Emblem Medicaid 4Q18 Formulary Updates

AFLURIA 2018-2019 SYRINGE Added to Formulary (BRAND) 10/1/2018 AFLURIA 2018-2019 VIAL Added to Formulary (BRAND) 10/1/2018 AFLURIA QUAD 2018-2019 SYRINGE Added to Formulary (BRAND) 10/1/2018 AFLURIA QUAD 2018-2019 VIAL Added to Formulary (BRAND) 10/1/2018 anastrozole 1 mg tablet Added Quantity Limits (generic) 11/1/2018 antacid 750 mg chewable tablet Added to Formulary (generic) 10/1/2018 arbinoxa 4 mg tablet Removed from Formulary 11/1/2018 arbinoxa 4 mg/5 ml liquid Removed from Formulary 11/1/2018 BACLOFEN 5 MG TABLET Added to Formulary (BRAND) 10/1/2018 BANZEL 200 MG TABLET Removed from Formulary 11/1/2018 BANZEL 40 MG/ML SUSPENSION Removed from Formulary 11/1/2018 BANZEL 400 MG TABLET Removed from Formulary 11/1/2018 bicalutamide 50 mg tablet Added Quantity Limits (generic) 11/1/2018 buprenorp-nalox 8-2 mg sl film Added to Formulary (generic) with Quantity Limits 10/1/2018 CAPRELSA 100 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 CAPRELSA 300 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 CELONTIN 300 MG KAPSEAL Removed from Formulary 11/1/2018 COTELLIC 20 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 dalfampridine er 10 mg tablet Added to Formulary (generic) with Prior Authorization 10/1/2018 ENDARI 5 GRAM POWDER PACKET Added to Formulary (BRAND) with Quantity Limits 10/1/2018 ERIVEDGE 150 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 exemestane 25 mg tablet Added Quantity Limits (generic) 11/1/2018 FARESTON 60 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 FLUAD 2018-2019 SYRINGE Added to Formulary (BRAND) 10/1/2018 FLUARIX QUAD 2018-2019 SYRINGE Added to Formulary (BRAND) 10/1/2018 FLUBLOK QUAD 2018-2019 SYRINGE Added to Formulary (BRAND) 10/1/2018 FLUCELVAX QUAD 2018-2019 SYR Added to Formulary (BRAND) 10/1/2018 FLUCELVAX QUAD 2018-2019 VIAL Added to Formulary (BRAND) 10/1/2018 FLULAVAL QUAD 2018-2019 SYR Added to Formulary (BRAND) 10/1/2018 FLULAVAL QUAD 2018-2019 VIAL Added to Formulary (BRAND) 10/1/2018 FLUMIST QUAD NASAL 2018-19 VAC Added to Formulary (BRAND) 10/1/2018 flutamide 125 mg capsule Added Quantity Limits (generic) 11/1/2018 FLUZONE HIGH-DOSE 2018-19 SYR Added to Formulary (BRAND) 10/1/2018

FLUZONE QUAD 2018-2019 SYRINGE Added to Formulary (BRAND) 10/1/2018 FLUZONE QUAD 2018-2019 VIAL Added to Formulary (BRAND) 10/1/2018 FLUZONE QUAD PEDI 2018-19 SYR Added to Formulary (BRAND) 10/1/2018 FREESTYLE LIBRE 10 DAY READER Added to Formulary (BRAND) with Quantity Limits and Prior Authorization 10/1/2018 FREESTYLE LIBRE 10 DAY SENSOR Added to Formulary (BRAND) with Quantity Limits 10/1/2018 gabapentin 100 mg capsule Added Quantity Limits (generic) 11/1/2018 gabapentin 300 mg capsule Added Quantity Limits (generic) 11/1/2018 gabapentin 400 mg capsule Added Quantity Limits (generic) 11/1/2018 gabapentin 600 mg tablet Added Quantity Limits (generic) 11/1/2018 gabapentin 800 mg tablet Added Quantity Limits (generic) 11/1/2018 GILOTRIF 20 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 GILOTRIF 30 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 GILOTRIF 40 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 HUMIRA PEN CROHN-UC-HS 80 MG Added to Formulary (BRAND) with Quantity Limits and Prior Authorization 10/1/2018 HUMIRA PEN PSOR-UVEI 80MG-40MG Added to Formulary (BRAND) with Quantity Limits and Prior Authorization 10/1/2018 IBRANCE 100 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 IBRANCE 125 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 IBRANCE 75 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 INLYTA 1 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 INLYTA 5 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 IRESSA 250 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 JAKAFI 10 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 JAKAFI 15 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 JAKAFI 20 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 JAKAFI 25 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 JAKAFI 5 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 JYNARQUE 45 MG-15 MG TABLET Added to Formulary (BRAND) with Prior Authorization 10/1/2018 JYNARQUE 60 MG-30 MG TABLET Added to Formulary (BRAND) with Prior Authorization 10/1/2018 JYNARQUE 90 MG-30 MG TABLET Added to Formulary (BRAND) with Prior Authorization 10/1/2018 ketoprofen 25 mg capsule Added to Formulary (generic) 10/1/2018 LENVIMA 12 MG DAILY DOSE Added to Formulary (BRAND) with Quantity Limits and Prior Authorization 10/1/2018 LENVIMA 14 MG DAILY DOSE Added Quantity Limits (BRAND) 11/1/2018 LENVIMA 4 MG CAPSULE Added to Formulary (BRAND) with Quantity Limits and Prior Authorization 10/1/2018

letrozole 2.5 mg tablet Added Quantity Limits (generic) 11/1/2018 LONSURF 15 MG-6.14 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 LONSURF 20 MG-8.19 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 LYNPARZA 50 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 LYRICA 100 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 LYRICA 150 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 LYRICA 20 MG/ML ORAL SOLUTION Added Quantity Limits (BRAND) 11/1/2018 LYRICA 200 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 LYRICA 225 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 LYRICA 25 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 LYRICA 300 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 LYRICA 50 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 LYRICA 75 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 LYSODREN 500 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 megestrol 20 mg tablet Added Quantity Limits (generic) 11/1/2018 megestrol 40 mg tablet Added Quantity Limits (generic) 11/1/2018 megestrol acet 40 mg/ml susp Added Quantity Limits (generic) 11/1/2018 MEKINIST 0.5 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 MEKINIST 2 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 miglustat 100 mg capsule Added to Formulary (generic) 10/1/2018 nilutamide 150 mg tablet Added Quantity Limits (generic) 11/1/2018 NINLARO 2.3 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 NINLARO 3 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 NINLARO 4 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 NORVIR 100 MG POWDER PACKET Added to Formulary (BRAND) with Quantity Limits 10/1/2018 ONFI 10 MG TABLET Removed from Formulary 11/1/2018 ONFI 2.5 MG/ML SUSPENSION Removed from Formulary 11/1/2018 ONFI 20 MG TABLET Removed from Formulary 11/1/2018 PEDIASURE SIDEKICKS LIQUID Added to Formulary (BRAND) 10/1/2018 PEGANONE 250 MG TABLET Removed from Formulary 11/1/2018 phytonadione 5 mg tablet Added to Formulary (generic) 10/1/2018 POMALYST 1 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 POMALYST 2 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018

POMALYST 3 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 POMALYST 4 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 PREVYMIS 240 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 PREVYMIS 480 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 REVLIMID 10 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 REVLIMID 15 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 REVLIMID 2.5 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 REVLIMID 20 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 REVLIMID 25 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 REVLIMID 5 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 RUBRACA 200 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 RUBRACA 250 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 RUBRACA 300 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 RYDAPT 25 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 SABRIL 500 MG POWDER PACKET Removed from Formulary 11/1/2018 SABRIL 500 MG TABLET Removed from Formulary 11/1/2018 SANTYL OINTMENT Added Quantity Limits (BRAND) 11/1/2018 SCOT-TUSSIN SENIOR LIQUID Added to Formulary (BRAND) 10/1/2018 STIVARGA 40 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 tamoxifen 10 mg tablet Added Quantity Limits (generic) 11/1/2018 tamoxifen 20 mg tablet Added Quantity Limits (generic) 11/1/2018 THALOMID 100 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 THALOMID 150 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 THALOMID 200 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 THALOMID 50 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 TRIMO-SAN JELLY Added to Formulary (BRAND) 10/1/2018 UCERIS 9 MG ER TABLET Removed from Formulary 11/1/2018 VENCLEXTA 10 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 VENCLEXTA 100 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 VENCLEXTA 50 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 VENCLEXTA STARTING PACK Added Quantity Limits (BRAND) 11/1/2018 vigabatrin 500 mg powder packt Added to Formulary (generic) with Prior Authorization 10/1/2018 XALKORI 200 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018

XALKORI 250 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 XIFAXAN 200 MG TABLET Added Prior Authorization (BRAND) 11/1/2018 XIFAXAN 550 MG TABLET Added Prior Authorization (BRAND) 11/1/2018 ZEJULA 100 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018 ZYDELIG 100 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 ZYDELIG 150 MG TABLET Added Quantity Limits (BRAND) 11/1/2018 ZYKADIA 150 MG CAPSULE Added Quantity Limits (BRAND) 11/1/2018