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Provider Bulletin: Opportunity to Change to Formulary Alternatives For 2022Release Date: December 1, 2021Dear Valued Provider,As the start of the new year approaches, we would like to provide you with a listof your members who will be impacted by changes to the formulary startingJanuary 1, 2022. In some cases, we will now have BRAND alternatives on theformulary available to members.This list of members will be provided to you via Sharepoint in the PharmacyFolder. The file is called “2022 Formulary Changes.”Please consider reviewing this list and making any appropriate changes as this willavoid any interruptions in patient care.In addition, attached is a summary of the formulary changes for 2022.Should you have any questions, please feel free to contact us at 305-422-9300,Option 4.Thank you.Doctors HealthCare Plans, IncPharmacy Department

2022 Formulary ChangesPlease note the following formulary changes effective JANUARY 1, 2022. Pleaseconsider the alternatives provided below.MEDICATION2022 CHANGE AND ALTERNATIVESADMELOG 100 UNIT/ML VIALThis medication was removed from the formulary. Alternatives include:HUMALOG OR LYUMJEVADMELOG SOLOSTAR 100 UNIT/MLThis medication was removed from the formulary. Alternatives include:HUMALOG OR LYUMJEVAMITIZA 24 MCG CAPSULESThis medication was removed from the formulary. Alternatives include:LUBIPROSTONE 24 MCG CAPSULESAMITIZA 8 MCG CAPSULEThis medication was removed from the formulary. Alternatives include:LUBIPROSTONE 8 MCG CAPSULESASMANEX HFA 100 MCG INHALERThis medication was removed from the formulary. Alternatives include:ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, QVAR REDIHALERASMANEX TWISTHALER 110 MCG#30This medication was removed from the formulary. Alternatives include:ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, QVAR REDIHALERASMANEX TWISTHALR 220 MCG#120This medication was removed from the formulary. Alternatives include:ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, QVAR REDIHALERBASAGLAR 100 UNIT/ML KWIKPENThis medication was removed from the formulary. Alternatives include:LANTUS OR TRESIBABEOVU 6 MG/0.05 ML VIALThis medication will now be covered under the Part B benefit. Theprescriber should fax a Prior Authorization form to the MedicalManagement Department at 7865780291BETIMOL 0.5% EYE DROPSThis medication was removed from the formulary. Alternatives include:ALPHAGAN, AZOPT EYE, LUMIGAN, COMBIGAN, RHOPRESSA, ROCKLATAN,VYZULTA, ZIOPTANBOTOX 200 UNIT VIALThis medication's tier increased to Tier 5 because it meets Tier 5 SpecialtyCriteria.BRINZOLAMIDE 1% EYE DROPSThis medication was removed from the formulary. Alternatives include:BRAND AZOPT 1% EYE DROPSBUDESONIDE-FORMOTEROL 160-4.5This medication was removed from the formulary. Alternatives include:BRAND SYMBICORTBUDESONIDE-FORMOTEROL 80-4.5This medication was removed from the formulary. Alternatives include:BRAND SYMBICORTBYDUREON BCISE 2 MG AUTOINJECTThis medication is now subject to Step Therapy*. Member must havetried and failed one of the following medications: TRULICITY, OZEMPIC,VICTOZA OR RYBELSUSCEQUA 0.09% SOLUTIONDIFICID 200 MG TABLETDULERA 200 MCG-5 MCG INHALERThis medication will now require a PA*. Xiidra and Restasis are preferred.This medication will now require a PA*.This medication was removed from the formulary. Alternatives include:SYMBICORT, ADVAIR DISKUS, ADVAIR HFA*For drugs with newly added Prior Authorization (PA) or Step Therapy (ST), if an existing member has aqualifying history claim for the drug, they will not be subject to PA or ST and will continue to have accessto the drug.

2022 Formulary ChangesPlease note the following formulary changes effective JANUARY 1, 2022. Pleaseconsider the alternatives provided below.MEDICATION2022 CHANGE AND ALTERNATIVESBRINZOLAMIDE 1% EYE DROPSThis medication was removed from the formulary. Alternatives includeAZOPT 1% EYE DROPS.DULERA 200 MCG-5 MCG INHALERThis medication was removed from the formulary. Alternatives include:SYMBICORT, ADVAIR DISKUS, ADVAIR HFADURYSTA 10 MCG IMPLANTThis medication will now be covered under the Part B benefit. Theprescriber should fax a Prior Authorization form to the MedicalManagement Department at 7865780291EYLEA 2 MG/0.05 ML SYRINGEThis medication will now be covered under the Part B benefit. Theprescriber should fax a Prior Authorization form to the MedicalManagement Department at 7865780291EYLEA 2 MG/0.05 ML VIALThis medication will now be covered under the Part B benefit. Theprescriber should fax a Prior Authorization form to the MedicalManagement Department at 7865780291FLUTICASONE-SALMETEROL 100-50This medication was removed from the formulary. Alternatives include:BRAND ADVAIR DISKUSFLUTICASONE-SALMETEROL 250-50This medication was removed from the formulary. Alternatives include:BRAND ADVAIR DISKUSFLUTICASONE-SALMETEROL 500-50This medication was removed from the formulary. Alternatives include:BRAND ADVAIR DISKUSICOSAPENT ETHYL 1 GRAM CAPSULEThis medication was removed from the formulary. Alternatives include:BRAND VASCEPAINSULIN ASPART 100 UNIT/ML PENThis medication was removed from the formulary. Alternatives include:NOVOLOG OR FIASPINSULIN ASPART 100 UNIT/ML VLThis medication was removed from the formulary. Alternatives include:NOVOLOG OR FIASPINSULIN ASPART PROT (MIX70-30)This medication was removed from the formulary. Alternatives include:NOVOLOG MIX 70-30INSULIN LISPRO 100 UNIT/ML PENThis medication was removed from the formulary. Alternatives include:HUMALOG OR LYUMJEVINSULIN LISPRO 100 UNIT/ML VLThis medication was removed from the formulary. Alternatives include:HUMALOG OR LYUMJEVINSULIN LISPRO JR 100 UNIT/MLThis medication was removed from the formulary. Alternatives include:HUMALOG JRINSULIN LISPRO MIX 75-25 KWKPNThis medication was removed from the formulary. Alternatives include:HUMALOG MIX 75-25INVOKAMET 150-1,000 MG TABLETThis medication was removed from the formulary. Alternatives include:XIGDUO XR OR SYNJARDY XR*For drugs with newly added Prior Authorization (PA) or Step Therapy (ST), if an existing member has aqualifying history claim for the drug, they will not be subject to PA or ST and will continue to have accessto the drug.

2022 Formulary ChangesPlease note the following formulary changes effective JANUARY 1, 2022. Pleaseconsider the alternatives provided below.MEDICATION2022 CHANGE AND ALTERNATIVESINVOKAMET 50-1,000 MG TABLETThis medication was removed from the formulary. Alternatives include:XIGDUO XR OR SYNJARDY XRINVOKAMET 50-500 MG TABLETThis medication was removed from the formulary. Alternatives include:XIGDUO XR OR SYNJARDY XRINVOKAMET XR 150-1,000 MG TABThis medication was removed from the formulary. Alternatives include:XIGDUO XR OR SYNJARDY XRINVOKANA 100 MG TABLETThis medication was removed from the formulary. Alternatives include:FARXIGA OR JARDIANCEINVOKANA 300 MG TABLETThis medication was removed from the formulary. Alternatives include:FARXIGA OR JARDIANCEKOMBIGLYZE XR 2.5-1,000 MG TABThis medication is now subject to Step Therapy*. Member must havetried and failed one of the following medications: JENTADUETO/XR,TRADJENTA, ONGLYZA, OR JANUVIAKOMBIGLYZE XR 5-1,000 MG TABThis medication is now subject to Step Therapy*. Member must havetried and failed one of the following medications: JENTADUETO/XR,TRADJENTA, ONGLYZA, OR JANUVIALASTACAFT 0.25% EYE DROPSThis medication was removed from the formulary. Alternatives include:CROMOLYN SODIUM DROPS, ALOMIDE DROPS, AZELASTINE HCL DROPS,EPINASTINE DROPSLEDIPASVIR-SOFOSBUVIR 90MG400MG TABThis medication was removed from the formulary. Alternatives include:BRAND HARVONI 90MG-400MG TAB 90MG-400MG TAB.LEVEMIR 100 UNIT/ML VIALThis medication was removed from the formulary. Alternatives include:Lantus, Lantus SoloStar, Tresiba, Tresiba FlexTouch U-100LEVEMIR FLEXTOUCH 100 UNIT/MLThis medication was removed from the formulary. Alternatives include:Lantus, Lantus SoloStar, Tresiba, Tresiba FlexTouch U-100LOTEMAX 0.5% EYE DROPSThis medication was removed from the formulary. Alternatives include:LOTEPREDNOL ETABONATE 0.5% DROPS GELLUCENTIS 0.5 MG/0.05 ML SYRINGThis medication will now be covered under the Part B benefit. Theprescriber should fax a Prior Authorization form to the MedicalManagement Department at 7865780291PAZEO 0.7% EYE DROPSThis medication was removed from the formulary. Alternatives include:OLOPATADINE HCL 0.1% EYE DROPS, OLOPATADINE HCL 0.2% EYE DROPS,EPINASTINE 0.05% EYE DROPS, BEPOTASTINE 1.5% EYE DROPS,AZELASTINE HCL 0.05% DROPSPRADAXA 110 MG CAPSULEThis medication is now subject to Step Therapy*. Member must havetried and failed one of the following medications: ELIQUIS OR XARELTO*For drugs with newly added Prior Authorization (PA) or Step Therapy (ST), if an existing member has aqualifying history claim for the drug, they will not be subject to PA or ST and will continue to have accessto the drug.

2022 Formulary ChangesPlease note the following formulary changes effective JANUARY 1, 2022. Pleaseconsider the alternatives provided below.MEDICATION2022 CHANGE AND ALTERNATIVESPRADAXA 150 MG CAPSULEThis medication is now subject to Step Therapy*. Member must havetried and failed one of the following medications: ELIQUIS OR XARELTOPRADAXA 75 MG CAPSULEThis medication is now subject to Step Therapy*. Member must havetried and failed one of the following medications: ELIQUIS OR XARELTOSOFOSBUVIR-VELPATASVIR 400-100This medication was removed from the formulary. Alternatives include:BRAND EPCLUSA 400-100TRIJARDY XR 12.5-2.5-1,000 MGThis medication's tier increased. Use alternatives on Tier 3 such asJANUVIA, TRADJENTA, ONGLYZA, FARXIGA, OR JARDIANCETRIJARDY XR 25-5-1,000 MG TABThis medication's tier increased. Use alternatives on Tier 3 such asJANUVIA, TRADJENTA, ONGLYZA, FARXIGA, OR JARDIANCETRIJARDY XR 5-2.5-1,000 MG TABThis medication's tier increased. Use alternatives on Tier 3 such asJANUVIA, TRADJENTA, ONGLYZA, FARXIGA, OR JARDIANCEWIXELA 100-50 INHUBThis medication was removed from the formulary. Alternatives include:ADVAIR DISKUS OR SYMBICORTWIXELA 250-50 INHUBThis medication was removed from the formulary. Alternatives include:ADVAIR DISKUS OR SYMBICORTWIXELA 500-50 INHUBThis medication was removed from the formulary. Alternatives include:ADVAIR DISKUS OR SYMBICORT*For drugs with newly added Prior Authorization (PA) or Step Therapy (ST), if an existing member has aqualifying history claim for the drug, they will not be subject to PA or ST and will continue to have accessto the drug.

EYLEA 2 MG/0.05 ML SYRINGE This medication will now be covered under the Part B benefit. The prescriber should fax a Prior Authorization form to the Medical Management Department at 7865780291 EYLEA 2 MG/0.05 ML VIAL This medication will now be covered under the Part B benefit. The prescriber should fax a Prior Authorization form to the Medical