UPHP MEDICAID FORMULARY Updates

October, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 ADMELOG insulin lispro REMOVE UM: B4G BRAND FOR GENERIC 10/01/2020 ADMELOG insulin lispro REMOVE UM: B4G BRAND FOR SOLOSTAR GENERIC 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone ADD TO FORMULARY Preferred hcl 10/01/2020 VIVITROL naltrexone microspheres ADD TO FORMULARY Preferred 10/01/2020 buprenorphine- buprenorphine hcl/naloxone ADD TO FORMULARY Preferred naloxone hcl 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone ADD TO FORMULARY Preferred hcl 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone ADD TO FORMULARY Preferred hcl 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone ADD TO FORMULARY Preferred hcl 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone ADD TO FORMULARY Preferred hcl 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone ADD TO FORMULARY Preferred hcl 10/01/2020 buprenorphine- buprenorphine hcl/naloxone ADD TO FORMULARY Preferred naloxone hcl 10/01/2020 buprenorphine- buprenorphine hcl/naloxone ADD TO FORMULARY Preferred naloxone hcl 10/01/2020 buprenorphine- buprenorphine hcl/naloxone ADD TO FORMULARY Preferred naloxone hcl 10/01/2020 buprenorphine- buprenorphine hcl/naloxone ADD TO FORMULARY Non-Preferred naloxone hcl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 1 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 buprenorphine- buprenorphine hcl/naloxone ADD TO FORMULARY Non-Preferred naloxone hcl 10/01/2020 testosterone testosterone REMOVE UM: COV Use brand over generic 10/01/2020 testosterone testosterone CHANGE UM: PANAME Non Preferred PA Clinical PA 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone ADD UM: CUSTOM Carve Out- Bill hcl MDCH FFS 10/01/2020 VIVITROL naltrexone microspheres ADD UM: CUSTOM Carve Out- Bill MDCH FFS 10/01/2020 buprenorphine- buprenorphine hcl/naloxone ADD UM: CUSTOM Carve Out- Bill naloxone hcl MDCH FFS 10/01/2020 buprenorphine- buprenorphine hcl/naloxone ADD UM: CUSTOM Carve Out- Bill naloxone hcl MDCH FFS 10/01/2020 buprenorphine- buprenorphine hcl/naloxone ADD UM: CUSTOM Carve Out- Bill naloxone hcl MDCH FFS 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone ADD UM: CUSTOM Carve Out- Bill hcl MDCH FFS 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone ADD UM: CUSTOM Carve Out- Bill hcl MDCH FFS 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone ADD UM: CUSTOM Carve Out- Bill hcl MDCH FFS 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone ADD UM: CUSTOM Carve Out- Bill hcl MDCH FFS 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone ADD UM: CUSTOM Carve Out- Bill hcl MDCH FFS 10/01/2020 buprenorphine- buprenorphine hcl/naloxone ADD UM: CUSTOM Carve Out- Bill naloxone hcl MDCH FFS 10/01/2020 buprenorphine- buprenorphine hcl/naloxone ADD UM: CUSTOM Carve Out- Bill naloxone hcl MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 2 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 buprenorphine- buprenorphine hcl/naloxone ADD UM: CUSTOM Carve Out- Bill naloxone hcl MDCH FFS 10/01/2020 buprenorphine- buprenorphine hcl/naloxone ADD UM: PANAME Non Preferred PA naloxone hcl 10/01/2020 clonidine clonidine REMOVE UM: COV Use brand over generic 10/01/2020 clonidine clonidine REMOVE UM: COV Use brand over generic 10/01/2020 clonidine clonidine REMOVE UM: COV Use brand over generic 10/01/2020 synthroid,levothyr levothyroxine sodium REMOVE UM: AGE oxine sodium,levothroid ,unithroid,levoxyl, levo-t,euthyrox 10/01/2020 synthroid,levothyr levothyroxine sodium REMOVE UM: AGE oxine sodium,levothroid ,unithroid,levoxyl, levo-t,euthyrox 10/01/2020 synthroid,levothyr levothyroxine sodium REMOVE UM: AGE oxine sodium,levothroid ,unithroid,levoxyl, levo-t,euthyrox 10/01/2020 synthroid,levothyr levothyroxine sodium REMOVE UM: AGE oxine sodium,levothroid ,unithroid,levoxyl, levo-t,euthyrox

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 3 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 synthroid,levothyr levothyroxine sodium REMOVE UM: AGE oxine sodium,levothroid ,unithroid,levoxyl, levo-t,euthyrox 10/01/2020 synthroid,levothyr levothyroxine sodium REMOVE UM: AGE oxine sodium,levothroid ,unithroid,levoxyl, levo-t,euthyrox 10/01/2020 synthroid,levothyr levothyroxine sodium REMOVE UM: AGE oxine sodium,levothroid ,unithroid,levoxyl, levo-t,euthyrox 10/01/2020 synthroid,levothyr levothyroxine sodium REMOVE UM: AGE oxine sodium,levothroid ,unithroid,levoxyl, levo-t 10/01/2020 synthroid,levothyr levothyroxine sodium REMOVE UM: AGE oxine sodium,levothroid ,unithroid,levoxyl, levo-t,euthyrox 10/01/2020 synthroid,levothyr levothyroxine sodium REMOVE UM: AGE oxine sodium,levothroid ,unithroid,levoxyl, levo-t,euthyrox 10/01/2020 synthroid,levothyr levothyroxine sodium REMOVE UM: AGE oxine sodium,levothroid ,unithroid,levoxyl, levo-t,euthyrox

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 4 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 synthroid,levothyr levothyroxine sodium REMOVE UM: AGE oxine sodium,levothroid ,unithroid,levoxyl, levo-t,euthyrox 10/01/2020 SYNTHROID levothyroxine sodium ADD UM: AGE Up to 12 yrs old 10/01/2020 SYNTHROID levothyroxine sodium ADD UM: AGE Up to 12 yrs old 10/01/2020 SYNTHROID levothyroxine sodium ADD UM: AGE Up to 12 yrs old 10/01/2020 SYNTHROID levothyroxine sodium ADD UM: AGE Up to 12 yrs old 10/01/2020 SYNTHROID levothyroxine sodium ADD UM: AGE Up to 12 yrs old 10/01/2020 SYNTHROID levothyroxine sodium ADD UM: AGE Up to 12 yrs old 10/01/2020 SYNTHROID levothyroxine sodium ADD UM: AGE Up to 12 yrs old 10/01/2020 SYNTHROID levothyroxine sodium ADD UM: AGE Up to 12 yrs old 10/01/2020 SYNTHROID levothyroxine sodium ADD UM: AGE Up to 12 yrs old 10/01/2020 SYNTHROID levothyroxine sodium ADD UM: AGE Up to 12 yrs old 10/01/2020 SYNTHROID levothyroxine sodium ADD UM: AGE Up to 12 yrs old 10/01/2020 SYNTHROID levothyroxine sodium ADD UM: AGE Up to 12 yrs old 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone REMOVE FROM Preferred Non-Formulary hcl FORMULARY 10/01/2020 VIVITROL naltrexone microspheres REMOVE FROM Preferred Non-Formulary FORMULARY 10/01/2020 buprenorphine- buprenorphine hcl/naloxone REMOVE FROM Non-Preferred Non-Formulary naloxone hcl FORMULARY 10/01/2020 doxycycline doxycycline hyclate REMOVE FROM Non-Formulary hyclate FORMULARY 10/01/2020 buprenorphine- buprenorphine hcl/naloxone REMOVE FROM Preferred Non-Formulary naloxone hcl FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 5 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 buprenorphine- buprenorphine hcl/naloxone REMOVE FROM Non-Preferred Non-Formulary naloxone hcl FORMULARY 10/01/2020 bupropion hcl bupropion hcl REMOVE FROM Non-Formulary sr,bupropion hcl FORMULARY er 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone REMOVE FROM Preferred Non-Formulary hcl FORMULARY 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone REMOVE FROM Preferred Non-Formulary hcl FORMULARY 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone REMOVE FROM Preferred Non-Formulary hcl FORMULARY 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone REMOVE FROM Preferred Non-Formulary hcl FORMULARY 10/01/2020 ZUBSOLV buprenorphine hcl/naloxone REMOVE FROM Preferred Non-Formulary hcl FORMULARY 10/01/2020 lactulose lactulose REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 buprenorphine- buprenorphine hcl/naloxone REMOVE FROM Preferred Non-Formulary naloxone hcl FORMULARY 10/01/2020 buprenorphine- buprenorphine hcl/naloxone REMOVE FROM Preferred Non-Formulary naloxone hcl FORMULARY 10/01/2020 buprenorphine- buprenorphine hcl/naloxone REMOVE FROM Preferred Non-Formulary naloxone hcl FORMULARY 10/01/2020 solifenacin solifenacin succinate REMOVE UM: COV Use brand over succinate generic 10/01/2020 solifenacin solifenacin succinate REMOVE UM: COV Use brand over succinate generic 10/01/2020 doxycycline doxycycline hyclate ADD TO FORMULARY Non-Formulary Non PDL hyclate 10/01/2020 tolterodine tolterodine tartrate ADD TO FORMULARY Non-Preferred tartrate er

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 6 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 tolterodine tolterodine tartrate ADD TO FORMULARY Non-Preferred tartrate er 10/01/2020 tolterodine tolterodine tartrate ADD TO FORMULARY Non-Preferred tartrate 10/01/2020 VANDAZOLE metronidazole REMOVE UM: COV Use brand over generic 10/01/2020 cetirizine hcl cetirizine hcl ADD TO FORMULARY Preferred 10/01/2020 cetirizine hcl cetirizine hcl ADD UM: DRUGCLASS ANTIHISTAMINE S - 2ND GENERATION 10/01/2020 cetirizine hcl cetirizine hcl ADD TO FORMULARY Preferred 10/01/2020 cetirizine hcl cetirizine hcl ADD UM: DRUGCLASS ANTIHISTAMINE S - 2ND GENERATION 10/01/2020 cetirizine hcl cetirizine hcl ADD TO FORMULARY Preferred 10/01/2020 cetirizine hcl cetirizine hcl ADD UM: DRUGCLASS ANTIHISTAMINE S - 2ND GENERATION 10/01/2020 cetirizine hcl cetirizine hcl CHANGE TIER Non-Preferred Preferred 10/01/2020 cetirizine hcl cetirizine hcl REMOVE UM: PANAME Non Preferred PA 10/01/2020 cetirizine hcl cetirizine hcl CHANGE TIER Preferred 10/01/2020 lactulose,constul lactulose ADD TO FORMULARY Non PDL ose 10/01/2020 CONSTULOSE lactulose REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 BAQSIMI glucagon CHANGE UM: QUANTITY 2 / 30 days 1 / 30 days 10/01/2020 BAQSIMI glucagon CHANGE UM: QUANTITY 1 / 30 days 2 / 30 days 10/01/2020 DRYSOL aluminum chloride REMOVE FROM Non PDL Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 7 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 CALCIDOL ergocalciferol (vitamin d2) ADD TO FORMULARY Non PDL 10/01/2020 CALCIDOL ergocalciferol (vitamin d2) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Non PDL 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 NIVA-FOL cyanocobalamin/folic ADD TO FORMULARY Non PDL acid/pyridoxine 10/01/2020 NIVA-FOL cyanocobalamin/folic ADD UM: CUSTOM Covered for acid/pyridoxine CSHCS only 10/01/2020 vitamin e vitamin e (dl-alpha ADD UM: CUSTOM Covered for tocopheryl acetate) CSHCS only 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic 10/01/2020 DIALYVITE 5000 multivitamins with minerals ADD UM: CUSTOM Covered for no.11/folic acid CSHCS only 10/01/2020 vitamin e vitamin e (dl-alpha ADD TO FORMULARY Non PDL tocopheryl acetate) 10/01/2020 vitamin e vitamin e (dl-alpha ADD UM: CUSTOM Covered for tocopheryl acetate) CSHCS only 10/01/2020 READY TO USE mineral oil ADD UM: CUSTOM Covered for ENEMA CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Non PDL 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 8 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 magnesium oxide magnesium oxide ADD TO FORMULARY Non PDL 10/01/2020 magnesium oxide magnesium oxide ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 ENEMEEZ docusate ADD UM: CUSTOM Covered for sodium/benzocaine CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 NANO VM 4-8 pediatric multivitamin ADD TO FORMULARY Non PDL no.15/ferrous fumarate/folic acid 10/01/2020 NANO VM 4-8 pediatric multivitamin ADD UM: CUSTOM Covered for no.15/ferrous fumarate/folic CSHCS only acid 10/01/2020 melatonin melatonin ADD TO FORMULARY Non PDL 10/01/2020 melatonin melatonin ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for DISPOSABLE phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic 10/01/2020 vitamin e vitamin e (dl-alpha ADD UM: CUSTOM Covered for tocopheryl acetate) CSHCS only 10/01/2020 vitamin e vitamin e ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 VIRT-GARD cyanocobalamin/folic ADD TO FORMULARY Non PDL acid/pyridoxine 10/01/2020 VIRT-GARD cyanocobalamin/folic ADD UM: CUSTOM Covered for acid/pyridoxine CSHCS only

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 9 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 PHOSPHOROUS sodium ADD UM: CUSTOM Covered for phosphate/potassium CSHCS only phosphates, monobasic and bibasic 10/01/2020 VP-VITE RX vitamin b complex no.3/folic ADD TO FORMULARY Non PDL acid/ascorbic acid(vitc)/biotin 10/01/2020 VP-VITE RX vitamin b complex no.3/folic ADD UM: CUSTOM Covered for acid/ascorbic CSHCS only acid(vitc)/biotin 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 sodium chloride sodium chloride for ADD UM: CUSTOM Covered for inhalation CSHCS only 10/01/2020 ENEMEEZ docusate ADD UM: CUSTOM Covered for sodium/benzocaine CSHCS only 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic 10/01/2020 ENEMEEZ docusate sodium ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 ENEMEEZ docusate sodium ADD UM: CUSTOM Covered for CSHCS only

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 10 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 NANO VM 1-3 pediatric multivitamin ADD TO FORMULARY Non PDL no.14/ferrous fumarate/folic acid 10/01/2020 NANO VM 1-3 pediatric multivitamin ADD UM: CUSTOM Covered for no.14/ferrous fumarate/folic CSHCS only acid 10/01/2020 MVW pediatric multivit ADD TO FORMULARY Non PDL COMPLETE no.22/cholecalciferol(d3)/ph FORMULATION ytonadione(k) D3000 10/01/2020 MVW pediatric multivit ADD UM: CUSTOM Covered for COMPLETE no.22/cholecalciferol(d3)/ph CSHCS only FORMULATION ytonadione(k) D3000 10/01/2020 MVW pediatric multivit ADD TO FORMULARY Non PDL COMPLETE no.22/cholecalciferol(d3)/ph FORMULTN ytonadione(k) MULTIVIT 10/01/2020 MVW pediatric multivit ADD UM: CUSTOM Covered for COMPLETE no.22/cholecalciferol(d3)/ph CSHCS only FORMULTN ytonadione(k) MULTIVIT 10/01/2020 MVW pediatric multivit ADD TO FORMULARY Non PDL COMPLETE no.22/cholecalciferol(d3)/ph FORMULATION ytonadione(k) D3000 10/01/2020 MVW pediatric multivit ADD UM: CUSTOM Covered for COMPLETE no.22/cholecalciferol(d3)/ph CSHCS only FORMULATION ytonadione(k) D3000 10/01/2020 RENO CAPS vitamin b complex and ADD UM: CUSTOM Covered for vitamin c no.20/folic acid CSHCS only 10/01/2020 VIRT-CAPS vitamin b complex and ADD UM: CUSTOM Covered for vitamin c no.20/folic acid CSHCS only

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 11 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 magnesium oxide magnesium oxide ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 calcium calcium gluconate ADD TO FORMULARY Non PDL gluconate 10/01/2020 calcium calcium gluconate ADD UM: CUSTOM Covered for gluconate CSHCS only 10/01/2020 NEPHRON FA vit b complex and vit c ADD TO FORMULARY Non PDL no.24/ferrous fumarate/folic acid 10/01/2020 NEPHRON FA vit b complex and vit c ADD UM: CUSTOM Covered for no.24/ferrous fumarate/folic CSHCS only acid 10/01/2020 NEPHRO-VITE vitamin b complex no.3/folic ADD TO FORMULARY Non PDL RX acid/ascorbic acid(vitc)/biotin 10/01/2020 NEPHRO-VITE vitamin b complex no.3/folic ADD UM: CUSTOM Covered for RX acid/ascorbic CSHCS only acid(vitc)/biotin 10/01/2020 mineral oil mineral oil ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 magnesium oxide magnesium oxide ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic 10/01/2020 MVW pediatric multivit ADD TO FORMULARY Non PDL COMPLETE no.61/cholecalciferol(d3)/ph FORMULATION ytonadione(k) D5000

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 12 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 MVW pediatric multivit ADD UM: CUSTOM Covered for COMPLETE no.61/cholecalciferol(d3)/ph CSHCS only FORMULATION ytonadione(k) D5000 10/01/2020 calcium calcium gluconate ADD TO FORMULARY Non PDL gluconate 10/01/2020 calcium calcium gluconate ADD UM: CUSTOM Covered for gluconate CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 hydralazine hcl hydralazine hcl ADD TO FORMULARY Non PDL 10/01/2020 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic 10/01/2020 magnesium magnesium ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 docusate sodium docusate sodium ADD TO FORMULARY Non PDL 10/01/2020 docusate sodium docusate sodium ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 calcium calcium gluconate ADD TO FORMULARY Non PDL gluconate 10/01/2020 calcium calcium gluconate ADD UM: CUSTOM Covered for gluconate CSHCS only 10/01/2020 magnesium oxide magnesium oxide ADD UM: CUSTOM Covered for CSHCS only

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 13 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic 10/01/2020 DEKAS vitamin a palmitate/vitamin ADD TO FORMULARY Non PDL ESSENTIAL d3/vitamin e/vit e tpgs/vit k1 10/01/2020 DEKAS vitamin a palmitate/vitamin ADD UM: CUSTOM Covered for ESSENTIAL d3/vitamin e/vit e tpgs/vit k1 CSHCS only 10/01/2020 DEKAS PLUS multivit with minerals ADD TO FORMULARY Non PDL no.53/folic acid/vit k1/ubidecarenone 10/01/2020 DEKAS PLUS multivit with minerals ADD UM: CUSTOM Covered for no.53/folic acid/vit CSHCS only k1/ubidecarenone 10/01/2020 DIALYVITE multivitamin-minerals ADD UM: CUSTOM Covered for SUPREME D no.25/folic acid/vitamin d3 CSHCS only 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic 10/01/2020 DEKAS PLUS pediatric multivitamin ADD TO FORMULARY Non PDL no.128/vitamin k 10/01/2020 DEKAS PLUS pediatric multivitamin ADD UM: CUSTOM Covered for no.128/vitamin k CSHCS only 10/01/2020 RENO CAPS vitamin b complex and ADD UM: CUSTOM Covered for vitamin c no.20/folic acid CSHCS only 10/01/2020 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 vitamin e vitamin e (dl-alpha ADD UM: CUSTOM Covered for tocopheryl acetate) CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 ergocalciferol ergocalciferol (vitamin d2) ADD TO FORMULARY Non PDL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 14 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 ergocalciferol ergocalciferol (vitamin d2) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Non PDL 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic 10/01/2020 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic 10/01/2020 DIALYVITE ZINC vitamin b complex ADD UM: CUSTOM Covered for no.11/folic acid/vit CSHCS only c/biotin/zinc oxide 10/01/2020 magnesium oxide magnesium oxide ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 DEKAS PLUS multivitamin-minerals ADD TO FORMULARY Non PDL no.56/folic acid/vit k1/ubidecarenone 10/01/2020 DEKAS PLUS multivitamin-minerals ADD UM: CUSTOM Covered for no.56/folic acid/vit CSHCS only k1/ubidecarenone 10/01/2020 DEKAS vit a palmitate/beta- ADD TO FORMULARY Non PDL ESSENTIAL carotene/vit d3/tocophersolan/vitamin k 10/01/2020 DEKAS vit a palmitate/beta- ADD UM: CUSTOM Covered for ESSENTIAL carotene/vit CSHCS only d3/tocophersolan/vitamin k 10/01/2020 NANOVM 9-18 pediatric multivitamin ADD TO FORMULARY Non PDL no.94/ferrous fumarate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 15 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 NANOVM 9-18 pediatric multivitamin ADD UM: CUSTOM Covered for no.94/ferrous fumarate CSHCS only 10/01/2020 NANOVM T-F pediatric multivitamin ADD TO FORMULARY Non PDL no.93/ferrous sulfate 10/01/2020 NANOVM T-F pediatric multivitamin ADD UM: CUSTOM Covered for no.93/ferrous sulfate CSHCS only 10/01/2020 DIALYVITE 3000 folic acid/vitamin b comp ADD UM: CUSTOM Covered for and CSHCS only c/selenium/minerals/zinc 10/01/2020 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 AQUADEKS multivitamin, minerals ADD UM: CUSTOM Covered for no.51/folic acid/vit CSHCS only k1/ubidecarenone 10/01/2020 hydralazine hcl hydralazine hcl ADD TO FORMULARY Non PDL 10/01/2020 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 DOCUSOL docusate sodium ADD TO FORMULARY Non PDL 10/01/2020 DOCUSOL docusate sodium ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 calcium calcium gluconate ADD TO FORMULARY Non PDL gluconate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 16 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 calcium calcium gluconate ADD UM: CUSTOM Covered for gluconate CSHCS only 10/01/2020 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 magnesium oxide magnesium oxide ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 NU-MAG magnesium chloride ADD TO FORMULARY Non PDL 10/01/2020 NU-MAG magnesium chloride ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 b-complex thiamine ADD UM: CUSTOM Covered for hcl/riboflavin/niacinamide/de CSHCS only xpanthenol/pyridoxine 10/01/2020 READY TO USE mineral oil ADD UM: CUSTOM Covered for ENEMA CSHCS only 10/01/2020 magnesium oxide magnesium oxide ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 MVW pediatric multivit ADD TO FORMULARY Non PDL COMPLETE no.61/cholecalciferol(d3)/ph FORMULTN ytonadione(k) MULTIVIT 10/01/2020 MVW pediatric multivit ADD UM: CUSTOM Covered for COMPLETE no.61/cholecalciferol(d3)/ph CSHCS only FORMULTN ytonadione(k) MULTIVIT 10/01/2020 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 17 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 MVW pediatric multivit ADD TO FORMULARY Non PDL COMPLETE no.22/cholecalciferol(d3)/ph FORMULTN ytonadione(k) MULTIVIT 10/01/2020 MVW pediatric multivit ADD UM: CUSTOM Covered for COMPLETE no.22/cholecalciferol(d3)/ph CSHCS only FORMULTN ytonadione(k) MULTIVIT 10/01/2020 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 MVW pediatric multivit ADD TO FORMULARY Non PDL COMPLETE no.77/cholecalciferol(d3)/ph FORMLTN ytonadione(k) PEDIATRIC 10/01/2020 MVW pediatric multivit ADD UM: CUSTOM Covered for COMPLETE no.77/cholecalciferol(d3)/ph CSHCS only FORMLTN ytonadione(k) PEDIATRIC 10/01/2020 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 DOCUSOL docusate sodium ADD TO FORMULARY Non PDL 10/01/2020 DOCUSOL docusate sodium ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 MVW pediatric multivit ADD TO FORMULARY Non PDL COMPLETE no.61/cholecalciferol(d3)/ph FORMULATION ytonadione(k) D3000 10/01/2020 MVW pediatric multivit ADD UM: CUSTOM Covered for COMPLETE no.61/cholecalciferol(d3)/ph CSHCS only FORMULATION ytonadione(k) D3000

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 18 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 MVW pediatric multivit ADD TO FORMULARY Non PDL COMPLETE no.22/cholecalciferol(d3)/ph FORMULTN ytonadione(k) MULTIVIT 10/01/2020 MVW pediatric multivit ADD UM: CUSTOM Covered for COMPLETE no.22/cholecalciferol(d3)/ph CSHCS only FORMULTN ytonadione(k) MULTIVIT 10/01/2020 WESTAB MAX cyanocobalamin/folic ADD TO FORMULARY Non PDL acid/pyridoxine 10/01/2020 WESTAB MAX cyanocobalamin/folic ADD UM: CUSTOM Covered for acid/pyridoxine CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 RENAL CAPS vitamin b complex and ADD UM: CUSTOM Covered for vitamin c no.20/folic acid CSHCS only 10/01/2020 MINERAL OIL mineral oil ADD UM: CUSTOM Covered for ENEMA CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 calcium calcium gluconate ADD TO FORMULARY Non PDL gluconate 10/01/2020 calcium calcium gluconate ADD UM: CUSTOM Covered for gluconate CSHCS only 10/01/2020 RENO CAPS vitamin b complex and ADD UM: CUSTOM Covered for vitamin c no.20/folic acid CSHCS only 10/01/2020 calcium calcium gluconate ADD TO FORMULARY Non PDL gluconate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 19 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 calcium calcium gluconate ADD UM: CUSTOM Covered for gluconate CSHCS only 10/01/2020 magnesium oxide magnesium oxide ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 BEELITH magnesium oxide/pyridoxine ADD UM: CUSTOM Covered for hcl (b6) CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 TRIPHROCAPS vitamin b complex and ADD UM: CUSTOM Covered for vitamin c no.20/folic acid CSHCS only 10/01/2020 vitamin e vitamin e ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 DIALYVITE folic acid/vitamin b complex ADD UM: CUSTOM Covered for and vitamin c CSHCS only 10/01/2020 sodium sodium ADD UM: CUSTOM Covered for phosphate phosphate,monobasic- CSHCS only dibasic 10/01/2020 calcium calcium gluconate ADD TO FORMULARY Non PDL gluconate 10/01/2020 calcium calcium gluconate ADD UM: CUSTOM Covered for gluconate CSHCS only 10/01/2020 ACTIVITE folic acid/vitamin b complex ADD TO FORMULARY Non PDL and vitamin c 10/01/2020 ACTIVITE folic acid/vitamin b complex ADD UM: CUSTOM Covered for and vitamin c CSHCS only 10/01/2020 ergocalciferol ergocalciferol (vitamin d2) ADD TO FORMULARY Non PDL 10/01/2020 ergocalciferol ergocalciferol (vitamin d2) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 20 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic 10/01/2020 hydralazine hcl hydralazine hcl ADD TO FORMULARY Non PDL 10/01/2020 hydralazine hcl hydralazine hcl ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 ferrous sulfate ferrous sulfate ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 calcium calcium gluconate ADD TO FORMULARY Non PDL gluconate 10/01/2020 calcium calcium gluconate ADD UM: CUSTOM Covered for gluconate CSHCS only 10/01/2020 vitamin e vitamin e (dl-alpha ADD UM: CUSTOM Covered for tocopheryl acetate) CSHCS only 10/01/2020 NEPHPLEX RX vit b complex no.3/folic ADD UM: CUSTOM Covered for acid/ascorbic acid/biotin/zinc CSHCS only oxid 10/01/2020 calcium calcium gluconate ADD TO FORMULARY Non PDL gluconate 10/01/2020 calcium calcium gluconate ADD UM: CUSTOM Covered for gluconate CSHCS only 10/01/2020 ENEMA sodium ADD UM: CUSTOM Covered for phosphate,monobasic/sodiu CSHCS only m phosphate,dibasic 10/01/2020 AQUADEKS pediatric multivitamin ADD UM: CUSTOM Covered for no.40/phytonadione (vit k1) CSHCS only 10/01/2020 calcium calcium gluconate ADD TO FORMULARY Non PDL gluconate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 21 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 calcium calcium gluconate ADD UM: CUSTOM Covered for gluconate CSHCS only 10/01/2020 calcium calcium gluconate ADD TO FORMULARY Non PDL gluconate 10/01/2020 calcium calcium gluconate ADD UM: CUSTOM Covered for gluconate CSHCS only 10/01/2020 vitamin d3 cholecalciferol (vitamin d3) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 ergocalciferol ergocalciferol (vitamin d2) ADD TO FORMULARY Non PDL 10/01/2020 ergocalciferol ergocalciferol (vitamin d2) ADD UM: CUSTOM Covered for CSHCS only 10/01/2020 calcium calcium gluconate ADD TO FORMULARY Non PDL gluconate 10/01/2020 calcium calcium gluconate ADD UM: CUSTOM Covered for gluconate CSHCS only 10/01/2020 celecoxib celecoxib REMOVE UM: COV 10/01/2020 celecoxib celecoxib REMOVE UM: COV 10/01/2020 celecoxib celecoxib REMOVE UM: COV 10/01/2020 celecoxib celecoxib REMOVE UM: COV 10/01/2020 ASMANEX mometasone furoate ADD UM: QUANTITY 1 / claim 10/01/2020 ASMANEX mometasone furoate ADD UM: QUANTITY 1 / claim 10/01/2020 ASMANEX mometasone furoate ADD UM: QUANTITY 1 / claim 10/01/2020 ASMANEX mometasone furoate ADD UM: QUANTITY 1 / claim 10/01/2020 aimsco condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 10/01/2020 condoms condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 10/01/2020 trustex condoms, latex, non- ADD UM: QUANTITY 36 / 30 days lubricated 10/01/2020 kimono microthin condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 22 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 trustex-ria condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 10/01/2020 trustex latex condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days condom 10/01/2020 kimono condoms, latex, non- ADD UM: QUANTITY 36 / 30 days lubricated 10/01/2020 trustex condom condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 10/01/2020 kimono microthin condoms, latex, non- ADD UM: QUANTITY 36 / 30 days lubricated 10/01/2020 fantasy condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 10/01/2020 fc2 female condoms, female ADD UM: QUANTITY 36 / 30 days condom 10/01/2020 trustex-ria condoms, latex, non- ADD UM: QUANTITY 36 / 30 days lubricated 10/01/2020 kimono maxx condoms, latex, non- ADD UM: QUANTITY 36 / 30 days lubricated 10/01/2020 kimono textured condoms, latex, lubricated ADD UM: QUANTITY 36 / 30 days 10/01/2020 purecomfort peak peak flow meter ADD UM: QUANTITY 4 / 365 days flow meter 10/01/2020 personal best peak flow meter ADD UM: QUANTITY 4 / 365 days 10/01/2020 KPN prenatal vitamin ADD UM: QUANTITY 1 / day calcium,iron,folic acid (less than 1 mg) 10/01/2020 RESTORIL temazepam ADD UM: QUANTITY 1 / day 10/01/2020 M-NATAL PLUS prenatal vits with calcium ADD UM: QUANTITY 1 / day no.72/ferrous fumarate/folic acid 10/01/2020 THRIVITE RX prenatal vitamin with ADD UM: QUANTITY 1 / day calcium no.76/iron,carbonyl/folic acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 23 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 bupropion hcl bupropion hcl CHANGE UM: QUANTITY 2 / day sr,bupropion hcl er 10/01/2020 HORIZANT gabapentin enacarbil ADD UM: QUANTITY 2 / day 10/01/2020 GRALISE gabapentin ADD UM: QUANTITY 3 / day 10/01/2020 HORIZANT gabapentin enacarbil ADD UM: QUANTITY 4 / day 10/01/2020 GRALISE gabapentin ADD UM: QUANTITY 6 / day 10/01/2020 bupropion hcl sr bupropion hcl ADD UM: QUANTITY 2 / day 10/01/2020 bupropion hcl sr bupropion hcl REMOVE UM: QUANTITY 10/01/2020 PULMOZYME dornase alfa REMOVE UM: QUANTITY 1 / day 10/01/2020 PULMOZYME dornase alfa ADD UM: QUANTITY 1 / day 10/01/2020 oxycodone hcl oxycodone hcl CHANGE UM: QUANTITY 120 / 30 Days 90 / 30 days 10/01/2020 EMGALITY galcanezumab-gnlm CHANGE UM: QUANTITY 1 / 30 Days 3 / 30 days SYRINGE 10/01/2020 NURTEC ODT rimegepant sulfate CHANGE UM: QUANTITY 14 / claim 15 / 30 days 10/01/2020 AVONEX PEN interferon beta-1a REMOVE UM: QUANTITY 4 / 28 days 10/01/2020 ZENPEP lipase/protease/amylase REMOVE UM: QUANTITY 480 / 30 days 10/01/2020 morphine sulfate morphine sulfate REMOVE UM: QUANTITY 120 / 30 Days 10/01/2020 TALTZ ixekizumab REMOVE UM: QUANTITY 1 / 28 Days AUTOINJECTOR 10/01/2020 ZENPEP lipase/protease/amylase REMOVE UM: QUANTITY 480 / 30 days 10/01/2020 TALTZ ixekizumab REMOVE UM: QUANTITY 1 / 28 Days AUTOINJECTOR (2 PACK) 10/01/2020 TALTZ ixekizumab REMOVE UM: QUANTITY 1 / 28 Days AUTOINJECTOR (3 PACK) 10/01/2020 TALTZ SYRINGE ixekizumab REMOVE UM: QUANTITY 1 / 28 Days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 24 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 chlorpropamide chlorpropamide REMOVE UM: AGE Up to 64 yrs old 10/01/2020 synthroid,levothyr levothyroxine sodium REMOVE UM: AGE oxine sodium,levothroid ,unithroid,levoxyl, levo-t 10/01/2020 prenatal 19 prenatal vits no.119/iron ADD UM: AGE 12.0 to 55.0 yrs fumarate/folic acid/docusate old sod. 10/01/2020 docusate sodium docusate sodium CHANGE TIER Non PDL 10/01/2020 NASAL triamcinolone acetonide ADD UM: PANAME Non Preferred PA ALLERGY 10/01/2020 TRULICITY dulaglutide ADD TO FORMULARY Non-Preferred 10/01/2020 TRULICITY dulaglutide ADD TO FORMULARY Non-Preferred 10/01/2020 NOVOLIN 70-30 insulin nph human CHANGE TIER Preferred Non-Preferred FLEXPEN isophane/insulin regular, human 10/01/2020 niacin er niacin CHANGE TIER Non PDL Non-Preferred 10/01/2020 dimethyl dimethyl fumarate ADD TO FORMULARY Non-Preferred fumarate 10/01/2020 dimethyl dimethyl fumarate ADD TO FORMULARY Non-Preferred fumarate 10/01/2020 DVORAH acetaminophen/caffeine/dihy ADD TO FORMULARY Non-Preferred drocodeine bitartrate 10/01/2020 TAB-A-VITE multivitamin with folic acid CHANGE TIER Non PDL 10/01/2020 b complex vitamin b complex ADD TO FORMULARY Non PDL 10/01/2020 TRI-LO- norgestimate-ethinyl ADD TO FORMULARY Non PDL ESTARYLLA estradiol

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 25 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 KPN prenatal vitamin ADD TO FORMULARY Non PDL calcium,iron,folic acid (less than 1 mg) 10/01/2020 JASMIEL ethinyl ADD TO FORMULARY Non PDL estradiol/drospirenone 10/01/2020 THRIVITE RX prenatal vitamin with ADD TO FORMULARY Non PDL calcium no.76/iron,carbonyl/folic acid 10/01/2020 bupropion hcl bupropion hcl ADD TO FORMULARY Non-Formulary Non PDL sr,bupropion hcl er 10/01/2020 multiple vitamins multivit with calcium, iron, ADD TO FORMULARY Non PDL for women and other minerals 10/01/2020 SOLUVITA-E vitamin e (dl-alpha ADD TO FORMULARY Non PDL tocopheryl acetate) 10/01/2020 lactulose lactulose CHANGE TIER Non PDL 10/01/2020 purecomfort peak peak flow meter ADD TO FORMULARY Non PDL flow meter 10/01/2020 M-NATAL PLUS prenatal vits with calcium ADD TO FORMULARY Non PDL no.72/ferrous fumarate/folic acid 10/01/2020 personal best peak flow meter ADD TO FORMULARY Non PDL 10/01/2020 ATHLETE'S clotrimazole CHANGE TIER Preferred FOOT 10/01/2020 loperamide,loper loperamide hcl CHANGE TIER Non PDL Preferred amide hcl 10/01/2020 wal-itin loratadine ADD TO FORMULARY Preferred 10/01/2020 ANTI- loperamide hcl CHANGE TIER Non PDL Preferred DIARRHEAL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 26 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 HUMULIN 70/30 insulin nph human CHANGE TIER Non-Preferred Preferred KWIKPEN isophane/insulin regular, human 10/01/2020 NON-DROWSY loratadine REMOVE FROM Preferred Non-Formulary ALLERGY FORMULARY 10/01/2020 ketoprofen ketoprofen REMOVE FROM Preferred Non-Formulary FORMULARY 10/01/2020 YOSPRALA aspirin/omeprazole REMOVE FROM Non-Preferred Non-Formulary FORMULARY 10/01/2020 YOSPRALA aspirin/omeprazole REMOVE FROM Non-Preferred Non-Formulary FORMULARY 10/01/2020 methadone hcl methadone hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY 10/01/2020 ACTONEL risedronate sodium REMOVE FROM Non-Preferred Non-Formulary FORMULARY 10/01/2020 chlorpropamide chlorpropamide REMOVE FROM Non-Preferred Non-Formulary FORMULARY 10/01/2020 ARANESP darbepoetin alfa in REMOVE FROM Non PDL Non-Formulary polysorbate 80 FORMULARY 10/01/2020 PANOXYL benzoyl peroxide REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 FIRST AID neomycin sulfate/bacitracin REMOVE FROM Non PDL Non-Formulary ANTIBIOTIC zinc/polymyxin b FORMULARY 10/01/2020 PAIN & FEVER acetaminophen REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 SALMON OIL- salmon oil/omega-3 fatty REMOVE FROM Non PDL Non-Formulary 1000 acids FORMULARY 10/01/2020 VIRT-NATE prenatal vits with calcium REMOVE FROM Non-Formulary no.73/ferrous fumarate/folic FORMULARY acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 27 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 chlorpropamide chlorpropamide REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 TAB-A-VITE multivitamin REMOVE FROM Non-Formulary FORMULARY 10/01/2020 AQUASOL E vitamin e REMOVE FROM Non-Formulary FORMULARY 10/01/2020 BISCOLAX bisacodyl REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 TRINESSA norgestimate-ethinyl REMOVE FROM Non-Formulary estradiol FORMULARY 10/01/2020 HEXALEN altretamine REMOVE FROM Non-Formulary FORMULARY 10/01/2020 multivitamins w- multivit with calcium, iron, REMOVE FROM Non-Formulary calcium-iron and other minerals FORMULARY 10/01/2020 INFANT'S PAIN acetaminophen REMOVE FROM Non PDL Non-Formulary RELIEF FORMULARY 10/01/2020 PEPTIC RELIEF bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 10/01/2020 aspirin aspirin/calcium REMOVE FROM Non PDL Non-Formulary buffered,buffered carbonate/magnesium FORMULARY aspirin 10/01/2020 PINAWAY pyrantel pamoate REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 NON-ASPIRIN acetaminophen REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 CARDIOTEK-RX folic acid/arginine REMOVE FROM Non PDL Non-Formulary hcl/cyanocobalamin/vit FORMULARY b6/black pepper

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 28 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 arthritis acetaminophen REMOVE FROM Non PDL Non-Formulary pain,arthritis pain FORMULARY relief,arthritis pain reliever 10/01/2020 VANDAZOLE metronidazole ADD UM: B4G BRAND FOR GENERIC 10/01/2020 CIPRODEX ciprofloxacin ADD UM: B4G BRAND FOR hcl/dexamethasone GENERIC 10/01/2020 E.E.S. 200 erythromycin ethylsuccinate ADD UM: B4G BRAND FOR GENERIC 10/01/2020 TECFIDERA dimethyl fumarate ADD UM: B4G BRAND FOR GENERIC 10/01/2020 TECFIDERA dimethyl fumarate ADD UM: B4G BRAND FOR GENERIC 10/01/2020 VESICARE solifenacin succinate REMOVE UM: B4G BRAND FOR GENERIC 10/01/2020 VESICARE solifenacin succinate REMOVE UM: B4G BRAND FOR GENERIC 10/01/2020 ANDROGEL testosterone REMOVE UM: B4G BRAND FOR GENERIC 10/01/2020 CATAPRES-TTS clonidine REMOVE UM: B4G BRAND FOR 1 GENERIC 10/01/2020 VENTOLIN HFA albuterol sulfate REMOVE UM: B4G BRAND FOR GENERIC 10/01/2020 ANDROGEL testosterone REMOVE UM: B4G BRAND FOR GENERIC 10/01/2020 METROGEL- metronidazole REMOVE UM: B4G BRAND FOR VAGINAL GENERIC 10/01/2020 CATAPRES-TTS clonidine REMOVE UM: B4G BRAND FOR 2 GENERIC

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 29 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 ANDROGEL testosterone REMOVE UM: B4G BRAND FOR GENERIC 10/01/2020 CATAPRES-TTS clonidine REMOVE UM: B4G BRAND FOR 3 GENERIC 10/01/2020 ANDROGEL testosterone REMOVE UM: B4G BRAND FOR GENERIC 10/01/2020 TRULICITY dulaglutide ADD UM: PANAME Non Preferred PA 10/01/2020 TRULICITY dulaglutide ADD UM: PANAME Non Preferred PA 10/01/2020 NOVOLIN 70-30 insulin nph human ADD UM: PANAME Non Preferred PA FLEXPEN isophane/insulin regular, human 10/01/2020 niacin er niacin ADD UM: PANAME Non Preferred PA 10/01/2020 dimethyl dimethyl fumarate ADD UM: PANAME Non Preferred PA fumarate 10/01/2020 dimethyl dimethyl fumarate ADD UM: PANAME Non Preferred PA fumarate 10/01/2020 DVORAH acetaminophen/caffeine/dihy ADD UM: PANAME Non Preferred PA drocodeine bitartrate 10/01/2020 YOSPRALA aspirin/omeprazole REMOVE UM: PANAME Non Preferred PA 10/01/2020 YOSPRALA aspirin/omeprazole REMOVE UM: PANAME Non Preferred PA 10/01/2020 CYCLOSET bromocriptine mesylate REMOVE UM: PANAME Non Preferred PA 10/01/2020 ACTONEL risedronate sodium REMOVE UM: PANAME Non Preferred PA 10/01/2020 PENLAC ciclopirox REMOVE UM: PANAME Non Preferred PA 10/01/2020 erythromycin erythromycin ethylsuccinate REMOVE UM: PANAME Non Preferred PA ethylsuccinate 10/01/2020 chlorpropamide chlorpropamide REMOVE UM: PANAME Non Preferred PA 10/01/2020 CALAN verapamil hcl REMOVE UM: PANAME Non Preferred PA 10/01/2020 methadone hcl methadone hcl REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 30 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 EPOGEN epoetin alfa CHANGE UM: PANAME Non Preferred PA Clinical PA 10/01/2020 EPOGEN epoetin alfa CHANGE UM: PANAME Non Preferred PA Clinical PA 10/01/2020 pretomanid pretomanid ADD UM: PANAME Clinical PA 10/01/2020 EPOGEN epoetin alfa CHANGE UM: PANAME Non Preferred PA Clinical PA 10/01/2020 EPOGEN epoetin alfa CHANGE UM: PANAME Non Preferred PA Clinical PA 10/01/2020 EPOGEN epoetin alfa CHANGE UM: PANAME Non Preferred PA Clinical PA 10/01/2020 EPOGEN epoetin alfa CHANGE UM: PANAME Non Preferred PA Clinical PA 10/01/2020 PROCRIT epoetin alfa REMOVE UM: PANAME Clinical PA 10/01/2020 ANDROGEL testosterone REMOVE UM: PANAME Clinical PA 10/01/2020 sevelamer hcl sevelamer hcl REMOVE UM: PANAME Clinical PA 10/01/2020 PROCRIT epoetin alfa REMOVE UM: PANAME Clinical PA 10/01/2020 LINZESS linaclotide REMOVE UM: PANAME Clinical PA 10/01/2020 PROCRIT epoetin alfa REMOVE UM: PANAME Clinical PA 10/01/2020 LINZESS linaclotide REMOVE UM: PANAME Clinical PA 10/01/2020 INTRON A interferon alfa-2b,recomb. REMOVE UM: PANAME Clinical PA 10/01/2020 ANDROGEL testosterone REMOVE UM: PANAME Clinical PA 10/01/2020 INTRON A interferon alfa-2b,recomb. REMOVE UM: PANAME Clinical PA 10/01/2020 PROCRIT epoetin alfa REMOVE UM: PANAME Clinical PA 10/01/2020 sevelamer sevelamer carbonate REMOVE UM: PANAME Clinical PA carbonate 10/01/2020 ANDROGEL testosterone REMOVE UM: PANAME Clinical PA 10/01/2020 LINZESS linaclotide REMOVE UM: PANAME Clinical PA 10/01/2020 NUTROPIN AQ somatropin REMOVE UM: PANAME Clinical PA NUSPIN 10/01/2020 sevelamer sevelamer carbonate REMOVE UM: PANAME Clinical PA carbonate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 31 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 ARANESP darbepoetin alfa in REMOVE UM: PANAME Clinical PA polysorbate 80 10/01/2020 DARAPRIM pyrimethamine REMOVE UM: PANAME Clinical PA 10/01/2020 PROCRIT epoetin alfa REMOVE UM: PANAME Clinical PA 10/01/2020 NUTROPIN AQ somatropin REMOVE UM: PANAME Clinical PA NUSPIN 10/01/2020 OTEZLA apremilast REMOVE UM: PANAME Clinical PA 10/01/2020 NUTROPIN AQ somatropin REMOVE UM: PANAME Clinical PA NUSPIN 10/01/2020 PROCRIT epoetin alfa REMOVE UM: PANAME Clinical PA 10/01/2020 BETHKIS tobramycin REMOVE UM: PANAME Clinical PA 10/01/2020 ANDROGEL testosterone REMOVE UM: PANAME Clinical PA 10/01/2020 ANDROGEL testosterone REMOVE UM: PANAME Clinical PA 10/01/2020 PROCRIT epoetin alfa REMOVE UM: PANAME Clinical PA 10/01/2020 stool softener docusate sodium ADD TO FORMULARY Non PDL 10/01/2020 CLEARLAX polyethylene glycol 3350 ADD TO FORMULARY Non PDL 10/01/2020 ora plus compounding vehicle ADD TO FORMULARY Preferred suspension sugar-free no.20 10/01/2020 ora-blend sf compound vehicle ADD TO FORMULARY Preferred suspension sugar-free no.1 10/01/2020 base, pcca wax base no.116 ADD TO FORMULARY Preferred polypeg 10/01/2020 sodium benzoate sodium benzoate ADD TO FORMULARY Preferred 10/01/2020 ora-sweet-sf compounding vehicle sugar- ADD TO FORMULARY Preferred free no.9 10/01/2020 ora-blend compounding vehicle ADD TO FORMULARY Preferred suspension no.19

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 32 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 creatine creatine monohydrate ADD TO FORMULARY Preferred monohydrate 10/01/2020 ora-sweet compounding vehicle syrup ADD TO FORMULARY Preferred no.23 10/01/2020 l-ornithine hcl ornithine hcl ADD TO FORMULARY Preferred 10/01/2020 l-ornithine hcl ornithine hcl ADD TO FORMULARY Preferred 10/01/2020 creatine creatine monohydrate ADD TO FORMULARY Preferred monohydrate 10/01/2020 sodium benzoate sodium benzoate ADD TO FORMULARY Preferred 10/01/2020 l-citrulline citrulline ADD TO FORMULARY Preferred 10/01/2020 l-ornithine hcl ornithine hcl ADD TO FORMULARY Preferred 10/01/2020 l-citrulline citrulline ADD TO FORMULARY Preferred 10/01/2020 coenzyme q10 ubidecarenone ADD TO FORMULARY Preferred 10/01/2020 coenzyme q10 ubidecarenone ADD TO FORMULARY Preferred 10/01/2020 sodium sodium bicarbonate ADD TO FORMULARY Preferred bicarbonate 10/01/2020 oral suspending compound vehicle ADD TO FORMULARY Preferred compound plus suspension sugar-free no.12 10/01/2020 penderm cream base no.34 ADD TO FORMULARY Preferred 10/01/2020 sodium benzoate sodium benzoate ADD TO FORMULARY Preferred 10/01/2020 penderm cream base no.34 ADD TO FORMULARY Preferred 10/01/2020 sodium benzoate sodium benzoate ADD TO FORMULARY Preferred 10/01/2020 penderm cream base no.34 ADD TO FORMULARY Preferred 10/01/2020 sodium benzoate sodium benzoate ADD TO FORMULARY Preferred 10/01/2020 penderm cream base no.34 ADD TO FORMULARY Preferred

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 33 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 blended compounding vehicle ADD TO FORMULARY Preferred suspending suspension no.14 compound 10/01/2020 penderm cream base no.34 ADD TO FORMULARY Preferred 10/01/2020 sodium sodium bicarbonate ADD TO FORMULARY Preferred bicarbonate 10/01/2020 penderm cream base no.34 ADD TO FORMULARY Preferred 10/01/2020 l-citrulline citrulline ADD TO FORMULARY Preferred 10/01/2020 creatine creatine monohydrate ADD TO FORMULARY Preferred monohydrate 10/01/2020 blended compounding vehicle ADD TO FORMULARY Preferred suspending suspension no.14 compound 10/01/2020 creatine creatine monohydrate ADD TO FORMULARY Preferred monohydrate 10/01/2020 pcca vanishing cream base no.29 ADD TO FORMULARY Preferred base 10/01/2020 coenzyme q10 ubidecarenone ADD TO FORMULARY Preferred 10/01/2020 pcca polyglycol polyethylene glycol 1450 ADD TO FORMULARY Preferred troche base 10/01/2020 l-ornithine hcl ornithine hcl ADD TO FORMULARY Preferred 10/01/2020 sodium sodium bicarbonate ADD TO FORMULARY Preferred bicarbonate 10/01/2020 l-ornithine hcl ornithine hcl ADD TO FORMULARY Preferred 10/01/2020 sodium sodium bicarbonate ADD TO FORMULARY Preferred bicarbonate 10/01/2020 sodium sodium bicarbonate ADD TO FORMULARY Preferred bicarbonate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 34 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 oral suspending compound vehicle ADD TO FORMULARY Preferred compound plus suspension sugar-free no.12 10/01/2020 sodium sodium bicarbonate ADD TO FORMULARY Preferred bicarbonate 10/01/2020 pcca base mineral oil, ADD TO FORMULARY Preferred anhydrous light/petrolatum,white/cetyl alc/stearyl alc 10/01/2020 sweetening compounding vehicle syrup ADD TO FORMULARY Preferred suspend no.23 compound 10/01/2020 sweetening compounding vehicle syrup ADD TO FORMULARY Preferred suspend no.23 compound 10/01/2020 sodium sodium bicarbonate ADD TO FORMULARY Preferred bicarbonate 10/01/2020 ARMONAIR fluticasone propionate REMOVE FROM Non PDL Non-Formulary RESPICLICK FORMULARY 10/01/2020 ARMONAIR fluticasone propionate REMOVE FROM Non PDL Non-Formulary RESPICLICK FORMULARY 10/01/2020 ARMONAIR fluticasone propionate REMOVE FROM Non PDL Non-Formulary RESPICLICK FORMULARY 10/01/2020 EMFLAZA deflazacort ADD TO FORMULARY Non PDL 10/01/2020 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 10/01/2020 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 10/01/2020 EMFLAZA deflazacort ADD TO FORMULARY Non PDL 10/01/2020 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 10/01/2020 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 10/01/2020 EMFLAZA deflazacort ADD TO FORMULARY Non PDL 10/01/2020 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 35 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 10/01/2020 EMFLAZA deflazacort ADD TO FORMULARY Non PDL 10/01/2020 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 10/01/2020 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 10/01/2020 EMFLAZA deflazacort ADD TO FORMULARY Non PDL 10/01/2020 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 10/01/2020 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 10/01/2020 metformin hcl metformin hcl ADD UM: COV Use brand over generic 10/01/2020 RIOMET metformin hcl ADD UM: B4G BRAND FOR GENERIC 10/01/2020 ciprofloxacin- ciprofloxacin ADD UM: COV Use brand over dexamethasone hcl/dexamethasone generic 10/01/2020 hydroxyzine hcl hydroxyzine hcl CHANGE TIER Preferred Non PDL 10/01/2020 buprenorphine- buprenorphine hcl/naloxone REMOVE UM: PANAME Non Preferred PA naloxone hcl 10/01/2020 GYNE-LOTRIMIN clotrimazole REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 infants' acetaminophen REMOVE FROM Non PDL Non-Formulary acetaminophen FORMULARY 10/01/2020 RULOX magnesium REMOVE FROM Non PDL Non-Formulary hydroxide/aluminum FORMULARY hydroxide/simethicone 10/01/2020 ALMACONE magnesium REMOVE FROM Non PDL Non-Formulary hydroxide/aluminum FORMULARY hydroxide/simethicone 10/01/2020 NU-MAG magnesium chloride REMOVE FROM Non PDL Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 36 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID FORMULARY 10/01/2020 NANOVM T-F pediatric multivitamin REMOVE FROM Non PDL Non-Formulary no.93/ferrous sulfate FORMULARY 10/01/2020 pain reliever acetaminophen REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID FORMULARY 10/01/2020 acetaminophen acetaminophen REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 DEKAS vit a palmitate/beta- REMOVE FROM Non PDL Non-Formulary ESSENTIAL carotene/vit FORMULARY d3/tocophersolan/vitamin k 10/01/2020 acetaminophen acetaminophen REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 lite coat aspirin aspirin REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 enovatizer ethyl alcohol REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 MONONESSA norgestimate-ethinyl REMOVE FROM Non PDL Non-Formulary estradiol FORMULARY 10/01/2020 CHILDREN'S acetaminophen REMOVE FROM Non PDL Non-Formulary NON-ASPIRIN FORMULARY 10/01/2020 DEKAS PLUS multivitamin-minerals REMOVE FROM Non PDL Non-Formulary no.56/folic acid/vit FORMULARY k1/ubidecarenone 10/01/2020 rubbing alcohol ethyl alcohol REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 INFANT'S PAIN acetaminophen REMOVE FROM Non PDL Non-Formulary RELIEF,INFANT FORMULARY S' PAIN RELIEF

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 37 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 MVW pediatric multivit REMOVE FROM Non PDL Non-Formulary COMPLETE no.77/cholecalciferol(d3)/ph FORMULARY FORMLTN ytonadione(k) PEDIATRIC 10/01/2020 MI-ACID magnesium REMOVE FROM Non PDL Non-Formulary hydroxide/aluminum FORMULARY hydroxide/simethicone 10/01/2020 MVW pediatric multivit REMOVE FROM Non PDL Non-Formulary COMPLETE no.22/cholecalciferol(d3)/ph FORMULARY FORMULTN ytonadione(k) MULTIVIT 10/01/2020 MVW pediatric multivit REMOVE FROM Non PDL Non-Formulary COMPLETE no.61/cholecalciferol(d3)/ph FORMULARY FORMULATION ytonadione(k) D3000 10/01/2020 ECOTRIN aspirin REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 ethyl alcohol ethyl alcohol REMOVE FROM Non-Formulary FORMULARY 10/01/2020 MAALOX magnesium REMOVE FROM Non PDL Non-Formulary ADVANCED hydroxide/aluminum FORMULARY hydroxide/simethicone 10/01/2020 isagel no rinse ethyl alcohol REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID FORMULARY 10/01/2020 WESTHROID thyroid,pork REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 NEPHRON FA vit b complex and vit c REMOVE FROM Non PDL Non-Formulary no.24/ferrous fumarate/folic FORMULARY acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 38 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID FORMULARY 10/01/2020 MI ACID,MI-ACID magnesium REMOVE FROM Non PDL Non-Formulary hydroxide/aluminum FORMULARY hydroxide/simethicone 10/01/2020 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID FORMULARY 10/01/2020 WESTHROID thyroid,pork REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 alcohol pads with isopropyl REMOVE FROM Non PDL Non-Formulary benzocaine,alcoh alcohol/benzocaine FORMULARY ol swabs with benzocaine 10/01/2020 PENLAC ciclopirox REMOVE FROM Non-Preferred Non-Formulary FORMULARY 10/01/2020 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID FORMULARY 10/01/2020 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID FORMULARY 10/01/2020 NANOVM 9-18 pediatric multivitamin REMOVE FROM Non PDL Non-Formulary no.94/ferrous fumarate FORMULARY 10/01/2020 lo-dose aspirin ec aspirin REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 MAPAP acetaminophen REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 vitamin e vitamin e (dl-alpha REMOVE FROM Non-Formulary tocopheryl acetate) FORMULARY 10/01/2020 WESTHROID thyroid,pork REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 39 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 OTEZLA apremilast REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID FORMULARY 10/01/2020 WESTHROID thyroid,pork REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID FORMULARY 10/01/2020 DOCUSOL docusate sodium REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 nitrofurantoin nitrofurantoin REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 DEKAS vitamin a palmitate/vitamin REMOVE FROM Non PDL Non-Formulary ESSENTIAL d3/vitamin e/vit e tpgs/vit k1 FORMULARY 10/01/2020 WP THYROID thyroid,pork REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 MVW pediatric multivit REMOVE FROM Non PDL Non-Formulary COMPLETE no.22/cholecalciferol(d3)/ph FORMULARY FORMULATION ytonadione(k) D3000 10/01/2020 WP THYROID thyroid,pork REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 WP THYROID thyroid,pork REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 hand sanitizer ethyl alcohol REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 WP THYROID thyroid,pork REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 WP THYROID thyroid,pork REMOVE FROM Non PDL Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 40 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 VIRT-GARD cyanocobalamin/folic REMOVE FROM Non PDL Non-Formulary acid/pyridoxine FORMULARY 10/01/2020 PREVIFEM norgestimate-ethinyl REMOVE FROM Non PDL Non-Formulary estradiol FORMULARY 10/01/2020 hand sanitizer ethyl alcohol REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 antiseptic bio- ethyl alcohol REMOVE FROM Non PDL Non-Formulary hand FORMULARY 10/01/2020 docusate sodium docusate sodium REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 NIVA-FOL cyanocobalamin/folic REMOVE FROM Non PDL Non-Formulary acid/pyridoxine FORMULARY 10/01/2020 calcium calcium gluconate REMOVE FROM Non-Formulary gluconate FORMULARY 10/01/2020 CHILDREN'S acetaminophen REMOVE FROM Non PDL Non-Formulary PAIN RELIEVER FORMULARY 10/01/2020 docetaxel docetaxel REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 WP THYROID thyroid,pork REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 DEKAS PLUS multivit with minerals REMOVE FROM Non PDL Non-Formulary no.53/folic acid/vit FORMULARY k1/ubidecarenone 10/01/2020 NANO VM 4-8 pediatric multivitamin REMOVE FROM Non PDL Non-Formulary no.15/ferrous fumarate/folic FORMULARY acid 10/01/2020 WESTHROID thyroid,pork REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 VP-VITE RX vitamin b complex no.3/folic REMOVE FROM Non PDL Non-Formulary acid/ascorbic FORMULARY acid(vitc)/biotin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 41 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 NANO VM 1-3 pediatric multivitamin REMOVE FROM Non PDL Non-Formulary no.14/ferrous fumarate/folic FORMULARY acid 10/01/2020 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID FORMULARY 10/01/2020 CALAN verapamil hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY 10/01/2020 calcium calcium carbonate REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 gelrite ethyl alcohol REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 ACTIVITE folic acid/vitamin b complex REMOVE FROM Non PDL Non-Formulary and vitamin c FORMULARY 10/01/2020 DEKAS PLUS pediatric multivitamin REMOVE FROM Non PDL Non-Formulary no.128/vitamin k FORMULARY 10/01/2020 amoxicillin- amoxicillin/potassium REMOVE FROM Non PDL Non-Formulary clavulanate pot er clavulanate FORMULARY 10/01/2020 BISMUTH bismuth subsalicylate REMOVE FROM Non PDL Non-Formulary MAXIMUM FORMULARY STRENGTH,PIN K BISMUTH 10/01/2020 MVW pediatric multivit REMOVE FROM Non PDL Non-Formulary COMPLETE no.61/cholecalciferol(d3)/ph FORMULARY FORMULATION ytonadione(k) D5000 10/01/2020 CYCLOSET bromocriptine mesylate REMOVE FROM Non-Preferred Non-Formulary FORMULARY 10/01/2020 NORTEMP acetaminophen REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 CALCIDOL ergocalciferol (vitamin d2) REMOVE FROM Non PDL Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 42 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 MINTOX magnesium REMOVE FROM Non PDL Non-Formulary hydroxide/aluminum FORMULARY hydroxide/simethicone 10/01/2020 PAIN & FEVER acetaminophen REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 maalox maximum magnesium REMOVE FROM Non PDL Non-Formulary strength hydroxide/aluminum FORMULARY hydroxide/simethicone 10/01/2020 WESTAB MAX cyanocobalamin/folic REMOVE FROM Non PDL Non-Formulary acid/pyridoxine FORMULARY 10/01/2020 isopropyl alcohol isopropyl alcohol REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 melatonin melatonin REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 NEPHRO-VITE vitamin b complex no.3/folic REMOVE FROM Non-Formulary RX acid/ascorbic FORMULARY acid(vitc)/biotin 10/01/2020 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID FORMULARY 10/01/2020 MVW pediatric multivit REMOVE FROM Non PDL Non-Formulary COMPLETE no.61/cholecalciferol(d3)/ph FORMULARY FORMULTN ytonadione(k) MULTIVIT 10/01/2020 WOMEN'S bisacodyl REMOVE FROM Non PDL Non-Formulary LAXATIVE FORMULARY 10/01/2020 ASPIR-LOW aspirin REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 LEVORA-28 levonorgestrel-ethinyl REMOVE FROM Non PDL Non-Formulary estradiol,levonorgestrel/ethi FORMULARY nyl estradiol 10/01/2020 DARAPRIM pyrimethamine REMOVE FROM Non PDL Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 43 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 WP THYROID thyroid,pork REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 WP THYROID thyroid,pork REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 epi-clenz ethyl alcohol REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID FORMULARY 10/01/2020 epi-clenz ethyl alcohol REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 SMOOTH calcium carbonate REMOVE FROM Non PDL Non-Formulary ANTACID,SMOO FORMULARY TH DISSOLVING ANTACID 10/01/2020 gelrite ethyl alcohol REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 isopropyl isopropyl alcohol REMOVE FROM Non PDL Non-Formulary alcohol,medi-first FORMULARY isopropyl alcohol 10/01/2020 ergocalciferol ergocalciferol (vitamin d2) REMOVE FROM Non-Formulary FORMULARY 10/01/2020 MAPAP acetaminophen REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 TETANUS- tetanus and diphtheria ADD TO FORMULARY Non PDL DIPHTERIA- toxoids, adsorbed, adult/pf DECAVAC 10/01/2020 TRINATAL prenatal vitamin ADD UM: GENDER Female ULTRA,VINATE no.18/iron,carbonyl/folic ULTRA,PRENAC acid/docusate sod,prenatal ARE,INATAL vit with calcium 18/iron/folic ULTRA,ULTRA acid/docusate sodium NATALCARE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 44 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 prenatal 19 prenatal vits no.119/iron ADD UM: GENDER Female fumarate/folic acid/docusate sod. 10/01/2020 TRINATAL prenatal vit with calcium ADD UM: GENDER Female GT,VINATE 16/iron/folic acid/docusate GT,NATALCARE sodium,prenatal vitamin ,VIRT-VITE GT no.16/iron,carbonyl/folic acid/docusate sod 10/01/2020 MYNATAL,INAT prenatal vitamins with ADD UM: GENDER Female AL GT calcium/iron,carb/docusate/f olic acid,prenatal vitamins with calcium/iron,carbonyl/docus ate/fa 10/01/2020 VINATE II prenatal vitamins with ADD UM: GENDER Female calcium/iron bis- glycinate/folic acid 10/01/2020 TRIMESIS prenatal without iron/folic ADD UM: GENDER Female RX,FOLINATAL acid/calcium PLUS carb/pyridoxine/b12 B,FOLBECAL,PR EMESIS RX,PREVITE RX,COMBI RX 10/01/2020 OBSTETRIX EC prenatal vitamins ADD UM: GENDER Female no.127/iron,carbonyl/folic acid/docusate 10/01/2020 OBSTETRIX prenatal vits ADD UM: GENDER Female DHA,OBTREX no.12/iron,carb/folic DHA acid/docusate/omega-3

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 45 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 triadvance,mynat prenatal vit with calcium ADD UM: GENDER Female al 15/iron/folic acid/docusate advance,prenatal sodium,prenatal vitamin ad,inatal no.15/iron,carbonyl/folic advance,advance acid/docusate sod d natalcare,virt- advance 10/01/2020 CITRANATAL B- prenatal vit with calcium ADD UM: GENDER Female CALM,TARON- comb BC no.63/iron,carbonyl/fa/b6,pre natal vit with calcium 63/iron,carb/folic acid/pyridoxine 10/01/2020 PREFERA prenatal vit no.21/iron ADD UM: GENDER Female OB,HEMENATAL polysacch,heme OB,VP-HEME polypep/folic acid OB 10/01/2020 SE-NATAL prenatal vitamins with ADD UM: GENDER Female 90,MYNATE 90 calcium/ferrous PLUS,PRENATA fumarate/docusate/fa,prenat L MR 90 FE al vitamins with calcium/ferrous fum/docusate/folic ac,prenatal vitamins/ferrous fumarate/docusate/folic acid 10/01/2020 prenatal multi- prenatal vits no.151/iron ADD UM: GENDER Female dha fum/folic acid/omega3/dha/epa/fish 10/01/2020 prenatal multi- prenatal vitamins combo ADD UM: GENDER Female dha,prenatal no.40/ferrous multivitamin-dha fumarate/fa/dha,prenatal vitamins no.40/ferrous fumarate/folic acid/dha

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 46 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 sildenafil citrate sildenafil citrate CHANGE UM: PULMONARY DRUGCLASS ARTERIAL HYPERTENSION (PAH) AGENTS 10/01/2020 sildenafil citrate sildenafil citrate CHANGE UM: COV Use brand over generic 10/01/2020 albuterol sulfate albuterol sulfate CHANGE UM: QUANTITY 1.2 / day hfa 10/01/2020 albuterol sulfate albuterol sulfate CHANGE UM: BETA hfa DRUGCLASS ADRENERGICS - SHORT ACTING 10/01/2020 albuterol sulfate albuterol sulfate CHANGE UM: COV Use brand over hfa generic 10/01/2020 EMFLAZA deflazacort REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 EMFLAZA deflazacort REMOVE UM: PANAME Clinical PA 10/01/2020 EMFLAZA deflazacort REMOVE UM: AGE At least 2 yrs old 10/01/2020 EMFLAZA deflazacort REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 EMFLAZA deflazacort REMOVE UM: PANAME Clinical PA 10/01/2020 EMFLAZA deflazacort REMOVE UM: AGE At least 2 yrs old 10/01/2020 EMFLAZA deflazacort REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 EMFLAZA deflazacort REMOVE UM: PANAME Clinical PA 10/01/2020 EMFLAZA deflazacort REMOVE UM: AGE At least 2 yrs old 10/01/2020 EMFLAZA deflazacort REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 EMFLAZA deflazacort REMOVE UM: PANAME Clinical PA 10/01/2020 EMFLAZA deflazacort REMOVE UM: AGE At least 2 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 47 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 EMFLAZA deflazacort REMOVE FROM Non PDL Non-Formulary FORMULARY 10/01/2020 EMFLAZA deflazacort REMOVE UM: PANAME Clinical PA 10/01/2020 EMFLAZA deflazacort REMOVE UM: AGE At least 2 yrs old 10/01/2020 EMFLAZA deflazacort ADD TO FORMULARY Non-Formulary Non PDL 10/01/2020 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 10/01/2020 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 10/01/2020 EMFLAZA deflazacort ADD TO FORMULARY Non-Formulary Non PDL 10/01/2020 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 10/01/2020 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 10/01/2020 EMFLAZA deflazacort ADD TO FORMULARY Non-Formulary Non PDL 10/01/2020 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 10/01/2020 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 10/01/2020 EMFLAZA deflazacort ADD TO FORMULARY Non-Formulary Non PDL 10/01/2020 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 10/01/2020 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 10/01/2020 EMFLAZA deflazacort ADD TO FORMULARY Non-Formulary Non PDL 10/01/2020 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 10/01/2020 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 10/01/2020 butenafine hcl butenafine hcl ADD UM: PANAME Non Preferred PA 10/01/2020 ALLER-EASE fexofenadine hcl ADD UM: PANAME Non Preferred PA 10/01/2020 ALLER-EASE fexofenadine hcl ADD UM: PANAME Non Preferred PA 10/01/2020 24 HOUR NASAL triamcinolone acetonide ADD UM: PANAME Non Preferred PA ALLERGY 10/01/2020 PROCRIT epoetin alfa ADD UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 48 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 PATADAY,PATA olopatadine hcl CHANGE UM: PANAME Non Preferred PA DAY ONCE DAILY RELIEF 10/01/2020 omeprazole- omeprazole/sodium CHANGE UM: PANAME Non Preferred PA sodium bicarbonate bicarbonate 10/01/2020 cetirizine hcl cetirizine hcl ADD UM: PANAME Non Preferred PA 10/01/2020 omeprazole omeprazole ADD UM: PANAME Non Preferred PA 10/01/2020 INTRON A interferon alfa-2b,recomb. ADD UM: PANAME Non Preferred PA 10/01/2020 levorphanol levorphanol tartrate ADD UM: PANAME Non Preferred PA tartrate 10/01/2020 INTRON A interferon alfa-2b,recomb. ADD UM: PANAME Non Preferred PA 10/01/2020 sevelamer sevelamer carbonate ADD UM: PANAME Non Preferred PA carbonate 10/01/2020 ANDROGEL testosterone ADD UM: PANAME Non Preferred PA 10/01/2020 sevelamer sevelamer carbonate ADD UM: PANAME Non Preferred PA carbonate 10/01/2020 NUTROPIN AQ somatropin ADD UM: PANAME Non Preferred PA NUSPIN 10/01/2020 ALLERGY fluticasone propionate ADD UM: PANAME Non Preferred PA RELIEF 10/01/2020 children's cetirizine hcl ADD UM: PANAME Non Preferred PA cetirizine hcl 10/01/2020 FLONASE fluticasone furoate ADD UM: PANAME Non Preferred PA SENSIMIST 10/01/2020 HEARTBURN lansoprazole ADD UM: PANAME Non Preferred PA TREATMENT 24 HOUR 10/01/2020 ALLERGY fexofenadine hcl ADD UM: PANAME Non Preferred PA RELIEF

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 49 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 CHILDREN'S fluticasone furoate ADD UM: PANAME Non Preferred PA FLONASE SENSIMIST 10/01/2020 ALLERGY cetirizine hcl ADD UM: PANAME Non Preferred PA RELIEF 10/01/2020 CHILDREN'S fluticasone propionate ADD UM: PANAME Non Preferred PA FLONASE ALLERGY RLF 10/01/2020 nadolol nadolol ADD UM: PANAME Non Preferred PA 10/01/2020 HEARTBURN esomeprazole magnesium ADD UM: PANAME Non Preferred PA TREATMENT 10/01/2020 FLONASE fluticasone propionate ADD UM: PANAME Non Preferred PA ALLERGY RELIEF 10/01/2020 cetirizine hcl cetirizine hcl ADD UM: PANAME Non Preferred PA 10/01/2020 tolterodine tolterodine tartrate ADD UM: PANAME Non Preferred PA tartrate er 10/01/2020 cetirizine hcl cetirizine hcl ADD UM: PANAME Non Preferred PA 10/01/2020 levalbuterol hcl levalbuterol hcl ADD UM: PANAME Non Preferred PA 10/01/2020 NOVOLIN 70-30 insulin nph human ADD UM: PANAME Non Preferred PA isophane/insulin regular, human,nph, human insulin isophane/insulin regular, human 10/01/2020 hydrocortisone- hydrocortisone/aloe vera ADD UM: PANAME Non Preferred PA aloe 10/01/2020 omeprazole omeprazole magnesium ADD UM: PANAME Non Preferred PA magnesium 10/01/2020 niacin niacin ADD UM: PANAME Non Preferred PA 10/01/2020 SYMJEPI epinephrine CHANGE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 50 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 ANDROGEL testosterone ADD UM: PANAME Non Preferred PA 10/01/2020 ANDROGEL testosterone ADD UM: PANAME Non Preferred PA 10/01/2020 PROCRIT epoetin alfa ADD UM: PANAME Non Preferred PA 10/01/2020 sevelamer hcl sevelamer hcl ADD UM: PANAME Non Preferred PA 10/01/2020 ANDROGEL testosterone ADD UM: PANAME Non Preferred PA 10/01/2020 PROCRIT epoetin alfa ADD UM: PANAME Non Preferred PA 10/01/2020 FUNGOID-D tolnaftate ADD UM: PANAME Non Preferred PA 10/01/2020 fexofenadine hcl fexofenadine hcl ADD UM: PANAME Non Preferred PA 10/01/2020 tolterodine tolterodine tartrate ADD UM: PANAME Non Preferred PA tartrate er 10/01/2020 PREVACID lansoprazole ADD UM: PANAME Non Preferred PA 24HR 10/01/2020 fexofenadine hcl fexofenadine hcl ADD UM: PANAME Non Preferred PA 10/01/2020 ANDROGEL testosterone ADD UM: PANAME Non Preferred PA 10/01/2020 LOTRIMIN AF clotrimazole ADD UM: PANAME Non Preferred PA 10/01/2020 PROCRIT epoetin alfa ADD UM: PANAME Non Preferred PA 10/01/2020 niacin niacin ADD UM: PANAME Non Preferred PA 10/01/2020 niacin niacin ADD UM: PANAME Non Preferred PA 10/01/2020 fexofenadine hcl fexofenadine hcl ADD UM: PANAME Non Preferred PA 10/01/2020 SCALPICIN hydrocortisone ADD UM: PANAME Non Preferred PA 10/01/2020 triamcinolone triamcinolone acetonide CHANGE UM: PANAME Non Preferred PA acetonide 10/01/2020 tolterodine tolterodine tartrate ADD UM: PANAME Non Preferred PA tartrate 10/01/2020 PATADAY olopatadine hcl ADD UM: PANAME Non Preferred PA TWICE DAILY RELIEF

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 51 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 lansoprazole lansoprazole CHANGE UM: PANAME Non Preferred PA 10/01/2020 niacin,plain niacin niacin CHANGE UM: PANAME Non Preferred PA 10/01/2020 PROCRIT epoetin alfa ADD UM: PANAME Non Preferred PA 10/01/2020 NUTROPIN AQ somatropin ADD UM: PANAME Non Preferred PA NUSPIN 10/01/2020 HUMULIN N insulin nph human isophane ADD UM: PANAME Non Preferred PA KWIKPEN 10/01/2020 PROCRIT epoetin alfa ADD UM: PANAME Non Preferred PA 10/01/2020 NUTROPIN AQ somatropin ADD UM: PANAME Non Preferred PA NUSPIN 10/01/2020 ACID REDUCER omeprazole magnesium ADD UM: PANAME Non Preferred PA 10/01/2020 esomeprazole esomeprazole magnesium CHANGE UM: PANAME Non Preferred PA magnesium 10/01/2020 SYMJEPI epinephrine CHANGE UM: PANAME Non Preferred PA 10/01/2020 PROCRIT epoetin alfa ADD UM: PANAME Non Preferred PA 10/01/2020 children's cetirizine hcl ADD UM: PANAME Non Preferred PA cetirizine hcl 10/01/2020 ARANESP darbepoetin alfa in ADD TO FORMULARY Non-Formulary Preferred polysorbate 80 10/01/2020 ARANESP darbepoetin alfa in ADD UM: PANAME Clinical PA polysorbate 80 10/01/2020 everolimus everolimus CHANGE TIER Non PDL 10/01/2020 everolimus everolimus CHANGE UM: QUANTITY 1 / day 10/01/2020 everolimus everolimus CHANGE UM: PANAME Clinical PA 10/01/2020 everolimus everolimus CHANGE TIER Non PDL 10/01/2020 everolimus everolimus CHANGE UM: QUANTITY 1 / day 10/01/2020 everolimus everolimus CHANGE UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 52 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 everolimus everolimus CHANGE TIER Non PDL 10/01/2020 everolimus everolimus CHANGE UM: QUANTITY 1 / day 10/01/2020 everolimus everolimus CHANGE UM: PANAME Clinical PA 10/01/2020 abiraterone abiraterone acetate CHANGE TIER Non PDL acetate 10/01/2020 abiraterone abiraterone acetate CHANGE UM: QUANTITY 4 / day acetate 10/01/2020 abiraterone abiraterone acetate CHANGE UM: PANAME Clinical PA acetate 10/01/2020 ARANESP darbepoetin alfa in REMOVE FROM Preferred Non-Formulary polysorbate 80 FORMULARY 10/01/2020 ARANESP darbepoetin alfa in REMOVE UM: PANAME Clinical PA polysorbate 80 10/01/2020 lansoprazole lansoprazole REMOVE FROM Non-Formulary FORMULARY 10/03/2020 doxycycline doxycycline hyclate REMOVE UM: CUSTOM Carve Out- Bill hyclate MDCH FFS 10/05/2020 CADUET amlodipine ADD UM: QUANTITY 1 / day besylate/atorvastatin calcium 10/05/2020 CADUET amlodipine ADD UM: QUANTITY 1 / day besylate/atorvastatin calcium 10/05/2020 simvastatin simvastatin ADD UM: QUANTITY 1 / day 10/05/2020 CRESTOR rosuvastatin calcium ADD UM: QUANTITY 1 / day 10/05/2020 CRESTOR rosuvastatin calcium ADD UM: QUANTITY 1 / day 10/05/2020 CRESTOR rosuvastatin calcium ADD UM: QUANTITY 1 / day

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 53 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/05/2020 CADUET amlodipine ADD UM: QUANTITY 1 / day besylate/atorvastatin calcium 10/05/2020 CADUET amlodipine ADD UM: QUANTITY 1 / day besylate/atorvastatin calcium 10/05/2020 CADUET amlodipine ADD UM: QUANTITY 1 / day besylate/atorvastatin calcium 10/05/2020 CADUET amlodipine ADD UM: QUANTITY 1 / day besylate/atorvastatin calcium 10/05/2020 fluvastatin fluvastatin sodium ADD UM: QUANTITY 1 / day sodium 10/05/2020 rosuvastatin rosuvastatin calcium ADD UM: QUANTITY 1 / day calcium 10/05/2020 rosuvastatin rosuvastatin calcium ADD UM: QUANTITY 1 / day calcium 10/05/2020 rosuvastatin rosuvastatin calcium ADD UM: QUANTITY 1 / day calcium 10/05/2020 rosuvastatin rosuvastatin calcium ADD UM: QUANTITY 1 / day calcium 10/05/2020 CADUET amlodipine ADD UM: QUANTITY 1 / day besylate/atorvastatin calcium 10/05/2020 fluvastatin er fluvastatin sodium ADD UM: QUANTITY 1 / day 10/05/2020 CADUET amlodipine ADD UM: QUANTITY 1 / day besylate/atorvastatin calcium 10/05/2020 EZALLOR rosuvastatin calcium ADD UM: QUANTITY 1 / day SPRINKLE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 54 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/05/2020 EZALLOR rosuvastatin calcium ADD UM: QUANTITY 1 / day SPRINKLE 10/05/2020 amlodipine- amlodipine ADD UM: QUANTITY 1 / day atorvastatin besylate/atorvastatin calcium 10/05/2020 amlodipine- amlodipine ADD UM: QUANTITY 1 / day atorvastatin besylate/atorvastatin calcium 10/05/2020 lovastatin lovastatin ADD UM: QUANTITY 1 / day 10/05/2020 LIPITOR atorvastatin calcium ADD UM: QUANTITY 1 / day 10/05/2020 lovastatin lovastatin ADD UM: QUANTITY 1 / day 10/05/2020 ALTOPREV lovastatin ADD UM: QUANTITY 1 / day 10/05/2020 ALTOPREV lovastatin ADD UM: QUANTITY 1 / day 10/05/2020 CRESTOR rosuvastatin calcium ADD UM: QUANTITY 1 / day 10/05/2020 EZALLOR rosuvastatin calcium ADD UM: QUANTITY 1 / day SPRINKLE 10/05/2020 EZALLOR rosuvastatin calcium ADD UM: QUANTITY 1 / day SPRINKLE 10/05/2020 LESCOL XL fluvastatin sodium ADD UM: QUANTITY 1 / day 10/05/2020 ALTOPREV lovastatin ADD UM: QUANTITY 1 / day 10/05/2020 simvastatin simvastatin ADD UM: QUANTITY 1 / day 10/05/2020 amlodipine- amlodipine ADD UM: QUANTITY 1 / day atorvastatin besylate/atorvastatin calcium 10/05/2020 amlodipine- amlodipine ADD UM: QUANTITY 1 / day atorvastatin besylate/atorvastatin calcium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 55 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/05/2020 amlodipine- amlodipine ADD UM: QUANTITY 1 / day atorvastatin besylate/atorvastatin calcium 10/05/2020 amlodipine- amlodipine ADD UM: QUANTITY 1 / day atorvastatin besylate/atorvastatin calcium 10/05/2020 amlodipine- amlodipine ADD UM: QUANTITY 1 / day atorvastatin besylate/atorvastatin calcium 10/05/2020 LIVALO pitavastatin calcium ADD UM: QUANTITY 1 / day 10/05/2020 ezetimibe- ezetimibe/simvastatin ADD UM: QUANTITY 1 / day simvastatin 10/05/2020 ezetimibe- ezetimibe/simvastatin ADD UM: QUANTITY 1 / day simvastatin 10/05/2020 amlodipine- amlodipine ADD UM: QUANTITY 1 / day atorvastatin besylate/atorvastatin calcium 10/05/2020 ZYPITAMAG pitavastatin magnesium ADD UM: QUANTITY 1 / day 10/05/2020 LIVALO pitavastatin calcium ADD UM: QUANTITY 1 / day 10/05/2020 pravastatin pravastatin sodium ADD UM: QUANTITY 1 / day sodium 10/05/2020 ZYPITAMAG pitavastatin magnesium ADD UM: QUANTITY 1 / day 10/05/2020 ZYPITAMAG pitavastatin magnesium ADD UM: QUANTITY 1 / day 10/05/2020 ezetimibe- ezetimibe/simvastatin ADD UM: QUANTITY 1 / day simvastatin 10/05/2020 ezetimibe- ezetimibe/simvastatin ADD UM: QUANTITY 1 / day simvastatin 10/05/2020 amlodipine- amlodipine ADD UM: QUANTITY 1 / day atorvastatin besylate/atorvastatin calcium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 56 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/05/2020 amlodipine- amlodipine ADD UM: QUANTITY 1 / day atorvastatin besylate/atorvastatin calcium 10/05/2020 amlodipine- amlodipine ADD UM: QUANTITY 1 / day atorvastatin besylate/atorvastatin calcium 10/05/2020 ZOCOR simvastatin ADD UM: QUANTITY 1 / day 10/05/2020 VYTORIN ezetimibe/simvastatin ADD UM: QUANTITY 1 / day 10/05/2020 VYTORIN ezetimibe/simvastatin ADD UM: QUANTITY 1 / day 10/05/2020 VYTORIN ezetimibe/simvastatin ADD UM: QUANTITY 1 / day 10/05/2020 VYTORIN ezetimibe/simvastatin ADD UM: QUANTITY 1 / day 10/05/2020 atorvastatin atorvastatin calcium ADD UM: QUANTITY 1 / day calcium 10/05/2020 lovastatin lovastatin ADD UM: QUANTITY 1 / day 10/05/2020 LIVALO pitavastatin calcium ADD UM: QUANTITY 1 / day 10/05/2020 ZOCOR simvastatin ADD UM: QUANTITY 1 / day 10/06/2020 PULMOZYME dornase alfa CHANGE UM: QUANTITY 1 / day 2.5 / day 10/07/2020 methocarbamol methocarbamol ADD TO FORMULARY Non-Preferred 10/08/2020 doxycycline doxycycline hyclate ADD TO FORMULARY Non PDL hyclate 10/08/2020 doxycycline doxycycline hyclate ADD TO FORMULARY Non PDL hyclate 10/14/2020 TRELEGY fluticasone ADD TO FORMULARY Non-Preferred ELLIPTA furoate/umeclidinium bromide/vilanterol trifenat 10/14/2020 TRELEGY fluticasone ADD UM: PANAME Non Preferred PA ELLIPTA furoate/umeclidinium bromide/vilanterol trifenat

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 57 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/16/2020 VESICARE solifenacin succinate REMOVE UM: B4G BRAND FOR GENERIC 10/16/2020 VESICARE solifenacin succinate REMOVE UM: B4G BRAND FOR GENERIC 10/23/2020 erythromycin erythromycin ethylsuccinate CHANGE TIER Non-Preferred Preferred ethylsuccinate 10/23/2020 erythromycin erythromycin ethylsuccinate REMOVE UM: PANAME Non Preferred PA ethylsuccinate 10/23/2020 erythromycin erythromycin ethylsuccinate CHANGE UM: MACROLIDES ethylsuccinate DRUGCLASS 10/23/2020 erythromycin erythromycin ethylsuccinate ADD UM: COV Use brand over ethylsuccinate generic 10/28/2020 HUMULIN 70/30 insulin nph human CHANGE TIER Non-Preferred Preferred KWIKPEN isophane/insulin regular, human

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 58 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

November, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/01/2020 PULMOZYME dornase alfa CHANGE UM: QUANTITY 1 / day 2.5 / day 11/02/2020 OXTELLAR XR oxcarbazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 OXTELLAR XR oxcarbazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PRECEDEX dexmedetomidine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 OXTELLAR XR oxcarbazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ICLUSIG ponatinib hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ICLUSIG ponatinib hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TOFRANIL imipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 alprazolam alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TRUVADA emtricitabine/tenofovir REMOVE UM: CUSTOM Carve Out- Bill disoproxil fumarate MDCH FFS 11/02/2020 TRUVADA emtricitabine/tenofovir REMOVE UM: CUSTOM Carve Out- Bill disoproxil fumarate MDCH FFS 11/02/2020 TRUVADA emtricitabine/tenofovir REMOVE UM: CUSTOM Carve Out- Bill disoproxil fumarate MDCH FFS 11/02/2020 PAXIL paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 flurazepam hcl flurazepam hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 59 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 tiagabine hcl tiagabine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 molindone hcl molindone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 QUILLIVANT XR methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 sertraline hcl sertraline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RYDAPT midostaurin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALUNBRIG brigatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BENEFIX factor ix human recombinant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIRAMUNE nevirapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 phenytoin phenytoin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LEXIVA fosamprenavir calcium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CAPRELSA vandetanib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CAPRELSA vandetanib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 aminocaproic aminocaproic acid REMOVE UM: CUSTOM Carve Out- Bill acid MDCH FFS 11/02/2020 RITALIN methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fosamprenavir fosamprenavir calcium REMOVE UM: CUSTOM Carve Out- Bill calcium MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 60 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 FOCALIN XR dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dexmethylphenid dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill ate hcl er MDCH FFS 11/02/2020 abacavir abacavir sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADYNOVATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, full length, peg MDCH FFS 11/02/2020 amitriptyline hcl amitriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CEREZYME imiglucerase REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XANAX alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ethosuximide ethosuximide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TRINTELLIX vortioxetine hydrobromide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TRINTELLIX vortioxetine hydrobromide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TRINTELLIX vortioxetine hydrobromide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZERIT stavudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PLASMANATE plasma protein fraction REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LATUDA lurasidone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PREZISTA darunavir ethanolate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 61 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 VIREAD tenofovir disoproxil fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIREAD tenofovir disoproxil fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIREAD tenofovir disoproxil fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIREAD tenofovir disoproxil fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 diazepam diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VALIUM diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TRETTEN factor xiii a-subunit, REMOVE UM: CUSTOM Carve Out- Bill recombinant MDCH FFS 11/02/2020 INREBIC fedratinib dihydrochloride REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ROZLYTREK entrectinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ROZLYTREK entrectinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIRAMUNE XR nevirapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GEODON ziprasidone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 nevirapine er nevirapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ORAP pimozide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 alprazolam alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 62 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 topiramate topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GALAFOLD migalastat hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XCOPRI cenobamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TYKERB lapatinib ditosylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 topiramate er topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 topiramate er topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 topiramate er topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 topiramate er topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XCOPRI cenobamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 topiramate er topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ELOCTATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, fc fusion MDCH FFS protein 11/02/2020 ELOCTATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, fc fusion MDCH FFS protein 11/02/2020 ELOCTATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, fc fusion MDCH FFS protein

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 63 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ELOCTATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, fc fusion MDCH FFS protein 11/02/2020 ELOCTATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, fc fusion MDCH FFS protein 11/02/2020 ELOCTATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, fc fusion MDCH FFS protein 11/02/2020 ELOCTATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, fc fusion MDCH FFS protein 11/02/2020 HETLIOZ tasimelteon REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BENEFIX factor ix human recombinant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 nefazodone hcl nefazodone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 oxcarbazepine oxcarbazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BENEFIX factor ix human recombinant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 phenobarbital phenobarbital REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZYPREXA ZYDIS olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clozapine clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XCOPRI cenobamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 64 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 XCOPRI cenobamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XCOPRI cenobamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XCOPRI cenobamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XCOPRI cenobamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XCOPRI cenobamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XCOPRI cenobamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 molindone hcl molindone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 olanzapine olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PENTICAN gabapentin/lidocaine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 trimipramine trimipramine maleate REMOVE UM: CUSTOM Carve Out- Bill maleate MDCH FFS 11/02/2020 SECONAL secobarbital sodium REMOVE UM: CUSTOM Carve Out- Bill SODIUM MDCH FFS 11/02/2020 GABAPAL gabapentin/lidocaine REMOVE UM: CUSTOM Carve Out- Bill hcl/gauze bandage/silicone MDCH FFS adhesive 11/02/2020 phenytoin sodium phenytoin sodium extended REMOVE UM: CUSTOM Carve Out- Bill extended MDCH FFS 11/02/2020 olanzapine odt olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 65 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 sertraline hcl sertraline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INVEGA TRINZA paliperidone palmitate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INVEGA TRINZA paliperidone palmitate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INVEGA TRINZA paliperidone palmitate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INVEGA TRINZA paliperidone palmitate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill ne-amphetamine saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 KLONOPIN clonazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KOGENATE FS antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recomb,full length (alb- MDCH FFS free),antihemophilic factor (fviii) recombinant,full length 11/02/2020 divalproex divalproex sodium REMOVE UM: CUSTOM Carve Out- Bill sodium er MDCH FFS 11/02/2020 DEPAKOTE ER divalproex sodium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DAKLINZA daclatasvir dihydrochloride REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZYKADIA ceritinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill ne-amphet er saccharate/amphetamine MDCH FFS sulf-aspartate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 66 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ZYPREXA ZYDIS olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RIBASPHERE ribavirin REMOVE UM: CUSTOM Carve Out- Bill RIBAPAK MDCH FFS 11/02/2020 clorazepate clorazepate dipotassium REMOVE UM: CUSTOM Carve Out- Bill dipotassium MDCH FFS 11/02/2020 RIBASPHERE ribavirin REMOVE UM: CUSTOM Carve Out- Bill RIBAPAK MDCH FFS 11/02/2020 divalproex divalproex sodium REMOVE UM: CUSTOM Carve Out- Bill sodium MDCH FFS 11/02/2020 ZONEGRAN zonisamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SYMFI LO efavirenz/lamivudine/tenofov REMOVE UM: CUSTOM Carve Out- Bill ir disoproxil fumarate MDCH FFS 11/02/2020 ADVATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recomb,full length (alb- MDCH FFS free),antihemophilic factor (fviii) recombinant,full length 11/02/2020 RECOMBINATE antihemophilic factor viii, REMOVE UM: CUSTOM Carve Out- Bill human recombinant MDCH FFS 11/02/2020 TROGARZO ibalizumab-uiyk REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ABILIFY aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 aripiprazole aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 aripiprazole aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 aripiprazole aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 67 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ABILIFY aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 aripiprazole aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ABILIFY aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ABILIFY aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 risperidone odt risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 risperidone odt risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 risperidone odt risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PRISTIQ desvenlafaxine succinate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PRISTIQ desvenlafaxine succinate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 aripiprazole aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 levetiracetam levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 risperidone odt risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 albumin (human) albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GABACAINE gabapentin/lidocaine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 nortriptyline hcl nortriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 68 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 topiramate topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 molindone hcl molindone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZUBSOLV buprenorphine hcl/naloxone REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 mirtazapine mirtazapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 bupropion hcl sr bupropion hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EPIVIR lamivudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 REMERON mirtazapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIDEX EC didanosine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BENEFIX factor ix human recombinant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 oxazepam oxazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZIAGEN abacavir sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 imipramine hcl imipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RESTORIL temazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DEPAKENE valproic acid REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SARAFEM fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 69 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 lamotrigine er lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine er lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 albumin (human) albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine er lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 COGENTIN benztropine mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DEXEDRINE dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine er lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 OBIZUR antihemophilic factor viii, REMOVE UM: CUSTOM Carve Out- Bill recombinant porcine MDCH FFS sequence 11/02/2020 tenofovir tenofovir disoproxil fumarate REMOVE UM: CUSTOM Carve Out- Bill disoproxil MDCH FFS fumarate 11/02/2020 AMICAR aminocaproic acid REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INTELENCE etravirine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 desipramine hcl desipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LAMICTAL XR lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (GREEN) MDCH FFS 11/02/2020 LAMICTAL XR lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (ORANGE) MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 70 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 LAMICTAL XR lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LAMICTAL XR lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (BLUE) MDCH FFS 11/02/2020 trifluoperazine hcl trifluoperazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PREZISTA darunavir ethanolate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LAMICTAL XR lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LAMICTAL XR lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TURALIO pexidartinib hydrochloride REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LAMICTAL XR lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 efavirenz efavirenz REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 levetiracetam- levetiracetam in sodium REMOVE UM: CUSTOM Carve Out- Bill nacl chloride, iso-osmotic MDCH FFS 11/02/2020 levetiracetam- levetiracetam in sodium REMOVE UM: CUSTOM Carve Out- Bill nacl chloride, iso-osmotic MDCH FFS 11/02/2020 levetiracetam- levetiracetam in sodium REMOVE UM: CUSTOM Carve Out- Bill nacl chloride, iso-osmotic MDCH FFS 11/02/2020 atomoxetine hcl atomoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 atomoxetine hcl atomoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 efavirenz-lamivu- efavirenz/lamivudine/tenofov REMOVE UM: CUSTOM Carve Out- Bill tenofov disop ir disoproxil fumarate MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 71 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 atomoxetine hcl atomoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 atomoxetine hcl atomoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 atomoxetine hcl atomoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clonazepam clonazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 thioridazine hcl thioridazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clonazepam clonazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clonazepam clonazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clonazepam clonazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CIMDUO lamivudine/tenofovir REMOVE UM: CUSTOM Carve Out- Bill disoproxil fumarate MDCH FFS 11/02/2020 SYMFI efavirenz/lamivudine/tenofov REMOVE UM: CUSTOM Carve Out- Bill ir disoproxil fumarate MDCH FFS 11/02/2020 clonazepam clonazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 phenobarbital phenobarbital REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 aripiprazole aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ABILIFY aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lorazepam lorazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 72 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 desipramine hcl desipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 haloperidol haloperidol lactate REMOVE UM: CUSTOM Carve Out- Bill lactate MDCH FFS 11/02/2020 NARDIL phenelzine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ACTIVE-PAC gabapentin/lidocaine REMOVE UM: CUSTOM Carve Out- Bill hcl/menthol MDCH FFS 11/02/2020 oxcarbazepine oxcarbazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KEPPRA levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BRUKINSA zanubrutinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 sapropterin sapropterin dihydrochloride REMOVE UM: CUSTOM Carve Out- Bill dihydrochloride MDCH FFS 11/02/2020 armodafinil armodafinil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 armodafinil armodafinil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 armodafinil armodafinil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PAXIL paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIRAMUNE XR nevirapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZYPREXA olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 nevirapine er nevirapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 73 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 KUVAN sapropterin dihydrochloride REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ORFADIN nitisinone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DIASTAT diazepam REMOVE UM: CUSTOM Carve Out- Bill ACUDIAL MDCH FFS 11/02/2020 DIASTAT diazepam REMOVE UM: CUSTOM Carve Out- Bill ACUDIAL MDCH FFS 11/02/2020 SEROQUEL XR quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SEROQUEL XR quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SEROQUEL XR quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALBUMINAR-5 albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NUPLAZID pimavanserin tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 diazepam diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 diazepam diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TASIGNA nilotinib hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INTERMEZZO zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INTERMEZZO zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FYCOMPA perampanel REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 74 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 INVIRASE saquinavir mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 AFSTYLA antihemophilic factor viii REMOVE UM: CUSTOM Carve Out- Bill recomb,single-chn,b-dom MDCH FFS truncated 11/02/2020 AFSTYLA antihemophilic factor viii REMOVE UM: CUSTOM Carve Out- Bill recomb,single-chn,b-dom MDCH FFS truncated 11/02/2020 abacavir- abacavir REMOVE UM: CUSTOM Carve Out- Bill lamivudine- sulfate/lamivudine/zidovudin MDCH FFS zidovudine e 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 thiothixene thiothixene REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BANZEL rufinamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BANZEL rufinamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RUBRACA rucaparib camsylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 methamphetamin methamphetamine hcl REMOVE UM: CUSTOM Carve Out- Bill e hcl MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 75 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 AFSTYLA antihemophilic factor viii REMOVE UM: CUSTOM Carve Out- Bill recomb,single-chn,b-dom MDCH FFS truncated 11/02/2020 AFSTYLA antihemophilic factor viii REMOVE UM: CUSTOM Carve Out- Bill recomb,single-chn,b-dom MDCH FFS truncated 11/02/2020 AFSTYLA antihemophilic factor viii REMOVE UM: CUSTOM Carve Out- Bill recomb,single-chn,b-dom MDCH FFS truncated 11/02/2020 AFSTYLA antihemophilic factor viii REMOVE UM: CUSTOM Carve Out- Bill recomb,single-chn,b-dom MDCH FFS truncated 11/02/2020 AFSTYLA antihemophilic factor viii REMOVE UM: CUSTOM Carve Out- Bill recomb,single-chn,b-dom MDCH FFS truncated 11/02/2020 pimozide pimozide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SURMONTIL trimipramine maleate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 haloperidol haloperidol lactate REMOVE UM: CUSTOM Carve Out- Bill lactate MDCH FFS 11/02/2020 RISPERDAL risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 paroxetine hcl paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PREZCOBIX darunavir REMOVE UM: CUSTOM Carve Out- Bill ethanolate/cobicistat MDCH FFS 11/02/2020 fluvoxamine fluvoxamine maleate REMOVE UM: CUSTOM Carve Out- Bill maleate er MDCH FFS 11/02/2020 fluvoxamine fluvoxamine maleate REMOVE UM: CUSTOM Carve Out- Bill maleate er MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 76 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 venlafaxine hcl venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KYPROLIS carfilzomib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 nortriptyline hcl nortriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RESTORIL temazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ARCALYST rilonacept REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ELELYSO taliglucerase alfa REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SARAFEM fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KALYDECO ivacaftor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clorazepate clorazepate dipotassium REMOVE UM: CUSTOM Carve Out- Bill dipotassium MDCH FFS 11/02/2020 INLYTA axitinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INLYTA axitinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TIVICAY PD dolutegravir sodium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PAMELOR nortriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ziprasidone ziprasidone mesylate REMOVE UM: CUSTOM Carve Out- Bill mesylate MDCH FFS 11/02/2020 LAMICTAL lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 77 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 dexmedetomidine dexmedetomidine hcl in 0.9 REMOVE UM: CUSTOM Carve Out- Bill -0.9% nacl % sodium chloride MDCH FFS 11/02/2020 LATUDA lurasidone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ARISTADA aripiprazole lauroxil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 tiagabine hcl tiagabine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TUKYSA tucatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 AMICAR aminocaproic acid REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PEMAZYRE pemigatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 MARPLAN isocarboxazid REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PEMAZYRE pemigatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PEMAZYRE pemigatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RETROVIR zidovudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 COMBIVIR lamivudine/zidovudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 topiramate topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 gabapentin gabapentin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 78 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 levetiracetam levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CARBAGLU carglumic acid REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SOLIRIS eculizumab REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 nortriptyline hcl nortriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIDEX EC didanosine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BERINERT c1 esterase inhibitor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamivudine lamivudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RESCRIPTOR delavirdine mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 AMYTAL amobarbital sodium REMOVE UM: CUSTOM Carve Out- Bill SODIUM MDCH FFS 11/02/2020 OCTAPLAS plasma human, blood group REMOVE UM: CUSTOM Carve Out- Bill b MDCH FFS 11/02/2020 CEPROTIN protein c, human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CEPROTIN protein c, human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HUMATE-P antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human/von willebrand MDCH FFS factor,human

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 79 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 HUMATE-P antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human/von willebrand MDCH FFS factor,human 11/02/2020 venlafaxine hcl venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 mirtazapine mirtazapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HUMATE-P antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human/von willebrand MDCH FFS factor,human 11/02/2020 SEROQUEL quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUTENT sunitinib malate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUTENT sunitinib malate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUTENT sunitinib malate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NEURONTIN gabapentin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamivudine- lamivudine/zidovudine REMOVE UM: CUSTOM Carve Out- Bill zidovudine MDCH FFS 11/02/2020 GEODON ziprasidone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DIACOMIT stiripentol REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fluoxetine hcl fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LITHOBID lithium carbonate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 80 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 levocarnitine sf levocarnitine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TUKYSA tucatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill ne-amphet er saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 MYDAYIS dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 MYDAYIS dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 MYDAYIS dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 FOCALIN dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 MYDAYIS dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 TOFRANIL imipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 desvenlafaxine er desvenlafaxine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 desvenlafaxine er desvenlafaxine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 olanzapine olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 venlafaxine hcl venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 81 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 LENVIMA lenvatinib mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EDLUAR zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EDLUAR zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ISENTRESS HD raltegravir potassium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RETROVIR zidovudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SELZENTRY maraviroc REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 quetiapine quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill fumarate er MDCH FFS 11/02/2020 quetiapine quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill fumarate er MDCH FFS 11/02/2020 APLENZIN bupropion hbr REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SEROQUEL XR quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SEROQUEL XR quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HEMLIBRA emicizumab-kxwh REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HEMLIBRA emicizumab-kxwh REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EMTRIVA emtricitabine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 82 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 REBINYN factor ix (human) REMOVE UM: CUSTOM Carve Out- Bill recombinant, pegylated MDCH FFS 11/02/2020 HEMLIBRA emicizumab-kxwh REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HEMLIBRA emicizumab-kxwh REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 REBINYN factor ix (human) REMOVE UM: CUSTOM Carve Out- Bill recombinant, pegylated MDCH FFS 11/02/2020 REBINYN factor ix (human) REMOVE UM: CUSTOM Carve Out- Bill recombinant, pegylated MDCH FFS 11/02/2020 emtricitabine emtricitabine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 thiothixene thiothixene REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LIPRITIN II gabapentin/lidocaine/prilocai REMOVE UM: CUSTOM Carve Out- Bill ne/transparent dressing MDCH FFS 11/02/2020 FINTEPLA fenfluramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 JULUCA dolutegravir REMOVE UM: CUSTOM Carve Out- Bill sodium/rilpivirine hcl MDCH FFS 11/02/2020 desvenlafaxine desvenlafaxine succinate REMOVE UM: CUSTOM Carve Out- Bill succinate er MDCH FFS 11/02/2020 desvenlafaxine desvenlafaxine succinate REMOVE UM: CUSTOM Carve Out- Bill succinate er MDCH FFS 11/02/2020 KEPPRA levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 felbamate felbamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 imipramine imipramine pamoate REMOVE UM: CUSTOM Carve Out- Bill pamoate MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 83 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 fluoxetine hcl fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CLOZARIL clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIDEX EC didanosine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 MEPSEVII vestronidase alfa-vjbk REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 quetiapine quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill fumarate MDCH FFS 11/02/2020 quetiapine quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill fumarate MDCH FFS 11/02/2020 SEROQUEL quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 QUILLICHEW ER methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SEROQUEL quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CEREBYX fosphenytoin sodium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CEREBYX fosphenytoin sodium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 QUILLICHEW ER methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 QUILLICHEW ER methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 gabapentin gabapentin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LIDOTIN gabapentin/lidocaine REMOVE UM: CUSTOM Carve Out- Bill hcl/silicone adhesive MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 84 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 TOPAMAX topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALECENSA alectinib hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 STRIBILD elvitegravir/cobicistat/emtrici REMOVE UM: CUSTOM Carve Out- Bill tabine/tenofovir disoproxil MDCH FFS 11/02/2020 paroxetine paroxetine mesylate REMOVE UM: CUSTOM Carve Out- Bill mesylate MDCH FFS 11/02/2020 phenobarbital phenobarbital REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 haloperidol haloperidol REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KOSELUGO selumetinib sulfate/vitamin e REMOVE UM: CUSTOM Carve Out- Bill tpgs MDCH FFS 11/02/2020 KOSELUGO selumetinib sulfate/vitamin e REMOVE UM: CUSTOM Carve Out- Bill tpgs MDCH FFS 11/02/2020 ADDERALL XR dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 ADDERALL XR dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 ADDERALL XR dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 ziprasidone hcl ziprasidone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill ne-amphet er saccharate/amphetamine MDCH FFS sulf-aspartate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 85 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 dextroamphetami dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill ne-amphet er saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 dextroamphetami dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill ne-amphet er saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 quazepam quazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PEGINTRON peginterferon alfa-2b REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ATIVAN lorazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill ne-amphet er saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 RISPERDAL risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PANHEMATIN hemin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 haloperidol haloperidol decanoate REMOVE UM: CUSTOM Carve Out- Bill decanoate,halop MDCH FFS eridol decanoate 100 11/02/2020 venlafaxine hcl er venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill ne-amphetamine saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 divalproex divalproex sodium REMOVE UM: CUSTOM Carve Out- Bill sodium MDCH FFS 11/02/2020 DILANTIN phenytoin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 86 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 CONCERTA methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 alprazolam alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 phenytoin phenytoin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 perphenazine- perphenazine/amitriptyline REMOVE UM: CUSTOM Carve Out- Bill amitriptyline hcl MDCH FFS 11/02/2020 SELZENTRY maraviroc REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KEPPRA levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KOATE antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human MDCH FFS 11/02/2020 KOATE antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human MDCH FFS 11/02/2020 KOATE antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human MDCH FFS 11/02/2020 levetiracetam levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ACTHREL corticorelin ovine triflutate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TRILEPTAL oxcarbazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADDERALL dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 nefazodone hcl nefazodone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KLONOPIN clonazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 87 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 gabapentin gabapentin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 triazolam triazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill la MDCH FFS 11/02/2020 SELZENTRY maraviroc REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EFFEXOR XR venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KALBITOR ecallantide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 levocarnitine levocarnitine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 APTIVUS tipranavir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CELEXA citalopram hydrobromide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DILANTIN phenytoin sodium extended REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FOCALIN dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 oxcarbazepine oxcarbazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 phenobarbital phenobarbital REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 nortriptyline hcl nortriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 haloperidol haloperidol REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 88 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 vigabatrin vigabatrin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 vigabatrin vigabatrin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FELBATOL felbamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DEPAKOTE divalproex sodium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZOLOFT sertraline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 oxcarbazepine oxcarbazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 tranexamic acid tranexamic acid REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NEXAVAR sorafenib tosylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lithium carbonate lithium carbonate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PLASBUMIN-5 albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 perphenazine- perphenazine/amitriptyline REMOVE UM: CUSTOM Carve Out- Bill amitriptyline hcl MDCH FFS 11/02/2020 BUMINATE albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 estazolam estazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FLEXBUMIN albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 paliperidone er paliperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 89 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 paliperidone er paliperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 paliperidone er paliperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZYDELIG idelalisib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZYDELIG idelalisib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DEPAKENE valproic acid (as sodium REMOVE UM: CUSTOM Carve Out- Bill salt) (valproate sodium) MDCH FFS 11/02/2020 oxazepam oxazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INVEGA paliperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INVEGA paliperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LYSTEDA tranexamic acid REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INVEGA paliperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 imipramine hcl imipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RITALIN LA methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill la,methylphenidat MDCH FFS e er (la) 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill la,methylphenidat MDCH FFS e er (la)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 90 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill la,methylphenidat MDCH FFS e er (la) 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill la,methylphenidat MDCH FFS e er (la) 11/02/2020 STRATTERA atomoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 STRATTERA atomoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 STRATTERA atomoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 tranexamic acid tranexamic acid REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clobazam clobazam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ONFI clobazam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 STRATTERA atomoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TRILEPTAL oxcarbazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUSTIVA efavirenz REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CORIFACT factor xiii REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS cd,methylphenida te hcl er (cd)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 91 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS cd,methylphenida te hcl er (cd) 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS cd,methylphenida te hcl er (cd) 11/02/2020 nortriptyline hcl nortriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BRISDELLE paroxetine mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 chlorpromazine chlorpromazine hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 zonisamide zonisamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KALETRA lopinavir/ritonavir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NUVIGIL armodafinil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 armodafinil armodafinil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EVOTAZ atazanavir sulfate/cobicistat REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 citalopram hbr citalopram hydrobromide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dexmethylphenid dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill ate hcl er MDCH FFS 11/02/2020 dexmethylphenid dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill ate hcl er MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 92 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 lorazepam lorazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dexmedetomidine dexmedetomidine hcl in 0.9 REMOVE UM: CUSTOM Carve Out- Bill -0.9% nacl % sodium chloride MDCH FFS 11/02/2020 PRECEDEX dexmedetomidine hcl in 0.9 REMOVE UM: CUSTOM Carve Out- Bill % sodium chloride MDCH FFS 11/02/2020 FOCALIN XR dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FOCALIN XR dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIMIZIM elosulfase alfa REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 risperidone risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ORKAMBI lumacaftor/ivacaftor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 APTIOM eslicarbazepine acetate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 APTIOM eslicarbazepine acetate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 thioridazine hcl thioridazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 APTIOM eslicarbazepine acetate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 APTIOM eslicarbazepine acetate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GABITRIL tiagabine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DIASTAT diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 93 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 HALDOL haloperidol decanoate REMOVE UM: CUSTOM Carve Out- Bill DECANOATE MDCH FFS 100 11/02/2020 thioridazine hcl thioridazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALBUKED-5 albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZUBSOLV buprenorphine hcl/naloxone REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 RESTORIL temazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 COMPLERA emtricitabine/rilpivirine REMOVE UM: CUSTOM Carve Out- Bill hcl/tenofovir disoproxil MDCH FFS fumarate 11/02/2020 NORVIR ritonavir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALBURX albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine REMOVE UM: CUSTOM Carve Out- Bill dimesylate MDCH FFS 11/02/2020 ALBURX albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SAPHRIS asenapine maleate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine REMOVE UM: CUSTOM Carve Out- Bill dimesylate MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine REMOVE UM: CUSTOM Carve Out- Bill dimesylate MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine REMOVE UM: CUSTOM Carve Out- Bill dimesylate MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 94 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 VYVANSE lisdexamfetamine REMOVE UM: CUSTOM Carve Out- Bill dimesylate MDCH FFS 11/02/2020 phenobarbital phenobarbital REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IBRANCE palbociclib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IBRANCE palbociclib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SAPHRIS asenapine maleate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IBRANCE palbociclib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine REMOVE UM: CUSTOM Carve Out- Bill dimesylate MDCH FFS 11/02/2020 ZIAGEN abacavir sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BANZEL rufinamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ELOCTATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, fc fusion MDCH FFS protein 11/02/2020 ELOCTATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, fc fusion MDCH FFS protein 11/02/2020 ELOCTATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, fc fusion MDCH FFS protein 11/02/2020 PROVIGIL modafinil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DEPAKOTE divalproex sodium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 95 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 LAMICTAL lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PEGANONE ethotoin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KOGENATE FS antihemophilic factor, hum REMOVE UM: CUSTOM Carve Out- Bill rec,antihemophilic factor MDCH FFS (fviii) recomb,full length (alb- free),antihemophilic factor (fviii) recombinant,full length 11/02/2020 FELBATOL felbamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SABRIL vigabatrin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HELIXATE FS antihemophilic factor viii, REMOVE UM: CUSTOM Carve Out- Bill human MDCH FFS recombinant,antihemophilic factor (fviii) recombinant,full length 11/02/2020 diazepam diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill ne-amphetamine saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 SABRIL vigabatrin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CARNITOR levocarnitine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 modafinil modafinil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 96 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 clonazepam clonazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CLOZARIL clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NEURONTIN gabapentin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TRILEPTAL oxcarbazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FANAPT iloperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 nitisinone nitisinone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FANAPT iloperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FANAPT iloperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FANAPT iloperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FANAPT iloperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ILARIS canakinumab/pf REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIMPAT lacosamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CELONTIN methsuximide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FANAPT iloperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FANAPT iloperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 97 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 FANAPT iloperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dexmethylphenid dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill ate hcl er MDCH FFS 11/02/2020 THROMBATE III antithrombin iii (human REMOVE UM: CUSTOM Carve Out- Bill plasma derived) MDCH FFS 11/02/2020 nitisinone nitisinone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 nitisinone nitisinone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fluphenazine hcl fluphenazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CAPLYTA lumateperone tosylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KISQALI ribociclib succinate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KISQALI ribociclib succinate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KISQALI ribociclib succinate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LIPRITIN gabapentin/lidocaine/prilocai REMOVE UM: CUSTOM Carve Out- Bill ne/transparent dressing MDCH FFS 11/02/2020 JIVI antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill rec, b-domain deleted peg- MDCH FFS aucl 11/02/2020 JIVI antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill rec, b-domain deleted peg- MDCH FFS aucl 11/02/2020 JIVI antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill rec, b-domain deleted peg- MDCH FFS aucl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 98 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 JIVI antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill rec, b-domain deleted peg- MDCH FFS aucl 11/02/2020 FAZACLO clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INVEGA paliperidone palmitate REMOVE UM: CUSTOM Carve Out- Bill SUSTENNA MDCH FFS 11/02/2020 INVEGA paliperidone palmitate REMOVE UM: CUSTOM Carve Out- Bill SUSTENNA MDCH FFS 11/02/2020 INVEGA paliperidone palmitate REMOVE UM: CUSTOM Carve Out- Bill SUSTENNA MDCH FFS 11/02/2020 KOGENATE FS antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recomb,full length (alb- MDCH FFS free),antihemophilic factor (fviii) recombinant,full length 11/02/2020 INVEGA paliperidone palmitate REMOVE UM: CUSTOM Carve Out- Bill SUSTENNA MDCH FFS 11/02/2020 INVEGA paliperidone palmitate REMOVE UM: CUSTOM Carve Out- Bill SUSTENNA MDCH FFS 11/02/2020 lithium carbonate lithium carbonate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ORFADIN nitisinone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CALQUENCE acalabrutinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ORFADIN nitisinone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ORFADIN nitisinone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ribavirin ribavirin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 99 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 DEXEDRINE dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 sertraline hcl sertraline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LAMICTAL lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 chlorpromazine chlorpromazine hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 FOCALIN XR dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FEIBA NF anti-inhibitor coagulant REMOVE UM: CUSTOM Carve Out- Bill complex MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill ne sulfate er MDCH FFS 11/02/2020 efavirenz efavirenz REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 desipramine hcl desipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PROVIGIL modafinil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALPHANATE antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human/von willebrand MDCH FFS factor,human 11/02/2020 REYATAZ atazanavir sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALPHANATE antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human/von willebrand MDCH FFS factor,human 11/02/2020 ALPHANATE antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human/von willebrand MDCH FFS factor,human

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 100 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ALPHANATE antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human/von willebrand MDCH FFS factor,human 11/02/2020 GABITRIL tiagabine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KUVAN sapropterin dihydrochloride REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 REMERON mirtazapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lorazepam lorazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 loxapine loxapine succinate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALBUKED-25 albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 buprenorphine- buprenorphine hcl/naloxone REMOVE UM: CUSTOM Carve Out- Bill naloxone hcl MDCH FFS 11/02/2020 buprenorphine- buprenorphine hcl/naloxone REMOVE UM: CUSTOM Carve Out- Bill naloxone hcl MDCH FFS 11/02/2020 SUSTIVA efavirenz REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clozapine odt clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clozapine odt clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fluphenazine hcl fluphenazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 chlorpromazine chlorpromazine hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 DAYVIGO lemborexant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 101 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 aminocaproic aminocaproic acid REMOVE UM: CUSTOM Carve Out- Bill acid MDCH FFS 11/02/2020 AMICAR aminocaproic acid REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VALTOCO diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZUBSOLV buprenorphine hcl/naloxone REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 ZUBSOLV buprenorphine hcl/naloxone REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 VALTOCO diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 REXULTI brexpiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 aripiprazole aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 REXULTI brexpiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 REXULTI brexpiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 REXULTI brexpiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RECOMBINATE antihemophilic factor viii, REMOVE UM: CUSTOM Carve Out- Bill human recombinant MDCH FFS 11/02/2020 RECOMBINATE antihemophilic factor viii, REMOVE UM: CUSTOM Carve Out- Bill human recombinant MDCH FFS 11/02/2020 ABILIFY aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIRACEPT nelfinavir mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 102 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 fluvoxamine fluvoxamine maleate REMOVE UM: CUSTOM Carve Out- Bill maleate MDCH FFS 11/02/2020 maprotiline hcl maprotiline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HEMOFIL M antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human MDCH FFS 11/02/2020 HEMOFIL M antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human MDCH FFS 11/02/2020 clomipramine hcl clomipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DEXEDRINE dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fluphenazine hcl fluphenazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 carbamazepine carbamazepine REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 amphetamine amphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill sulfate MDCH FFS 11/02/2020 amphetamine amphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill sulfate MDCH FFS 11/02/2020 EVEKEO amphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 carbamazepine carbamazepine REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 IXINITY factor ix human REMOVE UM: CUSTOM Carve Out- Bill recombinant, threonine 148 MDCH FFS 11/02/2020 carbamazepine carbamazepine REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 ZERIT stavudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 103 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ALPRAZOLAM alprazolam REMOVE UM: CUSTOM Carve Out- Bill INTENSOL MDCH FFS 11/02/2020 NUVIGIL armodafinil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 doxepin hcl doxepin hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IXINITY factor ix human REMOVE UM: CUSTOM Carve Out- Bill recombinant, threonine 148 MDCH FFS 11/02/2020 IXINITY factor ix human REMOVE UM: CUSTOM Carve Out- Bill recombinant, threonine 148 MDCH FFS 11/02/2020 temazepam temazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RESTORIL temazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 perphenazine perphenazine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine,lamot lamotrigine REMOVE UM: CUSTOM Carve Out- Bill rigine (blue) MDCH FFS 11/02/2020 lamotrigine,lamot lamotrigine REMOVE UM: CUSTOM Carve Out- Bill rigine (green) MDCH FFS 11/02/2020 DAYVIGO lemborexant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine,lamot lamotrigine REMOVE UM: CUSTOM Carve Out- Bill rigine (orange) MDCH FFS 11/02/2020 VALTOCO diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VALTOCO diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clonazepam clonazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 104 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 benztropine benztropine mesylate REMOVE UM: CUSTOM Carve Out- Bill mesylate MDCH FFS 11/02/2020 ESPEROCT antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill rec, b-dom truncated peg- MDCH FFS exei 11/02/2020 ESPEROCT antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill rec, b-dom truncated peg- MDCH FFS exei 11/02/2020 ESPEROCT antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill rec, b-dom truncated peg- MDCH FFS exei 11/02/2020 ESPEROCT antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill rec, b-dom truncated peg- MDCH FFS exei 11/02/2020 ESPEROCT antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill rec, b-dom truncated peg- MDCH FFS exei 11/02/2020 ADDERALL XR dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 LYRICA pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill ne sulfate MDCH FFS 11/02/2020 AYVAKIT avapritinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 AYVAKIT avapritinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 AYVAKIT avapritinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NUVIGIL armodafinil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 105 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 VYVANSE lisdexamfetamine REMOVE UM: CUSTOM Carve Out- Bill dimesylate MDCH FFS 11/02/2020 NUVIGIL armodafinil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DESCOVY emtricitabine/tenofovir REMOVE UM: CUSTOM Carve Out- Bill alafenamide fumarate MDCH FFS 11/02/2020 gabapentin gabapentin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LAMICTAL lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (BLUE) MDCH FFS 11/02/2020 LAMICTAL lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (GREEN) MDCH FFS 11/02/2020 LAMICTAL lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (ORANGE) MDCH FFS 11/02/2020 ABILIFY aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MAINTENA MDCH FFS 11/02/2020 ABILIFY aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MAINTENA MDCH FFS 11/02/2020 NOVOSEVEN coagulation factor viia REMOVE UM: CUSTOM Carve Out- Bill RT (recombinant) MDCH FFS 11/02/2020 EVEKEO amphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 olanzapine olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ISENTRESS raltegravir potassium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ISENTRESS raltegravir potassium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 trimipramine trimipramine maleate REMOVE UM: CUSTOM Carve Out- Bill maleate MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 106 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 tiagabine hcl tiagabine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 olanzapine- olanzapine/fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill fluoxetine hcl MDCH FFS 11/02/2020 olanzapine- olanzapine/fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill fluoxetine hcl MDCH FFS 11/02/2020 atazanavir sulfate atazanavir sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 olanzapine- olanzapine/fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill fluoxetine hcl MDCH FFS 11/02/2020 olanzapine- olanzapine/fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill fluoxetine hcl MDCH FFS 11/02/2020 DEPAKOTE divalproex sodium REMOVE UM: CUSTOM Carve Out- Bill SPRINKLE MDCH FFS 11/02/2020 miglustat miglustat REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZAVESCA miglustat REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SYMBYAX olanzapine/fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SYMBYAX olanzapine/fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SYMBYAX olanzapine/fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SYMBYAX olanzapine/fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 TAKHZYRO lanadelumab-flyo REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 107 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 amitriptyline hcl amitriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 stavudine stavudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RETROVIR zidovudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 didanosine didanosine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 REXULTI brexpiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 REXULTI brexpiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LEXAPRO escitalopram oxalate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RISPERDAL risperidone microspheres REMOVE UM: CUSTOM Carve Out- Bill CONSTA MDCH FFS 11/02/2020 escitalopram escitalopram oxalate REMOVE UM: CUSTOM Carve Out- Bill oxalate MDCH FFS 11/02/2020 ALPHANINE SD factor ix REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALPHANINE SD factor ix REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 WELLBUTRIN bupropion hcl REMOVE UM: CUSTOM Carve Out- Bill SR MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 108 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 DRIZALMA duloxetine hcl REMOVE UM: CUSTOM Carve Out- Bill SPRINKLE MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 VIEKIRA PAK ombitasvir/paritaprevir/ritona REMOVE UM: CUSTOM Carve Out- Bill vir/dasabuvir sodium MDCH FFS 11/02/2020 SURMONTIL trimipramine maleate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill ne-amphetamine saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 CERDELGA eliglustat tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALIQOPA copanlisib di-hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 didanosine didanosine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EMTRIVA emtricitabine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NORPRAMIN desipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RETEVMO selpercatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 109 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 dexmedetomidine dexmedetomidine hcl in 0.9 REMOVE UM: CUSTOM Carve Out- Bill -0.9% nacl % sodium chloride MDCH FFS 11/02/2020 RETEVMO selpercatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 triazolam triazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PROZAC fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NORPRAMIN desipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 zolpidem tartrate zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 maprotiline hcl maprotiline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 haloperidol haloperidol REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 amphetamine amphetamine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TABRECTA capmatinib hydrochloride REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TABRECTA capmatinib hydrochloride REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 imipramine imipramine pamoate REMOVE UM: CUSTOM Carve Out- Bill pamoate MDCH FFS 11/02/2020 ADASUVE loxapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lithium,lithium lithium citrate REMOVE UM: CUSTOM Carve Out- Bill citrate MDCH FFS 11/02/2020 TEGRETOL XR carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 110 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ATIVAN lorazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ribavirin ribavirin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PREZISTA darunavir ethanolate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 buprenorphine- buprenorphine hcl/naloxone REMOVE UM: CUSTOM Carve Out- Bill naloxone hcl MDCH FFS 11/02/2020 buprenorphine- buprenorphine hcl/naloxone REMOVE UM: CUSTOM Carve Out- Bill naloxone hcl MDCH FFS 11/02/2020 buprenorphine buprenorphine hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 buprenorphine buprenorphine hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 LAMICTAL XR lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 stavudine stavudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TROKENDI XR topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TROKENDI XR topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TROKENDI XR topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TROKENDI XR topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BUMINATE albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ARISTADA aripiprazole lauroxil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 111 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ARISTADA aripiprazole lauroxil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine er lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ARISTADA aripiprazole lauroxil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADVATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill UH,ADVATE recomb,full length (alb- MDCH FFS free),antihemophilic factor (fviii) recombinant,full length 11/02/2020 tranylcypromine tranylcypromine sulfate REMOVE UM: CUSTOM Carve Out- Bill sulfate MDCH FFS 11/02/2020 BEBULIN factor ix complex, REMOVE UM: CUSTOM Carve Out- Bill prothrombin cplx conc(pcc) MDCH FFS no.6, 3-factor 11/02/2020 paroxetine hcl paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ROWEEPRA levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BELSOMRA suvorexant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VRAYLAR cariprazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VRAYLAR cariprazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VRAYLAR cariprazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 sodium sodium phenylbutyrate REMOVE UM: CUSTOM Carve Out- Bill phenylbutyrate MDCH FFS 11/02/2020 BELSOMRA suvorexant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 112 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 BELSOMRA suvorexant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BELSOMRA suvorexant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KYPROLIS carfilzomib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADVATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant,full length MDCH FFS 11/02/2020 VRAYLAR cariprazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 paroxetine hcl paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 perphenazine perphenazine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill ne-amphetamine saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 carbamazepine carbamazepine REMOVE UM: CUSTOM Carve Out- Bill xr,carbamazepin MDCH FFS e er 11/02/2020 GILOTRIF afatinib dimaleate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CABOMETYX cabozantinib s-malate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CABOMETYX cabozantinib s-malate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GILOTRIF afatinib dimaleate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CABOMETYX cabozantinib s-malate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 113 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 VIMPAT lacosamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GILOTRIF afatinib dimaleate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZYPREXA olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FYCOMPA perampanel REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DAYTRANA methylphenidate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DAYTRANA methylphenidate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DAYTRANA methylphenidate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ORKAMBI lumacaftor/ivacaftor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 chlordiazepoxide- amitriptyline REMOVE UM: CUSTOM Carve Out- Bill amitriptyline,amitr hcl/chlordiazepoxide MDCH FFS iptyline- chlordiazepoxide 11/02/2020 REYATAZ atazanavir sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 REBETOL ribavirin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DAKLINZA daclatasvir dihydrochloride REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ATRYN antithrombin iii, human REMOVE UM: CUSTOM Carve Out- Bill recombinant MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 114 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 PROFILNINE factor ix complex REMOVE UM: CUSTOM Carve Out- Bill SD,PROFILNINE human,factor ix complex, MDCH FFS prothrombin cplx conc(pcc) no.4, 3-factor 11/02/2020 DOPRAM doxapram hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PROFILNINE factor ix complex REMOVE UM: CUSTOM Carve Out- Bill SD,PROFILNINE human,factor ix complex, MDCH FFS prothrombin cplx conc(pcc) no.4, 3-factor 11/02/2020 RIBASPHERE ribavirin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALPHANINE SD factor ix REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 droperidol droperidol REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 carbamazepine carbamazepine REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 EDURANT rilpivirine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HEMOFIL M antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human MDCH FFS 11/02/2020 lithium carbonate lithium carbonate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BOSULIF bosutinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BOSULIF bosutinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 115 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 HELIXATE FS antihemophilic factor viii, REMOVE UM: CUSTOM Carve Out- Bill human MDCH FFS recombinant,antihemophilic factor (fviii) recombinant,full length 11/02/2020 PEGASYS peginterferon alfa-2a REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FOCALIN XR dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FOCALIN XR dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FOCALIN XR dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ABILIFY aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MAINTENA MDCH FFS 11/02/2020 ABILIFY aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MAINTENA MDCH FFS 11/02/2020 dexmethylphenid dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill ate hcl er MDCH FFS 11/02/2020 DAYTRANA methylphenidate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dexmethylphenid dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill ate hcl er MDCH FFS 11/02/2020 dexmethylphenid dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill ate hcl er MDCH FFS 11/02/2020 ROWEEPRA levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ROWEEPRA levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 mirtazapine mirtazapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 116 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ZEJULA niraparib tosylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fluphenazine hcl fluphenazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill ne-amphetamine saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 doxepin hcl doxepin hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 loxapine loxapine succinate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PERSERIS risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PERSERIS risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RITALIN methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 levetiracetam levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 zonisamide zonisamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 zonisamide zonisamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dexmedetomidine dexmedetomidine hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 ZONEGRAN zonisamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine odt lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine odt lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 117 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 fluoxetine hcl fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine odt lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine odt lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (blue) MDCH FFS 11/02/2020 lamotrigine odt lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (green) MDCH FFS 11/02/2020 lamotrigine odt lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine odt lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (orange) MDCH FFS 11/02/2020 LAMICTAL XR lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADYNOVATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, full length, peg MDCH FFS 11/02/2020 ADYNOVATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, full length, peg MDCH FFS 11/02/2020 LAMICTAL ODT lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LAMICTAL ODT lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine er lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LAMICTAL ODT lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LAMICTAL ODT lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LAMICTAL ODT lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (GREEN) MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 118 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 LAMICTAL ODT lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (BLUE) MDCH FFS 11/02/2020 ziprasidone hcl ziprasidone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RIBAPAK,RIBAS ribavirin REMOVE UM: CUSTOM Carve Out- Bill PHERE MDCH FFS RIBAPAK 11/02/2020 VIMPAT lacosamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 gabapentin gabapentin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fluvoxamine fluvoxamine maleate REMOVE UM: CUSTOM Carve Out- Bill maleate MDCH FFS 11/02/2020 ATIVAN lorazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 olanzapine- olanzapine/fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill fluoxetine hcl MDCH FFS 11/02/2020 valproic acid valproic acid (as sodium REMOVE UM: CUSTOM Carve Out- Bill salt) (valproate sodium) MDCH FFS 11/02/2020 STRATTERA atomoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RIBAPAK,RIBAS ribavirin REMOVE UM: CUSTOM Carve Out- Bill PHERE MDCH FFS RIBAPAK 11/02/2020 amitriptyline hcl amitriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VERZENIO abemaciclib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FYCOMPA perampanel REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 119 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 VERZENIO abemaciclib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VERZENIO abemaciclib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VERZENIO abemaciclib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LITHOSTAT acetohydroxamic acid REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 bupropion hcl bupropion hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 phenobarbital phenobarbital REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HARVONI ledipasvir/sofosbuvir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HARVONI ledipasvir/sofosbuvir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALBUMINAR-25 albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RIBASPHERE ribavirin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 zidovudine zidovudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RIBASPHERE ribavirin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RIBASPHERE ribavirin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lorazepam lorazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lorazepam lorazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 120 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 BUPHENYL sodium phenylbutyrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LUMIZYME alglucosidase alfa REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PAMELOR nortriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TIVICAY dolutegravir sodium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 amoxapine amoxapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clobazam clobazam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clobazam clobazam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 QINLOCK ripretinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill ne-amphetamine saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 RECOMBINATE antihemophilic factor viii, REMOVE UM: CUSTOM Carve Out- Bill human recombinant MDCH FFS 11/02/2020 NEURONTIN gabapentin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KHEDEZLA desvenlafaxine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KHEDEZLA desvenlafaxine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 buspirone hcl buspirone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 121 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ALBUTEIN albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RISPERDAL risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 buprenorphine- buprenorphine hcl/naloxone REMOVE UM: CUSTOM Carve Out- Bill naloxone hcl MDCH FFS 11/02/2020 buprenorphine- buprenorphine hcl/naloxone REMOVE UM: CUSTOM Carve Out- Bill naloxone hcl MDCH FFS 11/02/2020 CLOZARIL clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CLOZARIL clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SECUADO asenapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SECUADO asenapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SECUADO asenapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUSTIVA efavirenz REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CRIXIVAN indinavir sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADDERALL XR dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 VYONDYS-53 golodirsen REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TRILEPTAL oxcarbazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SYMBYAX olanzapine/fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 122 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ADDERALL XR dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 CARBATROL carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 trazodone hcl trazodone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 levetiracetam levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CARBATROL carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ketamine hcl ketamine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KEPPRA levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clozapine clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PEXEVA paroxetine mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZYPREXA ZYDIS olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PEXEVA paroxetine mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LAMICTAL ODT lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (ORANGE) MDCH FFS 11/02/2020 PEXEVA paroxetine mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PEXEVA paroxetine mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EXONDYS-51 eteplirsen REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 123 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 haloperidol haloperidol REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PREZISTA darunavir ethanolate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lorazepam-0.9% lorazepam in 0.9 % sodium REMOVE UM: CUSTOM Carve Out- Bill nacl,lorazepam- chloride MDCH FFS ns 11/02/2020 primidone primidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADDERALL dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 NAGLAZYME galsulfase REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DAKLINZA daclatasvir dihydrochloride REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIDEX didanosine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HEMOFIL M antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human MDCH FFS 11/02/2020 divalproex divalproex sodium REMOVE UM: CUSTOM Carve Out- Bill sodium MDCH FFS 11/02/2020 VIIBRYD vilazodone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIIBRYD vilazodone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIIBRYD vilazodone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIRACEPT nelfinavir mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 124 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ORKAMBI lumacaftor/ivacaftor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ORKAMBI lumacaftor/ivacaftor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamotrigine lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fluphenazine hcl fluphenazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 citalopram hbr citalopram hydrobromide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 diazepam diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 REMERON mirtazapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dexmethylphenid dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill ate hcl er MDCH FFS 11/02/2020 FOCALIN XR dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 carbamazepine carbamazepine REMOVE UM: CUSTOM Carve Out- Bill xr,carbamazepin MDCH FFS e er 11/02/2020 perphenazine- perphenazine/amitriptyline REMOVE UM: CUSTOM Carve Out- Bill amitriptyline hcl MDCH FFS 11/02/2020 trazodone hcl trazodone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIVITROL naltrexone microspheres REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RISPERDAL risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 erlotinib hcl erlotinib hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 125 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 erlotinib hcl erlotinib hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 erlotinib hcl erlotinib hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LORAZEPAM lorazepam REMOVE UM: CUSTOM Carve Out- Bill INTENSOL MDCH FFS 11/02/2020 TARCEVA erlotinib hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TARCEVA erlotinib hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clomipramine hcl clomipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 MAVYRET glecaprevir/pibrentasvir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TARCEVA erlotinib hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 olanzapine odt olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lorazepam-d5w lorazepam in 5 % dextrose REMOVE UM: CUSTOM Carve Out- Bill and water MDCH FFS 11/02/2020 CONCERTA methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 thioridazine hcl thioridazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 modafinil modafinil REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NITYR nitisinone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NITYR nitisinone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 126 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 KALYDECO ivacaftor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NITYR nitisinone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KALYDECO ivacaftor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SURMONTIL trimipramine maleate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 COTEMPLA XR- methylphenidate REMOVE UM: CUSTOM Carve Out- Bill ODT MDCH FFS 11/02/2020 COTEMPLA XR- methylphenidate REMOVE UM: CUSTOM Carve Out- Bill ODT MDCH FFS 11/02/2020 COTEMPLA XR- methylphenidate REMOVE UM: CUSTOM Carve Out- Bill ODT MDCH FFS 11/02/2020 phenobarbital phenobarbital sodium REMOVE UM: CUSTOM Carve Out- Bill sodium MDCH FFS 11/02/2020 FYCOMPA perampanel REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FYCOMPA perampanel REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 carbamazepine carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 doxepin hcl doxepin hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 olanzapine olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 risperidone risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TRANXENE T- clorazepate dipotassium REMOVE UM: CUSTOM Carve Out- Bill TAB MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 127 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 amitriptyline hcl amitriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 diazepam diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LATUDA lurasidone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 REMERON mirtazapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RIXUBIS factor ix human recombinant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RIXUBIS factor ix human recombinant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RIXUBIS factor ix human recombinant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RIXUBIS factor ix human recombinant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 citalopram citalopram hydrobromide REMOVE UM: CUSTOM Carve Out- Bill hbr,citalopram MDCH FFS 11/02/2020 RIXUBIS factor ix human recombinant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lactulose lactulose REMOVE UM: CUSTOM 11/02/2020 abacavir abacavir sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 valproic acid valproate sodium,valproic REMOVE UM: CUSTOM Carve Out- Bill acid (as sodium salt) MDCH FFS (valproate sodium) 11/02/2020 quetiapine quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill fumarate MDCH FFS 11/02/2020 STIVARGA regorafenib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 128 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 perphenazine- perphenazine/amitriptyline REMOVE UM: CUSTOM Carve Out- Bill amitriptyline hcl MDCH FFS 11/02/2020 HELIXATE FS antihemophilic factor viii, REMOVE UM: CUSTOM Carve Out- Bill human MDCH FFS recombinant,antihemophilic factor (fviii) recombinant,full length 11/02/2020 TOPAMAX topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALBUMINEX albumin human-kjda REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALBUMINEX albumin human-kjda REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 imipramine imipramine pamoate REMOVE UM: CUSTOM Carve Out- Bill pamoate MDCH FFS 11/02/2020 VIRAMUNE nevirapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XOSPATA gilteritinib fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZARONTIN ethosuximide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 divalproex divalproex sodium REMOVE UM: CUSTOM Carve Out- Bill sodium er MDCH FFS 11/02/2020 VITRAKVI larotrectinib sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VITRAKVI larotrectinib sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VITRAKVI larotrectinib sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 pregabalin pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 129 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 pregabalin pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 pregabalin pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 pregabalin pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 pregabalin pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 pregabalin pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 doxapram hcl doxapram hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PAMELOR nortriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IMBRUVICA ibrutinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 pregabalin pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 pregabalin pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XANAX alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine REMOVE UM: CUSTOM Carve Out- Bill dimesylate MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine REMOVE UM: CUSTOM Carve Out- Bill dimesylate MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine REMOVE UM: CUSTOM Carve Out- Bill dimesylate MDCH FFS 11/02/2020 ZARONTIN ethosuximide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 130 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 SOVALDI sofosbuvir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PRECEDEX dexmedetomidine hcl in 0.9 REMOVE UM: CUSTOM Carve Out- Bill % sodium chloride MDCH FFS 11/02/2020 ZOLOFT sertraline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PARNATE tranylcypromine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SEVENFACT coagulation factor viia REMOVE UM: CUSTOM Carve Out- Bill recombinant-jncw MDCH FFS 11/02/2020 SEVENFACT coagulation factor viia REMOVE UM: CUSTOM Carve Out- Bill recombinant-jncw MDCH FFS 11/02/2020 didanosine didanosine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TOFRANIL imipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DIACOMIT stiripentol REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GAVRETO pralsetinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RISPERDAL risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DIACOMIT stiripentol REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SYMDEKO tezacaftor/ivacaftor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clonazepam clonazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 carbamazepine carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 131 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 pentobarbital pentobarbital sodium REMOVE UM: CUSTOM Carve Out- Bill sodium MDCH FFS 11/02/2020 ziprasidone hcl ziprasidone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 REMERON mirtazapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fluphenazine fluphenazine decanoate REMOVE UM: CUSTOM Carve Out- Bill decanoate MDCH FFS 11/02/2020 DYANAVEL XR amphetamine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EVEKEO ODT amphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill ne sulfate MDCH FFS er,dextroampheta mine sulfate 11/02/2020 dexmethylphenid dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill ate hcl MDCH FFS 11/02/2020 EVEKEO ODT amphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EVEKEO ODT amphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EVEKEO ODT amphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PLASBUMIN-25 albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 zidovudine zidovudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 amoxapine amoxapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 132 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 XYNTHA antihemophilic factor (factor REMOVE UM: CUSTOM Carve Out- Bill SOLOFUSE viii) recomb,b-domain MDCH FFS deleted 11/02/2020 haloperidol haloperidol REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NEURONTIN gabapentin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GABITRIL tiagabine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NERLYNX neratinib maleate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XANAX alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VOSEVI sofosbuvir/velpatasvir/voxila REMOVE UM: CUSTOM Carve Out- Bill previr MDCH FFS 11/02/2020 aripiprazole odt aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 aripiprazole odt aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KOGENATE FS antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recomb,full length (alb- MDCH FFS free),antihemophilic factor (fviii) recombinant,full length 11/02/2020 ZYPREXA olanzapine pamoate REMOVE UM: CUSTOM Carve Out- Bill RELPREVV MDCH FFS 11/02/2020 ZYPREXA olanzapine pamoate REMOVE UM: CUSTOM Carve Out- Bill RELPREVV MDCH FFS 11/02/2020 ZYPREXA olanzapine pamoate REMOVE UM: CUSTOM Carve Out- Bill RELPREVV MDCH FFS 11/02/2020 DEPAKOTE ER divalproex sodium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 133 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 CARBATROL carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 desipramine hcl desipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 meprobamate meprobamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CINRYZE c1 esterase inhibitor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 felbamate felbamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KINERET anakinra REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NUWIQ antihemophilic factor viii rec REMOVE UM: CUSTOM Carve Out- Bill hek cell, b-domain deleted MDCH FFS 11/02/2020 fluphenazine hcl fluphenazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IMBRUVICA ibrutinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IMBRUVICA ibrutinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IMBRUVICA ibrutinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IMBRUVICA ibrutinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 AMBIEN zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADDERALL dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 MYSOLINE primidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 134 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 TYBOST cobicistat REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 phenytoin sodium phenytoin sodium extended REMOVE UM: CUSTOM Carve Out- Bill extended MDCH FFS 11/02/2020 paroxetine hcl paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 imipramine imipramine pamoate REMOVE UM: CUSTOM Carve Out- Bill pamoate MDCH FFS 11/02/2020 VIZIMPRO dacomitinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIZIMPRO dacomitinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIZIMPRO dacomitinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EPIDIOLEX cannabidiol (cbd) REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RIASTAP fibrinogen REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XANAX alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 didanosine didanosine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EMSAM selegiline REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EMSAM selegiline REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EMSAM selegiline REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DEPAKOTE divalproex sodium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 135 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 risperidone risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 MODERIBA ribavirin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PHENYTEK phenytoin sodium extended REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TASIGNA nilotinib hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DORAL quazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 perphenazine perphenazine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ROWEEPRA XR levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FYCOMPA perampanel REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ROWEEPRA XR levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FYCOMPA perampanel REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 sapropterin sapropterin dihydrochloride REMOVE UM: CUSTOM Carve Out- Bill dihydrochloride MDCH FFS 11/02/2020 HELIXATE FS antihemophilic factor viii, REMOVE UM: CUSTOM Carve Out- Bill human MDCH FFS recombinant,antihemophilic factor (fviii) recombinant,full length 11/02/2020 sodium sodium phenylbutyrate REMOVE UM: CUSTOM Carve Out- Bill phenylbutyrate MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 136 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 KUVAN sapropterin dihydrochloride REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 sapropterin sapropterin dihydrochloride REMOVE UM: CUSTOM Carve Out- Bill dihydrochloride MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS cd,methylphenida te hcl er (cd) 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS cd,methylphenida te hcl er (cd) 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS cd,methylphenida te hcl er (cd) 11/02/2020 paliperidone er paliperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INVEGA paliperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EFFEXOR XR venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CARNITOR levocarnitine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 buspirone hcl buspirone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FOCALIN dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NORVIR ritonavir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 temazepam temazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 137 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ZENZEDI dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LEXIVA fosamprenavir calcium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZENZEDI dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ritonavir ritonavir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZENZEDI dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZENZEDI dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NORVIR ritonavir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 METADATE ER methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 benztropine benztropine mesylate REMOVE UM: CUSTOM Carve Out- Bill mesylate MDCH FFS 11/02/2020 cosyntropin cosyntropin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PRISTIQ desvenlafaxine succinate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RUCONEST c1 esterase inhibitor, REMOVE UM: CUSTOM Carve Out- Bill recombinant MDCH FFS 11/02/2020 imatinib mesylate imatinib mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 imatinib mesylate imatinib mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FLEXBUMIN albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 138 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 buspirone hcl buspirone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GLEEVEC imatinib mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KALETRA lopinavir/ritonavir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GLEEVEC imatinib mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RITALIN methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INTELENCE etravirine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TRIUMEQ abacavir sulfate/dolutegravir REMOVE UM: CUSTOM Carve Out- Bill sodium/lamivudine MDCH FFS 11/02/2020 clozapine odt clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clozapine odt clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lithium carbonate lithium carbonate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EPZICOM abacavir sulfate/lamivudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SPRYCEL dasatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SPRYCEL dasatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 WELLBUTRIN bupropion hcl REMOVE UM: CUSTOM Carve Out- Bill SR MDCH FFS 11/02/2020 alprazolam odt alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 139 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 alprazolam odt alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 alprazolam odt alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 alprazolam odt alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CONCERTA methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 alprazolam alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fluvoxamine fluvoxamine maleate REMOVE UM: CUSTOM Carve Out- Bill maleate MDCH FFS 11/02/2020 TRUVADA emtricitabine/tenofovir REMOVE UM: CUSTOM Carve Out- Bill disoproxil fumarate MDCH FFS 11/02/2020 duloxetine hcl duloxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 duloxetine hcl duloxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALPHANATE antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human/von willebrand MDCH FFS factor,human 11/02/2020 venlafaxine hcl venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CYMBALTA duloxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 duloxetine hcl duloxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CYMBALTA duloxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CYMBALTA duloxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 140 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 eszopiclone eszopiclone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 eszopiclone eszopiclone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 eszopiclone eszopiclone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 abacavir- abacavir sulfate/lamivudine REMOVE UM: CUSTOM Carve Out- Bill lamivudine MDCH FFS 11/02/2020 ZERIT stavudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 midazolam hcl midazolam hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALPROLIX factor ix recombinant, fc REMOVE UM: CUSTOM Carve Out- Bill fusion protein MDCH FFS 11/02/2020 ALPROLIX factor ix recombinant, fc REMOVE UM: CUSTOM Carve Out- Bill fusion protein MDCH FFS 11/02/2020 ALPROLIX factor ix recombinant, fc REMOVE UM: CUSTOM Carve Out- Bill fusion protein MDCH FFS 11/02/2020 LUNESTA eszopiclone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LUNESTA eszopiclone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LUNESTA eszopiclone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GEODON ziprasidone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALPROLIX factor ix recombinant, fc REMOVE UM: CUSTOM Carve Out- Bill fusion protein MDCH FFS 11/02/2020 MYALEPT metreleptin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 141 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 SYMDEKO tezacaftor/ivacaftor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ANAFRANIL clomipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 estazolam estazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EFFEXOR XR venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 duloxetine hcl duloxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 buspirone hcl buspirone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XALKORI crizotinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XALKORI crizotinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADVATE,ADVAT antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill E SH recombinant,full MDCH FFS length,antihemophilic factor (fviii) recomb,full length (alb- free) 11/02/2020 ADVATE,ADVAT antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill E H recombinant,full MDCH FFS length,antihemophilic factor (fviii) recomb,full length (alb- free) 11/02/2020 ADVATE,ADVAT antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill E L recombinant,full MDCH FFS length,antihemophilic factor (fviii) recomb,full length (alb- free)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 142 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ADVATE,ADVAT antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill E M recombinant,full MDCH FFS length,antihemophilic factor (fviii) recomb,full length (alb- free) 11/02/2020 TOPAMAX topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZEPATIER elbasvir/grazoprevir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 desipramine hcl desipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 amitriptyline hcl amitriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 venlafaxine hcl venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 albutein albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BIKTARVY bictegravir REMOVE UM: CUSTOM Carve Out- Bill sodium/emtricitabine/tenofov MDCH FFS ir alafenamide fumar 11/02/2020 XYNTHA antihemophilic factor (factor REMOVE UM: CUSTOM Carve Out- Bill SOLOFUSE viii) recomb,b-domain MDCH FFS deleted 11/02/2020 efavirenz-lamivu- efavirenz/lamivudine/tenofov REMOVE UM: CUSTOM Carve Out- Bill tenofov disop ir disoproxil fumarate MDCH FFS 11/02/2020 topiramate topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 desvenlafaxine desvenlafaxine succinate REMOVE UM: CUSTOM Carve Out- Bill succinate er MDCH FFS 11/02/2020 FABRAZYME agalsidase beta REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 143 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 mirtazapine mirtazapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 phenobarbital phenobarbital REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PEGASYS peginterferon alfa-2a REMOVE UM: CUSTOM Carve Out- Bill PROCLICK MDCH FFS 11/02/2020 PEGASYS peginterferon alfa-2a REMOVE UM: CUSTOM Carve Out- Bill PROCLICK MDCH FFS 11/02/2020 clorazepate clorazepate dipotassium REMOVE UM: CUSTOM Carve Out- Bill dipotassium MDCH FFS 11/02/2020 mirtazapine mirtazapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ULTOMIRIS ravulizumab-cwvz REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TOPAMAX topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 divalproex divalproex sodium REMOVE UM: CUSTOM Carve Out- Bill sodium MDCH FFS 11/02/2020 mirtazapine mirtazapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 COPIKTRA duvelisib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 COPIKTRA duvelisib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 risperidone risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PROZAC fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 risperidone risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 144 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 topiramate topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CONCERTA methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 SELZENTRY maraviroc REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SELZENTRY maraviroc REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lopinavir-ritonavir lopinavir/ritonavir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZYPREXA olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill er,methylphenida MDCH FFS te sr 11/02/2020 fluphenazine hcl fluphenazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 zidovudine zidovudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PAXIL CR paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SULFZIX sulfur/sodium sulfate/sodium REMOVE UM: CUSTOM Carve Out- Bill thiosulfate/folic acid MDCH FFS 11/02/2020 NUWIQ antihemophilic factor viii rec REMOVE UM: CUSTOM Carve Out- Bill hek cell, b-domain deleted MDCH FFS 11/02/2020 NUWIQ antihemophilic factor viii rec REMOVE UM: CUSTOM Carve Out- Bill hek cell, b-domain deleted MDCH FFS 11/02/2020 olanzapine odt olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 145 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 trihexyphenidyl trihexyphenidyl hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill ne sulfate er MDCH FFS 11/02/2020 FEIBA NF anti-inhibitor coagulant REMOVE UM: CUSTOM Carve Out- Bill complex MDCH FFS 11/02/2020 SPRYCEL dasatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PAXIL CR paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PAXIL CR paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ROZEREM ramelteon REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FEIBA NF anti-inhibitor coagulant REMOVE UM: CUSTOM Carve Out- Bill complex MDCH FFS 11/02/2020 SPRYCEL dasatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SPRYCEL dasatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 carbamazepine carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 risperidone risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KLONOPIN clonazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NEMBUTAL pentobarbital sodium REMOVE UM: CUSTOM Carve Out- Bill SODIUM MDCH FFS 11/02/2020 ADHANSIA XR methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 146 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ADHANSIA XR methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADHANSIA XR methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADHANSIA XR methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADHANSIA XR methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADHANSIA XR methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZYPREXA ZYDIS olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 zolpidem tartrate zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 zolpidem tartrate zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 albumin (human) albumin human REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 desvenlafaxine er desvenlafaxine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 desvenlafaxine er desvenlafaxine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NUWIQ antihemophilic factor viii rec REMOVE UM: CUSTOM Carve Out- Bill hek cell, b-domain deleted MDCH FFS 11/02/2020 HALDOL haloperidol lactate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GEODON ziprasidone mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 escitalopram escitalopram oxalate REMOVE UM: CUSTOM Carve Out- Bill oxalate MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 147 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 CELEXA citalopram hydrobromide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIIBRYD vilazodone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LYNPARZA olaparib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LYNPARZA olaparib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PAXIL paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 perphenazine- perphenazine/amitriptyline REMOVE UM: CUSTOM Carve Out- Bill amitriptyline hcl MDCH FFS 11/02/2020 HALCION triazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RISPERDAL risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INTUNIV guanfacine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KEPPRA levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INTUNIV guanfacine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 INTUNIV guanfacine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 guanfacine hcl er guanfacine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 guanfacine hcl er guanfacine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 diazepam diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 148 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 INTUNIV guanfacine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 sodium sodium benzoate/sodium REMOVE UM: CUSTOM Carve Out- Bill phenylacet-sod phenylacetate MDCH FFS benzoate 11/02/2020 AMMONUL sodium benzoate/sodium REMOVE UM: CUSTOM Carve Out- Bill phenylacetate MDCH FFS 11/02/2020 zolpidem tartrate zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 temazepam temazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clozapine clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 diazepam diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 valproic acid valproic acid REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TOPAMAX topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 trifluoperazine hcl trifluoperazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NEURONTIN gabapentin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 amitriptyline hcl amitriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 imipramine hcl imipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZYPREXA olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TEGRETOL carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 149 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 doxepin hcl doxepin hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fluoxetine hcl fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VALIUM diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 phenytoin sodium phenytoin sodium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lamivudine lamivudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 escitalopram escitalopram oxalate REMOVE UM: CUSTOM Carve Out- Bill oxalate MDCH FFS 11/02/2020 LEXAPRO escitalopram oxalate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LEXAPRO escitalopram oxalate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 nefazodone hcl nefazodone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 sertraline hcl sertraline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 phenobarbital phenobarbital sodium REMOVE UM: CUSTOM Carve Out- Bill sodium MDCH FFS 11/02/2020 CRIXIVAN indinavir sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fluoxetine dr fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 AMBIEN zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 150 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 PAMELOR nortriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IMBRUVICA ibrutinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 buspirone hcl buspirone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VERSACLOZ clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 topiramate topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 doxepin hcl doxepin hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DELSTRIGO doravirine/lamivudine/tenofo REMOVE UM: CUSTOM Carve Out- Bill vir disoproxil fumarate MDCH FFS 11/02/2020 FETZIMA levomilnacipran hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FETZIMA levomilnacipran hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FETZIMA levomilnacipran hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FETZIMA levomilnacipran hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FETZIMA levomilnacipran hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZERIT stavudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GENERLAC lactulose REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PIFELTRO doravirine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 151 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 paroxetine paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill er,paroxetine MDCH FFS hcl,paroxetine cr 11/02/2020 aminocaproic aminocaproic acid REMOVE UM: CUSTOM Carve Out- Bill acid MDCH FFS 11/02/2020 chlordiazepoxide chlordiazepoxide hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 paroxetine paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill er,paroxetine MDCH FFS cr,paroxetine hcl 11/02/2020 paroxetine paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill er,paroxetine MDCH FFS hcl,paroxetine cr 11/02/2020 ANAFRANIL clomipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HELIXATE FS antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant,full length MDCH FFS 11/02/2020 guanfacine hcl er guanfacine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 guanfacine hcl er guanfacine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PAXIL paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ATRIPLA efavirenz/emtricitabine/tenof REMOVE UM: CUSTOM Carve Out- Bill ovir disoproxil fumarate MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 olanzapine olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ENULOSE lactulose REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 152 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 chlorpromazine chlorpromazine hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 clozapine odt clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUBVENITE lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUBVENITE lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dexmethylphenid dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill ate hcl MDCH FFS 11/02/2020 VIREAD tenofovir disoproxil fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LYRICA pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LYRICA pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 zaleplon zaleplon REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LYRICA pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 trihexyphenidyl trihexyphenidyl hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 ACTHAR corticotropin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LYRICA pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LYRICA pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUBVENITE lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (BLUE) MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 153 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 LYRICA pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUBVENITE lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (GREEN) MDCH FFS 11/02/2020 LYRICA pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ramelteon ramelteon REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUBVENITE lamotrigine REMOVE UM: CUSTOM Carve Out- Bill (ORANGE) MDCH FFS 11/02/2020 LYRICA pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 stavudine stavudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUBVENITE lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUBVENITE lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 escitalopram escitalopram oxalate REMOVE UM: CUSTOM Carve Out- Bill oxalate MDCH FFS 11/02/2020 ALUNBRIG brigatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALUNBRIG brigatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DEPACON valproic acid (as sodium REMOVE UM: CUSTOM Carve Out- Bill salt) (valproate sodium) MDCH FFS 11/02/2020 lamivudine lamivudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADZENYS XR- amphetamine REMOVE UM: CUSTOM Carve Out- Bill ODT MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 154 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ADZENYS XR- amphetamine REMOVE UM: CUSTOM Carve Out- Bill ODT MDCH FFS 11/02/2020 ADZENYS XR- amphetamine REMOVE UM: CUSTOM Carve Out- Bill ODT MDCH FFS 11/02/2020 ADZENYS XR- amphetamine REMOVE UM: CUSTOM Carve Out- Bill ODT MDCH FFS 11/02/2020 ADZENYS XR- amphetamine REMOVE UM: CUSTOM Carve Out- Bill ODT MDCH FFS 11/02/2020 ADZENYS XR- amphetamine REMOVE UM: CUSTOM Carve Out- Bill ODT MDCH FFS 11/02/2020 ADDERALL dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 diazepam diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADZENYS ER amphetamine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EPIVIR lamivudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 thiothixene thiothixene REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SOVALDI sofosbuvir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 haloperidol haloperidol lactate REMOVE UM: CUSTOM Carve Out- Bill lactate MDCH FFS 11/02/2020 SOVALDI sofosbuvir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ATIVAN lorazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NINLARO ixazomib citrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 155 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 NINLARO ixazomib citrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 haloperidol haloperidol decanoate REMOVE UM: CUSTOM Carve Out- Bill decanoate MDCH FFS 11/02/2020 NINLARO ixazomib citrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 oxazepam oxazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZYKADIA ceritinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LAMICTAL lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 chlorpromazine chlorpromazine hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 ZYPREXA olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ARISTADA aripiprazole lauroxil, REMOVE UM: CUSTOM Carve Out- Bill INITIO submicronized MDCH FFS 11/02/2020 FABRAZYME agalsidase beta REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZENZEDI dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZENZEDI dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZENZEDI dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZOLOFT sertraline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADDERALL dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 156 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ZUBSOLV buprenorphine hcl/naloxone REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 FORFIVO XL bupropion hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZUBSOLV buprenorphine hcl/naloxone REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 RELEXXII methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 olanzapine odt olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALDURAZYME laronidase REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IRESSA gefitinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fosphenytoin fosphenytoin sodium REMOVE UM: CUSTOM Carve Out- Bill sodium MDCH FFS 11/02/2020 ANAFRANIL clomipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 MKO midazolam/ketamine REMOVE UM: CUSTOM Carve Out- Bill (MIDAZOLAM- hcl/ondansetron hcl MDCH FFS KETAMINE- ONDAN) 11/02/2020 bupropion xl bupropion hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fosphenytoin fosphenytoin sodium REMOVE UM: CUSTOM Carve Out- Bill sodium MDCH FFS 11/02/2020 ADYNOVATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, full length, peg MDCH FFS 11/02/2020 ADYNOVATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, full length, peg MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 157 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ADYNOVATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, full length, peg MDCH FFS 11/02/2020 ADYNOVATE antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant, full length, peg MDCH FFS 11/02/2020 TIVICAY dolutegravir sodium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TIVICAY dolutegravir sodium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lorazepam lorazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TASIGNA nilotinib hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 gabapentin gabapentin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 gabapentin gabapentin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill ne sulfate MDCH FFS 11/02/2020 mirtazapine mirtazapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DILANTIN-125 phenytoin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NAYZILAM midazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ethosuximide ethosuximide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BENEFIX factor ix human recombinant REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 pimozide pimozide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 158 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 TALZENNA talazoparib tosylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TALZENNA talazoparib tosylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 valproate sodium valproic acid (as sodium REMOVE UM: CUSTOM Carve Out- Bill salt) (valproate sodium) MDCH FFS 11/02/2020 ELAPRASE idursulfase REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RAVICTI glycerol phenylbutyrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 JORNAY PM methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 JORNAY PM methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 JORNAY PM methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 JORNAY PM methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 JORNAY PM methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fluoxetine hcl fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 bupropion hcl bupropion hcl REMOVE UM: CUSTOM Carve Out- Bill sr,bupropion hcl MDCH FFS er 11/02/2020 chlordiazepoxide- amitriptyline REMOVE UM: CUSTOM Carve Out- Bill amitriptyline,amitr hcl/chlordiazepoxide MDCH FFS iptyline- chlordiazepoxide 11/02/2020 venlafaxine hcl er venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 159 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 atazanavir sulfate atazanavir sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lithium carbonate lithium carbonate REMOVE UM: CUSTOM Carve Out- Bill er,lithium MDCH FFS carbonate 11/02/2020 atazanavir sulfate atazanavir sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FUZEON enfuvirtide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 amoxapine amoxapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NEURONTIN gabapentin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TEMIXYS lamivudine/tenofovir REMOVE UM: CUSTOM Carve Out- Bill disoproxil fumarate MDCH FFS 11/02/2020 meprobamate meprobamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HAEGARDA c1 esterase inhibitor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HAEGARDA c1 esterase inhibitor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VRAYLAR cariprazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KYPROLIS carfilzomib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 phenobarbital phenobarbital REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PHENYTEK phenytoin sodium extended REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 perphenazine perphenazine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 160 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 SEROQUEL quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIMPAT lacosamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIMPAT lacosamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PAXIL paroxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIMPAT lacosamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIMPAT lacosamide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 phenobarbital phenobarbital REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TRIKAFTA elexacaftor/tezacaftor/ivacaft REMOVE UM: CUSTOM Carve Out- Bill or MDCH FFS 11/02/2020 APLENZIN bupropion hbr REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 APLENZIN bupropion hbr REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 olanzapine olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FAZACLO clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADAGEN pegademase bovine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 flurazepam hcl flurazepam hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FAZACLO clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 161 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 FAZACLO clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PEGASYS peginterferon alfa-2a REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 amoxapine amoxapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill ne sulfate MDCH FFS 11/02/2020 SUBLOCADE buprenorphine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 STRATTERA atomoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 STRATTERA atomoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 tiagabine hcl tiagabine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HALDOL haloperidol decanoate REMOVE UM: CUSTOM Carve Out- Bill DECANOATE 50 MDCH FFS 11/02/2020 atomoxetine hcl atomoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 atomoxetine hcl atomoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BRIVIACT brivaracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BRIVIACT brivaracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RISPERDAL risperidone microspheres REMOVE UM: CUSTOM Carve Out- Bill CONSTA MDCH FFS 11/02/2020 BRIVIACT brivaracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 162 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 RISPERDAL risperidone microspheres REMOVE UM: CUSTOM Carve Out- Bill CONSTA MDCH FFS 11/02/2020 BRIVIACT brivaracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 trazodone hcl trazodone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BRIVIACT brivaracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DRIZALMA duloxetine hcl REMOVE UM: CUSTOM Carve Out- Bill SPRINKLE MDCH FFS 11/02/2020 BRIVIACT brivaracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DRIZALMA duloxetine hcl REMOVE UM: CUSTOM Carve Out- Bill SPRINKLE MDCH FFS 11/02/2020 FAZACLO clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DRIZALMA duloxetine hcl REMOVE UM: CUSTOM Carve Out- Bill SPRINKLE MDCH FFS 11/02/2020 trifluoperazine hcl trifluoperazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RISPERDAL risperidone microspheres REMOVE UM: CUSTOM Carve Out- Bill CONSTA MDCH FFS 11/02/2020 SUBLOCADE buprenorphine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 loxapine loxapine succinate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SEROQUEL XR quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BRIVIACT brivaracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 163 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 FIBRYGA fibrinogen REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 quetiapine quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill fumarate MDCH FFS 11/02/2020 IXINITY factor ix human REMOVE UM: CUSTOM Carve Out- Bill recombinant, threonine 148 MDCH FFS 11/02/2020 gabapentin gabapentin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IXINITY factor ix human REMOVE UM: CUSTOM Carve Out- Bill recombinant, threonine 148 MDCH FFS 11/02/2020 IXINITY factor ix human REMOVE UM: CUSTOM Carve Out- Bill recombinant, threonine 148 MDCH FFS 11/02/2020 temazepam temazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SPRITAM levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SPRITAM levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SPRITAM levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SPRITAM levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 KCENTRA human prothrombin complex REMOVE UM: CUSTOM Carve Out- Bill concentrate (pcc), 4-factor MDCH FFS 11/02/2020 levetiracetam levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LYRICA CR pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 164 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 LYRICA CR pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LYRICA CR pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUCRAID sacrosidase REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VELCADE bortezomib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 thiothixene thiothixene REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine REMOVE UM: CUSTOM Carve Out- Bill dimesylate MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine REMOVE UM: CUSTOM Carve Out- Bill dimesylate MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine REMOVE UM: CUSTOM Carve Out- Bill dimesylate MDCH FFS 11/02/2020 ALUNBRIG brigatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ONFI clobazam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 alprazolam alprazolam REMOVE UM: CUSTOM Carve Out- Bill er,alprazolam xr MDCH FFS 11/02/2020 XANAX XR alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XANAX XR alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XANAX XR alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ONFI clobazam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 165 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 alprazolam alprazolam REMOVE UM: CUSTOM Carve Out- Bill er,alprazolam xr MDCH FFS 11/02/2020 alprazolam alprazolam REMOVE UM: CUSTOM Carve Out- Bill er,alprazolam xr MDCH FFS 11/02/2020 alprazolam alprazolam REMOVE UM: CUSTOM Carve Out- Bill er,alprazolam xr MDCH FFS 11/02/2020 SILENOR doxepin hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 valproic acid valproic acid (as sodium REMOVE UM: CUSTOM Carve Out- Bill salt) (valproate sodium) MDCH FFS 11/02/2020 SILENOR doxepin hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PROZAC fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XANAX XR alprazolam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IDELVION factor ix REMOVE UM: CUSTOM Carve Out- Bill recombinant,albumin fusion MDCH FFS protein 11/02/2020 doxepin hcl doxepin hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 haloperidol haloperidol REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 doxepin hcl doxepin hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 doxepin hcl doxepin hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 MEKTOVI binimetinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 venlafaxine hcl er venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 166 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 venlafaxine hcl er venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fluoxetine hcl fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 fluoxetine hcl fluoxetine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 diazepam diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 olanzapine olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 venlafaxine hcl er venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RISPERDAL risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 venlafaxine hcl er venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 felbamate felbamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 chlorpromazine chlorpromazine hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 phenytoin sodium phenytoin sodium extended REMOVE UM: CUSTOM Carve Out- Bill extended MDCH FFS 11/02/2020 KALETRA lopinavir/ritonavir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIGADRONE vigabatrin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ALPROLIX factor ix recombinant, fc REMOVE UM: CUSTOM Carve Out- Bill fusion protein MDCH FFS 11/02/2020 chlordiazepoxide chlordiazepoxide hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 167 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 TRIZIVIR abacavir REMOVE UM: CUSTOM Carve Out- Bill sulfate/lamivudine/zidovudin MDCH FFS e 11/02/2020 ZOLOFT sertraline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dexmedetomidine dexmedetomidine hcl in 0.9 REMOVE UM: CUSTOM Carve Out- Bill -0.9% nacl % sodium chloride MDCH FFS 11/02/2020 dexmedetomidine dexmedetomidine hcl in 0.9 REMOVE UM: CUSTOM Carve Out- Bill -0.9% nacl % sodium chloride MDCH FFS 11/02/2020 VIDEX EC didanosine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PRECEDEX dexmedetomidine hcl in 0.9 REMOVE UM: CUSTOM Carve Out- Bill % sodium chloride MDCH FFS 11/02/2020 PRECEDEX dexmedetomidine hcl in 0.9 REMOVE UM: CUSTOM Carve Out- Bill % sodium chloride MDCH FFS 11/02/2020 VALIUM diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ORFADIN nitisinone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PIQRAY alpelisib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PIQRAY alpelisib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PIQRAY alpelisib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ziprasidone hcl ziprasidone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HARVONI ledipasvir/sofosbuvir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SOVALDI sofosbuvir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 168 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 desipramine hcl desipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RITALIN LA methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RITALIN LA methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EPIVIR lamivudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PROCENTRA dextroamphetamine sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 OCTAPLAS plasma human, blood group REMOVE UM: CUSTOM Carve Out- Bill a MDCH FFS 11/02/2020 OCTAPLAS plasma human, blood group REMOVE UM: CUSTOM Carve Out- Bill ab MDCH FFS 11/02/2020 RITALIN LA methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 OCTAPLAS plasma human, blood group REMOVE UM: CUSTOM Carve Out- Bill o MDCH FFS 11/02/2020 RUBRACA rucaparib camsylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RUBRACA rucaparib camsylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BOSULIF bosutinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 chlordiazepoxide chlordiazepoxide hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 TEGRETOL XR carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 HARVONI ledipasvir/sofosbuvir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 169 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ledipasvir- ledipasvir/sofosbuvir REMOVE UM: CUSTOM Carve Out- Bill sofosbuvir MDCH FFS 11/02/2020 INTELENCE etravirine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 nefazodone hcl nefazodone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IDELVION factor ix REMOVE UM: CUSTOM Carve Out- Bill recombinant,albumin fusion MDCH FFS protein 11/02/2020 lamotrigine lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IDELVION factor ix REMOVE UM: CUSTOM Carve Out- Bill recombinant,albumin fusion MDCH FFS protein 11/02/2020 DOVATO dolutegravir REMOVE UM: CUSTOM Carve Out- Bill sodium/lamivudine MDCH FFS 11/02/2020 IDELVION factor ix REMOVE UM: CUSTOM Carve Out- Bill recombinant,albumin fusion MDCH FFS protein 11/02/2020 phenytoin sodium phenytoin sodium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IDELVION factor ix REMOVE UM: CUSTOM Carve Out- Bill recombinant,albumin fusion MDCH FFS protein 11/02/2020 APTENSIO XR methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 bupropion xl bupropion hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SAPHRIS asenapine maleate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 170 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 WELLBUTRIN bupropion hcl REMOVE UM: CUSTOM Carve Out- Bill XL MDCH FFS 11/02/2020 bupropion xl bupropion hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lorazepam lorazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DESOXYN methamphetamine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 trazodone hcl trazodone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 lorazepam lorazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 risperidone risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NUPLAZID pimavanserin tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NUPLAZID pimavanserin tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 trifluoperazine hcl trifluoperazine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GENVOYA elvitegravir/cobicistat/emtrici REMOVE UM: CUSTOM Carve Out- Bill tabine/tenofovir alafenamide MDCH FFS 11/02/2020 bupropion hcl bupropion hcl REMOVE UM: CUSTOM Carve Out- Bill sr,bupropion hcl MDCH FFS er 11/02/2020 QUDEXY XR topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADDERALL dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 171 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 dexmedetomidine dexmedetomidine in 5 % REMOVE UM: CUSTOM Carve Out- Bill -d5w dextrose in water MDCH FFS 11/02/2020 dexmedetomidine dexmedetomidine in 5 % REMOVE UM: CUSTOM Carve Out- Bill -d5w dextrose in water MDCH FFS 11/02/2020 SYMPAZAN clobazam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LORBRENA lorlatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LORBRENA lorlatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SYMPAZAN clobazam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SYMPAZAN clobazam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ADDERALL dextroamphetamine sulf- REMOVE UM: CUSTOM Carve Out- Bill saccharate/amphetamine MDCH FFS sulf-aspartate 11/02/2020 QUDEXY XR topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 QUDEXY XR topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 QUDEXY XR topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TOPAMAX topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 QUDEXY XR topiramate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 bortezomib bortezomib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 phenytoin phenytoin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 172 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 GABITRIL tiagabine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CORTROSYN cosyntropin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 FELBATOL felbamate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LATUDA lurasidone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LATUDA lurasidone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZOLPIMIST zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NOVOEIGHT antihemophilic factor viii REMOVE UM: CUSTOM Carve Out- Bill recombinant, b-domain MDCH FFS truncated 11/02/2020 REYATAZ atazanavir sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NOVOEIGHT antihemophilic factor viii REMOVE UM: CUSTOM Carve Out- Bill recombinant, b-domain MDCH FFS truncated 11/02/2020 REYATAZ atazanavir sulfate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NOVOEIGHT antihemophilic factor viii REMOVE UM: CUSTOM Carve Out- Bill recombinant, b-domain MDCH FFS truncated 11/02/2020 NOVOEIGHT antihemophilic factor viii REMOVE UM: CUSTOM Carve Out- Bill recombinant, b-domain MDCH FFS truncated 11/02/2020 NOVOEIGHT antihemophilic factor viii REMOVE UM: CUSTOM Carve Out- Bill recombinant, b-domain MDCH FFS truncated

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 173 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 CYSTADANE betaine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ZYPREXA olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 NOVOEIGHT antihemophilic factor viii REMOVE UM: CUSTOM Carve Out- Bill recombinant, b-domain MDCH FFS truncated 11/02/2020 levetiracetam er levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ABILIFY MYCITE aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ABILIFY MYCITE aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ATIVAN lorazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PROFILNINE factor ix complex REMOVE UM: CUSTOM Carve Out- Bill SD,PROFILNINE human,factor ix complex, MDCH FFS prothrombin cplx conc(pcc) no.4, 3-factor 11/02/2020 KOGENATE FS antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recomb,full length (alb- MDCH FFS free),antihemophilic factor (fviii) recombinant,full length 11/02/2020 ISENTRESS raltegravir potassium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DILANTIN phenytoin sodium extended REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ABILIFY MYCITE aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 diazepam diazepam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 174 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 NUWIQ antihemophilic factor viii rec REMOVE UM: CUSTOM Carve Out- Bill hek cell, b-domain deleted MDCH FFS 11/02/2020 NUWIQ antihemophilic factor viii rec REMOVE UM: CUSTOM Carve Out- Bill hek cell, b-domain deleted MDCH FFS 11/02/2020 NUWIQ antihemophilic factor viii rec REMOVE UM: CUSTOM Carve Out- Bill hek cell, b-domain deleted MDCH FFS 11/02/2020 ABILIFY MYCITE aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ABILIFY MYCITE aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ABILIFY MYCITE aripiprazole REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BALVERSA erdafitinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 APTIVUS tipranavir/vitamin e tpgs REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 risperidone odt risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 clomipramine hcl clomipramine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 maprotiline hcl maprotiline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 stavudine stavudine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TEGRETOL XR carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KEPPRA XR levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUNOSI solriamfetol hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 175 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 SUNOSI solriamfetol hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 benztropine benztropine mesylate REMOVE UM: CUSTOM Carve Out- Bill mesylate MDCH FFS 11/02/2020 WELLBUTRIN bupropion hcl REMOVE UM: CUSTOM Carve Out- Bill SR MDCH FFS 11/02/2020 nefazodone hcl nefazodone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BALVERSA erdafitinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BUPHENYL sodium phenylbutyrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 BALVERSA erdafitinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ODEFSEY emtricitabine/rilpivirine REMOVE UM: CUSTOM Carve Out- Bill hcl/tenofovir alafenamide MDCH FFS fumarate 11/02/2020 phenelzine phenelzine sulfate REMOVE UM: CUSTOM Carve Out- Bill sulfate MDCH FFS 11/02/2020 ZYPREXA olanzapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 APTENSIO XR methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 APTENSIO XR methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 APTENSIO XR methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 APTENSIO XR methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 APTENSIO XR methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 176 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 APTENSIO XR methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VONVENDI von willebrand factor REMOVE UM: CUSTOM Carve Out- Bill (recombinant) MDCH FFS 11/02/2020 citalopram hbr citalopram hydrobromide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VONVENDI von willebrand factor REMOVE UM: CUSTOM Carve Out- Bill (recombinant) MDCH FFS 11/02/2020 zaleplon zaleplon REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 sofosbuvir- sofosbuvir/velpatasvir REMOVE UM: CUSTOM Carve Out- Bill velpatasvir MDCH FFS 11/02/2020 EPCLUSA sofosbuvir/velpatasvir REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 quetiapine quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill fumarate MDCH FFS 11/02/2020 aminocaproic aminocaproic acid REMOVE UM: CUSTOM Carve Out- Bill acid MDCH FFS 11/02/2020 KEPPRA XR levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 levetiracetam er levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KOVALTRY antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant,full length MDCH FFS 11/02/2020 lamotrigine lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 venlafaxine hcl er venlafaxine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 risperidone odt risperidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 177 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 KOVALTRY antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant,full length MDCH FFS 11/02/2020 primidone primidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KOVALTRY antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant,full length MDCH FFS 11/02/2020 KOVALTRY antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant,full length MDCH FFS 11/02/2020 KOVALTRY antihemophilic factor (fviii) REMOVE UM: CUSTOM Carve Out- Bill recombinant,full length MDCH FFS 11/02/2020 benztropine benztropine mesylate REMOVE UM: CUSTOM Carve Out- Bill mesylate MDCH FFS 11/02/2020 zolpidem tartrate zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 zolpidem tartrate zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 ALPROLIX factor ix recombinant, fc REMOVE UM: CUSTOM Carve Out- Bill fusion protein MDCH FFS 11/02/2020 protriptyline hcl protriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 PREZISTA darunavir ethanolate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 WILATE antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human/von willebrand MDCH FFS factor,human 11/02/2020 WILATE antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human/von willebrand MDCH FFS factor,human 11/02/2020 REVCOVI elapegademase-lvlr REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 178 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 MYSOLINE primidone REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 XYNTHA antihemophilic factor (factor REMOVE UM: CUSTOM Carve Out- Bill viii) recomb,b-domain MDCH FFS deleted 11/02/2020 XYNTHA antihemophilic factor (factor REMOVE UM: CUSTOM Carve Out- Bill viii) recomb,b-domain MDCH FFS deleted 11/02/2020 XYNTHA antihemophilic factor (factor REMOVE UM: CUSTOM Carve Out- Bill viii) recomb,b-domain MDCH FFS deleted 11/02/2020 XYNTHA antihemophilic factor (factor REMOVE UM: CUSTOM Carve Out- Bill viii) recomb,b-domain MDCH FFS deleted 11/02/2020 LAMICTAL lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SEROQUEL quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SUTENT sunitinib malate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VIDEX didanosine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KCENTRA human prothrombin complex REMOVE UM: CUSTOM Carve Out- Bill concentrate (pcc), 4-factor MDCH FFS 11/02/2020 VILTEPSO viltolarsen REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VPRIV velaglucerase alfa REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 protriptyline hcl protriptyline hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 179 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 doxepin hcl doxepin hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 LAMICTAL lamotrigine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 efavirenz efavirenz REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 pregabalin pregabalin REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SYMTUZA darunavir REMOVE UM: CUSTOM Carve Out- Bill eth/cobicistat/emtricitabine/t MDCH FFS enofovir alafenamide 11/02/2020 CELEXA citalopram hydrobromide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 quetiapine quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill fumarate er MDCH FFS 11/02/2020 quetiapine quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill fumarate er MDCH FFS 11/02/2020 quetiapine quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill fumarate er MDCH FFS 11/02/2020 CARNITOR SF levocarnitine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 quetiapine quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill fumarate MDCH FFS 11/02/2020 AMBIEN CR zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 AMBIEN CR zolpidem tartrate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ISENTRESS raltegravir potassium REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 TAGRISSO osimertinib mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 180 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 TAGRISSO osimertinib mesylate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 levocarnitine levocarnitine (with sugar) REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CYKLOKAPRON tranexamic acid REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 METHYLIN methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 METHYLIN methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 COTELLIC cobimetinib fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 GEODON ziprasidone hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 ATRYN antithrombin iii, human REMOVE UM: CUSTOM Carve Out- Bill recombinant MDCH FFS 11/02/2020 clozapine clozapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 VOTRIENT pazopanib hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 bupropion hcl bupropion hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 nevirapine nevirapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 181 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 nevirapine nevirapine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 MEKINIST trametinib dimethyl sulfoxide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IBRANCE palbociclib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IBRANCE palbociclib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 IBRANCE palbociclib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 DIACOMIT stiripentol REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 WELLBUTRIN bupropion hcl REMOVE UM: CUSTOM Carve Out- Bill XL MDCH FFS 11/02/2020 clonidine hcl er clonidine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KAPVAY clonidine hcl REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 RECOMBINATE antihemophilic factor viii, REMOVE UM: CUSTOM Carve Out- Bill human recombinant MDCH FFS 11/02/2020 MEKINIST trametinib dimethyl sulfoxide REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 trihexyphenidyl trihexyphenidyl hcl REMOVE UM: CUSTOM Carve Out- Bill hcl MDCH FFS 11/02/2020 TEGRETOL carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 182 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 BERINERT c1 esterase inhibitor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 SEROQUEL quetiapine fumarate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 MONONINE factor ix REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EQUETRO carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EQUETRO carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill er MDCH FFS 11/02/2020 SPRYCEL dasatinib REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 levetiracetam levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 COMETRIQ cabozantinib s-malate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 KEPPRA levetiracetam REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 COMETRIQ cabozantinib s-malate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 COMETRIQ cabozantinib s-malate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 loxapine loxapine succinate REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EPITOL carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 CARNITOR levocarnitine (with sugar) REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 183 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 KALYDECO ivacaftor REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 EQUETRO carbamazepine REMOVE UM: CUSTOM Carve Out- Bill MDCH FFS 11/02/2020 dexmethylphenid dexmethylphenidate hcl REMOVE UM: CUSTOM Carve Out- Bill ate hcl MDCH FFS 11/02/2020 trimipramine trimipramine maleate REMOVE UM: CUSTOM Carve Out- Bill maleate MDCH FFS 11/02/2020 WILATE antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human/von willebrand MDCH FFS factor,human 11/02/2020 tranexamic acid- tranexamic acid in sodium REMOVE UM: CUSTOM Carve Out- Bill nacl chloride,iso-osmotic MDCH FFS 11/02/2020 WILATE antihemophilic factor, REMOVE UM: CUSTOM Carve Out- Bill human/von willebrand MDCH FFS factor,human 11/02/2020 lithium carbonate lithium carbonate REMOVE UM: CUSTOM Carve Out- Bill er,lithium MDCH FFS carbonate 11/02/2020 NOVOSEVEN coagulation factor viia REMOVE UM: CUSTOM Carve Out- Bill RT (recombinant) MDCH FFS 11/02/2020 NOVOSEVEN coagulation factor viia REMOVE UM: CUSTOM Carve Out- Bill RT (recombinant) MDCH FFS 11/02/2020 NOVOSEVEN coagulation factor viia REMOVE UM: CUSTOM Carve Out- Bill RT (recombinant) MDCH FFS 11/02/2020 PIQRAY alpelisib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 DAYTRANA methylphenidate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 PIQRAY alpelisib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 184 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 DAYTRANA methylphenidate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 thioridazine hcl thioridazine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 DAYTRANA methylphenidate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 thioridazine hcl thioridazine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 thioridazine hcl thioridazine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 clomipramine clomipramine hcl CHANGE UM: CUSTOM CARVE OUT- hcl,anafranil BILL MDCH FFS 11/02/2020 DAYTRANA methylphenidate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 clomipramine clomipramine hcl CHANGE UM: CUSTOM CARVE OUT- hcl,anafranil BILL MDCH FFS 11/02/2020 qudexy topiramate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,topiramate er MDCH FFS BILL MDCH FFS 11/02/2020 clorazepate clorazepate dipotassium ADD UM: CUSTOM CARVE OUT- dipotassium,tranx BILL MDCH FFS ene t-tab 11/02/2020 clomipramine clomipramine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl,anafranil MDCH FFS BILL MDCH FFS 11/02/2020 qudexy topiramate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,topiramate er MDCH FFS BILL MDCH FFS 11/02/2020 clorazepate clorazepate dipotassium ADD UM: CUSTOM CARVE OUT- dipotassium,tranx BILL MDCH FFS ene t-tab 11/02/2020 REBETOL ribavirin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 185 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 clorazepate clorazepate dipotassium CHANGE UM: CUSTOM CARVE OUT- dipotassium,tranx BILL MDCH FFS ene t-tab 11/02/2020 nefazodone hcl nefazodone hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 intuniv,guanfacin guanfacine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- e hcl er MDCH FFS BILL MDCH FFS 11/02/2020 nefazodone hcl nefazodone hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 ARISTADA aripiprazole lauroxil CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VIIBRYD vilazodone hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 nefazodone hcl nefazodone hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 qudexy topiramate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,topiramate er MDCH FFS BILL MDCH FFS 11/02/2020 depakene,valproi valproic acid (as sodium ADD UM: CUSTOM CARVE OUT- c acid salt) (valproate BILL MDCH FFS sodium),valproate sodium 11/02/2020 qudexy topiramate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,topiramate er MDCH FFS BILL MDCH FFS 11/02/2020 nefazodone hcl nefazodone hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 REBINYN factor ix (human) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, pegylated MDCH FFS BILL MDCH FFS 11/02/2020 REBINYN factor ix (human) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, pegylated MDCH FFS BILL MDCH FFS 11/02/2020 thioridazine hcl thioridazine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 186 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ORFADIN nitisinone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 KOSELUGO selumetinib sulfate/vitamin e CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- tpgs MDCH FFS BILL MDCH FFS 11/02/2020 VIIBRYD vilazodone hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 KOSELUGO selumetinib sulfate/vitamin e CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- tpgs MDCH FFS BILL MDCH FFS 11/02/2020 VIIBRYD vilazodone hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 nefazodone hcl nefazodone hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 OXTELLAR XR oxcarbazepine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ZYKADIA ceritinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 suboxone,bupren buprenorphine hcl/naloxone CHANGE UM: CUSTOM CARVE OUT- orphine-naloxone hcl BILL MDCH FFS 11/02/2020 halcion,triazolam triazolam CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 seroquel quetiapine fumarate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,quetiapine MDCH FFS BILL MDCH FFS fumarate er 11/02/2020 suboxone,bupren buprenorphine hcl/naloxone CHANGE UM: CUSTOM CARVE OUT- orphine-naloxone hcl BILL MDCH FFS 11/02/2020 TAGRISSO osimertinib mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 TAGRISSO osimertinib mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 187 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 seroquel quetiapine fumarate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,quetiapine MDCH FFS BILL MDCH FFS fumarate er 11/02/2020 triazolam triazolam ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 seroquel quetiapine fumarate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,quetiapine MDCH FFS BILL MDCH FFS fumarate er 11/02/2020 NOVOSEVEN coagulation factor viia CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- RT (recombinant) MDCH FFS BILL MDCH FFS 11/02/2020 OXTELLAR XR oxcarbazepine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 OXTELLAR XR oxcarbazepine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 depakote,divalpro divalproex sodium CHANGE UM: CUSTOM CARVE OUT- ex sodium BILL MDCH FFS 11/02/2020 depakote,divalpro divalproex sodium CHANGE UM: CUSTOM CARVE OUT- ex sodium BILL MDCH FFS 11/02/2020 depakote,divalpro divalproex sodium CHANGE UM: CUSTOM CARVE OUT- ex sodium BILL MDCH FFS 11/02/2020 acamprosate acamprosate calcium ADD UM: CUSTOM CARVE OUT- calcium,campral BILL MDCH FFS 11/02/2020 HARVONI ledipasvir/sofosbuvir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 SOVALDI sofosbuvir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 clonidine hcl clonidine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- er,kapvay MDCH FFS BILL MDCH FFS 11/02/2020 VERZENIO abemaciclib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 188 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 VERZENIO abemaciclib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 PIQRAY alpelisib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 DAKLINZA daclatasvir dihydrochloride CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 DAKLINZA daclatasvir dihydrochloride CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 tegretol,carbama carbamazepine ADD UM: CUSTOM CARVE OUT- zepine BILL MDCH FFS 11/02/2020 VERZENIO abemaciclib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VERZENIO abemaciclib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 COTELLIC cobimetinib fumarate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 adderall,dextroa dextroamphetamine sulf- CHANGE UM: CUSTOM CARVE OUT- mphetamine- saccharate/amphetamine BILL MDCH FFS amphetamine sulf-aspartate 11/02/2020 adderall,dextroa dextroamphetamine sulf- ADD UM: CUSTOM CARVE OUT- mphetamine- saccharate/amphetamine BILL MDCH FFS amphetamine sulf-aspartate 11/02/2020 adderall,dextroa dextroamphetamine sulf- ADD UM: CUSTOM CARVE OUT- mphetamine- saccharate/amphetamine BILL MDCH FFS amphetamine,am sulf-aspartate phetamine salt combo 11/02/2020 PEGANONE ethotoin ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 STIVARGA regorafenib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 189 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 TUKYSA tucatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne-amphet saccharate/amphetamine MDCH FFS BILL MDCH FFS er,adderall xr sulf-aspartate 11/02/2020 dextroamphetami dextroamphetamine sulf- CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne-amphet saccharate/amphetamine MDCH FFS BILL MDCH FFS er,adderall xr sulf-aspartate 11/02/2020 ADAGEN pegademase bovine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 FANAPT iloperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 klonopin,clonaze clonazepam ADD UM: CUSTOM CARVE OUT- pam BILL MDCH FFS 11/02/2020 klonopin,clonaze clonazepam CHANGE UM: CUSTOM CARVE OUT- pam BILL MDCH FFS 11/02/2020 focalin dexmethylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,dexmethylphen MDCH FFS BILL MDCH FFS idate hcl er 11/02/2020 FANAPT iloperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 qudexy topiramate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,topiramate er MDCH FFS BILL MDCH FFS 11/02/2020 FANAPT iloperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 klonopin,clonaze clonazepam ADD UM: CUSTOM CARVE OUT- pam BILL MDCH FFS 11/02/2020 levetiracetam,kep levetiracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- pra,roweepra MDCH FFS BILL MDCH FFS 11/02/2020 TUKYSA tucatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 190 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 PEMAZYRE pemigatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 PEMAZYRE pemigatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 depakene,valproi valproic acid CHANGE UM: CUSTOM CARVE OUT- c acid BILL MDCH FFS 11/02/2020 CEREZYME imiglucerase ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 PEMAZYRE pemigatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 NINLARO ixazomib citrate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 aptensio methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,methylphenidat MDCH FFS BILL MDCH FFS e er 11/02/2020 aptensio methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,methylphenidat MDCH FFS BILL MDCH FFS e er 11/02/2020 aptensio methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,methylphenidat MDCH FFS BILL MDCH FFS e er 11/02/2020 oxazepam oxazepam ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 FANAPT iloperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 oxazepam oxazepam ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 FANAPT iloperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 FANAPT iloperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 191 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 oxazepam oxazepam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 levetiracetam,kep levetiracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- pra MDCH FFS BILL MDCH FFS 11/02/2020 forfivo bupropion hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xl,bupropion xl MDCH FFS BILL MDCH FFS 11/02/2020 aptensio methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,methylphenidat MDCH FFS BILL MDCH FFS e er 11/02/2020 aptensio methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,methylphenidat MDCH FFS BILL MDCH FFS e er 11/02/2020 aptensio methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,methylphenidat MDCH FFS BILL MDCH FFS e er 11/02/2020 BUNAVAIL buprenorphine hcl/naloxone ADD UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 BUNAVAIL buprenorphine hcl/naloxone ADD UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 levocarnitine,carn levocarnitine ADD UM: CUSTOM CARVE OUT- itor BILL MDCH FFS 11/02/2020 OCTAPLAS plasma human, blood group CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- o MDCH FFS BILL MDCH FFS 11/02/2020 ZYKADIA ceritinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 OCTAPLAS plasma human, blood group CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ab MDCH FFS BILL MDCH FFS 11/02/2020 dilantin- phenytoin CHANGE UM: CUSTOM CARVE OUT- 125,phenytoin BILL MDCH FFS 11/02/2020 BUNAVAIL buprenorphine hcl/naloxone ADD UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 192 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 FANAPT iloperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 APTIVUS tipranavir/vitamin e tpgs CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 FANAPT iloperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 BUTISOL butabarbital sodium ADD UM: CUSTOM CARVE OUT- SODIUM BILL MDCH FFS 11/02/2020 APLENZIN bupropion hbr CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 RETROVIR zidovudine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 JIVI antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- rec, b-domain deleted peg- MDCH FFS BILL MDCH FFS aucl 11/02/2020 JIVI antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- rec, b-domain deleted peg- MDCH FFS BILL MDCH FFS aucl 11/02/2020 IDELVION factor ix CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant,albumin fusion MDCH FFS BILL MDCH FFS protein 11/02/2020 IDELVION factor ix CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant,albumin fusion MDCH FFS BILL MDCH FFS protein 11/02/2020 XALKORI crizotinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 IDELVION factor ix CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant,albumin fusion MDCH FFS BILL MDCH FFS protein 11/02/2020 XALKORI crizotinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 193 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 SOVALDI sofosbuvir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 DELSTRIGO doravirine/lamivudine/tenofo CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- vir disoproxil fumarate MDCH FFS BILL MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- CHANGE UM: CUSTOM CARVE OUT- ne-amphet saccharate/amphetamine BILL MDCH FFS er,adderall xr sulf-aspartate 11/02/2020 dextroamphetami dextroamphetamine sulf- ADD UM: CUSTOM CARVE OUT- ne-amphet saccharate/amphetamine BILL MDCH FFS er,adderall xr sulf-aspartate 11/02/2020 dextroamphetami dextroamphetamine sulf- ADD UM: CUSTOM CARVE OUT- ne-amphet saccharate/amphetamine BILL MDCH FFS er,adderall xr sulf-aspartate 11/02/2020 SUNOSI solriamfetol hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 SUNOSI solriamfetol hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 OCTAPLAS plasma human, blood group CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- a MDCH FFS BILL MDCH FFS 11/02/2020 dilantin,phenytoin phenytoin CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 OCTAPLAS plasma human, blood group CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- b MDCH FFS BILL MDCH FFS 11/02/2020 IDELVION factor ix CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant,albumin fusion MDCH FFS BILL MDCH FFS protein 11/02/2020 VPRIV velaglucerase alfa CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 XYNTHA antihemophilic factor (factor ADD UM: CUSTOM CARVE OUT- SOLOFUSE viii) recomb,b-domain BILL MDCH FFS deleted

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 194 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 flurazepam flurazepam hcl ADD UM: CUSTOM CARVE OUT- hcl,dalmane BILL MDCH FFS 11/02/2020 flurazepam flurazepam hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl,dalmane MDCH FFS BILL MDCH FFS 11/02/2020 gabapentin gabapentin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 CRIXIVAN indinavir sulfate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 JIVI antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- rec, b-domain deleted peg- MDCH FFS BILL MDCH FFS aucl 11/02/2020 CRIXIVAN indinavir sulfate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 JIVI antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- rec, b-domain deleted peg- MDCH FFS BILL MDCH FFS aucl 11/02/2020 PEGINTRON peginterferon alfa-2b CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ELOCTATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, fc fusion MDCH FFS BILL MDCH FFS protein 11/02/2020 ELOCTATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, fc fusion MDCH FFS BILL MDCH FFS protein 11/02/2020 gabapentin gabapentin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 SECUADO asenapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 SECUADO asenapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 195 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 nembutal pentobarbital sodium ADD UM: CUSTOM CARVE OUT- sodium,pentobar BILL MDCH FFS bital sodium 11/02/2020 ALPRAZOLAM alprazolam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- INTENSOL MDCH FFS BILL MDCH FFS 11/02/2020 SECUADO asenapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 xanax,alprazolam alprazolam CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 intuniv,guanfacin guanfacine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- e hcl er MDCH FFS BILL MDCH FFS 11/02/2020 maprotiline hcl maprotiline hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 xanax,alprazolam alprazolam CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 PREZISTA darunavir ethanolate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 xanax,alprazolam alprazolam ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 maprotiline hcl maprotiline hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 xanax,alprazolam alprazolam ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 HELIXATE antihemophilic factor viii, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- FS,RECOMBINA human recombinant MDCH FFS BILL MDCH FFS TE 11/02/2020 intuniv,guanfacin guanfacine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- e hcl er MDCH FFS BILL MDCH FFS 11/02/2020 maprotiline hcl maprotiline hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 196 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 TYBOST cobicistat CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 XYNTHA antihemophilic factor (factor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SOLOFUSE viii) recomb,b-domain MDCH FFS BILL MDCH FFS deleted 11/02/2020 NORVIR ritonavir ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 ELOCTATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, fc fusion MDCH FFS BILL MDCH FFS protein 11/02/2020 levocarnitine,carn levocarnitine (with sugar) CHANGE UM: CUSTOM CARVE OUT- itor BILL MDCH FFS 11/02/2020 aptensio methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,methylphenidat MDCH FFS BILL MDCH FFS e er 11/02/2020 perphenazine perphenazine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 perphenazine perphenazine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 NORVIR ritonavir ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 ELOCTATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, fc fusion MDCH FFS BILL MDCH FFS protein 11/02/2020 perphenazine perphenazine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ELAPRASE idursulfase CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ELOCTATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, fc fusion MDCH FFS BILL MDCH FFS protein

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 197 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 perphenazine perphenazine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 ELOCTATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, fc fusion MDCH FFS BILL MDCH FFS protein 11/02/2020 EDLUAR zolpidem tartrate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ELOCTATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, fc fusion MDCH FFS BILL MDCH FFS protein 11/02/2020 ZENZEDI dextroamphetamine sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ZENZEDI dextroamphetamine sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 PEGINTRON peginterferon alfa-2b ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 emtriva,emtricitab emtricitabine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ine MDCH FFS BILL MDCH FFS 11/02/2020 intuniv,guanfacin guanfacine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- e hcl er MDCH FFS BILL MDCH FFS 11/02/2020 EDLUAR zolpidem tartrate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ritalin methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- la,methylphenidat MDCH FFS BILL MDCH FFS e la,methylphenidat e er (la) 11/02/2020 chlordiazepoxide- amitriptyline ADD UM: CUSTOM CARVE OUT- amitriptyline,amitr hcl/chlordiazepoxide BILL MDCH FFS iptyline- chlordiazepoxide, limbitrol ds

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 198 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 chlordiazepoxide- amitriptyline ADD UM: CUSTOM CARVE OUT- amitriptyline,limbit hcl/chlordiazepoxide BILL MDCH FFS rol,amitriptyline- chlordiazepoxide 11/02/2020 BRIVIACT brivaracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 BRIVIACT brivaracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 BRIVIACT brivaracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 BRIVIACT brivaracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 DAYVIGO lemborexant CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 SUCRAID sacrosidase CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 aminocaproic aminocaproic acid CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- acid,amicar MDCH FFS BILL MDCH FFS 11/02/2020 ADYNOVATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, full length, peg MDCH FFS BILL MDCH FFS 11/02/2020 BRIVIACT brivaracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 diazepam diazepam ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 TASIGNA nilotinib hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 perphenazine- perphenazine/amitriptyline ADD UM: CUSTOM CARVE OUT- amitriptyline hcl BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 199 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 perphenazine- perphenazine/amitriptyline ADD UM: CUSTOM CARVE OUT- amitriptyline,amitr hcl BILL MDCH FFS iptyline- perphenazine 11/02/2020 risperidone risperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- odt,risperdal m- MDCH FFS BILL MDCH FFS tab 11/02/2020 IDELVION factor ix CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant,albumin fusion MDCH FFS BILL MDCH FFS protein 11/02/2020 NITYR nitisinone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ZEJULA niraparib tosylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 BRIVIACT brivaracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 SPRITAM levetiracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 RIBASPHERE ribavirin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- RIBAPAK,MODE MDCH FFS BILL MDCH FFS RIBA 11/02/2020 ADYNOVATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, full length, peg MDCH FFS BILL MDCH FFS 11/02/2020 HAEGARDA c1 esterase inhibitor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 perphenazine- perphenazine/amitriptyline ADD UM: CUSTOM CARVE OUT- amitriptyline hcl BILL MDCH FFS 11/02/2020 RIBASPHERE ribavirin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- RIBAPAK,MODE MDCH FFS BILL MDCH FFS RIBA 11/02/2020 NITYR nitisinone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 200 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 perphenazine- perphenazine/amitriptyline CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- amitriptyline,amitr hcl MDCH FFS BILL MDCH FFS iptyline- perphenazine 11/02/2020 NITYR nitisinone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 perphenazine- perphenazine/amitriptyline ADD UM: CUSTOM CARVE OUT- amitriptyline hcl BILL MDCH FFS 11/02/2020 risperidone odt risperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 COMPLERA emtricitabine/rilpivirine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl/tenofovir disoproxil MDCH FFS BILL MDCH FFS fumarate 11/02/2020 clozapine clozapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- odt,fazaclo,cloza MDCH FFS BILL MDCH FFS pine 11/02/2020 clozapine clozapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- odt,fazaclo,cloza MDCH FFS BILL MDCH FFS pine 11/02/2020 SPRYCEL dasatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 WILATE antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human/von willebrand MDCH FFS BILL MDCH FFS factor,human 11/02/2020 WILATE antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human/von willebrand MDCH FFS BILL MDCH FFS factor,human 11/02/2020 dexedrine,dextro dextroamphetamine sulfate CHANGE UM: CUSTOM CARVE OUT- amphetamine BILL MDCH FFS sulfate er 11/02/2020 SAPHRIS asenapine maleate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 201 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 dexedrine,dextro dextroamphetamine sulfate ADD UM: CUSTOM CARVE OUT- amphetamine BILL MDCH FFS sulfate er 11/02/2020 dexedrine,dextro dextroamphetamine sulfate ADD UM: CUSTOM CARVE OUT- amphetamine BILL MDCH FFS sulfate er,dextroampheta mine sulfate 11/02/2020 INTELENCE etravirine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 XYNTHA antihemophilic factor (factor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- viii) recomb,b-domain MDCH FFS BILL MDCH FFS deleted 11/02/2020 XYNTHA antihemophilic factor (factor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- viii) recomb,b-domain MDCH FFS BILL MDCH FFS deleted 11/02/2020 XYNTHA antihemophilic factor (factor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- viii) recomb,b-domain MDCH FFS BILL MDCH FFS deleted 11/02/2020 dextroamphetami dextroamphetamine sulf- ADD UM: CUSTOM CARVE OUT- ne- saccharate/amphetamine BILL MDCH FFS amphetamine,ad sulf-aspartate derall,amphetami ne salt combo 11/02/2020 NINLARO ixazomib citrate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- ADD UM: CUSTOM CARVE OUT- ne- saccharate/amphetamine BILL MDCH FFS amphetamine,ad sulf-aspartate derall,amphetami ne salt combo 11/02/2020 XYNTHA antihemophilic factor (factor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- viii) recomb,b-domain MDCH FFS BILL MDCH FFS deleted

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 202 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 dextroamphetami dextroamphetamine sulf- CHANGE UM: CUSTOM CARVE OUT- ne- saccharate/amphetamine BILL MDCH FFS amphetamine,ad sulf-aspartate derall,amphetami ne salt combo 11/02/2020 dextroamphetami dextroamphetamine sulf- CHANGE UM: CUSTOM CARVE OUT- ne- saccharate/amphetamine BILL MDCH FFS amphetamine,ad sulf-aspartate derall,amphetami ne salt combo 11/02/2020 QINLOCK ripretinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VIDEX didanosine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 DAYVIGO lemborexant CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 valium,diazepam diazepam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 viramune nevirapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,nevirapine er MDCH FFS BILL MDCH FFS 11/02/2020 NINLARO ixazomib citrate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 methylin methylphenidate hcl ADD UM: CUSTOM CARVE OUT- er,methylphenida BILL MDCH FFS te er,metadate er 11/02/2020 valium,diazepam diazepam ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 valium,diazepam diazepam CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 EDURANT rilpivirine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 203 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ROZLYTREK entrectinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ROZLYTREK entrectinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 FEIBA VH anti-inhibitor coagulant ADD UM: CUSTOM CARVE OUT- IMMUNO,FEIBA complex BILL MDCH FFS NF 11/02/2020 lamictal lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- odt,lamotrigine MDCH FFS BILL MDCH FFS odt 11/02/2020 oxcarbazepine,tril oxcarbazepine ADD UM: CUSTOM CARVE OUT- eptal BILL MDCH FFS 11/02/2020 FEIBA VH anti-inhibitor coagulant ADD UM: CUSTOM CARVE OUT- IMMUNO,FEIBA complex BILL MDCH FFS NF 11/02/2020 oxcarbazepine,tril oxcarbazepine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- eptal MDCH FFS BILL MDCH FFS 11/02/2020 INREBIC fedratinib dihydrochloride CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 oxcarbazepine,tril oxcarbazepine ADD UM: CUSTOM CARVE OUT- eptal BILL MDCH FFS 11/02/2020 procentra,dextroa dextroamphetamine sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- mphetamine MDCH FFS BILL MDCH FFS sulfate,liquadd 11/02/2020 oxcarbazepine,tril oxcarbazepine ADD UM: CUSTOM CARVE OUT- eptal BILL MDCH FFS 11/02/2020 desvenlafaxine desvenlafaxine fumarate ADD UM: CUSTOM CARVE OUT- fumarate er BILL MDCH FFS 11/02/2020 chlorpromazine chlorpromazine hcl ADD UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 204 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 desvenlafaxine desvenlafaxine fumarate ADD UM: CUSTOM CARVE OUT- fumarate er BILL MDCH FFS 11/02/2020 REBINYN factor ix (human) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, pegylated MDCH FFS BILL MDCH FFS 11/02/2020 chlorpromazine chlorpromazine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 chlorpromazine chlorpromazine hcl ADD UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 chlorpromazine chlorpromazine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 chlorpromazine chlorpromazine hcl ADD UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 fazaclo,clozapine clozapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- odt MDCH FFS BILL MDCH FFS 11/02/2020 fazaclo,clozapine clozapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- odt MDCH FFS BILL MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- dimesylate MDCH FFS BILL MDCH FFS 11/02/2020 estazolam,proso estazolam ADD UM: CUSTOM CARVE OUT- m BILL MDCH FFS 11/02/2020 ORKAMBI lumacaftor/ivacaftor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- dimesylate MDCH FFS BILL MDCH FFS 11/02/2020 estazolam estazolam ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 BALVERSA erdafitinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ORKAMBI lumacaftor/ivacaftor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 205 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 BALVERSA erdafitinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ZUBSOLV buprenorphine hcl/naloxone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 ALDURAZYME laronidase CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 IRESSA gefitinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 evekeo,ampheta amphetamine sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- mine sulfate MDCH FFS BILL MDCH FFS 11/02/2020 kaletra,lopinavir- lopinavir/ritonavir ADD UM: CUSTOM CARVE OUT- ritonavir BILL MDCH FFS 11/02/2020 RUBRACA rucaparib camsylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lamictal lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,lamotrigine er MDCH FFS BILL MDCH FFS 11/02/2020 ISENTRESS raltegravir potassium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 kuvan,sapropteri sapropterin dihydrochloride CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- n dihydrochloride MDCH FFS BILL MDCH FFS 11/02/2020 lamictal lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,lamotrigine er MDCH FFS BILL MDCH FFS 11/02/2020 VIMIZIM elosulfase alfa CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 EMTRIVA emtricitabine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 evekeo,ampheta amphetamine sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- mine sulfate MDCH FFS BILL MDCH FFS 11/02/2020 nuvigil,armodafini armodafinil CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- l MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 206 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 geodon,ziprasido ziprasidone hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne hcl MDCH FFS BILL MDCH FFS 11/02/2020 gabitril,tiagabine tiagabine hcl ADD UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 geodon,ziprasido ziprasidone hcl CHANGE UM: CUSTOM CARVE OUT- ne hcl BILL MDCH FFS 11/02/2020 gabitril,tiagabine tiagabine hcl ADD UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 geodon,ziprasido ziprasidone hcl CHANGE UM: CUSTOM CARVE OUT- ne hcl BILL MDCH FFS 11/02/2020 gabitril,tiagabine tiagabine hcl ADD UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 DYANAVEL XR amphetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 AFSTYLA antihemophilic factor viii CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recomb,single-chn,b-dom MDCH FFS BILL MDCH FFS truncated 11/02/2020 AFSTYLA antihemophilic factor viii CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recomb,single-chn,b-dom MDCH FFS BILL MDCH FFS truncated 11/02/2020 FABRAZYME agalsidase beta CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 buspirone buspirone hcl ADD UM: CUSTOM CARVE OUT- hcl,buspar BILL MDCH FFS 11/02/2020 KALBITOR ecallantide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 buspar,buspirone buspirone hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 buspirone buspirone hcl ADD UM: CUSTOM CARVE OUT- hcl,buspar BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 207 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 DOVATO dolutegravir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- sodium/lamivudine MDCH FFS BILL MDCH FFS 11/02/2020 geodon,ziprasido ziprasidone hcl ADD UM: CUSTOM CARVE OUT- ne hcl BILL MDCH FFS 11/02/2020 EVOTAZ atazanavir sulfate/cobicistat CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 BALVERSA erdafitinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ORFADIN nitisinone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 parnate,tranylcyp tranylcypromine sulfate ADD UM: CUSTOM CARVE OUT- romine sulfate BILL MDCH FFS 11/02/2020 SPRITAM levetiracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 MARPLAN isocarboxazid ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 SPRITAM levetiracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 nardil,phenelzine phenelzine sulfate ADD UM: CUSTOM CARVE OUT- sulfate BILL MDCH FFS 11/02/2020 intermezzo,zolpid zolpidem tartrate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- em tartrate MDCH FFS BILL MDCH FFS 11/02/2020 RISPERDAL risperidone microspheres CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- CONSTA MDCH FFS BILL MDCH FFS 11/02/2020 lamictal lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,lamotrigine er MDCH FFS BILL MDCH FFS 11/02/2020 RISPERDAL risperidone microspheres CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- CONSTA MDCH FFS BILL MDCH FFS 11/02/2020 RISPERDAL risperidone microspheres CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- CONSTA MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 208 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 intermezzo,zolpid zolpidem tartrate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- em tartrate MDCH FFS BILL MDCH FFS 11/02/2020 HETLIOZ tasimelteon CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 risperidone risperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- odt,risperdal m- MDCH FFS BILL MDCH FFS tab 11/02/2020 risperidone risperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- odt,risperdal m- MDCH FFS BILL MDCH FFS tab 11/02/2020 zidovudine,retrovi zidovudine ADD UM: CUSTOM CARVE OUT- r BILL MDCH FFS 11/02/2020 lithium carbonate lithium carbonate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 abilify,aripiprazol aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- e MDCH FFS BILL MDCH FFS 11/02/2020 nevirapine,viramu nevirapine ADD UM: CUSTOM CARVE OUT- ne BILL MDCH FFS 11/02/2020 nevirapine,viramu nevirapine CHANGE UM: CUSTOM CARVE OUT- ne BILL MDCH FFS 11/02/2020 retrovir,zidovudin zidovudine CHANGE UM: CUSTOM CARVE OUT- e BILL MDCH FFS 11/02/2020 PEGASYS peginterferon alfa-2a CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 APTIVUS tipranavir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 COTEMPLA XR- methylphenidate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ODT MDCH FFS BILL MDCH FFS 11/02/2020 COTEMPLA XR- methylphenidate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ODT MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 209 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 symbyax,olanzap olanzapine/fluoxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ine-fluoxetine hcl MDCH FFS BILL MDCH FFS 11/02/2020 MYDAYIS dextroamphetamine sulf- CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- saccharate/amphetamine MDCH FFS BILL MDCH FFS sulf-aspartate 11/02/2020 MYDAYIS dextroamphetamine sulf- CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- saccharate/amphetamine MDCH FFS BILL MDCH FFS sulf-aspartate 11/02/2020 VIREAD tenofovir disoproxil fumarate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VIREAD tenofovir disoproxil fumarate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 LATUDA lurasidone hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VIREAD tenofovir disoproxil fumarate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 KALYDECO ivacaftor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 TABRECTA capmatinib hydrochloride CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 TABRECTA capmatinib hydrochloride CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 KALYDECO ivacaftor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 COTEMPLA XR- methylphenidate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ODT MDCH FFS BILL MDCH FFS 11/02/2020 TASIGNA nilotinib hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 RUCONEST c1 esterase inhibitor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 210 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 MONONINE,ALP factor ix CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- HANINE SD MDCH FFS BILL MDCH FFS 11/02/2020 lithium carbonate lithium carbonate CHANGE UM: CUSTOM CARVE OUT- er,lithium BILL MDCH FFS carbonate,lithobid 11/02/2020 ALPHANINE factor ix CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SD,MONONINE MDCH FFS BILL MDCH FFS 11/02/2020 lithium carbonate lithium carbonate ADD UM: CUSTOM CARVE OUT- er,lithium BILL MDCH FFS carbonate 11/02/2020 FIRDAPSE amifampridine phosphate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 KOGENATE antihemophilic factor (fviii) CHANGE UM: CUSTOM CARVE OUT- FS,HELIXATE recomb,full length (alb- BILL MDCH FFS FS,ADVATE,ADV free),antihemophilic factor ATE (fviii) recombinant,full length M,KOVALTRY 11/02/2020 haloperidol haloperidol ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 RETEVMO selpercatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ADVATE,ADVAT antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- E SH recombinant,full MDCH FFS BILL MDCH FFS length,antihemophilic factor (fviii) recomb,full length (alb- free) 11/02/2020 haloperidol haloperidol ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 KOGENATE antihemophilic factor (fviii) CHANGE UM: CUSTOM CARVE OUT- FS,HELIXATE recomb,full length (alb- BILL MDCH FFS FS,ADVATE,ADV free),antihemophilic factor ATE (fviii) recombinant,full length L,KOVALTRY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 211 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 MEPSEVII vestronidase alfa-vjbk CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 KOGENATE antihemophilic factor (fviii) CHANGE UM: CUSTOM CARVE OUT- FS,HELIXATE recomb,full length (alb- BILL MDCH FFS FS,ADVATE,ADV free),antihemophilic factor ATE (fviii) recombinant,full length H,KOVALTRY 11/02/2020 risperidone risperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- odt,risperdal m- MDCH FFS BILL MDCH FFS tab 11/02/2020 BANZEL rufinamide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 BANZEL rufinamide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 KOGENATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- FS,HELIXATE recomb,full length (alb- MDCH FFS BILL MDCH FFS FS,ADVATE,KO free),antihemophilic factor VALTRY (fviii) recombinant,full length 11/02/2020 precedex,dexme dexmedetomidine hcl in 0.9 CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- detomidine-0.9% % sodium chloride MDCH FFS BILL MDCH FFS nacl 11/02/2020 risperidone risperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- odt,risperdal m- MDCH FFS BILL MDCH FFS tab 11/02/2020 PLASMANATE plasma protein fraction ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 BELSOMRA suvorexant CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 BELSOMRA suvorexant CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 haloperidol haloperidol ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 212 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 RETEVMO selpercatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 BELSOMRA suvorexant CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 haloperidol haloperidol CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VIREAD tenofovir disoproxil fumarate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 haloperidol haloperidol ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 abilify,aripiprazol aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- e MDCH FFS BILL MDCH FFS 11/02/2020 haloperidol haloperidol ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 abilify,aripiprazol aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- e MDCH FFS BILL MDCH FFS 11/02/2020 abilify,aripiprazol aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- e MDCH FFS BILL MDCH FFS 11/02/2020 ramelteon,rozere ramelteon CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- m MDCH FFS BILL MDCH FFS 11/02/2020 NUWIQ antihemophilic factor viii rec CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hek cell, b-domain deleted MDCH FFS BILL MDCH FFS 11/02/2020 VIMPAT lacosamide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ESPEROCT antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- rec, b-dom truncated peg- MDCH FFS BILL MDCH FFS exei 11/02/2020 NUWIQ antihemophilic factor viii rec CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hek cell, b-domain deleted MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 213 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ESPEROCT antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- rec, b-dom truncated peg- MDCH FFS BILL MDCH FFS exei 11/02/2020 AYVAKIT avapritinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 NUWIQ antihemophilic factor viii rec CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hek cell, b-domain deleted MDCH FFS BILL MDCH FFS 11/02/2020 lithium,lithium lithium citrate ADD UM: CUSTOM CARVE OUT- citrate BILL MDCH FFS 11/02/2020 AYVAKIT avapritinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 AYVAKIT avapritinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lyrica,pregabalin pregabalin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 XYNTHA antihemophilic factor (factor ADD UM: CUSTOM CARVE OUT- SOLOFUSE viii) recomb,b-domain BILL MDCH FFS deleted 11/02/2020 XYNTHA antihemophilic factor (factor ADD UM: CUSTOM CARVE OUT- SOLOFUSE viii) recomb,b-domain BILL MDCH FFS deleted 11/02/2020 gabitril,tiagabine tiagabine hcl ADD UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 SPRITAM levetiracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ORKAMBI lumacaftor/ivacaftor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 irenka,duloxetine duloxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 PREZISTA darunavir ethanolate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 214 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 tegretol,carbama carbamazepine CHANGE UM: CUSTOM CARVE OUT- zepine BILL MDCH FFS 11/02/2020 FINTEPLA fenfluramine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 tykerb,lapatinib lapatinib ditosylate CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 KYPROLIS carfilzomib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ESPEROCT antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- rec, b-dom truncated peg- MDCH FFS BILL MDCH FFS exei 11/02/2020 APTIOM eslicarbazepine acetate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ESPEROCT antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- rec, b-dom truncated peg- MDCH FFS BILL MDCH FFS exei 11/02/2020 APTIOM eslicarbazepine acetate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ESPEROCT antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- rec, b-dom truncated peg- MDCH FFS BILL MDCH FFS exei 11/02/2020 JULUCA dolutegravir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- sodium/rilpivirine hcl MDCH FFS BILL MDCH FFS 11/02/2020 sustiva,efavirenz efavirenz CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 NOVOSEVEN coagulation factor viia CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- RT (recombinant) MDCH FFS BILL MDCH FFS 11/02/2020 focalin dexmethylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,dexmethylphen MDCH FFS BILL MDCH FFS idate hcl er

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 215 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 focalin dexmethylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,dexmethylphen MDCH FFS BILL MDCH FFS idate hcl er 11/02/2020 focalin dexmethylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,dexmethylphen MDCH FFS BILL MDCH FFS idate hcl er 11/02/2020 NOVOSEVEN coagulation factor viia CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- RT (recombinant) MDCH FFS BILL MDCH FFS 11/02/2020 NOVOSEVEN coagulation factor viia CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- RT (recombinant) MDCH FFS BILL MDCH FFS 11/02/2020 TIVICAY dolutegravir sodium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 neurontin,gabape gabapentin ADD UM: CUSTOM CARVE OUT- ntin BILL MDCH FFS 11/02/2020 lamictal lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,lamotrigine er MDCH FFS BILL MDCH FFS 11/02/2020 KYPROLIS carfilzomib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 strattera,atomoxe atomoxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- tine hcl MDCH FFS BILL MDCH FFS 11/02/2020 fluvoxamine fluvoxamine maleate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- maleate er,luvox MDCH FFS BILL MDCH FFS cr 11/02/2020 HEMLIBRA emicizumab-kxwh CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 fluvoxamine fluvoxamine maleate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- maleate er,luvox MDCH FFS BILL MDCH FFS cr 11/02/2020 HEMLIBRA emicizumab-kxwh CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 216 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 HEMLIBRA emicizumab-kxwh CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 HEMLIBRA emicizumab-kxwh CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 TRIUMEQ abacavir sulfate/dolutegravir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- sodium/lamivudine MDCH FFS BILL MDCH FFS 11/02/2020 buspirone buspirone hcl ADD UM: CUSTOM CARVE OUT- hcl,buspar BILL MDCH FFS 11/02/2020 NAGLAZYME galsulfase CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 LYNPARZA olaparib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 strattera,atomoxe atomoxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- tine hcl MDCH FFS BILL MDCH FFS 11/02/2020 strattera,atomoxe atomoxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- tine hcl MDCH FFS BILL MDCH FFS 11/02/2020 duloxetine duloxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl,cymbalta MDCH FFS BILL MDCH FFS 11/02/2020 strattera,atomoxe atomoxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- tine hcl MDCH FFS BILL MDCH FFS 11/02/2020 LYNPARZA olaparib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 duloxetine duloxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl,cymbalta MDCH FFS BILL MDCH FFS 11/02/2020 cymbalta,duloxeti duloxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne hcl MDCH FFS BILL MDCH FFS 11/02/2020 VIRACEPT nelfinavir mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 epzicom,abacavir abacavir sulfate/lamivudine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- -lamivudine MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 217 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 albuminar- albumin human CHANGE UM: CUSTOM CARVE OUT- 25,plasbumin- BILL MDCH FFS 25,alburx,albumin (human),albutein, albuked- 25,kedbumin 11/02/2020 RESCRIPTOR delavirdine mesylate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 TECHNIVIE ombitasvir/paritaprevir/ritona ADD UM: CUSTOM CARVE OUT- vir BILL MDCH FFS 11/02/2020 strattera,atomoxe atomoxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- tine hcl MDCH FFS BILL MDCH FFS 11/02/2020 PLASBUMIN- albumin human CHANGE UM: CUSTOM CARVE OUT- 5,ALBURX,ALBU BILL MDCH FFS TEIN,ALBUKED- 5 11/02/2020 ADHANSIA XR methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ADHANSIA XR methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ADHANSIA XR methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulfate CHANGE UM: CUSTOM CARVE OUT- ne BILL MDCH FFS sulfate,zenzedi,d extrostat,dexedri ne 11/02/2020 benztropine benztropine mesylate ADD UM: CUSTOM CARVE OUT- mesylate BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 218 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 dextroamphetami dextroamphetamine sulfate CHANGE UM: CUSTOM CARVE OUT- ne BILL MDCH FFS sulfate,zenzedi,d extrostat,dexedri ne 11/02/2020 benztropine benztropine mesylate ADD UM: CUSTOM CARVE OUT- mesylate BILL MDCH FFS 11/02/2020 ZENZEDI dextroamphetamine sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 truvada,emtricita emtricitabine/tenofovir CHANGE UM: CUSTOM CARVE OUT- bine-tenofovir disoproxil fumarate BILL MDCH FFS disop 11/02/2020 HEMOFIL M antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human MDCH FFS BILL MDCH FFS 11/02/2020 HEMOFIL M antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human MDCH FFS BILL MDCH FFS 11/02/2020 invega,paliperido paliperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne er MDCH FFS BILL MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 phenytoin sodium phenytoin sodium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 albumin (human) albumin human ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 VIMPAT lacosamide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 buminate,flexbum albumin human CHANGE UM: CUSTOM CARVE OUT- in,albumin BILL MDCH FFS (human)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 219 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 albuminar- albumin human CHANGE UM: CUSTOM CARVE OUT- 5,buminate,albu BILL MDCH FFS min (human),albutein, flexbumin 11/02/2020 abilify,aripiprazol aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- e MDCH FFS BILL MDCH FFS 11/02/2020 benztropine benztropine mesylate ADD UM: CUSTOM CARVE OUT- mesylate BILL MDCH FFS 11/02/2020 ADHANSIA XR methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 BELSOMRA suvorexant CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ADHANSIA XR methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 RIXUBIS,BENEFI factor ix human recombinant CHANGE UM: CUSTOM CARVE OUT- X BILL MDCH FFS 11/02/2020 ADHANSIA XR methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 RIXUBIS,BENEFI factor ix human recombinant CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- X MDCH FFS BILL MDCH FFS 11/02/2020 IBRANCE palbociclib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ZUBSOLV buprenorphine hcl/naloxone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 phenytoin sodium phenytoin sodium ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 MYDAYIS dextroamphetamine sulf- CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- saccharate/amphetamine MDCH FFS BILL MDCH FFS sulf-aspartate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 220 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ZUBSOLV buprenorphine hcl/naloxone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 ambien zolpidem tartrate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- cr,zolpidem MDCH FFS BILL MDCH FFS tartrate er 11/02/2020 MYDAYIS dextroamphetamine sulf- CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- saccharate/amphetamine MDCH FFS BILL MDCH FFS sulf-aspartate 11/02/2020 ambien zolpidem tartrate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- cr,zolpidem MDCH FFS BILL MDCH FFS tartrate er 11/02/2020 depakote divalproex sodium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- er,divalproex MDCH FFS BILL MDCH FFS sodium er,depakote 11/02/2020 depakote divalproex sodium ADD UM: CUSTOM CARVE OUT- er,divalproex BILL MDCH FFS sodium er 11/02/2020 CERDELGA eliglustat tartrate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 invega,paliperido paliperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne er MDCH FFS BILL MDCH FFS 11/02/2020 invega,paliperido paliperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne er MDCH FFS BILL MDCH FFS 11/02/2020 IBRANCE palbociclib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 IBRANCE palbociclib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 zaleplon,sonata zaleplon ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 221 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ALPHANATE antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human/von willebrand MDCH FFS BILL MDCH FFS factor,human 11/02/2020 ALPHANATE antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human/von willebrand MDCH FFS BILL MDCH FFS factor,human 11/02/2020 tranexamic acid- tranexamic acid in sodium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- nacl chloride,iso-osmotic MDCH FFS BILL MDCH FFS 11/02/2020 ALPHANATE antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human/von willebrand MDCH FFS BILL MDCH FFS factor,human 11/02/2020 phenobarbital phenobarbital ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 sabril,vigabatrin vigabatrin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 RIXUBIS,BENEFI factor ix human recombinant CHANGE UM: CUSTOM CARVE OUT- X BILL MDCH FFS 11/02/2020 sabril,vigabatrin,v vigabatrin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- igadrone MDCH FFS BILL MDCH FFS 11/02/2020 lamotrigine,lamict lamotrigine CHANGE UM: CUSTOM CARVE OUT- al,subvenite BILL MDCH FFS 11/02/2020 lamotrigine,lamict lamotrigine CHANGE UM: CUSTOM CARVE OUT- al,subvenite BILL MDCH FFS 11/02/2020 RESCRIPTOR delavirdine mesylate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 brisdelle,paroxeti paroxetine mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne mesylate MDCH FFS BILL MDCH FFS 11/02/2020 CELONTIN methsuximide ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 222 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ALPHANATE antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human/von willebrand MDCH FFS BILL MDCH FFS factor,human 11/02/2020 RIXUBIS,BENEFI factor ix human recombinant CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- X MDCH FFS BILL MDCH FFS 11/02/2020 RIXUBIS,BENEFI factor ix human recombinant CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- X MDCH FFS BILL MDCH FFS 11/02/2020 zaleplon,sonata zaleplon CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 THROMBATE III antithrombin iii (human ADD UM: CUSTOM CARVE OUT- plasma derived) BILL MDCH FFS 11/02/2020 fluoxetine hcl fluoxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 nuvigil,armodafini armodafinil CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- l MDCH FFS BILL MDCH FFS 11/02/2020 nuvigil,armodafini armodafinil CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- l MDCH FFS BILL MDCH FFS 11/02/2020 nuvigil,armodafini armodafinil CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- l MDCH FFS BILL MDCH FFS 11/02/2020 CORIFACT factor xiii CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 INVIRASE saquinavir mesylate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 ALPHANATE antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human/von willebrand MDCH FFS BILL MDCH FFS factor,human 11/02/2020 phenytoin sodium phenytoin sodium ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 zyprexa,olanzapi olanzapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 223 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 PERSERIS risperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 XYNTHA antihemophilic factor (factor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SOLOFUSE viii) recomb,b-domain MDCH FFS BILL MDCH FFS deleted 11/02/2020 onfi,clobazam clobazam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 pristiq,desvenlafa desvenlafaxine succinate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xine succinate er MDCH FFS BILL MDCH FFS 11/02/2020 PERSERIS risperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 pristiq,desvenlafa desvenlafaxine succinate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xine succinate er MDCH FFS BILL MDCH FFS 11/02/2020 lamotrigine,lamict lamotrigine CHANGE UM: CUSTOM CARVE OUT- al,subvenite BILL MDCH FFS 11/02/2020 lamictal lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,lamotrigine er MDCH FFS BILL MDCH FFS 11/02/2020 depakote divalproex sodium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- sprinkle,divalproe MDCH FFS BILL MDCH FFS x sodium 11/02/2020 lamotrigine,lamict lamotrigine CHANGE UM: CUSTOM CARVE OUT- al,subvenite BILL MDCH FFS 11/02/2020 lamotrigine,lamict lamotrigine ADD UM: CUSTOM CARVE OUT- al BILL MDCH FFS 11/02/2020 lamotrigine,lamict lamotrigine ADD UM: CUSTOM CARVE OUT- al BILL MDCH FFS 11/02/2020 PEGASYS peginterferon alfa-2a CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 strattera,atomoxe atomoxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- tine hcl MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 224 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 strattera,atomoxe atomoxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- tine hcl MDCH FFS BILL MDCH FFS 11/02/2020 VIRACEPT nelfinavir mesylate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 LYRICA CR pregabalin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl cd,metadate MDCH FFS BILL MDCH FFS cd,methylphenida te hcl er (cd) 11/02/2020 LYRICA CR pregabalin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl cd,metadate MDCH FFS BILL MDCH FFS cd,methylphenida te hcl er (cd) 11/02/2020 LYRICA CR pregabalin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl cd,metadate MDCH FFS BILL MDCH FFS cd,methylphenida te hcl er (cd) 11/02/2020 FUZEON enfuvirtide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 FABRAZYME agalsidase beta CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 FEIBA VH anti-inhibitor coagulant CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- IMMUNO,FEIBA complex MDCH FFS BILL MDCH FFS NF 11/02/2020 ATRYN antithrombin iii, human CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 225 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 INLYTA axitinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 RUKOBIA fostemsavir tromethamine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 LATUDA lurasidone hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 LATUDA lurasidone hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 INLYTA axitinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ARCALYST rilonacept CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 dextroamphetami dextroamphetamine sulf- CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne-amphet saccharate/amphetamine MDCH FFS BILL MDCH FFS er,adderall xr sulf-aspartate 11/02/2020 COMETRIQ cabozantinib s-malate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 RIBATAB,RIBAP ribavirin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- AK,RIBASPHER MDCH FFS BILL MDCH FFS E RIBAPAK,MODE RIBA 11/02/2020 COMETRIQ cabozantinib s-malate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ribasphere,ribavir ribavirin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- in MDCH FFS BILL MDCH FFS 11/02/2020 COMETRIQ cabozantinib s-malate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 buprenorphine- buprenorphine hcl/naloxone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- naloxone,suboxo hcl MDCH FFS BILL MDCH FFS ne

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 226 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 FYCOMPA perampanel CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 buprenorphine- buprenorphine hcl/naloxone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- naloxone,suboxo hcl MDCH FFS BILL MDCH FFS ne 11/02/2020 FYCOMPA perampanel CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 FYCOMPA perampanel CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 effexor venlafaxine hcl ADD UM: CUSTOM CARVE OUT- xr,venlafaxine hcl BILL MDCH FFS er 11/02/2020 escitalopram escitalopram oxalate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- oxalate,lexapro MDCH FFS BILL MDCH FFS 11/02/2020 FYCOMPA perampanel CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 REXULTI brexpiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 effexor venlafaxine hcl ADD UM: CUSTOM CARVE OUT- xr,venlafaxine hcl BILL MDCH FFS er 11/02/2020 FYCOMPA perampanel CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 RIBATAB,RIBAP ribavirin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- AK,RIBASPHER MDCH FFS BILL MDCH FFS E RIBAPAK,MODE RIBA 11/02/2020 effexor venlafaxine hcl ADD UM: CUSTOM CARVE OUT- xr,venlafaxine hcl BILL MDCH FFS er

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 227 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 FYCOMPA perampanel CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 RAVICTI glycerol phenylbutyrate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 effexor,venlafaxin venlafaxine hcl ADD UM: CUSTOM CARVE OUT- e hcl BILL MDCH FFS 11/02/2020 STRIBILD elvitegravir/cobicistat/emtrici CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- tabine/tenofovir disoproxil MDCH FFS BILL MDCH FFS 11/02/2020 loxapine,loxitane loxapine succinate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 tegretol,epitol,car carbamazepine CHANGE UM: CUSTOM CARVE OUT- bamazepine BILL MDCH FFS 11/02/2020 loxapine,loxitane loxapine succinate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 effexor,venlafaxin venlafaxine hcl ADD UM: CUSTOM CARVE OUT- e hcl BILL MDCH FFS 11/02/2020 loxapine,loxitane loxapine succinate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 effexor,venlafaxin venlafaxine hcl ADD UM: CUSTOM CARVE OUT- e hcl BILL MDCH FFS 11/02/2020 ULTOMIRIS ravulizumab-cwvz CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ALUNBRIG brigatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 loxapine,loxitane loxapine succinate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 venlafaxine venlafaxine hcl ADD UM: CUSTOM CARVE OUT- hcl,effexor BILL MDCH FFS 11/02/2020 ALUNBRIG brigatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 228 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 venlafaxine venlafaxine hcl ADD UM: CUSTOM CARVE OUT- hcl,effexor BILL MDCH FFS 11/02/2020 kuvan,sapropteri sapropterin dihydrochloride CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- n dihydrochloride MDCH FFS BILL MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 norvir,ritonavir ritonavir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- er,concerta MDCH FFS BILL MDCH FFS 11/02/2020 escitalopram escitalopram oxalate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- oxalate,lexapro MDCH FFS BILL MDCH FFS 11/02/2020 COPIKTRA duvelisib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 COPIKTRA duvelisib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 EPIDIOLEX cannabidiol (cbd) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 focalin,dexmethyl dexmethylphenidate hcl CHANGE UM: CUSTOM CARVE OUT- phenidate hcl BILL MDCH FFS 11/02/2020 focalin,dexmethyl dexmethylphenidate hcl ADD UM: CUSTOM CARVE OUT- phenidate hcl BILL MDCH FFS 11/02/2020 focalin,dexmethyl dexmethylphenidate hcl ADD UM: CUSTOM CARVE OUT- phenidate hcl BILL MDCH FFS 11/02/2020 XOSPATA gilteritinib fumarate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 depacon,valproat valproic acid (as sodium ADD UM: CUSTOM CARVE OUT- e sodium salt) (valproate sodium) BILL MDCH FFS 11/02/2020 modafinil,provigil modafinil CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 229 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 modafinil,provigil modafinil CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 HEMOFIL M antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human MDCH FFS BILL MDCH FFS 11/02/2020 phenobarbital phenobarbital ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 phenobarbital phenobarbital ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 zarontin,ethosuxi ethosuximide CHANGE UM: CUSTOM CARVE OUT- mide BILL MDCH FFS 11/02/2020 phenobarbital phenobarbital CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 HEMOFIL M antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human MDCH FFS BILL MDCH FFS 11/02/2020 GAVRETO pralsetinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 xanax alprazolam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,alprazolam MDCH FFS BILL MDCH FFS er,alprazolam xr 11/02/2020 xanax alprazolam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,alprazolam MDCH FFS BILL MDCH FFS er,alprazolam xr 11/02/2020 LORBRENA lorlatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 LORBRENA lorlatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 copegus,ribavirin, ribavirin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ribasphere,moder MDCH FFS BILL MDCH FFS iba 11/02/2020 cyklokapron,trane tranexamic acid CHANGE UM: CUSTOM CARVE OUT- xamic acid BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 230 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 zarontin,ethosuxi ethosuximide CHANGE UM: CUSTOM CARVE OUT- mide BILL MDCH FFS 11/02/2020 chlordiazepoxide chlordiazepoxide hcl ADD UM: CUSTOM CARVE OUT- hcl,librium BILL MDCH FFS 11/02/2020 atripla,efavirenz- efavirenz/emtricitabine/tenof CHANGE UM: CUSTOM CARVE OUT- emtric-tenofov ovir disoproxil fumarate BILL MDCH FFS disop 11/02/2020 PREZISTA darunavir ethanolate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 xanax alprazolam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,alprazolam MDCH FFS BILL MDCH FFS er,alprazolam xr 11/02/2020 chlordiazepoxide chlordiazepoxide hcl ADD UM: CUSTOM CARVE OUT- hcl,librium BILL MDCH FFS 11/02/2020 chlordiazepoxide chlordiazepoxide hcl ADD UM: CUSTOM CARVE OUT- hcl,librium BILL MDCH FFS 11/02/2020 invega,paliperido paliperidone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne er MDCH FFS BILL MDCH FFS 11/02/2020 ILARIS canakinumab/pf CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 focalin dexmethylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,dexmethylphen MDCH FFS BILL MDCH FFS idate hcl er 11/02/2020 methylphenidate methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl cd,metadate MDCH FFS BILL MDCH FFS cd,methylphenida te hcl er (cd) 11/02/2020 methylphenidate methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl cd,metadate MDCH FFS BILL MDCH FFS cd,methylphenida te hcl er (cd)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 231 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 RISPERDAL risperidone microspheres CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- CONSTA MDCH FFS BILL MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl cd,metadate MDCH FFS BILL MDCH FFS cd,methylphenida te hcl er (cd) 11/02/2020 ritalin methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- la,methylphenidat MDCH FFS BILL MDCH FFS e la,methylphenidat e er (la) 11/02/2020 ritalin methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- la,methylphenidat MDCH FFS BILL MDCH FFS e la,methylphenidat e er (la) 11/02/2020 LATUDA lurasidone hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VIZIMPRO dacomitinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 fluphenazine hcl fluphenazine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 tarceva,erlotinib erlotinib hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 SAPHRIS asenapine maleate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 TASIGNA nilotinib hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 tarceva,erlotinib erlotinib hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 VIZIMPRO dacomitinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 232 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 VIZIMPRO dacomitinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 tarceva,erlotinib erlotinib hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 QUILLICHEW ER methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 rebetol,ribavirin,ri ribavirin CHANGE UM: CUSTOM CARVE OUT- basphere BILL MDCH FFS 11/02/2020 ziagen,abacavir abacavir sulfate CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 APTIOM eslicarbazepine acetate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 QUILLIVANT XR methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 abilify,aripiprazol aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- e MDCH FFS BILL MDCH FFS 11/02/2020 CYSTADANE betaine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 ALPROLIX factor ix recombinant, fc CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- fusion protein MDCH FFS BILL MDCH FFS 11/02/2020 VONVENDI von willebrand factor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- (recombinant) MDCH FFS BILL MDCH FFS 11/02/2020 buprenorphine buprenorphine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl,subutex MDCH FFS BILL MDCH FFS 11/02/2020 buprenorphine buprenorphine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl,subutex MDCH FFS BILL MDCH FFS 11/02/2020 temazepam,resto temazepam ADD UM: CUSTOM CARVE OUT- ril BILL MDCH FFS 11/02/2020 LEXIVA fosamprenavir calcium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 233 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ADYNOVATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, full length, peg MDCH FFS BILL MDCH FFS 11/02/2020 PIFELTRO doravirine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 HAEGARDA c1 esterase inhibitor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 temazepam,resto temazepam ADD UM: CUSTOM CARVE OUT- ril BILL MDCH FFS 11/02/2020 temazepam,resto temazepam ADD UM: CUSTOM CARVE OUT- ril BILL MDCH FFS 11/02/2020 VONVENDI von willebrand factor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- (recombinant) MDCH FFS BILL MDCH FFS 11/02/2020 lexiva,fosampren fosamprenavir calcium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- avir calcium MDCH FFS BILL MDCH FFS 11/02/2020 BRUKINSA zanubrutinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 IXINITY factor ix human CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, threonine 148 MDCH FFS BILL MDCH FFS 11/02/2020 KISQALI ribociclib succinate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 phenytek,phenyto phenytoin sodium extended CHANGE UM: CUSTOM CARVE OUT- in sodium BILL MDCH FFS extended 11/02/2020 KISQALI ribociclib succinate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 phenytek,phenyto phenytoin sodium extended ADD UM: CUSTOM CARVE OUT- in sodium BILL MDCH FFS extended 11/02/2020 silenor,doxepin doxepin hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 234 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ritalin,methylin,m methylphenidate hcl ADD UM: CUSTOM CARVE OUT- ethylphenidate BILL MDCH FFS hcl 11/02/2020 silenor,doxepin doxepin hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 VRAYLAR cariprazine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 PREZISTA darunavir ethanolate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 ICLUSIG ponatinib hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ICLUSIG ponatinib hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 phenobarbital phenobarbital ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 OLEPTRO ER trazodone hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 phenobarbital phenobarbital ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 epivir,lamivudine lamivudine CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 CABOMETYX cabozantinib s-malate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 CABOMETYX cabozantinib s-malate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 epivir,lamivudine lamivudine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 phenobarbital phenobarbital ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 phenobarbital phenobarbital ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 235 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 KISQALI ribociclib succinate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 KCENTRA human prothrombin complex CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- concentrate (pcc), 4-factor MDCH FFS BILL MDCH FFS 11/02/2020 TRIKAFTA elexacaftor/tezacaftor/ivacaft CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- or MDCH FFS BILL MDCH FFS 11/02/2020 CABOMETYX cabozantinib s-malate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 venlafaxine hcl er venlafaxine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 OLEPTRO ER trazodone hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 venlafaxine hcl er venlafaxine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 venlafaxine hcl er venlafaxine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lorazepam,ativan lorazepam ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 sodium sodium phenylbutyrate CHANGE UM: CUSTOM CARVE OUT- phenylbutyrate,b BILL MDCH FFS uphenyl 11/02/2020 buphenyl,sodium sodium phenylbutyrate CHANGE UM: CUSTOM CARVE OUT- phenylbutyrate BILL MDCH FFS 11/02/2020 lorazepam,ativan lorazepam CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 QUILLICHEW ER methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lorazepam,ativan lorazepam CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 SPRAVATO esketamine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 236 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 SPRAVATO esketamine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 VIVITROL naltrexone microspheres CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 videx didanosine ADD UM: CUSTOM CARVE OUT- ec,didanosine BILL MDCH FFS 11/02/2020 levetiracetam,kep levetiracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- pra MDCH FFS BILL MDCH FFS 11/02/2020 videx didanosine CHANGE UM: CUSTOM CARVE OUT- ec,didanosine BILL MDCH FFS 11/02/2020 videx didanosine ADD UM: CUSTOM CARVE OUT- ec,didanosine BILL MDCH FFS 11/02/2020 videx didanosine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ec,didanosine MDCH FFS BILL MDCH FFS 11/02/2020 PEGINTRON peginterferon alfa-2b ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 gleevec,imatinib imatinib mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- mesylate MDCH FFS BILL MDCH FFS 11/02/2020 PEGINTRON peginterferon alfa-2b ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 gleevec,imatinib imatinib mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- mesylate MDCH FFS BILL MDCH FFS 11/02/2020 zerit,stavudine stavudine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 precedex,dexme dexmedetomidine hcl in 0.9 CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- detomidine-0.9% % sodium chloride MDCH FFS BILL MDCH FFS nacl 11/02/2020 zerit,stavudine stavudine CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 zerit,stavudine stavudine CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 237 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 levetiracetam levetiracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- er,keppra MDCH FFS BILL MDCH FFS xr,roweepra xr 11/02/2020 zerit,stavudine stavudine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 precedex,dexme dexmedetomidine hcl in 0.9 CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- detomidine-0.9% % sodium chloride MDCH FFS BILL MDCH FFS nacl 11/02/2020 IXINITY factor ix human CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, threonine 148 MDCH FFS BILL MDCH FFS 11/02/2020 zerit,stavudine stavudine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 IXINITY factor ix human CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, threonine 148 MDCH FFS BILL MDCH FFS 11/02/2020 SPRAVATO esketamine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 ALECENSA alectinib hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 QUILLICHEW ER methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ZELBORAF vemurafenib ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 ALPROLIX factor ix recombinant, fc CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- fusion protein MDCH FFS BILL MDCH FFS 11/02/2020 quetiapine quetiapine fumarate CHANGE UM: CUSTOM CARVE OUT- fumarate,seroque BILL MDCH FFS l 11/02/2020 ALPROLIX factor ix recombinant, fc CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- fusion protein MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 238 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 quetiapine quetiapine fumarate ADD UM: CUSTOM CARVE OUT- fumarate,seroque BILL MDCH FFS l 11/02/2020 JORNAY PM methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ALPROLIX factor ix recombinant, fc CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- fusion protein MDCH FFS BILL MDCH FFS 11/02/2020 SPRYCEL dasatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ISENTRESS raltegravir potassium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 JORNAY PM methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ALPROLIX factor ix recombinant, fc CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- fusion protein MDCH FFS BILL MDCH FFS 11/02/2020 quetiapine quetiapine fumarate CHANGE UM: CUSTOM CARVE OUT- fumarate,seroque BILL MDCH FFS l 11/02/2020 SPRYCEL dasatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VITEKTA elvitegravir ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 quetiapine quetiapine fumarate ADD UM: CUSTOM CARVE OUT- fumarate,seroque BILL MDCH FFS l 11/02/2020 ARISTADA aripiprazole lauroxil CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ARISTADA aripiprazole lauroxil CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 temazepam,resto temazepam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ril MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 239 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 AMYTAL amobarbital sodium ADD UM: CUSTOM CARVE OUT- SODIUM BILL MDCH FFS 11/02/2020 ARISTADA aripiprazole lauroxil CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 JORNAY PM methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 JORNAY PM methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ACTHREL corticorelin ovine triflutate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 PEXEVA paroxetine mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 PEXEVA paroxetine mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 PEXEVA paroxetine mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 PEXEVA paroxetine mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 vandetanib,caprel vandetanib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- sa MDCH FFS BILL MDCH FFS 11/02/2020 vandetanib,caprel vandetanib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- sa MDCH FFS BILL MDCH FFS 11/02/2020 ZYPREXA olanzapine pamoate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- RELPREVV MDCH FFS BILL MDCH FFS 11/02/2020 ISENTRESS raltegravir potassium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ADZENYS XR- amphetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ODT MDCH FFS BILL MDCH FFS 11/02/2020 VITEKTA elvitegravir ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 240 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ADZENYS XR- amphetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ODT MDCH FFS BILL MDCH FFS 11/02/2020 ADZENYS XR- amphetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ODT MDCH FFS BILL MDCH FFS 11/02/2020 ELOCTATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, fc fusion MDCH FFS BILL MDCH FFS protein 11/02/2020 ritalin,methylin,m methylphenidate hcl CHANGE UM: CUSTOM CARVE OUT- ethylphenidate BILL MDCH FFS hcl 11/02/2020 GABACAINE gabapentin/lidocaine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ELOCTATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, fc fusion MDCH FFS BILL MDCH FFS protein 11/02/2020 TURALIO pexidartinib hydrochloride CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ELOCTATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, fc fusion MDCH FFS BILL MDCH FFS protein 11/02/2020 ritalin,methylin,m methylphenidate hcl ADD UM: CUSTOM CARVE OUT- ethylphenidate BILL MDCH FFS hcl 11/02/2020 ZYPREXA olanzapine pamoate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- RELPREVV MDCH FFS BILL MDCH FFS 11/02/2020 symbyax,olanzap olanzapine/fluoxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ine-fluoxetine hcl MDCH FFS BILL MDCH FFS 11/02/2020 symbyax,olanzap olanzapine/fluoxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ine-fluoxetine hcl MDCH FFS BILL MDCH FFS 11/02/2020 JORNAY PM methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 241 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ZYPREXA olanzapine pamoate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- RELPREVV MDCH FFS BILL MDCH FFS 11/02/2020 BOSULIF bosutinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 RIASTAP fibrinogen CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 focalin dexmethylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,dexmethylphen MDCH FFS BILL MDCH FFS idate hcl er 11/02/2020 topiramate,topira topiramate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- gen,topamax MDCH FFS BILL MDCH FFS 11/02/2020 topiramate,topira topiramate ADD UM: CUSTOM CARVE OUT- gen,topamax BILL MDCH FFS 11/02/2020 H.P. corticotropin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ACTHAR,ACTHA MDCH FFS BILL MDCH FFS R 11/02/2020 topiramate,topira topiramate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- gen,topamax MDCH FFS BILL MDCH FFS 11/02/2020 SYMPAZAN clobazam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ADZENYS XR- amphetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ODT MDCH FFS BILL MDCH FFS 11/02/2020 nortriptyline nortriptyline hcl ADD UM: CUSTOM CARVE OUT- hcl,pamelor BILL MDCH FFS 11/02/2020 SYMPAZAN clobazam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ADZENYS XR- amphetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ODT MDCH FFS BILL MDCH FFS 11/02/2020 ADZENYS XR- amphetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ODT MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 242 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 TRETTEN factor xiii a-subunit, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant MDCH FFS BILL MDCH FFS 11/02/2020 ziagen,abacavir abacavir sulfate CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 suboxone,bupren buprenorphine hcl/naloxone CHANGE UM: CUSTOM CARVE OUT- orphine-naloxone hcl BILL MDCH FFS 11/02/2020 suboxone,bupren buprenorphine hcl/naloxone CHANGE UM: CUSTOM CARVE OUT- orphine-naloxone hcl BILL MDCH FFS 11/02/2020 zonisamide,zone zonisamide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- gran MDCH FFS BILL MDCH FFS 11/02/2020 zonisamide,zone zonisamide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- gran MDCH FFS BILL MDCH FFS 11/02/2020 SYMPAZAN clobazam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 topiramate,topam topiramate ADD UM: CUSTOM CARVE OUT- ax BILL MDCH FFS 11/02/2020 INTELENCE etravirine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 KALYDECO ivacaftor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 topamax,topiram topiramate ADD UM: CUSTOM CARVE OUT- ate,topiragen BILL MDCH FFS 11/02/2020 topiramate,topam topiramate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ax MDCH FFS BILL MDCH FFS 11/02/2020 amitriptyline hcl amitriptyline hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 CARBAGLU carglumic acid CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 amitriptyline amitriptyline hcl CHANGE UM: CUSTOM CARVE OUT- hcl,elavil BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 243 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 amitriptyline hcl amitriptyline hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 VIEKIRA PAK ombitasvir/paritaprevir/ritona CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- vir/dasabuvir sodium MDCH FFS BILL MDCH FFS 11/02/2020 amitriptyline hcl amitriptyline hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 amitriptyline hcl amitriptyline hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 amitriptyline hcl amitriptyline hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VOTRIENT pazopanib hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 abilify,aripiprazol aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- e MDCH FFS BILL MDCH FFS 11/02/2020 ALPHANINE SD factor ix CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 tegretol carbamazepine ADD UM: CUSTOM CARVE OUT- xr,carbamazepin BILL MDCH FFS e er 11/02/2020 ritalin methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- la,methylphenidat MDCH FFS BILL MDCH FFS e la,methylphenidat e er (la) 11/02/2020 tegretol carbamazepine ADD UM: CUSTOM CARVE OUT- xr,carbamazepin BILL MDCH FFS e xr,carbamazepin e er 11/02/2020 KCENTRA human prothrombin complex CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- concentrate (pcc), 4-factor MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 244 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 tegretol carbamazepine ADD UM: CUSTOM CARVE OUT- xr,carbamazepin BILL MDCH FFS e xr,carbamazepin e er 11/02/2020 lyrica,pregabalin pregabalin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 fluvoxamine fluvoxamine maleate ADD UM: CUSTOM CARVE OUT- maleate BILL MDCH FFS 11/02/2020 fluvoxamine fluvoxamine maleate ADD UM: CUSTOM CARVE OUT- maleate BILL MDCH FFS 11/02/2020 NUPLAZID pimavanserin tartrate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 fluvoxamine fluvoxamine maleate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- maleate MDCH FFS BILL MDCH FFS 11/02/2020 tofranil,imipramin imipramine hcl CHANGE UM: CUSTOM CARVE OUT- e hcl BILL MDCH FFS 11/02/2020 carbamazepine carbamazepine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 tofranil,imipramin imipramine hcl ADD UM: CUSTOM CARVE OUT- e hcl BILL MDCH FFS 11/02/2020 carbamazepine carbamazepine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 ammonul,sodium sodium benzoate/sodium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- phenylacet-sod phenylacetate MDCH FFS BILL MDCH FFS benzoate 11/02/2020 tofranil,imipramin imipramine hcl CHANGE UM: CUSTOM CARVE OUT- e hcl BILL MDCH FFS 11/02/2020 DRIZALMA duloxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SPRINKLE MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 245 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 lamictal odt lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- (green),lamotrigin MDCH FFS BILL MDCH FFS e odt (green) 11/02/2020 imipramine imipramine pamoate ADD UM: CUSTOM CARVE OUT- pamoate,tofranil- BILL MDCH FFS pm 11/02/2020 citalopram citalopram hydrobromide ADD UM: CUSTOM CARVE OUT- hbr,celexa BILL MDCH FFS 11/02/2020 imipramine imipramine pamoate ADD UM: CUSTOM CARVE OUT- pamoate,tofranil- BILL MDCH FFS pm 11/02/2020 citalopram citalopram hydrobromide CHANGE UM: CUSTOM CARVE OUT- hbr,celexa BILL MDCH FFS 11/02/2020 dopram,doxapra doxapram hcl CHANGE UM: CUSTOM CARVE OUT- m hcl BILL MDCH FFS 11/02/2020 citalopram citalopram hydrobromide ADD UM: CUSTOM CARVE OUT- hbr,citalopram,cel BILL MDCH FFS exa 11/02/2020 remeron,mirtazap mirtazapine CHANGE UM: CUSTOM CARVE OUT- ine BILL MDCH FFS 11/02/2020 citalopram citalopram hydrobromide ADD UM: CUSTOM CARVE OUT- hbr,celexa BILL MDCH FFS 11/02/2020 APTIOM eslicarbazepine acetate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 DRIZALMA duloxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SPRINKLE MDCH FFS BILL MDCH FFS 11/02/2020 DRIZALMA duloxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SPRINKLE MDCH FFS BILL MDCH FFS 11/02/2020 remeron,mirtazap mirtazapine CHANGE UM: CUSTOM CARVE OUT- ine BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 246 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 OLYSIO simeprevir sodium ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 enulose,lactulose lactulose CHANGE UM: CUSTOM CARVE OUT- ,generlac BILL MDCH FFS 11/02/2020 NUPLAZID pimavanserin tartrate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 prozac fluoxetine hcl ADD UM: CUSTOM CARVE OUT- weekly,fluoxetine BILL MDCH FFS dr 11/02/2020 BOSULIF bosutinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 nortriptyline nortriptyline hcl CHANGE UM: CUSTOM CARVE OUT- hcl,pamelor BILL MDCH FFS 11/02/2020 VRAYLAR cariprazine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 INVEGA paliperidone palmitate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SUSTENNA MDCH FFS BILL MDCH FFS 11/02/2020 nortriptyline nortriptyline hcl ADD UM: CUSTOM CARVE OUT- hcl,pamelor BILL MDCH FFS 11/02/2020 levetiracetam levetiracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- er,keppra MDCH FFS BILL MDCH FFS xr,roweepra xr 11/02/2020 INVEGA paliperidone palmitate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SUSTENNA MDCH FFS BILL MDCH FFS 11/02/2020 nortriptyline nortriptyline hcl CHANGE UM: CUSTOM CARVE OUT- hcl,pamelor BILL MDCH FFS 11/02/2020 INVEGA paliperidone palmitate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SUSTENNA MDCH FFS BILL MDCH FFS 11/02/2020 nortriptyline nortriptyline hcl ADD UM: CUSTOM CARVE OUT- hcl,pamelor BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 247 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 xanax alprazolam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,alprazolam MDCH FFS BILL MDCH FFS er,alprazolam xr 11/02/2020 INVEGA paliperidone palmitate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SUSTENNA MDCH FFS BILL MDCH FFS 11/02/2020 ZEPATIER elbasvir/grazoprevir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 INVEGA paliperidone palmitate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SUSTENNA MDCH FFS BILL MDCH FFS 11/02/2020 ALIQOPA copanlisib di-hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ZUBSOLV buprenorphine hcl/naloxone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 EPIDUO FORTE adapalene/benzoyl peroxide ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 MYALEPT metreleptin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 neurontin,gabape gabapentin ADD UM: CUSTOM CARVE OUT- ntin BILL MDCH FFS 11/02/2020 doxepin hcl doxepin hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 doxepin hcl doxepin hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 doxepin hcl doxepin hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 paxil,paroxetine paroxetine hcl ADD UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 ritalin methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- la,methylphenidat MDCH FFS BILL MDCH FFS e la

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 248 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 paxil,paroxetine paroxetine hcl CHANGE UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 ALBUMINEX albumin human-kjda CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 amoxapine amoxapine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 ALBUMINEX albumin human-kjda CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 epclusa,sofosbuv sofosbuvir/velpatasvir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ir-velpatasvir MDCH FFS BILL MDCH FFS 11/02/2020 VRAYLAR cariprazine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 paxil,paroxetine paroxetine hcl CHANGE UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 clozapine,clozaril clozapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VRAYLAR cariprazine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 paxil,paroxetine paroxetine hcl ADD UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 VRAYLAR cariprazine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 paxil,paroxetine paroxetine hcl CHANGE UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 doxepin hcl doxepin hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 doxepin hcl doxepin hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 doxepin hcl doxepin hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 249 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 SECONAL secobarbital sodium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SODIUM MDCH FFS BILL MDCH FFS 11/02/2020 imipramine imipramine pamoate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- pamoate,tofranil- MDCH FFS BILL MDCH FFS pm 11/02/2020 buspirone buspirone hcl ADD UM: CUSTOM CARVE OUT- hcl,vanspar BILL MDCH FFS 11/02/2020 imipramine imipramine pamoate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- pamoate,tofranil- MDCH FFS BILL MDCH FFS pm 11/02/2020 SUBLOCADE buprenorphine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 sarafem,fluoxetin fluoxetine hcl CHANGE UM: CUSTOM CARVE OUT- e hcl,rapiflux BILL MDCH FFS 11/02/2020 fluoxetine fluoxetine hcl ADD UM: CUSTOM CARVE OUT- hcl,prozac BILL MDCH FFS 11/02/2020 fluoxetine fluoxetine hcl ADD UM: CUSTOM CARVE OUT- hcl,prozac BILL MDCH FFS 11/02/2020 trizivir,abacavir- abacavir ADD UM: CUSTOM CARVE OUT- lamivudine- sulfate/lamivudine/zidovudin BILL MDCH FFS zidovudine e 11/02/2020 fluoxetine fluoxetine hcl CHANGE UM: CUSTOM CARVE OUT- hcl,sarafem BILL MDCH FFS 11/02/2020 INVEGA TRINZA paliperidone palmitate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 amoxapine amoxapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 fluoxetine fluoxetine hcl CHANGE UM: CUSTOM CARVE OUT- hcl,selfemra,proz BILL MDCH FFS ac

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 250 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 lexapro,escitalopr escitalopram oxalate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- am oxalate MDCH FFS BILL MDCH FFS 11/02/2020 SUBLOCADE buprenorphine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 fluoxetine fluoxetine hcl CHANGE UM: CUSTOM CARVE OUT- hcl,selfemra,proz BILL MDCH FFS ac 11/02/2020 amoxapine amoxapine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 amoxapine amoxapine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 protriptyline protriptyline hcl ADD UM: CUSTOM CARVE OUT- hcl,vivactil BILL MDCH FFS 11/02/2020 protriptyline protriptyline hcl ADD UM: CUSTOM CARVE OUT- hcl,vivactil BILL MDCH FFS 11/02/2020 DRIZALMA duloxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SPRINKLE MDCH FFS BILL MDCH FFS 11/02/2020 NUWIQ antihemophilic factor viii rec CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hek cell, b-domain deleted MDCH FFS BILL MDCH FFS 11/02/2020 norpramin,desipr desipramine hcl CHANGE UM: CUSTOM CARVE OUT- amine hcl BILL MDCH FFS 11/02/2020 niravam,alprazola alprazolam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- m odt MDCH FFS BILL MDCH FFS 11/02/2020 norpramin,desipr desipramine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- amine hcl MDCH FFS BILL MDCH FFS 11/02/2020 niravam,alprazola alprazolam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- m odt MDCH FFS BILL MDCH FFS 11/02/2020 norpramin,desipr desipramine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- amine hcl MDCH FFS BILL MDCH FFS 11/02/2020 phenobarbital phenobarbital ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 251 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 sustiva,efavirenz efavirenz ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 norpramin,desipr desipramine hcl ADD UM: CUSTOM CARVE OUT- amine hcl BILL MDCH FFS 11/02/2020 methamphetamin methamphetamine hcl ADD UM: CUSTOM CARVE OUT- e hcl,desoxyn BILL MDCH FFS 11/02/2020 norpramin,desipr desipramine hcl ADD UM: CUSTOM CARVE OUT- amine hcl BILL MDCH FFS 11/02/2020 sustiva,efavirenz efavirenz CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 EQUETRO carbamazepine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lamivudine- lamivudine/zidovudine ADD UM: CUSTOM CARVE OUT- zidovudine,combi BILL MDCH FFS vir 11/02/2020 zavesca,miglusta miglustat CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- t MDCH FFS BILL MDCH FFS 11/02/2020 lithium carbonate lithium carbonate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 VELCADE bortezomib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lithium carbonate lithium carbonate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 DIACOMIT stiripentol CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lithium carbonate lithium carbonate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl CHANGE UM: CUSTOM CARVE OUT- er,concerta BILL MDCH FFS 11/02/2020 felbatol,felbamate felbamate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 252 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 norpramin,desipr desipramine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- amine hcl MDCH FFS BILL MDCH FFS 11/02/2020 VIMPAT lacosamide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VIMPAT lacosamide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 felbatol,felbamate felbamate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl CHANGE UM: CUSTOM CARVE OUT- er,concerta BILL MDCH FFS 11/02/2020 felbatol,felbamate felbamate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 DIACOMIT stiripentol CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 NUWIQ antihemophilic factor viii rec CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hek cell, b-domain deleted MDCH FFS BILL MDCH FFS 11/02/2020 ZUBSOLV buprenorphine hcl/naloxone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 VERSACLOZ clozapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 DIACOMIT stiripentol CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 NUWIQ antihemophilic factor viii rec CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hek cell, b-domain deleted MDCH FFS BILL MDCH FFS 11/02/2020 ZUBSOLV buprenorphine hcl/naloxone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 DIACOMIT stiripentol CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 NUWIQ antihemophilic factor viii rec CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hek cell, b-domain deleted MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 253 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 doxepin hcl doxepin hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 VIMPAT lacosamide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VIMPAT lacosamide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 meprobamate meprobamate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 meprobamate meprobamate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 EQUETRO carbamazepine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 neurontin,gabape gabapentin ADD UM: CUSTOM CARVE OUT- ntin BILL MDCH FFS 11/02/2020 REXULTI brexpiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- dimesylate MDCH FFS BILL MDCH FFS 11/02/2020 venlafaxine hcl er venlafaxine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 epivir,lamivudine lamivudine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VIMPAT lacosamide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ALUNBRIG brigatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 klonopin,clonaze clonazepam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- pam MDCH FFS BILL MDCH FFS 11/02/2020 klonopin,clonaze clonazepam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- pam MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 254 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ALUNBRIG brigatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 RYDAPT midostaurin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 clozapine clozapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- odt,fazaclo MDCH FFS BILL MDCH FFS 11/02/2020 ABILIFY aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MAINTENA MDCH FFS BILL MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- dimesylate MDCH FFS BILL MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ABILIFY aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MAINTENA MDCH FFS BILL MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 levetiracetam,kep levetiracetam CHANGE UM: CUSTOM CARVE OUT- pra,roweepra BILL MDCH FFS 11/02/2020 reyataz,atazanavi atazanavir sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- r sulfate MDCH FFS BILL MDCH FFS 11/02/2020 reyataz,atazanavi atazanavir sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- r sulfate MDCH FFS BILL MDCH FFS 11/02/2020 trimipramine trimipramine maleate ADD UM: CUSTOM CARVE OUT- maleate,surmontil BILL MDCH FFS 11/02/2020 trimipramine trimipramine maleate ADD UM: CUSTOM CARVE OUT- maleate,surmontil BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 255 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 NERLYNX neratinib maleate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 trimipramine trimipramine maleate ADD UM: CUSTOM CARVE OUT- maleate,surmontil BILL MDCH FFS 11/02/2020 fluphenazine hcl fluphenazine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 klonopin,clonaze clonazepam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- pam MDCH FFS BILL MDCH FFS 11/02/2020 klonopin,clonaze clonazepam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- pam MDCH FFS BILL MDCH FFS 11/02/2020 klonopin,clonaze clonazepam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- pam MDCH FFS BILL MDCH FFS 11/02/2020 budeprion bupropion hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xl,wellbutrin MDCH FFS BILL MDCH FFS xl,bupropion xl 11/02/2020 remeron,mirtazap mirtazapine ADD UM: CUSTOM CARVE OUT- ine BILL MDCH FFS 11/02/2020 levetiracetam,kep levetiracetam CHANGE UM: CUSTOM CARVE OUT- pra,roweepra BILL MDCH FFS 11/02/2020 levetiracetam,kep levetiracetam ADD UM: CUSTOM CARVE OUT- pra BILL MDCH FFS 11/02/2020 niravam,alprazola alprazolam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- m odt MDCH FFS BILL MDCH FFS 11/02/2020 niravam,alprazola alprazolam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- m odt MDCH FFS BILL MDCH FFS 11/02/2020 budeprion bupropion hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xl,bupropion MDCH FFS BILL MDCH FFS xl,wellbutrin xl 11/02/2020 NOVOEIGHT antihemophilic factor viii CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, b-domain MDCH FFS BILL MDCH FFS truncated

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 256 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 IXINITY factor ix human CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, threonine 148 MDCH FFS BILL MDCH FFS 11/02/2020 phenytoin phenytoin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 NOVOEIGHT antihemophilic factor viii CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, b-domain MDCH FFS BILL MDCH FFS truncated 11/02/2020 NOVOEIGHT antihemophilic factor viii CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, b-domain MDCH FFS BILL MDCH FFS truncated 11/02/2020 NOVOEIGHT antihemophilic factor viii CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, b-domain MDCH FFS BILL MDCH FFS truncated 11/02/2020 NOVOEIGHT antihemophilic factor viii CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, b-domain MDCH FFS BILL MDCH FFS truncated 11/02/2020 NOVOEIGHT antihemophilic factor viii CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, b-domain MDCH FFS BILL MDCH FFS truncated 11/02/2020 bortezomib bortezomib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 IXINITY factor ix human CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, threonine 148 MDCH FFS BILL MDCH FFS 11/02/2020 escitalopram escitalopram oxalate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- oxalate,lexapro MDCH FFS BILL MDCH FFS 11/02/2020 ISENTRESS raltegravir potassium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lorazepam lorazepam CHANGE UM: CUSTOM CARVE OUT- intensol,lorazepa BILL MDCH FFS m 11/02/2020 lamotrigine lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- odt,lamictal odt MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 257 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ZENZEDI dextroamphetamine sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 zonisamide,zone zonisamide ADD UM: CUSTOM CARVE OUT- gran BILL MDCH FFS 11/02/2020 kuvan,sapropteri sapropterin dihydrochloride CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- n dihydrochloride MDCH FFS BILL MDCH FFS 11/02/2020 lunesta,eszopiclo eszopiclone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne MDCH FFS BILL MDCH FFS 11/02/2020 lunesta,eszopiclo eszopiclone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne MDCH FFS BILL MDCH FFS 11/02/2020 VOSEVI sofosbuvir/velpatasvir/voxila CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- previr MDCH FFS BILL MDCH FFS 11/02/2020 lunesta,eszopiclo eszopiclone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne MDCH FFS BILL MDCH FFS 11/02/2020 ZENZEDI dextroamphetamine sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 KOATE- antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- DVI,KOATE human MDCH FFS BILL MDCH FFS 11/02/2020 HELIXATE antihemophilic factor viii, ADD UM: CUSTOM CARVE OUT- FS,RECOMBINA human recombinant BILL MDCH FFS TE 11/02/2020 HELIXATE antihemophilic factor viii, ADD UM: CUSTOM CARVE OUT- FS,RECOMBINA human recombinant BILL MDCH FFS TE 11/02/2020 MONOCLATE- antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- P,KOATE- human MDCH FFS BILL MDCH FFS DVI,KOATE 11/02/2020 methylphenidate methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl,methylin MDCH FFS BILL MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl,methylin MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 258 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 methylin,methylp methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- henidate hcl MDCH FFS BILL MDCH FFS 11/02/2020 methylin,methylp methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- henidate hcl MDCH FFS BILL MDCH FFS 11/02/2020 methylin,methylp methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- henidate hcl MDCH FFS BILL MDCH FFS 11/02/2020 carbamazepine carbamazepine CHANGE UM: CUSTOM CARVE OUT- er,carbatrol BILL MDCH FFS 11/02/2020 ATRYN antithrombin iii, human CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant MDCH FFS BILL MDCH FFS 11/02/2020 carbamazepine carbamazepine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- er,carbatrol MDCH FFS BILL MDCH FFS 11/02/2020 carbamazepine carbamazepine CHANGE UM: CUSTOM CARVE OUT- er,carbatrol BILL MDCH FFS 11/02/2020 KOGENATE antihemophilic factor, hum ADD UM: CUSTOM CARVE OUT- FS,HELIXATE rec,antihemophilic factor viii, BILL MDCH FFS FS,RECOMBINA human recombinant TE 11/02/2020 risperidone,risper risperidone CHANGE UM: CUSTOM CARVE OUT- dal BILL MDCH FFS 11/02/2020 zyprexa olanzapine ADD UM: CUSTOM CARVE OUT- zydis,olanzapine BILL MDCH FFS odt 11/02/2020 VIIBRYD vilazodone hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 retrovir,zidovudin zidovudine ADD UM: CUSTOM CARVE OUT- e BILL MDCH FFS 11/02/2020 lamictal odt lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- (orange),lamotrigi MDCH FFS BILL MDCH FFS ne odt (orange)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 259 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 KOGENATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- FS,HELIXATE recomb,full length (alb- MDCH FFS BILL MDCH FFS FS,ADVATE free),antihemophilic factor UH,ADVATE,KO (fviii) recombinant,full length VALTRY 11/02/2020 quetiapine quetiapine fumarate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- fumarate,seroque MDCH FFS BILL MDCH FFS l 11/02/2020 zyprexa olanzapine CHANGE UM: CUSTOM CARVE OUT- zydis,olanzapine BILL MDCH FFS odt 11/02/2020 mirtazapine mirtazapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lamictal odt lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- (blue),lamotrigine MDCH FFS BILL MDCH FFS odt (blue) 11/02/2020 PEGASYS peginterferon alfa-2a CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- PROCLICK MDCH FFS BILL MDCH FFS 11/02/2020 RUBRACA rucaparib camsylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 KOATE- antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- DVI,KOATE human MDCH FFS BILL MDCH FFS 11/02/2020 RUBRACA rucaparib camsylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 IXINITY factor ix human CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, threonine 148 MDCH FFS BILL MDCH FFS 11/02/2020 PROFILNINE factor ix complex CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SD,PROFILNINE human,factor ix complex, MDCH FFS BILL MDCH FFS prothrombin cplx conc(pcc) no.4, 3-factor

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 260 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 BIKTARVY bictegravir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- sodium/emtricitabine/tenofov MDCH FFS BILL MDCH FFS ir alafenamide fumar 11/02/2020 KALYDECO ivacaftor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl ADD UM: CUSTOM CARVE OUT- er,concerta BILL MDCH FFS 11/02/2020 KALETRA lopinavir/ritonavir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 CINRYZE c1 esterase inhibitor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 TAFINLAR dabrafenib mesylate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 GALAFOLD migalastat hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 MEKINIST trametinib dimethyl sulfoxide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 PROFILNINE factor ix complex ADD UM: CUSTOM CARVE OUT- SD,PROFILNINE human,factor ix complex, BILL MDCH FFS prothrombin cplx conc(pcc) no.4, 3-factor 11/02/2020 MEKINIST trametinib dimethyl sulfoxide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 TAFINLAR dabrafenib mesylate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 CALQUENCE acalabrutinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 PROFILNINE factor ix complex CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- SD,PROFILNINE human,factor ix complex, MDCH FFS BILL MDCH FFS prothrombin cplx conc(pcc) no.4, 3-factor

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 261 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 SAPHRIS asenapine maleate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 orfadin,nitisinone nitisinone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 REXULTI brexpiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 cerebyx,fospheny fosphenytoin sodium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- toin sodium MDCH FFS BILL MDCH FFS 11/02/2020 zoloft,sertraline sertraline hcl CHANGE UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 zoloft,sertraline sertraline hcl CHANGE UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 zoloft,sertraline sertraline hcl CHANGE UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 zoloft,sertraline sertraline hcl CHANGE UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 paxil paroxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- cr,paroxetine MDCH FFS BILL MDCH FFS er,paroxetine hcl,paroxetine cr 11/02/2020 valproic acid valproic acid (as sodium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- salt) (valproate sodium) MDCH FFS BILL MDCH FFS 11/02/2020 LENVIMA lenvatinib mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lamictal lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- (blue),lamotrigine MDCH FFS BILL MDCH FFS ,lamotrigine (blue),subvenite (blue)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 262 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 paxil paroxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- cr,paroxetine MDCH FFS BILL MDCH FFS er,paroxetine hcl,paroxetine cr 11/02/2020 paxil paroxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- cr,paroxetine MDCH FFS BILL MDCH FFS er,paroxetine cr,paroxetine hcl 11/02/2020 orfadin,nitisinone nitisinone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 orfadin,nitisinone nitisinone CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 cerebyx,fospheny fosphenytoin sodium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- toin sodium MDCH FFS BILL MDCH FFS 11/02/2020 REXULTI brexpiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lyrica,pregabalin pregabalin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 naltrexone naltrexone hcl ADD UM: CUSTOM CARVE OUT- hcl,depade,revia BILL MDCH FFS 11/02/2020 adzenys amphetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- er,amphetamine MDCH FFS BILL MDCH FFS 11/02/2020 LITHOSTAT acetohydroxamic acid ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 methylphenidate methylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- er,relexxii MDCH FFS BILL MDCH FFS 11/02/2020 aminocaproic aminocaproic acid ADD UM: CUSTOM CARVE OUT- acid BILL MDCH FFS 11/02/2020 ADVATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant,full length MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 263 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 KYPROLIS carfilzomib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 budeprion bupropion hcl ADD UM: CUSTOM CARVE OUT- sr,wellbutrin BILL MDCH FFS sr,bupropion hcl sr 11/02/2020 ELELYSO taliglucerase alfa CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 budeprion bupropion hcl ADD UM: CUSTOM CARVE OUT- sr,wellbutrin BILL MDCH FFS sr,bupropion hcl sr 11/02/2020 bupropion bupropion hcl ADD UM: CUSTOM CARVE OUT- hcl,wellbutrin BILL MDCH FFS 11/02/2020 bupropion bupropion hcl ADD UM: CUSTOM CARVE OUT- hcl,wellbutrin BILL MDCH FFS 11/02/2020 FIBRYGA fibrinogen CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 quetiapine quetiapine fumarate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- fumarate,seroque MDCH FFS BILL MDCH FFS l 11/02/2020 SELZENTRY maraviroc CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 SELZENTRY maraviroc CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 BERINERT c1 esterase inhibitor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 PEGINTRON peginterferon alfa-2b ADD UM: CUSTOM CARVE OUT- REDIPEN BILL MDCH FFS 11/02/2020 PEGINTRON peginterferon alfa-2b ADD UM: CUSTOM CARVE OUT- REDIPEN BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 264 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 lamictal lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- (orange),lamotrigi MDCH FFS BILL MDCH FFS ne,lamotrigine (orange),subvenit e (orange) 11/02/2020 PEGINTRON peginterferon alfa-2b ADD UM: CUSTOM CARVE OUT- REDIPEN BILL MDCH FFS 11/02/2020 PEGINTRON peginterferon alfa-2b ADD UM: CUSTOM CARVE OUT- REDIPEN BILL MDCH FFS 11/02/2020 MEKTOVI binimetinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lamictal lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- (green),lamotrigin MDCH FFS BILL MDCH FFS e,lamotrigine (green),subvenite (green) 11/02/2020 AFSTYLA antihemophilic factor viii CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recomb,single-chn,b-dom MDCH FFS BILL MDCH FFS truncated 11/02/2020 VYVANSE lisdexamfetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- dimesylate MDCH FFS BILL MDCH FFS 11/02/2020 lyrica,pregabalin pregabalin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 AFSTYLA antihemophilic factor viii CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recomb,single-chn,b-dom MDCH FFS BILL MDCH FFS truncated 11/02/2020 AFSTYLA antihemophilic factor viii CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recomb,single-chn,b-dom MDCH FFS BILL MDCH FFS truncated 11/02/2020 lamictal lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- odt,lamotrigine MDCH FFS BILL MDCH FFS odt

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 265 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 aminocaproic aminocaproic acid ADD UM: CUSTOM CARVE OUT- acid,amicar BILL MDCH FFS 11/02/2020 levetiracetam levetiracetam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- dimesylate MDCH FFS BILL MDCH FFS 11/02/2020 trazodone trazodone hcl ADD UM: CUSTOM CARVE OUT- hcl,desyrel BILL MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- dimesylate MDCH FFS BILL MDCH FFS 11/02/2020 trazodone trazodone hcl ADD UM: CUSTOM CARVE OUT- hcl,desyrel BILL MDCH FFS 11/02/2020 lyrica,pregabalin pregabalin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 diazepam,diastat diazepam CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 trazodone hcl trazodone hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 GILOTRIF afatinib dimaleate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 trazodone hcl trazodone hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 GILOTRIF afatinib dimaleate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 GILOTRIF afatinib dimaleate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 khedezla,desvenl desvenlafaxine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- afaxine er MDCH FFS BILL MDCH FFS 11/02/2020 lamictal lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,lamotrigine er MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 266 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 khedezla,desvenl desvenlafaxine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- afaxine er MDCH FFS BILL MDCH FFS 11/02/2020 HUMATE-P antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human/von willebrand MDCH FFS BILL MDCH FFS factor,human 11/02/2020 abilify aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- discmelt,aripipraz MDCH FFS BILL MDCH FFS ole odt 11/02/2020 carnitor levocarnitine CHANGE UM: CUSTOM CARVE OUT- sf,levocarnitine sf BILL MDCH FFS 11/02/2020 clozapine,clozaril clozapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 clozaril,clozapine clozapine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 abilify aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- discmelt,aripipraz MDCH FFS BILL MDCH FFS ole odt 11/02/2020 valproic acid valproic acid (as sodium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- salt) (valproate sodium) MDCH FFS BILL MDCH FFS 11/02/2020 VITRAKVI larotrectinib sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 LATUDA lurasidone hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 FYCOMPA perampanel CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 clozaril,clozapine clozapine CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 zyprexa olanzapine ADD UM: CUSTOM CARVE OUT- zydis,olanzapine BILL MDCH FFS odt

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 267 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 olanzapine olanzapine CHANGE UM: CUSTOM CARVE OUT- odt,zyprexa zydis BILL MDCH FFS 11/02/2020 moban,molindon molindone hcl ADD UM: CUSTOM CARVE OUT- e hcl BILL MDCH FFS 11/02/2020 REXULTI brexpiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 REXULTI brexpiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 amicar,aminocap aminocaproic acid ADD UM: CUSTOM CARVE OUT- roic acid BILL MDCH FFS 11/02/2020 seroquel quetiapine fumarate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,quetiapine MDCH FFS BILL MDCH FFS fumarate er 11/02/2020 pristiq,desvenlafa desvenlafaxine succinate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xine succinate er MDCH FFS BILL MDCH FFS 11/02/2020 SEROQUEL XR quetiapine fumarate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ARISTADA aripiprazole lauroxil, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- INITIO submicronized MDCH FFS BILL MDCH FFS 11/02/2020 risperidone,risper risperidone ADD UM: CUSTOM CARVE OUT- dal BILL MDCH FFS 11/02/2020 diazepam diazepam CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 SUTENT sunitinib malate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ZYDELIG idelalisib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 PREZCOBIX darunavir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ethanolate/cobicistat MDCH FFS BILL MDCH FFS 11/02/2020 ZYDELIG idelalisib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 268 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 IMBRUVICA ibrutinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lyrica,pregabalin pregabalin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lyrica,pregabalin pregabalin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lyrica,pregabalin pregabalin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 moban,molindon molindone hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- e hcl MDCH FFS BILL MDCH FFS 11/02/2020 VITRAKVI larotrectinib sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 lyrica,pregabalin pregabalin CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VITRAKVI larotrectinib sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 tranexamic tranexamic acid CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- acid,lysteda MDCH FFS BILL MDCH FFS 11/02/2020 diazepam,diastat diazepam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- acudial MDCH FFS BILL MDCH FFS 11/02/2020 INVIRASE saquinavir mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 moban,molindon molindone hcl ADD UM: CUSTOM CARVE OUT- e hcl BILL MDCH FFS 11/02/2020 diazepam,diastat diazepam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- acudial MDCH FFS BILL MDCH FFS 11/02/2020 zyprexa,olanzapi olanzapine ADD UM: CUSTOM CARVE OUT- ne BILL MDCH FFS 11/02/2020 zyprexa,olanzapi olanzapine ADD UM: CUSTOM CARVE OUT- ne BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 269 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 zyprexa,olanzapi olanzapine CHANGE UM: CUSTOM CARVE OUT- ne BILL MDCH FFS 11/02/2020 levetiracetam- levetiracetam in sodium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- nacl chloride, iso-osmotic MDCH FFS BILL MDCH FFS 11/02/2020 levetiracetam- levetiracetam in sodium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- nacl chloride, iso-osmotic MDCH FFS BILL MDCH FFS 11/02/2020 FETZIMA levomilnacipran hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 levetiracetam- levetiracetam in sodium CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- nacl chloride, iso-osmotic MDCH FFS BILL MDCH FFS 11/02/2020 FETZIMA levomilnacipran hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 geodon,ziprasido ziprasidone mesylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ne mesylate MDCH FFS BILL MDCH FFS 11/02/2020 NEXAVAR sorafenib tosylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 NAYZILAM midazolam CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 zyprexa,olanzapi olanzapine ADD UM: CUSTOM CARVE OUT- ne BILL MDCH FFS 11/02/2020 DILANTIN phenytoin sodium extended CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 zyprexa,olanzapi olanzapine CHANGE UM: CUSTOM CARVE OUT- ne BILL MDCH FFS 11/02/2020 zyprexa,olanzapi olanzapine CHANGE UM: CUSTOM CARVE OUT- ne BILL MDCH FFS 11/02/2020 dilantin,phenytoin phenytoin sodium extended CHANGE UM: CUSTOM CARVE OUT- sodium extended BILL MDCH FFS 11/02/2020 desvenlafaxine er desvenlafaxine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 270 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 PREZISTA darunavir ethanolate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 IMBRUVICA ibrutinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ADYNOVATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, full length, peg MDCH FFS BILL MDCH FFS 11/02/2020 FETZIMA levomilnacipran hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 FETZIMA levomilnacipran hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ADYNOVATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, full length, peg MDCH FFS BILL MDCH FFS 11/02/2020 ADYNOVATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, full length, peg MDCH FFS BILL MDCH FFS 11/02/2020 risperidone,risper risperidone ADD UM: CUSTOM CARVE OUT- dal BILL MDCH FFS 11/02/2020 risperidone,risper risperidone ADD UM: CUSTOM CARVE OUT- dal BILL MDCH FFS 11/02/2020 viread,tenofovir tenofovir disoproxil fumarate ADD UM: CUSTOM CARVE OUT- disoproxil BILL MDCH FFS fumarate 11/02/2020 risperidone,risper risperidone ADD UM: CUSTOM CARVE OUT- dal BILL MDCH FFS 11/02/2020 ABILIFY aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MAINTENA MDCH FFS BILL MDCH FFS 11/02/2020 ABILIFY aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MAINTENA MDCH FFS BILL MDCH FFS 11/02/2020 REVCOVI elapegademase-lvlr CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 tranexamic tranexamic acid CHANGE UM: CUSTOM CARVE OUT- acid,cyklokapron BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 271 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 FETZIMA levomilnacipran hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 desvenlafaxine er desvenlafaxine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 HUMATE-P antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human/von willebrand MDCH FFS BILL MDCH FFS factor,human 11/02/2020 SUTENT sunitinib malate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 HUMATE-P antihemophilic factor, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human/von willebrand MDCH FFS BILL MDCH FFS factor,human 11/02/2020 SUTENT sunitinib malate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 SUTENT sunitinib malate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 risperidone,risper risperidone ADD UM: CUSTOM CARVE OUT- dal BILL MDCH FFS 11/02/2020 risperidone,risper risperidone CHANGE UM: CUSTOM CARVE OUT- dal BILL MDCH FFS 11/02/2020 MYOZYME,LUMI alglucosidase alfa CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ZYME MDCH FFS BILL MDCH FFS 11/02/2020 droperidol droperidol ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 ADYNOVATE antihemophilic factor (fviii) CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant, full length, peg MDCH FFS BILL MDCH FFS 11/02/2020 APLENZIN bupropion hbr CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 REYATAZ atazanavir sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 272 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 WAKIX pitolisant hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 WAKIX pitolisant hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 EQUETRO carbamazepine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 LAMICTAL XR lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- (ORANGE) MDCH FFS BILL MDCH FFS 11/02/2020 PREZISTA darunavir ethanolate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- dimesylate MDCH FFS BILL MDCH FFS 11/02/2020 remeron,mirtazap mirtazapine ADD UM: CUSTOM CARVE OUT- ine BILL MDCH FFS 11/02/2020 remeron,mirtazap mirtazapine ADD UM: CUSTOM CARVE OUT- ine BILL MDCH FFS 11/02/2020 reyataz,atazanavi atazanavir sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- r sulfate MDCH FFS BILL MDCH FFS 11/02/2020 CEPROTIN protein c, human CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 CEPROTIN protein c, human CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 remeron,mirtazap mirtazapine CHANGE UM: CUSTOM CARVE OUT- ine BILL MDCH FFS 11/02/2020 lamictal lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- odt,lamotrigine MDCH FFS BILL MDCH FFS odt 11/02/2020 VYVANSE lisdexamfetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- dimesylate MDCH FFS BILL MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- dimesylate MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 273 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 navane,thiothixen thiothixene ADD UM: CUSTOM CARVE OUT- e BILL MDCH FFS 11/02/2020 symbyax,olanzap olanzapine/fluoxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ine-fluoxetine hcl MDCH FFS BILL MDCH FFS 11/02/2020 BOSULIF bosutinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 navane,thiothixen thiothixene ADD UM: CUSTOM CARVE OUT- e BILL MDCH FFS 11/02/2020 BRINTELLIX,TRI vortioxetine hydrobromide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- NTELLIX MDCH FFS BILL MDCH FFS 11/02/2020 BANZEL rufinamide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 thiothixene thiothixene ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 BRINTELLIX,TRI vortioxetine hydrobromide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- NTELLIX MDCH FFS BILL MDCH FFS 11/02/2020 primidone,mysoli primidone ADD UM: CUSTOM CARVE OUT- ne BILL MDCH FFS 11/02/2020 primidone,mysoli primidone ADD UM: CUSTOM CARVE OUT- ne BILL MDCH FFS 11/02/2020 RECOMBINATE antihemophilic factor viii, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- human recombinant MDCH FFS BILL MDCH FFS 11/02/2020 symbyax,olanzap olanzapine/fluoxetine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- ine-fluoxetine hcl MDCH FFS BILL MDCH FFS 11/02/2020 BRINTELLIX,TRI vortioxetine hydrobromide CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- NTELLIX MDCH FFS BILL MDCH FFS 11/02/2020 navane,thiothixen thiothixene ADD UM: CUSTOM CARVE OUT- e BILL MDCH FFS 11/02/2020 viramune nevirapine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,nevirapine er MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 274 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 cortrosyn,cosyntr cosyntropin ADD UM: CUSTOM CARVE OUT- opin BILL MDCH FFS 11/02/2020 OBIZUR antihemophilic factor viii, CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recombinant porcine MDCH FFS BILL MDCH FFS sequence 11/02/2020 fluphenazine hcl fluphenazine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 fluphenazine hcl fluphenazine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 LAMICTAL XR lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- (GREEN) MDCH FFS BILL MDCH FFS 11/02/2020 fluphenazine hcl fluphenazine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 fluphenazine hcl fluphenazine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 LAMICTAL XR lamotrigine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- (BLUE) MDCH FFS BILL MDCH FFS 11/02/2020 EMSAM selegiline CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 EMSAM selegiline CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 KALETRA lopinavir/ritonavir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 APLENZIN bupropion hbr CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 EMSAM selegiline CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 trihexyphenidyl trihexyphenidyl hcl ADD UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 ABILIFY MYCITE aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 275 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 ABILIFY MYCITE aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ABILIFY MYCITE aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ritalin-sr,methylin methylphenidate hcl ADD UM: CUSTOM CARVE OUT- er,methylphenida BILL MDCH FFS te er,methylphenida te sr,metadate er 11/02/2020 VYVANSE lisdexamfetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- dimesylate MDCH FFS BILL MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- dimesylate MDCH FFS BILL MDCH FFS 11/02/2020 SOLIRIS eculizumab CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 KINERET anakinra ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 droperidol,inapsin droperidol ADD UM: CUSTOM CARVE OUT- e BILL MDCH FFS 11/02/2020 ABILIFY MYCITE aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ABILIFY MYCITE aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ABILIFY MYCITE aripiprazole CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 EVEKEO ODT amphetamine sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 SYMDEKO tezacaftor/ivacaftor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 EVEKEO ODT amphetamine sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 276 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 EVEKEO ODT amphetamine sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 EVEKEO ODT amphetamine sulfate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 VYVANSE lisdexamfetamine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- dimesylate MDCH FFS BILL MDCH FFS 11/02/2020 diazepam diazepam ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 INTELENCE etravirine CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 AFSTYLA antihemophilic factor viii CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recomb,single-chn,b-dom MDCH FFS BILL MDCH FFS truncated 11/02/2020 TALZENNA talazoparib tosylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 POTIGA ezogabine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 TALZENNA talazoparib tosylate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 POTIGA ezogabine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 POTIGA ezogabine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 trifluoperazine hcl trifluoperazine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 POTIGA ezogabine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 trifluoperazine hcl trifluoperazine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 SPRYCEL dasatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 277 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 trifluoperazine hcl trifluoperazine hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 precedex,dexme dexmedetomidine hcl ADD UM: CUSTOM CARVE OUT- detomidine hcl BILL MDCH FFS 11/02/2020 trifluoperazine hcl trifluoperazine hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/02/2020 bupropion hcl bupropion hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- sr,wellbutrin MDCH FFS BILL MDCH FFS sr,bupropion hcl er 11/02/2020 ORKAMBI lumacaftor/ivacaftor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 SPRYCEL dasatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 SPRYCEL dasatinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 ALPROLIX factor ix recombinant, fc CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- fusion protein MDCH FFS BILL MDCH FFS 11/02/2020 INVEGA TRINZA paliperidone palmitate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 BERINERT c1 esterase inhibitor CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 levocarnitine,carn levocarnitine CHANGE UM: CUSTOM CARVE OUT- itor BILL MDCH FFS 11/02/2020 focalin dexmethylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,dexmethylphen MDCH FFS BILL MDCH FFS idate hcl er 11/02/2020 focalin dexmethylphenidate hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,dexmethylphen MDCH FFS BILL MDCH FFS idate hcl er

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 278 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 IMBRUVICA ibrutinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 TROKENDI XR topiramate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 IMBRUVICA ibrutinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 TROKENDI XR topiramate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 IMBRUVICA ibrutinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 trihexyphenidyl trihexyphenidyl hcl CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- hcl MDCH FFS BILL MDCH FFS 11/02/2020 trihexyphenidyl trihexyphenidyl hcl ADD UM: CUSTOM CARVE OUT- hcl BILL MDCH FFS 11/02/2020 TROKENDI XR topiramate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 harvoni,ledipasvir ledipasvir/sofosbuvir CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- -sofosbuvir MDCH FFS BILL MDCH FFS 11/02/2020 IMBRUVICA ibrutinib CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 TROKENDI XR topiramate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 INVEGA TRINZA paliperidone palmitate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 INVEGA TRINZA paliperidone palmitate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- MDCH FFS BILL MDCH FFS 11/02/2020 AFSTYLA antihemophilic factor viii CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- recomb,single-chn,b-dom MDCH FFS BILL MDCH FFS truncated

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 279 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/02/2020 seroquel quetiapine fumarate CHANGE UM: CUSTOM Carve Out- Bill CARVE OUT- xr,quetiapine MDCH FFS BILL MDCH FFS fumarate er 11/03/2020 BUTISOL butabarbital sodium ADD UM: CUSTOM CARVE OUT- SODIUM BILL MDCH FFS 11/03/2020 XYNTHA antihemophilic factor (factor ADD UM: CUSTOM CARVE OUT- SOLOFUSE viii) recomb,b-domain BILL MDCH FFS deleted 11/03/2020 NORVIR ritonavir ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 PEGINTRON peginterferon alfa-2b ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 diazepam diazepam ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 FEIBA VH anti-inhibitor coagulant ADD UM: CUSTOM CARVE OUT- IMMUNO,FEIBA complex BILL MDCH FFS NF 11/03/2020 FEIBA VH anti-inhibitor coagulant ADD UM: CUSTOM CARVE OUT- IMMUNO,FEIBA complex BILL MDCH FFS NF 11/03/2020 desvenlafaxine desvenlafaxine fumarate ADD UM: CUSTOM CARVE OUT- fumarate er BILL MDCH FFS 11/03/2020 desvenlafaxine desvenlafaxine fumarate ADD UM: CUSTOM CARVE OUT- fumarate er BILL MDCH FFS 11/03/2020 XYNTHA antihemophilic factor (factor ADD UM: CUSTOM CARVE OUT- SOLOFUSE viii) recomb,b-domain BILL MDCH FFS deleted 11/03/2020 XYNTHA antihemophilic factor (factor ADD UM: CUSTOM CARVE OUT- SOLOFUSE viii) recomb,b-domain BILL MDCH FFS deleted 11/03/2020 RESCRIPTOR delavirdine mesylate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 280 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/03/2020 TECHNIVIE ombitasvir/paritaprevir/ritona ADD UM: CUSTOM CARVE OUT- vir BILL MDCH FFS 11/03/2020 INVIRASE saquinavir mesylate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 PREZISTA darunavir ethanolate ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 OLEPTRO ER trazodone hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 OLEPTRO ER trazodone hcl ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 PEGINTRON peginterferon alfa-2b ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 PEGINTRON peginterferon alfa-2b ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 zerit,stavudine stavudine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 VITEKTA elvitegravir ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 VITEKTA elvitegravir ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 carbamazepine carbamazepine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 carbamazepine carbamazepine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 OLYSIO simeprevir sodium ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 PEGINTRON peginterferon alfa-2b ADD UM: CUSTOM CARVE OUT- REDIPEN BILL MDCH FFS 11/03/2020 PEGINTRON peginterferon alfa-2b ADD UM: CUSTOM CARVE OUT- REDIPEN BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 281 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/03/2020 PEGINTRON peginterferon alfa-2b ADD UM: CUSTOM CARVE OUT- REDIPEN BILL MDCH FFS 11/03/2020 PEGINTRON peginterferon alfa-2b ADD UM: CUSTOM CARVE OUT- REDIPEN BILL MDCH FFS 11/03/2020 POTIGA ezogabine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 POTIGA ezogabine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 POTIGA ezogabine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 POTIGA ezogabine ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 11/03/2020 MAVYRET glecaprevir/pibrentasvir ADD UM: CUSTOM Carve-out 11/11/2020 albuterol sulfate albuterol sulfate REMOVE FROM Non PDL Non-Formulary FORMULARY 11/15/2020 8 HOUR PAIN acetaminophen REMOVE FROM Non PDL Non-Formulary RELIEF,8 HOUR FORMULARY PAIN RELIEVER,8 HOUR ACETAMINOPH EN,8HR ARTHRITIS PAIN,8HR ARTHRITIS PAIN RELIEF 11/15/2020 iron ferrous sulfate REMOVE FROM Non PDL Non-Formulary supplement,iron FORMULARY 11/15/2020 ferrous ferrous sulfate REMOVE FROM Non-Formulary sulfate,ferosul,iro FORMULARY n

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 282 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/15/2020 TRI-ESTARYLLA norgestimate-ethinyl REMOVE FROM Non PDL Non-Formulary estradiol FORMULARY 11/15/2020 LORYNA ethinyl REMOVE FROM Non PDL Non-Formulary estradiol/drospirenone FORMULARY 11/15/2020 TRI-PREVIFEM norgestimate-ethinyl REMOVE FROM Non PDL Non-Formulary estradiol FORMULARY 11/15/2020 iron ferrous sulfate REMOVE FROM Non PDL Non-Formulary FORMULARY 11/30/2020 toremifene citrate toremifene citrate CHANGE UM: PANAME Clinical PA 11/30/2020 cinacalcet hcl cinacalcet hcl CHANGE UM: QUANTITY 2 / day 11/30/2020 cinacalcet hcl cinacalcet hcl CHANGE UM: PANAME Clinical PA 11/30/2020 cinacalcet hcl cinacalcet hcl CHANGE TIER Non PDL 11/30/2020 cinacalcet hcl cinacalcet hcl CHANGE UM: QUANTITY 2 / day 11/30/2020 cinacalcet hcl cinacalcet hcl CHANGE UM: PANAME Clinical PA 11/30/2020 cinacalcet hcl cinacalcet hcl CHANGE TIER Non PDL 11/30/2020 cinacalcet hcl cinacalcet hcl CHANGE TIER Non PDL 11/30/2020 cinacalcet hcl cinacalcet hcl CHANGE UM: QUANTITY 4 / day 11/30/2020 cinacalcet hcl cinacalcet hcl CHANGE UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 283 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

December, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/01/2020 AIMOVIG erenumab-aooe CHANGE TIER Non-Preferred Preferred AUTOINJECTOR 12/01/2020 AIMOVIG erenumab-aooe CHANGE UM: PANAME Non Preferred PA Clinical PA AUTOINJECTOR 12/01/2020 AIMOVIG erenumab-aooe CHANGE TIER Non-Preferred Preferred AUTOINJECTOR 12/01/2020 AIMOVIG erenumab-aooe CHANGE UM: PANAME Non Preferred PA Clinical PA AUTOINJECTOR 12/01/2020 methocarbamol methocarbamol CHANGE TIER Non-Preferred Preferred 12/01/2020 methocarbamol methocarbamol CHANGE TIER Non-Preferred Preferred 12/01/2020 methocarbamol methocarbamol REMOVE UM: PANAME Non Preferred PA 12/01/2020 methocarbamol methocarbamol CHANGE UM: SKELETAL DRUGCLASS MUSCLE RELAXANTS 12/01/2020 methocarbamol methocarbamol CHANGE UM: SKELETAL DRUGCLASS MUSCLE RELAXANTS 12/01/2020 RETACRIT epoetin alfa-epbx ADD TO FORMULARY Preferred 12/01/2020 RETACRIT epoetin alfa-epbx ADD UM: DRUGCLASS HEMATOPOIETI C AGENTS 12/01/2020 RETACRIT epoetin alfa-epbx ADD UM: PANAME Clinical PA 12/01/2020 PFIZER COVID- covid-19 vaccine, mrna, ADD TO FORMULARY Preferred 19 VACCINE bnt162b2, lnp-s (pfizer)/pf (EUA) 12/01/2020 MODERNA covid-19 vaccine, mrna- ADD TO FORMULARY Preferred COVID-19 1273, lnp-s (moderna)/pf VACCINE (EUA)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 284 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/01/2020 medroxyprogeste medroxyprogesterone CHANGE TIER Non PDL rone acetate acetate 12/01/2020 medroxyprogeste medroxyprogesterone CHANGE UM: QUANTITY 1 / 75 days rone acetate acetate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 285 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/01/2020 gabapentin,valtoc gabapentin,diazepam,carba ADD UM: CUSTOM CARVE OUT- o,carbamazepine mazepine,midazolam BILL MDCH FFS ,midazolam hcl,quazepam,zolpidem hcl,doral,zolpide tartrate,haloperidol m decanoate,fluphenazine tartrate,haloperid decanoate,doxepin ol hcl,benztropine decanoate,fluphe mesylate,levetiracetam,preg nazine abalin,gabapentin/lidocaine,l decanoate,doxepi orazepam,gabapentin/lidoca n hcl,benztropine ine hcl/gauze mesylate,levetira bandage/silicone cetam,pregabalin adhesive,haloperidol ,pentican,lorazep lactate,pimozide,disulfiram,b am,gabapal,diaze uspirone hcl,bupropion pam,haloperidol hcl,trazodone hcl,lorazepam lactate,orap,disulf in 0.9 % sodium iram,buspirone chloride,lorazepam in 5 % hcl,bupropion dextrose and xl,trazodone water,ramelteon,guanfacine hcl,ambien,haldol hcl,gabapentin/lidocaine/pril decanoate ocaine/transparent 50,lorazepam- dressing,loxapine,sertraline 0.9% hcl,triazolam,aripiprazole,mo nacl,lorazepam- dafinil,antihemophilic factor, d5w,bupropion human/von willebrand hcl factor,human,lamivudine/ten sr,ramelteon,ativ ofovir disoproxil an,guanfacine hcl fumarate,dolutegravir er,lipritin sodium,efavirenz/lamivudine ii,cogentin,adasu /tenofovir disoproxil ve,neurontin,carb fumarate,dexmedetomidine amazepine hcl in 0.9 % sodium er,sertraline chloride,phenytoin sodium hcl,triazolam,aripi extended,phenobarbital,fact prazole,modafinil, or ix human wilate,cimduo,zol recombinant,quetiapine pimist,tivicay,qua fumarate,fluoxetine zepam,symfi,dex hcl,ibalizumab-

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 286 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value medetomidine- uiyk,mirtazapine,divalproex 0.9% sodium,desvenlafaxine nacl,phenytoin succinate,oxcarbazepine,top sodium iramate,maraviroc,raltegravir extended,phenob potassium,eszopiclone,elvite arbital,benefix,qu gravir/cobicistat/emtricitabin etiapine e/tenofovir fumarate,fluoxeti alafenamide,atomoxetine ne hcl,lumateperone hcl,trogarzo,mirta tosylate,gabapentin/lidocain zapine,divalproex e hcl/silicone sodium adhesive,lanadelumab- er,desvenlafaxine flyo,emtricitabine/tenofovir succinate alafenamide er,oxcarbazepine fumarate,brivaracetam,alpra ,divalproex zolam,methylphenidate sodium,topiramat hcl,daclatasvir e,selzentry,isentr dihydrochloride,phenobarbit ess al hd,lipritin,haldol,h sodium,emtricitabine/tenofov aldol decanoate ir disoproxil 100,eszopiclone, fumarate,ritonavir,nortriptylin genvoya,atomoxe e hcl,pimavanserin tine tartrate,clobazam,ribavirin,a hcl,caplyta,lidotin, nti-inhibitor coagulant takhzyro,tivicay complex,viltolarsen,factor ix pd,descovy,pimo complex, prothrombin cplx zide,briviact,alpra conc(pcc) no.6, 3- zolam factor,fluphenazine er,methylphenida hcl,venlafaxine te hcl,symfi hcl,dextroamphetamine sulf- lo,daklinza,pheno saccharate/amphetamine barbital sulf-aspartate,aminocaproic sodium,truvada,n acid,ixazomib orvir,nortriptyline citrate,asenapine hcl,nuplazid,clob maleate,dexmethylphenidat azam,ribasphere, e feiba hcl,palbociclib,efavirenz,sulf nf,viltepso,bebuli ur/sodium sulfate/sodium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 287 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value n,fluphenazine thiosulfate/folic hcl,venlafaxine acid,midazolam/ketamine hcl hcl/ondansetron er,dextroampheta hcl,peginterferon alfa- mine- 2a,chlorpromazine amphetamine,am hcl,escitalopram inocaproic oxalate,berotralstat acid,ninlaro,asen hydrochloride,rufinamide,clo apine zapine,dexmedetomidine maleate,dexmeth hcl,abacavir ylphenidate hcl sulfate,eteplirsen,coagulatio er,methylphenida n factor viia recombinant- te jncw,gabapentin/lidocaine er,ibrance,efavire hcl/menthol,cenobamate,tez nz,dextroamphet acaftor/ivacaftor,hemin,sofo amine-amphet sbuvir/velpatasvir,sofosbuvir er,sulfzix,mko ,ledipasvir/sofosbuvir,ravuliz (midazolam- umab-cwvz,citalopram ketamine- hydrobromide,emtricitabine/r ondan),temixys,p ilpivirine hcl/tenofovir egasys alafenamide proclick,chlorpro fumarate,golodirsen,ketamin mazine e hcl,darunavir hcl,escitalopram eth/cobicistat/emtricitabine/t oxalate,orladeyo, enofovir rufinamide,clozap alafenamide,dexmedetomidi ine,lorazepam- ne in 5 % dextrose in water ns,dexmedetomid ine hcl,abacavir,exon dys- 51,sevenfact,anta buse,active- pac,xcopri,preced ex,efavirenz- lamivu-tenofov disop,haloperidol decanoate 100,symdeko,pan

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 288 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value hematin,epclusa, sovaldi,harvoni,ul tomiris,citalopram hbr,odefsey,vyon dys- 53,onfi,ketamine hcl,symtuza,dex medetomidine- d5w 12/01/2020 MAVYRET glecaprevir/pibrentasvir CHANGE UM: CUSTOM Carve-out CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 289 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/01/2020 dexmethylphenid dexmethylphenidate CHANGE UM: CUSTOM CARVE OUT- CARVE OUT- ate hcl hcl,mirtazapine,gabapentin,l BILL MDCH FFS BILL MDCH FFS er,mirtazapine,ga evetiracetam,phenytoin,carb bapentin,levetirac amazepine,valproic etam acid,duloxetine er,phenytoin,carb hcl,lamotrigine,divalproex amazepine,valpro sodium,lorazepam,benztropi ic ne mesylate,sertraline acid,cymbalta,la hcl,doxapram motrigine,divalpro hcl,tasimelteon,dextroamph ex etamine sulf- sodium,lorazepa saccharate/amphetamine m,benztropine sulf- mesylate,sertralin aspartate,risperidone,venlaf e axine hcl,escitalopram hcl,dopram,hetlio oxalate,alprazolam,olanzapi z,dextroampheta ne,tranexamic mine- acid,clonazepam,modafinil,f amphetamine,ris actor xiii a-subunit, peridone,risperid recombinant,fosphenytoin one sodium,sapropterin odt,venlafaxine dihydrochloride,chlordiazepo hcl,escitalopram xide oxalate,alprazola hcl,temazepam,diphenhydra m mine xr,olanzapine,lyst hcl,phenobarbital,fluphenazi eda,klonopin,prov ne hcl,chlorpromazine igil,tretten,fosphe hcl,diazepam,lithium nytoin carbonate,lamivudine/zidovu sodium,kuvan,chl dine,trifluoperazine ordiazepoxide hcl,thioridazine hcl,temazepam,si hcl,nitisinone,indinavir mply sulfate,quetiapine sleep,phenobarbi fumarate,desvenlafaxine tal,nytol,fluphena fumarate,st. john's zine wort,fluoxetine hcl,chlorpromazin hcl,amitriptyline e hcl,paroxetine hcl,diazepam,lithi hcl,paliperidone,antihemophi

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 290 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value um carbonate lic factor, hum rec,zolpidem er,lamivudine- tartrate,paliperidone zidovudine,trifluo palmitate,albumin perazine human,trazodone hcl,thioridazine hcl,bupropion hcl,doxepin hcl,orfadin,z- hcl,risperidone sleep,crixivan,qu microspheres,asenapine etiapine maleate,dextroamphetamine fumarate,lamotrig sulfate,human prothrombin ine complex concentrate (pcc), er,desvenlafaxine 4-factor,antithrombin iii, fumarate human er,modafinil,olanz recombinant,nortriptyline apine odt,st. hcl,citalopram john's hydrobromide,buspirone wort,fluoxetine hcl,alglucosidase hcl,amitriptyline alfa,topiramate,zonisamide, hcl,paroxetine phenytoin sodium hcl,effexor,invega extended,aripiprazole,peram ,risperdal m- panel,triazolam,armodafinil, tab,kogenate elosulfase alfa,abacavir fs,risperdal,ambie sulfate,haloperidol,thiothixen n cr,invega e,eslicarbazepine sustenna,albumin acetate,ribavirin,peginterfero ar-5,trazodone n alfa-2a,atazanavir hcl,bupropion sulfate,saquinavir xl,bupropion hcl mesylate,ceritinib,enfuvirtide sr,bupropion ,atomoxetine hcl,doxepin hcl,antihemophilic factor hcl,risperdal (fviii) recombinant,full consta,albuminar length,raltegravir - potassium,olanzapine/fluoxe 25,saphris,dextro tine hcl,desvenlafaxine amphetamine succinate,dasatinib,bupropio sulfate,kcentra,du n hbr,tranylcypromine loxetine sulfate,stavudine,olanzapine hcl,atryn,nortriptyl pamoate,alpha-d- ine hcl,citalopram galactosidase,eszopiclone,zi hbr,alprazolam,v prasidone

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 291 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value enlafaxine hcl hcl,zaleplon,felbamate,butab er,buspirone arbital hcl,divalproex sodium,clozapine,loxapine sodium succinate,antihemophilic er,adderall,lumizy factor, human/von me,topiramate,tra willebrand nexamic factor,human,antihemophilic acid,zonisamide,l factor (fviii) recomb,full evetiracetam,clon length (alb-free),fluvoxamine azepam,nighttime maleate,factor sleep aid,sleep ix,antihemophilic factor viii, ii,phenytoin human sodium recombinant,methylphenidat extended,abilify e hcl,antihemophilic factor, maintena,ativan,d human,lithium exedrine,fycompa citrate,oxcarbazepine,zidovu ,xanax,xanax dine,pregabalin,clonidine xr,halcion,nuvigil, hcl,desvenlafaxine,ivacaftor, vimizim,cyklokapr lurasidone hcl,nefazodone on,abacavir,halop hcl,trimipramine eridol,thiothixene, maleate,protriptyline aptiom,copegus,p hcl,lamivudine,efavirenz,sod egasys,pegasys ium proclick,reyataz,i phenylbutyrate,nevirapine,i nvirase,zykadia,f mipramine uzeon,strattera,a pamoate,ziprasidone dvate,isentress,s mesylate,valproic acid (as ymbyax,prozac sodium salt) (valproate weekly,effexor sodium),ethosuximide,factor xr,pristiq,zyprexa, ix recombinant, fc fusion sprycel,aplenzin, protein,methsuximide,metrel parnate,zerit,zypr eptin,desipramine exa hcl,taliglucerase relprevv,zyprexa alfa,lopinavir/ritonavir,crizoti zydis,zenzedi,gas nib,sunitinib -x malate,axitinib,bosutinib,phe prevention,lithium nelzine carbonate,eszopi sulfate,maraviroc,lactase,rito clone,ziprasidone navir,plasma protein

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 292 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value hcl,zaleplon,felba fraction,delavirdine mate,edluar,butis mesylate,abacavir ol sulfate/lamivudine/zidovudin sodium,lorazepa e,abacavir m sulfate/lamivudine,dolutegra intensol,triazolam vir ,alprazolam sodium,estazolam,primidone intensol,clozapin ,doxylamine e,loxapine,humat succinate,didanosine,iloperi e-p,fluvoxamine done,nilotinib hcl,imatinib maleate,mononin mesylate,clorazepate e,helixate dipotassium,peginterferon fs,methylphenidat alfa- e 2b,canakinumab/pf,tiagabin hcl,methylphenid e hcl,flurazepam ate er,monoclate- hcl,valproate p,lithium,oxcarba sodium,perphenazine/amitri zepine,felbatol,zo ptyline hcl,imipramine lpidem tartrate hcl,lactulose,molindone er,zidovudine,lyri hcl,amoxapine,clomipramine ca,abilify,kapvay, hcl,hemin,chloral desvenlafaxine hydrate,levocarnitine,levocar er,kalydeco,latud nitine (with sugar),erlotinib a,nefazodone hcl,regorafenib,sorafenib hcl,surmontil,viva tosylate,trihexyphenidyl ctil,olanzapine- hcl,phenytoin fluoxetine sodium,lacosamide,oxazepa hcl,lamivudine,su m,ezogabine,acetohydroxa stiva,buphenyl,ne mic acid,fosamprenavir virapine,paxil,pax calcium,amitriptyline il cr,imipramine hcl/chlordiazepoxide,pazopa pamoate,protripty nib hcl,lapatinib line ditosylate,trametinib hcl,remeron,zolof dimethyl sulfoxide,darunavir t,navane,geodon, ethanolate,coagulation neurontin,dilantin, factor viia depacon,dilantin- (recombinant),ammonia,van 125,zarontin,alpr detanib,gefitinib,maprotiline olix,celontin,cere hcl,perphenazine,meprobam

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 293 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value byx,myalept,nevir ate,amobarbital apine sodium,secobarbital er,desipramine sodium,procyclidine hcl,khedezla,sero hcl,methylphenidate,mepho quel,elelyso,alph barbital,cellulase/amylase/lip anate,albutein,kal ase/protease,enzymes,diges etra,xalkori,sutent tive,methamphetamine ,inlyta,norpramin, hcl,factor ix complex bosulif,nardil,faza human,dexmedetomidine clo,selzentry,lact hcl in 0.9 % sodium ase,norvir,plasbu chloride,dexmedetomidine min- hcl,phenobarbital 5,plasmanate,retr sodium,pepsin/cellulase/sim ovir,epivir,ziagen, ethicone/whole rescriptor,combivi bile/pancreatin,aminocaproic r,trizivir,epzicom,t acid,droperidol,levomilnacipr ivicay,estazolam,l an actrase,focalin,rit hcl,cosyntropin,anakinra,vila alin zodone hcl,carglumic la,niravam,depak acid,protease/betaine ote hcl,ramelteon,pepsin/betain er,primidone,foca e hcl,tenofovir disoproxil lin xr,ritalin- fumarate,pexidartinib sr,ritalin,depakote hydrochloride,aripiprazole ,sleep aid,sleep lauroxil,lisdexamfetamine tablet,trileptal,dep dimesylate,digestive akene,depakote enzymes combo sprinkle,tegretol,t no.7,levetiracetam in sodium egretol xr,videx chloride, iso- ec,videx,fanapt,cl osmotic,antihemophilic ozaril,tasigna,gle factor (factor viii) recomb,b- evec,clorazepate domain dipotassium,lune deleted,emtricitabine/tenofo sta,sonata,pegint vir disoproxil ron fumarate,antihemophilic redipen,rebetol,p factor viii rec hek cell, b- egintron,keppra,t domain deleted,fedratinib opamax,ethosuxi dihydrochloride,tranexamic mide,ilaris,gabitril acid in sodium chloride,iso-

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 294 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value ,celexa,lamictal, osmotic,entrectinib,larotrecti methylin,buspar,fl nib sulfate,glycerol urazepam phenylbutyrate,afatinib hcl,zonegran,well dimaleate,clobazam,tipranav butrin ir,tipranavir/vitamin e xl,perphenazine- tpgs,atazanavir amitriptyline,imipr sulfate/cobicistat,darunavir amine ethanolate/cobicistat,osimert hcl,nighttime inib mesylate,antihemophilic sleep factor (fviii) recombinant, full gel,wellbutrin length, sr,epitol,lactulose peg,midazolam,pitolisant ,moban,carbama hcl,cobimetinib zepine fumarate,amphetamine er,lexapro,prozac sulfate,alpelisib,ixazomib ,alprazolam citrate,corticotropin,alectinib er,methylphenida hcl,amphetamine,vigabatrin, te hcl solriamfetol hcl,cariprazine cd,dexmethylphe hcl,lactase/rennet,elbasvir/gr nidate azoprevir,avapritinib,antihe hcl,methylphenid mophilic factor (fviii) rec, b- ate dom truncated peg- la,amoxapine,tofr exei,guanfacine anil- hcl,midazolam hcl,factor ix pm,clomipramine human recombinant, hcl,clozapine threonine 148,factor ix odt,budeprion human recombinant,protein xl,budeprion c, human,velaglucerase sr,ribavirin,dairy alfa,idursulfase,ledipasvir/so relief,selfemra,pa fosbuvir,sofosbuvir,lumacaft nhematin,chloral or/ivacaftor,elvitegravir/cobic hydrate,valium,so istat/emtricitabine/tenofovir minex max disoproxil,emtricitabine/rilpivi strength,sominex, rine hcl/tenofovir disoproxil levocarnitine,tarc fumarate,brexpiprazole,sele eva,stivarga,nexa giline,daclatasvir var,concerta,ultra dihydrochloride,ombitasvir/p sleep,lactase aritaprevir/ritonavir,lipase/lac enzyme,dextroa tase/amylase,elexacaftor/tez

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 295 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value mphetamine- acaftor/ivacaftor,efavirenz/e amphet mtricitabine/tenofovir er,abacavir- disoproxil lamivudine- fumarate,bortezomib,vortiox zidovudine,keppr etine a hydrobromide,gabapentin/lid xr,trihexyphenidyl ocaine,zanubrutinib,sulfur/so hcl,phenytoin dium sulfate/sodium sodium,valproate thiosulf/methyltetrahydrofola sodium,vimpat,ox te,asenapine,nelfinavir azepam,lamictal mesylate,etravirine,emtricita (orange),lamictal bine,fenfluramine (blue),lamictal hcl,pimozide,pegademase xr,lamictal xr bovine,suvorexant,abacavir (blue),lamictal xr sulfate/dolutegravir (orange),lamictal sodium/lamivudine,antihemo xr philic factor viii, recombinant (green),lamictal porcine odt,lamictal odt sequence,sacrosidase,elvite (orange),lamictal gravir,pentobarbital odt sodium,olaparib,ombitasvir/p (green),lamictal aritaprevir/ritonavir/dasabuvi odt r sodium,antihemophilic (blue),potiga,lami factor viii recombinant, b- ctal domain (green),moderiba truncated,selumetinib ,lithostat,lexiva,lit sulfate/vitamin e hium tpgs,pemigatinib,tucatinib,le citrate,limbitrol,lib nvatinib rium,votrient,tyke mesylate,palbociclib,ripretini rb,mekinist,wellb b,lemborexant,sodium utrin,prezista,refa benzoate/sodium cto,novoseven,no phenylacetate,capmatinib voseven rt,sleep hydrochloride,selpercatinib,a tabs,carbatrol,lact ntihemophilic factor (fviii) aid,lactaid fast recombinant, fc fusion act,loxitane,amm protein,eliglustat onia tartrate,ponatinib hcl,c1 aromatic,alprazol esterase inhibitor,

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 296 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value am odt,diastat recombinant,idelalisib,pralse acudial,topiragen, tinib,plasma human, blood pamelor,vandeta group a,plasma human, nib,caprelsa,iress blood group b,plasma a,seroquel human, blood group xr,maprotiline ab,plasma human, blood hcl,wal-sleep group o,corticorelin ovine z,wal- triflutate,miglustat,cobicistat, som,lactose fast pepsin/amylase/ox bile acting,tranxene extract/pancreatin/betaine sd,mysoline,diph hcl/papain,tryptophan,parox enhydramine etine hcl,chlordiazepox mesylate,acalabrutinib,factor ide- ix (human) recombinant, amitriptyline,perp pegylated,c1 esterase henazine,meprob inhibitor,emicizumab- amate,stavudine, kxwh,dolutegravir paroxetine sodium/rilpivirine er,prosom,addera hcl,vestronidase alfa- ll vjbk,abemaciclib,lorazepam xr,phenytek,amyt in 5 % dextrose and al water,lorazepam in 0.9 % sodium,seconal sodium sodium,kemadrin, chloride,pepsin/glutamic daytrana,metadat acid/betaine,copanlisib di- e er,metadate hcl,phenobarbital sodium in cd,mephobarbital 0.9 % sodium ,dayto- chloride,antithrombin iii anase,enzymax,d (human plasma extroamphetamin derived),neratinib e sulfate maleate,sofosbuvir/velpatas er,methampheta vir/voxilaprevir,antihemophili mine c factor viii recomb,single- hcl,profilnine chn,b-dom sd,ribasphere,me truncated,rucaparib thylin camsylate,laronidase,agalsi er,restoril,preced dase ex,luminal beta,imiglucerase,algluceras sodium,vanspar,a e,midostaurin,niraparib

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 297 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value mitriptyline- tosylate,rilpivirine chlordiazepoxide, hcl,brigatinib,digestive hemofil m,lactaid enzymes combo no.8/l. extra acidophilus/pectin, strength,digesple citrus,ribociclib n succinate,ethotoin,betaine,fu plus,aminocaproi cosyllactose/lacto-n- c acid,dairy neotetraose,fibrinogen,anti- digest,lac- inhibitor coagulant dose,droperidol,d complex,factor xiii,factor ix idanosine,anafra complex, prothrombin nil,tofranil,beano, complex conc. (pcc) comb. ultra dairy 6,isocarboxazid,eculizumab, digestive,dairy sulfur/sodium sulfate/sodium digestive,fetzima, thiosulfate/folic acid,von cortrosyn,kineret, willebrand factor enulose,dextrosta (recombinant),sofosbuvir/vel t,viibryd,dalmane, patasvir,carfilzomib,brivarac sarafem,carbaglu etam,ethyl alcohol/herbal ,somnote,viramu drugs,cabozantinib s- ne,sleep-eze malate,gabapentin/capsaicin 3,desyrel,trimipra /methyl mine salicylate/menthol,rilonacept maleate,fluoxetin ,gabapentin/lidocaine e hcl/menthol,rufinamide,facto dr,equetro,digesti r ix recombinant,albumin ve fusion enzymes,betazy protein,amylase/cellulase/lip me,pregabalin,ra ase/maltase/protease/lactas melteon,aripipraz e/invertase,stiripentol,interfe ole,dexmedetomi ron alfacon-1,dolutegravir dine sodium/lamivudine,erdafitini hcl,paliperidone b,amylase/protease/papain/ er,betaine papaya,ibrutinib,esketamine hcl,methylphenid hcl,gilteritinib ate sr,tenofovir fumarate,albumin human- disoproxil kjda,ravulizumab- fumarate,turalio,l cwvz,lorlatinib,elapegadema actaid se-lvlr,antihemophilic factor

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 298 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value ultra,aristada,arm (fviii) rec, b-domain deleted odafinil,vyvanse,c peg- osyntropin,superi aucl,doravirine/lamivudine/te or digestive nofovir disoproxil enzyme,aripipraz fumarate,doravirine,migalast ole at hcl,talazoparib odt,levetiracetam tosylate,duvelisib,dacomitini - b,cannabidiol nacl,xyntha,truva (cbd),aripiprazole lauroxil, da,carbamazepin submicronized,binimetinib,pi e mavanserin tartrate,factor ix xr,nuwiq,inrebic,tr complex, prothrombin cplx anexamic acid- conc(pcc) no.4, 3- nacl,rozlytrek,lam factor,factor ix complex, otrigine prothrombin complex conc. odt,vitrakvi,lamotr (pcc) comb. igine odt 4,cellulase/amylase/lipase/p (green),lamotrigin rotease/phenyltoloxamine/hy e odt oscy,galsulfase,ecallantide,t (orange),lamotrigi ezacaftor/ivacaftor,bictegravi ne odt r (blue),ravicti,gilotr sodium/emtricitabine/tenofov if,quetiapine ir alafenamide fumar fumarate er,clobazam,aptiv us,viramune xr,evotaz,prezcob ix,tagrisso,adyno vate,alburx,imatin ib mesylate,nayzila m,molindone hcl,nitisinone,wak ix,cotellic,amphet amine sulfate,piqray,met hylphenidate er (la),ninlaro,erlotin ib hcl,clonidine

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 299 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value hcl er,atazanavir sulfate,atomoxeti ne hcl,acthar,unisom sleep aid,adhansia xr,alecensa,dyan avel xr,xyntha solofuse,viread,vi gabatrin,evekeo odt,sunosi,mebar al,albumin (human),nighttim e sleep- aid,vraylar,quillic hew er,milk digestant,lactase fast acting,zepatier,ay vakit,esperoct,gu anfacine hcl er,amphetamine,r estfully sleep,midazolam hcl,aptensio xr,zzzquil,carnitor ,carnitor sf,abacavir- lamivudine,albuk ed-5,koate- dvi,koate,invega trinza,ixinity,amm onia inhalant,advate uh,advate sh,advate h,irenka,advate m,advate l,rixubis,gas

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 300 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value relief- prevention,bumin ate,recombinate,f lexbumin,efaviren z,ziprasidone mesylate,intuniv, amicar,paroxetin e cr,ceprotin,vpriv,e laprase,amitriptyli ne- perphenazine,har voni,sovaldi,levoc arnitine sf,orkambi,stribild ,complera,rexulti, drizalma sprinkle,emsam,d aklinza,technivie,t ri- zyme,trikafta,atrip la,bortezomib,bri ntellix,gabacaine, brukinsa,sulfzix,xi zflus,dexmedeto midine-0.9% nacl,secuado,ez nite sleep,viracept,nyt -time sleep,rozerem,int elence,emtriva,fin tepla,orap,adage n,desvenlafaxine succinate er,belsomra,trium eq,unisom,obizur, sucraid,trokendi xr,vitekta,evekeo,

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 301 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value nembutal sodium,procentra ,lynparza,viekira pak,novoeight,ko selugo,ormir,slee ping,pemazyre,tu kysa,lenvima,lact ose fast acting relief,ibrance,bea naid,fluvoxamine maleate er,qinlock,fosamp renavir calcium,sleepgels ,dayvigo,ammonu l,tabrecta,retevm o,eloctate,lithobid ,topiramate er,tiagabine hcl,roweepra,qud exy xr,fast sleep,dairy aid,amphetamine salt combo,anti- gas,sapropterin dihydrochloride,la patinib,cerdelga,i clusig,ruconest,d oxapram hcl,zydelig,gavret o,octaplas,acthrel ,miglustat,emtricit abine,tybost,enzy matic digestant,digestiv e enzyme,l- tryptophan,sleep- aid,emtricitabine- tenofovir

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 302 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value disop,efavirenz- emtric-tenofov disop,ribatab,pex eva,brisdelle,calq uence,citalopram, rebinyn,cinryze,h emlibra,juluca,me psevii,verzenio,p aroxetine mesylate,lorazep am- d5w,lorazepam- ns,lorazepam- 0.9% nacl,milco- zyme,mm- zyme,phenelzine sulfate,tranylcypr omine sulfate,lamotrigin e (blue),lamotrigine (green),lamotrigin e (orange),aliqopa, sodium phenylbutyrate,p henobarbital- 0.9% nacl,mydayis,forfi vo xl,haegarda,thro mbate iii,plasbumin- 25,nerlynx,alka- seltzer plus allergy,vosevi,ge nerlac,nityr,cotem pla xr- odt,afstyla,sodiu

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 303 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value m phenylacet-sod benzoate,rubraca ,myozyme,aldura zyme,fabrazyme, cerezyme,cereda se,desoxyn,benef ix,rydapt,abilify discmelt,zejula,e durant,pentobarbi tal sodium,alunbrig,i ntermezzo,kisqali ,peganone,cystad ane,oxtellar xr,methylphenidat e hcl er (cd),quillivant xr,lopinavir- ritonavir,glygest,f ast acting lactase,rest simply,riastap,fei ba vh immuno,corifact,b ebulin vh immuno,feiba nf,marplan,bupro pion hcl er,soliris,berinert, sod polysulthionate- folic acid,vonvendi,vie kira xr,epclusa,kyproli s,trintellix,briviact, elavil,h.p. acthar,velcade,zo lpidem

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 304 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value tartrate,lydia pinkham herbal,cabometyx ,smartrx gaba-v kit,wilate,arcalyst, smartrx gabakit,kovaltry,a dzenys xr- odt,banzel,sprita m,idelvion,diaco mit,limbitrol ds,infergen,dovat o,balversa,papay a enzyme,jornay pm,versacloz,tran xene t- tab,imbruvica,alb uked- 25,spravato,relex xii,xospata,sofos buvir- velpatasvir,sabril, onfi,enzymall,sile nor,ritonavir,liqua dd,rapiflux,albumi nex,ultomiris,riba sphere ribapak,diastat,za vesca,phenobarbi tal- ns,amoply,monar c-m,nytol quickcaps,uniso m sleepmelts,symp azan,lorbrena,led ipasvir- sofosbuvir,revcov i,abilify

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 305 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value mycite,inapsine,ji vi,delstrigo,pifeltr o,galafold,perseri s,oleptro er,sleep time,talzenna,cop iktra,vizimpro,epi diolex,aristada initio,mektovi,viga drone,subvenite (orange),subvenit e,subvenite (blue),subvenite (green),kedbumin ,fanatrex,compoz ,dairy digestive supplement,nupla zid,enzyme digest,cometriq,ri bapak,stavzor,me di- sleep,roweepra xr,luvox cr,adzenys er,alphanine sd,profilnine,fibry ga,lyrica cr,digex,naglazy me,kalbitor,symd eko,biktarvy 12/01/2020 tavaborole tavaborole ADD TO FORMULARY Non-Preferred 12/01/2020 tavaborole tavaborole ADD UM: DRUGCLASS ANTIFUNGALS, TOPICAL 12/01/2020 tavaborole tavaborole ADD UM: PANAME Clinical PA 12/01/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Preferred magnesium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 306 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/01/2020 esomeprazole esomeprazole magnesium ADD UM: DRUGCLASS PROTON PUMP magnesium INHIBITORS 12/01/2020 esomeprazole esomeprazole magnesium ADD UM: PANAME Non Preferred PA magnesium 12/01/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Preferred magnesium 12/01/2020 esomeprazole esomeprazole magnesium ADD UM: DRUGCLASS PROTON PUMP magnesium INHIBITORS 12/01/2020 esomeprazole esomeprazole magnesium ADD UM: PANAME Non Preferred PA magnesium 12/01/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Preferred magnesium 12/01/2020 esomeprazole esomeprazole magnesium ADD UM: DRUGCLASS PROTON PUMP magnesium INHIBITORS 12/01/2020 esomeprazole esomeprazole magnesium ADD UM: PANAME Non Preferred PA magnesium 12/01/2020 icosapent ethyl icosapent ethyl ADD TO FORMULARY Non-Preferred 12/01/2020 icosapent ethyl icosapent ethyl ADD UM: DRUGCLASS LIPOTROPICS: OTHER 12/01/2020 icosapent ethyl icosapent ethyl ADD UM: PANAME Clinical PA 12/01/2020 pantoprazole pantoprazole sodium ADD TO FORMULARY Preferred sodium 12/01/2020 pantoprazole pantoprazole sodium ADD UM: DRUGCLASS PROTON PUMP sodium INHIBITORS 12/01/2020 lidocaine pain lidocaine ADD TO FORMULARY Non PDL relief,lidocaine 12/01/2020 LIDOCAINE lidocaine ADD TO FORMULARY Non PDL PAIN RELIEF,PAIN RELIEF

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 307 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

January, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 clonidine clonidine CHANGE UM: QUANTITY 14 / claim 4 / 28 days 01/01/2021 CATAPRES-TTS clonidine CHANGE UM: QUANTITY 14 / claim 4 / 28 days 1 01/01/2021 clonidine clonidine CHANGE UM: QUANTITY 14 / claim 4 / 28 days 01/01/2021 CATAPRES-TTS clonidine CHANGE UM: QUANTITY 14 / claim 4 / 28 days 3 01/01/2021 clonidine clonidine CHANGE UM: QUANTITY 14 / claim 4 / 28 days 01/01/2021 CATAPRES-TTS clonidine CHANGE UM: QUANTITY 14 / claim 4 / 28 days 2 01/01/2021 CATAPRES clonidine hcl CHANGE TIER Non-Preferred Preferred 01/01/2021 CATAPRES clonidine hcl CHANGE TIER Non-Preferred Preferred 01/01/2021 CATAPRES clonidine hcl REMOVE UM: PANAME Non Preferred PA 01/01/2021 CATAPRES clonidine hcl CHANGE TIER Non-Preferred Preferred 01/01/2021 CATAPRES clonidine hcl REMOVE UM: PANAME Non Preferred PA 01/01/2021 CATAPRES clonidine hcl REMOVE UM: PANAME Non Preferred PA 01/01/2021 INVOKANA canagliflozin REMOVE UM: PANAME Clinical PA 01/01/2021 INVOKANA canagliflozin REMOVE UM: PANAME Clinical PA 01/01/2021 JARDIANCE empagliflozin REMOVE UM: PANAME Clinical PA 01/01/2021 JARDIANCE empagliflozin REMOVE UM: PANAME Clinical PA 01/01/2021 FARXIGA dapagliflozin propanediol REMOVE UM: PANAME Clinical PA 01/01/2021 FARXIGA dapagliflozin propanediol REMOVE UM: PANAME Clinical PA 01/01/2021 MAKENA hydroxyprogesterone ADD UM: Max duration 21 caproate QUANTITYCUSTOM weeks 01/01/2021 NEULASTA pegfilgrastim ADD UM: QUANTITY 0.6/14 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 308 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 NEULASTA pegfilgrastim ADD UM: QUANTITY 0.6/14 days ONPRO 01/01/2021 EMFLAZA deflazacort ADD TO FORMULARY Non PDL 01/01/2021 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 01/01/2021 EMFLAZA deflazacort ADD TO FORMULARY Non PDL 01/01/2021 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 01/01/2021 EMFLAZA deflazacort ADD TO FORMULARY Non PDL 01/01/2021 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 01/01/2021 EMFLAZA deflazacort ADD TO FORMULARY Non PDL 01/01/2021 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 01/01/2021 EMFLAZA deflazacort ADD TO FORMULARY Non PDL 01/01/2021 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 01/01/2021 MAKENA hydroxyprogesterone ADD UM: MAX DURATION caproate/pf QUANTITYCUSTOM 21 WEEKS 01/01/2021 hydroxyprogester hydroxyprogesterone ADD UM: 589777 one caproate caproate/pf QUANTITYCUSTOM 01/01/2021 FULPHILA pegfilgrastim-jmdb ADD UM: QUANTITY 0.6/14 days 01/01/2021 UDENYCA pegfilgrastim-cbqv ADD UM: QUANTITY 0.6/14 days 01/01/2021 hydroxyprogester hydroxyprogesterone ADD UM: Max duration 21 one caproate caproate QUANTITYCUSTOM weeks 01/01/2021 ZIEXTENZO pegfilgrastim-bmez ADD UM: QUANTITY 0.6/14 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 309 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 ARAZLO tazarotene REMOVE FROM Non-Formulary FORMULARY 01/01/2021 ISTURISA osilodrostat phosphate REMOVE FROM Non-Formulary FORMULARY 01/01/2021 ISTURISA osilodrostat phosphate REMOVE FROM Non-Formulary FORMULARY 01/01/2021 ISTURISA osilodrostat phosphate REMOVE FROM Non-Formulary FORMULARY 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD TO FORMULARY Non PDL 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: AGE 4 to 17 yrs old 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: PANAME Clinical PA 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: CUSTOM Patients who start before age 18 may continue 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD TO FORMULARY Non PDL 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: AGE 4 to 17 yrs old 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: PANAME Clinical PA 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: CUSTOM Patients who start before age 18 may continue 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD TO FORMULARY Non PDL 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: AGE 4 to 17 yrs old 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: PANAME Clinical PA 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: CUSTOM Patients who start before age 18 may continue 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD TO FORMULARY Non PDL 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: AGE 4 to 17 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 310 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: PANAME Clinical PA 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: CUSTOM Patients who start before age 18 may continue 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD TO FORMULARY Non PDL 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: AGE 4 to 17 yrs old 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: PANAME Clinical PA 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: CUSTOM Patients who start before age 18 may continue 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD TO FORMULARY Non PDL 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: AGE 4 to 17 yrs old 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: PANAME Clinical PA 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: CUSTOM Patients who start before age 18 may continue 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD TO FORMULARY Non PDL 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: AGE 4 to 17 yrs old 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: PANAME Clinical PA 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: CUSTOM Patients who start before age 18 may continue 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD TO FORMULARY Non PDL 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: AGE 4 to 17 yrs old 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: PANAME Clinical PA 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: CUSTOM Patients who start before age 18 may continue

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 311 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD TO FORMULARY Non PDL 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: AGE 4 to 17 yrs old 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: PANAME Clinical PA 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: CUSTOM Patients who start before age 18 may continue 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD TO FORMULARY Non PDL 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: AGE 4 to 17 yrs old 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: PANAME Clinical PA 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: CUSTOM Patients who start before age 18 may continue 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD TO FORMULARY Non PDL 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: AGE 4 to 17 yrs old 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: PANAME Clinical PA 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: CUSTOM Patients who start before age 18 may continue 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD TO FORMULARY Non PDL 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: AGE 4 to 17 yrs old 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: PANAME Clinical PA 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: CUSTOM Patients who start before age 18 may continue 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD TO FORMULARY Non PDL 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: AGE 4 to 17 yrs old 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 312 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 PALFORZIA peanut allergen powder-dnfp ADD UM: CUSTOM Patients who start before age 18 may continue 01/01/2021 TRULICITY dulaglutide ADD UM: DRUGCLASS INCRETIN MIMETICS 01/01/2021 TRULICITY dulaglutide ADD UM: DRUGCLASS INCRETIN MIMETICS 01/01/2021 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID,WESTH FORMULARY ROID-P,WP THYROID,WEST HROID 01/01/2021 drysol,aluminum aluminum chloride REMOVE FROM Non-Formulary chloride,hypercar FORMULARY e 01/01/2021 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID,WESTH FORMULARY ROID 01/01/2021 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID,WESTH FORMULARY ROID,WP THYROID 01/01/2021 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID,WESTH FORMULARY ROID-P,WP THYROID,WEST HROID 01/01/2021 AVONEX interferon beta-1a REMOVE FROM Non-Formulary FORMULARY 01/01/2021 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID,WESTH FORMULARY ROID

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 313 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID,WESTH FORMULARY ROID 01/01/2021 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID,WESTH FORMULARY ROID 01/01/2021 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID,WESTH FORMULARY ROID 01/01/2021 nature- thyroid,pork,thyroid REMOVE FROM Non PDL Non-Formulary throid,westhroid- FORMULARY p,wp thyroid,westhroid, thyroid 01/01/2021 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID,WESTH FORMULARY ROID-P,WP THYROID,WEST HROID 01/01/2021 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID,WESTH FORMULARY ROID,WP THYROID 01/01/2021 nature- thyroid,pork,thyroid REMOVE FROM Non PDL Non-Formulary throid,westhroid- FORMULARY p,wp thyroid,westhroid, thyroid 01/01/2021 NATURE- thyroid,pork REMOVE FROM Non PDL Non-Formulary THROID,WESTH FORMULARY ROID-P,WP THYROID,WEST HROID

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 314 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 OBTREX DHA prenatal vits REMOVE FROM Non-Formulary no.12/iron,carb/folic FORMULARY acid/docusate/omega-3 01/01/2021 THRIVITE 19 multivit-mins no.59/ferrous REMOVE FROM Non-Formulary fumarate/folic acid/docusate FORMULARY sod 01/01/2021 FERRAPLUS 90 iron, carbonyl/folic acid/vit REMOVE FROM Non-Formulary b12/vitamin c/docusate FORMULARY sodium 01/01/2021 HEMATRON-AF iron,carbonyl/docusate REMOVE FROM Non-Formulary sodium/b12-if/folic FORMULARY acid/multivit-min 01/01/2021 quinidine sulfate quinidine sulfate REMOVE FROM Non-Formulary FORMULARY 01/01/2021 PNV OB+DHA prenatal vit no.22/iron REMOVE FROM Non-Formulary cbn,glucon/folic FORMULARY acid/docusate/dha 01/01/2021 AFREZZA insulin regular, human REMOVE FROM Non-Formulary FORMULARY 01/01/2021 AFREZZA insulin regular, human REMOVE FROM Non-Formulary FORMULARY 01/01/2021 OTEZLA apremilast REMOVE FROM Non PDL Non-Formulary FORMULARY 01/01/2021 prenatal 19 prenatal vits no.115/iron REMOVE FROM Non-Formulary fumarate/folic acid/docusate FORMULARY sod. 01/01/2021 ALLERGY fexofenadine hcl REMOVE FROM Non-Preferred Non-Formulary RELIEF FORMULARY 01/01/2021 PREVACID lansoprazole REMOVE FROM Non-Preferred Non-Formulary 24HR FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 315 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 CITRANATAL prenatal vit no.73/iron REMOVE FROM Non-Formulary ASSURE carbony,gluc/folic FORMULARY acid/docusate/dha 01/01/2021 clemastine clemastine fumarate REMOVE FROM Non-Formulary fumarate FORMULARY 01/01/2021 gentamicin gentamicin sulfate REMOVE FROM Non-Formulary sulfate FORMULARY 01/01/2021 budesonide budesonide REMOVE FROM Non-Formulary FORMULARY 01/01/2021 LOMEDIA 24 FE norethindrone acetate- REMOVE FROM Non-Formulary ethinyl estradiol/ferrous FORMULARY fumarate 01/01/2021 TRINATAL GT prenatal vit with calcium REMOVE FROM Non-Formulary 16/iron/folic acid/docusate FORMULARY sodium 01/01/2021 FOLINATAL prenatal without iron/folic REMOVE FROM Non-Formulary PLUS B acid/calcium FORMULARY carb/pyridoxine/b12 01/01/2021 multivitamins- multivitamin-minerals REMOVE FROM Non-Formulary a,b,d,e,k,zn no.44/cholecalciferol (vit FORMULARY d3)/vit k1 01/01/2021 BENTYL dicyclomine hcl REMOVE FROM Non-Formulary FORMULARY 01/01/2021 FERRALET 90 iron carbonyl,gluc/folic REMOVE FROM Non-Formulary acid/vit b12/vit c/docusate FORMULARY sodium 01/01/2021 LMTHF- cyanocobalamin/levomefolat REMOVE FROM Non-Formulary PYRIDOXINE- e calcium/pyridoxine hcl (b6) FORMULARY CYANOCOBAL 01/01/2021 M-VIT multivitamin with minerals REMOVE FROM Non-Formulary no.63/ferrous fumarate/folic FORMULARY acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 316 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 ANTI- loperamide hcl REMOVE FROM Preferred Non-Formulary DIARRHEAL FORMULARY 01/01/2021 ANTIVERT meclizine hcl REMOVE FROM Non-Formulary FORMULARY 01/01/2021 OTIC CARE antipyrine/benzocaine REMOVE FROM Non-Formulary FORMULARY 01/01/2021 ZENCHENT norethindrone-ethinyl REMOVE FROM Non-Formulary estradiol FORMULARY 01/01/2021 ILOTYCIN erythromycin base REMOVE FROM Non-Formulary FORMULARY 01/01/2021 dextrose 5%- potassium chloride in REMOVE FROM Non-Formulary 0.45% nacl-kcl dextrose 5 %-0.45 % FORMULARY sodium chloride 01/01/2021 vitamins a,c,d pediatric multivit with a,c,d3 REMOVE FROM Non-Formulary and fluoride no.21/sodium fluoride FORMULARY 01/01/2021 CALAN verapamil hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY 01/01/2021 NARCAN naloxone hcl REMOVE FROM Non-Formulary FORMULARY 01/01/2021 heparin sodium heparin sodium,porcine REMOVE FROM Non PDL Non-Formulary FORMULARY 01/01/2021 ROBINUL glycopyrrolate REMOVE FROM Non-Formulary FORMULARY 01/01/2021 FLUORIDEX fluoride (sodium) REMOVE FROM Non-Formulary DAILY DEFENSE FORMULARY 01/01/2021 ORTHO TRI- norgestimate-ethinyl REMOVE FROM Non-Formulary CYCLEN LO estradiol FORMULARY 01/01/2021 ROBINUL glycopyrrolate REMOVE FROM Non-Formulary FORMULARY 01/01/2021 ROBINUL glycopyrrolate REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 317 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 CITRANATAL RX prenatal vits no.81/iron REMOVE FROM Non-Formulary carbonyl,gluc/folic FORMULARY acid/docusate 01/01/2021 RHINOCORT budesonide REMOVE FROM Non-Formulary AQUA FORMULARY 01/01/2021 sodium chloride 0.9 % sodium chloride REMOVE FROM Non-Formulary FORMULARY 01/01/2021 potassium potassium chloride REMOVE FROM Non-Formulary chloride FORMULARY 01/01/2021 CITRANATAL prenatal vit no.76/iron REMOVE FROM Non-Formulary DHA carbony,gluc/folic FORMULARY acid/docusate/dha 01/01/2021 NEXA PLUS prenatal vits no.53/iron REMOVE FROM Non-Formulary fum/folic acid/docusate FORMULARY calcium/dha 01/01/2021 MYNATE 90 prenatal vitamins with REMOVE FROM Non-Formulary PLUS calcium/ferrous FORMULARY fum/docusate/folic ac 01/01/2021 potassium citrate- potassium citrate/citric acid REMOVE FROM Non-Formulary citric acid FORMULARY 01/01/2021 ORTHO TRI- norgestimate-ethinyl REMOVE FROM Non-Formulary CYCLEN estradiol FORMULARY 01/01/2021 multivitamins- pediatric multivit REMOVE FROM Non-Formulary a,b,d,e,k,zn no.22/cholecalciferol(d3)/ph FORMULARY ytonadione(k) 01/01/2021 VIRT-ADVANCE prenatal vit with calcium REMOVE FROM Non-Formulary 15/iron/folic acid/docusate FORMULARY sodium 01/01/2021 loratadine loratadine REMOVE FROM Preferred Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 318 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 TRI-TABS DHA prenatal vits with calcium REMOVE FROM Non-Formulary no.87/iron bisgly/folic FORMULARY acid/dha 01/01/2021 dextrose 5%- potassium chloride in REMOVE FROM Non-Formulary 0.45% nacl-kcl dextrose 5 %-0.45 % FORMULARY sodium chloride 01/01/2021 sodium chloride 0.9 % sodium chloride REMOVE FROM Non-Formulary FORMULARY 01/01/2021 VP-CH-PNV prenatal vits REMOVE FROM Non-Formulary no.34/iron,carb/folic FORMULARY acid/docusate sodium/dha 01/01/2021 GILDESS 24 FE norethindrone acetate- REMOVE FROM Non-Formulary ethinyl estradiol/ferrous FORMULARY fumarate 01/01/2021 OBSTETRIX prenatal vits REMOVE FROM Non-Formulary DHA no.12/iron,carb/folic FORMULARY acid/docusate/omega-3 01/01/2021 VIRT-VITE cyanocobalamin/folic REMOVE FROM Non-Formulary FORTE acid/pyridoxine FORMULARY 01/01/2021 K-SOL potassium chloride REMOVE FROM Non-Formulary FORMULARY 01/01/2021 GABACAINE gabapentin/lidocaine REMOVE FROM Non-Formulary FORMULARY 01/01/2021 GILDESS norethindrone acetate- REMOVE FROM Non-Formulary ethinyl estradiol FORMULARY 01/01/2021 PRENAISSANCE prenatal vits with calcium REMOVE FROM Non-Formulary no.80/iron fum/folic FORMULARY acid/dss/dha 01/01/2021 polyethylene polyethylene glycol 3350 REMOVE FROM Non-Formulary glycol 3350 FORMULARY 01/01/2021 ANTIVERT meclizine hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 319 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 TERAZOL 7 terconazole REMOVE FROM Non-Formulary FORMULARY 01/01/2021 fluticasone fluticasone propionate REMOVE FROM Preferred Non-Formulary propionate FORMULARY 01/01/2021 PRENAISSANCE prenatal vit with calcium REMOVE FROM Non-Formulary PLUS no.69/iron/folic FORMULARY acid/docusate/dha 01/01/2021 GILDESS FE norethindrone acetate- REMOVE FROM Non-Formulary ethinyl estradiol/ferrous FORMULARY fumarate 01/01/2021 ROBINUL glycopyrrolate REMOVE FROM Non-Formulary FORMULARY 01/01/2021 GILDAGIA norethindrone-ethinyl REMOVE FROM Non-Formulary estradiol FORMULARY 01/01/2021 PRESTALIA perindopril REMOVE FROM Non-Formulary arginine/amlodipine besylate FORMULARY 01/01/2021 ampicillin ampicillin trihydrate REMOVE FROM Non-Formulary trihydrate FORMULARY 01/01/2021 PENLAC ciclopirox REMOVE FROM Non-Preferred Non-Formulary FORMULARY 01/01/2021 children's loratadine REMOVE FROM Preferred Non-Formulary loratadine FORMULARY 01/01/2021 TERAZOL 3 terconazole REMOVE FROM Non-Formulary FORMULARY 01/01/2021 CHATEAL levonorgestrel-ethinyl REMOVE FROM Non-Formulary estradiol FORMULARY 01/01/2021 ampicillin ampicillin trihydrate REMOVE FROM Non-Formulary trihydrate FORMULARY 01/01/2021 ROBINUL glycopyrrolate REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 320 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 AFREZZA insulin regular, human REMOVE FROM Non-Formulary FORMULARY 01/01/2021 BENTYL dicyclomine hcl REMOVE FROM Non-Formulary FORMULARY 01/01/2021 NITROPRESS nitroprusside sodium REMOVE FROM Non-Formulary FORMULARY 01/01/2021 propofol propofol REMOVE FROM Non-Formulary FORMULARY 01/01/2021 NUTRICAP folic acid/multivitamin with REMOVE FROM Non-Formulary iron, minerals FORMULARY 01/01/2021 triple-vitamin w- pediatric multivit with a,c,d3 REMOVE FROM Non-Formulary fluoride no.21/sodium fluoride FORMULARY 01/01/2021 ACTOPLUS MET pioglitazone hcl/metformin REMOVE FROM Non-Preferred Non-Formulary XR hcl FORMULARY 01/01/2021 doxycycline doxycycline hyclate REMOVE FROM Non-Formulary hyclate FORMULARY 01/01/2021 AUROGUARD antipyrine/benzocaine REMOVE FROM Non-Formulary FORMULARY 01/01/2021 acetic acid- acetic acid/aluminum REMOVE FROM Non-Formulary aluminum acetate FORMULARY 01/01/2021 tri-vit with fluoride/iron/vitamins a,c,and REMOVE FROM Non-Formulary fluoride-iron d FORMULARY 01/01/2021 MYNATAL prenatal vitamins with REMOVE FROM Non-Formulary calcium/iron,carb/docusate/f FORMULARY olic acid 01/01/2021 INATAL ULTRA prenatal vit with calcium REMOVE FROM Non-Formulary 18/iron/folic acid/docusate FORMULARY sodium 01/01/2021 MYNATAL prenatal vit with calcium REMOVE FROM Non-Formulary ADVANCE 15/iron/folic acid/docusate FORMULARY sodium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 321 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 VINATE ULTRA prenatal vit with calcium REMOVE FROM Non-Formulary 18/iron/folic acid/docusate FORMULARY sodium 01/01/2021 PNV-DHA + prenatal vits,calcium REMOVE FROM Non-Formulary DOCUSATE no.66/iron fum/folic FORMULARY acid/docusate/dha 01/01/2021 ORTHO- norgestimate-ethinyl REMOVE FROM Non-Formulary CYCLEN estradiol FORMULARY 01/01/2021 CESAMET nabilone REMOVE FROM Non-Formulary FORMULARY 01/01/2021 CIPRO I.V. ciprofloxacin REMOVE FROM Non-Formulary lactate/dextrose 5 % in FORMULARY water 01/01/2021 TARON-BC prenatal vit with calcium REMOVE FROM Non-Formulary 63/iron,carb/folic FORMULARY acid/pyridoxine 01/01/2021 ALL DAY cetirizine hcl REMOVE FROM Preferred Non-Formulary ALLERGY FORMULARY 01/01/2021 MAXFE iron REMOVE FROM Non-Formulary carb,bg/methylfolate/b12/ma FORMULARY g ascorbate/biotin/zinc/dss 01/01/2021 sodium chloride 0.9 % sodium chloride REMOVE FROM Non-Formulary FORMULARY 01/01/2021 LOTRISONE clotrimazole/betamethasone REMOVE FROM Non-Preferred Non-Formulary dipropionate FORMULARY 01/01/2021 TRINESSA norgestimate-ethinyl REMOVE FROM Non-Formulary estradiol FORMULARY 01/01/2021 VERAMYST fluticasone furoate REMOVE FROM Non-Formulary FORMULARY 01/01/2021 estropipate estropipate REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 322 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 VIRT-VITE GT prenatal vit with calcium REMOVE FROM Non-Formulary 16/iron/folic acid/docusate FORMULARY sodium 01/01/2021 KIMIDESS desogestrel-ethinyl REMOVE FROM Non-Formulary estradiol/ethinyl estradiol FORMULARY 01/01/2021 MONONESSA norgestimate-ethinyl REMOVE FROM Non PDL Non-Formulary estradiol FORMULARY 01/01/2021 CITRANATAL prenatal vitamin no.59/iron REMOVE FROM Non-Formulary HARMONY carb,fum/folic FORMULARY acid/docusate/dha 01/01/2021 ROBINUL glycopyrrolate REMOVE FROM Non-Formulary FORTE FORMULARY 01/01/2021 AVANDIA rosiglitazone maleate REMOVE FROM Non-Formulary FORMULARY 01/01/2021 ACTOPLUS MET pioglitazone hcl/metformin REMOVE FROM Non-Formulary XR hcl FORMULARY 01/01/2021 INATAL prenatal vit with calcium REMOVE FROM Non-Formulary ADVANCE 15/iron/folic acid/docusate FORMULARY sodium 01/01/2021 estropipate estropipate REMOVE FROM Non-Formulary FORMULARY 01/01/2021 CORDARONE amiodarone hcl REMOVE FROM Non-Formulary FORMULARY 01/01/2021 triamcinolone triamcinolone acetonide REMOVE FROM Non-Formulary acetonide FORMULARY 01/01/2021 NORLYROC norethindrone REMOVE FROM Non-Formulary FORMULARY 01/01/2021 lidocaine hcl lidocaine hcl/pf REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 323 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 FOLET ONE multivitamin no.39/iron REMOVE FROM Non-Formulary carb,bisgl/methylfolate/docu FORMULARY sate/dha 01/01/2021 SILA III triamcinolone REMOVE FROM Non-Formulary acetonide/gauze FORMULARY bandage/silicone, adhesive 01/01/2021 CITRANATAL 90 prenatal vit no.72/iron REMOVE FROM Non-Formulary DHA carbony,gluc/folic FORMULARY acid/docusate/dha 01/01/2021 FOLBECAL prenatal without iron/folic REMOVE FROM Non-Formulary acid/calcium FORMULARY carb/pyridoxine/b12 01/01/2021 LEVORA-28 levonorgestrel-ethinyl REMOVE FROM Non-Formulary estradiol FORMULARY 01/01/2021 VINATE GT prenatal vit with calcium REMOVE FROM Non-Formulary 16/iron/folic acid/docusate FORMULARY sodium 01/01/2021 HEMENATAL OB prenatal vit no.21/iron REMOVE FROM Non-Formulary polysacch,heme FORMULARY polypep/folic acid 01/01/2021 ALTAVERA levonorgestrel/ethinyl REMOVE FROM Non-Formulary estradiol FORMULARY 01/01/2021 ADENOSCAN adenosine REMOVE FROM Non-Formulary FORMULARY 01/01/2021 naphazoline hcl naphazoline hcl REMOVE FROM Non-Formulary FORMULARY 01/01/2021 sodium chloride sodium chloride 0.45 % REMOVE FROM Non-Formulary FORMULARY 01/01/2021 TRIADVANCE prenatal vit with calcium REMOVE FROM Non-Formulary 15/iron/folic acid/docusate FORMULARY sodium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 324 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 TL GARD RX cyanocobalamin/folic REMOVE FROM Non-Formulary acid/pyridoxine FORMULARY 01/01/2021 PREVIFEM norgestimate-ethinyl REMOVE FROM Non PDL Non-Formulary estradiol FORMULARY 01/01/2021 PRESTALIA perindopril REMOVE FROM Non-Formulary arginine/amlodipine besylate FORMULARY 01/01/2021 PEPCID famotidine REMOVE FROM Non-Formulary FORMULARY 01/01/2021 GILDESS FE norethindrone acetate- REMOVE FROM Non-Formulary ethinyl estradiol/ferrous FORMULARY fumarate 01/01/2021 ESTARYLLA norgestimate-ethinyl REMOVE FROM Non-Formulary estradiol FORMULARY 01/01/2021 antipyrine- antipyrine/benzocaine REMOVE FROM Non-Formulary benzocaine FORMULARY 01/01/2021 ZURAMPIC lesinurad REMOVE FROM Non-Formulary FORMULARY 01/01/2021 TARON-PREX multivitamin no.53/ferrous REMOVE FROM Non-Formulary PRENATAL fum/folic acid/docusate/dha FORMULARY 01/01/2021 PRESTALIA perindopril REMOVE FROM Non-Formulary arginine/amlodipine besylate FORMULARY 01/01/2021 OBSTETRIX EC prenatal vitamins REMOVE FROM Non-Formulary no.127/iron,carbonyl/folic FORMULARY acid/docusate 01/01/2021 propofol propofol REMOVE FROM Non-Formulary FORMULARY 01/01/2021 VIRT-VITE cyanocobalamin/folic REMOVE FROM Non-Formulary acid/pyridoxine FORMULARY 01/01/2021 VINATE II prenatal vitamins with REMOVE FROM Non-Formulary calcium/iron bis- FORMULARY glycinate/folic acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 325 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 dextrose 5%- dextrose 5 % and 0.2 % REMOVE FROM Non-Formulary 0.225% nacl sodium chloride FORMULARY 01/01/2021 hydroxyprogester hydroxyprogesterone CHANGE UM: 589777 Maximum one caproate caproate/pf QUANTITYCUSTOM approval of 21 weeks 01/01/2021 EMFLAZA deflazacort REMOVE FROM Non PDL Non-Formulary FORMULARY 01/01/2021 EMFLAZA deflazacort REMOVE UM: PANAME Clinical PA 01/01/2021 EMFLAZA deflazacort REMOVE UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort REMOVE FROM Non PDL Non-Formulary FORMULARY 01/01/2021 EMFLAZA deflazacort REMOVE UM: PANAME Clinical PA 01/01/2021 EMFLAZA deflazacort REMOVE UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort REMOVE FROM Non PDL Non-Formulary FORMULARY 01/01/2021 EMFLAZA deflazacort REMOVE UM: PANAME Clinical PA 01/01/2021 EMFLAZA deflazacort REMOVE UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort REMOVE FROM Non PDL Non-Formulary FORMULARY 01/01/2021 EMFLAZA deflazacort REMOVE UM: PANAME Clinical PA 01/01/2021 EMFLAZA deflazacort REMOVE UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort REMOVE FROM Non PDL Non-Formulary FORMULARY 01/01/2021 EMFLAZA deflazacort REMOVE UM: PANAME Clinical PA 01/01/2021 EMFLAZA deflazacort REMOVE UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort ADD TO FORMULARY Non-Formulary Non PDL 01/01/2021 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 326 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 EMFLAZA deflazacort ADD TO FORMULARY Non-Formulary Non PDL 01/01/2021 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 01/01/2021 EMFLAZA deflazacort ADD TO FORMULARY Non-Formulary Non PDL 01/01/2021 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 01/01/2021 EMFLAZA deflazacort ADD TO FORMULARY Non-Formulary Non PDL 01/01/2021 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 01/01/2021 EMFLAZA deflazacort ADD TO FORMULARY Non-Formulary Non PDL 01/01/2021 EMFLAZA deflazacort ADD UM: AGE At least 2 yrs old 01/01/2021 EMFLAZA deflazacort ADD UM: PANAME Clinical PA 01/01/2021 SYNTHROID levothyroxine sodium REMOVE UM: AGE Up to 12 yrs old 01/01/2021 SYNTHROID levothyroxine sodium REMOVE UM: AGE Up to 12 yrs old 01/01/2021 SYNTHROID levothyroxine sodium REMOVE UM: AGE Up to 12 yrs old 01/01/2021 SYNTHROID levothyroxine sodium REMOVE UM: AGE Up to 12 yrs old 01/01/2021 SYNTHROID levothyroxine sodium REMOVE UM: AGE Up to 12 yrs old 01/01/2021 SYNTHROID levothyroxine sodium REMOVE UM: AGE Up to 12 yrs old 01/01/2021 SYNTHROID levothyroxine sodium REMOVE UM: AGE Up to 12 yrs old 01/01/2021 SYNTHROID levothyroxine sodium REMOVE UM: AGE Up to 12 yrs old 01/01/2021 SYNTHROID levothyroxine sodium REMOVE UM: AGE Up to 12 yrs old 01/01/2021 SYNTHROID levothyroxine sodium REMOVE UM: AGE Up to 12 yrs old 01/01/2021 SYNTHROID levothyroxine sodium REMOVE UM: AGE Up to 12 yrs old 01/01/2021 NITRONAL nitroglycerin ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 327 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 VOLUVEN hydroxyethyl starch 130/0.4 ADD UM: MED Medical Drug in 0.9 % sodium chloride 01/01/2021 ETOPOPHOS etoposide phosphate ADD UM: MED Medical Drug 01/01/2021 ellence,epirubicin epirubicin hcl ADD UM: MED Medical Drug hcl 01/01/2021 dopamine hcl in dopamine hcl in dextrose 5 ADD UM: MED Medical Drug 5% dextrose % in water 01/01/2021 GAMUNEX- immune ADD UM: MED Medical Drug C,GAMMAKED globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 01/01/2021 WINRHO SDF rho(d) immune ADD UM: MED Medical Drug globulin/maltose 01/01/2021 GAMUNEX- immune ADD UM: MED Medical Drug C,GAMMAKED globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 01/01/2021 WINRHO SDF rho(d) immune ADD UM: MED Medical Drug globulin/maltose 01/01/2021 GAMUNEX- immune ADD UM: MED Medical Drug C,GAMMAKED globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 01/01/2021 doxorubicin doxorubicin hcl ADD UM: MED Medical Drug hcl,adriamycin 01/01/2021 WINRHO SDF rho(d) immune ADD UM: MED Medical Drug globulin/maltose 01/01/2021 doxorubicin doxorubicin hcl ADD UM: MED Medical Drug hcl,adriamycin 01/01/2021 WINRHO SDF rho(d) immune ADD UM: MED Medical Drug globulin/maltose 01/01/2021 GAMUNEX- immune ADD UM: MED Medical Drug C,GAMMAKED globulin,gamma(igg)/glycine/ iga average 46 mcg/ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 328 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 GAMUNEX- immune ADD UM: MED Medical Drug C,GAMMAKED globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 01/01/2021 topotecan hcl topotecan hcl ADD UM: MED Medical Drug 01/01/2021 mitoxantrone mitoxantrone hcl ADD UM: MED Medical Drug hcl,novantrone 01/01/2021 virazole,ribavirin ribavirin ADD UM: MED Medical Drug 01/01/2021 TRELSTAR triptorelin pamoate ADD UM: MED Medical Drug 01/01/2021 XIAFLEX collagenase clostridium ADD UM: MED Medical Drug histolyticum 01/01/2021 TRELSTAR triptorelin pamoate ADD UM: MED Medical Drug 01/01/2021 dopamine hcl dopamine hcl ADD UM: MED Medical Drug 01/01/2021 prochlorperazine prochlorperazine edisylate ADD UM: MED Medical Drug edisylate,compaz ine 01/01/2021 ellence,epirubicin epirubicin hcl ADD UM: MED Medical Drug hcl 01/01/2021 dopamine hcl dopamine hcl ADD UM: MED Medical Drug 01/01/2021 dopamine hcl in dopamine hcl in dextrose 5 ADD UM: MED Medical Drug 5% dextrose % in water,dopamine hcl/dextrose 5 % in water 01/01/2021 OZURDEX dexamethasone ADD UM: MED Medical Drug 01/01/2021 MICRHOGAM rho(d) immune globulin ADD UM: MED Medical Drug ULTRA- FILTERED PLUS,MICRHOG AM,HYPERRHO S-D 01/01/2021 oxaliplatin oxaliplatin ADD UM: MED Medical Drug 01/01/2021 SYNRIBO omacetaxine mepesuccinate ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 329 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 quinidine quinidine gluconate ADD UM: MED Medical Drug gluconate 01/01/2021 neoprofen,ibuprof ibuprofen lysine/pf ADD UM: MED Medical Drug en lysine 01/01/2021 HEPAGAM B hepatitis b immune ADD UM: MED Medical Drug globulin/maltose 01/01/2021 HEPAGAM B hepatitis b immune ADD UM: MED Medical Drug globulin/maltose 01/01/2021 dobutamine hcl- dobutamine hcl in dextrose ADD UM: MED Medical Drug d5w,dobutamine 5 % in water,dobutamine hcl in dextrose hcl/dextrose 5 % in water 01/01/2021 dobutamine hcl- dobutamine hcl in dextrose ADD UM: MED Medical Drug d5w 5 % in water 01/01/2021 epirubicin hcl epirubicin hcl ADD UM: MED Medical Drug 01/01/2021 lmd 10% with 5% dextran 40 in dextrose 5 % ADD UM: MED Medical Drug dextrose,dextran in water,dextran 40/dextrose 40 in dextrose 5 % in water 5% 01/01/2021 ADRENALIN epinephrine ADD UM: MED Medical Drug CHLORIDE,ADR ENALIN 01/01/2021 VARIZIG varicella-zoster immune ADD UM: MED Medical Drug globulin (human) 01/01/2021 leucovorin leucovorin calcium ADD UM: MED Medical Drug calcium 01/01/2021 leucovorin leucovorin calcium ADD UM: MED Medical Drug calcium 01/01/2021 IODOPEN sodium iodide ADD UM: MED Medical Drug 01/01/2021 ringers injection ringer's solution,ringers ADD UM: MED Medical Drug solution

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 330 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 sodium sodium bicarbonate ADD UM: MED Medical Drug bicarbonate,sodiu m bicarbonate- water 01/01/2021 NEUT sodium bicarbonate ADD UM: MED Medical Drug 01/01/2021 sodium sodium bicarbonate ADD UM: MED Medical Drug bicarbonate 01/01/2021 irinotecan hcl irinotecan hcl ADD UM: MED Medical Drug 01/01/2021 potassium potassium chloride ADD UM: MED Medical Drug chloride 01/01/2021 UVADEX methoxsalen ADD UM: MED Medical Drug 01/01/2021 DEPOCYT cytarabine liposome/pf ADD UM: MED Medical Drug 01/01/2021 sodium lactate sodium lactate ADD UM: MED Medical Drug 01/01/2021 glycopyrrolate,ro glycopyrrolate ADD UM: MED Medical Drug binul 01/01/2021 dactinomycin,cos dactinomycin ADD UM: MED Medical Drug megen 01/01/2021 LMD 10% WITH dextran 40 in 0.9 % sodium ADD UM: MED Medical Drug 0.9% SOD chloride CHLORIDE 01/01/2021 leucovorin leucovorin calcium ADD UM: MED Medical Drug calcium 01/01/2021 potassium potassium chloride ADD UM: MED Medical Drug chloride 01/01/2021 allopurinol allopurinol sodium ADD UM: MED Medical Drug sodium,aloprim 01/01/2021 leucovorin leucovorin calcium ADD UM: MED Medical Drug calcium 01/01/2021 leucovorin leucovorin calcium ADD UM: MED Medical Drug calcium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 331 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 calcium leucovorin calcium ADD UM: MED Medical Drug folinate,leucovori n calcium 01/01/2021 gablofen,baclofen baclofen ADD UM: MED Medical Drug 01/01/2021 gemcitabine hcl gemcitabine hcl ADD UM: MED Medical Drug 01/01/2021 MIOSTAT carbachol ADD UM: MED Medical Drug 01/01/2021 fludarabine fludarabine phosphate ADD UM: MED Medical Drug phosphate 01/01/2021 CATHFLO alteplase ADD UM: MED Medical Drug ACTIVASE 01/01/2021 vumon,teniposide teniposide ADD UM: MED Medical Drug 01/01/2021 GLASSIA alpha-1-proteinase inhibitor ADD UM: MED Medical Drug 01/01/2021 taxotere,docetax docetaxel ADD UM: MED Medical Drug el 01/01/2021 PEDITRACE zinc,copper,manganese ADD UM: MED Medical Drug chl/sod selen/sod fluoride/pot iodide 01/01/2021 TYSABRI natalizumab ADD UM: MED Medical Drug 01/01/2021 eloxatin,oxaliplati oxaliplatin ADD UM: MED Medical Drug n 01/01/2021 amiodarone hcl amiodarone hcl ADD UM: MED Medical Drug 01/01/2021 dopamine hcl dopamine hcl ADD UM: MED Medical Drug 01/01/2021 dopamine hcl in dopamine hcl in dextrose 5 ADD UM: MED Medical Drug 5% dextrose % in water,dopamine hcl/dextrose 5 % in water 01/01/2021 TRIESENCE triamcinolone acetonide/pf ADD UM: MED Medical Drug 01/01/2021 zinc sulfate zinc sulfate ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 332 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 ak- fluorescein sodium ADD UM: MED Medical Drug fluor,fluorescein lite,fluorescein sodium 01/01/2021 fluorescite,ak- fluorescein sodium ADD UM: MED Medical Drug fluor,fluorescein lite,fluorescein sodium 01/01/2021 taxol,paclitaxel,o paclitaxel ADD UM: MED Medical Drug nxol 01/01/2021 nexium esomeprazole sodium ADD UM: MED Medical Drug i.v.,esomeprazole sodium 01/01/2021 JETREA ocriplasmin/pf ADD UM: MED Medical Drug 01/01/2021 doxorubicin doxorubicin hcl ADD UM: MED Medical Drug hcl,adriamycin 01/01/2021 famotidine famotidine/pf ADD UM: MED Medical Drug 01/01/2021 LUCENTIS ranibizumab ADD UM: MED Medical Drug 01/01/2021 taxotere,docetax docetaxel ADD UM: MED Medical Drug el 01/01/2021 nitroglycerin in nitroglycerin in 5 % dextrose ADD UM: MED Medical Drug d5w in water 01/01/2021 zinecard,dexrazo dexrazoxane hcl ADD UM: MED Medical Drug xane 01/01/2021 IONOSOL MB- electrolyte-mb ADD UM: MED Medical Drug DEXTROSE 5% solution/dextrose 5 % in water 01/01/2021 ZALTRAP ziv-aflibercept ADD UM: MED Medical Drug 01/01/2021 ZALTRAP ziv-aflibercept ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 333 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 fludarabine fludarabine phosphate ADD UM: MED Medical Drug phosphate,fludar a 01/01/2021 zinc gluconate zinc gluconate ADD UM: MED Medical Drug 01/01/2021 gemzar,gemcitabi gemcitabine hcl ADD UM: MED Medical Drug ne hcl 01/01/2021 floxuridine floxuridine ADD UM: MED Medical Drug 01/01/2021 gemzar,gemcitabi gemcitabine hcl ADD UM: MED Medical Drug ne hcl 01/01/2021 TOXICOLOGY saliva collection ADD UM: MED Medical Drug SALIVA device/ibuprofen COLLECTION 01/01/2021 PROLIA denosumab ADD UM: MED Medical Drug 01/01/2021 bumetanide bumetanide ADD UM: MED Medical Drug 01/01/2021 IONOSOL B electrolyte-b ADD UM: MED Medical Drug WITH solution/dextrose 5 % in DEXTROSE 5% water 01/01/2021 HYPERTET S-D tetanus immune globulin/pf ADD UM: MED Medical Drug 01/01/2021 dextrose 5%- potassium chloride in ADD UM: MED Medical Drug 1/2ns-kcl dextrose 5 %-0.45 % sodium chloride 01/01/2021 dextrose 5%- potassium chloride in ADD UM: MED Medical Drug 1/2ns-kcl dextrose 5 %-0.45 % sodium chloride 01/01/2021 ALEVICYN,LEVI hypochlorous acid/sod ADD UM: MED Medical Drug CYN chlor/sod sulfate/sod phosphate,mono 01/01/2021 dextrose 5%- potassium chloride in ADD UM: MED Medical Drug 1/2ns-kcl dextrose 5 %-0.45 % sodium chloride

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 334 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 DAUNOXOME daunorubicin citrate ADD UM: MED Medical Drug liposomal 01/01/2021 norflex,orphenadr orphenadrine citrate ADD UM: MED Medical Drug ine citrate 01/01/2021 THAM tromethamine ADD UM: MED Medical Drug 01/01/2021 zantac,ranitidine ranitidine hcl ADD UM: MED Medical Drug hcl 01/01/2021 REMICADE infliximab ADD UM: MED Medical Drug 01/01/2021 ALEVICYN,SP sod mg fluo/sodium ADD UM: MED Medical Drug ANTIPRURITIC,L phos/nacl/hypochlorous EVICYN acid/sod hypochlor 01/01/2021 CYTOGAM cytomegalovirus immune ADD UM: MED Medical Drug globulin (human),cytomegalovirus immune glob 01/01/2021 orphenadrine orphenadrine citrate ADD UM: MED Medical Drug citrate 01/01/2021 chromium chromic chloride ADD UM: MED Medical Drug 01/01/2021 BOTOX onabotulinumtoxina ADD UM: MED Medical Drug 01/01/2021 zinc chloride zinc chloride ADD UM: MED Medical Drug 01/01/2021 oxytocin,pitocin oxytocin ADD UM: MED Medical Drug 01/01/2021 nitroglycerin in nitroglycerin in 5 % dextrose ADD UM: MED Medical Drug d5w in water 01/01/2021 SURVANTA beractant ADD UM: MED Medical Drug 01/01/2021 nitroglycerin in nitroglycerin in 5 % dextrose ADD UM: MED Medical Drug d5w in water 01/01/2021 nitroglycerin in nitroglycerin in 5 % dextrose ADD UM: MED Medical Drug d5w in water

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 335 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 nitroglycerin in nitroglycerin in 5 % dextrose ADD UM: MED Medical Drug d5w in water 01/01/2021 docetaxel docetaxel ADD UM: MED Medical Drug 01/01/2021 SIMULECT basiliximab ADD UM: MED Medical Drug 01/01/2021 HEXTEND hetastarch/electrolyte ADD UM: MED Medical Drug LACTATED solution,lactated ELECTROLYTE 01/01/2021 SOLTAMOX tamoxifen citrate ADD UM: MED Medical Drug 01/01/2021 levophed,norepin norepinephrine bitartrate ADD UM: MED Medical Drug ephrine bitartrate 01/01/2021 sodium chloride 0.9 % sodium chloride ADD UM: MED Medical Drug 01/01/2021 XOFIGO radium-223 dichloride ADD UM: MED Medical Drug 01/01/2021 eloxatin,oxaliplati oxaliplatin ADD UM: MED Medical Drug n 01/01/2021 torisel,temsirolim temsirolimus ADD UM: MED Medical Drug us 01/01/2021 AMVISC hyaluronate sodium ADD UM: MED Medical Drug 01/01/2021 AMVISC PLUS hyaluronate sodium ADD UM: MED Medical Drug 01/01/2021 ILUVIEN fluocinolone acetonide ADD UM: MED Medical Drug 01/01/2021 gablofen,baclofen baclofen ADD UM: MED Medical Drug 01/01/2021 gablofen,baclofen baclofen ADD UM: MED Medical Drug 01/01/2021 indomethacin,ind indomethacin sodium ADD UM: MED Medical Drug ocin i.v. 01/01/2021 NEXAVIR liver extract (beef-pork) ADD UM: MED Medical Drug 01/01/2021 GABLOFEN baclofen ADD UM: MED Medical Drug 01/01/2021 levothyroxine levothyroxine sodium ADD UM: MED Medical Drug sodium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 336 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 levothyroxine levothyroxine sodium ADD UM: MED Medical Drug sodium 01/01/2021 doxorubicin doxorubicin hcl ADD UM: MED Medical Drug hcl,adriamycin 01/01/2021 doxorubicin doxorubicin hcl ADD UM: MED Medical Drug hcl,adriamycin 01/01/2021 THYMOGLOBUL anti-thymocyte ADD UM: MED Medical Drug IN globulin,rabbit 01/01/2021 corvert,ibutilide ibutilide fumarate ADD UM: MED Medical Drug fumarate 01/01/2021 vinorelbine vinorelbine tartrate ADD UM: MED Medical Drug tartrate,navelbine 01/01/2021 DISCOVISC chondroitin sulfate a ADD UM: MED Medical Drug sodium/hyaluronate sodium 01/01/2021 protamine sulfate protamine sulfate ADD UM: MED Medical Drug 01/01/2021 vinorelbine vinorelbine tartrate ADD UM: MED Medical Drug tartrate,navelbine 01/01/2021 CUROSURF poractant alfa ADD UM: MED Medical Drug 01/01/2021 cytarabine cytarabine/pf ADD UM: MED Medical Drug 01/01/2021 MARQIBO vincristine sulfate liposomal ADD UM: MED Medical Drug 01/01/2021 vincasar vincristine sulfate ADD UM: MED Medical Drug pfs,vincristine sulfate 01/01/2021 SURFAXIN lucinactant ADD UM: MED Medical Drug 01/01/2021 MEDIHONEY honey ADD UM: MED Medical Drug 01/01/2021 irinotecan irinotecan hcl ADD UM: MED Medical Drug hcl,camptosar 01/01/2021 irinotecan irinotecan hcl ADD UM: MED Medical Drug hcl,camptosar

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 337 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 TNKASE tenecteplase ADD UM: MED Medical Drug 01/01/2021 promethazine promethazine hcl ADD UM: MED Medical Drug hcl,phenergan 01/01/2021 RYANODEX dantrolene sodium ADD UM: MED Medical Drug 01/01/2021 promethazine promethazine hcl ADD UM: MED Medical Drug hcl,phenergan 01/01/2021 valstar,valrubicin valrubicin ADD UM: MED Medical Drug 01/01/2021 amifostine,ethyol amifostine crystalline ADD UM: MED Medical Drug 01/01/2021 famotidine famotidine in sodium ADD UM: MED Medical Drug chloride, iso-osmotic/pf 01/01/2021 famotidine famotidine ADD UM: MED Medical Drug 01/01/2021 HYPERHEP B hepatitis b immune globulin ADD UM: MED Medical Drug 01/01/2021 HYPERHEP B hepatitis b immune globulin ADD UM: MED Medical Drug 01/01/2021 PREMARIN estrogens, conjugated ADD UM: MED Medical Drug 01/01/2021 nexium esomeprazole sodium ADD UM: MED Medical Drug i.v.,esomeprazole sodium 01/01/2021 BOTOX onabotulinumtoxina ADD UM: MED Medical Drug COSMETIC 01/01/2021 dextrose in dextrose 5 % in lactated ADD UM: MED Medical Drug lactated ringers,dextrose 5% in ringers,dextrose ringers in ringers injection 01/01/2021 PHOTOFRIN porfimer sodium ADD UM: MED Medical Drug 01/01/2021 isuprel,isoprotere isoproterenol hcl ADD UM: MED Medical Drug nol hcl 01/01/2021 SIMULECT basiliximab ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 338 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 liothyronine liothyronine sodium ADD UM: MED Medical Drug sodium,triostat 01/01/2021 ATROPEN atropine sulfate ADD UM: MED Medical Drug 01/01/2021 dobutamine hcl- dobutamine hcl in dextrose ADD UM: MED Medical Drug d5w 5 % in water 01/01/2021 ephedrine sulfate ephedrine sulfate ADD UM: MED Medical Drug 01/01/2021 dobutamine hcl dobutamine hcl ADD UM: MED Medical Drug 01/01/2021 dobutamine hcl dobutamine hcl ADD UM: MED Medical Drug 01/01/2021 prochlorperazine prochlorperazine edisylate ADD UM: MED Medical Drug edisylate 01/01/2021 EUFLEXXA hyaluronate sodium ADD UM: MED Medical Drug 01/01/2021 metastron,stronti strontium-89 chloride ADD UM: MED Medical Drug um-89 chloride 01/01/2021 GEL-ONE hyaluronate sod, cross- ADD UM: MED Medical Drug linked 01/01/2021 LUCENTIS ranibizumab ADD UM: MED Medical Drug 01/01/2021 PROLEUKIN aldesleukin ADD UM: MED Medical Drug 01/01/2021 ABRAXANE paclitaxel protein-bound ADD UM: MED Medical Drug 01/01/2021 PLASMA-LYTE electrolyte-148 solution ADD UM: MED Medical Drug 148 01/01/2021 nipent,pentostatin pentostatin ADD UM: MED Medical Drug 01/01/2021 osmitrol,mannitol mannitol ADD UM: MED Medical Drug 01/01/2021 osmitrol,mannitol mannitol ADD UM: MED Medical Drug 01/01/2021 mannitol,osmitrol mannitol ADD UM: MED Medical Drug 01/01/2021 clolar,clofarabine clofarabine ADD UM: MED Medical Drug 01/01/2021 caffeine caffeine citrate,caffeine ADD UM: MED Medical Drug citrate,cafcit citrated

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 339 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 M.V.I. multivitamin infusion, ADD UM: MED Medical Drug PEDIATRIC pediatric no.2 with vitamin k 01/01/2021 INFUVITE multivitamin infusion, ADD UM: MED Medical Drug PEDIATRIC pediatric no.1 with vitamin k 01/01/2021 heparin lock,hep- heparin sodium,porcine ADD UM: MED Medical Drug lock 01/01/2021 NORMOSOL-R electrolyte-r solution ADD UM: MED Medical Drug 01/01/2021 decitabine,dacog decitabine ADD UM: MED Medical Drug en 01/01/2021 aminophylline aminophylline ADD UM: MED Medical Drug 01/01/2021 aminophylline aminophylline ADD UM: MED Medical Drug 01/01/2021 OCTAGAM immune ADD UM: MED Medical Drug globulin,gamm(igg)/maltose/ iga greater than 50 mcg/ml 01/01/2021 etoposide,toposa etoposide ADD UM: MED Medical Drug r 01/01/2021 MEDIHONEY honey ADD UM: MED Medical Drug 01/01/2021 doxorubicin doxorubicin hcl ADD UM: MED Medical Drug hcl,adriamycin 01/01/2021 doxil,doxorubicin doxorubicin hcl pegylated ADD UM: MED Medical Drug hcl liposomal liposome,lipodox, lipodox 50 01/01/2021 DEPO- estradiol cypionate ADD UM: MED Medical Drug ESTRADIOL 01/01/2021 NPLATE romiplostim ADD UM: MED Medical Drug 01/01/2021 NPLATE romiplostim ADD UM: MED Medical Drug 01/01/2021 metoclopramide metoclopramide hcl ADD UM: MED Medical Drug hcl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 340 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 neomycin- neomycin sulfate/polymyxin ADD UM: MED Medical Drug polymyxin b sulfate b,neosporin g.u. irrigant 01/01/2021 NORMOSOL-R electrolyte-r ADD UM: MED Medical Drug AND DEXTROSE solution/dextrose 5 % in water 01/01/2021 metoclopramide metoclopramide hcl ADD UM: MED Medical Drug hcl,reglan 01/01/2021 theophylline in theophylline in dextrose 5 % ADD UM: MED Medical Drug 5% dextrose in water,theophylline/dextrose 5 % in water 01/01/2021 ETHAMOLIN ethanolamine oleate ADD UM: MED Medical Drug 01/01/2021 NORMOSOL-R electrolyte-r (ph 7.4) ADD UM: MED Medical Drug PH 7.4 01/01/2021 aminophylline aminophylline ADD UM: MED Medical Drug 01/01/2021 VANTAS histrelin acetate ADD UM: MED Medical Drug 01/01/2021 istodax,romidepsi romidepsin ADD UM: MED Medical Drug n 01/01/2021 enalaprilat enalaprilat dihydrate ADD UM: MED Medical Drug 01/01/2021 carboplatin,parap carboplatin ADD UM: MED Medical Drug latin 01/01/2021 estradiol estradiol valerate ADD UM: MED Medical Drug valerate,delestro gen 01/01/2021 potassium potassium chloride in water ADD UM: MED Medical Drug chloride for injection, sterile 01/01/2021 delestrogen,estra estradiol valerate ADD UM: MED Medical Drug diol valerate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 341 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 estradiol estradiol valerate ADD UM: MED Medical Drug valerate,delestro gen 01/01/2021 sodium chloride 0.9 % sodium chloride ADD UM: MED Medical Drug 01/01/2021 LIORESAL baclofen ADD UM: MED Medical Drug INTRATHECAL 01/01/2021 epinephrine epinephrine ADD UM: MED Medical Drug 01/01/2021 RADIGEL acemannan/allantoin ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 342 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 adria- intravenous ADD UM: MED Medical Drug oncoline,acticoat equipment,silver/foam surgical,allevyn bandage,foam adhesive,allevyn, bandage,silver allevyn ag sulfadiazine/foam gentle,allevyn bandage,insulin admin. ag,humapen supplies,diaphragms, arc- memoir,humapen spring,diaphragm fitting luxura hd,ortho set,arc-spring,blood all-flex,hema administration access equipment,anesthesia port,spinal-22 w- tray,nerve stimulator bupiv-epi- device,vial,empty,inhaler, ephed,spinal assist devices,inhaler, assist anesthesia devices, accessories,syringe tray,cont epidural accessory,medical supply, w-bupiv- miscellaneous,diaphragms, epi,reliefband,con wide seal,inhaler,assist t epidural w- device with small lidocaine- mask,inhaler,assist device epi,sterile empty with medium vial,inspirease,no mask,inhaler,assist device rdipen 5,nordipen with large mask,suppository 15,pro-ception mold,syringe, disposable fertility pak,wide irrigation, 70 seal ml,nebulizer,peak flow diaphragm,aeroc meter/inhaler, assist hamber plus flow- devices,peak flow vu,suppository meter,needles, blood mold,toomey collection,needles, syringe,aeroeclip disposable,syringe, se ii,aerotrach disposable, 1 ml,syringe, plus,aerochambe disposable, 12 ml,syringe, r z-stat disposable, 3 ml,syringe, plus,aerochambe disposable, 6 ml,syringe r with with needle,disposable, 6 flowsignal,aeroge ml,syringe with ar asthma action needle,disposable,insulin 1 kit,truzone peak ml,syringe with

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 343 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value flow needle,insulin,0.5 ml,ostomy meter,aerochamb kit,polyhexamethylene er biguanide/gauze mv,aerochamber bandage,bismuth mini,monoject tribromophenate/petrolatum, blood white,iodoform,gauze collection,hypode bandage,gel rmic dressing,porcine acell needle,monoject submucosa,meshed,porcine luer lock tb submucosa, syringe,monoject fenestrated,porcine acellular syringe,monoject small intestine submucosa, pharmacy fenestrated,feeder tray,monoject container,feeder container insulin with gravity set,pump syringe,monoject, set,drainage nutriport bag,catheter,catheterization balloon,curity tray,urinary amd,kerlix amd bag/catheterization bandage,xerofor tray,compression m petrolatum stocking,thigh high,regular dressing,xerofor length,small m,kerlix circumf,compression amd,curity stocking,thigh high,short iodoform,curafil,s length,small pectragel,oasis circumfer,compression ultra,wound stocking,thigh high,regular matrix,burn length,medium matrix,monoject circum,compression luer stocking,thigh high,regular adapter,argyle,t.e length,large .d. sequnt circumf,compression compress stocking,thigh high,long device,kangaroo length,small gravity circumfer.,compression set,kangaroo 924 stocking,thigh high,regular safety length,x-small screw,dover circ.,compression advantage,dover stocking,thigh high,short

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 344 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value premium,dover length,medium advantage circumf.,compression drainage,touch- stocking,thigh high,long trol,robinson length,x-small clear vinyl circumf.,compression catheter,kenguar stocking,thigh high,long d,curity,mono- length,medium flo,dover red circumfer,compression rubber robibson stocking,thigh high,long cath,dover latex length,large foley circumfer.,compression catheter,dover stocking,thigh high,short universal,dover length,large coated latex circumfer,compression foley,t.e.d. anti- stocking,thigh high,reg embolism length,x-large stocking,pudenda circumfer,compression l & stocking,thigh high,long parasympathetic, length,extra-large whitacre spinal circ,compression stocking, needle,security knee high, regular length, bead needle, small,compression stocking, local,blunt knee high, regular length, needle,filter medium,compression needle,eclipse stocking,knee high,regular needle,needle,ins length,large ulin circumf.,compression syringe,ulticare stocking,knee high,regular syringe,ulticare,le length,x-large ver lock circum,compression cannula,interlink stocking,knee high,long syringe w- length,small cannula,integra circumferen,compression syringe,allergist stocking,knee high,long syringe,allergist length,medium tray,syringe- circumfer.,compression needle,eclipse stocking,knee high,long syringe,safety length, large syringe- circumfer.,compression

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 345 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value needle,safetyglid stocking,knee high,long e allergy length, x-large syringe,syringe,a circumf.,needles, spinal- mielle vaginal anesthetic,blunt needle, trainer,rapport disposable,needles, vacuum filter,needles, safety,syringe, therapy,rapport needle, safety 1.5 ml,self- ring loading contained disposal system,carrasyn unit,syringe with hydrogel needle,disposable, 1 wound,insyte ml,syringe with cannula, autoguard,insyte disposable, 10 iv catheter,saf-t- ml,syringe,safety with intima iv needle,3 ml,syring w-needl catheter,nexiva,m 0.5 ml,kit-tray,syringe with yelogram needle,disposable, 0.5 tray,minielite,micr ml,syringe,safety with o elite,inspiration needle,1 ml,syringe, elite disposable, 5 ml,syringe, filter,innospire disposable, 30 replacement ml,miscellaneous medical filter,sidestream supply,vacuum erection mask,sami the device system,penile seal constriction ring mask,catheter,pri systm,syringe reusable, 3 meaire,quake,lite ml,intravenous aire,misterneb catheter,intravenous compressor,inspir catheter kit,myelogram ation tray,nebulizer elite,inspiration,si accessories,mucus clearing destream,mistern device,compressor, for eb pediatric nebulizer,nebulizer and compressor,innos compressor,spirometers and pire accessories,nebulizer/compr elegance,mistern essor, for nebulizer,blood- eb glucose meter, nebulizer,innospir wireless,insulin pump e essence,pflex syringe, 3 ml,insulin pump trainer,asthmapa syringe, 1.8 ml,silver

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 346 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value ck i,asthmapack sulfate/non-adherent ii,asthmapack bandage,silver sulfate/foam iii,asthmapack bandage,middle ear inflation children's,thresho device,sub-q administration ld imt,threshold set, bifurcated,sub-q pep,optihaler,opti administration set, chamber,sidestre trifurcated,sub-q am plus,micro administration set, quad- plus,sidestream furcated,subcutaneous nebulizer,sami administration set,injection the ports,infusion set for insulin seal,litetouch,opti pump,urinary onhome,mini plus bag/catheter,insulin pump nebulizer,opticha cartridge,subcutaneous mber insulin pump,diabetic diamond,procha supplies,miscell,sub-q mber,paradigm insulin delivery device, 40 link blood unit, disposable,sub-q glucose,thinset,fif insulin delivery device, 30 ty50 unit, disposable,sub-q reservoir,restore insulin delivery device, 20 contact layer unit,disposable,cervical silver,restore,ear cap,syringe with popper,neria needle,insulin multi,neria,insuflo disposable,0.5 ml,syringe n,i-port,infusion with needle,insulin set,pillow mask disposable,0.3 ml,syringe for with needle,insulin,0.3 children,silicone ml,syringe,safety with mask,nose needle,12 ml,syringe with clip,rubber cannula,disposable 12 mouthpiece,all ml,syringe with cannula, flow 1000,all flow disposable, 3 ml,syringe 2000,all flow with cannula, disposable, 6 3000 pft,all flow ml,syringe with 3000 kit,all flow needle,disposable,syringe 4000,all flow with needle, insulin, safety, 5000,all flow 1 ml,syringe with needle, 6000,all flow insulin, safety, 0.3

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 347 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 7000,advance ml,syringe with needle, plus insulin, safety, 0.5 intermittent,pocke ml,alcohol swab t chamber,mini- cap,syringe,safety with wright peak flow needle,5 ml,syringe,safety meter,breathrite,p with needle,10 rodigy mini- ml,silver/calcium mist,omnipod,glu alginate,calcium cocom autolink,v- alginate/honey,nasal go 40,v-go 30,v- exhalation resistance go device,blood-glucose 20,femcap,terum transmitter,blood-glucose o meter,continuous,blood- surguard2,needle glucose sensor,blood- -pro glucose edge,monoject meter,continuous/blood- control glucose syringe,monoject transmitter,conception safety assistance supplies syringe,safety combination no.1,colostomy syringe with bag, non-sterile,ostomy shield,monoject supply,sub-q infusion pump smartip accessory,subcutaneous cannula,monoject infusion pump magellan,magella accessory,sub-q n tuberculin administration set,insulin syringe,magellan pump/infusion set/blood- tb safety glucose syringe,magellan meter,container,empty,denta insulin safety l suction syrng,magellan device/chlorhexidine insulin gl/dental swab comb syringe,kendall no.1,dental suction disinfectant device/chlorhexidine/dental cap,restore swab 1/mouthwash,spray calcium applicator kit, sterile,transfer alginate,medihon device, closed ey,riteflo,provent system,needle injector, luer, hr,provent closed system,needle

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 348 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value sr,provent,dexco injector, luer lock, closed m g4,seven system,connector luer lock, plus,seven closed system,infusion system adapter, closed system,y- sensor,conceptio site line connector, closed n,jetco-spray system,assembly system, cannula,breatheri vial to transfer device, te,breatherite closed system,clamp, iv spacer-neonate tubing,intravenous msk,breatherite piggyback administration spacer-infant set,pen needle, mask,breatherite diabetic,hydrocolloid spacer-sm chld dressing,silver,prothrombin msk,breatherite time test strips,amniotic fluid spacer-lg chld detection test,topical cream msk,breatherite metered-dose spacer-adult device,silver/hydrocolloid mask,breatherite dressing,defibrillator,automa spacer-large tic,external,transfer mask,breatherite sets,prothrombin time/inr spacer-medium test meter,fecal collector w- mask,breatherite charcoal spacer-small filter/catheter/syringe, mask,assura,sen dispos,fecal collector with sura click ostomy charcoal pouch,sensura filter/catheter/syringe,gastro flex ostomy base stomy tube,jejunostomy plate,sensura tube,feeding pump,gravity ostomy base feeding set,needles, plate,sensura flex subcutaneous set,iv ostomy administration set,iv admin pouch,female self extension set,iv catheter,conveen administration set/needles, coude intermtnt reusable,iv infusion cath,e-z pump,blood-glucose spacer,accu-chek transmitter/blood-glucose spirit,accu-chek sensor,transcutaneous tender,accu-chek electrical nerve stimulators rapid d,accu- (tens units),infusion set with

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 349 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value chek,accu-chek insulin pump body,insulin ultraflex,accu- pump controller,diaphragms, chek ultraflex coil spring,diaphragms, flat ii,flexlink plus spring,feeder container with infusion pump set,incont set,exacta-mix device,muscle calibration,exacta toner,elt,allantoin,venous -mix eva,devilbiss flow controller,dialysis pulmomate,pulm (peritoneal) kits,contracept o-aide,devilbiss barrier dev, vented,iv pulmo- infusion pump aide,devilbiss accessory,needles, safety disposable huber, disposable,activated nebulizer,devilbis charcoal/silver,ring s pessary,intravenous compact,sunrise administration extension set compressor- with filter,intravenous nebulizer,devilbis administration set,polyvinyl s traveler,q-care alcohol/gentian rx,zymogenetics violet/methylene spray blue,dressing, applicator,phasea collagen/sodium l alginate/carboxymethylcellul protector,phaseal ose,dressing,collagen/silver/ injector sod luer,phaseal alginate/carboxymethylcellul connector ose,intravenous luer,phaseal administration extension adapter,phaseal set,transfer set/syringe, y-site,phaseal disposable/bandages,compr assembly ession/tubing,honey/hydroco fixture,phaseal lloid dressing,sub-q insulin infusion,phaseal pump, continuous glucose secondary monitoring set,pen system,methylene needle,acapella,r blue/gentian violet/foam eplicare bandage,diaphragms, ultra,replicare contoured,spirometer with ultra drug delivery

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 350 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value sacrum,acticoat adapters,foam/gauze 7,acticoat,pari lc bandage/lidocaine/chlorhexi plus dine/isopropyl nebulizer,mouthpi alcohol,enteral pump ece,filter, valve accessory for fat set for ll & lc,filter hydrolysis,syringe, insulin u- pad,baby 500 with needle, disposable, conversion pack 0.5 ml,gas pressurized 1,baby hemostatic spray device and conversion pack accessories,silver/bandage/f 2,mask set with oam/gauze/lidocaine/chlorhe y-piece,trek s xidin/isopropanol,subcutane portable pwr ous bolus insulin patch kit,eflow scf pump, 200 unit, aerosol disposable,flash glucose head,eflow scf sensor,flash glucose nebulizer scanning reader,syringe, handset,smartma enfit 1 ml, sterile,syringe, sk kids,lc d enfit 6 ml, sterile,syringe, nebulizer set,lc enfit 35 ml, sterile,syringe, plus,baby enfit 60 ml, sterile,syringe, nebulizer,lc enfit 3 ml, sterile,syringe, star,sinustar,lc enfit 12 ml, sterile,syringe sprint cap, enfit,non- nebulizer,pari sterile,gastrostomy tube, sinus aerosol enfit,syringe, enfit 60 ml, system,pari lc non-sterile,feeder container sprint sinus,vios with gravity set, aerosol delivery enfit,transcutaneous system,trek s electrical nerve combo pack,trek stimulators(tens)/electrodes, s compact gel-matrix pad dressing, compressor,alter silicone,tens unit a nebulizer,eflow electrodes,syringe, scf,proneb ultra disposable, 20 ml,syringe, ii,proneb ultra ii disposable, 10 deluxe,microspac ml,subcutaneous er,microchamber, administration set, ace aerosol cloud safety,glucose

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 351 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value enhancer,easiven sensor,implantable,continuo t,coaguchek,nor us/dexamethasone m- acetate,pen injector ject,amniscreen,p device,silver/silicone/foam cca accupen- bandage,covid-19 molecular 15,freedom nucleic acid test precision assay,covid-19 control swab airless,watchhale kit,covid-19 igg/igm test r,aerochamber,sil cassette,silicone verseal adhesive,covid-19 antigen hydrogel,e-z immunoassay test,covid-19, spacer influenza a, influenza b pedspak,flutter,h antigen immunoassay test eartstream fr2,hi- volume pumping chamber,coaguc hek xs,inset 30 tubing,comfort short,comfort,con tact detach infusion set,onetouch ping,insulin pump,cartridge,in set infusion set,animas 2020,inset 30 infusion set,flexi- seal fms,primabella,fle xi-seal signal fms,flexiflo,reusa ble nebulizer kit,magna- port,flexiflo quantum,embrac e,patrol,gravity feeding set,flexiflo

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 352 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value magna-port,airs disposable nebulizer,comp- air elite compressor syst,microair mesh nebulizer,comp- air nebulizer compressor,polyfi n,minimed reservoir,paradig m,sof-set,polyfin qr,paradigm infusion,quick release soft teflon,sof-set micro,paradigm silhouette,silhoue tte,minimed infusion,sure- t,sof- sensor,guardian rt starter kit,paradigm real- time,guardian real- time,guardian rt system,replacem ent pediatric monitor,paradigm insulin pump pathway,quick- set paradigm,minime d,guardian test plug,paradigm insulin pump,revel

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 353 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value programmable pump,guardian rt charger,minilink real-time transmitter,sure-t paradigm,mio infusion set,sen- serter,tens 502,tens 504,erapid nebulizer handset,air filter,baby conversion kit,erapid nebulizer,vortex,v ortex holding chamber- toddler,vortex holding chamber- child,vortex vhc ladybug mask,vortex vhc frog mask,response ii,touch ii,piston ii,aeroeclipse,aer ochamber plus z stat,monaghan z stat,snap insulin pump-infusion set,snap insulin pump controller,t:slim,cl eo 90 infusion set,pulmoneb lt compressor nebul,freestyle navigator,ortho-

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 354 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value diaphragm,omnitr ope pen 5,kangaroo epump set,ventstream nebulizer,zoey,ad vance hydro,pelvic muscle trainer,acticoat flex 3,asthma control,heartstart, diab,carrasyn spray gel,deltec cozmo,infusion,d eltec cozmo cleo infusion set,actis,reservoir ,real-time starter kit,enlite glucose sensor,minimed 530g,enlite,enlite serter,dexcom g5-g4 sensor,single shot epidural- lidocaine,inpersol w-o auto shutoff valv,inpersol-auto shutoff valve,cont epidural tray w- drugs,cont epidural-lido-epi t-dose,cont epidural tray,spinal-22- bupiv-dex-ephed- epi,spinal-25- bupiv-dex-ephed-

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 355 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value epi,spinal- anesthesia tray,cont epidural-bupiv- lidocaine,caudal w-lidocaine- epinephrine,spina l-22-tet-ephed- epi-iodine,nerve block tray w- lidocaine,spinal- 25 w-tetra-ephed- epi,saddle block anesthesia tray,saddleblock anesthesia tray,spinal-22 whitacre w-lido- dext,spinal whitacre anesthesia,cont epidural w-pov- iodine,continuous pediatric caudal,cont epidural w-lido- epi-iodin,lea's shield,h-tronplus adapter,h-tron plus-piston rod,h- tron plus,d- tronplus adapter,accu- chek d-tron plus,amigo insulin pump,adapter w- disp mouthpiece,mout

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 356 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value hpiece for truzone peak fl,mask, pediatric,proneb, pep pressure monitor,bubbles the fish,pep nebulizer,lc nebulizer,e-z spacer mask,e-z spacer & mask,gripper plus,actisorb,sim plechoice,simplec hoice quick,aerochamb er plus,airs pediatric aerosol mask,continuous glucose sensor,evacare pessary,novopen echo,sootheneb mesh nebulizer,filtered extension set,rate flow regulator iv set,aerobika,i- port advance,allevyn ag adhesive,allevyn life,hydrofera blue,acticoat flex 7,replicare,replica re thin,biostep,biost ep ag,space chamber

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 357 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value plus,compact space chamber plus,microbore extension set,vascuderm hydrogel wound,varithena administration pack,allevyn heel,aeroneb go,innospire deluxe,innospire mini,inspiracham ber,aeroneb go nebulizer,devilbis s pulmoneb lt comp- neb,animas vibe,apogee hc intermittent,hydro fera blue ready,t:flex,caya contoured,flexich amber,mistassist kit,mistassist,dex com g5,t:90,t:slim g4,aerovent plus,vacustim black,ebase controller,relizorb ,t:30 infusion set,compact space chamber,my mdi portable nebuliser,soothen eb compressor nebulizer,clever choice holding

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 358 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value chamber,portable nebulizer system,pediatric frog nebulizer,pediatri c dog nebulizer,pediatri c dinosaur nebulizer,t:slim x2,minimed pro- set,minimed 630g,minimed 630g guardian start kt,keragel,clever choice nebulizer,insulin syringe u- 500,raplixa delivery kit,vacustim silver,clever choice whisper aire ped,vixone nebulizer,truneb nebulizer,vapro plus intermitt catheter,speedica th,keragelt,oneto uch via,minimed 670g,flexichambe r mask,guardian sensor 3,guardian link 3,home nebulizer plus sidestream,dexco m,autosoft 90,magic3

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 359 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value intermittent catheter,apogee ic intermittent cathetr,freestyle libre 10 day sensor,freestyle libre 10 day reader,ombra compressor system,monoject enfit syringe,monoject enfit syringe cap,compat enfit gastrotube,autos oft 30,varisoft infusion set,trusteel infusion set,inpen (for humalog),inpen (for novolog or fiasp),piston enfit syringe,enteral gravity bag set- enfit,cefaly,sil- k,magellan safety syringe,norm-ject tuberkulin syringe,pro comfort tens unit,pro comfort tens electrode,norm- ject syringe,assure id insulin safety,lc plus nebulizer- ped

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 360 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value mask,dexcom g6,autosoft xc,silivex,cicatrac e pad,scarcinpad,s oft-glide saf-q infusion set,t:slim x2 with basal- iq,omnipod dash 5 pack pod,willis the whale compressr neb,omnipod dash pdm kit,freestyle libre 14 day sensor,freestyle libre 14 day reader,eversense smart transmitter,evers ense sensor- holder,lofric,guar dian connect transmitter,silasti c catheter,flyp nebulizer,siltrex,v go 20,vgo 30,vgo 40,pro comfort spacer with mask,procare compressor nebulizer,innospir e go nebulizer,kelotop, derm- silk,scarsilk,q-cliq pen (for natpara),dover

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 361 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value foley catheter,procare pediatric nebulizer,magella n safety needle,procare spacer with adult mask,procare spacer with child mask,aura portaneb,aceso ag,cellpad,cequr simplicity,xerofor m non-occlusive dressng,cequr simplicity inserter,hyperson iq nebulizer cartridge,minime d sure t,minimed silhouette,minime d mio,id now covid-19 test kit,id now covid- 19 control kit,rapid response covid-19 test,polytoza,t:sli m x2 control- iq,cicasil,strataxrt ,stratactx,freestyl e libre 2 sensor,freestyle libre 2 reader,sofia sars antigen fia,prosilk,pediatri c comp-air compres

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 362 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value neb,minimed quick set,space chamber-small mask,space chamber-medium mask,space chamber-large mask,space chamber,binaxno w covid-19 ag card,minimed 770g,lofric primo nelaton,stratagrt, sofia2 flu-sars antigen fia,szosil 01/01/2021 bcg (tice strain) bcg live ADD UM: MED Medical Drug 01/01/2021 XOLAIR omalizumab ADD UM: MED Medical Drug 01/01/2021 potassium potassium chloride in water ADD UM: MED Medical Drug chloride for injection, sterile 01/01/2021 RETISERT fluocinolone acetonide ADD UM: MED Medical Drug 01/01/2021 sodium sodium chloride 0.9 % ADD UM: MED Medical Drug chloride,normal (flush),0.9 % sodium saline chloride flush,monoject prefill advanced,monoje ct prefill,monoject 0.9% sodium chloride,saline flush,syrex,posifl ush saline,monoject sodium chloride flush,clearshield sodium chlor flush

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 363 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 alprostadil alprostadil ADD UM: MED Medical Drug 01/01/2021 procainamide hcl procainamide hcl ADD UM: MED Medical Drug 01/01/2021 procainamide hcl procainamide hcl ADD UM: MED Medical Drug 01/01/2021 levophed norepinephrine bitartrate ADD UM: MED Medical Drug bitartrate,norepin ephrine bitartrate 01/01/2021 AVEED testosterone undecanoate ADD UM: MED Medical Drug 01/01/2021 ELITEK rasburicase ADD UM: MED Medical Drug 01/01/2021 epinephrine,adre epinephrine ADD UM: MED Medical Drug nalin chloride,adrenalin 01/01/2021 fusilev,levoleucov levoleucovorin calcium ADD UM: MED Medical Drug orin calcium 01/01/2021 docetaxel docetaxel ADD UM: MED Medical Drug 01/01/2021 docetaxel docetaxel ADD UM: MED Medical Drug 01/01/2021 docetaxel docetaxel ADD UM: MED Medical Drug 01/01/2021 PROSTIN VR alprostadil ADD UM: MED Medical Drug PEDIATRIC 01/01/2021 sodium sodium bicarbonate ADD UM: MED Medical Drug bicarbonate 01/01/2021 ATROPEN atropine sulfate ADD UM: MED Medical Drug 01/01/2021 ATROPEN atropine sulfate ADD UM: MED Medical Drug 01/01/2021 carboplatin carboplatin ADD UM: MED Medical Drug 01/01/2021 atropine sulfate atropine sulfate ADD UM: MED Medical Drug 01/01/2021 atropine sulfate atropine sulfate ADD UM: MED Medical Drug 01/01/2021 ONCASPAR pegaspargase ADD UM: MED Medical Drug 01/01/2021 cisplatin cisplatin ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 364 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 dextrose in dextrose 5 % in ADD UM: MED Medical Drug ringers injection ringer's,dextrose 5% in ringers 01/01/2021 GAMMAGARD immune ADD UM: MED Medical Drug LIQUID globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml 01/01/2021 PRIVIGEN immune globulin,gamma ADD UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 01/01/2021 DOCEFREZ docetaxel ADD UM: MED Medical Drug 01/01/2021 DOCEFREZ docetaxel ADD UM: MED Medical Drug 01/01/2021 docetaxel docetaxel ADD UM: MED Medical Drug 01/01/2021 ACTIVASE alteplase ADD UM: MED Medical Drug 01/01/2021 hyalgan,supartz,s hyaluronate sodium ADD UM: MED Medical Drug upartz fx,genvisc 850,visco- 3,trivisc,sodium hyaluronate,trilur on 01/01/2021 ACTIVASE alteplase ADD UM: MED Medical Drug 01/01/2021 GAMUNEX,BIVI immune ADD UM: MED Medical Drug GAM globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml 01/01/2021 HYALGAN hyaluronate sodium ADD UM: MED Medical Drug 01/01/2021 VAPRISOL-5% conivaptan hcl/dextrose 5 % ADD UM: MED Medical Drug DEXTROSE,VAP in water RISOL 01/01/2021 cellcept,mycophe mycophenolate mofetil hcl ADD UM: MED Medical Drug nolate mofetil 01/01/2021 VISCOAT chondroitin sulfate a ADD UM: MED Medical Drug sodium/hyaluronate sodium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 365 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 potassium potassium chloride in water ADD UM: MED Medical Drug chloride for injection, sterile 01/01/2021 potassium potassium chloride in water ADD UM: MED Medical Drug chloride,potassiu for injection, sterile m chloride-water 01/01/2021 potassium potassium ADD UM: MED Medical Drug chloride chloride,potassium chloride in water for injection, sterile 01/01/2021 potassium potassium chloride in water ADD UM: MED Medical Drug chloride for injection, sterile 01/01/2021 MULTITRACE-4 zinc sulfate/cupric ADD UM: MED Medical Drug sulfate/manganese sulf/chromic chloride 01/01/2021 CELLUGEL,OCU hypromellose ADD UM: MED Medical Drug COAT 01/01/2021 ARALAST alpha-1-proteinase inhibitor ADD UM: MED Medical Drug NP,PROLASTIN, ARALAST 01/01/2021 ISOLYTE S electrolyte-s (ph 7.4) ADD UM: MED Medical Drug 01/01/2021 ISOLYTE S electrolyte-s solution ADD UM: MED Medical Drug 01/01/2021 ZEMAIRA,ARAL alpha-1-proteinase inhibitor ADD UM: MED Medical Drug AST NP,PROLASTIN, PROLASTIN C,ARALAST 01/01/2021 vazculep,phenyle phenylephrine hcl ADD UM: MED Medical Drug phrine hcl 01/01/2021 LIORESAL baclofen ADD UM: MED Medical Drug INTRATHECAL 01/01/2021 LIORESAL baclofen ADD UM: MED Medical Drug INTRATHECAL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 366 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 ALFERON N interferon alfa-n3 ADD UM: MED Medical Drug 01/01/2021 JEVTANA cabazitaxel ADD UM: MED Medical Drug 01/01/2021 ORTHOVISC hyaluronate sodium ADD UM: MED Medical Drug 01/01/2021 TESTOPEL testosterone ADD UM: MED Medical Drug 01/01/2021 sodium 0.9 % sodium chloride ADD UM: MED Medical Drug chloride,sodium chloride-water 01/01/2021 copper chloride cupric chloride ADD UM: MED Medical Drug 01/01/2021 sodium chloride sodium chloride 5 % ADD UM: MED Medical Drug 01/01/2021 sodium chloride sodium chloride 3 % ADD UM: MED Medical Drug 01/01/2021 furosemide furosemide ADD UM: MED Medical Drug 01/01/2021 NEXTERONE amiodarone in dextrose, iso- ADD UM: MED Medical Drug osmotic 01/01/2021 KEPIVANCE palifermin ADD UM: MED Medical Drug 01/01/2021 mesnex,mesna mesna ADD UM: MED Medical Drug 01/01/2021 amiodarone hcl amiodarone hcl ADD UM: MED Medical Drug 01/01/2021 furosemide furosemide ADD UM: MED Medical Drug 01/01/2021 NEXTERONE amiodarone in dextrose, iso- ADD UM: MED Medical Drug osmotic 01/01/2021 BELEODAQ belinostat ADD UM: MED Medical Drug 01/01/2021 HYPERHEP B hepatitis b immune globulin ADD UM: MED Medical Drug 01/01/2021 sodium sodium bicarbonate ADD UM: MED Medical Drug bicarbonate 01/01/2021 selenium selenium ADD UM: MED Medical Drug 01/01/2021 sodium sodium bicarbonate ADD UM: MED Medical Drug bicarbonate 01/01/2021 ZANOSAR streptozocin ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 367 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 sodium sodium bicarbonate ADD UM: MED Medical Drug bicarbonate,sodiu m bicarbonate- water 01/01/2021 SOTRADECOL sodium tetradecyl sulfate ADD UM: MED Medical Drug 01/01/2021 vinblastine vinblastine sulfate ADD UM: MED Medical Drug sulfate 01/01/2021 ZOLADEX goserelin acetate ADD UM: MED Medical Drug 01/01/2021 ZOLADEX goserelin acetate ADD UM: MED Medical Drug 01/01/2021 atropine sulfate atropine sulfate ADD UM: MED Medical Drug 01/01/2021 atropine sulfate atropine sulfate ADD UM: MED Medical Drug 01/01/2021 hetastarch in hetastarch in 0.9 % sodium ADD UM: MED Medical Drug ns,hespan,hetast chloride arch-0.9% nacl 01/01/2021 zinecard,dexrazo dexrazoxane hcl ADD UM: MED Medical Drug xane 01/01/2021 terbutaline sulfate terbutaline sulfate ADD UM: MED Medical Drug 01/01/2021 VASHE WOUND sodium chloride irrigating ADD UM: MED Medical Drug THERAPY,VASH solution/hypochlorous acid E WOUND 01/01/2021 manganese manganese chloride ADD UM: MED Medical Drug chloride 01/01/2021 CUROSURF poractant alfa ADD UM: MED Medical Drug 01/01/2021 azacitidine,vidaza azacitidine ADD UM: MED Medical Drug 01/01/2021 hycamtin,topotec topotecan hcl ADD UM: MED Medical Drug an hcl 01/01/2021 VISUDYNE verteporfin ADD UM: MED Medical Drug 01/01/2021 GABLOFEN baclofen ADD UM: MED Medical Drug 01/01/2021 THERACYS bcg live ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 368 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 GABLOFEN baclofen ADD UM: MED Medical Drug 01/01/2021 GABLOFEN baclofen ADD UM: MED Medical Drug 01/01/2021 GAMMAPLEX immune ADD UM: MED Medical Drug globulin,gamm(igg)/sorbitol/ glycin/iga 0 to 50 mcg/ml 01/01/2021 camptosar,irinote irinotecan hcl ADD UM: MED Medical Drug can hcl 01/01/2021 mitomycin,mutam mitomycin ADD UM: MED Medical Drug ycin 01/01/2021 mitomycin,mutam mitomycin ADD UM: MED Medical Drug ycin 01/01/2021 mitomycin,mutam mitomycin ADD UM: MED Medical Drug ycin 01/01/2021 PROVENGE sipuleucel-t/lactated ringers ADD UM: MED Medical Drug solution 01/01/2021 VISIONBLUE trypan blue ADD UM: MED Medical Drug 01/01/2021 NULOJIX belatacept ADD UM: MED Medical Drug 01/01/2021 daunorubicin daunorubicin hcl ADD UM: MED Medical Drug hcl,cerubidine 01/01/2021 daunorubicin hcl daunorubicin hcl ADD UM: MED Medical Drug 01/01/2021 ELITEK rasburicase ADD UM: MED Medical Drug 01/01/2021 dextrose 10%- dextrose 10 % and 0.45 % ADD UM: MED Medical Drug 0.45% nacl sodium chloride 01/01/2021 HYPERRAB S- rabies immune globulin/pf ADD UM: MED Medical Drug D,IMOGAM RABIES- HT,KEDRAB 01/01/2021 bleomycin sulfate bleomycin sulfate ADD UM: MED Medical Drug 01/01/2021 docetaxel docetaxel ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 369 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 IXEMPRA ixabepilone ADD UM: MED Medical Drug 01/01/2021 IXEMPRA ixabepilone ADD UM: MED Medical Drug 01/01/2021 bleomycin bleomycin sulfate ADD UM: MED Medical Drug sulfate,bleo 15k 01/01/2021 gemcitabine hcl gemcitabine hcl ADD UM: MED Medical Drug 01/01/2021 sodium chloride sodium chloride ADD UM: MED Medical Drug 01/01/2021 gemcitabine hcl gemcitabine hcl ADD UM: MED Medical Drug 01/01/2021 sodium chloride sodium chloride ADD UM: MED Medical Drug 01/01/2021 gemcitabine hcl gemcitabine hcl ADD UM: MED Medical Drug 01/01/2021 SYNVISC-ONE hylan g-f 20 ADD UM: MED Medical Drug 01/01/2021 ERWINAZE asparaginase (erwinia ADD UM: MED Medical Drug chrysanthemi) 01/01/2021 fluorouracil,adruci fluorouracil ADD UM: MED Medical Drug l 01/01/2021 EYLEA aflibercept ADD UM: MED Medical Drug 01/01/2021 fluorouracil,adruci fluorouracil ADD UM: MED Medical Drug l 01/01/2021 fluorouracil,adruci fluorouracil ADD UM: MED Medical Drug l 01/01/2021 fluorouracil fluorouracil ADD UM: MED Medical Drug 01/01/2021 dextrose 5%- dextrose 5 % and 0.45 % ADD UM: MED Medical Drug 0.45% sodium chloride nacl,dextrose with sodium chloride

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 370 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 dextrose 5%- dextrose 5 % and 0.9 % ADD UM: MED Medical Drug 0.9% sodium chloride nacl,dextrose with sodium chloride 01/01/2021 HALAVEN eribulin mesylate ADD UM: MED Medical Drug 01/01/2021 TPN sodium/potassium/magnesiu ADD UM: MED Medical Drug ELECTROLYTES m/calcium/chloride/acetate II 01/01/2021 HYPERLYTE CR sodium/potassium/magnesiu ADD UM: MED Medical Drug m/calcium/chloride/acetate 01/01/2021 NUTRILYTE sodium/potassium/magnes/c ADD UM: MED Medical Drug alcium/chloride/acetate/gluc onate 01/01/2021 OMIDRIA phenylephrine hcl/ketorolac ADD UM: MED Medical Drug tromethamine 01/01/2021 oxaliplatin oxaliplatin ADD UM: MED Medical Drug 01/01/2021 faslodex,fulvestra fulvestrant ADD UM: MED Medical Drug nt 01/01/2021 INFASURF calfactant ADD UM: MED Medical Drug 01/01/2021 DYSPORT abobotulinumtoxina ADD UM: MED Medical Drug 01/01/2021 vincasar vincristine sulfate ADD UM: MED Medical Drug pfs,vincristine sulfate 01/01/2021 cytarabine cytarabine/pf ADD UM: MED Medical Drug 01/01/2021 ASCLERA polidocanol ADD UM: MED Medical Drug 01/01/2021 ATRAPRO hypochlorous acid/sodium ADD UM: MED Medical Drug DERMAL SPRAY hypochlorite/sod chlorid/elec.water 01/01/2021 ASCLERA polidocanol ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 371 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 dextrose 5%- dextrose 5 % and 0.2 % ADD UM: MED Medical Drug 0.2% sodium chloride nacl,dextrose 5%-0.225% nacl 01/01/2021 adenocard,adeno adenosine ADD UM: MED Medical Drug sine 01/01/2021 dextrose 10%- dextrose 10 % and 0.2 % ADD UM: MED Medical Drug 0.2% nacl sodium chloride 01/01/2021 adenosine adenosine ADD UM: MED Medical Drug 01/01/2021 swabflush,kendall sodium chloride 0.9 % ADD UM: MED Medical Drug 0.9% nacl with (flush) cap 01/01/2021 FIRMAGON degarelix acetate ADD UM: MED Medical Drug 01/01/2021 FIRMAGON degarelix acetate ADD UM: MED Medical Drug 01/01/2021 XGEVA denosumab ADD UM: MED Medical Drug 01/01/2021 GAMUNEX-C immune ADD UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 01/01/2021 levothyroxine levothyroxine sodium ADD UM: MED Medical Drug sodium 01/01/2021 XYLOCAINE lidocaine hcl/pf ADD UM: MED Medical Drug IV,XYLOCAINE IV FOR CARDIAC 01/01/2021 VORAXAZE glucarpidase ADD UM: MED Medical Drug 01/01/2021 dopamine hcl in dopamine hcl in dextrose 5 ADD UM: MED Medical Drug 5% dextrose % in water 01/01/2021 lidocaine hcl lidocaine hcl/pf ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 372 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 dextrose 5%- dextrose 5 % and 0.3 % ADD UM: MED Medical Drug 0.33% sodium chloride nacl,dextrose 5%-0.3% nacl 01/01/2021 dopamine hcl in dopamine hcl in dextrose 5 ADD UM: MED Medical Drug 5% dextrose % in water,dopamine hcl/dextrose 5 % in water 01/01/2021 tarabine cytarabine ADD UM: MED Medical Drug pfs,cytarabine 01/01/2021 VARIZIG varicella-zoster immune ADD UM: MED Medical Drug globulin/maltose 01/01/2021 cytarabine cytarabine/pf ADD UM: MED Medical Drug 01/01/2021 lidocaine hcl lidocaine hcl/pf ADD UM: MED Medical Drug 01/01/2021 lidocaine hcl lidocaine hcl/pf,lidocaine hcl ADD UM: MED Medical Drug 01/01/2021 HYPERHEP B hepatitis b immune globulin ADD UM: MED Medical Drug 01/01/2021 sodium acetate sodium acetate ADD UM: MED Medical Drug 01/01/2021 chlorothiazide chlorothiazide sodium ADD UM: MED Medical Drug sodium,diuril sodium,sodium diuril 01/01/2021 lidocaine hcl in lidocaine hcl in dextrose 5% ADD UM: MED Medical Drug 5% dextrose in water/pf,lidocaine hcl/dextrose 5%-water/pf 01/01/2021 NABI-HB hepatitis b immune globulin ADD UM: MED Medical Drug 01/01/2021 nitroglycerin nitroglycerin ADD UM: MED Medical Drug 01/01/2021 lidocaine hcl in lidocaine hcl in dextrose 5% ADD UM: MED Medical Drug 5% dextrose in water/pf,lidocaine hcl/dextrose 5%-water/pf 01/01/2021 dopamine hcl dopamine hcl ADD UM: MED Medical Drug 01/01/2021 sodium acetate sodium acetate ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 373 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 revonto,dantrium, dantrolene sodium ADD UM: MED Medical Drug dantrolene sodium 01/01/2021 ARRANON nelarabine ADD UM: MED Medical Drug 01/01/2021 NABI-HB hepatitis b immune globulin ADD UM: MED Medical Drug 01/01/2021 dopamine hcl dopamine hcl ADD UM: MED Medical Drug 01/01/2021 epirubicin hcl epirubicin hcl ADD UM: MED Medical Drug 01/01/2021 idamycin idarubicin hcl ADD UM: MED Medical Drug pfs,idarubicin hcl 01/01/2021 sotradecol,sodiu sodium tetradecyl sulfate ADD UM: MED Medical Drug m tetradecyl sulfate 01/01/2021 sodium chloride 0.9 % sodium chloride ADD UM: MED Medical Drug 01/01/2021 potassium chl- potassium chloride in 0.9 % ADD UM: MED Medical Drug normal saline sodium chloride 01/01/2021 potassium chl- potassium chloride in 0.9 % ADD UM: MED Medical Drug normal saline sodium chloride 01/01/2021 scopolamine scopolamine hydrobromide ADD UM: MED Medical Drug hydrobromide 01/01/2021 TRACE zinc sulfate/cupric ADD UM: MED Medical Drug ELEMENTS-4 sulfate/manganese sulf/chromic chloride 01/01/2021 MULTITRACE-5 zinc sulfate/copper ADD UM: MED Medical Drug sulfate/manganese/chromiu m/selenium 01/01/2021 MULTITRACE-4 zinc sulfate/cupric ADD UM: MED Medical Drug sulfate/manganese sulf/chromic chloride 01/01/2021 levoleucovorin levoleucovorin calcium ADD UM: MED Medical Drug calcium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 374 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 MULTITRACE-5 zinc sulfate/copper ADD UM: MED Medical Drug sulfate/manganese/chromiu m/selenium 01/01/2021 MULTITRACE-4 zinc sulfate/cupric ADD UM: MED Medical Drug sulfate/manganese sulf/chromic chloride 01/01/2021 MULTITRACE-4 zinc sulfate/cupric ADD UM: MED Medical Drug sulfate/manganese sulf/chromic chloride 01/01/2021 dextrose 2.5%- dextrose 2.5 % and 0.45 % ADD UM: MED Medical Drug 0.45% sodium chloride nacl,dextrose with sodium chloride 01/01/2021 zantac,ranitidine ranitidine hcl ADD UM: MED Medical Drug hcl 01/01/2021 TPN sodium/potassium/magnesiu ADD UM: MED Medical Drug ELECTROLYTES m/calcium/chloride/acetate ,NUTRILYTE II 01/01/2021 OCTAGAM immune ADD UM: MED Medical Drug globulin,gamm(igg)/maltose/ iga greater than 50 mcg/ml 01/01/2021 venelex,dermulce balsam peru/castor oil ADD UM: MED Medical Drug ra,bpco,balsam peru-castor oil 01/01/2021 epinephrine epinephrine ADD UM: MED Medical Drug hcl/pf,epinephrine/pf 01/01/2021 D3-2000 cholecalciferol (vitamin d3) ADD TO FORMULARY Non PDL 01/01/2021 adapalene adapalene ADD TO FORMULARY Non PDL 01/01/2021 adapalene adapalene ADD UM: QUANTITY 45 / 30 days 01/01/2021 CATAPRES clonidine hcl CHANGE TIER Preferred Non-Preferred

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 375 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 CATAPRES clonidine hcl ADD UM: PANAME Non Preferred PA 01/01/2021 CATAPRES clonidine hcl CHANGE TIER Preferred Non-Preferred 01/01/2021 CATAPRES clonidine hcl ADD UM: PANAME Non Preferred PA 01/01/2021 CATAPRES clonidine hcl CHANGE TIER Preferred Non-Preferred 01/01/2021 CATAPRES clonidine hcl ADD UM: PANAME Non Preferred PA 01/01/2021 clindamycin- clindamycin REMOVE UM: PANAME benzoyl peroxide phosphate/benzoyl peroxide 01/01/2021 clindamycin- clindamycin REMOVE UM: PANAME Clinical PA benzoyl peroxide phosphate/benzoyl peroxide 01/01/2021 cyclophosphamid cyclophosphamide ADD UM: QUANTITY 60 / 30 days e 01/01/2021 cyclophosphamid cyclophosphamide REMOVE UM: PANAME Clinical PA e 01/01/2021 cyclophosphamid cyclophosphamide ADD UM: QUANTITY 60 / 30 days e 01/01/2021 cyclophosphamid cyclophosphamide REMOVE UM: PANAME Clinical PA e 01/01/2021 erythromycin- erythromycin base/benzoyl ADD TO FORMULARY Non PDL benzoyl peroxide peroxide 01/01/2021 capsaicin capsaicin REMOVE FROM Non PDL Non-Formulary FORMULARY 01/01/2021 lidocaine lidocaine ADD TO FORMULARY Non PDL 01/01/2021 lidocaine lidocaine ADD UM: QUANTITY 100 / 30 days 01/01/2021 lidocaine hcl lidocaine hcl ADD TO FORMULARY Non PDL 01/01/2021 lidocaine hcl lidocaine hcl ADD UM: QUANTITY 85 / 30 days 01/01/2021 EMEND aprepitant CHANGE TIER Preferred Non-Preferred 01/01/2021 KYNMOBI apomorphine hcl ADD TO FORMULARY Non-Preferred

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 376 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 KYNMOBI apomorphine hcl ADD UM: DRUGCLASS ANTIPARKINSO N'S AGENTS - DOPAMINE AGONISTS 01/01/2021 KYNMOBI apomorphine hcl ADD UM: PANAME Clinical PA 01/01/2021 KYNMOBI apomorphine hcl ADD TO FORMULARY Non-Preferred 01/01/2021 KYNMOBI apomorphine hcl ADD UM: DRUGCLASS ANTIPARKINSO N'S AGENTS - DOPAMINE AGONISTS 01/01/2021 KYNMOBI apomorphine hcl ADD UM: PANAME Clinical PA 01/01/2021 KYNMOBI apomorphine hcl ADD TO FORMULARY Non-Preferred 01/01/2021 KYNMOBI apomorphine hcl ADD UM: DRUGCLASS ANTIPARKINSO N'S AGENTS - DOPAMINE AGONISTS 01/01/2021 KYNMOBI apomorphine hcl ADD UM: PANAME Clinical PA 01/01/2021 KYNMOBI apomorphine hcl ADD TO FORMULARY Non-Preferred 01/01/2021 KYNMOBI apomorphine hcl ADD UM: DRUGCLASS ANTIPARKINSO N'S AGENTS - DOPAMINE AGONISTS 01/01/2021 KYNMOBI apomorphine hcl ADD UM: PANAME Clinical PA 01/01/2021 KYNMOBI apomorphine hcl ADD TO FORMULARY Non-Preferred 01/01/2021 KYNMOBI apomorphine hcl ADD UM: DRUGCLASS ANTIPARKINSO N'S AGENTS - DOPAMINE AGONISTS 01/01/2021 KYNMOBI apomorphine hcl ADD UM: PANAME Clinical PA 01/01/2021 KYNMOBI apomorphine hcl ADD TO FORMULARY Non-Preferred

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 377 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 KYNMOBI apomorphine hcl ADD UM: DRUGCLASS ANTIPARKINSO N'S AGENTS - DOPAMINE AGONISTS 01/01/2021 KYNMOBI apomorphine hcl ADD UM: PANAME Clinical PA 01/01/2021 LYUMJEV insulin lispro-aabc ADD TO FORMULARY Non-Preferred KWIKPEN U-200 01/01/2021 LYUMJEV insulin lispro-aabc ADD UM: QUANTITY 90 / claim KWIKPEN U-200 01/01/2021 LYUMJEV insulin lispro-aabc ADD UM: AGE At least 18 yrs KWIKPEN U-200 old 01/01/2021 LYUMJEV insulin lispro-aabc ADD UM: DRUGCLASS INSULINS, KWIKPEN U-200 RAPID ACTING 01/01/2021 LYUMJEV insulin lispro-aabc ADD UM: PANAME Clinical PA KWIKPEN U-200 01/01/2021 LYUMJEV insulin lispro-aabc ADD TO FORMULARY Non-Preferred KWIKPEN U-100 01/01/2021 LYUMJEV insulin lispro-aabc ADD UM: QUANTITY 90 / claim KWIKPEN U-100 01/01/2021 LYUMJEV insulin lispro-aabc ADD UM: AGE At least 18 yrs KWIKPEN U-100 old 01/01/2021 LYUMJEV insulin lispro-aabc ADD UM: DRUGCLASS INSULINS, KWIKPEN U-100 RAPID ACTING 01/01/2021 LYUMJEV insulin lispro-aabc ADD UM: PANAME Clinical PA KWIKPEN U-100 01/01/2021 LYUMJEV insulin lispro-aabc ADD TO FORMULARY Non-Preferred 01/01/2021 LYUMJEV insulin lispro-aabc ADD UM: QUANTITY 90 / claim 01/01/2021 LYUMJEV insulin lispro-aabc ADD UM: AGE At least 18 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 378 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 LYUMJEV insulin lispro-aabc ADD UM: DRUGCLASS INSULINS, RAPID ACTING 01/01/2021 LYUMJEV insulin lispro-aabc ADD UM: PANAME Clinical PA 01/01/2021 LICART diclofenac epolamine ADD TO FORMULARY Non-Preferred 01/01/2021 LICART diclofenac epolamine ADD UM: QUANTITY 15 / 30 days 01/01/2021 LICART diclofenac epolamine ADD UM: DRUGCLASS NON- STEROIDAL ANTI- INFLAMMATORY DRUGS (NSAIDS) 01/01/2021 LICART diclofenac epolamine ADD UM: PANAME Clinical PA 01/01/2021 ORIAHNN elagolix ADD TO FORMULARY Preferred sodium/estradiol/norethindro ne acetate 01/01/2021 ORIAHNN elagolix ADD UM: AGE At least 18 yrs sodium/estradiol/norethindro old ne acetate 01/01/2021 ORIAHNN elagolix ADD UM: PANAME Clinical PA sodium/estradiol/norethindro ne acetate 01/01/2021 XEPI ozenoxacin ADD TO FORMULARY Non-Preferred 01/01/2021 XEPI ozenoxacin ADD UM: QUANTITY 60 / 30 days 01/01/2021 XEPI ozenoxacin ADD UM: DRUGCLASS TOPICAL ANTIBIOTICS 01/01/2021 XEPI ozenoxacin ADD UM: PANAME Clinical PA 01/01/2021 ZEPOSIA ozanimod hydrochloride ADD TO FORMULARY Non-Preferred 01/01/2021 ZEPOSIA ozanimod hydrochloride ADD UM: DRUGCLASS MULTIPLE SCLEROSIS AGENTS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 379 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 ZEPOSIA ozanimod hydrochloride ADD UM: PANAME Clinical PA 01/01/2021 ZEPOSIA ozanimod hydrochloride ADD TO FORMULARY Non-Preferred 01/01/2021 ZEPOSIA ozanimod hydrochloride ADD UM: DRUGCLASS MULTIPLE SCLEROSIS AGENTS 01/01/2021 ZEPOSIA ozanimod hydrochloride ADD UM: PANAME Clinical PA 01/01/2021 ZEPOSIA ozanimod hydrochloride ADD TO FORMULARY Non-Preferred 01/01/2021 ZEPOSIA ozanimod hydrochloride ADD UM: DRUGCLASS MULTIPLE SCLEROSIS AGENTS 01/01/2021 ZEPOSIA ozanimod hydrochloride ADD UM: PANAME Clinical PA 01/01/2021 EVRYSDI risdiplam ADD UM: CUSTOM Carve-Out. Bill MDHHS FFs. 01/01/2021 PRIMLEV oxycodone REMOVE FROM Non-Preferred Non-Formulary hcl/acetaminophen FORMULARY 01/01/2021 PRIMLEV oxycodone REMOVE FROM Non-Preferred Non-Formulary hcl/acetaminophen FORMULARY 01/01/2021 PRIMLEV oxycodone REMOVE FROM Non-Preferred Non-Formulary hcl/acetaminophen FORMULARY 01/01/2021 TOSYMRA sumatriptan ADD UM: QUANTITY 6 / claim 01/01/2021 NEXLETOL bempedoic acid CHANGE UM: PANAME Non Preferred PA Clinical PA 01/01/2021 flavoxate hcl flavoxate hcl ADD TO FORMULARY Non-Preferred 01/01/2021 flavoxate hcl flavoxate hcl ADD UM: PANAME Non Preferred PA 01/01/2021 DIFICID fidaxomicin ADD TO FORMULARY Non-Preferred 01/01/2021 DIFICID fidaxomicin ADD UM: DRUGCLASS GASTROINTEST INAL ANTIBIOTICS 01/01/2021 DIFICID fidaxomicin ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 380 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 RETACRIT epoetin alfa-epbx ADD TO FORMULARY Preferred 01/01/2021 RETACRIT epoetin alfa-epbx ADD UM: PANAME Clinical PA 01/01/2021 SILAPAP acetaminophen ADD TO FORMULARY Non PDL 01/01/2021 nitazoxanide nitazoxanide ADD TO FORMULARY Non-Preferred 01/01/2021 nitazoxanide nitazoxanide ADD UM: DRUGCLASS GASTROINTEST INAL ANTIBIOTICS 01/01/2021 nitazoxanide nitazoxanide ADD UM: PANAME Clinical PA 01/01/2021 ORGOVYX relugolix ADD TO FORMULARY Non PDL 01/01/2021 ORGOVYX relugolix ADD UM: PANAME Clinical PA 01/01/2021 omeprazole omeprazole ADD TO FORMULARY Non-Preferred 01/01/2021 omeprazole omeprazole ADD UM: PANAME Non Preferred PA 01/01/2021 E.E.S. 200 erythromycin ethylsuccinate REMOVE UM: B4G BRAND FOR GENERIC 01/01/2021 erythromycin erythromycin ethylsuccinate REMOVE UM: COV Use brand over ethylsuccinate generic 01/01/2021 EMEND aprepitant REMOVE UM: B4G BRAND FOR GENERIC 01/01/2021 adapalene adapalene REMOVE FROM Non PDL Non-Formulary FORMULARY 01/01/2021 adapalene adapalene REMOVE FROM Non PDL Non-Formulary FORMULARY 01/01/2021 adapalene adapalene REMOVE FROM Non PDL Non-Formulary FORMULARY 01/01/2021 VESTURA ethinyl ADD TO FORMULARY Non PDL estradiol/drospirenone 01/01/2021 ZYPITAMAG pitavastatin magnesium REMOVE FROM Non-Preferred Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 381 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 ZYPITAMAG pitavastatin magnesium REMOVE UM: QUANTITY 1 / day 01/13/2021 magnesium magnesium REMOVE FROM Non PDL Non-Formulary FORMULARY 01/13/2021 KLOR-CON-EF potassium bicarbonate/citric ADD TO FORMULARY Non PDL acid 01/13/2021 methylergonovine methylergonovine maleate ADD TO FORMULARY Non PDL maleate 01/13/2021 AMITIZA lubiprostone ADD UM: B4G BRAND FOR GENERIC 01/13/2021 AMITIZA lubiprostone ADD UM: B4G BRAND FOR GENERIC 01/13/2021 lubiprostone lubiprostone ADD TO FORMULARY Non-Preferred 01/13/2021 lubiprostone lubiprostone ADD UM: DRUGCLASS GI MOTILITY, CHRONIC 01/13/2021 lubiprostone lubiprostone ADD UM: PANAME Non Preferred PA 01/13/2021 lubiprostone lubiprostone ADD UM: COV Use brand over generic 01/13/2021 lubiprostone lubiprostone ADD TO FORMULARY Non-Preferred 01/13/2021 lubiprostone lubiprostone ADD UM: DRUGCLASS GI MOTILITY, CHRONIC 01/13/2021 lubiprostone lubiprostone ADD UM: PANAME Non Preferred PA 01/13/2021 lubiprostone lubiprostone ADD UM: COV Use brand over generic 01/13/2021 TECFIDERA dimethyl fumarate ADD UM: B4G BRAND FOR GENERIC 01/13/2021 dimethyl dimethyl fumarate ADD UM: COV Use brand over fumarate generic 01/13/2021 ULTRA FRESH carboxymethylcellulose ADD TO FORMULARY Non PDL sodium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 382 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/13/2021 METHERGINE methylergonovine maleate REMOVE FROM Non PDL Non-Formulary FORMULARY 01/13/2021 METHERGINE methylergonovine maleate REMOVE UM: AGE At least 12 yrs old 01/13/2021 METHERGINE methylergonovine maleate REMOVE UM: QUANTITY 28 / 180 days 01/13/2021 methylergonovine methylergonovine maleate ADD UM: QUANTITY 28 / 180 days maleate 01/13/2021 PATADAY ONCE olopatadine hcl ADD TO FORMULARY Non-Preferred DAILY RELIEF 01/13/2021 PATADAY ONCE olopatadine hcl ADD UM: DRUGCLASS OPHTHALMIC DAILY RELIEF ANTIHISTAMINE S 01/13/2021 PATADAY ONCE olopatadine hcl ADD UM: PANAME Non Preferred PA DAILY RELIEF 01/13/2021 compact space inhaler,assist device with ADD TO FORMULARY Non PDL chamber large mask 01/13/2021 compact space inhaler,assist device with ADD UM: QUANTITY 4 / 365 days chamber large mask 01/13/2021 compact space inhaler,assist device with ADD TO FORMULARY Non PDL chamber medium mask 01/13/2021 compact space inhaler,assist device with ADD UM: QUANTITY 4 / 365 days chamber medium mask 01/13/2021 compact space inhaler,assist device with ADD TO FORMULARY Non PDL chamber small mask 01/13/2021 compact space inhaler,assist device with ADD UM: QUANTITY 4 / 365 days chamber small mask 01/13/2021 compact space inhaler,assist device with REMOVE UM: MED Medical Drug chamber small mask 01/13/2021 compact space inhaler,assist device with REMOVE UM: MED Medical Drug chamber medium mask

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 383 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/13/2021 compact space inhaler,assist device with REMOVE UM: MED Medical Drug chamber large mask 01/13/2021 compact space inhaler, assist devices REMOVE UM: MED Medical Drug chamber plus 01/13/2021 AKYNZEO fosnetupitant chloride ADD TO FORMULARY Non-Preferred hcl/palonosetron hcl 01/13/2021 AKYNZEO fosnetupitant chloride ADD UM: QUANTITY 1 / claim hcl/palonosetron hcl 01/13/2021 AKYNZEO fosnetupitant chloride ADD UM: DRUGCLASS ANTIEMETICS hcl/palonosetron hcl 01/13/2021 AKYNZEO fosnetupitant chloride ADD UM: PANAME Clinical PA hcl/palonosetron hcl 01/13/2021 VESICARE LS solifenacin succinate ADD TO FORMULARY Non-Preferred 01/13/2021 VESICARE LS solifenacin succinate ADD UM: DRUGCLASS URINARY TRACT ANTISPASMODI CS 01/13/2021 VESICARE LS solifenacin succinate ADD UM: PANAME Non Preferred PA 01/13/2021 TEPMETKO tepotinib hcl ADD UM: CUSTOM Carve-Out Bill MDHHS FFS 01/13/2021 VOCABRIA cabotegravir sodium ADD UM: CUSTOM Carve-Out Bill MDHHS FFS 01/13/2021 REBIF interferon beta-1a/albumin CHANGE TIER Preferred Non-Preferred REBIDOSE human 01/13/2021 REBIF interferon beta-1a/albumin ADD UM: PANAME Non Preferred PA REBIDOSE human

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 384 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

February, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2021 erythromycin erythromycin ethylsuccinate CHANGE TIER Non-Preferred Preferred ethylsuccinate 02/01/2021 erythromycin erythromycin ethylsuccinate REMOVE UM: COV Use brand over ethylsuccinate generic 02/01/2021 erythromycin erythromycin ethylsuccinate REMOVE UM: PANAME Non Preferred PA ethylsuccinate 02/01/2021 tramadol hcl er tramadol hcl CHANGE TIER Non-Preferred Preferred 02/01/2021 tramadol hcl er tramadol hcl REMOVE UM: PANAME Non Preferred PA 02/01/2021 tramadol hcl er tramadol hcl CHANGE TIER Non-Preferred Preferred 02/01/2021 tramadol hcl er tramadol hcl REMOVE UM: PANAME Non Preferred PA 02/01/2021 tramadol hcl er tramadol hcl CHANGE TIER Non-Preferred Preferred 02/01/2021 tramadol hcl er tramadol hcl REMOVE UM: PANAME Non Preferred PA 02/01/2021 BUTRANS buprenorphine CHANGE TIER Non-Preferred Preferred 02/01/2021 BUTRANS buprenorphine REMOVE UM: PANAME Non Preferred PA 02/01/2021 BUTRANS buprenorphine CHANGE TIER Non-Preferred Preferred 02/01/2021 BUTRANS buprenorphine REMOVE UM: PANAME Non Preferred PA 02/01/2021 BUTRANS buprenorphine CHANGE TIER Non-Preferred Preferred 02/01/2021 BUTRANS buprenorphine REMOVE UM: PANAME Non Preferred PA 02/01/2021 BUTRANS buprenorphine CHANGE TIER Non-Preferred Preferred 02/01/2021 BUTRANS buprenorphine REMOVE UM: PANAME Non Preferred PA 02/01/2021 BUTRANS buprenorphine CHANGE TIER Non-Preferred Preferred 02/01/2021 BUTRANS buprenorphine REMOVE UM: PANAME Non Preferred PA 02/01/2021 tramadol hcl- tramadol hcl/acetaminophen CHANGE TIER Non-Preferred Preferred acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 385 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2021 tramadol hcl- tramadol hcl/acetaminophen REMOVE UM: PANAME Non Preferred PA acetaminophen 02/01/2021 clonidine clonidine CHANGE TIER Preferred Non-Preferred 02/01/2021 clonidine clonidine ADD UM: PANAME Non Preferred PA 02/01/2021 clonidine clonidine CHANGE TIER Preferred Non-Preferred 02/01/2021 clonidine clonidine ADD UM: PANAME Non Preferred PA 02/01/2021 clonidine clonidine CHANGE TIER Preferred Non-Preferred 02/01/2021 clonidine clonidine ADD UM: PANAME Non Preferred PA 02/01/2021 CATAPRES-TTS clonidine ADD UM: COV Use brand over 1 generic 02/01/2021 CATAPRES-TTS clonidine ADD UM: B4G BRAND FOR 1 GENERIC 02/01/2021 CATAPRES-TTS clonidine ADD UM: COV Use brand over 3 generic 02/01/2021 CATAPRES-TTS clonidine ADD UM: B4G BRAND FOR 3 GENERIC 02/01/2021 CATAPRES-TTS clonidine ADD UM: COV Use brand over 2 generic 02/01/2021 CATAPRES-TTS clonidine ADD UM: B4G BRAND FOR 2 GENERIC 02/01/2021 carbidopa- carbidopa/levodopa CHANGE TIER Non-Preferred Preferred levodopa er,carbidopa- levodopa 02/01/2021 carbidopa- carbidopa/levodopa REMOVE UM: PANAME Non Preferred PA levodopa er,carbidopa- levodopa

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 386 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2021 carbidopa- carbidopa/levodopa CHANGE TIER Non-Preferred Preferred levodopa er,carbidopa- levodopa 02/01/2021 carbidopa- carbidopa/levodopa REMOVE UM: PANAME Non Preferred PA levodopa er,carbidopa- levodopa 02/01/2021 NEUPRO rotigotine ADD UM: QUANTITY 30 / 30 days 02/01/2021 NEUPRO rotigotine ADD UM: QUANTITY 30 / 30 days 02/01/2021 NEUPRO rotigotine ADD UM: QUANTITY 30 / 30 days 02/01/2021 NEUPRO rotigotine ADD UM: QUANTITY 30 / 30 days 02/01/2021 NEUPRO rotigotine ADD UM: QUANTITY 30 / 30 days 02/01/2021 NEUPRO rotigotine ADD UM: QUANTITY 30 / 30 days 02/01/2021 SAVELLA milnacipran hcl ADD UM: QUANTITY 60 / 30 days 02/01/2021 SAVELLA milnacipran hcl ADD UM: QUANTITY 60 / 30 days 02/01/2021 SAVELLA milnacipran hcl ADD UM: QUANTITY 60 / 30 days 02/01/2021 SAVELLA milnacipran hcl ADD UM: QUANTITY 60 / 30 days 02/01/2021 SAVELLA milnacipran hcl ADD UM: QUANTITY 60 / 30 days 02/01/2021 RELPAX eletriptan hydrobromide CHANGE TIER Preferred Non-Preferred 02/01/2021 RELPAX eletriptan hydrobromide ADD UM: PANAME Non Preferred PA 02/01/2021 RELPAX eletriptan hydrobromide REMOVE UM: B4G BRAND FOR GENERIC 02/01/2021 RELPAX eletriptan CHANGE TIER Preferred Non-Preferred hydrobromide,eletriptan hbr 02/01/2021 RELPAX eletriptan ADD UM: PANAME Non Preferred PA hydrobromide,eletriptan hbr

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 387 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2021 RELPAX eletriptan REMOVE UM: B4G BRAND FOR hydrobromide,eletriptan hbr GENERIC 02/01/2021 eletriptan hbr eletriptan hydrobromide REMOVE UM: COV Use brand over generic 02/01/2021 eletriptan hbr eletriptan hydrobromide REMOVE UM: COV Use brand over generic 02/01/2021 IMITREX sumatriptan CHANGE TIER Non-Preferred Preferred 02/01/2021 IMITREX sumatriptan REMOVE UM: PANAME Non Preferred PA 02/01/2021 IMITREX sumatriptan CHANGE TIER Non-Preferred Preferred 02/01/2021 IMITREX sumatriptan REMOVE UM: PANAME Non Preferred PA 02/01/2021 sumatriptan sumatriptan ADD UM: COV Use brand over generic 02/01/2021 sumatriptan sumatriptan ADD UM: COV Use brand over generic 02/01/2021 ZOMIG zolmitriptan CHANGE TIER Preferred Non-Preferred 02/01/2021 ZOMIG zolmitriptan ADD UM: PANAME Non Preferred PA 02/01/2021 ZOMIG zolmitriptan CHANGE TIER Preferred Non-Preferred 02/01/2021 ZOMIG zolmitriptan ADD UM: PANAME Non Preferred PA 02/01/2021 HORIZANT gabapentin enacarbil CHANGE UM: QUANTITY 4 / day 2 / day 02/01/2021 GRALISE gabapentin CHANGE UM: QUANTITY 3 / day 02/01/2021 betamethasone betamethasone dipropionate CHANGE TIER Non-Preferred Preferred dipropionate 02/01/2021 betamethasone betamethasone dipropionate REMOVE UM: PANAME Non Preferred PA dipropionate 02/01/2021 betamethasone betamethasone dipropionate CHANGE TIER Non-Preferred Preferred dipropionate 02/01/2021 betamethasone betamethasone dipropionate REMOVE UM: PANAME Non Preferred PA dipropionate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 388 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2021 REBIF interferon beta-1a/albumin CHANGE TIER Preferred Non-Preferred REBIDOSE human 02/01/2021 REBIF interferon beta-1a/albumin ADD UM: PANAME Non Preferred PA REBIDOSE human 02/01/2021 REBIF interferon beta-1a/albumin CHANGE TIER Preferred Non-Preferred REBIDOSE human 02/01/2021 REBIF interferon beta-1a/albumin ADD UM: PANAME Non Preferred PA REBIDOSE human 02/01/2021 REBIF interferon beta-1a/albumin CHANGE TIER Preferred Non-Preferred human 02/01/2021 REBIF interferon beta-1a/albumin ADD UM: PANAME Non Preferred PA human 02/01/2021 REBIF interferon beta-1a/albumin CHANGE TIER Preferred Non-Preferred human 02/01/2021 REBIF interferon beta-1a/albumin ADD UM: PANAME Non Preferred PA human 02/01/2021 REBIF interferon beta-1a/albumin CHANGE TIER Preferred Non-Preferred human 02/01/2021 REBIF interferon beta-1a/albumin ADD UM: PANAME Non Preferred PA human 02/01/2021 EUCRISA crisaborole CHANGE TIER Non-Preferred Preferred 02/01/2021 EUCRISA crisaborole CHANGE UM: PANAME Non Preferred PA Clinical PA 02/01/2021 LUCEMYRA lofexidine hcl CHANGE TIER Non PDL Non-Preferred 02/01/2021 LUCEMYRA lofexidine hcl CHANGE UM: QUANTITY 16 / day 224/14 days 02/01/2021 ORILISSA elagolix sodium CHANGE TIER Non PDL Preferred 02/01/2021 ORILISSA elagolix sodium CHANGE TIER Non PDL Preferred 02/01/2021 clindamycin clindamycin CHANGE TIER Non-Preferred Preferred phos-benzoyl phosphate/benzoyl peroxide perox

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 389 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2021 clindamycin clindamycin REMOVE UM: PANAME Non Preferred PA phos-benzoyl phosphate/benzoyl peroxide perox 02/01/2021 clonidine hcl clonidine hcl CHANGE TIER Preferred 02/01/2021 clonidine hcl clonidine hcl CHANGE TIER Preferred 02/01/2021 clonidine hcl clonidine hcl CHANGE TIER Preferred 02/01/2021 NEXIUM esomeprazole magnesium CHANGE TIER Non-Preferred Preferred 02/01/2021 NEXIUM esomeprazole magnesium CHANGE TIER Non-Preferred Preferred 02/01/2021 NEXIUM esomeprazole magnesium CHANGE TIER Non-Preferred Preferred 02/01/2021 NEXIUM esomeprazole magnesium CHANGE TIER Non-Preferred Preferred 02/01/2021 NEXIUM esomeprazole magnesium CHANGE TIER Non-Preferred Preferred 02/01/2021 NEXIUM esomeprazole magnesium CHANGE TIER Non-Preferred Preferred 02/01/2021 NEXIUM esomeprazole magnesium CHANGE TIER Non-Preferred Preferred 02/01/2021 clindamycin clindamycin REMOVE UM: PANAME Clinical PA phos-benzoyl phosphate/benzoyl peroxide perox 02/01/2021 betamethasone betamethasone dipropionate CHANGE TIER Non-Preferred Preferred dipropionate 02/01/2021 betamethasone betamethasone dipropionate REMOVE UM: PANAME Non Preferred PA dipropionate 02/01/2021 NEXLIZET bempedoic acid/ezetimibe ADD TO FORMULARY Non-Preferred 02/01/2021 NEXLIZET bempedoic acid/ezetimibe ADD UM: AGE At least 18 yrs old 02/01/2021 NEXLIZET bempedoic acid/ezetimibe ADD UM: PANAME Non Preferred PA 02/01/2021 NEXLIZET bempedoic acid/ezetimibe ADD UM: DRUGCLASS LIPOTROPICS: OTHER 02/01/2021 NEXIUM esomeprazole magnesium REMOVE UM: PANAME Non Preferred PA 02/01/2021 NEXIUM esomeprazole magnesium REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 390 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2021 NEXIUM esomeprazole magnesium REMOVE UM: PANAME Non Preferred PA 02/01/2021 NEXIUM esomeprazole magnesium REMOVE UM: PANAME Non Preferred PA 02/01/2021 NEXIUM esomeprazole magnesium REMOVE UM: PANAME Non Preferred PA 02/01/2021 NEXIUM esomeprazole magnesium ADD UM: B4G BRAND FOR GENERIC 02/01/2021 NEXIUM esomeprazole magnesium ADD UM: B4G BRAND FOR GENERIC 02/01/2021 NEXIUM esomeprazole magnesium REMOVE UM: B4G BRAND FOR GENERIC 02/01/2021 NEXIUM esomeprazole magnesium REMOVE UM: B4G BRAND FOR GENERIC 02/01/2021 NEXIUM esomeprazole magnesium ADD UM: B4G BRAND FOR GENERIC 02/01/2021 NEXIUM esomeprazole magnesium ADD UM: B4G BRAND FOR GENERIC 02/01/2021 NEXIUM esomeprazole magnesium ADD UM: B4G BRAND FOR GENERIC 02/01/2021 NEXIUM esomeprazole magnesium CHANGE TIER Preferred Non-Preferred 02/01/2021 NEXIUM esomeprazole magnesium CHANGE TIER Preferred Non-Preferred 02/01/2021 NEXIUM esomeprazole magnesium ADD UM: B4G BRAND FOR GENERIC 02/01/2021 NEXIUM esomeprazole magnesium ADD UM: B4G BRAND FOR GENERIC 02/01/2021 NEXIUM esomeprazole magnesium REMOVE UM: B4G BRAND FOR GENERIC 02/01/2021 NEXIUM esomeprazole magnesium REMOVE UM: B4G BRAND FOR GENERIC 02/01/2021 DIFFERIN adapalene REMOVE FROM Non PDL Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 391 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2021 DIFFERIN adapalene REMOVE UM: QUANTITY 45 / 30 days 02/01/2021 tavaborole tavaborole ADD TO FORMULARY Non-Preferred 02/01/2021 tavaborole tavaborole ADD UM: PANAME Clinical PA 02/01/2021 ASMANEX mometasone furoate ADD UM: QUANTITY 1 / 28 days 02/01/2021 FLOVENT HFA fluticasone propionate CHANGE UM: QUANTITY 4.3 / Day 10.6 / 30 days 02/01/2021 FLOVENT HFA fluticasone propionate CHANGE UM: QUANTITY 2.1 / Day 12 / 30 days 02/01/2021 FLOVENT HFA fluticasone propionate CHANGE UM: QUANTITY 1.3 / Day 24 / 30 days 02/01/2021 SPIRIVA tiotropium bromide ADD UM: QUANTITY 4 / 30 days RESPIMAT 02/01/2021 ATROVENT HFA ipratropium bromide CHANGE UM: QUANTITY 0.9 / Day 25.8 / 30 days 02/01/2021 PROAIR HFA albuterol sulfate CHANGE UM: QUANTITY 1.2 / Day 17 / 30 days 02/01/2021 PROVENTIL albuterol sulfate CHANGE UM: QUANTITY 1.2 / Day 13.4 / 30 days HFA 02/01/2021 XOPENEX HFA levalbuterol tartrate CHANGE UM: QUANTITY 0.9 / Day 30 / 30 days 02/01/2021 SPIRIVA tiotropium bromide ADD UM: QUANTITY 4 / 30 days RESPIMAT 02/01/2021 levalbuterol levalbuterol tartrate CHANGE UM: QUANTITY 0.9 / Day 30 / 30 days tartrate hfa 02/01/2021 CATAPRES-TTS clonidine REMOVE UM: COV Use brand over 1 generic 02/01/2021 CATAPRES-TTS clonidine REMOVE UM: COV Use brand over 3 generic 02/01/2021 CATAPRES-TTS clonidine REMOVE UM: COV Use brand over 2 generic 02/01/2021 clonidine clonidine ADD UM: COV Use brand over generic 02/01/2021 clonidine clonidine ADD UM: COV Use brand over generic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 392 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2021 clonidine clonidine ADD UM: COV Use brand over generic 02/01/2021 SPIRIVA tiotropium bromide CHANGE UM: QUANTITY 2 / Day 30 / 30 days 02/01/2021 SPIRIVA tiotropium bromide CHANGE UM: QUANTITY 2 / Day 5 / 5 days 02/01/2021 SPIRIVA tiotropium bromide CHANGE UM: QUANTITY 2 / Day 90 / 90 days 02/01/2021 SEREVENT salmeterol xinafoate CHANGE UM: QUANTITY 2 / Day 28 / 30 days DISKUS 02/01/2021 SEREVENT salmeterol xinafoate CHANGE UM: QUANTITY 2 / Day 60 / 30 days DISKUS 02/01/2021 VENTOLIN HFA albuterol sulfate CHANGE UM: QUANTITY 1.2 / Day 36 / 30 days 02/01/2021 VENTOLIN HFA albuterol sulfate CHANGE UM: QUANTITY 1.2 / Day 16 / 30 days 02/01/2021 albuterol sulfate albuterol sulfate CHANGE UM: QUANTITY 1.2 / day 17 / 30 days hfa 02/01/2021 albuterol sulfate albuterol sulfate CHANGE UM: QUANTITY 1.2 / day 13.4 / 30 days hfa 02/01/2021 albuterol sulfate albuterol sulfate CHANGE UM: QUANTITY 1.2 / day 36 / 30 days hfa 02/01/2021 azithromycin azithromycin REMOVE UM: QUANTITY 6 / claim 02/01/2021 NURTEC ODT rimegepant sulfate CHANGE UM: QUANTITY 15 / 30 days 16 / 34 days 02/01/2021 celecoxib celecoxib CHANGE UM: QUANTITY 2 / day 02/01/2021 CELEBREX celecoxib CHANGE UM: QUANTITY 1 / Day 2 / day 02/01/2021 celecoxib celecoxib CHANGE UM: QUANTITY 2 / day 02/01/2021 celecoxib celecoxib CHANGE UM: QUANTITY 2 / day 02/01/2021 CELEBREX celecoxib CHANGE UM: QUANTITY 1 / Day 2 / day 02/01/2021 celecoxib celecoxib CHANGE UM: QUANTITY 2 / day 02/01/2021 CELEBREX celecoxib CHANGE UM: QUANTITY 1 / Day 2 / day 02/01/2021 CELEBREX celecoxib CHANGE UM: QUANTITY 1 / Day 2 / day

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 393 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2021 MYLANTA,MYLA magnesium ADD TO FORMULARY Non PDL NTA MAXIMUM hydroxide/aluminum STRENGTH,MYL hydroxide/simethicone ANTA DOUBLE- STRENGTH 02/03/2021 zolmitriptan zolmitriptan ADD TO FORMULARY Non-Preferred 02/03/2021 zolmitriptan zolmitriptan ADD UM: PANAME Non Preferred PA 02/03/2021 zolmitriptan zolmitriptan ADD UM: DRUGCLASS ANTIMIGRAINE AGENTS, TRIPTANS 02/03/2021 zolmitriptan zolmitriptan ADD TO FORMULARY Non-Preferred 02/03/2021 zolmitriptan zolmitriptan ADD UM: DRUGCLASS ANTIMIGRAINE AGENTS, TRIPTANS 02/03/2021 zolmitriptan zolmitriptan ADD UM: PANAME Non Preferred PA 02/09/2021 ALYQ tadalafil CHANGE TIER Non-Preferred Preferred 02/09/2021 ALYQ tadalafil CHANGE UM: PANAME Non Preferred PA Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 394 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

March, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 fentanyl fentanyl citrate ADD UM: CUSTOM Cumulative MED citrate,actiq 120 mg/day Edit 03/01/2021 exalgo,hydromor hydromorphone hcl ADD UM: CUSTOM Cumulative MED phone er 120 mg/day Edit 03/01/2021 methadone hcl methadone hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 carisoprodol carisoprodol/aspirin/codeine ADD UM: CUSTOM Cumulative MED compound- phosphate,codeine 120 mg/day Edit codeine,carisopro phosphate/carisoprodol/aspi dol-aspirin- rin codeine 03/01/2021 fentanyl- fentanyl citrate/bupivacaine ADD UM: CUSTOM Cumulative MED bupivacaine- hcl in 0.9 % sodium 120 mg/day Edit 0.9% nacl chloride/pf 03/01/2021 exalgo,hydromor hydromorphone hcl ADD UM: CUSTOM Cumulative MED phone er 120 mg/day Edit 03/01/2021 fentanyl,duragesi fentanyl ADD UM: CUSTOM Cumulative MED c 120 mg/day Edit 03/01/2021 fentanyl,duragesi fentanyl ADD UM: CUSTOM Cumulative MED c 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in ADD UM: CUSTOM Cumulative MED hcl-d5w dextrose 5 %-water/pf 120 mg/day Edit 03/01/2021 vicodin hydrocodone ADD UM: CUSTOM Cumulative MED es,hydrocodone- bitartrate/acetaminophen 120 mg/day Edit acetaminophen,x odol 7.5-300

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 395 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 fentanyl fentanyl citrate ADD UM: CUSTOM Cumulative MED citrate,actiq 120 mg/day Edit 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED ns,fentanyl sodium chloride/pf 120 mg/day Edit citrate-0.9% nacl 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 fentanyl,duragesi fentanyl ADD UM: CUSTOM Cumulative MED c 120 mg/day Edit 03/01/2021 fentanyl,duragesi fentanyl ADD UM: CUSTOM Cumulative MED c 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl/pf ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 kadian,morphine morphine sulfate ADD UM: CUSTOM Cumulative MED sulfate er 120 mg/day Edit 03/01/2021 XTAMPZA ER oxycodone myristate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 XTAMPZA ER oxycodone myristate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 XTAMPZA ER oxycodone myristate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 XTAMPZA ER oxycodone myristate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 XTAMPZA ER oxycodone myristate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 396 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 fentanyl- fentanyl citrate/bupivacaine ADD UM: CUSTOM Cumulative MED bupivacaine- hcl in 0.9 % sodium 120 mg/day Edit ns,fentanyl- chloride/pf bupivacaine- 0.9% nacl 03/01/2021 LAZANDA fentanyl citrate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl- fentanyl citrate/bupivacaine ADD UM: CUSTOM Cumulative MED bupivacaine- hcl in 0.9 % sodium 120 mg/day Edit ns,fentanyl- chloride/pf bupivacaine- 0.9% nacl 03/01/2021 hydromorphone hydromorphone hcl/pf ADD UM: CUSTOM Cumulative MED hcl,dilaudid-hp 120 mg/day Edit 03/01/2021 acetamin-caff- acetaminophen/caffeine/dihy ADD UM: CUSTOM Cumulative MED dihydrocodeine,p drocodeine bitartrate 120 mg/day Edit anlor,dvorah 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl- fentanyl citrate/ropivacaine ADD UM: CUSTOM Cumulative MED ropivacaine- hcl/sodium chloride 0.9%/pf 120 mg/day Edit ns,fentanyl- ropivacaine-0.9% nacl 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 fentanyl citrate- fentanyl citrate in dextrose ADD UM: CUSTOM Cumulative MED d5w 5% in water/pf 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 fentanyl fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED citrate,fentanyl 120 mg/day Edit citrate-water

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 397 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl,dilaudid,dilau 120 mg/day Edit did-5 03/01/2021 fentora,fentanyl fentanyl citrate ADD UM: CUSTOM Cumulative MED citrate 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 fentora,fentanyl fentanyl citrate ADD UM: CUSTOM Cumulative MED citrate 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl- fentanyl citrate/bupivacaine ADD UM: CUSTOM Cumulative MED bupivacaine- hcl in 0.9 % sodium 120 mg/day Edit ns,fentanyl- chloride/pf bupivacaine- 0.9% nacl 03/01/2021 butorphanol butorphanol tartrate ADD UM: CUSTOM Cumulative MED tartrate 120 mg/day Edit 03/01/2021 fentora,fentanyl fentanyl citrate ADD UM: CUSTOM Cumulative MED citrate 120 mg/day Edit 03/01/2021 fentora,fentanyl fentanyl citrate ADD UM: CUSTOM Cumulative MED citrate 120 mg/day Edit 03/01/2021 fentora,fentanyl fentanyl citrate ADD UM: CUSTOM Cumulative MED citrate 120 mg/day Edit 03/01/2021 PROLATE oxycodone ADD UM: CUSTOM Cumulative MED hcl/acetaminophen 120 mg/day Edit 03/01/2021 acetaminophen- acetaminophen with codeine ADD UM: CUSTOM Cumulative MED codeine phosphate 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 398 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED er,morphine 120 mg/day Edit sulfate,morphine sulfate cr,ms contin,oramorph sr 03/01/2021 fentanyl citrate- fentanyl citrate in dextrose ADD UM: CUSTOM Cumulative MED d5w 5% in water/pf 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 methadone hcl methadone hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 exalgo,hydromor hydromorphone hcl ADD UM: CUSTOM Cumulative MED phone er 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 butalb-caff- butalbital/acetaminophen/caf ADD UM: CUSTOM Cumulative MED acetaminoph- feine/codeine phosphate 120 mg/day Edit codein,butalb- acetaminoph- caff- codein,fioricet with codeine,phrenilin- caffeine-codeine

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 399 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED er,morphine 120 mg/day Edit sulfate,ms contin,oramorph sr,morphine sulfate cr 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED er,morphine 120 mg/day Edit sulfate,ms contin,oramorph sr,morphine sulfate cr 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED er,morphine 120 mg/day Edit sulfate,morphine sulfate cr,ms contin,oramorph sr 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 400 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 codeine sulfate codeine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 codeine sulfate codeine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 oxycodone hcl- oxycodone hcl/aspirin ADD UM: CUSTOM Cumulative MED aspirin,endodan, 120 mg/day Edit percodan 03/01/2021 codeine sulfate codeine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 acetaminophen- acetaminophen with codeine ADD UM: CUSTOM Cumulative MED codeine phosphate 120 mg/day Edit 03/01/2021 tylenol-codeine acetaminophen with codeine ADD UM: CUSTOM Cumulative MED no.3,acetaminop phosphate 120 mg/day Edit hen-codeine 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 tylenol-codeine acetaminophen with codeine ADD UM: CUSTOM Cumulative MED no.4,acetaminop phosphate 120 mg/day Edit hen-codeine 03/01/2021 morphine sulfate morphine sulfate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 fentanyl- fentanyl citrate/bupivacaine ADD UM: CUSTOM Cumulative MED bupivacaine- hcl in 0.9 % sodium 120 mg/day Edit ns,fentanyl- chloride/pf bupivacaine- 0.9% nacl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 401 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 fentanyl- fentanyl citrate/bupivacaine ADD UM: CUSTOM Cumulative MED bupivacaine- hcl in 0.9 % sodium 120 mg/day Edit ns,fentanyl- chloride/pf bupivacaine- 0.9% nacl 03/01/2021 fiorinal with codeine ADD UM: CUSTOM Cumulative MED codeine phosphate/butalbital/aspirin/ 120 mg/day Edit #3,butalbital caffeine compound- codeine,ascomp with codeine,asa- butalb-caffeine- codeine 03/01/2021 avinza,morphine morphine sulfate ADD UM: CUSTOM Cumulative MED sulfate er 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED er,avinza 120 mg/day Edit 03/01/2021 conzip,tramadol tramadol hcl ADD UM: CUSTOM Cumulative MED hcl er 120 mg/day Edit 03/01/2021 conzip,tramadol tramadol hcl ADD UM: CUSTOM Cumulative MED hcl er 120 mg/day Edit 03/01/2021 conzip,tramadol tramadol hcl ADD UM: CUSTOM Cumulative MED hcl er 120 mg/day Edit 03/01/2021 primalev,nalocet, oxycodone ADD UM: CUSTOM Cumulative MED oxycodone- hcl/acetaminophen 120 mg/day Edit acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 402 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 primlev,oxycodon oxycodone ADD UM: CUSTOM Cumulative MED e- hcl/acetaminophen 120 mg/day Edit acetaminophen,p rolate 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 primlev,oxycodon oxycodone ADD UM: CUSTOM Cumulative MED e- hcl/acetaminophen 120 mg/day Edit acetaminophen,p rolate 03/01/2021 primlev,oxycodon oxycodone ADD UM: CUSTOM Cumulative MED e- hcl/acetaminophen 120 mg/day Edit acetaminophen,p rolate 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED ns,fentanyl sodium chloride/pf 120 mg/day Edit citrate-0.9% nacl 03/01/2021 hydromorphone hydromorphone hcl in sterile ADD UM: CUSTOM Cumulative MED hcl-water water/pf 120 mg/day Edit 03/01/2021 hydrocodone- hydrocodone ADD UM: CUSTOM Cumulative MED acetaminophen bitartrate/acetaminophen 120 mg/day Edit 03/01/2021 fentanyl fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED citrate,fentanyl 120 mg/day Edit citrate-sterile water 03/01/2021 NUCYNTA ER tapentadol hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 NUCYNTA ER tapentadol hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 ultracet,tramadol tramadol hcl/acetaminophen ADD UM: CUSTOM Cumulative MED hcl- 120 mg/day Edit acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 403 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 tramadol hcl er tramadol hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 BUPRENEX buprenorphine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED citrate,sublimaze 120 mg/day Edit 03/01/2021 buprenorphine buprenorphine hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 acetaminophen- acetaminophen with codeine ADD UM: CUSTOM Cumulative MED codeine phosphate 120 mg/day Edit 03/01/2021 BELBUCA buprenorphine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 oxycodone hcl oxycodone hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 NUCYNTA ER tapentadol hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 methadone hcl- methadone hydrochloride in ADD UM: CUSTOM Cumulative MED 0.9% nacl 0.9 % sodium chloride 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 404 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 fentanyl- fentanyl citrate/ropivacaine ADD UM: CUSTOM Cumulative MED ropivacaine- hcl/sodium chloride 0.9%/pf 120 mg/day Edit ns,fentanyl- ropivacaine-0.9% nacl 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 BELBUCA buprenorphine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 BELBUCA buprenorphine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 BELBUCA buprenorphine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 BELBUCA buprenorphine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 NUCYNTA ER tapentadol hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 BELBUCA buprenorphine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 NUCYNTA ER tapentadol hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 oxycodone oxycodone hcl ADD UM: CUSTOM Cumulative MED hcl,dazidox 120 mg/day Edit 03/01/2021 nalbuphine hcl nalbuphine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 MORPHABOND morphine sulfate ADD UM: CUSTOM Cumulative MED ER 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 405 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 nalbuphine hcl nalbuphine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 tramadol tramadol hcl ADD UM: CUSTOM Cumulative MED hcl,ultram 120 mg/day Edit 03/01/2021 MORPHABOND morphine sulfate ADD UM: CUSTOM Cumulative MED ER 120 mg/day Edit 03/01/2021 MORPHABOND morphine sulfate ADD UM: CUSTOM Cumulative MED ER 120 mg/day Edit 03/01/2021 MORPHABOND morphine sulfate ADD UM: CUSTOM Cumulative MED ER 120 mg/day Edit 03/01/2021 MITIGO morphine sulfate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in ADD UM: CUSTOM Cumulative MED hcl-d5w dextrose 5 %-water/pf 120 mg/day Edit 03/01/2021 acetaminophen- acetaminophen with codeine ADD UM: CUSTOM Cumulative MED codeine phosphate 120 mg/day Edit 03/01/2021 butorphanol butorphanol tartrate ADD UM: CUSTOM Cumulative MED tartrate,stadol 120 mg/day Edit 03/01/2021 butorphanol butorphanol tartrate ADD UM: CUSTOM Cumulative MED tartrate 120 mg/day Edit 03/01/2021 oxycodone hcl- ibuprofen/oxycodone hcl ADD UM: CUSTOM Cumulative MED ibuprofen,combu 120 mg/day Edit nox 03/01/2021 levorphanol levorphanol tartrate ADD UM: CUSTOM Cumulative MED tartrate,levo- 120 mg/day Edit dromoran 03/01/2021 OXECTA,OXAYD oxycodone hcl ADD UM: CUSTOM Cumulative MED O,ROXYBOND 120 mg/day Edit 03/01/2021 INFUMORPH morphine sulfate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 406 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 LAZANDA fentanyl citrate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 DEMEROL meperidine hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine morphine sulfate/pf ADD UM: CUSTOM Cumulative MED sulfate,astramorp 120 mg/day Edit h-pf 03/01/2021 morphine morphine sulfate/pf ADD UM: CUSTOM Cumulative MED sulfate,astramorp 120 mg/day Edit h-pf 03/01/2021 meperidine hcl meperidine hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 MITIGO morphine sulfate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 DILAUDID hydromorphone hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 SUBSYS fentanyl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 SUBSYS fentanyl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 meperidine hcl meperidine hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 DEMEROL meperidine hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 DEMEROL meperidine hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 DEMEROL meperidine hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 407 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 DEMEROL meperidine hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 morphine morphine sulfate/pf ADD UM: CUSTOM Cumulative MED sulfate,duramorp 120 mg/day Edit h,astramorph-pf 03/01/2021 hydromorphone hydromorphone hcl/pf ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 INFUMORPH morphine sulfate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl/pf ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 morphine morphine sulfate/pf ADD UM: CUSTOM Cumulative MED sulfate,duramorp 120 mg/day Edit h,astramorph-pf 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 sufentanil sufentanil citrate ADD UM: CUSTOM Cumulative MED citrate,sufenta 120 mg/day Edit 03/01/2021 sufentanil citrate sufentanil citrate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl fentanyl citrate ADD UM: CUSTOM Cumulative MED citrate,actiq 120 mg/day Edit 03/01/2021 ultiva,remifentanil remifentanil hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 belladonna- opium/belladonna alkaloids ADD UM: CUSTOM Cumulative MED opium 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 408 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 fentanyl fentanyl citrate ADD UM: CUSTOM Cumulative MED citrate,actiq 120 mg/day Edit 03/01/2021 fentanyl fentanyl citrate ADD UM: CUSTOM Cumulative MED citrate,actiq 120 mg/day Edit 03/01/2021 ultiva,remifentanil remifentanil hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 ultiva,remifentanil remifentanil hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 belladonna- opium/belladonna alkaloids ADD UM: CUSTOM Cumulative MED opium 120 mg/day Edit 03/01/2021 fentanyl fentanyl citrate ADD UM: CUSTOM Cumulative MED citrate,actiq 120 mg/day Edit 03/01/2021 diskets,methados methadone hcl ADD UM: CUSTOM Cumulative MED e,methadone hcl 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 EMBEDA morphine sulfate/naltrexone ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 EMBEDA morphine sulfate/naltrexone ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 EMBEDA morphine sulfate/naltrexone ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 EMBEDA morphine sulfate/naltrexone ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 EMBEDA morphine sulfate/naltrexone ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 409 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 hydromorphone hydromorphone hcl in sterile ADD UM: CUSTOM Cumulative MED hcl-water water/pf 120 mg/day Edit 03/01/2021 dolophine methadone hcl ADD UM: CUSTOM Cumulative MED hcl,methadone 120 mg/day Edit hcl,methadose 03/01/2021 dolophine methadone hcl ADD UM: CUSTOM Cumulative MED hcl,methadone 120 mg/day Edit hcl 03/01/2021 BELBUCA buprenorphine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl- fentanyl citrate/bupivacaine ADD UM: CUSTOM Cumulative MED bupivacaine-ns hcl in 0.9 % sodium 120 mg/day Edit chloride/pf 03/01/2021 fentanyl- fentanyl citrate/bupivacaine ADD UM: CUSTOM Cumulative MED bupivacaine- hcl in 0.9 % sodium 120 mg/day Edit ns,fentanyl- chloride/pf bupivacaine- 0.9% nacl 03/01/2021 fentanyl- fentanyl citrate/bupivacaine ADD UM: CUSTOM Cumulative MED bupivacaine- hcl in 0.9 % sodium 120 mg/day Edit ns,fentanyl- chloride/pf bupivacaine- 0.9% nacl 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 meperidine hcl meperidine hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 410 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in sterile ADD UM: CUSTOM Cumulative MED hcl-water water/pf 120 mg/day Edit 03/01/2021 ROXYBOND oxycodone hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 ROXYBOND oxycodone hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 TALWIN pentazocine lactate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 methadone methadone hcl ADD UM: CUSTOM Cumulative MED hcl,methadone 120 mg/day Edit intensol,methado se 03/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 DEMEROL meperidine hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 EMBEDA morphine sulfate/naltrexone ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 methadone hcl methadone hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl- fentanyl citrate/bupivacaine ADD UM: CUSTOM Cumulative MED bupivacaine- hcl in 0.9 % sodium 120 mg/day Edit 0.9% nacl chloride/pf 03/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 411 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 zohydro hydrocodone bitartrate ADD UM: CUSTOM Cumulative MED er,hydrocodone 120 mg/day Edit bitartrate er 03/01/2021 zohydro hydrocodone bitartrate ADD UM: CUSTOM Cumulative MED er,hydrocodone 120 mg/day Edit bitartrate er 03/01/2021 zohydro hydrocodone bitartrate ADD UM: CUSTOM Cumulative MED er,hydrocodone 120 mg/day Edit bitartrate er 03/01/2021 fentanyl,duragesi fentanyl ADD UM: CUSTOM Cumulative MED c 120 mg/day Edit 03/01/2021 reprexain,hydroc hydrocodone/ibuprofen ADD UM: CUSTOM Cumulative MED odone- 120 mg/day Edit ibuprofen,ibudon e 03/01/2021 fentanyl fentanyl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED ns,fentanyl sodium chloride/pf 120 mg/day Edit citrate-0.9% nacl 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% sodium chloride/pf 120 mg/day Edit nacl,morphine sulfate-nacl 03/01/2021 hydrocodone- hydrocodone ADD UM: CUSTOM Cumulative MED acetaminophen,n bitartrate/acetaminophen,hy 120 mg/day Edit orco,lortab,lorcet drocodone plus bit/acetaminophen 03/01/2021 hydrocodone- hydrocodone ADD UM: CUSTOM Cumulative MED acetaminophen,n bitartrate/acetaminophen,hy 120 mg/day Edit orco,lorcet,lortab drocodone bit/acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 412 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 zohydro hydrocodone bitartrate ADD UM: CUSTOM Cumulative MED er,hydrocodone 120 mg/day Edit bitartrate er 03/01/2021 fentanyl fentanyl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl fentanyl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 zohydro hydrocodone bitartrate ADD UM: CUSTOM Cumulative MED er,hydrocodone 120 mg/day Edit bitartrate er 03/01/2021 tramadol hcl tramadol hcl ADD UM: CUSTOM Cumulative MED er,ryzolt 120 mg/day Edit 03/01/2021 zohydro hydrocodone bitartrate ADD UM: CUSTOM Cumulative MED er,hydrocodone 120 mg/day Edit bitartrate er 03/01/2021 tramadol hcl tramadol hcl ADD UM: CUSTOM Cumulative MED er,ryzolt 120 mg/day Edit 03/01/2021 tramadol hcl tramadol hcl ADD UM: CUSTOM Cumulative MED er,ryzolt 120 mg/day Edit 03/01/2021 LAZANDA fentanyl citrate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 DILAUDID hydromorphone hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 413 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 fentanyl- fentanyl citrate/ropivacaine ADD UM: CUSTOM Cumulative MED ropivacaine-0.9% hcl/sodium chloride 0.9%/pf 120 mg/day Edit nacl,fentanyl- ropivacaine-ns 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl- fentanyl citrate/bupivacaine ADD UM: CUSTOM Cumulative MED bupivacaine- hcl in 0.9 % sodium 120 mg/day Edit 0.9% nacl chloride/pf 03/01/2021 KADIAN morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 QDOLO tramadol hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydrocodone- hydrocodone ADD UM: CUSTOM Cumulative MED acetaminophen bitartrate/acetaminophen 120 mg/day Edit 03/01/2021 butrans,buprenor buprenorphine ADD UM: CUSTOM Cumulative MED phine 120 mg/day Edit 03/01/2021 fentanyl- fentanyl citrate/ropivacaine ADD UM: CUSTOM Cumulative MED ropivacaine- hcl/sodium chloride 0.9%/pf 120 mg/day Edit ns,fentanyl- ropivacaine-0.9% nacl 03/01/2021 nalbuphine hcl nalbuphine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 414 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 hydrocodone- hydrocodone ADD UM: CUSTOM Cumulative MED acetaminophen,h bitartrate/acetaminophen 120 mg/day Edit ycet 03/01/2021 nalbuphine hcl nalbuphine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 exalgo,hydromor hydromorphone hcl ADD UM: CUSTOM Cumulative MED phone er 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 apadaz,benzhydr benzhydrocodone ADD UM: CUSTOM Cumulative MED ocodone- hcl/acetaminophen 120 mg/day Edit acetaminophen 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED ns,fentanyl sodium chloride/pf 120 mg/day Edit citrate-0.9% nacl 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 buprenorphine buprenorphine hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 butalb- butalbital/acetaminophen/caf ADD UM: CUSTOM Cumulative MED acetaminoph- feine/codeine phosphate 120 mg/day Edit caff- codein,fioricet with codeine 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 415 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 fentanyl- fentanyl citrate/bupivacaine ADD UM: CUSTOM Cumulative MED bupivacaine- hcl in 0.9 % sodium 120 mg/day Edit 0.9% nacl chloride/pf 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 oxymorphone hcl oxymorphone hcl ADD UM: CUSTOM Cumulative MED er,opana er 120 mg/day Edit 03/01/2021 oxymorphone hcl oxymorphone hcl ADD UM: CUSTOM Cumulative MED er,opana er 120 mg/day Edit 03/01/2021 oxymorphone hcl oxymorphone hcl ADD UM: CUSTOM Cumulative MED er,opana er 120 mg/day Edit 03/01/2021 fentanyl- fentanyl citrate/ropivacaine ADD UM: CUSTOM Cumulative MED ropivacaine-0.9% hcl/sodium chloride 0.9%/pf 120 mg/day Edit nacl 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 methadone hcl methadone hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 tramadol hcl tramadol hcl ADD UM: CUSTOM Cumulative MED er,ultram er 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 416 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 butrans,buprenor buprenorphine ADD UM: CUSTOM Cumulative MED phine 120 mg/day Edit 03/01/2021 butrans,buprenor buprenorphine ADD UM: CUSTOM Cumulative MED phine 120 mg/day Edit 03/01/2021 avinza,morphine morphine sulfate ADD UM: CUSTOM Cumulative MED sulfate er 120 mg/day Edit 03/01/2021 avinza,morphine morphine sulfate ADD UM: CUSTOM Cumulative MED sulfate er 120 mg/day Edit 03/01/2021 fentanyl citrate- fentanyl citrate in dextrose ADD UM: CUSTOM Cumulative MED d5w 5% in water/pf 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl- fentanyl citrate/ropivacaine ADD UM: CUSTOM Cumulative MED ropivacaine-0.9% hcl/sodium chloride 0.9%/pf 120 mg/day Edit nacl 03/01/2021 avinza,morphine morphine sulfate ADD UM: CUSTOM Cumulative MED sulfate er 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl- fentanyl citrate/ropivacaine ADD UM: CUSTOM Cumulative MED ropivacaine- hcl/sodium chloride 0.9%/pf 120 mg/day Edit ns,fentanyl- ropivacaine-0.9% nacl 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 417 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 butrans,buprenor buprenorphine ADD UM: CUSTOM Cumulative MED phine 120 mg/day Edit 03/01/2021 OLINVYK oliceridine fumarate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 OLINVYK oliceridine fumarate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 tramadol hcl tramadol hcl ADD UM: CUSTOM Cumulative MED er,ultram er 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 avinza,morphine morphine sulfate ADD UM: CUSTOM Cumulative MED sulfate er 120 mg/day Edit 03/01/2021 OLINVYK oliceridine fumarate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 dilaudid,hydromo hydromorphone hcl/pf ADD UM: CUSTOM Cumulative MED rphone hcl 120 mg/day Edit 03/01/2021 reprexain,ibudon hydrocodone/ibuprofen ADD UM: CUSTOM Cumulative MED e,hydrocodone- 120 mg/day Edit ibuprofen,xylon 10 03/01/2021 NUCYNTA tapentadol hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 NUCYNTA tapentadol hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 418 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 NUCYNTA tapentadol hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 oxycodone oxycodone hcl ADD UM: CUSTOM Cumulative MED hcl,oxyir 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 methadone hcl methadone hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 DSUVIA sufentanil citrate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl,dilaudid 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 419 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 oxycodone oxycodone hcl ADD UM: CUSTOM Cumulative MED hcl,oxycodone 120 mg/day Edit concentrate,roxic odone intensol,eth- oxydose 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl,dilaudid 120 mg/day Edit 03/01/2021 oxycodone oxycodone hcl ADD UM: CUSTOM Cumulative MED hcl,roxicodone 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl,dilaudid 120 mg/day Edit 03/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 kadian,morphine morphine sulfate ADD UM: CUSTOM Cumulative MED sulfate er 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 alfentanil alfentanil hcl ADD UM: CUSTOM Cumulative MED hcl,alfenta 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 420 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED ns,fentanyl sodium chloride/pf 120 mg/day Edit citrate-0.9% nacl 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED er,morphine 120 mg/day Edit sulfate,ms contin 03/01/2021 DEMEROL meperidine hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 DEMEROL meperidine hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 DEMEROL meperidine hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 DILAUDID hydromorphone hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 DILAUDID hydromorphone hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl/pf ADD UM: CUSTOM Cumulative MED hcl,dilaudid-hp 120 mg/day Edit 03/01/2021 DILAUDID hydromorphone hcl/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 ZOLVIT,LORTAB hydrocodone ADD UM: CUSTOM Cumulative MED bitartrate/acetaminophen 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl ADD UM: CUSTOM Cumulative MED hcl 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 421 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 SUBSYS fentanyl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydrocodone- hydrocodone ADD UM: CUSTOM Cumulative MED acetaminophen bitartrate/acetaminophen 120 mg/day Edit 03/01/2021 fentanyl- fentanyl citrate/bupivacaine ADD UM: CUSTOM Cumulative MED bupivacaine- hcl in 0.9 % sodium 120 mg/day Edit ns,fentanyl- chloride/pf bupivacaine- 0.9% nacl 03/01/2021 kadian,morphine morphine sulfate ADD UM: CUSTOM Cumulative MED sulfate er 120 mg/day Edit 03/01/2021 hydrocodone- hydrocodone ADD UM: CUSTOM Cumulative MED acetaminophen bitartrate/acetaminophen 120 mg/day Edit 03/01/2021 SUBSYS fentanyl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 kadian,morphine morphine sulfate ADD UM: CUSTOM Cumulative MED sulfate er 120 mg/day Edit 03/01/2021 SUBSYS fentanyl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 butrans,buprenor buprenorphine ADD UM: CUSTOM Cumulative MED phine 120 mg/day Edit 03/01/2021 morphine morphine sulfate ADD UM: CUSTOM Cumulative MED sulfate,roxanol 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 422 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 trezix,acetamin- acetaminophen/caffeine/dihy ADD UM: CUSTOM Cumulative MED caff- drocodeine bitartrate 120 mg/day Edit dihydrocodeine 03/01/2021 hydromorphone hydromorphone hcl in sterile ADD UM: CUSTOM Cumulative MED hcl-water water/pf 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hysingla hydrocodone bitartrate ADD UM: CUSTOM Cumulative MED er,hydrocodone 120 mg/day Edit bitartrate er 03/01/2021 levorphanol levorphanol tartrate ADD UM: CUSTOM Cumulative MED tartrate 120 mg/day Edit 03/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 423 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 vicodin,hydrocod hydrocodone ADD UM: CUSTOM Cumulative MED one- bitartrate/acetaminophen 120 mg/day Edit acetaminophen,x odol 5-300 03/01/2021 SUBSYS fentanyl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 SUBSYS fentanyl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% sodium chloride/pf 120 mg/day Edit nacl,fentanyl citrate-ns 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED ns,fentanyl sodium chloride/pf 120 mg/day Edit citrate-0.9% nacl 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 fentanyl fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED citrate,fentanyl 120 mg/day Edit citrate-ns 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 meperidine hcl- meperidine hcl in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 424 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 tramadol hcl tramadol hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 vicodin hydrocodone ADD UM: CUSTOM Cumulative MED hp,hydrocodone- bitartrate/acetaminophen 120 mg/day Edit acetaminophen,x odol 10-300 03/01/2021 oxycodone oxycodone hcl ADD UM: CUSTOM Cumulative MED hcl,roxicodone 120 mg/day Edit 03/01/2021 oxycodone oxycodone hcl ADD UM: CUSTOM Cumulative MED hcl,roxicodone 120 mg/day Edit 03/01/2021 ABSTRAL fentanyl citrate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 ABSTRAL fentanyl citrate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 roxicet,oxycodon oxycodone ADD UM: CUSTOM Cumulative MED e- hcl/acetaminophen 120 mg/day Edit acetaminophen,p ercocet,endocet 03/01/2021 ABSTRAL fentanyl citrate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 ABSTRAL fentanyl citrate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 endocet,oxycodo oxycodone ADD UM: CUSTOM Cumulative MED ne- hcl/acetaminophen 120 mg/day Edit acetaminophen,p ercocet

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 425 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 oxycodone- oxycodone ADD UM: CUSTOM Cumulative MED acetaminophen,o hcl/acetaminophen 120 mg/day Edit xycodone hcl- acetaminophen,p ercocet,endocet 03/01/2021 hysingla hydrocodone bitartrate ADD UM: CUSTOM Cumulative MED er,hydrocodone 120 mg/day Edit bitartrate er 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 oxycodone- oxycodone ADD UM: CUSTOM Cumulative MED acetaminophen,p hcl/acetaminophen 120 mg/day Edit ercocet,endocet 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 DEMEROL meperidine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 oxycontin,oxycod oxycodone hcl ADD UM: CUSTOM Cumulative MED one hcl er 120 mg/day Edit 03/01/2021 oxycontin,oxycod oxycodone hcl ADD UM: CUSTOM Cumulative MED one hcl er 120 mg/day Edit 03/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in 0.9 % ADD UM: CUSTOM Cumulative MED hcl-0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 ABSTRAL fentanyl citrate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 426 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 meperidine hcl meperidine hcl,meperidine ADD UM: CUSTOM Cumulative MED hcl/pf 120 mg/day Edit 03/01/2021 DEMEROL meperidine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 ABSTRAL fentanyl citrate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 kadian,morphine morphine sulfate ADD UM: CUSTOM Cumulative MED sulfate er 120 mg/day Edit 03/01/2021 pentazocine- pentazocine hcl/naloxone ADD UM: CUSTOM Cumulative MED naloxone hcl 120 mg/day Edit hcl,talwin nx 03/01/2021 morphine sulfate morphine sulfate ADD UM: CUSTOM Cumulative MED 120 mg/day Edit 03/01/2021 kadian,morphine morphine sulfate ADD UM: CUSTOM Cumulative MED sulfate er 120 mg/day Edit 03/01/2021 kadian,morphine morphine sulfate ADD UM: CUSTOM Cumulative MED sulfate er 120 mg/day Edit 03/01/2021 hysingla hydrocodone bitartrate ADD UM: CUSTOM Cumulative MED er,hydrocodone 120 mg/day Edit bitartrate er 03/01/2021 kadian,morphine morphine sulfate ADD UM: CUSTOM Cumulative MED sulfate er 120 mg/day Edit 03/01/2021 hysingla hydrocodone bitartrate ADD UM: CUSTOM Cumulative MED er,hydrocodone 120 mg/day Edit bitartrate er 03/01/2021 hysingla hydrocodone bitartrate ADD UM: CUSTOM Cumulative MED er,hydrocodone 120 mg/day Edit bitartrate er

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 427 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 vicoprofen,hydroc hydrocodone/ibuprofen ADD UM: CUSTOM Cumulative MED odone- 120 mg/day Edit ibuprofen,hydroc odone bit- ibuprofen,reprexa in 03/01/2021 hysingla hydrocodone bitartrate ADD UM: CUSTOM Cumulative MED er,hydrocodone 120 mg/day Edit bitartrate er 03/01/2021 hysingla hydrocodone bitartrate ADD UM: CUSTOM Cumulative MED er,hydrocodone 120 mg/day Edit bitartrate er 03/01/2021 hydrocodone- hydrocodone ADD UM: CUSTOM Cumulative MED acetaminophen,v bitartrate/acetaminophen 120 mg/day Edit erdrocet 03/01/2021 demerol,meperidi meperidine hcl ADD UM: CUSTOM Cumulative MED ne hcl,meperitab 120 mg/day Edit 03/01/2021 demerol,meperidi meperidine hcl ADD UM: CUSTOM Cumulative MED ne hcl 120 mg/day Edit 03/01/2021 norco,hydrocodo hydrocodone ADD UM: CUSTOM Cumulative MED ne- bitartrate/acetaminophen,hy 120 mg/day Edit acetaminophen,lo drocodone rtab,lorcet hd bit/acetaminophen 03/01/2021 oxymorphone hcl oxymorphone hcl ADD UM: CUSTOM Cumulative MED er,opana er 120 mg/day Edit 03/01/2021 oxycontin,oxycod oxycodone hcl ADD UM: CUSTOM Cumulative MED one hcl er 120 mg/day Edit 03/01/2021 oxycontin,oxycod oxycodone hcl ADD UM: CUSTOM Cumulative MED one hcl er 120 mg/day Edit 03/01/2021 oxycontin,oxycod oxycodone hcl ADD UM: CUSTOM Cumulative MED one hcl er 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 428 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 apadaz,benzhydr benzhydrocodone ADD UM: CUSTOM Cumulative MED ocodone- hcl/acetaminophen 120 mg/day Edit acetaminophen 03/01/2021 oxycontin,oxycod oxycodone hcl ADD UM: CUSTOM Cumulative MED one hcl er 120 mg/day Edit 03/01/2021 apadaz,benzhydr benzhydrocodone ADD UM: CUSTOM Cumulative MED ocodone- hcl/acetaminophen 120 mg/day Edit acetaminophen 03/01/2021 tramadol hcl tramadol hcl ADD UM: CUSTOM Cumulative MED er,ultram er 120 mg/day Edit 03/01/2021 oxycontin,oxycod oxycodone hcl ADD UM: CUSTOM Cumulative MED one hcl er 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride/pf 120 mg/day Edit 03/01/2021 fentanyl citrate- fentanyl citrate in 0.9 % ADD UM: CUSTOM Cumulative MED ns,fentanyl sodium chloride/pf 120 mg/day Edit citrate-0.9% nacl 03/01/2021 OXAYDO,OXEC oxycodone hcl ADD UM: CUSTOM Cumulative MED TA 120 mg/day Edit 03/01/2021 hydromorphone hydromorphone hcl in ADD UM: CUSTOM Cumulative MED hcl-nacl sodium chloride, iso- 120 mg/day Edit osmotic/pf 03/01/2021 oxymorphone oxymorphone hcl ADD UM: CUSTOM Cumulative MED hcl,opana 120 mg/day Edit 03/01/2021 oxymorphone oxymorphone hcl ADD UM: CUSTOM Cumulative MED hcl,opana 120 mg/day Edit 03/01/2021 meperidine hcl meperidine hcl ADD UM: CUSTOM Cumulative MED 120 mg/day Edit

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 429 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/01/2021 oxycodone oxycodone hcl ADD UM: CUSTOM Cumulative MED hcl,dazidox 120 mg/day Edit 03/01/2021 oxycodone oxycodone hcl ADD UM: CUSTOM Cumulative MED hcl,roxicodone 120 mg/day Edit 03/01/2021 oxymorphone hcl oxymorphone hcl ADD UM: CUSTOM Cumulative MED er,opana er 120 mg/day Edit 03/01/2021 oxymorphone hcl oxymorphone hcl ADD UM: CUSTOM Cumulative MED er,opana er 120 mg/day Edit 03/01/2021 oxymorphone hcl oxymorphone hcl ADD UM: CUSTOM Cumulative MED er,opana er 120 mg/day Edit 03/01/2021 morphine sulfate- morphine sulfate in 0.9 % ADD UM: CUSTOM Cumulative MED 0.9% nacl sodium chloride 120 mg/day Edit 03/04/2021 JANSSEN covid-19 vac, ad26.cov2.s ADD TO FORMULARY Non PDL COVID-19 (janssen)/pf VACCINE (EUA)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 430 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

April, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 pediatric dinosaur nebulizer and compressor REMOVE UM: MED Medical Drug nebulizer 04/30/2021 aerochamber z- inhaler, assist devices REMOVE UM: MED Medical Drug stat plus 04/30/2021 aerochamber z- inhaler,assist device with REMOVE UM: MED Medical Drug stat small mask plus,aerochambe r plus z stat 04/30/2021 aerochamber z- inhaler,assist device with REMOVE UM: MED Medical Drug stat medium mask plus,aerochambe r plus z stat 04/30/2021 inspiration elite nebulizer accessories REMOVE UM: MED Medical Drug filter 04/30/2021 LEVICYN hypochlorous acid/sod REMOVE UM: MED Medical Drug chlor/sod sulfate/sod phosphate,mono 04/30/2021 sidestream nebulizer REMOVE UM: MED Medical Drug nebulizer,sidestre am 04/30/2021 GAMMAPLEX immune REMOVE UM: MED Medical Drug globulin,gamm(igg)/sorbitol/ glycin/iga 0 to 50 mcg/ml 04/30/2021 aerochamber z- inhaler, assist devices REMOVE UM: MED Medical Drug stat plus,aerochambe r plus z stat 04/30/2021 levothyroxine levothyroxine sodium REMOVE UM: MED Medical Drug sodium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 431 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 clever choice inhaler,assist device with REMOVE UM: MED Medical Drug holding chamber small mask 04/30/2021 clever choice inhaler,assist device with REMOVE UM: MED Medical Drug holding chamber medium mask 04/30/2021 paclitaxel paclitaxel REMOVE UM: MED Medical Drug 04/30/2021 epinephrine epinephrine REMOVE UM: MED Medical Drug hcl/pf,epinephrine/pf 04/30/2021 comfort short infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 q-care rx dental suction REMOVE UM: MED Medical Drug device/chlorhexidine/dental swab 1/mouthwash 04/30/2021 pflex trainer spirometers and accessories REMOVE UM: MED Medical Drug 04/30/2021 threshold imt spirometers and accessories REMOVE UM: MED Medical Drug 04/30/2021 sensura ostomy ostomy supply REMOVE UM: MED Medical Drug base plate 04/30/2021 threshold pep spirometers and accessories REMOVE UM: MED Medical Drug 04/30/2021 conception conception assistance REMOVE UM: MED Medical Drug supplies combination no.1 04/30/2021 cytarabine cytarabine/pf REMOVE UM: MED Medical Drug 04/30/2021 medihoney calcium alginate/honey REMOVE UM: MED Medical Drug 04/30/2021 pediatric dog nebulizer and compressor REMOVE UM: MED Medical Drug nebulizer 04/30/2021 mesna mesna REMOVE UM: MED Medical Drug 04/30/2021 acticoat surgical silver/foam bandage REMOVE UM: MED Medical Drug 04/30/2021 my mdi portable nebulizer and compressor REMOVE UM: MED Medical Drug nebuliser 04/30/2021 IONOSOL MB- electrolyte-mb REMOVE UM: MED Medical Drug DEXTROSE 5% solution/dextrose 5 % in water

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 432 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 bleomycin sulfate bleomycin sulfate REMOVE UM: MED Medical Drug 04/30/2021 acticoat surgical silver/foam bandage REMOVE UM: MED Medical Drug 04/30/2021 acticoat surgical silver/foam bandage REMOVE UM: MED Medical Drug 04/30/2021 sodium hyaluronate sodium REMOVE UM: MED Medical Drug hyaluronate 04/30/2021 dopamine hcl in dopamine hcl in dextrose 5 REMOVE UM: MED Medical Drug 5% dextrose % in water,dopamine hcl/dextrose 5 % in water 04/30/2021 paradigm infusion subcutaneous infusion pump REMOVE UM: MED Medical Drug accessory 04/30/2021 freestyle libre 10 flash glucose scanning REMOVE UM: MED Medical Drug day reader reader 04/30/2021 dopamine hcl dopamine hcl REMOVE UM: MED Medical Drug 04/30/2021 dopamine hcl dopamine hcl REMOVE UM: MED Medical Drug 04/30/2021 dopamine hcl dopamine hcl REMOVE UM: MED Medical Drug 04/30/2021 procainamide hcl procainamide hcl REMOVE UM: MED Medical Drug 04/30/2021 compact space inhaler, assist devices REMOVE UM: MED Medical Drug chamber 04/30/2021 monoject syringe,safety with needle,1 REMOVE UM: MED Medical Drug magellan ml 04/30/2021 medihoney calcium alginate/honey REMOVE UM: MED Medical Drug 04/30/2021 doxorubicin hcl doxorubicin hcl pegylated REMOVE UM: MED Medical Drug liposome liposomal 04/30/2021 famotidine famotidine REMOVE UM: MED Medical Drug 04/30/2021 PROSTIN VR alprostadil REMOVE UM: MED Medical Drug PEDIATRIC 04/30/2021 pro comfort tens transcutaneous electrical REMOVE UM: MED Medical Drug unit nerve stimulators(tens)/electrodes

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 433 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 filter needle needles, filter REMOVE UM: MED Medical Drug 04/30/2021 metoclopramide metoclopramide hcl REMOVE UM: MED Medical Drug hcl 04/30/2021 exel syringe, disposable, 5 ml REMOVE UM: MED syringe,syringe 04/30/2021 PARAPLATIN carboplatin REMOVE UM: MED Medical Drug 04/30/2021 monoject luer intravenous equipment REMOVE UM: MED Medical Drug adapter 04/30/2021 monoject blood needles, blood collection REMOVE UM: MED Medical Drug collection 04/30/2021 revel subcutaneous insulin pump REMOVE UM: MED Medical Drug programmable pump 04/30/2021 monoject blood needles, blood collection REMOVE UM: MED Medical Drug collection 04/30/2021 monoject blood needles, blood collection REMOVE UM: MED Medical Drug collection 04/30/2021 dopamine hcl dopamine hcl REMOVE UM: MED Medical Drug 04/30/2021 WINRHO SDF rho(d) immune REMOVE UM: MED Medical Drug globulin/maltose 04/30/2021 WINRHO SDF rho(d) immune REMOVE UM: MED Medical Drug globulin/maltose 04/30/2021 sinustar nebulizer and compressor REMOVE UM: MED Medical Drug 04/30/2021 ranitidine hcl ranitidine hcl REMOVE UM: MED Medical Drug 04/30/2021 PHENERGAN promethazine hcl REMOVE UM: MED 04/30/2021 CAFCIT caffeine citrate,caffeine REMOVE UM: MED Medical Drug citrated 04/30/2021 ACTIVASE alteplase REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 434 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 vapro plus urinary bag/catheter REMOVE UM: MED intermitt catheter 04/30/2021 PHOTOFRIN porfimer sodium REMOVE UM: MED Medical Drug 04/30/2021 TRACE zinc sulfate/cupric REMOVE UM: MED Medical Drug ELEMENTS-4 sulfate/manganese sulf/chromic chloride 04/30/2021 enteral gravity feeder container with gravity REMOVE UM: MED Medical Drug bag set-enfit set, enfit 04/30/2021 monoject blood needles, blood collection REMOVE UM: MED Medical Drug collection 04/30/2021 sinustar nebulizer REMOVE UM: MED Medical Drug 04/30/2021 LIORESAL baclofen REMOVE UM: MED Medical Drug INTRATHECAL 04/30/2021 sodium sodium bicarbonate REMOVE UM: MED Medical Drug bicarbonate 04/30/2021 quake mucus clearing device REMOVE UM: MED Medical Drug 04/30/2021 nitroglycerin in nitroglycerin in 5 % dextrose REMOVE UM: MED Medical Drug d5w in water 04/30/2021 isoproterenol hcl isoproterenol hcl REMOVE UM: MED 04/30/2021 PRIVIGEN immune globulin,gamma REMOVE UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 04/30/2021 ETHAMOLIN ethanolamine oleate REMOVE UM: MED Medical Drug 04/30/2021 ORTHOVISC hyaluronate sodium REMOVE UM: MED Medical Drug 04/30/2021 nitroglycerin in nitroglycerin in 5 % dextrose REMOVE UM: MED Medical Drug d5w in water 04/30/2021 sami the seal nebulizer accessories REMOVE UM: MED Medical Drug mask

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 435 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 nitroglycerin in nitroglycerin in 5 % dextrose REMOVE UM: MED Medical Drug d5w in water 04/30/2021 home nebulizer nebulizer and compressor REMOVE UM: MED Medical Drug plus sidestream 04/30/2021 nitroglycerin in nitroglycerin in 5 % dextrose REMOVE UM: MED Medical Drug d5w in water 04/30/2021 oasis ultra,wound porcine acell REMOVE UM: MED Medical Drug matrix submucosa,meshed 04/30/2021 ZANTAC ranitidine hcl REMOVE UM: MED Medical Drug 04/30/2021 sodium sodium bicarbonate REMOVE UM: MED Medical Drug bicarbonate 04/30/2021 OSMITROL mannitol REMOVE UM: MED Medical Drug 04/30/2021 wound matrix porcine acellular small REMOVE UM: MED Medical Drug intestine submucosa, fenestrated 04/30/2021 monoject smartip syringe with cannula, REMOVE UM: MED Medical Drug cannula disposable, 3 ml 04/30/2021 monoject smartip syringe with REMOVE UM: MED Medical Drug cannula cannula,disposable 12 ml 04/30/2021 nitroglycerin in nitroglycerin in 5 % dextrose REMOVE UM: MED Medical Drug d5w in water 04/30/2021 topotecan hcl topotecan hcl REMOVE UM: MED Medical Drug 04/30/2021 binaxnow covid- covid-19 antigen REMOVE UM: MED Medical Drug 19 ag card immunoassay test 04/30/2021 valrubicin valrubicin REMOVE UM: MED Medical Drug 04/30/2021 allevyn life foam bandage REMOVE UM: MED Medical Drug 04/30/2021 allevyn life foam bandage REMOVE UM: MED Medical Drug 04/30/2021 curity amd gauze bandage REMOVE UM: MED Medical Drug 04/30/2021 allevyn life foam bandage REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 436 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 femcap cervical cap REMOVE UM: MED Medical Drug 04/30/2021 femcap cervical cap REMOVE UM: MED Medical Drug 04/30/2021 touch-trol catheter REMOVE UM: MED Medical Drug 04/30/2021 WINRHO SDF rho(d) immune REMOVE UM: MED Medical Drug globulin/maltose 04/30/2021 WINRHO SDF rho(d) immune REMOVE UM: MED Medical Drug globulin/maltose 04/30/2021 procare spacer inhaler,assist device with REMOVE UM: MED Medical Drug with adult mask large mask 04/30/2021 monoject insulin syringe with REMOVE UM: MED syringe needle,disposable,insulin 1 ml 04/30/2021 VORAXAZE glucarpidase REMOVE UM: MED Medical Drug 04/30/2021 ZOLADEX goserelin acetate REMOVE UM: MED Medical Drug 04/30/2021 onetouch ping subcutaneous insulin pump REMOVE UM: MED Medical Drug 04/30/2021 norm-ject syringe syringe, disposable, 10 ml REMOVE UM: MED Medical Drug 04/30/2021 norm-ject syringe syringe, disposable, 20 ml REMOVE UM: MED Medical Drug 04/30/2021 procare spacer inhaler,assist device with REMOVE UM: MED Medical Drug with child mask medium mask 04/30/2021 TPN sodium/potassium/magnesiu REMOVE UM: MED Medical Drug ELECTROLYTES m/calcium/chloride/acetate II 04/30/2021 optichamber inhaler, assist devices, REMOVE UM: MED Medical Drug accessories 04/30/2021 vortex holding inhaler,assist device with REMOVE UM: MED Medical Drug chamber-toddler small mask 04/30/2021 curity amd polyhexamethylene REMOVE UM: MED Medical Drug biguanide/gauze bandage

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 437 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 innospire nebulizer accessories REMOVE UM: MED Medical Drug replacement filter 04/30/2021 coaguchek prothrombin time test strips REMOVE UM: MED Medical Drug 04/30/2021 acticoat silver REMOVE UM: MED Medical Drug 04/30/2021 VOLUVEN hydroxyethyl starch 130/0.4 REMOVE UM: MED Medical Drug in 0.9 % sodium chloride 04/30/2021 freestyle libre 14 flash glucose scanning REMOVE UM: MED Medical Drug day reader reader 04/30/2021 aeroeclipse ii nebulizer REMOVE UM: MED Medical Drug 04/30/2021 freestyle libre 14 flash glucose sensor REMOVE UM: MED Medical Drug day sensor 04/30/2021 altera nebulizer nebulizer REMOVE UM: MED Medical Drug 04/30/2021 XIAFLEX collagenase clostridium REMOVE UM: MED Medical Drug histolyticum 04/30/2021 smartmask kids nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 medihoney calcium alginate/honey REMOVE UM: MED Medical Drug 04/30/2021 space chamber inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 dopamine hcl in dopamine hcl in dextrose 5 REMOVE UM: MED Medical Drug 5% dextrose % in water 04/30/2021 dopamine hcl in dopamine hcl in dextrose 5 REMOVE UM: MED Medical Drug 5% dextrose % in water,dopamine hcl/dextrose 5 % in water 04/30/2021 dopamine hcl in dopamine hcl/dextrose 5 % REMOVE UM: MED Medical Drug 5% dextrose in water,dopamine hcl in dextrose 5 % in water 04/30/2021 guardian link 3 blood-glucose transmitter REMOVE UM: MED Medical Drug 04/30/2021 dopamine hcl in dopamine hcl/dextrose 5 % REMOVE UM: MED Medical Drug 5% dextrose in water,dopamine hcl in dextrose 5 % in water

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 438 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 neomycin- neomycin sulfate/polymyxin REMOVE UM: MED polymyxin b b sulfate 04/30/2021 varithena transfer set/syringe, REMOVE UM: MED Medical Drug administration disposable/bandages,compr pack ession/tubing 04/30/2021 potassium potassium chloride in water REMOVE UM: MED Medical Drug chloride,potassiu for injection, sterile m chloride-water 04/30/2021 AMVISC PLUS hyaluronate sodium REMOVE UM: MED Medical Drug 04/30/2021 OCTAGAM immune REMOVE UM: MED Medical Drug globulin,gamm(igg)/maltose/ iga greater than 50 mcg/ml 04/30/2021 monoject smartip syringe with cannula, REMOVE UM: MED Medical Drug cannula disposable, 6 ml 04/30/2021 dexcom g6 blood-glucose transmitter REMOVE UM: MED Medical Drug 04/30/2021 MULTITRACE-5 zinc sulfate/copper REMOVE UM: MED Medical Drug sulfate/manganese/chromiu m/selenium 04/30/2021 dexcom g6 blood-glucose REMOVE UM: MED Medical Drug meter,continuous 04/30/2021 mio infusion set infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 dexcom g6 blood-glucose sensor REMOVE UM: MED Medical Drug 04/30/2021 monoject syringe with REMOVE UM: MED Medical Drug needle,disposable, 6 ml 04/30/2021 medihoney honey/hydrocolloid dressing REMOVE UM: MED Medical Drug 04/30/2021 medihoney honey/hydrocolloid dressing REMOVE UM: MED Medical Drug 04/30/2021 JEVTANA cabazitaxel REMOVE UM: MED Medical Drug 04/30/2021 REMICADE infliximab REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 439 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 mycophenolate mycophenolate mofetil hcl REMOVE UM: MED Medical Drug mofetil 04/30/2021 assure id insulin syringe with needle, insulin, REMOVE UM: MED safety safety, 1 ml 04/30/2021 assure id insulin syringe with needle, insulin, REMOVE UM: MED safety safety, 0.5 ml 04/30/2021 devilbiss pulmo- compressor, for nebulizer REMOVE UM: MED Medical Drug aide 04/30/2021 magic3 catheter REMOVE UM: MED Medical Drug intermittent catheter 04/30/2021 PROVENGE sipuleucel-t/lactated ringers REMOVE UM: MED Medical Drug solution 04/30/2021 ear popper middle ear inflation device REMOVE UM: MED Medical Drug 04/30/2021 syringe syringe reusable, 3 ml REMOVE UM: MED Medical Drug 04/30/2021 asthmapack peak flow meter/inhaler, REMOVE UM: MED Medical Drug children's assist devices 04/30/2021 furosemide furosemide REMOVE UM: MED Medical Drug 04/30/2021 ONCASPAR pegaspargase REMOVE UM: MED Medical Drug 04/30/2021 SOTRADECOL sodium tetradecyl sulfate REMOVE UM: MED Medical Drug 04/30/2021 acticoat flex 3 silver REMOVE UM: MED Medical Drug 04/30/2021 aura portaneb nebulizer REMOVE UM: MED Medical Drug 04/30/2021 sofia sars antigen covid-19 antigen REMOVE UM: MED Medical Drug fia immunoassay test 04/30/2021 MIOSTAT carbachol REMOVE UM: MED Medical Drug 04/30/2021 safety syringe- syringe,safety with needle,3 REMOVE UM: MED Medical Drug needle ml 04/30/2021 cisplatin cisplatin REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 440 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 mannitol mannitol REMOVE UM: MED Medical Drug 04/30/2021 t:flex subcutaneous insulin pump REMOVE UM: MED Medical Drug 04/30/2021 LMD 10% WITH dextran 40 in 0.9 % sodium REMOVE UM: MED Medical Drug 0.9% SOD chloride CHLORIDE 04/30/2021 microbore iv admin extension REMOVE UM: MED Medical Drug extension set- set,intravenous sl,microbore administration extension set extension set 04/30/2021 quick-set infusion set for insulin pump REMOVE UM: MED Medical Drug paradigm 04/30/2021 ZINECARD dexrazoxane REMOVE UM: MED Medical Drug hcl,dexrazoxane 04/30/2021 t:slim x2 with subcutaneous insulin pump REMOVE UM: MED Medical Drug basal-iq 04/30/2021 sootheneb nebulizer and compressor REMOVE UM: MED Medical Drug compressor nebulizer 04/30/2021 CYTOGAM cytomegalovirus immune REMOVE UM: MED Medical Drug globulin (human),cytomegalovirus immune glob 04/30/2021 monoject syringe syringe with REMOVE UM: MED needle,disposable, 6 ml 04/30/2021 ZALTRAP ziv-aflibercept REMOVE UM: MED Medical Drug 04/30/2021 monoject syringe syringe with REMOVE UM: MED needle,disposable, 6 ml 04/30/2021 monoject syringe syringe, disposable, 6 ml REMOVE UM: MED Medical Drug 04/30/2021 ZALTRAP ziv-aflibercept REMOVE UM: MED Medical Drug 04/30/2021 leucovorin leucovorin calcium REMOVE UM: MED Medical Drug calcium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 441 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 mouthpiece nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 NULOJIX belatacept REMOVE UM: MED Medical Drug 04/30/2021 piston enfit syringe, enfit 60 ml, non- REMOVE UM: MED Medical Drug syringe sterile 04/30/2021 freestyle libre 10 flash glucose sensor REMOVE UM: MED Medical Drug day sensor 04/30/2021 HYPERRAB S-D rabies immune globulin/pf REMOVE UM: MED Medical Drug 04/30/2021 HYPERTET S-D tetanus immune globulin/pf REMOVE UM: MED Medical Drug 04/30/2021 HYPERRHO S-D rho(d) immune globulin REMOVE UM: MED Medical Drug 04/30/2021 leucovorin leucovorin calcium REMOVE UM: MED Medical Drug calcium 04/30/2021 promethazine hcl promethazine hcl REMOVE UM: MED 04/30/2021 contact detach infusion set for insulin pump REMOVE UM: MED Medical Drug infusion set 04/30/2021 monoject syringe syringe, disposable, 12 ml REMOVE UM: MED Medical Drug 04/30/2021 pen needle pen needle, diabetic REMOVE UM: MED Medical Drug 04/30/2021 paradigm insulin pump syringe, 1.8 ml REMOVE UM: MED Medical Drug 04/30/2021 dexcom g5 blood-glucose transmitter REMOVE UM: MED Medical Drug 04/30/2021 dexcom blood-glucose REMOVE UM: MED Medical Drug meter,continuous 04/30/2021 monoject syringe syringe with REMOVE UM: MED needle,disposable, 6 ml 04/30/2021 potassium chl- potassium chloride in 0.9 % REMOVE UM: MED Medical Drug normal saline sodium chloride 04/30/2021 monoject syringe syringe with REMOVE UM: MED Medical Drug needle,disposable, 6 ml,syringe w- needle,disposab,6ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 442 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 VENELEX balsam peru/castor oil REMOVE UM: MED Medical Drug 04/30/2021 IONOSOL B electrolyte-b REMOVE UM: MED Medical Drug WITH solution/dextrose 5 % in DEXTROSE 5% water 04/30/2021 dexcom g5 blood-glucose REMOVE UM: MED Medical Drug meter,continuous 04/30/2021 VISCO-3 hyaluronate sodium REMOVE UM: MED Medical Drug 04/30/2021 soft-glide saf-q subcutaneous administration REMOVE UM: MED Medical Drug infusion set set, safety 04/30/2021 soft-glide saf-q subcutaneous administration REMOVE UM: MED Medical Drug infusion set set, safety 04/30/2021 lc d nebulizer set nebulizer REMOVE UM: MED Medical Drug 04/30/2021 strataxrt gel dressing REMOVE UM: MED Medical Drug 04/30/2021 hypodermic needles, disposable REMOVE UM: MED Medical Drug needle 04/30/2021 stratactx gel dressing REMOVE UM: MED Medical Drug 04/30/2021 hypodermic needles, disposable REMOVE UM: MED needle 04/30/2021 potassium potassium chloride REMOVE UM: MED chloride,potassiu m chloride proamp 04/30/2021 acticoat flex 3 silver REMOVE UM: MED Medical Drug 04/30/2021 acticoat flex 3 silver REMOVE UM: MED Medical Drug 04/30/2021 SYNRIBO omacetaxine mepesuccinate REMOVE UM: MED Medical Drug 04/30/2021 acticoat flex 7 silver REMOVE UM: MED Medical Drug 04/30/2021 magellan insulin syringe with needle, insulin, REMOVE UM: MED Medical Drug safety syrng safety, 1 ml 04/30/2021 eclipse needle needles, safety REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 443 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 BIVIGAM immune REMOVE UM: MED Medical Drug globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml 04/30/2021 eclipse needle needles, safety REMOVE UM: MED Medical Drug 04/30/2021 acticoat flex 3 silver REMOVE UM: MED Medical Drug 04/30/2021 replicare ultra hydrocolloid dressing REMOVE UM: MED Medical Drug 04/30/2021 mistassist kit spirometer with drug REMOVE UM: MED Medical Drug delivery adapters 04/30/2021 replicare,replicar hydrocolloid dressing REMOVE UM: MED Medical Drug e ultra 04/30/2021 levoleucovorin levoleucovorin calcium REMOVE UM: MED Medical Drug calcium 04/30/2021 OMIDRIA phenylephrine hcl/ketorolac REMOVE UM: MED Medical Drug tromethamine 04/30/2021 ulticare syringe syringe, needle, safety 1.5 REMOVE UM: MED Medical Drug ml,self-contained disposal unit 04/30/2021 vortex inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 vortex holding inhaler,assist device with REMOVE UM: MED Medical Drug chamber-child medium mask 04/30/2021 hypodermic needles, disposable REMOVE UM: MED Medical Drug needle 04/30/2021 apogee ic catheter REMOVE UM: MED Medical Drug intermittent cathetr 04/30/2021 VARIZIG varicella-zoster immune REMOVE UM: MED Medical Drug globulin/maltose 04/30/2021 hypodermic needles, disposable REMOVE UM: MED Medical Drug needle 04/30/2021 HYALGAN hyaluronate sodium REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 444 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 hypodermic needles, disposable REMOVE UM: MED needle 04/30/2021 i-port advance injection ports REMOVE UM: MED Medical Drug 04/30/2021 hypodermic needles, disposable REMOVE UM: MED needle 04/30/2021 pro-ception medical supply, REMOVE UM: MED Medical Drug fertility pak miscellaneous 04/30/2021 NORMOSOL-R electrolyte-r solution REMOVE UM: MED Medical Drug 04/30/2021 REVONTO dantrolene sodium REMOVE UM: MED Medical Drug 04/30/2021 SIMULECT basiliximab REMOVE UM: MED Medical Drug 04/30/2021 CAMPTOSAR irinotecan hcl REMOVE UM: MED Medical Drug 04/30/2021 eclipse syringe syringe,safety with needle,3 REMOVE UM: MED Medical Drug ml 04/30/2021 airs disposable nebulizer REMOVE UM: MED Medical Drug nebulizer 04/30/2021 irinotecan hcl irinotecan hcl REMOVE UM: MED Medical Drug 04/30/2021 space chamber inhaler, assist devices REMOVE UM: MED Medical Drug plus 04/30/2021 TRIESENCE triamcinolone acetonide/pf REMOVE UM: MED Medical Drug 04/30/2021 silivex gel-matrix pad dressing, REMOVE UM: MED Medical Drug silicone 04/30/2021 cefaly transcutaneous electrical REMOVE UM: MED Medical Drug nerve stimulators(tens)/electrodes 04/30/2021 TYSABRI natalizumab REMOVE UM: MED Medical Drug 04/30/2021 pro comfort tens tens unit electrodes REMOVE UM: MED Medical Drug electrode 04/30/2021 acticoat flex 7 silver REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 445 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 neria multi sub-q administration set, REMOVE UM: MED Medical Drug bifurcated 04/30/2021 acticoat flex 7 silver REMOVE UM: MED Medical Drug 04/30/2021 insulin syringe syringe with REMOVE UM: MED needle,insulin,0.5 ml,syringe with needle,insulin disposable,0.5 ml 04/30/2021 norm-ject syringe, disposable, 1 ml REMOVE UM: MED Medical Drug tuberkulin syringe 04/30/2021 replicare,replicar hydrocolloid dressing REMOVE UM: MED Medical Drug e thin 04/30/2021 aminophylline aminophylline REMOVE UM: MED 04/30/2021 aminophylline aminophylline REMOVE UM: MED Medical Drug 04/30/2021 optichamber inhaler, assist devices REMOVE UM: MED Medical Drug diamond 04/30/2021 allevyn life foam bandage REMOVE UM: MED Medical Drug 04/30/2021 magic3 catheter REMOVE UM: MED Medical Drug intermittent catheter 04/30/2021 dextrose 2.5%- dextrose 2.5 % and 0.45 % REMOVE UM: MED 0.45% sodium chloride nacl,dextrose with sodium chloride 04/30/2021 DELESTROGEN estradiol valerate REMOVE UM: MED Medical Drug 04/30/2021 ISOLYTE S electrolyte-s solution REMOVE UM: MED Medical Drug 04/30/2021 FASLODEX fulvestrant REMOVE UM: MED Medical Drug 04/30/2021 stratagrt gel dressing REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 446 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 sofia2 flu-sars covid-19, influenza a, REMOVE UM: MED Medical Drug antigen fia influenza b antigen immunoassay test 04/30/2021 XGEVA denosumab REMOVE UM: MED Medical Drug 04/30/2021 carrasyn gel dressing REMOVE UM: MED Medical Drug hydrogel wound,carrasyn gel 04/30/2021 magellan insulin syringe with needle, insulin, REMOVE UM: MED Medical Drug safety syrng safety, 0.5 ml 04/30/2021 insuflon subcutaneous administration REMOVE UM: MED Medical Drug set 04/30/2021 gemcitabine hcl gemcitabine hcl REMOVE UM: MED Medical Drug 04/30/2021 IODOPEN sodium iodide REMOVE UM: MED Medical Drug 04/30/2021 idarubicin hcl idarubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 t:slim g4 subcutaneous insulin pump REMOVE UM: MED Medical Drug 04/30/2021 t:90 infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 clever choice inhaler,assist device with REMOVE UM: MED Medical Drug holding chamber large mask 04/30/2021 gemcitabine hcl gemcitabine hcl REMOVE UM: MED Medical Drug 04/30/2021 gemcitabine hcl gemcitabine hcl REMOVE UM: MED Medical Drug 04/30/2021 dexcom g4 blood-glucose REMOVE UM: MED Medical Drug meter,continuous 04/30/2021 pari lc plus nebulizer accessories REMOVE UM: MED Medical Drug nebulizer,reusabl e nebulizer kit 04/30/2021 t:90 infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 quick release soft infusion set for insulin pump REMOVE UM: MED Medical Drug teflon

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 447 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 gemcitabine hcl gemcitabine hcl REMOVE UM: MED Medical Drug 04/30/2021 metoclopramide metoclopramide hcl REMOVE UM: MED Medical Drug hcl 04/30/2021 leucovorin leucovorin calcium REMOVE UM: MED Medical Drug calcium 04/30/2021 curafil gel dressing REMOVE UM: MED Medical Drug 04/30/2021 mitomycin mitomycin REMOVE UM: MED Medical Drug 04/30/2021 aerochamber mv inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 VINCASAR PFS vincristine sulfate REMOVE UM: MED Medical Drug 04/30/2021 primeaire inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 derm-silk gel-matrix pad dressing, REMOVE UM: MED Medical Drug silicone 04/30/2021 SOTRADECOL sodium tetradecyl sulfate REMOVE UM: MED Medical Drug 04/30/2021 THYMOGLOBUL anti-thymocyte REMOVE UM: MED Medical Drug IN globulin,rabbit 04/30/2021 LEVOPHED norepinephrine bitartrate REMOVE UM: MED BITARTRATE,LE VOPHED 04/30/2021 enlite blood-glucose REMOVE UM: MED Medical Drug transmitter/blood-glucose sensor 04/30/2021 allevyn ag silver sulfadiazine/foam REMOVE UM: MED Medical Drug bandage 04/30/2021 PREMARIN estrogens, conjugated REMOVE UM: MED Medical Drug 04/30/2021 allevyn ag silver sulfadiazine/foam REMOVE UM: MED Medical Drug bandage 04/30/2021 allevyn ag silver sulfadiazine/foam REMOVE UM: MED Medical Drug bandage

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 448 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 potassium potassium chloride in water REMOVE UM: MED Medical Drug chloride for injection, sterile 04/30/2021 minimed reservoir insulin pump syringe, 3 ml REMOVE UM: MED Medical Drug 04/30/2021 MULTITRACE-4 zinc sulfate/cupric REMOVE UM: MED Medical Drug sulfate/manganese sulf/chromic chloride 04/30/2021 needle needles, safety REMOVE UM: MED Medical Drug 04/30/2021 teniposide teniposide REMOVE UM: MED Medical Drug 04/30/2021 vios aerosol nebulizer and compressor REMOVE UM: MED Medical Drug delivery system 04/30/2021 LIPODOX doxorubicin hcl pegylated REMOVE UM: MED Medical Drug liposomal 04/30/2021 TNKASE tenecteplase REMOVE UM: MED Medical Drug 04/30/2021 replicare hydrocolloid dressing REMOVE UM: MED Medical Drug 04/30/2021 inset infusion set infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 inset 30 infusion infusion set for insulin pump REMOVE UM: MED Medical Drug set 04/30/2021 ibutilide fumarate ibutilide fumarate REMOVE UM: MED Medical Drug 04/30/2021 DERMULCERA balsam peru/castor oil REMOVE UM: MED Medical Drug 04/30/2021 SUPARTZ FX hyaluronate sodium REMOVE UM: MED Medical Drug 04/30/2021 SWABFLUSH sodium chloride 0.9 % REMOVE UM: MED Medical Drug (flush) 04/30/2021 minimed quick infusion set for insulin pump REMOVE UM: MED Medical Drug set 04/30/2021 minimed quick infusion set for insulin pump REMOVE UM: MED Medical Drug set 04/30/2021 minimed quick infusion set for insulin pump REMOVE UM: MED Medical Drug set

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 449 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 accu-chek rapid d subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 t:slim insulin pump cartridge REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 devilbiss traveler nebulizer and compressor REMOVE UM: MED Medical Drug 04/30/2021 HEPAGAM B hepatitis b immune REMOVE UM: MED Medical Drug globulin/maltose 04/30/2021 allevyn foam bandage,adhesive REMOVE UM: MED Medical Drug adhesive,allevyn bandage 04/30/2021 minimed quick infusion set for insulin pump REMOVE UM: MED Medical Drug set 04/30/2021 TRIVISC hyaluronate sodium REMOVE UM: MED Medical Drug 04/30/2021 ETHYOL amifostine crystalline REMOVE UM: MED Medical Drug 04/30/2021 eversense smart blood-glucose transmitter REMOVE UM: MED Medical Drug transmitter 04/30/2021 BPCO balsam peru/castor oil REMOVE UM: MED 04/30/2021 baclofen baclofen REMOVE UM: MED Medical Drug 04/30/2021 comfort infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 leucovorin leucovorin calcium REMOVE UM: MED Medical Drug calcium 04/30/2021 acticoat silver REMOVE UM: MED Medical Drug 04/30/2021 comfort infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 osmitrol mannitol REMOVE UM: MED Medical Drug 04/30/2021 glycopyrrolate glycopyrrolate REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 450 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 portable nebulizer and compressor REMOVE UM: MED Medical Drug nebulizer system 04/30/2021 comfort short infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 GABLOFEN baclofen REMOVE UM: MED Medical Drug 04/30/2021 pediatric frog nebulizer and compressor REMOVE UM: MED Medical Drug nebulizer 04/30/2021 comfort short infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 dextrose 5%- dextrose 5 % and 0.3 % REMOVE UM: MED 0.33% sodium chloride nacl,dextrose 5%-0.3% nacl 04/30/2021 AVEED testosterone undecanoate REMOVE UM: MED Medical Drug 04/30/2021 comfort short infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 PROLIA denosumab REMOVE UM: MED Medical Drug 04/30/2021 kendall alcohol swab cap REMOVE UM: MED Medical Drug disinfectant cap 04/30/2021 DOCEFREZ docetaxel REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 syringe,safety with needle,5 REMOVE UM: MED Medical Drug ml 04/30/2021 terumo surguard2 syringe,safety with REMOVE UM: MED Medical Drug needle,10 ml 04/30/2021 DOCEFREZ docetaxel REMOVE UM: MED Medical Drug 04/30/2021 baby conversion nebulizer accessories REMOVE UM: MED Medical Drug pack 1 04/30/2021 baby conversion nebulizer accessories REMOVE UM: MED Medical Drug pack 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 451 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 i-port advance injection ports REMOVE UM: MED Medical Drug 04/30/2021 guardian test diabetic supplies,miscell REMOVE UM: MED Medical Drug plug 04/30/2021 monoject syringe syringe, disposable, 3 ml REMOVE UM: MED Medical Drug 04/30/2021 phaseal infusion clamp, iv tubing REMOVE UM: MED Medical Drug 04/30/2021 minimed sure t infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 CAMPTOSAR irinotecan hcl REMOVE UM: MED Medical Drug 04/30/2021 DACOGEN decitabine REMOVE UM: MED Medical Drug 04/30/2021 caffeine citrate caffeine citrate REMOVE UM: MED Medical Drug 04/30/2021 spectragel gel dressing REMOVE UM: MED Medical Drug 04/30/2021 FUSILEV levoleucovorin calcium REMOVE UM: MED Medical Drug 04/30/2021 TPN sodium/potassium/magnesiu REMOVE UM: MED Medical Drug ELECTROLYTES m/calcium/chloride/acetate 04/30/2021 baclofen baclofen REMOVE UM: MED Medical Drug 04/30/2021 baclofen baclofen REMOVE UM: MED Medical Drug 04/30/2021 accu-chek spirit sub-q infusion pump REMOVE UM: MED Medical Drug accessory,subcutaneous infusion pump accessory 04/30/2021 PEDITRACE zinc,copper,manganese REMOVE UM: MED Medical Drug chl/sod selen/sod fluoride/pot iodide 04/30/2021 bumetanide bumetanide REMOVE UM: MED Medical Drug 04/30/2021 sen-serter diabetic supplies,miscell REMOVE UM: MED Medical Drug 04/30/2021 restore silver/calcium alginate REMOVE UM: MED Medical Drug 04/30/2021 mistassist spirometers and accessories REMOVE UM: MED Medical Drug 04/30/2021 decitabine decitabine REMOVE UM: MED Medical Drug 04/30/2021 ELITEK rasburicase REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 452 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 DIURIL chlorothiazide sodium REMOVE UM: MED Medical Drug SODIUM,SODIU M DIURIL 04/30/2021 pro comfort inhaler,assist device with REMOVE UM: MED Medical Drug spacer with mask small mask 04/30/2021 VISIONBLUE trypan blue REMOVE UM: MED Medical Drug 04/30/2021 pro comfort inhaler,assist device with REMOVE UM: MED Medical Drug spacer with mask large mask 04/30/2021 cytarabine cytarabine/pf REMOVE UM: MED Medical Drug 04/30/2021 adenosine adenosine REMOVE UM: MED Medical Drug 04/30/2021 neria multi sub-q administration set, REMOVE UM: MED Medical Drug trifurcated 04/30/2021 neria multi sub-q administration set, REMOVE UM: MED Medical Drug quad-furcated 04/30/2021 minimed infusion set for insulin pump REMOVE UM: MED Medical Drug silhouette 04/30/2021 TRELSTAR triptorelin pamoate REMOVE UM: MED Medical Drug 04/30/2021 TRELSTAR triptorelin pamoate REMOVE UM: MED Medical Drug 04/30/2021 sil-k gel-matrix pad dressing, REMOVE UM: MED Medical Drug silicone 04/30/2021 dexrazoxane dexrazoxane hcl REMOVE UM: MED Medical Drug 04/30/2021 potassium potassium chloride in water REMOVE UM: MED Medical Drug chloride for injection, sterile 04/30/2021 devilbiss nebulizer and compressor REMOVE UM: MED Medical Drug pulmoneb lt comp-neb 04/30/2021 mask set with y- nebulizer accessories REMOVE UM: MED Medical Drug piece

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 453 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 quick-set infusion set for insulin pump REMOVE UM: MED Medical Drug paradigm 04/30/2021 restore silver sulfate/foam bandage REMOVE UM: MED Medical Drug 04/30/2021 restore silver sulfate/foam bandage REMOVE UM: MED Medical Drug 04/30/2021 UVADEX methoxsalen REMOVE UM: MED Medical Drug 04/30/2021 furosemide furosemide REMOVE UM: MED 04/30/2021 wide seal diaphragms, wide seal REMOVE UM: MED Medical Drug diaphragm 04/30/2021 zinc chloride zinc chloride REMOVE UM: MED Medical Drug 04/30/2021 space chamber- inhaler,assist device with REMOVE UM: MED Medical Drug large mask large mask 04/30/2021 ZANOSAR streptozocin REMOVE UM: MED Medical Drug 04/30/2021 space chamber- inhaler,assist device with REMOVE UM: MED Medical Drug medium mask medium mask 04/30/2021 replacement diabetic supplies,miscell REMOVE UM: MED Medical Drug pediatric monitor 04/30/2021 eversense glucose REMOVE UM: MED Medical Drug sensor-holder sensor,implantable,continuo us/dexamethasone acetate 04/30/2021 all flow 5000 nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 all flow 5000 nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 prochlorperazine prochlorperazine edisylate REMOVE UM: MED Medical Drug edisylate 04/30/2021 MARQIBO vincristine sulfate liposomal REMOVE UM: MED Medical Drug 04/30/2021 comfort infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 replicare hydrocolloid dressing REMOVE UM: MED Medical Drug 04/30/2021 replicare,replicar hydrocolloid dressing REMOVE UM: MED Medical Drug e thin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 454 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 acticoat flex 7 silver REMOVE UM: MED Medical Drug 04/30/2021 acticoat flex 3 silver REMOVE UM: MED Medical Drug 04/30/2021 acticoat flex 7 silver REMOVE UM: MED Medical Drug 04/30/2021 neria subcutaneous administration REMOVE UM: MED Medical Drug set 04/30/2021 allergist tray syringe with REMOVE UM: MED Medical Drug needle,disposable, 0.5 ml 04/30/2021 guardian rt starter diabetic supplies,miscell REMOVE UM: MED Medical Drug kit 04/30/2021 rapport vacuum vacuum erection device REMOVE UM: MED Medical Drug therapy system 04/30/2021 magellan insulin syringe with needle, insulin, REMOVE UM: MED Medical Drug safety syrng safety, 0.3 ml 04/30/2021 space chamber- inhaler,assist device with REMOVE UM: MED Medical Drug small mask small mask 04/30/2021 TESTOPEL testosterone REMOVE UM: MED Medical Drug 04/30/2021 acticoat flex 3 silver REMOVE UM: MED Medical Drug 04/30/2021 flyp nebulizer nebulizer REMOVE UM: MED Medical Drug 04/30/2021 acticoat flex 7 silver REMOVE UM: MED Medical Drug 04/30/2021 docetaxel docetaxel REMOVE UM: MED Medical Drug 04/30/2021 docetaxel docetaxel REMOVE UM: MED Medical Drug 04/30/2021 hypodermic needles, disposable REMOVE UM: MED Medical Drug needle 04/30/2021 ace aerosol cloud inhaler, assist devices REMOVE UM: MED Medical Drug enhancer 04/30/2021 kelotop gel-matrix pad dressing, REMOVE UM: MED Medical Drug silicone

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 455 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 animas vibe sub-q insulin pump, REMOVE UM: MED Medical Drug continuous glucose monitoring system 04/30/2021 TAXOTERE docetaxel REMOVE UM: MED Medical Drug 04/30/2021 TAXOTERE docetaxel REMOVE UM: MED Medical Drug 04/30/2021 GABLOFEN baclofen REMOVE UM: MED Medical Drug 04/30/2021 MONOJECT sodium chloride 0.9 % REMOVE UM: MED Medical Drug PREFILL (flush),0.9 % sodium ADVANCED chloride 04/30/2021 GABLOFEN baclofen REMOVE UM: MED Medical Drug 04/30/2021 GABLOFEN baclofen REMOVE UM: MED Medical Drug 04/30/2021 GABLOFEN baclofen REMOVE UM: MED Medical Drug 04/30/2021 minimed 530g subcutaneous insulin pump REMOVE UM: MED Medical Drug 04/30/2021 GABLOFEN baclofen REMOVE UM: MED Medical Drug 04/30/2021 interlink syringe syringe with cannula, REMOVE UM: MED Medical Drug w-cannula disposable, 10 ml 04/30/2021 GABLOFEN baclofen REMOVE UM: MED Medical Drug 04/30/2021 lever lock syringe accessory REMOVE UM: MED Medical Drug cannula 04/30/2021 normal saline sodium chloride 0.9 % REMOVE UM: MED Medical Drug flush (flush) 04/30/2021 dover universal catheterization tray REMOVE UM: MED Medical Drug 04/30/2021 contact detach infusion set for insulin pump REMOVE UM: MED Medical Drug infusion set 04/30/2021 orphenadrine orphenadrine citrate REMOVE UM: MED Medical Drug citrate 04/30/2021 HEXTEND hetastarch/electrolyte REMOVE UM: MED Medical Drug LACTATED solution,lactated ELECTROLYTE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 456 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 DANTRIUM dantrolene sodium REMOVE UM: MED Medical Drug 04/30/2021 dobutamine hcl- dobutamine hcl in dextrose REMOVE UM: MED Medical Drug d5w 5 % in water 04/30/2021 lofric catheter REMOVE UM: MED Medical Drug 04/30/2021 guardian sensor blood-glucose sensor REMOVE UM: MED Medical Drug 3 04/30/2021 HYPERHEP B hepatitis b immune globulin REMOVE UM: MED 04/30/2021 CLEARSHIELD sodium chloride 0.9 % REMOVE UM: MED Medical Drug SODIUM CHLOR (flush) FLUSH 04/30/2021 t:slim x2 subcutaneous insulin pump REMOVE UM: MED Medical Drug 04/30/2021 BOTOX onabotulinumtoxina REMOVE UM: MED Medical Drug COSMETIC 04/30/2021 MONOJECT sodium chloride 0.9 % REMOVE UM: MED Medical Drug 0.9% SODIUM (flush) CHLORIDE,MON OJECT SODIUM CHLORIDE FLUSH 04/30/2021 flexichamber inhaler, assist devices, REMOVE UM: MED Medical Drug mask accessories 04/30/2021 flexichamber inhaler, assist devices, REMOVE UM: MED Medical Drug mask accessories 04/30/2021 dextrose 10%- dextrose 10 % and 0.2 % REMOVE UM: MED Medical Drug 0.2% sodium chloride nacl,dextrose 10%-1/4ns 04/30/2021 lc star nebulizer REMOVE UM: MED Medical Drug 04/30/2021 lc plus nebulizer REMOVE UM: MED Medical Drug 04/30/2021 procare pediatric nebulizer and compressor REMOVE UM: MED Medical Drug nebulizer

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 457 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 fulvestrant fulvestrant REMOVE UM: MED 04/30/2021 polyfin qr subcutaneous infusion pump REMOVE UM: MED Medical Drug accessory 04/30/2021 PROLASTIN C alpha-1-proteinase inhibitor REMOVE UM: MED Medical Drug 04/30/2021 NEOPROFEN ibuprofen lysine/pf REMOVE UM: MED Medical Drug 04/30/2021 trek s compact nebulizer and REMOVE UM: MED Medical Drug compressor compressor,nebulizer/compr essor, for nebulizer 04/30/2021 trek s portable nebulizer accessories REMOVE UM: MED Medical Drug pwr kit 04/30/2021 hi-volume transfer sets REMOVE UM: MED Medical Drug pumping chamber 04/30/2021 trek s combo nebulizer and compressor REMOVE UM: MED Medical Drug pack 04/30/2021 flexichamber inhaler, assist devices, REMOVE UM: MED Medical Drug mask accessories 04/30/2021 filter, valve set for nebulizer accessories REMOVE UM: MED Medical Drug ll & lc 04/30/2021 hetastarch in hetastarch in 0.9 % sodium REMOVE UM: MED Medical Drug ns,hetastarch- chloride 0.9% nacl 04/30/2021 all flow 3000 pft nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 inset 30 tubing subcutaneous infusion pump REMOVE UM: MED Medical Drug accessory 04/30/2021 all flow 3000 kit nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 inset 30 tubing subcutaneous infusion pump REMOVE UM: MED Medical Drug accessory 04/30/2021 lc sprint nebulizer nebulizer REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 458 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 dover latex foley catheter REMOVE UM: MED catheter 04/30/2021 dextrose in dextrose 5 % in REMOVE UM: MED Medical Drug ringers injection ringer's,dextrose 5% in ringers 04/30/2021 scarsilk gel-matrix pad dressing, REMOVE UM: MED Medical Drug silicone 04/30/2021 NAVELBINE vinorelbine tartrate REMOVE UM: MED Medical Drug 04/30/2021 tens 502 transcutaneous electrical REMOVE UM: MED Medical Drug nerve stimulators (tens units) 04/30/2021 curity drainage bag REMOVE UM: MED Medical Drug 04/30/2021 toomey syringe syringe, disposable REMOVE UM: MED Medical Drug irrigation, 70 ml 04/30/2021 dextrose 5%- dextrose 5 % and 0.45 % REMOVE UM: MED 0.45% sodium chloride nacl,dextrose with sodium chloride 04/30/2021 mannitol mannitol REMOVE UM: MED Medical Drug 04/30/2021 SYNVISC-ONE hylan g-f 20 REMOVE UM: MED Medical Drug 04/30/2021 erapid nebulizer nebulizer accessories REMOVE UM: MED Medical Drug handset 04/30/2021 riteflo inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 cleo 90 infusion infusion set for insulin pump REMOVE UM: MED Medical Drug set 04/30/2021 XYLOCAINE lidocaine hcl/pf REMOVE UM: MED Medical Drug IV,XYLOCAINE IV FOR CARDIAC

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 459 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 dextrose 10%- dextrose 10 % and 0.45 % REMOVE UM: MED Medical Drug 0.45% nacl sodium chloride 04/30/2021 oxytocin oxytocin REMOVE UM: MED Medical Drug 04/30/2021 NEUT sodium bicarbonate REMOVE UM: MED Medical Drug 04/30/2021 NABI-HB hepatitis b immune globulin REMOVE UM: MED Medical Drug 04/30/2021 ARRANON nelarabine REMOVE UM: MED Medical Drug 04/30/2021 paradigm subcutaneous infusion pump REMOVE UM: MED Medical Drug silhouette accessory 04/30/2021 XOFIGO radium-223 dichloride REMOVE UM: MED Medical Drug 04/30/2021 paradigm insulin pump syringe, 3 ml REMOVE UM: MED Medical Drug 04/30/2021 minimed sure t infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 minimed sure t infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 cleo 90 infusion infusion set for insulin pump REMOVE UM: MED Medical Drug set 04/30/2021 docetaxel docetaxel REMOVE UM: MED Medical Drug 04/30/2021 blunt needle blunt needle, disposable REMOVE UM: MED Medical Drug 04/30/2021 IDAMYCIN PFS idarubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 devilbiss compressor, for nebulizer REMOVE UM: MED Medical Drug pulmomate 04/30/2021 inspirachamber inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 inspirachamber inhaler,assist device with REMOVE UM: MED Medical Drug small mask 04/30/2021 inspirachamber inhaler,assist device with REMOVE UM: MED Medical Drug medium mask 04/30/2021 fludarabine fludarabine phosphate REMOVE UM: MED Medical Drug phosphate 04/30/2021 phenylephrine hcl phenylephrine hcl REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 460 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 MESNEX mesna REMOVE UM: MED Medical Drug 04/30/2021 ADRIAMYCIN doxorubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 sensura flex ostomy supply REMOVE UM: MED Medical Drug ostomy pouch 04/30/2021 breatherite inhaler,assist device with REMOVE UM: MED Medical Drug spacer-adult large mask mask 04/30/2021 ATRAPRO hypochlorous acid/sodium REMOVE UM: MED Medical Drug DERMAL SPRAY hypochlorite/sod chlorid/elec.water 04/30/2021 breatherite inhaler,assist device with REMOVE UM: MED Medical Drug spacer-lg chld medium mask msk 04/30/2021 silicone mask inhaler, assist devices, REMOVE UM: MED Medical Drug accessories 04/30/2021 breatherite inhaler,assist device with REMOVE UM: MED Medical Drug spacer-sm chld small mask msk 04/30/2021 speedicath catheter REMOVE UM: MED Medical Drug 04/30/2021 ZANTAC ranitidine hcl REMOVE UM: MED Medical Drug 04/30/2021 acticoat silver REMOVE UM: MED Medical Drug 04/30/2021 breathrite inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 kangaroo gravity feeder container with gravity REMOVE UM: MED set set 04/30/2021 breathrite inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 breatherite inhaler,assist device with REMOVE UM: MED Medical Drug spacer-infant small mask mask 04/30/2021 acticoat silver REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 461 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 breatherite inhaler,assist device with REMOVE UM: MED Medical Drug spacer-neonate small mask msk 04/30/2021 DEPO- estradiol cypionate REMOVE UM: MED Medical Drug ESTRADIOL 04/30/2021 ulticare,tuberculin syringe with REMOVE UM: MED Medical Drug syringe-needle needle,disposable, 1 ml 04/30/2021 daunorubicin hcl daunorubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 syringe,safety with REMOVE UM: MED Medical Drug needle,10 ml 04/30/2021 sensura flex ostomy supply REMOVE UM: MED Medical Drug ostomy base plate 04/30/2021 minimed reservoir insulin pump syringe, 1.8 ml REMOVE UM: MED Medical Drug 04/30/2021 FIRMAGON degarelix acetate REMOVE UM: MED Medical Drug 04/30/2021 FIRMAGON degarelix acetate REMOVE UM: MED Medical Drug 04/30/2021 snap insulin insulin pump controller REMOVE UM: MED Medical Drug pump controller 04/30/2021 levothyroxine levothyroxine sodium REMOVE UM: MED Medical Drug sodium 04/30/2021 potassium potassium REMOVE UM: MED Medical Drug chloride chloride,potassium chloride in water for injection, sterile 04/30/2021 breatherite inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 litetouch inhaler, assist devices, REMOVE UM: MED Medical Drug accessories 04/30/2021 id now covid-19 covid-19 molecular nucleic REMOVE UM: MED Medical Drug test kit acid test assay

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 462 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 sodium 0.9 % sodium chloride REMOVE UM: MED Medical Drug chloride,sodium chloride-water 04/30/2021 accu-chek insulin pump/infusion REMOVE UM: MED Medical Drug set/blood-glucose meter 04/30/2021 pulmoneb lt nebulizer and compressor REMOVE UM: MED Medical Drug compressor nebul 04/30/2021 pcca accupen-15 topical cream metered-dose REMOVE UM: MED Medical Drug device 04/30/2021 minilink real-time blood-glucose transmitter REMOVE UM: MED Medical Drug transmitter 04/30/2021 amiodarone hcl amiodarone hcl REMOVE UM: MED Medical Drug 04/30/2021 LIORESAL baclofen REMOVE UM: MED Medical Drug INTRATHECAL 04/30/2021 NEXAVIR liver extract (beef-pork) REMOVE UM: MED Medical Drug 04/30/2021 accu-chek rapid d subcutaneous administration REMOVE UM: MED Medical Drug set 04/30/2021 kangaroo 924 pump set REMOVE UM: MED Medical Drug safety screw 04/30/2021 estradiol valerate estradiol valerate REMOVE UM: MED 04/30/2021 mitomycin mitomycin REMOVE UM: MED Medical Drug 04/30/2021 minimed infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 guardian real- blood-glucose REMOVE UM: MED Medical Drug time meter,continuous/blood- glucose transmitter 04/30/2021 leucovorin leucovorin calcium REMOVE UM: MED Medical Drug calcium 04/30/2021 sodium acetate sodium acetate REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 463 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 AK-FLUOR fluorescein sodium REMOVE UM: MED Medical Drug 04/30/2021 CLOLAR clofarabine REMOVE UM: MED Medical Drug 04/30/2021 restore non-adherent REMOVE UM: MED Medical Drug bandage,silver/calcium alginate 04/30/2021 wide seal diaphragms, wide seal REMOVE UM: MED Medical Drug diaphragm 04/30/2021 monoject syringe, disposable, 1 ml REMOVE UM: MED pharmacy tray 04/30/2021 assura colostomy bag, non-sterile REMOVE UM: MED Medical Drug 04/30/2021 GAMMAGARD immune REMOVE UM: MED Medical Drug LIQUID globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml 04/30/2021 insulin syringe syringe with REMOVE UM: MED needle,disposable,insulin 1 ml 04/30/2021 bcg (tice strain) bcg live REMOVE UM: MED Medical Drug 04/30/2021 monoject safety syringe,safety with REMOVE UM: MED Medical Drug syringe needle,12 ml 04/30/2021 enlite glucose blood-glucose sensor REMOVE UM: MED Medical Drug sensor 04/30/2021 truneb nebulizer nebulizer REMOVE UM: MED Medical Drug 04/30/2021 vixone nebulizer nebulizer REMOVE UM: MED Medical Drug 04/30/2021 TRIOSTAT liothyronine sodium REMOVE UM: MED Medical Drug 04/30/2021 sodium chloride sodium chloride 0.9 % REMOVE UM: MED (flush),0.9 % sodium chloride 04/30/2021 omnipod dash 5 insulin pump cartridge REMOVE UM: MED Medical Drug pack pod

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 464 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 i-port injection ports REMOVE UM: MED Medical Drug 04/30/2021 dover red rubber catheter REMOVE UM: MED Medical Drug robibson cath 04/30/2021 omnipod dash insulin pump controller REMOVE UM: MED Medical Drug pdm kit 04/30/2021 epirubicin hcl epirubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 FIRMAGON degarelix acetate REMOVE UM: MED Medical Drug 04/30/2021 PITOCIN oxytocin REMOVE UM: MED Medical Drug 04/30/2021 air filter nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 balsam peru- balsam peru/castor oil REMOVE UM: MED Medical Drug castor oil 04/30/2021 epirubicin hcl epirubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 sodium sodium bicarbonate REMOVE UM: MED Medical Drug bicarbonate,sodiu m bicarbonate- water 04/30/2021 sodium sodium bicarbonate REMOVE UM: MED Medical Drug bicarbonate 04/30/2021 saf-t-intima iv intravenous catheter kit REMOVE UM: MED catheter 04/30/2021 HYALGAN hyaluronate sodium REMOVE UM: MED Medical Drug 04/30/2021 integra syringe syringe,safety with needle,3 REMOVE UM: MED Medical Drug ml 04/30/2021 ephedrine sulfate ephedrine sulfate REMOVE UM: MED Medical Drug 04/30/2021 provent nasal exhalation resistance REMOVE UM: MED Medical Drug sr,provent device 04/30/2021 autosoft xc infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 MEDIHONEY honey REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 465 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 ibuprofen lysine ibuprofen lysine/pf REMOVE UM: MED Medical Drug 04/30/2021 procainamide hcl procainamide hcl REMOVE UM: MED Medical Drug 04/30/2021 norepinephrine norepinephrine bitartrate REMOVE UM: MED bitartrate 04/30/2021 easivent inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 monoject syringe with REMOVE UM: MED Medical Drug needle,insulin,0.5 ml 04/30/2021 monoject syringe with REMOVE UM: MED needle,disposable 04/30/2021 truzone peak flow peak flow meter REMOVE UM: MED Medical Drug meter 04/30/2021 mannitol mannitol REMOVE UM: MED Medical Drug 04/30/2021 mini plus nebulizer REMOVE UM: MED Medical Drug nebulizer 04/30/2021 sidestream mask nebulizer accessories REMOVE UM: MED 04/30/2021 wide seal diaphragms, wide seal REMOVE UM: MED Medical Drug diaphragm 04/30/2021 sodium chloride sodium chloride 5 % REMOVE UM: MED Medical Drug 04/30/2021 ADRENALIN epinephrine REMOVE UM: MED Medical Drug CHLORIDE,ADR ENALIN 04/30/2021 hypodermic needles, disposable REMOVE UM: MED needle 04/30/2021 topotecan hcl topotecan hcl REMOVE UM: MED Medical Drug 04/30/2021 dover coated urinary bag/catheterization REMOVE UM: MED Medical Drug latex foley tray 04/30/2021 LEVICYN sod mg fluo/sodium REMOVE UM: MED Medical Drug phos/nacl/hypochlorous acid/sod hypochlor

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 466 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 monoject enfit syringe, enfit 12 ml, REMOVE UM: MED syringe sterile,syringe, enfit 12 ml, non-sterile 04/30/2021 alprostadil alprostadil REMOVE UM: MED Medical Drug 04/30/2021 insulin syringe syringe with REMOVE UM: MED needle,disposable,insulin 1 ml 04/30/2021 eclipse needle needles, safety REMOVE UM: MED Medical Drug 04/30/2021 pocket chamber inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 dextrose 5%- dextrose 5 % and 0.2 % REMOVE UM: MED 0.2% sodium chloride nacl,dextrose 5%-0.225% nacl 04/30/2021 insulin syringe syringe with REMOVE UM: MED needle,insulin,0.5 ml,syringe with needle,insulin disposable,0.5 ml 04/30/2021 hypodermic needles, disposable REMOVE UM: MED needle 04/30/2021 pediatric comp- nebulizer and compressor REMOVE UM: MED Medical Drug air compres neb 04/30/2021 aeroneb go nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 prochamber inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 dexcom g4 blood-glucose transmitter REMOVE UM: MED Medical Drug 04/30/2021 dexcom blood-glucose sensor REMOVE UM: MED Medical Drug g4,dexcom g5-g4 sensor 04/30/2021 NEXTERONE amiodarone in dextrose, iso- REMOVE UM: MED Medical Drug osmotic 04/30/2021 innospire mini nebulizer and compressor REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 467 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 autosoft 30 infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 dexcom g4 blood-glucose REMOVE UM: MED Medical Drug meter,continuous 04/30/2021 NEXTERONE amiodarone in dextrose, iso- REMOVE UM: MED Medical Drug osmotic 04/30/2021 ADRENALIN epinephrine REMOVE UM: MED Medical Drug CHLORIDE,ADR ENALIN 04/30/2021 willis the whale nebulizer and compressor REMOVE UM: MED Medical Drug compressr neb 04/30/2021 aerochamber inhaler, assist devices REMOVE UM: MED Medical Drug with flowsignal 04/30/2021 biostep ag dressing,collagen/silver/sod REMOVE UM: MED Medical Drug alginate/carboxymethylcellul ose 04/30/2021 biostep ag dressing,collagen/silver/sod REMOVE UM: MED Medical Drug alginate/carboxymethylcellul ose 04/30/2021 syringe-needle syringe,safety with needle,1 REMOVE UM: MED Medical Drug ml 04/30/2021 ulticare syringe with REMOVE UM: MED Medical Drug needle,disposable, 1 ml 04/30/2021 prosilk gel-matrix pad dressing, REMOVE UM: MED Medical Drug silicone 04/30/2021 inpen (for insulin admin. supplies REMOVE UM: MED Medical Drug humalog) 04/30/2021 inpen (for insulin admin. supplies REMOVE UM: MED Medical Drug novolog or fiasp) 04/30/2021 ELLENCE epirubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 cytarabine cytarabine/pf REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 468 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 keragelt gel dressing REMOVE UM: MED Medical Drug 04/30/2021 MULTITRACE-4 zinc sulfate/cupric REMOVE UM: MED Medical Drug sulfate/manganese sulf/chromic chloride 04/30/2021 safety syringe syringe,safety with needle,3 REMOVE UM: MED Medical Drug with shield ml 04/30/2021 kerlix amd polyhexamethylene REMOVE UM: MED Medical Drug bandage biguanide/gauze bandage 04/30/2021 t.e.d. anti- compression stocking, knee REMOVE UM: MED Medical Drug embolism high, regular length, small stocking 04/30/2021 ISTODAX romidepsin REMOVE UM: MED Medical Drug 04/30/2021 ISOLYTE S electrolyte-s (ph 7.4) REMOVE UM: MED Medical Drug 04/30/2021 all flow 1000 nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 MUTAMYCIN mitomycin REMOVE UM: MED Medical Drug 04/30/2021 all flow 1000 nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 kerlix amd polyhexamethylene REMOVE UM: MED Medical Drug biguanide/gauze bandage 04/30/2021 omnipod subcutaneous insulin pump REMOVE UM: MED Medical Drug 04/30/2021 ZINECARD dexrazoxane REMOVE UM: MED Medical Drug hcl,dexrazoxane 04/30/2021 nitroglycerin nitroglycerin REMOVE UM: MED Medical Drug 04/30/2021 femcap cervical cap REMOVE UM: MED Medical Drug 04/30/2021 lofric catheter REMOVE UM: MED Medical Drug 04/30/2021 GAMUNEX-C immune REMOVE UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 04/30/2021 vortex vhc frog inhaler,assist device with REMOVE UM: MED Medical Drug mask medium mask

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 469 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 vortex vhc inhaler,assist device with REMOVE UM: MED Medical Drug ladybug mask small mask 04/30/2021 minimed 630g blood-glucose transmitter REMOVE UM: MED Medical Drug guardian start kt 04/30/2021 LUCENTIS ranibizumab REMOVE UM: MED Medical Drug 04/30/2021 monoject syringe,safety with needle,3 REMOVE UM: MED Medical Drug magellan ml 04/30/2021 q-cliq pen (for pen injector device REMOVE UM: MED Medical Drug natpara) 04/30/2021 VISCOAT chondroitin sulfate a REMOVE UM: MED Medical Drug sodium/hyaluronate sodium 04/30/2021 q-care rx dental suction REMOVE UM: MED Medical Drug device/chlorhexidine gl/dental swab comb no.1 04/30/2021 OCTAGAM immune REMOVE UM: MED Medical Drug globulin,gamm(igg)/maltose/ iga greater than 50 mcg/ml 04/30/2021 VIRAZOLE ribavirin REMOVE UM: MED Medical Drug 04/30/2021 monoject insulin syringe with REMOVE UM: MED Medical Drug syringe needle,insulin,0.3 ml 04/30/2021 monoject insulin syringe with REMOVE UM: MED Medical Drug syringe needle,insulin,0.5 ml 04/30/2021 wide seal diaphragms, wide seal REMOVE UM: MED Medical Drug diaphragm 04/30/2021 monoject insulin syringe with REMOVE UM: MED Medical Drug syringe needle,insulin,0.5 ml 04/30/2021 sidestream nebulizer REMOVE UM: MED Medical Drug 04/30/2021 microchamber inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 caya contoured diaphragms, contoured REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 470 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 azacitidine azacitidine REMOVE UM: MED Medical Drug 04/30/2021 pen needle,pen pen needle, diabetic REMOVE UM: MED needles 04/30/2021 erapid nebulizer nebulizer REMOVE UM: MED Medical Drug 04/30/2021 adenosine adenosine REMOVE UM: MED Medical Drug 04/30/2021 sodium lactate sodium lactate REMOVE UM: MED Medical Drug 04/30/2021 pulmo-aide compressor, for nebulizer REMOVE UM: MED Medical Drug 04/30/2021 dobutamine hcl dobutamine hcl REMOVE UM: MED Medical Drug 04/30/2021 dobutamine hcl dobutamine hcl REMOVE UM: MED Medical Drug 04/30/2021 dobutamine hcl- dobutamine hcl in dextrose REMOVE UM: MED Medical Drug d5w 5 % in water 04/30/2021 OCUCOAT hypromellose REMOVE UM: MED Medical Drug 04/30/2021 szosil silicone adhesive REMOVE UM: MED Medical Drug 04/30/2021 accu-chek subcutaneous infusion pump REMOVE UM: MED Medical Drug accessory 04/30/2021 monoject syringe,safety with needle,1 REMOVE UM: MED Medical Drug magellan ml 04/30/2021 romidepsin romidepsin REMOVE UM: MED Medical Drug 04/30/2021 keragel gel dressing REMOVE UM: MED Medical Drug 04/30/2021 silhouette subcutaneous infusion pump REMOVE UM: MED Medical Drug accessory 04/30/2021 comp-air nebulizer and REMOVE UM: MED Medical Drug nebulizer compressor,nebulizer/compr compressor essor, for nebulizer 04/30/2021 bleomycin sulfate bleomycin sulfate REMOVE UM: MED Medical Drug 04/30/2021 omnipod insulin pump cartridge REMOVE UM: MED Medical Drug 04/30/2021 aceso ag silver/silicone/foam bandage REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 471 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 aerochamber inhaler, assist devices REMOVE UM: MED Medical Drug plus flow-vu 04/30/2021 altera nebulizer nebulizer REMOVE UM: MED Medical Drug 04/30/2021 sure-t paradigm infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 dextrose 5%- potassium chloride in REMOVE UM: MED Medical Drug 1/2ns-kcl dextrose 5 %-0.45 % sodium chloride 04/30/2021 scarcinpad gel-matrix pad dressing, REMOVE UM: MED Medical Drug silicone 04/30/2021 irinotecan hcl irinotecan hcl REMOVE UM: MED Medical Drug 04/30/2021 INFASURF calfactant REMOVE UM: MED Medical Drug 04/30/2021 DELESTROGEN estradiol valerate REMOVE UM: MED Medical Drug 04/30/2021 lofric primo catheter REMOVE UM: MED Medical Drug nelaton 04/30/2021 biostep dressing, collagen/sodium REMOVE UM: MED Medical Drug alginate/carboxymethylcellul ose 04/30/2021 gemcitabine hcl gemcitabine hcl REMOVE UM: MED Medical Drug 04/30/2021 biostep dressing, collagen/sodium REMOVE UM: MED Medical Drug alginate/carboxymethylcellul ose 04/30/2021 accu-chek spirit sub-q infusion pump REMOVE UM: MED Medical Drug accessory,subcutaneous infusion pump accessory 04/30/2021 trusteel infusion infusion set for insulin pump REMOVE UM: MED Medical Drug set 04/30/2021 varisoft infusion infusion set for insulin pump REMOVE UM: MED Medical Drug set 04/30/2021 trusteel infusion infusion set for insulin pump REMOVE UM: MED Medical Drug set

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 472 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 t.e.d. anti- compression stocking,thigh REMOVE UM: MED Medical Drug embolism high,regular length,small stocking circumf,compression stocking,thigh high,short length,small circumfer,compression stocking,thigh high,regular length,medium circum,compression stocking,thigh high,regular length,large circumf,compression stocking,thigh high,long length,small circumfer.,compression stocking,thigh high,regular length,x-small circ.,compression stocking,thigh high,short length,medium circumf.,compression stocking,thigh high,long length,x-small circumf.,compression stocking,thigh high,long length,medium circumfer,compression stocking,thigh high,long length,large circumfer.,compression stocking,thigh high,short length,large circumfer,compression stocking,thigh high,reg length,x-large circumfer,compression stocking,thigh high,long length,extra-large circ,compression stocking,

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 473 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value knee high, regular length, medium,compression stocking, knee high, regular length, small,compression stocking,knee high,regular length,large circumf.,compression stocking,knee high,regular length,x-large circum,compression stocking,knee high,long length,small circumferen,compression stocking,knee high,long length,medium circumfer.,compression stocking,knee high,long length, large circumfer.,compression stocking,knee high,long length, x-large circumf. 04/30/2021 varisoft infusion infusion set for insulin pump REMOVE UM: MED Medical Drug set 04/30/2021 VASHE WOUND sodium chloride irrigating REMOVE UM: MED Medical Drug THERAPY,VASH solution/hypochlorous acid E WOUND 04/30/2021 proneb ultra ii nebulizer/compressor, for REMOVE UM: MED Medical Drug nebulizer,nebulizer and compressor 04/30/2021 chlorothiazide chlorothiazide sodium REMOVE UM: MED Medical Drug sodium 04/30/2021 liothyronine liothyronine sodium REMOVE UM: MED Medical Drug sodium 04/30/2021 IXEMPRA ixabepilone REMOVE UM: MED Medical Drug 04/30/2021 famotidine famotidine/pf REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 474 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 autosoft 90 infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 ARALAST NP alpha-1-proteinase inhibitor REMOVE UM: MED Medical Drug 04/30/2021 ARALAST NP alpha-1-proteinase inhibitor REMOVE UM: MED Medical Drug 04/30/2021 phaseal protector transfer device, closed REMOVE UM: MED Medical Drug system 04/30/2021 phaseal protector transfer device, closed REMOVE UM: MED Medical Drug system 04/30/2021 phaseal protector transfer device, closed REMOVE UM: MED Medical Drug system 04/30/2021 ISUPREL isoproterenol hcl REMOVE UM: MED Medical Drug 04/30/2021 prochlorperazine prochlorperazine edisylate REMOVE UM: MED Medical Drug edisylate 04/30/2021 KEPIVANCE palifermin REMOVE UM: MED Medical Drug 04/30/2021 DYSPORT abobotulinumtoxina REMOVE UM: MED Medical Drug 04/30/2021 novopen echo insulin admin. supplies REMOVE UM: MED Medical Drug 04/30/2021 selenium selenium REMOVE UM: MED Medical Drug 04/30/2021 aerobika mucus clearing device REMOVE UM: MED Medical Drug 04/30/2021 amiodarone hcl amiodarone hcl REMOVE UM: MED Medical Drug 04/30/2021 rate flow intravenous administration REMOVE UM: MED Medical Drug regulator iv set set 04/30/2021 nexiva intravenous catheter REMOVE UM: MED Medical Drug 04/30/2021 optichamber inhaler,assist device with REMOVE UM: MED Medical Drug diamond small mask 04/30/2021 nexiva intravenous catheter REMOVE UM: MED Medical Drug 04/30/2021 optichamber inhaler,assist device with REMOVE UM: MED Medical Drug diamond medium mask 04/30/2021 nexiva intravenous catheter REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 475 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 nexiva intravenous catheter REMOVE UM: MED Medical Drug 04/30/2021 liteaire inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 VISUDYNE verteporfin REMOVE UM: MED Medical Drug 04/30/2021 freestyle libre 2 flash glucose sensor REMOVE UM: MED Medical Drug sensor 04/30/2021 IXEMPRA ixabepilone REMOVE UM: MED Medical Drug 04/30/2021 ZEMAIRA alpha-1-proteinase inhibitor REMOVE UM: MED Medical Drug 04/30/2021 pen needle,pen pen needle, diabetic REMOVE UM: MED needles 04/30/2021 potassium potassium chloride in water REMOVE UM: MED Medical Drug chloride for injection, sterile 04/30/2021 nutriport balloon ostomy kit REMOVE UM: MED Medical Drug 04/30/2021 wide seal diaphragms, wide seal REMOVE UM: MED Medical Drug diaphragm 04/30/2021 t:slim subcutaneous insulin pump REMOVE UM: MED Medical Drug 04/30/2021 sodium tetradecyl sodium tetradecyl sulfate REMOVE UM: MED Medical Drug sulfate 04/30/2021 PLASMA-LYTE electrolyte-148 solution REMOVE UM: MED Medical Drug 148 04/30/2021 MULTITRACE-5 zinc sulfate/copper REMOVE UM: MED Medical Drug sulfate/manganese/chromiu m/selenium 04/30/2021 microspacer inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 allopurinol allopurinol sodium REMOVE UM: MED Medical Drug sodium 04/30/2021 sodium sodium bicarbonate REMOVE UM: MED Medical Drug bicarbonate,sodiu m bicarbonate- water

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 476 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 LUCENTIS ranibizumab REMOVE UM: MED Medical Drug 04/30/2021 insulin syringe syringe with REMOVE UM: MED needle,disposable,insulin 1 ml 04/30/2021 sootheneb mesh nebulizer REMOVE UM: MED Medical Drug nebulizer 04/30/2021 cellpad gel-matrix pad dressing, REMOVE UM: MED Medical Drug silicone 04/30/2021 manganese manganese chloride REMOVE UM: MED Medical Drug chloride 04/30/2021 VINCASAR PFS vincristine sulfate REMOVE UM: MED Medical Drug 04/30/2021 contact detach infusion set for insulin pump REMOVE UM: MED Medical Drug infusion set 04/30/2021 KEDRAB rabies immune globulin/pf REMOVE UM: MED Medical Drug 04/30/2021 atropine sulfate atropine sulfate REMOVE UM: MED Medical Drug 04/30/2021 freestyle libre 2 flash glucose scanning REMOVE UM: MED Medical Drug reader reader 04/30/2021 XOLAIR omalizumab REMOVE UM: MED Medical Drug 04/30/2021 sodium sodium bicarbonate REMOVE UM: MED Medical Drug bicarbonate 04/30/2021 BELEODAQ belinostat REMOVE UM: MED Medical Drug 04/30/2021 DOXIL doxorubicin hcl pegylated REMOVE UM: MED Medical Drug liposomal 04/30/2021 easivent inhaler, assist devices, REMOVE UM: MED Medical Drug accessories 04/30/2021 baby nebulizer nebulizer REMOVE UM: MED Medical Drug 04/30/2021 minimed 770g subcutaneous insulin pump REMOVE UM: MED Medical Drug 04/30/2021 etoposide etoposide REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 477 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 wide seal diaphragms, wide seal REMOVE UM: MED Medical Drug diaphragm 04/30/2021 myelogram tray myelogram tray REMOVE UM: MED Medical Drug 04/30/2021 sof-set infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 floxuridine floxuridine REMOVE UM: MED Medical Drug 04/30/2021 female self catheter REMOVE UM: MED Medical Drug catheter 04/30/2021 easivent inhaler, assist devices, REMOVE UM: MED Medical Drug accessories 04/30/2021 strontium-89 strontium-89 chloride REMOVE UM: MED Medical Drug chloride 04/30/2021 magellan safety syringe,safety with needle,1 REMOVE UM: MED Medical Drug syringe ml 04/30/2021 allevyn heel foam bandage REMOVE UM: MED Medical Drug 04/30/2021 baby conversion nebulizer accessories REMOVE UM: MED Medical Drug kit 04/30/2021 monoject enfit syringe, enfit 35 ml, sterile REMOVE UM: MED Medical Drug syringe 04/30/2021 monoject enfit syringe, enfit 60 ml, sterile REMOVE UM: MED Medical Drug syringe 04/30/2021 minimed infusion set for insulin pump REMOVE UM: MED Medical Drug silhouette 04/30/2021 insyte iv catheter intravenous catheter REMOVE UM: MED Medical Drug 04/30/2021 minimed infusion set for insulin pump REMOVE UM: MED Medical Drug silhouette 04/30/2021 mitoxantrone hcl mitoxantrone hcl REMOVE UM: MED Medical Drug 04/30/2021 TOPOSAR etoposide REMOVE UM: MED Medical Drug 04/30/2021 restore calcium silver/calcium alginate REMOVE UM: MED Medical Drug alginate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 478 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 minimed infusion set for insulin pump REMOVE UM: MED Medical Drug silhouette 04/30/2021 carboplatin carboplatin REMOVE UM: MED Medical Drug 04/30/2021 minimed mio infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 TOXICOLOGY saliva collection REMOVE UM: MED Medical Drug SALIVA device/ibuprofen COLLECTION 04/30/2021 sodium chloride 0.9 % sodium chloride REMOVE UM: MED 04/30/2021 minimed mio infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 apogee hc catheter REMOVE UM: MED Medical Drug intermittent 04/30/2021 apogee hc catheter REMOVE UM: MED Medical Drug intermittent 04/30/2021 apogee hc catheter REMOVE UM: MED Medical Drug intermittent 04/30/2021 monoject enfit syringe cap, enfit,non-sterile REMOVE UM: MED Medical Drug syringe cap 04/30/2021 VANTAS histrelin acetate REMOVE UM: MED Medical Drug 04/30/2021 monoject enfit syringe, enfit 3 ml, sterile REMOVE UM: MED Medical Drug syringe 04/30/2021 monoject enfit syringe, enfit 6 ml, sterile REMOVE UM: MED Medical Drug syringe 04/30/2021 insyte iv catheter intravenous catheter REMOVE UM: MED Medical Drug 04/30/2021 levoleucovorin levoleucovorin calcium REMOVE UM: MED Medical Drug calcium 04/30/2021 monoject enfit syringe, enfit 1 ml, sterile REMOVE UM: MED Medical Drug syringe 04/30/2021 ADRIAMYCIN doxorubicin hcl REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 479 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 optichamber inhaler,assist device with REMOVE UM: MED Medical Drug diamond large mask 04/30/2021 ADRIAMYCIN doxorubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 SIMULECT basiliximab REMOVE UM: MED Medical Drug 04/30/2021 oasis ultra porcine acellular small REMOVE UM: MED Medical Drug intestine submucosa, fenestrated 04/30/2021 minimed mio infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 ebase controller compressor, for nebulizer REMOVE UM: MED Medical Drug 04/30/2021 sodium chloride sodium chloride REMOVE UM: MED Medical Drug 04/30/2021 ASCLERA polidocanol REMOVE UM: MED Medical Drug 04/30/2021 filtered extension intravenous administration REMOVE UM: MED Medical Drug set extension set with filter 04/30/2021 monoject insulin syringe with REMOVE UM: MED syringe needle,disposable,insulin 1 ml 04/30/2021 leucovorin leucovorin calcium REMOVE UM: MED Medical Drug calcium 04/30/2021 carboplatin carboplatin REMOVE UM: MED Medical Drug 04/30/2021 filter pad nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 ombra nebulizer and compressor REMOVE UM: MED Medical Drug compressor system 04/30/2021 sami the seal nebulizer and compressor REMOVE UM: MED Medical Drug 04/30/2021 heparin lock heparin sodium,porcine REMOVE UM: MED Medical Drug 04/30/2021 innospire deluxe nebulizer and compressor REMOVE UM: MED Medical Drug 04/30/2021 guardian connect blood-glucose transmitter REMOVE UM: MED Medical Drug transmitter

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 480 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 relizorb enteral pump accessory for REMOVE UM: MED Medical Drug fat hydrolysis 04/30/2021 enalaprilat enalaprilat dihydrate REMOVE UM: MED Medical Drug 04/30/2021 LIORESAL baclofen REMOVE UM: MED Medical Drug INTRATHECAL 04/30/2021 oasis ultra porcine acellular small REMOVE UM: MED Medical Drug intestine submucosa, fenestrated 04/30/2021 varisoft infusion infusion set for insulin pump REMOVE UM: MED Medical Drug set 04/30/2021 dantrolene dantrolene sodium REMOVE UM: MED Medical Drug sodium 04/30/2021 acticoat 7 silver REMOVE UM: MED Medical Drug 04/30/2021 DELESTROGEN estradiol valerate REMOVE UM: MED Medical Drug 04/30/2021 ringers injection ringer's solution,ringers REMOVE UM: MED Medical Drug solution 04/30/2021 CATHFLO alteplase REMOVE UM: MED Medical Drug ACTIVASE 04/30/2021 v-go 20,vgo 20 sub-q insulin delivery REMOVE UM: MED Medical Drug device, 20 unit,disposable 04/30/2021 COSMEGEN dactinomycin REMOVE UM: MED Medical Drug 04/30/2021 v-go 40,vgo 40 sub-q insulin delivery REMOVE UM: MED Medical Drug device, 40 unit, disposable 04/30/2021 v-go 30,vgo 30 sub-q insulin delivery REMOVE UM: MED Medical Drug device, 30 unit, disposable 04/30/2021 insyte autoguard intravenous catheter REMOVE UM: MED 04/30/2021 ASCLERA polidocanol REMOVE UM: MED Medical Drug 04/30/2021 atropine sulfate atropine sulfate REMOVE UM: MED Medical Drug 04/30/2021 curity iodoform iodoform REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 481 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 silhouette infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 silastic catheter catheter REMOVE UM: MED Medical Drug 04/30/2021 CELLUGEL hypromellose REMOVE UM: MED Medical Drug 04/30/2021 acticoat surgical silver/foam bandage REMOVE UM: MED Medical Drug 04/30/2021 mini-wright peak peak flow meter REMOVE UM: MED Medical Drug flow meter 04/30/2021 chromium chromic chloride REMOVE UM: MED Medical Drug 04/30/2021 vixone nebulizer nebulizer REMOVE UM: MED Medical Drug 04/30/2021 t:slim x2 control- subcutaneous insulin pump REMOVE UM: MED Medical Drug iq 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 levothyroxine levothyroxine sodium REMOVE UM: MED Medical Drug sodium 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 clever choice nebulizer and compressor REMOVE UM: MED Medical Drug nebulizer 04/30/2021 GAMMAKED immune REMOVE UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 04/30/2021 accu-chek tender subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set 04/30/2021 accu-chek tender subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set 04/30/2021 GAMMAKED immune REMOVE UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 482 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 CELLCEPT mycophenolate mofetil hcl REMOVE UM: MED Medical Drug 04/30/2021 GAMMAKED immune REMOVE UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 mono-flo drainage bag REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 GAMUNEX-C immune REMOVE UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 04/30/2021 accu-chek tender subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 ATROPEN atropine sulfate REMOVE UM: MED Medical Drug 04/30/2021 wide seal diaphragms, wide seal REMOVE UM: MED Medical Drug diaphragm 04/30/2021 siltrex gel-matrix pad dressing, REMOVE UM: MED Medical Drug silicone 04/30/2021 ATROPEN atropine sulfate REMOVE UM: MED Medical Drug 04/30/2021 GAMUNEX-C immune REMOVE UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 04/30/2021 HYPERLYTE CR sodium/potassium/magnesiu REMOVE UM: MED Medical Drug m/calcium/chloride/acetate 04/30/2021 kangaroo epump feeder container with pump REMOVE UM: MED set set 04/30/2021 GAMUNEX-C immune REMOVE UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 483 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 aerochamber z- inhaler,assist device with REMOVE UM: MED Medical Drug stat large mask plus,aerochambe r plus z stat 04/30/2021 flexi-seal signal fecal collector with charcoal REMOVE UM: MED Medical Drug fms filter/catheter/syringe 04/30/2021 MEDIHONEY honey REMOVE UM: MED Medical Drug 04/30/2021 aerogear asthma peak flow meter/inhaler, REMOVE UM: MED Medical Drug action kit assist devices 04/30/2021 terbutaline sulfate terbutaline sulfate REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 accu-chek subcutaneous administration REMOVE UM: MED Medical Drug ultraflex set,sub-q administration set 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED Medical Drug 04/30/2021 GAMMAKED immune REMOVE UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 04/30/2021 GAMMAKED immune REMOVE UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 04/30/2021 accu-chek subcutaneous administration REMOVE UM: MED Medical Drug ultraflex set,sub-q administration set 04/30/2021 monoject luer syringe, disposable, 1 ml REMOVE UM: MED Medical Drug lock tb syringe 04/30/2021 accu-chek tender subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set 04/30/2021 accu-chek tender subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 484 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 irinotecan hcl irinotecan hcl REMOVE UM: MED Medical Drug 04/30/2021 irinotecan hcl irinotecan hcl REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 syringe,safety with needle,5 REMOVE UM: MED Medical Drug ml 04/30/2021 ribavirin ribavirin REMOVE UM: MED Medical Drug 04/30/2021 CUROSURF poractant alfa REMOVE UM: MED Medical Drug 04/30/2021 easivent inhaler, assist devices, REMOVE UM: MED Medical Drug accessories 04/30/2021 CUROSURF poractant alfa REMOVE UM: MED Medical Drug 04/30/2021 innospire nebulizer and compressor REMOVE UM: MED Medical Drug elegance 04/30/2021 innospire nebulizer and compressor REMOVE UM: MED Medical Drug essence 04/30/2021 litetouch inhaler, assist devices, REMOVE UM: MED Medical Drug accessories 04/30/2021 litetouch inhaler, assist devices, REMOVE UM: MED Medical Drug accessories 04/30/2021 kenguard catheter REMOVE UM: MED Medical Drug 04/30/2021 VAZCULEP phenylephrine hcl REMOVE UM: MED Medical Drug 04/30/2021 dextrose in dextrose 5 % in lactated REMOVE UM: MED Medical Drug lactated ringers ringers 04/30/2021 revel subcutaneous insulin pump REMOVE UM: MED Medical Drug programmable pump 04/30/2021 infusion set infusion set for insulin pump REMOVE UM: MED 04/30/2021 HYPERHEP B hepatitis b immune globulin REMOVE UM: MED Medical Drug 04/30/2021 kenguard catheterization tray REMOVE UM: MED Medical Drug 04/30/2021 CAMPTOSAR irinotecan hcl REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 485 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 wide seal diaphragms, wide seal REMOVE UM: MED Medical Drug diaphragm 04/30/2021 indomethacin indomethacin sodium REMOVE UM: MED Medical Drug 04/30/2021 FLUORESCITE fluorescein sodium REMOVE UM: MED Medical Drug 04/30/2021 daunorubicin hcl daunorubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 t:slim g4 insulin pump cartridge REMOVE UM: MED Medical Drug 04/30/2021 cequr simplicity diabetic supplies,miscell REMOVE UM: MED Medical Drug inserter 04/30/2021 RYANODEX dantrolene sodium REMOVE UM: MED Medical Drug 04/30/2021 NUTRILYTE sodium/potassium/magnes/c REMOVE UM: MED Medical Drug alcium/chloride/acetate/gluc onate 04/30/2021 protamine sulfate protamine sulfate REMOVE UM: MED Medical Drug 04/30/2021 fludarabine fludarabine phosphate REMOVE UM: MED Medical Drug phosphate 04/30/2021 amifostine amifostine crystalline REMOVE UM: MED Medical Drug 04/30/2021 t:flex insulin pump cartridge REMOVE UM: MED Medical Drug 04/30/2021 allevyn ag silver sulfadiazine/foam REMOVE UM: MED Medical Drug bandage 04/30/2021 LMD 10% WITH dextran 40 in dextrose 5 % REMOVE UM: MED Medical Drug 5% DEXTROSE in water 04/30/2021 nexiva intravenous catheter REMOVE UM: MED Medical Drug 04/30/2021 lidocaine hcl lidocaine hcl/pf REMOVE UM: MED Medical Drug 04/30/2021 nexiva intravenous catheter REMOVE UM: MED Medical Drug 04/30/2021 lidocaine hcl lidocaine hcl/pf REMOVE UM: MED Medical Drug 04/30/2021 dobutamine hcl- dobutamine hcl in dextrose REMOVE UM: MED Medical Drug d5w,dobutamine 5 % in water,dobutamine hcl in dextrose hcl/dextrose 5 % in water

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 486 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 doxorubicin hcl doxorubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 lidocaine hcl lidocaine hcl/pf REMOVE UM: MED Medical Drug 04/30/2021 clever choice nebulizer and compressor REMOVE UM: MED Medical Drug whisper aire ped 04/30/2021 replicare ultra hydrocolloid dressing REMOVE UM: MED Medical Drug sacrum 04/30/2021 nexiva intravenous catheter REMOVE UM: MED Medical Drug 04/30/2021 gemcitabine hcl gemcitabine hcl REMOVE UM: MED Medical Drug 04/30/2021 phaseal injector needle injector, luer lock, REMOVE UM: MED Medical Drug luer closed system 04/30/2021 acticoat 7 silver REMOVE UM: MED Medical Drug 04/30/2021 innospire go nebulizer REMOVE UM: MED Medical Drug nebulizer 04/30/2021 GLASSIA alpha-1-proteinase inhibitor REMOVE UM: MED Medical Drug 04/30/2021 acticoat 7 silver REMOVE UM: MED Medical Drug 04/30/2021 phaseal assembly system, vial to REMOVE UM: MED Medical Drug assembly fixture transfer device, closed system 04/30/2021 ZOLADEX goserelin acetate REMOVE UM: MED Medical Drug 04/30/2021 epinephrine epinephrine REMOVE UM: MED Medical Drug 04/30/2021 potassium chl- potassium chloride in 0.9 % REMOVE UM: MED Medical Drug normal saline sodium chloride 04/30/2021 pari lc sprint nebulizer REMOVE UM: MED Medical Drug sinus 04/30/2021 nexiva intravenous catheter REMOVE UM: MED Medical Drug 04/30/2021 polytoza silicone adhesive REMOVE UM: MED Medical Drug 04/30/2021 replicare,replicar hydrocolloid dressing REMOVE UM: MED Medical Drug e thin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 487 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 replicare hydrocolloid dressing REMOVE UM: MED Medical Drug 04/30/2021 replicare hydrocolloid dressing REMOVE UM: MED Medical Drug 04/30/2021 doxorubicin hcl doxorubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 doxorubicin hcl doxorubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 doxorubicin hcl doxorubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 theophylline in theophylline in dextrose 5 % REMOVE UM: MED Medical Drug 5% dextrose in water,theophylline/dextrose 5 % in water 04/30/2021 aerotrach plus inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 advance plus urinary bag/catheter REMOVE UM: MED Medical Drug intermittent 04/30/2021 vixone nebulizer nebulizer REMOVE UM: MED Medical Drug 04/30/2021 advance plus catheter REMOVE UM: MED Medical Drug intermittent 04/30/2021 lidocaine hcl in lidocaine hcl in dextrose 5% REMOVE UM: MED Medical Drug 5% dextrose in water/pf,lidocaine hcl/dextrose 5%-water/pf 04/30/2021 monoject insulin syringe with REMOVE UM: MED syringe needle,disposable,insulin 1 ml 04/30/2021 lidocaine hcl in lidocaine hcl in dextrose 5% REMOVE UM: MED Medical Drug 5% dextrose in water/pf,lidocaine hcl/dextrose 5%-water/pf 04/30/2021 atropine sulfate atropine sulfate REMOVE UM: MED Medical Drug 04/30/2021 NEXIUM I.V. esomeprazole sodium REMOVE UM: MED Medical Drug 04/30/2021 hypersoniq nebulizer accessories REMOVE UM: MED Medical Drug nebulizer cartridge

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 488 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 vincristine sulfate vincristine sulfate REMOVE UM: MED Medical Drug 04/30/2021 potassium potassium chloride in water REMOVE UM: MED Medical Drug chloride for injection, sterile 04/30/2021 sodium chloride sodium chloride REMOVE UM: MED Medical Drug 04/30/2021 HALAVEN eribulin mesylate REMOVE UM: MED Medical Drug 04/30/2021 eclipse syringe syringe,safety with needle,3 REMOVE UM: MED Medical Drug ml 04/30/2021 cicatrace pad gel-matrix pad dressing, REMOVE UM: MED Medical Drug silicone 04/30/2021 esomeprazole esomeprazole sodium REMOVE UM: MED Medical Drug sodium 04/30/2021 HYPERHEP B hepatitis b immune globulin REMOVE UM: MED 04/30/2021 esomeprazole esomeprazole sodium REMOVE UM: MED Medical Drug sodium 04/30/2021 magellan insulin syringe with needle, insulin, REMOVE UM: MED Medical Drug syringe safety, 0.5 ml 04/30/2021 comfort infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 magellan syringe,safety with needle,1 REMOVE UM: MED Medical Drug tuberculin syringe ml 04/30/2021 magellan insulin syringe with needle, insulin, REMOVE UM: MED Medical Drug syringe safety, 0.3 ml 04/30/2021 aerochamber inhaler, assist devices REMOVE UM: MED Medical Drug mini 04/30/2021 autosoft xc infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 phaseal connector luer lock, closed REMOVE UM: MED Medical Drug connector luer system 04/30/2021 dexrazoxane dexrazoxane hcl REMOVE UM: MED Medical Drug 04/30/2021 GEL-ONE hyaluronate sod, cross- REMOVE UM: MED Medical Drug linked

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 489 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 allevyn ag gentle silver sulfadiazine/foam REMOVE UM: MED Medical Drug bandage 04/30/2021 allevyn ag gentle silver sulfadiazine/foam REMOVE UM: MED Medical Drug bandage 04/30/2021 allevyn ag gentle silver sulfadiazine/foam REMOVE UM: MED Medical Drug bandage 04/30/2021 allevyn ag gentle silver sulfadiazine/foam REMOVE UM: MED Medical Drug bandage 04/30/2021 AMVISC hyaluronate sodium REMOVE UM: MED Medical Drug 04/30/2021 vinorelbine vinorelbine tartrate REMOVE UM: MED Medical Drug tartrate 04/30/2021 aeroneb go nebulizer REMOVE UM: MED Medical Drug nebulizer 04/30/2021 dexcom g4 blood-glucose REMOVE UM: MED Medical Drug meter,continuous 04/30/2021 dactinomycin dactinomycin REMOVE UM: MED Medical Drug 04/30/2021 copper chloride cupric chloride REMOVE UM: MED Medical Drug 04/30/2021 vinorelbine vinorelbine tartrate REMOVE UM: MED Medical Drug tartrate 04/30/2021 allevyn ag silver sulfadiazine/foam REMOVE UM: MED Medical Drug adhesive bandage 04/30/2021 allevyn ag silver sulfadiazine/foam REMOVE UM: MED Medical Drug adhesive bandage 04/30/2021 BOTOX onabotulinumtoxina REMOVE UM: MED Medical Drug 04/30/2021 allevyn ag silver sulfadiazine/foam REMOVE UM: MED Medical Drug adhesive bandage 04/30/2021 dexcom g4 blood-glucose REMOVE UM: MED Medical Drug meter,continuous 04/30/2021 NIPENT pentostatin REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 490 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 EYLEA aflibercept REMOVE UM: MED Medical Drug 04/30/2021 phaseal adapter infusion adapter, closed REMOVE UM: MED Medical Drug system 04/30/2021 phaseal injector needle injector, luer, closed REMOVE UM: MED Medical Drug luer system 04/30/2021 phaseal y-site y-site line connector, closed REMOVE UM: MED Medical Drug system 04/30/2021 SURVANTA beractant REMOVE UM: MED Medical Drug 04/30/2021 ERWINAZE asparaginase (erwinia REMOVE UM: MED Medical Drug chrysanthemi) 04/30/2021 restore contact silver sulfate/non-adherent REMOVE UM: MED Medical Drug layer silver bandage 04/30/2021 GAMUNEX-C immune REMOVE UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 04/30/2021 vinblastine vinblastine sulfate REMOVE UM: MED Medical Drug sulfate 04/30/2021 GAMUNEX-C immune REMOVE UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 04/30/2021 MICRHOGAM rho(d) immune globulin REMOVE UM: MED Medical Drug ULTRA- FILTERED PLUS 04/30/2021 EUFLEXXA hyaluronate sodium REMOVE UM: MED Medical Drug 04/30/2021 DISCOVISC chondroitin sulfate a REMOVE UM: MED Medical Drug sodium/hyaluronate sodium 04/30/2021 ABRAXANE paclitaxel protein-bound REMOVE UM: MED Medical Drug 04/30/2021 microair mesh nebulizer REMOVE UM: MED Medical Drug nebulizer 04/30/2021 ILUVIEN fluocinolone acetonide REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 491 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 safetyglide syringe with REMOVE UM: MED Medical Drug allergy syringe needle,disposable, 1 ml 04/30/2021 provent nasal exhalation resistance REMOVE UM: MED Medical Drug device 04/30/2021 minimed 670g subcutaneous insulin pump REMOVE UM: MED Medical Drug 04/30/2021 freestyle blood-glucose sensor REMOVE UM: MED Medical Drug navigator 04/30/2021 paradigm real- blood-glucose REMOVE UM: MED Medical Drug time transmitter/blood-glucose sensor 04/30/2021 argyle medical supply, REMOVE UM: MED Medical Drug miscellaneous 04/30/2021 pari sinus aerosol nebulizer and compressor REMOVE UM: MED Medical Drug system 04/30/2021 cytarabine cytarabine REMOVE UM: MED Medical Drug 04/30/2021 ADRIAMYCIN doxorubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 ADRIAMYCIN doxorubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 ADRIAMYCIN doxorubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 dextrose 5%- dextrose 5 % and 0.9 % REMOVE UM: MED 0.9% sodium chloride nacl,dextrose with sodium chloride 04/30/2021 sensura click ostomy supply REMOVE UM: MED Medical Drug ostomy pouch 04/30/2021 cequr simplicity subcutaneous bolus insulin REMOVE UM: MED Medical Drug patch pump, 200 unit, disposable 04/30/2021 normal saline sodium chloride 0.9 % REMOVE UM: MED Medical Drug flush (flush)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 492 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 xeroform non- bismuth REMOVE UM: MED Medical Drug occlusive tribromophenate/petrolatum, dressng white 04/30/2021 NAVELBINE vinorelbine tartrate REMOVE UM: MED Medical Drug 04/30/2021 NPLATE romiplostim REMOVE UM: MED Medical Drug 04/30/2021 vincristine sulfate vincristine sulfate REMOVE UM: MED Medical Drug 04/30/2021 ATROPEN atropine sulfate REMOVE UM: MED Medical Drug 04/30/2021 NPLATE romiplostim REMOVE UM: MED Medical Drug 04/30/2021 allergist tray syring w-needl 0.5 ml,kit-tray REMOVE UM: MED Medical Drug 04/30/2021 sidestream plus nebulizer REMOVE UM: MED Medical Drug 04/30/2021 ETOPOPHOS etoposide phosphate REMOVE UM: MED Medical Drug 04/30/2021 insulin syringe u- syringe, insulin u-500 with REMOVE UM: MED Medical Drug 500 needle, disposable, 0.5 ml 04/30/2021 allevyn foam bandage REMOVE UM: MED Medical Drug 04/30/2021 sodium chloride sodium chloride 3 % REMOVE UM: MED Medical Drug 04/30/2021 allevyn foam bandage REMOVE UM: MED Medical Drug 04/30/2021 allevyn foam bandage REMOVE UM: MED Medical Drug 04/30/2021 MUTAMYCIN mitomycin REMOVE UM: MED Medical Drug 04/30/2021 allevyn foam bandage REMOVE UM: MED Medical Drug 04/30/2021 allevyn foam bandage REMOVE UM: MED Medical Drug adhesive,allevyn 04/30/2021 enlite serter diabetic supplies,miscell REMOVE UM: MED Medical Drug 04/30/2021 dover foley catheter REMOVE UM: MED Medical Drug catheter 04/30/2021 HYCAMTIN topotecan hcl REMOVE UM: MED Medical Drug 04/30/2021 allevyn foam bandage REMOVE UM: MED Medical Drug adhesive,allevyn

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 493 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 OZURDEX dexamethasone REMOVE UM: MED Medical Drug 04/30/2021 tens 504 transcutaneous electrical REMOVE UM: MED Medical Drug nerve stimulators (tens units) 04/30/2021 TRILURON hyaluronate sodium REMOVE UM: MED Medical Drug 04/30/2021 IMOGAM rabies immune globulin/pf REMOVE UM: MED Medical Drug RABIES-HT 04/30/2021 HESPAN hetastarch in 0.9 % sodium REMOVE UM: MED Medical Drug chloride 04/30/2021 terumo surguard2 syringe,safety with needle,3 REMOVE UM: MED Medical Drug ml 04/30/2021 magellan safety needles, safety REMOVE UM: MED Medical Drug needle 04/30/2021 VAPRISOL-5% conivaptan hcl/dextrose 5 % REMOVE UM: MED Medical Drug DEXTROSE,VAP in water RISOL 04/30/2021 terumo surguard2 syringe,safety with needle,3 REMOVE UM: MED Medical Drug ml 04/30/2021 magellan tb syringe,safety with needle,1 REMOVE UM: MED Medical Drug safety syringe ml 04/30/2021 terumo surguard2 syringe,safety with needle,3 REMOVE UM: MED Medical Drug ml 04/30/2021 terumo surguard2 syringe,safety with needle,1 REMOVE UM: MED Medical Drug ml 04/30/2021 ADRUCIL fluorouracil REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 syringe,safety with needle,1 REMOVE UM: MED Medical Drug ml 04/30/2021 minimed 630g subcutaneous insulin pump REMOVE UM: MED Medical Drug 04/30/2021 ADRUCIL fluorouracil REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 494 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 terumo surguard2 syringe,safety with needle,1 REMOVE UM: MED Medical Drug ml 04/30/2021 ADRUCIL fluorouracil REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 syringe,safety with needle,3 REMOVE UM: MED Medical Drug ml 04/30/2021 doxorubicin hcl doxorubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 clofarabine clofarabine REMOVE UM: MED Medical Drug 04/30/2021 estradiol valerate estradiol valerate REMOVE UM: MED 04/30/2021 flexichamber inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 ACTIVASE alteplase REMOVE UM: MED Medical Drug 04/30/2021 dextrose 5%- potassium chloride in REMOVE UM: MED Medical Drug 1/2ns-kcl dextrose 5 %-0.45 % sodium chloride 04/30/2021 xeroform bismuth REMOVE UM: MED Medical Drug petrolatum tribromophenate/petrolatum, dressing white 04/30/2021 LIPODOX 50 doxorubicin hcl pegylated REMOVE UM: MED Medical Drug liposomal 04/30/2021 dover latex foley catheter REMOVE UM: MED Medical Drug catheter 04/30/2021 curity amd polyhexamethylene REMOVE UM: MED biguanide/gauze bandage 04/30/2021 fluorouracil fluorouracil REMOVE UM: MED 04/30/2021 sof-set micro infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 glucocom diabetic supplies,miscell REMOVE UM: MED Medical Drug autolink 04/30/2021 fluorouracil fluorouracil REMOVE UM: MED Medical Drug 04/30/2021 fluorouracil fluorouracil REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 495 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 epinephrine,epin epinephrine REMOVE UM: MED Medical Drug ephrine convenience kit 04/30/2021 terumo surguard2 syringe,safety with needle,3 REMOVE UM: MED Medical Drug ml 04/30/2021 fluorouracil fluorouracil REMOVE UM: MED Medical Drug 04/30/2021 ALFERON N interferon alfa-n3 REMOVE UM: MED Medical Drug 04/30/2021 allergist tray syringe with REMOVE UM: MED Medical Drug needle,disposable, 1 ml 04/30/2021 atropine sulfate atropine sulfate REMOVE UM: MED Medical Drug 04/30/2021 AK-FLUOR fluorescein sodium REMOVE UM: MED Medical Drug 04/30/2021 sof-sensor blood-glucose sensor REMOVE UM: MED Medical Drug 04/30/2021 aerovent plus inhaler, assist devices REMOVE UM: MED Medical Drug 04/30/2021 terumo surguard2 syringe,safety with needle,3 REMOVE UM: MED Medical Drug ml 04/30/2021 M.V.I. multivitamin infusion, REMOVE UM: MED Medical Drug PEDIATRIC pediatric no.2 with vitamin k 04/30/2021 NORMOSOL-R electrolyte-r REMOVE UM: MED Medical Drug AND DEXTROSE solution/dextrose 5 % in water 04/30/2021 guardian rt diabetic supplies,miscell REMOVE UM: MED Medical Drug system 04/30/2021 guardian rt diabetic supplies,miscell REMOVE UM: MED Medical Drug charger 04/30/2021 OSMITROL mannitol REMOVE UM: MED Medical Drug 04/30/2021 coaguchek xs prothrombin time/inr test REMOVE UM: MED Medical Drug meter 04/30/2021 SURFAXIN lucinactant REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 496 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 dextrose 5%- potassium chloride in REMOVE UM: MED Medical Drug 1/2ns-kcl dextrose 5 %-0.45 % sodium chloride 04/30/2021 CORVERT ibutilide fumarate REMOVE UM: MED Medical Drug 04/30/2021 robinson clear catheter REMOVE UM: MED Medical Drug vinyl catheter 04/30/2021 oxaliplatin oxaliplatin REMOVE UM: MED Medical Drug 04/30/2021 silhouette infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 oxaliplatin oxaliplatin REMOVE UM: MED Medical Drug 04/30/2021 insulin syringe syringe with REMOVE UM: MED needle,insulin,0.5 ml,syringe with needle,insulin disposable,0.5 ml 04/30/2021 sunrise compressor, for nebulizer REMOVE UM: MED Medical Drug compressor- nebulizer 04/30/2021 phaseal intravenous piggyback REMOVE UM: MED Medical Drug secondary set administration set 04/30/2021 MUTAMYCIN mitomycin REMOVE UM: MED Medical Drug 04/30/2021 filter needle needles, filter REMOVE UM: MED Medical Drug 04/30/2021 docetaxel docetaxel REMOVE UM: MED Medical Drug 04/30/2021 docetaxel docetaxel REMOVE UM: MED Medical Drug 04/30/2021 docetaxel docetaxel REMOVE UM: MED Medical Drug 04/30/2021 monoject control syringe, disposable, 12 ml REMOVE UM: MED Medical Drug syringe 04/30/2021 famotidine famotidine in sodium REMOVE UM: MED Medical Drug chloride, iso-osmotic/pf 04/30/2021 aerochamber inhaler,assist device with REMOVE UM: MED Medical Drug plus flow-vu medium mask

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 497 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 aerochamber inhaler,assist device with REMOVE UM: MED Medical Drug plus flow-vu small mask 04/30/2021 RETISERT fluocinolone acetonide REMOVE UM: MED Medical Drug 04/30/2021 VALSTAR valrubicin REMOVE UM: MED Medical Drug 04/30/2021 zinc sulfate zinc sulfate REMOVE UM: MED Medical Drug 04/30/2021 amielle vaginal miscellaneous medical REMOVE UM: MED Medical Drug trainer supply,medical supply, miscellaneous 04/30/2021 sodium acetate sodium acetate REMOVE UM: MED Medical Drug 04/30/2021 xeroform bismuth REMOVE UM: MED Medical Drug petrolatum tribromophenate/petrolatum, dressing white 04/30/2021 aerochamber inhaler,assist device with REMOVE UM: MED Medical Drug plus flow-vu large mask 04/30/2021 THAM tromethamine REMOVE UM: MED Medical Drug 04/30/2021 allevyn foam bandage REMOVE UM: MED Medical Drug adhesive,allevyn 04/30/2021 epirubicin hcl epirubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 PROLEUKIN aldesleukin REMOVE UM: MED Medical Drug 04/30/2021 ranitidine hcl ranitidine hcl REMOVE UM: MED Medical Drug 04/30/2021 autosoft xc infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 t:slim x2 insulin pump cartridge REMOVE UM: MED Medical Drug 04/30/2021 lc plus nebulizer- nebulizer REMOVE UM: MED Medical Drug ped mask 04/30/2021 silicone mask nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 accu-chek rapid d subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 498 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 kendall 0.9% nacl sodium chloride 0.9 % REMOVE UM: MED Medical Drug with cap (flush) 04/30/2021 accu-chek rapid d subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set 04/30/2021 pillow mask for nebulizer accessories REMOVE UM: MED Medical Drug children 04/30/2021 rubber nebulizer accessories REMOVE UM: MED Medical Drug mouthpiece 04/30/2021 all flow 6000 nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 accu-chek tender subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set 04/30/2021 nose clip nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 prodigy mini-mist nebulizer REMOVE UM: MED Medical Drug 04/30/2021 accu-chek subcutaneous administration REMOVE UM: MED Medical Drug ultraflex set,sub-q administration set 04/30/2021 xeroform bismuth REMOVE UM: MED Medical Drug tribromophenate/petrolatum, white 04/30/2021 INFUVITE multivitamin infusion, REMOVE UM: MED Medical Drug PEDIATRIC pediatric no.1 with vitamin k 04/30/2021 temsirolimus temsirolimus REMOVE UM: MED Medical Drug 04/30/2021 t:30 infusion set infusion set for insulin pump REMOVE UM: MED Medical Drug 04/30/2021 procare nebulizer and compressor REMOVE UM: MED Medical Drug compressor nebulizer 04/30/2021 mitomycin mitomycin REMOVE UM: MED Medical Drug 04/30/2021 devilbiss nebulizer REMOVE UM: MED Medical Drug disposable nebulizer

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 499 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 sure-t subcutaneous infusion pump REMOVE UM: MED Medical Drug accessory,sub-q infusion pump accessory 04/30/2021 all flow 4000 nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 accu-chek spirit subcutaneous infusion pump REMOVE UM: MED Medical Drug accessory 04/30/2021 all flow 4000 nebulizer accessories REMOVE UM: MED Medical Drug 04/30/2021 inspirachamber inhaler,assist device with REMOVE UM: MED Medical Drug large mask 04/30/2021 GENVISC 850 hyaluronate sodium REMOVE UM: MED Medical Drug 04/30/2021 oxaliplatin oxaliplatin REMOVE UM: MED 04/30/2021 accu-chek rapid d subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set 04/30/2021 accu-chek rapid d subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set 04/30/2021 TORISEL temsirolimus REMOVE UM: MED Medical Drug 04/30/2021 SOLTAMOX tamoxifen citrate REMOVE UM: MED Medical Drug 04/30/2021 accu-chek subcutaneous administration REMOVE UM: MED Medical Drug ultraflex set,sub-q administration set 04/30/2021 accu-chek subcutaneous administration REMOVE UM: MED Medical Drug ultraflex,accu- set,sub-q administration set chek ultraflex ii 04/30/2021 VIDAZA azacitidine REMOVE UM: MED Medical Drug 04/30/2021 ALOPRIM allopurinol sodium REMOVE UM: MED Medical Drug 04/30/2021 NORMOSOL-R electrolyte-r (ph 7.4) REMOVE UM: MED Medical Drug PH 7.4 04/30/2021 accu-chek rapid d subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 500 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/30/2021 accu-chek subcutaneous administration REMOVE UM: MED Medical Drug ultraflex,accu- set,sub-q administration set chek ultraflex ii 04/30/2021 cicasil gel-matrix pad dressing, REMOVE UM: MED Medical Drug silicone 04/30/2021 accu-chek rapid d subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set 04/30/2021 oxaliplatin oxaliplatin REMOVE UM: MED 04/30/2021 accu-chek rapid d subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set 04/30/2021 sodium chloride 0.9 % sodium chloride REMOVE UM: MED 04/30/2021 accu-chek rapid d subcutaneous administration REMOVE UM: MED Medical Drug set,sub-q administration set 04/30/2021 terumo surguard2 needles, safety REMOVE UM: MED 04/30/2021 ELITEK rasburicase REMOVE UM: MED Medical Drug 04/30/2021 acticoat silver REMOVE UM: MED Medical Drug 04/30/2021 epirubicin hcl epirubicin hcl REMOVE UM: MED Medical Drug 04/30/2021 acticoat silver/hydrocolloid REMOVE UM: MED Medical Drug dressing,silver 04/30/2021 acticoat silver REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 501 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

May, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 medroxyprogeste medroxyprogesterone ADD TO FORMULARY Non PDL rone acetate acetate 05/01/2021 medroxyprogeste medroxyprogesterone ADD UM: QUANTITY 1 / 75 days rone acetate acetate 05/01/2021 lidocaine lidocaine ADD TO FORMULARY Non PDL 05/01/2021 lidocaine lidocaine ADD UM: PANAME Clinical PA 05/01/2021 carboxymethylcel carboxymethylcellulose ADD TO FORMULARY Non PDL lulose sodium sodium 05/01/2021 carboxymethylcel carboxymethylcellulose ADD UM: DRUGCLASS URINARY lulose sodium sodium TRACT ANTISPASMODI CS 05/01/2021 lidocaine pain lidocaine ADD UM: QUANTITY 30 / 30 days relief,lidocaine 05/01/2021 ALKINDI hydrocortisone ADD TO FORMULARY Non PDL SPRINKLE 05/01/2021 ALKINDI hydrocortisone ADD UM: AGE Up to 4 yrs old SPRINKLE 05/01/2021 ALKINDI hydrocortisone ADD UM: PANAME Clinical PA SPRINKLE 05/01/2021 ALKINDI hydrocortisone ADD UM: DRUGCLASS URINARY SPRINKLE TRACT ANTISPASMODI CS 05/01/2021 ALKINDI hydrocortisone ADD TO FORMULARY Non PDL SPRINKLE 05/01/2021 ALKINDI hydrocortisone ADD UM: AGE Up to 4 yrs old SPRINKLE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 502 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ALKINDI hydrocortisone ADD UM: PANAME Clinical PA SPRINKLE 05/01/2021 ALKINDI hydrocortisone ADD UM: DRUGCLASS URINARY SPRINKLE TRACT ANTISPASMODI CS 05/01/2021 ALKINDI hydrocortisone ADD TO FORMULARY Non PDL SPRINKLE 05/01/2021 ALKINDI hydrocortisone ADD UM: AGE Up to 4 yrs old SPRINKLE 05/01/2021 ALKINDI hydrocortisone ADD UM: PANAME Clinical PA SPRINKLE 05/01/2021 ALKINDI hydrocortisone ADD UM: DRUGCLASS URINARY SPRINKLE TRACT ANTISPASMODI CS 05/01/2021 ALKINDI hydrocortisone ADD TO FORMULARY Non PDL SPRINKLE 05/01/2021 ALKINDI hydrocortisone ADD UM: AGE Up to 4 yrs old SPRINKLE 05/01/2021 ALKINDI hydrocortisone ADD UM: PANAME Clinical PA SPRINKLE 05/01/2021 ALKINDI hydrocortisone ADD UM: DRUGCLASS URINARY SPRINKLE TRACT ANTISPASMODI CS 05/01/2021 ENSPRYNG satralizumab-mwge ADD TO FORMULARY Non PDL 05/01/2021 ENSPRYNG satralizumab-mwge ADD UM: QUANTITY 1 / 28 days 05/01/2021 ENSPRYNG satralizumab-mwge ADD UM: AGE At least 18 yrs old 05/01/2021 ENSPRYNG satralizumab-mwge ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 503 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 XYWAV sodium oxybate/calcium ADD TO FORMULARY Non PDL oxybate/magnesium oxybate/pot oxybate 05/01/2021 XYWAV sodium oxybate/calcium ADD UM: QUANTITY 540 / 30 days oxybate/magnesium oxybate/pot oxybate 05/01/2021 XYWAV sodium oxybate/calcium ADD UM: AGE At least 8 yrs old oxybate/magnesium oxybate/pot oxybate 05/01/2021 XYWAV sodium oxybate/calcium ADD UM: PANAME Clinical PA oxybate/magnesium oxybate/pot oxybate 05/01/2021 carboxymethylcel carboxymethylcellulose REMOVE UM: URINARY lulose sodium sodium DRUGCLASS TRACT ANTISPASMODI CS 05/01/2021 ALKINDI hydrocortisone REMOVE UM: URINARY SPRINKLE DRUGCLASS TRACT ANTISPASMODI CS 05/01/2021 ALKINDI hydrocortisone REMOVE UM: URINARY SPRINKLE DRUGCLASS TRACT ANTISPASMODI CS 05/01/2021 ALKINDI hydrocortisone REMOVE UM: URINARY SPRINKLE DRUGCLASS TRACT ANTISPASMODI CS 05/01/2021 ALKINDI hydrocortisone REMOVE UM: URINARY SPRINKLE DRUGCLASS TRACT ANTISPASMODI CS 05/01/2021 FOLTX cyanocobalamin/levomefolat REMOVE FROM Non PDL Non-Formulary e calcium/pyridoxine hcl (b6) FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 504 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 L-METHYL-B6- mecobalamin/levomefolate REMOVE FROM Non PDL Non-Formulary B12 calcium/pyridoxal phosphate FORMULARY 05/01/2021 L-METHYL-MC cyanocobalamin/levomefolat REMOVE FROM Non PDL Non-Formulary e FORMULARY calcium/pyridoxine/riboflavin 05/01/2021 NESTABS DHA prenatal vits with calcium REMOVE FROM Non PDL Non-Formulary no.87/iron bisgly/folic FORMULARY acid/dha 05/01/2021 MYCAPSSA octreotide acetate REMOVE FROM Non-Formulary FORMULARY 05/01/2021 bumetanide bumetanide REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 bumetanide bumetanide REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 LAMPIT nifurtimox REMOVE FROM Non-Formulary FORMULARY 05/01/2021 LAMPIT nifurtimox REMOVE FROM Non-Formulary FORMULARY 05/01/2021 bumetanide bumetanide REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 NESTABS DHA prenatal vits with calcium REMOVE UM: GENDER Female no.87/iron bisgly/folic acid/dha 05/01/2021 NESTABS DHA prenatal vits with calcium REMOVE UM: AGE 12.0 to 55.0 yrs no.87/iron bisgly/folic old acid/dha 05/01/2021 NESTABS DHA prenatal vits with calcium REMOVE UM: QUANTITY 2 / day no.87/iron bisgly/folic acid/dha 05/01/2021 EUCRISA crisaborole CHANGE UM: QUANTITY 100 / 30 Days 100 / 30 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 505 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 LIDOCAINE lidocaine ADD TO FORMULARY Non PDL PAIN RELIEF,PAIN RELIEF 05/01/2021 LIDOCAINE lidocaine ADD UM: QUANTITY 30 / 30 days PAIN RELIEF,PAIN RELIEF 05/01/2021 dihydroergotamin dihydroergotamine mesylate REMOVE FROM Non-Formulary e mesylate FORMULARY 05/01/2021 riluzole riluzole REMOVE FROM Non-Formulary FORMULARY 05/01/2021 LOTEMAX loteprednol etabonate REMOVE FROM Non-Formulary FORMULARY 05/01/2021 dobutamine hcl- dobutamine hcl in dextrose REMOVE FROM Non-Formulary d5w,dobutamine 5 % in water,dobutamine FORMULARY hcl in dextrose hcl/dextrose 5 % in water 05/01/2021 dobutamine hcl- dobutamine hcl in dextrose REMOVE FROM Non-Formulary d5w 5 % in water FORMULARY 05/01/2021 MYTESI crofelemer REMOVE FROM Non-Formulary FORMULARY 05/01/2021 morphine sulfate morphine sulfate REMOVE FROM Non-Formulary FORMULARY 05/01/2021 morphine sulfate morphine sulfate REMOVE FROM Non-Formulary FORMULARY 05/01/2021 NAROPIN ropivacaine hcl/pf REMOVE FROM Non-Formulary FORMULARY 05/01/2021 lidocaine- lidocaine hcl/epinephrine REMOVE FROM Non-Formulary epinephrine bitartrate FORMULARY 05/01/2021 epinephrine epinephrine REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 506 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 isosorbide isosorbide dinitrate REMOVE FROM Non-Formulary dinitrate FORMULARY 05/01/2021 ondansetron hcl ondansetron hcl/pf REMOVE FROM Non-Formulary FORMULARY 05/01/2021 DEMEROL meperidine hcl/pf REMOVE FROM Non-Formulary FORMULARY 05/01/2021 sodium sodium bicarbonate REMOVE FROM Non-Formulary bicarbonate FORMULARY 05/01/2021 DEMEROL meperidine hcl/pf REMOVE FROM Non-Formulary FORMULARY 05/01/2021 SAMSCA tolvaptan REMOVE FROM Non-Formulary FORMULARY 05/01/2021 DEMEROL meperidine hcl/pf REMOVE FROM Non-Formulary FORMULARY 05/01/2021 vancomycin hcl- vancomycin in 5 % dextrose REMOVE FROM Non-Formulary d5w in water FORMULARY 05/01/2021 doxercalciferol doxercalciferol REMOVE FROM Non-Formulary FORMULARY 05/01/2021 potassium potassium chloride REMOVE FROM Non-Formulary chloride FORMULARY 05/01/2021 ISORDIL isosorbide dinitrate REMOVE FROM Non-Formulary FORMULARY 05/01/2021 FINACEA azelaic acid REMOVE FROM Non-Formulary FORMULARY 05/01/2021 UKONIQ umbralisib tosylate REMOVE FROM Non-Formulary FORMULARY 05/01/2021 MIRVASO brimonidine tartrate REMOVE FROM Non-Formulary FORMULARY 05/01/2021 tolvaptan tolvaptan REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 507 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 methoxsalen methoxsalen REMOVE FROM Non-Formulary FORMULARY 05/01/2021 doxercalciferol doxercalciferol REMOVE FROM Non-Formulary FORMULARY 05/01/2021 bupivacaine hcl- bupivacaine REMOVE FROM Non-Formulary epinephrine hcl/epinephrine/pf FORMULARY 05/01/2021 vancomycin hcl- vancomycin in 5 % dextrose REMOVE FROM Non-Formulary d5w in water FORMULARY 05/01/2021 bupivacaine hcl bupivacaine hcl/pf REMOVE FROM Non-Formulary FORMULARY 05/01/2021 prochlorperazine prochlorperazine edisylate REMOVE FROM Non-Formulary edisylate FORMULARY 05/01/2021 metoclopramide metoclopramide hcl REMOVE FROM Non-Formulary hcl odt FORMULARY 05/01/2021 metoclopramide metoclopramide hcl REMOVE FROM Non-Formulary hcl odt FORMULARY 05/01/2021 metronidazole metronidazole REMOVE FROM Non-Formulary FORMULARY 05/01/2021 sodium chloride sodium chloride REMOVE FROM Non-Formulary FORMULARY 05/01/2021 ADRENALIN epinephrine REMOVE FROM Non-Formulary CHLORIDE,ADR FORMULARY ENALIN 05/01/2021 doxercalciferol doxercalciferol REMOVE FROM Non-Formulary FORMULARY 05/01/2021 epinephrine epinephrine REMOVE FROM Non-Formulary FORMULARY 05/01/2021 dobutamine hcl dobutamine hcl REMOVE FROM Non-Formulary FORMULARY 05/01/2021 dobutamine hcl- dobutamine hcl in dextrose REMOVE FROM Non-Formulary d5w 5 % in water FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 508 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 albuterol sulfate albuterol sulfate REMOVE FROM Non-Formulary FORMULARY 05/01/2021 DEMEROL meperidine hcl/pf REMOVE FROM Non-Formulary FORMULARY 05/01/2021 DEMEROL meperidine hcl/pf REMOVE FROM Non-Formulary FORMULARY 05/01/2021 cimetidine cimetidine hcl REMOVE FROM Non-Formulary FORMULARY 05/01/2021 calcipotriene calcipotriene REMOVE FROM Non-Formulary FORMULARY 05/01/2021 hydromorphone hydromorphone hcl REMOVE FROM Non-Formulary hcl FORMULARY 05/01/2021 SORILUX calcipotriene REMOVE FROM Non-Formulary FORMULARY 05/01/2021 sodium sodium bicarbonate REMOVE FROM Non-Formulary bicarbonate FORMULARY 05/01/2021 heparin sodium heparin sodium,porcine/pf REMOVE FROM Non-Formulary FORMULARY 05/01/2021 atropine sulfate atropine sulfate REMOVE FROM Non-Formulary FORMULARY 05/01/2021 MOTOFEN difenoxin hcl/atropine sulfate REMOVE FROM Non-Formulary FORMULARY 05/01/2021 NAROPIN ropivacaine hcl/pf REMOVE FROM Non-Formulary FORMULARY 05/01/2021 loteprednol loteprednol etabonate REMOVE FROM Non-Formulary etabonate FORMULARY 05/01/2021 BUTRANS buprenorphine CHANGE UM: QUANTITY 6 / 28 Days 6 / 28 days 05/01/2021 BUTRANS buprenorphine ADD UM: B4G BRAND FOR GENERIC

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 509 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 BUTRANS buprenorphine ADD UM: B4G BRAND FOR GENERIC 05/01/2021 BUTRANS buprenorphine CHANGE UM: QUANTITY 6 / 28 Days 6 / 28 days 05/01/2021 BUTRANS buprenorphine ADD UM: B4G BRAND FOR GENERIC 05/01/2021 BUTRANS buprenorphine CHANGE UM: QUANTITY 6 / 28 Days 6 / 28 days 05/01/2021 BUTRANS buprenorphine ADD UM: B4G BRAND FOR GENERIC 05/01/2021 BUTRANS buprenorphine CHANGE UM: QUANTITY 6 / 28 Days 6 / 28 days 05/01/2021 BUTRANS buprenorphine ADD UM: B4G BRAND FOR GENERIC 05/01/2021 buprenorphine buprenorphine ADD UM: COV Use brand over generic 05/01/2021 buprenorphine buprenorphine ADD UM: COV Use brand over generic 05/01/2021 buprenorphine buprenorphine ADD UM: COV Use brand over generic 05/01/2021 buprenorphine buprenorphine ADD UM: COV Use brand over generic 05/01/2021 buprenorphine buprenorphine ADD UM: COV Use brand over generic 05/01/2021 TAMIFLU oseltamivir phosphate ADD UM: B4G BRAND FOR GENERIC 05/01/2021 TAMIFLU oseltamivir phosphate ADD UM: B4G BRAND FOR GENERIC 05/01/2021 TAMIFLU oseltamivir phosphate ADD UM: B4G BRAND FOR GENERIC 05/01/2021 TAMIFLU oseltamivir phosphate ADD UM: B4G BRAND FOR GENERIC

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 510 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 SYMJEPI epinephrine CHANGE TIER Non-Preferred 05/01/2021 SYMJEPI epinephrine CHANGE TIER Non-Preferred 05/01/2021 ANDROGEL testosterone CHANGE UM: PANAME Non Preferred PA Clinical PA 05/01/2021 testosterone testosterone CHANGE UM: PANAME Non Preferred PA Clinical PA 05/01/2021 ANDROGEL testosterone CHANGE UM: PANAME Non Preferred PA Clinical PA 05/01/2021 testosterone testosterone CHANGE UM: PANAME Non Preferred PA Clinical PA 05/01/2021 XELJANZ tofacitinib citrate ADD TO FORMULARY Non-Preferred 05/01/2021 XELJANZ tofacitinib citrate ADD UM: DRUGCLASS BIOLOGICS 05/01/2021 XELJANZ tofacitinib citrate ADD UM: PANAME Clinical PA 05/01/2021 OZEMPIC semaglutide ADD TO FORMULARY Non-Preferred 05/01/2021 OZEMPIC semaglutide ADD UM: DRUGCLASS INCRETIN MIMETICS 05/01/2021 OZEMPIC semaglutide ADD UM: PANAME Clinical PA 05/01/2021 PROCTOCORT hydrocortisone ADD TO FORMULARY Non-Preferred 05/01/2021 PROCTOCORT hydrocortisone ADD UM: PANAME Non Preferred PA 05/01/2021 XYWAV sodium oxybate/calcium CHANGE UM: AGE At least 8 yrs old At least 7 yrs old oxybate/magnesium oxybate/pot oxybate 05/01/2021 XYREM sodium oxybate ADD UM: AGE At least 7 yrs old 05/01/2021 ALA-CORT hydrocortisone REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 ALA-CORT hydrocortisone REMOVE UM: PANAME Non Preferred PA 05/01/2021 VITA-RESPA cyanocobalamin/folic REMOVE FROM Non PDL Non-Formulary acid/pyridoxine FORMULARY 05/01/2021 ELIXOPHYLLIN theophylline anhydrous REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 511 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 methyclothiazide methyclothiazide REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 theophylline theophylline anhydrous REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 MENEST estrogens,esterified REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 BEVYXXA betrixaban maleate REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 BEVYXXA betrixaban maleate REMOVE UM: PANAME Non Preferred PA 05/01/2021 BEVYXXA betrixaban maleate REMOVE UM: QUANTITY 43 / 42 days 05/01/2021 BEVYXXA betrixaban maleate REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 BEVYXXA betrixaban maleate REMOVE UM: PANAME Non Preferred PA 05/01/2021 BEVYXXA betrixaban maleate REMOVE UM: QUANTITY 43 / 42 days 05/01/2021 hydroxyzine hcl hydroxyzine hcl REMOVE FROM Non-Formulary FORMULARY 05/01/2021 trandolapril- trandolapril/verapamil hcl REMOVE FROM Non-Preferred Non-Formulary verapamil,trandol FORMULARY april-verapamil er 05/01/2021 trandolapril- trandolapril/verapamil hcl REMOVE UM: PANAME Non Preferred PA verapamil,trandol april-verapamil er 05/01/2021 ampicillin ampicillin trihydrate REMOVE FROM Non PDL Non-Formulary trihydrate FORMULARY 05/01/2021 theophylline theophylline anhydrous REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 meperidine hcl meperidine hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 meperidine hcl meperidine hcl REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 512 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 HUMIRA adalimumab REMOVE FROM Preferred Non-Formulary FORMULARY 05/01/2021 mvc-fluoride pediatric multivitamins REMOVE FROM Non PDL Non-Formulary combination no.12/sodium FORMULARY fluoride,pediatric multivitamin no.12 with sodium fluoride 05/01/2021 mvc-fluoride pediatric multivitamins REMOVE UM: QUANTITY 1 / day combination no.12/sodium fluoride,pediatric multivitamin no.12 with sodium fluoride 05/01/2021 mvc-fluoride pediatric multivitamins REMOVE FROM Non PDL Non-Formulary combination no.12/sodium FORMULARY fluoride,pediatric multivitamin no.12 with sodium fluoride 05/01/2021 mvc-fluoride pediatric multivitamins REMOVE UM: QUANTITY 1 / day combination no.12/sodium fluoride,pediatric multivitamin no.12 with sodium fluoride 05/01/2021 mvc-fluoride pediatric multivitamins REMOVE FROM Non PDL Non-Formulary combination no.12/sodium FORMULARY fluoride,pediatric multivitamin no.12 with sodium fluoride 05/01/2021 mvc-fluoride pediatric multivitamins REMOVE UM: QUANTITY 1 / day combination no.12/sodium fluoride,pediatric multivitamin no.12 with sodium fluoride

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 513 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 multi-vitamin w- pediatric multivitamin REMOVE FROM Non PDL Non-Formulary fluoride,multivita combination no.2/sodium FORMULARY mins with fluoride,pediatric fluoride,multivita multivitamin no.82 with min and sodium fluoride,pediatric fluoride,multivita multivitamin no.2/sodium min with fluoride fluoride,pediatric multivitamin no.150 with sodium fluoride 05/01/2021 multi-vitamin w- pediatric multivitamin REMOVE UM: QUANTITY 2 / day fluoride,multivita combination no.2/sodium mins with fluoride,pediatric fluoride,multivita multivitamin no.82 with min and sodium fluoride,pediatric fluoride,multivita multivitamin no.2/sodium min with fluoride fluoride,pediatric multivitamin no.150 with sodium fluoride 05/01/2021 multi-vitamin w- pediatric multivitamin REMOVE FROM Non PDL Non-Formulary fluoride,multivita combination no.2/sodium FORMULARY mins with fluoride,pediatric fluoride,multivita multivitamin no.2/sodium min with fluoride fluoride 05/01/2021 multi-vitamin w- pediatric multivitamin REMOVE UM: QUANTITY 2 / day fluoride,multivita combination no.2/sodium mins with fluoride,pediatric fluoride,multivita multivitamin no.2/sodium min with fluoride fluoride 05/01/2021 ROXYBOND oxycodone hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 ROXYBOND oxycodone hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 ROXYBOND oxycodone hcl REMOVE UM: QUANTITY 90 / 30 Days 05/01/2021 ROXYBOND oxycodone hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 514 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ROXYBOND oxycodone hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 ROXYBOND oxycodone hcl REMOVE UM: QUANTITY 120 / 30 Days 05/01/2021 sumatriptan sumatriptan succinate REMOVE FROM Preferred Non-Formulary succinate FORMULARY 05/01/2021 sumatriptan sumatriptan succinate REMOVE UM: QUANTITY 4 / claim succinate 05/01/2021 prenatal-u multivitamin combination REMOVE FROM Non PDL Non-Formulary no.51/ferrous fumarate/folic FORMULARY acid 05/01/2021 prenatal-u multivitamin combination REMOVE UM: GENDER Female no.51/ferrous fumarate/folic acid 05/01/2021 prenatal-u multivitamin combination REMOVE UM: QUANTITY 1 / day no.51/ferrous fumarate/folic acid 05/01/2021 flurbiprofen flurbiprofen REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 flurbiprofen flurbiprofen REMOVE UM: PANAME Non Preferred PA 05/01/2021 OGESTREL norgestrel-ethinyl estradiol REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 sodium chloride sodium chloride for REMOVE FROM Non PDL Non-Formulary inhalation FORMULARY 05/01/2021 VOL-NATE prenatal vits with calcium REMOVE FROM Non PDL Non-Formulary no.73/ferrous fumarate/folic FORMULARY acid 05/01/2021 VOL-NATE prenatal vits with calcium REMOVE UM: GENDER Female no.73/ferrous fumarate/folic acid 05/01/2021 VOL-NATE prenatal vits with calcium REMOVE UM: QUANTITY 1 / day no.73/ferrous fumarate/folic acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 515 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 metipranolol metipranolol REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 prenatal low iron prenatal vits with calcium REMOVE FROM Non PDL Non-Formulary #74/ferrous fumarate/folic FORMULARY acid,prenatal vits with calcium no.74/ferrous fumarate/folic acid 05/01/2021 prenatal low iron prenatal vits with calcium REMOVE UM: GENDER Female #74/ferrous fumarate/folic acid,prenatal vits with calcium no.74/ferrous fumarate/folic acid 05/01/2021 prenatal low iron prenatal vits with calcium REMOVE UM: QUANTITY 1 / day #74/ferrous fumarate/folic acid,prenatal vits with calcium no.74/ferrous fumarate/folic acid 05/01/2021 MYNATAL-Z prenatal vitamins with REMOVE FROM Non PDL Non-Formulary calcium/ferrous FORMULARY fumarate/folic acid 05/01/2021 MYNATAL-Z prenatal vitamins with REMOVE UM: GENDER Female calcium/ferrous fumarate/folic acid 05/01/2021 MYNATAL-Z prenatal vitamins with REMOVE UM: QUANTITY 1 / day calcium/ferrous fumarate/folic acid 05/01/2021 HUMIRA adalimumab REMOVE FROM Preferred Non-Formulary FORMULARY 05/01/2021 prenatal vitamins prenatal vitamins/ferrous REMOVE FROM Non-Formulary fumarate/folic acid FORMULARY 05/01/2021 homatropine,hom homatropine hbr REMOVE FROM Non PDL Non-Formulary atropine FORMULARY hydrobromide

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 516 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 prenatal 19 prenatal vits with calcium REMOVE FROM Non PDL Non-Formulary no.115/iron fumarate/folic FORMULARY acid 05/01/2021 prenatal 19 prenatal vits with calcium REMOVE UM: GENDER Female no.115/iron fumarate/folic acid 05/01/2021 prenatal 19 prenatal vits with calcium REMOVE UM: QUANTITY 1 / day no.115/iron fumarate/folic acid 05/01/2021 TRINATE prenatal vits with calcium REMOVE FROM Non PDL Non-Formulary no.73/ferrous fumarate/folic FORMULARY acid 05/01/2021 TRINATE prenatal vits with calcium REMOVE UM: GENDER Female no.73/ferrous fumarate/folic acid 05/01/2021 TRINATE prenatal vits with calcium REMOVE UM: QUANTITY 1 / day no.73/ferrous fumarate/folic acid 05/01/2021 SUPERVITE lysine hcl/vitamin b REMOVE FROM Non PDL Non-Formulary complex/folic acid/zinc FORMULARY 05/01/2021 GLEOSTINE lomustine REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 GLEOSTINE lomustine REMOVE UM: PANAME Clinical PA 05/01/2021 GLEOSTINE lomustine REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 GLEOSTINE lomustine REMOVE UM: PANAME Clinical PA 05/01/2021 GLEOSTINE lomustine REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 GLEOSTINE lomustine REMOVE UM: PANAME Clinical PA 05/01/2021 AVONEX interferon beta-1a/albumin REMOVE FROM Preferred Non-Formulary human FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 517 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 AVONEX interferon beta-1a/albumin REMOVE UM: QUANTITY 4 / claim human 05/01/2021 chlorothiazide chlorothiazide REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 ALA-SCALP hydrocortisone REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 ALA-SCALP hydrocortisone REMOVE UM: PANAME Non Preferred PA 05/01/2021 MYNATAL PLUS prenatal vitamins with REMOVE FROM Non PDL Non-Formulary calcium/ferrous FORMULARY fumarate/folic acid 05/01/2021 MYNATAL PLUS prenatal vitamins with REMOVE UM: GENDER Female calcium/ferrous fumarate/folic acid 05/01/2021 MYNATAL PLUS prenatal vitamins with REMOVE UM: QUANTITY 1 / day calcium/ferrous fumarate/folic acid 05/01/2021 prenatal plus prenatal vits with calcium REMOVE FROM Non PDL Non-Formulary no.72/iron,carbonyl/folic acid FORMULARY 05/01/2021 prenatal plus prenatal vits with calcium REMOVE UM: GENDER Female no.72/iron,carbonyl/folic acid 05/01/2021 prenatal plus prenatal vits with calcium REMOVE UM: QUANTITY 1 / day no.72/iron,carbonyl/folic acid 05/01/2021 metaproterenol metaproterenol sulfate REMOVE FROM Non PDL Non-Formulary sulfate FORMULARY 05/01/2021 metaproterenol metaproterenol sulfate REMOVE FROM Non PDL Non-Formulary sulfate FORMULARY 05/01/2021 FORTAVIT multivit with iron, REMOVE FROM Non PDL Non-Formulary mins/dietary sup FORMULARY 4/dna/ribonucleic acid 05/01/2021 ULTRAVATE X halobetasol propionate/lactic REMOVE FROM Non-Preferred Non-Formulary acid FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 518 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ULTRAVATE X halobetasol propionate/lactic REMOVE UM: PANAME Non Preferred PA acid 05/01/2021 ULTRAVATE X halobetasol propionate/lactic REMOVE FROM Non-Preferred Non-Formulary acid FORMULARY 05/01/2021 ULTRAVATE X halobetasol propionate/lactic REMOVE UM: PANAME Non Preferred PA acid 05/01/2021 chlorothiazide chlorothiazide REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 TRIGLIDE fenofibrate nanocrystallized REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 TRIGLIDE fenofibrate nanocrystallized REMOVE UM: PANAME Non Preferred PA 05/01/2021 GELNIQUE oxybutynin chloride REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 GELNIQUE oxybutynin chloride REMOVE UM: PANAME Non Preferred PA 05/01/2021 hydroxyzine hcl hydroxyzine hcl REMOVE FROM Preferred Non-Formulary FORMULARY 05/01/2021 hydroxyzine hcl hydroxyzine hcl REMOVE FROM Preferred Non-Formulary FORMULARY 05/01/2021 ONMEL itraconazole REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 ONMEL itraconazole REMOVE UM: PANAME Non Preferred PA 05/01/2021 FIBRICOR fenofibric acid REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 FIBRICOR fenofibric acid REMOVE UM: PANAME Non Preferred PA 05/01/2021 FIBRICOR fenofibric acid REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 FIBRICOR fenofibric acid REMOVE UM: PANAME Non Preferred PA 05/01/2021 ULTRAVATE halobetasol propionate REMOVE FROM Non-Preferred Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 519 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ULTRAVATE halobetasol propionate REMOVE UM: PANAME Non Preferred PA 05/01/2021 ABSTRAL fentanyl citrate REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 ABSTRAL fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 ABSTRAL fentanyl citrate REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 ABSTRAL fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 QMIIZ ODT meloxicam REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 QMIIZ ODT meloxicam REMOVE UM: PANAME Non Preferred PA 05/01/2021 QMIIZ ODT meloxicam REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 QMIIZ ODT meloxicam REMOVE UM: PANAME Non Preferred PA 05/01/2021 MORPHABOND morphine sulfate REMOVE FROM Preferred Non-Formulary ER FORMULARY 05/01/2021 ABSTRAL fentanyl citrate REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 ABSTRAL fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 ULTRAVATE halobetasol propionate REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 ULTRAVATE halobetasol propionate REMOVE UM: PANAME Non Preferred PA 05/01/2021 MORPHABOND morphine sulfate REMOVE FROM Preferred Non-Formulary ER FORMULARY 05/01/2021 MICORT-HC hydrocortisone acetate REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 MICORT-HC hydrocortisone acetate REMOVE UM: PANAME Non Preferred PA 05/01/2021 MICORT-HC hydrocortisone acetate REMOVE FROM Non-Preferred Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 520 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 MICORT-HC hydrocortisone acetate REMOVE UM: PANAME Non Preferred PA 05/01/2021 ABSTRAL fentanyl citrate REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 ABSTRAL fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 VICODIN HP hydrocodone REMOVE FROM Non-Preferred Non-Formulary bitartrate/acetaminophen FORMULARY 05/01/2021 VICODIN HP hydrocodone REMOVE UM: PANAME Non Preferred PA bitartrate/acetaminophen 05/01/2021 ABSTRAL fentanyl citrate REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 ABSTRAL fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 ABSTRAL fentanyl citrate REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 ABSTRAL fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 CORDRAN flurandrenolide REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 CORDRAN flurandrenolide REMOVE UM: PANAME Non Preferred PA 05/01/2021 MORPHABOND morphine sulfate REMOVE FROM Preferred Non-Formulary ER FORMULARY 05/01/2021 MORPHABOND morphine sulfate REMOVE FROM Preferred Non-Formulary ER FORMULARY 05/01/2021 TIVORBEX indomethacin, REMOVE FROM Non-Preferred Non-Formulary submicronized FORMULARY 05/01/2021 TIVORBEX indomethacin, REMOVE UM: PANAME Non Preferred PA submicronized 05/01/2021 TIVORBEX indomethacin, REMOVE FROM Non-Preferred Non-Formulary submicronized FORMULARY 05/01/2021 TIVORBEX indomethacin, REMOVE UM: PANAME Non Preferred PA submicronized

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 521 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 TAMIFLU oseltamivir phosphate REMOVE UM: B4G BRAND FOR GENERIC 05/01/2021 TAMIFLU oseltamivir phosphate REMOVE UM: B4G BRAND FOR GENERIC 05/01/2021 TAMIFLU oseltamivir phosphate REMOVE UM: B4G BRAND FOR GENERIC 05/01/2021 TAMIFLU oseltamivir phosphate REMOVE UM: B4G BRAND FOR GENERIC 05/01/2021 AKYNZEO fosnetupitant chloride REMOVE FROM Non-Preferred Non-Formulary hcl/palonosetron hcl FORMULARY 05/01/2021 AKYNZEO fosnetupitant chloride REMOVE UM: PANAME Clinical PA hcl/palonosetron hcl 05/01/2021 AKYNZEO fosnetupitant chloride REMOVE UM: QUANTITY 1 / claim hcl/palonosetron hcl 05/01/2021 TRI-VI-SOL vitamin a palmitate/ascorbic ADD TO FORMULARY Non PDL acid/cholecalciferol (vit d3) 05/01/2021 PROLATE oxycodone ADD TO FORMULARY Non-Preferred hcl/acetaminophen 05/01/2021 PROLATE oxycodone ADD UM: PANAME Non Preferred PA hcl/acetaminophen 05/01/2021 PROLATE oxycodone ADD UM: DRUGCLASS NARCOTICS – hcl/acetaminophen SHORT AND INTERMEDIATE ACTING 05/01/2021 TRULICITY dulaglutide CHANGE TIER Non-Preferred Preferred 05/01/2021 TRULICITY dulaglutide CHANGE TIER Non-Preferred Preferred 05/01/2021 TRULICITY dulaglutide CHANGE TIER Non-Preferred Preferred 05/01/2021 TRULICITY dulaglutide CHANGE TIER Non-Preferred Preferred 05/01/2021 TRULICITY dulaglutide REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 522 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 TRULICITY dulaglutide REMOVE UM: PANAME Non Preferred PA 05/01/2021 TRULICITY dulaglutide REMOVE UM: PANAME Non Preferred PA 05/01/2021 TRULICITY dulaglutide REMOVE UM: PANAME Non Preferred PA 05/01/2021 MAXALT MLT rizatriptan benzoate ADD TO FORMULARY Non-Preferred 05/01/2021 MAXALT MLT rizatriptan benzoate ADD UM: QUANTITY 18 / claim 05/01/2021 MAXALT MLT rizatriptan benzoate ADD UM: DRUGCLASS ANTIMIGRAINE AGENTS, TRIPTANS 05/01/2021 MAXALT MLT rizatriptan benzoate ADD UM: PANAME Clinical PA 05/01/2021 ZITHROMAX azithromycin REMOVE UM: QUANTITY 6 / claim 05/01/2021 CATAPRES-TTS clonidine CHANGE UM: QUANTITY 4 / 28 days 14 / 102 days 1 05/01/2021 clonidine clonidine CHANGE UM: QUANTITY 4 / 28 days 14 / 102 days 05/01/2021 clonidine clonidine CHANGE UM: QUANTITY 4 / 28 days 14 / 102 days 05/01/2021 CATAPRES-TTS clonidine CHANGE UM: QUANTITY 4 / 28 days 14 / 102 days 3 05/01/2021 clonidine clonidine CHANGE UM: QUANTITY 4 / 28 days 14 / 102 days 05/01/2021 CATAPRES-TTS clonidine CHANGE UM: QUANTITY 4 / 28 days 14 / 102 days 2 05/01/2021 sevelamer hcl sevelamer hcl CHANGE TIER Preferred Non-Preferred 05/01/2021 isoflurane isoflurane ADD UM: MED Medical Drug 05/01/2021 BLINCYTO blinatumomab ADD UM: MED Medical Drug 05/01/2021 doxorubicin hcl doxorubicin hcl ADD UM: MED Medical Drug 05/01/2021 ZINACEF cefuroxime sodium ADD UM: MED Medical Drug 05/01/2021 GAMMAPLEX immune ADD UM: MED Medical Drug globulin,gamm(igg)/sorbitol/ glycin/iga 0 to 50 mcg/ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 523 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 methylprednisolo methylprednisolone acetate ADD UM: MED Medical Drug ne acetate 05/01/2021 RUCONEST c1 esterase inhibitor, ADD UM: MED Medical Drug recombinant 05/01/2021 DEPO-MEDROL methylprednisolone acetate ADD UM: MED Medical Drug 05/01/2021 paclitaxel paclitaxel ADD UM: MED Medical Drug 05/01/2021 KALBITOR ecallantide ADD UM: MED Medical Drug 05/01/2021 mesna mesna ADD UM: MED Medical Drug 05/01/2021 NIMBEX cisatracurium besylate ADD UM: MED Medical Drug 05/01/2021 cytarabine cytarabine/pf ADD UM: MED Medical Drug 05/01/2021 bleomycin sulfate bleomycin sulfate ADD UM: MED Medical Drug 05/01/2021 dopamine hcl in dopamine hcl in dextrose 5 ADD UM: MED Medical Drug 5% dextrose % in water,dopamine hcl/dextrose 5 % in water 05/01/2021 CELESTONE betamethasone ADD UM: MED Medical Drug acetate/betamethasone sodium phosphate 05/01/2021 dopamine hcl dopamine hcl ADD UM: MED Medical Drug 05/01/2021 dopamine hcl dopamine hcl ADD UM: MED Medical Drug 05/01/2021 AMIDATE etomidate ADD UM: MED Medical Drug 05/01/2021 doxorubicin hcl doxorubicin hcl pegylated ADD UM: MED Medical Drug liposome liposomal 05/01/2021 FERAHEME ferumoxytol ADD UM: MED Medical Drug 05/01/2021 PROSTIN VR alprostadil ADD UM: MED Medical Drug PEDIATRIC 05/01/2021 XYLOCAINE- lidocaine hcl/pf ADD UM: MED Medical Drug MPF 05/01/2021 TECENTRIQ atezolizumab ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 524 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 atracurium atracurium besylate ADD UM: MED Medical Drug besylate 05/01/2021 DARZALEX daratumumab- ADD UM: MED Medical Drug FASPRO hyaluronidase-fihj 05/01/2021 dopamine hcl dopamine hcl ADD UM: MED Medical Drug 05/01/2021 cytarabine cytarabine/pf ADD UM: MED Medical Drug 05/01/2021 OCREVUS ocrelizumab ADD UM: MED Medical Drug 05/01/2021 cytarabine cytarabine/pf ADD UM: MED Medical Drug 05/01/2021 FLEBOGAMMA immune globulin,gamma ADD UM: MED Medical Drug DIF (igg)/sorbitol/iga 0 to 50 mcg/ml 05/01/2021 ACTIVASE alteplase ADD UM: MED Medical Drug 05/01/2021 XYLOCAINE lidocaine hcl ADD UM: MED Medical Drug 05/01/2021 PHOTOFRIN porfimer sodium ADD UM: MED Medical Drug 05/01/2021 DEPACON valproic acid (as sodium ADD UM: MED Medical Drug salt) (valproate sodium) 05/01/2021 CAMPATH alemtuzumab ADD UM: MED Medical Drug 05/01/2021 BOTOX onabotulinumtoxina ADD UM: MED Medical Drug 05/01/2021 LIORESAL baclofen ADD UM: MED Medical Drug INTRATHECAL 05/01/2021 PRIVIGEN immune globulin,gamma ADD UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 05/01/2021 calcium chloride calcium chloride ADD UM: MED Medical Drug 05/01/2021 ETHAMOLIN ethanolamine oleate ADD UM: MED Medical Drug 05/01/2021 ABELCET amphotericin b lipid complex ADD UM: MED Medical Drug 05/01/2021 ORTHOVISC hyaluronate sodium ADD UM: MED Medical Drug 05/01/2021 dibucaine dibucaine ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 525 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 LUPRON leuprolide acetate ADD UM: MED Medical Drug DEPOT-PED 05/01/2021 OSMITROL mannitol ADD UM: MED Medical Drug 05/01/2021 ANASCORP centruroides (scorpion) ADD UM: MED Medical Drug polyvalent antivenom 05/01/2021 ZINACEF cefuroxime sodium ADD UM: MED Medical Drug 05/01/2021 RECLAST zoledronic acid in mannitol ADD UM: MED Medical Drug and water for injection,zoledronic acid in mannitol & water for injection 05/01/2021 ropivacaine hcl ropivacaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 topotecan hcl topotecan hcl ADD UM: MED Medical Drug 05/01/2021 polymyxin b polymyxin b sulfate ADD UM: MED Medical Drug sulfate 05/01/2021 GAMMAPLEX immune globulin,gamma ADD UM: MED Medical Drug (igg)/glycine/iga 0 to 50 mcg/ml 05/01/2021 melphalan hcl melphalan hcl ADD UM: MED Medical Drug 05/01/2021 ZOLADEX goserelin acetate ADD UM: MED Medical Drug 05/01/2021 XOLAIR omalizumab ADD UM: MED Medical Drug 05/01/2021 VORAXAZE glucarpidase ADD UM: MED Medical Drug 05/01/2021 BAL IN OIL dimercaprol ADD UM: MED Medical Drug 05/01/2021 ZEVALIN kit for prep yttrium- ADD UM: MED Medical Drug 90/ibritumomab tiuxetan/albumin human 05/01/2021 metoprolol metoprolol tartrate ADD UM: MED Medical Drug tartrate 05/01/2021 HEMABATE carboprost tromethamine ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 526 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 CUBICIN daptomycin ADD UM: MED Medical Drug 05/01/2021 HERCEPTIN trastuzumab-hyaluronidase- ADD UM: MED Medical Drug HYLECTA oysk 05/01/2021 OPDIVO nivolumab ADD UM: MED Medical Drug 05/01/2021 ERBITUX cetuximab ADD UM: MED Medical Drug 05/01/2021 ERBITUX cetuximab ADD UM: MED Medical Drug 05/01/2021 XIAFLEX collagenase clostridium ADD UM: MED Medical Drug histolyticum 05/01/2021 OPDIVO nivolumab ADD UM: MED Medical Drug 05/01/2021 dopamine hcl in dopamine hcl in dextrose 5 ADD UM: MED Medical Drug 5% dextrose % in water 05/01/2021 ADCETRIS brentuximab vedotin ADD UM: MED Medical Drug 05/01/2021 dopamine hcl in dopamine hcl in dextrose 5 ADD UM: MED Medical Drug 5% dextrose % in water,dopamine hcl/dextrose 5 % in water 05/01/2021 dopamine hcl in dopamine hcl/dextrose 5 % ADD UM: MED Medical Drug 5% dextrose in water,dopamine hcl in dextrose 5 % in water 05/01/2021 dopamine hcl in dopamine hcl/dextrose 5 % ADD UM: MED Medical Drug 5% dextrose in water,dopamine hcl in dextrose 5 % in water 05/01/2021 ZEMURON rocuronium bromide ADD UM: MED Medical Drug 05/01/2021 HYQVIA IG immune ADD UM: MED Medical Drug COMPONENT globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml 05/01/2021 OCTAGAM immune ADD UM: MED Medical Drug globulin,gamm(igg)/maltose/ iga greater than 50 mcg/ml 05/01/2021 ELIGARD leuprolide acetate ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 527 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 TREANDA bendamustine hcl ADD UM: MED Medical Drug 05/01/2021 etomidate etomidate ADD UM: MED Medical Drug 05/01/2021 argatroban- argatroban in sodium ADD UM: MED Medical Drug sodium chloride chloride, iso-osmotic 05/01/2021 BREVITAL methohexital sodium ADD UM: MED Medical Drug SODIUM 05/01/2021 thiotepa thiotepa ADD UM: MED Medical Drug 05/01/2021 JEVTANA cabazitaxel ADD UM: MED Medical Drug 05/01/2021 REMICADE infliximab ADD UM: MED Medical Drug 05/01/2021 LUPRON leuprolide acetate ADD UM: MED Medical Drug DEPOT-PED 05/01/2021 FERRLECIT sodium ferric gluconate ADD UM: MED Medical Drug complex in sucrose 05/01/2021 LEXISCAN regadenoson ADD UM: MED Medical Drug 05/01/2021 PROVENGE sipuleucel-t/lactated ringers ADD UM: MED Medical Drug solution 05/01/2021 KYPROLIS carfilzomib ADD UM: MED Medical Drug 05/01/2021 bacitracin bacitracin ADD UM: MED Medical Drug 05/01/2021 ONCASPAR pegaspargase ADD UM: MED Medical Drug 05/01/2021 DEPO-MEDROL methylprednisolone acetate ADD UM: MED Medical Drug 05/01/2021 MIOSTAT carbachol ADD UM: MED Medical Drug 05/01/2021 KRYSTEXXA pegloticase ADD UM: MED Medical Drug 05/01/2021 CLAFORAN cefotaxime sodium ADD UM: MED Medical Drug 05/01/2021 cisplatin cisplatin ADD UM: MED Medical Drug 05/01/2021 ZEMPLAR paricalcitol ADD UM: MED Medical Drug 05/01/2021 DEXFERRUM iron dextran complex ADD UM: MED Medical Drug 05/01/2021 AKTEN lidocaine hcl/pf ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 528 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 mannitol mannitol ADD UM: MED Medical Drug 05/01/2021 bupivacaine hcl bupivacaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 MONOVISC hyaluronate sodium, ADD UM: MED Medical Drug stabilized 05/01/2021 ZINECARD dexrazoxane ADD UM: MED Medical Drug hcl,dexrazoxane 05/01/2021 BREVITAL methohexital sodium ADD UM: MED Medical Drug SODIUM 05/01/2021 CLAFORAN cefotaxime sodium ADD UM: MED Medical Drug 05/01/2021 PENTAM 300 pentamidine isethionate ADD UM: MED Medical Drug 05/01/2021 CYTOGAM cytomegalovirus immune ADD UM: MED Medical Drug globulin (human),cytomegalovirus immune glob 05/01/2021 bupivacaine hcl bupivacaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 bupivacaine hcl bupivacaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 ZALTRAP ziv-aflibercept ADD UM: MED Medical Drug 05/01/2021 ZALTRAP ziv-aflibercept ADD UM: MED Medical Drug 05/01/2021 NULOJIX belatacept ADD UM: MED Medical Drug 05/01/2021 HYPERRAB S-D rabies immune globulin/pf ADD UM: MED Medical Drug 05/01/2021 HYPERTET S-D tetanus immune globulin/pf ADD UM: MED Medical Drug 05/01/2021 THYROSAFE potassium iodide ADD UM: MED Medical Drug 05/01/2021 IMFINZI durvalumab ADD UM: MED Medical Drug 05/01/2021 INFLECTRA infliximab-dyyb ADD UM: MED Medical Drug 05/01/2021 ifosfamide ifosfamide ADD UM: MED Medical Drug 05/01/2021 KETALAR ketamine hcl ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 529 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 HYQVIA immune ADD UM: MED Medical Drug globulin,gamma(igg) human/hyaluronidase, human recomb 05/01/2021 HYQVIA immune ADD UM: MED Medical Drug globulin,gamma(igg) human/hyaluronidase, human recomb 05/01/2021 HYQVIA immune ADD UM: MED Medical Drug globulin,gamma(igg) human/hyaluronidase, human recomb 05/01/2021 HYQVIA immune ADD UM: MED Medical Drug globulin,gamma(igg) human/hyaluronidase, human recomb 05/01/2021 HYQVIA immune ADD UM: MED Medical Drug globulin,gamma(igg) human/hyaluronidase, human recomb 05/01/2021 SYNRIBO omacetaxine mepesuccinate ADD UM: MED Medical Drug 05/01/2021 HIZENTRA immune globulin,gamma ADD UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 05/01/2021 CARIMUNE NF immune ADD UM: MED Medical Drug NANOFILTERED globulin,gamm(igg)/sucrose/ iga greater than 50 mcg/ml 05/01/2021 CARIMUNE NF immune ADD UM: MED Medical Drug NANOFILTERED globulin,gamm(igg)/sucrose/ iga greater than 50 mcg/ml 05/01/2021 BIVIGAM immune ADD UM: MED Medical Drug globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 530 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 RIXUBIS factor ix human recombinant ADD UM: MED Medical Drug 05/01/2021 HIZENTRA immune globulin,gamma ADD UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 05/01/2021 RIXUBIS factor ix human recombinant ADD UM: MED Medical Drug 05/01/2021 HIZENTRA immune globulin,gamma ADD UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 05/01/2021 CARIMUNE NF immune ADD UM: MED Medical Drug NANOFILTERED globulin,gamm(igg)/sucrose/ iga greater than 50 mcg/ml 05/01/2021 ULTIVA remifentanil hcl ADD UM: MED Medical Drug 05/01/2021 RIXUBIS factor ix human recombinant ADD UM: MED Medical Drug 05/01/2021 RIXUBIS factor ix human recombinant ADD UM: MED Medical Drug 05/01/2021 RIXUBIS factor ix human recombinant ADD UM: MED Medical Drug 05/01/2021 HYALGAN hyaluronate sodium ADD UM: MED Medical Drug 05/01/2021 VARIZIG varicella-zoster immune ADD UM: MED Medical Drug globulin (human) 05/01/2021 REVONTO dantrolene sodium ADD UM: MED Medical Drug 05/01/2021 SIMULECT basiliximab ADD UM: MED Medical Drug 05/01/2021 CAMPTOSAR irinotecan hcl ADD UM: MED Medical Drug 05/01/2021 HIZENTRA immune globulin,gamma ADD UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 05/01/2021 LUPRON DEPOT leuprolide acetate ADD UM: MED Medical Drug 05/01/2021 TRIESENCE triamcinolone acetonide/pf ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 531 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 LUPRON leuprolide acetate ADD UM: MED Medical Drug DEPOT,LUPRON DEPOT (LUPANETA) 05/01/2021 TYSABRI natalizumab ADD UM: MED Medical Drug 05/01/2021 HIZENTRA immune globulin,gamma ADD UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 05/01/2021 GAMMAGARD S- immune ADD UM: MED Medical Drug D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml 05/01/2021 XEOMIN incobotulinumtoxina ADD UM: MED Medical Drug 05/01/2021 NATRECOR nesiritide ADD UM: MED Medical Drug 05/01/2021 aminophylline aminophylline ADD UM: MED Medical Drug 05/01/2021 MYCAMINE micafungin sodium ADD UM: MED Medical Drug 05/01/2021 aminophylline aminophylline ADD UM: MED Medical Drug 05/01/2021 ARZERRA ofatumumab ADD UM: MED Medical Drug 05/01/2021 sufentanil citrate sufentanil citrate ADD UM: MED Medical Drug 05/01/2021 TRELSTAR triptorelin pamoate ADD UM: MED Medical Drug 05/01/2021 FASLODEX fulvestrant ADD UM: MED Medical Drug 05/01/2021 XGEVA denosumab ADD UM: MED Medical Drug 05/01/2021 NIMBEX cisatracurium besylate ADD UM: MED Medical Drug 05/01/2021 gemcitabine hcl gemcitabine hcl ADD UM: MED Medical Drug 05/01/2021 idarubicin hcl idarubicin hcl ADD UM: MED Medical Drug 05/01/2021 PROTOPAM pralidoxime chloride ADD UM: MED Medical Drug CHLORIDE 05/01/2021 gemcitabine hcl gemcitabine hcl ADD UM: MED Medical Drug 05/01/2021 gemcitabine hcl gemcitabine hcl ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 532 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 NAROPIN ropivacaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 argatroban argatroban ADD UM: MED Medical Drug 05/01/2021 gemcitabine hcl gemcitabine hcl ADD UM: MED Medical Drug 05/01/2021 BACIIM bacitracin ADD UM: MED Medical Drug 05/01/2021 INJECTAFER ferric carboxymaltose ADD UM: MED Medical Drug 05/01/2021 mitomycin mitomycin ADD UM: MED Medical Drug 05/01/2021 VINCASAR PFS vincristine sulfate ADD UM: MED Medical Drug 05/01/2021 THYMOGLOBUL anti-thymocyte ADD UM: MED Medical Drug IN globulin,rabbit 05/01/2021 LEVOPHED norepinephrine bitartrate ADD UM: MED Medical Drug BITARTRATE,LE VOPHED 05/01/2021 NESACAINE- chloroprocaine hcl/pf ADD UM: MED Medical Drug MPF 05/01/2021 ZINACEF cefuroxime sodium/water for ADD UM: MED Medical Drug injection,sterile 05/01/2021 CORTROSYN cosyntropin ADD UM: MED Medical Drug 05/01/2021 teniposide teniposide ADD UM: MED Medical Drug 05/01/2021 LIPODOX doxorubicin hcl pegylated ADD UM: MED Medical Drug liposomal 05/01/2021 TNKASE tenecteplase ADD UM: MED Medical Drug 05/01/2021 lidocaine hcl lidocaine hcl ADD UM: MED Medical Drug 05/01/2021 ibutilide fumarate ibutilide fumarate ADD UM: MED Medical Drug 05/01/2021 ifosfamide ifosfamide ADD UM: MED Medical Drug 05/01/2021 ifosfamide ifosfamide ADD UM: MED Medical Drug 05/01/2021 SUPARTZ FX hyaluronate sodium ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 533 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 FLUBLOK 2014- influenza virus vaccine tv ADD UM: MED Medical Drug 2015 2014-2015(18 yrs, older)recomb/pf 05/01/2021 ERYTHROCIN erythromycin lactobionate ADD UM: MED Medical Drug LACTOBIONATE 05/01/2021 dacarbazine dacarbazine ADD UM: MED Medical Drug 05/01/2021 FLEBOGAMMA immune globulin,gamma ADD UM: MED Medical Drug DIF (igg)/sorbitol/iga 0 to 50 mcg/ml 05/01/2021 ULTIVA remifentanil hcl ADD UM: MED Medical Drug 05/01/2021 GAMMAGARD S- immune ADD UM: MED Medical Drug D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml 05/01/2021 GAMMAGARD S- immune ADD UM: MED Medical Drug D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml 05/01/2021 osmitrol mannitol ADD UM: MED Medical Drug 05/01/2021 nalbuphine hcl nalbuphine hcl ADD UM: MED Medical Drug 05/01/2021 SENSORCAINE- bupivacaine hcl/pf ADD UM: MED Medical Drug MPF,SENSORC AINE 05/01/2021 sensorcaine- bupivacaine hcl/pf ADD UM: MED Medical Drug mpf,sensorcaine 05/01/2021 methylene blue methylene blue ADD UM: MED Medical Drug 05/01/2021 GABLOFEN baclofen ADD UM: MED Medical Drug 05/01/2021 HIZENTRA immune globulin,gamma ADD UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 05/01/2021 DARZALEX daratumumab ADD UM: MED Medical Drug 05/01/2021 THYROGEN thyrotropin alfa ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 534 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 doxapram hcl doxapram hcl ADD UM: MED Medical Drug 05/01/2021 PROLIA denosumab ADD UM: MED Medical Drug 05/01/2021 YERVOY ipilimumab ADD UM: MED Medical Drug 05/01/2021 YERVOY ipilimumab ADD UM: MED Medical Drug 05/01/2021 KETALAR ketamine hcl ADD UM: MED Medical Drug 05/01/2021 pamidronate pamidronate disodium ADD UM: MED Medical Drug disodium 05/01/2021 DOCEFREZ docetaxel ADD UM: MED Medical Drug 05/01/2021 DOCEFREZ docetaxel ADD UM: MED Medical Drug 05/01/2021 CLAFORAN cefotaxime sodium ADD UM: MED Medical Drug 05/01/2021 DACOGEN decitabine ADD UM: MED Medical Drug 05/01/2021 CAMPTOSAR irinotecan hcl ADD UM: MED Medical Drug 05/01/2021 DESFERAL deferoxamine mesylate ADD UM: MED Medical Drug MESYLATE 05/01/2021 FUSILEV levoleucovorin calcium ADD UM: MED Medical Drug 05/01/2021 CLEVIPREX clevidipine butyrate ADD UM: MED Medical Drug 05/01/2021 CLEVIPREX clevidipine butyrate ADD UM: MED Medical Drug 05/01/2021 deferoxamine deferoxamine mesylate ADD UM: MED Medical Drug mesylate 05/01/2021 NAROPIN ropivacaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 GEMZAR gemcitabine hcl ADD UM: MED Medical Drug 05/01/2021 decitabine decitabine ADD UM: MED Medical Drug 05/01/2021 MYOBLOC rimabotulinumtoxinb ADD UM: MED Medical Drug 05/01/2021 ELITEK rasburicase ADD UM: MED Medical Drug 05/01/2021 cytarabine cytarabine/pf ADD UM: MED Medical Drug 05/01/2021 INTEGRILIN eptifibatide ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 535 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 adenosine adenosine ADD UM: MED Medical Drug 05/01/2021 NUCALA mepolizumab ADD UM: MED Medical Drug 05/01/2021 NUCALA mepolizumab ADD UM: MED Medical Drug 05/01/2021 TRELSTAR triptorelin pamoate ADD UM: MED Medical Drug 05/01/2021 TRELSTAR triptorelin pamoate ADD UM: MED Medical Drug 05/01/2021 SOLIRIS eculizumab ADD UM: MED Medical Drug 05/01/2021 KYPROLIS carfilzomib ADD UM: MED Medical Drug 05/01/2021 dexrazoxane dexrazoxane hcl ADD UM: MED Medical Drug 05/01/2021 UVADEX methoxsalen ADD UM: MED Medical Drug 05/01/2021 ZANOSAR streptozocin ADD UM: MED Medical Drug 05/01/2021 MARQIBO vincristine sulfate liposomal ADD UM: MED Medical Drug 05/01/2021 BERINERT c1 esterase inhibitor ADD UM: MED Medical Drug 05/01/2021 ALIMTA pemetrexed disodium ADD UM: MED Medical Drug 05/01/2021 REGONOL pyridostigmine bromide ADD UM: MED Medical Drug 05/01/2021 PERJETA pertuzumab ADD UM: MED Medical Drug 05/01/2021 docetaxel docetaxel ADD UM: MED Medical Drug 05/01/2021 docetaxel docetaxel ADD UM: MED Medical Drug 05/01/2021 ANECTINE succinylcholine chloride ADD UM: MED Medical Drug 05/01/2021 AVASTIN bevacizumab ADD UM: MED Medical Drug 05/01/2021 ANGIOMAX bivalirudin ADD UM: MED Medical Drug 05/01/2021 LUPRON DEPOT leuprolide acetate ADD UM: MED Medical Drug 05/01/2021 ELIGARD leuprolide acetate ADD UM: MED Medical Drug 05/01/2021 TAXOTERE docetaxel ADD UM: MED Medical Drug 05/01/2021 TAXOTERE docetaxel ADD UM: MED Medical Drug 05/01/2021 GABLOFEN baclofen ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 536 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 GABLOFEN baclofen ADD UM: MED Medical Drug 05/01/2021 DORIBAX doripenem ADD UM: MED Medical Drug 05/01/2021 GABLOFEN baclofen ADD UM: MED Medical Drug 05/01/2021 GABLOFEN baclofen ADD UM: MED Medical Drug 05/01/2021 SYNERCID quinupristin/dalfopristin ADD UM: MED Medical Drug 05/01/2021 GABLOFEN baclofen ADD UM: MED Medical Drug 05/01/2021 GABLOFEN baclofen ADD UM: MED Medical Drug 05/01/2021 BENLYSTA belimumab ADD UM: MED Medical Drug 05/01/2021 MIOCHOL-E acetylcholine chloride ADD UM: MED Medical Drug 05/01/2021 MYCAMINE micafungin sodium ADD UM: MED Medical Drug 05/01/2021 ERAXIS (WATER anidulafungin ADD UM: MED Medical Drug DILUENT) 05/01/2021 ERAXIS (WATER anidulafungin ADD UM: MED Medical Drug DILUENT) 05/01/2021 phentolamine phentolamine mesylate ADD UM: MED Medical Drug mesylate 05/01/2021 dobutamine hcl- dobutamine hcl in dextrose ADD UM: MED Medical Drug d5w 5 % in water 05/01/2021 DANTRIUM dantrolene sodium ADD UM: MED Medical Drug 05/01/2021 HYPERHEP B hepatitis b immune globulin ADD UM: MED Medical Drug 05/01/2021 vecuronium vecuronium bromide ADD UM: MED Medical Drug bromide 05/01/2021 TIMENTIN ticarcillin ADD UM: MED Medical Drug disodium/potassium clavulanate 05/01/2021 vecuronium vecuronium bromide ADD UM: MED Medical Drug bromide

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 537 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 BOTOX onabotulinumtoxina ADD UM: MED Medical Drug COSMETIC 05/01/2021 esmolol hcl esmolol hcl ADD UM: MED Medical Drug 05/01/2021 CORLOPAM fenoldopam mesylate ADD UM: MED Medical Drug 05/01/2021 cladribine cladribine ADD UM: MED Medical Drug 05/01/2021 LUPRON leuprolide acetate ADD UM: MED Medical Drug DEPOT-PED 05/01/2021 PROLASTIN C alpha-1-proteinase inhibitor ADD UM: MED Medical Drug 05/01/2021 cisatracurium cisatracurium besylate ADD UM: MED Medical Drug besylate 05/01/2021 NEOPROFEN ibuprofen lysine/pf ADD UM: MED Medical Drug 05/01/2021 DEPOCYT cytarabine liposome/pf ADD UM: MED Medical Drug 05/01/2021 chloroprocaine chloroprocaine hcl/pf ADD UM: MED Medical Drug hcl 05/01/2021 LUPRON DEPOT leuprolide acetate ADD UM: MED Medical Drug 05/01/2021 ELOXATIN oxaliplatin ADD UM: MED Medical Drug 05/01/2021 ELOXATIN oxaliplatin ADD UM: MED Medical Drug 05/01/2021 chloroprocaine chloroprocaine hcl/pf ADD UM: MED Medical Drug hcl 05/01/2021 LUPRON DEPOT leuprolide acetate ADD UM: MED Medical Drug 05/01/2021 REOPRO abciximab ADD UM: MED Medical Drug 05/01/2021 pamidronate pamidronate disodium ADD UM: MED Medical Drug disodium 05/01/2021 NAVELBINE vinorelbine tartrate ADD UM: MED Medical Drug 05/01/2021 DOPRAM doxapram hcl ADD UM: MED Medical Drug 05/01/2021 ADENOSCAN adenosine ADD UM: MED Medical Drug 05/01/2021 SYNVISC-ONE hylan g-f 20 ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 538 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 mannitol mannitol ADD UM: MED Medical Drug 05/01/2021 XYLOCAINE lidocaine hcl/pf ADD UM: MED Medical Drug IV,XYLOCAINE IV FOR CARDIAC 05/01/2021 oxytocin oxytocin ADD UM: MED Medical Drug 05/01/2021 ARRANON nelarabine ADD UM: MED Medical Drug 05/01/2021 ULTIVA remifentanil hcl ADD UM: MED Medical Drug 05/01/2021 XOFIGO radium-223 dichloride ADD UM: MED Medical Drug 05/01/2021 triamcinolone triamcinolone acetonide ADD UM: MED Medical Drug acetonide 05/01/2021 PRIALT ziconotide acetate ADD UM: MED Medical Drug 05/01/2021 PRIALT ziconotide acetate ADD UM: MED Medical Drug 05/01/2021 docetaxel docetaxel ADD UM: MED Medical Drug 05/01/2021 IDAMYCIN PFS idarubicin hcl ADD UM: MED Medical Drug 05/01/2021 DUODOTE pralidoxime ADD UM: MED Medical Drug chloride/atropine sulfate 05/01/2021 fludarabine fludarabine phosphate ADD UM: MED Medical Drug phosphate 05/01/2021 MESNEX mesna ADD UM: MED Medical Drug 05/01/2021 ropivacaine hcl ropivacaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 KYPROLIS carfilzomib ADD UM: MED Medical Drug 05/01/2021 SENSORCAINE- bupivacaine hcl/pf ADD UM: MED Medical Drug MPF,SENSORC AINE 05/01/2021 NEO- phenylephrine hcl ADD UM: MED Medical Drug SYNEPHRINE 05/01/2021 LOPRESSOR metoprolol tartrate ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 539 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ZANTAC ranitidine hcl ADD UM: MED Medical Drug 05/01/2021 calcium chloride calcium chloride ADD UM: MED Medical Drug 05/01/2021 neostigmine neostigmine methylsulfate ADD UM: MED Medical Drug methylsulfate 05/01/2021 daunorubicin hcl daunorubicin hcl ADD UM: MED Medical Drug 05/01/2021 SOLU-MEDROL methylprednisolone sodium ADD UM: MED Medical Drug succinate 05/01/2021 NESACAINE- chloroprocaine hcl/pf ADD UM: MED Medical Drug MPF 05/01/2021 adenosine adenosine ADD UM: MED Medical Drug 05/01/2021 chloramphenicol chloramphenicol sod ADD UM: MED Medical Drug sod succinate succinate 05/01/2021 LIORESAL baclofen ADD UM: MED Medical Drug INTRATHECAL 05/01/2021 pancuronium pancuronium bromide ADD UM: MED Medical Drug bromide 05/01/2021 acetylcysteine acetylcysteine ADD UM: MED Medical Drug 05/01/2021 SUFENTA sufentanil citrate ADD UM: MED Medical Drug 05/01/2021 mitomycin mitomycin ADD UM: MED Medical Drug 05/01/2021 QUELICIN succinylcholine chloride ADD UM: MED Medical Drug 05/01/2021 YONDELIS trabectedin ADD UM: MED Medical Drug 05/01/2021 AGGRASTAT tirofiban hcl monohydrate in ADD UM: MED Medical Drug 0.9 % sodium chloride 05/01/2021 AGGRASTAT tirofiban hcl monohydrate in ADD UM: MED Medical Drug 0.9 % sodium chloride 05/01/2021 ACETADOTE acetylcysteine ADD UM: MED Medical Drug 05/01/2021 PREPIDIL dinoprostone ADD UM: MED Medical Drug 05/01/2021 CLOLAR clofarabine ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 540 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 cidofovir cidofovir ADD UM: MED Medical Drug 05/01/2021 VIBATIV telavancin hcl ADD UM: MED Medical Drug 05/01/2021 VIBATIV telavancin hcl ADD UM: MED Medical Drug 05/01/2021 BLOXIVERZ neostigmine methylsulfate ADD UM: MED Medical Drug 05/01/2021 KETALAR ketamine hcl ADD UM: MED Medical Drug 05/01/2021 GAMMAGARD immune ADD UM: MED Medical Drug LIQUID globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml 05/01/2021 bcg (tice strain) bcg live ADD UM: MED Medical Drug 05/01/2021 pralidoxime pralidoxime chloride ADD UM: MED Medical Drug chloride 05/01/2021 BLOXIVERZ neostigmine methylsulfate ADD UM: MED Medical Drug 05/01/2021 pamidronate pamidronate disodium ADD UM: MED Medical Drug disodium 05/01/2021 ELIGARD leuprolide acetate ADD UM: MED Medical Drug 05/01/2021 propofol propofol ADD UM: MED Medical Drug 05/01/2021 DESFERAL deferoxamine mesylate ADD UM: MED Medical Drug 05/01/2021 LEMTRADA alemtuzumab ADD UM: MED Medical Drug 05/01/2021 epirubicin hcl epirubicin hcl ADD UM: MED Medical Drug 05/01/2021 LUPRON leuprolide acetate ADD UM: MED Medical Drug DEPOT-PED 05/01/2021 PITOCIN oxytocin ADD UM: MED Medical Drug 05/01/2021 LINCOCIN lincomycin hcl ADD UM: MED Medical Drug 05/01/2021 epirubicin hcl epirubicin hcl ADD UM: MED Medical Drug 05/01/2021 HYALGAN hyaluronate sodium ADD UM: MED Medical Drug 05/01/2021 ephedrine sulfate ephedrine sulfate ADD UM: MED Medical Drug 05/01/2021 VISTIDE cidofovir ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 541 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 milrinone in 5% milrinone lactate/dextrose 5 ADD UM: MED Medical Drug dextrose % in water 05/01/2021 milrinone in 5% milrinone lactate/dextrose 5 ADD UM: MED Medical Drug dextrose % in water 05/01/2021 norepinephrine norepinephrine bitartrate ADD UM: MED Medical Drug bitartrate 05/01/2021 SENSORCAINE bupivacaine hcl ADD UM: MED Medical Drug 05/01/2021 GAMUNEX immune ADD UM: MED Medical Drug globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml 05/01/2021 TIMENTIN ticarcillin ADD UM: MED Medical Drug disodium/potassium clavulanate 05/01/2021 ropivacaine hcl ropivacaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 ALOXI palonosetron hcl ADD UM: MED Medical Drug 05/01/2021 RITUXAN rituximab/hyaluronidase, ADD UM: MED Medical Drug HYCELA human recombinant 05/01/2021 mannitol mannitol ADD UM: MED Medical Drug 05/01/2021 RITUXAN rituximab/hyaluronidase, ADD UM: MED Medical Drug HYCELA human recombinant 05/01/2021 SUPRANE desflurane ADD UM: MED Medical Drug 05/01/2021 topotecan hcl topotecan hcl ADD UM: MED Medical Drug 05/01/2021 TECENTRIQ atezolizumab ADD UM: MED Medical Drug 05/01/2021 ELLENCE epirubicin hcl ADD UM: MED Medical Drug 05/01/2021 HERCEPTIN trastuzumab ADD UM: MED Medical Drug 05/01/2021 cytarabine cytarabine/pf ADD UM: MED Medical Drug 05/01/2021 ketamine hcl ketamine hcl ADD UM: MED Medical Drug 05/01/2021 RENFLEXIS infliximab-abda ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 542 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ISTODAX romidepsin ADD UM: MED Medical Drug 05/01/2021 EMEND fosaprepitant dimeglumine ADD UM: MED Medical Drug 05/01/2021 BREVIBLOC esmolol hcl ADD UM: MED Medical Drug 05/01/2021 ZINECARD dexrazoxane ADD UM: MED Medical Drug hcl,dexrazoxane 05/01/2021 SOLU-MEDROL methylprednisolone sodium ADD UM: MED Medical Drug succinate 05/01/2021 GAMUNEX-C immune ADD UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 05/01/2021 BLINCYTO blinatumomab ADD UM: MED Medical Drug 05/01/2021 LUCENTIS ranibizumab ADD UM: MED Medical Drug 05/01/2021 betamethasone betamethasone ADD UM: MED Medical Drug sod phos- acetate/betamethasone acetate,betameth sodium phosphate asone acetate- sod phos 05/01/2021 OCTAGAM immune ADD UM: MED Medical Drug globulin,gamm(igg)/maltose/ iga greater than 50 mcg/ml 05/01/2021 CINRYZE c1 esterase inhibitor ADD UM: MED Medical Drug 05/01/2021 cisatracurium cisatracurium besylate ADD UM: MED Medical Drug besylate 05/01/2021 DEPODUR morphine sulfate ADD UM: MED Medical Drug liposomal/pf 05/01/2021 pentostatin pentostatin ADD UM: MED Medical Drug 05/01/2021 CYANOKIT hydroxocobalamin ADD UM: MED Medical Drug 05/01/2021 XYLOCAINE- lidocaine hcl/pf ADD UM: MED Medical Drug MPF

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 543 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 azacitidine azacitidine ADD UM: MED Medical Drug 05/01/2021 methylprednisolo methylprednisolone sodium ADD UM: MED Medical Drug ne sod succinate succ,methylpredn isolone sodium succ 05/01/2021 BOTOX onabotulinumtoxina ADD UM: MED Medical Drug COSMETIC 05/01/2021 NESACAINE chloroprocaine hcl ADD UM: MED Medical Drug 05/01/2021 THERACYS bcg live ADD UM: MED Medical Drug 05/01/2021 dobutamine hcl dobutamine hcl ADD UM: MED Medical Drug 05/01/2021 dobutamine hcl- dobutamine hcl in dextrose ADD UM: MED Medical Drug d5w 5 % in water 05/01/2021 dobutamine hcl in dobutamine hcl/dextrose 5 ADD UM: MED Medical Drug dextrose % in water 05/01/2021 SYNERA lidocaine/tetracaine ADD UM: MED Medical Drug 05/01/2021 sevoflurane sevoflurane ADD UM: MED Medical Drug 05/01/2021 mepivacaine hcl mepivacaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 RITUXAN rituximab ADD UM: MED Medical Drug 05/01/2021 EMPLICITI elotuzumab ADD UM: MED Medical Drug 05/01/2021 EMPLICITI elotuzumab ADD UM: MED Medical Drug 05/01/2021 bleomycin sulfate bleomycin sulfate ADD UM: MED Medical Drug 05/01/2021 neostigmine neostigmine methylsulfate ADD UM: MED Medical Drug methylsulfate 05/01/2021 XOLAIR omalizumab ADD UM: MED Medical Drug 05/01/2021 ZINACEF ISO- cefuroxime ADD UM: MED Medical Drug OSMOTIC sodium/dextrose, iso- DEXTROSE osmotic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 544 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ASTHMANEFRIN racepinephrine hcl ADD UM: MED Medical Drug STARTER KIT 05/01/2021 irinotecan hcl irinotecan hcl ADD UM: MED Medical Drug 05/01/2021 INFASURF calfactant ADD UM: MED Medical Drug 05/01/2021 DORIBAX doripenem ADD UM: MED Medical Drug 05/01/2021 gemcitabine hcl gemcitabine hcl ADD UM: MED Medical Drug 05/01/2021 S2 racepinephrine hcl ADD UM: MED Medical Drug RACEPINEPHRI NE 05/01/2021 ADRIAMYCIN doxorubicin hcl ADD UM: MED Medical Drug 05/01/2021 DAUNOXOME daunorubicin citrate ADD UM: MED Medical Drug liposomal 05/01/2021 OPDIVO nivolumab ADD UM: MED Medical Drug 05/01/2021 REMODULIN treprostinil sodium ADD UM: MED Medical Drug 05/01/2021 IXEMPRA ixabepilone ADD UM: MED Medical Drug 05/01/2021 ARALAST NP alpha-1-proteinase inhibitor ADD UM: MED Medical Drug 05/01/2021 ARALAST NP alpha-1-proteinase inhibitor ADD UM: MED Medical Drug 05/01/2021 butorphanol butorphanol tartrate ADD UM: MED Medical Drug tartrate 05/01/2021 ISUPREL isoproterenol hcl ADD UM: MED Medical Drug 05/01/2021 BREVITAL methohexital sodium ADD UM: MED Medical Drug SODIUM 05/01/2021 sod ferric sodium ferric gluconate ADD UM: MED Medical Drug gluconate complex in sucrose complex 05/01/2021 CLAFORAN cefotaxime sodium ADD UM: MED Medical Drug 05/01/2021 KEPIVANCE palifermin ADD UM: MED Medical Drug 05/01/2021 DYSPORT abobotulinumtoxina ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 545 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 PROVOCHOLIN methacholine chloride ADD UM: MED Medical Drug E 05/01/2021 amiodarone hcl amiodarone hcl ADD UM: MED Medical Drug 05/01/2021 a-methapred methylprednisolone sodium ADD UM: MED Medical Drug succinate 05/01/2021 VISUDYNE verteporfin ADD UM: MED Medical Drug 05/01/2021 IXEMPRA ixabepilone ADD UM: MED Medical Drug 05/01/2021 deferoxamine deferoxamine mesylate ADD UM: MED Medical Drug mesylate 05/01/2021 ZEMAIRA alpha-1-proteinase inhibitor ADD UM: MED Medical Drug 05/01/2021 MYOBLOC rimabotulinumtoxinb ADD UM: MED Medical Drug 05/01/2021 TIMENTIN ticarcillin ADD UM: MED Medical Drug disodium/potassium clavulanate 05/01/2021 allopurinol allopurinol sodium ADD UM: MED Medical Drug sodium 05/01/2021 ALIMTA pemetrexed disodium ADD UM: MED Medical Drug 05/01/2021 ZEMPLAR paricalcitol ADD UM: MED Medical Drug 05/01/2021 LUCENTIS ranibizumab ADD UM: MED Medical Drug 05/01/2021 VINCASAR PFS vincristine sulfate ADD UM: MED Medical Drug 05/01/2021 XOLAIR omalizumab ADD UM: MED Medical Drug 05/01/2021 BELEODAQ belinostat ADD UM: MED Medical Drug 05/01/2021 DOXIL doxorubicin hcl pegylated ADD UM: MED Medical Drug liposomal 05/01/2021 PITRESSIN vasopressin ADD UM: MED Medical Drug 05/01/2021 etoposide etoposide ADD UM: MED Medical Drug 05/01/2021 ASTHMANEFRIN racepinephrine hcl ADD UM: MED Medical Drug REFILL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 546 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 floxuridine floxuridine ADD UM: MED Medical Drug 05/01/2021 vasopressin vasopressin ADD UM: MED Medical Drug 05/01/2021 BICNU carmustine ADD UM: MED Medical Drug 05/01/2021 IFEX ifosfamide ADD UM: MED Medical Drug 05/01/2021 mitoxantrone hcl mitoxantrone hcl ADD UM: MED Medical Drug 05/01/2021 TOPOSAR etoposide ADD UM: MED Medical Drug 05/01/2021 antivenin antivenin,latrodectus ADD UM: MED Medical Drug latrodectus mactans mactans 05/01/2021 TREANDA bendamustine hcl ADD UM: MED Medical Drug 05/01/2021 carboplatin carboplatin ADD UM: MED Medical Drug 05/01/2021 VANTAS histrelin acetate ADD UM: MED Medical Drug 05/01/2021 GAMMAGARD S- immune ADD UM: MED Medical Drug D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml 05/01/2021 ADRIAMYCIN doxorubicin hcl ADD UM: MED Medical Drug 05/01/2021 ADRIAMYCIN doxorubicin hcl ADD UM: MED Medical Drug 05/01/2021 ADRIAMYCIN doxorubicin hcl ADD UM: MED Medical Drug 05/01/2021 POLOCAINE,PO mepivacaine hcl/pf ADD UM: MED Medical Drug LOCAINE-MPF 05/01/2021 dantrolene dantrolene sodium ADD UM: MED Medical Drug sodium 05/01/2021 BENLYSTA belimumab ADD UM: MED Medical Drug 05/01/2021 SIMULECT basiliximab ADD UM: MED Medical Drug 05/01/2021 MYOBLOC rimabotulinumtoxinb ADD UM: MED Medical Drug 05/01/2021 INTEGRILIN eptifibatide ADD UM: MED Medical Drug 05/01/2021 VENOFER iron sucrose complex ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 547 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 JETREA ocriplasmin/pf ADD UM: MED Medical Drug 05/01/2021 carboplatin carboplatin ADD UM: MED Medical Drug 05/01/2021 SYLVANT siltuximab ADD UM: MED Medical Drug 05/01/2021 SENSORCAINE bupivacaine hcl ADD UM: MED Medical Drug 05/01/2021 SYLVANT siltuximab ADD UM: MED Medical Drug 05/01/2021 SYNVISC hylan g-f 20 ADD UM: MED Medical Drug 05/01/2021 CYRAMZA ramucirumab ADD UM: MED Medical Drug 05/01/2021 XYLOCAINE- lidocaine hcl/pf ADD UM: MED Medical Drug MPF,XYLOCAIN E 05/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: MED Medical Drug 05/01/2021 ZINACEF cefuroxime sodium ADD UM: MED Medical Drug 05/01/2021 enalaprilat enalaprilat dihydrate ADD UM: MED Medical Drug 05/01/2021 LIORESAL baclofen ADD UM: MED Medical Drug INTRATHECAL 05/01/2021 COSMEGEN dactinomycin ADD UM: MED Medical Drug 05/01/2021 tetracaine hcl tetracaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 racepinephrine racepinephrine hcl ADD UM: MED Medical Drug 05/01/2021 BENDEKA bendamustine hcl ADD UM: MED Medical Drug 05/01/2021 ifosfamide ifosfamide ADD UM: MED Medical Drug 05/01/2021 fomepizole fomepizole ADD UM: MED Medical Drug 05/01/2021 GAMMAKED immune ADD UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 05/01/2021 GAMMAKED immune ADD UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 548 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 GAMMAKED immune ADD UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 05/01/2021 GAMUNEX-C immune ADD UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 05/01/2021 PORTRAZZA necitumumab ADD UM: MED Medical Drug 05/01/2021 NAROPIN ropivacaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 MIRENA levonorgestrel ADD UM: MED Medical Drug 05/01/2021 MARCAINE bupivacaine hcl ADD UM: MED Medical Drug 05/01/2021 GAMUNEX-C immune ADD UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 05/01/2021 GAMUNEX-C immune ADD UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 05/01/2021 SOLU-MEDROL methylprednisolone sodium ADD UM: MED Medical Drug succinate 05/01/2021 botulism antitoxin botulism antitoxin ADD UM: MED Medical Drug heptavalent heptavalent a,b,c,d,e,f,g(equine)/maltose 05/01/2021 CEREBYX fosphenytoin sodium ADD UM: MED Medical Drug 05/01/2021 ZOMETA zoledronic acid ADD UM: MED Medical Drug 05/01/2021 CEREBYX fosphenytoin sodium ADD UM: MED Medical Drug 05/01/2021 VYEPTI eptinezumab-jjmr ADD UM: MED Medical Drug 05/01/2021 GAMASTAN S-D immune ADD UM: MED Medical Drug globulin,gamma(igg)/glycine 05/01/2021 DURACLON clonidine hcl/pf ADD UM: MED Medical Drug 05/01/2021 VENTAVIS iloprost tromethamine ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 549 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 GAMMAKED immune ADD UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 05/01/2021 GAMMAKED immune ADD UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 05/01/2021 TEFLARO ceftaroline fosamil acetate ADD UM: MED Medical Drug 05/01/2021 TEFLARO ceftaroline fosamil acetate ADD UM: MED Medical Drug 05/01/2021 irinotecan hcl irinotecan hcl ADD UM: MED Medical Drug 05/01/2021 VENTAVIS iloprost ADD UM: MED Medical Drug tromethamine,iloprost 05/01/2021 irinotecan hcl irinotecan hcl ADD UM: MED Medical Drug 05/01/2021 HIZENTRA immune globulin,gamma ADD UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 05/01/2021 NESACAINE chloroprocaine hcl ADD UM: MED Medical Drug 05/01/2021 CUROSURF poractant alfa ADD UM: MED Medical Drug 05/01/2021 CUROSURF poractant alfa ADD UM: MED Medical Drug 05/01/2021 VENOFER iron sucrose complex ADD UM: MED Medical Drug 05/01/2021 TERRELL isoflurane ADD UM: MED Medical Drug 05/01/2021 physostigmine physostigmine salicylate ADD UM: MED Medical Drug salicylate 05/01/2021 ATGAM lymphocyte immune ADD UM: MED Medical Drug globulin,antithymocyte (equine) 05/01/2021 GAZYVA obinutuzumab ADD UM: MED Medical Drug 05/01/2021 COMPOUND 347 enflurane ADD UM: MED Medical Drug 05/01/2021 pralidoxime pralidoxime chloride ADD UM: MED Medical Drug chloride

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 550 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 DEXFERRUM iron dextran complex ADD UM: MED Medical Drug 05/01/2021 docetaxel docetaxel ADD UM: MED Medical Drug 05/01/2021 HYPERHEP B hepatitis b immune globulin ADD UM: MED Medical Drug 05/01/2021 methylprednisolo methylprednisolone sodium ADD UM: MED Medical Drug ne sod succinate succ,methylpredn isolone sodium succ 05/01/2021 DILAUDID-HP hydromorphone hcl/pf ADD UM: MED Medical Drug 05/01/2021 CAMPTOSAR irinotecan hcl ADD UM: MED Medical Drug 05/01/2021 daunorubicin hcl daunorubicin hcl ADD UM: MED Medical Drug 05/01/2021 RYANODEX dantrolene sodium ADD UM: MED Medical Drug 05/01/2021 protamine sulfate protamine sulfate ADD UM: MED Medical Drug 05/01/2021 fludarabine fludarabine phosphate ADD UM: MED Medical Drug phosphate 05/01/2021 amifostine amifostine crystalline ADD UM: MED Medical Drug 05/01/2021 IFEX ifosfamide ADD UM: MED Medical Drug 05/01/2021 GAMMAGARD S- immune ADD UM: MED Medical Drug D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml 05/01/2021 VECTIBIX panitumumab ADD UM: MED Medical Drug 05/01/2021 nalbuphine hcl nalbuphine hcl ADD UM: MED Medical Drug 05/01/2021 lidocaine hcl lidocaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 dobutamine hcl- dobutamine hcl in dextrose ADD UM: MED Medical Drug d5w,dobutamine 5 % in water,dobutamine hcl in dextrose hcl/dextrose 5 % in water 05/01/2021 lidocaine hcl lidocaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 doxorubicin hcl doxorubicin hcl ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 551 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 BREVIBLOC esmolol hcl in sodium ADD UM: MED Medical Drug chloride, iso-osmotic 05/01/2021 lidocaine hcl lidocaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 flumazenil flumazenil ADD UM: MED Medical Drug 05/01/2021 BENLYSTA belimumab ADD UM: MED Medical Drug 05/01/2021 lidocaine hcl lidocaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 lidocaine hcl lidocaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 ARZERRA ofatumumab ADD UM: MED Medical Drug 05/01/2021 EXPAREL bupivacaine liposome/pf ADD UM: MED Medical Drug 05/01/2021 gemcitabine hcl gemcitabine hcl ADD UM: MED Medical Drug 05/01/2021 ADENOCARD adenosine ADD UM: MED Medical Drug 05/01/2021 AMIDATE etomidate ADD UM: MED Medical Drug 05/01/2021 LUPRON leuprolide acetate ADD UM: MED Medical Drug DEPOT,LUPRON DEPOT (LUPANETA) 05/01/2021 GLASSIA alpha-1-proteinase inhibitor ADD UM: MED Medical Drug 05/01/2021 ZOLADEX goserelin acetate ADD UM: MED Medical Drug 05/01/2021 BENLYSTA belimumab ADD UM: MED Medical Drug 05/01/2021 doxorubicin hcl doxorubicin hcl ADD UM: MED Medical Drug 05/01/2021 doxorubicin hcl doxorubicin hcl ADD UM: MED Medical Drug 05/01/2021 doxorubicin hcl doxorubicin hcl ADD UM: MED Medical Drug 05/01/2021 NUCALA mepolizumab ADD UM: MED Medical Drug 05/01/2021 lidocaine hcl in lidocaine hcl in dextrose 5% ADD UM: MED Medical Drug 5% dextrose in water/pf,lidocaine hcl/dextrose 5%-water/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 552 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 lidocaine hcl in lidocaine hcl in dextrose 5% ADD UM: MED Medical Drug 5% dextrose in water/pf,lidocaine hcl/dextrose 5%-water/pf 05/01/2021 methylprednisolo methylprednisolone sodium ADD UM: MED Medical Drug ne sod succinate succ,methylpredn isolone sodium succ 05/01/2021 CROFAB antivenin,crotalidae ADD UM: MED Medical Drug fab(ovin) 05/01/2021 VECTIBIX panitumumab ADD UM: MED Medical Drug 05/01/2021 TOTECT dexrazoxane hcl ADD UM: MED Medical Drug 05/01/2021 KADCYLA ado-trastuzumab emtansine ADD UM: MED Medical Drug 05/01/2021 vincristine sulfate vincristine sulfate ADD UM: MED Medical Drug 05/01/2021 VENOFER iron sucrose complex ADD UM: MED Medical Drug 05/01/2021 rocuronium rocuronium bromide ADD UM: MED Medical Drug bromide 05/01/2021 DIPRIVAN propofol ADD UM: MED Medical Drug 05/01/2021 KADCYLA ado-trastuzumab emtansine ADD UM: MED Medical Drug 05/01/2021 HALAVEN eribulin mesylate ADD UM: MED Medical Drug 05/01/2021 HYPERHEP B hepatitis b immune globulin ADD UM: MED Medical Drug 05/01/2021 clonidine hcl clonidine hcl/pf ADD UM: MED Medical Drug 05/01/2021 MARCAINE bupivacaine hcl ADD UM: MED Medical Drug 05/01/2021 GEL-ONE hyaluronate sod, cross- ADD UM: MED Medical Drug linked 05/01/2021 dexrazoxane dexrazoxane hcl ADD UM: MED Medical Drug 05/01/2021 ZINACEF cefuroxime sodium ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 553 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 vinorelbine vinorelbine tartrate ADD UM: MED Medical Drug tartrate 05/01/2021 butorphanol butorphanol tartrate ADD UM: MED Medical Drug tartrate 05/01/2021 dactinomycin dactinomycin ADD UM: MED Medical Drug 05/01/2021 KEYTRUDA pembrolizumab ADD UM: MED Medical Drug 05/01/2021 XEOMIN incobotulinumtoxina ADD UM: MED Medical Drug 05/01/2021 vinorelbine vinorelbine tartrate ADD UM: MED Medical Drug tartrate 05/01/2021 FORANE isoflurane ADD UM: MED Medical Drug 05/01/2021 lidocaine hcl lidocaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 INFED iron dextran complex ADD UM: MED Medical Drug 05/01/2021 BOTOX onabotulinumtoxina ADD UM: MED Medical Drug 05/01/2021 NIPENT pentostatin ADD UM: MED Medical Drug 05/01/2021 EYLEA aflibercept ADD UM: MED Medical Drug 05/01/2021 BERINERT c1 esterase inhibitor ADD UM: MED Medical Drug 05/01/2021 ZINACEF cefuroxime sodium ADD UM: MED Medical Drug 05/01/2021 XEOMIN incobotulinumtoxina ADD UM: MED Medical Drug 05/01/2021 CLAFORAN cefotaxime sodium ADD UM: MED Medical Drug 05/01/2021 SURVANTA beractant ADD UM: MED Medical Drug 05/01/2021 ERWINAZE asparaginase (erwinia ADD UM: MED Medical Drug chrysanthemi) 05/01/2021 vinblastine vinblastine sulfate ADD UM: MED Medical Drug sulfate 05/01/2021 GAMUNEX-C immune ADD UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 554 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 GAMUNEX-C immune ADD UM: MED Medical Drug globulin,gamma(igg)/glycine/ iga average 46 mcg/ml 05/01/2021 MICRHOGAM rho(d) immune globulin ADD UM: MED Medical Drug ULTRA- FILTERED PLUS 05/01/2021 EUFLEXXA hyaluronate sodium ADD UM: MED Medical Drug 05/01/2021 ABRAXANE paclitaxel protein-bound ADD UM: MED Medical Drug 05/01/2021 pamidronate pamidronate disodium ADD UM: MED Medical Drug disodium 05/01/2021 pamidronate pamidronate disodium ADD UM: MED Medical Drug disodium 05/01/2021 BREVIBLOC esmolol hcl in sodium ADD UM: MED Medical Drug chloride, iso-osmotic 05/01/2021 milrinone lactate milrinone lactate ADD UM: MED Medical Drug 05/01/2021 DYSPORT abobotulinumtoxina ADD UM: MED Medical Drug 05/01/2021 GEMZAR gemcitabine hcl ADD UM: MED Medical Drug 05/01/2021 fentanyl citrate fentanyl citrate/pf ADD UM: MED Medical Drug 05/01/2021 MITOSOL mitomycin ADD UM: MED Medical Drug 05/01/2021 HYMOVIS hyaluronate sodium, ADD UM: MED Medical Drug modified, non-crosslinked 05/01/2021 ADRIAMYCIN doxorubicin hcl ADD UM: MED Medical Drug 05/01/2021 XYLOCAINE- lidocaine hcl/pf ADD UM: MED Medical Drug MPF,XYLOCAIN E 05/01/2021 ACTEMRA tocilizumab ADD UM: MED Medical Drug 05/01/2021 ACTEMRA tocilizumab ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 555 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 water,sterile water for injection,sterile ADD UM: MED Medical Drug water for prolastin-c,sterile water for activase,sterile water for gammagard,steril e water for berinert,sterile water for aralast np,sterile water for humate- p,sterile water for zemaira,sterile water (grifols factor),sterile water for tnkase,sterile water (shire) 05/01/2021 ACTEMRA tocilizumab ADD UM: MED Medical Drug 05/01/2021 HERCEPTIN trastuzumab ADD UM: MED Medical Drug 05/01/2021 FOLOTYN pralatrexate ADD UM: MED Medical Drug 05/01/2021 FOLOTYN pralatrexate ADD UM: MED Medical Drug 05/01/2021 NAVELBINE vinorelbine tartrate ADD UM: MED Medical Drug 05/01/2021 vincristine sulfate vincristine sulfate ADD UM: MED Medical Drug 05/01/2021 THYROSHIELD potassium iodide ADD UM: MED Medical Drug 05/01/2021 ETOPOPHOS etoposide phosphate ADD UM: MED Medical Drug 05/01/2021 ERYTHROCIN erythromycin lactobionate ADD UM: MED Medical Drug LACTOBIONATE 05/01/2021 HYCAMTIN topotecan hcl ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 556 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 VELETRI epoprostenol sodium ADD UM: MED Medical Drug (arginine),epoprostenol sodium 05/01/2021 IMOGAM rabies immune globulin/pf ADD UM: MED Medical Drug RABIES-HT 05/01/2021 argatroban-0.9% argatroban in 0.9 % sodium ADD UM: MED Medical Drug nacl chloride 05/01/2021 VAPRISOL-5% conivaptan hcl/dextrose 5 % ADD UM: MED Medical Drug DEXTROSE,VAP in water RISOL 05/01/2021 ELIGARD leuprolide acetate ADD UM: MED Medical Drug 05/01/2021 metoprolol metoprolol tartrate ADD UM: MED Medical Drug tartrate 05/01/2021 ADRUCIL fluorouracil ADD UM: MED Medical Drug 05/01/2021 ADRUCIL fluorouracil ADD UM: MED Medical Drug 05/01/2021 ZOMETA zoledronic acid in mannitol ADD UM: MED Medical Drug and water for injection 05/01/2021 ADRUCIL fluorouracil ADD UM: MED Medical Drug 05/01/2021 ketamine hcl ketamine hcl ADD UM: MED Medical Drug 05/01/2021 doxorubicin hcl doxorubicin hcl ADD UM: MED Medical Drug 05/01/2021 ACTIVASE alteplase ADD UM: MED Medical Drug 05/01/2021 LIPODOX 50 doxorubicin hcl pegylated ADD UM: MED Medical Drug liposomal 05/01/2021 CINQAIR reslizumab ADD UM: MED Medical Drug 05/01/2021 fluorouracil fluorouracil ADD UM: MED Medical Drug 05/01/2021 fluorouracil fluorouracil ADD UM: MED Medical Drug 05/01/2021 fluorouracil fluorouracil ADD UM: MED Medical Drug 05/01/2021 fluorouracil fluorouracil ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 557 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 antivenin antivenin,micrurus fulvius ADD UM: MED Medical Drug micrurus fulvius 05/01/2021 ketamine hcl ketamine hcl ADD UM: MED Medical Drug 05/01/2021 CERUBIDINE daunorubicin hcl ADD UM: MED Medical Drug 05/01/2021 ENTEREG alvimopan ADD UM: MED Medical Drug 05/01/2021 CLAFORAN cefotaxime sodium ADD UM: MED Medical Drug 05/01/2021 ONIVYDE irinotecan liposomal ADD UM: MED Medical Drug 05/01/2021 OSMITROL mannitol ADD UM: MED Medical Drug 05/01/2021 SURFAXIN lucinactant ADD UM: MED Medical Drug 05/01/2021 NITROPRESS nitroprusside sodium ADD UM: MED Medical Drug 05/01/2021 CORVERT ibutilide fumarate ADD UM: MED Medical Drug 05/01/2021 oxaliplatin oxaliplatin ADD UM: MED Medical Drug 05/01/2021 oxaliplatin oxaliplatin ADD UM: MED Medical Drug 05/01/2021 docetaxel docetaxel ADD UM: MED Medical Drug 05/01/2021 triamcinolone triamcinolone acetonide ADD UM: MED Medical Drug acetonide 05/01/2021 docetaxel docetaxel ADD UM: MED Medical Drug 05/01/2021 docetaxel docetaxel ADD UM: MED Medical Drug 05/01/2021 SOLU-MEDROL methylprednisolone sodium ADD UM: MED Medical Drug succinate 05/01/2021 VALSTAR valrubicin ADD UM: MED Medical Drug 05/01/2021 IXIARO japanese encephalitis ADD UM: MED Medical Drug vaccine/pf 05/01/2021 ACTHAR corticotropin ADD UM: MED Medical Drug 05/01/2021 epirubicin hcl epirubicin hcl ADD UM: MED Medical Drug 05/01/2021 PROLEUKIN aldesleukin ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 558 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ranitidine hcl ranitidine hcl ADD UM: MED Medical Drug 05/01/2021 HYQVIA HY hyaluronidase, human ADD UM: MED Medical Drug COMPONENT recomb. 05/01/2021 VELETRI epoprostenol sodium ADD UM: MED Medical Drug 05/01/2021 HYQVIA HY hyaluronidase, human ADD UM: MED Medical Drug COMPONENT recomb. 05/01/2021 CARBOCAINE mepivacaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 CARBOCAINE mepivacaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 HYQVIA IG immune ADD UM: MED Medical Drug COMPONENT globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml 05/01/2021 POLOCAINE,PO mepivacaine hcl/pf ADD UM: MED Medical Drug LOCAINE-MPF 05/01/2021 CARBOCAINE mepivacaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 POLOCAINE,PO mepivacaine hcl/pf ADD UM: MED Medical Drug LOCAINE-MPF 05/01/2021 GELSYN-3 hyaluronate sodium ADD UM: MED Medical Drug 05/01/2021 mitomycin mitomycin ADD UM: MED Medical Drug 05/01/2021 TYGACIL tigecycline ADD UM: MED Medical Drug 05/01/2021 GENVISC 850 hyaluronate sodium ADD UM: MED Medical Drug 05/01/2021 alfentanil hcl alfentanil hcl ADD UM: MED Medical Drug 05/01/2021 oxaliplatin oxaliplatin ADD UM: MED Medical Drug 05/01/2021 HYQVIA HY hyaluronidase, human ADD UM: MED Medical Drug COMPONENT recomb. 05/01/2021 HYQVIA IG immune ADD UM: MED Medical Drug COMPONENT globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 559 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 SOLU-MEDROL methylprednisolone sodium ADD UM: MED Medical Drug succinate/pf 05/01/2021 MACUGEN pegaptanib sodium ADD UM: MED Medical Drug 05/01/2021 TORISEL temsirolimus ADD UM: MED Medical Drug 05/01/2021 dacarbazine dacarbazine ADD UM: MED Medical Drug 05/01/2021 HYQVIA HY hyaluronidase, human ADD UM: MED Medical Drug COMPONENT recomb. 05/01/2021 HYQVIA IG immune ADD UM: MED Medical Drug COMPONENT globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml 05/01/2021 VIDAZA azacitidine ADD UM: MED Medical Drug 05/01/2021 SOLU-MEDROL methylprednisolone sodium ADD UM: MED Medical Drug succinate/pf 05/01/2021 HYQVIA IG immune ADD UM: MED Medical Drug COMPONENT globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml 05/01/2021 ALOPRIM allopurinol sodium ADD UM: MED Medical Drug 05/01/2021 HYQVIA HY hyaluronidase, human ADD UM: MED Medical Drug COMPONENT recomb. 05/01/2021 oxaliplatin oxaliplatin ADD UM: MED Medical Drug 05/01/2021 ELITEK rasburicase ADD UM: MED Medical Drug 05/01/2021 methylprednisolo methylprednisolone acetate ADD UM: MED Medical Drug ne acetate 05/01/2021 NAROPIN ropivacaine hcl/pf ADD UM: MED Medical Drug 05/01/2021 epirubicin hcl epirubicin hcl ADD UM: MED Medical Drug 05/01/2021 cosyntropin cosyntropin ADD UM: MED Medical Drug 05/01/2021 CERVIDIL dinoprostone ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 560 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 EUFLEXXA hyaluronate sodium ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ABRAXANE paclitaxel protein-bound ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 BLINCYTO blinatumomab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 JEVTANA cabazitaxel ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 LEMTRADA alemtuzumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 GAMMAPLEX immune ADD UM: CUSTOM Medical globulin,gamm(igg)/sorbitol/ Pharmacy Drug glycin/iga 0 to 50 mcg/ml 05/01/2021 BENLYSTA belimumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 REMICADE infliximab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 LUPRON leuprolide acetate ADD UM: CUSTOM Medical DEPOT-PED Pharmacy Drug 05/01/2021 BENDEKA bendamustine hcl ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 LUPRON leuprolide acetate ADD UM: CUSTOM Medical DEPOT-PED Pharmacy Drug 05/01/2021 DYSPORT abobotulinumtoxina ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 GAMMAKED immune ADD UM: CUSTOM Medical globulin,gamma(igg)/glycine/ Pharmacy Drug iga average 46 mcg/ml 05/01/2021 GAMMAKED immune ADD UM: CUSTOM Medical globulin,gamma(igg)/glycine/ Pharmacy Drug iga average 46 mcg/ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 561 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 GAMMAKED immune ADD UM: CUSTOM Medical globulin,gamma(igg)/glycine/ Pharmacy Drug iga average 46 mcg/ml 05/01/2021 HYMOVIS hyaluronate sodium, ADD UM: CUSTOM Medical modified, non-crosslinked Pharmacy Drug 05/01/2021 GAMUNEX-C immune ADD UM: CUSTOM Medical globulin,gamma(igg)/glycine/ Pharmacy Drug iga average 46 mcg/ml 05/01/2021 PORTRAZZA necitumumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 BOTOX onabotulinumtoxina ADD UM: CUSTOM Medical COSMETIC Pharmacy Drug 05/01/2021 PROVENGE sipuleucel-t/lactated ringers ADD UM: CUSTOM Medical solution Pharmacy Drug 05/01/2021 GAMUNEX-C immune ADD UM: CUSTOM Medical globulin,gamma(igg)/glycine/ Pharmacy Drug iga average 46 mcg/ml 05/01/2021 GAMUNEX-C immune ADD UM: CUSTOM Medical globulin,gamma(igg)/glycine/ Pharmacy Drug iga average 46 mcg/ml 05/01/2021 ACTEMRA tocilizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ACTEMRA tocilizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ACTEMRA tocilizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HERCEPTIN trastuzumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 LUPRON leuprolide acetate ADD UM: CUSTOM Medical DEPOT-PED Pharmacy Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 562 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 OPDIVO nivolumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 KRYSTEXXA pegloticase ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HYALGAN hyaluronate sodium ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 VYEPTI eptinezumab-jjmr ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 GAMMAKED immune ADD UM: CUSTOM Medical globulin,gamma(igg)/glycine/ Pharmacy Drug iga average 46 mcg/ml 05/01/2021 GAMMAKED immune ADD UM: CUSTOM Medical globulin,gamma(igg)/glycine/ Pharmacy Drug iga average 46 mcg/ml 05/01/2021 LUPRON DEPOT leuprolide acetate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HIZENTRA immune globulin,gamma ADD UM: CUSTOM Medical (igg)/proline/iga 0 to 50 Pharmacy Drug mcg/ml 05/01/2021 SUPARTZ FX hyaluronate sodium ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 MONOVISC hyaluronate sodium, ADD UM: CUSTOM Medical stabilized Pharmacy Drug 05/01/2021 ALOXI palonosetron hcl ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ELIGARD leuprolide acetate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 RITUXAN rituximab/hyaluronidase, ADD UM: CUSTOM Medical HYCELA human recombinant Pharmacy Drug 05/01/2021 LUPRON DEPOT leuprolide acetate ADD UM: CUSTOM Medical Pharmacy Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 563 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 DYSPORT abobotulinumtoxina ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 FLEBOGAMMA immune globulin,gamma ADD UM: CUSTOM Medical DIF (igg)/sorbitol/iga 0 to 50 Pharmacy Drug mcg/ml 05/01/2021 RITUXAN rituximab/hyaluronidase, ADD UM: CUSTOM Medical HYCELA human recombinant Pharmacy Drug 05/01/2021 ZALTRAP ziv-aflibercept ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 TECENTRIQ atezolizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 SYNVISC-ONE hylan g-f 20 ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ZALTRAP ziv-aflibercept ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 GAZYVA obinutuzumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 GAMMAGARD S- immune ADD UM: CUSTOM Medical D globulin,gamm(igg)/glycine/g Pharmacy Drug lucose/iga 0 to 50 mcg/ml 05/01/2021 GAMMAGARD S- immune ADD UM: CUSTOM Medical D globulin,gamm(igg)/glycine/g Pharmacy Drug lucose/iga 0 to 50 mcg/ml 05/01/2021 DARZALEX daratumumab- ADD UM: CUSTOM Medical FASPRO hyaluronidase-fihj Pharmacy Drug 05/01/2021 TECENTRIQ atezolizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 MYOBLOC rimabotulinumtoxinb ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 CINQAIR reslizumab ADD UM: CUSTOM Medical Pharmacy Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 564 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 OCREVUS ocrelizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 FLEBOGAMMA immune globulin,gamma ADD UM: CUSTOM Medical DIF (igg)/sorbitol/iga 0 to 50 Pharmacy Drug mcg/ml 05/01/2021 IMFINZI durvalumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 INFLECTRA infliximab-dyyb ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ALIMTA pemetrexed disodium ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HIZENTRA immune globulin,gamma ADD UM: CUSTOM Medical (igg)/proline/iga 0 to 50 Pharmacy Drug mcg/ml 05/01/2021 DARZALEX daratumumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 BOTOX onabotulinumtoxina ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HERCEPTIN trastuzumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 PROLIA denosumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 YERVOY ipilimumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 YERVOY ipilimumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 PRIVIGEN immune globulin,gamma ADD UM: CUSTOM Medical (igg)/proline/iga 0 to 50 Pharmacy Drug mcg/ml 05/01/2021 RENFLEXIS infliximab-abda ADD UM: CUSTOM Medical Pharmacy Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 565 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 XOLAIR omalizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ONIVYDE irinotecan liposomal ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 BELEODAQ belinostat ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ORTHOVISC hyaluronate sodium ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 LUPRON leuprolide acetate ADD UM: CUSTOM Medical DEPOT-PED Pharmacy Drug 05/01/2021 HYQVIA immune ADD UM: CUSTOM Medical globulin,gamma(igg) Pharmacy Drug human/hyaluronidase, human recomb 05/01/2021 HYQVIA immune ADD UM: CUSTOM Medical globulin,gamma(igg) Pharmacy Drug human/hyaluronidase, human recomb 05/01/2021 HYQVIA immune ADD UM: CUSTOM Medical globulin,gamma(igg) Pharmacy Drug human/hyaluronidase, human recomb 05/01/2021 HYQVIA immune ADD UM: CUSTOM Medical globulin,gamma(igg) Pharmacy Drug human/hyaluronidase, human recomb 05/01/2021 VECTIBIX panitumumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HYQVIA immune ADD UM: CUSTOM Medical globulin,gamma(igg) Pharmacy Drug human/hyaluronidase, human recomb

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 566 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 SYNRIBO omacetaxine mepesuccinate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 FUSILEV levoleucovorin calcium ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HIZENTRA immune globulin,gamma ADD UM: CUSTOM Medical (igg)/proline/iga 0 to 50 Pharmacy Drug mcg/ml 05/01/2021 BIVIGAM immune ADD UM: CUSTOM Medical globulin,gamm(igg)/glycine/i Pharmacy Drug ga greater than 50 mcg/ml 05/01/2021 HIZENTRA immune globulin,gamma ADD UM: CUSTOM Medical (igg)/proline/iga 0 to 50 Pharmacy Drug mcg/ml 05/01/2021 HIZENTRA immune globulin,gamma ADD UM: CUSTOM Medical (igg)/proline/iga 0 to 50 Pharmacy Drug mcg/ml 05/01/2021 BENLYSTA belimumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ARZERRA ofatumumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 LUPRON leuprolide acetate ADD UM: CUSTOM Medical DEPOT,LUPRON Pharmacy Drug DEPOT (LUPANETA) 05/01/2021 ZOLADEX goserelin acetate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HYALGAN hyaluronate sodium ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 GAMUNEX-C immune ADD UM: CUSTOM Medical globulin,gamma(igg)/glycine/ Pharmacy Drug iga average 46 mcg/ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 567 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 BENLYSTA belimumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 MYOBLOC rimabotulinumtoxinb ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 TREANDA bendamustine hcl ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 BLINCYTO blinatumomab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 NUCALA mepolizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 NUCALA mepolizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 OCTAGAM immune ADD UM: CUSTOM Medical globulin,gamm(igg)/maltose/ Pharmacy Drug iga greater than 50 mcg/ml 05/01/2021 GAMMAPLEX immune globulin,gamma ADD UM: CUSTOM Medical (igg)/glycine/iga 0 to 50 Pharmacy Drug mcg/ml 05/01/2021 NUCALA mepolizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ZOLADEX goserelin acetate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 VANTAS histrelin acetate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 XOLAIR omalizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 TRELSTAR triptorelin pamoate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HIZENTRA immune globulin,gamma ADD UM: CUSTOM Medical (igg)/proline/iga 0 to 50 Pharmacy Drug mcg/ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 568 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 TRELSTAR triptorelin pamoate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 LUPRON DEPOT leuprolide acetate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 LUPRON leuprolide acetate ADD UM: CUSTOM Medical DEPOT,LUPRON Pharmacy Drug DEPOT (LUPANETA) 05/01/2021 TYSABRI natalizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 VECTIBIX panitumumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 KADCYLA ado-trastuzumab emtansine ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HIZENTRA immune globulin,gamma ADD UM: CUSTOM Medical (igg)/proline/iga 0 to 50 Pharmacy Drug mcg/ml 05/01/2021 HALAVEN eribulin mesylate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 KADCYLA ado-trastuzumab emtansine ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 BENLYSTA belimumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 MYOBLOC rimabotulinumtoxinb ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 XEOMIN incobotulinumtoxina ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HYQVIA HY hyaluronidase, human ADD UM: CUSTOM Medical COMPONENT recomb. Pharmacy Drug 05/01/2021 HERCEPTIN trastuzumab-hyaluronidase- ADD UM: CUSTOM Medical HYLECTA oysk Pharmacy Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 569 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 MARQIBO vincristine sulfate liposomal ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 BOTOX onabotulinumtoxina ADD UM: CUSTOM Medical COSMETIC Pharmacy Drug 05/01/2021 HYQVIA HY hyaluronidase, human ADD UM: CUSTOM Medical COMPONENT recomb. Pharmacy Drug 05/01/2021 OPDIVO nivolumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ERBITUX cetuximab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ERBITUX cetuximab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HYQVIA IG immune ADD UM: CUSTOM Medical COMPONENT globulin,gamm(igg)/glycine/i Pharmacy Drug ga greater than 50 mcg/ml 05/01/2021 ARZERRA ofatumumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 GEL-ONE hyaluronate sod, cross- ADD UM: CUSTOM Medical linked Pharmacy Drug 05/01/2021 SYLVANT siltuximab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 SYLVANT siltuximab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 SYNVISC hylan g-f 20 ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 CYRAMZA ramucirumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ALIMTA pemetrexed disodium ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 OPDIVO nivolumab ADD UM: CUSTOM Medical Pharmacy Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 570 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 YONDELIS trabectedin ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ADCETRIS brentuximab vedotin ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 GELSYN-3 hyaluronate sodium ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 TRELSTAR triptorelin pamoate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 FASLODEX fulvestrant ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 XEOMIN incobotulinumtoxina ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 XGEVA denosumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 PERJETA pertuzumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 KEYTRUDA pembrolizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 GENVISC 850 hyaluronate sodium ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 RITUXAN rituximab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HYQVIA IG immune ADD UM: CUSTOM Medical COMPONENT globulin,gamm(igg)/glycine/i Pharmacy Drug ga greater than 50 mcg/ml 05/01/2021 AVASTIN bevacizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HYQVIA HY hyaluronidase, human ADD UM: CUSTOM Medical COMPONENT recomb. Pharmacy Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 571 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 HYQVIA IG immune ADD UM: CUSTOM Medical COMPONENT globulin,gamm(igg)/glycine/i Pharmacy Drug ga greater than 50 mcg/ml 05/01/2021 EMPLICITI elotuzumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 BOTOX onabotulinumtoxina ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 OCTAGAM immune ADD UM: CUSTOM Medical globulin,gamm(igg)/maltose/ Pharmacy Drug iga greater than 50 mcg/ml 05/01/2021 EMPLICITI elotuzumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ELIGARD leuprolide acetate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HYQVIA HY hyaluronidase, human ADD UM: CUSTOM Medical COMPONENT recomb. Pharmacy Drug 05/01/2021 GAMMAGARD immune ADD UM: CUSTOM Medical LIQUID globulin,gamm(igg)/glycine/i Pharmacy Drug ga greater than 50 mcg/ml 05/01/2021 HYQVIA IG immune ADD UM: CUSTOM Medical COMPONENT globulin,gamm(igg)/glycine/i Pharmacy Drug ga greater than 50 mcg/ml 05/01/2021 TREANDA bendamustine hcl ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 HYQVIA IG immune ADD UM: CUSTOM Medical COMPONENT globulin,gamm(igg)/glycine/i Pharmacy Drug ga greater than 50 mcg/ml 05/01/2021 HYQVIA HY hyaluronidase, human ADD UM: CUSTOM Medical COMPONENT recomb. Pharmacy Drug 05/01/2021 XEOMIN incobotulinumtoxina ADD UM: CUSTOM Medical Pharmacy Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 572 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 GAMUNEX-C immune ADD UM: CUSTOM Medical globulin,gamma(igg)/glycine/ Pharmacy Drug iga average 46 mcg/ml 05/01/2021 LUPRON DEPOT leuprolide acetate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 GAMUNEX-C immune ADD UM: CUSTOM Medical globulin,gamma(igg)/glycine/ Pharmacy Drug iga average 46 mcg/ml 05/01/2021 ELIGARD leuprolide acetate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 ELIGARD leuprolide acetate ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 XOLAIR omalizumab ADD UM: CUSTOM Medical Pharmacy Drug 05/01/2021 REFRESH carboxymethylcellulose REMOVE FROM Non PDL Non-Formulary TEARS sodium FORMULARY 05/01/2021 EUCRISA crisaborole ADD UM: AGE At least 0.25 yrs old 05/01/2021 BAFIERTAM monomethyl fumarate ADD TO FORMULARY Non-Preferred 05/01/2021 BAFIERTAM monomethyl fumarate ADD UM: QUANTITY 120 / 30 days 05/01/2021 BAFIERTAM monomethyl fumarate ADD UM: PANAME Non Preferred PA 05/01/2021 BREZTRI budesonide/glycopyrrolate/f ADD TO FORMULARY Non-Preferred AEROSPHERE ormoterol fumarate 05/01/2021 BREZTRI budesonide/glycopyrrolate/f ADD UM: PANAME Non Preferred PA AEROSPHERE ormoterol fumarate 05/01/2021 KESIMPTA PEN ofatumumab ADD TO FORMULARY Non-Preferred 05/01/2021 KESIMPTA PEN ofatumumab ADD UM: PANAME Non Preferred PA 05/01/2021 FOLTANX mecobalamin/levomefolate REMOVE FROM Non PDL Non-Formulary calcium/pyridoxal phosphate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 573 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 METAFOLBIC cyanocobalamin/levomefolat REMOVE FROM Non PDL Non-Formulary e FORMULARY calcium/pyridoxine/riboflavin 05/01/2021 FOLBIC RF cyanocobalamin/levomefolat REMOVE FROM Non PDL Non-Formulary e calcium/pyridoxine hcl (b6) FORMULARY 05/01/2021 SEMGLEE PEN insulin glargine,human ADD TO FORMULARY Non-Preferred recombinant analog 05/01/2021 SEMGLEE PEN insulin glargine,human ADD UM: QUANTITY 90 / claim recombinant analog 05/01/2021 SEMGLEE PEN insulin glargine,human ADD UM: PANAME Non Preferred PA recombinant analog 05/01/2021 SEMGLEE insulin glargine,human ADD TO FORMULARY Non-Preferred recombinant analog 05/01/2021 SEMGLEE insulin glargine,human ADD UM: QUANTITY 90 / claim recombinant analog 05/01/2021 SEMGLEE insulin glargine,human ADD UM: PANAME Non Preferred PA recombinant analog 05/01/2021 ONGENTYS opicapone ADD TO FORMULARY Non-Preferred 05/01/2021 ONGENTYS opicapone ADD UM: PANAME Non Preferred PA 05/01/2021 ONGENTYS opicapone ADD TO FORMULARY Non-Preferred 05/01/2021 ONGENTYS opicapone ADD UM: PANAME Non Preferred PA 05/01/2021 fenofibrate fenofibrate,micronized CHANGE TIER Non-Preferred Preferred 05/01/2021 fenofibrate fenofibrate,micronized REMOVE UM: PANAME Non Preferred PA 05/01/2021 fenofibrate fenofibrate,micronized CHANGE TIER Non-Preferred Preferred 05/01/2021 fenofibrate fenofibrate,micronized REMOVE UM: PANAME Non Preferred PA 05/01/2021 fenofibrate fenofibrate,micronized CHANGE TIER Non-Preferred Preferred 05/01/2021 fenofibrate fenofibrate,micronized REMOVE UM: PANAME Non Preferred PA 05/01/2021 azelastine hcl azelastine hcl CHANGE TIER Non-Preferred Preferred

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 574 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 azelastine hcl azelastine hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 enalapril- enalapril CHANGE TIER Non-Preferred Preferred hydrochlorothiazi maleate/hydrochlorothiazide de,enalapril maleate-hctz 05/01/2021 enalapril- enalapril REMOVE UM: PANAME Non Preferred PA hydrochlorothiazi maleate/hydrochlorothiazide de,enalapril maleate-hctz 05/01/2021 enalapril- enalapril CHANGE TIER Non-Preferred Preferred hydrochlorothiazi maleate/hydrochlorothiazide de 05/01/2021 enalapril- enalapril REMOVE UM: PANAME Non Preferred PA hydrochlorothiazi maleate/hydrochlorothiazide de 05/01/2021 LETAIRIS ambrisentan CHANGE TIER Preferred Non-Preferred 05/01/2021 LETAIRIS ambrisentan REMOVE UM: B4G BRAND FOR GENERIC 05/01/2021 LETAIRIS ambrisentan CHANGE TIER Preferred Non-Preferred 05/01/2021 LETAIRIS ambrisentan REMOVE UM: B4G BRAND FOR GENERIC 05/01/2021 ketorolac ketorolac tromethamine CHANGE TIER Preferred Non-Preferred tromethamine 05/01/2021 ketorolac ketorolac tromethamine ADD UM: PANAME Non Preferred PA tromethamine 05/01/2021 acular ketorolac tromethamine CHANGE TIER Preferred Non-Preferred 05/01/2021 acular ketorolac tromethamine ADD UM: PANAME Non Preferred PA 05/01/2021 TRAVATAN Z travoprost CHANGE TIER Preferred Non-Preferred 05/01/2021 TRAVATAN Z travoprost ADD UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 575 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 TRAVATAN Z travoprost REMOVE UM: B4G BRAND FOR GENERIC 05/01/2021 travoprost travoprost REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 travoprost travoprost REMOVE UM: COV Use brand over generic 05/01/2021 travoprost travoprost REMOVE UM: PANAME Non Preferred PA 05/01/2021 ambrisentan ambrisentan CHANGE UM: PANAME Non Preferred PA Clinical PA 05/01/2021 ambrisentan ambrisentan REMOVE UM: COV Use brand over generic 05/01/2021 ambrisentan ambrisentan CHANGE UM: PANAME Non Preferred PA Clinical PA 05/01/2021 ambrisentan ambrisentan REMOVE UM: COV Use brand over generic 05/01/2021 amlodipine- amlodipine CHANGE TIER Non-Preferred Preferred olmesartan besylate/olmesartan medoxomil 05/01/2021 amlodipine- amlodipine REMOVE UM: PANAME Non Preferred PA olmesartan besylate/olmesartan medoxomil 05/01/2021 amlodipine- amlodipine CHANGE TIER Non-Preferred Preferred olmesartan besylate/olmesartan medoxomil 05/01/2021 amlodipine- amlodipine REMOVE UM: PANAME Non Preferred PA olmesartan besylate/olmesartan medoxomil 05/01/2021 amlodipine- amlodipine CHANGE TIER Non-Preferred Preferred olmesartan besylate/olmesartan medoxomil 05/01/2021 amlodipine- amlodipine REMOVE UM: PANAME Non Preferred PA olmesartan besylate/olmesartan medoxomil

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 576 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 olmesartan olmesartan medoxomil CHANGE TIER Non-Preferred Preferred medoxomil 05/01/2021 olmesartan olmesartan medoxomil REMOVE UM: PANAME Non Preferred PA medoxomil 05/01/2021 olmesartan- olmesartan CHANGE TIER Non-Preferred Preferred hydrochlorothiazi medoxomil/hydrochlorothiazi de de 05/01/2021 olmesartan- olmesartan REMOVE UM: PANAME Non Preferred PA hydrochlorothiazi medoxomil/hydrochlorothiazi de de 05/01/2021 olmesartan- olmesartan CHANGE TIER Non-Preferred Preferred hydrochlorothiazi medoxomil/hydrochlorothiazi de de 05/01/2021 olmesartan- olmesartan REMOVE UM: PANAME Non Preferred PA hydrochlorothiazi medoxomil/hydrochlorothiazi de de 05/01/2021 amlodipine- amlodipine CHANGE TIER Non-Preferred Preferred olmesartan besylate/olmesartan medoxomil 05/01/2021 amlodipine- amlodipine REMOVE UM: PANAME Non Preferred PA olmesartan besylate/olmesartan medoxomil 05/01/2021 olmesartan olmesartan medoxomil CHANGE TIER Non-Preferred Preferred medoxomil 05/01/2021 olmesartan olmesartan medoxomil REMOVE UM: PANAME Non Preferred PA medoxomil 05/01/2021 olmesartan olmesartan medoxomil CHANGE TIER Non-Preferred Preferred medoxomil 05/01/2021 olmesartan olmesartan medoxomil REMOVE UM: PANAME Non Preferred PA medoxomil

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 577 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 olmesartan- olmesartan CHANGE TIER Non-Preferred Preferred hydrochlorothiazi medoxomil/hydrochlorothiazi de de 05/01/2021 olmesartan- olmesartan REMOVE UM: PANAME Non Preferred PA hydrochlorothiazi medoxomil/hydrochlorothiazi de de 05/01/2021 dorzolamide- dorzolamide hcl/timolol CHANGE TIER Preferred Non-Preferred timolol maleate/pf 05/01/2021 dorzolamide- dorzolamide hcl/timolol ADD UM: PANAME Non Preferred PA timolol maleate/pf 05/01/2021 ambrisentan ambrisentan CHANGE TIER Non-Preferred Preferred 05/01/2021 ambrisentan ambrisentan CHANGE TIER Non-Preferred Preferred 05/01/2021 timolol maleate timolol maleate/pf ADD TO FORMULARY Non-Preferred 05/01/2021 timolol maleate timolol maleate/pf ADD UM: PANAME Non Preferred PA 05/01/2021 timolol maleate timolol maleate/pf ADD UM: DRUGCLASS GLAUCOMA – BETA BLOCKERS 05/01/2021 IMITREX sumatriptan ADD UM: B4G BRAND FOR GENERIC 05/01/2021 IMITREX sumatriptan ADD UM: B4G BRAND FOR GENERIC 05/01/2021 EMEND aprepitant ADD UM: PANAME Non Preferred PA 05/01/2021 moxifloxacin moxifloxacin hcl CHANGE UM: COV Use brand over generic 05/01/2021 esomeprazole esomeprazole magnesium ADD UM: COV Use brand over magnesium generic 05/01/2021 esomeprazole esomeprazole magnesium ADD UM: COV Use brand over magnesium generic 05/01/2021 esomeprazole esomeprazole magnesium ADD UM: COV Use brand over magnesium generic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 578 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 dimethyl dimethyl fumarate ADD UM: COV Use brand over fumarate generic 05/01/2021 dimethyl dimethyl fumarate ADD UM: COV Use brand over fumarate generic 05/01/2021 testosterone testosterone REMOVE UM: COV Use brand over generic 05/01/2021 testosterone testosterone REMOVE UM: COV Use brand over generic 05/01/2021 testosterone testosterone REMOVE UM: COV Use brand over generic 05/01/2021 aprepitant aprepitant REMOVE UM: COV Use brand over generic 05/01/2021 hydroxyzine hcl hydroxyzine hcl ADD TO FORMULARY Non-Formulary Preferred 05/01/2021 hydroxyzine hcl hydroxyzine hcl REMOVE FROM Preferred Non-Formulary FORMULARY 05/01/2021 moxifloxacin moxifloxacin hcl REMOVE UM: COV Use brand over generic 05/01/2021 nadolol nadolol ADD TO FORMULARY Non-Preferred 05/01/2021 apraclonidine hcl apraclonidine hcl CHANGE TIER Preferred Non-Preferred 05/01/2021 apraclonidine hcl apraclonidine hcl ADD UM: PANAME Non Preferred PA 05/01/2021 travoprost travoprost ADD TO FORMULARY Non-Formulary Non-Preferred 05/01/2021 travoprost travoprost ADD UM: PANAME Non Preferred PA 05/01/2021 OSCIMIN SR hyoscyamine sulfate ADD TO FORMULARY Non PDL 05/01/2021 levorphanol levorphanol tartrate ADD TO FORMULARY Non-Preferred tartrate 05/01/2021 levalbuterol hcl levalbuterol hcl ADD TO FORMULARY Non-Preferred 05/01/2021 docusate sodium docusate sodium ADD TO FORMULARY Non-Formulary Non PDL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 579 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 dimethyl dimethyl fumarate ADD TO FORMULARY Non-Preferred fumarate 05/01/2021 dimethyl dimethyl fumarate ADD UM: PANAME Non Preferred PA fumarate 05/01/2021 VIRT-GARD cyanocobalamin/folic ADD TO FORMULARY Non-Formulary Non PDL acid/pyridoxine 05/01/2021 VP-VITE RX vitamin b complex no.3/folic ADD TO FORMULARY Non-Formulary Non PDL acid/ascorbic acid(vitc)/biotin 05/01/2021 NU-MAG magnesium chloride ADD TO FORMULARY Non-Formulary Non PDL 05/01/2021 WESTAB MAX cyanocobalamin/folic ADD TO FORMULARY Non-Formulary Non PDL acid/pyridoxine 05/01/2021 iron ferrous sulfate ADD TO FORMULARY Non-Formulary Non PDL supplement,iron 05/01/2021 dayhist allergy clemastine fumarate ADD TO FORMULARY Non PDL 05/01/2021 theophylline theophylline anhydrous ADD TO FORMULARY Non PDL 05/01/2021 iron ferrous sulfate ADD TO FORMULARY Non-Formulary Non PDL 05/01/2021 senna sennosides ADD TO FORMULARY Non PDL 05/01/2021 ALLERGY clemastine fumarate ADD TO FORMULARY Non PDL RELIEF 05/01/2021 SENOKOT sennosides ADD TO FORMULARY Non PDL 05/01/2021 CENTRUM multivitamin/ferrous ADD TO FORMULARY Non PDL ADULTS fumarate/folic acid 05/01/2021 DUPIXENT PEN dupilumab ADD TO FORMULARY Non-Preferred 05/01/2021 DUPIXENT PEN dupilumab ADD UM: DRUGCLASS IMMUNOMODUL ATORS: ATOPIC DERMATITIS 05/01/2021 DUPIXENT PEN dupilumab ADD UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 580 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 lactulose lactulose CHANGE UM: CUSTOM CARVE OUT- BILL MDCH FFS 05/01/2021 lactulose lactulose REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 bupropion hcl bupropion hcl REMOVE FROM Non-Formulary sr,bupropion hcl FORMULARY er 05/01/2021 bupropion hcl sr bupropion hcl ADD TO FORMULARY Non PDL 05/01/2021 bupropion hcl sr bupropion hcl ADD UM: QUANTITY 2 / day 05/01/2021 ZENPEP lipase/protease/amylase REMOVE FROM Non-Formulary FORMULARY 05/01/2021 ZENPEP lipase/protease/amylase REMOVE FROM Non-Formulary FORMULARY 05/01/2021 MAXALT MLT rizatriptan benzoate REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 MAXALT MLT rizatriptan benzoate REMOVE UM: PANAME Clinical PA 05/01/2021 MAXALT MLT rizatriptan benzoate REMOVE UM: ANTIMIGRAINE DRUGCLASS AGENTS, TRIPTANS 05/01/2021 MAXALT MLT rizatriptan benzoate REMOVE UM: QUANTITY 18 / claim 05/01/2021 ondansetron hcl ondansetron hcl REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 ondansetron hcl ondansetron hcl REMOVE UM: QUANTITY 1 / day 05/01/2021 ZYPITAMAG pitavastatin magnesium REMOVE UM: PANAME Non Preferred PA 05/01/2021 ZYPITAMAG pitavastatin magnesium REMOVE UM: LIPOTROPICS: DRUGCLASS STATINS 05/01/2021 ZONTIVITY vorapaxar sulfate REMOVE UM: PANAME Non Preferred PA 05/01/2021 MAVENCLAD cladribine REMOVE UM: PANAME Non Preferred PA 05/01/2021 BROVANA arformoterol tartrate REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 581 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 DUEXIS ibuprofen/famotidine REMOVE UM: PANAME Non Preferred PA 05/01/2021 MAVENCLAD cladribine REMOVE UM: PANAME Non Preferred PA 05/01/2021 MAVENCLAD cladribine REMOVE UM: PANAME Non Preferred PA 05/01/2021 MAVENCLAD cladribine REMOVE UM: PANAME Non Preferred PA 05/01/2021 EMBEDA morphine sulfate/naltrexone REMOVE UM: PANAME Non Preferred PA hcl 05/01/2021 neomycin sulfate neomycin sulfate REMOVE UM: PANAME Non Preferred PA 05/01/2021 EMBEDA morphine sulfate/naltrexone REMOVE UM: PANAME Non Preferred PA hcl 05/01/2021 EMBEDA morphine sulfate/naltrexone REMOVE UM: PANAME Non Preferred PA hcl 05/01/2021 testosterone testosterone REMOVE UM: PANAME Non Preferred PA 05/01/2021 ACTIQ fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 ARNUITY fluticasone furoate REMOVE UM: PANAME Non Preferred PA ELLIPTA 05/01/2021 CIMZIA certolizumab pegol REMOVE UM: PANAME Non Preferred PA 05/01/2021 testosterone testosterone REMOVE UM: PANAME Non Preferred PA 05/01/2021 FOSRENOL lanthanum carbonate REMOVE UM: PANAME Non Preferred PA 05/01/2021 AKYNZEO netupitant/palonosetron hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 REVATIO sildenafil citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 HUMATROPE somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 MAVENCLAD cladribine REMOVE UM: PANAME Non Preferred PA 05/01/2021 MAVENCLAD cladribine REMOVE UM: PANAME Non Preferred PA 05/01/2021 MAVENCLAD cladribine REMOVE UM: PANAME Non Preferred PA 05/01/2021 VIOKACE lipase/protease/amylase REMOVE UM: PANAME Non Preferred PA 05/01/2021 fentanyl citrate fentanyl citrate REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 582 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 OZEMPIC semaglutide REMOVE UM: PANAME Non Preferred PA 05/01/2021 OZEMPIC semaglutide REMOVE UM: PANAME Non Preferred PA 05/01/2021 TOUJEO insulin glargine,human REMOVE UM: PANAME Non Preferred PA SOLOSTAR recombinant analog 05/01/2021 ZORVOLEX diclofenac submicronized REMOVE UM: PANAME Non Preferred PA 05/01/2021 PROTOPIC tacrolimus REMOVE UM: PANAME Non Preferred PA 05/01/2021 tacrolimus tacrolimus REMOVE UM: PANAME Non Preferred PA 05/01/2021 EMBEDA morphine sulfate/naltrexone REMOVE UM: PANAME Non Preferred PA hcl 05/01/2021 XHANCE fluticasone propionate REMOVE UM: PANAME Non Preferred PA 05/01/2021 EMBEDA morphine sulfate/naltrexone REMOVE UM: PANAME Non Preferred PA hcl 05/01/2021 EMBEDA morphine sulfate/naltrexone REMOVE UM: PANAME Non Preferred PA hcl 05/01/2021 colchicine colchicine REMOVE UM: PANAME 05/01/2021 STRIVERDI olodaterol hcl REMOVE UM: PANAME Non Preferred PA RESPIMAT 05/01/2021 ASMANEX HFA mometasone furoate REMOVE UM: PANAME Non Preferred PA 05/01/2021 KEVZARA sarilumab REMOVE UM: PANAME Non Preferred PA 05/01/2021 PROCRIT epoetin alfa REMOVE UM: PANAME Non Preferred PA 05/01/2021 INBRIJA levodopa REMOVE UM: PANAME Non Preferred PA 05/01/2021 ZELNORM tegaserod hydrogen maleate REMOVE UM: PANAME Non Preferred PA 05/01/2021 budesonide budesonide REMOVE UM: PANAME Non Preferred PA 05/01/2021 HUMATROPE somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 KEVZARA sarilumab REMOVE UM: PANAME Non Preferred PA 05/01/2021 MAYZENT siponimod REMOVE UM: PANAME Non Preferred PA 05/01/2021 MAYZENT siponimod REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 583 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 DUPIXENT dupilumab REMOVE UM: PANAME Non Preferred PA SYRINGE 05/01/2021 MAYZENT siponimod REMOVE UM: PANAME Non Preferred PA 05/01/2021 PERTZYE lipase/protease/amylase REMOVE UM: PANAME Non Preferred PA 05/01/2021 aliskiren aliskiren hemifumarate REMOVE UM: PANAME Non Preferred PA 05/01/2021 VELPHORO sucroferric oxyhydroxide REMOVE UM: PANAME Non Preferred PA 05/01/2021 SEROSTIM somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 KERYDIN tavaborole REMOVE UM: PANAME Non Preferred PA 05/01/2021 alosetron hcl alosetron hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 AJOVY fremanezumab-vfrm REMOVE UM: PANAME Non Preferred PA SYRINGE 05/01/2021 ORENITRAM ER treprostinil diolamine REMOVE UM: PANAME Non Preferred PA 05/01/2021 FOSRENOL lanthanum carbonate REMOVE UM: PANAME Non Preferred PA 05/01/2021 FOSRENOL lanthanum carbonate REMOVE UM: PANAME Non Preferred PA 05/01/2021 ORENITRAM ER treprostinil diolamine REMOVE UM: PANAME Non Preferred PA 05/01/2021 ORENITRAM ER treprostinil diolamine REMOVE UM: PANAME Non Preferred PA 05/01/2021 ORENITRAM ER treprostinil diolamine REMOVE UM: PANAME Non Preferred PA 05/01/2021 XELJANZ XR tofacitinib citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 fentanyl citrate fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 OTEZLA apremilast REMOVE UM: PANAME Non Preferred PA 05/01/2021 aliskiren aliskiren hemifumarate REMOVE UM: PANAME Non Preferred PA 05/01/2021 CICLODAN ciclopirox REMOVE UM: PANAME Non Preferred PA 05/01/2021 VUMERITY diroximel fumarate REMOVE UM: PANAME Non Preferred PA 05/01/2021 TEKTURNA aliskiren hemifumarate REMOVE UM: PANAME Non Preferred PA 05/01/2021 LOVAZA omega-3 acid ethyl esters REMOVE UM: PANAME

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 584 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 fentanyl citrate fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 TEKTURNA aliskiren hemifumarate REMOVE UM: PANAME Non Preferred PA 05/01/2021 fentanyl citrate fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 MAKENA hydroxyprogesterone REMOVE UM: PANAME Non Preferred PA caproate/pf 05/01/2021 fentanyl citrate fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 fentanyl citrate fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 BELBUCA buprenorphine hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 MOTEGRITY prucalopride succinate REMOVE UM: PANAME Non Preferred PA 05/01/2021 fentanyl citrate fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 BELBUCA buprenorphine hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 voriconazole voriconazole REMOVE UM: PANAME Non Preferred PA 05/01/2021 BELBUCA buprenorphine hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 ORENITRAM ER treprostinil diolamine REMOVE UM: PANAME Non Preferred PA 05/01/2021 BELBUCA buprenorphine hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 MOTEGRITY prucalopride succinate REMOVE UM: PANAME Non Preferred PA 05/01/2021 BELBUCA buprenorphine hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 FENTORA fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 UBRELVY ubrogepant REMOVE UM: PANAME Non Preferred PA 05/01/2021 UBRELVY ubrogepant REMOVE UM: PANAME Non Preferred PA 05/01/2021 FENTORA fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 FENTORA fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 FENTORA fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 FENTORA fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 testosterone testosterone REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 585 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 TALTZ ixekizumab REMOVE UM: PANAME Non Preferred PA AUTOINJECTOR 05/01/2021 TRULANCE plecanatide REMOVE UM: PANAME Non Preferred PA 05/01/2021 FLONASE fluticasone furoate REMOVE UM: PANAME Non Preferred PA SENSIMIST 05/01/2021 TALTZ ixekizumab REMOVE UM: PANAME Non Preferred PA AUTOINJECTOR (2 PACK) 05/01/2021 BELBUCA buprenorphine hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 TALTZ ixekizumab REMOVE UM: PANAME Non Preferred PA AUTOINJECTOR (3 PACK) 05/01/2021 BELBUCA buprenorphine hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 CHILDREN'S fluticasone furoate REMOVE UM: PANAME Non Preferred PA FLONASE SENSIMIST 05/01/2021 TALTZ SYRINGE ixekizumab REMOVE UM: PANAME Non Preferred PA 05/01/2021 testosterone testosterone REMOVE UM: PANAME Non Preferred PA 05/01/2021 MAKENA hydroxyprogesterone REMOVE UM: PANAME Non Preferred PA caproate 05/01/2021 SPORANOX itraconazole REMOVE UM: PANAME Non Preferred PA 05/01/2021 TEKTURNA HCT aliskiren REMOVE UM: PANAME Non Preferred PA hemifumarate/hydrochlorothi azide 05/01/2021 GLOPERBA colchicine REMOVE UM: PANAME Non Preferred PA 05/01/2021 voriconazole voriconazole REMOVE UM: PANAME Non Preferred PA 05/01/2021 TEKTURNA HCT aliskiren REMOVE UM: PANAME Non Preferred PA hemifumarate/hydrochlorothi azide

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 586 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 TEKTURNA HCT aliskiren REMOVE UM: PANAME Non Preferred PA hemifumarate/hydrochlorothi azide 05/01/2021 TEKTURNA HCT aliskiren REMOVE UM: PANAME Non Preferred PA hemifumarate/hydrochlorothi azide 05/01/2021 TOUJEO MAX insulin glargine,human REMOVE UM: PANAME Non Preferred PA SOLOSTAR recombinant analog 05/01/2021 PRIMLEV oxycodone REMOVE UM: PANAME Non Preferred PA hcl/acetaminophen 05/01/2021 PRIMLEV oxycodone REMOVE UM: PANAME Non Preferred PA hcl/acetaminophen 05/01/2021 DALIRESP roflumilast REMOVE UM: PANAME Non Preferred PA 05/01/2021 ANDROGEL testosterone REMOVE UM: PANAME Non Preferred PA 05/01/2021 PRIMLEV oxycodone REMOVE UM: PANAME Non Preferred PA hcl/acetaminophen 05/01/2021 ANDROGEL testosterone REMOVE UM: PANAME Non Preferred PA 05/01/2021 TREMFYA guselkumab REMOVE UM: PANAME Non Preferred PA 05/01/2021 ASMANEX HFA mometasone furoate REMOVE UM: PANAME Non Preferred PA 05/01/2021 ARNUITY fluticasone furoate REMOVE UM: PANAME Non Preferred PA ELLIPTA 05/01/2021 sevelamer hcl sevelamer hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 esomeprazole esomeprazole strontium REMOVE UM: PANAME Non Preferred PA strontium 05/01/2021 PROCRIT epoetin alfa REMOVE UM: PANAME Non Preferred PA 05/01/2021 fentanyl citrate fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 ASMANEX HFA mometasone furoate REMOVE UM: PANAME Non Preferred PA 05/01/2021 testosterone testosterone REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 587 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 FORTESTA testosterone REMOVE UM: PANAME Non Preferred PA 05/01/2021 ANDROGEL testosterone REMOVE UM: PANAME Non Preferred PA 05/01/2021 AZILECT rasagiline mesylate REMOVE UM: PANAME Non Preferred PA 05/01/2021 AZILECT rasagiline mesylate REMOVE UM: PANAME Non Preferred PA 05/01/2021 SAIZEN somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 ACTIQ fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 XIFAXAN rifaximin REMOVE UM: PANAME Non Preferred PA 05/01/2021 ZORVOLEX diclofenac submicronized REMOVE UM: PANAME Non Preferred PA 05/01/2021 PROTOPIC tacrolimus REMOVE UM: PANAME Non Preferred PA 05/01/2021 omega-3 acid omega-3 acid ethyl esters REMOVE UM: PANAME Non Preferred PA ethyl esters 05/01/2021 BAFIERTAM monomethyl fumarate REMOVE UM: PANAME Non Preferred PA 05/01/2021 pimecrolimus pimecrolimus REMOVE UM: PANAME Non Preferred PA 05/01/2021 ALVESCO ciclesonide REMOVE UM: PANAME 05/01/2021 ALVESCO ciclesonide REMOVE UM: PANAME 05/01/2021 RENVELA sevelamer carbonate REMOVE UM: PANAME Non Preferred PA 05/01/2021 PERTZYE lipase/protease/amylase REMOVE UM: PANAME Non Preferred PA 05/01/2021 tacrolimus tacrolimus REMOVE UM: PANAME Non Preferred PA 05/01/2021 EFFIENT prasugrel hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 PROLATE oxycodone REMOVE UM: PANAME Non Preferred PA hcl/acetaminophen 05/01/2021 tolbutamide tolbutamide REMOVE UM: PANAME Non Preferred PA 05/01/2021 EFFIENT prasugrel hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 itraconazole itraconazole REMOVE UM: PANAME Non Preferred PA 05/01/2021 ADEMPAS riociguat REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 588 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ADEMPAS riociguat REMOVE UM: PANAME Non Preferred PA 05/01/2021 DERMASORB triamcinolone REMOVE UM: PANAME Non Preferred PA TA acetonide/emollient combination no.86 05/01/2021 DERMASORB hydrocortisone/skin cleanser REMOVE UM: PANAME Non Preferred PA HC combination no.35 05/01/2021 ADEMPAS riociguat REMOVE UM: PANAME Non Preferred PA 05/01/2021 VASCEPA icosapent ethyl REMOVE UM: PANAME Non Preferred PA 05/01/2021 RENAGEL sevelamer hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 ADEMPAS riociguat REMOVE UM: PANAME Non Preferred PA 05/01/2021 PROCRIT epoetin alfa REMOVE UM: PANAME Non Preferred PA 05/01/2021 ADEMPAS riociguat REMOVE UM: PANAME Non Preferred PA 05/01/2021 CRESEMBA isavuconazonium sulfate REMOVE UM: PANAME Non Preferred PA 05/01/2021 SILIQ brodalumab REMOVE UM: PANAME Non Preferred PA 05/01/2021 SAIZEN- somatropin REMOVE UM: PANAME Non Preferred PA SAIZENPREP 05/01/2021 RELISTOR methylnaltrexone bromide REMOVE UM: PANAME Non Preferred PA 05/01/2021 RELISTOR methylnaltrexone bromide REMOVE UM: PANAME Non Preferred PA 05/01/2021 PROCRIT epoetin alfa REMOVE UM: PANAME Non Preferred PA 05/01/2021 testosterone testosterone REMOVE UM: PANAME Non Preferred PA 05/01/2021 VIBERZI eluxadoline REMOVE UM: PANAME Non Preferred PA 05/01/2021 COLCRYS colchicine REMOVE UM: PANAME Non Preferred PA 05/01/2021 NUTROPIN AQ somatropin REMOVE UM: PANAME Non Preferred PA NUSPIN 05/01/2021 OMNITROPE somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 bosentan bosentan REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 589 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 XULTOPHY 100- insulin degludec/liraglutide REMOVE UM: PANAME Non Preferred PA 3.6 05/01/2021 PLEGRIDY PEN peginterferon beta-1a REMOVE UM: PANAME Non Preferred PA 05/01/2021 PLEGRIDY peginterferon beta-1a REMOVE UM: PANAME Non Preferred PA 05/01/2021 PLEGRIDY peginterferon beta-1a REMOVE UM: PANAME Non Preferred PA 05/01/2021 XADAGO safinamide mesylate REMOVE UM: PANAME Non Preferred PA 05/01/2021 XADAGO safinamide mesylate REMOVE UM: PANAME Non Preferred PA 05/01/2021 SYMPROIC naldemedine tosylate REMOVE UM: PANAME Non Preferred PA 05/01/2021 ACTIQ fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 EZALLOR rosuvastatin calcium REMOVE UM: PANAME Non Preferred PA SPRINKLE 05/01/2021 EZALLOR rosuvastatin calcium REMOVE UM: PANAME Non Preferred PA SPRINKLE 05/01/2021 PLEGRIDY PEN peginterferon beta-1a REMOVE UM: PANAME Non Preferred PA 05/01/2021 PANCREAZE lipase/protease/amylase REMOVE UM: PANAME Non Preferred PA 05/01/2021 KEVZARA sarilumab REMOVE UM: PANAME Non Preferred PA 05/01/2021 PANCREAZE lipase/protease/amylase REMOVE UM: PANAME Non Preferred PA 05/01/2021 PANCREAZE lipase/protease/amylase REMOVE UM: PANAME Non Preferred PA 05/01/2021 PANCREAZE lipase/protease/amylase REMOVE UM: PANAME Non Preferred PA 05/01/2021 fentanyl citrate fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 voriconazole voriconazole REMOVE UM: PANAME Non Preferred PA 05/01/2021 KEVZARA sarilumab REMOVE UM: PANAME Non Preferred PA 05/01/2021 rasagiline rasagiline mesylate REMOVE UM: PANAME Non Preferred PA mesylate 05/01/2021 naproxen- naproxen/esomeprazole REMOVE UM: PANAME Non Preferred PA esomeprazole magnesium mag

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 590 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 naproxen- naproxen/esomeprazole REMOVE UM: PANAME Non Preferred PA esomeprazole magnesium mag 05/01/2021 VIMOVO naproxen/esomeprazole REMOVE UM: PANAME Non Preferred PA magnesium 05/01/2021 VIMOVO naproxen/esomeprazole REMOVE UM: PANAME Non Preferred PA magnesium 05/01/2021 rasagiline rasagiline mesylate REMOVE UM: PANAME Non Preferred PA mesylate 05/01/2021 PANCREAZE lipase/protease/amylase REMOVE UM: PANAME Non Preferred PA 05/01/2021 DESOWEN desonide REMOVE UM: PANAME Non Preferred PA 05/01/2021 EZALLOR rosuvastatin calcium REMOVE UM: PANAME Non Preferred PA SPRINKLE 05/01/2021 SEROSTIM somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 EZALLOR rosuvastatin calcium REMOVE UM: PANAME Non Preferred PA SPRINKLE 05/01/2021 XELJANZ tofacitinib citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 PREVACID lansoprazole REMOVE UM: PANAME Non Preferred PA 24HR 05/01/2021 JUBLIA efinaconazole REMOVE UM: PANAME Non Preferred PA 05/01/2021 AURYXIA ferric citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 PROCRIT epoetin alfa REMOVE UM: PANAME Non Preferred PA 05/01/2021 VFEND voriconazole REMOVE UM: PANAME Non Preferred PA 05/01/2021 MIACALCIN calcitonin,salmon,synthetic REMOVE UM: PANAME Non Preferred PA 05/01/2021 SOLIQUA 100-33 insulin glargine,human REMOVE UM: PANAME Non Preferred PA recombinant analog/lixisenatide 05/01/2021 DIFICID fidaxomicin REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 591 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 VASCEPA icosapent ethyl REMOVE UM: PANAME Non Preferred PA 05/01/2021 ketorolac ketorolac tromethamine REMOVE UM: PANAME Non Preferred PA tromethamine 05/01/2021 SPRIX ketorolac tromethamine REMOVE UM: PANAME Non Preferred PA 05/01/2021 TYMLOS abaloparatide REMOVE UM: PANAME Non Preferred PA 05/01/2021 itraconazole itraconazole REMOVE UM: PANAME Non Preferred PA 05/01/2021 DALIRESP roflumilast REMOVE UM: PANAME Non Preferred PA 05/01/2021 MAKENA hydroxyprogesterone REMOVE UM: PANAME Non Preferred PA caproate/pf 05/01/2021 QBRELIS lisinopril REMOVE UM: PANAME Non Preferred PA 05/01/2021 CRINONE progesterone, REMOVE UM: PANAME Non Preferred PA micronized,progesterone,mi cronized 05/01/2021 RYTARY carbidopa/levodopa REMOVE UM: PANAME Non Preferred PA 05/01/2021 RYTARY carbidopa/levodopa REMOVE UM: PANAME Non Preferred PA 05/01/2021 RYTARY carbidopa/levodopa REMOVE UM: PANAME Non Preferred PA 05/01/2021 ENTYVIO vedolizumab REMOVE UM: PANAME Non Preferred PA 05/01/2021 RYTARY carbidopa/levodopa REMOVE UM: PANAME Non Preferred PA 05/01/2021 NUTROPIN AQ somatropin REMOVE UM: PANAME Non Preferred PA NUSPIN 05/01/2021 OMNITROPE somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 NUTROPIN AQ somatropin REMOVE UM: PANAME Non Preferred PA NUSPIN 05/01/2021 PULMICORT budesonide REMOVE UM: PANAME Non Preferred PA FLEXHALER 05/01/2021 PULMICORT budesonide REMOVE UM: PANAME Non Preferred PA FLEXHALER

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 592 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ACTOPLUS MET pioglitazone hcl/metformin REMOVE UM: PANAME Non Preferred PA XR hcl 05/01/2021 ZOMACTON somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 ARNUITY fluticasone furoate REMOVE UM: PANAME Non Preferred PA ELLIPTA 05/01/2021 SAIZEN somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 XELJANZ XR tofacitinib citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 LOTRONEX alosetron hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 ACTIQ fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 ACTIQ fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 ZOMACTON somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 XTAMPZA ER oxycodone myristate REMOVE UM: PANAME Non Preferred PA 05/01/2021 sevelamer sevelamer carbonate REMOVE UM: PANAME Non Preferred PA carbonate 05/01/2021 XTAMPZA ER oxycodone myristate REMOVE UM: PANAME Non Preferred PA 05/01/2021 sevelamer sevelamer carbonate REMOVE UM: PANAME Non Preferred PA carbonate 05/01/2021 RELISTOR methylnaltrexone bromide REMOVE UM: PANAME Non Preferred PA 05/01/2021 XTAMPZA ER oxycodone myristate REMOVE UM: PANAME Non Preferred PA 05/01/2021 XTAMPZA ER oxycodone myristate REMOVE UM: PANAME Non Preferred PA 05/01/2021 XIFAXAN rifaximin REMOVE UM: PANAME Non Preferred PA 05/01/2021 FOSRENOL lanthanum carbonate REMOVE UM: PANAME Non Preferred PA 05/01/2021 EPANED enalapril maleate REMOVE UM: PANAME Non Preferred PA 05/01/2021 ALLERGY fexofenadine hcl REMOVE UM: PANAME Non Preferred PA RELIEF 05/01/2021 PRALUENT PEN alirocumab REMOVE UM: PANAME Non Preferred PA 05/01/2021 FOSRENOL lanthanum carbonate REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 593 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 fentanyl citrate fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 PRALUENT PEN alirocumab REMOVE UM: PANAME 05/01/2021 FORTEO teriparatide REMOVE UM: PANAME Non Preferred PA 05/01/2021 omeprazole omeprazole magnesium REMOVE UM: PANAME magnesium 05/01/2021 NEXLIZET bempedoic acid/ezetimibe REMOVE UM: PANAME Non Preferred PA 05/01/2021 AJOVY fremanezumab-vfrm REMOVE UM: PANAME Non Preferred PA AUTOINJECTOR 05/01/2021 alosetron hcl alosetron hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 HUMATROPE somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 PERTZYE lipase/protease/amylase REMOVE UM: PANAME Non Preferred PA 05/01/2021 ZORBTIVE somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 XELJANZ tofacitinib citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 PERTZYE lipase/protease/amylase REMOVE UM: PANAME Non Preferred PA 05/01/2021 HUMATROPE somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 ILUMYA tildrakizumab-asmn REMOVE UM: PANAME Non Preferred PA 05/01/2021 bosentan bosentan REMOVE UM: PANAME Non Preferred PA 05/01/2021 ONGENTYS opicapone REMOVE UM: PANAME Non Preferred PA 05/01/2021 SKYRIZI risankizumab-rzaa REMOVE UM: PANAME Non Preferred PA 05/01/2021 OTEZLA apremilast REMOVE UM: PANAME Non Preferred PA 05/01/2021 VIOKACE lipase/protease/amylase REMOVE UM: PANAME 05/01/2021 CRINONE progesterone, micronized REMOVE UM: PANAME Non Preferred PA 05/01/2021 VOGELXO testosterone REMOVE UM: PANAME Non Preferred PA 05/01/2021 VOGELXO testosterone REMOVE UM: PANAME Non Preferred PA 05/01/2021 VOGELXO testosterone REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 594 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ONGENTYS opicapone REMOVE UM: PANAME Non Preferred PA 05/01/2021 PHOSLYRA calcium acetate REMOVE UM: PANAME Non Preferred PA 05/01/2021 SAVAYSA edoxaban tosylate REMOVE UM: PANAME Non Preferred PA 05/01/2021 TRACLEER bosentan REMOVE UM: PANAME Non Preferred PA 05/01/2021 TESTIM testosterone REMOVE UM: PANAME Non Preferred PA 05/01/2021 SAVAYSA edoxaban tosylate REMOVE UM: PANAME Non Preferred PA 05/01/2021 OMNITROPE somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 LOTRISONE clotrimazole/betamethasone REMOVE UM: PANAME Non Preferred PA dipropionate 05/01/2021 INBRIJA levodopa REMOVE UM: PANAME Non Preferred PA 05/01/2021 ciclopirox ciclopirox REMOVE UM: PANAME Non Preferred PA 05/01/2021 SKYRIZI (2 risankizumab-rzaa REMOVE UM: PANAME Non Preferred PA SYRINGES) KIT 05/01/2021 GOCOVRI amantadine hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 GELNIQUE oxybutynin chloride REMOVE UM: PANAME Non Preferred PA 05/01/2021 VFEND voriconazole REMOVE UM: PANAME Non Preferred PA 05/01/2021 GOCOVRI amantadine hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 VIBERZI eluxadoline REMOVE UM: PANAME Non Preferred PA 05/01/2021 VFEND voriconazole REMOVE UM: PANAME Non Preferred PA 05/01/2021 ADCIRCA tadalafil REMOVE UM: PANAME Non Preferred PA 05/01/2021 DUPIXENT dupilumab REMOVE UM: PANAME Non Preferred PA SYRINGE 05/01/2021 LOTRONEX alosetron hcl REMOVE UM: PANAME Non Preferred PA 05/01/2021 ANDRODERM testosterone REMOVE UM: PANAME Non Preferred PA 05/01/2021 SIVEXTRO tedizolid phosphate REMOVE UM: PANAME Non Preferred PA 05/01/2021 ANDRODERM testosterone REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 595 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 XTAMPZA ER oxycodone myristate REMOVE UM: PANAME Non Preferred PA 05/01/2021 RELISTOR methylnaltrexone bromide REMOVE UM: PANAME Non Preferred PA 05/01/2021 lanthanum lanthanum carbonate REMOVE UM: PANAME Non Preferred PA carbonate 05/01/2021 PROCRIT epoetin alfa REMOVE UM: PANAME Non Preferred PA 05/01/2021 lanthanum lanthanum carbonate REMOVE UM: PANAME Non Preferred PA carbonate 05/01/2021 SAVAYSA edoxaban tosylate REMOVE UM: PANAME Non Preferred PA 05/01/2021 CIMZIA certolizumab pegol REMOVE UM: PANAME Non Preferred PA 05/01/2021 RENVELA sevelamer carbonate REMOVE UM: PANAME Non Preferred PA 05/01/2021 RENVELA sevelamer carbonate REMOVE UM: PANAME Non Preferred PA 05/01/2021 CIMZIA certolizumab pegol REMOVE UM: PANAME Non Preferred PA 05/01/2021 SEROSTIM somatropin REMOVE UM: PANAME Non Preferred PA 05/01/2021 CICLODAN ciclopirox/urea/camphor/me REMOVE UM: PANAME Non Preferred PA nthol/eucalyptol 05/01/2021 DVORAH acetaminophen/caffeine/dihy REMOVE UM: PANAME Non Preferred PA drocodeine bitartrate 05/01/2021 ciclopirox ciclopirox/urea/camphor/me REMOVE UM: PANAME Non Preferred PA nthol/eucalyptol 05/01/2021 PROCRIT epoetin alfa REMOVE UM: PANAME Non Preferred PA 05/01/2021 SPORANOX itraconazole REMOVE UM: PANAME Non Preferred PA 05/01/2021 fentanyl citrate fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 TREMFYA guselkumab REMOVE UM: PANAME Non Preferred PA 05/01/2021 ACTIQ fentanyl citrate REMOVE UM: PANAME Non Preferred PA 05/01/2021 lanthanum lanthanum carbonate REMOVE UM: PANAME Non Preferred PA carbonate 05/01/2021 KESIMPTA PEN ofatumumab REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 596 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 MAVENCLAD cladribine ADD UM: PANAME Clinical PA 05/01/2021 ZONTIVITY vorapaxar sulfate ADD UM: PANAME Clinical PA 05/01/2021 BROVANA arformoterol tartrate ADD UM: PANAME Clinical PA 05/01/2021 DUEXIS ibuprofen/famotidine ADD UM: PANAME Clinical PA 05/01/2021 MAVENCLAD cladribine ADD UM: PANAME Clinical PA 05/01/2021 MAVENCLAD cladribine ADD UM: PANAME Clinical PA 05/01/2021 MAVENCLAD cladribine ADD UM: PANAME Clinical PA 05/01/2021 neomycin sulfate neomycin sulfate ADD UM: PANAME Clinical PA 05/01/2021 testosterone testosterone ADD UM: PANAME Clinical PA 05/01/2021 ACTIQ fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 ARNUITY fluticasone furoate ADD UM: PANAME Clinical PA ELLIPTA 05/01/2021 CIMZIA certolizumab pegol ADD UM: PANAME Clinical PA 05/01/2021 AKYNZEO netupitant/palonosetron hcl ADD UM: PANAME Clinical PA 05/01/2021 testosterone testosterone ADD UM: PANAME Clinical PA 05/01/2021 FOSRENOL lanthanum carbonate ADD UM: PANAME Clinical PA 05/01/2021 REVATIO sildenafil citrate ADD UM: PANAME Clinical PA 05/01/2021 HUMATROPE somatropin ADD UM: PANAME Clinical PA 05/01/2021 MAVENCLAD cladribine ADD UM: PANAME Clinical PA 05/01/2021 MAVENCLAD cladribine ADD UM: PANAME Clinical PA 05/01/2021 MAVENCLAD cladribine ADD UM: PANAME Clinical PA 05/01/2021 VIOKACE lipase/protease/amylase ADD UM: PANAME Clinical PA 05/01/2021 fentanyl citrate fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 OZEMPIC semaglutide ADD UM: PANAME Clinical PA 05/01/2021 OZEMPIC semaglutide ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 597 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 TOUJEO insulin glargine,human ADD UM: PANAME Clinical PA SOLOSTAR recombinant analog 05/01/2021 ZORVOLEX diclofenac submicronized ADD UM: PANAME Clinical PA 05/01/2021 PROTOPIC tacrolimus ADD UM: PANAME Clinical PA 05/01/2021 tacrolimus tacrolimus ADD UM: PANAME Clinical PA 05/01/2021 XHANCE fluticasone propionate ADD UM: PANAME Clinical PA 05/01/2021 colchicine colchicine ADD UM: PANAME Clinical PA 05/01/2021 ASMANEX HFA mometasone furoate ADD UM: PANAME Clinical PA 05/01/2021 STRIVERDI olodaterol hcl ADD UM: PANAME Clinical PA RESPIMAT 05/01/2021 KEVZARA sarilumab ADD UM: PANAME Clinical PA 05/01/2021 PROCRIT epoetin alfa ADD UM: PANAME Clinical PA 05/01/2021 INBRIJA levodopa ADD UM: PANAME Clinical PA 05/01/2021 ZELNORM tegaserod hydrogen maleate ADD UM: PANAME Clinical PA 05/01/2021 budesonide budesonide ADD UM: PANAME Clinical PA 05/01/2021 HUMATROPE somatropin ADD UM: PANAME Clinical PA 05/01/2021 KEVZARA sarilumab ADD UM: PANAME Clinical PA 05/01/2021 MAYZENT siponimod ADD UM: PANAME Clinical PA 05/01/2021 MAYZENT siponimod ADD UM: PANAME Clinical PA 05/01/2021 DUPIXENT dupilumab ADD UM: PANAME Clinical PA SYRINGE 05/01/2021 MAYZENT siponimod ADD UM: PANAME Clinical PA 05/01/2021 PERTZYE lipase/protease/amylase ADD UM: PANAME Clinical PA 05/01/2021 aliskiren aliskiren hemifumarate ADD UM: PANAME Clinical PA 05/01/2021 VELPHORO sucroferric oxyhydroxide ADD UM: PANAME Clinical PA 05/01/2021 SEROSTIM somatropin ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 598 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 AJOVY fremanezumab-vfrm ADD UM: PANAME Clinical PA SYRINGE 05/01/2021 KERYDIN tavaborole ADD UM: PANAME Clinical PA 05/01/2021 alosetron hcl alosetron hcl ADD UM: PANAME Clinical PA 05/01/2021 FOSRENOL lanthanum carbonate ADD UM: PANAME Clinical PA 05/01/2021 ORENITRAM ER treprostinil diolamine ADD UM: PANAME Clinical PA 05/01/2021 FOSRENOL lanthanum carbonate ADD UM: PANAME Clinical PA 05/01/2021 ORENITRAM ER treprostinil diolamine ADD UM: PANAME Clinical PA 05/01/2021 ORENITRAM ER treprostinil diolamine ADD UM: PANAME Clinical PA 05/01/2021 ORENITRAM ER treprostinil diolamine ADD UM: PANAME Clinical PA 05/01/2021 XELJANZ XR tofacitinib citrate ADD UM: PANAME Clinical PA 05/01/2021 fentanyl citrate fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 OTEZLA apremilast ADD UM: PANAME Clinical PA 05/01/2021 aliskiren aliskiren hemifumarate ADD UM: PANAME Clinical PA 05/01/2021 CICLODAN ciclopirox ADD UM: PANAME Clinical PA 05/01/2021 VUMERITY diroximel fumarate ADD UM: PANAME Clinical PA 05/01/2021 LOVAZA omega-3 acid ethyl esters ADD UM: PANAME Clinical PA 05/01/2021 TEKTURNA aliskiren hemifumarate ADD UM: PANAME Clinical PA 05/01/2021 fentanyl citrate fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 TEKTURNA aliskiren hemifumarate ADD UM: PANAME Clinical PA 05/01/2021 fentanyl citrate fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 MAKENA hydroxyprogesterone ADD UM: PANAME Clinical PA caproate/pf 05/01/2021 fentanyl citrate fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 fentanyl citrate fentanyl citrate ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 599 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 BELBUCA buprenorphine hcl ADD UM: PANAME Clinical PA 05/01/2021 MOTEGRITY prucalopride succinate ADD UM: PANAME Clinical PA 05/01/2021 BELBUCA buprenorphine hcl ADD UM: PANAME Clinical PA 05/01/2021 fentanyl citrate fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 BELBUCA buprenorphine hcl ADD UM: PANAME Clinical PA 05/01/2021 voriconazole voriconazole ADD UM: PANAME Clinical PA 05/01/2021 ORENITRAM ER treprostinil diolamine ADD UM: PANAME Clinical PA 05/01/2021 BELBUCA buprenorphine hcl ADD UM: PANAME Clinical PA 05/01/2021 MOTEGRITY prucalopride succinate ADD UM: PANAME Clinical PA 05/01/2021 BELBUCA buprenorphine hcl ADD UM: PANAME Clinical PA 05/01/2021 FENTORA fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 UBRELVY ubrogepant ADD UM: PANAME Clinical PA 05/01/2021 UBRELVY ubrogepant ADD UM: PANAME Clinical PA 05/01/2021 FENTORA fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 FENTORA fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 FENTORA fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 FENTORA fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 TALTZ ixekizumab ADD UM: PANAME Clinical PA AUTOINJECTOR 05/01/2021 testosterone testosterone ADD UM: PANAME Clinical PA 05/01/2021 TRULANCE plecanatide ADD UM: PANAME Clinical PA 05/01/2021 TALTZ ixekizumab ADD UM: PANAME Clinical PA AUTOINJECTOR (2 PACK) 05/01/2021 BELBUCA buprenorphine hcl ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 600 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 TALTZ ixekizumab ADD UM: PANAME Clinical PA AUTOINJECTOR (3 PACK) 05/01/2021 BELBUCA buprenorphine hcl ADD UM: PANAME Clinical PA 05/01/2021 TALTZ SYRINGE ixekizumab ADD UM: PANAME Clinical PA 05/01/2021 testosterone testosterone ADD UM: PANAME Clinical PA 05/01/2021 MAKENA hydroxyprogesterone ADD UM: PANAME Clinical PA caproate 05/01/2021 SPORANOX itraconazole ADD UM: PANAME Clinical PA 05/01/2021 GLOPERBA colchicine ADD UM: PANAME Clinical PA 05/01/2021 TEKTURNA HCT aliskiren ADD UM: PANAME Clinical PA hemifumarate/hydrochlorothi azide 05/01/2021 TEKTURNA HCT aliskiren ADD UM: PANAME Clinical PA hemifumarate/hydrochlorothi azide 05/01/2021 voriconazole voriconazole ADD UM: PANAME Clinical PA 05/01/2021 TEKTURNA HCT aliskiren ADD UM: PANAME Clinical PA hemifumarate/hydrochlorothi azide 05/01/2021 TEKTURNA HCT aliskiren ADD UM: PANAME Clinical PA hemifumarate/hydrochlorothi azide 05/01/2021 TOUJEO MAX insulin glargine,human ADD UM: PANAME Clinical PA SOLOSTAR recombinant analog 05/01/2021 DALIRESP roflumilast ADD UM: PANAME Clinical PA 05/01/2021 ANDROGEL testosterone ADD UM: PANAME Clinical PA 05/01/2021 ANDROGEL testosterone ADD UM: PANAME Clinical PA 05/01/2021 TREMFYA guselkumab ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 601 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ARNUITY fluticasone furoate ADD UM: PANAME Clinical PA ELLIPTA 05/01/2021 ASMANEX HFA mometasone furoate ADD UM: PANAME Clinical PA 05/01/2021 sevelamer hcl sevelamer hcl ADD UM: PANAME Clinical PA 05/01/2021 PROCRIT epoetin alfa ADD UM: PANAME Clinical PA 05/01/2021 ASMANEX HFA mometasone furoate ADD UM: PANAME Clinical PA 05/01/2021 fentanyl citrate fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 testosterone testosterone ADD UM: PANAME Clinical PA 05/01/2021 ANDROGEL testosterone ADD UM: PANAME Clinical PA 05/01/2021 FORTESTA testosterone ADD UM: PANAME Clinical PA 05/01/2021 AZILECT rasagiline mesylate ADD UM: PANAME Clinical PA 05/01/2021 AZILECT rasagiline mesylate ADD UM: PANAME Clinical PA 05/01/2021 SAIZEN somatropin ADD UM: PANAME Clinical PA 05/01/2021 ACTIQ fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 XIFAXAN rifaximin ADD UM: PANAME Clinical PA 05/01/2021 ZORVOLEX diclofenac submicronized ADD UM: PANAME Clinical PA 05/01/2021 BAFIERTAM monomethyl fumarate ADD UM: PANAME Clinical PA 05/01/2021 omega-3 acid omega-3 acid ethyl esters ADD UM: PANAME Clinical PA ethyl esters 05/01/2021 PROTOPIC tacrolimus ADD UM: PANAME Clinical PA 05/01/2021 ALVESCO ciclesonide ADD UM: PANAME Clinical PA 05/01/2021 pimecrolimus pimecrolimus ADD UM: PANAME Clinical PA 05/01/2021 ALVESCO ciclesonide ADD UM: PANAME Clinical PA 05/01/2021 PERTZYE lipase/protease/amylase ADD UM: PANAME Clinical PA 05/01/2021 RENVELA sevelamer carbonate ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 602 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 tacrolimus tacrolimus ADD UM: PANAME Clinical PA 05/01/2021 EFFIENT prasugrel hcl ADD UM: PANAME Clinical PA 05/01/2021 EFFIENT prasugrel hcl ADD UM: PANAME Clinical PA 05/01/2021 itraconazole itraconazole ADD UM: PANAME Clinical PA 05/01/2021 ADEMPAS riociguat ADD UM: PANAME Clinical PA 05/01/2021 ADEMPAS riociguat ADD UM: PANAME Clinical PA 05/01/2021 ADEMPAS riociguat ADD UM: PANAME Clinical PA 05/01/2021 ADEMPAS riociguat ADD UM: PANAME Clinical PA 05/01/2021 VASCEPA icosapent ethyl ADD UM: PANAME Clinical PA 05/01/2021 RENAGEL sevelamer hcl ADD UM: PANAME Clinical PA 05/01/2021 ADEMPAS riociguat ADD UM: PANAME Clinical PA 05/01/2021 PROCRIT epoetin alfa ADD UM: PANAME Clinical PA 05/01/2021 CRESEMBA isavuconazonium sulfate ADD UM: PANAME Clinical PA 05/01/2021 SILIQ brodalumab ADD UM: PANAME Clinical PA 05/01/2021 SAIZEN- somatropin ADD UM: PANAME Clinical PA SAIZENPREP 05/01/2021 RELISTOR methylnaltrexone bromide ADD UM: PANAME Clinical PA 05/01/2021 RELISTOR methylnaltrexone bromide ADD UM: PANAME Clinical PA 05/01/2021 PROCRIT epoetin alfa ADD UM: PANAME Clinical PA 05/01/2021 testosterone testosterone ADD UM: PANAME Clinical PA 05/01/2021 VIBERZI eluxadoline ADD UM: PANAME Clinical PA 05/01/2021 COLCRYS colchicine ADD UM: PANAME Clinical PA 05/01/2021 NUTROPIN AQ somatropin ADD UM: PANAME Clinical PA NUSPIN 05/01/2021 OMNITROPE somatropin ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 603 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 bosentan bosentan ADD UM: PANAME Clinical PA 05/01/2021 XULTOPHY 100- insulin degludec/liraglutide ADD UM: PANAME Clinical PA 3.6 05/01/2021 PLEGRIDY PEN peginterferon beta-1a ADD UM: PANAME Clinical PA 05/01/2021 PLEGRIDY peginterferon beta-1a ADD UM: PANAME Clinical PA 05/01/2021 PLEGRIDY peginterferon beta-1a ADD UM: PANAME Clinical PA 05/01/2021 XADAGO safinamide mesylate ADD UM: PANAME Clinical PA 05/01/2021 XADAGO safinamide mesylate ADD UM: PANAME Clinical PA 05/01/2021 SYMPROIC naldemedine tosylate ADD UM: PANAME Clinical PA 05/01/2021 ACTIQ fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 EZALLOR rosuvastatin calcium ADD UM: PANAME Clinical PA SPRINKLE 05/01/2021 EZALLOR rosuvastatin calcium ADD UM: PANAME Clinical PA SPRINKLE 05/01/2021 PLEGRIDY PEN peginterferon beta-1a ADD UM: PANAME Clinical PA 05/01/2021 KEVZARA sarilumab ADD UM: PANAME Clinical PA 05/01/2021 PANCREAZE lipase/protease/amylase ADD UM: PANAME Clinical PA 05/01/2021 PANCREAZE lipase/protease/amylase ADD UM: PANAME Clinical PA 05/01/2021 PANCREAZE lipase/protease/amylase ADD UM: PANAME Clinical PA 05/01/2021 PANCREAZE lipase/protease/amylase ADD UM: PANAME Clinical PA 05/01/2021 fentanyl citrate fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 voriconazole voriconazole ADD UM: PANAME Clinical PA 05/01/2021 KEVZARA sarilumab ADD UM: PANAME Clinical PA 05/01/2021 rasagiline rasagiline mesylate ADD UM: PANAME Clinical PA mesylate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 604 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 naproxen- naproxen/esomeprazole ADD UM: PANAME Clinical PA esomeprazole magnesium mag 05/01/2021 naproxen- naproxen/esomeprazole ADD UM: PANAME Clinical PA esomeprazole magnesium mag 05/01/2021 VIMOVO naproxen/esomeprazole ADD UM: PANAME Clinical PA magnesium 05/01/2021 VIMOVO naproxen/esomeprazole ADD UM: PANAME Clinical PA magnesium 05/01/2021 rasagiline rasagiline mesylate ADD UM: PANAME Clinical PA mesylate 05/01/2021 PANCREAZE lipase/protease/amylase ADD UM: PANAME Clinical PA 05/01/2021 EZALLOR rosuvastatin calcium ADD UM: PANAME Clinical PA SPRINKLE 05/01/2021 EZALLOR rosuvastatin calcium ADD UM: PANAME Clinical PA SPRINKLE 05/01/2021 SEROSTIM somatropin ADD UM: PANAME Clinical PA 05/01/2021 XELJANZ tofacitinib citrate ADD UM: PANAME Clinical PA 05/01/2021 JUBLIA efinaconazole ADD UM: PANAME Clinical PA 05/01/2021 AURYXIA ferric citrate ADD UM: PANAME Clinical PA 05/01/2021 PROCRIT epoetin alfa ADD UM: PANAME Clinical PA 05/01/2021 VFEND voriconazole ADD UM: PANAME Clinical PA 05/01/2021 MIACALCIN calcitonin,salmon,synthetic ADD UM: PANAME Clinical PA 05/01/2021 SOLIQUA 100-33 insulin glargine,human ADD UM: PANAME Clinical PA recombinant analog/lixisenatide 05/01/2021 DIFICID fidaxomicin ADD UM: PANAME Clinical PA 05/01/2021 VASCEPA icosapent ethyl ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 605 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ketorolac ketorolac tromethamine ADD UM: PANAME Clinical PA tromethamine 05/01/2021 SPRIX ketorolac tromethamine ADD UM: PANAME Clinical PA 05/01/2021 DALIRESP roflumilast ADD UM: PANAME Clinical PA 05/01/2021 TYMLOS abaloparatide ADD UM: PANAME Clinical PA 05/01/2021 itraconazole itraconazole ADD UM: PANAME Clinical PA 05/01/2021 MAKENA hydroxyprogesterone ADD UM: PANAME Clinical PA caproate/pf 05/01/2021 QBRELIS lisinopril ADD UM: PANAME Clinical PA 05/01/2021 CRINONE progesterone, ADD UM: PANAME Clinical PA micronized,progesterone,mi cronized 05/01/2021 RYTARY carbidopa/levodopa ADD UM: PANAME Clinical PA 05/01/2021 RYTARY carbidopa/levodopa ADD UM: PANAME Clinical PA 05/01/2021 RYTARY carbidopa/levodopa ADD UM: PANAME Clinical PA 05/01/2021 ENTYVIO vedolizumab ADD UM: PANAME Clinical PA 05/01/2021 RYTARY carbidopa/levodopa ADD UM: PANAME Clinical PA 05/01/2021 NUTROPIN AQ somatropin ADD UM: PANAME Clinical PA NUSPIN 05/01/2021 NUTROPIN AQ somatropin ADD UM: PANAME Clinical PA NUSPIN 05/01/2021 OMNITROPE somatropin ADD UM: PANAME Clinical PA 05/01/2021 PULMICORT budesonide ADD UM: PANAME Clinical PA FLEXHALER 05/01/2021 PULMICORT budesonide ADD UM: PANAME Clinical PA FLEXHALER 05/01/2021 ZOMACTON somatropin ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 606 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ARNUITY fluticasone furoate ADD UM: PANAME Clinical PA ELLIPTA 05/01/2021 SAIZEN somatropin ADD UM: PANAME Clinical PA 05/01/2021 XELJANZ XR tofacitinib citrate ADD UM: PANAME Clinical PA 05/01/2021 LOTRONEX alosetron hcl ADD UM: PANAME Clinical PA 05/01/2021 ACTIQ fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 ACTIQ fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 XTAMPZA ER oxycodone myristate ADD UM: PANAME Clinical PA 05/01/2021 ZOMACTON somatropin ADD UM: PANAME Clinical PA 05/01/2021 sevelamer sevelamer carbonate ADD UM: PANAME Clinical PA carbonate 05/01/2021 XTAMPZA ER oxycodone myristate ADD UM: PANAME Clinical PA 05/01/2021 sevelamer sevelamer carbonate ADD UM: PANAME Clinical PA carbonate 05/01/2021 RELISTOR methylnaltrexone bromide ADD UM: PANAME Clinical PA 05/01/2021 XTAMPZA ER oxycodone myristate ADD UM: PANAME Clinical PA 05/01/2021 XTAMPZA ER oxycodone myristate ADD UM: PANAME Clinical PA 05/01/2021 EPANED enalapril maleate ADD UM: PANAME Clinical PA 05/01/2021 XIFAXAN rifaximin ADD UM: PANAME Clinical PA 05/01/2021 FOSRENOL lanthanum carbonate ADD UM: PANAME Clinical PA 05/01/2021 PRALUENT PEN alirocumab ADD UM: PANAME Clinical PA 05/01/2021 FOSRENOL lanthanum carbonate ADD UM: PANAME Clinical PA 05/01/2021 fentanyl citrate fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 PRALUENT PEN alirocumab ADD UM: PANAME Clinical PA 05/01/2021 FORTEO teriparatide ADD UM: PANAME Clinical PA 05/01/2021 NEXLIZET bempedoic acid/ezetimibe ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 607 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 AJOVY fremanezumab-vfrm ADD UM: PANAME Clinical PA AUTOINJECTOR 05/01/2021 alosetron hcl alosetron hcl ADD UM: PANAME Clinical PA 05/01/2021 HUMATROPE somatropin ADD UM: PANAME Clinical PA 05/01/2021 PERTZYE lipase/protease/amylase ADD UM: PANAME Clinical PA 05/01/2021 ZORBTIVE somatropin ADD UM: PANAME Clinical PA 05/01/2021 XELJANZ tofacitinib citrate ADD UM: PANAME Clinical PA 05/01/2021 PERTZYE lipase/protease/amylase ADD UM: PANAME Clinical PA 05/01/2021 HUMATROPE somatropin ADD UM: PANAME Clinical PA 05/01/2021 ILUMYA tildrakizumab-asmn ADD UM: PANAME Clinical PA 05/01/2021 bosentan bosentan ADD UM: PANAME Clinical PA 05/01/2021 ONGENTYS opicapone ADD UM: PANAME Clinical PA 05/01/2021 SKYRIZI risankizumab-rzaa ADD UM: PANAME Clinical PA 05/01/2021 OTEZLA apremilast ADD UM: PANAME Clinical PA 05/01/2021 VIOKACE lipase/protease/amylase ADD UM: PANAME Clinical PA 05/01/2021 CRINONE progesterone, micronized ADD UM: PANAME Clinical PA 05/01/2021 VOGELXO testosterone ADD UM: PANAME Clinical PA 05/01/2021 VOGELXO testosterone ADD UM: PANAME Clinical PA 05/01/2021 VOGELXO testosterone ADD UM: PANAME Clinical PA 05/01/2021 ONGENTYS opicapone ADD UM: PANAME Clinical PA 05/01/2021 PHOSLYRA calcium acetate ADD UM: PANAME Clinical PA 05/01/2021 SAVAYSA edoxaban tosylate ADD UM: PANAME Clinical PA 05/01/2021 TRACLEER bosentan ADD UM: PANAME Clinical PA 05/01/2021 TESTIM testosterone ADD UM: PANAME Clinical PA 05/01/2021 INBRIJA levodopa ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 608 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 SAVAYSA edoxaban tosylate ADD UM: PANAME Clinical PA 05/01/2021 OMNITROPE somatropin ADD UM: PANAME Clinical PA 05/01/2021 ciclopirox ciclopirox ADD UM: PANAME Clinical PA 05/01/2021 SKYRIZI (2 risankizumab-rzaa ADD UM: PANAME Clinical PA SYRINGES) KIT 05/01/2021 GOCOVRI amantadine hcl ADD UM: PANAME Clinical PA 05/01/2021 GELNIQUE oxybutynin chloride ADD UM: PANAME Clinical PA 05/01/2021 GOCOVRI amantadine hcl ADD UM: PANAME Clinical PA 05/01/2021 VFEND voriconazole ADD UM: PANAME Clinical PA 05/01/2021 VIBERZI eluxadoline ADD UM: PANAME Clinical PA 05/01/2021 ADCIRCA tadalafil ADD UM: PANAME Clinical PA 05/01/2021 VFEND voriconazole ADD UM: PANAME Clinical PA 05/01/2021 DUPIXENT dupilumab ADD UM: PANAME Clinical PA SYRINGE 05/01/2021 LOTRONEX alosetron hcl ADD UM: PANAME Clinical PA 05/01/2021 ANDRODERM testosterone ADD UM: PANAME Clinical PA 05/01/2021 SIVEXTRO tedizolid phosphate ADD UM: PANAME Clinical PA 05/01/2021 ANDRODERM testosterone ADD UM: PANAME Clinical PA 05/01/2021 XTAMPZA ER oxycodone myristate ADD UM: PANAME Clinical PA 05/01/2021 RELISTOR methylnaltrexone bromide ADD UM: PANAME Clinical PA 05/01/2021 lanthanum lanthanum carbonate ADD UM: PANAME Clinical PA carbonate 05/01/2021 lanthanum lanthanum carbonate ADD UM: PANAME Clinical PA carbonate 05/01/2021 PROCRIT epoetin alfa ADD UM: PANAME Clinical PA 05/01/2021 SAVAYSA edoxaban tosylate ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 609 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 CIMZIA certolizumab pegol ADD UM: PANAME Clinical PA 05/01/2021 RENVELA sevelamer carbonate ADD UM: PANAME Clinical PA 05/01/2021 RENVELA sevelamer carbonate ADD UM: PANAME Clinical PA 05/01/2021 CIMZIA certolizumab pegol ADD UM: PANAME Clinical PA 05/01/2021 CICLODAN ciclopirox/urea/camphor/me ADD UM: PANAME Clinical PA nthol/eucalyptol 05/01/2021 SEROSTIM somatropin ADD UM: PANAME Clinical PA 05/01/2021 ciclopirox ciclopirox/urea/camphor/me ADD UM: PANAME Clinical PA nthol/eucalyptol 05/01/2021 PROCRIT epoetin alfa ADD UM: PANAME Clinical PA 05/01/2021 fentanyl citrate fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 SPORANOX itraconazole ADD UM: PANAME Clinical PA 05/01/2021 TREMFYA guselkumab ADD UM: PANAME Clinical PA 05/01/2021 ACTIQ fentanyl citrate ADD UM: PANAME Clinical PA 05/01/2021 KESIMPTA PEN ofatumumab ADD UM: PANAME Clinical PA 05/01/2021 lanthanum lanthanum carbonate ADD UM: PANAME Clinical PA carbonate 05/01/2021 DUPIXENT PEN dupilumab CHANGE UM: PANAME Non Preferred PA Clinical PA 05/01/2021 KPN prenatal vitamin REMOVE UM: QUANTITY 1 / day calcium,iron,folic acid (less than 1 mg) 05/01/2021 MIGRANOW sumatriptan REMOVE UM: QUANTITY 1 / 30 days succinate/menthol/camphor 05/01/2021 M-NATAL PLUS prenatal vits with calcium REMOVE UM: QUANTITY 1 / day no.72/ferrous fumarate/folic acid 05/01/2021 kimono microthin condoms, latex, lubricated ADD UM: QUANTITY 1.2 / day aqua lube

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 610 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 morphine sulfate morphine sulfate ADD UM: QUANTITY 120 / 30 days 05/01/2021 multi-vitamin w- pediatric multivitamin CHANGE UM: QUANTITY 2 / day fluoride,multivita combination no.2/sodium mins with fluoride,pediatric fluoride,multivita multivitamin no.82 with min and sodium fluoride,pediatric fluoride,multivita multivitamin no.2/sodium min with fluoride fluoride,pediatric multivitamin no.150 with sodium fluoride 05/01/2021 multi-vitamin w- pediatric multivitamin CHANGE UM: QUANTITY 2 / day fluoride,multivita combination no.2/sodium mins with fluoride,pediatric fluoride,polyvitam multivitamin no.2/sodium ins- fluoride fluoride,multivita min with fluoride 05/01/2021 TOTAL diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old ALLERGY 05/01/2021 GERI-DRYL diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old 05/01/2021 DOTTI estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 LOPREEZA estradiol/norethindrone REMOVE UM: AGE Up to 64 yrs old acetate 05/01/2021 PEDIA IRON ferrous sulfate REMOVE UM: AGE Up to 12 yrs old 05/01/2021 AMABELZ estradiol/norethindrone REMOVE UM: AGE Up to 64 yrs old acetate 05/01/2021 NIGHTTIME diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old ALLERGY RELIEF

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 611 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 prenatal prenatal vits with calcium REMOVE UM: AGE multivitamins,pre 95/ferrous fumarate/folic natal multivitamin acid,prenatal vitamins no.121/ferrous fumarate/folic acid 05/01/2021 prenatal prenatal vitamins with REMOVE UM: AGE 12.0 to 55.0 yrs calcium/ferrous old fumarate/folic acid 05/01/2021 DOTTI estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 DOTTI estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 TRI-VITE WITH pediatric multivit with a,c,d3 REMOVE UM: AGE Up to 12 yrs old FLUORIDE no.21/sodium fluoride 05/01/2021 DIPHEN diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old 05/01/2021 DOTTI estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 tri-vite with pediatric multivit with a,c,d3 REMOVE UM: AGE Up to 12 yrs old fluoride no.21/sodium fluoride 05/01/2021 DOTTI estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 KAPVAY clonidine hcl REMOVE UM: AGE At least 3 yrs old 05/01/2021 ACTIVELLA estradiol/norethindrone REMOVE UM: AGE Up to 64 yrs old acetate 05/01/2021 VALIUM diazepam REMOVE UM: AGE Up to 64 yrs old 05/01/2021 ferrous sulfate ferrous sulfate REMOVE UM: AGE Up to 12 yrs old 05/01/2021 FIORINAL butalbital/aspirin/caffeine REMOVE UM: AGE Up to 64 yrs old 05/01/2021 M-NATAL PLUS prenatal vits with calcium REMOVE UM: AGE 12.0 to 55.0 yrs no.72/ferrous fumarate/folic old acid 05/01/2021 thyroid thyroid,pork REMOVE UM: AGE Up to 64 yrs old 05/01/2021 PHENADOZ promethazine hcl REMOVE UM: AGE 2.0 to 64.0 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 612 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 FYAVOLV norethindrone acetate- REMOVE UM: AGE Up to 64 yrs old ethinyl estradiol 05/01/2021 THYROID thyroid,pork REMOVE UM: AGE Up to 64 yrs old 05/01/2021 THYROID thyroid,pork REMOVE UM: AGE Up to 64 yrs old 05/01/2021 AMABELZ estradiol/norethindrone REMOVE UM: AGE Up to 64 yrs old acetate 05/01/2021 thyroid thyroid,pork REMOVE UM: AGE Up to 64 yrs old 05/01/2021 prenatal formula prenatal vit with calcium REMOVE UM: AGE 12.0 to 55.0 yrs no.131/ferrous fumarate/folic old acid,prenatal vitamins with calcium/ferrous fumarate/folic acid,prenatal vits with calcium 95/ferrous fumarate/folic acid 05/01/2021 KPN prenatal vitamin REMOVE UM: AGE 12.0 to 55.0 yrs calcium,iron,folic acid (less old than 1 mg) 05/01/2021 THYROID thyroid,pork REMOVE UM: AGE Up to 64 yrs old 05/01/2021 BENADRYL diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old ALLERGY 05/01/2021 ALORA estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 vitamins a,c,d pediatric multivit with a,c,d3 REMOVE UM: AGE Up to 12 yrs old and fluoride no.21/sodium fluoride 05/01/2021 prenatal prenatal vits with calcium REMOVE UM: AGE 12.0 to 55.0 yrs 95/ferrous fumarate/folic old acid 05/01/2021 EMEND aprepitant REMOVE UM: AGE At least 12 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 613 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 vitamins a,c,d pediatric multivit with a,c,d3 REMOVE UM: AGE Up to 12 yrs old and no.21/sodium fluoride fluoride,vitamins a,d,c and fluoride 05/01/2021 FYAVOLV norethindrone acetate- REMOVE UM: AGE Up to 64 yrs old ethinyl estradiol 05/01/2021 aspirin aspirin/calcium REMOVE UM: AGE 40.0 to 79.0 yrs buffered,buffered carbonate/magnesium old aspirin 05/01/2021 METADATE ER methylphenidate hcl REMOVE UM: AGE At least 3 yrs old 05/01/2021 ACTIVELLA estradiol/norethindrone REMOVE UM: AGE Up to 64 yrs old acetate 05/01/2021 VALIUM diazepam REMOVE UM: AGE Up to 64 yrs old 05/01/2021 VALIUM diazepam REMOVE UM: AGE Up to 64 yrs old 05/01/2021 ALLERGY diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old MEDICATION 05/01/2021 ALER-CAPS diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old 05/01/2021 LOPREEZA estradiol/norethindrone REMOVE UM: AGE Up to 64 yrs old acetate 05/01/2021 VIBRAMYCIN doxycycline monohydrate REMOVE UM: AGE Up to 12 yrs old 05/01/2021 NORPACE disopyramide phosphate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 NORPACE disopyramide phosphate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 SYMAX-SL hyoscyamine sulfate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 GENGRAF cyclosporine, modified REMOVE UM: AGE Up to 12 yrs old 05/01/2021 PHARBEDRYL diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 614 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 prenatal 19 prenatal vits with calcium REMOVE UM: AGE no.115/iron fumarate/folic acid,prenatal vits with calcium 118/ferrous fumarate/folic acid 05/01/2021 PHARBEDRYL diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old 05/01/2021 FEMHRT norethindrone acetate- REMOVE UM: AGE Up to 64 yrs old ethinyl estradiol 05/01/2021 CHILDREN'S ferrous sulfate REMOVE UM: AGE Up to 12 yrs old IRON 05/01/2021 MIMVEY LO estradiol/norethindrone REMOVE UM: AGE Up to 64 yrs old acetate 05/01/2021 AUGMENTIN amoxicillin/potassium REMOVE UM: AGE Up to 12 yrs old clavulanate 05/01/2021 MACRODANTIN nitrofurantoin macrocrystal REMOVE UM: AGE Up to 64 yrs old 05/01/2021 ESTRACE estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 OSCIMIN SL hyoscyamine sulfate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 OSCIMIN hyoscyamine sulfate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 NULEV hyoscyamine sulfate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 LEVSIN-SL hyoscyamine sulfate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 FLUORITAB fluoride (sodium) REMOVE UM: AGE Up to 16 yrs old 05/01/2021 PROMETHEGAN promethazine hcl REMOVE UM: AGE 2.0 to 64.0 yrs old 05/01/2021 CLIMARA estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 AMPYRA dalfampridine REMOVE UM: AGE 18.0 to 70.0 yrs old 05/01/2021 CLIMARA estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 MENEST estrogens,esterified REMOVE UM: AGE Up to 64 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 615 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 BEVYXXA betrixaban maleate REMOVE UM: AGE At least 18 yrs old 05/01/2021 OSCIMIN hyoscyamine sulfate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 PNV-VP-U multivitamin combination REMOVE UM: AGE 12.0 to 55.0 yrs no.51/ferrous fumarate/folic old acid 05/01/2021 BEVYXXA betrixaban maleate REMOVE UM: AGE At least 18 yrs old 05/01/2021 ALLERGY diphenhydramine hcl REMOVE UM: AGE RELIEF 05/01/2021 FEMARA letrozole REMOVE UM: AGE At least 18 yrs old 05/01/2021 ESTRACE estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 ECOTRIN aspirin REMOVE UM: AGE 40.0 to 79.0 yrs old 05/01/2021 SYMAX-SR hyoscyamine sulfate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 MIMVEY estradiol/norethindrone REMOVE UM: AGE Up to 64 yrs old acetate 05/01/2021 prenatal-u multivitamin combination REMOVE UM: AGE 12.0 to 55.0 yrs no.51/ferrous fumarate/folic old acid 05/01/2021 LEVBID hyoscyamine sulfate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 prenatal prenatal vits with calcium REMOVE UM: AGE 12.0 to 55.0 yrs complete no.21/ferrous fumarate/folic old acid 05/01/2021 prenatal prenatal vitamins no.62/folic REMOVE UM: AGE 12.0 to 55.0 yrs acid/omega-3s/dha/epa/fish old oil 05/01/2021 MINIVELLE estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 VIVELLE-DOT estradiol REMOVE UM: AGE Up to 64 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 616 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 BANOPHEN diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old 05/01/2021 ASPIR-TRIN aspirin REMOVE UM: AGE 40.0 to 79.0 yrs old 05/01/2021 DIPHENHIST diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old 05/01/2021 CELLCEPT mycophenolate mofetil REMOVE UM: AGE Up to 12 yrs old 05/01/2021 PROMETHEGAN promethazine hcl REMOVE UM: AGE 2.0 to 64.0 yrs old 05/01/2021 prenatal plus prenatal vits with calcium REMOVE UM: AGE 12.0 to 55.0 yrs no.72/iron,carbonyl/folic acid old 05/01/2021 MYNATAL PLUS prenatal vitamins with REMOVE UM: AGE 12.0 to 55.0 yrs calcium/ferrous old fumarate/folic acid 05/01/2021 prenatal prenatal vits with calcium REMOVE UM: AGE 12.0 to 55.0 yrs vitamins,prenatal, 95/ferrous fumarate/folic old prenatal vitamin acid 05/01/2021 HYOSYNE hyoscyamine sulfate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 CLEOCIN clindamycin palmitate hcl REMOVE UM: AGE Up to 12 yrs old PEDIATRIC 05/01/2021 hydroxyzine hcl hydroxyzine hcl REMOVE UM: AGE 05/01/2021 TRINATE prenatal vits with calcium REMOVE UM: AGE 12.0 to 55.0 yrs no.73/ferrous fumarate/folic old acid 05/01/2021 VIVELLE-DOT estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 PHENADOZ promethazine hcl REMOVE UM: AGE 2.0 to 64.0 yrs old 05/01/2021 ECPIRIN aspirin REMOVE UM: AGE 40.0 to 79.0 yrs old 05/01/2021 VIVELLE-DOT estradiol REMOVE UM: AGE Up to 64 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 617 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 COMPLETE diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old ALLERGY 05/01/2021 NEORAL cyclosporine, modified REMOVE UM: AGE Up to 12 yrs old 05/01/2021 MACROBID nitrofurantoin REMOVE UM: AGE Up to 64 yrs old monohydrate/macrocrystals 05/01/2021 ALLERGY diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old 05/01/2021 MINIVELLE estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 NIVA-PLUS multivitamin-minerals REMOVE UM: AGE 12.0 to 55.0 yrs no.60/ferrous fumarate/folic old acid 05/01/2021 HYOSYNE hyoscyamine sulfate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 ED-SPAZ hyoscyamine sulfate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 BANOPHEN diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old 05/01/2021 FE C PLUS iron,carbonyl/ascorbic REMOVE UM: AGE Up to 12 yrs old acid/cyanocobalamin/folic acid 05/01/2021 RETIN-A tretinoin REMOVE UM: AGE Up to 30 yrs old 05/01/2021 ALLER-G-TIME diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old 05/01/2021 buffered aspirin aspirin/calcium REMOVE UM: AGE 40.0 to 79.0 yrs carbonate/magnesium old 05/01/2021 ALLERGY diphenhydramine hcl REMOVE UM: AGE RELIEF 05/01/2021 ESTRACE estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 VINATE-M prenatal vits with calcium REMOVE UM: AGE 12.0 to 55.0 yrs 136/ferrous fumarate/folic old acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 618 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 prenatal low iron prenatal vits with calcium REMOVE UM: AGE 12.0 to 55.0 yrs #74/ferrous fumarate/folic old acid,prenatal vits with calcium no.74/ferrous fumarate/folic acid 05/01/2021 MINIVELLE estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 MINIVELLE estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 FLUORITAB fluoride (sodium) REMOVE UM: AGE Up to 16 yrs old 05/01/2021 ALORA estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 MYNATAL-Z prenatal vitamins with REMOVE UM: AGE 12.0 to 55.0 yrs calcium/ferrous old fumarate/folic acid 05/01/2021 BANOPHEN diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old 05/01/2021 ALLERGY diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old MEDICINE,ALLE RGY MEDICATION 05/01/2021 WAL-DRYL diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old ALLERGY 05/01/2021 VIVELLE-DOT estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 ALORA estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 complete allergy diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old 05/01/2021 JINTELI norethindrone acetate- REMOVE UM: AGE Up to 64 yrs old ethinyl estradiol 05/01/2021 SYMAX hyoscyamine sulfate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 CLIMARA estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 BENADRYL diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 619 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ICAR-C PLUS iron,carbonyl/ascorbic REMOVE UM: AGE Up to 12 yrs old acid/cyanocobalamin/folic acid 05/01/2021 CLIMARA estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 LEVSIN hyoscyamine sulfate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 AVITA tretinoin REMOVE UM: AGE Up to 30 yrs old 05/01/2021 complete allergy diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old 05/01/2021 CLIMARA estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 COMPLETE diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old ALLERGY 05/01/2021 ALLERGY diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old 05/01/2021 ANASPAZ hyoscyamine sulfate REMOVE UM: AGE Up to 64 yrs old 05/01/2021 MACRODANTIN nitrofurantoin macrocrystal REMOVE UM: AGE Up to 64 yrs old 05/01/2021 CLIMARA estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 ROCALTROL calcitriol REMOVE UM: AGE Up to 12 yrs old 05/01/2021 PROMETHEGAN promethazine hcl REMOVE UM: AGE 2.0 to 64.0 yrs old 05/01/2021 ALORA estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 ALLERGY diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old RELIEF 05/01/2021 FER-IN-SOL ferrous sulfate REMOVE UM: AGE Up to 12 yrs old 05/01/2021 VIVELLE-DOT estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 diphenhydramine diphenhydramine hcl REMOVE UM: AGE hcl 05/01/2021 THERANATAL prenatal vitamins REMOVE UM: AGE 12.0 to 55.0 yrs no.28/ferrous fumarate/folic old acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 620 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 prenatal prenatal vitamins with REMOVE UM: AGE 12.0 to 55.0 yrs vitamins,prenatal calcium/ferrous old fumarate/folic acid,prenatal vitamins/ferrous fumarate/folic acid 05/01/2021 ALLERGY,ALLE diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old RGY RELIEF 05/01/2021 WAL-DRYL diphenhydramine hcl REMOVE UM: AGE Up to 64 yrs old 05/01/2021 MINIVELLE estradiol REMOVE UM: AGE Up to 64 yrs old 05/01/2021 mvc-fluoride pediatric multivitamins REMOVE UM: AGE Up to 12 yrs old combination no.12/sodium fluoride,pediatric multivitamin no.12 with sodium fluoride 05/01/2021 mvc-fluoride pediatric multivitamins REMOVE UM: AGE Up to 12 yrs old combination no.12/sodium fluoride,pediatric multivitamin no.12 with sodium fluoride 05/01/2021 mvc-fluoride pediatric multivitamins REMOVE UM: AGE Up to 12 yrs old combination no.12/sodium fluoride,pediatric multivitamin no.12 with sodium fluoride 05/01/2021 AUGMENTIN ES- amoxicillin/potassium REMOVE UM: AGE Up to 12 yrs old 600 clavulanate 05/01/2021 O-CAL FA multivitamin with minerals ADD UM: AGE 12.0 to 55.0 yrs no.61/ferrous fumarate/folic old acid 05/01/2021 SE-NATAL-19 prenatal vitamins ADD UM: AGE 12.0 to 55.0 yrs no.119/iron fumarate/folic old acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 621 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 CLASSIC prenatal vit with calcium ADD UM: AGE 12.0 to 55.0 yrs PRENATAL no.126/ferrous fumarate/folic old acid 05/01/2021 iron ferrous gluconate REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 HAIR, SKIN AND multivitamin with iron and REMOVE FROM Non PDL Non-Formulary NAILS minerals/folic acid/biotin FORMULARY 05/01/2021 DECUBI VITE multivitamin/folic acid/zinc REMOVE FROM Non PDL Non-Formulary sulfate/ascorbic acid FORMULARY 05/01/2021 EMBEDA morphine sulfate/naltrexone REMOVE FROM Non-Preferred Non-Formulary hcl FORMULARY 05/01/2021 TODAY nonoxynol 9 REMOVE FROM Non PDL Non-Formulary CONTRACEPTIV FORMULARY E SPONGE 05/01/2021 EMBEDA morphine sulfate/naltrexone REMOVE FROM Non-Preferred Non-Formulary hcl FORMULARY 05/01/2021 COMPLEX B-100 vitamin b complex REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 EMBEDA morphine sulfate/naltrexone REMOVE FROM Non-Preferred Non-Formulary hcl FORMULARY 05/01/2021 A THRU Z multivitamin with iron and REMOVE FROM Non PDL Non-Formulary SELECT other minerals/lutein FORMULARY 05/01/2021 APETIGEN vitamin b complex/lysine REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 b-50 complex vitamin b complex/folic acid REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 ONE DAILY FOR multivit with minerals/folic REMOVE FROM Non PDL Non-Formulary WOMEN 50+ acid/ginkgo biloba leaf FORMULARY ADV,ONE extract DAILY,ONE DAILY WOMEN'S 50+

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 622 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 MULTI-DELYN multivitamin/ferrous REMOVE FROM Non PDL Non-Formulary gluconate FORMULARY 05/01/2021 COMPLEX B-50 calcium carbonate/vitamin b REMOVE FROM Non PDL Non-Formulary complex/folic acid FORMULARY 05/01/2021 wheat germ oil wheat germ oil REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 multi-vitamin folic acid/multivit with REMOVE FROM Non PDL Non-Formulary minerals/lutein FORMULARY 05/01/2021 OPTISOURCE multivit with calcium- REMOVE FROM Non PDL Non-Formulary mins/iron fumarate/folic FORMULARY acid/vit k 05/01/2021 ARTIFICIAL dextran 70/hypromellose REMOVE FROM Non PDL Non-Formulary TEARS FORMULARY 05/01/2021 SLOW RELEASE ferrous sulfate,ferrous REMOVE FROM Non PDL Non-Formulary IRON sulfate, dried FORMULARY 05/01/2021 FIBER psyllium seed (with REMOVE FROM Non PDL Non-Formulary dextrose) FORMULARY 05/01/2021 GERI-MUCIL psyllium husk/aspartame REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 prenatal 19 prenatal vits with calcium REMOVE FROM Non-Formulary no.115/iron fumarate/folic FORMULARY acid,prenatal vits with calcium 118/ferrous fumarate/folic acid 05/01/2021 calcium 500-vit calcium REMOVE FROM Non PDL Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 05/01/2021 nitroglycerin nitroglycerin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 acetaminophen acetaminophen REMOVE FROM Non PDL Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 623 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 b complex vitamin b complex REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 SEA-OMEGA omega-3 fatty REMOVE FROM Non PDL Non-Formulary acids/dha/epa/other omega- FORMULARY 3s/fish oil 05/01/2021 FOSFREE calcium/multivitamin with REMOVE FROM Non PDL Non-Formulary iron FORMULARY 05/01/2021 THERAGRAN-M multivitamin-minerals/folic REMOVE FROM Non PDL Non-Formulary PREMIER 50 acid/co q10/lycopene/lutein FORMULARY PLUS 05/01/2021 A THRU Z multivits with calcium and REMOVE FROM Non PDL Non-Formulary minerals/iron/folic FORMULARY acid/lycopene 05/01/2021 MAGONATE magnesium carbonate REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 CERALYTE-70 sodium/chloride REMOVE FROM Non PDL Non-Formulary salt/potassium/citrate FORMULARY 05/01/2021 calcium 500 + calcium REMOVE FROM Non PDL Non-Formulary vitamin d carbonate/cholecalciferol FORMULARY (vitamin d3) 05/01/2021 ADULT ONE multivitamin with REMOVE FROM Non PDL Non-Formulary DAILY minerals/folic acid FORMULARY GUMMIES 05/01/2021 AQUA-E vitamin e mixed/tocotrienol REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 one daily with multivitamin with REMOVE FROM Non PDL Non-Formulary iron iron,multivitamins with iron FORMULARY 05/01/2021 niacin flush- niacin (inositol niacinate) REMOVE FROM Non PDL Non-Formulary free,niacin flush FORMULARY free,niacin 05/01/2021 calcium calcium carbonate REMOVE FROM Non PDL Non-Formulary carbonate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 624 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ULTRA FREEDA multivits with calcium and REMOVE FROM Non PDL Non-Formulary minerals/iron fumarate/folic FORMULARY acid 05/01/2021 THERA-TABS M multivits with calcium and REMOVE FROM Non PDL Non-Formulary minerals/iron fumarate/folic FORMULARY acid 05/01/2021 FOLBEE PLUS folic acid/vitamin b complex REMOVE FROM Non PDL Non-Formulary and vitamin c FORMULARY 05/01/2021 ONE DAILY multivitamin with REMOVE FROM Non PDL Non-Formulary MULTIVITAMIN- minerals/ferrous sulfate FORMULARY MINERAL 05/01/2021 SLOW-MAG magnesium chloride REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 ONE-A-DAY multivitamin with REMOVE FROM Non PDL Non-Formulary VITACRAVES minerals/folic acid FORMULARY IMMUNITY 05/01/2021 EMBEDA morphine sulfate/naltrexone REMOVE FROM Non-Preferred Non-Formulary hcl FORMULARY 05/01/2021 EMBEDA morphine sulfate/naltrexone REMOVE FROM Non-Preferred Non-Formulary hcl FORMULARY 05/01/2021 EMBEDA morphine sulfate/naltrexone REMOVE FROM Non-Preferred Non-Formulary hcl FORMULARY 05/01/2021 SENTRY multivitamin with REMOVE FROM Non PDL Non-Formulary SENIOR minerals/folic FORMULARY acid/lycopene/lutein 05/01/2021 ONE DAILY multivitamin with REMOVE FROM Non PDL Non-Formulary WOMENS 50 minerals/folic acid,folic FORMULARY PLUS acid/multivitamin w-minerals 05/01/2021 ONE-A-DAY multivit, calcium, REMOVE FROM Non PDL Non-Formulary WEIGHTSMART iron,minerals/folic acid/herb FORMULARY complex 145

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 625 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 vitamin d3 cholecalciferol (vitamin d3) REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 LUBRICANT carboxymethylcellulose REMOVE FROM Non PDL Non-Formulary EYE DROP sodium FORMULARY 05/01/2021 ONE-A-DAY multivitamin with REMOVE FROM Non PDL Non-Formulary MEN minerals/folic acid FORMULARY VITACRAVES 05/01/2021 magnesium magnesium citrate REMOVE FROM Non PDL Non-Formulary citrate FORMULARY 05/01/2021 JASMIEL ethinyl REMOVE FROM Non PDL Non-Formulary estradiol/drospirenone FORMULARY 05/01/2021 BODY, HAIR, multivit,calcium,iron,min/folic REMOVE FROM Non PDL Non-Formulary SKIN AND NAILS acid/choline/inositol/paba FORMULARY 05/01/2021 MEN'S ONE multivitamin with minerals REMOVE FROM Non PDL Non-Formulary DAILY FORMULARY 05/01/2021 CYTO B7 biotin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 DAILY multivitamin with REMOVE FROM Non PDL Non-Formulary GUMMIES minerals/folic acid FORMULARY 05/01/2021 K-PAX IMMUNE multivit-minerals/iron REMOVE FROM Non PDL Non-Formulary SUPPORT picolin/folic/calcium/d3/amin FORMULARY o acid 05/01/2021 ARTIFICIAL glycerin/propylene glycol REMOVE FROM Non PDL Non-Formulary TEARS FORMULARY 05/01/2021 EYE ALLERGY naphazoline hcl/pheniramine REMOVE FROM Non PDL Non-Formulary RELIEF maleate FORMULARY 05/01/2021 MEDTYCHOLL-B vitamin b complex/liver REMOVE FROM Non PDL Non-Formulary COMPLEX W- extract FORMULARY LIVER 05/01/2021 CERTA PLUS folic acid/multivit with iron, REMOVE FROM Non PDL Non-Formulary minerals/lutein FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 626 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 HOMOCYSTEIN cyanocobalamin/folic REMOVE FROM Non PDL Non-Formulary E FORMULA acid/pyridoxine FORMULARY 05/01/2021 natural psyllium psyllium husk/aspartame REMOVE FROM Non PDL Non-Formulary fiber FORMULARY 05/01/2021 ARTIFICIAL dextran 70/hypromellose REMOVE FROM Non PDL Non-Formulary TEARS FORMULARY 05/01/2021 ONE-A-DAY multivitamin with REMOVE FROM Non PDL Non-Formulary WOMEN minerals/folic acid FORMULARY VITACRAVES 05/01/2021 M-NATAL PLUS prenatal vits with calcium REMOVE FROM Non PDL Non-Formulary no.72/ferrous fumarate/folic FORMULARY acid 05/01/2021 CENTRUM multivit with REMOVE FROM Non PDL Non-Formulary SPECIALIST calcium,iron,minerals/folic FORMULARY HEART acid/phytosterol 05/01/2021 niacin niacin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 prenatal prenatal vits with calcium REMOVE FROM Non PDL Non-Formulary complete no.21/ferrous fumarate/folic FORMULARY acid 05/01/2021 ONE DAILY multivitamin with minerals REMOVE FROM Non PDL Non-Formulary PLUS FORMULARY MINERALS 05/01/2021 CERASPORT sodium chloride/potassium REMOVE FROM Non PDL Non-Formulary chloride/sodium citrate/rice FORMULARY syrup 05/01/2021 prenatal prenatal vitamins no.62/folic REMOVE FROM Non PDL Non-Formulary acid/omega-3s/dha/epa/fish FORMULARY oil 05/01/2021 vitamin e,vitamin vitamin e (dl-alpha REMOVE FROM Non PDL Non-Formulary e-oil,vitamin e oil tocopheryl acetate) FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 627 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 PROTECT PLUS multivit- REMOVE FROM Non PDL Non-Formulary SO min/methyltetrahydrofolate FORMULARY glucos/co-q10/dietary 26 05/01/2021 fish oil omega-3 fatty acids REMOVE FROM Non PDL Non-Formulary concentrate FORMULARY 05/01/2021 QUINTABS-M multivits with calcium and REMOVE FROM Non PDL Non-Formulary minerals/iron fumarate/folic FORMULARY acid 05/01/2021 SPECTRAVITE multivits with calcium and REMOVE FROM Non-Formulary MEN'S minerals/iron/folic FORMULARY acid/lycopene 05/01/2021 magnesium magnesium amino acid REMOVE FROM Non PDL Non-Formulary chelate FORMULARY 05/01/2021 vitamin e vitamin e acetate REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 MERIBIN biotin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 FLUMIST QUAD influenza vaccine REMOVE FROM Non PDL Non-Formulary 2020-2021 quadrivalent live 2020-2021 FORMULARY (2 yrs-49 yrs) 05/01/2021 SUPER multivitamin with REMOVE FROM Non PDL Non-Formulary MULTIPLE minerals/folic acid/dietary FORMULARY suppl no.19 05/01/2021 DAILY VITE multivitamin with iron REMOVE FROM Non PDL Non-Formulary WITH IRON FORMULARY 05/01/2021 magnesium magnesium gluconate REMOVE FROM Non PDL Non-Formulary gluconate FORMULARY 05/01/2021 alendronate alendronate sodium REMOVE FROM Preferred Non-Formulary sodium FORMULARY 05/01/2021 vitamin b vitamin b complex REMOVE FROM Non PDL Non-Formulary complex FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 628 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 MAG magnesium glycinate REMOVE FROM Non PDL Non-Formulary GLYCINATE FORMULARY 05/01/2021 THERATRUM multivitamin with iron and REMOVE FROM Non PDL Non-Formulary COMPLETE other minerals/lutein FORMULARY 05/01/2021 LYLEQ norethindrone REMOVE FROM Non-Formulary FORMULARY 05/01/2021 FOLINIC-PLUS leucovorin calcium/pyridoxal REMOVE FROM Non PDL Non-Formulary phosphate/mecobalamin FORMULARY 05/01/2021 IRON ferrous sulfate, dried REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 VITALEE multivitamin with REMOVE FROM Non PDL Non-Formulary minerals/folic acid FORMULARY 05/01/2021 chlorpheniramine chlorpheniramine maleate REMOVE FROM Non PDL Non-Formulary maleate FORMULARY 05/01/2021 CENTRUM MEN multivits with calcium and REMOVE FROM Non PDL Non-Formulary minerals/iron/folic FORMULARY acid/lycopene 05/01/2021 SOLO multivitamin with REMOVE FROM Non PDL Non-Formulary minerals/folic FORMULARY acid/phytonadione 05/01/2021 niacin niacin (inositol niacinate) REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 TRUEPLUS multivitamin with REMOVE FROM Non PDL Non-Formulary MULTIVITAMIN minerals/folic FORMULARY acid/phytonadione 05/01/2021 COMPANION multivitamin with REMOVE FROM Non PDL Non-Formulary minerals/folic acid FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 629 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 CENTRUM multivits w-ca, other REMOVE FROM Non PDL Non-Formulary ULTRA MEN'S min/iron/folic FORMULARY acid/lycopene,multivits with calcium and minerals/iron/folic acid/lycopene 05/01/2021 miconazole 3 miconazole nitrate/skin REMOVE FROM Non PDL Non-Formulary cleanser no.17 on wipe FORMULARY 05/01/2021 nitroglycerin nitroglycerin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 vitamin e vitamin e acid succinate REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 ESSENTIAL multivitamin with REMOVE FROM Non PDL Non-Formulary MAN 50+ minerals/folic FORMULARY acid/lycopene/lutein 05/01/2021 MAXIMUM multivit with calcium, iron, REMOVE FROM Non PDL Non-Formulary DAILY and other minerals FORMULARY MULTIVITAMIN 05/01/2021 FLONASE fluticasone furoate REMOVE FROM Non-Preferred Non-Formulary SENSIMIST FORMULARY 05/01/2021 vitamin e vitamin e (dl-alpha REMOVE FROM Non PDL Non-Formulary tocopheryl acetate),vitamin FORMULARY e acetate 05/01/2021 CHILDREN'S fluticasone furoate REMOVE FROM Non-Preferred Non-Formulary FLONASE FORMULARY SENSIMIST 05/01/2021 APETIGEN vitamin b complex/ferrous REMOVE FROM Non PDL Non-Formulary PLUS gluconate/zinc oxide/lysine FORMULARY 05/01/2021 GYNOL II nonoxynol 9 REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 vitamin e vitamin e REMOVE FROM Non PDL Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 630 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 biotin plus- multivitamin- REMOVE FROM Non PDL Non-Formulary calcium & vit d3 mins/calcium/biotin/cholecal FORMULARY ciferol/folic acid 05/01/2021 MULTILEX T-M multivitamin with REMOVE FROM Non PDL Non-Formulary minerals/ferrous fumarate FORMULARY 05/01/2021 ESSENTIAL folic acid/multivit with REMOVE FROM Non PDL Non-Formulary WOMAN 50+ minerals/lutein FORMULARY 05/01/2021 ULTRA B-100 vitamin b complex REMOVE FROM Non PDL Non-Formulary COMPLEX FORMULARY 05/01/2021 VINATE-M prenatal vits with calcium REMOVE FROM Non PDL Non-Formulary 136/ferrous fumarate/folic FORMULARY acid 05/01/2021 vitamin cholecalciferol (vitamin d3) REMOVE FROM Non PDL Non-Formulary d3,vitamin d FORMULARY 05/01/2021 MAGBID ER magnesium l-lactate REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 MULTI FOR HER multivit with calcium- REMOVE FROM Non PDL Non-Formulary mins/iron fumarate/folic FORMULARY acid/vit k 05/01/2021 purecomfort peak peak flow meter REMOVE FROM Non PDL Non-Formulary flow meter FORMULARY 05/01/2021 biotin biotin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 vitamin e vitamin e acid succinate REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 vitamin e vitamin e REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 vitamin e vitamin e acid succinate REMOVE FROM Non PDL Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 631 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 b complex with vitamin b complex with REMOVE FROM Non PDL Non-Formulary vitamin c,b- vitamin c combination FORMULARY complex with vit c no.3,vitamin b complex & vit c no.3 05/01/2021 WOMEN'S multivitamin with REMOVE FROM Non PDL Non-Formulary MULTIVITAMIN minerals/folic acid FORMULARY 05/01/2021 MEN'S multivitamin with REMOVE FROM Non PDL Non-Formulary MULTIVITAMIN minerals/folic acid FORMULARY 05/01/2021 esomeprazole esomeprazole strontium REMOVE FROM Non-Preferred Non-Formulary strontium FORMULARY 05/01/2021 multivitamins with multivitamin with minerals REMOVE FROM Non PDL Non-Formulary minerals FORMULARY 05/01/2021 niacin niacin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 SUPER OMEGA- omega-3 fatty acids REMOVE FROM Non PDL Non-Formulary 3 FORMULARY 05/01/2021 QUINTABS-M multivitamin with REMOVE FROM Non PDL Non-Formulary IRON FREE minerals/folic acid FORMULARY 05/01/2021 SUPER multivit with REMOVE FROM Non PDL Non-Formulary MULTIPLE-LOW iron,minerals/folic FORMULARY IRON acid/dietary supp. no.24 05/01/2021 ONE-A-DAY multivit-minerals/folic REMOVE FROM Non PDL Non-Formulary MEN'S 50 PLUS acid/lycopene/ginkgo leaf FORMULARY extract 05/01/2021 ALBA-LYBE lysine hcl/vitamin b complex REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 magnesium magnesium oxide REMOVE FROM Non-Formulary FORMULARY 05/01/2021 SLO-NIACIN niacin REMOVE FROM Non PDL Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 632 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 WOMEN'S ONE multivits with calcium and REMOVE FROM Non PDL Non-Formulary DAILY,ONE minerals/iron fumarate/folic FORMULARY DAILY acid WOMEN'S,ONE DAILY WOMEN'S HEALTH 05/01/2021 complex b-100 vitamin b complex/folic acid REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 multivitamins with multivitamin with REMOVE FROM Non PDL Non-Formulary iron iron,multivitamins with iron FORMULARY 05/01/2021 DAILY multivit with minerals/folic REMOVE FROM Non PDL Non-Formulary MULTIPLE acid/ginkgo biloba leaf FORMULARY extract 05/01/2021 FREEDAVITE multivitamin with REMOVE FROM Non PDL Non-Formulary minerals/ferrous FORMULARY fumarate/folic acid 05/01/2021 ACTICAL calcium REMOVE FROM Non PDL Non-Formulary carbonate/magnesium FORMULARY oxide/vitamin d2/bioflavonoids 05/01/2021 PROLATE oxycodone REMOVE FROM Non-Preferred Non-Formulary hcl/acetaminophen FORMULARY 05/01/2021 tolbutamide tolbutamide REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 LUBRICANT glycerin/propylene glycol REMOVE FROM Non PDL Non-Formulary EYE FORMULARY 05/01/2021 COMPLETE multivit,calcium,minerals/iro REMOVE FROM Non PDL Non-Formulary n/folic acid/lycopene/lutein FORMULARY 05/01/2021 CENTRAVITES folic REMOVE FROM Non PDL Non-Formulary acid/multivit,calcium,iron,oth FORMULARY er mins/lycopene/lutein

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 633 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ONE DAILY folic acid/multivitamin with REMOVE FROM Non PDL Non-Formulary COMPLETE iron, minerals FORMULARY 05/01/2021 THERANATAL prenatal vitamins REMOVE FROM Non PDL Non-Formulary no.28/ferrous fumarate/folic FORMULARY acid 05/01/2021 ESSENTIAL multivitamin with iron and REMOVE FROM Non PDL Non-Formulary BALANCE other FORMULARY minerals/lutein,multivitamin 05/01/2021 nitroglycerin nitroglycerin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 DERMASORB triamcinolone REMOVE FROM Non-Preferred Non-Formulary TA acetonide/emollient FORMULARY combination no.86 05/01/2021 PEDIAVANCE sodium/potassium/chloride/z REMOVE FROM Non PDL Non-Formulary inc/dextrose/fructose FORMULARY 05/01/2021 DERMASORB hydrocortisone/skin cleanser REMOVE FROM Non-Preferred Non-Formulary HC combination no.35 FORMULARY 05/01/2021 CLEARLAX polyethylene glycol 3350 REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 acetaminophen acetaminophen REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 CENTRUM multivitamin with REMOVE FROM Non PDL Non-Formulary CHEWABLES minerals/iron,carbonyl/folic FORMULARY acid/vit k1 05/01/2021 prenatal multi- prenatal vits no.151/iron REMOVE FROM Non PDL Non-Formulary dha fum/folic FORMULARY acid/omega3/dha/epa/fish 05/01/2021 HAIR, SKIN AND multivit,calcium,minerals/ferr REMOVE FROM Non PDL Non-Formulary NAILS ous glucon/folic acid/biotin FORMULARY 05/01/2021 magnesium magnesium REMOVE FROM Non PDL Non-Formulary oxide/magnesium amino FORMULARY acid chelate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 634 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 UNICOMPLEX-M multivitamin with iron and REMOVE FROM Non PDL Non-Formulary other minerals FORMULARY 05/01/2021 PAIN RELIEF acetaminophen REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 SLO-NIACIN niacin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 UROMAG,URO- magnesium oxide REMOVE FROM Non PDL Non-Formulary MAG FORMULARY 05/01/2021 ONE DAILY FOR folic acid/multivitamin with REMOVE FROM Non PDL Non-Formulary WOMEN iron, minerals FORMULARY 05/01/2021 HAIR, SKIN AND multivitamin with REMOVE FROM Non PDL Non-Formulary NAILS minerals/folic acid/biotin FORMULARY 05/01/2021 NO FLUSH niacin (inositol niacinate) REMOVE FROM Non PDL Non-Formulary NIACIN FORMULARY 05/01/2021 MAGINEX magnesium aspartate hcl REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 biotin biotin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 MYVITALIFE multivitamin with minerals REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 vitamin e vitamin e mixed REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 SIDEROL iron/liver extract/vitamin b REMOVE FROM Non PDL Non-Formulary comp and c/minerals FORMULARY 05/01/2021 ALGAL OMEGA- docosahexaenoic acid REMOVE FROM Non PDL Non-Formulary 3 DHA FORMULARY 05/01/2021 vitamin e vitamin e mixed REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 APETEX vitamin b complex/lysine REMOVE FROM Non PDL Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 635 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 b complex with b- vit REMOVE FROM Non PDL Non-Formulary 12 b2/niacinamide/pyridoxine FORMULARY hcl (b6)/vit b12/dexpanthenol 05/01/2021 CHEWABLE- multivitamin REMOVE FROM Non PDL Non-Formulary VITE FORMULARY 05/01/2021 biotin biotin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 vitamin e vitamin e mixed REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 NEPHRONEX vitamin b complex with REMOVE FROM Non PDL Non-Formulary vitamin c no.10/folic acid FORMULARY 05/01/2021 omega-3 fish oil omega-3 fatty REMOVE FROM Non PDL Non-Formulary acids/docosahexaenoic FORMULARY acid/epa/fish oil 05/01/2021 vitamins a-d-e vitamin a palmitate/beta- REMOVE FROM Non PDL Non-Formulary carotene/vit d2/vit FORMULARY e/selenium 05/01/2021 DAILY multivits with calcium and REMOVE FROM Non PDL Non-Formulary MULTIPLE minerals/iron fumarate/folic FORMULARY acid 05/01/2021 METAMUCIL psyllium husk/aspartame REMOVE FROM Non PDL Non-Formulary SUGAR- FORMULARY FREE,METAMU CIL 05/01/2021 EYE HEALTH beta-carotene(a) w-c and REMOVE FROM Non PDL Non-Formulary PLUS e/lutein/minerals FORMULARY LUTEIN,EYE HEALTH AND LUTEIN 05/01/2021 NEPHRONEX-SL vitamin b complex with REMOVE FROM Non PDL Non-Formulary vitamin c no.19/folic FORMULARY acid/vitamin d3

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 636 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 niacin niacin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 METAMUCIL psyllium husk/aspartame REMOVE FROM Non PDL Non-Formulary MULTIHEALTH FORMULARY FIBER 05/01/2021 NATURAL vit b complex 100 REMOVE FROM Non PDL Non-Formulary BALANCED B- combination no.2/herbs FORMULARY 100 05/01/2021 niacin flush free niacin (inositol niacinate) REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 biotin biotin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 MAG-TAB SR magnesium l-lactate REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 wal-itin loratadine REMOVE FROM Preferred Non-Formulary FORMULARY 05/01/2021 STRESS vit b complex/vit c/folic REMOVE FROM Non PDL Non-Formulary FORMULA WITH acid/ferrous fumarate/vit e FORMULARY IRON acet 05/01/2021 STRESS vit b complex/vit c/folic REMOVE FROM Non PDL Non-Formulary FORMULA WITH acid/ferrous sulfate/vit e acet FORMULARY IRON 05/01/2021 REESE'S pyrantel pamoate REMOVE FROM Non PDL Non-Formulary PINWORM FORMULARY 05/01/2021 ONE-A-DAY multivitamin with minerals REMOVE FROM Non PDL Non-Formulary MAXIMUM FORMULARY FORMULA 05/01/2021 MONISTAT 7 miconazole nitrate REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 FOLPLEX 2.2 cyanocobalamin/folic REMOVE FROM Non PDL Non-Formulary acid/pyridoxine FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 637 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 PARVLEX ferrous fumarate/folic REMOVE FROM Non PDL Non-Formulary acid/vitamin b comp and FORMULARY c/minerals 05/01/2021 B-COMPLEX thiamine REMOVE FROM Non PDL Non-Formulary WITH B-12 hcl/riboflavin/niacinamide/cy FORMULARY anocobalamin/protease 05/01/2021 magnesium magnesium chloride REMOVE FROM Non PDL Non-Formulary chloride FORMULARY 05/01/2021 SUPER QUINTS vitamin b complex REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 vitamin e vitamin e,vitamin e acetate REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 HARD NAILS biotin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 SUPER B-50 vitamin b complex REMOVE FROM Non PDL Non-Formulary COMPLEX FORMULARY 05/01/2021 DESOWEN desonide REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 SUNVITE multivit-mins/iron REMOVE FROM Non PDL Non-Formulary fumarate/folic acid/vit FORMULARY k/lycopene/lutein 05/01/2021 VCF nonoxynol 9 REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 CREAMY ACNE benzoyl peroxide REMOVE FROM Non PDL Non-Formulary FACE FORMULARY 05/01/2021 PREVACID lansoprazole REMOVE FROM Non-Formulary 24HR FORMULARY 05/01/2021 ONE-A-DAY multivitamin with REMOVE FROM Non PDL Non-Formulary MEN'S 50 PLUS minerals/folic acid/vitamin FORMULARY k1/lycopene

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 638 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ONE-A-DAY multivit,calcium,min/ferrous REMOVE FROM Non PDL Non-Formulary WOMEN'S fum/folic FORMULARY acid/guarana/caffeine 05/01/2021 FIBER SMOOTH psyllium seed (with sugar) REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 MEN'S DAILY multivitamin with REMOVE FROM Non PDL Non-Formulary FORMULA minerals/folic acid/lycopene FORMULARY 05/01/2021 calcium citrate - calcium REMOVE FROM Non-Formulary vitamin d,calcium citrate/cholecalciferol FORMULARY citrate-vitamin d3 (vitamin d3) 05/01/2021 BIOPETIT vitamin b complex/lysine REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 hydrocortisone hydrocortisone REMOVE FROM Preferred Non-Formulary FORMULARY 05/01/2021 B-100 vitamin b complex 100 REMOVE FROM Non PDL Non-Formulary COMPLEX,BALA combination no.2 FORMULARY NCED B-100 05/01/2021 ONE-A-DAY multivitamin/folic REMOVE FROM Non PDL Non-Formulary VITACRAVES acid/docosahexanoic acid FORMULARY OMEGA-3 05/01/2021 CORVITE FREE multivit with minerals REMOVE FROM Non PDL Non-Formulary no.6/folic FORMULARY acid/lutein/lycopene/coq10 05/01/2021 biotin biotin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 D3-2000 cholecalciferol (vitamin d3) REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 COMPLETE multivit with iron, REMOVE FROM Non PDL Non-Formulary PREMIUM minerals/ginkgo biloba FORMULARY VITAMIN ext/panax ginseng 05/01/2021 niacin,plain niacin niacin REMOVE FROM Non PDL Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 639 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 b complex with thiamine REMOVE FROM Non PDL Non-Formulary vitamin c m.nit/riboflavin/niacin/ca FORMULARY pantothenate/b6/b12/c/fa 05/01/2021 ONE DAILY multivit with calcium, iron, REMOVE FROM Non PDL Non-Formulary WITH CALCIUM- and other minerals FORMULARY IRON 05/01/2021 vitamin e vitamin e mixed REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 PROCERV HP multivit-minerals/iron REMOVE FROM Non PDL Non-Formulary fumarate/folic acid/vit FORMULARY k/green tea 05/01/2021 SOLUVITA-E vitamin e (dl-alpha REMOVE FROM Non PDL Non-Formulary tocopheryl acetate) FORMULARY 05/01/2021 ADULT multivitamin with REMOVE FROM Non PDL Non-Formulary MULTIVITAMIN minerals/folic acid FORMULARY GUMMIES,ADUL T MULTI GUMMIES 05/01/2021 ONE DAILY multivitamin with REMOVE FROM Non PDL Non-Formulary ESSENTIAL minerals/folic acid FORMULARY 05/01/2021 vitamin e vitamin e mixed REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 OPCON-A naphazoline hcl/pheniramine REMOVE FROM Non PDL Non-Formulary maleate FORMULARY 05/01/2021 magnesium magnesium oxide REMOVE FROM Non PDL Non-Formulary oxide,magnesium FORMULARY 05/01/2021 MAG64 magnesium chloride REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 MONOCAPS multivitamin with REMOVE FROM Non PDL Non-Formulary minerals/ferrous FORMULARY fumarate/folic acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 640 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ONE DAILY multivitamin with minerals REMOVE FROM Non PDL Non-Formulary ENERGY FORMULARY 05/01/2021 WOMEN'S multivit with calcium, iron, REMOVE FROM Non PDL Non-Formulary DAILY and other minerals FORMULARY FORMULA 05/01/2021 vitamin cholecalciferol (vitamin d3) REMOVE FROM Non PDL Non-Formulary d3,vitamin d FORMULARY 05/01/2021 CENTURY multivitamin,ca,min/folic REMOVE FROM Non PDL Non-Formulary MATURE acid/vitamin FORMULARY k/lycopene/lutein 05/01/2021 QUIN B vitamin b comp and c/folic REMOVE FROM Non PDL Non-Formulary STRONG acid/zinc FORMULARY 05/01/2021 niacinamide niacinamide REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 niacin niacin (inositol niacinate) REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 magnesium,mag magnesium oxide REMOVE FROM Non PDL Non-Formulary nesium oxide FORMULARY 05/01/2021 magnesium magnesium gluconate REMOVE FROM Non PDL Non-Formulary gluconate FORMULARY 05/01/2021 VITATRUM multivit,calcium,minerals/iro REMOVE FROM Non PDL Non-Formulary n/folic acid/lycopene/lutein FORMULARY 05/01/2021 triamterene- triamterene/hydrochlorothiaz REMOVE FROM Non PDL Non-Formulary hydrochlorothiazi ide FORMULARY d,triamterene- hctz 05/01/2021 BIOCAL calcium carbonate/vit REMOVE FROM Non PDL Non-Formulary d3/magnesium oxide/folic FORMULARY acid/vit k 05/01/2021 OCUTABS beta-carotene (vitamin a) REMOVE FROM Non PDL Non-Formulary with vitamins c and FORMULARY e/minerals

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 641 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 balanced b- folic acid/vitamin b complex REMOVE FROM Non-Formulary complex,b- and vitamin c,folic FORMULARY complex with acid/vitamin b comp w-c vitamin c,super b- complex,super b complex,b- complex,super vitamin b,b- complex plus vitamin c,super vitamin b complex,super b complex-vitamin c,vitamin b complex-vitamin c 05/01/2021 BABY AYR sodium chloride REMOVE FROM Non PDL Non-Formulary SALINE FORMULARY 05/01/2021 ULTRA FRESH carboxymethylcellulose REMOVE FROM Non PDL Non-Formulary sodium FORMULARY 05/01/2021 DAILY multivit-minerals/folic acid/vit REMOVE FROM Non PDL Non-Formulary MULTIVITAMIN k/lycopene/lutein/co q10 FORMULARY 05/01/2021 b-100 complex vitamin b complex 100 REMOVE FROM Non PDL Non-Formulary combination no.2 FORMULARY 05/01/2021 multiple vitamin multivitamin with minerals REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 DAILY multivitamin/ferrous REMOVE FROM Non PDL Non-Formulary MULTIVITAMIN- fumarate/folic acid FORMULARY IRON,MULTIVIT AMIN WITH IRON 05/01/2021 DAILY VITAMIN multivitamin with REMOVE FROM Non PDL Non-Formulary + IRON iron,multivitamins with iron FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 642 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ALLERGY fexofenadine hcl REMOVE FROM Non-Preferred Non-Formulary RELIEF FORMULARY 05/01/2021 OPURITY iron,carbonyl/folic REMOVE FROM Non PDL Non-Formulary MULTIVITAMIN acid/multivit with minerals FORMULARY 05/01/2021 OMNICAP multivitamin with REMOVE FROM Non PDL Non-Formulary minerals/folic acid FORMULARY 05/01/2021 KPN prenatal vitamin REMOVE FROM Non PDL Non-Formulary calcium,iron,folic acid (less FORMULARY than 1 mg) 05/01/2021 hair, skin and multivitamin with minerals REMOVE FROM Non PDL Non-Formulary nails,hair, skin & FORMULARY nails 05/01/2021 omeprazole omeprazole magnesium REMOVE FROM Non-Formulary magnesium FORMULARY 05/01/2021 oyster shell calcium REMOVE FROM Non PDL Non-Formulary calcium w-vit carbonate/cholecalciferol FORMULARY d,oyster shell (vitamin d3) calcium-vit d3 05/01/2021 magnesium magnesium REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 PROTECT multivit- REMOVE FROM Non PDL Non-Formulary CARDIO AF min/methyltetrahydrofolate FORMULARY gl/co-q10/dha/epa/diet27 05/01/2021 TYLENOL acetaminophen REMOVE FROM Non PDL Non-Formulary EXTRA FORMULARY STRENGTH 05/01/2021 essential daily multivit with calcium, iron, REMOVE FROM Non PDL Non-Formulary and other minerals FORMULARY 05/01/2021 FIBER psyllium husk (with sugar) REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 ultra b-100 vitamin b complex REMOVE FROM Non PDL Non-Formulary complex FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 643 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 mega biotin biotin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 ZARAH ethinyl REMOVE FROM Non PDL Non-Formulary estradiol/drospirenone FORMULARY 05/01/2021 BIO-35 multivit,calcium,mins/iron/foli REMOVE FROM Non PDL Non-Formulary c FORMULARY acid/lutein/lycopen/herb175 05/01/2021 SLOW RELEASE ferrous sulfate REMOVE FROM Non PDL Non-Formulary IRON FORMULARY 05/01/2021 VITRUM 50 multivitamin with REMOVE FROM Non PDL Non-Formulary PLUS SENIOR minerals/folic FORMULARY acid/lycopene/lutein 05/01/2021 COMPLETE multivitamin,therapeutic with REMOVE FROM Non PDL Non-Formulary MULTIVITAMIN iron and minerals FORMULARY 05/01/2021 vitamin d3 cholecalciferol (vitamin d3) REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 FOLBEE PLUS folic acid/vitamin b comp REMOVE FROM Non PDL Non-Formulary CZ and c/copper/zinc oxide FORMULARY 05/01/2021 base, pcca wax base no.116 REMOVE FROM Preferred Non-Formulary polypeg FORMULARY 05/01/2021 CENTURY multivit with REMOVE FROM Non PDL Non-Formulary CARDIO calcium,iron,minerals/folic FORMULARY acid/phytosterol 05/01/2021 vitamin b vitamin b complex REMOVE FROM Non PDL Non-Formulary complex,b FORMULARY complex 05/01/2021 BALANCE B-100 vitamin b complex/folic acid REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 b complex vitamin b complex/folic acid REMOVE FROM Non PDL Non-Formulary number 1 FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 644 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 vitamin b vitamin b complex REMOVE FROM Non PDL Non-Formulary complex FORMULARY 05/01/2021 BIOCEL multivitamin with REMOVE FROM Non PDL Non-Formulary minerals/folic FORMULARY acid/lycopene/lutein 05/01/2021 BALANCE B-50 vitamin b complex/folic acid REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 biotin biotin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 REGULOID psyllium husk (with sugar) REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 ONE DAILY folic acid/multivitamin with REMOVE FROM Non PDL Non-Formulary MAXIMUM iron, minerals,folic FORMULARY acid/multivits w-fe,other min 05/01/2021 REGULOID psyllium husk (with sugar) REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 ONE DAILY multivitamin with minerals REMOVE FROM Non PDL Non-Formulary COMPLETE FORMULARY 05/01/2021 ONE DAILY multivit with calcium, iron, REMOVE FROM Non PDL Non-Formulary WOMEN'S and other minerals FORMULARY 05/01/2021 multiple vitamins multivit with calcium, iron, REMOVE FROM Non PDL Non-Formulary for women and other minerals FORMULARY 05/01/2021 MAG-G magnesium gluconate REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 ONE-A-DAY multivit,calcium,min/ferrous REMOVE FROM Non PDL Non-Formulary ENERGY fum/folic FORMULARY acid/guarana/caffeine 05/01/2021 ONE-A-DAY multivitamin with calcium, REMOVE FROM Non PDL Non-Formulary WOMEN'S minerals/iron/folic acid/lutein FORMULARY HEALTHY SKIN

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 645 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 b-complex with folic acid/vitamin b complex REMOVE FROM Non PDL Non-Formulary vitamin c and vitamin c FORMULARY 05/01/2021 ONE-A-DAY multivitamin with calcium, REMOVE FROM Non PDL Non-Formulary MENOPAUSE mineral/folic acid/soy FORMULARY FORMULA isoflavone 05/01/2021 prenatal dha docosahexanoic REMOVE FROM Non PDL Non-Formulary acid,docosahexaenoic acid FORMULARY 05/01/2021 ONE-A-DAY multivits with calcium and REMOVE FROM Non PDL Non-Formulary WOMEN'S minerals/iron fumarate/folic FORMULARY PETITES acid 05/01/2021 niacin niacin (inositol niacinate) REMOVE FROM Non PDL Non-Formulary inositol,niacin FORMULARY 05/01/2021 LOTRISONE clotrimazole/betamethasone REMOVE FROM Non-Formulary dipropionate FORMULARY 05/01/2021 DIABETES folic acid/multivit with REMOVE FROM Non PDL Non-Formulary HEALTH minerals/lutein FORMULARY FORMULA 05/01/2021 ULTRA FREEDA multivitamin with calcium REMOVE FROM Non PDL Non-Formulary and minerals/folic acid FORMULARY 05/01/2021 PRO-CAL calcium REMOVE FROM Non PDL Non-Formulary phosphat/magnesium FORMULARY hydroxide/vit c/vit d3/phosphorus 05/01/2021 SUPER multivit with REMOVE FROM Non PDL Non-Formulary GINSENG minerals/ginseng FORMULARY MULTIVITAMIN 05/01/2021 MEN'S ONE multivitamin with REMOVE FROM Non PDL Non-Formulary DAILY,ONE minerals/folic acid/vitamin FORMULARY DAILY k1/lycopene MEN'S,ONE DAILY MEN'S HEALTH

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 646 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 biotin biotin REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 magnesium magnesium REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 MAGOX magnesium oxide REMOVE FROM Non PDL Non-Formulary 400,MAGOX FORMULARY 05/01/2021 pcca base mineral oil, REMOVE FROM Preferred Non-Formulary anhydrous light/petrolatum,white/cetyl FORMULARY alc/stearyl alc 05/01/2021 STRESS vitamin b complex/minerals REMOVE FROM Non PDL Non-Formulary FORMULA FORMULARY 05/01/2021 ONE DAILY multivit, calcium, REMOVE FROM Non PDL Non-Formulary HEALTHY iron,minerals/folic acid/herb FORMULARY WEIGHT complex 145 05/01/2021 prenatal prenatal vits with calcium REMOVE FROM Non PDL Non-Formulary vitamin,prenatal 137/ferrous fumarate/folic FORMULARY vitamins,prenatal acid,prenatal vitamins with calcium/ferrous fumarate/folic acid,prenatal vit with calcium no.130/ferrous fumarate/folic acid,prenatal vitamins/ferrous fumarate/folic acid 05/01/2021 calcium,chewable calcium REMOVE FROM Non-Formulary calcium carbonate/cholecalciferol FORMULARY (vitamin d3) 05/01/2021 VITACEL multivitamin with REMOVE FROM Non PDL Non-Formulary minerals/folic FORMULARY acid/lycopene/lutein 05/01/2021 ESSENTIAL multivitamin with REMOVE FROM Non PDL Non-Formulary MAN minerals/folic FORMULARY acid/lycopene/lutein

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 647 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 magnesium magnesium gluconate REMOVE FROM Non PDL Non-Formulary gluconate FORMULARY 05/01/2021 ARTIFICIAL dextran 70/hypromellose REMOVE FROM Non PDL Non-Formulary TEARS FORMULARY 05/01/2021 WOMEN'S calcium/magnesium/vit b REMOVE FROM Non PDL Non-Formulary COMPLEX comp/vitamin d3/herbal FORMULARY complex no.61 05/01/2021 ONE-A-DAY multivitamin with REMOVE FROM Non PDL Non-Formulary MEN'S minerals/folic acid/vitamin FORMULARY k1/lycopene 05/01/2021 BALANCED B-50 vitamin b complex REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 ARKALIOX sulbutiamine REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 BREWER'S yeast, dried (saccharomyces REMOVE FROM Non PDL Non-Formulary YEAST cerevisiae) FORMULARY 05/01/2021 prenatal prenatal vitamins with REMOVE FROM Non PDL Non-Formulary vitamins,prenatal calcium/ferrous FORMULARY fumarate/folic acid,prenatal vitamins/ferrous fumarate/folic acid 05/01/2021 ONE-A-DAY multivitamin with REMOVE FROM Non PDL Non-Formulary VITACRAVES minerals/folic acid FORMULARY SOUR,ONE-A- DAY VITACRAVES 05/01/2021 ora plus compounding vehicle REMOVE FROM Non-Formulary suspension sugar-free no.20 FORMULARY 05/01/2021 DVORAH acetaminophen/caffeine/dihy REMOVE FROM Non-Preferred Non-Formulary drocodeine bitartrate FORMULARY 05/01/2021 THEREMS-H multivitamin,therapeutic with REMOVE FROM Non PDL Non-Formulary iron and minerals FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 648 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 SPECTRAVITE multivitamin with REMOVE FROM Non PDL Non-Formulary SENIOR minerals/folic FORMULARY acid/lycopene/lutein 05/01/2021 MULTILEX multivitamin with REMOVE FROM Non PDL Non-Formulary minerals/ferrous sulfate FORMULARY 05/01/2021 ferrous ferrous sulfate ADD TO FORMULARY Non-Formulary Non PDL sulfate,iron 05/01/2021 vitamin cholecalciferol (vitamin d3) REMOVE UM: CUSTOM d3,vitamin d 05/01/2021 vitamin e vitamin e (dl-alpha REMOVE FROM Non-Formulary tocopheryl acetate) FORMULARY 05/01/2021 ferrous sulfate ferrous sulfate REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 THERA-M multivit,therapeutic with REMOVE FROM Non PDL Non-Formulary calcium,iron,minerals/folic FORMULARY acid 05/01/2021 vitamin e vitamin e,vitamin e REMOVE FROM Non PDL Non-Formulary acetate,vitamin e (dl-alpha FORMULARY tocopheryl acetate) 05/01/2021 hydroxyzine hcl hydroxyzine hcl REMOVE FROM Non-Formulary FORMULARY 05/01/2021 slow release iron ferrous sulfate REMOVE FROM Non PDL Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 649 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 calcium citrate- calcium REMOVE FROM Non PDL Non-Formulary d,calcium citrate - citrate/cholecalciferol FORMULARY vitamin d,calcium (vitamin d3) citrate-vit d3,calcium citrate-vitamin d3,calcium citrate - vitamin d3,calcium citrate- vitamin d,calcium citrate- vit d 05/01/2021 meperidine hcl meperidine hcl REMOVE FROM Non-Formulary FORMULARY 05/01/2021 bacitracin zinc bacitracin zinc REMOVE FROM Non-Formulary FORMULARY 05/01/2021 multi-vitamin w- pediatric multivitamin REMOVE FROM Non-Formulary fluoride,multivita combination no.2/sodium FORMULARY mins with fluoride,pediatric fluoride,multivita multivitamin no.82 with min and sodium fluoride,pediatric fluoride,multivita multivitamin no.2/sodium min with fluoride fluoride,pediatric multivitamin no.150 with sodium fluoride 05/01/2021 multi-vitamin w- pediatric multivitamin REMOVE FROM Non-Formulary fluoride,multivita combination no.2/sodium FORMULARY mins with fluoride,pediatric fluoride,polyvitam multivitamin no.2/sodium ins- fluoride fluoride,multivita min with fluoride 05/01/2021 calcium 600 + vit calcium REMOVE FROM Non PDL Non-Formulary d carbonate/cholecalciferol FORMULARY (vitamin d3)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 650 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 NATURAL psyllium seed (with REMOVE FROM Non PDL Non-Formulary VEGETABLE dextrose) FORMULARY POWDER 05/01/2021 NATURAL DAILY psyllium husk/aspartame REMOVE FROM Non PDL Non-Formulary FIBER FORMULARY 05/01/2021 vitamin e vitamin e acetate,vitamin e REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 FISH OIL omega-3 fatty REMOVE FROM Non PDL Non-Formulary acids/dha/epa/other omega- FORMULARY 3s/fish oil 05/01/2021 prenatal prenatal vits with calcium REMOVE FROM Non PDL Non-Formulary vitamins,prenatal, 95/ferrous fumarate/folic FORMULARY prenatal vitamin acid 05/01/2021 THERA-M multivitamin,therapeutic with REMOVE FROM Non PDL Non-Formulary iron and minerals,multivits,th FORMULARY w-fe,other min 05/01/2021 KONSYL psyllium husk (with sugar) REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 LUBRICANT propylene REMOVE FROM Non PDL Non-Formulary EYE,LUBRICATI glycol/polyethylene glycol FORMULARY NG 400 TEARS,LUBRIC ATING EYE 05/01/2021 FIBER psyllium husk (with sugar) REMOVE FROM Non PDL Non-Formulary THERAPY,FIBE FORMULARY R 05/01/2021 vitamin e vitamin e (dl-alpha REMOVE FROM Non PDL Non-Formulary tocopheryl acetate) FORMULARY 05/01/2021 THERAPEUTIC- multivits with calcium and REMOVE FROM Non PDL Non-Formulary M minerals/iron fumarate/folic FORMULARY acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 651 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 ONE DAILY multivitamin with REMOVE FROM Non PDL Non-Formulary minerals/folic acid/lycopene FORMULARY 05/01/2021 vitamin b- folic acid/vitamin b complex REMOVE FROM Non PDL Non-Formulary complex with vit c and c/rice bran FORMULARY 05/01/2021 FIBER methylcellulose (with sugar) REMOVE FROM Non PDL Non-Formulary THERAPY FORMULARY 05/01/2021 fish oil omega-3 fatty REMOVE FROM Non PDL Non-Formulary acids/docosahexanoic FORMULARY acid/epa/fish oil,omega-3 fatty acids/docosahexaenoic acid/epa/fish oil 05/01/2021 vitamin e vitamin e,vitamin e acetate REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 NATURAL FIBER psyllium seed (with REMOVE FROM Non PDL Non-Formulary dextrose),psyllium seed FORMULARY (with sugar),psyllium seed 05/01/2021 NATURAL FIBER psyllium seed/aspartame REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 fish oil omega-3 fatty REMOVE FROM Non PDL Non-Formulary acids/docosahexanoic FORMULARY acid/epa/fish oil 05/01/2021 A THRU Z multivitamin with REMOVE FROM Non PDL Non-Formulary SELECT minerals/folic FORMULARY acid/lycopene/lutein 05/01/2021 vitamin e vitamin e (dl-alpha REMOVE FROM Non PDL Non-Formulary tocopheryl acetate) FORMULARY 05/01/2021 ferrous gluconate ferrous gluconate REMOVE FROM Non PDL Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 652 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 A THRU Z multivit,calcium,minerals/iro REMOVE FROM Non PDL Non-Formulary n/folic FORMULARY acid/lycopene/lutein,multivit, calcium,other min/ferrous fumarate/fa/lycopene/lut 05/01/2021 CENTURY multivits with calcium and REMOVE FROM Non PDL Non-Formulary ULTIMATE minerals/iron/folic FORMULARY MEN'S acid/lycopene 05/01/2021 WAL-MUCIL psyllium husk/aspartame REMOVE FROM Non PDL Non-Formulary FORMULARY 05/01/2021 fish oil omega-3 fatty acids/fish REMOVE FROM Non PDL Non-Formulary oil,omega-3 fatty FORMULARY acids/dha/epa/other omega- 3s/fish oil 05/01/2021 natural fiber psyllium seed (with REMOVE FROM Non PDL Non-Formulary powder dextrose),psyllium seed FORMULARY (with sugar) 05/01/2021 METAMUCIL psyllium seed (with REMOVE FROM Non PDL Non-Formulary OT,METAMUCIL sugar),psyllium seed (with FORMULARY dextrose) 05/01/2021 magnesium,mag magnesium oxide REMOVE FROM Non PDL Non-Formulary nesium oxide FORMULARY 05/01/2021 oyster shell calcium REMOVE FROM Non PDL Non-Formulary calcium-vitamin carbonate/cholecalciferol FORMULARY d,oyster shell (vitamin d3) calcium 05/01/2021 DAILY VITAMIN multivitamin with minerals REMOVE FROM Non PDL Non-Formulary FORMULA- FORMULARY MINERALS 05/01/2021 prenatal vitamins prenatal vitamins with REMOVE FROM Non PDL Non-Formulary calcium/ferrous FORMULARY fumarate/folic acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 653 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2021 vitamin b vitamin b complex/folic acid REMOVE FROM Non PDL Non-Formulary complex,b- FORMULARY complex,vitamin b-50 complex 05/01/2021 theophylline theophylline anhydrous ADD TO FORMULARY Non-Formulary Non PDL 05/01/2021 theophylline theophylline anhydrous ADD TO FORMULARY Non-Formulary Non PDL 05/01/2021 OTEZLA apremilast ADD TO FORMULARY Non-Formulary Non-Preferred 05/01/2021 OTEZLA apremilast ADD UM: DRUGCLASS BIOLOGICS 05/01/2021 OTEZLA apremilast ADD UM: PANAME Clinical PA 05/01/2021 OTEZLA apremilast REMOVE FROM Non-Preferred Non-Formulary FORMULARY 05/01/2021 OTEZLA apremilast REMOVE UM: PANAME Clinical PA 05/01/2021 OTEZLA apremilast REMOVE UM: BIOLOGICS DRUGCLASS 05/01/2021 PLEGRIDY peginterferon beta-1a ADD TO FORMULARY Non-Preferred 05/01/2021 PLEGRIDY peginterferon beta-1a ADD UM: DRUGCLASS MULTIPLE SCLEROSIS AGENTS 05/01/2021 PLEGRIDY peginterferon beta-1a ADD UM: PANAME Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 654 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

June, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/01/2021 HIZENTRA immune globulin,gamma REMOVE UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 06/01/2021 HIZENTRA immune globulin,gamma REMOVE UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 06/01/2021 HIZENTRA immune globulin,gamma REMOVE UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 06/01/2021 HIZENTRA immune globulin,gamma REMOVE UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 06/01/2021 HIZENTRA immune globulin,gamma REMOVE UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 06/01/2021 HIZENTRA immune globulin,gamma REMOVE UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 06/01/2021 HIZENTRA immune globulin,gamma REMOVE UM: MED Medical Drug (igg)/proline/iga 0 to 50 mcg/ml 06/03/2021 LYLEQ norethindrone ADD TO FORMULARY Non PDL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 655 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

July, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 INGREZZA valbenazine tosylate ADD TO FORMULARY Non PDL 07/01/2021 INGREZZA valbenazine tosylate ADD UM: AGE At least 18 yrs old 07/01/2021 INGREZZA valbenazine tosylate ADD UM: PANAME Clinical PA 07/01/2021 INGREZZA valbenazine tosylate ADD TO FORMULARY Non PDL 07/01/2021 INGREZZA valbenazine tosylate ADD UM: AGE At least 18 yrs old 07/01/2021 INGREZZA valbenazine tosylate ADD UM: PANAME Clinical PA 07/01/2021 INGREZZA valbenazine tosylate ADD TO FORMULARY Non PDL 07/01/2021 INGREZZA valbenazine tosylate ADD UM: AGE At least 18 yrs old 07/01/2021 INGREZZA valbenazine tosylate ADD UM: PANAME Clinical PA 07/01/2021 INGREZZA valbenazine tosylate ADD TO FORMULARY Non PDL INITIATION PACK 07/01/2021 INGREZZA valbenazine tosylate ADD UM: AGE At least 18 yrs INITIATION old PACK 07/01/2021 INGREZZA valbenazine tosylate ADD UM: PANAME Clinical PA INITIATION PACK 07/01/2021 AUSTEDO deutetrabenazine ADD TO FORMULARY Non PDL 07/01/2021 AUSTEDO deutetrabenazine ADD UM: AGE At least 18 yrs old 07/01/2021 AUSTEDO deutetrabenazine ADD UM: PANAME Clinical PA 07/01/2021 AUSTEDO deutetrabenazine ADD TO FORMULARY Non PDL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 656 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 AUSTEDO deutetrabenazine ADD UM: AGE At least 18 yrs old 07/01/2021 AUSTEDO deutetrabenazine ADD UM: PANAME Clinical PA 07/01/2021 AUSTEDO deutetrabenazine ADD TO FORMULARY Non PDL 07/01/2021 AUSTEDO deutetrabenazine ADD UM: AGE At least 18 yrs old 07/01/2021 AUSTEDO deutetrabenazine ADD UM: PANAME Clinical PA 07/01/2021 hydrocortisone hydrocortisone ADD TO FORMULARY Non PDL 07/01/2021 hydrocortisone hydrocortisone acetate ADD TO FORMULARY Non PDL acetate,hemorrho idal hc 07/01/2021 hydrocortisone- hydrocortisone ADD TO FORMULARY Non PDL pramoxine acetate/pramoxine hcl 07/01/2021 hydrocortisone- hydrocortisone ADD TO FORMULARY Non PDL pramoxine acetate/pramoxine hcl 07/01/2021 hydrocortisone- hydrocortisone ADD TO FORMULARY Non PDL pramoxine acetate/pramoxine hcl 07/01/2021 hydrocortisone hydrocortisone acetate ADD TO FORMULARY Non PDL acetate 07/01/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non PDL Non-Formulary acetate FORMULARY 07/01/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non PDL Non-Formulary acetate FORMULARY 07/01/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non PDL Non-Formulary acetate FORMULARY 07/01/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non PDL Non-Formulary acetate FORMULARY 07/01/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non PDL Non-Formulary acetate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 657 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non PDL Non-Formulary acetate FORMULARY 07/01/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non PDL Non-Formulary acetate FORMULARY 07/01/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non PDL Non-Formulary acetate FORMULARY 07/01/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non PDL Non-Formulary acetate FORMULARY 07/01/2021 ELURYNG etonogestrel/ethinyl estradiol ADD TO FORMULARY Non PDL 07/01/2021 TYLENOL- acetaminophen with codeine REMOVE FROM Non-Preferred Non-Formulary CODEINE NO.3 phosphate FORMULARY 07/01/2021 TYLENOL- acetaminophen with codeine REMOVE UM: PANAME Non Preferred PA CODEINE NO.3 phosphate 07/01/2021 TYLENOL- acetaminophen with codeine REMOVE UM: NARCOTICS – CODEINE NO.3 phosphate DRUGCLASS SHORT AND INTERMEDIATE ACTING 07/01/2021 SKYRIZI risankizumab-rzaa ADD TO FORMULARY Non-Preferred 07/01/2021 SKYRIZI risankizumab-rzaa ADD UM: PANAME Clinical PA 07/01/2021 SKYRIZI PEN risankizumab-rzaa ADD TO FORMULARY Non-Preferred 07/01/2021 SKYRIZI PEN risankizumab-rzaa ADD UM: PANAME Clinical PA 07/01/2021 SKYRIZI risankizumab-rzaa ADD UM: DRUGCLASS BIOLOGICS 07/01/2021 SKYRIZI PEN risankizumab-rzaa ADD UM: DRUGCLASS BIOLOGICS 07/01/2021 ZENPEP lipase/protease/amylase REMOVE UM: PANAME Clinical PA 07/01/2021 ZENPEP lipase/protease/amylase REMOVE UM: PANAME Clinical PA 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 658 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 659 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS 07/01/2021 lactulose lactulose ADD TO FORMULARY Non-Formulary Non PDL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 660 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 lactulose lactulose REMOVE UM: CUSTOM CARVE OUT- BILL MDCH FFS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 661 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 levo- levorphanol CHANGE UM: CUSTOM Cumulative MED dromoran,fentany tartrate,fentanyl,oxycodone 90 mg/day l,endocet,hydroco hcl/acetaminophen,hydroco done- done acetaminophen,a bitartrate/acetaminophen,ac cetaminophen- etaminophen with codeine codeine,oxycodo phosphate,morphine ne- sulfate,meperidine acetaminophen,k hcl,fentanyl citrate,codeine adian,demerol,on sulfate,hydromorphone solis,morphine hcl,oxymorphone sulfate,codeine hcl,methadone sulfate,hydromor hcl,oxycodone phone hcl,butorphanol hcl,oxymorphone tartrate,codeine hcl,methadone phosphate,hydrocodone/ibu hcl,levorphanol profen,tramadol tartrate,oxycodon hcl,propoxyphene e hcl,butorphanol napsylate/acetaminophen,pr tartrate,meperidin opoxyphene e hcl,methadone hcl,butalbital/acetaminophen intensol,roxicet,d /caffeine/codeine olophine phosphate,tramadol hcl,diskets,tylenol hcl/acetaminophen,carisopr -codeine odol/aspirin/codeine no.3,tylenol- phosphate,ibuprofen/oxycod codeine one hcl,propoxyphene no.4,codeine hcl/acetaminophen,oxycodo phosphate,vicodi ne hcl/aspirin,meperidine n,vicodin hcl/pf,fentanyl es,vicodin citrate/pf,nalbuphine hp,vicoprofen,tra hcl,pentazocine madol lactate,buprenorphine hcl,propoxyphene hcl,morphine nap- sulfate/pf,hydromorphone acetaminophen,p hcl/pf,alfentanil ropoxyphene hcl,sufentanil hcl,fentanyl citrate,morphine citrate,zolvit,lorta sulfate/dextrose 5%-

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 662 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value b,hydrocodone- water/pf,dihydrocodeine ibuprofen,oxymor bitartrate/acetaminophen/caf phone hcl er,co- feine,codeine gesic,butalb-caff- phosphate/butalbital/aspirin/ acetaminoph- caffeine,opium/belladonna codein,tramadol alkaloids,pentazocine hcl- hcl/naloxone acetaminophen,c hcl,pentazocine arisoprodol hcl/acetaminophen,oxycodo compound- ne hcl/oxycodone codeine,morphin terephthalate/aspirin,hydroc e sulfate odone er,oxycodone hcl- bit/acetaminophen,tapentad ibuprofen,capital ol w- hcl,acetaminophen/caffeine/ codeine,propoxyp dihydrocodeine hene hcl- bitartrate,morphine sulfate in acetaminophen,o 0.9 % sodium xycodone hcl- chloride/pf,fentanyl citrate in aspirin,methados 0.9 % sodium e,nalbuphine chloride/pf,methadone hcl,talwin,bupren hydrochloride in 0.9 % orphine sodium hcl,alfentanil chloride,hydromorphone hcl,sufentanil hcl/bupivacaine hcl in 0.9% citrate,morphine sodium sulfate in chloride/pf,hydromorphone dextrose,hydroge hcl in 0.9 % sodium sic,panlor chloride/pf,meperidine hcl in ss,butalbital 0.9 % sodium compound- chloride,fentanyl codeine,belladon citrate/bupivacaine hcl in 0.9 na- % sodium opium,pentazocin chloride/pf,fentanyl e-naloxone citrate/ropivacaine hcl,pentazocine- hcl/sodium chloride acetaminophen,o 0.9%/pf,sufentanil xycodone- citrate/pf,morphine sulfate aspirin,butalb- liposomal/pf,morphine

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 663 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value acetaminoph- sulfate/naltrexone caff- hcl,buprenorphine,tramadol codein,duramorp hcl/glucosamine h,infumorph,marg sulfate,hydromorphone hcl esic h,lorcet in 0.9 % sodium plus,lorcet 10- chloride,morphine sulfate in 650,balacet 0.9 % sodium 325,tramadol hcl chloride,aspirin/caffeine/dihy er,oxycodone hcl- drocodeine acetaminophen,s bitartrate,morphine sulfate in ublimaze,sufenta, sodium chloride, iso- alfenta,buprenex, osmotic/pf,codeine hycet,ryzolt,nucy phosphate/carisoprodol/aspi nta,avinza,aceta rin,morphine minoph-caff- sulfate/dextrose 5 % in dihydrocodein,mo water,remifentanil hcl in 0.9 rphine sulfate % sodium cr,opana chloride/pf,sufentanil er,oxycontin,perc citrate/bupivacaine hcl/0.9 % ocet,meperitab,d sodium uragesic,darvocet chloride/pf,propoxyphene -n napsylate,fentanyl citrate in 100,opana,dilaudi dextrose 5% in d,xodol 10- water/pf,hydromorphone hcl 300,magnacet,da in dextrose 5 %- rvon,fentora,exal water/pf,remifentanil go,endodan,zerlo hcl,tramadol hcl/dietary r,subsys,ultracet, supplement,misc. ultram er,xodol 5- cb.11,hydrocodone 300,xodol 7.5- bitartrate/acetaminophen/die 300,trezix,xolox,r tary supplement oxicodone,primle #11,dihydrocodeine v,morphine bitartrate/aspirin/caffeine,fen sulfate-0.9% tanyl nacl,fentanyl citrate/droperidol,aspirin/cod citrate-0.9% eine phosphate,meperidine nacl,methadone hcl/promethazine hcl-0.9% hcl,hydrocodone nacl,hydromorph bitartrate,fentanyl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 664 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value one-bupivacaine- hcl,meperidine hcl in 0.9 % ns,hydromorphon sodium e hcl-0.9% chloride/pf,hydromorphone nacl,morphine hcl/ropivacaine in 0.9 % sulfate- sodium d5w,meperidine chloride/pf,oxycodone hcl-0.9% myristate,hydromorphone nacl,fentanyl- hcl in sterile bupivacaine- water/pf,benzhydrocodone ns,fentanyl- hcl/acetaminophen,oliceridin ropivacaine- e fumarate,hydromorphone ns,fentanyl hcl in sodium chloride, iso- citrate- osmotic/pf ns,reprexain,dep odur,ms contin,oramorph sr,norco,actiq,em beda,butrans,nuc ynta er,abstral,synapr yn,hydromorphon e- bupivacaine,mep eridine hcl- ns,synalgos- dc,ultram,tylox,ib udone,cocet plus,cocet,lazand a,ascomp with codeine,morphin e sulfate-nacl,iso- osm,maxidone,fio ricet with codeine,fiorinal with codeine #3,zydone,conzip ,darvocet a500,hydrocodon e bit-

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 665 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value ibuprofen,aspirin- caffeine- dihydrocodein,sta gesic,dilaudid- hp,rybix odt,oxecta,fentan yl-bupivacaine- 0.9% nacl,fentanyl- ropivacaine-0.9% nacl,remifentanil hcl- ns,hydromorph- bupivac-0.9% nacl,sufentanil- bupivac-0.9% nacl,astramorph- pf,percodan,asa- butalb-caffeine- codeine,zamicet, oxycodone concentrate,caris oprodol-aspirin- codeine,propoxac et-n 100,darvon- n,darvocet-n 50,roxicodone intensol,fentanyl citrate- d5w,hydromorph one hcl- d5w,ultiva,theratr amadol- 60,theratramadol- 90,theracodophe n- 325,theracodoph en- 650,theracodoph

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 666 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value en-low- 90,talacen,talwin nx,combunox,pan lor dc,polygesic,roxa nol,eth- oxydose,anexsia, primalev,fentanyl with droperidol,dilaudi d- 5,hydrocet,phreni lin-caffeine- codeine,aspirin with codeine,meprozin e,dolorex forte,meperidine- promethazine,oxy ir,stadol,hydromo rphone hcl- ns,numorphan,da zidox,alcet,vopac ,zohydro er,xartemis xr,lorcet,lorcet hd,hydromorphon e er,verdrocet,xylo n 10,oxycodone hcl er,hysingla er,ionsys,acetami n-caff- dihydrocodeine,o xaydo,belbuca,hy dromorph-ropiva- 0.9% nacl,xtampza er,arymo

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 667 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value er,morphabond er,buprenorphine, fentanyl citrate- sterile water,remifentanil hcl,fentanyl citrate- water,panlor,nalo cet,roxybond,miti go,hydromorphon e hcl- water,dvorah,dsu via,apadaz,benzh ydrocodone- acetaminophen,h ydrocodone bitartrate er,prolate,qdolo,o linvyk,hydromorp hone hcl- nacl,morphine sulfate-nacl 07/01/2021 losartan losartan potassium CHANGE TIER Preferred potassium 07/01/2021 losartan losartan potassium CHANGE UM: ANGIOTENSIN potassium DRUGCLASS RECEPTOR ANTAGONISTS 07/01/2021 ALL DAY PAIN naproxen sodium CHANGE TIER Preferred RELIEF 07/01/2021 ALL DAY PAIN naproxen sodium CHANGE UM: NON- RELIEF DRUGCLASS STEROIDAL ANTI- INFLAMMATORY DRUGS (NSAIDS)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 668 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 atorvastatin atorvastatin calcium CHANGE TIER Preferred calcium 07/01/2021 atorvastatin atorvastatin calcium CHANGE UM: QUANTITY 1 / day calcium 07/01/2021 atorvastatin atorvastatin calcium CHANGE UM: LIPOTROPICS: calcium DRUGCLASS STATINS 07/01/2021 atorvastatin atorvastatin calcium CHANGE TIER Preferred calcium 07/01/2021 atorvastatin atorvastatin calcium CHANGE UM: QUANTITY 1 / day calcium 07/01/2021 atorvastatin atorvastatin calcium CHANGE UM: LIPOTROPICS: calcium DRUGCLASS STATINS 07/01/2021 atorvastatin atorvastatin calcium CHANGE TIER Preferred calcium 07/01/2021 atorvastatin atorvastatin calcium CHANGE UM: LIPOTROPICS: calcium DRUGCLASS STATINS 07/01/2021 atorvastatin atorvastatin calcium CHANGE TIER Preferred calcium 07/01/2021 atorvastatin atorvastatin calcium CHANGE UM: QUANTITY 1 / day calcium 07/01/2021 atorvastatin atorvastatin calcium CHANGE UM: LIPOTROPICS: calcium DRUGCLASS STATINS 07/01/2021 nystatin nystatin CHANGE TIER Preferred 07/01/2021 nystatin nystatin CHANGE UM: ANTIFUNGALS, DRUGCLASS ORAL 07/01/2021 oxybutynin oxybutynin chloride CHANGE TIER Preferred chloride er 07/01/2021 oxybutynin oxybutynin chloride CHANGE UM: URINARY chloride er DRUGCLASS TRACT ANTISPASMODI CS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 669 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 oxybutynin oxybutynin chloride CHANGE TIER Preferred chloride er 07/01/2021 oxybutynin oxybutynin chloride CHANGE UM: URINARY chloride er DRUGCLASS TRACT ANTISPASMODI CS 07/01/2021 oxybutynin oxybutynin chloride CHANGE TIER Preferred chloride er 07/01/2021 oxybutynin oxybutynin chloride CHANGE UM: URINARY chloride er DRUGCLASS TRACT ANTISPASMODI CS 07/01/2021 labetalol hcl labetalol hcl CHANGE TIER Preferred 07/01/2021 labetalol hcl labetalol hcl CHANGE UM: BETA DRUGCLASS BLOCKERS 07/01/2021 labetalol hcl labetalol hcl CHANGE TIER Preferred 07/01/2021 labetalol hcl labetalol hcl CHANGE UM: BETA DRUGCLASS BLOCKERS 07/01/2021 diltiazem 24hr er diltiazem hcl CHANGE TIER Preferred (cd),diltiazem 24hr cd,diltiazem 24hr er,diltiazem er 07/01/2021 diltiazem 24hr er diltiazem hcl CHANGE UM: CALCIUM (cd),diltiazem DRUGCLASS CHANNEL 24hr cd,diltiazem BLOCKERS - 24hr er,diltiazem NON- er DIHYDROPYRIDI NE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 670 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 diltiazem 24hr er diltiazem hcl CHANGE TIER Preferred (cd),diltiazem 24hr cd,diltiazem 24hr er,diltiazem er 07/01/2021 diltiazem 24hr er diltiazem hcl CHANGE UM: CALCIUM (cd),diltiazem DRUGCLASS CHANNEL 24hr cd,diltiazem BLOCKERS - 24hr er,diltiazem NON- er DIHYDROPYRIDI NE 07/01/2021 diltiazem 24hr er diltiazem hcl CHANGE TIER Preferred (cd),diltiazem 24hr cd,diltiazem 24hr er,diltiazem er 07/01/2021 diltiazem 24hr er diltiazem hcl CHANGE UM: CALCIUM (cd),diltiazem DRUGCLASS CHANNEL 24hr cd,diltiazem BLOCKERS - 24hr er,diltiazem NON- er DIHYDROPYRIDI NE 07/01/2021 diltiazem 24hr er diltiazem hcl CHANGE TIER Preferred (cd),diltiazem 24hr cd,diltiazem 24hr er,diltiazem er 07/01/2021 diltiazem 24hr er diltiazem hcl CHANGE UM: CALCIUM (cd),diltiazem DRUGCLASS CHANNEL 24hr cd,diltiazem BLOCKERS - 24hr er,diltiazem NON- er DIHYDROPYRIDI NE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 671 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 diltiazem 24hr er diltiazem hcl CHANGE TIER Preferred (cd),diltiazem 24hr er 07/01/2021 diltiazem 24hr er diltiazem hcl CHANGE UM: CALCIUM (cd),diltiazem DRUGCLASS CHANNEL 24hr er BLOCKERS - NON- DIHYDROPYRIDI NE 07/01/2021 bisoprolol- bisoprolol CHANGE TIER Preferred hydrochlorothiazi fumarate/hydrochlorothiazid de,bisoprolol e fumarate-hctz 07/01/2021 bisoprolol- bisoprolol CHANGE UM: BETA hydrochlorothiazi fumarate/hydrochlorothiazid DRUGCLASS BLOCKERS de,bisoprolol e fumarate-hctz 07/01/2021 bisoprolol- bisoprolol CHANGE TIER Preferred hydrochlorothiazi fumarate/hydrochlorothiazid de,bisoprolol e fumarate-hctz 07/01/2021 bisoprolol- bisoprolol CHANGE UM: BETA hydrochlorothiazi fumarate/hydrochlorothiazid DRUGCLASS BLOCKERS de,bisoprolol e fumarate-hctz 07/01/2021 bisoprolol- bisoprolol CHANGE TIER Preferred hydrochlorothiazi fumarate/hydrochlorothiazid de,bisoprolol e fumarate-hctz 07/01/2021 bisoprolol- bisoprolol CHANGE UM: BETA hydrochlorothiazi fumarate/hydrochlorothiazid DRUGCLASS BLOCKERS de,bisoprolol e fumarate-hctz 07/01/2021 atenolol atenolol CHANGE TIER Preferred

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 672 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 atenolol atenolol CHANGE UM: BETA DRUGCLASS BLOCKERS 07/01/2021 atenolol atenolol CHANGE TIER Preferred 07/01/2021 atenolol atenolol CHANGE UM: BETA DRUGCLASS BLOCKERS 07/01/2021 atenolol atenolol CHANGE TIER Preferred 07/01/2021 atenolol atenolol CHANGE UM: BETA DRUGCLASS BLOCKERS 07/01/2021 clobetasol clobetasol propionate CHANGE TIER Preferred propionate 07/01/2021 clobetasol clobetasol propionate CHANGE UM: TOPICAL propionate DRUGCLASS STEROIDS – VERY HIGH POTENCY 07/01/2021 hydroxyzine hydroxyzine pamoate CHANGE TIER Preferred pamoate 07/01/2021 hydroxyzine hydroxyzine pamoate CHANGE UM: ANTI-ANXIETY - pamoate DRUGCLASS GENERAL 07/01/2021 hydroxyzine hydroxyzine pamoate CHANGE TIER Preferred pamoate 07/01/2021 hydroxyzine hydroxyzine pamoate CHANGE UM: ANTI-ANXIETY - pamoate DRUGCLASS GENERAL 07/01/2021 amlodipine amlodipine besylate CHANGE TIER Preferred besylate 07/01/2021 amlodipine amlodipine besylate CHANGE UM: CALCIUM besylate DRUGCLASS CHANNEL BLOCKERS - DIHYDROPYRIDI NE 07/01/2021 amlodipine amlodipine besylate CHANGE TIER Preferred besylate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 673 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 amlodipine amlodipine besylate CHANGE UM: CALCIUM besylate DRUGCLASS CHANNEL BLOCKERS - DIHYDROPYRIDI NE 07/01/2021 pantoprazole pantoprazole sodium CHANGE TIER Preferred sodium 07/01/2021 pantoprazole pantoprazole sodium CHANGE UM: PROTON PUMP sodium DRUGCLASS INHIBITORS 07/01/2021 pantoprazole pantoprazole sodium CHANGE TIER Preferred sodium 07/01/2021 pantoprazole pantoprazole sodium CHANGE UM: PROTON PUMP sodium DRUGCLASS INHIBITORS 07/01/2021 linezolid linezolid CHANGE TIER Preferred 07/01/2021 linezolid linezolid CHANGE UM: QUANTITY 28 / claim 07/01/2021 linezolid linezolid CHANGE UM: OXAZOLIDINON DRUGCLASS ES 07/01/2021 nifedipine nifedipine CHANGE TIER Preferred 07/01/2021 nifedipine nifedipine CHANGE UM: CALCIUM DRUGCLASS CHANNEL BLOCKERS - DIHYDROPYRIDI NE 07/01/2021 oseltamivir oseltamivir phosphate CHANGE TIER Preferred phosphate 07/01/2021 oseltamivir oseltamivir phosphate CHANGE UM: ANTIVIRALS - phosphate DRUGCLASS INFLUENZA 07/01/2021 oseltamivir oseltamivir phosphate CHANGE TIER Preferred phosphate 07/01/2021 oseltamivir oseltamivir phosphate CHANGE UM: ANTIVIRALS - phosphate DRUGCLASS INFLUENZA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 674 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 oseltamivir oseltamivir phosphate CHANGE TIER Preferred phosphate 07/01/2021 oseltamivir oseltamivir phosphate CHANGE UM: ANTIVIRALS - phosphate DRUGCLASS INFLUENZA 07/01/2021 nystatin nystatin CHANGE TIER Preferred 07/01/2021 nystatin nystatin CHANGE UM: ANTIFUNGALS, DRUGCLASS TOPICAL 07/01/2021 olopatadine hcl olopatadine hcl CHANGE TIER Preferred 07/01/2021 olopatadine hcl olopatadine hcl CHANGE UM: OPHTHALMIC DRUGCLASS ANTIHISTAMINE S 07/01/2021 olopatadine hcl olopatadine hcl CHANGE TIER Preferred 07/01/2021 olopatadine hcl olopatadine hcl CHANGE UM: OPHTHALMIC DRUGCLASS ANTIHISTAMINE S 07/01/2021 olopatadine hcl olopatadine hcl ADD UM: DRUGCLASS NASAL ANTIHISTAMINE S 07/01/2021 losartan losartan potassium CHANGE TIER Preferred potassium 07/01/2021 losartan losartan potassium CHANGE UM: ANGIOTENSIN potassium DRUGCLASS RECEPTOR ANTAGONISTS 07/01/2021 losartan losartan potassium CHANGE TIER Preferred potassium 07/01/2021 losartan losartan potassium CHANGE UM: ANGIOTENSIN potassium DRUGCLASS RECEPTOR ANTAGONISTS 07/01/2021 cefdinir cefdinir CHANGE TIER Preferred

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 675 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 cefdinir cefdinir CHANGE UM: CEPHALOSPORI DRUGCLASS NS - 3RD GENERATION 07/01/2021 albuterol sulfate albuterol sulfate CHANGE TIER Preferred 07/01/2021 clotrimazole clotrimazole CHANGE TIER Preferred 07/01/2021 clotrimazole clotrimazole CHANGE UM: ANTIFUNGALS, DRUGCLASS TOPICAL 07/01/2021 loratadine loratadine CHANGE TIER Preferred 07/01/2021 loratadine loratadine CHANGE UM: ANTIHISTAMINE DRUGCLASS S - 2ND GENERATION 07/01/2021 children's ibuprofen CHANGE TIER Preferred ibuprofen 07/01/2021 children's ibuprofen CHANGE UM: NON- ibuprofen DRUGCLASS STEROIDAL ANTI- INFLAMMATORY DRUGS (NSAIDS) 07/01/2021 enoxaparin enoxaparin sodium CHANGE TIER Preferred sodium 07/01/2021 enoxaparin enoxaparin sodium CHANGE UM: ANTICOAGULAN sodium DRUGCLASS TS 07/01/2021 triamcinolone triamcinolone acetonide CHANGE TIER Preferred acetonide 07/01/2021 triamcinolone triamcinolone acetonide CHANGE UM: TOPICAL acetonide DRUGCLASS STEROIDS – HIGH POTENCY 07/01/2021 memantine hcl memantine hcl CHANGE TIER Preferred 07/01/2021 memantine hcl memantine hcl CHANGE UM: ALZHEIMER'S DRUGCLASS DEMENTIA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 676 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 memantine hcl memantine hcl CHANGE TIER Preferred 07/01/2021 memantine hcl memantine hcl CHANGE UM: ALZHEIMER'S DRUGCLASS DEMENTIA 07/01/2021 fenofibrate fenofibrate CHANGE TIER Preferred 07/01/2021 fenofibrate fenofibrate CHANGE UM: LIPOTROPICS: DRUGCLASS FIBRIC ACID DERIVATIVES 07/01/2021 ANTIFUNGAL clotrimazole CHANGE TIER Preferred 07/01/2021 ANTIFUNGAL clotrimazole CHANGE UM: ANTIFUNGALS, DRUGCLASS TOPICAL 07/01/2021 cyclobenzaprine cyclobenzaprine hcl CHANGE TIER Preferred hcl 07/01/2021 cyclobenzaprine cyclobenzaprine hcl CHANGE UM: SKELETAL hcl DRUGCLASS MUSCLE RELAXANTS 07/01/2021 budesonide budesonide CHANGE TIER Preferred 07/01/2021 diclofenac diclofenac sodium CHANGE TIER Preferred sodium 07/01/2021 diclofenac diclofenac sodium CHANGE UM: NON- sodium DRUGCLASS STEROIDAL ANTI- INFLAMMATORY DRUGS (NSAIDS) 07/01/2021 ALL DAY cetirizine hcl ADD TO FORMULARY Preferred ALLERGY 07/01/2021 ALL DAY cetirizine hcl CHANGE UM: ANTIHISTAMINE ALLERGY DRUGCLASS S - 2ND GENERATION 07/01/2021 eye itch relief ketotifen fumarate CHANGE TIER Preferred

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 677 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 eye itch relief ketotifen fumarate CHANGE UM: OPHTHALMIC DRUGCLASS ANTIHISTAMINE S 07/01/2021 fenofibrate fenofibrate CHANGE TIER Preferred 07/01/2021 fenofibrate fenofibrate CHANGE UM: LIPOTROPICS: DRUGCLASS FIBRIC ACID DERIVATIVES 07/01/2021 chlorzoxazone chlorzoxazone CHANGE TIER Preferred 07/01/2021 chlorzoxazone chlorzoxazone CHANGE UM: SKELETAL DRUGCLASS MUSCLE RELAXANTS 07/01/2021 chlorzoxazone chlorzoxazone CHANGE TIER Preferred 07/01/2021 chlorzoxazone chlorzoxazone CHANGE UM: SKELETAL DRUGCLASS MUSCLE RELAXANTS 07/01/2021 fexofenadine hcl fexofenadine hcl CHANGE TIER Non-Preferred 07/01/2021 fexofenadine hcl fexofenadine hcl CHANGE UM: ANTIHISTAMINE DRUGCLASS S - 2ND GENERATION 07/01/2021 methadone hcl methadone hcl CHANGE TIER Non-Preferred 07/01/2021 methadone hcl methadone hcl CHANGE UM: NARCOTICS – DRUGCLASS LONG ACTING 07/01/2021 fexofenadine hcl fexofenadine hcl CHANGE TIER Non-Preferred 07/01/2021 fexofenadine hcl fexofenadine hcl CHANGE UM: ANTIHISTAMINE DRUGCLASS S - 2ND GENERATION 07/01/2021 lansoprazole lansoprazole CHANGE TIER Non-Preferred 07/01/2021 lansoprazole lansoprazole CHANGE UM: PROTON PUMP DRUGCLASS INHIBITORS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 678 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 esomeprazole esomeprazole magnesium CHANGE TIER Non-Preferred magnesium 07/01/2021 esomeprazole esomeprazole magnesium CHANGE UM: PROTON PUMP magnesium DRUGCLASS INHIBITORS 07/01/2021 omeprazole omeprazole CHANGE TIER Non-Preferred 07/01/2021 omeprazole omeprazole CHANGE UM: PROTON PUMP DRUGCLASS INHIBITORS 07/01/2021 omeprazole omeprazole magnesium CHANGE TIER Non-Preferred magnesium 07/01/2021 omeprazole omeprazole magnesium CHANGE UM: PROTON PUMP magnesium DRUGCLASS INHIBITORS 07/01/2021 omeprazole omeprazole magnesium CHANGE UM: PANAME Non Preferred PA magnesium 07/01/2021 niacin niacin CHANGE TIER Non-Preferred 07/01/2021 niacin niacin CHANGE UM: LIPOTROPICS: DRUGCLASS NIACIN DERIVATIVES 07/01/2021 PRALUENT PEN alirocumab CHANGE TIER Non-Preferred 07/01/2021 PRALUENT PEN alirocumab CHANGE UM: QUANTITY 2 / 28 days 07/01/2021 PRALUENT PEN alirocumab CHANGE UM: LIPOTROPICS: DRUGCLASS PCSK9 INHIBITORS 07/01/2021 hydrocortisone hydrocortisone CHANGE TIER Non PDL 07/01/2021 levothyroxine levothyroxine sodium CHANGE TIER Non PDL sodium 07/01/2021 levothyroxine levothyroxine sodium CHANGE TIER Non PDL sodium 07/01/2021 levothyroxine levothyroxine sodium CHANGE TIER Non PDL sodium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 679 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 levothyroxine levothyroxine sodium CHANGE TIER Non PDL sodium 07/01/2021 levothyroxine levothyroxine sodium CHANGE TIER Non PDL sodium 07/01/2021 levothyroxine levothyroxine sodium CHANGE TIER Non PDL sodium 07/01/2021 levothyroxine levothyroxine sodium CHANGE TIER Non PDL sodium 07/01/2021 levothyroxine levothyroxine sodium CHANGE TIER Non PDL sodium 07/01/2021 pilocarpine hcl pilocarpine hcl CHANGE TIER Non PDL 07/01/2021 norgestimate- norgestimate-ethinyl CHANGE TIER Non PDL ethinyl estradiol estradiol 07/01/2021 nicotine patch nicotine CHANGE TIER Non PDL 07/01/2021 leucovorin leucovorin calcium CHANGE TIER Non PDL calcium 07/01/2021 docusate calcium docusate calcium CHANGE TIER Non PDL 07/01/2021 MONISTAT 7 miconazole nitrate CHANGE TIER Non PDL 07/01/2021 MONISTAT 7 miconazole nitrate CHANGE UM: GENDER Female 07/01/2021 spironolactone spironolactone CHANGE TIER Non PDL 07/01/2021 spironolactone spironolactone CHANGE UM: QUANTITY 2 / day 07/01/2021 ALLERGY chlorpheniramine maleate CHANGE TIER Non PDL RELIEF 07/01/2021 bacitracin bacitracin CHANGE TIER Non PDL 07/01/2021 midazolam hcl midazolam hcl CHANGE TIER Non PDL 07/01/2021 midazolam hcl midazolam hcl CHANGE UM: QUANTITY 4 / 30 days 07/01/2021 leflunomide leflunomide CHANGE TIER Non PDL 07/01/2021 leflunomide leflunomide CHANGE UM: QUANTITY 1 / day

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 680 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 leflunomide leflunomide CHANGE TIER Non PDL 07/01/2021 leflunomide leflunomide CHANGE UM: QUANTITY 1 / day 07/01/2021 meclizine hcl meclizine hcl CHANGE TIER Non PDL 07/01/2021 potassium potassium chloride CHANGE TIER Non PDL chloride 07/01/2021 chlorthalidone chlorthalidone CHANGE TIER Non PDL 07/01/2021 chlorthalidone chlorthalidone CHANGE UM: QUANTITY 4 / day 07/01/2021 chlorthalidone chlorthalidone CHANGE TIER Non PDL 07/01/2021 chlorthalidone chlorthalidone CHANGE UM: QUANTITY 4 / day 07/01/2021 leucovorin leucovorin calcium CHANGE TIER Non PDL calcium 07/01/2021 leucovorin leucovorin calcium CHANGE TIER Non PDL calcium 07/01/2021 leucovorin leucovorin calcium CHANGE TIER Non PDL calcium 07/01/2021 bacitracin zinc bacitracin zinc CHANGE TIER Non PDL 07/01/2021 calcium 600-vit calcium CHANGE TIER Non PDL d3,calcium 600 + carbonate/cholecalciferol vit d,calcium with (vitamin d3) vitamin d 07/01/2021 acetaminophen,a acetaminophen CHANGE TIER Non PDL cetaminophen es 07/01/2021 spironolactone spironolactone CHANGE TIER Non PDL 07/01/2021 spironolactone spironolactone CHANGE UM: QUANTITY 2 / day 07/01/2021 acetaminophen acetaminophen CHANGE TIER Non PDL er,acetaminophe n 8 hour,acetaminop hen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 681 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 famotidine famotidine CHANGE TIER Non PDL 07/01/2021 estradiol estradiol CHANGE TIER Non PDL 07/01/2021 estradiol estradiol CHANGE UM: AGE Up to 64 yrs old 07/01/2021 estradiol estradiol CHANGE TIER Non PDL 07/01/2021 estradiol estradiol CHANGE UM: AGE Up to 64 yrs old 07/01/2021 estradiol estradiol CHANGE TIER Non PDL 07/01/2021 estradiol estradiol CHANGE UM: AGE Up to 64 yrs old 07/01/2021 methotrexate methotrexate sodium CHANGE TIER Non PDL 07/01/2021 ethambutol hcl ethambutol hcl CHANGE TIER Non PDL 07/01/2021 ethambutol hcl ethambutol hcl CHANGE TIER Non PDL 07/01/2021 hydrocortisone hydrocortisone CHANGE TIER Non PDL 07/01/2021 nicotine patch nicotine CHANGE TIER Non PDL 07/01/2021 nicotine patch nicotine CHANGE UM: QUANTITY 1 / day 07/01/2021 nitroglycerin nitroglycerin CHANGE TIER Non PDL 07/01/2021 vancomycin hcl vancomycin hcl CHANGE TIER Non PDL 07/01/2021 vancomycin hcl vancomycin hcl REMOVE FROM Non PDL Non-Formulary FORMULARY 07/01/2021 TYLENOL acetaminophen CHANGE TIER Non PDL 07/01/2021 toremifene citrate toremifene citrate CHANGE TIER Non PDL 07/01/2021 hydrocortisone hydrocortisone CHANGE TIER Non PDL 07/01/2021 hydroxychloroqui hydroxychloroquine sulfate CHANGE TIER Non PDL ne sulfate 07/01/2021 sodium sodium polystyrene CHANGE TIER Non PDL polystyrene sulfonate sulfonate 07/01/2021 heparin sodium heparin sodium,porcine CHANGE TIER Non PDL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 682 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 vitamin d3 cholecalciferol (vitamin d3) CHANGE TIER Non PDL 07/01/2021 spironolactone spironolactone CHANGE TIER Non PDL 07/01/2021 spironolactone spironolactone CHANGE UM: QUANTITY 2 / day 07/01/2021 nicotine nicotine CHANGE TIER Non PDL patch,nicotine 07/01/2021 nicotine nicotine CHANGE UM: QUANTITY 1 / day patch,nicotine 07/01/2021 neomycin- neomycin sulfate/polymyxin CHANGE TIER Non PDL polymyxin-hc b sulfate/hydrocortisone 07/01/2021 CHILDREN'S acetaminophen CHANGE TIER Non PDL TYLENOL 07/01/2021 STOMACH bismuth subsalicylate CHANGE TIER Non PDL RELIEF 07/01/2021 STOMACH bismuth subsalicylate CHANGE TIER Non PDL RELIEF 07/01/2021 senna plus sennosides/docusate CHANGE TIER Non PDL sodium 07/01/2021 pain relief acetaminophen CHANGE TIER Non PDL 07/01/2021 entecavir entecavir CHANGE TIER Non PDL 07/01/2021 entecavir entecavir CHANGE UM: QUANTITY 1 / day 07/01/2021 entecavir entecavir CHANGE TIER Non PDL 07/01/2021 entecavir entecavir CHANGE UM: QUANTITY 1 / day 07/01/2021 calcium 250-vit calcium CHANGE TIER Non PDL d3,oyster shell carbonate/cholecalciferol calcium-vit d3 (vitamin d3) 07/01/2021 vitamin d3 cholecalciferol (vitamin d3) CHANGE TIER Non PDL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 683 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 calcium 600 + vit calcium CHANGE TIER Non PDL d,calcium 600-vit carbonate/cholecalciferol d3,super calcium (vitamin d3) 600-vit d3,calcium with vitamin d 07/01/2021 FEROSUL ferrous sulfate ADD TO FORMULARY Non PDL 07/01/2021 ferrous sulfate ferrous sulfate CHANGE TIER Non PDL 07/01/2021 ferrous sulfate ferrous sulfate CHANGE UM: AGE Up to 12 yrs old 07/01/2021 CERTAVITE- multivitamin/ferrous CHANGE TIER Non PDL ANTIOXIDANT fumarate/folic acid 07/01/2021 easy touch syringe with CHANGE TIER Non PDL insulin syringe needle,disposable,insulin 1 ml 07/01/2021 vitamin e,vitamin vitamin e (dl-alpha CHANGE TIER Non PDL e-200 tocopheryl acetate) 07/01/2021 calcium 600-vit calcium CHANGE TIER Non PDL d3 carbonate/cholecalciferol (vitamin d3) 07/01/2021 BAYER aspirin CHANGE TIER Non PDL CHEWABLE ASPIRIN 07/01/2021 BAYER aspirin CHANGE UM: QUANTITY 1 / day CHEWABLE ASPIRIN 07/01/2021 prenatal vitamin prenatal vits with calcium CHANGE TIER Non PDL plus low iron no.72/ferrous fumarate/folic acid 07/01/2021 prenatal vitamin prenatal vits with calcium CHANGE UM: QUANTITY 1 / day plus low iron no.72/ferrous fumarate/folic acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 684 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 prenatal vitamin prenatal vits with calcium CHANGE UM: AGE 12.0 to 55.0 yrs plus low iron no.72/ferrous fumarate/folic old acid 07/01/2021 prenatal vitamin prenatal vits with calcium CHANGE UM: GENDER Female plus low iron no.72/ferrous fumarate/folic acid 07/01/2021 veo insulin syringe with CHANGE TIER Non PDL syringe needle,insulin,0.5 ml 07/01/2021 veo insulin syringe with CHANGE TIER Non PDL syringe needle,insulin,0.3 ml 07/01/2021 veo insulin syringe with CHANGE TIER Non PDL syringe needle,disposable,insulin 1 ml 07/01/2021 veo insulin syringe with needle,insulin CHANGE TIER Non PDL syringe 0.3 ml (half unit mark) 07/01/2021 incontrol pen pen needle, diabetic CHANGE TIER Non PDL needle 07/01/2021 TAB-A-VITE multivitamin/ferrous CHANGE TIER Non PDL MULTIVIT WITH sulfate/folic acid IRON 07/01/2021 ethyl ethyl alcohol ADD TO FORMULARY Non-Formulary Non PDL alcohol,rubbing alcohol 07/01/2021 purell,hand ethyl alcohol ADD TO FORMULARY Non PDL sanitizer,germ defense,renewal hand sanitizer,antisepti c gel,gel- stat,gelrite,bodi line,sanix,germ-x

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 685 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 hurrisept,hand ethyl alcohol ADD TO FORMULARY Non-Formulary Non PDL sanitizer,epi- clenz,enovatizer 07/01/2021 epi-clenz ethyl alcohol ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 gelrite ethyl alcohol ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 alcohol pads with isopropyl ADD TO FORMULARY Non-Formulary Non PDL benzocaine,alcoh alcohol/benzocaine ol swabs with benzocaine,pain relief swabs- benzocaine 07/01/2021 isagel no ethyl alcohol ADD TO FORMULARY Non-Formulary Non PDL rinse,prevacare 07/01/2021 isopropyl alcohol isopropyl alcohol ADD TO FORMULARY Non-Formulary Non PDL 07/01/2021 isopropyl isopropyl alcohol ADD TO FORMULARY Non-Formulary Non PDL alcohol,medi-first isopropyl alcohol 07/01/2021 antiseptic bio- ethyl alcohol ADD TO FORMULARY Non-Formulary Non PDL hand 07/01/2021 PROLATE oxycodone ADD TO FORMULARY Non-Formulary Non-Preferred hcl/acetaminophen 07/01/2021 PROLATE oxycodone ADD UM: PANAME Non Preferred PA hcl/acetaminophen 07/01/2021 lansoprazole lansoprazole CHANGE TIER Non-Preferred 07/01/2021 lansoprazole lansoprazole CHANGE UM: PROTON PUMP DRUGCLASS INHIBITORS 07/01/2021 lansoprazole lansoprazole CHANGE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 686 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 prenatal multi- prenatal vitamins combo REMOVE UM: GENDER Female dha,prenatal no.40/ferrous multivitamin-dha fumarate/fa/dha,prenatal vitamins no.40/ferrous fumarate/folic acid/dha 07/01/2021 prenatal multi- prenatal vits no.151/iron REMOVE UM: GENDER Female dha fum/folic acid/omega3/dha/epa/fish 07/01/2021 miconazole miconazole nitrate ADD TO FORMULARY Non PDL nitrate,miconazol e 7 07/01/2021 miconazole miconazole nitrate ADD UM: GENDER Female nitrate,miconazol e 7 07/01/2021 M-NATAL PLUS prenatal vits with calcium ADD TO FORMULARY Non-Formulary Non PDL no.72/ferrous fumarate/folic acid 07/01/2021 M-NATAL PLUS prenatal vits with calcium ADD UM: QUANTITY 1 / day no.72/ferrous fumarate/folic acid 07/01/2021 M-NATAL PLUS prenatal vits with calcium ADD UM: AGE 12.0 to 55.0 yrs no.72/ferrous fumarate/folic old acid 07/01/2021 WESTAB PLUS prenatal vits with calcium ADD TO FORMULARY Non PDL no.72/ferrous fumarate/folic acid 07/01/2021 WESTAB PLUS prenatal vits with calcium ADD UM: QUANTITY 1 / day no.72/ferrous fumarate/folic acid 07/01/2021 WESTAB PLUS prenatal vits with calcium ADD UM: AGE 12.0 to 55.0 yrs no.72/ferrous fumarate/folic old acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 687 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 WESTAB PLUS prenatal vits with calcium ADD UM: GENDER Female no.72/ferrous fumarate/folic acid 07/01/2021 niacin niacin REMOVE FROM Non PDL Non-Formulary FORMULARY 07/01/2021 theophylline theophylline anhydrous REMOVE FROM Non PDL Non-Formulary FORMULARY 07/01/2021 stool softener docusate sodium REMOVE FROM Non PDL Non-Formulary FORMULARY 07/01/2021 FIBER psyllium husk/aspartame REMOVE FROM Non PDL Non-Formulary THERAPY,FIBE FORMULARY R 07/01/2021 theophylline theophylline anhydrous REMOVE FROM Non PDL Non-Formulary FORMULARY 07/01/2021 ANTACID magnesium REMOVE FROM Non PDL Non-Formulary hydroxide/aluminum FORMULARY hydroxide/simethicone 07/01/2021 ASPERCREME lidocaine hcl REMOVE FROM Non-Formulary LIDOCAINE FORMULARY 07/01/2021 ASPERCREME lidocaine REMOVE FROM Non PDL Non-Formulary LIDOCAINE FORMULARY 07/01/2021 omega-3 omega-3 fatty acids REMOVE FROM Non PDL Non-Formulary FORMULARY 07/01/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non PDL Non-Formulary acetate FORMULARY 07/01/2021 hydrocortisone- hydrocortisone REMOVE FROM Non PDL Non-Formulary pramoxine acetate/pramoxine hcl FORMULARY 07/01/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non PDL Non-Formulary acetate FORMULARY 07/01/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non PDL Non-Formulary acetate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 688 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non PDL Non-Formulary acetate FORMULARY 07/01/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non PDL Non-Formulary acetate FORMULARY 07/01/2021 hydrocortisone hydrocortisone acetate ADD TO FORMULARY Non-Formulary Non PDL acetate 07/01/2021 hydrocortisone hydrocortisone acetate ADD TO FORMULARY Non-Formulary Non PDL acetate 07/01/2021 hydrocortisone hydrocortisone acetate ADD TO FORMULARY Non-Formulary Non PDL acetate 07/01/2021 hydrocortisone hydrocortisone acetate ADD TO FORMULARY Non-Formulary Non PDL acetate 07/01/2021 hydrocortisone hydrocortisone acetate ADD TO FORMULARY Non-Formulary Non PDL acetate 07/01/2021 hydrocortisone hydrocortisone acetate ADD TO FORMULARY Non-Formulary Non PDL acetate 07/01/2021 PROAIR albuterol sulfate CHANGE UM: QUANTITY 1 / 30 days DIGIHALER 07/01/2021 PROAIR albuterol sulfate CHANGE UM: BETA DIGIHALER DRUGCLASS ADRENERGICS - SHORT ACTING 07/01/2021 nicotine patch nicotine CHANGE UM: QUANTITY 1 / day 07/01/2021 ketorolac ketorolac tromethamine CHANGE UM: QUANTITY 5 / claim tromethamine 07/01/2021 ketorolac ketorolac tromethamine CHANGE UM: NON- tromethamine DRUGCLASS STEROIDAL ANTI- INFLAMMATORY DRUGS (NSAIDS)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 689 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 prenatal prenatal vitamins with REMOVE UM: AGE 12.0 to 55.0 yrs vitamins,right calcium/ferrous old step prenatal fumarate/folic acid,prenatal vitamins,prenatal vitamins/ferrous s,prenatal fumarate/folic acid,prenatal vits w- ca,fe,fa(<1mg),prenatal vitamins/ferrous sulfate/folic acid 07/01/2021 lunesta,eszopiclo eszopiclone REMOVE UM: AGE At least 18 yrs ne old 07/01/2021 lunesta,eszopiclo eszopiclone REMOVE UM: AGE At least 18 yrs ne old 07/01/2021 lunesta,eszopiclo eszopiclone REMOVE UM: AGE At least 18 yrs ne old 07/01/2021 valium,diazepam diazepam REMOVE UM: AGE 07/01/2021 valium,diazepam diazepam REMOVE UM: AGE 07/01/2021 clonidine hcl clonidine hcl REMOVE UM: AGE er,kapvay 07/01/2021 valium,diazepam diazepam REMOVE UM: AGE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 690 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 benadryl diphenhydramine hcl ADD UM: AGE Up to 65 yrs old allergy,allergy relief,genahist,wa l-dryl allergy,nighttime allergy relief,diphenhist,d iphenhydramine hcl,banophen,anti histamine,valu- dryl allergy medicine,allergy medicine,complet e allergy,allergy,all ergy medication,diphe dryl,vicks qlearquil nighttime,diphedr yl allergy,aler- tab,diphen,aller- g-time,simply allergy,geri- dryl,complete allergy relief,total allergy 07/01/2021 THERANATAL prenatal vitamins REMOVE UM: QUANTITY 1 / day no.28/ferrous fumarate/folic acid 07/01/2021 LEVAQUIN levofloxacin REMOVE UM: QUANTITY 14 / claim 07/01/2021 prenatal prenatal vits with calcium REMOVE UM: QUANTITY 1 / day vitamins,prenatal, 95/ferrous fumarate/folic prenatal vitamin acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 691 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 VINATE-M prenatal vits with calcium REMOVE UM: QUANTITY 1 / day 136/ferrous fumarate/folic acid 07/01/2021 prenatal prenatal vitamins with REMOVE UM: QUANTITY 1 / day vitamins,prenatal calcium/ferrous fumarate/folic acid,prenatal vitamins/ferrous fumarate/folic acid 07/01/2021 prenatal prenatal vits with calcium REMOVE UM: QUANTITY 1 / day vitamin,prenatal 137/ferrous fumarate/folic vitamins,prenatal acid,prenatal vitamins with calcium/ferrous fumarate/folic acid,prenatal vit with calcium no.130/ferrous fumarate/folic acid,prenatal vitamins/ferrous fumarate/folic acid 07/01/2021 prenatal multi- prenatal vits no.151/iron REMOVE UM: QUANTITY 1 / day dha fum/folic acid/omega3/dha/epa/fish 07/01/2021 prenatal 19 prenatal vits with calcium REMOVE UM: QUANTITY no.115/iron fumarate/folic acid,prenatal vits with calcium 118/ferrous fumarate/folic acid 07/01/2021 prenatal prenatal vits with calcium REMOVE UM: QUANTITY 1 / day complete no.21/ferrous fumarate/folic acid 07/01/2021 prenatal prenatal vitamins no.62/folic REMOVE UM: QUANTITY 1 / day acid/omega-3s/dha/epa/fish oil

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 692 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 multi-vitamin w- pediatric multivitamin ADD TO FORMULARY Non-Formulary Non PDL fluoride,multivita combination no.2/sodium mins with fluoride,pediatric fluoride,polyvitam multivitamin no.2/sodium ins- fluoride fluoride,multivita min with fluoride 07/01/2021 multi-vitamin w- pediatric multivitamin ADD TO FORMULARY Non-Formulary Non PDL fluoride,multivita combination no.2/sodium mins with fluoride,pediatric fluoride,multivita multivitamin no.82 with min and sodium fluoride,pediatric fluoride,multivita multivitamin no.2/sodium min with fluoride fluoride,pediatric multivitamin no.150 with sodium fluoride 07/01/2021 ASMANEX mometasone furoate CHANGE UM: QUANTITY 1 / claim 1 / 30 days 07/01/2021 ASMANEX mometasone furoate CHANGE UM: QUANTITY 1 / claim 1 / 30 days 07/01/2021 ASMANEX mometasone furoate CHANGE UM: QUANTITY 1 / claim 1 / 30 days 07/01/2021 PULMICORT budesonide CHANGE UM: QUANTITY 2 / claim 1 / 30 days FLEXHALER 07/01/2021 ASMANEX mometasone furoate CHANGE UM: QUANTITY 1 / 28 days 1 / 30 days 07/01/2021 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 1 / day 07/01/2021 oxycodone hcl er oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 1 / day 07/01/2021 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 120 / 30 days 07/01/2021 oxycodone hcl er oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 120 / 30 days 07/01/2021 PULMICORT budesonide CHANGE UM: QUANTITY 2 / claim 2 / 30 days FLEXHALER 07/01/2021 oxycodone hcl er oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 45 / 30 days 07/01/2021 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 45 / 30 days 07/01/2021 XTAMPZA ER oxycodone myristate CHANGE UM: QUANTITY 60 / 30 Days 45 / 30 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 693 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 oxycodone hcl oxycodone hcl CHANGE UM: QUANTITY 120 / 30 Days 60 / 30 days 07/01/2021 oxycodone hcl er oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 60 / 30 days 07/01/2021 ROXICODONE oxycodone hcl CHANGE UM: QUANTITY 120 / 30 Days 60 / 30 days 07/01/2021 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 60 / 30 days 07/01/2021 oxycodone hcl oxycodone hcl CHANGE UM: QUANTITY 120 / 30 Days 90 / 30 days 07/01/2021 oxymorphone hcl oxymorphone hcl CHANGE UM: QUANTITY 120 / 30 Days 90 / 30 days 07/01/2021 OPANA oxymorphone hcl CHANGE UM: QUANTITY 120 / 30 Days 90 / 30 days 07/01/2021 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 90 / 30 days 07/01/2021 oxycodone hcl er oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 90 / 30 days 07/01/2021 oxycodone oxycodone hcl CHANGE UM: QUANTITY 120 / 30 Days 90 / 30 days hcl,oxycodone concentrate 07/01/2021 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 180 / 30 Days 90 / 30 days 07/01/2021 DILAUDID hydromorphone hcl CHANGE UM: QUANTITY 180 / 30 Days 165 / 30 days 07/01/2021 hydromorphone hydromorphone hcl CHANGE UM: QUANTITY 180 / 30 Days 165 / 30 days hcl 07/01/2021 SYMBICORT budesonide/formoterol CHANGE UM: QUANTITY 10.2 / 30 days 20.4 / 30 days fumarate 07/01/2021 SYMBICORT budesonide/formoterol CHANGE UM: QUANTITY 10.2 / 30 days 20.4 / 30 days fumarate 07/01/2021 budesonide- budesonide/formoterol CHANGE UM: QUANTITY 10.2 / 30 days 20.4 / 30 days formoterol fumarate fumarate 07/01/2021 budesonide- budesonide/formoterol CHANGE UM: QUANTITY 10.2 / 30 days 20.4 / 30 days formoterol fumarate fumarate 07/01/2021 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 22 / 30 days 07/01/2021 oxycodone hcl er oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 22 / 30 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 694 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 REPATHA evolocumab CHANGE UM: QUANTITY 35 / 28 Days 7 / 28 days PUSHTRONEX 07/01/2021 DILAUDID hydromorphone hcl CHANGE UM: QUANTITY 90 / 30 Days 84 / 30 days 07/01/2021 VOL-PLUS multivitamin-minerals ADD UM: QUANTITY 1 / day no.60/ferrous fumarate/folic acid,prenatal vits with calcium #74/ferrous fumarate/folic acid 07/01/2021 MAKENA hydroxyprogesterone ADD UM: QUANTITY 21 weeks / caproate/pf lifetime 07/01/2021 MAKENA hydroxyprogesterone ADD UM: QUANTITY 21 weeks / caproate lifetime 07/01/2021 hydroxyprogester hydroxyprogesterone ADD UM: QUANTITY 21 weeks / one caproate caproate lifetime 07/01/2021 hydroxyprogester hydroxyprogesterone ADD UM: QUANTITY 21 weeks / one caproate caproate/pf lifetime

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 695 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

August, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 penicillin v penicillin v potassium REMOVE UM: AGE Up to 12 yrs old potassium 08/01/2021 amoxicillin- amoxicillin/potassium REMOVE UM: AGE Up to 12 yrs old clavulanate clavulanate potass,amox tr- potassium clavulanate 08/01/2021 amoxicillin amoxicillin REMOVE UM: AGE Up to 12 yrs old 08/01/2021 doxycycline doxycycline monohydrate REMOVE UM: AGE Up to 12 yrs old monohydrate,dox ycycline 08/01/2021 amoxicillin- amoxicillin/potassium REMOVE UM: AGE Up to 12 yrs old clavulanate clavulanate potass,amox tr- potassium clavulanate 08/01/2021 penicillin v penicillin v potassium REMOVE UM: AGE Up to 12 yrs old potassium 08/01/2021 amoxicillin amoxicillin REMOVE UM: AGE Up to 12 yrs old 08/01/2021 amoxicillin- amoxicillin/potassium REMOVE UM: AGE Up to 12 yrs old clavulanate clavulanate potass,amox tr- potassium clavulanate 08/01/2021 amoxicillin- amoxicillin/potassium REMOVE UM: AGE Up to 12 yrs old clavulanate clavulanate potass,amox tr- potassium clavulanate 08/01/2021 amoxicillin amoxicillin REMOVE UM: AGE Up to 12 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 696 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 amoxicillin amoxicillin REMOVE UM: AGE Up to 12 yrs old 08/01/2021 amoxicillin- amoxicillin/potassium REMOVE UM: AGE Up to 12 yrs old clavulanate clavulanate potass,amox tr- potassium clavulanate 08/01/2021 amoxicillin- amoxicillin/potassium REMOVE UM: AGE Up to 12 yrs old clavulanate clavulanate potass 08/01/2021 amoxicillin amoxicillin REMOVE UM: AGE Up to 12 yrs old 08/01/2021 amoxicillin amoxicillin REMOVE UM: AGE Up to 12 yrs old 08/01/2021 TILIA FE norethindrone acetate- REMOVE FROM Non PDL Non-Formulary ethinyl estradiol/ferrous FORMULARY fumarate,norethindrone a-e estradiol/ferrous fumarate 08/01/2021 OCELLA ethinyl REMOVE FROM Non PDL Non-Formulary estradiol/drospirenone FORMULARY 08/01/2021 clemastine clemastine fumarate REMOVE FROM Non PDL Non-Formulary fumarate FORMULARY 08/01/2021 cromolyn sodium cromolyn sodium REMOVE FROM Non PDL Non-Formulary FORMULARY 08/01/2021 potassium citrate potassium citrate ADD TO FORMULARY Non PDL er 08/01/2021 CUVPOSA glycopyrrolate ADD TO FORMULARY Non PDL 08/01/2021 CUVPOSA glycopyrrolate ADD UM: AGE Up to 12 yrs old 08/01/2021 hydrocortisone hydrocortisone ADD TO FORMULARY Non PDL 08/01/2021 ASMANEX mometasone furoate CHANGE UM: QUANTITY 1 / claim 1 / 30 days 08/01/2021 ASMANEX mometasone furoate CHANGE UM: QUANTITY 1 / claim 1 / 30 days 08/01/2021 ASMANEX mometasone furoate CHANGE UM: QUANTITY 1 / claim 1 / 30 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 697 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 ASMANEX mometasone furoate CHANGE UM: QUANTITY 1 / claim 1 / 30 days 08/01/2021 ASMANEX mometasone furoate CHANGE UM: QUANTITY 1 / 28 days 1 / 30 days 08/01/2021 ZOKINVY lonafarnib ADD UM: CUSTOM CARVE OUT- BILL MDCH FFS 08/01/2021 REDITREX methotrexate/pf REMOVE FROM Non-Formulary FORMULARY 08/01/2021 REDITREX methotrexate/pf REMOVE FROM Non-Formulary FORMULARY 08/01/2021 REDITREX methotrexate/pf REMOVE FROM Non-Formulary FORMULARY 08/01/2021 REDITREX methotrexate/pf REMOVE FROM Non-Formulary FORMULARY 08/01/2021 REDITREX methotrexate/pf REMOVE FROM Non-Formulary FORMULARY 08/01/2021 REDITREX methotrexate/pf REMOVE FROM Non-Formulary FORMULARY 08/01/2021 REDITREX methotrexate/pf REMOVE FROM Non-Formulary FORMULARY 08/01/2021 REDITREX methotrexate/pf REMOVE FROM Non-Formulary FORMULARY 08/01/2021 LUPKYNIS voclosporin REMOVE FROM Non-Formulary FORMULARY 08/01/2021 MINOLIRA ER minocycline hcl REMOVE FROM Non-Formulary FORMULARY 08/01/2021 MINOLIRA ER minocycline hcl REMOVE FROM Non-Formulary FORMULARY 08/01/2021 GIMOTI metoclopramide hcl REMOVE FROM Non-Formulary FORMULARY 08/01/2021 VERQUVO vericiguat ADD TO FORMULARY Non PDL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 698 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 VERQUVO vericiguat ADD UM: QUANTITY 1 / day 08/01/2021 VERQUVO vericiguat ADD UM: AGE At least 18 yrs old 08/01/2021 VERQUVO vericiguat ADD UM: PANAME Clinical PA 08/01/2021 VERQUVO vericiguat ADD TO FORMULARY Non PDL 08/01/2021 VERQUVO vericiguat ADD UM: QUANTITY 1 / day 08/01/2021 VERQUVO vericiguat ADD UM: AGE At least 18 yrs old 08/01/2021 VERQUVO vericiguat ADD UM: PANAME Clinical PA 08/01/2021 VERQUVO vericiguat ADD TO FORMULARY Non PDL 08/01/2021 VERQUVO vericiguat ADD UM: QUANTITY 1 / day 08/01/2021 VERQUVO vericiguat ADD UM: AGE At least 18 yrs old 08/01/2021 VERQUVO vericiguat ADD UM: PANAME Clinical PA 08/01/2021 EYSUVIS loteprednol etabonate ADD TO FORMULARY Non PDL 08/01/2021 EYSUVIS loteprednol etabonate ADD UM: QUANTITY 8.3 / 14 days 08/01/2021 EYSUVIS loteprednol etabonate ADD UM: AGE At least 18 yrs old 08/01/2021 EYSUVIS loteprednol etabonate ADD UM: PANAME Clinical PA 08/01/2021 lidocaine lidocaine ADD UM: QUANTITY 3 / day 08/01/2021 XTANDI enzalutamide ADD TO FORMULARY Non PDL 08/01/2021 XTANDI enzalutamide ADD UM: QUANTITY 2 / day 08/01/2021 XTANDI enzalutamide ADD UM: PANAME Clinical PA 08/01/2021 FULPHILA pegfilgrastim-jmdb CHANGE UM: QUANTITY 0.6/14 days 1 / 30 days 08/01/2021 KAPSPARGO metoprolol succinate ADD UM: QUANTITY 1 / 30 days SPRINKLE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 699 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 KAPSPARGO metoprolol succinate ADD UM: QUANTITY 1 / 30 days SPRINKLE 08/01/2021 ZAFEMY norelgestromin/ethinyl ADD TO FORMULARY Non PDL estradiol 08/01/2021 ZAFEMY norelgestromin/ethinyl ADD UM: QUANTITY 9 / 84 days estradiol 08/01/2021 AZOPT brinzolamide ADD UM: B4G BRAND FOR GENERIC 08/01/2021 brinzolamide brinzolamide ADD TO FORMULARY Non-Preferred 08/01/2021 brinzolamide brinzolamide ADD UM: DRUGCLASS GLAUCOMA – CARBONIC ANHYDRASE INHIBITORS 08/01/2021 brinzolamide brinzolamide ADD UM: PANAME Non Preferred PA 08/01/2021 brinzolamide brinzolamide ADD UM: COV Use brand over generic 08/01/2021 AJOVY fremanezumab-vfrm ADD UM: DRUGCLASS ANTIMIGRAINE AUTOINJECTOR AGENTS, CGRP INHIBITORS 08/01/2021 SANTYL collagenase clostridium REMOVE FROM Non PDL Non-Formulary histolyticum FORMULARY 08/01/2021 SANTYL collagenase clostridium REMOVE UM: QUANTITY 60 / 30 days histolyticum 08/01/2021 granisetron hcl granisetron hcl ADD UM: QUANTITY 15 / claim 08/01/2021 ZITHROMAX azithromycin REMOVE UM: QUANTITY 6 / claim 08/01/2021 GLUCOPHAGE metformin hcl REMOVE FROM Non-Preferred Non-Formulary XR FORMULARY 08/01/2021 GLUCOPHAGE metformin hcl REMOVE UM: PANAME Non Preferred PA XR

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 700 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 GLUCOPHAGE metformin hcl REMOVE UM: ORAL XR DRUGCLASS HYPOGLYCEMI CS – BIGUANIDES 08/01/2021 GLUCOPHAGE metformin hcl REMOVE FROM Non-Preferred Non-Formulary XR FORMULARY 08/01/2021 GLUCOPHAGE metformin hcl REMOVE UM: PANAME Non Preferred PA XR 08/01/2021 GLUCOPHAGE metformin hcl REMOVE UM: ORAL XR DRUGCLASS HYPOGLYCEMI CS – BIGUANIDES 08/01/2021 GLUCOPHAGE metformin hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY 08/01/2021 GLUCOPHAGE metformin hcl REMOVE UM: PANAME Non Preferred PA 08/01/2021 GLUCOPHAGE metformin hcl REMOVE UM: ORAL DRUGCLASS HYPOGLYCEMI CS – BIGUANIDES 08/01/2021 GLUCOPHAGE metformin hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY 08/01/2021 GLUCOPHAGE metformin hcl REMOVE UM: PANAME Non Preferred PA 08/01/2021 GLUCOPHAGE metformin hcl REMOVE UM: ORAL DRUGCLASS HYPOGLYCEMI CS – BIGUANIDES 08/01/2021 GLUCOPHAGE metformin hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY 08/01/2021 GLUCOPHAGE metformin hcl REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 701 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 GLUCOPHAGE metformin hcl REMOVE UM: ORAL DRUGCLASS HYPOGLYCEMI CS – BIGUANIDES 08/01/2021 NIZORAL ketoconazole REMOVE FROM Non-Preferred Non-Formulary FORMULARY 08/01/2021 NIZORAL ketoconazole REMOVE UM: PANAME Non Preferred PA 08/01/2021 NIZORAL ketoconazole REMOVE UM: ANTIFUNGALS, DRUGCLASS TOPICAL 08/01/2021 hydrocodone hydrocodone bitartrate ADD TO FORMULARY Non-Preferred bitartrate er 08/01/2021 hydrocodone hydrocodone bitartrate ADD UM: DRUGCLASS NARCOTICS – bitartrate er LONG ACTING 08/01/2021 hydrocodone hydrocodone bitartrate ADD UM: PANAME Non Preferred PA bitartrate er 08/01/2021 hydrocodone hydrocodone bitartrate ADD TO FORMULARY Non-Preferred bitartrate er 08/01/2021 hydrocodone hydrocodone bitartrate ADD UM: DRUGCLASS NARCOTICS – bitartrate er LONG ACTING 08/01/2021 hydrocodone hydrocodone bitartrate ADD UM: PANAME Non Preferred PA bitartrate er 08/01/2021 hydrocodone hydrocodone bitartrate ADD TO FORMULARY Non-Preferred bitartrate er 08/01/2021 hydrocodone hydrocodone bitartrate ADD UM: DRUGCLASS NARCOTICS – bitartrate er LONG ACTING 08/01/2021 hydrocodone hydrocodone bitartrate ADD UM: PANAME Non Preferred PA bitartrate er 08/01/2021 hydrocodone hydrocodone bitartrate ADD TO FORMULARY Non-Preferred bitartrate er 08/01/2021 hydrocodone hydrocodone bitartrate ADD UM: DRUGCLASS NARCOTICS – bitartrate er LONG ACTING

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 702 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 hydrocodone hydrocodone bitartrate ADD UM: PANAME Non Preferred PA bitartrate er 08/01/2021 hydrocodone hydrocodone bitartrate ADD TO FORMULARY Non-Preferred bitartrate er 08/01/2021 hydrocodone hydrocodone bitartrate ADD UM: DRUGCLASS NARCOTICS – bitartrate er LONG ACTING 08/01/2021 hydrocodone hydrocodone bitartrate ADD UM: PANAME Non Preferred PA bitartrate er 08/01/2021 hydrocodone hydrocodone bitartrate ADD TO FORMULARY Non-Preferred bitartrate er 08/01/2021 hydrocodone hydrocodone bitartrate ADD UM: DRUGCLASS NARCOTICS – bitartrate er LONG ACTING 08/01/2021 hydrocodone hydrocodone bitartrate ADD UM: PANAME Non Preferred PA bitartrate er 08/01/2021 hydrocodone hydrocodone bitartrate ADD TO FORMULARY Non-Preferred bitartrate er 08/01/2021 hydrocodone hydrocodone bitartrate ADD UM: DRUGCLASS NARCOTICS – bitartrate er LONG ACTING 08/01/2021 hydrocodone hydrocodone bitartrate ADD UM: PANAME Non Preferred PA bitartrate er 08/01/2021 vitamin e vitamin e (dl-alpha REMOVE FROM Non PDL Non-Formulary tocopheryl acetate) FORMULARY 08/01/2021 vitamin e vitamin e (dl-alpha REMOVE FROM Non PDL Non-Formulary tocopheryl acetate) FORMULARY 08/01/2021 fentanyl fentanyl ADD UM: QUANTITY 10 / claim 08/01/2021 fentanyl fentanyl ADD UM: QUANTITY 10 / claim 08/01/2021 fentanyl fentanyl ADD UM: QUANTITY 10 / claim 08/01/2021 MAXALT MLT rizatriptan benzoate CHANGE UM: QUANTITY 12 / claim 18 / claim 08/01/2021 MAXALT rizatriptan benzoate CHANGE UM: QUANTITY 12 / claim 18 / claim

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 703 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 rizatriptan rizatriptan benzoate CHANGE UM: QUANTITY 12 / claim 18 / claim 08/01/2021 rizatriptan rizatriptan benzoate CHANGE UM: QUANTITY 12 / claim 18 / claim 08/01/2021 rizatriptan rizatriptan benzoate CHANGE UM: QUANTITY 12 / claim 18 / claim 08/01/2021 rizatriptan rizatriptan benzoate CHANGE UM: QUANTITY 12 / claim 18 / claim 08/01/2021 PATANOL olopatadine hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY 08/01/2021 PATANOL olopatadine hcl REMOVE UM: PANAME Non Preferred PA 08/01/2021 PATANOL olopatadine hcl REMOVE UM: OPTHALMIC DRUGCLASS ANTIHISTAMINE S 08/01/2021 REPATHA evolocumab CHANGE UM: QUANTITY 35 / 28 Days 7 / 28 days PUSHTRONEX 08/01/2021 itraconazole itraconazole ADD UM: QUANTITY 840 / claim 08/01/2021 hydromorphone hydromorphone hcl CHANGE UM: QUANTITY 180 / 30 Days 165 / 30 days hcl 08/01/2021 hydromorphone hydromorphone hcl CHANGE UM: QUANTITY 90 / 30 Days 84 / 30 days hcl 08/01/2021 oxymorphone hcl oxymorphone hcl CHANGE UM: QUANTITY 120 / 30 Days 90 / 30 days 08/01/2021 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 90 / 30 days 08/01/2021 oxycodone oxycodone hcl CHANGE UM: QUANTITY 120 / 30 Days 90 / 30 days hcl,oxycodone concentrate 08/01/2021 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 180 / 30 Days 90 / 30 days 08/01/2021 oxycodone hcl oxycodone hcl CHANGE UM: QUANTITY 120 / 30 Days 60 / 30 days 08/01/2021 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 60 / 30 days 08/01/2021 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 120 / 30 days 08/01/2021 XTAMPZA ER oxycodone myristate CHANGE UM: QUANTITY 60 / 30 Days 45 / 30 days 08/01/2021 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 45 / 30 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 704 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 30 / 30 days 08/01/2021 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 22 / 30 days 08/01/2021 oxycodone hcl oxycodone hcl CHANGE UM: QUANTITY 120 / 30 Days 90 / 30 days 08/01/2021 AIMOVIG erenumab-aooe CHANGE UM: QUANTITY 1 / 30 days 3 / 90 days AUTOINJECTOR 08/01/2021 EMGALITY galcanezumab-gnlm CHANGE UM: QUANTITY 1 / 30 Days 3 / 90 days SYRINGE 08/01/2021 EMGALITY PEN galcanezumab-gnlm CHANGE UM: QUANTITY 1 / 30 Days 3 / 90 days 08/01/2021 AJOVY fremanezumab-vfrm CHANGE UM: QUANTITY 1.5 / 30 Days 4.5 / 90 days SYRINGE 08/01/2021 AJOVY fremanezumab-vfrm CHANGE UM: QUANTITY 1.5 / 30 Days 4.5 / 90 days AUTOINJECTOR 08/01/2021 AIMOVIG erenumab-aooe CHANGE UM: QUANTITY 2 / 30 Days 6 / 90 days AUTOINJECTOR 08/01/2021 EMGALITY galcanezumab-gnlm CHANGE UM: QUANTITY 3 / 30 days 9 / 90 days SYRINGE 08/01/2021 LEVAQUIN levofloxacin REMOVE FROM Non-Preferred Non-Formulary FORMULARY 08/01/2021 LEVAQUIN levofloxacin REMOVE UM: PANAME Non Preferred PA 08/01/2021 LEVAQUIN levofloxacin REMOVE UM: QUANTITY 14 / claim 08/01/2021 LEVAQUIN levofloxacin REMOVE FROM Non-Preferred Non-Formulary FORMULARY 08/01/2021 LEVAQUIN levofloxacin REMOVE UM: PANAME Non Preferred PA 08/01/2021 LEVAQUIN levofloxacin REMOVE UM: QUANTITY 28 / claim 08/01/2021 LUMAKRAS sotorasib ADD TO FORMULARY Non PDL 08/01/2021 LUMAKRAS sotorasib ADD UM: PANAME Clinical PA 08/01/2021 FIBRICOR fenofibric acid ADD TO FORMULARY Non-Formulary Non-Preferred 08/01/2021 FIBRICOR fenofibric acid ADD UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 705 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 FIBRICOR fenofibric acid ADD TO FORMULARY Non-Formulary Non-Preferred 08/01/2021 FIBRICOR fenofibric acid ADD UM: PANAME Non Preferred PA 08/01/2021 theophylline theophylline anhydrous ADD TO FORMULARY Non-Formulary Non PDL 08/01/2021 theophylline theophylline anhydrous ADD TO FORMULARY Non-Formulary Non PDL 08/01/2021 ROXYBOND oxycodone hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY 08/01/2021 ROXYBOND oxycodone hcl REMOVE UM: QUANTITY 90 / 30 Days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 706 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 sprycel,bosulif,inl dasatinib,bosutinib,axitinib,s CHANGE UM: CUSTOM CARVE OUT- yta,sutent,xalkori, unitinib BILL MDCH FFS gleevec,tasigna,t malate,crizotinib,imatinib ykerb,votrient,ires mesylate,nilotinib sa,vandetanib,ca hcl,lapatinib prelsa,gilotrif,com ditosylate,pazopanib etriq,tarceva,stiva hcl,gefitinib,vandetanib,afati rga,nexavar,velca nib dimaleate,cabozantinib de,kyprolis,iclusig s-malate,erlotinib ,imbruvica,zykadi hcl,regorafenib,sorafenib a,zydelig,lynparz tosylate,bortezomib,carfilzo a,ibrance,lenvima mib,ponatinib ,tagrisso,ninlaro,a hcl,ibrutinib,ceritinib,idelalisi lecensa,imatinib b,olaparib,palbociclib,lenvati mesylate,cabome nib mesylate,osimertinib tyx,rubraca,kisqal mesylate,ixazomib i,zejula,rydapt,alu citrate,alectinib hcl,rucaparib nbrig,nerlynx,aliq camsylate,ribociclib opa,verzenio,calq succinate,niraparib uence,bortezomi tosylate,midostaurin,brigatini b,copiktra,vizimpr b,neratinib o,talzenna,lorbre maleate,copanlisib di- na,vitrakvi,xospat hcl,abemaciclib,acalabrutini a,balversa,erlotini b,duvelisib,dacomitinib,talaz b oparib hcl,piqray,turalio,r tosylate,lorlatinib,larotrectini ozlytrek,inrebic,br b sulfate,gilteritinib ukinsa,ayvakit,pe fumarate,erdafitinib,alpelisib, mazyre,tukysa,ret pexidartinib evmo,tabrecta,qi hydrochloride,entrectinib,fed nlock,gavreto,lap ratinib atinib,tepmetko,u dihydrochloride,zanubrutinib koniq,fotivda,trus ,avapritinib,pemigatinib,tucat eltiq inib,selpercatinib,capmatinib hydrochloride,ripretinib,prals etinib,tepotinib hcl,umbralisib tosylate,tivozanib hcl,infigratinib phosphate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 707 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 LEVAQUIN levofloxacin REMOVE UM: QUINOLONES DRUGCLASS 08/01/2021 LEVAQUIN levofloxacin REMOVE UM: QUINOLONES DRUGCLASS 08/01/2021 bepotastine bepotastine besilate ADD TO FORMULARY Non-Preferred besilate 08/01/2021 bepotastine bepotastine besilate ADD UM: DRUGCLASS OPHTHALMIC besilate ANTIHISTAMINE S 08/01/2021 bepotastine bepotastine besilate ADD UM: PANAME Non Preferred PA besilate 08/01/2021 arformoterol arformoterol tartrate ADD TO FORMULARY Non-Preferred tartrate 08/01/2021 arformoterol arformoterol tartrate ADD UM: DRUGCLASS BETA tartrate ADRENERGICS - LONG ACTING 08/01/2021 arformoterol arformoterol tartrate ADD UM: PANAME Clinical PA tartrate 08/01/2021 DILAUDID hydromorphone hcl CHANGE UM: QUANTITY 180 / 30 Days 165 / 30 days 08/01/2021 DILAUDID hydromorphone hcl CHANGE UM: QUANTITY 90 / 30 Days 84 / 30 days 08/01/2021 oxycodone hcl er oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 60 / 30 days 08/01/2021 ROXICODONE oxycodone hcl CHANGE UM: QUANTITY 120 / 30 Days 60 / 30 days 08/01/2021 OPANA oxymorphone hcl CHANGE UM: QUANTITY 120 / 30 Days 90 / 30 days 08/01/2021 oxycodone hcl er oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 90 / 30 days 08/01/2021 oxycodone hcl er oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 45 / 30 days 08/01/2021 oxycodone hcl er oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 22 / 30 days 08/01/2021 oxycodone hcl er oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 30 / 30 days 08/01/2021 oxycodone hcl er oxycodone hcl CHANGE UM: QUANTITY 180 / 30 Days 120 / 30 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 708 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 IMPEKLO clobetasol propionate ADD TO FORMULARY Non-Preferred 08/01/2021 IMPEKLO clobetasol propionate ADD UM: DRUGCLASS TOPICAL STEROIDS – VERY HIGH POTENCY 08/01/2021 IMPEKLO clobetasol propionate ADD UM: PANAME Non Preferred PA 08/01/2021 NYVEPRIA pegfilgrastim-apgf ADD TO FORMULARY Preferred 08/01/2021 NYVEPRIA pegfilgrastim-apgf ADD UM: DRUGCLASS COLONY STIMULATING FACTORS 08/01/2021 PULMICORT budesonide CHANGE UM: QUANTITY 2 / claim 1 / 30 days FLEXHALER 08/01/2021 PULMICORT budesonide CHANGE UM: PANAME Non Preferred PA Clinical PA FLEXHALER 08/01/2021 PULMICORT budesonide CHANGE UM: QUANTITY 2 / claim 2 / 30 days FLEXHALER 08/01/2021 ASMANEX HFA mometasone furoate ADD UM: QUANTITY 13 / 30 days 08/01/2021 ASMANEX HFA mometasone furoate CHANGE UM: PANAME Non Preferred PA Clinical PA 08/01/2021 ASMANEX HFA mometasone furoate ADD UM: QUANTITY 13 / 30 days 08/01/2021 ASMANEX HFA mometasone furoate CHANGE UM: PANAME Non Preferred PA Clinical PA 08/01/2021 ASMANEX HFA mometasone furoate ADD UM: QUANTITY 13 / 30 days 08/01/2021 ASMANEX HFA mometasone furoate CHANGE UM: PANAME Non Preferred PA Clinical PA 08/01/2021 azithromycin azithromycin REMOVE UM: AGE Up to 12 yrs old 08/01/2021 azithromycin azithromycin REMOVE UM: AGE Up to 12 yrs old 08/01/2021 ZITHROMAX azithromycin REMOVE UM: AGE Up to 12 yrs old 08/01/2021 ZITHROMAX azithromycin REMOVE UM: AGE Up to 12 yrs old 08/01/2021 ciclopirox ciclopirox CHANGE TIER Non-Preferred Preferred 08/01/2021 ciclopirox ciclopirox CHANGE UM: PANAME Non Preferred PA Clinical PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 709 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 nystatin nystatin CHANGE TIER Non-Preferred Preferred 08/01/2021 nystatin nystatin REMOVE UM: PANAME Non Preferred PA 08/01/2021 tinidazole tinidazole CHANGE TIER Non-Preferred Preferred 08/01/2021 tinidazole tinidazole REMOVE UM: PANAME Non Preferred PA 08/01/2021 tinidazole tinidazole CHANGE TIER Non-Preferred Preferred 08/01/2021 tinidazole tinidazole REMOVE UM: PANAME Non Preferred PA 08/01/2021 ketoconazole ketoconazole CHANGE TIER Non-Preferred Preferred 08/01/2021 ketoconazole ketoconazole REMOVE UM: PANAME Non Preferred PA 08/01/2021 INCRUSE umeclidinium bromide CHANGE TIER Non-Preferred Preferred ELLIPTA 08/01/2021 INCRUSE umeclidinium bromide REMOVE UM: PANAME Non Preferred PA ELLIPTA 08/01/2021 ANORO umeclidinium CHANGE TIER Non-Preferred Preferred ELLIPTA bromide/vilanterol trifenatate 08/01/2021 ANORO umeclidinium REMOVE UM: PANAME Non Preferred PA ELLIPTA bromide/vilanterol trifenatate 08/01/2021 ciprofloxacin ciprofloxacin CHANGE TIER Non-Preferred Preferred 08/01/2021 ciprofloxacin ciprofloxacin REMOVE UM: PANAME Non Preferred PA 08/01/2021 ciclopirox ciclopirox olamine CHANGE TIER Non-Preferred Preferred 08/01/2021 ciclopirox ciclopirox olamine REMOVE UM: PANAME Non Preferred PA 08/01/2021 SPIRIVA tiotropium bromide CHANGE TIER Non-Preferred Preferred RESPIMAT 08/01/2021 SPIRIVA tiotropium bromide REMOVE UM: PANAME Non Preferred PA RESPIMAT 08/01/2021 ciprofloxacin ciprofloxacin CHANGE TIER Non-Preferred Preferred 08/01/2021 ciprofloxacin ciprofloxacin REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 710 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 SPIRIVA tiotropium bromide CHANGE TIER Non-Preferred Preferred RESPIMAT 08/01/2021 SPIRIVA tiotropium bromide REMOVE UM: PANAME Non Preferred PA RESPIMAT 08/01/2021 moxifloxacin moxifloxacin hcl CHANGE TIER Non-Preferred Preferred 08/01/2021 moxifloxacin moxifloxacin hcl REMOVE UM: PANAME Non Preferred PA 08/01/2021 VENTOLIN HFA albuterol sulfate CHANGE TIER Non-Preferred Preferred 08/01/2021 VENTOLIN HFA albuterol sulfate REMOVE UM: PANAME Non Preferred PA 08/01/2021 VENTOLIN HFA albuterol sulfate ADD UM: B4G BRAND FOR GENERIC 08/01/2021 VENTOLIN HFA albuterol sulfate CHANGE TIER Non-Preferred Preferred 08/01/2021 VENTOLIN HFA albuterol sulfate REMOVE UM: PANAME Non Preferred PA 08/01/2021 VENTOLIN HFA albuterol sulfate ADD UM: B4G BRAND FOR GENERIC 08/01/2021 ZOVIRAX acyclovir CHANGE TIER Non-Preferred Preferred 08/01/2021 ZOVIRAX acyclovir REMOVE UM: PANAME Non Preferred PA 08/01/2021 ZOVIRAX acyclovir ADD UM: B4G BRAND FOR GENERIC 08/01/2021 metronidazole metronidazole CHANGE TIER Non-Preferred Preferred 08/01/2021 metronidazole metronidazole REMOVE UM: GENDER Female 08/01/2021 metronidazole metronidazole REMOVE UM: PANAME Non Preferred PA 08/01/2021 clindamycin clindamycin phosphate CHANGE TIER Non-Preferred Preferred phosphate 08/01/2021 clindamycin clindamycin phosphate REMOVE UM: GENDER Female phosphate 08/01/2021 clindamycin clindamycin phosphate REMOVE UM: PANAME Non Preferred PA phosphate 08/01/2021 neomycin sulfate neomycin sulfate CHANGE TIER Non-Preferred Preferred

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 711 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 neomycin sulfate neomycin sulfate REMOVE UM: PANAME Non Preferred PA 08/01/2021 CLINDESSE clindamycin phosphate CHANGE TIER Preferred Non-Preferred 08/01/2021 CLINDESSE clindamycin phosphate ADD UM: PANAME Non Preferred PA 08/01/2021 cefixime cefixime CHANGE TIER Preferred Non-Preferred 08/01/2021 cefixime cefixime ADD UM: PANAME Non Preferred PA 08/01/2021 E.E.S. 200 erythromycin ethylsuccinate CHANGE TIER Preferred Non-Preferred 08/01/2021 E.E.S. 200 erythromycin ethylsuccinate ADD UM: PANAME Non Preferred PA 08/01/2021 cefixime cefixime CHANGE TIER Preferred Non-Preferred 08/01/2021 cefixime cefixime ADD UM: PANAME Non Preferred PA 08/01/2021 ciclopirox ciclopirox olamine CHANGE TIER Preferred Non-Preferred 08/01/2021 ciclopirox ciclopirox olamine ADD UM: PANAME Non Preferred PA 08/01/2021 VANDAZOLE metronidazole CHANGE TIER Preferred Non-Preferred 08/01/2021 VANDAZOLE metronidazole ADD UM: PANAME Non Preferred PA 08/01/2021 VANDAZOLE metronidazole REMOVE UM: B4G BRAND FOR GENERIC 08/01/2021 CIPRO ciprofloxacin CHANGE TIER Preferred Non-Preferred 08/01/2021 CIPRO ciprofloxacin ADD UM: PANAME Non Preferred PA 08/01/2021 CIPRO ciprofloxacin REMOVE UM: B4G BRAND FOR GENERIC 08/01/2021 VIGAMOX moxifloxacin hcl CHANGE TIER Preferred Non-Preferred 08/01/2021 VIGAMOX moxifloxacin hcl ADD UM: PANAME Non Preferred PA 08/01/2021 VIGAMOX moxifloxacin hcl REMOVE UM: B4G BRAND FOR GENERIC 08/01/2021 CIPRO ciprofloxacin CHANGE TIER Preferred Non-Preferred 08/01/2021 CIPRO ciprofloxacin ADD UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 712 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 CIPRO ciprofloxacin REMOVE UM: B4G BRAND FOR GENERIC 08/01/2021 PROVENTIL albuterol sulfate CHANGE TIER Preferred Non-Preferred HFA 08/01/2021 PROVENTIL albuterol sulfate ADD UM: PANAME Non Preferred PA HFA 08/01/2021 PROVENTIL albuterol sulfate REMOVE UM: B4G BRAND FOR HFA GENERIC 08/01/2021 TRELEGY fluticasone CHANGE TIER Non-Preferred Preferred ELLIPTA furoate/umeclidinium bromide/vilanterol trifenat 08/01/2021 TRELEGY fluticasone REMOVE UM: PANAME Non Preferred PA ELLIPTA furoate/umeclidinium bromide/vilanterol trifenat 08/01/2021 TRELEGY fluticasone CHANGE TIER Non-Preferred Preferred ELLIPTA furoate/umeclidinium bromide/vilanterol trifenat 08/01/2021 TRELEGY fluticasone REMOVE UM: PANAME Non Preferred PA ELLIPTA furoate/umeclidinium bromide/vilanterol trifenat 08/01/2021 SYMBICORT budesonide/formoterol CHANGE UM: QUANTITY 10.2 / 30 days 20.4 / 30 days fumarate 08/01/2021 SYMBICORT budesonide/formoterol CHANGE UM: QUANTITY 10.2 / 30 days 20.4 / 30 days fumarate 08/01/2021 budesonide- budesonide/formoterol CHANGE UM: QUANTITY 10.2 / 30 days 20.4 / 30 days formoterol fumarate fumarate 08/01/2021 budesonide- budesonide/formoterol CHANGE UM: QUANTITY 10.2 / 30 days 20.4 / 30 days formoterol fumarate fumarate 08/01/2021 PANCREAZE lipase/protease/amylase ADD TO FORMULARY Non-Preferred

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 713 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 PANCREAZE lipase/protease/amylase ADD UM: DRUGCLASS PANCREATIC ENZYMES 08/01/2021 PANCREAZE lipase/protease/amylase ADD UM: PANAME Non Preferred PA 08/01/2021 fexofenadine hcl fexofenadine hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY 08/01/2021 fexofenadine hcl fexofenadine hcl REMOVE UM: PANAME Non Preferred PA 08/01/2021 fexofenadine hcl fexofenadine hcl REMOVE UM: ANTIHISTAMINE DRUGCLASS S - 2ND GENERATION 08/01/2021 formoterol formoterol fumarate ADD TO FORMULARY Non-Preferred fumarate 08/01/2021 formoterol formoterol fumarate ADD UM: DRUGCLASS BETA fumarate ADRENERGICS - LONG ACTING 08/01/2021 formoterol formoterol fumarate ADD UM: PANAME Non Preferred PA fumarate 08/01/2021 PROVENTIL albuterol sulfate CHANGE TIER Non-Preferred HFA 08/01/2021 PROVENTIL albuterol sulfate CHANGE UM: PANAME Non Preferred PA HFA 08/01/2021 PROVENTIL albuterol sulfate REMOVE UM: B4G HFA 08/01/2021 KLOXXADO naloxone hcl ADD TO FORMULARY Non PDL 08/01/2021 KLOXXADO naloxone hcl ADD UM: QUANTITY 2 / 90 days 08/01/2021 SANTYL collagenase clostridium ADD TO FORMULARY Non-Formulary Non PDL histolyticum 08/01/2021 SANTYL collagenase clostridium ADD UM: QUANTITY 60 / 30 days histolyticum 08/01/2021 tramadol hcl er tramadol hcl CHANGE TIER Non-Preferred Preferred

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 714 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2021 tramadol hcl er tramadol hcl REMOVE UM: PANAME Non Preferred PA 08/01/2021 tramadol hcl er tramadol hcl CHANGE TIER Non-Preferred Preferred 08/01/2021 tramadol hcl er tramadol hcl REMOVE UM: PANAME Non Preferred PA 08/01/2021 tramadol hcl er tramadol hcl CHANGE TIER Non-Preferred Preferred 08/01/2021 tramadol hcl er tramadol hcl REMOVE UM: PANAME Non Preferred PA 08/01/2021 neomycin sulfate neomycin sulfate REMOVE UM: PANAME Clinical PA 08/01/2021 metronidazole metronidazole REMOVE UM: COV Use brand over generic 08/01/2021 ciprofloxacin ciprofloxacin REMOVE UM: COV Use brand over generic 08/01/2021 ciprofloxacin ciprofloxacin REMOVE UM: COV Use brand over generic 08/09/2021 varenicline varenicline tartrate ADD TO FORMULARY Non PDL tartrate 08/09/2021 varenicline varenicline tartrate ADD TO FORMULARY Non PDL tartrate 08/11/2021 BETIMOL timolol ADD TO FORMULARY Non-Preferred 08/11/2021 BETIMOL timolol ADD UM: PANAME Non Preferred PA 08/11/2021 BETIMOL timolol ADD TO FORMULARY Non-Preferred 08/11/2021 BETIMOL timolol ADD UM: PANAME Non Preferred PA 08/11/2021 MYRBETRIQ mirabegron ADD TO FORMULARY Non-Preferred 08/11/2021 MYRBETRIQ mirabegron ADD UM: DRUGCLASS URINARY TRACT ANTISPASMODI CS 08/11/2021 MYRBETRIQ mirabegron ADD UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 715 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/11/2021 BETIMOL timolol ADD UM: DRUGCLASS GLAUCOMA – BETA BLOCKERS 08/11/2021 BETIMOL timolol ADD UM: DRUGCLASS GLAUCOMA – BETA BLOCKERS 08/12/2021 ibuprofen- ibuprofen/famotidine ADD TO FORMULARY Non-Preferred famotidine 08/12/2021 ibuprofen- ibuprofen/famotidine ADD UM: DRUGCLASS NON- famotidine STEROIDAL ANTI- INFLAMMATORY DRUGS (NSAIDS) 08/12/2021 ibuprofen- ibuprofen/famotidine ADD UM: PANAME Clinical PA famotidine 08/23/2021 FLUZONE HIGH- influenza virus vaccine ADD TO FORMULARY Non PDL DOSE QUAD quadrival split 2021-22(65 yr 2021-22 up)/pf 08/23/2021 FLUZONE QUAD influenza virus vaccine ADD TO FORMULARY Non PDL 2021-2022 quadrival 2021-2022(6 mos and up)/pf 08/23/2021 FLUZONE QUAD influenza virus vaccine ADD TO FORMULARY Non PDL 2021-2022 quadrivalent 2021-22 (6 mos and up) 08/23/2021 FLUAD QUAD influenza vaccine ADD TO FORMULARY Non PDL 2021-2022 quadrivalent 2021-22 (65 yr up)/mf59c.1/pf 08/23/2021 FLUMIST QUAD influenza vaccine ADD TO FORMULARY Non PDL 2021-2022 quadrivalent live 2021-2022 (2 yrs-49 yrs)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 716 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/23/2021 FLULAVAL influenza virus vaccine ADD TO FORMULARY Non PDL QUAD 2021- quadrival 2021-2022(6 mos 2022 and up)/pf 08/23/2021 FLUCELVAX flu vaccine quadriv 2021- ADD TO FORMULARY Non PDL QUAD 2021- 2022(2 years and older)cell 2022 derived 08/23/2021 FLUARIX QUAD influenza virus vaccine ADD TO FORMULARY Non PDL 2021-2022 quadrival 2021-2022(6 mos and up)/pf 08/23/2021 FLUBLOK QUAD influenza virus vaccine qv ADD TO FORMULARY Non PDL 2021-2022 2021-22(18 yrs and older)rcmb/pf 08/23/2021 FLUCELVAX flu vaccine quad 2021- ADD TO FORMULARY Non PDL QUAD 2021- 2022(2 years and older)cell 2022 derived/pf 08/23/2021 AFLURIA QUAD influenza virus vaccine ADD TO FORMULARY Non PDL 2021-22 (3YR quadrivalent 2021-22 (36 UP) mos up)/pf 08/23/2021 FLUZONE QUAD influenza virus vaccine ADD TO FORMULARY Non PDL 2021-2022 quadrival 2021-2022(6 mos and up)/pf 08/23/2021 AFLURIA QUAD influenza virus vaccine ADD TO FORMULARY Non PDL 2021-2022 quadrivalent 2021-22 (6 mos and up) 08/23/2021 AFLURIA QUAD influenza virus vaccine ADD TO FORMULARY Non PDL 2021-22 (6- quadrival 2021-22 (6 mos- 35MO) 35 mos)/pf 08/23/2021 FLUCELVAX flu vaccine quad 2021- ADD UM: AGE At least 2 yrs old QUAD 2021- 2022(2 years and older)cell 2022 derived/pf 08/23/2021 FLUCELVAX flu vaccine quadriv 2021- ADD UM: AGE At least 2 yrs old QUAD 2021- 2022(2 years and older)cell 2022 derived

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 717 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/23/2021 FLUAD QUAD influenza vaccine ADD UM: AGE At least 65 yrs 2021-2022 quadrivalent 2021-22 (65 yr old up)/mf59c.1/pf 08/23/2021 FLUMIST QUAD influenza vaccine ADD UM: AGE 2 to 49 yrs old 2021-2022 quadrivalent live 2021-2022 (2 yrs-49 yrs) 08/23/2021 FLUZONE QUAD influenza virus vaccine ADD UM: AGE At least 0.5 yrs 2021-2022 quadrival 2021-2022(6 mos old and up)/pf 08/23/2021 FLULAVAL influenza virus vaccine ADD UM: AGE At least 0.5 yrs QUAD 2021- quadrival 2021-2022(6 mos old 2022 and up)/pf 08/23/2021 FLUARIX QUAD influenza virus vaccine ADD UM: AGE At least 0.5 yrs 2021-2022 quadrival 2021-2022(6 mos old and up)/pf 08/23/2021 FLUZONE QUAD influenza virus vaccine ADD UM: AGE At least 0.5 yrs 2021-2022 quadrival 2021-2022(6 mos old and up)/pf 08/23/2021 AFLURIA QUAD influenza virus vaccine ADD UM: AGE 0.5 to 4 yrs old 2021-22 (6- quadrival 2021-22 (6 mos- 35MO) 35 mos)/pf 08/23/2021 FLUZONE HIGH- influenza virus vaccine ADD UM: AGE At least 65 yrs DOSE QUAD quadrival split 2021-22(65 yr old 2021-22 up)/pf 08/23/2021 AFLURIA QUAD influenza virus vaccine ADD UM: AGE At least 4 yrs old 2021-22 (3YR quadrivalent 2021-22 (36 UP) mos up)/pf 08/23/2021 FLUZONE QUAD influenza virus vaccine ADD UM: AGE At least 0.5 yrs 2021-2022 quadrivalent 2021-22 (6 mos old and up) 08/23/2021 AFLURIA QUAD influenza virus vaccine ADD UM: AGE At least 0.5 yrs 2021-2022 quadrivalent 2021-22 (6 mos old and up)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 718 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/23/2021 FLUBLOK QUAD influenza virus vaccine qv ADD UM: AGE At least 18 yrs 2021-2022 2021-22(18 yrs and old older)rcmb/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 719 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

September, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2021 SYNAGIS palivizumab ADD UM: QUANTITY 5 / 365 days 09/01/2021 SYNAGIS palivizumab ADD UM: QUANTITY 5 / 365 days 09/01/2021 enalapril maleate enalapril maleate ADD TO FORMULARY Non-Preferred 09/01/2021 enalapril maleate enalapril maleate ADD UM: DRUGCLASS ACE INHIBITORS 09/01/2021 enalapril maleate enalapril maleate ADD UM: PANAME Non Preferred PA 09/01/2021 buprenorphine buprenorphine hcl ADD TO FORMULARY Non-Preferred hcl 09/01/2021 buprenorphine buprenorphine hcl ADD UM: QUANTITY 60 / 30 days hcl 09/01/2021 buprenorphine buprenorphine hcl ADD UM: DRUGCLASS NARCOTICS – hcl LONG ACTING 09/01/2021 buprenorphine buprenorphine hcl ADD UM: PANAME Clinical PA hcl 09/01/2021 buprenorphine buprenorphine hcl ADD TO FORMULARY Non-Preferred hcl 09/01/2021 buprenorphine buprenorphine hcl ADD UM: QUANTITY 60 / 30 days hcl 09/01/2021 buprenorphine buprenorphine hcl ADD UM: DRUGCLASS NARCOTICS – hcl LONG ACTING 09/01/2021 buprenorphine buprenorphine hcl ADD UM: PANAME Clinical PA hcl 09/01/2021 buprenorphine buprenorphine hcl ADD TO FORMULARY Non-Preferred hcl 09/01/2021 buprenorphine buprenorphine hcl ADD UM: QUANTITY 60 / 30 days hcl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 720 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2021 buprenorphine buprenorphine hcl ADD UM: DRUGCLASS NARCOTICS – hcl LONG ACTING 09/01/2021 buprenorphine buprenorphine hcl ADD UM: PANAME Clinical PA hcl 09/01/2021 buprenorphine buprenorphine hcl ADD TO FORMULARY Non-Preferred hcl 09/01/2021 buprenorphine buprenorphine hcl ADD UM: QUANTITY 60 / 30 days hcl 09/01/2021 buprenorphine buprenorphine hcl ADD UM: DRUGCLASS NARCOTICS – hcl LONG ACTING 09/01/2021 buprenorphine buprenorphine hcl ADD UM: PANAME Clinical PA hcl 09/01/2021 buprenorphine buprenorphine hcl ADD TO FORMULARY Non-Preferred hcl 09/01/2021 buprenorphine buprenorphine hcl ADD UM: QUANTITY 60 / 30 days hcl 09/01/2021 buprenorphine buprenorphine hcl ADD UM: DRUGCLASS NARCOTICS – hcl LONG ACTING 09/01/2021 buprenorphine buprenorphine hcl ADD UM: PANAME Clinical PA hcl 09/01/2021 buprenorphine buprenorphine hcl ADD TO FORMULARY Non-Preferred hcl 09/01/2021 buprenorphine buprenorphine hcl ADD UM: QUANTITY 60 / 30 days hcl 09/01/2021 buprenorphine buprenorphine hcl ADD UM: DRUGCLASS NARCOTICS – hcl LONG ACTING 09/01/2021 buprenorphine buprenorphine hcl ADD UM: PANAME Clinical PA hcl 09/01/2021 buprenorphine buprenorphine hcl ADD TO FORMULARY Non-Preferred hcl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 721 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2021 buprenorphine buprenorphine hcl ADD UM: QUANTITY 60 / 30 days hcl 09/01/2021 buprenorphine buprenorphine hcl ADD UM: DRUGCLASS NARCOTICS – hcl LONG ACTING 09/01/2021 buprenorphine buprenorphine hcl ADD UM: PANAME Clinical PA hcl 09/01/2021 FLULAVAL influenza virus vaccine REMOVE FROM Non PDL Non-Formulary QUAD 2020- quadrival 2020-2021(6 mos FORMULARY 2021 and up)/pf 09/01/2021 FLULAVAL influenza virus vaccine REMOVE UM: AGE At least 0.5 yrs QUAD 2020- quadrival 2020-2021(6 mos old 2021 and up)/pf 09/01/2021 FLUARIX QUAD influenza virus vaccine REMOVE FROM Non PDL Non-Formulary 2020-2021 quadrival 2020-2021(6 mos FORMULARY and up)/pf 09/01/2021 FLUARIX QUAD influenza virus vaccine REMOVE UM: AGE At least 0.5 yrs 2020-2021 quadrival 2020-2021(6 mos old and up)/pf 09/01/2021 FLUCELVAX flu vaccine quadriv 2020- REMOVE FROM Non PDL Non-Formulary QUAD 2020- 2021(4 years and older)cell FORMULARY 2021 derived 09/01/2021 FLUCELVAX flu vaccine quadriv 2020- REMOVE UM: AGE At least 4 yrs old QUAD 2020- 2021(4 years and older)cell 2021 derived 09/01/2021 FLUAD QUAD influenza vaccine REMOVE FROM Non PDL Non-Formulary 2020-2021 quadrivalent 2020-21 (65 yr FORMULARY up)/mf59c.1/pf 09/01/2021 FLUAD QUAD influenza vaccine REMOVE UM: AGE At least 65 yrs 2020-2021 quadrivalent 2020-21 (65 yr old up)/mf59c.1/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 722 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2021 FLUAD 2020- influenza vaccine tvs 2020- REMOVE FROM Non PDL Non-Formulary 2021 21 (65 yr up)/adjuvant FORMULARY mf59c.1/pf 09/01/2021 FLUAD 2020- influenza vaccine tvs 2020- REMOVE UM: AGE At least 65 yrs 2021 21 (65 yr up)/adjuvant old mf59c.1/pf 09/01/2021 FLUZONE HIGH- influenza virus vaccine REMOVE FROM Non PDL Non-Formulary DOSE QUAD quadrival split 2020-21(65 yr FORMULARY 2020-21 up)/pf 09/01/2021 FLUZONE HIGH- influenza virus vaccine REMOVE UM: AGE At least 65 yrs DOSE QUAD quadrival split 2020-21(65 yr old 2020-21 up)/pf 09/01/2021 FLUCELVAX flu vaccine quad 2020- REMOVE FROM Non PDL Non-Formulary QUAD 2020- 2021(4 years and older)cell FORMULARY 2021 derived/pf 09/01/2021 FLUCELVAX flu vaccine quad 2020- REMOVE UM: AGE At least 4 yrs old QUAD 2020- 2021(4 years and older)cell 2021 derived/pf 09/01/2021 AFLURIA QUAD influenza virus vaccine REMOVE FROM Non PDL Non-Formulary 2020-2021 quadrivalent 2020-21 (6 mos FORMULARY and up) 09/01/2021 AFLURIA QUAD influenza virus vaccine REMOVE UM: AGE At least 0.5 yrs 2020-2021 quadrivalent 2020-21 (6 mos old and up) 09/01/2021 AFLURIA QUAD influenza virus vaccine REMOVE FROM Non PDL Non-Formulary 2020-21 (3YR quadrivalent 2020-21 (36 FORMULARY UP) mos up)/pf 09/01/2021 AFLURIA QUAD influenza virus vaccine REMOVE UM: AGE At least 3 yrs old 2020-21 (3YR quadrivalent 2020-21 (36 UP) mos up)/pf 09/01/2021 AFLURIA QUAD influenza virus vaccine REMOVE FROM Non PDL Non-Formulary 2020-21 (6- quadrival 2020-21 (6 mos- FORMULARY 35MO) 35 mos)/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 723 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2021 AFLURIA QUAD influenza virus vaccine REMOVE UM: AGE 0.5 to 3 yrs old 2020-21 (6- quadrival 2020-21 (6 mos- 35MO) 35 mos)/pf 09/01/2021 FLUZONE QUAD influenza virus vaccine REMOVE FROM Non PDL Non-Formulary 2020-2021 quadrival 2020-2021(6 mos FORMULARY and up)/pf 09/01/2021 FLUZONE QUAD influenza virus vaccine REMOVE UM: AGE At least 0.5 yrs 2020-2021 quadrival 2020-2021(6 mos old and up)/pf 09/01/2021 FLUBLOK QUAD influenza virus vaccine qv REMOVE FROM Non PDL Non-Formulary 2020-2021 2020-21(18 yrs and FORMULARY older)rcmb/pf 09/01/2021 FLUBLOK QUAD influenza virus vaccine qv REMOVE UM: AGE At least 18 yrs 2020-2021 2020-21(18 yrs and old older)rcmb/pf 09/01/2021 FLUZONE QUAD influenza virus vaccine REMOVE FROM Non PDL Non-Formulary 2020-2021 quadrivalent 2020-21 (6 mos FORMULARY and up) 09/01/2021 FLUZONE QUAD influenza virus vaccine REMOVE UM: AGE At least 0.5 yrs 2020-2021 quadrivalent 2020-21 (6 mos old and up) 09/01/2021 FLUZONE QUAD influenza virus vaccine REMOVE FROM Non PDL Non-Formulary 2020-2021 quadrival 2020-2021(6 mos FORMULARY and up)/pf 09/01/2021 FLUZONE QUAD influenza virus vaccine REMOVE UM: AGE At least 0.5 yrs 2020-2021 quadrival 2020-2021(6 mos old and up)/pf 09/01/2021 adapalene adapalene ADD TO FORMULARY Non PDL 09/01/2021 DIFFERIN adapalene ADD TO FORMULARY Non-Formulary Non PDL 09/06/2021 ENABLEX darifenacin hydrobromide REMOVE FROM Non-Preferred Non-Formulary FORMULARY 09/06/2021 ENABLEX darifenacin hydrobromide REMOVE UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 724 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/06/2021 ENABLEX darifenacin hydrobromide REMOVE UM: URINARY DRUGCLASS TRACT ANTISPASMODI CS 09/06/2021 ENABLEX darifenacin hydrobromide REMOVE FROM Non-Preferred Non-Formulary FORMULARY 09/06/2021 ENABLEX darifenacin hydrobromide REMOVE UM: PANAME Non Preferred PA 09/06/2021 ENABLEX darifenacin hydrobromide REMOVE UM: URINARY DRUGCLASS TRACT ANTISPASMODI CS 09/14/2021 ivermectin ivermectin ADD UM: QUANTITY 10 / 30 days 09/15/2021 nebivolol hcl nebivolol hcl ADD TO FORMULARY Non-Preferred 09/15/2021 nebivolol hcl nebivolol hcl ADD UM: DRUGCLASS BETA BLOCKERS 09/15/2021 nebivolol hcl nebivolol hcl ADD UM: PANAME Non Preferred PA 09/15/2021 nebivolol hcl nebivolol hcl ADD UM: COV Use brand over generic 09/15/2021 nebivolol hcl nebivolol hcl ADD TO FORMULARY Non-Preferred 09/15/2021 nebivolol hcl nebivolol hcl ADD UM: DRUGCLASS BETA BLOCKERS 09/15/2021 nebivolol hcl nebivolol hcl ADD UM: PANAME Non Preferred PA 09/15/2021 nebivolol hcl nebivolol hcl ADD UM: COV Use brand over generic 09/15/2021 nebivolol hcl nebivolol hcl ADD TO FORMULARY Non-Preferred 09/15/2021 nebivolol hcl nebivolol hcl ADD UM: DRUGCLASS BETA BLOCKERS 09/15/2021 nebivolol hcl nebivolol hcl ADD UM: PANAME Non Preferred PA

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 725 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/15/2021 nebivolol hcl nebivolol hcl ADD UM: COV Use brand over generic 09/15/2021 nebivolol hcl nebivolol hcl ADD TO FORMULARY Non-Preferred 09/15/2021 nebivolol hcl nebivolol hcl ADD UM: DRUGCLASS BETA BLOCKERS 09/15/2021 nebivolol hcl nebivolol hcl ADD UM: PANAME Non Preferred PA 09/15/2021 nebivolol hcl nebivolol hcl ADD UM: COV Use brand over generic 09/15/2021 BYSTOLIC nebivolol hcl ADD UM: B4G BRAND FOR GENERIC 09/15/2021 BYSTOLIC nebivolol hcl ADD UM: B4G BRAND FOR GENERIC 09/15/2021 BYSTOLIC nebivolol hcl ADD UM: B4G BRAND FOR GENERIC 09/15/2021 BYSTOLIC nebivolol hcl ADD UM: B4G BRAND FOR GENERIC

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 726 UPDATED 09/2021 UPHP MEDICAID FORMULARY Updates

November, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/01/2021 promethazine hcl promethazine hcl ADD UM: QUANTITY 2 / day 11/01/2021 promethazine hcl promethazine hcl ADD UM: QUANTITY 4 / day 11/01/2021 promethazine hcl promethazine hcl ADD UM: QUANTITY 4 / day 11/01/2021 budesonide ec budesonide ADD TO FORMULARY Non PDL 11/01/2021 budesonide ec budesonide ADD UM: PANAME Clinical PA 11/01/2021 budesonide ec budesonide ADD UM: 16 QUANTITYCUSTOM weeks/4months – 9mg once daily (induction); 3 months – 6mg once daily (maintenance); 1 month – 3mg once daily (taper) 11/01/2021 cimetidine cimetidine hcl ADD TO FORMULARY Non-Formulary Non PDL 11/01/2021 NARCAN naloxone hcl CHANGE UM: QUANTITY 2 / 90 days 6 / 90 days 11/01/2021 BRONCHITOL mannitol ADD TO FORMULARY Non PDL 11/01/2021 BRONCHITOL mannitol ADD UM: QUANTITY 560 / 28 days 11/01/2021 BRONCHITOL mannitol ADD UM: AGE At least 18 yrs old 11/01/2021 BRONCHITOL mannitol ADD UM: PANAME Clinical PA 11/01/2021 KLOXXADO naloxone hcl CHANGE UM: QUANTITY 2 / 90 days 6 / 90 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 727 UPDATED 09/2021