Medicare Part D 2017 Formulary Changes Service To Senior

Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization, quantity limits and/or step therapy restrictions 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. However, if the U.S. Food and Drug Administration (FDA) determines 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. The table below outlines changes made to our formulary throughout 2017. VERSION: 17 2017 FORMULARY ADDITIONS UPDATE AS OF APRIL 1, 2017: FORMULARY ID: 00017195

Formulary additions, reductions in preferred or tiered cost-sharing status, or removal of Utilization Management to an existing formulary drug

Description of Effective Date of Utilization Management Covered Drug Name Alternate Drug Name Change Change Tier Notes

AMIFOSTINE INJ 500MG AMIFOSTINE DELETION 4/1/2017 5 PA AMIODARONE TAB 100MG PACERONE ADDITION 4/1/2017 2 DOXYCYCL HYC INJ 100MG DOXY DELETION 4/1/2017 2 PA LOPIN/RITON SOL 80-20/ML KALETRA ADDITION 4/1/2017 2 QL (480 PER 30 DAYS) MENINGOCOCCAL POLYSACCHARIDE MENOMUNE INJ A/C/Y/W VACCINE DELETION 4/1/2017 4 ETHINYL ESTRADIOL AND NECON TAB 1/35 NORETHINDRONE DELETION 4/1/2017 1

8-MOP CAP 10MG METHOXSALEN DELETION 3/1/2017 3 PA ABACA/LAMIVU TAB 600-300 EPZICOM ADDITION 3/1/2017 2 QL (30 PER 30 DAYS)

QL = Quanity Limit, PA = Prior Authorization, ST = Step Therapy, 90 = Available for 90 days 1 Material ID#: H0545_FUY2010_197 Covered drug is indicated in bold. 3/31/2017 CMS Approval 6/29/2010 Description of Effective Date of Utilization Management Covered Drug Name Alternate Drug Name Change Change Tier Notes

A-HYDROCORT INJ 100MG CORTEF DELETION 3/1/2017 4 PA BUPROBAN TAB 150MG BUPROPION DELETION 3/1/2017 2 QL (90 PER 30 DAYS) HUMAN PAPILLOMAVIRUS (HPV) BIVALENT(TYPES CERVARIX INJ 16,18) RECMB VAC DELETION 3/1/2017 4 DOCEFREZ INJ 20MG DOCETAXEL DELETION 3/1/2017 5 PA ERGOMAR SUB 2MG ERGOTAMINE DELETION 3/1/2017 2 EZETIMIBE TAB 10MG ZETIA ADDITION 3/1/2017 2 QL (30 PER 30 DAYS) GENGRAF CAP 50MG NEORAL ADDITION 3/1/2017 4 PA QL (30 PER 30 DAYS), HUMALOG INJ 100/ML INSULIN LISPRO ADDITION 3/1/2017 6 (90) TIER QL (30 PER 30 DAYS), HUMALOG INJ 100/ML INSULIN LISPRO REDUCTION 3/1/2017 6 (90) QL (30 PER 30 DAYS), HUMALOG KWIK INJ 100/ML INSULIN LISPRO ADDITION 3/1/2017 6 (90) TIER KLOR-CON M20 TAB 20MEQ ER MICRO-K/KLOR-CON/K-TAB REDUCTION 3/1/2017 1 (90) KYPROLIS SOL 30MG CARFILZOMB ADDITION 3/1/2017 5 PA KYPROLIS SOL 60MG CARFILZOMB ADDITION 3/1/2017 5 PA LANTUS INJ SOLOSTAR INSULIN GLARGINE ADDITION 3/1/2017 4 QL (30 PER 30 DAYS) LARTRUVO INJ 10MG/ML OLARATUMAB ADDITION 3/1/2017 5 PA MENEST TAB 2.5MG ESTERIFIED ESTROGENS DELETION 3/1/2017 2

METHOTREXATE INJ 25MG/ML METHOTREXATE ADDITION 3/1/2017 1 PA NAPHAZOLINE SOL 0.1% OP NAPHAZOLINE DELETION 3/1/2017 1 PROCARDIA XL, ADALAT NIFEDICAL XL TAB 30MG CC DELETION 3/1/2017 2 PROCARDIA XL, ADALAT NIFEDICAL XL TAB 60MG CC DELETION 3/1/2017 2 QL = Quanity Limit, PA = Prior Authorization, ST = Step Therapy, 90 = Available for 90 days 2 Material ID#: H0545_FUY2010_197 Covered drug is indicated in bold. 3/31/2017 CMS Approval 6/29/2010 Description of Effective Date of Utilization Management Covered Drug Name Alternate Drug Name Change Change Tier Notes

NILUTAMIDE TAB 150MG NILANDRON ADDITION 3/1/2017 2 QL (30 PER 30 DAYS) RANITIDINE INJ 150/6ML ZANTAC DELETION 3/1/2017 2 PA RASAGILINE TAB 0.5MG AZILECT ADDITION 3/1/2017 4 RASAGILINE TAB 1MG AZILECT ADDITION 3/1/2017 4 QL (30 PER 30 DAYS), ROSUVASTATIN TAB 10MG CRESTOR ADDITION 3/1/2017 2 (90) QL (30 PER 30 DAYS), ROSUVASTATIN TAB 20MG CRESTOR ADDITION 3/1/2017 2 (90) QL (30 PER 30 DAYS), ROSUVASTATIN TAB 40MG CRESTOR ADDITION 3/1/2017 2 (90) QL (30 PER 30 DAYS), ROSUVASTATIN TAB 5MG CRESTOR ADDITION 3/1/2017 2 (90) RUBRACA TAB 200MG RUCAPARIB ADDITION 3/1/2017 5 PA RUBRACA TAB 300MG RUCAPARIB ADDITION 3/1/2017 5 PA

STAVUDINE SOL 1MG/ML ZERIT DELETION 3/1/2017 2 QL (2400 PER 30 DAYS) TRAVOPROST DRO 0.004% TRAVATAN DELETION 3/1/2017 2 TYZEKA TAB 600MG TELBIVUDINE DELETION 3/1/2017 5 PA VITEKTA TAB 150MG ELVITEGRAVIR DELETION 3/1/2017 5 QL (30 PER 30 DAYS) VITEKTA TAB 85MG ELVITEGRAVIR DELETION 3/1/2017 5 QL (30 PER 30 DAYS) XIIDRA DRO 5% LIFITEGRAST ADDITION 3/1/2017 4 QL (60 PER 30 DAYS) YONDELIS INJ 1MG TRABECTEDIN ADDITION 3/1/2017 5 PA

ZERIT SOL 1MG/ML STAVUDINE ADDITION 3/1/2017 4 QL (2400 PER 30 DAYS)

QL = Quanity Limit, PA = Prior Authorization, ST = Step Therapy, 90 = Available for 90 days 3 Material ID#: H0545_FUY2010_197 Covered drug is indicated in bold. 3/31/2017 CMS Approval 6/29/2010 Description of Effective Date of Utilization Management Covered Drug Name Alternate Drug Name Change Change Tier Notes

QL = Quanity Limit, PA = Prior Authorization, ST = Step Therapy, 90 = Available for 90 days 4 Material ID#: H0545_FUY2010_197 Covered drug is indicated in bold. 3/31/2017 CMS Approval 6/29/2010 Description of Effective Date of Utilization Management Covered Drug Name Alternate Drug Name Change Change Tier Notes

QL = Quanity Limit, PA = Prior Authorization, ST = Step Therapy, 90 = Available for 90 days 5 Material ID#: H0545_FUY2010_197 Covered drug is indicated in bold. 3/31/2017 CMS Approval 6/29/2010