Pharmacy Policy and Formulary Changes

Long Acting Injectable AntiPsychotics

NH.PHAR.289 Buprenorphine Implant

NH.PHAR.288 Eteplirsen

NH.PHAR.125 Xolair Omalizumab

NH.PHAR.115 Pegloticase (Krystexxa)

NH.PHAR.111 Cabozantinib (Cometriq, Cabometyx)

NH.PHAR.100 Axitinib (Inlyta)

NH.PHAR.98 Ruxolitinib

Final CP.PHAR.369 Alectinib (Alecensa) 12.12.17

Final CP.PHAR.368 Pemetrexed (Alimta) 11.23.17

Final CP.PHAR.367 Letermovir (Prevymis) 12.05.17

Final CP.PHAR.366 Acalabrutinib (Calquence) 12.06.17

Final CP.PHAR.350 Rucaparib (Rubraca) 11.13.17

Final CP.PHAR.345 Abaloparatide (Tymlos) 11.15.17

Final CP.PHAR.341 Deutetrabenazine (Austedo) 11.27.17

Final CP.PHAR.336 Dupilumab (Dupixent) 12.01.17

Final CP.PHAR.334 Ribociclib (Kisqali, Kisqali Femara) 12.06.17

Final CP.PHAR.333 Avelumab (Bavencio).11.20.17

Final CP.PHAR.331 Deflazacort (Emflaza) 11.12.17

Final CP.PHAR.330 Protein C Concentrate Human (Ceprotin).11.16.17

Final CP.PHAR.329 Siluximab (Sylvant) 12.01.17

Final CP.PHAR.301 Erwinia Asparaginase (Erwinaze) 12.11.17

Final CP.PHAR.300 Bezlotoxumab (Zinplava)

Final CP.PHAR.298 Afatinib (Gilotrif) 11.13.17

Final CP.PHAR.235 Atezolizumab (Tecentriq) 11.10.17

Final CP.PHAR.327 Nusinersen (Spinraza) 12.01.17

Final CP.PHAR.226 Fondaparinux (Arixtra).12.06.17

Final CP.PHAR.225 Dalteparin (Fragmin).12.06.17

Final CP.PHAR.224 Enoxaparin (Lovenox).12.06.17

Final CP.PHAR.223 Reslizumab (Cinqair) 11.07.17

Final CP.PHAR.234.Ferric Carboxymaltose (Injectafer).12.01.17

Final CP.PHAR.213 Lumacaftor-ivacaftor (Orkambi) 11.16.17

Final CP.PHAR.212 Dornase alfa (Pulmozyme) 11.13.17

Final CP.PHAR.211 Tobramycin 11.13.17

Final CP.PHAR.210 Ivacaftor (Kalydeco) 11.16.17

Final CP.PHAR.214 Desmopressin (DDAVP, Stimate) 11.29.17

Final CP.PHAR.208 Sodium phenylbutyrate (Buphenyl) 11.15.17

Final CP.PHAR.204 Trabectedin (Yondelis) 11.13.17

Final CP.PHAR.203 Cosyntropin (Cortrosyn) 11.13.17

Final CP.PHAR.202 C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) 12.01.17

Final CP.PHAR.209 Aztreonam (Cayston) 11.13.17

Final CP.PHAR.199 Treprostinil (Orenitram, Remodulin, Tyvaso) 12.06.17

Final CP.PHAR.198 Tadalafil (Adcirca) 12.06.17

Final CP.PHAR.197 Sildenafil (Revatio) 12.06.17

Final CP.PHAR.200 (Mepolizumab) Nucala 11.06.17

Final CP.PHAR.195 Riociguat (Adempas) 12.06.17

Final CP.PHAR.194 Macitentan (Opsumit) 12.06.17

Final CP.PHAR.193 Iloprost (Ventavis) 12.06.17

Final CP.PHAR.192 Epoprostenol (Flolan, Veletri) 12.06.17

Final CP.PHAR.196 Selexipag (Uptravi) 12.06.17

Final CP.PHAR.190 Ambrisentan (Letairis) 12.06.17

Final CP.PHAR.189 Ibandronate injection (Boniva) 11.16.17

Final CP.PHAR.188 Teriparatide (Forteo) 11.16.17

Final CP.PHAR.187 Verteporfin (Visudyne) 12.01.17

Final CP.PHAR.191 Bosentan (Tracleer) 12.06.17

Final CP.PHAR.179 Romiplostim (Nplate) 11.15.17

Final CP.PHAR.186 Ranibizumab (Lucentis) 12.01.17

Final CP.PHAR.185 Pegaptanib (Macugen) 12.01.17

Final CP.PHAR.184 Aflibercept (Eylea) 12.01.17

Final CP.PHAR.181 Hemin (Panhematin) 12.01.17

Final CP.PHAR.177 Ecallantide (Kalbitor) 12.01.17

Final CP.PHAR.168 Corticotropin (H.P. Acthar) 12.13.17

Final CP.PHAR.167.Iron Sucrose (Venofer).12.01.17

Final CP.PHAR.178 Icatibant (Firazyr) 12.01.17

Final CP.PHAR.165.Ferumoxytol (Feraheme).12.01.17

Final CP.PHAR.125 Palbociclib (Ibrance) 11.15.17

Final CP.PHAR.121 Nivolumab (Opdivo) 12.05.17

Final CP.PHAR.119.Ramucirumab (Cyramza).12.01.17

Final CP.PHAR.166.Ferric Gluconate (Ferrlecit).12.01.17

Final CP.PHAR.111 Cabozantinib (Cabometyx, Cometriq) 11.08.17

Final CP.PHAR.101 Mifepristone (Korlym).11.28.17

Final CP.PHAR.115 Pegloticase (Krystexxa) 11.22.17

Final CP.PHAR.114.Teduglutide (Gattex).12.01.17

Final CP.PHAR.93 Bevacizumab (Avastin) 12.01.17

Final CP.PHAR.97 Eculizumab (Soliris) 12.12.17

Final CP.PHAR.94 Alpha-1 Proteinase Inhibitors 12.05.17

Final CP.PHAR.91 Vemurafenib (Zelboraf) 12.13.17

Final CP.PHAR.80 Vandetanib (Caprelsa) 11.21.17

Final CP.PHAR.98.Ruxolitinib (Jakafi).11.22.17

Final CP.PHAR.63 Everolimus (Afinitor, Afinitor Disperz) 11.09.17

Final CP.PHAR.61 Cinacalcet (Sensipar) 11.21.17

Final CP.PHAR.59 Zoledronic Acid (Reclast, Zometa) 11.22.17

Final CP.PHAR.52 Interferon Gamma- 1b (Actimmune) 11.10.17

Final CP.PHAR.74 Erlotinib (Tarceva) 12.02.17

Final CP.PHAR.40 Octreotide (Sandostatin, Sandostatin LAR).11.30.17

Final CP.PHAR.14 Hydroxyprogesterone caproate (Makena) 12.01.17

Final CP.PHAR.01 Omalizumab (Xolair) 11.07.17

Final CP.PHAR.43 Sapropterin (Kuvan).11.17.17

Final 1Q18 Centene combined EM Guidelines Summary Table

Final PDL Update  Medicaid

Guidelines

NH.PMN.62 Tedizolid _Sivextro

NH.PMN.57_febuxostat_Uloric

NH.PMN.54_clobazam_Onfi

NH.PST.08_Mesalamine_Oral_Therapy

NH.PPA.15_milnacipran_Savella

NH.PPA.01_celecoxib_Celebrex

NH.PMN.21 Becaplermin _Regranex_

NH.PMN.20 Aspirin_.Dipyridamole _Aggrenox_

NH.PMN.17 droxidopa_Northera

NH.PMN.15 asenapine _Saphris_

NH.PMN.22 Brand Name Override

NH.PMN.07 Levalbuterol _Xopenex_

NH PMN_ 36_lisdexamfetamine_Vyvanse

Final CP.PST.19 SGLT2 inhibitors 11.28.17

Final CP.PST.18 DPP-4 inhibitors 11.28.17

NH.PMN.10_methylphenidate_transdermal_patch_Daytrana

Final CP.PST.08 Mesalamine Oral Therapy

Final CP.PMN.109 Suvorexant (Belsomra) 12.13.17

Final CP.PMN.108 Latanoprostene Bunod (Vyzulta) 12.12.17

Final CP.PMN.107 Topical Immunomodulators 12.05.17

Final CP.PST.14 GLP-1 receptor agonists 11.28.17

Final CP.PMN.105 Tavaborole (Kerydin) 11.03.17

Final CP.PMN.104 Tasimelteon (Hetlioz) 12.01.17

Final CP.PMN.103 Secnidazole (Solosec) 11.27.17

Final CP.PMN.102 Rolapitant (Varubi) 12.06.17

Final CP.PMN.106 Tiludronate (Skelid) 12.01.17

Final CP.PMN.100 Risedronate (Actonel, Atelvia)

Final CP.PMN.98 Pimecrolimus (Elidel) 12.05.17

Final CP.PMN.96 Ibandronate Oral (Boniva) 12.03.17

Final CP.PMN.99 Prasterone (Intrarosa) 11.22.17

Final CP.PMN.101 Rivastigmine (Exelon)

Final CP.PMN.94 Etidronate (Didronel) 12.01.17

Final CP.PMN.93 Dextromethorphan-Quinidine (Nuedexta) 11.30.17

Final CP.PMN.92 CNS Stimulants

Final CP.PMN.91Cariprazine (Vraylar)

Final CP.PMN.95 Fluticasone propionate (Xhance) 11.22.17

Final CP.PMN.89 Amantadine ER (Gocovri) 11.22.17

Final CP.PMN.88 Alendronate (Binosto, Fosamax plus D)

Final CP.PMN.87 Plecanatide (Trulance) 11.06.17

Final CP.PMN.90 Benznidazole 11.28.17

Final CP.PMN.77 Ezetimibe-Simvastatin (Vytorin) 11.13.17

Final CP.PMN.71 Linaclotide (Linzess) 11.07.17

Final CP.PMN.67 Sacubitril and valsartan (Entresto) 11.01.17

Final CP.PMN.62 Tedizolid (Sivextro)

Final CP.PMN.78 Ezetimibe (Zetia) 11.09.17

Final CP.PMN.52 Omega-3-Acid Ethyl Esters (Lovaza).11.16.17

Final CP.PMN.34 Ranolazine (Ranexa) 12.12.17

Final CP.PMN.25 Efinaconazole (Jublia) 11.03.17

Final CP.PMN.24 Ciclopirox (Penlac) 10.30.17

Final CP.PMN.57 Febuxostat (Uloric) 12.01.17

Final CP.PMN.20 Aspirin-dipyridamole (Aggrenox) 11.13.17

Final CP.PMN.15 Asenapine (Saphris)

Final CP.PMN.07 Levalbuterol (Xopenex) 10.26.17

Final CP.PMN.05 Rifapentine (Priftin)

Final CP.PMN.21 Becaplermin (Regranex) 11.20.17

CP.PPA.15 milnacipran (Savella)

CP.PPA.01 celecoxib (Celebrex)

CP.PMN.54 clobazam (Onfi)

Final CP.PMN.04 Non-Calcium Phophate Binders 12.04.17

Policies & Procedures

NH.PHAR.135_Drug_Utilization_Review

NH.PHAR.14 Pharmacy Lock-In

NH.PHAR.13 Pharmacy & Therapeutics Committee

NH.PHAR.08 Pharmacy-Prior-Authorization-and-Medical-Necessity-Criteria

NH.PHAR.02 Approval-of-Brand-Name-Override

Final - Medicaid 1Q18 P and P Summary

Quarter 2 2017

Lantus will be removed from formulary as of July 5th, 2017

Q2 Guidelines

Q2 Policy & Procedures

Clinical Policy Summary Table

CP.PHAR.14 Hydroxyprogesterone Caproate

CP.PHAR.40 Octreotide

CP.PHAR.43 Sapropterin

CP.PHAR.59 Zoledronic acid

CP.PHAR.61 Cinacalcet

CP.PHAR.63 Everolimus

CP.PHAR.80 Vandetanib

CP.PHAR.91 Vemurafenib

CP.PHAR.93 Bevacizumab

CP.PHAR.94 Alpha-1 Proteinase Inhibitors

CP.PHAR.97 Eculizumab

CP.PHAR.101 Mifepristone

CP.PHAR.109 Tesamorelin

CP.PHAR.114 Teduglutide

CP.PHAR.119 Ramucirumab

CP.PHAR.121 Nivolumab

CP.PHAR.126 Ibrutinib

CP.PHAR.165 Ferumoxytol

CP.PHAR.166 Ferric Gluconate

CP.PHAR.167 Iron Sucrose

CP.PHAR.168 Corticotropin

CP.PHAR.177 Ecallantide

CP.PHAR.178 Icatibant

CP.PHAR.179 Romiplostim

CP.PHAR.180.Eltrombopag

CP.PHAR.181 Hemin

CP.PHAR.184 Aflibercept

CP.PHAR.185 Pegaptanib

CP.PHAR.186 Ranibizumab

CP.PHAR.187 Verteporfin

CP.PHAR.188 Teriparatide

CP.PHAR.189 Ibandronate

CP.PHAR.190 Ambrisentan

CP.PHAR.191 Bosentan

CP.PHAR.192 Epoprostenol

CP.PHAR.193 Iloprost

CP.PHAR.194 Macitentan

CP.PHAR.195 Riociguat

CP.PHAR.196 Selexipag

CP.PHAR.197 Sildenafil

CP.PHAR.198 Tadalafil

CP.PHAR.199 Treprostinil

CP.PHAR.200 Mepolizumab

CP.PHAR.201.Belatacept

CP.PHAR.202 C1 Esterase Inhibitors

CP.PHAR.203 Cosyntropin

CP.PHAR.204 Trabectedin

CP.PHAR.205 TPN IDPN

CP.PHAR.208 Sodium phenylbutyrate

CP.PHAR.209 Aztreonam

CP.PHAR.210 Ivacaftor

CP.PHAR.211 Tobramycin

CP.PHAR.212 Dornase Alfa

CP.PHAR.213 Lumacaftor-Ivacaftor

CP.PHAR.214 Desmopressin

CP.PHAR.223 Reslizumab_1

CP.PHAR.224 Enoxaparin

CP.PHAR.225 Dalteparin

CP.PHAR.226 Fondaparinux

CP.PHAR.234 Ferric Carboxymaltose

CP.PHAR.235 Atezolizumab

CP.PHAR.318 Eribulin Mesylate

CP.PHAR.319 Ipilimumab

CP.PHAR.320 Necitumumab

CP.PHAR.321 Panitumumab

CP.PHAR.322 Pembrolizumab

CP.PHAR.323 Plerixafor

CP.PHAR.324 Temsirolimus

CP.PHAR.325 Ziv-Aflibercept

CP.PHAR.326 Olaratumab

CP.PHAR.328 Asfotase Alfa.3.16.17

CP.PHAR.329 Siltuximab

CP.PHAR.330 Protein C Concentrate Human

CP.PHAR.331 deflazacort

CP.PHAR.332.Pasireotide

CP.PHAR.333 Avelumab

CP.PHAR.334 Ribociclib

CP.PHAR.335 Ocrelizumab.05.08.17

CP.PHAR.336 Dupilumab

NH.PHAR.98 Ruxolitinib

NH.PHAR.100 Axitinib (Inlyta)

NH.PHAR.111 Cabozantinib (Cometriq, Cabometyx)

NH.PHAR.115 Pegloticase (Krystexxa)

NH.PHAR.289 Buprenorphine Implant

Guidelines

3Q17 Marketplace Summary Table

HIM.PA.49 lacosamide (Vimpat) FINAL

HIM.PA.50 isotretinoin (Claravis, Myorisan, Zenatane) 4.17 FINAL

HIM.PA.51 oral bisphosphonates 4.17 FINAL

HIM.PA.53 GLP-1 Receptor Agonists FINAL

HIM.PA.54 Celecoxib (Celebrex) FINAL

HIM.PA.55 Aspirin-extended-release dipyridamole (Aggrenox) FINAL

HIM.PA.56 topical immunomodulators 4.17 FINAL

HIM.PA.57 Modafinil (Provigil) FINAL

HIM.PA.58 DPP-4 Inhibitors FINAL

HIM.PA.59 Atypical Antipsychotics 4.7.17 FINAL

HIM.PA.60 ezogabine (Potiga) FINAL

HIM.PA.61 Desmopressin acetate (DDAVP) 4.17 FINAL

HIM.PA.62 Aprepitant (Emend) FINAL

HIM.PA.63 Famiciclovir (Famvir) FINAL

HIM.PA.64 Pregabalin (Lyrica) FINAL

HIM.PA.66 atomoxetine (Strattera) FINAL

HIM.PA.67 Febuxostat (Uloric) FINAL

HIM.PA.68 rifaximin (Xifaxan) 4.17 FINAL

HIM.PA.71 topical acne FINAL

HIM.PA.73 Inhaled corticosteroids FINAL

HIM.PA.74 Inhaled Long-acting Beta Agonists and Combination Products FINAL

HIM.PA.75 levalbuterol (Xopenex) FINAL

HIM.PA.78 emtricitabine tenofovir (Truvada) 4.17 FINAL

HIM.PA.79 lubiprostone (Amitiza) FINAL

HIM.PA.81 Risperidone ODT, M-Tab, Solution FINAL

HIM.PA.85 dolasetron (Anzemet) 4.7.17 FINAL

HIM.PA.86 tapentadol (Nucynta) 4.7.17 FINAL

HIM.PA.87 topical testosterone 4.7.17 FINAL

HIM.PA.89 rasagiline (Azilect) FINAL

HIM.PA.90 rufinamide (Banzel) FINAL

HIM.PA.93 mometasone (Nasonex) FINAL

HIM.PA.94 Armodafinil (Nuvigil) FINAL

HIM.PA.95 Telbivudine (Tyzeka) FINAL

HIM.PA.97 Long Acting Opiods FINAL

HIM.PA.98 guanfacine ER (Intuniv) FINAL

HIM.PA.99 risperidone (Risperdal Consta) FINAL

HIM.PA.103 Brand name override and non-formulary medication FINAL

HIM.PA.107 Cysteamine (Cystaran) FINAL

HIM.PA.108 isavuconazonium (Cresemba) FINAL

HIM.PA.109 Step Therapy Criteria_final

HIM.PA.SP1 sofosbuvir.velpatasvir (Epclusa) FINAL

HIM.PA.SP2 sofosbuvir (Sovaldi) FINAL

HIM.PA.SP3 ledipasvir.Sofosbuvir (Harvoni) FINAL

HIM.PA.SP5 Olaprib (Lynparza) FINAL

Policies and Procedures

3Q17 Marketplace Policies and Procedures Summary Table

HIM.PHAR.15 Pharmacy Exception Requests - CZ

HIM.PHAR.18-Pharmacy_Lock-In_Program

Removal of Brand Name Only for the Below Medications:

Depakote 125mg, 250mg, 500mg, 250mg ER, 500g ER, 125mg Sprinkles

Tegretol 200mg, 100mg/5ml Suspension, 100mg XR, 200mg XR, 400mg XR

Guidelines

3Q17 Medicaid Guideline Summary Table 6.12.17_v2mme

CP.PMN.09 Lindane shampoo Q3 2017

CP.PMN.19 Aprepitant (Emend) Q3 2017

CP.PMN.25 Efinaconazole (Jublia) Q3 2017

CP.PMN.26 Famciclovir (Famvir) Q3 2017

CP.PMN.31 Fluticasone-salmeterol (Advair Diskus, Advair HFA) Q3 2017

CP.PMN.40 Acitretin (Soriatane) Q3 2017

CP.PMN.46 Roflumilast (Daliresp) Q3 2017

CP.PMN.52 Omega-3-acid ethyl esters (Lovaza) Q3 2017

CP.PMN.60 SSRI SNRI Duplicate Therapy Q3 2017

CP.PMN.63 Dexmethylphenidate ER (Focalin XR) Q3 2017

CP.PMN.65 Vortioxetine (Trintellix) Q3 2017

CP.PMN.69 Inhaled combination LAA-LABA

CP.PMN.XX Buprenorphine (Subutex) Q3 2017

CP.PMN.XX Buprenorphine-naloxone (Suboxone, Bunavail, Zubsolv) Q3 2017

CP.PMN.XX. Timothy Grass Pollen Allergen Extract (Grastek) Q3 2017

CP.PMN.XX.Mixed Pollens Allergen Extract (Oralair) Q3 2017

CP.PMN.XX.Short ragweed pollen allergen extract (Ragwitek) Q3 2017

CP.PPA.09 Epinephrine (Epipen, Epipen Jr) Q3 2017

CP.PPA.19 Pimavanserin (Nuplazid)

CP.PPA.XX DPP-4 inhibitors

CP.PPA.XX SGLT2 inhibitors

CP.PST.03 Anti-allergy ophthalmics Q3 2017

NH PMN 47 Xifaxan

NH.PMN.11Oral-Antiemetics_5-HT3-Antagonists

NH.PMN.15 asenapine _Saphris_

NH.PMN.16 Request-for-Medically-Necessary-Drug-not-on-the-PDL

NH.PMN.18 Varenicline-Chantix

NH.PMN.37 Guanfacine  ER (Intuniv)

NH.PMN.53 Off Label Use

NH.PMN.59 Quantity Limit Overrides

NH.PPA.02 Desmopressin Acetate (DDAVP)

NH.PPA.17 Aripiprazole (Abilify)

NH.PST.05 Exemestane Step Therapy

Policies and Procedures

CC.PHAR.14 Generic Drug Additions to PDL - Track changes

CC.PHAR.15 Line Extension Additions to PDL - Track changes