2018 OPEN FORMULARY Updates
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- Juliet Conley
- 5 years ago
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1 January, /01/2018 OPDIVO nivolumab 01/01/2018 KEVZARA sarilumab 01/01/2018 KEVZARA sarilumab 01/01/2018 AIMOVIG AUTOINJECTOR,AIMOVIG AUTOINJECTOR (2 PACK) erenumab-aooe 01/02/2018 glucose in water dextrose 5 % in water CHANGE TIER Generics 01/02/2018 glucose in water dextrose 5 % in water CHANGE TIER Generics 01/02/2018 glucose in water dextrose 5 % in water CHANGE TIER Generics 01/02/2018 glucose in water dextrose 5 % in water CHANGE TIER Generics 01/03/2018 carbinoxamine maleate 01/03/2018 CLINIMIX N14G30E 01/03/2018 CLINIMIX N9G15E 01/03/2018 CLINIMIX N9G20E carbinoxamine maleate amino acids 4.25 %/dextrose 15 %/electrolytes no.25 amino acid 2.75 %/dextrose 7.5 %/electrolytes no.12 amino acid 2.75 % no.2/dextrose 10 %/electrolytes no.29 PAGE 1 UPDATED 09/2018
2 01/03/2018 tenofovir disoproxil fumarate tenofovir disoproxil fumarate 01/05/2018 OKEBO doxycycline monohydrate 01/12/2018 atazanavir sulfate atazanavir sulfate 01/12/2018 atazanavir sulfate atazanavir sulfate 01/12/2018 atazanavir sulfate atazanavir sulfate 01/12/2018 CLENPIQ sodium picosulfate/magnesium oxide/citric acid 01/12/2018 SUBLOCADE buprenorphine 01/12/2018 SUBLOCADE buprenorphine 01/15/2018 CINVANTI aprepitant 01/15/2018 PREVYMIS letermovir 01/15/2018 PREVYMIS letermovir 01/15/2018 PREVYMIS letermovir 01/15/2018 PREVYMIS letermovir 01/17/2018 efavirenz efavirenz Generics 01/17/2018 efavirenz efavirenz Generics 01/17/2018 estradiol estradiol Generics 01/17/2018 LYRICA CR pregabalin 01/17/2018 LYRICA CR pregabalin 01/17/2018 LYRICA CR pregabalin PAGE 2 UPDATED 09/2018
3 01/17/2018 methylphenidate er methylphenidate hcl 01/24/2018 ADMELOG insulin lispro 01/24/2018 ADMELOG SOLOSTAR insulin lispro 01/24/2018 ALUNBRIG brigatinib 01/24/2018 ALUNBRIG brigatinib 01/24/2018 ALUNBRIG brigatinib 01/24/2018 PROLASTIN C alpha-1-proteinase inhibitor 01/24/2018 PROLASTIN C alpha-1-proteinase inhibitor ADD UM: LIMITEDACCESS Limited Access 01/24/2018 romidepsin romidepsin 01/24/2018 SOLOSEC secnidazole 01/24/2018 STEGLATRO ertugliflozin pidolate 01/24/2018 STEGLATRO ertugliflozin pidolate ADD UM: QUANTITY 30 / 30 DAYS 01/24/2018 STEGLATRO ertugliflozin pidolate 01/24/2018 STEGLATRO ertugliflozin pidolate ADD UM: QUANTITY 60 / 30 DAYS 01/24/2018 XIGDUO XR dapagliflozin propanediol/metformin hcl 01/24/2018 XIGDUO XR dapagliflozin propanediol/metformin hcl ADD UM: QUANTITY Preferred 60 / 30 DAYS 01/26/2018 STELARA ustekinumab 01/26/2018 XURIDEN uridine triacetate 01/26/2018 MYLOTARG gemtuzumab ozogamicin 01/26/2018 PROFENO fenoprofen calcium Preferred PAGE 3 UPDATED 09/2018
4 01/26/2018 AKTIPAK erythromycin base/benzoyl peroxide Non-Formulary 01/26/2018 bortezomib bortezomib 01/26/2018 dactinomycin dactinomycin 01/26/2018 DEMEROL meperidine hcl/pf REMOVE FROM FORMULARY Non-Formulary 01/26/2018 valacyclovir valacyclovir hcl CHANGE UM: QUANTITY 30 / 30 DAYS 120 / 30 DAYS 01/29/2018 buprenorphine hcl 01/29/2018 buprenorphine hcl buprenorphine hcl REMOVE UM: QUANTITY 100 / 30 OVER buprenorphine hcl REMOVE UM: QUANTITY 25 / 30 OVER 01/29/2018 VALTREX valacyclovir hcl CHANGE UM: QUANTITY 30 / 30 DAYS 120 / 30 DAYS 01/29/2018 PHRENILIN FORTE 01/29/2018 PHRENILIN FORTE butalbital/acetaminophen/caf feine butalbital/acetaminophen/caf feine ADD UM: QUANTITY 360 / 30 OVER 01/30/2018 LEVO-T levothyroxine sodium Preferred 01/30/2018 LEVO-T levothyroxine sodium Preferred 01/30/2018 LEVO-T levothyroxine sodium Preferred 01/30/2018 LEVO-T levothyroxine sodium Preferred 01/30/2018 LEVO-T levothyroxine sodium Preferred 01/30/2018 LEVO-T levothyroxine sodium Preferred 01/30/2018 LEVO-T levothyroxine sodium Preferred 01/30/2018 LEVO-T levothyroxine sodium Preferred 01/30/2018 LEVO-T levothyroxine sodium Preferred 01/30/2018 LEVO-T levothyroxine sodium Preferred 01/30/2018 LEVO-T levothyroxine sodium Preferred PAGE 4 UPDATED 09/2018
5 01/30/2018 LEVO-T levothyroxine sodium Preferred 01/30/2018 PHRENILIN FORTE butalbital/acetaminophen/caf feine REMOVE FROM FORMULARY Non-Formulary PAGE 5 UPDATED 09/2018
6 February, /01/2018 IMPOYZ clobetasol propionate 02/01/2018 morphine sulfate morphine sulfate ADD UM: QUANTITY 400 / 30 OVER 02/01/2018 morphine sulfate morphine sulfate 02/02/2018 oxycodone hcl er oxycodone hcl CHANGE UM: QUANTITY 90 / 30 DAYS 02/02/2018 AMNESTEEM isotretinoin 02/02/2018 VICODIN hydrocodone bitartrate/acetaminophen 02/02/2018 VICODIN ES hydrocodone bitartrate/acetaminophen 02/02/2018 VICODIN HP hydrocodone bitartrate/acetaminophen 02/02/2018 hydrocodoneacetaminophen 02/02/2018 hydrocodoneacetaminophen 02/02/2018 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen hydrocodone bitartrate/acetaminophen hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY CHANGE UM: QUANTITY CHANGE UM: QUANTITY CHANGE UM: QUANTITY CHANGE UM: QUANTITY CHANGE UM: QUANTITY 360 / 30 OVER 360 / 30 OVER 360 / 30 OVER 360 / 30 OVER 360 / 30 OVER 360 / 30 OVER 390 / 30 OVER 390 / 30 OVER 390 / 30 OVER 390 / 30 OVER 390 / 30 OVER 390 / 30 OVER 02/07/2018 ADZENYS ER amphetamine 02/07/2018 ELIQUIS apixaban Preferred 02/07/2018 NOCTIVA desmopressin acetate PAGE 6 UPDATED 09/2018
7 02/07/2018 NOCTIVA desmopressin acetate 02/07/2018 STEGLUJAN ertugliflozin pidolate/sitagliptin phosphate 02/07/2018 STEGLUJAN ertugliflozin pidolate/sitagliptin phosphate 02/07/2018 STEGLUJAN ertugliflozin pidolate/sitagliptin phosphate 02/07/2018 STEGLUJAN ertugliflozin pidolate/sitagliptin phosphate 02/12/2018 VANATOL S butalbital/acetaminophen/caf feine ADD UM: QUANTITY ADD UM: QUANTITY 30 / 30 DAYS 30 / 30 DAYS 02/12/2018 COREMINO minocycline hcl 02/12/2018 COREMINO minocycline hcl Generics 02/12/2018 COREMINO minocycline hcl 02/14/2018 NOLIX flurandrenolide 02/14/2018 efavirenz efavirenz Generics 02/20/2018 haloperidol lactate 02/20/2018 SEGLUROMET ertugliflozin pidolate/metformin hcl 02/20/2018 SEGLUROMET ertugliflozin pidolate/metformin hcl 02/20/2018 SEGLUROMET ertugliflozin pidolate/metformin hcl haloperidol lactate Generics ADD UM: QUANTITY 60 / 30 DAYS PAGE 7 UPDATED 09/2018
8 02/20/2018 SEGLUROMET ertugliflozin pidolate/metformin hcl 02/20/2018 SEGLUROMET ertugliflozin pidolate/metformin hcl 02/20/2018 SEGLUROMET ertugliflozin pidolate/metformin hcl 02/20/2018 SEGLUROMET ertugliflozin pidolate/metformin hcl 02/20/2018 SEGLUROMET ertugliflozin pidolate/metformin hcl ADD UM: QUANTITY ADD UM: QUANTITY ADD UM: QUANTITY 60 / 30 DAYS 60 / 30 DAYS 60 / 30 DAYS 02/20/2018 XHANCE fluticasone propionate 02/26/2018 ROWEEPRA XR levetiracetam Generics 02/26/2018 omnipod insulin pump cartridge 02/26/2018 omnipod subcutaneous insulin pump PAGE 8 UPDATED 09/2018
9 March, /01/2018 XODOL hydrocodone bitartrate/acetaminophen 03/01/2018 XODOL hydrocodone bitartrate/acetaminophen 03/01/2018 XODOL hydrocodone bitartrate/acetaminophen CHANGE UM: QUANTITY CHANGE UM: QUANTITY CHANGE UM: QUANTITY 360 / 30 OVER 360 / 30 OVER 360 / 30 OVER 390 / 30 OVER 390 / 30 OVER 390 / 30 OVER 03/05/2018 TAPERDEX dexamethasone Generics 03/05/2018 TAPERDEX dexamethasone 03/05/2018 BIKTARVY bictegravir sodium/emtricitabine/tenofov ir alafenamide fumar 03/05/2018 hydrocortisone butyrate hydrocortisone butyrate Preferred 03/05/2018 trientine hcl trientine hcl 03/07/2018 ERLEADA apalutamide 03/07/2018 LONHALA MAGNAIR REFILL 03/07/2018 LONHALA MAGNAIR STARTER glycopyrrolate/nebulizer accessories glycopyrrolate/nebulizer and accessories 03/07/2018 memantine hcl er memantine hcl Generics 03/07/2018 memantine hcl er memantine hcl Generics 03/07/2018 memantine hcl er memantine hcl Generics 03/07/2018 memantine hcl er memantine hcl Generics PAGE 9 UPDATED 09/2018
10 03/07/2018 minocycline hcl er 03/07/2018 minocycline hcl er 03/07/2018 PANLOR acetaminophen/caffeine/dihy drocodeine bitartrate 03/07/2018 PANLOR acetaminophen/caffeine/dihy drocodeine bitartrate 03/07/2018 sumatriptan succnaproxen sod 03/07/2018 sumatriptan succnaproxen sod minocycline hcl minocycline hcl sumatriptan succinate/naproxen sodium sumatriptan succinate/naproxen sodium ADD UM: QUANTITY ADD UM: QUANTITY Generics 300 / 30 DAYS Generics 18 / 30 DAYS 03/07/2018 SYMDEKO tezacaftor/ivacaftor 03/12/2018 SUBLOCADE buprenorphine REMOVE FROM FORMULARY 03/12/2018 SUBLOCADE buprenorphine REMOVE FROM FORMULARY Non-Formulary Non-Formulary 03/26/2018 GLATOPA glatiramer acetate 03/26/2018 IMBRUVICA ibrutinib 03/26/2018 IMBRUVICA ibrutinib ADD UM: QUANTITY 120 / 30 DAYS 03/26/2018 IMBRUVICA ibrutinib 03/26/2018 IMBRUVICA ibrutinib ADD UM: QUANTITY 60 / 30 DAYS 03/26/2018 IMBRUVICA ibrutinib 03/26/2018 IMBRUVICA ibrutinib ADD UM: QUANTITY 30 / 30 DAYS 03/26/2018 IMBRUVICA ibrutinib 03/26/2018 IMBRUVICA ibrutinib ADD UM: QUANTITY 240 / 30 DAYS 03/26/2018 MAKENA hydroxyprogesterone caproate/pf PAGE 10 UPDATED 09/2018
11 03/26/2018 BONJESTA doxylamine succinate/pyridoxine hcl (b6) 03/26/2018 IMBRUVICA ibrutinib 03/26/2018 IMBRUVICA ibrutinib ADD UM: QUANTITY 30 / 30 DAYS 03/26/2018 methylphenidate la,methylphenidat e er methylphenidate hcl Generics PAGE 11 UPDATED 09/2018
12 April, /01/2018 esomeprazole strontium esomeprazole strontium 04/01/2018 DYANAVEL XR amphetamine 04/01/2018 PANLOR acetaminophen/caffeine/dihy drocodeine bitartrate CHANGE UM: QUANTITY 300 / 30 DAYS 300 / 30 OVER 04/01/2018 isotretinoin isotretinoin Generics 04/01/2018 isotretinoin isotretinoin Generics 04/01/2018 isotretinoin isotretinoin 04/01/2018 isotretinoin isotretinoin Generics 04/03/2018 NATROBA spinosad 04/03/2018 TAPERDEX dexamethasone CHANGE TIER Generics 04/03/2018 methylphenidate er methylphenidate hcl CHANGE UM: QUANTITY 30 / 30 DAYS 60 / 30 DAYS 04/04/2018 XHANCE fluticasone propionate Non-Formulary 04/04/2018 palonosetron hcl palonosetron hcl 04/04/2018 palonosetron hcl palonosetron hcl 04/04/2018 RHOPRESSA netarsudil mesylate 04/04/2018 TASIGNA nilotinib hcl 04/04/2018 TROGARZO ibalizumab-uiyk PAGE 12 UPDATED 09/2018
13 04/04/2018 ZYPITAMAG pitavastatin magnesium 04/04/2018 ZYPITAMAG pitavastatin magnesium ADD UM: QUANTITY 30 / 30 DAYS 04/04/2018 ZYPITAMAG pitavastatin magnesium 04/04/2018 ZYPITAMAG pitavastatin magnesium ADD UM: QUANTITY 30 / 30 DAYS 04/04/2018 ZYPITAMAG pitavastatin magnesium 04/04/2018 ZYPITAMAG pitavastatin magnesium ADD UM: QUANTITY 30 / 30 DAYS 04/09/2018 DALIRESP roflumilast Preferred 04/09/2018 lansoprazole lansoprazole Generics 04/09/2018 lansoprazole lansoprazole Generics 04/09/2018 ritonavir ritonavir Preferred 04/09/2018 SYMFI LO efavirenz/lamivudine/tenofov ir disoproxil fumarate 04/09/2018 tiagabine hcl tiagabine hcl 04/09/2018 tiagabine hcl tiagabine hcl 04/09/2018 TYDEMY drospirenone/ethinyl estradiol/levomefolate calcium 04/16/2018 CIMDUO lamivudine/tenofovir disoproxil fumarate 04/16/2018 SYMFI efavirenz/lamivudine/tenofov ir disoproxil fumarate 04/16/2018 TOUJEO MAX SOLOSTAR insulin glargine,human recombinant analog Generics Preferred PAGE 13 UPDATED 09/2018
14 04/25/2018 ABILIFY MAINTENA aripiprazole PAGE 14 UPDATED 09/2018
15 May, /01/2018 TAMIFLU oseltamivir phosphate 05/01/2018 EFFIENT prasugrel hcl CHANGE TIER Preferred 05/01/2018 SUSTIVA efavirenz CHANGE TIER Preferred 05/01/2018 EFFIENT prasugrel hcl CHANGE TIER Preferred 05/01/2018 KELNOR 1-50 ethynodiol diacetate-ethinyl estradiol Generics 05/01/2018 XHANCE fluticasone propionate Non-Formulary 05/01/2018 hydrocortisonepramoxine hydrocortisone acetate/pramoxine hcl Generics 05/01/2018 RHOPRESSA netarsudil mesylate CHANGE TIER 05/02/2018 tiagabine hcl tiagabine hcl CHANGE TIER 05/02/2018 tiagabine hcl tiagabine hcl CHANGE TIER 05/02/2018 tiagabine hcl tiagabine hcl CHANGE TIER Preferred Preferred Preferred 05/02/2018 tiagabine hcl tiagabine hcl Preferred 05/14/2018 HYPERRAB rabies immune globulin/pf Preferred 05/17/2018 miglustat miglustat 05/17/2018 miglustat miglustat ADD UM: LIMITEDACCESS Limited Access 05/17/2018 AUVI-Q epinephrine PAGE 15 UPDATED 09/2018
16 05/17/2018 CRYSVITA burosumab-twza 05/17/2018 CRYSVITA burosumab-twza 05/17/2018 CRYSVITA burosumab-twza 05/17/2018 DECADRON dexamethasone Generics 05/17/2018 praziquantel praziquantel Preferred 05/21/2018 ganciclovir sodium ganciclovir sodium Generics PAGE 16 UPDATED 09/2018
17 June, /01/2018 HUMIRA PEDIATRIC CROHN'S adalimumab 06/01/2018 HUMIRA PEN adalimumab 06/01/2018 HUMIRA PEDIATRIC CROHN'S adalimumab 06/01/2018 HUMIRA adalimumab 06/01/2018 HUMIRA adalimumab 06/01/2018 HUMIRA adalimumab 06/04/2018 HUMIRA adalimumab ADD UM: QUANTITY 2 / 28 DAYS 06/04/2018 HUMIRA PEDIATRIC CROHN'S 06/04/2018 HUMIRA PEDIATRIC CROHN'S adalimumab ADD UM: QUANTITY 3 / 180 DAYS adalimumab ADD UM: QUANTITY 2 / 180 DAYS 06/04/2018 HUMIRA adalimumab ADD UM: QUANTITY 4 / 28 DAYS 06/04/2018 HUMIRA PEN adalimumab ADD UM: QUANTITY 4 / 28 DAYS 06/04/2018 CETRAXAL ciprofloxacin hcl 06/04/2018 TRI-VYLIBRA norgestimate-ethinyl estradiol 06/04/2018 VYLIBRA norgestimate-ethinyl estradiol Generics Generics 06/04/2018 OSPHENA ospemifene PAGE 17 UPDATED 09/2018
18 06/04/2018 CONCERTA methylphenidate hcl CHANGE UM: QUANTITY 30 / 30 DAYS 60 / 30 DAYS 06/04/2018 JYNARQUE tolvaptan 06/04/2018 JYNARQUE tolvaptan ADD UM: LIMITEDACCESS Limited Access 06/04/2018 JYNARQUE tolvaptan 06/04/2018 JYNARQUE tolvaptan ADD UM: LIMITEDACCESS Limited Access 06/04/2018 JYNARQUE tolvaptan 06/04/2018 JYNARQUE tolvaptan ADD UM: LIMITEDACCESS Limited Access 06/05/2018 doxycycline hyclate 06/06/2018 AKYNZEO fosnetupitant chloride hcl/palonosetron hcl doxycycline hyclate Generics 06/06/2018 HUMIRA adalimumab ADD UM: QUANTITY 2 / 28 DAYS 06/06/2018 ANDEXXA coagulation factor xa,inactivated-zhzo (recombinant) 06/06/2018 baclofen baclofen 06/06/2018 NORVIR ritonavir 06/06/2018 TAVALISSE fostamatinib disodium 06/06/2018 TAVALISSE fostamatinib disodium ADD UM: QUANTITY 60 / 30 DAYS 06/06/2018 TAVALISSE fostamatinib disodium ADD UM: LIMITEDACCESS Limited Access 06/06/2018 TAVALISSE fostamatinib disodium 06/06/2018 TAVALISSE fostamatinib disodium ADD UM: QUANTITY 60 / 30 DAYS 06/06/2018 TAVALISSE fostamatinib disodium ADD UM: LIMITEDACCESS Limited Access 06/06/2018 colesevelam hcl colesevelam hcl Preferred PAGE 18 UPDATED 09/2018
19 06/06/2018 OSMOLEX ER amantadine hcl 06/06/2018 OSMOLEX ER amantadine hcl 06/06/2018 OSMOLEX ER amantadine hcl 06/18/2018 AIMOVIG AUTOINJECTOR 06/18/2018 AIMOVIG AUTOINJECTOR 06/18/2018 AIMOVIG AUTOINJECTOR (2 PACK) 06/18/2018 AIMOVIG AUTOINJECTOR (2 PACK) 06/18/2018 ARNUITY ELLIPTA 06/18/2018 ARNUITY ELLIPTA erenumab-aooe erenumab-aooe ADD UM: QUANTITY 2 / 30 DAYS erenumab-aooe erenumab-aooe ADD UM: QUANTITY 2 / 30 DAYS fluticasone furoate Preferred fluticasone furoate ADD UM: QUANTITY 30 / 30 DAYS 06/18/2018 LUCEMYRA lofexidine hcl 06/18/2018 prednisolonegatifloxacin prednisolone acetate/gatifloxacin 06/26/2018 MILI norgestimate-ethinyl estradiol 06/26/2018 TRI-MILI norgestimate-ethinyl estradiol Generics Generics PAGE 19 UPDATED 09/2018
20 July, /02/2018 HUMIRA PEDIATRIC CROHN'S 07/02/2018 HUMIRA PEDIATRIC CROHN'S adalimumab CHANGE UM: QUANTITY 2 / 180 DAYS 2 / 30 DAYS adalimumab CHANGE UM: QUANTITY 3 / 180 DAYS 3 / 30 DAYS 07/02/2018 pilocarpine hcl pilocarpine hcl CHANGE TIER Generics 07/02/2018 pilocarpine hcl pilocarpine hcl CHANGE TIER Generics 07/02/2018 pilocarpine hcl pilocarpine hcl CHANGE TIER Generics 07/03/2018 moxifloxacin moxifloxacin hcl/sodium chloride, iso-osmotic CHANGE TIER Generics 07/12/2018 LOTENSIN benazepril hcl 07/16/2018 DOPTELET avatrombopag maleate 07/16/2018 PALYNZIQ pegvaliase-pqpz 07/16/2018 PALYNZIQ pegvaliase-pqpz ADD UM: LIMITEDACCESS Limited Access 07/16/2018 DOPTELET avatrombopag maleate ADD UM: LIMITEDACCESS Limited Access 07/16/2018 PALYNZIQ pegvaliase-pqpz 07/16/2018 PALYNZIQ pegvaliase-pqpz ADD UM: LIMITEDACCESS Limited Access 07/16/2018 PALYNZIQ pegvaliase-pqpz 07/16/2018 PALYNZIQ pegvaliase-pqpz ADD UM: LIMITEDACCESS Limited Access 07/16/2018 YONSA abiraterone acetate, submicronized 07/23/2018 OLUMIANT baricitinib PAGE 20 UPDATED 09/2018
21 07/23/2018 RETACRIT epoetin alfa-epbx 07/23/2018 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 07/23/2018 RETACRIT epoetin alfa-epbx 07/23/2018 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 07/23/2018 RETACRIT epoetin alfa-epbx Preferred 07/23/2018 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 07/23/2018 RETACRIT epoetin alfa-epbx Preferred 07/23/2018 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 07/23/2018 RETACRIT epoetin alfa-epbx Preferred 07/23/2018 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 07/23/2018 RETACRIT epoetin alfa-epbx Preferred 07/23/2018 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 07/23/2018 RETACRIT epoetin alfa-epbx Preferred 07/23/2018 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 07/23/2018 RETACRIT epoetin alfa-epbx Preferred 07/23/2018 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 07/23/2018 RETACRIT epoetin alfa-epbx 07/23/2018 AIMOVIG AUTOINJECTOR,AIMOVIG AUTOINJECTOR (2 PACK) 07/25/2018 buprenorphinenaloxone 07/25/2018 buprenorphinenaloxone erenumab-aooe buprenorphine hcl/naloxone hcl buprenorphine hcl/naloxone hcl REMOVE FROM FORMULARY ADD UM: QUANTITY Non-Formulary Generics 90 / 30 DAYS PAGE 21 UPDATED 09/2018
22 07/25/2018 IMVEXXY estradiol 07/25/2018 IMVEXXY estradiol 07/25/2018 ROXYBOND oxycodone hcl 07/25/2018 ROXYBOND oxycodone hcl ADD UM: QUANTITY 180 / 30 OVER 07/25/2018 ROXYBOND oxycodone hcl 07/25/2018 ROXYBOND oxycodone hcl ADD UM: QUANTITY 180 / 30 OVER 07/25/2018 ROXYBOND oxycodone hcl 07/25/2018 ROXYBOND oxycodone hcl ADD UM: QUANTITY 360 / 30 OVER 07/25/2018 XELJANZ tofacitinib citrate 07/26/2018 hydromorphone hcl 07/26/2018 hydromorphone hcl 07/26/2018 hydromorphone hcl hydromorphone hcl/pf CHANGE UM: QUANTITY 150 / 30 DAYS 150 / 30 OVER hydromorphone hcl/pf Generics hydromorphone hcl/pf ADD UM: QUANTITY 75 / 30 OVER 07/26/2018 KEDRAB rabies immune globulin/pf 07/26/2018 ertapenem ertapenem sodium Preferred 07/26/2018 GLYCATE glycopyrrolate 07/26/2018 hydromorphone hcl hydromorphone hcl/pf PAGE 22 UPDATED 09/2018
23 07/26/2018 hydromorphone hcl hydromorphone hcl/pf ADD UM: QUANTITY 2400 / 30 OVER PAGE 23 UPDATED 09/2018
24 August, /01/2018 RETACRIT epoetin alfa-epbx Preferred 08/01/2018 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 08/01/2018 RETACRIT epoetin alfa-epbx Preferred 08/01/2018 RETACRIT epoetin alfa-epbx Preferred 08/01/2018 RETACRIT epoetin alfa-epbx 08/01/2018 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 08/01/2018 RETACRIT epoetin alfa-epbx 08/01/2018 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 08/01/2018 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 08/01/2018 miglustat miglustat CHANGE TIER 08/01/2018 miglustat miglustat CHANGE UM: LIMITEDACCESS Limited Access 08/01/2018 budesonide er budesonide 08/07/2018 ARISTADA INITIO aripiprazole lauroxil, submicronized 08/07/2018 BRAFTOVI encorafenib 08/07/2018 BRAFTOVI encorafenib 08/07/2018 FULPHILA pegfilgrastim-jmdb 08/07/2018 hydroxyprogester one caproate hydroxyprogesterone caproate/pf 08/07/2018 ketoprofen ketoprofen Generics 08/07/2018 MEKTOVI binimetinib 08/07/2018 MEKTOVI binimetinib ADD UM: LIMITEDACCESS Limited Access PAGE 24 UPDATED 09/2018
25 08/07/2018 RELEXXII methylphenidate hcl 08/09/2018 clindamycin phosphate clindamycin phosphate 08/09/2018 desoximetasone desoximetasone Generics 08/09/2018 KAPSPARGO SPRINKLE 08/09/2018 KAPSPARGO SPRINKLE 08/09/2018 KAPSPARGO SPRINKLE metoprolol succinate metoprolol succinate metoprolol succinate 08/09/2018 luliconazole luliconazole 08/09/2018 NUPLAZID pimavanserin tartrate 08/09/2018 NUPLAZID pimavanserin tartrate ADD UM: QUANTITY 60 / 30 DAYS 08/09/2018 NUPLAZID pimavanserin tartrate 08/09/2018 NUPLAZID pimavanserin tartrate ADD UM: QUANTITY 30 / 30 DAYS 08/09/2018 SYMTUZA darunavir eth/cobicistat/emtricitabine/t enofovir alafenamide 08/09/2018 TIBSOVO ivosidenib 08/09/2018 KAPSPARGO SPRINKLE metoprolol succinate PAGE 25 UPDATED 09/2018
26 January, /01/2019 miglustat miglustat 01/01/2019 CRYSVITA burosumab-twza REMOVE FROM FORMULARY 01/01/2019 CRYSVITA burosumab-twza REMOVE FROM FORMULARY 01/01/2019 CRYSVITA burosumab-twza REMOVE FROM FORMULARY 01/01/2019 drospirenone-eth estra-levomef drospirenone/ethinyl estradiol/levomefolate calcium 01/01/2019 MIRENA levonorgestrel REMOVE FROM FORMULARY Non-Formulary Non-Formulary Non-Formulary Generics Non-Formulary 01/01/2019 RETACRIT epoetin alfa-epbx Preferred 01/01/2019 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 01/01/2019 RETACRIT epoetin alfa-epbx Preferred 01/01/2019 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 01/01/2019 RETACRIT epoetin alfa-epbx Preferred 01/01/2019 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 01/01/2019 RETACRIT epoetin alfa-epbx 01/01/2019 RETACRIT epoetin alfa-epbx ADD UM: QUANTITY 12 / 28 DAYS 01/01/2019 RETACRIT epoetin alfa-epbx 01/01/2019 morphine sulfate morphine sulfate 01/01/2019 morphine sulfate morphine sulfate ADD UM: QUANTITY 1000 / 30 OVER PAGE 26 UPDATED 09/2018
27 01/01/2019 budesonide er budesonide PAGE 27 UPDATED 09/2018
HAP/Midwest Health Advantage MI Health Link (MMP) Updates
January, 2018 01/01/2018 hydrocortisone butyrate hydrocortisone butyrate 01/01/2018 MIRVASO brimonidine tartrate 01/01/2018 AZACTAM aztreonam 01/01/2018 AZACTAM aztreonam 01/01/2018 mesalamine mesalamine
Upper Peninsula MI Health Link Updates
January, 2018 01/01/2018 TAMIFLU oseltamivir phosphate CHANGE UM: QUANTITY 720 / 365 days 720 / 365 OVER 01/01/2018 oseltamivir phosphate 01/01/2018 oseltamivir phosphate 01/01/2018 oseltamivir phosphate
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March, 2018 03/01/2018 clindacin p clindamycin phosphate 03/01/2018 glatiramer acetate 03/01/2018 glatiramer acetate 03/01/2018 oseltamivir phosphate 03/01/2018 oseltamivir phosphate 03/01/2018 ADACEL
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5-Fluorouracil HPLC/ UHPLC Yes USP 4017 30 5mL 2 7-keto DHEA HPLC/ UHPLC Yes Medisca 4258 180 5mL 1 Acetaminophen HPLC/ UHPLC Yes USP 4406 5mL 2 Acetylcysteine HPLC/ UHPLC Yes USP 4255 60 5mL 1 Adenosine
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Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 fentanyl citrate 200 mcg lozenge hd morphine sulfate 30 mg tablet er oxymorphone hcl 7.5 mg tab er 12h Opioid Analgesics, Short-acting
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TABLE OF CONTENTS (Click on a link below to view the section.)
Follow the links below to access the complete formularies for Plans: Health Plan Acne Allergy Allergic Anaphylactic Reaction Allergic Conjunctivitis Allergic Rhinitis Asthma Atopic Dermatitis Behavioral
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