March/April 2017 Effective Date Brand Name Name Type of Change Previous Value New Value SPS sodium polystyrene sulfonate/sorbitol solution ORKAMBI ADRENACLICK ADRENACLICK levalbuterol tartrate hfa EXONDYS 51 EXONDYS 51 mesalamine PEDIARIX lumacaftor/ivacaftor epinephrine epinephrine levalbuterol tartrate eteplirsen eteplirsen mesalamine hep b virus,rcmb/dipth,pertus(acell ),tet,polio vaccine/pf KINRIX diphtheria, pertussis(acell),tetanus,polio vaccine/pf IMOGAM RABIES-HT rabies immune globulin/pf GAMMAGARD S- immune D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml GAMMAGARD S- immune D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml mycophenolate mofetil mycophenolate mofetil hcl Brands Brands Brands Brands Brands BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 1 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value ORENCIA CLICKJECT abatacept INFLECTRA infliximab-dyyb ethynodiol-ethinyl ethynodiol diacetate-ethinyl estradiol estradiol AMABELZ AMABELZ FEMYNOR LARISSIA ALYACEN CAMRESE LO estradiol/norethindrone acetate estradiol/norethindrone acetate norgestimate-ethinyl estradiol levonorgestrel-ethinyl estradiol norethindrone-ethinyl estradiol levonorgestrel/ethinyl estradiol and ethinyl estradiol norethin-eth norethindrone-ethinyl estra-ferrous fum estradiol/ferrous fumarate drospirenone-eth drospirenone/ethinyl estra-levomef estradiol/levomefolate calcium prednisone prednisone flurandrenoli TRIDESILON flurandrenoli soni REMOVE FROM FORMULARY MYTESI crofelemer Non- Drug BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 2 UPDATED 04/2017
Effective Date Brand Name RELISTOR OCALIVA Name methylnaltrexone bromi obeticholic acid Type of Change Previous Value New Value Brands OCALIVA obeticholic acid PANCREAZE PERTZYE clindamycin phos-tretinoin MICORT-HC ALA-CORT lipase/protease/amylase lipase/protease/amylase clindamycin phosphate/tretinoin hydrocortisone acetate hydrocortisone Brands Brands methylphenidate methylphenidate hcl hcl cd,methylphenida te hcl er methylphenidate methylphenidate hcl hcl cd,methylphenida te hcl er GONITRO nitroglycerin nitroglycerin REPATHA PUSHTRONEX nitroglycerin nitroglycerin nitroglycerin evolocumab QBRELIS lisinopril olmesartan medoxomil olmesartan medoxomil Brands Brands Brands AFREZZA insulin regular, human Brands BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 3 UPDATED 04/2017
Effective Date Brand Name AFREZZA Name insulin regular, human BASAGLAR insulin glargine,human KWIKPEN U-100 recombinant analog INVOKAMET XR canagliflozin/metformin hcl INVOKAMET XR canagliflozin/metformin hcl INVOKAMET XR canagliflozin/metformin hcl INVOKAMET XR canagliflozin/metformin hcl metformin hcl er metformin hcl Type of Change Previous Value New Value metformin hcl er metformin hcl oseltamivir phosphate oseltamivir phosphate oseltamivir phosphate abacavirlamivudine oseltamivir phosphate oseltamivir phosphate oseltamivir phosphate abacavir sulfate/lamivudine valganciclovir hcl valganciclovir hcl quetiapine fumarate er quetiapine fumarate er quetiapine fumarate er quetiapine fumarate er quetiapine fumarate quetiapine fumarate quetiapine fumarate quetiapine fumarate Brands Brands Brands Brands Brands Brands BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 4 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value quetiapine fumarate er rasagiline mesylate rasagiline mesylate pramipexole er KYPROLIS KYPROLIS RUBRACA RUBRACA epirubicin hcl nilutami YONDELIS TREXIMET ergotaminecaffeine allopurinol sodium quetiapine fumarate rasagiline mesylate rasagiline mesylate pramipexole di-hcl carfilzomib carfilzomib rucaparib camsylate rucaparib camsylate epirubicin hcl nilutami trabectedin sumatriptan succinate/naproxen sodium ergotamine tartrate/caffeine allopurinol sodium REMOVE FROM FORMULARY Brands GAMASTAN S-D immune Brands globulin,gamma(igg)/glycine LARTRUVO EMEND aprepitant aprepitant olaratumab aprepitant aprepitant aprepitant Brands BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 5 UPDATED 04/2017
Effective Date Brand Name aprepitant aprepitant NAMZARIC memantine hcl/donepezil hcl NAMZARIC NAMZARIC erythromycin ethylsuccinate ofloxacin EVZIO nitroglycerin Name Type of Change Previous Value New Value memantine hcl/donepezil hcl memantine hcl/donepezil hcl erythromycin ethylsuccinate ofloxacin naloxone hcl nitroglycerin CAZIANT sogestrel-ethinyl estradiol norgestimateethinyl estradiol norgestimate-ethinyl estradiol YUVAFEM estradiol AMETHIA LO levonorgestrel/ethinyl estradiol and ethinyl estradiol Non- Drug Non- Drug Non- Drug Brands norethindron- norethindrone acetate- ethinyl estradiol ethinyl estradiol ZARAH ethinyl estradiol/drospirenone prednisone prednisone ezetimibe ezetimibe ethacrynic acid ethacrynic acid BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 6 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value olmesartan-hctz olmesartan medoxomil/ besylate/hydrochlorothiazi olmesartan-hctz olmesartan medoxomil/ besylate/hydrochlorothiazi olmesartan- -hctz olmesartan medoxomil/ besylate/hydrochlorothiazi olmesartan- olmesartan hydrochlorothiazi medoxomil/hydrochlorothiazi olmesartan- olmesartan hydrochlorothiazi medoxomil/hydrochlorothiazi olmesartan- olmesartan hydrochlorothiazi medoxomil/hydrochlorothiazi olmesartan olmesartan olmesartan olmesartan olmesartan-hctz besylate/olmesartan medoxomil besylate/olmesartan medoxomil besylate/olmesartan medoxomil besylate/olmesartan medoxomil olmesartan medoxomil/ besylate/hydrochlorothiazi BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 7 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value olmesartan-hctz olmesartan medoxomil olmesartan medoxomil aprepitant OTREXUP daptomycin omeprazolesodium bicarbonate omeprazolesodium bicarbonate besylate atorvastatin calcium atorvastatin calcium metoprolol tartrate metoprolol succinate metoprolol succinate metoprolol succinate olmesartan medoxomil/ besylate/hydrochlorothiazi olmesartan medoxomil olmesartan medoxomil aprepitant methotrexate/pf daptomycin omeprazole/sodium bicarbonate omeprazole/sodium bicarbonate besylate atorvastatin calcium atorvastatin calcium metoprolol tartrate metoprolol succinate metoprolol succinate metoprolol succinate REMOVE FROM FORMULARY REMOVE FROM FORMULARY Brands BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 8 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value fenofibrate fenofibrate nanocrystallized fenofibrate fenofibrate pravastatin sodium warfarin sodium warfarin sodium warfarin sodium warfarin sodium nifedipine er,nifedipine pravastatin sodium warfarin sodium warfarin sodium warfarin sodium warfarin sodium nifedipine nifedipine nifedipine er,nifedipine nifedipine er nifedipine glipizi er glipizi glipizi xl glipizi duloxetine hcl duloxetine hcl duloxetine hcl glimepiri duloxetine hcl glimepiri BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 9 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value NIFEDICAL XL nifedipine NIFEDICAL XL nifedipine enalapril maleate enalapril maleate diltiazem er diltiazem hcl ADD UM: QUANTITY diltiazem 24hr cd diltiazem hcl diltiazem 24hr er diltiazem hcl diltiazem 24hr er,diltiazem er diltiazem hcl bumetani bumetani bumetani bumetani pioglitazone hcl pioglitazone hcl pioglitazone hcl pioglitazone hcl azathioprine azathioprine sodium sodium abacavirlamivudine abacavir sulfate/lamivudine ELIQUIS apixaban CHANGE UM: QUANTITY oxybutynin chlori er oxybutynin chlori CHANGE UM: QUANTITY 2 / 1 DAYS 1 / 1 DAYS 1 / 1 DAYS 74 / 30 DAYS 2 / 1 DAYS BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 10 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value GENTAK gentamicin sulfate hydrocortisone hydrocortisone hydrocortisone hydrocortisone ACTEMRA tocilizumab SF 5000 PLUS sodium fluori ZERIT stavudine lopinavir-ritonavir lopinavir/ritonavir norgestimateethinyl estradiol norgestimate-ethinyl estradiol azithromycin azithromycin REMOVE UM: QUANTITY oxiconazole nitrate oxiconazole nitrate SOLU-MEDROL methylprednisolone sodium succinate/pf,methylprednisol one sodium succinate spironolactone spironolactone torsemi verapamil er,verapamil hcl verapamil sr spironolactone spironolactone torsemi verapamil hcl verapamil hcl 10 / 30 DAYS Brands Brands BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 11 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value warfarin sodium warfarin sodium warfarin sodium warfarin sodium warfarin sodium warfarin sodium ramipril ramipril propranolol hcl propranolol hcl propranolol hcl propranolol hcl metoprolol succinate metoprolol succinate metformin hcl er metformin hcl lamotrigine lamotrigine labetalol hcl isosorbi mononitrate er glipizimetformin fenofibrate labetalol hcl isosorbi mononitrate glipizi/metformin hcl fenofibrate nanocrystallized enalapril- enalapril hydrochlorothiazi maleate/hydrochlorothiazi enalapril maleate enalapril maleate PAGE 12 BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value enalapril maleate enalapril maleate duloxetine hcl diltiazem 24hr er,diltiazem er duloxetine hcl diltiazem hcl diltiazem 24hr cd diltiazem hcl diltiazem 24hr er diltiazem hcl diltiazem 24hr er,diltiazem er diltiazem hcl diltiazem 24hr cd diltiazem hcl diltiazem 24hr er diltiazem hcl diltiazem 24hr er diltiazem hcl diltiazem 24hr er diltiazem hcl diltiazem 24hr cd diltiazem hcl diltiazem 24hr er,diltiazem er abacavir bumetani diltiazem 24hr er,diltiazem er diltiazem hcl abacavir sulfate bumetani diltiazem hcl BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 13 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value diltiazem 24hr er diltiazem hcl diltiazem 24hr cd diltiazem hcl diltiazem 24hr er diltiazem hcl acarbose acarbose acetazolami acetazolami acetazolami acetazolami valsartan besylate/valsartan captopril captopril DILT-XR diltiazem hcl diltiazem hcl diltiazem hcl diltiazem hcl fenofibrate fenofibrate diltiazem hcl fenofibrate,micronized fenofibrate glipizi- glipizi/metformin hcl metformin irbesartan- irbesartan/hydrochlorothiazi hydrochlorothiazi BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 14 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value lamivudine lamivudine lamivudine lamivudine nisoldipine nisoldipine propranolol hcl propranolol hcl propranolol hcl propranolol hcl propranolol hcl propranolol hcl er,propranolol hcl propranolol hcl er,propranolol hcl propranolol hcl er,propranolol hcl propranolol hcl er,propranolol hcl quinapril hcl verapamil er,verapamil hcl verapamil sr verapamil er verapamil sr zidovudine propranolol hcl propranolol hcl propranolol hcl quinapril hcl verapamil hcl verapamil hcl verapamil hcl verapamil hcl zidovudine BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 15 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value besylate besylate CHANGE UM: QUANTITY 2 / 1 DAYS 3 / 1 DAYS SOLU-MEDROL methylprednisolone sodium succinate DILT-CD,DILT- XR diltiazem hcl Brands BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 16 UPDATED 04/2017
June 2017 Effective Date Brand Name Name Type of Change Previous Value New Value sotalol,sotalol af sotalol hcl acarbose acarbose acebutolol hcl acebutolol hcl atorvastatin besylate/atorvastatin calcium atorvastatin atorvastatin valsartan valsartan-hctz besylate/atorvastatin calcium besylate/atorvastatin calcium besylate/valsartan besylate/valsartan/hydrochlo rothiazi valsartan-hctz besylate/valsartan/hydrochlo rothiazi benazepril- benazepril hydrochlorothiazi hcl/hydrochlorothiazi benazepril- benazepril hydrochlorothiazi hcl/hydrochlorothiazi BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 17 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value benazepril- benazepril hydrochlorothiazi hcl/hydrochlorothiazi bisoprolol fumarate bisoprolol fumarate captopril captopril captopril/hydrochlorothiazi captoprilhydrochlorothiazi er er er er telmisartan telmisartan telmisartan telmisartan timolol maleate timolol maleate quinapril hcl quinapril hcl BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 18 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value quinapril- quinapril hydrochlorothiazi hcl/hydrochlorothiazi quinapril- quinapril hydrochlorothiazi hcl/hydrochlorothiazi propafenone hcl propafenone hcl nisoldipine mexiletine hcl nisoldipine mexiletine hcl metoprolol- metoprolol hydrochlorothiazi tartrate/hydrochlorothiazi fenofibrate fenofibrate,micronized fenofibric acid fenofibric acid (choline) diltiazem 24hr er diltiazem hcl diltiazem hcl diltiazem hcl diltiazem 12hr er diltiazem hcl diltiazem 12hr er diltiazem hcl DILT-CD,DILT- diltiazem hcl XR verapamil hcl verapamil hcl BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 19 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value pravastatin sodium butalbital compoundcoine,asacoine phosphate/butalbital/aspirin/ caffeine butalb-caffeinecoine pravastatin sodium JOLIVETTE norethindrone cyclopentolate hcl cyclopentolate hcl svenlafaxine succinate er svenlafaxine succinate er svenlafaxine succinate er besylatebenazepril besylatebenazepril besylatebenazepril besylatebenazepril cyclopentolate hcl cyclopentolate hcl svenlafaxine succinate svenlafaxine succinate svenlafaxine succinate besylate/benazepril hcl besylate/benazepril hcl besylate/benazepril hcl besylate/benazepril hcl BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 20 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value besylatebenazepril besylatebenazepril besylate/benazepril hcl besylate/benazepril hcl glipizi glipizi er,glipizi xl valsartan valsartan valsartan valsartan valsartan valsartan valsartan valsartan valsartan- valsartan/hydrochlorothiazid hydrochlorothiazi e valsartan- valsartan/hydrochlorothiazid hydrochlorothiazi e valsartan- valsartan/hydrochlorothiazid hydrochlorothiazi e valsartan- valsartan/hydrochlorothiazid hydrochlorothiazi e valsartan- valsartan/hydrochlorothiazid hydrochlorothiazi e BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 21 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value irbesartan irbesartan irbesartan irbesartan cansartan cilexetil captopril irbesartan irbesartan cansartan cilexetil captopril fosinopril sodium fosinopril sodium fosinopril sodium fosinopril sodium pioglitazoneglimepiri pioglitazonemetformin pioglitazonemetformin glyburi glyburi glyburi pioglitazone hcl/glimepiri pioglitazone hcl/metformin hcl pioglitazone hcl/metformin hcl glyburi glyburi glyburi BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 22 UPDATED 04/2017
Effective Date Brand Name Name Type of Change Previous Value New Value NAMZARIC memantine hcl/donepezil hcl Non- Drug NAMZARIC memantine hcl/donepezil hcl Non- Drug SELZENTRY SELZENTRY maraviroc maraviroc methylphenidate methylphenidate hcl la EMFLAZA EMFLAZA EMFLAZA EMFLAZA EMFLAZA flurandrenoli prednisolone sodium phosphate prednisolone sodium phosphate LINZESS LINZESS calcium acetate butalbitalacetaminophen flazacort flazacort flazacort flazacort flazacort flurandrenoli prednisolone sod phosphate Brands Brands prednisolone sod phosphate linacloti linacloti calcium acetate butalbital/acetaminophen methylphenidate methylphenidate hcl er,methylphenida te la ADD UM: QUANTITY REMOVE FROM FORMULARY 1 / 1 DAYS Brands BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 23 UPDATED 04/2017