Magellan Rx Formulary Precision Formulary Updates

The Magellan Rx Management Pharmacy & Therapeutics Committee (P&T) and Value Assessment Committee (VAC) meet periodically to review the status of drugs on the formulary and determine updates that are needed due to newly approved products, changes in practice guidelines, updates in FDA approved labeling and/or changes in financial implications. The following is the list of determinations made through this review process for the Magellan Rx Precision commercial formularies.

NEW DRUGS

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

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

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

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

KEPPRA 500 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

KEPPRA 750 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

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

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

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

LAMICTAL 150 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL 200 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

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

LAMICTAL 25 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

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

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

LAMICTAL ODT 200 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL ODT 25 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL ODT 50 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

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

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

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

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

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

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

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

LAMICTAL XR 200 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20 LABEL NAME INDICATIONS SIMILAR PRODUCTSª CHANGE TYPE PRECISION PRECISION UM EFFECTIVE DATE

LAMICTAL XR 25 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL XR 250 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL XR 300 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

LAMICTAL XR 50 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

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

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

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

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

LAMOTRIGINE 150 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LAMOTRIGINE 200 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

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

LAMOTRIGINE 25 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

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

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

LAMOTRIGINE ER 200 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LAMOTRIGINE ER 25 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LAMOTRIGINE ER 250 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LAMOTRIGINE ER 300 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LAMOTRIGINE ER 50 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

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

LAMOTRIGINE ODT 200 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LAMOTRIGINE ODT 25 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

LAMOTRIGINE ODT 50 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

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

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

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

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

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

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

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

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

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

LEVETIRACETAM 500 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

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

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

2019 Magellan Rx Management, LLC. All rights expressly reserved. 2 LABEL NAME INDICATIONS SIMILAR PRODUCTSª CHANGE TYPE PRECISION PRECISION UM EFFECTIVE DATE

LEVETIRACETAM 750 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

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

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

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

OXCARBAZEPINE 300 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

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

OXCARBAZEPINE 600 MG TABLET anticonvulsant NTI TAG ADDITION GEN add NTI tag Jul-20

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

OXTELLAR XR 300 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

OXTELLAR XR 600 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

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

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

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

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

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

SPRITAM 500 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

SPRITAM 750 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

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

TRILEPTAL 300 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

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

TRILEPTAL 600 MG TABLET anticonvulsant NTI TAG ADDITION NPB add NTI tag Jul-20

CHOLECAL DF 95 MCG-1 MG TABLET NEW BRAND NF May-20 vitamin deficiency; vitamin deficiency prevention CIFRAZOL, DURACHOL

EPINEPHRINE PROFESSIONAL KIT NEW BRAND NF May-20 Treatment of anaphylaxis in adults and children EPINEPHRINESNAP-EMS KIT

EPINEPHRINE PROFESSIONL EMS KT NEW BRAND NF May-20 Treatment of anaphylaxis in adults and children EPINEPHRINESNAP-EMS KIT

PHENOBARB-HYO-ATROP-SCOP ELIX NEW GENERIC NF May-20 Duodenal ulcer PHENOHYTRO ELIXIR

PHENOBARB-HYOSC-ATROP-SCOP TAB NEW GENERIC NF May-20 Duodenal ulcer BELLADONNA-PHENOBARBITAL TAB

AZESCHEW CHEWABLE TABLET NEW BRAND NF May-20 Prenatal/postnatal supplement chew vitamin ALIVE PRENATAL GUMMY, CLASSIC PRENATAL

VOLNEA 0.15-0.02-0.01 MG TAB NEW GENERIC GEN May-20 pregnancy contraception AZURETTE 28 DAY, MIRCETTE 28 DAY

ZIPRASIDONE 20 MG/ML VIAL NEW GENERIC GEN May-20 Agitation associated with Schizophrenia GEODON 20 MG/ML

AZELASTIN-FLUTIC 137-50MCG SPR NEW GENERIC GEN QL: 0.8/day May-20 seasonal allergic rhinitis DYMISTA NASAL SPRAY

JAIMIESS 0.15-0.03-0.01 MG TAB NEW GENERIC GEN QL: 91 Days May-20 pregnancy contraception AMETHIA, SEASONIQUE

LOJAIMIESS 0.1-0.02-0.01 TAB NEW GENERIC GEN QL: 91 Days May-20 pregnancy contraception AMETHIA LO, LOSEASONIQUE

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

2019 Magellan Rx Management, LLC. All rights expressly reserved. 3 LABEL NAME INDICATIONS SIMILAR PRODUCTSª CHANGE TYPE PRECISION PRECISION UM EFFECTIVE DATE

SODIUM FLUORIDE 5000 PPM CREAM NEW GENERIC GEN May-20 prevention of dental caries FLUORIDE 5000 PPM

AJOVY 225 MG/1.5 ML AUTOINJECT NEW BRAND NF May-20 migraine prevention AJOVY 225 MG/1.5 ML SYRINGE

PROMACTA 25 MG SUSPENSION PCKT aplastic anemia; severe thrombocytopenia in refractory chronic ITP; NEW FORMULATION NPS PA May-20 thrombocytopenia associated with chronic hepatitis C PROMACTA 12.5 MG SUSPEN, PROMACTA 25 MG

HIZENTRA 1 GRAM/5 ML SYRINGE Immunoglobulin used to treat Primary Immunodeficiency (PI) and Chronic NEW FORMULATION NPS PA May-20 Inflammatory Demyelinating Polyneuropathy (CIDP) HIZENTRA VIAL

HIZENTRA 2 GRAM/10 ML SYRINGE Immunoglobulin used to treat Primary Immunodeficiency (PI) and Chronic NEW FORMULATION NPS PA May-20 Inflammatory Demyelinating Polyneuropathy (CIDP) HIZENTRA VIAL

HIZENTRA 4 GRAM/20 ML SYRINGE Immunoglobulin used to treat Primary Immunodeficiency (PI) and Chronic NEW FORMULATION NPS PA May-20 Inflammatory Demyelinating Polyneuropathy (CIDP) HIZENTRA VIAL

ARAZLO 0.045% LOTION NEW BRAND NF Oct-20 acne vulgaris TAZAROTENE 0.1% CREAM, ALTRENO LOTION 0.05%

INSULIN LISPRO JR 100 UNIT/ML NEW GENERIC NF Jul-20 Diabetes mellitus HUMALOG JR 100 UNIT/ML KWIKPEN

INSULIN LISPRO MIX 75-25 KWKPN HUMALOG MIX 75-25 KWKPN NEW GENERIC NF Jul-20 Diabetes mellitus

KOSELUGO 10 MG CAPSULE NEW BRAND NPS PA, QL: 4 cap/day Oct-20 Pediatric neurofibromatosis type 1 with plexiform neurofibromas

KOSELUGO 25 MG CAPSULE NEW BRAND NPS PA, QL: 4 cap/day Oct-20 Pediatric neurofibromatosis type 1 with plexiform neurofibromas

NEXLETOL 180 MG TABLET atherosclerotic cardiovascular disease; heterozygous familial EZETIMIBE, FENOFIBRATE NEW BRAND NPB PA, QL: 1 tab/day Oct-20 hypercholesterolemia

PEMAZYRE 13.5 MG TABLET NEW BRAND NPS PA, QL: 0.67/day Oct-20 cholangiocarcinoma with FGFR2 fusion or rearrangement

PEMAZYRE 4.5 MG TABLET NEW BRAND NPS PA, QL: 0.67/day Oct-20 cholangiocarcinoma with FGFR2 fusion or rearrangement

PEMAZYRE 9 MG TABLET NEW BRAND NPS PA, QL: 0.67/day Oct-20 cholangiocarcinoma with FGFR2 fusion or rearrangement

TUKYSA 150 MG TABLET NEW BRAND NPS PA, QL: 4 tabs/day Oct-20 Indicated in combination with trastuzumab and capecitabine for treatment of HERCEPTIN, KANJINTI, OGIVRI adult patients with advanced unresectable or metastatic HER2-positive breast TUKYSA 50 MG TABLET cancer, including patients with brain metastases, who have received one or NEW BRAND NPS PA, QL: 4 tabs/day Oct-20 more prior antiHER2-based regimens in the metastatic setting. HERCEPTIN, KANJINTI, OGIVRI

XCOPRI 100 MG TABLET NEW BRAND NPB PA, QL: 400 mg/day Oct-20 partial-onset seizures OXCARBAZEPINE TABLETS, APTIOM TABLETS

XCOPRI 150 MG TABLET NEW BRAND NPB PA, QL: 400 mg/day Oct-20 partial-onset seizures OXCARBAZEPINE TABLETS, APTIOM TABLETS

XCOPRI 200 MG TABLET NEW BRAND NPB PA, QL: 400 mg/day Oct-20 partial-onset seizures OXCARBAZEPINE TABLETS, APTIOM TABLETS

XCOPRI 250 MG DAILY DOSE PACK NEW BRAND NPB PA, QL: 400 mg/day Oct-20 partial-onset seizures OXCARBAZEPINE TABLETS, APTIOM TABLETS

XCOPRI 350 MG DAILY DOSE PACK NEW BRAND NPB PA, QL: 400 mg/day Oct-20 partial-onset seizures OXCARBAZEPINE TABLETS, APTIOM TABLETS

POSACONAZOLE DR 100 MG TABLET Treatment of oropharyngeal candidiasis and prophylaxis of invasive COVERAGE UPDATE NF-->GEN May-20 Aspergillus and Candida Infections NOXAFIL DR 100 MG TABLET

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

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

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

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

QL ADDITION PS PA, QL: 0.04/day May-20 XOLAIR 75 MG/0.5 ML SYRINGE moderate to severe asthma; chronic idiopathic urticaria DUPIXENT, NUCALA Jun-20 BASADROX WOUND GEL Management of 1st and 2nd degree burns NEW BRAND NF

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

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Jun-20 CICASIL 2"X5.5" PAD Managing hypertrophic, hyperpigmented and keloid scar tissue. NEW BRAND NF adrenalin Jun-20 EPINEPHRINE 30 MG/30 ML VIAL septic shock; anaphylaxis; allergic reaction NEW GENERIC NF Elecare Jr Jun-20 EQUACARE JR POWDER Amino-acid based nutritional powder NEW BRAND NF Relief of the inflammatory and pruritic manifestations of corticosteroid- Halog cream, Halog ointment, halcinonide Jun-20 HALOG 0.1% SOLUTION responsive dermatoses NEW FORMULATION NF to slow kidney function decline in adults at risk of rapidly progressing Jun-20 JYNARQUE 15 MG-15 MG TABLET autosomal dominant polycystic kidney disease NEW FORMULATION NPS PA, QL: 2/day to slow kidney function decline in adults at risk of rapidly progressing Jun-20 JYNARQUE 30 MG-15 MG TABLET autosomal dominant polycystic kidney disease NEW FORMULATION NPS PA, QL: 2/day Clinical dietary management of suboptimal nutritional status in patients Jun-20 LORMATE CAPSULE taking methotrexate NEW BRAND NF norg-ethin estradiol Jun-20 NORGESTIMATE-EE 0.25-0.035 MG acne vulgaris; pregnancy contraception NEW GENERIC GEN GL Nymalize solution Jun-20 NYMALIZE 30 MG/5 ML ORAL SYRNG subarachnoid intracranial hemorrhage NEW FORMULATION NPB QL: 60/day Nymalize solution Jun-20 NYMALIZE 60 MG/10 ML ORAL SYRN subarachnoid intracranial hemorrhage NEW FORMULATION NPB QL: 60/day amantadine Jun-20 OSMOLEX ER 322 MG DAILY DOSE idiopathic parkinsonism; drug-induced extrapyramidal reaction NEW FORMULATION NPS PA, QL: 2/day

POLYTOZA PATCH non-invasive management of old and new hypertrophic or keloid scars NEW BRAND NF Jun-20 Jun-20 T:SLIM X2 CONTROL-IQ PUMP subcutaneous insulin pump NEW BRAND NF hyponatremia, in HF patients and syndrome of inappropriate antidiuretic Samsca Jun-20 TOLVAPTAN 30 MG TABLET hormone secretion (SIADH) NEW GENERIC GEN SP, PA, QL: 2/day cutaneous T-cell lymphoma; skin inflammation; seborrheic dermatitis; atopic dermatitis; contact dermatitis; allergic dermatitis; discoid lupus NF Jun-20 erythematosus; granuloma annulare; plaque psoriasis; pruritus ani; genital TRIVIX KIT organ pruritus NEW GENERIC Jun-20 ZIONODIL 3% LOTION pruritus of skin; skin irritation; minor skin wound pain NEW GENERIC NF Jun-20 ZIONODIL-100 3% LOTION pruritus of skin; skin irritation; minor skin wound pain NEW GENERIC NF METHERGINE 0.2 MG TABLET QL ADDITION Jul-20 postpartum hemorrhage, prevention of uterine inertia GEN QL: 6/day METHYLERGONOVINE 0.2 MG TABLET QL ADDITION Jul-20 postpartum hemorrhage, prevention of uterine inertia GEN QL: 6/day METHYLPHENIDATE ER 10 MG CAP Aptensio XR Oct-20 attention-deficit hyperactivity disorder NEW GENERIC GEN QL, add ST METHYLPHENIDATE ER 15 MG CAP Aptensio XR Oct-20 attention-deficit hyperactivity disorder NEW GENERIC GEN QL, add ST METHYLPHENIDATE ER 20 MG CAP Aptensio XR Oct-20 attention-deficit hyperactivity disorder NEW GENERIC GEN QL, add ST

METHYLPHENIDATE ER 30 MG CAP Aptensio XR GEN Oct-20 attention-deficit hyperactivity disorder NEW GENERIC QL, add ST

METHYLPHENIDATE ER 40 MG CAP Aptensio XR GEN Oct-20 attention-deficit hyperactivity disorder NEW GENERIC QL, add ST

METHYLPHENIDATE ER 50 MG CAP Aptensio XR GEN Oct-20 attention-deficit hyperactivity disorder NEW GENERIC QL, add ST

METHYLPHENIDATE ER 60 MG CAP Aptensio XR GEN Oct-20 attention-deficit hyperactivity disorder NEW GENERIC QL, add ST

CRESTOR 10 MG TABLET rosuvastatin, atorvastatin ST ADDITION NF add ST in Oct-20 adjudication, QL hypercholesterolemia, homozygous familial hypercholesterolemia, CRESTOR 20 MG TABLET atherosclerotic cardiovascular disease, hyperlipidemia, heterozygous familial rosuvastatin, atorvastatin ST ADDITION NF add ST in Oct-20 hypercholesterolemia, hypertriglyceridemia, mixed hyperlipidemia, adjudication, QL myocardial infarction prevention, primary dysbetalipoproteinemia, primary CRESTOR 40 MG TABLET prevention of coronary heart disease, prevention of transient ischemic attack, rosuvastatin, atorvastatin ST ADDITION NF add ST in Oct-20 prevention of cerebrovascular accident adjudication, QL

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

2019 Magellan Rx Management, LLC. All rights expressly reserved. 5 hypercholesterolemia, homozygous familial hypercholesterolemia, atherosclerotic cardiovascular disease, hyperlipidemia, heterozygous familial hypercholesterolemia, hypertriglyceridemia, mixed hyperlipidemia, myocardial infarction prevention, primary dysbetalipoproteinemia, primary prevention of coronary heart disease, prevention of transient ischemic attack, LABEL NAME prevention INDICATIONSof cerebrovascular accident SIMILAR PRODUCTSª CHANGE TYPE PRECISION PRECISION UM EFFECTIVE DATE

CRESTOR 5 MG TABLET rosuvastatin, atorvastatin ST ADDITION NF add ST in Oct-20 adjudication, QL

DRUG CHANGES NF Oct-20 FIASP 100 UNIT/ML FLEXTOUCH diabetes mellitus Humalog

DRUG CHANGES NF Oct-20 FIASP 100 UNIT/ML VIAL diabetes mellitus Humalog

DRUG CHANGES NF Oct-20 FIASP PENFILL 100 UNIT/ML CART diabetes mellitus Humalog

DRUG CHANGES NF Oct-20 INSULIN ASPART 100 UNIT/ML CRT diabetes mellitus Humalog

DRUG CHANGES NF Oct-20 INSULIN ASPART 100 UNIT/ML PEN diabetes mellitus Humalog

DRUG CHANGES NF Oct-20 INSULIN ASPART 100 UNIT/ML VL diabetes mellitus Humalog

DRUG CHANGES NF Oct-20 INSULIN ASPART PROT-INSULN ASP diabetes mellitus Humalog

DRUG CHANGES NF Oct-20 INSULIN LISPRO 100 UNIT/ML PEN diabetes mellitus Humalog

DRUG CHANGES NF Oct-20 INSULIN LISPRO 100 UNIT/ML VL diabetes mellitus Humalog

DRUG CHANGES NF Oct-20 INSULIN LISPRO JR 100 UNIT/ML diabetes mellitus Humalog

DRUG CHANGES NF Oct-20 INSULIN LISPRO MIX 75-25 KWKPN diabetes mellitus Humalog

DRUG CHANGES NF Oct-20 ADMELOG 100 UNIT/ML VIAL diabetes mellitus Humalog

DRUG CHANGES NF Oct-20 ADMELOG SOLOSTAR 100 UNIT/ML diabetes mellitus Humalog

DRUG CHANGES NF Oct-20 APIDRA 100 UNITS/ML VIAL diabetes mellitus Humalog

DRUG CHANGES NF Oct-20 APIDRA SOLOSTAR 100 UNITS/ML diabetes mellitus Humalog

DRUG CHANGES NF Jul-20 RELISTOR 150 MG TABLET opioid-induced constipation Symproic, Movantik

DRUG CHANGES NPS remove QL Oct-20 CERDELGA 84 MG CAPSULE Gaucher disease type 1 Zavesca, miglustat

DRUG CHANGES GEN QL, add ST Oct-20 AZELASTIN-FLUTIC 137-50MCG SPR seasonal allergic rhinitis Dymista Indicated for the topical treatment of inflammatory lesions of non-nodular moderate to severe acne vulgaris in adults and pediatric patients 9 years of DRUG CHANGES NF Jul-20 AMZEEQ 4% FOAM age and older generic topical retinoids

DRUG CHANGES NF Oct-20 RETIN-A MICRO PUMP 0.06% GEL Acne vulgaris generic topical retinoids

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

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DRUG CHANGES NF Oct-20 RETIN-A MICRO PUMP 0.08% GEL Acne vulgaris generic topical retinoids

DRUG CHANGES NF-->NPB add QL (2/fill) Jul-20 SYMJEPI 0.15 MG/0.3 ML SYRINGE Anaphylaxis generic epinephrine

DRUG CHANGES NF-->NPB add QL (2/fill) Jul-20 SYMJEPI 0.3 MG/0.3 ML SYRINGE Anaphylaxis generic epinephrine

ACCU-CHEK AVIVA PLUS TEST STRP DRUG CHANGES NF Oct-20 test strip; NDC 65702043810 One Touch test strips

ACCU-CHEK GUIDE TEST STRIP DRUG CHANGES NF Oct-20 test strip; NDCs 65702071910, 65702070195 One Touch test strips

RELION NOVOLIN 70-30 VIAL DRUG CHANGES NF Oct-20 diabetes mellitus; NDC 00169183702 Humulin

RELION NOVOLIN 70-30 FLEXPEN DRUG CHANGES NF Oct-20 diabetes mellitus; NDC 00169300725 Humulin

RELION NOVOLIN N 100 UNIT/ML DRUG CHANGES NF Oct-20 diabetes mellitus; NDC 00169183402 Humulin

RELION NOVOLIN R 100 UNIT/ML DRUG CHANGES NF Oct-20 diabetes mellitus: NDC 00169183302 Humulin

Topical retinoid indicated for the topical treatment of acne vulgaris in patients DRUG CHANGES NPB-->NF Oct-20 AKLIEF 0.005% CREAM 9 years of age and older generic topical retinoids

reduction of intraocular pressure (IOP) in patients with open-angle glaucoma DRUG CHANGES keep NF Jul-20 VYZULTA 0.024% OPHTH SOLUTION or ocular hypertension. latanoprost, travoprost

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

antifungal DRUG CHANGES GEN-->NF Oct-20 CICLODAN 0.77% CREAM

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

antifungal DRUG CHANGES GEN-->NF Oct-20 CLOTRIMAZOLE-BETAMETHASONE LOT

antifungal DRUG CHANGES NPB-->NF Oct-20 ECOZA 1% FOAM

antifungal DRUG CHANGES NPB-->NF Oct-20 ERTACZO 2% CREAM

antifungal DRUG CHANGES NPB-->NF Oct-20 EXELDERM 1% CREAM

antifungal DRUG CHANGES NPB-->NF Oct-20 EXELDERM 1% SOLUTION

antifungal DRUG CHANGES GEN Oct-20 NAFTIFINE HCL 1% CREAM add ST

antifungal DRUG CHANGES GEN Oct-20 NAFTIFINE HCL 2% CREAM add ST

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

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antifungal DRUG CHANGES GEN Oct-20 NAFTIFINE HCL 1% GEL add ST

antifungal DRUG CHANGES NPB-->NF Oct-20 NAFTIN 2% CREAM

antifungal DRUG CHANGES NPB-->NF Oct-20 NAFTIN 1% GEL

antifungal DRUG CHANGES NPB-->NF Oct-20 NAFTIN 2% GEL

antifungal DRUG CHANGES GEN Oct-20 OXICONAZOLE NITRATE 1% CREAM add ST

antifungal DRUG CHANGES NPB-->NF Oct-20 OXISTAT 1% CREAM

antifungal DRUG CHANGES NPB-->NF Oct-20 OXISTAT 1% LOTION

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

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

antifungal DRUG CHANGES NPB-->NF Oct-20 EXTINA 2% FOAM

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

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

antifungal DRUG CHANGES add NF flag Oct-20 KETODAN 2% FOAM

antifungal DRUG CHANGES add NF flag Jun-20 LOPROX 0.77% CREAM

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

antifungal DRUG CHANGES NPB-->NF Oct-20 LUZU 1% CREAM

antifungal DRUG CHANGES NPB-->NF Jun-20 MENTAX 1% CREAM

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

antifungal DRUG CHANGES NPB-->NF Jun-20 VUSION OINTMENT

DRUG CHANGES keep NF Oct-20 SOLODYN ER 55 MG TABLET acne vulgaris minocycline ER tablet

DRUG CHANGES keep NF Oct-20 SOLODYN ER 65 MG TABLET acne vulgaris minocycline ER tablet

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

2019 Magellan Rx Management, LLC. All rights expressly reserved. 8 LABEL NAME INDICATIONS SIMILAR PRODUCTSª CHANGE TYPE PRECISION PRECISION UM EFFECTIVE DATE

DRUG CHANGES keep NF Oct-20 SOLODYN ER 80 MG TABLET acne vulgaris minocycline ER tablet

DRUG CHANGES keep NF Oct-20 SOLODYN ER 105 MG TABLET acne vulgaris minocycline ER tablet

DRUG CHANGES keep NF Oct-20 SOLODYN ER 115 MG TABLET acne vulgaris minocycline ER tablet

DRUG CHANGES GEN QL, no revised ST Oct-20 COREMINO ER 135 MG TABLET acne vulgaris minocycline ER tablet

DRUG CHANGES GEN QL, no revised ST Oct-20 COREMINO ER 90 MG TABLET acne vulgaris minocycline ER tablet

DRUG CHANGES GEN QL, no revised ST Oct-20 COREMINO ER 45 MG TABLET acne vulgaris minocycline ER tablet

DRUG CHANGES GEN QL, no revised ST Oct-20 MINOCYCLINE ER 105 MG TABLET acne vulgaris Solodyn ER, Coremino ER

DRUG CHANGES GEN QL, no revised ST Oct-20 MINOCYCLINE ER 115 MG TABLET acne vulgaris Solodyn ER, Coremino ER

DRUG CHANGES GEN QL, no revised ST Oct-20 MINOCYCLINE ER 135 MG TABLET acne vulgaris Solodyn ER, Coremino ER

DRUG CHANGES GEN QL, no revised ST Oct-20 MINOCYCLINE ER 90 MG TABLET acne vulgaris Solodyn ER, Coremino ER

DRUG CHANGES GEN QL, no revised ST Oct-20 MINOCYCLINE ER 80 MG TABLET acne vulgaris Solodyn ER, Coremino ER

DRUG CHANGES GEN QL, no revised ST Oct-20 MINOCYCLINE ER 65 MG TABLET acne vulgaris Solodyn ER, Coremino ER

DRUG CHANGES GEN QL, no revised ST Oct-20 MINOCYCLINE ER 55 MG TABLET acne vulgaris Solodyn ER, Coremino ER

DRUG CHANGES GEN QL, no revised ST Oct-20 MINOCYCLINE ER 45 MG TABLET acne vulgaris Solodyn ER, Coremino ER

CRITERIA UPDATE NF Jul-20 BASAGLAR 100 UNIT/ML KWIKPEN diabetes mellitus Lantus, Levemir, Toujeo, Tresiba ST (allow HF CRITERIA UPDATE NF-->PB Jul-20 FARXIGA 5 MG TABLET type 2 diabetes, heart failure Jardiance, Invokana diagnosis) ST (allow HF CRITERIA UPDATE NF-->PB Jul-20 FARXIGA 10 MG TABLET type 2 diabetes, heart failure Jardiance, Invokana diagnosis)

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

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VALUE ASSESSMENT COMMITTEE HIGHLIGHTS

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

ZERVIATE 0.24% EYE DROP NEW BRAND NF Jul-20 allergic conjunctivitis OLOPATADINE, AZELASTINE, PAZEO

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

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

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

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

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

ARMODAFINIL, MODAFINIL, DRUG CHANGES NPB-->PB PA, QL Oct-20 SUNOSI 75 MG TABLET Narcolepsy Syndrome; Sleepiness Due To Obstructive Sleep Apnea

ARMODAFINIL, MODAFINIL, DRUG CHANGES NPB-->PB PA, QL Oct-20 SUNOSI 150 MG TABLET Narcolepsy Syndrome; Sleepiness Due To Obstructive Sleep Apnea XIMINO ER 135 MG CAPSULE acne vulgaris MINOCYCLINE ER CAPSULE DRUG CHANGES NF Oct-20 XIMINO ER 90 MG CAPSULE acne vulgaris MINOCYCLINE ER CAPSULE DRUG CHANGES NF Oct-20 XIMINO ER 45 MG CAPSULE acne vulgaris MINOCYCLINE ER CAPSULE DRUG CHANGES NF Oct-20 SOLODYN ER 55 MG TABLET acne vulgaris MINOCYCLINE ER TABLET DRUG CHANGES NF-->NPB QL Oct-20 SOLODYN ER 65 MG TABLET acne vulgaris MINOCYCLINE ER TABLET DRUG CHANGES NF-->NPB QL Oct-20 SOLODYN ER 80 MG TABLET acne vulgaris MINOCYCLINE ER TABLET DRUG CHANGES NF-->NPB QL Oct-20 SOLODYN ER 105 MG TABLET acne vulgaris MINOCYCLINE ER TABLET DRUG CHANGES NF-->NPB QL Oct-20 SOLODYN ER 115 MG TABLET acne vulgaris MINOCYCLINE ER TABLET DRUG CHANGES NF-->NPB QL Oct-20 MINOCYCLINE ER 135 MG CAPSULE NEW GENERIC NF Oct-20 acne vulgaris XIMINO ER CAPSULE

MINOCYCLINE ER 45 MG CAPSULE NEW GENERIC NF Oct-20 acne vulgaris XIMINO ER CAPSULE

MINOCYCLINE ER 90 MG CAPSULE NEW GENERIC NF Oct-20 acne vulgaris XIMINO ER CAPSULE relapsing fever, bartonellosis, syphilis, gingivostomatitis, upper respiratory pneumococcal infection, bacterial pneumonia, mycoplasmal pneumonia, lymphogranuloma venereum, granuloma inguinale, sinusitis, genitourinary Chlamydia trachomatis infection, fusospirochetal pharyngitis, yaws, acne DRUG CHANGES NPB-->NF Oct-20 vulgaris, bacterial urinary tract infection, acute bacterial otitis media, pharyngitis, cholera, plague, tularemia, anthrax, brucellosis, listeriosis, skin MINOCIN 100 MG PELLETIZED CAP rickettsialpox,and skin structure relapsing infection, fever, meningococcal bartonellosis, carrier,syphilis, actinomycosis, gingivostomatitis, upper MINOCYCLINE CAPSULE respiratory pneumococcal infection, bacterial pneumonia, mycoplasmal pneumonia, lymphogranuloma venereum, granuloma inguinale, sinusitis, genitourinary Chlamydia trachomatis infection, fusospirochetal pharyngitis, yaws, acne vulgaris, bacterial urinary tract infection, acute bacterial otitis DRUG CHANGES NPB-->NF Oct-20 media, pharyngitis, cholera, plague, tularemia, anthrax, brucellosis, listeriosis, meningococcal carrier, skin and skin structure infection, actinomycosis, Ureaplasma urealyticum infection, Campylobacter fetus infection, psittacosis, MINOCIN 75 MG PELLETIZED CAP relapsingtrachoma, fever, inclusion bartonellosis, conjunctivitis syphilis, caused gingivostomatitis, by Chlamydia trachomatis, upper respiratory typhus MINOCYCLINE CAPSULE pneumococcal infection, bacterial pneumonia, mycoplasmal pneumonia, sinusitis, lymphogranuloma venereum, granuloma inguinale, genitourinary Chlamydia trachomatis infection, fusospirochetal pharyngitis, yaws, acne vulgaris, bacterial urinary tract infection, acute bacterial otitis media, DRUG CHANGES NPB-->NF Oct-20 pharyngitis, cholera, plague, tularemia, anthrax, brucellosis, listeriosis, skin and skin structure infection, meningococcal carrier, actinomycosis, MINOCIN 50 MG PELLETIZED CAP Ureaplasma urealyticum infection, Campylobacter fetus infection, psittacosis, MINOCYCLINE CAPSULE

DRUG CHANGES GEN QL, revise ST Oct-20 COREMINO ER 135 MG TABLET acne vulgaris MINOCYCLINE ER TABLET

DRUG CHANGES GEN QL, revise ST Oct-20 COREMINO ER 90 MG TABLET acne vulgaris MINOCYCLINE ER TABLET

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DRUG CHANGES GEN QL, revise ST Oct-20

COREMINO ER 45 MG TABLET granulomaacne vulgaris inguinale, lymphogranuloma venereum, acne vulgaris, Rocky MINOCYCLINE ER TABLET Mountain spotted fever, boutonneuse fever, rectal Chlamydia trachomatis infection, upper respiratory pneumococcal infection, cholera, genitourinary QL, revise ST Oct-20 Chlamydia trachomatis infection, plague, Campylobacter fetus infection, Q DRUG CHANGES NF DOXYCYCLINE HYC DR 200 MG TAB lymphogranulomafever, rickettsialpox, venereum, yaws, tularemia, granuloma rickettsial inguinale, infection, acne vulgaris, malaria Rockyprevention, Mountain spotted fever, boutonneuse fever, rectal Chlamydia trachomatis infection, upper respiratory pneumococcal infection, cholera, genitourinary QL, revise ST Oct-20 Chlamydia trachomatis infection, Campylobacter fetus infection, plague, Q DRUG CHANGES NF DOXYCYCLINE HYC DR 100 MG TAB lymphogranulomafever, rickettsialpox, venereum, yaws, tularemia, granuloma rickettsial inguinale, infection, acne vulgaris, malaria Rockyprevention, Mountain spotted fever, boutonneuse fever, rectal Chlamydia trachomatis infection, upper respiratory pneumococcal infection, cholera, genitourinary QL, revise ST Oct-20 Chlamydia trachomatis infection, plague, Campylobacter fetus infection, Q DRUG CHANGES NF DOXYCYCLINE HYC DR 150 MG TAB lymphogranulomafever, rickettsialpox, venereum, yaws, tularemia, granuloma rickettsial inguinale, infection, acne vulgaris, malaria Rockyprevention, Mountain spotted fever, boutonneuse fever, rectal Chlamydia trachomatis infection, upper respiratory pneumococcal infection, cholera, genitourinary QL, revise ST Oct-20 Chlamydia trachomatis infection, Campylobacter fetus infection, plague, Q DRUG CHANGES NF DOXYCYCLINE HYC DR 75 MG TAB lymphogranulomafever, rickettsialpox, venereum, yaws, tularemia, acne vulgaris, rickettsial Rocky infection, Mountain malaria spotted prevention, fever, granuloma inguinale, rectal Chlamydia trachomatis infection, upper respiratory pneumococcal infection, cholera, boutonneuse fever, QL, revise ST Oct-20 genitourinary Chlamydia trachomatis infection, Campylobacter fetus DRUG CHANGES NF DOXYCYCLINE HYC DR 50 MG TAB infection, Q fever, yaws, plague, tularemia, rickettsialpox, rickettsial infection,

DRUG CHANGES GEN QL, revise ST Oct-20 MINOCYCLINE ER 105 MG TABLET acne vulgaris SOLODYN ER

DRUG CHANGES GEN QL, revise ST Oct-20 MINOCYCLINE ER 115 MG TABLET acne vulgaris SOLODYN ER

DRUG CHANGES GEN QL, revise ST Oct-20 MINOCYCLINE ER 80 MG TABLET acne vulgaris SOLODYN ER

DRUG CHANGES GEN QL, revise ST Oct-20 MINOCYCLINE ER 65 MG TABLET acne vulgaris SOLODYN ER

DRUG CHANGES GEN QL, revise ST Oct-20 MINOCYCLINE ER 55 MG TABLET acne vulgaris SOLODYN ER

DRUG CHANGES GEN QL, revise ST Oct-20 MINOCYCLINE ER 135 MG TABLET acne vulgaris, acne vulgaris COREMINO ER

DRUG CHANGES GEN QL, revise ST Oct-20 MINOCYCLINE ER 90 MG TABLET acne vulgaris, acne vulgaris COREMINO ER

DRUG CHANGES GEN QL, revise ST Oct-20

MINOCYCLINE ER 45 MG TABLET relapsingacne vulgaris, fever, acne bartonellosis, vulgaris syphilis, gingivostomatitis, upper respiratory COREMINO ER pneumococcal infection, bacterial pneumonia, mycoplasmal pneumonia, lymphogranuloma venereum, granuloma inguinale, sinusitis, genitourinary DRUG CHANGES GEN add ST Oct-20 MINOCYCLINE HCL 100 MG TABLET rickettsialpox,Chlamydia trachomatis relapsing infection, fever, bartonellosis, fusospirochetal syphilis, pharyngitis, gingivostomatitis, yaws, acne upper respiratory pneumococcal infection, bacterial pneumonia, mycoplasmal pneumonia, lymphogranuloma venereum, granuloma inguinale, sinusitis, DRUG CHANGES GEN add ST Oct-20 MINOCYCLINE HCL 75 MG TABLET relapsinggenitourinary fever, Chlamydia bartonellosis, trachomatis syphilis, infection, gingivostomatitis, fusospirochetal upper respiratorypharyngitis, pneumococcal infection, bacterial pneumonia, mycoplasmal pneumonia, lymphogranuloma venereum, granuloma inguinale, sinusitis, genitourinary DRUG CHANGES GEN add ST Oct-20 MINOCYCLINE HCL 50 MG TABLET Chlamydia trachomatis infection, fusospirochetal pharyngitis, yaws, acne

RIFAMPIN DRUG CHANGES GEN-->NPB PA, QL Oct-20 PRETOMANID 200 MG TABLET pulmonary multi-drug resistant M. tuberculosis

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rheumatoid arthritis in pt at high gastric ulcer risk, osteoarthritis in patient at high gastric ulcer risk, ankylosing spondylitis in pt at high gastric ulcer risk, DRUG CHANGES NF Oct-20 VIMOVO DR 500-20 MG TABLET polyarticular juvenile idiopathic arthritis NAPROXEN-ESOMEPRAZOLE rheumatoid arthritis in pt at high gastric ulcer risk, osteoarthritis in patient at NAPROXEN-ESOMEPRAZ DR 375-20MG high gastric ulcer risk, ankylosing spondylitis in pt at high gastric ulcer risk, DRUG CHANGES NF Oct-20 polyarticular juvenile idiopathic arthritis VIMOVO, DUEXIS rheumatoid arthritis in pt at high gastric ulcer risk, osteoarthritis in patient at NAPROXEN-ESOMEPRAZ DR 500-20MG high gastric ulcer risk, ankylosing spondylitis in pt at high gastric ulcer risk, DRUG CHANGES NF Oct-20 polyarticular juvenile idiopathic arthritis VIMOVO, DUEXIS

osteoarthritis in patient at high gastric ulcer risk, rheumatoid arthritis in pt at DRUG CHANGES NF Oct-20 DUEXIS 800-26.6 MG TABLET cutaneoushigh gastric T-cell ulcer lymphoma, risk non-Hodgkin's lymphoma, diffuse large B-cell VIMOVO, NAPROXEN-ESOMEPRAZOLE lymphoma, contact dermatitis, dermatitis herpetiformis, pemphigus, acute lymphoid leukemia, chronic lymphoid leukemia, erythema multiforme, DRUG CHANGES NF Oct-20 RAYOS DR 1 MG TABLET cutaneousexfoliative dermatitis,T-cell lymphoma, pure red non-Hodgkin's cell aplasia associated lymphoma, with diffuse CLL, large serum B-cell DEXAMETHASONE TABLET, HYDROCORTISONE TABLET lymphoma, contact dermatitis, dermatitis herpetiformis, pemphigus, acute lymphoid leukemia, chronic lymphoid leukemia, erythema multiforme, DRUG CHANGES NF Oct-20 RAYOS DR 2 MG TABLET exfoliative dermatitis, pure red cell aplasia associated with CLL, serum DEXAMETHASONE TABLET, HYDROCORTISONE TABLET

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

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

DRUG CHANGES GEN QL, add ST Oct-20 DICLOFENAC SODIUM 1% GEL osteoarthritis of the knee, osteoarthritis VOLTARIN 1% GEL add Excluded type 2 diabetes mellitus, type 1 diabetes mellitus, hyperglycemia, diabetic DRUG CHANGES 99 May-20 NOVOLIN R 100 UNIT/ML FLEXPEN coma, hyperkalemia, diabetic ketoacidosis HUMULIN Products flag add Excluded DRUG CHANGES 99 May-20 NOVOLIN N 100 UNIT/ML FLEXPEN type 2 diabetes mellitus, type 1 diabetes mellitus HUMULIN Products flag add Excluded DRUG CHANGES 99 May-20 RELION NOVOLIN N U-100 FLEXPEN type 2 diabetes mellitus, type 1 diabetes mellitus HUMULIN Products flag add Excluded type 2 diabetes mellitus, type 1 diabetes mellitus, hyperglycemia, diabetic DRUG CHANGES 99 May-20 RELION NOVOLIN R U-100 FLEXPEN coma, hyperkalemia, diabetic ketoacidosis HUMULIN Products flag

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

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

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

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KEY: ABBREVIATION DEFINITION GEN Generic GEN (S) Generic (Specialty) PB Preferred Brand NPB Non-Preferred Brand PS Preferred Specialty NPS/SP Non-Preferred Specialty/Specialty NF Non-Formulary QL Quantity Limit ST Step Therapy PA Prior Authorization MED Medical Flag BSP Benefit Shift Program * Manage consistent with other drugs in class, unless otherwise specified ª Clinically similar products

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

2019 Magellan Rx Management, LLC. All rights expressly reserved. 13