Magellan Rx Formulary - GatorCare · Magellan Rx Formulary Precision Formulary Updates The Magellan...

LABEL NAME INDICATIONS SIMILAR PRODUCTSª CHANGE TYPE PRECISION PRECISION UM EFFECTIVE DATE

KEPPRA 1,000 MG TABLETanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

KEPPRA 100 MG/ML ORAL SOLNanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

KEPPRA 250 MG TABLETanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20



KEPPRA XR 500 MG TABLETanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

KEPPRA XR 750 MG TABLETanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL 100 MG TABLETanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20



LAMICTAL 25 MG DISPER TABLETanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20


LAMICTAL 5 MG DISPER TABLETanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL ODT 100 MG TABLETanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20




LAMICTAL ODT START KIT (BLUE)anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL ODT START KIT (GREEN)anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL ODT START KT (ORANGE)anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL TAB START KIT (BLUE)anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL TAB START KIT (GREEN)anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL TB START KIT (ORANGE)anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL XR 100 MG TABLETanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20


Magellan Rx FormularyPrecision Formulary Updates

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 determine updates that are needed due to newly approved products, changes in

practice guidelines, updates in FDA approved labeling and/or changes in financial implications. The following is the list of determinations made through this review process for the Magellan Rx Precision commercial formularies.

NEW DRUGS






LAMICTAL XR START KIT (BLUE)anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL XR START KIT (GREEN)anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL XR START KIT (ORANGE)anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMOTRIGINE 100 MG TABLETanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20



LAMOTRIGINE 25 MG DISPER TABanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20


LAMOTRIGINE 5 MG DISPER TABLETanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LAMOTRIGINE ER 100 MG TABLETanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20






LAMOTRIGINE ODT 100 MG TABLETanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20




LAMOTRIGINE ODT KIT (BLUE)anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LAMOTRIGINE ODT KIT (GREEN)anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LAMOTRIGINE ODT KIT (ORANGE)anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LAMOTRIGINE TAB START KIT-BLUEanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LAMOTRIGINE TAB START KT-GREENanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LAMOTRIGINE TAB START KT-ORANGanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LEVETIRACETAM 1,000 MG TABLETanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LEVETIRACETAM 100 MG/ML SOLNanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LEVETIRACETAM 250 MG TABLETanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20


LEVETIRACETAM 500 MG/5 ML SOLNanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

If you have questions on this update, please contact your Magellan Rx Management account manager. This document is not intended for member distribution.

2019 Magellan Rx Management, LLC. All rights expressly reserved.

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LEVETIRACETAM ER 500 MG TABLETanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LEVETIRACETAM ER 750 MG TABLETanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

OXCARBAZEPINE 150 MG TABLETanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20


OXCARBAZEPINE 300 MG/5 ML SUSPanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20


OXTELLAR XR 150 MG TABLETanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20



ROWEEPRA 1,000 MG TABLETanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

ROWEEPRA 500 MG TABLETanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

ROWEEPRA 750 MG TABLETanticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

SPRITAM 1,000 MG TABLETanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

SPRITAM 250 MG TABLETanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20



TRILEPTAL 150 MG TABLETanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20


TRILEPTAL 300 MG/5 ML SUSPanticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20


CHOLECAL DF 95 MCG-1 MG TABLETvitamin deficiency; vitamin deficiency prevention CIFRAZOL, DURACHOL

NEW BRAND NF May-20

EPINEPHRINE PROFESSIONAL KITTreatment of anaphylaxis in adults and children EPINEPHRINESNAP-EMS KIT

NEW BRAND NF May-20

EPINEPHRINE PROFESSIONL EMS KTTreatment of anaphylaxis in adults and children EPINEPHRINESNAP-EMS KIT

NEW BRAND NF May-20

PHENOBARB-HYO-ATROP-SCOP ELIXDuodenal ulcer PHENOHYTRO ELIXIR

NEW GENERIC NF May-20

PHENOBARB-HYOSC-ATROP-SCOP TABDuodenal ulcer BELLADONNA-PHENOBARBITAL TAB

NEW GENERIC NF May-20

AZESCHEW CHEWABLE TABLETPrenatal/postnatal supplement chew vitamin ALIVE PRENATAL GUMMY, CLASSIC PRENATAL

NEW BRAND NF May-20

VOLNEA 0.15-0.02-0.01 MG TABpregnancy contraception AZURETTE 28 DAY, MIRCETTE 28 DAY

NEW GENERIC GEN May-20

ZIPRASIDONE 20 MG/ML VIALAgitation associated with Schizophrenia GEODON 20 MG/ML


AZELASTIN-FLUTIC 137-50MCG SPRseasonal allergic rhinitis DYMISTA NASAL SPRAY

NEW GENERIC GEN QL: 0.8/day May-20

JAIMIESS 0.15-0.03-0.01 MG TABpregnancy contraception AMETHIA, SEASONIQUE

NEW GENERIC GEN QL: 91 Days May-20

LOJAIMIESS 0.1-0.02-0.01 TABpregnancy contraception AMETHIA LO, LOSEASONIQUE

NEW GENERIC GEN QL: 91 Days May-20



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SODIUM FLUORIDE 5000 PPM CREAMprevention of dental caries FLUORIDE 5000 PPM


AJOVY 225 MG/1.5 ML AUTOINJECTmigraine prevention AJOVY 225 MG/1.5 ML SYRINGE

NEW BRAND NF May-20

PROMACTA 25 MG SUSPENSION PCKT aplastic anemia; severe thrombocytopenia in refractory chronic ITP;

thrombocytopenia associated with chronic hepatitis C PROMACTA 12.5 MG SUSPEN, PROMACTA 25 MGNEW FORMULATION NPS PA May-20

HIZENTRA 1 GRAM/5 ML SYRINGE Immunoglobulin used to treat Primary Immunodeficiency (PI) and Chronic

Inflammatory Demyelinating Polyneuropathy (CIDP) HIZENTRA VIALNEW FORMULATION NPS PA May-20





ARAZLO 0.045% LOTIONacne vulgaris TAZAROTENE 0.1% CREAM, ALTRENO LOTION 0.05%

NEW BRAND NF Oct-20

INSULIN LISPRO JR 100 UNIT/MLDiabetes mellitus HUMALOG JR 100 UNIT/ML KWIKPEN

NEW GENERIC NF Jul-20

INSULIN LISPRO MIX 75-25 KWKPNDiabetes mellitus

HUMALOG MIX 75-25 KWKPN NEW GENERIC NF Jul-20

KOSELUGO 10 MG CAPSULEPediatric neurofibromatosis type 1 with plexiform neurofibromas

NEW BRAND NPS PA, QL: 4 cap/day Oct-20

KOSELUGO 25 MG CAPSULEPediatric neurofibromatosis type 1 with plexiform neurofibromas

NEW BRAND NPS PA, QL: 4 cap/day Oct-20

NEXLETOL 180 MG TABLET atherosclerotic cardiovascular disease; heterozygous familial

hypercholesterolemia

EZETIMIBE, FENOFIBRATE NEW BRAND NPB PA, QL: 1 tab/day Oct-20

PEMAZYRE 13.5 MG TABLETcholangiocarcinoma with FGFR2 fusion or rearrangement

NEW BRAND NPS PA, QL: 0.67/day Oct-20

PEMAZYRE 4.5 MG TABLETcholangiocarcinoma with FGFR2 fusion or rearrangement


PEMAZYRE 9 MG TABLETcholangiocarcinoma with FGFR2 fusion or rearrangement


TUKYSA 150 MG TABLETHERCEPTIN, KANJINTI, OGIVRI

NEW BRAND NPS PA, QL: 4 tabs/day Oct-20

TUKYSA 50 MG TABLETHERCEPTIN, KANJINTI, OGIVRI

NEW BRAND NPS PA, QL: 4 tabs/day Oct-20

XCOPRI 100 MG TABLETpartial-onset seizures OXCARBAZEPINE TABLETS, APTIOM TABLETS

NEW BRAND NPB PA, QL: 400 mg/day Oct-20





XCOPRI 250 MG DAILY DOSE PACKpartial-onset seizures OXCARBAZEPINE TABLETS, APTIOM TABLETS


XCOPRI 350 MG DAILY DOSE PACKpartial-onset seizures OXCARBAZEPINE TABLETS, APTIOM TABLETS


POSACONAZOLE DR 100 MG TABLET Treatment of oropharyngeal candidiasis and prophylaxis of invasive

Aspergillus and Candida Infections NOXAFIL DR 100 MG TABLETCOVERAGE UPDATE NF-->GEN May-20

FASENRA 30 MG/ML SYRINGE severe asthma DUPIXENT, NUCALAQL ADDITION PS PA, QL: 0.04/day May-20

FASENRA PEN 30 MG/ML severe asthma DUPIXENT, NUCALAQL ADDITION PS PA, QL: 0.04/day May-20

XOLAIR 150 MG VIAL moderate to severe asthma; chronic idiopathic urticaria DUPIXENT, NUCALAQL ADDITION PS PA, QL: 0.22/day May-20

XOLAIR 150 MG/ML SYRINGE moderate to severe asthma; chronic idiopathic urticaria DUPIXENT, NUCALAQL ADDITION PS PA, QL: 0.15/day May-20

XOLAIR 75 MG/0.5 ML SYRINGE moderate to severe asthma; chronic idiopathic urticaria DUPIXENT, NUCALAQL ADDITION PS PA, QL: 0.04/day May-20

BASADROX WOUND GEL Management of 1st and 2nd degree burns NEW BRAND NF Jun-20

Indicated in combination with trastuzumab and capecitabine for treatment of

adult patients with advanced unresectable or metastatic HER2-positive breast

cancer, including patients with brain metastases, who have received one or

more prior antiHER2-based regimens in the metastatic setting.



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CICASIL 2"X5.5" PAD Managing hypertrophic, hyperpigmented and keloid scar tissue. NEW BRAND NF Jun-20

EPINEPHRINE 30 MG/30 ML VIAL septic shock; anaphylaxis; allergic reactionadrenalin

NEW GENERIC NF Jun-20

EQUACARE JR POWDER Amino-acid based nutritional powderElecare Jr

NEW BRAND NF Jun-20

HALOG 0.1% SOLUTIONRelief of the inflammatory and pruritic manifestations of corticosteroid-

responsive dermatosesHalog cream, Halog ointment, halcinonide

NEW FORMULATION NF Jun-20

JYNARQUE 15 MG-15 MG TABLETto slow kidney function decline in adults at risk of rapidly progressing

autosomal dominant polycystic kidney disease NEW FORMULATION NPS PA, QL: 2/day Jun-20

JYNARQUE 30 MG-15 MG TABLETto slow kidney function decline in adults at risk of rapidly progressing

autosomal dominant polycystic kidney disease NEW FORMULATION NPS PA, QL: 2/day Jun-20

LORMATE CAPSULEClinical dietary management of suboptimal nutritional status in patients

taking methotrexate NEW BRAND NF Jun-20

NORGESTIMATE-EE 0.25-0.035 MG acne vulgaris; pregnancy contraceptionnorg-ethin estradiol

NEW GENERIC GEN GL Jun-20

NYMALIZE 30 MG/5 ML ORAL SYRNG subarachnoid intracranial hemorrhageNymalize solution

NEW FORMULATION NPB QL: 60/day Jun-20

NYMALIZE 60 MG/10 ML ORAL SYRN subarachnoid intracranial hemorrhageNymalize solution

NEW FORMULATION NPB QL: 60/day Jun-20

OSMOLEX ER 322 MG DAILY DOSE idiopathic parkinsonism; drug-induced extrapyramidal reactionamantadine

NEW FORMULATION NPS PA, QL: 2/day Jun-20

POLYTOZA PATCH non-invasive management of old and new hypertrophic or keloid scars NEW BRAND NF Jun-20

T:SLIM X2 CONTROL-IQ PUMP subcutaneous insulin pump NEW BRAND NF Jun-20

TOLVAPTAN 30 MG TABLET hyponatremia, in HF patients and syndrome of inappropriate antidiuretic

hormone secretion (SIADH)Samsca

NEW GENERIC GEN SP, PA, QL: 2/day Jun-20

TRIVIX KIT

cutaneous T-cell lymphoma; skin inflammation; seborrheic dermatitis; atopic

dermatitis; contact dermatitis; allergic dermatitis; discoid lupus

erythematosus; granuloma annulare; plaque psoriasis; pruritus ani; genital

organ pruritus NEW GENERIC

NF Jun-20

ZIONODIL 3% LOTION pruritus of skin; skin irritation; minor skin wound pain NEW GENERIC NF Jun-20

ZIONODIL-100 3% LOTION pruritus of skin; skin irritation; minor skin wound pain NEW GENERIC NF Jun-20

METHERGINE 0.2 MG TABLET postpartum hemorrhage, prevention of uterine inertia QL ADDITION GEN QL: 6/day Jul-20

METHYLERGONOVINE 0.2 MG TABLET postpartum hemorrhage, prevention of uterine inertia QL ADDITION GEN QL: 6/day Jul-20

METHYLPHENIDATE ER 10 MG CAP attention-deficit hyperactivity disorderAptensio XR

NEW GENERIC GEN QL, add ST Oct-20





METHYLPHENIDATE ER 30 MG CAPattention-deficit hyperactivity disorder

Aptensio XR

NEW GENERICGEN

QL, add STOct-20


Aptensio XR

NEW GENERICGEN

QL, add STOct-20


Aptensio XR

NEW GENERICGEN

QL, add STOct-20


Aptensio XR

NEW GENERICGEN

QL, add STOct-20

CRESTOR 10 MG TABLET rosuvastatin, atorvastatin ST ADDITION NF add ST in

adjudication, QLOct-20





hypercholesterolemia, homozygous familial hypercholesterolemia,

atherosclerotic cardiovascular disease, hyperlipidemia, heterozygous familial

hypercholesterolemia, hypertriglyceridemia, mixed hyperlipidemia,

myocardial infarction prevention, primary dysbetalipoproteinemia, primary

prevention of coronary heart disease, prevention of transient ischemic attack,

prevention of cerebrovascular accident



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FIASP 100 UNIT/ML FLEXTOUCH diabetes mellitus Humalog

DRUG CHANGES NF Oct-20

FIASP 100 UNIT/ML VIAL diabetes mellitus Humalog


FIASP PENFILL 100 UNIT/ML CART diabetes mellitus Humalog


INSULIN ASPART 100 UNIT/ML CRT diabetes mellitus Humalog


INSULIN ASPART 100 UNIT/ML PEN diabetes mellitus Humalog


INSULIN ASPART 100 UNIT/ML VL diabetes mellitus Humalog


INSULIN ASPART PROT-INSULN ASP diabetes mellitus Humalog


INSULIN LISPRO 100 UNIT/ML PEN diabetes mellitus Humalog


INSULIN LISPRO 100 UNIT/ML VL diabetes mellitus Humalog


INSULIN LISPRO JR 100 UNIT/ML diabetes mellitus Humalog


INSULIN LISPRO MIX 75-25 KWKPN diabetes mellitus Humalog


ADMELOG 100 UNIT/ML VIAL diabetes mellitus Humalog


ADMELOG SOLOSTAR 100 UNIT/ML diabetes mellitus Humalog


APIDRA 100 UNITS/ML VIAL diabetes mellitus Humalog


APIDRA SOLOSTAR 100 UNITS/ML diabetes mellitus Humalog


RELISTOR 150 MG TABLET opioid-induced constipation Symproic, Movantik

DRUG CHANGES NF Jul-20

CERDELGA 84 MG CAPSULE Gaucher disease type 1 Zavesca, miglustat

DRUG CHANGES NPS remove QL Oct-20

AZELASTIN-FLUTIC 137-50MCG SPR seasonal allergic rhinitis Dymista

DRUG CHANGES GEN QL, add ST Oct-20

AMZEEQ 4% FOAM

Indicated for the topical treatment of inflammatory lesions of non-nodular

moderate to severe acne vulgaris in adults and pediatric patients 9 years of

age and older generic topical retinoids

DRUG CHANGES NF Jul-20

RETIN-A MICRO PUMP 0.06% GEL Acne vulgaris generic topical retinoids


hypercholesterolemia, homozygous familial hypercholesterolemia,

atherosclerotic cardiovascular disease, hyperlipidemia, heterozygous familial

hypercholesterolemia, hypertriglyceridemia, mixed hyperlipidemia,

myocardial infarction prevention, primary dysbetalipoproteinemia, primary

prevention of coronary heart disease, prevention of transient ischemic attack,

prevention of cerebrovascular accident



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RETIN-A MICRO PUMP 0.08% GEL Acne vulgaris generic topical retinoids


SYMJEPI 0.15 MG/0.3 ML SYRINGE Anaphylaxis generic epinephrine

DRUG CHANGES NF-->NPB add QL (2/fill) Jul-20

SYMJEPI 0.3 MG/0.3 ML SYRINGE Anaphylaxis generic epinephrine

DRUG CHANGES NF-->NPB add QL (2/fill) Jul-20

ACCU-CHEK AVIVA PLUS TEST STRPtest strip; NDC 65702043810 One Touch test strips


ACCU-CHEK GUIDE TEST STRIPtest strip; NDCs 65702071910, 65702070195 One Touch test strips


RELION NOVOLIN 70-30 VIALdiabetes mellitus; NDC 00169183702 Humulin


RELION NOVOLIN 70-30 FLEXPENdiabetes mellitus; NDC 00169300725 Humulin


RELION NOVOLIN N 100 UNIT/MLdiabetes mellitus; NDC 00169183402 Humulin


RELION NOVOLIN R 100 UNIT/MLdiabetes mellitus: NDC 00169183302 Humulin


AKLIEF 0.005% CREAMTopical retinoid indicated for the topical treatment of acne vulgaris in patients

9 years of age and older generic topical retinoids

DRUG CHANGES NPB-->NF Oct-20

VYZULTA 0.024% OPHTH SOLUTIONreduction of intraocular pressure (IOP) in patients with open-angle glaucoma

or ocular hypertension. latanoprost, travoprost

DRUG CHANGES keep NF Jul-20

VYZULTA 0.024% OPHTH SOLUTIONreduction of intraocular pressure (IOP) in patients with open-angle glaucoma

or ocular hypertension. latanoprost, travoprost

DRUG CHANGES keep NF Jul-20

BENSAL HP 3% OINTMENTantifungal DRUG CHANGES NPB-->NF Oct-20

CICLODAN 0.77% CREAMantifungal DRUG CHANGES GEN-->NF Oct-20

CICLODAN 0.77% CREAM KITantifungal DRUG CHANGES NPB-->NF Oct-20

CLOTRIMAZOLE-BETAMETHASONE LOTantifungal DRUG CHANGES GEN-->NF Oct-20

ECOZA 1% FOAMantifungal DRUG CHANGES NPB-->NF Oct-20

ERTACZO 2% CREAMantifungal DRUG CHANGES NPB-->NF Oct-20

EXELDERM 1% CREAMantifungal DRUG CHANGES NPB-->NF Oct-20

EXELDERM 1% SOLUTIONantifungal DRUG CHANGES NPB-->NF Oct-20

NAFTIFINE HCL 1% CREAMantifungal DRUG CHANGES GEN

add STOct-20

NAFTIFINE HCL 2% CREAMantifungal DRUG CHANGES GEN

add STOct-20



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NAFTIFINE HCL 1% GELantifungal DRUG CHANGES GEN

add STOct-20

NAFTIN 2% CREAMantifungal DRUG CHANGES NPB-->NF Oct-20

NAFTIN 1% GELantifungal DRUG CHANGES NPB-->NF Oct-20

NAFTIN 2% GELantifungal DRUG CHANGES NPB-->NF Oct-20

OXICONAZOLE NITRATE 1% CREAMantifungal DRUG CHANGES GEN

add STOct-20

OXISTAT 1% CREAMantifungal DRUG CHANGES NPB-->NF Oct-20

OXISTAT 1% LOTIONantifungal DRUG CHANGES NPB-->NF Oct-20

SULCONAZOLE NITRATE 1% CREAMantifungal DRUG CHANGES GEN-->NF Oct-20

SULCONAZOLE NITRATE 1% SOLNantifungal DRUG CHANGES GEN-->NF Oct-20

EXTINA 2% FOAMantifungal DRUG CHANGES NPB-->NF Oct-20

KETOCONAZOLE 2% FOAMantifungal; Authorized generic NDCs 00378700701, 00378700750 DRUG CHANGES GEN-->NF Oct-20

KETOCONAZOLE 2% FOAMantifungal; ANDA NDCs 45802053232, 45802053233 DRUG CHANGES GEN-->NF Jun-20

KETODAN 2% FOAMantifungal DRUG CHANGES add NF flag Oct-20

LOPROX 0.77% CREAMantifungal DRUG CHANGES add NF flag Jun-20

LOPROX 0.77% TOPICAL SUSPantifungal DRUG CHANGES NPB-->NF Oct-20

LUZU 1% CREAMantifungal DRUG CHANGES NPB-->NF Oct-20

MENTAX 1% CREAMantifungal DRUG CHANGES NPB-->NF Jun-20

MICONAZOLE-ZINC-PETRO 0.25-15%antifungal DRUG CHANGES GEN-->NF Oct-20

VUSION OINTMENTantifungal DRUG CHANGES NPB-->NF Jun-20

SOLODYN ER 55 MG TABLET acne vulgaris minocycline ER tablet

DRUG CHANGES keep NF Oct-20





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COREMINO ER 135 MG TABLET acne vulgaris minocycline ER tablet

DRUG CHANGES GEN QL, no revised ST Oct-20





MINOCYCLINE ER 105 MG TABLET acne vulgaris Solodyn ER, Coremino ER
















BASAGLAR 100 UNIT/ML KWIKPEN diabetes mellitus Lantus, Levemir, Toujeo, Tresiba

CRITERIA UPDATE NF Jul-20

FARXIGA 5 MG TABLET type 2 diabetes, heart failure Jardiance, Invokana

CRITERIA UPDATE NF-->PBST (allow HF

diagnosis)Jul-20

FARXIGA 10 MG TABLET type 2 diabetes, heart failure Jardiance, Invokana

CRITERIA UPDATE NF-->PBST (allow HF

diagnosis)Jul-20

CEREZYME 400 UNIT VIAL enzyme replacement therapy for type I Gaucher disease Elelyso, VprivCRITERIA UPDATE NPB revise PA, BSP Oct-20



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ZERVIATE 0.24% EYE DROPallergic conjunctivitis OLOPATADINE, AZELASTINE, PAZEO

NEW BRAND NF Jul-20

TRIJARDY XR 10-5-1,000 MG TAB type 2 diabetes mellitus GLYXAMBI, QTERN, STEGLUJANNEW BRAND PB QL: 1/day, class ST Jul-20

TRIJARDY XR 25-5-1,000 MG TAB type 2 diabetes mellitus GLYXAMBI, QTERN, STEGLUJANNEW BRAND PB QL: 1/day, class ST Jul-20

TRIJARDY XR 12.5-2.5-1,000 MG type 2 diabetes mellitus GLYXAMBI, QTERN, STEGLUJANNEW BRAND PB QL: 2/day, class ST Jul-20

TRIJARDY XR 5-2.5-1,000 MG TAB type 2 diabetes mellitus GLYXAMBI, QTERN, STEGLUJANNEW BRAND PB QL: 2/day, class ST Jul-20

NURTEC ODT 75 MG TABLET CGRP for acute treatment of migraine UBRELVYNEW BRAND NPB PA, QL: 2/30 days Jul-20

SUNOSI 75 MG TABLET Narcolepsy Syndrome; Sleepiness Due To Obstructive Sleep Apnea

ARMODAFINIL, MODAFINIL, DRUG CHANGES NPB-->PB PA, QL Oct-20

SUNOSI 150 MG TABLET Narcolepsy Syndrome; Sleepiness Due To Obstructive Sleep Apnea

ARMODAFINIL, MODAFINIL, DRUG CHANGES NPB-->PB PA, QL Oct-20

XIMINO ER 135 MG CAPSULE acne vulgaris MINOCYCLINE ER CAPSULE DRUG CHANGES NF Oct-20



SOLODYN ER 55 MG TABLET acne vulgaris MINOCYCLINE ER TABLET DRUG CHANGES NF-->NPB QL Oct-20





MINOCYCLINE ER 135 MG CAPSULEacne vulgaris XIMINO ER CAPSULE

NEW GENERIC NF Oct-20





MINOCIN 100 MG PELLETIZED CAP

relapsing fever, bartonellosis, syphilis, gingivostomatitis, upper respiratory

pneumococcal infection, bacterial pneumonia, mycoplasmal pneumonia,

lymphogranuloma venereum, granuloma inguinale, sinusitis, genitourinary

Chlamydia trachomatis infection, fusospirochetal pharyngitis, yaws, acne

vulgaris, bacterial urinary tract infection, acute bacterial otitis media,

pharyngitis, cholera, plague, tularemia, anthrax, brucellosis, listeriosis, skin

and skin structure infection, meningococcal carrier, actinomycosis, MINOCYCLINE CAPSULE



rickettsialpox, relapsing fever, bartonellosis, syphilis, gingivostomatitis, upper

respiratory pneumococcal infection, bacterial pneumonia, mycoplasmal

pneumonia, lymphogranuloma venereum, granuloma inguinale, sinusitis,

genitourinary Chlamydia trachomatis infection, fusospirochetal pharyngitis,

yaws, acne vulgaris, bacterial urinary tract infection, acute bacterial otitis

media, pharyngitis, cholera, plague, tularemia, anthrax, brucellosis, listeriosis,

meningococcal carrier, skin and skin structure infection, actinomycosis,

Ureaplasma urealyticum infection, Campylobacter fetus infection, psittacosis,

trachoma, inclusion conjunctivitis caused by Chlamydia trachomatis, typhus MINOCYCLINE CAPSULE





sinusitis, lymphogranuloma venereum, granuloma inguinale, genitourinary

Chlamydia trachomatis infection, fusospirochetal pharyngitis, yaws, acne

vulgaris, bacterial urinary tract infection, acute bacterial otitis media,

pharyngitis, cholera, plague, tularemia, anthrax, brucellosis, listeriosis, skin

and skin structure infection, meningococcal carrier, actinomycosis,

Ureaplasma urealyticum infection, Campylobacter fetus infection, psittacosis, MINOCYCLINE CAPSULE


COREMINO ER 135 MG TABLET acne vulgaris MINOCYCLINE ER TABLET

DRUG CHANGES GEN QL, revise ST Oct-20



VALUE ASSESSMENT COMMITTEE HIGHLIGHTS



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DOXYCYCLINE HYC DR 200 MG TAB

granuloma inguinale, lymphogranuloma venereum, acne vulgaris, Rocky

Mountain spotted fever, boutonneuse fever, rectal Chlamydia trachomatis

infection, upper respiratory pneumococcal infection, cholera, genitourinary

Chlamydia trachomatis infection, plague, Campylobacter fetus infection, Q

fever, rickettsialpox, yaws, tularemia, rickettsial infection, malaria prevention,

DRUG CHANGES NF QL, revise ST Oct-20


lymphogranuloma venereum, granuloma inguinale, acne vulgaris, Rocky



Chlamydia trachomatis infection, Campylobacter fetus infection, plague, Q







Chlamydia trachomatis infection, plague, Campylobacter fetus infection, Q







Chlamydia trachomatis infection, Campylobacter fetus infection, plague, Q




lymphogranuloma venereum, acne vulgaris, Rocky Mountain spotted fever,

granuloma inguinale, rectal Chlamydia trachomatis infection, upper

respiratory pneumococcal infection, cholera, boutonneuse fever,

genitourinary Chlamydia trachomatis infection, Campylobacter fetus

infection, Q fever, yaws, plague, tularemia, rickettsialpox, rickettsial infection,


MINOCYCLINE ER 105 MG TABLET acne vulgaris SOLODYN ER










MINOCYCLINE ER 135 MG TABLET acne vulgaris, acne vulgaris COREMINO ER






MINOCYCLINE HCL 100 MG TABLET




Chlamydia trachomatis infection, fusospirochetal pharyngitis, yaws, acne DRUG CHANGES GEN add ST Oct-20


rickettsialpox, relapsing fever, bartonellosis, syphilis, gingivostomatitis, upper

respiratory pneumococcal infection, bacterial pneumonia, mycoplasmal

pneumonia, lymphogranuloma venereum, granuloma inguinale, sinusitis,

genitourinary Chlamydia trachomatis infection, fusospirochetal pharyngitis, DRUG CHANGES GEN add ST Oct-20





Chlamydia trachomatis infection, fusospirochetal pharyngitis, yaws, acne DRUG CHANGES GEN add ST Oct-20

PRETOMANID 200 MG TABLET pulmonary multi-drug resistant M. tuberculosis

RIFAMPIN DRUG CHANGES GEN-->NPB PA, QL Oct-20



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VIMOVO DR 375-20 MG TABLET

rheumatoid arthritis in pt at high gastric ulcer risk, osteoarthritis in patient at

high gastric ulcer risk, ankylosing spondylitis in pt at high gastric ulcer risk,

polyarticular juvenile idiopathic arthritis NAPROXEN-ESOMEPRAZOLE


VIMOVO DR 500-20 MG TABLET

rheumatoid arthritis in pt at high gastric ulcer risk, osteoarthritis in patient at


polyarticular juvenile idiopathic arthritis NAPROXEN-ESOMEPRAZOLE


NAPROXEN-ESOMEPRAZ DR 375-20MGrheumatoid arthritis in pt at high gastric ulcer risk, osteoarthritis in patient at


polyarticular juvenile idiopathic arthritis VIMOVO, DUEXIS


NAPROXEN-ESOMEPRAZ DR 500-20MGrheumatoid arthritis in pt at high gastric ulcer risk, osteoarthritis in patient at


polyarticular juvenile idiopathic arthritis VIMOVO, DUEXIS


DUEXIS 800-26.6 MG TABLETosteoarthritis in patient at high gastric ulcer risk, rheumatoid arthritis in pt at

high gastric ulcer risk VIMOVO, NAPROXEN-ESOMEPRAZOLEDRUG CHANGES NF Oct-20

RAYOS DR 1 MG TABLET

cutaneous T-cell lymphoma, non-Hodgkin's lymphoma, diffuse large B-cell

lymphoma, contact dermatitis, dermatitis herpetiformis, pemphigus, acute

lymphoid leukemia, chronic lymphoid leukemia, erythema multiforme,

exfoliative dermatitis, pure red cell aplasia associated with CLL, serum DEXAMETHASONE TABLET, HYDROCORTISONE TABLETDRUG CHANGES NF Oct-20

RAYOS DR 2 MG TABLET

cutaneous T-cell lymphoma, non-Hodgkin's lymphoma, diffuse large B-cell

lymphoma, contact dermatitis, dermatitis herpetiformis, pemphigus, acute

lymphoid leukemia, chronic lymphoid leukemia, erythema multiforme,

exfoliative dermatitis, pure red cell aplasia associated with CLL, serum DEXAMETHASONE TABLET, HYDROCORTISONE TABLETDRUG CHANGES NF Oct-20

RAYOS DR 5 MG TABLET oc DEXAMETHASONE TABLET, HYDROCORTISONE TABLETDRUG CHANGES NF Oct-20

PENNSAID 2% PUMP osteoarthritis, osteoarthritis of the knee DICLOFENAC SODIUM 1% GELDRUG CHANGES NF Oct-20

DICLOFENAC SODIUM 1% GEL osteoarthritis of the knee, osteoarthritis VOLTARIN 1% GELDRUG CHANGES GEN QL, add ST Oct-20

NOVOLIN R 100 UNIT/ML FLEXPENtype 2 diabetes mellitus, type 1 diabetes mellitus, hyperglycemia, diabetic

coma, hyperkalemia, diabetic ketoacidosis HUMULINDRUG CHANGES 99

add Excluded

Products flagMay-20

NOVOLIN N 100 UNIT/ML FLEXPEN type 2 diabetes mellitus, type 1 diabetes mellitus HUMULINDRUG CHANGES 99

add Excluded

Products flagMay-20

RELION NOVOLIN N U-100 FLEXPEN type 2 diabetes mellitus, type 1 diabetes mellitus HUMULINDRUG CHANGES 99

add Excluded

Products flagMay-20

RELION NOVOLIN R U-100 FLEXPENtype 2 diabetes mellitus, type 1 diabetes mellitus, hyperglycemia, diabetic

coma, hyperkalemia, diabetic ketoacidosis HUMULINDRUG CHANGES 99

add Excluded

Products flagMay-20

TRINAZ TABLET pregnancy, lactating mother ZALVIT TABLETDRUG CHANGES 99 add NF flag Oct-20

PREGENNA TABLET pregnancy, lactating mother ZALVIT TABLETDRUG CHANGES 99 add NF flag Oct-20

ZALVIT TABLET pregnancy, lactating mother ZALVIT TABLETDRUG CHANGES NPB-->NF Oct-20



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KEY:

ABBREVIATION DEFINITION

GEN Generic

GEN (S) Generic (Specialty)

PB Preferred Brand

NPB Non-Preferred Brand

PS Preferred Specialty

NPS/SP Non-Preferred Specialty/Specialty

NF Non-Formulary

QL Quantity Limit

ST Step Therapy

PA Prior Authorization

MED Medical Flag

BSP Benefit Shift Program

* Manage consistent with other drugs in class, unless otherwise specified

ª Clinically similar products



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