FORMULARY CHANGES EFFECTIVE 11/01/2020

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Retiree RxCare may add or remove drugs from our formulary during the year. If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy restrictions to a drug and/or move a drug to a higher cost-sharing tier, we will notify you of the change at least 60 days before the date that the change becomes effective.

There are two exceptions to the 60-day advance member notification requirement:

1. If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary.

2. When the FDA approves a first time generic for a brand name drug, we may immediately allow a brand to generic substitution. Notification to the member will be made but can occur after the substitution is made.

FORMULARY CHANGES EFFECTIVE 11/01/2020

Medication Name Change Description

dimethyl fumarate 120-240 mg capsule dr - Added

- PA Added: TECFIDERA (s)

- QL Added: 120 / 365 OVER TIME doxycycline hyclate 80 mg tablet dr - Added

efavirenz/emtricit/tenofovr df 600-200mg tablet - Added - QL Added: 30 / 30 DAYS efavirenz/lamivu/tenofov disop 400-300 mg tablet - Added - QL Added: 30 / 30 DAYS efavirenz/lamivu/tenofov disop 600- 300mg tablet - Added - QL Added: 30 / 30 DAYS emtricitabine/tenofovir (tdf) 200-300 mg tablet - Added - QL Added: 30 / 30 DAYS fosfomycin tromethamine 3 g packet - Added

lapatinib ditosylate 250 mg tablet - Added

- PA Added: Tykerb (s) MENQUADFI VIAL

meningococcal vaccine a,c,y and w-135,conj tetanus toxoid/pf

- Added

metoclopramide hcl 10 mg tab rapdis - ST Added: Gimoti - Score metoclopramide hcl 10 mg tablet - ST Added: Gimoti - Score metoclopramide hcl 10 mg/10ml solution - ST Added: Gimoti - Score

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metoclopramide hcl 5 mg tab rapdis - ST Added: Gimoti - Score metoclopramide hcl 5 mg tablet - ST Added: Gimoti - Score metoclopramide hcl 5 mg/5 ml solution - ST Added: Gimoti - Score POLIVY 30 MG VIAL

polatuzumab vedotin-piiq

- Added

- PA Added: Polivy (s) TRELEGY ELLIPTA 200-62.5-25

fluticasone furoate/umeclidinium bromide/vilanterol trifenat

- Added

- QL Added: 60 BLISTERS (1 INHALER) / 30 DAYS

XYWAV 0.5 GM/ML ORAL SOLUTION sodium oxybate/calcium oxybate/magnesium oxybate/pot oxybate

- Added

- QL Added: 540 / 30 DAYS - PA Added: Xywav (s)

FORMULARY CHANGES EFFECTIVE 10/01/2020

cefepime hcl 100 g bulkbaginj - Added CYSTADROPS 0.37% EYE DROPS

cysteamine hcl

- Added

- QL Added: 20 ML / 28 DAYS - PA Added: Cystadrops (s) emtricitabine 200 mg capsule - Added

KESIMPTA 20 MG/0.4 ML PEN ofatumumab

- Added

- PA Added: Kesimpta (s) MYCAPSSA DR 20 MG CAPSULE

octreotide acetate - QL Removed: 112 / 28 DAYS ONUREG 200 MG TABLET azacitidine - Added - PA Added: Onureg (s) ONUREG 300 MG TABLET azacitidine - Added - PA Added: Onureg (s) peg3350/sod sul/nacl/kcl/asb/c 7.5-2.691g powd pack - Added

sapropterin dihydrochloride 100 mg powd pack

- Added

- PA Added: Kuvan (s) sapropterin dihydrochloride 100 mg tablet

sol

- Added

- PA Added: Kuvan (s) sapropterin dihydrochloride 500 mg powd

pack

- Added

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FORMULARY CHANGES EFFECTIVE 09/01/2020

BAFIERTAM DR 95 MG CAPSULE monomethyl fumarate - Added - QL Added: 120 / 30 DAYS - PA Added: Bafiertam (s) CYCLOPHOSPHAMIDE 1 GM/5 ML VL cyclophosphamide - Added CYCLOPHOSPHAMIDE 500 MG/2.5 ML cyclophosphamide - Added

deferasirox 180 mg gran pack - Added

- PA Added: DEFERASIROX (s) deferasirox 360 mg gran pack - Added

- PA Added: DEFERASIROX (s) deferasirox 90 mg gran pack - Added

- PA Added: DEFERASIROX (s) DOJOLVI LIQUID triheptanoin - Added - PA Added: Dojolvi (s) ENBREL 25 MG/0.5 ML VIAL etanercept - Added - PA Added: Enbrel (s)

everolimus 0.25 mg tablet - PA Change: Zortress (s) to Part D vs Part B

GEODON 20 MG/ML VIAL

ziprasidone mesylate - QL Removed: 60 / 30 DAYS ibuprofen 400 mg tablet - Added

metyrosine 250 mg capsule - Added MONJUVI 200 MG VIAL tafasitamab-cxix - Added - PA Added: Monjuvi (s) ORTIKOS ER 6 MG CAPSULE budesonide - Added ORTIKOS ER 9 MG CAPSULE budesonide - Added

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ziprasidone mesylate fnl 20mg/1 vial - QL Removed: 60 / 30 DAYS ZORTRESS 0.25 MG TABLET

everolimus - PA Change: Zortress (s) to Part D vs _{Part B} ZORTRESS 0.5 MG TABLET

everolimus - PA Change: Zortress (s) to Part D vs _{Part B} ZORTRESS 0.75 MG TABLET

everolimus - PA Change: Zortress (s) to Part D vs _{Part B} ZORTRESS 1 MG TABLET

everolimus - PA Change: Zortress (s) to Part D vs _{Part B}

FORMULARY CHANGES EFFECTIVE 08/01/2020

AKYNZEO 235-0.25 MG VIAL

fosnetupitant chloride hcl/palonosetron hcl - Added BYNFEZIA 2,500 MCG/ML PEN

octreotide acetate

- Added

- PA Added: Bynfezia (s) desonide 0.05 % gel (gram) - Added

DUPIXENT 300 MG/2 ML PEN dupilumab

- Added

- QL Added: 8 ML (4 PENS) / 28 DAYS - PA Added: DUPIXENT (s) FERRIPROX 1,000 MG TAB(2X/DAY) deferiprone - Added - PA Added: Ferriprox (s) FINTEPLA 2.2 MG/ML SOLUTION fenfluramine hcl - Added - PA Added: Fintepla (s) NEXLETOL 180 MG TABLET bempedoic acid - Added - QL Added: 30 / 30 DAYS - PA Added: Nexletol (s) PHESGO 1,200-600MG-30,000 UNIT pertuzumab-trastuzumab-hyaluronidase-zzxf - Added - PA Added: Phesgo (s) PHESGO 600-600 MG-20,000 UNIT pertuzumab-trastuzumab-hyaluronidase-zzxf - Added - PA Added: Phesgo (s) RUKOBIA ER 600 MG TABLET

fostemsavir tromethamine - Added SIRTURO 20 MG TABLET

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TIVICAY PD 5 MG TAB FOR SUSP

dolutegravir sodium - Added

UPLIZNA 100 MG/10 ML VIAL inebilizumab-cdon

- Added

- PA Added: Uplizna (s) XPOVIO 40 MG ONCE WEEKLY DOSE

selinexor

- Added

- PA Added: XPOVIO (s) XPOVIO 40 MG TWICE WEEKLY DOSE

selinexor

- Added

- PA Added: XPOVIO (s) XPOVIO 60 MG TWICE WEEKLY DOSE

selinexor - Added - PA Added: XPOVIO (s) ZEPZELCA 4 MG VIAL lurbinectedin - Added - PA Added: Zepzelca (s)

FORMULARY CHANGES EFFECTIVE 07/01/2020

DURYSTA 10 MCG IMPLANT

bimatoprost - Added

HARVONI 33.75-150 MG PELLET PK ledipasvir/sofosbuvir

- Added

- QL Added: 168 / 365 OVER TIME - PA Added: HARVONI (s)

HARVONI 45-200 MG PELLET PACKT ledipasvir/sofosbuvir

- Added

- QL Added: 336 / 365 OVER TIME - PA Added: HARVONI (s)

JYNARQUE 15 MG-15 MG TABLET

tolvaptan - Added

JYNARQUE 30 MG-15 MG TABLET

tolvaptan - Added

loperamide hcl 1mg/7.5ml liquid - Added metformin hcl 500 mg/5ml solution

- ST Added: DPP4 inhibitors - sCORE MVASI 100 MG/4 ML VIAL

bevacizumab-awwb - Added

MVASI 400 MG/16 ML VIAL

bevacizumab-awwb - Added

ORIAHNN 300-1-0.5MG/300MG CAPS elagolix sodium/estradiol/norethindrone acetate

- Added

- QL Added: 56 / 28 DAYS - PA Added: Oriahnn (s)

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oxycodone hcl/acetaminophen 10mg- 300mg tablet - Added oxycodone hcl/acetaminophen 5 mg- 300mg tablet - Added oxycodone hcl/acetaminophen 7.5-300 mg tablet - Added QINLOCK 50 MG TABLET ripretinib - Added - PA Added: Qinlock (s) RETEVMO 40 MG CAPSULE selpercatinib - Added - PA Added: Retevmo (s) RETEVMO 80 MG CAPSULE selpercatinib - Added - PA Added: Retevmo (s) RUXIENCE 100 MG/10 ML VIAL rituximab-pvvr - Added - PA Added: Ruxience (s) RUXIENCE 500 MG/50 ML VIAL rituximab-pvvr - Added - PA Added: Ruxience (s) TABRECTA 150 MG TABLET capmatinib hydrochloride - Added - PA Added: Tabrecta (s) TABRECTA 200 MG TABLET capmatinib hydrochloride - Added - QL Added: 120 / 30 DAYS - PA Added: Tabrecta (s) TRIJARDY XR 10-5-1,000 MG TAB empagliflozin/linagliptin/metformin hcl - Added - ST Added: SGLT2 DPP4 Combo Therapy - sCORE TRIJARDY XR 12.5-2.5-1,000 MG empagliflozin/linagliptin/metformin hcl - Added - ST Added: SGLT2 DPP4 Combo Therapy - sCORE TRIJARDY XR 25-5-1,000 MG TAB empagliflozin/linagliptin/metformin hcl - Added - ST Added: SGLT2 DPP4 Combo Therapy - sCORE TRIJARDY XR 5-2.5-1,000 MG TAB empagliflozin/linagliptin/metformin hcl - Added - ST Added: SGLT2 DPP4 Combo Therapy - sCORE ZEPOSIA 0.23-0.46 MG START PCK ozanimod hydrochloride - AddeD - PA Added: Zeposia (s)

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ZEPOSIA 0.23-0.46-0.92 MG KIT ozanimod hydrochloride - Added - PA Added: Zeposia (s) ZEPOSIA 0.92 MG CAPSULE ozanimod hydrochloride - Added - PA Added: Zeposia (s) - QL Added: 30 / 30 DAYS ZIRABEV 100 MG/4 ML VIAL bevacizumab-bvzr - Added - PA Added: Zirabev (s) ZIRABEV 400 MG/16 ML VIAL bevacizumab-bvzr - Added - PA Added: Zirabev (s)

FORMULARY CHANGES EFFECTIVE 06/01/2020

epinephrine 1 mg/ml vial - Added GVOKE HYPOPEN 0.5 MG/0.1 ML glucagon - Added GVOKE HYPOPEN 1 MG/0.2 ML glucagon - Added ISTURISA 1 MG TABLET osilodrostat phosphate - Added - PA Added: Isturisa (s) ISTURISA 10 MG TABLET osilodrostat phosphate - Added - PA Added: Isturisa (s) ISTURISA 5 MG TABLET osilodrostat phosphate - Added - PA Added: Isturisa (s) KOSELUGO 10 MG CAPSULE selumetinib sulfate/vitamin e tpgs - Added - PA Added: Koselugo (s) KOSELUGO 25 MG CAPSULE selumetinib sulfate/vitamin e tpgs - Added - PA Added: Koselugo (s) micafungin sodium 100 mg vial - Added

micafungin sodium 50 mg vial - Added NYMALIZE 60 MG/10 ML ORAL SYRN

nimodipine - Added ONTRUZANT 150 MG VIAL trastuzumab-dttb - Added - PA Added: Ontruzant (s) ONTRUZANT 420 MG VIAL trastuzumab-dttb - Added - PA Added: Ontruzant (s)

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PEMAZYRE 13.5 MG TABLET pemigatinib - Added - PA Added: Pemazyre (s) - QL Added: 30 / 30 DAYS PEMAZYRE 4.5 MG TABLET pemigatinib - Added - PA Added: Pemazyre (s) - QL Added: 30 / 30 DAYS PEMAZYRE 9 MG TABLET pemigatinib - Added - PA Added: Pemazyre (s) - QL Added: 30 / 30 DAYS ROMIDEPSIN 27.5 MG/5.5 ML VIAL romidepsin - Added - PA Added: Istodax (s) thiotepa 100 mg vial - Added

TRODELVY 180 MG VIAL sacituzumab govitecan-hziy - Added - PA Added: Trodelvy (s) TUKYSA 150 MG TABLET tucatinib - Added - PA Added: Tukysa (s) TUKYSA 50 MG TABLET tucatinib - Added - PA Added: Tukysa (s)

FORMULARY CHANGES EFFECTIVE 05/01/2020

albuterol sulfate 90 mcg hfa aer ad - Added

- QL Added: 48 / 30 DAYS diazoxide 50 mg/ml oral susp - Added

esomeprazole magnesium 10 mg suspdr pkt

- Added

- QL Added: 60 / 30 DAYS esomeprazole magnesium 20 mg suspdr

pkt

- Added

- QL Added: 60 / 30 DAYS esomeprazole magnesium 40 mg suspdr

pkt

- Added

- QL Added: 60 / 30 DAYS HIZENTRA 1 GRAM/5 ML SYRINGE

immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml

- Added

- PA Added: HIZENTRA (s) HIZENTRA 2 GRAM/10 ML SYRINGE

immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml

- Added

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HIZENTRA 4 GRAM/20 ML SYRINGE immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml

- Added

- PA Added: HIZENTRA (s) INSULIN LISPRO JR 100 UNIT/ML

insulin lispro - Added

INSULIN LISPRO MIX 75-25 KWKPN

insulin lispro protamine and insulin lispro - Added PENTACEL VIAL KIT

diphtheria,pertussis(acell),tetanus,polio/haemophil us b/pf - Added PROMACTA 25 MG SUSPENSION PCKT eltrombopag olamine - Added - PA Added: Promacta (s) PROVENTIL HFA 90 MCG INHALER

albuterol sulfate - Added - QL Added: 13.4 / 30 DAYS TERIPARATIDE 620 MCG/2.48 ML teriparatide - Added - PA Added: Teriparatide (s) ULTRA FLO PEN NEEDLES 12MM 29G

pen needle, diabetic

- Added

- QL Added: 200 / 30 DAYS ULTRA FLO SYR 0.3 ML 29GX1/2"

syringe with needle,insulin,0.3 ml

- Added

- QL Added: 200 / 30 DAYS UNIFINE SAFECONTROL 30GX5/16"

pen needle, diabetic disposable, safety

- Added

- QL Added: 200 / 30 DAYS VENTOLIN HFA 90 MCG INHALER

albuterol sulfate - Added - QL Added: 48 / 30 DAYS XCOPRI 100 MG TABLET cenobamate - Added - PA Added: Xcopri (s) XCOPRI 12.5-25 MG TITRATION PK cenobamate - Added - PA Added: Xcopri (s) XCOPRI 150 MG TABLET cenobamate - Added to Tier 4 - PA Added: Xcopri (s) XCOPRI 150-200 MG TITRATION PK cenobamate - Added - PA Added: Xcopri (s) XCOPRI 200 MG TABLET cenobamate - Added - PA Added: Xcopri (s) XCOPRI 250 MG DAILY DOSE PACK

cenobamate

- Added

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XCOPRI 350 MG DAILY DOSE PACK cenobamate - Added - PA Added: Xcopri (s) XCOPRI 50 MG TABLET cenobamate - Added - PA Added: Xcopri (s) XCOPRI 50-100 MG TITRATION PAK

cenobamate - Added - PA Added: Xcopri (s) XOPENEX 0.31 MG/3 ML SOLUTION levalbuterol hcl - Added

- PA Added: Part D vs Part B - QL Added: 540 / 30 DAYS XOPENEX 0.63 MG/3 ML SOLUTION

levalbuterol hcl

- Added

- PA Added: Part D vs Part B - QL Added: 540 / 30 DAYS XOPENEX 1.25 MG/3 ML SOLUTION

levalbuterol hcl

- Added

- QL Added: 270 / 30 DAYS - PA Added: Part D vs Part B XOPENEX CONC 1.25 MG/0.5 ML

levalbuterol hcl

- Added

- PA Added: Part D vs Part B - QL Added: 90 / 30 DAYS XOPENEX HFA 45 MCG INHALER

levalbuterol tartrate

- Added

- QL Added: 30 / 30 DAYS

FORMULARY CHANGES EFFECTIVE 04/01/2020

ABOUTTIME PEN NEEDLE 30G X 8MM pen needle, diabetic

- Added

- QL Added: 200 / 30 DAYS ABOUTTIME PEN NEEDLE 31G X 5MM

- Added

- Added - QL Added: 200 / 30 DAYS azelastine/fluticasone 137-50 mcg spray/pump - Added - QL Added: 23 / 30 DAYS BAQSIMI 3 MG SPRAY ONE PACK

glucagon - Added

BAQSIMI 3 MG SPRAY TWO PACK

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butalbital/acetaminophen 25mg-325mg tablet

- Added

- PA Added: HRM - Butalbital carboplatin 10 mg/ml vial - Added

dapsone 7.5 % gel w/pump - Added desog-e.estradiol/e.estradiol 21-5 (28)

tablet

- Added

EUTHYROX 100 MCG TABLET

levothyroxine sodium - Added

everolimus 0.25 mg tablet - Added

- PA Added: Zortress (s) everolimus 0.5 mg tablet - Added

- PA Added: Zortress (s) everolimus 0.75 mg tablet - Added

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FLUOROPLEX 1% CREAM fluorouracil - Added GVOKE 0.5 MG/0.1 ML SYRINGE glucagon - Added GVOKE 1 MG/0.2 ML SYRINGE glucagon - Added IBRANCE 100 MG TABLET palbociclib - Added - PA Added: Ibrance (s) IBRANCE 125 MG TABLET palbociclib - Added - PA Added: Ibrance (s) IBRANCE 75 MG TABLET palbociclib - Added - PA Added: Ibrance (s) irinotecan hcl 300mg/15ml vial - Added

l-norgest/e.estradiol-e.estrad 100-20(84) tbdspk 3mo - Added - QL Added: 91 / 91 DAYS l-norgest/e.estradiol-e.estrad 150-30(84) tbdspk 3mo - Added - QL Added: 91 / 91 DAYS naproxen/esomeprazole mag 375mg- 20mg tab ir dr - Added - QL Added: 60 / 30 DAYS - PA Added: VIMOVO (s) naproxen/esomeprazole mag 500mg- 20mg tab ir dr - Added - QL Added: 60 / 30 DAYS - PA Added: VIMOVO (s) NURTEC ODT 75 MG TABLET

rimegepant sulfate

- Added

- PA Added: Nurtec (s)

- QL Added: 8 / 30 OVER TIME oxycodone hcl/acetaminophen 2.5-300 mg tablet - Added potassium phos,m-basic-d-basic 3mmol/ml vial - Added PROCYSBI DR 300 MG GRANULE PKT cysteamine bitartrate - Added - PA Added: Procysbi (s) PROCYSBI DR 75 MG GRANULE PKT cysteamine bitartrate - Added - PA Added: Procysbi (s) pyrimethamine 25 mg tablet - Added

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REYVOW 100 MG TABLET lasmiditan succinate

- Added

- PA Added: Reyvow (s)

- QL Added: 4 / 30 OVER TIME REYVOW 50 MG TABLET

lasmiditan succinate

- Added

- PA Added: Reyvow (s)

- QL Added: 4 / 30 OVER TIME

SARCLISA 100 MG/5 ML VIAL isatuximab-irfc - Added - PA Added: Sarclisa (s) SARCLISA 500 MG/25 ML VIAL isatuximab-irfc - Added - PA Added: Sarclisa (s) triamcinolone acetonide 0.05 % oint. (g) - Added

UNIFINE SAFECONTROL 30GX3/16" pen needle, diabetic disposable, safety

- Added

- QL Added: 200 / 30 DAYS VANISHPOINT INS 1 ML 30GX3/16"

syringe with needle, insulin, safety, 1 ml

- Added

- QL Added: 200 / 30 DAYS ziprasidone mesylate fnl 20mg/1 vial - Added

- QL Added: 60 / 30 DAYS

FORMULARY CHANGES EFFECTIVE 03/01/2020

ASMANEX HFA 50 MCG INHALER mometasone furoate - Added - QL Added: 13 / 30 DAYS AYVAKIT 100 MG TABLET avapritinib - Added AYVAKIT 200 MG TABLET avapritinib - Added AYVAKIT 300 MG TABLET avapritinib - Added butalb/acetaminophen/caffeine 50-325/15 solution - Added - PA Added: HRM - Butalbital calcipotriene/betamethasone 0.005-.064 suspension - Added CAPLYTA 42 MG CAPSULE lumateperone tosylate - Added - QL Added: 30 / 30 DAYS - ST Added: ATYPICAL ANTIPSYCHOTICS - SCORE

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diltiazem hcl 120 mg cap sa 24h - Added diltiazem hcl 180 mg cap sa 24h - Added diltiazem hcl 240 mg cap sa 24h - Added diltiazem hcl 300 mg cap sa 24h - Added diltiazem hcl 420 mg cap sa 24h - Added DULERA 50 MCG-5 MCG INHALER

mometasone furoate/formoterol fumarate

- Added

- QL Added: 13 / 30 DAYS EASY TOUCH SAF PEN NDL 30G 5MM

pen needle, diabetic, safety - Added FETROJA 1 GRAM VIAL

cefiderocol sulfate tosylate - Added ketorolac tromethamine 15.75 mg spray - Added

- QL Added: 5 / 30 OVER TIME PALFORZIA 12 MG (LEVEL 3)

peanut allergen powder-dnfp

- Added

- PA Added: Palforzia (s) PALFORZIA 120 MG (LEVEL 7)

- Added

- PA Added: Palforzia (s) PALFORZIA 300 MG (MAINTENANCE)

- Added

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PALFORZIA 6 MG (LEVEL 2) peanut allergen powder-dnfp

- Added

- PA Added: Palforzia (s) PALFORZIA INITIAL DOSE PACK

- Added - PA Added: Palforzia (s) RIOMET ER 500 MG/5 ML SUSP metformin hcl - Added RYBELSUS 14 MG TABLET semaglutide - Added - QL Added: 30 / 30 DAYS RYBELSUS 3 MG TABLET semaglutide - Added

- QL Added: 60 / 365 OVER TIME RYBELSUS 7 MG TABLET semaglutide - Added - QL Added: 30 / 30 DAYS TAZVERIK 200 MG TABLET tazemetostat hydrobromide - Added - PA Added: Tazverik (s) TEPEZZA 500 MG VIAL teprotumumab-trbw - Added - PA Added: Tepezza (s) tramadol hcl 100 mg tablet - Added

trientine hcl 250 mg capsule - Added TRIKAFTA 100/50/75 MG-150 MG elexacaftor/tezacaftor/ivacaftor - Added - QL Added: 84 / 28 DAYS - PA Added: Trikafta (s) UBRELVY 100 MG TABLET ubrogepant - Added UBRELVY 50 MG TABLET ubrogepant - Added

VALTOCO 10 MG NASAL SPRAY

diazepam - Added

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XELJANZ XR 22 MG TABLET tofacitinib citrate

- Added

- PA Added: XELJANZ (s)

FORMULARY CHANGES EFFECTIVE 02/01/2020

ADCETRIS 50 MG VIAL brentuximab vedotin - Added - PA Added: Adcetris (s) BRUKINSA 80 MG CAPSULE zanubrutinib - Added - PA Added: Brukinsa (s) bupivacaine hcl/pf 2.5 mg/ml ampul - Added

DIVIGEL 1.25 MG GEL PACKET

estradiol - Added ENHERTU 100 MG VIAL fam-trastuzumab deruxtecan-nxki - Added - PA Added: Enhertu (s) ESTROGEL 0.06% GEL estradiol - Added

KRO PEN NEEDLE 4MM X 33G pen needle, diabetic

- Added QL Added: 200 / 30 DAYS

NOVOLIN N 100 UNIT/ML FLEXPEN

insulin nph human isophane - Added PADCEV 20 MG VIAL enfortumab vedotin-ejfv - Added - PA Added: Padcev (s) PADCEV 30 MG VIAL enfortumab vedotin-ejfv - Added - PA Added: Padcev (s) penicillamine 250 mg tablet - Added

pentamidine isethionate 300 mg vial-neb - Added

- PA Added: Part D vs Part B prednisolone sodium phosphate 15 mg/5

ml solution

- Added

PURE COMFORT ALCOHOL 70% PADS

alcohol antiseptic pads - Added PURE COMFORT PEN NDL 32G 4MM

- Added

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PURE COMFORT PEN NDL 32G 5MM pen needle, diabetic

- Added

- QL Added: 200 / 30 DAYS PURE COMFORT PEN NDL 32G 6MM

- Added

- QL Added: 200 / 30 DAYS PURE COMFORT PEN NDL 32G 8MM

- Added

- QL Added: 200 / 30 DAYS RELION NOVOLIN N U-100 FLEXPEN

insulin nph human isophane - Added ULTIGUARD SAFE PACK 31GX1/4"

pen needle, diabetic, remover and disposal unit

- Added

- QL Added: 200 / 30 DAYS ULTIGUARD SAFE PACK 31GX5/16"

- Added

- QL Added: 200 / 30 DAYS ULTIGUARD SAFE PACK 32GX1/4"

- Added

- QL Added: 200 / 30 DAYS QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, B/D = Medicare Part B versus Part D determination

AER = Aerosol, CAP = Capsule, CON = Concentrate, CRE = Cream, DRO = Drops, ER = Extended Release, ENE = Enema, GRA = Granules, INH = Inhalation, INJ = Injection, LOT = Lotion, NEB = Nebulizer, ODT = Orally Disintegrating, OIN = Ointment, OP = Ophthalmic, POW = Powder, SHA = Shampoo, SOL = Solution, SPR = Spray, SUB = Sublingual, SUP = Suppository, SUS = Suspension, TAB = Tablet, CHW = Chewable