2015 Medicare Part D Formulary Change We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorizations, quantity limits and/or step therapy restrictions on a drug (or move a drug to a higher cost-sharing tier), we will let you know of the change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration 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 and let you know.

The product changes noted below will be implemented on the Medicare Part D Plan: New Added Products: Effective 11/1/2015 Drug

Reason

Cost sharing**

Restrictions***

azithromycin 250 mg tablet (6 pack)

New Drug

Tier 1

DAKLINZA 30 MG TABLET

New Drug

Tier 4

PA

DAKLINZA 60 MG TABLET

New Drug

Tier 4

PA

EPIDUO FORTE 0.3 %-2.5 % TOPICAL GEL WITH PUMP

New Drug

Tier 3

PA

ethacrynate sodium 50 mg intravenous solution

New Drug

Tier 1

fenoprofen 400 mg capsule

New Drug

Tier 3

FINACEA 15 % TOPICAL FOAM

New Drug

Tier 3

ISORDIL 40 MG TABLET

New Drug

Tier 3

ISORDIL TITRADOSE 5 MG TABLET

New Drug

Tier 3

megestrol 625 mg/5 ml oral suspension

New Drug

Tier 1

naproxen sodium er 375 mg tablet,extended release 24hr mphase

New Drug

Tier 1

ORAVIG 50 MG BUCCAL TABLET

New Drug

Tier 3

OTREXUP (PF) 7.5 MG/0.4 ML SUBCUTANEOUS AUTOINJECTOR

New Drug

Tier 3

phenoxybenzamine 10 mg capsule

New Drug

Tier 1

PRALUENT PEN 150 MG/ML SUBCUTANEOUS PEN INJECTOR

New Drug

Tier 4

Updated: 11/2015

ST

ST

PA QL

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

Drug

Reason

Cost sharing**

Restrictions***

PRALUENT PEN 75 MG/ML SUBCUTANEOUS PEN INJECTOR

New Drug

Tier 4

PA QL

PRALUENT SYRINGE 150 MG/ML SUBCUTANEOUS PRALUENT SYRINGE 75 MG/ML SUBCUTANEOUS pramipexole er 3 mg tablet,extended release 24 hr pramipexole er 4.5 mg tablet,extended release 24 hr TECHNIVIE 12.5 MG-75 MG-50 MG TABLET tetrabenazine 12.5 mg tablet tetrabenazine 25 mg tablet thiotepa 15 mg solution for injection ZOVIRAX 800 MG TABLET

New Drug New Drug New Drug New Drug New Drug New Drug New Drug New Drug New Drug

Tier 4 Tier 4 Tier 1 Tier 1 Tier 4 Tier 1 Tier 1 Tier 4 Tier 3

PA QL PA QL

PA PA PA

Future Removed Products: Effective 11/1/2015 Drug

Reason

Alternative*

CRESEMBA 186 MG CAPSULE

Removed from Formulary

Please contact your doctor.

DEMADEX 100 MG TABLET

Removed from Formulary

Please contact your doctor.

FLAGYL ER 750 MG TABLET,EXTENDED RELEASE

Removed from Formulary

Please contact your doctor.

LOPRESSOR 5 MG/5 ML INTRAVENOUS SOLUTION

Removed from Formulary

Please contact your doctor.

PERCODAN 4.8355 MG-325 MG TABLET

Removed from Formulary

Please contact your doctor.

TEVETEN HCT 600 MG-25 MG TABLET

Removed from Formulary

Please contact your doctor.

VOLTAREN-XR 100 MG TABLET,EXTENDED RELEASE Removed from Formulary

Please contact your doctor.

ZIPSOR 25 MG CAPSULE

Please contact your doctor.

Removed from Formulary

Cost Sharing Tier Changes: There were no cost sharing tier changes this month New Added Products: Effective 10/1/2015 Drug

Reason

Cost sharing**

Restrictions***

ACTEMRA 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION

New Drug

Tier 4

PA

ACTEMRA 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION

New Drug

Tier 4

PA

AFREZZA 8 UNIT (60)/12 UNIT (30) CARTRIDGE WITH INHALATION DEVICE

New Drug

Tier 3

almotriptan malate 12.5 mg tablet

New Drug

Tier 1

QL

almotriptan malate 6.25 mg tablet

New Drug

Tier 1

QL

Updated: 11/2015

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

Drug

Reason

Cost sharing**

Restrictions***

aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase

New Drug

Tier 1

AVASTIN 25 MG/ML INTRAVENOUS SOLUTION (16 ML)

New Drug

Tier 2

bexarotene 75 mg capsule

New Drug

Tier 4

budesonide 1 mg/2 ml suspension for nebulization

New Drug

Tier 1

CLINDESSE 2 % VAGINAL CREAM,EXTENDED RELEASE

New Drug

Tier 3

CYRAMZA 10 MG/ML INTRAVENOUS SOLUTION

New Drug

Tier 4

PA

CYRAMZA 10 MG/ML INTRAVENOUS SOLUTION (50 ML)

New Drug

Tier 4

PA

ENTRESTO 24 MG-26 MG TABLET

New Drug

Tier 2

PA

ENTRESTO 49 MG-51 MG TABLET

New Drug

Tier 2

PA

ENTRESTO 97 MG-103 MG TABLET

New Drug

Tier 2

PA

fenofibrate 120 mg tablet

New Drug

Tier 3

ketoconazole 2 % topical foam

New Drug

Tier 1

KEYTRUDA 100 MG/4 ML (25 MG/ML) INTRAVENOUS SOLUTION

New Drug

Tier 4

KIMIDESS (28) 0.15 MG-0.02 MG (21)/0.01 MG (5) TABLET

New Drug

Tier 1

LAYOLIS FE 0.8 MG-25 MCG (24)/75 MG (4) CHEWABLE TABLET

New Drug

Tier 1

memantine 10 mg tablet

New Drug

Tier 1

PA

memantine 5 mg tablet

New Drug

Tier 1

PA

memantine 5 mg-10 mg tablets in a dose pack

New Drug

Tier 3

PA

MOXIFLOXACIN 400 MG/250 ML-SODIUM ACET,SULWATER INTRAVENOUS PIGGYBACK

New Drug

Tier 3

ORKAMBI 200 MG-125 MG TABLET

New Drug

Tier 4

pramipexole er 0.375 mg tablet,extended release 24 hr

New Drug

Tier 1

PSORCON 0.05 % TOPICAL CREAM

New Drug

Tier 3

pyridostigmine bromide er 180 mg tablet,extended release

New Drug

Tier 1

REXULTI 0.25 MG TABLET

New Drug

Tier 4

REXULTI 0.5 MG TABLET

New Drug

Tier 4

REXULTI 1 MG TABLET

New Drug

Tier 4

REXULTI 2 MG TABLET

New Drug

Tier 4

Updated: 11/2015

PA

PA ST

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

Drug

Reason

Cost sharing**

Restrictions***

REXULTI 3 MG TABLET

New Drug

Tier 4

REXULTI 4 MG TABLET

New Drug

Tier 4

sumatriptan 4 mg/0.5 ml subcutaneous cartridge (refill)

New Drug

Tier 1

QL

sumatriptan 6 mg/0.5 ml subcutaneous cartridge (refill)

New Drug

Tier 1

QL

sumatriptan 6 mg/0.5 ml subcutaneous pen injector (auto-injector)

New Drug

Tier 1

QL

VECAMYL 2.5 MG TABLET

New Drug

Tier 4

Future Removed Products: Effective 10/1/2015 Drug

Reason

Alternative*

APEXICON 0.05 % TOPICAL OINTMENT

Removed from Formulary

Please contact your doctor.

AVINZA 75 MG CAPSULE, EXTENDED RELEASE

Removed from Formulary

Please contact your doctor.

cefditoren pivoxil 200 mg tablet

Removed from Formulary

Please contact your doctor.

CORTISPORIN 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION

Removed from Formulary

Please contact your doctor.

ENJUVIA 0.625 MG TABLET

Removed from Formulary

Please contact your doctor.

ERBITUX 100 MG/50 ML INTRAVENOUS SOLUTION

Removed from Formulary

Please contact your doctor.

FACTIVE 320 MG TABLET

Removed from Formulary

Please contact your doctor.

foscarnet 24 mg/ml intravenous solution

Removed from Formulary

Please contact your doctor.

ISORDIL 40 MG TABLET

Removed from Formulary

Please contact your doctor.

ISORDIL TITRADOSE 5 MG TABLET

Removed from Formulary

Please contact your doctor.

KADCYLA 100 MG INTRAVENOUS SOLUTION

Removed from Formulary

Please contact your doctor.

LAC-HYDRIN 12 % LOTION

Removed from Formulary

Please contact your doctor.

ofloxacin 300 mg tablet

Removed from Formulary

Please contact your doctor.

OXECTA 5 MG TABLET,ORAL ONLY(NOT FEEDING TUBES)

Removed from Formulary

Please contact your doctor.

OXECTA 7.5 MG TABLET,ORAL ONLY(NOT FEEDING TUBES)

Removed from Formulary

Please contact your doctor.

PAMINE 2.5 MG TABLET

Removed from Formulary

Please contact your doctor.

PAMINE FORTE 5 MG TABLET

Removed from Formulary

Please contact your doctor.

ROXICET 5 MG-325 MG/5 ML ORAL SOLUTION

Removed from Formulary

Please contact your doctor.

SPECTRACEF 400 MG TABLET

Removed from Formulary

Please contact your doctor.

spinosad 0.9 % topical suspension

Removed from Formulary

Please contact your doctor.

Updated: 11/2015

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

Drug

Reason

Alternative*

SUCLEAR 210 GRAM-17.5 GRAM-3.13 GRAM ORAL SOLUTION & SOLN FOR RECONST

Removed from Formulary

Please contact your doctor.

TEKAMLO 150 MG-10 MG TABLET

Removed from Formulary

Please contact your doctor.

TEKAMLO 150 MG-5 MG TABLET

Removed from Formulary

Please contact your doctor.

TEKAMLO 300 MG-10 MG TABLET

Removed from Formulary

Please contact your doctor.

TEKAMLO 300 MG-5 MG TABLET

Removed from Formulary

Please contact your doctor.

TETANUS TOXOID,ADSORBED (PF) 5 LF UNIT/0.5 ML INTRAMUSCULAR SUSPENSION

Removed from Formulary

Please contact your doctor.

TEVETEN 600 MG TABLET

Removed from Formulary

Please contact your doctor.

TEVETEN HCT 600 MG-12.5 MG TABLET

Removed from Formulary

Please contact your doctor.

TRANXENE T-TAB 15 MG TABLET

Removed from Formulary

Please contact your doctor.

U-CORT 1 %-10 % TOPICAL CREAM

Removed from Formulary

Please contact your doctor.

VECTIBIX 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION

Removed from Formulary

Please contact your doctor.

YERVOY 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION

Removed from Formulary

Please contact your doctor.

Cost Sharing Tier Changes: There were no cost sharing tier changes this month. New Added Products: Effective 09/01/2015 Drug alosetron 0.5 mg tablet alosetron 1 mg tablet AVONEX 30 MCG/0.5 ML INTRAMUSCULAR PEN KIT BREO ELLIPTA 200 MCG-25 MCG/DOSE POWDER FOR INHALATION CEDAX 90 MG/5 ML ORAL SUSPENSION COSENTYX PEN 150 MG/ML SUBCUTANEOUS dexmethylphenidate er 20 mg capsule,extended release biphasic5050

Updated: 11/2015

Reason New Drug New Drug New Drug

Cost Sharing** Tier 4 Tier 4 Tier 4

New Drug

Tier 2

New Drug

Tier 3

New Drug

Tier 4

New Drug

Tier 1

Restrictions***

PA QL QL

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

doxycycline monohydrate 50 mg tablet duloxetine 40 mg capsule,delayed release ENBREL SURECLICK 50 MG/ML (0.98 ML) SUBCUTANEOUS PEN INJECTOR glatopa 20mg/ml subcutaneous syringe HUMALOG 100 UNIT/ML SUBCUTANEOUS CARTRIDGE HUMALOG KWIKPEN 100 UNIT/ML SUBCUTANEOUS HUMALOG KWIKPEN 200 UNIT/ML (3 ML) SUBCUTANEOUS HYPERRAB S/D (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION HYPERRAB S/D (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION (10 ML) IRENKA 40 MG CAPSULE,DELAYED RELEASE junel fe 24 1 mg-20 mcg (24)/75 mg (4) tablet k-tab 8 meq tablet, extended release KUVAN 500 MG ORAL POWDER PACKET l norgest&e estradiol-e estrad 0.15 mg-30 mcg (84)/10 mcg(7) tabs,3mos linezolid 600 mg tablet naftifine 1 % topical cream NOVOLOG PENFILL 100 UNIT/ML SUBCUTANEOUS CARTRIDGE NUTRILIPID 20 % INTRAVENOUS EMULSION PEGASYS PROCLICK 180 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR risedronate 30 mg tablet risedronate 35 mg tablet risedronate 35 mg tablet (12 pack) risedronate 5 mg tablet RITALIN LA 60 MG CAPSULE,EXTENDED RELEASE sildenafil 10 mg/12.5 ml intravenous solution SIMPONI 100 MG/ML

Updated: 11/2015

New Drug

Tier 1

ST

New Drug

Tier 1

ST

New Drug

Tier 4

PA QL

New Drug

Tier 4

PA QL

New Drug

Tier 2

New Drug

Tier 2

New Drug

Tier 2

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 1

New Drug New Drug

Tier 1 Tier 4

New Drug

Tier 1

New Drug New Drug New Drug

Tier 4 Tier 3 Tier 2

New Drug

Tier 3

PA

New Drug

Tier 4

QL

New Drug New Drug New Drug New Drug Formulary Addition New Drug

Tier 1 Tier 1 Tier 1 Tier 1 Tier 3

QL QL QL QL

Tier 4

PA

New Drug

Tier 4

PA

ST

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

SUBCUTANEOUS PEN INJECTOR SIMPONI 50 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR STIOLTO RESPIMAT 2.5 MCG-2.5 MCG/ACTUATION SOLUTION FOR INHALATION tramadol er 100 mg capsule 24h,extended release(25-75) tramadol er 200 mg capsule 24h,extended release(25-75) tramadol er 300 mg capsule 24 hr,extended release TRETIN-X 0.0375 % TOPICAL CREAM VARIZIG 125 UNIT/1.2 ML INTRAMUSCULAR SOLUTION zamicet 10 mg-325 mg/15 ml oral solution

New Drug

Tier 4

PA

New Drug

Tier 3

New Drug

Tier 3

QL

New Drug

Tier 3

QL

New Drug

Tier 3

QL

New Drug New Drug

Tier 3 Tier 4

PA

New Drug

Tier 1

QL

Removed Products: Effective 09/01/2015 Drug ABILIFY DISCMELT 10 MG DISINTEGRATING TABLET ABILIFY DISCMELT 15 MG DISINTEGRATING TABLET AVANDAMET 2 MG-500 MG TABLET AVANDAMET 4 MG-500 MG TABLET AVANDARYL 4 MG-1 MG TABLET AVANDARYL 4 MG-2 MG TABLET AVANDARYL 8 MG-4 MG TABLET AVINZA 120 MG CAPSULE, EXTENDED RELEASE AVINZA 30 MG CAPSULE, EXTENDED RELEASE AVINZA 45 MG CAPSULE, EXTENDED RELEASE AVINZA 60 MG CAPSULE, EXTENDED RELEASE AVINZA 90 MG CAPSULE, EXTENDED RELEASE DILAUDID (PF) 1 MG/ML INJECTION SOLUTION LAC-HYDRIN 12 % TOPICAL CREAM NAPROSYN 125 MG/5 ML ORAL

Updated: 11/2015

Reason Removed from Formulary

Alternative* Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary

Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary Removed from Formulary

Please contact your doctor. Please contact your doctor.

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

SUSPENSION PENNSAID 1.5 % TOPICAL DROPS VICTRELIS 200 MG CAPSULE

Removed from Formulary Removed from Formulary

Please contact your doctor. Please contact your doctor.

Cost Sharing Tier Changes: There were no cost sharing tier changes this month New Added Products: Effective 08/01/2015 Drug ABSORICA 25 MG CAPSULE ABSORICA 35 MG CAPSULE APTENSIO XR 10 MG CAPSULE,EXTENDED RELEASE SPRINKLE APTENSIO XR 15 MG CAPSULE,EXTENDED RELEASE SPRINKLE APTENSIO XR 20 MG CAPSULE,EXTENDED RELEASE SPRINKLE APTENSIO XR 30 MG CAPSULE,EXTENDED RELEASE SPRINKLE APTENSIO XR 40 MG CAPSULE,EXTENDED RELEASE SPRINKLE APTENSIO XR 50 MG CAPSULE,EXTENDED RELEASE SPRINKLE APTENSIO XR 60 MG CAPSULE,EXTENDED RELEASE SPRINKLE aripiprazole 10 mg tablet aripiprazole 15 mg tablet aripiprazole 2 mg tablet aripiprazole 20 mg tablet aripiprazole 30 mg tablet aripiprazole 5 mg tablet BERINERT 500 UNIT (10 ML) INTRAVENOUS KIT clozapine 150 mg disintegrating tablet

Updated: 11/2015

Reason New Drug New Drug New Drug

Cost Sharing** Tier 3 Tier 3 Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug New Drug New Drug New Drug New Drug New Drug New Drug

Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 1 Tier 4

New Drug

Tier 3

Restrictions***

QL QL QL QL QL QL

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

clozapine 200 mg disintegrating tablet CORLANOR 5 MG TABLET CORLANOR 7.5 MG TABLET CRESEMBA 186 MG CAPSULE CRESEMBA 372 MG INTRAVENOUS SOLUTION DDAVP 0.1 MG/ML (REFRIGERATE) NASAL SOLUTION doxycycline monohydrate 100 mg capsule doxycycline monohydrate 100 mg tablet doxycycline monohydrate 50 mg capsule epinephrine 0.3 mg/0.3 ml (1:1,000) injection,auto-injector FOSRENOL 1,000 MG ORAL POWDER PACKET FOSRENOL 750 MG ORAL POWDER PACKET JUXTAPID 30 MG CAPSULE JUXTAPID 40 MG CAPSULE JUXTAPID 60 MG CAPSULE metoclopramide 5 mg disintegrating tablet NEUPOGEN 300 MCG/ML INJECTION SOLUTION nitrofurantoin macrocrystal 100 mg capsule norethindrone acetate-ethinyl estradiol 0.5 mg-2.5 mcg tablet norethindrone acetate-ethinyl estradiol 1 mg-5 mcg tablet OCTAGAM 10 % INTRAVENOUS SOLUTION OCTAGAM 5 % INTRAVENOUS SOLUTION PROAIR RESPICLICK 90 MCG/ACTUATION BREATH ACTIVATED RASUVO (PF) 10 MG/0.2 ML SUBCUTANEOUS AUTO-INJECTOR RASUVO (PF) 12.5 MG/0.25 ML

Updated: 11/2015

New Drug

Tier 3

New Drug New Drug New Drug New Drug

Tier 2 Tier 2 Tier 4 Tier 4

New Drug

Tier 3

New Drug

Tier 1

ST

New Drug

Tier 1

ST

New Drug

Tier 1

ST

New Drug

Tier 1

QL

New Drug

Tier 3

New Drug

Tier 3

New Drug New Drug New Drug New Drug

Tier 4 Tier 4 Tier 4 Tier 1

LA LA LA

New Drug

Tier 4

PA

New Drug

Tier 1

New Drug

Tier 1

New Drug

Tier 1

New Drug

Tier 4

PA

New Drug

Tier 4

PA

New Drug

Tier 2

New Drug

Tier 3

New Drug

Tier 3

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

SUBCUTANEOUS AUTO-INJECTOR RASUVO (PF) 15 MG/0.3 ML SUBCUTANEOUS AUTO-INJECTOR RASUVO (PF) 17.5 MG/0.35 ML SUBCUTANEOUS AUTO-INJECTOR RASUVO (PF) 20 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR RASUVO (PF) 22.5 MG/0.45 ML SUBCUTANEOUS AUTO-INJECTOR RASUVO (PF) 25 MG/0.5 ML SUBCUTANEOUS AUTO-INJECTOR RASUVO (PF) 27.5 MG/0.55 ML SUBCUTANEOUS AUTO-INJECTOR RASUVO (PF) 30 MG/0.6 ML SUBCUTANEOUS AUTO-INJECTOR RASUVO (PF) 7.5 MG/0.15 ML SUBCUTANEOUS AUTO-INJECTOR REBIF REBIDOSE 22 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR REBIF REBIDOSE 44 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR REBIF REBIDOSE 8.8 MCG/0.2 ML-22 MCG/0.5 ML (6) SUBCUTANEOUS PEN INJ. risedronate 35 mg tablet,delayed release SAPHRIS (BLACK CHERRY) 2.5 MG SUBLINGUAL TABLET TIVORBEX 20 MG CAPSULE TIVORBEX 40 MG CAPSULE tolcapone 100 mg tablet ZOMACTON 10 MG SUBCUTANEOUS SOLUTION ZOMACTON 5 MG SUBCUTANEOUS SOLUTION

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 4

PA QL

New Drug

Tier 4

PA QL

New Drug

Tier 4

PA QL

New Drug

Tier 1

QL

New Drug

Tier 2

New Drug New Drug New Drug New Drug

Tier 3 Tier 3 Tier 4 Tier 4

ST ST

New Drug

Tier 4

PA

PA

Removed Products: Effective 08/01/2015 Drug ABILIFY 9.75 MG/1.3 ML INTRAMUSCULAR SOLUTION DORYX 150 MG TABLET,DELAYED RELEASE DORYX 200 MG TABLET,DELAYED

Updated: 11/2015

Reason Removed from Formulary

Alternative* Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

RELEASE KETODAN KIT 2 % TOPICAL COMBO PACK LUFYLLIN 200 MG TABLET NEXIUM 20 MG INTRAVENOUS SOLUTION quinidine sulfate er 300 mg tablet,extended release ROCEPHIN 1 GRAM SOLUTION FOR INJECTION ROXICET 5 MG-325 MG TABLET TEV-TROPIN 5 MG SUBCUTANEOUS SOLUTION TORSEMIDE 20 MG/2 ML (10 MG/ML) INTRAVENOUS SOLUTION VECAMYL 2.5 MG TABLET

Removed from Formulary

Please contact your doctor.

Removed from Formulary Removed from Formulary

Please contact your doctor. Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary Removed from Formulary

Please contact your doctor. Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Cost Sharing Tier Changes: There were no cost sharing tier changes this month

New Added Products: Effective 07/01/2015 Drug ARANESP 10 MCG/0.4 ML (IN POLYSORBATE) INJECTION SYRINGE bimatoprost 0.03 % eye drops cefixime 100 mg/5 ml oral suspension cefixime 200 mg/5 ml oral suspension FRAGMIN 25,000 ANTI-XA UNIT/ML SUBCUTANEOUS SOLUTION FRAGMIN 7,500 ANTI-XA UNIT/0.3 ML SUBCUTANEOUS SYRINGE JADENU 180 MG TABLET JADENU 360 MG TABLET JADENU 90 MG TABLET KALYDECO 50 MG ORAL GRANULES IN PACKET KALYDECO 75 MG ORAL GRANULES IN PACKET LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION levonorgestrel-ethinyl estradiol 0.1 mg20 mcg tablet

Updated: 11/2015

Reason Formulary Addition

Cost Sharing** Tier 2

New Drug New Drug New Drug New Drug

Tier 1 Tier 1 Tier 1 Tier 3

New Drug

Tier 4

New Drug New Drug New Drug New Drug

Tier 4 Tier 4 Tier 4 Tier 4

New Drug

Tier 4

New Drug

Tier 4

New Drug

Tier 1

Restrictions*** PA ST

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

levonorgestrel-ethinyl estradiol 90 mcg20 mcg tablet methylphenidate 10 mg chewable tablet methylphenidate 2.5 mg chewable tablet methylphenidate 5 mg chewable tablet NATPARA 100 MCG/DOSE SUBCUTANEOUS CARTRIDGE NATPARA 25 MCG/DOSE SUBCUTANEOUS CARTRIDGE NATPARA 50 MCG/DOSE SUBCUTANEOUS CARTRIDGE NATPARA 75 MCG/DOSE SUBCUTANEOUS CARTRIDGE norethin-ethinyl estradiol-iron 0.8 mg-25 mcg(24)/75 mg(4) chew tablet potassium chloride 20 meq/15 ml oral liquid potassium chloride 40 meq/15 ml oral liquid PRISTIQ 25 MG TABLET,EXTENDED RELEASE QUADRACEL (PF) 15 LF-48 MCG-5 LF UNIT/0.5 ML INTRAMUSCULAR SUSPENSION triamcinolone acetonide 0.147 mg/gram topical aerosol TUDORZA PRESSAIR 400 MCG/ACTUATION BREATH ACTIVATED (30 ACTUAT)

New Drug

Tier 1

New Drug New Drug New Drug New Drug

Tier 1 Tier 1 Tier 1 Tier 4

LA

New Drug

Tier 4

LA

New Drug

Tier 4

LA

New Drug

Tier 4

LA

New Drug

Tier 1

New Drug

Tier 1

New Drug

Tier 1

New Drug

Tier 2

New Drug

Tier 2

New Drug

Tier 1

ST

New Drug

Tier 3

QL

ST

Removed Products: Effective 07/01/2015 Drug

ABILIFY 1 MG/ML ORAL SOLUTION AMTURNIDE 150 MG-5 MG-12.5 MG TABLET AMTURNIDE 300 MG-10 MG-12.5 MG TABLET AMTURNIDE 300 MG-10 MG-25 MG TABLET AMTURNIDE 300 MG-5 MG-12.5 MG TABLET AMTURNIDE 300 MG-5 MG-25 MG TABLET ANDROXY 10 MG TABLET ANTARA 130 MG CAPSULE ANTARA 43 MG CAPSULE AVANDAMET 4 MG-1,000 MG TABLET

Updated: 11/2015

Reason

Alternative*

Removed from Formulary Removed from Formulary

Please contact your doctor. Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary

Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor.

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

CAMPRAL 333 MG TABLET,DELAYED RELEASE CEDAX 90 MG/5 ML ORAL SUSPENSION DDAVP 0.1 MG/ML (REFRIGERATE) NASAL SOLUTION DILACOR XR 240 MG CAPSULE, EXTENDED RELEASE FLONASE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION KADIAN 130 MG CAPSULE,EXTENDED RELEASE KADIAN 150 MG CAPSULE,EXTENDED RELEASE LUVOX CR 100 MG CAPSULE,EXTENDED RELEASE LUVOX CR 150 MG CAPSULE,EXTENDED RELEASE omega-3 acid ethyl esters 1 gram capsule OPTIVAR 0.05 % EYE DROPS pantoprazole 40 mg intravenous solution PEDI-DRI 100,000 UNIT/GRAM TOPICAL POWDER UNIRETIC 15 MG-12.5 MG TABLET UNIVASC 15 MG TABLET UNIVASC 7.5 MG TABLET

Removed from Formulary

Please contact your doctor.

Removed from Formulary Removed from Formulary

Please contact your doctor. Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary Removed from Formulary

Please contact your doctor. Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary Removed from Formulary Removed from Formulary

Please contact your doctor. Please contact your doctor. Please contact your doctor.

Cost Sharing Tier Changes: There were no cost sharing tier changes this month To see if your drug is on this list please refer to the tables below.

New Added Products: Effective 06/01/2015 Drug ADDERALL 7.5 MG TABLET ADRUCIL 500 MG/10 ML INTRAVENOUS SOLUTION ampicillin-sulbactam 1.5 gram intravenous solution ARANESP 10 MCG/0.4 ML (IN POLYSORBATE) INJECTION SYRINGE ASHLYNA 0.15 MG-30 MCG (84)/10

Updated: 11/2015

Reason New Drug

Cost Sharing** Tier 3

New Drug

Tier 1

New Drug

Tier 1

New Drug

Tier 4

New Drug

Tier 1

Restrictions***

PA

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

MCG(7) TABLETS,3 MONTH DOSE PACK BEXSERO (PF) 50MCG-50MCG50MCG-25MCG/0.5ML INTRAMUSCULAR SYRINGE BOTOX 200 UNIT INJECTION CEFEPIME 1 GRAM/50 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK CEFEPIME 2 GRAM/50 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK CHANTIX CONTINUING MONTH BOX 1 MG TABLET clobetasol 0.05 % topical spray CORMAX 0.05 % TOPICAL SOLUTION CRINONE 4 % VAGINAL GEL CRINONE 8 % VAGINAL GEL DAUNOXOME 2 MG/ML INTRAVENOUS SOLUTION desmopressin 0.1 mg/ml (refrigerate) nasal solution dihydroergotamine 0.5 mg/pump act. (4 mg/ml) nasal spray ELESTRIN 0.87 GRAM/ACTUATION (0.06%) TRANSDERMAL GEL PUMP FARYDAK 10 MG CAPSULE FARYDAK 15 MG CAPSULE FARYDAK 20 MG CAPSULE FENTANYL 37.5 MCG/HOUR TRANSDERMAL PATCH FENTANYL 62.5 MCG/HOUR TRANSDERMAL PATCH FENTANYL 87.5 MCG/HOUR TRANSDERMAL PATCH FLEBOGAMMA DIF 10 % INTRAVENOUS SOLUTION GAMMAKED 1 GRAM/10 ML (10 %) INJECTION SOLUTION ibandronate 3 mg/3 ml intravenous syringe ICLUSIG 45 MG TABLET LENVIMA 10 MG/DAY (10 MG [1]/DAY) CAPSULE

Updated: 11/2015

New Drug

Tier 2

New Drug

Tier 2

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 2

New Drug New Drug New Drug New Drug

Tier 1 Tier 1 Tier 3 Tier 3

New Drug

Tier 4

PA

ST ST PA

New Drug

Tier 1

New Drug

Tier 1

QL

New Drug

Tier 3

QL

New Drug New Drug New Drug

Tier 4 Tier 4 Tier 4

PA PA PA

New Drug

Tier 3

QL

New Drug

Tier 4

QL

New Drug

Tier 4

QL

New Drug

Tier 4

PA

New Drug

Tier 3

PA

New Drug

Tier 1

PA

New Drug

Tier 4

PA QL

New Drug

Tier 4

PA

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

LENVIMA 14 MG (10 MG[1]-4 MG[1])/DAY CAPSULE LENVIMA 20 MG/DAY (10 MG [2]/DAY) CAPSULE LENVIMA 24 MG (10 MG[2]-4 MG[1])/DAY CAPSULE LEVETIRACETAM 1,000 MG/100 ML IN SOD.CHLORIDE (ISO-OSM) IV PIGGYBACK LEVETIRACETAM 1,500 MG/100 ML IN SOD.CHLORIDE (ISO-OSM) IV PIGGYBACK LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK LOESTRIN 1.5/30 (21) 1.5 MG-30 MCG TABLET LOESTRIN 1/20 (21) 1 MG-20 MCG TABLET LOESTRIN FE 1.5/30 (28) 1.5 MG-30 MCG (21)/75 MG (7) TABLET LOESTRIN FE 1/20 (28) 1 MG-20 MCG (21)/75 MG (7) TABLET MIRCERA 200 MCG/0.3 ML INJECTION SYRINGE MOVANTIK 12.5 MG TABLET MOVANTIK 25 MG TABLET naproxen sodium er 500 mg tablet,extended release 24hr mphase NATESTO 5.5 MG/0.122 GRAM PER ACTUATION NASAL GEL PUMP NUVESSA 1.3 % VAGINAL GEL omega-3 acid ethyl esters 1 gram capsule ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SYRINGE OTEZLA STARTER 10 MG (4)-20 MG (4)-30 MG(47) TABLETS IN A DOSE PACK pramipexole er 0.75 mg tablet,extended release 24 hr pramipexole er 1.5 mg tablet,extended release 24 hr PRIFTIN 150 MG TABLET

Updated: 11/2015

New Drug

Tier 4

PA

New Drug

Tier 4

PA

New Drug

Tier 4

PA

New Drug

Tier 2

New Drug

Tier 2

New Drug

Tier 2

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug New Drug

Tier 2 Tier 2

New Drug

Tier 1

ST

New Drug

Tier 3

PA

New Drug

Tier 3

New Drug

Tier 1

New Drug

Tier 1

New Drug

Tier 4

New Drug

Tier 1

New Drug

Tier 1

New Drug

Tier 2

PA

PA

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

RELISTOR 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RELISTOR 8 MG/0.4 ML SUBCUTANEOUS SYRINGE SAIZEN 8.8 MG SUBCUTANEOUS SOLUTION TAZICEF 1 GRAM SOLUTION FOR INJECTION TAZICEF 2 GRAM SOLUTION FOR INJECTION TAZICEF 6 GRAM SOLUTION FOR INJECTION TENIVAC (PF) 5 LF UNIT-2 LF UNIT/0.5 ML INTRAMUSCULAR SYRINGE testosterone cypionate 200 mg/ml intramuscular oil TOUJEO SOLOSTAR 300 UNIT/ML (1.5 ML) SUBCUTANEOUS INSULIN PEN trandolapril 1 mg-verapamil er 240 mg tablet, immed & ext release 24hr trandolapril 2 mg-verapamil er 180 mg tablet, immed & ext release 24hr trandolapril 2 mg-verapamil er 240 mg tablet, immed & ext release 24hr trandolapril 4 mg-verapamil er 240 mg tablet, immed & ext release 24hr TYPHIM VI 25 MCG/0.5 ML INTRAMUSCULAR SYRINGE ZENATANE 30 MG CAPSULE ZYPREXA RELPREVV 210 MG INTRAMUSCULAR SUSPENSION

New Drug

Tier 2

New Drug

Tier 2

New Drug

Tier 4

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 2

New Drug

Tier 1

New Drug

Tier 2

New Drug

Tier 1

New Drug

Tier 1

New Drug

Tier 1

New Drug

Tier 1

New Drug

Tier 2

New Drug

Tier 1

New Drug

Tier 4

PA

LA

Removed Products: Effective 06/01/2015 Drug AKNE-MYCIN 2 % TOPICAL OINTMENT ARICEPT ODT 10 MG DISINTEGRATING TABLET ARICEPT ODT 5 MG DISINTEGRATING TABLET ASTELIN 137 MCG NASAL SPRAY AEROSOL AVANDARYL 4 MG-4 MG TABLET

Updated: 11/2015

Reason Removed from Formulary Removed from Formulary

Alternative* Please contact your doctor. Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

AVANDARYL 8 MG-2 MG TABLET CENESTIN 0.3 MG TABLET CENESTIN 0.45 MG TABLET CENESTIN 0.625 MG TABLET CENESTIN 0.9 MG TABLET DANTRIUM 100 MG CAPSULE FRAGMIN 7,500 ANTI-XA UNIT/0.3 ML SUBCUTANEOUS SYRINGE KADIAN 70 MG CAPSULE,EXTENDED RELEASE LO MINASTRIN FE 1 MG-10 MCG (24)/10 MCG (2) TABLET CHEW AND TABLET LOXITANE 5 MG CAPSULE mafenide 50 gram topical packet ORAPRED 15 MG/5 ML ORAL SOLUTION PURINETHOL 50 MG TABLET RAZADYNE 4 MG/ML ORAL SOLUTION REVIA 50 MG TABLET SANCTURA 20 MG TABLET SUPRAX 400 MG TABLET TARGRETIN 1 % TOPICAL GEL ULESFIA 5 % LOTION VOSOL-HC 1 %-2 % EAR DROPS ZAROXOLYN 2.5 MG TABLET ZAROXOLYN 5 MG TABLET ZEMPLAR 4 MCG CAPSULE

Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary

Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary

Please contact your doctor.

Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary

Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor.

Cost Sharing Tier Changes: Effective 06/01/2015 Drug

KERYDIN 5 % TOPICAL SOLUTION WITH APPLICATOR PAZEO 0.7% EYE DROPS

New Tier

Old Tier

2

3

2

3

Restrictions***

New Added Products: Effective 05/01/2015 Drug ABILIFY MAINTENA 300 MG SUSPENSION,EXTENDED REL.

Updated: 11/2015

Reason New Drug

Cost Sharing**

Restrictions***

Tier

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

INTRAMUSCULAR SYRINGE ABILIFY MAINTENA 400 MG SUSPENSION,EXTENDED REL. INTRAMUSCULAR SYRINGE BONIVA 150 MG TABLET

4 New Drug

Tier 4

New Drug

Tier 3

CARBIDOPA ER 23.75 MGLEVODOPA 95 MG CAPSULE,EXTENDED RELEASE (8 HOUR) CARBIDOPA ER 36.25 MGLEVODOPA 145 MG CAPSULE,EXTENDED RELEASE (8 HOUR) CARBIDOPA ER 48.75 MGLEVODOPA 195 MG CAPSULE,EXTENDED RELEASE (8 HOUR) CARBIDOPA ER 61.25 MGLEVODOPA 245 MG CAPSULE,EXTENDED RELEASE (8 HOUR) CEREBYX 500 MG PE/10 ML INJECTION SOLUTION COLY-MYCIN S 3.3 MG-3 MG-10 MG-0.5 MG/ML EAR DROPS,SUSPENSION CORTISPORIN-TC 3.3 MG-3 MG-10 MG-0.5 MG/ML EAR DROPS,SUSPENSION COSENTYX PEN (2 PENS) 300 MG (150 MG/ML) SUBCUTANEOUS DANTRIUM 25 MG CAPSULE

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 3

Formulary Addition

Tier 3

New Drug

Tier 3

New Drug

Tier 3

New Drug

Tier 4

New Drug

DANTRIUM 50 MG CAPSULE

New Drug

DELESTROGEN 10 MG/ML INTRAMUSCULAR OIL DELESTROGEN 20 MG/ML INTRAMUSCULAR OIL DELESTROGEN 40 MG/ML INTRAMUSCULAR OIL dexmethylphenidate er 10 mg capsule,extended release biphasic5050 DUOPA 4.63 MG-20 MG/ML SUSPENSION IN J-TUBE PUMP esomeprazole magnesium 20 mg

New Drug

Tier 3 Tier 3 Tier 3 Tier 3 Tier 3

Updated: 11/2015

New Drug New Drug New Drug

Tier 1

New Drug

Tier 3 Tier

New Drug

QL

PA QL

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

capsule,delayed release EVEKEO 10 MG TABLET

New Drug

EVEKEO 5 MG TABLET

New Drug

EVOTAZ 300 MG-150 MG TABLET

New Drug

GILDESS 24 FE 1 MG-20 MCG (24)/75 MG (4) TABLET GLEOSTINE 10 MG CAPSULE

New Drug

GLEOSTINE 100 MG CAPSULE

New Drug

GLEOSTINE 40 MG CAPSULE

New Drug

GLYXAMBI 10 MG-5 MG TABLET

New Drug

GLYXAMBI 25 MG-5 MG TABLET

New Drug

IBRANCE 100 MG CAPSULE

New Drug

IBRANCE 125 MG CAPSULE

New Drug

IBRANCE 75 MG CAPSULE

New Drug

lamotrigine 100 mg disintegrating tablet

New Drug

lamotrigine 200 mg disintegrating tablet

New Drug

lamotrigine 25 mg disintegrating tablet

New Drug

lamotrigine 50 mg disintegrating tablet

New Drug

LOPREEZA 0.5 MG-0.1 MG TABLET

New Drug

LOPREEZA 1 MG-0.5 MG TABLET

New Drug

PAZEO 0.7 % EYE DROPS

New Drug

PREZCOBIX 800 MG-150 MG TABLET

New Drug

QNASL 40 MCG/ACTUATION NASAL AEROSOL SPRAY RHEUMATREX 2.5 MG TABLETS IN A DOSE PACK (DOSE PACK 12)

New Drug New Drug

Tier 3

PA

RHEUMATREX 2.5 MG TABLETS IN A DOSE PACK (DOSE PACK 16)

New Drug

Tier 3

PA

Updated: 11/2015

New Drug

1 Tier 3 Tier 3 Tier 4 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 4 Tier 3

PA PA

ST ST PA PA PA

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

RHEUMATREX 2.5 MG TABLETS IN A DOSE PACK (DOSE PACK 20)

New Drug

Tier 3

PA

RHEUMATREX 2.5 MG TABLETS IN A DOSE PACK (DOSE PACK 8)

New Drug

PA

SIGNIFOR LAR 20 MG INTRAMUSCULAR SUSPENSION SIGNIFOR LAR 40 MG INTRAMUSCULAR SUSPENSION SIGNIFOR LAR 60 MG INTRAMUSCULAR SUSPENSION SOTYLIZE 5 MG/ML ORAL SOLUTION

New Drug

TRIANEX 0.05 % TOPICAL OINTMENT

New Drug

TRIOSTAT 10 MCG/ML INTRAVENOUS SOLUTION VITEKTA 150 MG TABLET

New Drug

VITEKTA 85 MG TABLET

New Drug

ZUBSOLV 8.6 MG-2.1 MG SUBLINGUAL TABLET

New Drug

Tier 3 Tier 4 Tier 4 Tier 4 Tier 2 Tier 1 Tier 3 Tier 4 Tier 4 Tier 2

New Drug New Drug New Drug

New Drug

ST

PA QL

New Added Products: Effective 04/01/2015 Drug ACTIQ 200 MCG LOZENGE ON A HANDLE APEXICON 0.05 % TOPICAL OINTMENT AVEED 750 MG/3 ML (250MG/ML) INTRAMUSCULAR SOLUTION CEREBYX 500 MG PE/10 ML INJECTION SOLUTION colchicine 0.6 mg capsule colchicine 0.6 mg tablet EMBEDA 20 MG-0.8 MG CAPSULE, EXTEND RELEASE, ORAL ONLY EMBEDA 30 MG-1.2 MG CAPSULE, EXTEND RELEASE, ORAL ONLY EMBEDA 50 MG-2 MG CAPSULE, EXTEND RELEASE, ORAL ONLY EMBEDA 60 MG-2.4 MG CAPSULE, EXTEND RELEASE, ORAL ONLY EMBEDA 80 MG-3.2 MG CAPSULE, EXTEND RELEASE, ORAL ONLY EMBEDA 100 MG-4 MG CAPSULE, EXTEND RELEASE, ORAL ONLY

Updated: 11/2015

Reason

Cost Sharing**

Restrictions**

Formulary Addition

Tier 4

PA QL

Formulary Addition

Tier 3

ST

Formulary Addition

Tier 3

Formulary Addition

Tier 4

Formulary Addition Formulary Addition

Tier 3 Tier 3

Formulary Addition

Tier 3

QL

Formulary Addition

Tier 3

QL

Formulary Addition

Tier 4

QL

Formulary Addition

Tier 4

QL

Formulary Addition

Tier 4

QL

Formulary Addition

Tier 4

QL

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

estradiol 0.025 mg/24 hr semiweekly transdermal patch estradiol 0.0375 mg/24 hr semiweekly transdermal patch estradiol 0.05 mg/24 hr semiweekly transdermal patch estradiol 0.075 mg/24 hr semiweekly transdermal patch estradiol 0.1 mg/24 hr semiweekly transdermal patch KAPVAY 0.1 MG TABLET,EXTENDED RELEASE lamivudine 10 mg/ml oral solution linezolid 600 mg/300 ml intravenous solution LYNPARZA 50 MG CAPSULE MACRODANTIN 50 MG CAPSULE NAMENDA 10 MG TABLET NAMENDA 5 MG TABLET NAMENDA TITRATION PAK 5 MG-10 MG TABLETS IN A DOSE PACK ONEXTON 1.2 % (1 % BASE)-3.75 % TOPICAL GEL OPDIVO 40 MG/4 ML INTRAVENOUS SOLUTION ORAPRED ODT 10 MG DISINTEGRATING TABLET PARICALCITOL 2 MCG/ML SOLUTION FOR HEMODIALYSIS PORT INJECTION REYATAZ 50 MG ORAL POWDER PACKET RUCONEST 2,100 UNIT INTRAVENOUS SOLUTION RYTARY 23.75 MG-95 MG CAPSULE,EXTENDED RELEASE RYTARY 36.25 MG-145 MG CAPSULE,EXTENDED RELEASE RYTARY 48.75 MG-195 MG CAPSULE,EXTENDED RELEASE RYTARY 61.25 MG-245 MG CAPSULE,EXTENDED RELEASE SAVAYSA 15 MG TABLET SAVAYSA 30 MG TABLET SAVAYSA 60 MG TABLET SOOLANTRA 1 % TOPICAL CREAM testosterone 1 % (25 mg/2.5 gram) transdermal gel packet TINDAMAX 500 MG TABLET

Updated: 11/2015

Formulary Addition

Tier 1

QL

Formulary Addition

Tier 1

QL

Formulary Addition

Tier 1

QL

Formulary Addition

Tier 1

QL

Formulary Addition

Tier 1

QL

Formulary Addition

Tier 3

Formulary Addition

Tier 1

Formulary Addition

Tier 4

Formulary Addition Formulary Addition Formulary Addition Formulary Addition

Tier 4 Tier 3 Tier 2 Tier 2

PA

Formulary Addition

Tier 2

PA

Formulary Addition

Tier 3

Formulary Addition

Tier 4

Formulary Addition

Tier 3

Formulary Addition

Tier 3

Formulary Addition

Tier 4

Formulary Addition

Tier 4

Formulary Addition

Tier 3

Formulary Addition

Tier 3

Formulary Addition

Tier 3

Formulary Addition

Tier 3

Formulary Addition Formulary Addition Formulary Addition Formulary Addition

Tier 3 Tier 3 Tier 3 Tier 3

Formulary Addition

Tier 3

Formulary Addition

Tier 3

PA PA

PA

PA

PA

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

VYVANSE 10 MG CAPSULE ZERBAXA 1.5 GRAM INTRAVENOUS SOLUTION ZUPLENZ 4 MG ORAL SOLUBLE FILM ZUPLENZ 8 MG ORAL SOLUBLE FILM

Formulary Addition

Tier 3

Formulary Addition

Tier 4

Formulary Addition Formulary Addition

Tier 3 Tier 3

PA PA

Removed Products: Effective 4/1/2015 Drug BIAXIN XL 500 MG TABLET,EXTENDED RELEASE BIAXIN XL PAK 500 MG TABLET,EXTENDED RELEASE BONIVA 150 MG TABLET COLY-MYCIN M PARENTERAL 150 MG SOLUTION FOR INJECTION COLY-MYCIN S 3.3 MG-3 MG-10 MG-0.5 MG/ML EAR DROPS,SUSPENSION CORTISPORIN-TC 3.3 MG-3 MG-10 MG-0.5 MG/ML EAR DROPS,SUSPENSION CRINONE 4 % VAGINAL GEL CRINONE 8 % VAGINAL GEL DANTRIUM 25 MG CAPSULE DANTRIUM 50 MG CAPSULE DELESTROGEN 10 MG/ML INTRAMUSCULAR OIL DELESTROGEN 20 MG/ML INTRAMUSCULAR OIL DELESTROGEN 40 MG/ML INTRAMUSCULAR OIL GLYCATE 1.5 MG TABLET LUFYLLIN 400 MG TABLET ofloxacin 200 mg tablet QVAR 80 MCG/ ACTUATION AEROSOL SANCTURA XR 60 MG CAPSULE,EXTENDED RELEASE VIVACTIL 10 MG TABLET VIVACTIL 5 MG TABLET ZAMICET 10 MG-325 MG/15 ML ORAL SOLUTION

Reason

Alternative*

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary Removed from Plan Formulary Removed from Plan Formulary Removed from Plan Formulary

Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary Removed from Plan Formulary Removed from Plan Formulary Removed from Plan Formulary

Please contact your doctor. Please contact your doctor. Please contact your doctor. Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary Removed from Plan Formulary

Please contact your doctor. Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Cost Sharing Tier Changes: Effective 4/1/2015 Drug ARNUITY ELLIPTA 100 MCG/ACTUATION ARNUITY ELLIPTA 200

Updated: 11/2015

New Tier

Old Tier

2

3

2

3

Restrictions***

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

MCG/ACTUATION RENVELA 800 MG TABLET RENVELA 2.4 GRAM POWDER IN PACKET RENVELA 0.8 GRAM POWDER IN PACKET

2

3

2

3

2

3

New Added Products: Effective 03/01/2015 Drug ADDERALL 5 MG TABLET AFREZZA 4 UNIT (30)/8 UNIT (60) CARTRIDGE WITH INHALATION DEVICE AFREZZA 4 UNIT (60)/8 UNIT (30) CARTRIDGE WITH INHALATION DEVICE AFREZZA 4 UNIT CARTRIDGE WITH INHALATION DEVICE AKYNZEO 300 MG-0.5 MG CAPSULE ALCAINE 0.5 % EYE DROPS AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS SOLUTION AMINOSYN-HBC 7% INTRAVENOUS SOLUTION AMINOSYN-RF 5.2 % INTRAVENOUS SOLUTION amlodipine 10 mg-valsartan 160 mg tablet amlodipine 10 mg-valsartan 160 mghydrochlorothiazide 12.5 mg tablet amlodipine 10 mg-valsartan 160 mghydrochlorothiazide 25 mg tablet amlodipine 10 mg-valsartan 320 mg tablet amlodipine 10 mg-valsartan 320 mghydrochlorothiazide 25 mg tablet amlodipine 5 mg-valsartan 160 mg tablet amlodipine 5 mg-valsartan 160 mghydrochlorothiazide 12.5 mg tablet amlodipine 5 mg-valsartan 160 mghydrochlorothiazide 25 mg tablet amlodipine 5 mg-valsartan 320 mg tablet ANDROGEL 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET

Updated: 11/2015

Reason

Cost Sharing**

Restrictions***

Formulary Addition

Tier 3

Formulary Addition

Tier 3

Formulary Addition

Tier 3

Formulary Addition

Tier 3

Formulary Addition Formulary Addition

Tier 4 Tier 3

PA

Formulary Addition

Tier 2

PA

Formulary Addition

Tier 2

PA

Formulary Addition

Tier 2

PA

Formulary Addition

Tier 1

ST

Formulary Addition

Tier 1

ST

Formulary Addition

Tier 1

ST

Formulary Addition

Tier 1

ST

Formulary Addition

Tier 1

ST

Formulary Addition

Tier 1

ST

Formulary Addition

Tier 1

ST

Formulary Addition

Tier 1

ST

Formulary Addition

Tier 1

ST

Formulary Addition

Tier 2

PA

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

Drug ANDROGEL 1.25 GRAM/ACTUATION (1%) TRANSDERMAL GEL PUMP ANDROGEL 1.62 % (20.25 MG/1.25 GRAM) TRANSDERMAL GEL PACKET ANDROGEL 1.62 % (40.5 MG/2.5 GRAM) TRANSDERMAL GEL PACKET ARNUITY ELLIPTA 100 MCG/ACTUATION POWDER FOR INHALATION ARNUITY ELLIPTA 200 MCG/ACTUATION POWDER FOR INHALATION ASMANEX HFA 100 MCG/ACTUATION AEROSOL INHALER ASMANEX HFA 200 MCG/ACTUATION AEROSOL INHALER atropine 1 % eye drops AUBRA 0.1 MG-20 MCG TABLET AURYXIA 210 MG IRON TABLET AVC VAGINAL 15 % CREAM BELEODAQ 500 MG INTRAVENOUS SOLUTION BELSOMRA 10 MG TABLET BELSOMRA 15 MG TABLET BELSOMRA 20 MG TABLET BELSOMRA 5 MG TABLET BENZACLIN 1 %-5 % TOPICAL GEL BUNAVAIL 2.1 MG-0.3 MG BUCCAL FILM BUNAVAIL 4.2 MG-0.7 MG BUCCAL FILM BUNAVAIL 6.3 MG-1 MG BUCCAL FILM BUTRANS 7.5 MCG/HOUR TRANSDERMAL PATCH BYDUREON 2 MG/0.65 ML SUBCUTANEOUS PEN INJECTOR celecoxib 100 mg capsule celecoxib 200 mg capsule celecoxib 400 mg capsule celecoxib 50 mg capsule CERDELGA 84 MG CAPSULE CIPRO XR 1,000 MG TABLET,EXTENDED RELEASE CIPRO XR 500 MG TABLET,EXTENDED RELEASE

Updated: 11/2015

Reason

Cost Sharing**

Restrictions***

Formulary Addition

Tier 2

PA

Formulary Addition

Tier 2

PA

Formulary Addition

Tier 2

PA

Formulary Addition

Tier 3

Formulary Addition

Tier 3

Formulary Addition

Tier 2

Formulary Addition

Tier 2

Formulary Addition Formulary Addition Formulary Addition Formulary Addition

Tier 1 Tier 1 Tier 4 Tier 3

Formulary Addition

Tier 4

Formulary Addition Formulary Addition Formulary Addition Formulary Addition Formulary Addition

Tier 3 Tier 3 Tier 3 Tier 3 Tier 3

ST ST ST ST

Formulary Addition

Tier 3

PA QL

Formulary Addition

Tier 3

PA QL

Formulary Addition

Tier 3

PA QL

Formulary Addition

Tier 2

QL

Formulary Addition

Tier 2

PA QL

Formulary Addition Formulary Addition Formulary Addition Formulary Addition Formulary Addition

Tier 1 Tier 1 Tier 1 Tier 1 Tier 4

Formulary Addition

Tier 3

Formulary Addition

Tier 3

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

Drug CLINDAGEL 1 % TOPICAL CLINIMIX E 4.25 % IN 10 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION CLODAN 0.05 % SHAMPOO CLORPRES 0.2 MG-15 MG TABLET clozapine 100 mg disintegrating tablet clozapine 12.5 mg disintegrating tablet clozapine 25 mg disintegrating tablet DALVANCE 500 MG INTRAVENOUS SOLUTION DEBLITANE 0.35 MG TABLET DELYLA (28) 0.1 MG-20 MCG TABLET desogestrel-e.estradiol 0.15 mg-0.02 mg(21)/e.estrad 0.01 mg(5) tablet DEXEDRINE 10 MG TABLET DEXEDRINE 5 MG TABLET dexmethylphenidate er 5 mg capsule,extended release biphasic50-50 DIGITEK 125 MCG TABLET DIGITEK 250 MCG TABLET DOXY-100 100 MG INTRAVENOUS SOLUTION DUAC 1.2 % (1 % BASE)-5 % TOPICAL GEL entecavir 0.5 mg tablet entecavir 1 mg tablet epinephrine 0.15 mg/0.15 ml (1:1,000) injection,auto-injector ESBRIET 267 MG CAPSULE EVOCLIN 1 % TOPICAL FOAM FALMINA (28) 0.1 MG-20 MCG TABLET fluorometholone 0.1 % eye drops,suspension fluorouracil 0.5 % topical cream FREAMINE HBC 6.9 % INTRAVENOUS SOLUTION furosemide 10 mg/ml injection syringe GARAMYCIN 0.3 % EYE DROPS GARDASIL (PF) 20MCG-40MCG40MCG-20MCG/0.5ML

Updated: 11/2015

Reason

Cost Sharing**

Restrictions***

Formulary Addition

Tier 3

Formulary Addition

Tier 3

PA

Formulary Addition Formulary Addition

Tier 1 Tier 1

ST

Formulary Addition

Tier 1

Formulary Addition

Tier 1

Formulary Addition

Tier 1

Formulary Addition

Tier 3

Formulary Addition Formulary Addition

Tier 1 Tier 1

Formulary Addition

Tier 1

Formulary Addition Formulary Addition

Tier 1 Tier 1

Formulary Addition

Tier 1

Formulary Addition Formulary Addition

Tier 1 Tier 1

Formulary Addition

Tier 1

Formulary Addition

Tier 3

Formulary Addition Formulary Addition

Tier 4 Tier 4

Formulary Addition

Tier 1

QL

Formulary Addition Formulary Addition

Tier 4 Tier 3

PA QL

Formulary Addition

Tier 1

Formulary Addition

Tier 1

Formulary Addition

Tier 4

Formulary Addition

Tier 3

Formulary Addition

Tier 1

Formulary Addition

Tier 1

Formulary Addition

Tier 2

PA

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

Drug INTRAMUSCULAR SYRINGE GARDASIL 9 (PF) 0.5 ML INTRAMUSCULAR SUSPENSION GARDASIL 9 (PF) 0.5 ML INTRAMUSCULAR SYRINGE GILDESS 1.5 MG-30 MCG TABLET HARVONI 90 MG-400 MG TABLET HETLIOZ 20 MG CAPSULE HUMIRA 10 MG/0.2 ML SUBCUTANEOUS SYRINGE KIT hydrocodone 2.5 mg-acetaminophen 325 mg tablet hydromorphone er 32 mg tablet,extended release 24 hr HYSINGLA ER 100 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE HYSINGLA ER 120 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE HYSINGLA ER 20 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE HYSINGLA ER 30 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE HYSINGLA ER 40 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE HYSINGLA ER 60 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE HYSINGLA ER 80 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE ICLUSIG 15 MG TABLET ILOTYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT INCRUSE ELLIPTA 62.5 MCG/ACTUATION POWDER FOR INHALATION INTRON A 18 MILLION UNIT (1 ML) SOLUTION FOR INJECTION INTRON A 50 MILLION UNIT (1 ML) SOLUTION FOR INJECTION INVOKAMET 150 MG-1,000 MG TABLET INVOKAMET 150 MG-500 MG TABLET INVOKAMET 50 MG-1,000 MG TABLET

Updated: 11/2015

Reason

Cost Sharing**

Restrictions***

Formulary Addition

Tier 2

Formulary Addition

Tier 2

Formulary Addition Formulary Addition Formulary Addition

Tier 1 Tier 4 Tier 4

PA QL

Formulary Addition

Tier 4

PA QL

Formulary Addition

Tier 1

QL

Formulary Addition

Tier 4

QL

Formulary Addition

Tier 4

QL

Formulary Addition

Tier 4

QL

Formulary Addition

Tier 3

QL

Formulary Addition

Tier 3

QL

Formulary Addition

Tier 3

QL

Formulary Addition

Tier 3

QL

Formulary Addition

Tier 4

QL

Formulary Addition

Tier 4

PA QL

Formulary Addition

Tier 3

Formulary Addition

Tier 3

Formulary Addition

Tier 4

Formulary Addition

Tier 4

Formulary Addition

Tier 2

QL

Formulary Addition

Tier 2

QL

Formulary Addition

Tier 2

QL

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

Drug INVOKAMET 50 MG-500 MG TABLET IPOL 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SYRINGE ivermectin 3 mg tablet JARDIANCE 10 MG TABLET JARDIANCE 25 MG TABLET KERYDIN 5 % TOPICAL SOLUTION WITH APPLICATOR KEYTRUDA 50 MG INTRAVENOUS SOLUTION LARIN 1.5/30 (21) 1.5 MG-30 MCG TABLET LOCOID 0.1 % LOTION LOCOID 0.1 % TOPICAL CREAM LOCOID 0.1 % TOPICAL OINTMENT LOCOID 0.1 % TOPICAL SOLUTION LOPRESSOR 100 MG TABLET MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION SOLUTION MINIVELLE 0.025 MG/24 HR TRANSDERMAL PATCH MINOCIN 100 MG CAPSULE MINOCIN 50 MG CAPSULE MINOCIN 75 MG CAPSULE MIRCERA 100 MCG/0.3 ML INJECTION SYRINGE MIRCERA 50 MCG/0.3 ML INJECTION SYRINGE MIRCERA 75 MCG/0.3 ML INJECTION SYRINGE MIRVASO 0.33 % TOPICAL GEL MORPHINE 10 MG/ML INTRAVENOUS SYRINGE MORPHINE 8 MG/ML INTRAVENOUS SYRINGE mycophenolate mofetil 200 mg/ml oral suspension NEO-SYNALAR 0.5 %-0.025 % TOPICAL CREAM NEUAC 1.2 % (1 % BASE)-5 % TOPICAL GEL NIKKI (28) 3 MG-20 MCG TABLET norethindrone 1 mg & eth. estradiol 20 mcg (24)-iron 75 mg (4) tablet NORLYROC 0.35 MG TABLET NORTHERA 100 MG CAPSULE

Updated: 11/2015

Reason

Cost Sharing**

Restrictions***

Formulary Addition

Tier 2

QL

Formulary Addition

Tier 2

Formulary Addition Formulary Addition Formulary Addition

Tier 1 Tier 3 Tier 3

Formulary Addition

Tier 3

Formulary Addition

Tier 4

Formulary Addition

Tier 1

Formulary Addition Formulary Addition Formulary Addition Formulary Addition Formulary Addition

Tier 3 Tier 3 Tier 3 Tier 3 Tier 3

Formulary Addition

Tier 1

Formulary Addition

Tier 3

Formulary Addition Formulary Addition Formulary Addition

Tier 3 Tier 3 Tier 3

ST ST ST

Formulary Addition

Tier 3

PA

Formulary Addition

Tier 3

PA

Formulary Addition

Tier 3

PA

Formulary Addition

Tier 3

Formulary Addition

Tier 3

QL

Formulary Addition

Tier 3

QL

Formulary Addition

Tier 4

PA

Formulary Addition

Tier 3

Formulary Addition

Tier 1

Formulary Addition

Tier 1

Formulary Addition

Tier 1

Formulary Addition Formulary Addition

Tier 1 Tier 4

QL QL

ST ST ST ST

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

Drug NORTHERA 200 MG CAPSULE NORTHERA 300 MG CAPSULE NUTRESTORE 5 GRAM ORAL POWDER PACKET NUTRILIPID 20 % INTRAVENOUS EMULSION NUVIGIL 200 MG TABLET OFEV 100 MG CAPSULE OFEV 150 MG CAPSULE olopatadine 0.6 % nasal spray oxycodone er 10 mg tablet,crush resistant,extended release 12 hr oxycodone er 20 mg tablet,crush resistant,extended release 12 hr oxycodone er 40 mg tablet,crush resistant,extended release 12 hr oxycodone er 80 mg tablet,crush resistant,extended release 12 hr PARICALCITOL 5 MCG/ML SOLUTION FOR HEMODIALYSIS PORT INJECTION PLEGRIDY 125 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR PLEGRIDY 125 MCG/0.5 ML SUBCUTANEOUS SYRINGE PLEGRIDY 63 MCG/0.5 ML-94 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR potassium chloride er 8 meq tablet,extended release potassium citrate er 15 meq (1,620 mg) tablet,extended release prednisolone 10 mg disintegrating tablet prednisolone 15 mg disintegrating tablet prednisolone 30 mg disintegrating tablet PROCTOSOL HC 2.5 % RECTAL CREAM PROCYSBI 25 MG CAPSULE,DELAYED RELEASE SPRINKLE PROCYSBI 75 MG CAPSULE,DELAYED RELEASE SPRINKLE proparacaine 0.5 % eye drops PURIXAN 20 MG/ML ORAL SUSPENSION

Updated: 11/2015

Reason

Cost Sharing**

Restrictions***

Formulary Addition Formulary Addition

Tier 4 Tier 4

Formulary Addition

Tier 3

Formulary Addition

Tier 3

PA

Formulary Addition Formulary Addition Formulary Addition Formulary Addition

Tier 3 Tier 4 Tier 4 Tier 1

PA PA QL PA QL QL

Formulary Addition

Tier 3

QL

Formulary Addition

Tier 3

QL

Formulary Addition

Tier 3

QL

Formulary Addition

Tier 4

QL

Formulary Addition

Tier 3

Formulary Addition

Tier 4

QL

Formulary Addition

Tier 4

QL

Formulary Addition

Tier 4

QL

Formulary Addition

Tier 1

Formulary Addition

Tier 1

Formulary Addition

Tier 1

PA

Formulary Addition

Tier 1

PA

Formulary Addition

Tier 1

PA

Formulary Addition

Tier 1

Formulary Addition

Tier 4

Formulary Addition

Tier 4

Formulary Addition

Tier 1

Formulary Addition

Tier 4

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

Drug QVAR 80mcg/actuation aerosol RECOMBIVAX HB (PF) 10 MCG/ML INTRAMUSCULAR SYRINGE RECOMBIVAX HB (PF) 5 MCG/0.5 ML INTRAMUSCULAR SYRINGE REVATIO 10 MG/ML ORAL SUSPENSION ROXICET 5 MG-325 MG TABLET SHAROBEL 0.35 MG TABLET sirolimus 1 mg tablet sirolimus 2 mg tablet SOMAVERT 25 MG SUBCUTANEOUS SOLUTION SOMAVERT 30 MG SUBCUTANEOUS SOLUTION SPIRIVA RESPIMAT 2.5 MCG/ACTUATION SOLUTION FOR INHALATION STRIVERDI RESPIMAT 2.5 MCG/ACTUATION SOLUTION FOR INHALATION SUMAVEL DOSEPRO 4 MG/0.5 ML SUBCUTANEOUS NEEDLE-FREE INJECTOR SUTENT 37.5 MG CAPSULE Symbicort 80-4.5mcg/actuation HFA aersosol inhaler tacrolimus 0.03 % topical ointment tacrolimus 0.1 % topical ointment TARINA FE 1 MG-20 MCG (21)/75 MG (7) TABLET testosterone 1 % (50 mg/5 gram) transdermal gel packet testosterone 1.25 gram/actuation (1%) transdermal gel pump testosterone 10 mg/0.5 gram/actuation transdermal gel pump testosterone 50 mg/5 gram (1 %) transdermal gel topiramate xr 100 mg capsule sprinkle,extended release 24 hr topiramate xr 150 mg capsule sprinkle,extended release 24 hr topiramate xr 200 mg capsule sprinkle,extended release 24 hr

Updated: 11/2015

Reason

Cost Sharing**

Restrictions***

Formulary Addition

Tier 2

QL

Formulary Addition

Tier 2

PA

Formulary Addition

Tier 2

PA

Formulary Addition

Tier 4

PA QL

Formulary Addition Formulary Addition Formulary Addition Formulary Addition

Tier 1 Tier 1 Tier 1 Tier 4

QL

Formulary Addition

Tier 4

Formulary Addition

Tier 4

Formulary Addition

Tier 2

Formulary Addition

Tier 3

Formulary Addition

Tier 3

Formulary Addition

Tier 4

PA QL

Formulary Addition

Tier 2

QL

Formulary Addition Formulary Addition

Tier 1 Tier 1

PA PA

Formulary Addition

Tier 1

Formulary Addition

Tier 3

PA

Formulary Addition

Tier 3

PA

Formulary Addition

Tier 3

PA

Formulary Addition

Tier 3

PA

Formulary Addition

Tier 3

PA

Formulary Addition

Tier 3

PA

Formulary Addition

Tier 3

PA

PA PA

QL

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

Drug topiramate xr 25 mg capsule sprinkle,extended release 24 hr topiramate xr 50 mg capsule sprinkle,extended release 24 hr TREANDA 45 MG/0.5 ML INTRAVENOUS SOLUTION tretinoin microspheres 0.04 % topical gel with pump tretinoin microspheres 0.1 % topical gel with pump TREZIX 16 MG-320.5 MG-30 MG CAPSULE TRIUMEQ 600 MG-50 MG-300 MG TABLET TRULICITY 0.75 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR TRULICITY 1.5 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR TRUMENBA 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE TYBOST 150 MG TABLET UCERIS 2 MG/ACTUATION RECTAL FOAM VALCHLOR 0.016 % TOPICAL GEL valganciclovir 450 mg tablet valsartan 160 mg tablet valsartan 320 mg tablet valsartan 40 mg tablet valsartan 80 mg tablet VAQTA (PF) 50 UNIT/ML INTRAMUSCULAR SUSPENSION VAQTA (PF) 50 UNIT/ML INTRAMUSCULAR SYRINGE VIEKIRA PAK 12.5 MG-75 MG-50 MG/250 MG TABLETS IN A DOSE PACK VOGELXO 1.25 GRAM/ACTUATION (1%) TRANSDERMAL GEL PUMP VOGELXO 50 MG/5 GRAM (1 %) TRANSDERMAL GEL VOSOL-HC 1 %-2 % EAR DROPS WYMZYA FE 0.4 MG-35 MCG (21)/75 MG (7) CHEWABLE TABLET XARELTO 15 MG (42)-20 MG (9) TABLETS IN A DOSE PACK XIGDUO XR 10 MG-1,000 MG

Updated: 11/2015

Reason

Cost Sharing**

Restrictions***

Formulary Addition

Tier 3

PA

Formulary Addition

Tier 3

PA

Formulary Addition

Tier 4

Formulary Addition

Tier 1

PA

Formulary Addition

Tier 1

PA

Formulary Addition

Tier 3

QL

Formulary Addition

Tier 4

Formulary Addition

Tier 3

PA QL

Formulary Addition

Tier 3

PA QL

Formulary Addition

Tier 2

Formulary Addition

Tier 3

Formulary Addition

Tier 3

Formulary Addition Formulary Addition Formulary Addition Formulary Addition Formulary Addition Formulary Addition

Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1

Formulary Addition

Tier 2

Formulary Addition

Tier 2

Formulary Addition

Tier 4

PA QL

Formulary Addition

Tier 3

PA

Formulary Addition

Tier 3

PA

Formulary Addition

Tier 3

Formulary Addition

Tier 1

Formulary Addition

Tier 2

Formulary Addition

Tier 3

ST ST ST ST

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

Drug TABLET,EXTENDED RELEASE XIGDUO XR 10 MG-500 MG TABLET,EXTENDED RELEASE XIGDUO XR 5 MG-1,000 MG TABLET,EXTENDED RELEASE XIGDUO XR 5 MG-500 MG TABLET,EXTENDED RELEASE ZENPEP 40,000-136,000-218,000 UNIT CAPSULE,DELAYED RELEASE ZOVIRAX 200 MG CAPSULE ZYDELIG 100 MG TABLET ZYDELIG 150 MG TABLET

Reason

Cost Sharing**

Formulary Addition

Tier 3

Formulary Addition

Tier 3

Formulary Addition

Tier 3

Formulary Addition

Tier 4

Formulary Addition Formulary Addition Formulary Addition

Tier 3 Tier 4 Tier 4

Restrictions***

PA PA

Removed Products: Effective 3/1/2015 Drug CARDENE SR 30 MG CAPSULE,EXTENDED RELEASE CARDENE SR 60 MG CAPSULE,EXTENDED RELEASE cefotaxime 10 gram solution for injection CLARINEX-D 24 HOUR 5 MG-240 MG TABLET,EXTENDED RELEASE cyclophosphamide 25 mg tablet cyclophosphamide 50 mg tablet DOCEFREZ 80 MG INTRAVENOUS SOLUTION erythromycin-sulfisoxazole 200 mg-600 mg/5 ml oral suspension ESTRASORB 2.5 MG/GRAM (1.74 GRAM) TRANSDERMAL EMULSION PACKET GRANISOL 1 MG/5 ML ORAL SOLUTION HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV HEPATASOL 8 % INTRAVENOUS SOLUTION INCIVEK 375 MG TABLET KAPVAY 0.1 MG TABLET,EXTENDED RELEASE lidocaine (pf) 10 mg/ml (1 %) injection solution MOXATAG 775 MG TABLET,EXTENDED RELEASE ORTHO EVRA 150 MCG-35 MCG/24 HR TRANSDERMAL PATCH PEPCID 40 MG TABLET PRIFTIN 150 MG TABLET Symbicort 80-4.5mcg/actuation HFA aersosol

Updated: 11/2015

Reason

Alternative*

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary Removed from Plan Formulary

Please contact your doctor. Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary Removed from Plan Formulary Removed from Plan Formulary

Please contact your doctor. Please contact your doctor. Please contact your doctor.

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

inhaler TIMENTIN 3.1 GRAM INTRAVENOUS SOLUTION UNIRETIC 7.5 MG-12.5 MG TABLET XYLOCAINE-MPF 10 MG/ML (1 %) INJECTION SOLUTION

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Removed from Plan Formulary

Please contact your doctor.

Cost Sharing Tier Changes: Effective 3/1/2015 Drug Duavee 0.45-20mg tablet enoxaparin 120mg/0.8 mL syringe enoxaparin 150mg/mL syringe Grastek 2,800BAU tablet ibandronate 3mg/3 mL solution Sandimmune 100mg/mL solution Zontivity 2.08mg tablet

New Tier 3

Old Tier 2

4 4 3 2 3 3

1 1 2 1 2 2

Restrictions***

PA PA

For more information about how these changes may affect your cost-sharing, such as copayments or coinsurance, or for more information about asking for an updated coverage determination or a formulary exception, please see the plan Evidence of Coverage. Alternative drugs are drugs in the same therapeutic category/class as the affected drug. Only your doctor can determine alternative drugs that are appropriate for you given the individualized nature of drug therapy. Please talk to your doctor about any changes or recommendations to your medical care and prescription drug therapy. Alternative drugs and additional information about formulary changes can be found on the plan formulary, *Indicates a restriction of Step Therapy, Prior Authorization or Quantity Limits may exist. [LA] = Limited Access, [PA] = Prior Authorization, [QL] = Quantity Limit, [ST] = Step Therapy HIP Health Plan of New York (HIP) is a Medicare Advantage organization with a Medicare contract. Group Health Incorporated (GHI) is a Medicare Advantage organization and a standalone prescription drug plan with a Medicare contract. HIP and GHI are EmblemHealth companies.

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

Updated: 11/2015

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

Beneficiaries must use network pharmacies to access their premium and/or copayment/coinsurance may change on January 1, 2016. This document includes EmblemHealth Medicare PDP partial formulary as of November 1, 2015. For a complete, updated formulary, please visit our Web site at http://www.emblemhealth.com/medicare or call the Customer Service number below: For alternative formats or language, please call Customer Service toll free at: EmblemHealth Medicare PDP: 1-800-585-5786, 24 hours a day, 7 days a week TTY/TDD users should call 1-800-899-2114, 24 hours a day, 7 days a week 15111 v17

Updated: 11/2015

Y0026_124336 Approved 01/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.