Express Communications


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06-01-12

Medicare Part D Formulary Change The product changes noted below will be implemented on the Medicare Part D Plan for the following Express Scripts Medicare Part D clients:

Express Communications

Client Name Phoenix Health Plan

Rx Group Number PH7A

New Added Products: Effective 07/01/2012 Drug ESCITALOPRAM OXALATE 5 MG/5 ML FLUVASTATIN SODIUM 20 MG CAP FLUVASTATIN SODIUM 40 MG CAP IBANDRONATE SODIUM 150 MG TAB IRBESARTAN 150 MG TABLET IRBESARTAN 300 MG TABLET IRBESARTAN 75 MG TABLET IRBESARTAN-HCTZ 150-12.5 MG TB IRBESARTAN-HCTZ 300-12.5 MG TB LATUDA 20 MG TABLET POTIGA 200 MG TABLET POTIGA 300 MG TABLET POTIGA 400 MG TABLET POTIGA 50 MG TABLET QUETIAPINE FUMARATE 100 MG TAB QUETIAPINE FUMARATE 200 MG TAB QUETIAPINE FUMARATE 25 MG TAB QUETIAPINE FUMARATE 300 MG TAB QUETIAPINE FUMARATE 400 MG TAB QUETIAPINE FUMARATE 50 MG TAB VANCOMYCIN HCL 125 MG CAPSULE VANCOMYCIN HCL 250 MG CAPSULE

Reason New Drug New Drug New Drug New Add New Drug New Drug New Drug New Drug New Drug New Drug New Drug New Drug New Drug New Drug New Drug New Drug New Drug New Drug New Drug New Drug New Drug New Drug

Cost sharing** Non-Preferred Generic Non-Preferred Generic Non-Preferred Generic Non-Preferred Generic Non-Preferred Generic Non-Preferred Generic Non-Preferred Generic Non-Preferred Generic Non-Preferred Generic Preferred Brand Preferred Brand Preferred Brand Preferred Brand Preferred Brand Non-Preferred Generic Non-Preferred Generic Non-Preferred Generic Non-Preferred Generic Non-Preferred Generic Non-Preferred Generic Specialty Specialty

Restrictions*** QLL QLL QLL

QLL

QLL QLL QLL QLL QLL QLL

*Consult your Medical provider for changes or recommendations to your medical care and prescription therapy **Please consult the plan benefit design for copay/coinsurance amounts ***Indicates a restriction of Step Therapy, Prior Authorization or Quantity Level Limits may exist

[LA] = Limited Access, [PA] = Prior Authorization, [QLL] = Quantity Level Limit, [ST] = Step Therapy MHP-C4T LCG

Log onto www.express-scripts.com for patient eligibility, rejection assistance, and more.

Drug VIIBRYD TITRATION PACK XERESE 5%-1% CREAM

Reason New Drug New Drug

Cost sharing** Preferred Brand Preferred Brand

Restrictions*** QLL, ST

Express Communications

Removed Products: Effective 07/01/2012 Drug ANTABUSE 250 MG TABLET ANTABUSE 500 MG TABLET DERMOTIC OIL 0.01% EAR DROPS EPIVIR 150 MG TABLET EPIVIR 300 MG TABLET FELBATOL 400 MG TABLET FELBATOL 600 MG TABLET FELBATOL 600 MG/5 ML SUSP MALARONE 250-100 MG TABLET METHERGINE 0.2 MG TABLET PRIMAXIN 250 MG VIAL PRIMAXIN 500 MG VIAL

Reason Alternative Generic Available DISULFIRAM Generic Available DISULFIRAM Generic Available FLUOCINOLONE ACETONIDE OIL Generic Available LAMIVUDINE Generic Available LAMIVUDINE Generic Available FELBAMATE Generic Available FELBAMATE Generic Available FELBAMATE Generic Available ATOVAQUONE-PROGUANIL HCL Generic Available METHYLERGONOVINE MALEATE Generic Available IMIPENEM-CILASTATIN SODIUM Generic Available IMIPENEM-CILASTATIN SODIUM

Cost Sharing Tier Updates: There were no Cost Sharing Tier Updates this month. Future Removed Products: Eff Date Drug Reason 08/01/2012 GASTROCROM 100 MG/5 ML CONC Generic Added 09/01/2012 ZYPREXA 10 MG VIAL Generic Added

Alternative* CROMOLYN SODIUM 100 MG/5 ML OLANZAPINE 10 MG VIAL

*Consult your Medical provider for changes or recommendations to your medical care and prescription therapy **Please consult the plan benefit design for copay/coinsurance amounts ***Indicates a restriction of Step Therapy, Prior Authorization or Quantity Level Limits may exist

[LA] = Limited Access, [PA] = Prior Authorization, [QLL] = Quantity Level Limit, [ST] = Step Therapy MHP-C4T LCG