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 01/01/2018 kionex sodium polystyrene sulfonate/sorbitol solution,sodium polystyrene sulfonate 01/01/2018 RESTASIS,REST ASIS MULTIDOSE oseltamivir phosphate CHANGE UM: QUANTITY 110 / 365 OVER oseltamivir phosphate CHANGE UM: QUANTITY 112 / 365 OVER oseltamivir phosphate CHANGE UM: QUANTITY 60 / 365 OVER CHANGE TIER cyclosporine CHANGE TIER PAGE 1 UPDATED 11/2018
March, 2018 03/01/2018 eletriptan hbr eletriptan hydrobromide 03/01/2018 eletriptan hbr eletriptan hydrobromide ADD UM: QUANTITY 12 / 30 OVER 03/01/2018 03/01/2018 fosamprenavir calcium 03/01/2018 lanthanum carbonate 03/01/2018 lanthanum carbonate 03/01/2018 lanthanum carbonate fosamprenavir calcium lanthanum carbonate lanthanum carbonate lanthanum carbonate 03/01/2018 meropenem meropenem 03/01/2018 mesalamine mesalamine 03/01/2018 moxifloxacin moxifloxacin hcl 03/01/2018 oseltamivir phosphate 03/01/2018 oseltamivir phosphate oseltamivir phosphate oseltamivir phosphate ADD UM: QUANTITY 720 / 365 OVER 03/01/2018 oxaliplatin oxaliplatin 03/01/2018 paroxetine mesylate 03/01/2018 paroxetine mesylate 03/01/2018 piperacillintazobactam paroxetine mesylate ADD UM: QUANTITY 30 / 30 DAYS paroxetine mesylate piperacillin sodium/tazobactam sodium PAGE 2 UPDATED 11/2018
03/01/2018 peg 3350- electrolyte 03/01/2018 potassium chloride peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride potassium chloride 03/01/2018 prasugrel hcl prasugrel hcl 03/01/2018 prasugrel hcl prasugrel hcl 03/01/2018 sevelamer carbonate sevelamer carbonate 03/01/2018 vigabatrin vigabatrin 03/01/2018 isibloom desogestrel-ethinyl 03/01/2018 desogestrelethinyl 03/01/2018 ethynodiol-ethinyl 03/01/2018 norgestimateethinyl 03/01/2018 levonorg-eth estrad eth estrad 03/01/2018 levonorg-eth estrad eth estrad desogestrel-ethinyl ethynodiol diacetate-ethinyl norgestimate-ethinyl levonorgestrel/ethinyl and ethinyl levonorgestrel/ethinyl and ethinyl 03/01/2018 ADACEL TDAP diphtheria,pertussis(acellular ),tetanus vaccine/pf ADD UM: QUANTITY 91 / 91 DAYS 03/01/2018 HAVRIX hepatitis a virus vaccine/pf 03/01/2018 VAQTA hepatitis a virus vaccine/pf 03/01/2018 HUMALOG JUNIOR KWIKPEN insulin lispro PAGE 3 UPDATED 11/2018
03/01/2018 BYDUREON BCISE 03/01/2018 BYDUREON BCISE exenatide microspheres ADD UM: QUANTITY 3.4 / 28 DAYS exenatide microspheres 03/01/2018 BENLYSTA belimumab 03/01/2018 BENLYSTA belimumab 03/01/2018 FASENRA benralizumab 03/01/2018 TREMFYA guselkumab 03/01/2018 HAVRIX hepatitis a virus vaccine/pf 03/01/2018 TWINRIX hepatitis a virus and hepatitis b virus vaccine/pf 03/01/2018 VAQTA hepatitis a virus vaccine/pf 03/01/2018 OPDIVO nivolumab 03/01/2018 RADICAVA edaravone 03/01/2018 PREVYMIS letermovir 03/01/2018 VENTOLIN HFA albuterol sulfate 03/01/2018 VENTOLIN HFA albuterol sulfate ADD UM: QUANTITY 48 / 30 DAYS 03/01/2018 GOCOVRI amantadine hcl 03/01/2018 GOCOVRI amantadine hcl 03/01/2018 RAYALDEE calcifediol 03/01/2018 PREVYMIS letermovir 03/01/2018 LUPRON DEPOT-PED leuprolide acetate CHANGE UM: QUANTITY 1 / 112 days 1 / 84 OVER 03/01/2018 TRISENOX arsenic trioxide 03/01/2018 VERZENIO abemaciclib 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS PAGE 4 UPDATED 11/2018
03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 VERZENIO abemaciclib 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 VERZENIO abemaciclib 03/01/2018 VERZENIO abemaciclib 03/01/2018 VERZENIO abemaciclib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 CALQUENCE acalabrutinib ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 CALQUENCE acalabrutinib 03/01/2018 KADCYLA ado-trastuzumab emtansine 03/01/2018 ZENPEP lipase/protease/amylase 03/01/2018 TREANDA bendamustine hcl 03/01/2018 BOSULIF bosutinib 03/01/2018 PROLENSA bromfenac sodium 03/01/2018 PROLENSA bromfenac sodium ADD UM: QUANTITY 12 / 365 OVER 03/01/2018 NOVAREL chorionic gonadotropin, human 03/01/2018 clindacin p clindamycin phosphate 03/01/2018 ALIQOPA copanlisib di-hcl 03/01/2018 VYXEOS daunorubicin/cytarabine liposomal 03/01/2018 BAXDELA delafloxacin meglumine 03/01/2018 BAXDELA delafloxacin meglumine 03/01/2018 JULUCA dolutegravir sodium/rilpivirine hcl 03/01/2018 JULUCA dolutegravir sodium/rilpivirine hcl ADD UM: QUANTITY 30 / 30 DAYS PAGE 5 UPDATED 11/2018
03/01/2018 GLYXAMBI empagliflozin/linagliptin 03/01/2018 GLYXAMBI empagliflozin/linagliptin ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 GLYXAMBI empagliflozin/linagliptin 03/01/2018 GLYXAMBI empagliflozin/linagliptin ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 IDHIFA enasidenib mesylate 03/01/2018 IDHIFA enasidenib mesylate ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 IDHIFA enasidenib mesylate ADD UM: QUANTITY 30 / 30 DAYS 03/01/2018 IDHIFA enasidenib mesylate 03/01/2018 profeno fenoprofen calcium 03/01/2018 MYLOTARG gemtuzumab ozogamicin 03/01/2018 MAVYRET glecaprevir/pibrentasvir ADD UM: QUANTITY 336 / 365 OVER 03/01/2018 MAVYRET glecaprevir/pibrentasvir 03/01/2018 RENFLEXIS infliximab-abda 03/01/2018 amnesteem isotretinoin 03/01/2018 amnesteem isotretinoin 03/01/2018 amnesteem isotretinoin 03/01/2018 PREVYMIS letermovir 03/01/2018 PREVYMIS letermovir 03/01/2018 XIIDRA lifitegrast ADD UM: QUANTITY 60 / 30 DAYS 03/01/2018 XIIDRA lifitegrast 03/01/2018 VABOMERE meropenem/vaborbactam 03/01/2018 XATMEP methotrexate 03/01/2018 NEVANAC nepafenac ADD UM: QUANTITY 6 / 30 OVER PAGE 6 UPDATED 11/2018
03/01/2018 NEVANAC nepafenac 03/01/2018 NERLYNX neratinib maleate ADD UM: QUANTITY 180 / 30 DAYS 03/01/2018 NERLYNX neratinib maleate 03/01/2018 NYMALIZE nimodipine 03/01/2018 LYNPARZA olaparib 03/01/2018 LYNPARZA olaparib 03/01/2018 PROAIR HFA albuterol sulfate CHANGE UM: QUANTITY 17 / 30 days 17 / 30 DAYS 03/01/2018 TAMIFLU oseltamivir phosphate 03/01/2018 TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 112 / 365 OVER 03/01/2018 TAMIFLU oseltamivir phosphate 03/01/2018 TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 60 / 365 OVER 03/01/2018 TAMIFLU oseltamivir phosphate 03/01/2018 TAMIFLU oseltamivir phosphate ADD UM: QUANTITY 110 / 365 OVER 03/01/2018 klor-con potassium chloride 03/01/2018 VOSEVI sofosbuvir/velpatasvir/voxila previr 03/01/2018 VOSEVI sofosbuvir/velpatasvir/voxila previr ADD UM: QUANTITY 84 / 365 OVER 03/01/2018 SYNDROS dronabinol ADD UM: QUANTITY 120 / 30 DAYS 03/01/2018 SYNDROS dronabinol 03/01/2018 XURIDEN uridine triacetate ADD UM: QUANTITY 120 / 30 DAYS 03/01/2018 XURIDEN uridine triacetate 03/01/2018 INGREZZA valbenazine tosylate 03/01/2018 INGREZZA valbenazine tosylate ADD UM: QUANTITY 30 / 30 DAYS PAGE 7 UPDATED 11/2018
03/01/2018 glatiramer acetate 03/01/2018 glatiramer acetate 03/01/2018 glatiramer acetate 03/01/2018 glatiramer acetate 03/01/2018 haloperidol decanoate glatiramer acetate ADD UM: QUANTITY 30 / 30 DAYS glatiramer acetate glatiramer acetate ADD UM: QUANTITY 12 / 28 DAYS glatiramer acetate haloperidol decanoate 03/01/2018 morphine sulfate morphine sulfate 03/01/2018 methotrexate methotrexate sodium 03/01/2018 carvedilol er carvedilol phosphate 03/01/2018 timolol maleate timolol maleate 03/01/2018 methylphenidate la 03/01/2018 methylphenidate la 03/01/2018 methylphenidate er methylphenidate hcl methylphenidate hcl ADD UM: QUANTITY 30 / 30 DAYS methylphenidate hcl CHANGE UM: QUANTITY 30 / 30 days 30 / 30 DAYS 03/01/2018 testosterone testosterone 03/01/2018 scopolamine scopolamine 03/01/2018 adapalenebenzoyl peroxide adapalene/benzoyl peroxide 03/01/2018 aripiprazole aripiprazole ADD UM: QUANTITY 750 / 30 DAYS 03/01/2018 aripiprazole aripiprazole 03/01/2018 bortezomib bortezomib PAGE 8 UPDATED 11/2018
03/01/2018 caspofungin acetate 03/01/2018 caspofungin acetate caspofungin acetate caspofungin acetate 03/01/2018 dactinomycin dactinomycin 03/01/2018 dapsone dapsone 03/01/2018 doxycycline hyclate 03/01/2018 doxycycline hyclate doxycycline hyclate doxycycline hyclate 03/01/2018 efavirenz efavirenz 03/01/2018 eletriptan hbr eletriptan hydrobromide ADD UM: QUANTITY 12 / 30 OVER 03/01/2018 eletriptan hbr eletriptan hydrobromide 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE UM: QUANTITY 60 / 30 days 60 / 30 DAYS 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE UM: QUANTITY 60 / 30 days 60 / 30 DAYS 03/01/2018 ENTRESTO sacubitril/valsartan CHANGE UM: QUANTITY 60 / 30 days 60 / 30 DAYS PAGE 9 UPDATED 11/2018
April, 2018 04/01/2018 medroxyprogeste rone acetate 04/01/2018 medroxyprogeste rone acetate medroxyprogesterone acetate medroxyprogesterone acetate 04/01/2018 altavera levonorgestrel-ethinyl 04/01/2018 kurvelo levonorgestrel-ethinyl CHANGE TIER CHANGE UM: QUANTITY 1 / 90 OVER 04/01/2018 enskyce desogestrel-ethinyl 04/01/2018 SELZENTRY maraviroc 04/01/2018 EMFLAZA deflazacort 04/01/2018 EMFLAZA deflazacort 04/01/2018 EMFLAZA deflazacort 04/01/2018 EMFLAZA deflazacort 04/01/2018 EMFLAZA deflazacort 04/01/2018 levetiracetam er,roweepra xr 04/01/2018 levetiracetam er,roweepra xr levetiracetam CHANGE TIER levetiracetam CHANGE TIER 04/01/2018 HERCEPTIN trastuzumab 04/01/2018 SHINGRIX varicella-zoster virus glycoprotein e,rec/as01b adjuvant/pf 04/01/2018 ALUNBRIG brigatinib 04/01/2018 ALUNBRIG brigatinib ADD UM: QUANTITY 30 / 30 DAYS PAGE 10 UPDATED 11/2018
04/01/2018 ALUNBRIG brigatinib 04/01/2018 ALUNBRIG brigatinib ADD UM: QUANTITY 30 / 30 DAYS 04/01/2018 ELIQUIS apixaban 04/01/2018 ELIQUIS apixaban ADD UM: QUANTITY 148 / 365 OVER 04/01/2018 CINVANTI aprepitant 04/01/2018 ZENPEP lipase/protease/amylase 04/01/2018 04/01/2018 tenofovir disoproxil fumarate tenofovir disoproxil fumarate 04/01/2018 atazanavir sulfate atazanavir sulfate 04/01/2018 atazanavir sulfate atazanavir sulfate 04/01/2018 atazanavir sulfate atazanavir sulfate 04/01/2018 doripenem doripenem 04/01/2018 levonorgestreleth levonorgestrel-ethinyl REMOVE UM: QUANTITY 91 / 91 days 04/01/2018 carvedilol er carvedilol phosphate 04/01/2018 carvedilol er carvedilol phosphate 04/01/2018 carvedilol er carvedilol phosphate 04/01/2018 ALUNBRIG brigatinib 04/01/2018 ALUNBRIG brigatinib ADD UM: QUANTITY 60 / 365 OVER 04/01/2018 NUCALA mepolizumab CHANGE UM: QUANTITY 1 / 28 days 3 / 28 DAYS PAGE 11 UPDATED 11/2018
May, 2018 05/01/2018 XTAMPZA ER oxycodone myristate 05/01/2018 XTAMPZA ER oxycodone myristate 05/01/2018 XTAMPZA ER oxycodone myristate 05/01/2018 XTAMPZA ER oxycodone myristate 05/01/2018 haloperidol lactate haloperidol lactate 05/01/2018 XTAMPZA ER oxycodone myristate 05/01/2018 ENDARI glutamine 05/01/2018 QVAR REDIHALER 05/01/2018 QVAR REDIHALER 05/01/2018 QVAR REDIHALER 05/01/2018 QVAR REDIHALER beclomethasone dipropionate beclomethasone dipropionate beclomethasone dipropionate beclomethasone dipropionate ADD UM: QUANTITY ADD UM: QUANTITY 21.2 / 30 DAYS 21.2 / 30 DAYS 05/01/2018 SYMDEKO tezacaftor/ivacaftor 05/01/2018 SYMDEKO tezacaftor/ivacaftor ADD UM: QUANTITY 56 / 28 DAYS 05/01/2018 ERLEADA apalutamide 05/01/2018 ERLEADA apalutamide ADD UM: QUANTITY 120 / 30 DAYS 05/01/2018 BIKTARVY bictegravir sodium/emtricitabine/tenofov ir alafenamide fumar 05/01/2018 BIKTARVY bictegravir sodium/emtricitabine/tenofov ir alafenamide fumar ADD UM: QUANTITY 30 / 30 DAYS PAGE 12 UPDATED 11/2018
05/01/2018 sumatriptan succnaproxen sod 05/01/2018 sumatriptan succnaproxen sod sumatriptan succinate/naproxen sodium sumatriptan succinate/naproxen sodium ADD UM: QUANTITY 9 / 30 OVER 05/01/2018 isotretinoin isotretinoin 05/01/2018 digox digoxin CHANGE TIER 05/01/2018 isotretinoin isotretinoin 05/01/2018 isotretinoin isotretinoin 05/01/2018 nolix flurandrenolide 05/01/2018 efavirenz efavirenz 05/01/2018 abacavir abacavir sulfate 05/01/2018 trientine hcl trientine hcl 05/01/2018 VIDEX EC didanosine 05/01/2018 efavirenz efavirenz 05/01/2018 isotretinoin isotretinoin 05/01/2018 levonorg-eth estrad eth estrad 05/01/2018 levonorg-eth estrad eth estrad levonorgestrel/ethinyl and ethinyl levonorgestrel/ethinyl and ethinyl ADD UM: QUANTITY 91 / 91 DAYS 05/01/2018 memantine hcl er memantine hcl 05/01/2018 memantine hcl er memantine hcl ADD UM: QUANTITY 30 / 30 DAYS 05/01/2018 memantine hcl er memantine hcl 05/01/2018 memantine hcl er memantine hcl ADD UM: QUANTITY 30 / 30 DAYS 05/01/2018 memantine hcl er memantine hcl 05/01/2018 memantine hcl er memantine hcl ADD UM: QUANTITY 30 / 30 DAYS PAGE 13 UPDATED 11/2018
05/01/2018 memantine hcl er memantine hcl 05/01/2018 memantine hcl er memantine hcl ADD UM: QUANTITY 30 / 30 DAYS 05/01/2018 naloxone hcl naloxone hcl 05/01/2018 ZENPEP lipase/protease/amylase 05/01/2018 ZENPEP lipase/protease/amylase 05/01/2018 digox digoxin 05/01/2018 digox digoxin ADD UM: QUANTITY 30 / 30 DAYS PAGE 14 UPDATED 11/2018
June, 2018 06/01/2018 ABILIFY MAINTENA aripiprazole 06/01/2018 ALIMTA pemetrexed disodium 06/01/2018 DALIRESP roflumilast 06/01/2018 EPIPEN 2-PAK epinephrine 06/01/2018 EPIPEN JR 2- PAK epinephrine 06/01/2018 glatopa glatiramer acetate 06/01/2018 glatopa glatiramer acetate ADD UM: QUANTITY 12 / 28 DAYS 06/01/2018 HAEGARDA c1 esterase inhibitor 06/01/2018 HAEGARDA c1 esterase inhibitor 06/01/2018 hydrocortisonepramoxine hydrocortisone acetate/pramoxine hcl 06/01/2018 ILARIS canakinumab/pf 06/01/2018 ILARIS canakinumab/pf ADD UM: QUANTITY 2 / 28 DAYS 06/01/2018 IMBRUVICA ibrutinib 06/01/2018 IMBRUVICA ibrutinib 06/01/2018 IMBRUVICA ibrutinib 06/01/2018 IMBRUVICA ibrutinib 06/01/2018 INTRON A interferon alfa-2b,recomb. 06/01/2018 ISENTRESS HD raltegravir potassium 06/01/2018 kelnor 1-50 ethynodiol diacetate-ethinyl PAGE 15 UPDATED 11/2018
06/01/2018 lamotrigine,lamot rigine (blue) 06/01/2018 lamotrigine,lamot rigine (green) 06/01/2018 lamotrigine,lamot rigine (orange) lamotrigine lamotrigine lamotrigine 06/01/2018 lansoprazole lansoprazole 06/01/2018 lansoprazole lansoprazole ADD UM: QUANTITY 30 / 30 DAYS 06/01/2018 lansoprazole lansoprazole 06/01/2018 lansoprazole lansoprazole ADD UM: QUANTITY 30 / 30 DAYS 06/01/2018 levoleucovorin calcium 06/01/2018 MAKENA hydroxyprogesterone caproate/pf levoleucovorin calcium 06/01/2018 mesalamine mesalamine 06/01/2018 ORFADIN nitisinone 06/01/2018 palonosetron hcl palonosetron hcl 06/01/2018 palonosetron hcl palonosetron hcl 06/01/2018 PLEGRIDY peginterferon beta-1a 06/01/2018 PLEGRIDY peginterferon beta-1a ADD UM: QUANTITY 2 / 365 OVER 06/01/2018 ritonavir ritonavir 06/01/2018 RUBRACA rucaparib camsylate 06/01/2018 RUBRACA rucaparib camsylate ADD UM: QUANTITY 120 / 30 DAYS 06/01/2018 SYLVANT siltuximab 06/01/2018 SYMFI LO efavirenz/lamivudine/tenofov ir disoproxil fumarate PAGE 16 UPDATED 11/2018
06/01/2018 SYMFI LO efavirenz/lamivudine/tenofov ir disoproxil fumarate ADD UM: QUANTITY 30 / 30 DAYS 06/01/2018 tiagabine hcl tiagabine hcl 06/01/2018 tiagabine hcl tiagabine hcl 06/01/2018 TRESIBA FLEXTOUCH U- 100 06/01/2018 TRESIBA FLEXTOUCH U- 200 06/01/2018 triamcinolone acetonide 06/01/2018 tydemy drospirenone/ethinyl /levomefolate calcium insulin degludec insulin degludec triamcinolone acetonide 06/01/2018 VIRAMUNE nevirapine 06/01/2018 ZYTIGA abiraterone acetate 06/01/2018 melodetta 24 fe norethindrone acetateethinyl /ferrous fumarate 06/01/2018 SYNAGIS palivizumab 06/01/2018 IMBRUVICA ibrutinib PAGE 17 UPDATED 11/2018
July, 2018 07/01/2018 virtussin ac codeine phosphate/guaifenesin 07/01/2018 HUMIRA adalimumab 07/01/2018 HUMIRA PEDIATRIC CROHN'S adalimumab 07/01/2018 HUMIRA PEN adalimumab 07/01/2018 HUMIRA PEDIATRIC CROHN'S adalimumab 07/01/2018 HUMIRA adalimumab 07/01/2018 ZENPEP lipase/protease/amylase 07/01/2018 BENZNIDAZOLE benznidazole 07/01/2018 BENZNIDAZOLE benznidazole 07/01/2018 syeda ethinyl /drospirenone 07/01/2018 tri-vylibra norgestimate-ethinyl 07/01/2018 vylibra norgestimate-ethinyl 07/01/2018 TOUJEO MAX SOLOSTAR 07/01/2018 methylphenidate la,methylphenidat e er insulin glargine,human recombinant analog methylphenidate hcl PAGE 18 UPDATED 11/2018
07/01/2018 methylphenidate la,methylphenidat e er 07/01/2018 methylphenidate er 07/01/2018 methylphenidate er methylphenidate hcl ADD UM: QUANTITY 180 / 30 DAYS methylphenidate hcl methylphenidate hcl ADD UM: QUANTITY 30 / 30 DAYS 07/01/2018 TASIGNA nilotinib hcl PAGE 19 UPDATED 11/2018
August, 2018 08/01/2018 baclofen baclofen 08/01/2018 ciprofloxacin hcl ciprofloxacin hcl 08/01/2018 colesevelam hcl colesevelam hcl 08/01/2018 estarylla norgestimate-ethinyl 08/01/2018 mili norgestimate-ethinyl 08/01/2018 tri-mili norgestimate-ethinyl 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 30 / 30 DAYS 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 60 / 30 DAYS 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 30 / 30 DAYS 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl ADD UM: QUANTITY 60 / 30 DAYS 08/01/2018 HUMIRA adalimumab 08/01/2018 SYNJARDY XR empagliflozin/metformin hcl 08/01/2018 NORVIR ritonavir 08/01/2018 SYMFI efavirenz/lamivudine/tenofov ir disoproxil fumarate 08/01/2018 SYMFI efavirenz/lamivudine/tenofov ir disoproxil fumarate ADD UM: QUANTITY 30 / 30 DAYS 08/01/2018 TAVALISSE fostamatinib disodium PAGE 20 UPDATED 11/2018
08/01/2018 TAVALISSE fostamatinib disodium ADD UM: QUANTITY 60 / 30 DAYS 08/01/2018 TAVALISSE fostamatinib disodium 08/01/2018 TAVALISSE fostamatinib disodium ADD UM: QUANTITY 60 / 30 DAYS 08/01/2018 JYNARQUE tolvaptan 08/01/2018 JYNARQUE tolvaptan ADD UM: QUANTITY 56 / 28 DAYS 08/01/2018 JYNARQUE tolvaptan 08/01/2018 JYNARQUE tolvaptan ADD UM: QUANTITY 56 / 28 DAYS 08/01/2018 JYNARQUE tolvaptan 08/01/2018 JYNARQUE tolvaptan ADD UM: QUANTITY 56 / 28 DAYS 08/21/2018 GLEOSTINE lomustine 08/21/2018 GLEOSTINE lomustine 08/21/2018 GLEOSTINE lomustine PAGE 21 UPDATED 11/2018
October, 2018 10/01/2018 budesonide er budesonide 10/01/2018 BROMSITE bromfenac sodium 10/01/2018 BROMSITE bromfenac sodium ADD UM: QUANTITY 20 / 365 OVER 10/01/2018 TRELEGY ELLIPTA 10/01/2018 TRELEGY ELLIPTA fluticasone furoate/umeclidinium bromide/vilanterol trifenat fluticasone furoate/umeclidinium bromide/vilanterol trifenat 10/01/2018 CIMDUO lamivudine/tenofovir disoproxil fumarate 10/01/2018 CIMDUO lamivudine/tenofovir disoproxil fumarate 10/01/2018 YONSA abiraterone acetate, submicronized ADD UM: QUANTITY ADD UM: QUANTITY 60 / 30 DAYS 30 / 30 DAYS 10/01/2018 LUCEMYRA lofexidine hcl 10/01/2018 LUCEMYRA lofexidine hcl ADD UM: QUANTITY 480 / 30 DAYS 10/01/2018 OLUMIANT baricitinib 10/01/2018 XELJANZ tofacitinib citrate 10/01/2018 miglustat miglustat 10/01/2018 ILEVRO nepafenac CHANGE UM: QUANTITY 6 / 30 days 6 / 30 OVER 10/01/2018 COTELLIC cobimetinib fumarate REMOVE UM: QUANTITY 90 / 30 days 10/02/2018 oseltamivir phosphate oseltamivir phosphate CHANGE UM: QUANTITY 110 / 365 days 110 / 365 OVER PAGE 22 UPDATED 11/2018
10/02/2018 ESTRING CHANGE UM: QUANTITY 1 / 90 days 1 / 90 OVER PAGE 23 UPDATED 11/2018
November, 2018 11/01/2018 HUMIRA PEN CROHN-UC-HS STARTER 11/01/2018 HUMIRA PEN PSORIASIS- UVEITIS adalimumab adalimumab 11/01/2018 RHOPRESSA netarsudil mesylate 11/01/2018 RHOPRESSA netarsudil mesylate ADD UM: QUANTITY 2.5 / 25 DAYS 11/01/2018 incassia norethindrone 11/01/2018 ALPHAGAN P brimonidine tartrate 11/01/2018 SPIRIVA RESPIMAT 11/01/2018 STIOLTO RESPIMAT tiotropium bromide CHANGE UM: QUANTITY 4 / 30 days 8 / 28 DAYS tiotropium bromide/olodaterol hcl CHANGE UM: QUANTITY 4 / 30 days 8 / 28 DAYS PAGE 24 UPDATED 11/2018