Magellan Rx Standard Formulary Formulary Updates First Quarter 2019

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1 Magellan Rx Standard Formulary Formulary Updates First Quarter 2019 The Magellan Rx Management Pharmacy & Therapeutics Committee (P&T) and Value Assessment Committee (VAC) meet periodically to review the status of drugs on the formulary and make recommendations due to newly approved products, changes in practice guidelines, updates in FDA approved labeling and/or changes in financial implications. Effective Date of Changes: 1/1/2019 Traditional Drug List* *Non-Specialty Drugs Additions to Formulary DRUG NAME TIER / PREFERENCE EFFECTIVE DATE Orilissa Non-Preferred 1/1/2019 Roxybond Non-Preferred 1/1/2019 Exclusions from Formulary None Tier / Preference Changes DRUG NAME TIER / PREFERENCE EFFECTIVE DATE Acuvail Non-Preferred 1/1/2019 Amitiza Non-Preferred 1/1/2019 Eliquis Preferred 1/1/2019 Flolipid Non-Preferred 1/1/2019 Fosrenol chew tablet Non-Preferred 1/1/2019 Glyxambi Preferred 1/1/2019 Movantik Preferred 1/1/2019 Ozempic Preferred 1/1/2019 Prolensa Preferred 1/1/2019 Renvela 800 mg tablet Non-Preferred 1/1/2019 Symproic Preferred 1/1/2019 Tresiba Preferred 1/1/2019 Welchol Non-Preferred 1/1/2019 Utilization Management (UM) UM Edits Additions Drug PA ST QL AE Amitiza Bromsite Duzallo Ilevro Drug PA ST QL AE

2 Drug PA ST QL AE Nevanac Roxybond Orilissa Drug PA ST QL AE Vraylar arelto starter pack UM Edit Removals If a drug is available in brand and generic edits would be removed from both products Drug PA ST QL AE Flolipid Vraylar Specialty Drug List For plans that do not have a defined specialty drug benefit utilizing the MRx Specialty Drug List, the drugs below will be tiered based on the drug s brand or generic status. Generic drugs (italics) will be Tier 1 and brand drugs will be Tier 3. New Specialty Drugs Drug PA QL AE Medical EFFECTIVE DATE Fulphila 1/1/2019 Palynziq 1/1/2019 Drug PA QL AE EFFECTIVE DATE Sublocade 1/1/2019 Tier / Preference Changes DRUG NAME TIER / PREFERENCE EFFECTIVE DATE Glatopa Non-Preferred Specialty 1/1/2019 Genvisc Non-Preferred Specialty 11/1/2018 Legend: PA: Prior Authorization QL: Quantity Limit ST: Step Therapy AE: Age Edit

3 GlobalHealth s High Cost (non-preferred) Generic Drug List GlobalHealth continuously monitors generic medications to offer the best overall health care value at the lowest possible tier. A Generic Drug is equivalent to its brand name counterpart. While generic medications are usually less expensive than brand name medications, certain generics are not always the lowest cost option. There are times where a generic alternative can be more expensive than other generic medications within the same therapeutically class. The following is the 2019 list of High Cost Generics. For additional questions on lower cost options please consult your primary care physician or contact Magellan at Please Note: High Cost Generics will process at Tier 3 copays. Drug Classification 5-LIPOYGENASE INHIBITORS ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETIC ADRENERGICS, AROMATIC, NON-CATECHOLAMINE ALPHA/BETA-ADRENERGIC BLOCKING AGENTS ANALGESICS, NARCOTIC AGONIST AND NSAID COMBINATION ANALGESICS, NARCOTICS Drug Name ZILEUTON ER 600 MG TABLET BENAZEPRIL-HCTZ MG TAB BENAZEPRIL-HCTZ MG TAB BENAZEPRIL-HCTZ MG TAB BENAZEPRIL-HCTZ MG TAB DEEDRINE 5 MG TABLET METHAMPHETAMINE 5 MG TABLET CARVEDILOL ER 10 MG CAPSULE CARVEDILOL ER 20 MG CAPSULE CARVEDILOL ER 40 MG CAPSULE CARVEDILOL ER 80 MG CAPSULE HYDROCODONE-IBUPROFEN HYDROCODONE-IBUPROFEN MG FENTANYL 37.5 MCG/HR PATCH FENTANYL 62.5 MCG/HR PATCH FENTANYL CIT OTFC 1,200 MCG FENTANYL CIT OTFC 1,600 MCG FENTANYL CITRATE OTFC 200 MCG FENTANYL CITRATE OTFC 400 MCG FENTANYL CITRATE OTFC 600 MCG HYDROMORPHONE 1 MG/ML SOLN HYDROMORPHONE 3 MG SUPPOS HYDROMORPHONE 5 MG/5 ML SOLN

4 ANALGESICS, NARCOTICS ANDROGENIC AGENTS ANTIDIURETIC AND VASOPRESSOR HORMONES ANTIEMETIC/ANTIVERTIGO AGENTS ANTIFUNGAL ANTIBIOTICS ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS ANTIHYPERTENSIVES, ACE INHIBITORS Continued HYDROMORPHONE HCL ER 12 MG TAB HYDROMORPHONE HCL ER 8 MG TAB LEVORPHANOL 2 MG TABLET MORPHINE 2 MG/ML CARPUJECT MORPHINE SULF 30 MG SUPPOS MORPHINE SULF ER 200 MG TABLET MORPHINE SULFATE ER 120 MG CAP MORPHINE SULFATE ER 60 MG CAP MORPHINE SULFATE ER 80 MG CAP MORPHINE SULFATE ER 90 MG CAP OYCODONE HCL 100 MG/5 ML SOLN OYCODONE HCL 5 MG CAPSULE OYCODONE HCL 5 MG/5 ML SOLN OYMORPHONE HCL ER 10 MG TAB OYMORPHONE HCL ER 15 MG TAB OYMORPHONE HCL ER 20 MG TAB OYMORPHONE HCL ER 30 MG TAB OYMORPHONE HCL ER 40 MG TAB OYMORPHONE HCL ER 5 MG TABLET TRAMADOL HCL ER 100 MG CAPSULE TRAMADOL HCL ER 200 MG CAPSULE TRAMADOL HCL ER 300 MG CAPSULE TESTOSTERONE 30 MG/1.5 ML PUMP DESMOPRESSIN AC 4 MCG/ML VIAL APREPITANT MG PACK GRISEOFULVIN MICRO 500 MG TAB GRISEOFULVIN ULTRA 125 MG TAB GRISEOFULVIN ULTRA 250 MG TAB FLUVASTATIN ER 80 MG TABLET FLUVASTATIN SODIUM 20 MG CAP FLUVASTATIN SODIUM 40 MG CAP CAPTOPRIL 100 MG TABLET CAPTOPRIL 12.5 MG TABLET CAPTOPRIL 25 MG TABLET CAPTOPRIL 50 MG TABLET

5 ANTIHYPERTENSIVES, SYMPATHOLYTIC ANTIMIGRAINE PREPARATIONS ANTIPARKINSONISM DRUGS, ANTICHOLINERGIC ANTIPARKINSONISM DRUGS, OTHER ANTITUSSIVES, NON-NARCOTIC BELLADONNA ALKALOIDS BETA-ADRENERGIC AGENTS BETA-BLOCKERS AND THIAZIDE, THIAZIDE-LIKE DIURETICS BILE SALT SEQUESTRANTS BONE RESORPTION INHIBITORS CALCIUM CHANNEL BLOCKING AGENTS CLONIDINE 0.1 MG/DAY PATCH CLONIDINE 0.2 MG/DAY PATCH CLONIDINE 0.3 MG/DAY PATCH ALMOTRIPTAN MALATE 12.5 MG TAB ALMOTRIPTAN MALATE 6.25 MG TAB DIHYDROERGOTAMINE 4 MG/ML SPRY FROVATRIPTAN SUCC 2.5 MG TAB BENZTROPINE 2 MG/2 ML AMPULE BROMOCRIPTINE 2.5 MG TABLET BROMOCRIPTINE 5 MG CAPSULE ENTACAPONE 200 MG TABLET BENZONATATE 150 MG CAPSULE BENZONATATE 200 MG CAPSULE PHENOHYTRO TABLET TERBUTALINE SULFATE 2.5 MG TAB TERBUTALINE SULFATE 5 MG TAB NADOLOL-BENDROFLU 80-5 MG TAB COLESTIPOL HCL 1 GM TABLET COLESTIPOL HCL GRANULES COLESTIPOL HCL GRANULES PACKET COLESTIPOL MICRONIZED 1 GM TAB RISEDRONATE SOD DR 35 MG TAB RISEDRONATE SODIUM 150 MG TAB NICARDIPINE 30 MG CAPSULE NIMODIPINE 30 MG CAPSULE NISOLDIPINE ER 17 MG TABLET NISOLDIPINE ER 20 MG TABLET NISOLDIPINE ER 25.5 MG TABLET NISOLDIPINE ER 30 MG TABLET NISOLDIPINE ER 34 MG TABLET NISOLDIPINE ER 40 MG TABLET NISOLDIPINE ER 8.5 MG TABLET

6 CALCIUM CHANNEL BLOCKING AGENTS CARBONIC ANHYDRASE INHIBITORS CHOLINESTERASE INHIBITORS CHRONIC INFLAM. COLON D, 5-A-SALICYLAT, RECTAL T DIGITALIS GLYCOSIDES EAR PREPARATIONS ANTI-INFLAMMATORY ELECTROLYTE DEPLETERS ESTROGENIC AGENTS EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS EYE ANTI-INFLAMMATORY AGENTS GLUCOCORTICOIDS GLUCOCORTICOIDS, ORALLY INHALED HEPARIN AND RELATED PREPARATIONS HISTAMINE H2-RECEPTOR INHIBITORS LEUKOTRIENE RECEPTOR ANTAGONISTS LIPOTROPICS Continued VERAPAMIL 360 MG CAP PELLET METHAZOLAMIDE 50 MG TABLET PYRIDOSTIGMINE ER 180 MG TAB MESALAMINE 4 GM/60 ML KIT DIGOIN 0.05 MG/ML SOLUTION FLUOCINOLONE OIL 0.01% EAR DRP SEVELAMER 2.4 GM POWDER PACKET ESTRADIOL TDS MG/DAY ESTRADIOL VALERATE 20 MG/ML VL ESTRADIOL VALERATE 40 MG/ML VL NEO-POLYCIN HC EYE OINTMENT BROMFENAC SODIUM 0.09% EYE DRP BETAMETHASONE AC-SP 6 MG/ML VL BUDESONIDE EC 3 MG CAPSULE CORTISONE 25 MG TABLET BUDESONIDE 1 MG/2 ML INH SUSP FONDAPARINU 10 MG/0.8 ML SYR FONDAPARINU 2.5 MG/0.5 ML SYR FONDAPARINU 5 MG/0.4 ML SYR FONDAPARINU 7.5 MG/0.6 ML SYR FAMOTIDINE 40 MG/5 ML SUSP NIZATIDINE 15 MG/ML SOLUTION MONTELUKAST SOD 4 MG GRANULES NIACIN ER 1,000 MG TABLET NIACIN ER 500 MG TABLET NIACIN ER 750 MG TABLET

7 LOCAL ANESTHETICS LOOP DIURETICS MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS NARCOTIC ANALGESIC AND NON-SALICYLATE ANALGESIC NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMB. NSAIDS, CYCLOOYGENASE INHIBITOR - TYPE ANALGESICS OPHTHALMIC ANTIBIOTICS POTASSIUM REPLACEMENT POTASSIUM SPARING DIURETICS LIDOCAINE HCL 0.5% VIAL BUMETANIDE 1 MG TABLET BUMETANIDE 2 MG TABLET BIMATOPROST 0.03% EYE DROPS BRIMONIDINE TARTRATE 0.15% DRP ENDOCET MG TABLET ENDOCET TABLET ENDOCET MG TABLET HYDROCODONE-ACETAMIN MG HYDROCODONE-ACETAMIN MG HYDROCODONE-ACETAMIN HYDROCODONE-ACETAMN /15 OYCODON-ACETAMINOPHEN HYDROCOD-CPM-PSEUDOEP /5 HYDROCODONE-HOMATROPINE DICLOFENAC SOD DR 25 MG TAB KETOPROFEN 50 MG CAPSULE KETOPROFEN ER 200 MG CAPSULE MECLOFENAMATE 100 MG CAPSULE MECLOFENAMATE 50 MG CAPSULE OAPROZIN 600 MG CAPLET OAPROZIN 600 MG TABLET TOLMETIN SODIUM 400 MG CAP BACITRACIN 500 UNIT/GM OPHTH BACITRACIN-POLYMYIN EYE OINT GATIFLOACIN 0.5% EYE DROPS POTASSIUM CL 10% (20 MEQ/15 ML POTASSIUM CL 20 MEQ PACKET POTASSIUM CL 20% (40 MEQ/15 ML EPLERENONE 25 MG TABLET EPLERENONE 50 MG TABLET

8 SEDATIVE-HYPNOTICS, NON-BARBITURATE SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) SKELETAL MUSCLE RELAANTS TOPICAL ANTIFUNGAL/ANTI-INFLAMMATORY, STEROID AGENT TOPICAL ANTIFUNGALS TOPICAL ANTI-INFLAMMATORY STEROIDAL ZOLPIDEM TART 1.75 MG TAB SL ZOLPIDEM TART 3.5 MG TABLET SL FLUOETINE DR 90 MG CAPSULE FLUOETINE HCL 10 MG TABLET FLUOETINE HCL 20 MG TABLET FLUOETINE HCL 60 MG TABLET CARISOPRODOL 250 MG TABLET CYCLOBENZAPRINE 7.5 MG TABLET DANTROLENE SODIUM 100 MG CAP DANTROLENE SODIUM 25 MG CAP DANTROLENE SODIUM 50 MG CAP METAALONE 400 MG TABLET METAALONE 800 MG TABLET TIZANIDINE HCL 2 MG CAPSULE TIZANIDINE HCL 4 MG CAPSULE TIZANIDINE HCL 6 MG CAPSULE CLOTRIMAZOLE-BETAMETHASONE LOT KETOCONAZOLE 2% FOAM NYSTATIN-TRIAMCINOLONE OINTM BETAMETHASONE VALER 0.12% FOAM CLOBETASOL 0.05% TOPICAL LOTN CLOBETASOL EMOLLNT 0.05% FOAM CLOBETASOL EMULSION 0.05% FOAM CLOBETASOL PROP 0.05% FOAM CLOBETASOL PROP 0.05% SPRAY CLOCORTOLONE 0.1% CREAM PUMP CLOCORTOLONE PIVALATE 0.1% CRM DESOIMETASONE 0.05% CREAM DESOIMETASONE 0.05% OINTMENT DIFLORASONE 0.05% CREAM DIFLORASONE 0.05% OINTMENT FLUOCINOLONE 0.01% SCALP OIL FLUOCINOLONE 0.01% SOLUTION FLUOCINOLONE 0.025% CREAM FLUOCINOLONE 0.025% OINTMENT

9 TOPICAL ANTIPARASITICS TOPICAL SULFONAMIDES T FOR ADHD - SELECTIVE ALPHA-2 RECEPTOR AGONIST VAGINAL ANTIFUNGALS LINDANE 1% SHAMPOO MALATHION 0.5% LOTION AVAR-E GREEN EMOLLIENT CREAM CLONIDINE HCL ER 0.1 MG TABLET TERCONAZOLE 80 MG SUPPOSITORY

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