorasone diacetate betamethasone dipropionate 0.05% augmented cream cream 0.05% (generic Tier 1 to Tier 3 (generic Diprolene AF), fluocinonide 0.05% cream (generic Apexicon E) Lidex) fluocinolone 0.01% alclometasone 0.05% cream (generic Aclovate), Tier 1 to Tier 3 cream (generic Synalar) triamcinolone 0.025% cream (generic Kenalog) fluocinolone 0.01% oil alclometasone 0.05% cream (generic Aclovate), (generic Derma- Tier 1 to Tier 3 betamethasone valerate 0.1% lotion (generic Valisone), Smoothe/FS) triamcinolone 0.025% cream/lotion (generic Kenalog) fluocinolone 0.01% betamethasone valerate 0.1% lotion (generic Valisone), solution (generic Tier 1 to Tier 3 triamcinolone 0.025% lotion (generic Kenalog) Synalar) fluocinolone 0.025% betamethasone valerate 0.1% cream (generic Valisone), Tier 1 to Tier 3 cream (generic Synalar) prednicarbate 0.1% cream (generic Dermatop)

Medications moving to a higher tier – continued Tier Therapeutic Use Medication Name Lower-Cost Options Placement fluocinolone 0.025% prednicarbate 0.1% ointment (generic Dermatop), ointment (generic Tier 1 to Tier 3 triamcinolone 0.025% ointment (generic Kenalog) Synalar) fluticasone propionate 0.05% lotion (generic Tier 1 to Tier 3 triamcinolone acetonide 0.1% lotion (generic Kenalog) Cutivate) halobetasol propionate clobetasol propionate 0.05% emollient cream 0.05% cream (generic Tier 1 to Tier 3 (generic Temovate E) Ultravate) Skin Conditions halobetasol propionate clobetasol propionate 0.05% emollient ointment (generic 0.05% ointment Tier 1 to Tier 3 Temovate E) (generic Ultravate) hydrocortisone valerate fluticasone propionate 0.05% cream (generic Cutivate), 0.2% cream (generic Tier 1 to Tier 3 prednicarbate 0.1% cream (generic Dermatop) Westcort) hydrocortisone valerate prednicarbate 0.1% ointment (generic Dermatop), 0.2% ointment (generic Tier 1 to Tier 3 triamcinolone 0.025% ointment (generic Kenalog) Westcort)

Medications with new benefit coverage The following medications were previously not covered under most benefit plans and are now eligible for coverage.

Therapeutic Use Medication Name Tier Placement clindamycin 1.2%/benzoyl Acne peroxide 5% gel (generic Tier 3 Duac)2 Alzheimer's Disease Namenda XR2 Tier 3

Ulcers, Heartburn, and Reflux Prevacid Solutab2, * Tier 3

2. Precertification (sometimes referred to as preauthorization) is already required. * Covered for children under the age of 6 and precertification is required for members over the age of 6.

Medications no longer covered under most of our benefit plans3 When several medications work in the same way, we may choose to not cover the higher-cost option. The medications listed below will no longer be covered under many of our pharmacy benefit plans.

New Benefit Therapeutic Use Medication Name Lower Cost Options Coverage Skin Conditions SelRx Excluded3 selenium sulfide shampoo omeprazole (generic Prilosec), pantoprazole (generic Protonix), Nexium capsules Excluded3 rabeprazole (generic Aciphex), Dexilant, Nexium Suspension**, Ulcers, Heartburn, Prevacid SoluTab** and Reflux omeprazole (generic Prilosec), pantoprazole (generic Protonix), Prevacid capsules Excluded3 rabeprazole (generic Aciphex), Dexilant, Nexium Suspension*, Prevacid SoluTab*

3. In New Jersey, prescription drug products that include components available in over-the-counter form or equivalent are not covered under the pharmacy benefit plans; in New York, this includes non-FDA approved legend drugs, non-legend drugs and drugs available over-the-counter that do not require a prescription order or refill by federal or state law before being dispensed. Any prescription drug product that is therapeutically equivalent to an over-the-counter drug is not covered unless it is determined to be medically necessary. *Covered for children under the age of 6 and precertification is required for members over the age of 6.

Medications that require precertification (New York only) The medications listed below require your physician to provide additional prescribing information to determine if coverage is available. Sometimes this may mean that another medication will need to be tried first before a medication will be covered under your benefit.

Therapeutic Medication Name New Benefit Coverage Lower Cost Options Use Atralin Precertification4 tretinoin (generic Retin-A) clindamycin clindamycin solution (generic Cleocin T) plus OTC benzoyl 1%/benzoyl peroxide Precertification4 peroxide, clindamycin 1.2%/benzoyl peroxide 5% (generic 5% (generic Duac) BenzaClin) gel Fabior Precertification5 tretinoin (generic Retin-A), Tazorac gel Acne clindamycin solution (generic Cleocin T) plus OTC benzoyl Neuac 1.2%-5% Kit Precertification5 peroxide, clindamycin 1.2%/benzoyl peroxide 5% (generic Duac) Tretin-X 0.0375 Precertification4 tretinoin (generic Retin-A) cream Tretin-X 0.075 cream Precertification5 tretinoin (generic Retin-A) Tretin-X Kit Precertification4 tretinoin (generic Retin-A) Aubra, Aviane, Delyla, Falmina Lessina, Lutera, Orsythia, Falessa Kit Precertification5 Sronyx, (generics Alesse, Levlite) Gildess Fe, Junel Fe, Larin Fe, Microgestin Fe (branded Lo Minastrin FE Precertification5 generics for Loestrin Fe), Contraceptive Ortho Evra (Brand norelgestromin/ethinyl estradiol topical patch, Xulane (generic Precertification4 Only) Ortho Evra) Introvale, Jolessa, Quasense (generics for Seasonale); Quartette Precertification5 Amethia, Camrese, Daysee (generic for Seasonique); Amethia Lo, Camrese Lo (generic for LoSeasonique) Cough and chlorpheniramine/hydrocodone/pseudoephedrine (generic Zutripro (Brand Only) Precertification4 Cold Zutripro) Desvenlafaxine venlafaxine extended-release capsule (generic Effexor XR), Precertification5 (fumarate) Pristiq venlafaxine extended-release capsule (generic Effexor XR), Depression Khedezla Precertification5 Pristiq paroxetine (generic Paxil), paroxetine extended-release Pexeva Precertification4 (generic Paxil CR) Excessive Glycate Precertification5 glycopyrrolate (generic Robinul) Secretions ciclopirox (generic Loprox), econazole (generic Spectazole), Ertaczo Precertification4 ketoconazole (generic Nizoral), OTC Lamisil AT, Lotrimin, Lotrimin AF ciclopirox (generic Loprox), econazole (generic Spectazole), Luzu Precertification4 ketoconazole (generic Nizoral), OTC Lamisil AT, Lotrimin, Lotrimin AF ciclopirox (generic Loprox), econazole (generic Spectazole), Naftin 1% cream and Precertification4 ketoconazole (generic Nizoral), OTC Lamisil AT, Lotrimin, gel Fungal Lotrimin AF Infections ciclopirox (generic Loprox), econazole (generic Spectazole), Naftin 2% cream Precertification4 ketoconazole (generic Nizoral), OTC Lamisil AT, Lotrimin, Lotrimin AF ciclopirox (generic Loprox), econazole (generic Spectazole), Naftin 2% gel Precertification5 ketoconazole (generic Nizoral), OTC Lamisil AT, Lotrimin, Lotrimin AF nystatin/triamcinolone nystatin cream (generic Mycostatin) + triamcinolone 0.1% (generic Mycolog II) Precertification4 cream or ointment (generic Kenalog) cream & ointment

Medications that require precertification (New York only) – continued Therapeutic Medication Name New Benefit Coverage Lower Cost Options Use ciclopirox (generic Loprox), econazole (generic Spectazole), Fungal Oxistat Lotion Precertification4 ketoconazole (generic Nizoral), OTC Lamisil AT, Lotrimin, Infections Lotrimin Vusion Precertification4 nystatin cream (generic Mycostatin), OTC miconazole cream Micardis (Brand Only) Precertification4 losartan (generic Cozaar), telmisartan (generic Micardis) High Blood Pressure Micardis HCT (Brand losartan/hydrochlorothiazide (generic Hyzaar), Precertification4 Only) telmisartan/hydrochlorothiazide (generic Micardis HCT) Antara 43 mg, 130 mg (brand and Precertification4 fenofibrate 54 mg, 160 mg (generic Lofibra) generic) Antara 30 mg, 90 mg, Precertification5 fenofibrate 54 mg, 160 mg (generic Lofibra) (brand and generic) Fenoglide Precertification4 fenofibrate 54 mg, 160 mg (generic Lofibra) Fibricor 35 mg, 105 mg (brand and Precertification4 fenofibrate 54 mg, 160 mg (generic Lofibra) generic) High Lipofen (brand and Precertification4 fenofibrate 54 mg, 160 mg (generic Lofibra) Cholesterol generic) Lofibra 67 mg, 134 mg, 200 mg capsule Precertification4 fenofibrate 54 mg, 160 mg (generic Lofibra) (brand and generic) Lofibra 54 mg, 160 Precertification4 fenofibrate 54 mg, 160 mg (generic Lofibra) mg (Brand only) Lovaza (Brand Only) Precertification4 omega-3-acid ethyl esters (generic Lovaza), Vascepa

Triglide Precertification4 fenofibrate 54 mg, 160 mg (generic Lofibra) Viramune XR (Brand HIV Precertification4 nevirapine extended-release (generic Viramune XR) Only) Hormone Cenestin Precertification4 estradiol tablet (generic Estrace), Enjuvia, Premarin Replacement Avelox Tablet (Brand Precertification4 moxifloxacin tablets (generic Avelox) Only) Cipro Suspension Precertification4 ciprofloxacin oral suspension (generic Cipro Suspension) (Brand Only) Infections doxycycline 75 mg doxycycline hyclate (generic Morgidox, Vibramycin), capsule (generic Precertification4 doxycycline monohydrate 50 mg or 100 mg (generic Monodox) Monodox) Mepron Suspension Precertification4 atovaquone suspension (generic Mepron) (Brand Only) Osteoporosis Evista (Brand Only) Precertification4 raloxifene (generic Evista) Active-Pac with Precertification5 gabapentin (generic Neurontin) Gabapentin 300 morphine sulfate extended-release tablet (generic MS Contin), Avinza (Brand Only) Precertification4 morphine sulfate extended-release capsule (generic Avinza), Nucynta ER, Opana ER, Oxycontin Pain Duragesic Precertification4 fentanyl transdermal patch (generic Duragesic) Fioricet with Codeine 50 mg/325 mg/40 butalbital/acetaminophen/caffeine/codeine phosphate 50 Precertification4 mg/30 mg (Brand mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine) Only)

Medications that require precertification (New York only) – continued

Therapeutic Medication Name New Benefit Coverage Lower Cost Options Use Fioricet with Codeine 50 mg/300 mg/40 butalbital/acetaminophen/caffeine/codeine phosphate 50 Precertification5 mg/30 mg (brand and mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine) generic) diclofenac potassium (generic Cataflam), diclofenac sodium Pain Zorvolex Precertification5 (generic Voltaren), ibuprofen (generic Motrin), naproxen (generic Anaprox, Anaprox DS, Naprosyn) Phosphate Renvela tablets Precertification4 sevelamer carbonate (generic Renvela) Binder (Brand Only) betamethasone 0.05% augmented gel (generic Diprolene), Clobex Lotion (brand Precertification4 clobetasol 0.05% gel (generic Temovate), clobetasol 0.05% and generic) solution (generic Temovate) clobetasol 0.05% gel (generic Temovate), clobetasol 0.05% Clodan Kit Precertification5 lotion (generic Temovate) Cloderm (Brand clocortolone 0.1% cream (generic Cloderm), mometasone Precertification4 Only) furoate cream 0.1 % (generic Elocon) Neo-Synalar Kit Precertification5 fluocinolone cream (generic Lidex) plus OTC Neosporin

Noritate Precertification4 metronidazole 0.75% cream (generic Metrocream) Skin betamethasone 0.05% augmented gel (generic Diprolene), Conditions Olux foam (brand and Precertification4 clobetasol propionate 0.05% gel (generic Temovate), generic) clobetasol 0.05% solution (generic Temovate) betamethasone 0.05% augmented gel (generic Diprolene), Olux-E foam (brand Precertification4 clobetasol propionate 0.05% gel (generic Temovate), and generic) clobetasol 0.05% solution (generic Temovate) Taclonex Ointment Precertification4 betamethasone/calcipotriene ointment (generic Taclonex) (Brand Only) desoximetasone 0.05% gel (generic Topicort), fluocinolone Topicort spray Precertification5 0.05% solution (generic Lidex) Utopic Precertification5 urea 40% eszopiclone (generic Lunesta), zaleplon (generic Sonata), Sleep Lunesta (Brand Only) Precertification4 zolpidem (generic Ambien) Symptoms associated paroxetine (generic Paxil), paroxetine extended-release Brisdelle Precertification5 with (generic Paxil CR) menopause Transplant Astagraf XL Precertification5 tacrolimus (generic Prograf) omeprazole (generic Prilosec), pantoprazole (generic Aciphex Sprinkle Precertification5 Protonix), rabeprazole (generic Aciphex), Dexilant, Nexium Suspension*, Prevacid Solu-Tab* Ulcers, omeprazole (generic Prilosec), pantoprazole (generic Heartburn, Prilosec Suspension Precertification4 Protonix), rabeprazole (generic Aciphex), Dexilant, Nexium and Reflux Suspension*, Prevacid Solu-Tab* omeprazole (generic Prilosec), pantoprazole (generic Protonix Granules for Precertification4 Protonix), rabeprazole (generic Aciphex), Dexilant, Nexium Suspension Suspension*, Prevacid Solu-Tab*

Medications that require precertification (New York only) – continued

Therapeutic Medication Name New Benefit Coverage Lower Cost Options Use acyclovir capsule or tablet (generic Zovirax), famciclovir tablet Denavir Precertification4 Viral (generic Famvir), valacyclovir tablet (generic Valtrex) Infections acyclovir capsule or tablet (generic Zovirax), famciclovir tablet Zovirax cream Precertification4 (generic Famvir), valacyclovir tablet (generic Valtrex)

4. For impacted plans, these medications may also move to the highest tier (Tier 3). Please refer to additional coverage language to determine exclusion status. For New York, medications may be excluded unless medically necessary. 5. These medications were excluded at launch in New York (unless medically necessary) – precertification may already be in place. They are covered in New Jersey. *Covered for children under the age of 6 and precertification is required for members over the age of 6.

For more information Please contact your Oxford representative for more information or visit oxfordhealth.com.

©2014 Oxford Health Plans LLC. All rights reserved. UnitedHealthcare® Please note that not all PDL updates apply to all groups depending on and the dimensional U logo are registered marks owned by UnitedHealth state regulations, additional coverage and Summary Plan Descriptions Group, Inc. All branded medications are trademarks or registered (SPDs). Oxford HMO products are underwritten by Oxford Health Plans trademarks of their respective owners. Applies to Advantage PDL. (NY), Inc. and Oxford Health Plans (NJ), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc. NY and NJ Member 1/15 C1516-01 MS-14-523 Rev. 1